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REPORTS OF ORIGINAL INVESTIGATIONS
When are parents helpful? A randomized clinical trial
of the efficacy of parental presence for pediatric anesthesia
Quand les parents sont-ils utiles? une e
´tude clinique randomise
´e
sur l’efficacite
´de la pre
´sence parentale lors d’une anesthe
´sie
pe
´diatrique
Kristi D. Wright, PhD •Sherry H. Stewart, PhD •
G. Allen Finley, MD
Received: 17 February 2010 / Accepted: 11 May 2010 / Published online: 25 May 2010
ÓCanadian Anesthesiologists’ Society 2010
Abstract
Purpose To examine the utility of parental presence to
alleviate anxiety in a narrow age range of children
undergoing outpatient surgery. We hypothesized that
parental presence would lower anxiety scores as measured
by the modified Yale Preoperative Anxiety Scale (mYPAS)
at two time-points during pediatric outpatient surgery, i.e.,
separation from parents and placement of the face mask for
anesthetic induction.
Method Sixty-one children ages three to six years
scheduled for various day surgery procedures participated
in this study. The children were assigned randomly to
either parental presence (n =30) or parental absence
(n =31) groups. Observer-rated anxiety was measured by
the mYPAS at five time-points during the surgery
experience.
Results Child anxiety was significantly lower in the
parental presence group than in the parental absence
group at the time-point when the children in the parental
absence group were separated from their parents,
t[59] =2.15 (P =0.001). However, no significant group
differences in anxiety scores were noted at other time-
points.
Conclusions Our results suggest that anxiety levels in
children undergoing day surgical procedures differ as a
function of parental presence at the point when children
are separated from parents. Future research should
examine the types of interactions that occur during this
time-point that may explain this finding.
Re
´sume
´
Objectif Examiner l’utilite
´d’une pre
´sence parentale
pour soulager l’anxie
´te
´chez les enfants dont l’a
ˆge est dans
une plage restreinte subissant une chirurgie ambulatoire.
Nous avons e
´mis l’hypothe
`se qu’une pre
´sence parentale
diminuerait les scores d’anxie
´te
´tels que mesure
´s par
l’e
´chelle d’anxie
´te
´pre
´ope
´ratoire de Yale (mYPAS)
modifie
´ea
`deux moments dans le temps lors d’une
chirurgie ambulatoire chez l’enfant, soit a
`la se
´paration de
l’enfant des parents et au moment de l’application du
masque facial pour l’induction de l’anesthe
´sie.
Me
´thode Soixante et un enfants a
ˆge
´s de trois a
`six ans et
devant subir diffe
´rentes interventions chirurgicales en
ambulatoire ont participe
´a
`l’e
´tude. Les enfants ont e
´te
´
randomise
´sa
`soit une pre
´sence parentale (n =30), soit
l’absence parentale (n =31). L’anxie
´te
´telle qu’e
´value
´e
par l’observateur a e
´te
´mesure
´ea
`l’aide de l’e
´chelle
mYPAS a
`cinq moments pendant l’expe
´rience chirurgicale.
Re
´sultats L’anxie
´te
´des enfants e
´tait significativement
plus basse dans le groupe pre
´sence parentale que dans le
groupe absence parentale au moment ou
`les enfants dans le
groupe absence parentale e
´taient se
´pare
´s de leurs parents,
K. D. Wright, PhD (&)
Department of Psychology, University of Regina, Regina,
SK S4P 0A2, Canada
e-mail: kristi.wright@uregina.ca
S. H. Stewart, PhD G. Allen Finley, MD
Department of Psychology, Dalhousie University, Halifax,
NS, Canada
S. H. Stewart, PhD
Department of Psychiatry, Dalhousie University, Halifax,
NS, Canada
G. Allen Finley, MD
Department of Anesthesia, Dalhousie University, IWK Health
Centre, Halifax, NS, Canada
123
Can J Anesth/J Can Anesth (2010) 57:751–758
DOI 10.1007/s12630-010-9333-1
t[59] =2,15 (P =0,001). Cependant, aucune diffe
´rence
significative n’a e
´te
´observe
´e entre les groupes au niveau
des scores d’anxie
´te
´aux autres moments.
