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Parental presence is often employed to alleviate distress in children within the context of surgery under general anesthesia. The critical component of this intervention may not be the presence of the parent per se, but more importantly the behaviors in which the parent and child engage when the parent is present. The purpose of the current study was to examine the sequential and reciprocal relationships between parental behaviors and child distress during induction of general anesthesia. Participants were 32 children (3-6 years) receiving dental surgery as a day surgery procedure, and their parents. A modified Child Adult Medical Procedures Interaction Scale-Revised was used to code parent and child behaviors. Initial child distress led to increased parental provision of reassurance and decreased provision of physical comfort. Our findings may inform the development of preoperative preparation programs whereby parents can be appropriately educated about what behaviors will be helpful/unhelpful for their child during induction of general anesthesia.
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A Sequential Examination of Parent–Child Interactions
at Anesthetic Induction
Kristi D. Wright Sherry H. Stewart
G. Allen Finley Mateen Raazi
Published online: 29 October 2014
ÓSpringer Science+Business Media New York 2014
Abstract Parental presence is often employed to alleviate
distress in children within the context of surgery under
general anesthesia. The critical component of this inter-
vention may not be the presence of the parent per se, but
more importantly the behaviors in which the parent and
child engage when the parent is present. The purpose of the
current study was to examine the sequential and reciprocal
relationships between parental behaviors and child distress
during induction of general anesthesia. Participants were
32 children (3–6 years) receiving dental surgery as a day
surgery procedure, and their parents. A modified Child
Adult Medical Procedures Interaction Scale-Revised was
used to code parent and child behaviors. Initial child dis-
tress led to increased parental provision of reassurance and
decreased provision of physical comfort. Our findings may
inform the development of preoperative preparation
programs whereby parents can be appropriately educated
about what behaviors will be helpful/unhelpful for their
child during induction of general anesthesia.
Keywords Anesthesia Preoperative anxiety Children
Parental behaviors Measurement
Introduction
Allowing parents to be present at the induction of general
anesthesia just prior to surgery (‘‘parental presence’’) is one
type of intervention employed to alleviate anxiety and
distress in children undergoing a surgical procedure. The
efficacy of this intervention has received considerable
attention throughout the years (see reviews by Chundamala
et al. 2009; Piira et al. 2005; Strom, 2012; Wright et al.
2007; Yip et al. 2009). An overwhelming amount of evi-
dence seems to suggest that child anxiety during anesthetic
induction is not impacted by the mere presence/absence of
a parent. That is, in controlled investigations where parents
are randomly assigned to parental presence/absence
groups, child anxiety frequently does not differ across
groups (e.g., Wright et al. 2010). In spite of this evidence,
the use of parental presence continues to be regarded as a
viable intervention method in clinical practice. In fact, the
most recent survey examining the trends in the practice of
anesthesiologists in employing parental presence across the
U.S. indicated that parents are increasingly allowed to be
present during induction (Kain et al. 2004). More recently,
we completed a survey of 200 Canadian anesthesiologists’
practices for alleviating anxiety in children and adolescents
(Wright et al. 2013). Overall, our findings suggested that
parental presence is encouraged very frequently in Canada
today. Specifically, 71 % of our respondents indicated that
K. D. Wright (&)
Department of Psychology, University of Regina, Regina,
SK S4S 0A2, Canada
e-mail: kristi.wright@uregina.ca
S. H. Stewart G. A. Finley
Department of Psychology, Dalhousie University, Halifax, NS,
Canada
S. H. Stewart
Department of Psychiatry, Dalhousie University, Halifax, NS,
Canada
G. A. Finley
Department of Anesthesia, IWK Health Centre, Dalhousie
University, Halifax, NS, Canada
M. Raazi
Department of Anesthesiology, Perioperative Medicine and Pain
Management, University of Saskatchewan, Saskatoon, SK,
Canada
123
J Clin Psychol Med Settings (2014) 21:374–385
DOI 10.1007/s10880-014-9413-4
the hospitals where they are employed allowed or
encouraged parental presence. Employing parental pre-
sence may be seen as preferable since other intervention
methods (e.g., sedative premedication) have associated
time restrictions, negative side-effects, and/or increased
health care costs.
Review of the existing findings in the literature leads
one to consider that there may be moderators of the rela-
tionship between parental presence and child anxiety and
distress. It may be the case that in some situations parental
presence is helpful, in others harmful, and yet in others
neutral. One possible moderator may be the actual behav-
iors that parents engage in during the anesthetic induction
experience. Chambers (2003) was one of the first to note
that there has been a surprising lack of coordination
between investigations that examine parental presence
during medical procedures (e.g., those requiring general
anesthesia) and investigations that describe and quantify
what parents actually do during these procedures. It has
been speculated that what a parent says and does while
being present during medical procedures may be the criti-
cal component, not necessarily whether the parent was
physically present or absent per se (Piira & von Baeyer
2001). According to Piira et al. (2005), it appears that
parents are not routinely informed about what they could
do to improve their child’s experience when parents are
present during a medical procedure (e.g., those requiring
general anesthesia) and that parents desire information
regarding how they could best help their child in such a
situation. The combination of parental presence, coupled
with information provision, may improve parent and child
outcomes when parents are present during medical proce-
dures such as anesthetic induction. Nevertheless, the cur-
rent literature lacks evidence to suggest which types of
behaviors would be most useful for parents to employ in
the surgery context; there is limited knowledge of which
particular parental behaviors are associated with decreased
child anxiety and distress in this context. Similarly, there is
limited evidence on which behaviors parents should avoid
in this context, i.e., which particular parental behaviors are
associated with increased child anxiety and distress in this
context. Albeit outside the surgery context, during painful
medical procedures such as immunizations, bone marrow
aspirations, and lumbar punctures, and during experimental
pain tasks, certain parental behaviors have been demon-
strated to be associated with child distress (e.g., Blount
et al. 1989,1990,1991; Bush & Cockrell, 1987; Noel et al.
