PEDIATRIC ANESTHESIA SECTION EDITOR WILLIAM J. GREELEY

SOCIETY FOR PEDIATRIC ANESTHESIA

Preoperative Preparation Programs in Children: A Comparative Examination

Zeev N. Kain, MD?, Lisa A. Caramico, MD*, Linda C. Mayes, MD-Q, Janice L. Genevro, PhD§,

Marc H. Bornstein, PhD§, and Maura B. Hofstadter, PhD*

Departments of *Anesthesiology, tl’ediatrics, aChild Study Center and Children’s Clinical Research Center, Yale University School of Medicine, New Haven, Connecticut; and SNational Institute of Child Health and Human Development, Bethesda, Maryland

We sought to determine whether an extensive behav- ioral preparation program for children undergoing sur- gery is more effective than a limited behavioral pro- gram. The primary end point was child and parent anxiety during the preoperative period. Secondary end points included behavior of the child during the induc- tion of anesthesia and the postoperative recovery pe- riod. Several days before surgery, children (n = 75) aged 2-12 yr randomly received either an information- based program (OR tour), an information + modeling- based program (OR tour + videotape), or an informa- tion + modeling + coping-based program (OR tour + videotape + child-life preparation). Using behavioral and physiological measures of anxiety, we found that children who received the extensive program exhibited less anxiety immediately after the intervention, in the holding area on the day of surgery, and on separation to the operating room. These findings, however, achieved statistical significance only in the holding area on the

day of surgery (44[10-721 vs 32[8-501 vs 9[6-331; P = 0.02). Similarly, parents in the extensive program were significantly less anxious on the day of surgery in the preoperative holding area, as assessed by behavioral (P = 0.015) and physiological measures (P = 0.01). In contrast, no differences were found among the groups during the induction of anesthesia, recovery room pe- riod, or 2 wk postoperatively. We conclude that chil- dren and parents who received the extensive preopera- tive preparation program exhibited lower levels of anxiety during the preoperative period, but not during the intraoperative or postoperative periods. Implica- tions: The extensive behavioral preoperative program that we undertook had limited anxiolytic effects. These effects were localized to the preoperative period and did not extended to the induction of anesthesia or the postoperative recovery period.

(Anesth Analg 1998;87:1249-55)

B ehavioral preoperative preparation has been ad- vocated in the psychological and medical litera- ture, and an estimated 78% of all major chil-

dren’s hospitals offer such programs to children and their parents (1). Indeed, most studies suggest that behavioral preparation for children undergoing anes- thesia and surgery reduces anxiety and enhances cop- ing (2-4). These preparation programs may provide narrative information, an orientation tour, role re- hearsal using dolls, a puppet show, child-life prepa- ration or, the teaching of coping and relaxation skills to children and their parents (4-6).

Supported by The Arthur Vining Davis Foundations and the National Institutes of Health (MO1 RR06022-08).

Presented in part on February 14, 1998 at the annual meeting of the Society for Pediatric Anesthesia, Phoenix, AZ.

Accepted for publication August 28, 1998. Address correspondence and reprint requests to Zeev N. Kain,

MD, Department of Anesthesiology, Yale University School of Med- icine, 333 Cedar Street, New Haven, CT 06510. Address e-mail to kain@biomed.med.yale.edu.

01998 by the International Anesthesia Research Society 0003.2999/98/$5.00

Although there is a general agreement about the de- sirability of these programs, recommendations regard- ing the content of preoperative preparation for children differ widely. In the 196Os, preparation programs were recommended to primarily provide information, encour- age emotional expression, and establish trust between the medical staff and the child (7). In the mid-1970s, however, there was a shift toward modeling preparation programs (8). With modeling, the child indirectly expe- riences anesthesia and surgery by viewing a video or a puppet show. By the late 198Os, the literature indicated that effective preparation should include not only mod- eling but also child-life preparation, teaching of coping skills, and involvement of parents (4). In a recent article, a panel of experts rated the teaching of coping skills as the most effective intervention, followed by modeling, and then an operating room (OR) tour (1).