Conclusions Nos re
´sultats sugge
`rent que les niveaux
d’anxie
´te
´des enfants subissant des interventions
chirurgicales en ambulatoire diffe
`rent en fonction de la
pre
´sence parentale au moment ou
`les enfants sont se
´pare
´s
de leurs parents. A
`l’avenir, les recherches devraient
examiner le type d’interactions qui surviennent a
`ce
moment de fac¸on a
`expliquer cette de
´couverte.
Preoperative anxiety is a relatively common phenomenon
in children. In fact, approximately 40-60% of children
experience anxiety regarding an impending surgical expe-
rience.
1
Elevated levels of preoperative anxiety have been
associated with difficulty in anesthetic induction and the
development of postoperative maladaptive behavioural
changes.
2,3
There has been support for allowing parents to
be present during anesthetic induction in order to alleviate
preoperative anxiety in their children. The efficacy of this
strategy has been explored within the literature and find-
ings have been inconsistent.
4-7
When parents are given the
option to be present/absent during anesthetic induction,
reductions in child anxiety are observed within groups
where parents are present.
8,9
However, results of investi-
gations where parents were randomly assigned to be
present/absent during anesthetic induction have not been as
positive. In some investigations, no differences in child
anxiety were observed across parental presence/absence
groups,
10-13
while in other studies,
14
child anxiety was
found to be elevated in parental presence groups. To date,
no randomized controlled trials have found parental pres-
ence to be an effective anxiety-reducing intervention, in
particular at anesthetic induction, when compared with
parental-absence groups. Additionally, a methodological
concern with many of the studies highlighted above is the
wide age range of the participants, i.e., ages 1-12 yr. Per-
haps children at certain stages of development benefit from
parental presence, but these findings may be lost when
researchers draw on a wide age range.
The purpose of the present study was to provide a fur-
ther examination of the utility of parental presence as a
method of alleviating anxiety in children undergoing day
surgery procedures. In particular, we wanted to improve on
the methodological limitation of the existing literature by
employing a sample with a narrower age range, i.e., ages 3-
6yr vs ages 1-12 yr. Employing a narrower age range
facilitates better investigation into the utility of this method
of intervention in a younger patient population. It was
hypothesized that parental presence would lower anxiety
scores, as measured by the modified Yale Preoperative
Anxiety Scale (mYPAS)
15
at two time-points during
pediatric outpatient surgery. Specifically, we were inter-
ested in examining anxiety at anesthetic induction and also
at the time-point when children are separated from their
parents – a potentially stressful time-point that is often
overlooked in similar studies.
Method
Participants
The participants were children recruited during 2004 and
2005 who were scheduled for various day surgery proce-
dures (Table 1) at the IWK Health Centre (IWK), a tertiary
care pediatric hospital in Halifax, Nova Scotia, Canada.
Exclusion criteria included children who had a history of
central nervous system disease, psychiatric disease, liver
disease, renal disease, cancer, or neurological or cognitive
impairment or disease. Children with a history of gastro-
esophageal reflux disease were also excluded, as induction
was standardized to inhalation by mask.
16
The study was
approved by the IWK Health Centre Research Ethics
Board. We also obtained written informed consent from the
children’s parents and verbal assent from the children prior
to participation. No participants received premedication.
This study, which realized a 76% participation rate from all
of the potential participants contacted, was a part of a
larger set of studies examining the impact of parental
presence/absence on preoperative anxiety in children.
A
The
analysis that we report herein was the primary focus of the
larger set of studies.
Table 1 Types of surgeries
Surgery type % n
Ear, nose and throat (ENT) 80.3 49
General surgery 8.2 5
Urology 8.2 5
Gastroenterology 1.6 1
Plastics 1.6 1
ENT =tonsillectomy, adenoidectomy, myringotomy, ear debride-
ment, laryngoscopy, release of tongue tie; General surgery =
herniorraphy; Gastroenterology =gastroscopy with biopsy; Plas-
tics =lesion excision
A
Wright KD. Parental resence during anaesthetic induction: inves-
tigations of the effects of parent and child traits and parent-child
interactions on child anxiety levels. (Doctoral Dissertation, Dalhousie
University, 2006). Dissertation Abstracts International,67/11,AAT
NR19611.
752 K. D. Wright et al.
123
Measure
Modified yale preoperative anxiety scale
The mYPAS is an observer-rated scale designed to measure
a child’s level of anxiety in the preoperative setting.