2010; Walker et al. 2006; Williams et al. 2011). These
behaviors include reassuring comments, apologies to the
child, indicating empathy, giving control to the child, and
criticism of the child by the parent.
Employing a revised perioperative version of the Child
Adult Medical Procedures Interaction Scale (P-CAMPIS;
Caldwell-Andrews et al. 2005), Chorney et al. (2009)
examined associations between observed adult (i.e., anes-
thesiologist, nurse, and parent) behaviors and children’s
distress and coping in a sample of 293 two- to ten-year-old
children undergoing anesthetic induction with a parent
present; they made several important observations. First,
positive associations were observed between behaviors
termed ‘adult emotion-focused behaviors’ (i.e., empathy
and reassurance), and child distress and negative associa-
tions were observed between these adult behaviors and
child coping behaviors. Second, humor and distracting talk
(termed Adult distracting behavior) showed the opposite
patterns. Third, Chorney et al. (2009, p. 1,295) examined
the behavior of medical re-interpretation, i.e., ‘‘attempts to
provide information on the induction procedure while re-
framing the procedure as less threatening (perhaps even
fun)’’. When this behavior was observed in anesthesiolo-
gists, a positive association was seen in terms of child
coping behaviors; however, when the same behavior was
observed in parents, a positive association was observed
with child distress. This study has contributed key findings
to the literature, but the study examined the associations
between adult and child behaviors at the same time point.
In order to determine causality, i.e., which adult behaviors
cause child behaviors during the induction of general
anesthesia, we need to know that the adult behavior pre-
cedes the child behavior. It may also be the case that child
distress ‘pulls for’ certain behaviors on the part of the
parent (e.g., Horstmann 2003; Hudson et al. 2008; Huebner
& Izard 1988; Shipman et al. 2003). For example, a dis-
tressed child may elicit more provision of reassurance or of
physical comfort from a parent, which may in turn nega-
tively (or positively) impact child distress. The use of
sequential modeling allows for the examination of such
reciprocal relationships by allowing for testing of the
possibility that child behaviors precede and significantly
contribute to later parental behaviors in the context of the
induction of general anesthesia.
Given the status of the current literature, it appears that
exploration of sequential relationships between parent and
child behaviors during anesthetic induction is warranted. It
is anticipated that examination of the sequential relation-
ships between parent and child behaviors at the induction
of general anesthesia may shed some light on why empir-
ical investigations into the effectiveness of parental pre-
sence to reduce child preoperative anxiety has produced
inconsistent results. The primary purpose of the present
study was to examine the sequential association between
Child Distress behaviors and Adult (i.e., parent) Distress-
Promoting behaviors during anesthetic induction. Specifi-
cally, we hypothesized that Adult Distress-Promoting
behaviors (e.g., reassuring comments, apologies to the
child, indicating empathy, giving control to the child, and
J Clin Psychol Med Settings (2014) 21:374–385 375
123
criticism of the child by the parent) would be associated
with later child distress behaviors. As noted previously, an
association has been demonstrated between such parent
behaviors and child distress in the anesthesia context (e.g.,
Chorney et al. 2009), post-anesthesia care (Chorney et al.
2013), and other painful medical procedures such as
immunizations and bone marrow aspirations and lumbar
punctures (e.g., Blount et al. 1990,1989; Blount et al.
1991; Bush & Cockrell 1987; Noel et al. 2010; Walker
et al. 2006; Williams et al. 2011).
Method
Participants
The participants were 32 children, ages three through
6 years (mean age 4.56 years; SD =1.06 years), sched-
uled to receive dental surgery as a day surgery procedure at
the Department of Dentistry and Oral Maxillofacial Sur-
gery, Royal University Hospital (RUH) in Saskatoon,
Saskatchewan, Canada. Our age range (i.e., 3–6 years)
represents the age range of the majority of patients who are
provided dental intervention under anesthesia at RUH. In
turn, this age range represents a group that is more likely to
have a parent present during the induction of anesthesia.
More importantly, a methodological concern with many of
the studies in this research area is the wide age range of the
participants, (i.e., ages 1–12 years). We improved on this
limitation by employing a more narrow age range (i.e.,
3–6 years). This improvement allows us to examine the
relationship between child and parent behaviors in a sam-
ple with less variability in cognitive capacity. Two par-
ticipants’ data were not used in analyses. One participant’s
parent was not present during anesthetic induction.
Therefore, we were unable to examine the relationship
between parent and child behaviors during anesthetic
induction and had to exclude the data as a result. The
second child whose data were not used had a significant
visual impairment. The child was unable to participate
fully, so we excluded this participant’s data as well. The
analyzed sample consisted of 16 males (mean
age =4.52 years; SD =1.04 years) and 14 females (mean
age =4.65 years; SD =1.14 years). Ethnicity in the
sample was primarily Aboriginal (53.3 %) and Caucasian
(43.3 %). Mothers participated primarily (n=25 of the 30
parents) and the average age of all parents was 30.27 years
(SD =5.65 years). All participants received a dental
check-up, cleaning, two X-rays, and fluoride. Of the par-
ticipants: 93.0 % (n=28) had stainless steel crowns
placed (number of crowns ranged from 1 to 8); 80.0 %
(n=24) had amalgams completed (number of amalgams
ranged from 1 to 7); 80.0 % (n=24) had pulpotomies
completed, i.e., removal of the soft tissue in the pulp
chamber to address infection or inflammation (number of
pulpotomies ranged from 1 to 8); 43.3 % (n=13) had
tooth extractions (number of extractions ranged from 1 to
7); and 6.7 % (n=2) had sealants placed for preventative
reasons. All children required general anesthesia to com-
plete their procedures. Any child aged 3–6 years who was
scheduled for dental surgery as a day surgery procedure at
the RUH Department of Dentistry and Oral Maxillofacial
Surgery was considered for inclusion, unless he or she met
any of several exclusionary criteria. Aside from dental
health problems as noted above, it was our goal to have an
otherwise healthy sample of children. Thus, a child was
excluded if he or she had been diagnosed with central
nervous system disease, psychiatric disease, liver disease,
renal disease, or cancer. If a child was cognitively
impaired, he or she was excluded as the researchers needed
to be able to communicate with him or her. Also, if the
child had been diagnosed with having gastroesophageal
reflux disease they were excluded, since someone with this
condition may be anesthetized with an IV induction as
opposed to a mask (Cheong et al. 1999), and it was nec-
essary to standardize the method of induction. The infor-
mation relating to these criteria was obtained either from
the child’s parent and/or from their case file (with the
parent’s consent). The study was approved by the Uni-
versity of Saskatchewan Behavioral Research Ethics
Board. Finally, this study had an 83 % participation rate
from all of the potential participants contacted. The pri-
mary reason for a parent declining to participate in the
present study was lack of interest.