Although many previous investigations have com- pared groups undergoing the above behavioral prepa- ration programs with control groups (2,9), there are few

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1250 PEDIATRIC ANESTHESIA KAIN ET AL. BEHAVIORAL PREPARATION IN CHILDREN

ANESTH ANALG 1998;87:1249-55

studies contrasting these preoperative programs with each other. Furthermore, because highly rated tech- niques (e.g., coping) are associated with increased oper- ational costs compared with lower rated techniques (e.g., tour), a comparative efficacy study is indicated. In this study, we sought to determine which type of behavioral preoperative preparation program is most effective: a tour of the OR (information-based), a tour + a commer- cially available videotape (information + modeling- based), or a tour + a videotape + child-life preparation (information + modeling + coping-based).

Methods The primary clinical end point of this randomized, con- trolled trial was anxiety of the child and parent in the preoperative period, as defined by behavioral and phys- iological instruments. Secondary end points included the behavior of the child during the induction of anesthesia and the recovery period. Consecutive outpatients aged 2-12 yr, ASA physical status I or II, scheduled to un- dergo general anesthesia and elective outpatient surgery, such as herniorrhaphy and tonsillectomy, were consid- ered for enrollment. Patients were excluded from the study if they had a history of previous surgery, hospi- talization, prematurity, chronic illness, or developmental delay. After the parents gave written, informed consent, randomization was decided with a random number ta- ble. The use of sedative premeditation and parental presence during induction of anesthesia (PPIA) was pro- hibited during this study. PPIA was used, however, as rescue therapy as detailed in the protocol below. The study was approved by the institutional review board, and written, informed consent was obtained from the parents.

During the visit, children in all groups underwent a nursing evaluation of functional health status and a preoperative evaluation by an anesthesiologist. In ad- dition, children and their parents were randomly as- signed to receive one of the following three types of behavioral programs: information based program (OR tour); information + modeling-based program (OR tour + videotape), information + modeling + coping- based program (OR tour + videotape + child life).

For the information-based program, participants re- ceived a short (10 min) tour of the OR. The tour included a brief explanation about the sequence of events and was modified based on the age of the child.

For the information + modeling-based program, participants received a tour of the OR and a commer- cially available animated videotape (A Hospital Pip with Dr. Bip, KiDz-Med Inc., 1994) that shows a child undergoing surgery. The children and their parents watched the model experience all perioperative steps from admission to discharge.

For the information + modeling + coping-based program, participants received a tour of the OR and a

videotape and child-life preparation. The child-life program lasted 30 min and provided information about the perioperative experience, as well as role rehearsal. This component was tailored to the specific surgery and age of the child. The session began with a story illustrated by photos taken in the OR of a doll going through each step experienced on the day of surgery. The medical play was modeled after classic role-playing. Children were offered the opportunity to participate in perioperative activities, such as listening to the doll’s heart, attaching electrocardiographic leads, and putting the doll “to sleep.”

Timing of behavioral preparation relative to the day of surgery has been identified as a significant variable af- fecting the response of the child to the intervention (3,9). Furthermore, the ideal timing varies based on the age of the child (3,9). In this study, therefore, children aged 2-4 yr were scheduled to receive the behavioral inter- vention l-2 days before surgery, whereas children aged 5-12 yr were scheduled to receive the behavioral inter- vention 5-10 days before surgery.

Data regarding the following behavioral assessment tools are reported in Appendix 1. Two psychologists (blind to group assignment) served as assessors and administered the various instruments: EASI Instrument of child temperament (lo), State-Trait Anxiety Inventory (STAI) (ll), Visual Analog Anxiety Scale (VAS) (12), Venham Picture Test (VET) (13), Yale Preoperative Anx- iety Scale (YPAS) (14), Monitor Blunter Style Scale (MBSS) (15), Coping Cards (CC) (16), and Post Hospital- ization Behavior Questionnaire (PHBQ) (17,18).

