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of Anesthesia
Jill MacLaren Chorney, PhD*
Zeev N. Kain, MD, MBA
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METHODS
Participants
Participants in this study were children with ASA
physical status I or II who were a part of the National
Institute of Health funded Behavioral InteractionsPerioperative (BIP) study. The BIP study is a largescale multi-year project assessing the main effects and
moderators of adult behaviors on childrens perioperative distress. Children recruited for the BIP study
were aged 210 yr undergoing outpatient surgery
with general anesthesia. Exclusion criteria included
children with chronic illness, children with developmental delay, and children with parents who did not
speak English. This current report includes 293 children who were part of the BIP study. Forty-eight
percent of these children were female, and most were
non-Hispanic Caucasian (85.7%). Thirty-five percent
of children had previous experience with surgery. The
most common surgical procedures were tonsillectomy
and/or adenoidectomy (n 96), followed by pressureequalizing tube placement (n 47), endoscopy (n 40),
urological procedures (n 28), hernia repairs (n 21),
and dermatological procedures (n 14).
Vol. 109, No. 5, November 2009
Measures
Yale Preoperative Anxiety Scale (mYPAS) (Child)1
This observational measure of preoperative anxiety
was developed and validated in previous investigations. The mYPAS consists of 27 items in five categories of behavior indicating anxiety in young children
(Activity, Emotional expressivity, State of arousal, and
Vocalization). Using kappa statistics, all mYPAS categories have good to excellent interobserver and intraobserver reliability (0.73 0.91), and when validated
against other global behavioral measures of anxiety,
the mYPAS had good validity (r 0.64). The mYPAS
score ranges from 22.5 to 100 with higher scores
indicating greater anxiety. Since its development, this
scale has been used in multiple investigations.8 11
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Code
Type
No. displaying
behavior
(% of sample)
Cry
Scream
Nonverbal resistance
Verbal resistance
Negative verbal emotion
Request support
Information seeking
Coping statement
Positive affect
Informing status
Medical play
Nonprocedural talk
Medical talk
Humor
S
S
S
E
E
E
E
E
E
E
E
E
E
E
76 (26.0)
7 (2.1)
98 (33.6)
64 (19.6)
28 (8.6)
42 (12.9)
59 (18.1)
22 (7.5)
17 (5.2)
85 (26.1)
151 (46.3)
93 (28.5)
76 (23.3)
66 (22.6)
Median proportion of
observation behavior
was displayed (range)
18.1 (1.357.5)
7.7 (1.720.9)
13.4 (0.658.3)
Median rate of
behavior
per minute (range)a
0.50 (0.225.73)
0.32 (0.172.82)
0.34 (0.162.32)
0.34 (0.172.05)
0.29 (0.132.69)
0.26 (0.190.50)
0.31 (0.161.51)
0.47 (0.153.43)
0.55 (0.133.08)
0.30 (0.131.22)
0.33 (0.162.94)
to discuss reliability statistics and disagreements. Raters were considered trained when they met a kappa
criterion of 0.80 with the first author on training tapes.
Coding Process
Administration of the R-PCAMPIS was facilitated
by using Observer XT (Noldus), a behavioranalysis software package with the capabilities to
code behaviors of one individual, or the interactions
of many. This system allows for the linking of
particular behaviors (e.g., nonverbal resistance) to
the subject who initiated the behavior (e.g., child).
In addition, the system allows each behavior coded
to be linked to the subject to whom the behavior was
directed (e.g., toward anesthesiologist). Data coding
was accomplished in passes, with each behavior
coded in a separate pass. Coding data in passes
ensured that behaviors that were not mutually exclusive (i.e., cry and nonverbal resistance) were
independently coded for duration. Real-time secondto-second data coding was used with onsets and
offsets of state behaviors and onsets of event behaviors recorded. Although this methodology is time
consuming, it ensures maximum reliability and validity of coding. Coding required approximately 4 h
per participant.
Behaviors were coded into four phases: 1) behaviors occurring from the time the child left the
holding room until they arrived at the OR door
(walk to OR), 2) behaviors occurring from the time
the child enters the OR to the time the mask is
introduced (OR entry), 3) behaviors occurring from
the time the child is notified of the mask to the time
the mask is placed and remains in place (mask
notification), and 4) behaviors occurring from the
time the mask is placed to the time the child makes
their last conscious movement (mask placement).