Measures
Modified Child–Adult Medical Procedure Interaction
Scale-Revised (Modified CAMPIS-R).
The CAMPIS-R (Blount et al. 1997) is an observational
behavior rating scale for assessing: (1) Child procedural
distress and coping; and (2) Adult coping-promoting
behaviors and distress-promoting behaviors as displayed by
the children’s parents and the medical personnel who are
present during medical procedures. Typically, the behav-
iors of parent, medical staff, and child are videotaped and
later coded in accordance with a dichotomous rating
(present/absent) on six dimensions: Child Coping, Child
Distress, Child Neutral, Adult Coping-Promoting, Adult
Distress-Promoting, and Adult Neutral. (An updated ver-
sion of the P-CAMPIS was not available to us during the
planning stages of the present research because the
P-CAMPIS developers were examining the psychometric
properties of the instrument).
Our modified CAMPIS-R consisted of four dimensions:
Child Coping, Child Distress, Adult Coping-Promoting,
376 J Clin Psychol Med Settings (2014) 21:374–385
123
and Adult Distress-Promoting. In the present study we
examined only child distress and adult distress-promoting
(exhibited by parents or guardians only) behaviors.
Behaviors previously coded in the original CAMPIS-R as
‘Child Distress behaviors’ include crying, screaming,
verbal resistance, request of emotional support, verbal fear,
verbal pain, verbal emotion, and information seeking.
Finally, behaviors previously coded in the original CAM-
PIS-R as ‘Adult Distress-Promoting behaviors’ include
reassuring comments, apologies, empathic statements to
child, giving control to child, criticism, and provision of
physical comfort. In the present study, the coding system
was expanded by including additional potential child dis-
tress behaviors, i.e., physical request of support, observed
restraint of child, flailing, and physical resistance. These
behaviors were included as they are behaviors specific to
this particular context, i.e., anesthetic induction. Anecdotal
reports from health professionals who work in this context
indicate they observe these behaviors when children are
distressed in these situations. We believed the existing
CAMPIS-R codes did not adequately capture these
behaviors. Further, previous research has demonstrated
associations between elevated preoperative anxiety and
such behaviors (e.g., Lumley et al. 1993). They were
classified based on face validity for inclusion in the cate-
gory of interest, i.e., child distress.
Child and parent behaviors were videotaped during the
induction of general anesthesia. Two coders, blind to the
study hypotheses, coded the tapes at a later date. Raters
coded the videotapes in two passes: child codes were rated
first and then parent codes. Behaviors were coded as being
present or absent during 5 s increments for 1.5 min during
anesthetic induction. This 1.5 min period began as the
child entered the operating room (OR) until anesthetic
induction was complete. Inter-rater reliabilities were cal-
culated on 20 % of the participant tapes at anesthetic
induction. Most codes had highly skewed distributions.
Kappa measurements are extremely sensitive and do not
accurately reflect inter-rater agreement (Bakeman &
Gottman 1997; Conger 1980; Light 1971; Zwick 1988) and
are overly punishing for low base rate behavior (Feinstein
& Cicchetti 1990). Thus, percent agreement was used. For
anesthetic induction, the inter-rater reliabilities were as
follows: child distress behaviors =97 % and adult dis-
tress-promoting behaviors =95 %.
Procedure
When a child had been scheduled for a dental day surgery
procedure at the RUH Department of Dentistry and Oral
Maxillofacial Surgery and met all of the inclusion criteria, an
information package (i.e., information letter and consent
form) was sent to the child’s parent(s)/guardian(s). A
researcher followed up the information package by con-
tacting a parent/guardian by telephone to inquire about
participation. If a parent/guardian was willing to allow his or
her child to participate, the researcher arranged to meet with
the parent(s)/guardian(s) and child on the day of surgery.
Prior to the child’s surgery, parental consent and child
verbal assent were obtained. Parental consent and child
verbal assent was obtained for all components of the study
(including having the anesthetic induction videotaped)
after the nature of the study was fully explained to them.
Parents provided consent to having the anesthetic induction
videotaped. The video camera was held by a researcher at
the base of bed where the surgical procedure was taking
place. The anesthetic induction procedure was impacted as
little as possible by the presence of the researchers. The
anesthesiologist performed a pre-anesthetic assessment to
determine the child’s medical eligibility for the study. All
children received acetaminophen suspension 10 mgkg
-1
(Children’s TylenolTM, grape-flavoured, McNeil Con-
sumer Products, Guelph, ON, Canada) prior to surgery. The
child’s behavior was videotaped as he/she walked into the
OR and until anesthetic induction was complete. The child
was brought (either walked or was carried) into the oper-
ating room and placed on the bed. The parent sat beside the
bed. A finger pulse oximeter was placed on the child’s
finger. The child was shown the anesthetic mask and the
mask was placed over the nose and mouth by the anes-
thesiologist and the child was asked to breathe into the
mask. The nurse helped to facilitate a smooth induction
(i.e., help position child on bed, help position child to
receive anesthesia, reduce movement of child by applying
subtle pressure on/around child’s body, and aid in
restraining child if necessary). Once the induction was
complete, the parent was escorted to the waiting area. The
child awoke in the recovery room. The parent was called to
the recovery room once the child was awake. Once the
child returned to the day surgery area from the recovery
room, the researcher met with the child and parent(s) and
the child was given a sheet of stickers as a token of thanks
for his/her participation.