For cortisol analysis, samples was transferred imme- diately into a tube containing heparin. After mixing, the blood was centrifuged at 4000 rpm for 2 min, and the plasma was stored at ~70°C. Plasma cortisol was deter- mined in duplicate using radioimmunoassay kits from Diagnostic System Laboratories (Webster, TX). Samples were analyzed in a single large batch, duplicates agreed within 15%, and quality assessment samples were well within the manufacturer’s defined range.

Two to ten days before surgery, subjects identified from the OR schedule were contacted by telephone, and a preoperative visit was scheduled.

Once written consent was obtained, subjects were randomized to one of the three groups. Baseline meas- ures, such as temperament of child (EASI), trait anxi- ety of parent (STAI-T), and coping style of child (CC) and parent (MBSS), were obtained. Anxiety of the child (VPT, observational VAS) and of the parent (STAI, DBP/SBP, HR) was evaluated before (T,) and after the intervention (TJ.

On the day of surgery, the anxiety of the child (VPT, observational VAS) and of the parent (STAI, SBP/DBP, HR) was assessed in the holding area (TJ and on sepa- ration to the OR (TJ. If a subject exhibited unacceptable distress and anxiety on separation to the OR, PPIA was

ANESTH ANALG PEDIATRIC ANESTHESIA KAIN ET AL. 1251 1998;87:1249-55 BEHAVIORAL PREPARATION IN CHILDREN

Table 1. Characteristics of Study Subjects and Their Parents

Child’s age (yr) Gender % (M/F) Anxiety score for previous medical encounters EASI

Emotionality Activity Sociability Impulsivity

STAI-T Parent VPT

Group 1 (n = 24)

7 t 3.1 43/57 6 (O-81)

Group 2 (n = 25)

5 -c 2.2 48/52

10 (O-80)

Group 3 (n = 24)

5 2 2.8 42/58

11 (O-100)

12 + 3.6 15 + 3.7 19 k 2.5 12 t 3.6 38 k 7.9

8 (8-14)

12 k 4.1 16 ? 3.5 18 ? 3.3 13 +- 3.5 41 r 8.8

9 (8-15)

11 2 4.4 18 + 4.3 18 t 2.6 14 + 3.5 38 -+ 8.8

9 (8-13)

Values are mean 2 SD or median (range). EASI = Emotionality, Activity, Sociability and Impulsivity Instrument; STAI-T = State-Trait Anxiety Inventory, Trait Anxiety Score; VPT = Venham Picture Test.

allowed (rescue therapy). The decision for rescue ther- apy was made solely by the anesthesiologist managing the case (who was blinded to group assignment). Anes- thesia was induced in all subjects using an O,/N*O/ halothane technique. The behavior of the child during induction was evaluated by an independent, blind as- sessor (YPAS). Rating was performed at two time points: entering the OR (Ts) and during the introduction of the anesthesia mask (T6). After induction, blood was ob- tained for serum cortisol analysis. Anesthesia was main- tained with O,/N,O and isoflurane; IV fentanyl (l-3 pglkg) was administered based on the decision of the attending anesthesiologist.

In the postanesthesia care unit (PACU), the incidence of adverse effects, time to discharge, and time to first fluid intake were recorded. Nurses were asked to rate the cooperation of the child with regard to the oxygen mask, pulse oximetry probe, and IV cannula (T7).

Two weeks after surgery, parents were contacted by telephone by a research nurse (blinded to group as- signment), and the PHBQ was completed.

The primary end point of this study was the anxiety of the child and the parents in the preoperative hold- ing area on the day of surgery, and data obtained in a previous investigation were used to calculate sample size (9). Based on an expected effect-size of 40%, 01 of 0.05 (two-tail), and power of 0.80, 75 subjects were needed to complete this investigation.

Descriptive statistics provide an overview of the relations between the child and parent variables and the anxiety level of the child and parent. Normally distributed data are presented as mean t SD, whereas skewed data are presented as medians and interquar- tile ranges (25%-75%). The differences among groups were examined by using one-way analysis of variance (ANOVA) and Kruskal-Wallis one-way ANOVA (for skewed data). Categorical data were examined by us- ing 2 analysis. Repeated-measures ANOVAs were conducted to assess changes in behavioral and physi- ological measures of anxiety for the children and par- ents over the various time points (Tim7).