14
The
scale consists of 27 items in five categories: activity,
vocalizations, emotional expressiveness, state of apparent
arousal, and use of parents (omitted in this study). Each
category is scored from 1-4, with the exception of vocal-
izations, which is scored from 1-6. Partial weights for each
category are calculated and then added together to obtain a
total score that ranges from 0-100 for each time-point. The
mYPAS has shown good concurrent validity (r=0.79) in
predicting children’s State Trait Anxiety Inventory for
Children – State subscale scores
17
in the surgery context
.14
The scale also has good construct validity, as scores have
been shown to increase from baseline to anesthetic induc-
tion
18
, and to have good inter-rater reliability.
14
Since there
was an inconsistency in the availability of parent to child
throughout the five time-points (i.e., only half of the par-
ents accompanied their child during the induction), we
dropped the use of the parent scale.
18
The first rater was
present during the induction and the second rater coded the
mYPAS via videotape.
Experimental design
Prior to the day of surgery, the participants were randomly
assigned to one of two groups (parental presence [n=30]
vs parental absence [n=31]) using a random number
generator, and the randomization code was placed in a
sealed envelope. Parents, children, anesthesiologists, and
research assistants were blind to group assignment until
meeting with the anesthesiologist just prior to leaving the
day surgery room. One research assistant was present
throughout the day surgery procedure to complete observer
anxiety ratings. A second research assistant videotaped the
anesthetic induction. At a later date, a second rater inde-
pendently scored the mYPAS via video tape for a random
20% of the study participants in order to calculate inter-
rater reliability.
Tasks and procedure
Once a child met the study inclusion criteria and was
scheduled for a day surgery procedure at the IWK, an
information package (i.e., information letter and consent
form) regarding the study was sent to the child’s parents
one to two weeks prior to the scheduled surgery time.
Three days before the day of surgery, a researcher con-
tacted the parents by telephone and asked about their
interest in having their child participate in the study. If the
parents were willing, the researcher arranged to meet with
the parent(s) and child on the day of surgery.
Approximately 90 min before the child’s surgery, the
researcher met with both the child and the parent(s) to
obtain parental written informed consent for the child’s
participation in the study and to obtain the child’s verbal
assent. Once the informed consent/assent process was
completed, the child’s observer-rated anxiety was assessed
using the mYPAS. Children were rated on all subscales
except the ‘‘use of parent’’ subscale (due to the study
design). Observer-rated anxiety (mYPAS) was assessed at
five time-points: 1) 90 min before surgery (baseline 1); 2)
five minutes before surgery (baseline 2); 3) leaving the day
surgery room for the operating room (OR) (separation); 4)
when the anesthetic mask was placed on the child’s face
(induction); and 5) when the child returned to the day
surgery area from the recovery room (day surgery).
Once the child returned to the day surgery area from the
recovery room, the researcher met with the child and par-
ent(s) once more to administer the observer-rated measure
(day surgery). The child was given a sheet of stickers as a
token of thanks for his/her participation.
Statistical considerations
Six separate sets of analyses were completed: 1) a series of
univariate analyses of variance (ANOVA) were completed
in order to investigate whether demographic information
(i.e., sex, previous surgery, surgery type) influenced mY-
PAS scores at the two most stressful time-points (i.e.,
separation and induction); 2) an inter-class correlation was
computed to examine inter-rater reliability of mYPAS
ratings at induction; 3) a bivariate correlation was com-
puted between age and mYPAS scores at the two stressful
time-points to examine the influence of age on mYPAS
scores; 4) between- and within-group comparisons using
a 2 x 5 repeated measures ANOVA was performed on
mYPAS total scores (i.e., group: parental presence vs
parental absence x mYPAS assessment time: baseline 1 vs
baseline 2 vs separation vs induction vs day surgery);
5) dependent sample Student’s ttests were performed
between mYPAS scores at the successive time-points
during the surgery experience to determine the instant/s of
significant differences; and 6) appropriate post hoc tests
were conducted in the case of any significant results or
interactions from the ANOVA.
The sample size was computed a priori for the two
groups using analysis of variance estimates. The primary
end point was the observer-rated child anxiety on intro-
duction of the anesthesia mask as assessed by the
mYPAS.
14
Given a medium effect size (i.e., f=0.25), a
power of 80%, and an alpha statistic of 0.05, approximately
30 participants were needed in each group.
