3 Perioperative Behavioral Stress in Children
Intraoperative Clinical Outcomes
INTEREST IN CHILDREN’S PERIOPERATIVE behavior has increased dramatically over the past 20 years. Specifically, the recognition of the importance of developmental factors in perioperative research has created a dramatic growth of investigation in this area. In this chapter, we discuss developmental considerations that are relevant to the child’s perioperative experience (cognitive development, attachment and separation, temperament). We then offer a review and synthesis of recent data on preoperative anxiety and maladaptive behavioral and cognitive outcomes associated with surgery and anesthesia.
Cognitive Development and Understanding of Illness
The perioperative period is stressful for many individuals undergoing surgery, and this is especially true for children. Children’s stress during the perioperative period results from multiple sources, one of which is a limited understanding of illness and the need for surgery. Early developmental theorists (e.g., Piaget,1,2 Werner3) suggested that a child’s understanding of illness changes qualitatively as cognitive maturation occurs. The most widely cited model for understanding a child’s perspective on illness posits that the child’s understanding of illness evolves from prelogical explanations, such as phenomenism (e.g., magical thinking), to concrete-logical explanations, such as contamination (e.g., eating bad food), to formal-logical explanations (e.g., physiologic causes), and differences in understanding occur according to the child’s differentiation between the self and others.4
Children’s understanding of the treatments for illnesses is thought to follow a similar developmental pattern. In terms of surgery, a child’s concepts are particularly underdeveloped. Young children have difficulty defining “an operation,” suggesting that it is the same as being sick, going for a doctor’s checkup, or taking a nap.5 Given these developmental considerations, it is not surprising that young children are more likely to have misconceptions about hospitalization and surgery than are older children and adults,6 and therefore are at unique and disparate risk for perioperative stress.
Attachment style is another developmental consideration unique to children in the perioperative setting. Although adults also undergo separation from family, the separation of children from their parents is particularly stressful and affected by the parent-child relationship.
Coping with separation is a lifelong challenge that is inevitable and necessary for a child’s normal, healthy development.7 Separation experiences, such as saying good-bye at school or sleeping overnight at a friend’s house, facilitate normal childhood psychological growth and personality organization by mobilizing opportunities for learning and adaptation. Other separation experiences, especially those occurring in the context of loss, illness, or other stressors, can precipitate states of confusion, anger, and anxiety. Brief separations, such as those associated with surgery, are most stressful for infants, toddlers, and preschool-aged children. Indeed, for school-aged children, responses to separation may reflect, in part, response patterns established early in the preschool years.7 For children with biologically based vulnerabilities, such as a sensitivity to novelty and changes in routines, even expected separations may impose a greater degree of stress than for less sensitive children.7 Similarly, for children with developmental delay, separation may be experienced with a degree of anxiety and developmental stress more like that experienced by a younger child.
Attachment affects a child’s response to separation and is shaped through early experiences with the primary caregiver. Through these interactions, an infant has the opportunity to develop a sense of trust and security in the reliability and predictability of his or her relationship and the world.8 The style of attachment exhibited by infants is evident in their responses to brief separations from the primary caregiver and is conceptualized as secure, insecure, or anxious.
Children who are more “securely attached” to their parents deal more adaptively with the stress of brief separation and with the novelty of the hospital experience. Such children are more willing to explore their world and respond positively to their caregivers’ return, using the caregivers as a secure, stable base from which to approach strangers and new situations.9,10 In contrast, children classified as “anxiously attached” to their parents tend to be distressed in unfamiliar situations, like the perioperative environment, even in the presence of their caregivers. When their parents return after brief separations, these infants exhibit anger and distress and avoid physical contact. Another form of “insecure attachment” is avoidance. Avoidant children do not explore their surroundings as much as securely attached infants, rarely show distress at separation, and tend to ignore their parents on reuniting. Conversely, “insecurely attached” infants are more easily distressed by even brief separations and spend more time trying to stay close to their parents. They are less likely to explore and adapt positively to new situations.