Previous research has identified parental trait anxiety, the age of the child, and the child’s temperament to be important indicators of intervention outcome for chil- dren during the induction of anesthesia (19-21). Thus, these variables were used as covariates in analyses of the child’s anxiety during the induction of anesthesia. To localize the effects, we performed three two-factor ANO- VAs with Tukey’s procedure for child’s anxiety during the induction of anesthesia. Effects of parental coping style on child’s and parent’s anxiety in the holding area were also examined. Statistical significance was accepted at P < 0.05. All analyses were performed on an intention to treat basis, and data were analyzed by using SPSS version 6.1.1 (SPSS Inc, Chicago, IL).

Results Seventy-five subjects were recruited for this study. Two subjects, however, were excluded because of ma- jor protocol violations. Therefore, 73 subjects were included in the final analysis. Rescue therapy (PPIA) was necessary for one subject in Group 1, two subjects in Group 2, and one subject in Group 3. No significant differences were found across the three groups for any of the demographic variables (Table 1).

A repeated-measures ANOVA for child’s anxiety failed to reveal significant effects of group on changes in anxiety over time (Figure 1). One-way ANOVA demon- strated that children who received the extensive pro- gram exhibited less anxiety immediately after the behav- ioral intervention, in the holding area on the day of surgery, and on separation to the OR. These findings, however, achieved statistical significance only in the holding area on the day of surgery (44 [lo-721 vs 32 [S-50] vs 9 [6-331; P = 0.02). Post hoc analysis localized the effects between Group 1 and Group 3 (Figure 1).

In contrast to the findings during the preoperative period, there were no differences among the groups during the induction of anesthesia, as assessed by behavioral (YPAS) and physiological (cortisol) meas- ures (Table 2). This persisted after the child’s age,

1252 PEDIATRIC ANESTHESIA KAIN ET AL. ANESTH ANALG BEHAVIORAL PREPARATION IN CHILDREN 1998;87:1249-55

60 . Group 1

70 -- FT .

_.~_ T ----. Group 2

.-.-.-_-- . Gro”p 3 .-- - 0 60

g 5 50 B 25 40 z E w 30 P fi

20

10

” POStlllti?WentlOfl Holding separation

Time Points

Figure 1. Changes in observed anxiety of the child over various time points. Values are medians and interquartile ranges (25%-75%). VAS = visual analog scale.

Table 2. Selected Behavioral and Physiologic Anxiety Scores Among the Children

Type of assessment Induction 1” Induction 2b

Behavioral WAS

Group 1 46 (23-88) 46 (23-83) Group 2 36 (23-100) 44 (23-100) Group 3 46 (23-96) 52 (23-100)

Physiological Serum cortisol (&mL)

Group 1 14 t 4.3 Group 2 14 c 4.7 Group 3 15 + 5.5

Values are median (range) or mean 2 SD. YPAS = Yale Preoperative Anxiety Scale (applied to all ages). a Entry into operating room. b Introduction of anesthesia mask.

temperament, and parental trait anxiety were used as covariates. Finally, there were no differences among the three groups with regard to PACU outcome vari- ables, such as incidence of vomiting, time to first oral fluid intake, and all of the nurses ratings. There were also no differences in the incidence of negative behav- ioral changes 2 wk after surgery.

Next, children’s coping strategy ratings were corre- lated with observed anxiety in the preoperative holding area (controlling for preintervention observed anxiety). For logistical reasons, coping data were obtained only in a subsample of children (n = 22). Neither the child’s gender nor age related significantly to children’s ratings of the coping strategies. Because of sample size restric- tions, it was not possible to directly test whether the relation between intervention group and observed anx- iety was moderated by children’s perceptions of the value of different coping strategies. Significant associa- tions were found, however, between anxiety in the pre- operative holding area and children’s ratings of “asking for information” (Y = 0.43, P = 0.03) and “talking with my mom” (Y = 0.42, P = 0.04) as ways of dealing with

fear. These associations indicate that children who rated these strategies positively also had lower levels of ob- served anxiety (conversely, children who rated these strategies less positively had higher levels of anxiety). Thus, children who preferred “information seeking” and “parental support” coping strategies may have been more receptive to the types of interventions offered in this investigation, all of which were oriented toward the provision of information.

