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The Relationship Between Children's

Fears and Behavior During a Painful
Event
Published online: 07 Jun 2010.

To cite this article: (1986) The Relationship Between Children's Fears and Behavior During a
Painful Event, Children's Health Care, 14:3, 142-145, DOI: 10.1207/s15326888chc1403_3

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 The Relationship Between Children's Fears and
Behavior During a Painful Event
Marlon E Broome
The purpose of thlr study uas to explore the
relatlonshrp betneeri the lebel of fear of rned~cal
experlences reported b~ chlldren and therr ob-
served beha\lol In ION-and hlgh-threat niedlcal
Downloaded by [New York University] at 12:16 06 January 2015
sltuatrons One hundred and tuenty-elght chll-
dren \rho part~rlpatedIn a health screenlng
cltntc uere Inter\ ~ e u e duslng a 12-~temMedlcal
Fear Questlonnarre Thetr behattor was ob-
served durlng an tntertleu (lou threat) and
uhen the\ leeelbed an Imlliunlfatron (htgh
threat) I he results ~nd~cated that chlldren u ho
are h~gherln fear demonstrate niore negattve
behablors dur tng both sltuatlons than those lou
in fear Also all rhildreri behabed more nega-
trbel, In the htgh-threat than the low-threat
sltuatton Inipltcatlons for practltloners who
uorL utth chlldren In med~ralsettlngs are pre-
sented
T h e study of chlldren's fears span several
decades (Bauer, 1976, Croake, 1969, Jerslld &
Homes, 1975) These studles lnvest~gatedthe
type of fears reported by chlldren and the prev-
alence of these fears across age groups Most
reveal a developmental sequence In t h e struc-
ture of fears Chlldren generally decrease In
fearfulness as they grow older and the lntenslty
of partrcular types of fear vary according t o the
age of the chlld (Bauer, 1976, Miller, 1979)
Children's fears of medtcal exoerlences have
1
not been a major focus o r part of the lnvestlga-
tlon of chlldrens' fears A "med~calfear sub-
scale" was Included as part of the general fear
survey by Scherer and Nakamurer (1968) but
contalned only e ~ g h tItems, some of whlch d ~ d
not appear to relate to med~calexperlences a t
The author would llke to thank Beta Omrcron chapter,
Ftgma Theta Tau, for the fundrng for thts study
Marron E Broorne, RN, PhD, ts Asststant Professor,
School of Nurstng, Medtcal College of Georgaa, Augusta,
Grorgaa
( orrespondencr shouldbe addressed to Manon P Broome,
Rhr, PhD, BF 113, School of Nurs~ng,Medtcal College of
Georgra, Augusta, G A 30912
face value (I e , "I a m a f r a ~ dof sharp objects ")
Astln (1977) explored the fears of hospltal~zed
a n d nonhospltallzed chlldren using o n e of these
general fear scales (Croake, 1969) She found
n o slgnlficant differences In t h e number of fears
reported by the groups Agaln, though, few of
the general fears In the scale related rpec~fically
to common experlences found In health care
settlngs
Menke (19 8 1) presents a study of school-aged
chlldren's perceptions of stress In the hospital In
whlch subjects played a game developed by the
author Thls game ellc~tedresponses from the
chlldren that lnd~catedwhlch particular med~cal
events, persons, o r procedures the chlldren
found stressful E~ghty-SIX percent of the chil-
dren rated the needle as stressful a n d 36% rated
physlc~ansas stressful However, d u e to the de-
scrlptlve nature of the study, ~t IS not clear how
the stress ratlngs were assoc~atedwlth the child's
actual behav~oral response to hosp~tallzat~on
T h a t IS, d ~ chlldren
d who reported they were
hlghly fearful also behave more negatlvely dur-
Ing hospltal~zat~on o r other stressful med~cal
procedures?
T h e purpose of thls study was to lnvestlgate
t h ~ srelatlonshlp between chlldren's self-report
of fear of med~calexperlences and thew behav-
lor durlng a health screenlng examlnatlon T h e
screenlng contatned both a sltuatlon In whlch
the chlld was mterv~ewedabout h ~ os r her med-
~ c a lfears and a sltuatlon In whlch the chlld
recelved a n ~mmunlzatlon T h e questions thls
study explored b e r e (a) d o chlldren who report
h ~ g h e rlevels of fear of med~calexperlences re-
spond more negatlvely durlng stressful medlcal
procedure than chlldren who a r e low In fear,
a n d (b) does the b e h a v ~ o rof chlldren d ~ f f e r
between a low- and a h~gh-threatsltuatlon In a
medlcal setting'
METHOD
T h e sample for t h ~ sstudy cons~stedof 128
chlldren aged 4 t o 7 years (M = 5 1 years) who
partlc~pated In a preschool health screenlng
 CHC, WINTER 1986, VOL 14, m) 3