Data Analysis
Descriptive statistics were computed for demographic data
and frequency of child and adult behaviors (see Table 1for
frequency of child and adult behaviors). Bivariate corre-
lations were computed to examine the relationship between
child distress behaviors and adult distress-promoting
behaviors at anesthetic induction. Structural equation
models were constructed and analyzed using the maximum
likelihood variance–covariance estimation method in
AMOS 22.0. Structural equation modeling (SEM) was
utilized in order to test the potential sequential
J Clin Psychol Med Settings (2014) 21:374–385 377
123
relationships between child distress behaviors and adult
distress-promoting behaviors (and vice versa) from the
point at which the child entered the operating room until
anesthetic induction was complete.
Results
Relationship Between Child and Adult Behaviors
Relationship Between Child Distress and Adult Distress-
Promoting Behavior
A modified CAMPIS-R was employed to examine the
specific behaviors that children and their parents engaged
in as well as their interactions during anesthetic induction,
i.e., Child Distress behaviors and Adult Distress-Promoting
behaviors. Bivariate correlations were computed separately
for the observed Child Distress and Adult Distress-Pro-
moting behaviors. All observed Child Distress behaviors
with the exception of two, Physical Request of Support and
Negative Emotion, demonstrated significant positive asso-
ciations with one another. The significant correlations
ranged from .51 (p\.01), between Cry and Verbal
Resistance, to 1.00 (p\.001), between Verbal Pain and
child Restraint). One Child Distress behavior, Verbal Fear,
showed some association with other behaviors, but this was
not consistent. With respect to adult behaviors, only one set
of behaviors were significantly associated, Physical Com-
fort and Giving Control (r =-.41, p\.05); these have
been classified as distress-promoting behaviors in previous
research. This association was in the negative direction,
which suggests that it is not tapping the same construct.
Given these findings, the individual behaviors that
comprise the overall child and adult behavior categories
were modified. It appears that only one overall behavior
category deserves composite scoring: Child Distress. For
the most part, all behaviors in this category were signifi-
cantly positively intercorrelated. The one behavior that was
not intercorrelated with other Child Distress behaviors was
Verbal Fear. However, the Verbal Fear code has high face
validity for inclusion in a Child Distress composite score,
and so we decided to include Verbal Fear in the overall
Child Distress behavior category. However, physical
request of support and negative emotion were excluded
from the overall Child Distress behavior category as they
had no significant associations with other Child Distress
behaviors. The Child Distress behavior composite score
was coded by re-examining the data coding sheets and
providing only 1 point for 1 or more Child Distress
behavior(s) observed during each 5-second interval indi-
cating the presence of child distress in that interval.
Table 1 Modified CAMPIS-R Child Distress and Adult Distress-
promoting behavior descriptions
Behaviors Example %
Observed
a
Child Distress Behaviors
Cry 1. ‘Sobbing’
2. Crying sounds
13.6
Scream 1. Sharp, shrill, harsh, high tones
2. Shrieks
2.2
Verbal resistance 1. ‘‘Stop!’
2. ‘Don’t!’
4.2
Verbal request of
support
1. ‘Hold me’
2. ‘Help me’
0
Physical request
of support
b
1. Grabbing or holding parent’s
hand
2. Reaching for parent
58.9
Verbal fear 1. ‘I am afraid’
2. ‘I am scared’
4.5
Verbal pain 1. ‘That hurts’
2. ‘It stings’
0.6
Negative
emotion
1. ‘I hate doctors’
2. ‘I don’t like doing this’
2.5
Information
seeking
1. ‘Will you let me know when
you’re ready to start?’
2. ‘What does that balloon do?’
0
Restraint of child NA 1.7
Flail
b
NA 0.2
Physical
resistance
b
NA 13.8
Adult Distress-Promoting Behaviors
Reassure 1. ‘You’re Ok’
2. ‘You’ll be awake before you
know it’
5.9
Empathy 1. ‘I know this is hard’
2. ‘I know it hurts’
0
Physical comfort 1. The parent holds the child’s
hand
2. The parent hugs the child
89.8
Giving control 1. ‘Which way do you want to
lay?’
2. ‘Where do you want your toy?’
4.3
Apology 1. ‘I am sorry you have to go
through this’
2. ‘Jaime, we don’t like doing this
either’
0
Criticism 1. ‘Timmy, you are not being a big
boy’
2. ‘You didn’t use your breathing
that time like I told you to’
0
a
% observed =% of behaviors observed in a specific category out of
the total number of behaviors observed
b
These are behaviors that were new to the modified CAMPIS-R
378 J Clin Psychol Med Settings (2014) 21:374–385
123
Relationship Between Child Distress Composite Score
and Adult Distress-Promoting Behaviors
Bivariate correlations were computed between the Child
Distress composite score and the three separate Adult
Distress-Promoting Behaviors: (1) Adult provision of
Physical Comfort, (2) Adult provision of Reassurance, and
(3) Adult Giving Control at anesthetic induction (see
Table 2). The association between parental provision of
Reassurance and Child Distress was significant (r=.50
p\.01); the positive direction of the association suggests
that child distress may ‘pull for’ parents to provide reas-
surance to the child, and/or that parents who provide
reassurance to their children cause increased distress in the
child. This correlation is consistent with the notion of
parental provision of Reassurance to the child as a parental
Distress-Promoting behavior as suggested by previous
work with the CAMPIS in other contexts (e.g., Blount
et al., 1989).