Parents who received the extensive preparation re- ported that they were significantly less anxious (STAI) in the preoperative holding area on the day of surgery compared with parents in the two other groups (P = 0.047) (Table 3). When parental coping style (MBSS) was controlled for in a factorial ANOVA, there were significant main effects of group (F = 4.67, P = 0.015) and coping style (F = 4.09, P = 0.025).

A repeated-measures ANOVA that examined paren- tal diastolic blood pressure (Ti-s) demonstrated a main effect of time (F[2,17] = 9.7; P = 0.002) and a group X

time interaction (F[4] = 3.9; P = 0.01). Post hoc analysis revealed that parents in the extensive preparation group had lower diastolic blood pressure immediately after the intervention (P = 0.01) and in the preoperative holding area on the day of surgery, compared with the minimal preparation group (P = 0.003) (Table 3). Furthermore, parents of children who received the extensive prepara- tion also had significantly lower systolic blood pressure (P = 0.01) in the holding area compared with the two other study groups (Table 3).

Discussion Under the conditions of this study, children and par- ents who received an extensive behavioral program manifested less anxiety during the preoperative pe- riod. It is important to emphasize, however, that this extensive intervention was not more effective with regard to a child’s behavior during the induction of anesthesia, in the PACU, or 2 wk postoperatively. Thus, one must decide whether the additional cost associated with child-life specialists is justified by re- duction of anxiety only preoperatively.

The results of this study are consistent with an earlier study conducted with hospitalized children (22). Peterson and Shigetomi (22) contrasted informa- tion preparation to filmed modeling and to coping plus filmed modeling. Results indicated that children who received coping plus modeling techniques expe- rienced less distress during their hospital experience (22). To the best of our knowledge, there are no reports in the literature contrasting child-life preparation to a tour or to videotape preparation. Child-life programs have become the standard in most major children’s hospitals, and their number has doubled since 1965

ANESTH ANALG PEDlATRIC ANESTHESIA KAIN ET AL. 1253 1998;87:1249-55 BEHAVIORAL PREPARATION IN CHILDREN

Table 3. Selected Behavioral and Physiological Anxiety Scores Among the Parents of Study Subjects

Type of Assessment Preintervention Postintervention

Self-Report STAIS

Group 1 47 t- 10.3 44 -c 14.2 Group 2 43 ? 11.8 39 i- 10.0 Group 3 42 i- 15.2 38 -t 11.3

Physiological SBP (mm Hg)

Group 1 134 (110-149) 143 (105-149) Group 2 120 (95-147) 115 (109-129) Group 3 113 (106-140) 123 (106-135)

DBP (mm Hg) Group 1 83(61-98) 81(70-102) Group 2 69(51-89) 74(68-82) Group 3 76(65-88) 72(54-81)$

Values are mean 2 SD or median (range). STAI = State-Trait Anxietv Scale, State Anxietv; SBP = svstolic blood pressure; DBI’ = disatolic blood pressure.

Holding area

52 +- 11.0 49 -t 13.0

44 i 12.2"

140 (123-145) 114 (109-123) 119 (llO-145)$

90 (83-100) 73(70-80) 72 (68-81)t

It I’ = 0.047. t P = 0.003. i P = 0.01.

(6). Child-life specialists facilitate coping and the ad- justment of children and parents by providing play experiences, presenting information about the events and procedures, and establishing supportive relation- ships with children and parents. In making informa- tion accessible to children, child-life specialists incor- porate descriptions of the sensations that children will experience, provide opportunities for children to ex- amine and manipulate equipment to be used in their care, and encourage rehearsal with dolls.