F~fty-fivepercent of t h e chtldren were Cauca- CHART 1

slan, 45% were female CHILD MEDICAL FEAR OUES TIOh'N 4IRE
After consent to partlclpate In the study was
obtalned, the chlld was brought to a room In No1
whlch the lnvestlgator asked the chlld t o re- dl dl1

spond to questions o n the Med~calFear Ques- 1 I am afra~dof hablng to

tlonnalre Thls lntervlew w ~ t hthe chlld was go to the hosp~tll -
labeled S ~ t u a t ~ o1-Low
n T h r e a t Durlng the 2 1 am afra~dof havrng to
lntervlew the child's behavtor was rated uslng a get a shot fro111 the
5-polnt behav~oral observat~on ratlng scale nurse or doctor -
After the chlld completed the lntervlew he/she 3 1 an1 dfrald of golng to
was taken by the parent to another room In the doctor -
whlch heishe recelved a n lmmunrzatlon T h e 4 1 am afratd of gomg to
lmmunlzatlon was labeled S ~ t u a t ~ o2-H~ghn the dentrst -
Threat T h e child's b e h a v ~ o rdurlng the Immu- 5 1 am afra~dof habrng m,
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nlzatlon was rated uslng the same behav~oral finger stuck -

observat~onratlng scale employed In the first 6 1 am afrald of the w h ~ t e
sltuatlon coat doctors and nurses
wear -
INSTRUMENTS 7 1 am afra~dof seelng
T h e Med~calFear Questlonnalre cons~stedof blood from a cut In 111,
1 2 Items developed by the lnvestlgator after a sh~n -
revlew of the l~teratureand based on her expe- 8 1 am afrdrd of the doctor
rlence w ~ t hchlldren In health care settlngs (see and nurse looh~ngIn nl\
Chart 1) Quest~onso n the scale requlred that ear -
the chlld state how fearful h e o r she was of each 9 1 am afra~dof the doctor
Item uslng a 3-polnt, forced-cholce format (1 = or nurse lrstenmg to rny
not at all, 2 = a Irttle, 3 = a lot) heart -