Parental presence for pediatric anesthesia 753
123
Results
Sixty-one children aged three through six years (mean
age =5.22 yr, standard deviation [SD] =1.02 yr) partic-
ipated. Ethnicity in the sample was primarily Caucasian
(90.3%). In order to investigate whether demographic
information influenced mYPAS scores, a series of univar-
iate ANOVA were performed for the two stressful time-
points (i.e., separation and induction). In an effort to reduce
the overall number of analyses, the focus was placed on the
two stressful time-points that were of primary clinical
interest. The results of these analyses indicated that
mYPAS scores at separation did not differ significantly as a
function of sex (F[1,59] =0.24; P=0.63), previous sur-
gery
B
(F[1,59] =0.01; P=0.91), or surgery type
(F[1,59] =0.27; P=0.60).
C
The results of these analyses
indicated similarly that mYPAS scores at induction did not
differ significantly as a function of sex (F[1,59] =0.04;
P=0.84), previous surgery (F[1,59] =0.35; P=0.56),
or type of surgery (F[1,59] =0.63; P=0.43). In order to
examine whether age had a significant association with
anxiety scores, bivariate correlations were computed
between age and mYPAS scores at the two stressful time-
points. No significant correlations were found between age
and mYPAS scores (r=0.01; P=0.92 [separation] and
r=-0.14; P=0.28 [induction]). The non-significant
correlations suggest that mYPAS scores do not vary as a
result of age, at least within the narrower age range tested
in the present study. For this investigation, inter-class
correlations were computed between two mYPAS raters
(the second rater was blind to the investigation hypotheses)
for a randomly selected 20% of the participants and they
yielded r=0.89.
Impact of parental presence on children’s preoperative
anxiety
Results from a 2 x 5 repeated measures ANOVA (group:
parental presence vs parental absence x mYPAS assess-
ment time: baseline 1 vs baseline 2 vs separation vs
induction vs day surgery) showed a main effect for time-
point (F[4,212] =32.28; P=0.00) but not for parental
presence group (F[1,53] =2.15; P=0.15). A marginally
significant interaction was observed (F[4,212] =2.18;
P=0.07). The mean, SD,median, and interquartile range
of mYPAS scores are presented in Table 2. To further
examine the main effect of time for the mYPAS, dependent
sample Student’s ttests were performed between means at
successive time-points to determine the instances of sig-
nificant differences. There was a significant increase in
observer scores from baseline 2 (five minutes before
leaving day surgery) to separation (t[59] =2.72;
P=0.01), separation to induction (t[60] =6.41), and a
significant decrease from induction to day surgery
(t[55] =-5.47). There was no significant increase from
baseline 1 (waiting room) to baseline 2 (five minutes before
leaving day surgery).
Upon visual examination of Table 2, it appeared that
there may be a significant difference between parental
presence/absence groups at separation. Given that direc-
tional predictions were made a priori and given the
marginal group x assessment time interaction, a one-tailed
independent sample Student’s ttest was used to examine
this possible group difference. Results suggest that mYPAS
scores were indeed significantly different between groups
at separation (t[59] =2.15; P=0.001; effect size =
0.27). At separation from parents immediately prior to
entry into the OR, the mYPAS scores for children in the
Table 2 Descriptive statistics for mYPAS scores for parental presence/absence groups
Assessment time-point Parental presence Parental absence
Mean (SD) Median IQR Mean (SD) Median IQR
Baseline 1 26.51(5.56) 23.00 6.25 28.06(6.84) 23.00 10.25
Baseline 2 26.09(6.26) 23.00 4.61 28.00(6.79) 25.00 10.25
Separation* 26.71(6.72) 23.00 5.56 38.87(20.89) 33.25 20.75
Induction 54.18(27.90) 43.75 48.56 52.75(24.27) 50.00 39.75
Day surgery 35.93(16.66) 29.25 12.88 34.31(6.59) 35.11 10.25
mYPAS =modified Yale Preoperative Anxiety Scale;
12
SD =standard deviation; IQR =interquartile range; baseline 1 =child in the waiting
room; baseline 2 =five minutes prior to leaving the day surgery room; stress 1 =separation from parents (or at similar time point if separation
did not occur); stress 2 =anesthetic mask placement; day surgery =child returned to day surgery; mYPAS total score possible range from 23 to
100; *Significant group difference at this time-point
B
Approximately 61% (n=37) of the sample had no previous
surgery experience. Approximately 30% (n=9) of the parental
presence group and 48% (n=15) of the parental absence group had
at least one previous surgery experience.