Previous studies have found, through behavioral and physiological responses, that the induction of anesthesia is the most stressful event the child experiences during the perioperative period (20,21). Thus, it seems that the more extensive intervention was effective for low-stress periods, such as preoperative holding, but not for high- stress periods, such as the induction of anesthesia. The level of anxiety at particularly high-stress times may inhibit children’s productively remembering or thinking about what they had learned during the preoperative program. If so, reminding the child of strategies or tech- niques during times of high-stress may help to reduce anxiety. An interesting future study may be to promote productive remembering in the children during periop- erative high-stress events.

In this study, children who were involved in active engagement of the situation did better with the behav- ioral interventions offered. That is, children who pre- ferred information seeking coping strategies benefited as a group from the various interventions used in this trial. This finding is not surprising considering that all the interventions that were offered in this trial con- tained significant amounts of perioperative informa- tion. In contrast, children who preferred avoidance coping strategies found the interventions used in this

trial less effective. For this group of children, we rec- ommend that other types of interventions (including less information and direct engagement in the situa- tion, and more assistance in the use of distraction techniques) might be effective.

The findings of this study should be viewed in light of several methodological issues. First, several variables were controlled to increase the internal validity of the investigation. Because the timing of behavioral prepara- tion relative to the day of surgery has been identified as affecting the response of the child to the intervention (3,9), we controlled for this variable. Similarly, the effec- tiveness of preoperative interventions is dependent on previous experience with surgical interventions. That is, for the child with a history of surgery, behavioral prep- aration may result in sensitization, producing an exag- gerated emotional response (3,9). Thus, only children with no history of surgery were enrolled.

Second, this study did not use a no-intervention comparison group. This selection can be considered a methodological flaw, but we considered it a necessity. Angel1 (23) suggested that only when there is no known effective treatment is it ethical to compare a new treatment with a placebo. When effective treat- ment exists, the control group of a study must receive the best known treatment (23). Although there is a disagreement with regard to the best type of preoper- ative preparation, there is consensus that some type of preoperative preparation should be offered to children undergoing surgery.

Third, because measuring anxiety is complex, we used both behavioral and physiological instruments to assess the child’s and parent’s behavior. Indeed, our results were replicated with four different types of measures: observation of a child’s behavior, a child’s cortisol response, parental self-report of anxiety, and

1254 PEDIATRIC ANESTHESIA KAIN ET AL. BEHAVIORAL PREPARATION IN CHILDREN

ANESTH ANALG 1998;87:1249-55

parental sympathetic response. In addition to obser- vational anxiety measures, we attempted to use self- report anxiety assessments in young children. This was done using the VPT, which is widely used in the dental literature (13). We found that this instrument is not appropriate for children in the perioperative set- ting because it lacks discriminative sensitivity.

Finally, although children in Group 3 exhibited less anxiety immediately after the intervention and on sep- aration to the OR, this did not reach statistical signif- icance. As shown in Figure 1, however, the range of observed anxiety in children in this study was quite large. Although a possible type II error can account for the lack of statistical significance when comparing the groups after intervention and on separation to the OR, it does not explain the findings during the induction of anesthesia, PACU, and 2 wk postoperatively. Thus, even if we presume that a type II error did occur, the extensive behavioral intervention is more effective only at the preoperative period and has no effect on intraoperative and postoperative outcomes.

In conclusion, our study’s assessment of a behav- ioral program revealed that although more extensive (and expensive) preparation resulted in better anxiety control, this was limited to the preoperative period. Pediatric surgery center personnel should consider these factors and individualize their prescription of preparation programs based on available resources. Individualization of preparation programs may also be based on characteristics of children that are fairly easy to ascertain, including previous history of sur- gery, previous negative medical experiences, and age. Assessments of children’s perceptions of the value of different coping strategies may also be used to pro- vide information that would help to individualize preparation programs and to maximize the effective- ness of available resources.