The association between parental provision of Giving
Control to the child and Child Distress behaviors was also
significant (r=.41 p\.05); the positive direction of the
association similarly suggests that child distress may ‘pull
for’ parents to give control to the child, or that parents who
give control to their distressed child may further increase
the child’s distress. As above, this finding is consistent with
previous work with the CAMPIS (e.g., Blount et al. 1989),
which suggests that parent Giving Control to the child in
such situations can increase Child Distress. Adult provision
of Physical Comfort was not significantly related to Child
Distress.
Sequential Relationship Between Parent and Child
Behaviors
Potential sequential and reciprocal associations were
explored between Child Distress and parental provision of
Reassurance, and parental Giving Control. Additionally,
we examined the potential sequential association between
Child Distress and the remaining potential Adult Distress-
Promoting Behavior, i.e., parental provision of Physical
Comfort. Although a significant relationship was not
observed between the Physical Comfort and Child Distress
total scores (collapsed across observation intervals), this
does not negate a potential sequential relationship(s) at
certain observation intervals. To examine the sequential
relationship between Child Distress behaviors and these
three potential Adult Distress-Promoting behaviors, struc-
tural equation models were constructed and analyzed using
the maximum likelihood variance–covariance estimation
method AMOS 22.0. Structural equation modeling (SEM)
was utilized in order to test the potential sequential rela-
tionships between observable child and parent behaviors
during induction of general anesthesia.
For the purpose of sequential analyses, parent and child
behaviors were recorded in 5-second intervals for a total of
90 s during induction of general anesthesia, which included
the time of child entry to the operating room until com-
pletion of anesthetic induction. To accommodate the small
sample size (n=30), the 18 5-second intervals were col-
lapsed into three 30-second segments, with each segment
composed of six 5-second intervals. Having three segments
allows for one replication of any observed sequential
effect.
Using AMOS, six models were built to examine the
sequential relationships between child and parent behaviors
during anesthetic induction. Specifically, two models were
built for each Child Distress and Adult Distress-Promoting
Behavior pair. The sequential association between parental
Giving Control could not be examined due to the low base
rate observed for the parent behavior of Giving Control
across the three intervals. Thus, there remained two models
to examine sequential relationships when parental behavior
preceded the child behavior, and two additional models to
examine sequential relationships when child behavior
preceded parental behavior. These models are discussed
below.
Figures 1,2and 3show results for the three models that
were examined and statistically fit the data. At the top of
each figure is the 1.5-minute observational timeline, which
is divided into three 30-second blocks, Time 1, Time 2, and
Time 3, that depict the progression of time moving from
left to right across the figure. Figures 2and 3display
results for two models in which Child Distress at Time 1 is
an initiator of parent behavior at Time 2, either parental
effort to provide Reassurance (Fig. 2, Model 3), or parental
effort to provide Physical Comfort (Fig. 3, Model 4). Thus,
Fig. 2shows Child Distress at Time 1 as an initiator and
predictor of Parent Reassurance at Time 2, with the
downward pointing arrow linking the child’s behavior as
Table 2 Correlations between Child and Adult behaviors observed
during the 1.5 min period from which the child entered the OR until
anesthetic induction was complete
Reassurance
by adult
Physical
Comfort
by adult
Giving
Control
by adult
Child
Distress
total
Reassurance by adult
Physical Comfort
by adult
-.181
Giving Control
by adult
.015 -.408*
Child Distress total .495** -.235 .413*
*p\.05
** p\.01
J Clin Psychol Med Settings (2014) 21:374–385 379
123
predictor to the parent’s response. Figure 3depicts Child
Distress at Time 1 as an initiator and predictor of Parent
Provision of Physical Comfort at Time 2, with the down-
ward pointing arrow illustrating a possible causal linkage.
Figure 1, Model 2, portrays a reverse temporal sequence of
behaviors in which Parent Provision of Physical Comfort at
Time 1 is positioned as a potential initiator and predictor of
Child Distress at Time 2, with the downward pointing
arrow linking the parent’s behavior as a potential predictor
of the child’s response. It is noteworthy that no Figure is
presented for Model 1, the fourth model examined, and
which focused on the possible sequential relationship of
parent’s Reassurance at Time 1 as a potential predictor of
Child Distress at Time 2. No Figure is presented because,
as noted below, that model did not statistically fit the data.
In each figure, the values next to each vector arrow that
connects behavior at a prior Time point to a behavior at the
following Time point, are the unstandardized regression
weights that demonstrate the degree of association between
the two observed behaviors. The values that appear in
smaller rectangles attached to each observed variable are
error terms and speak to the amount of variance in each
observed variable.
Following the recommendations of Hu and Bentler
(1998), multiple indices of model fit were used in evalu-
ating the goodness of fit of the four models calculated: v
2
/
df (values should be \2.0), Comparative Fit Index (CFI;
values should be close to .95), Root Mean Square Error of
Approximation (RMSEA; values should be around .05),
and Standardized Root Mean Square Residual (SRMR;
values should be around .08). In addition to the afore-
mentioned fit indices, the individual models were examined
for theoretical fit. Models examining the influence of parent
behavior on child behavior will be examined first, followed
by models examining the influence of child behavior on
parent behavior.
Fig. 1 Model 2: Parent
provision of physical comfort as
initiator of child distress.
**p\.01; ***p\.001
Fig. 2 Model 3: Child distress
as initiator of parent
reassurance. **p\.01;
***p\.001
380 J Clin Psychol Med Settings (2014) 21:374–385
123
Results for model for which no Figure is shown, Model
1, examined the sequential association between Parent
Reassurance and Child Distress, with parental provision of
reassurance preceding child distress, suggested that the
model did not fit the data. The model Chi square was
significant, suggesting a poor fit, v
2
(5) =61.28, p=.000.