Responses of young children to the stress of the perioperative period also reflect the child’s temperament. Temperament refers to stable emotional and behavioral responses (e.g., emotionality, activity, attention, reactivity, sociability, etc.) that appear in infancy and are thought to be primarily genetic in nature.11 Three main dimensions have been proposed to classify infant temperament: emotionality, activity, and sociability.12 Emotionality refers to the ease with which an infant becomes aroused or anxious, especially in situations that might lead to fear, such as perioperative settings. Activity refers to the infant’s customary level of energy and intensity of behavior. Sociability reflects the infant’s tendency to approach or avoid others. These behavioral dimensions of temperament are also reflected in physiologic responses related to anxiety.13,14 In long-term studies, infants who are inhibited in the face of novelty continue to be so through early school age.15 Thus, temperament as a behavioral descriptor appears to characterize an enduring cluster of traits reflecting reactivity and anxiety regulation in the face of novelty.
In light of these issues, the child’s developmental level is an important consideration in the perioperative period, especially as it relates to the child’s perioperative behavior. The remainder of this chapter addresses specific behavioral issues related to surgery in children, including anxiety in the preoperative period as well as postoperative behavioral outcomes, such as emergence delirium, sleep, and other maladaptive behavioral changes.
Anxiety in children undergoing anesthesia and surgery is characterized by feelings of tension, apprehension, and nervousness.16 This response is attributed to separating from parents, loss of control, uncertainty about anesthesia, and uncertainty about the surgery and its outcome.16 It is estimated that 40% to 60% of children develop significant fear and anxiety before their surgery.17 Furthermore, separation from parents and induction of anesthesia have been found to be the most stressful times during the surgical and anesthesia experience. Some children verbalize their fears explicitly, whereas others express their anxiety only by behavioral changes. Children may appear scared or agitated, breathe deeply, tremble, stop talking or playing, and start to cry. Some may wet or soil themselves, display increased motor tone, and actively attempt to escape from medical personnel.18 These behaviors may give children some sense of control in the situation and thereby diminish the damaging effects of a sense of helplessness.16,18 In addition to the behavioral manifestations detailed here, several studies have documented that anxiety before surgery is associated with neuroendocrine changes, such as increased serum cortisol, epinephrine, growth hormone, and adrenocorticotropic hormone levels, as well as increased natural killer cell activity.19,20 Significant correlations between heart rate, blood pressure, and behavioral ratings of anxiety have also been reported.21,22
Preoperative anxiety is a clinically important phenomenon that should be treated as any other clinical phenomenon or disease. In epidemiologic terms, all diseases are characterized operationally by risk factors, interventions, and outcomes; preoperative anxiety is no exception. We review the phenomenon of preoperative anxiety using the classic epidemiologic model of a disease (Fig. 3-1).
FIGURE 3-1 Operational overview of perioperative anxiety. CAM, Complementary alternative medicine; PPIA, parental presence during induction of anesthesia.
Identifying the risk factors for preoperative anxiety is important because the routine use of pharmacologic and behavioral interventions is associated with both advantages and disadvantages. Routine administration of sedative premedication may increase indirect pharmacy costs, the need for nursing staff, and appropriately monitored bed space in the preoperative holding area. Children undergoing extremely short outpatient procedures may also experience delayed discharge. Similarly, behavioral preparation programs administered preoperatively are associated with increased hospital operational costs. Likewise, anxious children can use hospital resources that would be reduced with appropriate pharmacologic preparation. Thus, identifying children who are at a particularly high risk for developing extreme anxiety and distress before surgery would help guide the most effective use of limited resources.
Variation in children’s behavioral responses to the perioperative experience has its origin in at least four domains:
Age and developmental maturity
Previous experience with medical procedures and illness
Individual capacity for affect regulation and trait (baseline) anxiety
Previous studies that examined the behavioral responses to induction of anesthesia in children did so in terms of these four domains.23–27 Children between the ages of 1 and 5 years are at greatest risk for developing extreme anxiety and distress. This is not surprising because separation anxiety often does not peak until 1 year of age and children older than the age of 5 years can more easily cope with new and unpredictable situations. A history of previous stressful medical encounters, such as with previous hospitalization, affects how a child reacts to new medical encounters; these are important risk factors for preoperative anxiety. Children who are shy and inhibited, as identified by temperament tests, and those who lack good social adaptive abilities, are also at increased risk for developing anxiety and distress before surgery.27
Parental characteristics also have a strong influence on a child’s behavior during the perioperative experience. Children of parents who are more anxious, children of parents who use avoidance coping mechanisms, and children of separated or divorced parents all appear to be at high risk for developing preoperative anxiety.28 Because children of anxious parents are more likely to experience high levels of preoperative anxiety, it is important to identify the predictors of increased parental preoperative anxiety. Parent gender (mothers are more anxious than fathers29), the child’s age (under 1 year), children with repeated hospital admissions, and the child’s temperament are all predictors of increased parental preoperative anxiety.28,30,31,32 Identification of children and parents who are at the greatest risk for preoperative anxiety and distress allows for appropriate intervention for this “at risk” population.