Appendix 1 Tempevamen t

The EASI Instrument of child temperament (10) is a standardized tool that assesses temperament in chil- dren and is used widely in the literature. This instru- ment includes 20 items in four behavioral categories: emotionality, activity, sociability, and impulsivity. A parent is presented with individual patterns of behav- iors and responses to daily events and is asked to rate the child on a five-point scale. A score ranges from 5 to 25 for each category, with higher scores indicating higher baseline emotionality, activity, sociability, or impulsivity. The instrument has good validity when compared against other measures of temperament for young children.

Anxiety Modulation

The YPAS (14) is an observational measure of preop- erative anxiety that was developed and validated in an investigation involving 58 children. The YPAS con- sists of 27 items in five categories of behavior indicat- ing anxiety in young children (activity, emotional ex- pressivity, state of arousal, vocalization, and use of parents). Using K statistics, all YPAS categories have been demonstrated to have good to excellent inter- and intraobserver reliability (0.73-0.91), and when validated against other global behavioral measures of anxiety, the YPAS had good validity (Y = 0.64).

The STAI (11) is a widely used self-report anxiety assessment instrument. More than 1000 studies using the STAI have been published in peer-reviewed liter- ature. The questionnaire contains two separate 20- item, self-report rating scales for measuring trait and state anxiety. Parents responded on a four-point scale, total scores for situational and baseline questions sep- arately range from 20 to 80, with higher scores denot- ing higher levels of anxiety. Test-retest correlations for the STAI are high (0.73-0.86).

The VAS (12) is widely used as both a self-report and observational measure of anxiety. For the purpose of this study, the VAS was used as an observational measure to rate the children. The VAS rating system consists of a loo-mm line that pictorially represents two behavioral extremes at either end of the contin- uum, i.e., “not anxious” and “extremely anxious.” Test-retest reliability of the VAS ranges from 0.61 to 0.73 when measured on adjacent days. Also, when used to measure anxiety, the VAS has good validity against a depression scale (Y = 0.64-0.67).

The VPT (13) is a children’s (age 2-6 yr) self-report measure of anxiety that is used extensively in the dental literature. The instrument consists of eight pic- ture sets, each depicting an anxious and a nonanxious child. Subjects are presented with pairs of pictures and asked to choose the child who most reflects how they feel. Internal consistency (a Kuder-Richardeson) of the test is 0.838 (13), and test-retest is reported to be 93% in a sample of 64 children undergoing dental treat- ment (13).

Coping Style

The MBSS (15) is a standardized tool developed for patients undergoing medical procedures and identifies information seeking (high monitor)/information avoid- ers (low monitors) and distracters (high blunters)/ nondistracters (low blunters). The MBSS assesses coping style through four scenarios of stressful situations (i.e., you are on an airplane that is experiencing severe tur- bulence). A list of eight possible reactions to the situation is presented, and participants are asked to check each behavior in which they would engage in that situation

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(i.e., look for exits or watch the in-flight movie). This measure has excellent reliability and validity.

CC (16) is an instrument was used to obtain children’s ratings of the value of different strategies for coping with fear in a hypothetical situation. That is, children are told the story of John/Jill, who is anxious because he/she must have a tooth pulled at the dentist. The children are next given different behaviors (i.e., think about some- thing else, run away, talk to mom) in which John/Jill engages and are asked to indicate whether the behavior is a good or bad thing to do in this situation. This measure has good reliability and validity.

Postoperative Behavior

The PHBQ (17,lS) is a self-report questionnaire for parents that is widely used in the literature and is designed to evaluate maladaptive behavioral re- sponses and developmental regression in children af- ter surgery. The PHBQ consists of 27 items frequently cited in the literature as common behavioral responses of children after surgery. Six categories of anxiety are incorporated in this instrument, including general anxiety, separation anxiety, sleep anxiety, eating dis- turbances, aggression against authority, and apathy/ withdrawal. For each item, parents rated the extent to which each behavior changed in frequency compared with before surgery. This instrument shows accept- able test-retest reliability, good agreement with psy- chiatric interviews with parents, and predicts changes as a function of preoperative interventions.

The authors thank Paul G. Barash, MD, for his critical review of this manuscript.

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