After the responses were analyred from the
128 chlldren In thls study, a Cronbach's alpha
of r = 8 4 was obtalned, lndtcatlng the Instru-
ment had a h ~ g hdegree of tnternal consistency
All 12 orlglnal Items were retamed for final
analyses
T h e Chlld Behav~orObservat~onRatlng Scale
was adapted from o n e reported by Frankl,
S h ~ e r e&
, Fogels (1962) In whlch the behav~or
of chlldren was rated durlng dental treatment
T h e orrglnal scale cons~stedof 4 polnts o n a
continuum ranglng from very negatlve t o very
poslt~veresponses Examples of the very nega-
tlve behav~orcategory Include refusal of treat-
ment, forceful crylng, and hostlllty T h e very
posltlve category contalns behav~orssuch as n o
slgn of fear, Interest In procedures, and appro-
prlate verbal contact For purposes of t h ~ study,
s T h e scores obtained on the Med~calFear
a fifth category was added that was labeled
"neutral" behav~ors,I e , n o fac~almovement,
n o crylng, etc Frankl e t al (1962) reported a n
Interrater rellabll~tyagreement of 97% T h e
Interrater rel~abll~ty for t h ~ study
s was 90% (Sit-
uatlon 1) and 88% ( S ~ t u a t ~ o2)n T h e lower
rellabll~tyestimates for thls study may have re-
sulted from a strlcter crrterlon of observer
agreement used In the present study Observer
agreement for the Frankl study was obtalned by
10 1 am afra~dof hab ~ n the
g
doctor or nurse look In
my throat -
1 1 I am afra~d of lylng
down on the uble rn the
doctor s office -
12 1 am afrdrd of gettlng
niv temperature uLen -
calculating the percentage of agreement by ob-
serving o n only two categorles (posltlve behav~or
= 1 o r 2, negatlve behav~or= -1 o r -2) and
not exact agreement uslng t h e 5 categorles as
was done In the present study (-2, -1, 0, + I ,
+2)
RESULTS
Questlonnalre vaned across t h e entlre poss~ble
range from 12 t o 3 6 (M = 1 7 8 , S D = 5 3) T h e
fear scores were correlated w ~ t hthe child's be-
h a v ~ o rdurlng t h e lntervlew ( r = 25, p < 05)
a n d during the lmmunlzatlon (r = - 26, < 05),
tndtcatlng that c h ~ l d r e nwho were h ~ g h e In
r fear
were more l~kelyt o demonstrate negatlve be-
h a v ~ o rin both sltuatlons
T h e children's observed b e h a v ~ o rdurlng- the
low stress sltuatlon ranged from 2 t o 5 (1 = very
 negatlve, 5 = very posltlve) wlth a mean of 4 6
(SD = 77) Behavlor In the htgh stress sltuatlon
ranged from 1 to 5 wlth a mean of 3 2 (SD =
1 4) A repeated measures analysls of varlance
wa5 performed with the repeated factor belng
the sltuatlon and the between factor belng level
of fear A medlan spllt was done on the fear
scores to obtaln t ~ o ' ~ r o of
u ~chlldren,
s those
hlgh In fear and those low In fear T h e child's
observed behavlor In both sltuattons was the
dependent measure
T h e analysls revealed two slgnrficant maln
effects, one effect for fear level (F(2, 128) =
6 12, p < 003) and one effect for sltuatton (F(1,
128) = 1 15, p < 0000 1) Chlldren were s ~ g n ~ f -
Downloaded by [New York University] at 12:16 06 January 2015
lcantly more negatlve durlng the lmmunlzatlon
than during the lntervlew Also, chlldren who
reported themselves htgh In fear were s~gnlfi-
cantly more negatlve In thew behav~orIn both
sltuatlons than chlldren low In fear
DISCUSSION
T h e data In thls study provlde some support
for evldence of a r e l a t ~ o n s h ~between
p level of
fear of med~calexperlences a chlld reports and
the child's actual behav~ordurlng a med~cal
procedure Even In a group of chlldren who a r e
generally low In medtcal fear those who report
relatively hlgher levels of fear will be less PSI-
ttve In both low- and hlgh-stress sltuatlons It
also appears that chlldren a r e able t o dlscr1m1-
nate between sltuatlons as reflected In thew
slgnlficantly lower behav~orald~stressscores In
low-stress sttuatlons O n e of the llmltatlons of
thts study was the lack of a counterbalanced
deslgn Ideally, half of the chlldren would have