Pharmacologic (e.g., administration of premedications) and behavioral (e.g., psychological preparation programs) interventions are used to treat preoperative anxiety and distress in children and their parents.17,33
Preoperative Preparation Programs
Psychological preparation for children undergoing anesthesia and surgery has been widely advocated. These preparation programs may provide narrative information, an orientation tour of the operative facility, role rehearsal using dolls, modeling using videotapes or a puppet show, child life preparation, or coping education and relaxation skills.34,35,36
Although there is general agreement in the medical community about the benefit of preparation programs, recommendations regarding the content of behavioral preoperative preparation differ widely. Early programs were information oriented and often incorporated modeling techniques using videos or a puppet show.37,38 These techniques were augmented in the late 1980s with child life preparation and coping skills education.35 Child life specialists are trained individuals who facilitate development of coping skills and the adjustment of children and parents to the perioperative environment by providing play experiences, presenting information about events and procedures, and establishing supportive relationships with children and parents.36 Currently, the development of coping skills is considered the most effective preoperative intervention, followed by modeling, play therapy, operating room (OR) tour, and printed material.39 Interestingly, coping skills preparation with child life specialists was associated with less anxiety on the day of surgery when compared to lesser rated techniques; however, no differences were found immediately or up to 2 weeks after surgery.40 Thus, from a cost-effectiveness point of view, one must decide whether the additional cost associated with child life specialists is justified by reduction of anxiety only during the preoperative period.
It is important that preparation programs are tailored to the individual, age-appropriate needs of each child. Several variables have been identified as influencing the response of children to preparation programs.28 For example, children who are 6 years of age or older benefit most if they participate in a preparation program more than 5 days before the scheduled surgery and benefit least if the program is given only 1 day before surgery. In fact, older children prepared a week in advance showed an increase in anxiety level during and immediately after the preparation program, but demonstrated a gradual decrease in anxiety during the 5 days before the time of surgery.41 To avoid increasing excessive anticipatory anxiety, older children should be given enough time to process the new information and to rehearse newly acquired coping skills. It is also important to realize that there may be a negative effect of a preparation program on children younger than 3 years of age. This may be a result of their inability to distinguish fantasy from reality.1 A reality-based preparation program may do little to calm young children and may even exacerbate anxiety or sensitize the young child to the surgery. From age 3 to 6 years, children demonstrate an increasing ability to distinguish fantasy from reality and by the age of 6 this distinction is usually accomplished.1 Therefore, to provide the most benefit, both the age of the child and timing must be factored into delivery of the program.