Similarly, all individual fit statistics were poor (v
2
/
df =12.26; CFI =.71; RMSEA =.62) with the exception
of SRMR =.04. The fact that Model 1 did not fit the data
suggests that parental provision of reassurance is neither
helpful nor harmful in this context.
As shown in Fig. 1, Model 2 examined the sequential
relationship between Parent Physical Comfort and Child
Distress, with parent provision of physical comfort pre-
ceding child distress. The findings suggest that the model
fit the data. The model Chi square was not significant,
suggesting good fit, v
2
(5) =4.44, p=.488. Similarly, the
individual fit statistics were all excellent (v
2
/df =0.88;
CFI =1.00; RMSEA =.00) with the exception of
SRMR =.13. In Model 2, there was no relation between
initial parental provision of physical comfort (Time 1) and
child distress (Time 2; i.e., r=.00). Later parental pro-
vision of physical comfort to the child at Time 2 showed a
mildly positive association with increased child distress at
Time 3 (r=.11), but the effect was not significant. There-
fore, while the direction of the association suggests that
parental provision of physical comfort to the child just
prior to mask placement may be a distress-promoting
behavior, that trend was weak and not confirmed.
As shown in Fig. 2, Model 3 examined the sequential
relationship between Child Distress and Parent Reassurance,
with child distress preceding parental reassurance. The
findings suggest that the model fit the data. The model Chi
square was not significant, suggesting good fit, v
2
(5) =7.00,
p=.221. Similarly, the individual fit statistics were good
(v
2
/df =1.40; CFI =.98; SRMR =.05), with the excep-
tion of RMSEA =.12. Consistent with theoretical predic-
tion, Model 3 demonstrated a moderate positive association
between initial child distress at Time 1 and increased
parental reassurance at Time 2 (r= .32, p= .004). However,
later child distress at Time 2 showed a poor association with
subsequent increased parental reassurance at Time 3 (r= .04,
p= .176).
As shown in Fig. 3, Model 4 examined the sequential
relationship between Child Distress and Parent Physical
Comfort, with child distress preceding parental provision of
physical comfort to the child. The findings suggest that the
model fit the data, v
2
(5) =1.44, p=.920. The individual
fit statistics were all excellent (v
2
/df =0.29; CFI =1.00;
RMSEA =.00; SRMR =.04). The direction of the rela-
tions between initial child distress and provision of later
physical comfort by the parent in Model 4 suggests that, in
contrast to theoretical prediction, increased child distress is
associated with less parental provision of physical comfort
(r’s =-.45 and -.21, respectively). In this model the
association between initial child distress and parental pro-
vision of physical comfort at Time 1 neared significance
(i.e., p=.05), while the association between child distress
and provision of later physical comfort at Time 2 was not
significant (i.e., p=.14). This variability may help to
explain why there was no overall significant association
observed between child distress and parental provision of
physical comfort in the initial bivariate correlations.
In summary, results suggest that three of the four
sequential models tested fit the data. Initial parental pro-
vision of reassurance appeared to neither positively nor
negatively impact sequential child distress. However, ini-
tial child distress may lead to increased parental provision
of reassurance and decreased provision of physical
comfort.
Fig. 3 Model 4: Child distress
as initiator of parent provision
of physical comfort. *p\.05;
**p\.01; ***p\.001
J Clin Psychol Med Settings (2014) 21:374–385 381
123
Discussion
Using a modified version of the CAMPIS-R (Blount et al.,
1997), we examined potential sequential associations
between specific parental behaviors, i.e., parental provision
of Reassurance, and parental provision of Physical Com-
fort, and Child Distress to determine whether these parental
behaviors preceded and possibly contributed to child dis-
tress and/or whether they were parental responses to child
distress during anesthetic induction. Our findings are novel
in that the examination of sequential associations extends
the current understanding of the relationship between adult
and child behaviors in this context (e.g., Chorney et al.
2009) and assists in examining potential reciprocal rela-
tionships between child and parent behaviors. Our primary
findings are discussed below.
First, provision of reassurance by parents was overall
related to greater child distress in bivariate correlations.
However, the examination of sequential relations revealed
that parental reassurance did not lead to increased child
distress. Rather, child distress preceded increased parental
provision of reassurance. Findings regarding the positive
relationship between parental provision of reassurance and
child distress have been fairly consistent (e.g., Blount et al.
1989; Manimala et al. 2000), with one exception (i.e.,
Gonzalez et al. 1993). McMurtry et al. (2006) speculated
that although the exact mechanism by which reassurance
contributes to child distress is unknown, reassurance may
be transmitted via words, facial expressions, and intonation
of voice. McMurtry et al. (2010) designed an experimental
study to examine this possibility in children 5-10 years of
age undergoing a painful medical procedure (i.e., veni-
puncture). They found that the children provided higher
ratings of fear during reassurance than during distraction
while performing experimental tasks. Our findings, that
child distress is more likely a cause than a consequence of
reassurance, appear inconsistent with McMurtry’s et al.
(2010) findings. However, McMurtry et al. (2010) did not
employ a sequential approach to collection or interpretation
of their data and therefore the reciprocal nature of this
relationship cannot be judged. Specifically, we do not
know if children in the McMurtry et al. (2010) study in fact
experienced distress prior to the provision of reassurance
by parents, we only know that they endorsed increased fear
during provision of reassurance by parents and that this
was greater than the fear endorsed during provision of
distraction by parents. McMurtry’s et al. (2010) findings,
coupled with our findings, highlight the complexity of the
relationship between parental provision of reassurance and
child distress. Future research is necessary to clarify this
relationship further.