recelved the Immunlzatlon first a n d the Inter-
view second, wlth the other half experlenclng
the lntervlew first and the lmmunlzatlon second
Thls was not possible d u e t o l~rnltatlonsof sched-
ullng and sequencing of the cllnlc vls~t Also,
although a few chlldren may have found the
IntervleN more threatening than the Immunt-
zatlon, most chlldren report the lnlectlon t o be
one of the most t h r e a t e n ~ nex-per~ences
~ In
health care (Ellerton, Caty, & Rltchle, 1985,
Menke, 1981)
Chlld fear questlonnalres generally deal wlth
such toplcs as polltlcal, supernatural, domest~c,
and personal fears (Croake, 1969) and not fears
such as those encountered In medlcal sltuatlons
(I e , seelng blood, patn, ~rnmobll~ty, etc ) Inter-
estlngly, most health professions textbooks state
that ~t 1s the preschool chrld who IS most fearful
of bodily injury and mutllat~on (Nelson,
Vaughn, McKay, & Bernman, 1979, Whaley &
Wong, 1979), a n d yet, e m p ~ n c a ls t u d ~ e sre-
ported rn the developmental l~teraturehave
found that it 1s the late school-aged chtld that
most fears bodily harm (Bauer, 1976, Jersrld &
Holmes, 1935) Perhaps these dlscrepant vlews
about fears of bodily harm could be resolved by
argulng that preschoolers a r e more sltuatlon
specific In thelr fears than a r e late school-aged
chlldren T h a t a, perhaps preschoolers will be
most l~kelyt o verbalize these fears more fre-
quently when In med~cal environment than
when a t home o r a t school where the typ~cal
developmental study of fears 1s conducted T h ~ s
obv~ouslysuggests that chlldren's fears a t d~ffer-
ent ages should be evaluated In both med~cal
a n d nonmedical settlngs t o determlne ~f the
aforementioned reasoning about the dlscrepant
findlngs a r e v a l ~ d
Studles of chlldren's fears need t o use multi-
ple measures t o valldate the child's self-report
of fear Do chlldren who report h ~ g h e rlevels of
fear rate a stressful experience as more palnful
o r anxlety producing than chlldren who a r e not?
Does preparatlon for medlcal experlences re-
duce chlldren's fears of med~calexperiences?
Menke (1981) d ~ not d find any slgnlficant d ~ f -
ferences In chlldren's ratlngs of stressful expe-
rlences a n d thew level of preparatlon o r amount
of tlme they were hospltidlzed T h ~ may s mean
that chlldren come Into the medlcal envlron-
ment wlth preset levels of fears More lnvestl-
gatlon needs to be done comparing well and
hospltal~zedchlldren's fear levels In order t o
IMPLICATIONS FOR PRACTICE
T h e major findlng In thls study was confir-
matlon of the fact that lndlv~dualchlldren d o
d ~ f f e rIn thew degree of fear about medlcal
experlences a n d that there IS some r e l a t ~ o n s h ~ p
between these fears and the child's behav~orA
tool such as the o n e used In thls study can be
used as a slmple screening tool w ~ t hchlldren
who a r e hospltallzed and/or undergoing a stress-
ful procedure T h e tool could be used In several
ways Practit~onerscould ask chlldren to re-
spond t o the 1 2 Items t o determlne what the
chlld 1s most a n d least a f r a ~ dof Explanat~ons
a n d opportunltles t o get t o know more about
the exper~ence(s)the chlld 1s most afrald of may
lessen the child's fear
T h e tool could also be very useful IS generat-
Ing dlscusslon wlth a chlld who IS retlcent durlng
hospltallzat~on T h e practltloner would ask the
lntervlew Items In such a way that the chlld
would be answering for other chlldren, e g , "Do
 CHC, WINTER 1986, VOL. 14, No 3
vou thlnl. most chlldren are a Ilttle, a lot, or not
at all afratd of Other uses would Include
use of the Items as a pre-post evaluatton tool to
see IS preparation or therapeutic pla, IS effec-
tlve Researchers and r l ~ n ~ c ~ aInn shealth care
settlngs need to ~ o r together
l niost effect~vel)
In uslng well-des~gnedstudles to answer some of
these Important questions
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