C
Surgery type coded as ear, nose, and throat surgery (e.g.,
tonsillectomies, adenoidectomies, myringotomies, ear debridements,
laryngoscopies, release of tongue tie) vs other surgeries (e.g.,
Urology: circumcisions, orchidopexies, or ovchidectomies; General
Surgery: herniorraphies; Gastroenterology: gastroscopy with biopsy;
and Plastics: lesion excision).
754 K. D. Wright et al.
123
parental absence group were significantly higher than the
scores for children in the parental presence group who were
tested at the same time-point prior to surgery. The tests of
between condition differences in mYPAS scores at the
other four time-points revealed no significant differences
between groups, not even at the theoretically most stressful
time-point of anesthetic induction (Table 2).
Discussion
The primary purpose of this study was to examine whether
preoperative child anxiety could be alleviated by parental
presence. We chose to conduct a randomized controlled
trial design employing a narrower age range of children
than in previous studies. We also intended to examine the
stress observed at parental separation and at anesthetic
induction. Our results were partially consistent with the
hypotheses. At the time-point when children are typically
separated from parents, preoperative child anxiety was
found to be significantly higher in the parental absence
group than in the parental presence group. Research
methodology in this area sometimes measures anxiety at
the separation time-point, but group differences at this
time-point are not typically a focus of discussion. For
example, Kain et al.
11
conducted a randomized controlled
trial in an examination of the effectiveness of parental
presence vs premedication (i.e., midazolam) in alleviating
preoperative anxiety, and they found group differences in
levels of anxiety at the separation time-point. Similar
findings were highlighted in another study by Kain et al.
19
Although the purpose of their study was not an exploration
of the effectiveness of parental presence as an intervention
and the parents generally did not accompany their children
into the OR, parental accompaniment was offered in the
case that the child was extremely anxious (11 children
required this option). No differences in anxiety at the
separation time-point were noted between children whose
parents either did or did not accompany them into the OR.
The latter study differed from our study in that parental
presence at induction was not randomized. Cameron et al.
8
examined the timing of separation from parents. The par-
ents were not assigned randomly; rather, parents who chose
to accompany their child and were given permission from
the participating anesthesiologist were able to be present
during induction (n=38). Parents who either chose not to
accompany their child or were not permitted by the anes-
thesiologist were given the option of either accompanying
their child to the theatre holding bay area (n=22) or
remaining in the day surgery ward (n=14). Child anxiety
(based on an observer-rated five-point scale) at induction
was found to be higher when separation occurred in the
theatre holding bay area than when separation occurred in
the ward. Cameron et al. speculated that highly anxious
parents may have been aware of the detrimental effect of
their own anxiety and chose to separate earlier. Interest-
ingly, separation in the ward was also associated with
elevated child anxiety at induction. Cameron et al. further
speculated that levels of child anxiety might have increased
in the holding bay as a function of the child observing
anxious behaviour of his or her parent, and this increased
anxiety carried through to induction. Our findings indicated
that children had higher levels of anxiety at the separation
time-point in our parental absence vs parental presence
condition, and this finding appears to be in contrast to the
results of the aforementioned studies. However, it is
important to note that there are methodological differences
and/or limitations amongst these studies that limit the
comparability of findings. Specifically, there are differ-
ences in terms of the variability in: 1) the time-point when
separation took place (i.e., relative to time of induction);
2) the type of observer-rated measure of child anxiety used;
3) the comparison of group differences at the separation
time-point; and 4) random assignment vs self-selection of
participants. In terms of examining child anxiety at the
separation time-point, our study improved on the limita-
tions of past work: by using a randomized controlled trial
design where parents were assigned randomly to either
parental present or parental absent conditions; by measur-
ing observer-rated anxiety using the widely employed and
psychometrically sound mYPAS at time-points during the
day surgery process that are consistent with the literature;
and by statistically examining subsequent group differ-
ences at the separation time-point.
Cameron et al.
8
also found that children whose parents
were present during induction were less anxious than those
whose parents were absent. Providing parents the oppor-
tunity to ‘‘self-select’’ presence or absence during
anesthetic induction, rather than employ random assign-
ment, is seen as contributing to the divergence in the
literature. Perhaps more important than the simple presence
or absence of parents, the specific characteristics, qualities,
and/or behaviours of the parents who choose to be present
are critical factors associated with changes in child anxiety.