Second, even though there was no overall significant
association between parental provision of physical comfort
and child distress in bivariate correlations, this did not
negate a potential sequential relationship(s) at certain
observation intervals. Therefore, we chose to examine the
potential sequential relationship between these variables. In
fact, Models 2 and 4 demonstrated a good fit to the data
suggesting a sequential relationship between parental pro-
vision of physical comfort and child distress. Yet, the
relationship was not straightforward. The sequential rela-
tions were opposite in direction depending on the actor
(i.e., parent behavior preceding child behavior and vice
versa). Specifically, parental provision of physical comfort
appeared to lead to greater distress in the child but this
association was not significant. Greater distress in the
child, on the other hand, was associated with less provision
of physical comfort by the parent. With respect to the
latter, it could be the case that children who exhibit
extreme distress may require more physical assistance from
medical staff (e.g., restraint) and therefore parents may not
be in a position to provide physical comfort. With respect
to the former, parental provision of physical comfort
appeared to have little to no impact on child distress. Our
findings suggest that the relationship between parental
provision of physical comfort and child distress is not
straightforward and that there may be a time factor at play,
i.e., provision of physical comfort closer to time of
induction may facilitate child distress, which warrants
subsequent examination.
Limitations
Although the present investigation’s findings are note-
worthy, there were a number of possible limitations that
deserve mention. First, our sample size was small (i.e., 30)
for SEM. As such, our results should be interpreted with
caution. Further research is required to replicate our find-
ings in a larger sample. Second, related to the first limita-
tion, given our small sample size, we were unable to
examine potential cultural differences. It is certainly pos-
sible that some parental behaviors are more helpful or
harmful in certain cultural groups due to different cultural
practices in parenting. Third, all medical personnel
involved with this investigation were very cooperative.
Nevertheless, at times there were some instructions made
to the parents that may have impacted the results reported
herein, i.e., parents were often instructed to sit on a chair
beside their child and told that they could hold their child’s
hand. Our intent was to observe natural behaviors between
parent and child during anesthetic induction; however it
appears that behaviors that take place within the operating
room, as commonly directed by medical staff, may at times
have been observed instead. Parents may have behaved
quite differently without the direction of medical
382 J Clin Psychol Med Settings (2014) 21:374–385
123
personnel. These instructions may have increased parental
provision of physical comfort, for example, when parents
may have normally engaged in a different behavior. It is
also not known what variables influenced medical staff to
instruct some parents to engage in provision of physical
comfort (e.g., Did the parent appear particularly distressed?
Or did the child? Or was this instruction simply more likely
to occur when there was more time for the medical staff to
focus on assisting the parent such as in the case of a
cooperative child?). In turn, we did not focus on the
behaviors of the medical personnel and, as such, did not
from the outset of this study plan on systematically
observing and coding their behaviors. Our findings may
have been strengthened if we had included the medical
personnel’s behavior as a focus of investigation as we
would have been able to examine the impact of their
behavior on child distress.
In line with the above, it is important to note that there
are some limitations to inferring causation from the
sequential analysis employed. Specifically, the sequential
analyses demonstrated that there is a confirmed direction-
ality within the relationship between distress and parental
provision of reassurance. However, these analyses do not
prove causality (i.e., that parental provision of reassurance
caused increased child distress). Our findings are a step in
the right direction in determining what causes increased
child distress as causality requires directionality (i.e., A
cannot cause B unless A precedes B, but A preceding B is
not enough to determine that A caused B). Rather than
demonstrating a causal relationship, the fact that parental
provision of reassurance preceded increased child distress
at induction could also be explained if both variables were
caused by a third variable such as child anxious/shy tem-
perament (which could both cause increased reassurance to
the child prior to mask placement and increased child
distress at mask placement).
Fourth, the physical set up of the RUH Department of
Dentistry and Oral Maxillofacial Surgery may have
impacted anxiety ratings and/or behavior. The OR is down
the hall from the waiting room and recovery room is beside
the OR. Often one could hear children in distress (i.e.,
crying or screaming). Hearing other children’s distress may
have elevated individual children’s ratings of anxiety or
possibly reduced levels of participation. In order to
examine the impact of this variable it may be necessary for
future investigations in this type of setting to inquire if the
participants are bothered by hearing other children in dis-
tress and if so whether this experience impacted their
anxiety ratings or behavior. Future studies might also
artificially control for this factor (i.e., put up sound barri-
ers) or investigate its impact through experimental
manipulation. While it is important to acknowledge the
possible impact of this variable, it should also be
recognized that this is simply an aspect of conducting
research in the real world. Fifth, it is also important to note
that our sample was comprised of healthy participants
undergoing dental day surgery procedures. Our findings
may not generalize to children undergoing more complex
day surgery procedures and/or procedures that require
inpatient stay following surgery.
Future Directions
There are a number of interesting directions for future
research on this topic. First, the interaction between parent
and child behaviors and their impact on reduction of anx-
iety and distress need to be examined using the newly
designed P-CAMPIS (Caldwell-Andrews et al. 2005).
Second, employing a more sophisticated, fine-grained sta-
tistical approach (i.e., time-window sequential analysis)
will allow us to understand the temporal contingency
between behaviors observed during anesthetic induction
(Chorney et al. 2010). This type of analysis would allow us
to determine sequential relationships in both forward and
backward directions within a specific time-window. Third,
the behavior of the medical personnel during anesthetic
induction should be included in future research designs as a
means to fully understand the complexity of interactions
between medical staff, parents, and children. Fourth,
evaluating the impact of variables inherent in certain set-
tings, i.e., patients being able to hear other patient’s dis-
tress, on participant distress would better inform us of
whether and how these types of ‘real world’ issues impact
child anxiety and distress in the pediatric surgery context.
Fifth, it would be advantageous to examine potential sim-
ilarities or differences in parent–child interactions across
more simple versus complex medical procedures including
those that require inpatient hospital stay following surgery.