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Data obtained from the R-PCAMPIS include duration of state behaviors and frequency of event
behaviors across phase.
Data Exporting and Compiling
Data were exported from Observer XT into text files
and were then imported into a computer program,
General Sequential Analysis Querier (GSEQ) for compilation. GSEQ was used to calculate summary data
on the frequency, duration, and rate of behaviors
across phases. Summary data were then imported into
SPSS 17 for further analysis (for details on analyses
conducted, see Statistical Analysis section).
Reliability Assessment
Interrater reliability of individual behavioral codes
was assessed by having two research assistants overlap on 10% of participants. Timed-event kappa coefficients were in the good-to-excellent range (range
0.771.0). Reliability assessment and discussion was a
process repeated weekly throughout coding. One reliability subject was coded per week; once kappa
values were calculated, coders met with the first
author to discuss disagreements. Decisions on valid
placement of behaviors into codes were incorporated
into the final version of the observational records.
Procedure
All procedures were approved by the Yale Human
Investigation Committee (New Haven, CT). Participants were recruited by phone between 1 wk and 1
day before surgery or on the morning of surgery.
Parents provided written informed consent, and children provided written assent as age appropriate (i.e.,
children older than 7 yr). After giving informed consent, parents completed a demographic questionnaire
and measures relevant to the larger BIP study. All
children were accompanied to the OR by one parent
and no child received any sedative premedication. A
ANESTHESIA & ANALGESIA
Statistical Analyses
Statistical analyses were performed in a series of
steps. First, descriptive data on the proportion of
children displaying individual behaviors are reported.
The varying length of observation was accounted for
by dividing the duration of state behaviors by total
observation time and multiplying by 100; therefore
resulting in a statistic of the proportion of observation
time during which a child displayed a particular state
code. Frequency of event codes was divided by number of seconds in the observation and multiplied by 60
to obtain a rate of code display per minute. Descriptive data on the relevant statistic for each code are
presented. Next, patterns of childrens behaviors
across phases of induction were examined using repeated measures analyses of variance for each behavior. Bonferroni corrected P values were used to control
for familywise error. Visual inspection was used to
group behaviors that showed similar phase profiles,
and a summary score for each profile was calculated
for each child (sum of rate or proportion of codes in
that profile). The relation between age and behavior
profile was examined using one-way analysis of variance to compare mean profile scores across age group
(23 yr, 4 6 yr, and 710 yr). Construct validity of
behavior profiles was examined using correlations
and hierarchical regression controlling for child age.
Data compilation and summarization were accomplished using GSEQ for Windows (Bakeman and
Quera, Atlanta, GA) and was analyzed using SPSS 17
(SPSS, Chicago, IL).
RESULTS
Overall Prevalence of Childrens Behaviors
The proportion of children displaying each behavior is shown in Table 1. The highest proportion of
children displayed engagement in medical play which
was usually indicative of children being involved in
medical play with anesthesiologists (e.g., playing astronaut with the mask). The next most common
Vol. 109, No. 5, November 2009
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Figure 2. Profiles of child behavior across phase of induction. a, Acute Distress profile. b, Anticipatory Distress profile. c, Early
Regulating profile. d, Procedure Engage profile.