In addition to age and timing, previous experience in a hospital setting also influences the effectiveness of a preparation program. A child who was previously hospitalized is more likely to develop an exaggerated emotional response to a behavioral preoperative preparation program and the perioperative experience.28,41–43 Information about what will occur, as demonstrated by sensory expectation and doll play, does not provide new information for these children. Furthermore, if the child has had a previous negative medical experience, the routine preparation may increase anxiety by triggering negative memories. In this case, alternative behavioral interventions, such as extensive individualized coping-skills training combined with desensitization and actual practice, may be better suited and indicated.42
Because increased parental preoperative anxiety has been shown to result in increased preoperative anxiety in their children, preparation programs for surgery should also be directed at parents.23 Although various interventions are routinely used to reduce a child’s anxiety, there is a paucity of information regarding interventions directed toward reducing parental anxiety.44 One study demonstrated that parental preoperative anxiety decreased after viewing an educational videotape.45 Most studies to date suggest that preoperative preparation programs for children reduce preoperative anxiety and enhance coping.35,41,46
Children whose parents have been taught to be active in distracting their child during stressful medical events may evidence lower anxiety compared to parents who receive no intervention.47 Indeed, this was the case in a randomized controlled trial evaluating a family-centered behavioral preparation program (ADVANCE) (Table 3-1). Parents and children who received ADVANCE were less anxious before and during induction of anesthesia than parents and children who did not receive this program. In fact, ADVANCE was as successful as midazolam in managing children’s compliance with and anxiety at induction of anesthesia (Table 3-2).48 It is important to note that ADVANCE also decreased the time spent in the postanesthesia care unit and decreased the analgesic requirements during the postoperative period. A major disadvantage of ADVANCE, however, is its high cost and personnel requirements. Accordingly, efforts to dismantle this multimodal intervention indicate that behavioral shaping through exposing children to the anesthesia mask before surgery and distraction on the day of surgery proved to be the most effective components of the program.49
Distraction on the day of surgery
Video modeling and education before surgery
Adding parents to the child’s surgical experience and promoting family-centered care
No excessive reassurance—a suggestion made to parents for communication with children about surgery
Coaching of parents by researchers to help them succeed
Exposure/shaping of the child via induction mask practice (the mask placed over the child’s nose and mouth to deliver anesthetic drugs)
Reproduced with permission from Kain ZN, Caldwell-Andrews AA, Mayes LC, et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007;106:65-74.
Parental Presence during Induction of Anesthesia
It is well established that most parents and children prefer to remain together during procedures such as immunization, bone marrow aspiration, and dental treatment.50,51 Several survey studies have also indicated that most parents prefer to be present during induction of anesthesia regardless of the child’s age or previous surgical experience.52,53 This is even the case for those parents who have had previous experience with pharmacologic interventions. Indeed, parents of children undergoing repeated surgery were likely to request parental presence regardless of their experience with prior parental presence or premedication with midazolam.54 That is, even if children were calm after midazolam during their first surgery, parents still preferred to be present during induction of anesthesia during subsequent surgeries.
It is important to note, however, that parental presence during induction of anesthesia (PPIA) does not necessarily equate with appropriate choice of interventions. For example, mothers who were most highly motivated to be present at induction of anesthesia also reported high levels of anxiety and their children were more distressed at induction.55 Indeed, more than 90% of parents report some degree of anxiety during the anesthesia induction process.56 The most upsetting factors include seeing their child become flaccid during induction and separation from their child.56 This observation was confirmed by a study that examined heart rate, blood pressure, and skin conductance levels in mothers as they observed their child’s induction of anesthesia.57 Mothers who were present during induction of anesthesia showed a moderate increase in heart rate and blood pressure (Fig. 3-2). However, no cardiac arrhythmias or ischemic episodes were noted. Another study examined whether parental auricular acupuncture would reduce parental preoperative anxiety and thus allow children to benefit from parental presence during induction of anesthesia.58 A multivariate model demonstrated that children whose mothers had received the acupuncture intervention were significantly less anxious on entrance to the OR and during placement of the anesthesia mask on their child’s face.
FIGURE 3-2 Changes in parental heart rate from baseline measurement until after induction of anesthesia. Data are reported as mean ± SE (standard error). Asterisks indicate time points at which differences between groups are statistically significant (P < 0.05). BPM, Beats per minute; OR, operating room; PPIA, parental presence during induction of anesthesia.
(From Kain ZN, Caldwell-Andrews AA, Mayes LC, et al. Parental presence during induction of anesthesia: physiological effects on parents. Anesthesiology 2003;98:58-64.)
Potential benefits from PPIA include minimizing the need for premedication and avoiding the screaming and struggling of the child that may result on separation from the parents. Whether PPIA decreases child anxiety during induction and affects the long-term behavior effects of surgery and anesthesia remain controversial. Common objections to PPIA include concern about disruption of the OR routine, compromising operative sterility, crowded ORs, and a possible adverse reaction of the parent. For some children, their behavioral response to stress may be more negative when a parent is present than when the parent is absent.59 In several reports, PPIA resulted in disruptive behavior, parents refusing to leave the room when requested, and even removal of a child from the OR by a grandmother during the second stage of anesthesia.60,61 However, one report has described a 4-year experience with 3086 children in a freestanding ambulatory surgery center in which no parent needed to be escorted from the OR because of undue anxiety and only two parents developed syncope, with prompt recovery.62