As alluded to by Cameron et al., parental anxiety was
found to be associated with child anxiety and distress
during anesthetic induction.
1,20-22
Specifically, elevated
parental anxiety (most often measured by the State-Trait
Anxiety Inventory – State subscale)
23
is positively associ-
ated with elevated child anxiety in the preoperative
context. To clarify the relationship between parent and
child anxiety further, Kain, Caldwell-Andrews, Maranets,
Nelson, and Mayes
24
used previously collected data (586
children aged 2-12 yr) to explore whether parental pres-
ence during anesthetic induction is useful in reducing child
anxiety on the basis of the interaction between the child’s
Parental presence for pediatric anesthesia 755
123
and parents’ baseline anxieties. They found that the pres-
ence of a calm parent was beneficial for alleviating child
anxiety during induction in a baseline anxious child. In
contrast, the presence of an anxious parent had no benefit
for either baseline calm or anxious children. The behav-
iours that parents engage in while present require
consideration.
The ages of children in our study ranged from 3-6 yr vs
1-12 yr in comparable studies.
8-14
This age distribution
may have influenced previous findings. The older child’s
cognitive capacity and understanding of the surgery expe-
rience becomes more sophisticated.
25
The focus of
children’s fear and worry follows a developmental pattern:
younger children’s fears and worries are based on imagi-
nary themes (ghosts, monsters), while older children have
more realistic fears involving bodily injury. Older children
have improved behavioural competence and social evalu-
ation,
25,26
and Bauer
25
asserts that these findings reflect
developmental changes in children’s perception of reality.
The beneficial effect of specific anxiolytic interventions
may be diminished beyond detection when older children
are included. Investigations that have examined the effect
of age on the anesthetic induction experience have pro-
duced conflicting results. For example, Bevan et al.
20
examined preoperative anxiety in 134 children ages two to
ten years in a pediatric day surgical centre. They found that
younger children were more anxious at induction than
older children. An additional investigation
27
found children
ages two to six years significantly more likely to exhibit
problematic behaviour upon separation from their parents
than children ages seven to eight years. In turn, Kain,
Mayes, O’Connor, and Cicchetti
1
found that children older
than age seven years were more anxious than children aged
four to seven years in the preoperative holding area (day
surgery room). They based their finding on an observer-
rated visual analogue scale. In contrast, a large survey
conducted by Holm-Knudsen et al.
28
demonstrated that
distress during anesthetic induction was not associated with
age. Given that some studies have shown an association
between child age and preoperative anxiety, Kain, Mayes,
Weisman, and Hofstadter
29
asserted that age may be a
‘‘surrogate marker’’ for other factors that may have an
impact on a child’s surgical experience. These factors
include cognitive abilities, the ability to draw on different
coping strategies to help with anxious feelings, and social
adaptive abilities (i.e., those behaviours that children use to
respond to usual or daily experiences). In this particular
investigation, Kain et al.
29
sought to examine the rela-
tionship between preoperative anxiety and the cognitive
abilities, emotions, and adaptive abilities in 60 children
aged three to ten years undergoing elective surgery. Results
showed that children’s social adaptive capabilities (i.e.,
behaviours that children use to respond to usual or daily
experiences) were an independent predictor of children’s
preoperative anxiety. Our findings demonstrated no sig-
nificant association between age and anxiety at separation
or anesthetic induction, at least with respect to this more
restricted age range, i.e., 3-6 yr.
Our findings were consistent with previous findings that
parental presence exerted no effect on child anxiety at
anesthetic induction; rather, we observed effects only
when children in the parental absence group were sepa-
rated from their parents. At first glance, these beneficial
effects of parental presence might be taken as evidence of
the utility of this intervention by advocates for allowing
parents into the OR. This decreased anxiety in the parental
presence group was short-lived, however, as it did not
persist at anesthetic induction only a few minutes later.
Alleviating and, perhaps more appropriately, preventing
anxiety at this latter time-point is particularly critical, as
elevated anxiety at induction has been associated with
crying, sudden urination, increased motor tone, and
attempts to escape from the medical personnel.
30-32
In
fact, it has been noted that up to 25% of children have
required physical restraint to facilitate anesthetic induc-
tion,
33
a situation that can lead to increased stress in both
children and medical personnel.