Sixth, experimental studies designed to examine the com-
plex associations between parental provision of physical
comfort and child distress and between parental provision
of reassurance and child distress are required. For example,
a subsequent investigation could experimentally manipu-
late the provision of physical comfort (e.g., parents would
be randomly assigned to either provide physical comfort
such as instructions to hold a child’s hand, or to not provide
physical comfort but still be present within the operating
room during anesthetic induction). Experimental investi-
gations would provide us with a better understanding of the
potential causal impact that provision of physical comfort
has on child distress at anesthetic induction. Improved
understanding of the subtleties of these parent behaviors
will aid in designing appropriate prevention and interven-
tion strategies for child distress associated with anesthetic
induction. Such information will be useful for professionals
J Clin Psychol Med Settings (2014) 21:374–385 383
123
working with children and their parents and or guardians
who are awaiting surgical procedures to take place (i.e.,
anesthesiologists, child life specialists, nurses, and
psychologists).
The knowledge that parents are engaging in behaviors
that may increase child anxiety and distress and possibly
make the child’s anesthetic induction experience unpleas-
ant may decrease the likelihood that anesthesiologists
would allow parents to be present during the anesthetic
induction. This decision may be premature, as these find-
ings provide a basis for subsequent research designed to
identify or clarify the particular behaviors that parents
should engage in while being present during anesthetic
induction in an effort to promote less child anxiety and
distress behaviors or, at the very least, to have information
to provide to parents that they should not engage in par-
ticular behaviors if they are to be present in the OR with
their child.
Acknowledgement Dr. Wright was supported by a Fellowship from
Canadian Institutes of Health Research at the time the research was
conducted. Dr. Stewart was supported by a Killam Research Profes-
sorship from the Dalhousie Faculty of Science. Dr. Finley was sup-
ported by a Dalhousie University Clinical Research Scholar Award at
the time the research was conducted.
Conflict of interest Dr. Wright, Dr. Stewart, Dr. Finley, and Dr.
Raazi declare that they have no conflict of interest.
Informed Consent All procedures followed were in accordance
with the ethical standards of the responsible committee on human
experimentation (institutional and national) and with the Helsinki
Declaration of 1975, as revised in 2000. Informed consent was
obtained from all patients for being included in the study.
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... Researchers indicate positive correlation between the parent's anxiety level and the child's distress level after surgery [13]. A parent's presence near the child during hospitalisation and painful medical procedures is treated as an important strategy in helping the child cope with the difficult situation of treatment [14]. It is not so much a parent's presence itself during medical procedure that is important as the behaviours the parent engages in with the child-what he or she says and does [14]. ...
... A parent's presence near the child during hospitalisation and painful medical procedures is treated as an important strategy in helping the child cope with the difficult situation of treatment [14]. It is not so much a parent's presence itself during medical procedure that is important as the behaviours the parent engages in with the child-what he or she says and does [14]. It can be said that parents' behaviour towards children is one of the risk factors for increased distress among children related to the medical procedures they undergo [9]. ...
... The scale has high internal consistency coefficients (from 0.83 to 0.92) [2,48]. In our study, we used EVENDOL scale as an observational measure (for children aged 2-7) and as a measure of pain based on the child's interview (for children aged [8][9][10][11][12][13][14][15]. ...
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Background The authors suggest that research in the area of parental presence during induction of anesthesia should shift to emphasize what parents actually do during induction, rather than focusing simply on their presence. As a first step, the authors aimed to develop a behavioral coding system that would measure child and adult interactions in the perioperative environment. Methods The authors enrolled 45 parents and children (aged 2-12 yr) undergoing elective surgery and general anesthesia. A multidisciplinary team examined videotapes and transcriptions of interactions between children, parents, and medical personnel in the holding room and operating room. The team used an existing scale, the Child-Adult Medical Procedure Interaction Scale, as the prototype for the development of a new perioperative behavioral coding system. The research team conducted extensive revisions to the original scale and added multiple codes to the original scale, including nonverbal codes. Interrater reliability was assessed using weighted kappa statistics. Construct validity was also examined. Results The final Perioperative Child-Adult Medical Procedure Interaction Scale contains 40 codes in four domains. Analyses showed excellent reliability overall for verbal and nonverbal codes. Kappa values averaged 0.87 for verbal codes characterizing adult vocalizations, 0.92 for verbal codes characterizing child vocalizations, and 0.88 for nonverbal codes. Construct validity was demonstrated by finding the hypothesized associations between certain scale codes and children's anxiety (P = 0.0001). Conclusion Showing excellent reliability, the Perioperative Child-Adult Medical Procedure Interaction Scale is an appropriate tool for assessing child-adult behavioral interaction during the perioperative period. When sequential analyses are conducted and target behaviors are identified, empirically based parent preparation programs can be developed.
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Background: Many children experience significant distress before and after surgery. Previous studies indicate that healthcare providers' and parents' behaviors may influence children's outcomes. This study examines the influence of adults' behaviors on children's distress and coping in the postanesthesia care unit. Methods: Children aged 2-10 yr were videotaped during their postanesthesia care unit stay (n = 146). Adult and child behaviors were coded from video, including the onset, duration, and order of behaviors. Correlations were used to examine relations between behaviors, and time-window sequential statistical analyses were used to examine whether adult behaviors cued or followed children's distress and coping. Results: Sequential analysis demonstrated that children were significantly less likely to become distressed after an adult used empathy, distraction, or coping/assurance talk than they were at any other time. Conversely, if a child was already distressed, children were significantly more likely to remain distressed if an adult used reassurance or empathy than they were at any other time. Children were more likely to display coping behavior (e.g., distraction, nonprocedural talk) after an adult used this behavior. Conclusions: Adults can influence children's distress and coping in the postanesthesia care unit. Empathy, distraction, and assurance talk may be helpful in keeping a child from becoming distressed, and nonprocedural talk and distraction may cue children to cope. Reassurance should be avoided when a child is already distressed.