F-value for phase on Scream was large, it was statistically nonsignificant, likely because of the small
sample size F (1,2) 15.4, P 0.056. The second
profile included event behaviors that showed a peak
at mask notification and a sharp decrease at mask
placement. These behaviors were in two conceptual
groups: those that were termed Procedural Engagement including medical talk, informing on status,
and positive affect about the procedure and those that
were termed Anticipatory Distress including requesting support, negative verbal emotion, and verbal
resistance. Medical talk, positive affect, and verbal
resistance demonstrated significant quadratic patterns, Fquad 6.46, 6.47, and 12.22, respectively, P
0.05 for all behaviors. Quadratic trends across phase
for informing status, requesting support, and negative
verbal emotion were not statistically significant. The
final profile of behaviors included those that peaked
early in the phases, either on the walk to the OR or on
OR entry. This profile was termed Early Regulatory
Behaviors and included information seeking, nonprocedural talk, humor, and coping statements. Linear
trends were significant for information seeking and
nonprocedural talk, Fs 8.73 and 3.88, respectively,
P 0.01 for all behaviors. Results were nonsignificant
for humor and coping statements. Medical play
showed a pattern that was between Early Regulatory
and Procedural Engagement with peaks on the walk
to the OR and at mask notification. Notably, the
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Anticipatory Distress were both significantly positively correlated with mYPAS scores, rs 0.778 and
0.453, respectively, Ps 0.001. Scores on the Early
Behavior and Procedure Engagement profiles were
significantly negatively correlated with mYPAS
scores, rs 0.218 and 0.186, respectively, Ps
0.01. Given that behavior profiles differed by age, a
hierarchical regression was conducted to control for
age. Child age was entered in Block 1 of the model,
and the four behavior profiles were entered simultaneously in Block 2. The four profiles accounted for
significant variance in mYPAS scores above and
beyond child age, r2 change 0.513, P 0.001. The
Acute and Anticipatory Distress and Early Regulatory Behaviors profiles had significant standardized
coefficients at the P 0.05 level. The standardized
coefficient for the Procedural Engagement profile
was nonsignificant.
To further explore the utility of these behavior
profiles in identifying children at risk for anxiety, we
examined the relations between behaviors exhibited
on the walk to the OR and childrens distress at
induction as assessed by the mYPAS. Similar to overall findings, there was a significant positive correlation
between Acute and Anticipatory Distress behaviors
on the walk to the OR and childrens anxiety at
anesthesia induction, rs 0.146 and 0.197, respectively, P 0.01. Childrens display of Early Regulatory Behaviors was significantly negatively correlated
with childrens anxiety at induction, r 0.123, P
0.05. There was no significant association between
Procedural Engagement on the walk and childrens
anxiety at induction.
DISCUSSION
Results of this study indicated that more than 40%
of children displayed distress during the process of
anesthesia induction. Approximately 17% of children
showed significant distress characterized by at least
Vol. 109, No. 5, November 2009
three of the following: attempts to escape the procedure, verbal protestations, crying, screaming, or verbally communicating fear or sadness. Although
younger children were significantly more likely to
display distress than older children, almost 30% of
710-yr-old children indicated distress in some way.
The most common child behavior was nonverbal
resistance (i.e., tried to push mask away), with children doing so, on average, 18.4% of the entire observation period and 42% of the time in which the mask
was placed.
Two profiles of distress behaviors were identified
in our data. One profile, termed Acute Distress, contained behaviors that increased over phases of induction, peaking at the point at which the mask was
placed. These behaviors, especially nonverbal resistance, are those that are particularly problematic as
they could interfere with the induction being accomplished in a smooth manner. Not surprisingly,
younger children were higher on these types of behaviors. The second profile of distress behaviors
termed Anticipatory Distress contained behaviors
that peaked at mask notification including verbalizations of negative emotion and attempts to delay the
procedure. It is notable that Anticipatory Distress may
be artificially low at mask placement because the mask
limits verbalizations on the part of the child. For this
reason, attending to verbal distress behaviors earlier
in the induction (i.e., at mask notification) could be a
more accurate assessment of distress in older children
than looking for crying or other Acute Distress. It is
notable that there was a significant association between these behavior profiles on the walk to the OR
and childrens distress at induction; not surprisingly
children who show distress behavior early are more
likely to be distressed later in the induction. This
finding highlights the importance of addressing childrens distress early in the induction process. Important in and of themselves, the relations between these
behaviors and clinically-relevant recovery outcomes
should be examined.
A strength of this study is its attention to a wide
range of behaviors rather than being limited to only
the evaluation of distress. A focus on family-centered
care mandates attention not only to distress but also to
families overall experience in the health care setting.13
This study identified a profile of behaviors that are
common early in the induction process (when children
are less distressed), but sharply decrease at induction.
Behaviors in this profile, including distracting nonprocedural talk, have been identified in the procedural
pain literature as coping behaviors5 and may serve a
similar function during induction. Supporting the
importance of these behaviors, a negative association
was evidenced between childrens use of Early Regulatory Behaviors and distress. Children who displayed
more of these behaviors on the walk to the OR (as well
as throughout the induction period) showed less distress at anesthesia induction. Similar to the findings of
2009 International Anesthesia Research Society
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