34
A number of limitations of this study must be consid-
ered. All medical personnel who were involved in this
investigation were very helpful; however, at times some
instructions medical personnel gave to the parents may
have impacted the results. When parents entered the OR,
they often were instructed to sit on a chair beside their
child and were told they were allowed to hold their child’s
hand. These instructions may have directed the behaviour
of the parents (e.g., the behaviour may not have been the
natural choice of the parents) and may have impacted child
anxiety during anesthetic induction. Parental presence
might have been more effective if they were allowed to use
their own coping strategies. On the other hand, given
previous research where parental presence was associated
with increased child anxiety,
14
parental presence might
have been more harmful if parents were not provided with
these instructions. Experimental examination of the asso-
ciation between types of comforting behaviours and child
anxiety during anesthetic induction deserves further
examination.
Selection bias is another factor to consider. Participation
in this investigation was quite good (76% participation rate);
however, it is important to consider that there may be a
reason why some families did not participate. For example,
the most anxious parents, those likely to impart more anxiety
on their children, may also have been more likely to refuse to
participate. Therefore, we may have missed an entire group
of very anxious children and/or parents. A higher partici-
pation rate may have produced differences in observer-rated
756 K. D. Wright et al.
123
anxiety at anesthetic induction. Also, in completing the
observer-rated anxiety measure (mYPAS), it was impossible
to have raters blinded to parental presence.
Our results suggest that anxiety levels in children
undergoing day surgical procedures differ as a function of
parental presence at the point when children are separated
from parents. Specifically, children in the parental presence
group had significantly lower anxiety scores than the
parental absence group at this time-point. It would be
interesting to investigate what types of parent-child inter-
actions take place during this time-point that may explain
this finding. However, it may be difficult to record (e.g.,
videotape) what occurs during this time-point, as the day
surgery room is quite busy and many people are quickly
entering and exiting this room. These findings also high-
light the notion that intervention should take place at an
earlier time-point, thereby possibly reducing the intensity
and/or duration of child anxiety. For instance, parents and
children could be provided education and training with
respect to coping strategies prior to the day of surgery.
MacLaren and Kain
35
initially examined the utility of a
brief behavioural intervention, including shaping and
exposure, to address children’s preoperative anxiety. This
intervention was shown to significantly increase compli-
ance and to lessen the course of anxiety throughout the
surgery experience.
Recent research has demonstrated a move towards a
family-centred approach to child surgical preparation.
36
Within this framework parental presence is one component;
however parental presence alone remains employed across
clinical practice.
D,37
Findings from the present study and
others can facilitate the development of the components of
family-centred programs. Specifically, our findings suggest
that the separation time-point is particularly critical, and
despite the family-centred preparation program described by
Kain et al.,
36
not all parents will be present during induction
for a number of reasons (e.g., parent is extremely anxious,
parent is ill, decision by anesthesiologist to not have parent
present). Therefore, our findings highlight that the separa-
tion time-point requires further examination and
consideration when intervention components are developed.
Anesthesiologists attempt to make the anesthetic
induction experience as easy as possible for the patient.
The knowledge that parents are effective in reducing child
anxiety at separation and not at anesthetic induction may
decrease the likelihood of anesthesiologists allowing par-
ents to be present during the anesthetic induction.
However, future studies in this area are needed to clarify
the timing and nature of parental presence during anes-
thetic induction of the younger pediatric population.
Acknowledgements We sincerely thank the nursing staff of the
IWK Health Centre Children’s Day Surgery Unit; the surgeons and
office staff of the Division of Otolaryngology, Urology, General
Surgery, Gastroenterology, and Plastic Surgery; and the members of
the Department of Pediatric Anesthesia for their cooperation and
support. We also thank Michelle Coffin, Alyson Currie, Jessica Fer-
guson, Kathy MacDonald, and Matthew Murphy for their careful
work in administration, data collection, and data coding for the study.
Funding sources Funding for this study was provided by IWK
Health Centre Research Services. Kristi D. Wright PhD was sup-
ported by a Fellowship from Canadian Institutes of Health Research
at the time the research was conducted. Dr. Stewart is supported by a
Killam Research Professorship from the Dalhousie Faculty of Sci-
ence. Dr. Finley was supported by a Dalhousie University Clinical
Research Scholar Award at the time the research was conducted.
Competing interests None declared.
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