Episode Transcript
Hello! I‘m Dr. Fiona Patrao and I’m a pediatric anesthesiologist at Seattle Children’s Hospital. In this podcast we are going to talk about developmental differences in anxiety and pain coping skills across the pediatric spectrum. We will be specifically focusing on the perioperative environment and how children cope with the stress of a surgical procedure. We will delve into what contributes to the development of coping skills and discuss techniques we can use to help a child cope with their stress.
We have all been faced with the tearful patient and occasionally with the patient who’s trying to make a quick getaway for an exit! 40-60% of pediatric patients experience anxiety and fear in the perioperative period. There are many factors that can contribute to anxiety, and we will get into this in more detail, but in brief, risk factors for pre-operative anxiety can include younger age, previous healthcare experience, pre-existing behavioral problems and high parental anxiety.
This anxiety can have a significant impact on a patient’s perioperative course. Intraoperatively, stress and fear can activate the sympathetic nervous and neuroendocrine system and set off a cascade of events which, in addition to making patients more hyperaware of their surroundings, also increases their heart rate and blood pressure, and increases anesthetic requirements for induction and maintenance. Postoperatively, anxiety has been found to be associated with increased incidence of emergence delirium, increased pain, and increased need for analgesic medication. And- unfortunately, the effects of anxiety are not confined to the immediate postoperative phase. Kotiniemi et al and Kain et al found that perioperative distress can contribute to general anxiety, disruptions in sleep, nighttime crying, enuresis, and new-onset negative behavioral changes such as temper tantrums or worsened separation anxiety in up to 54% of patients in the 2 weeks following surgery. Nearly 20% of these children continued to have some of these behavior changes at 6 months and 6% have behaviors persisting at 1 year.
There is also a strong relationship between this preoperative anxiety and postoperative pain. The activation of the sympathetic nervous system, I just mentioned, causes increased awareness of pain, leading to a lower pain threshold and greater pain perception. We must also remember that a child’s memory of their pain is an important predictor for future pain experiences. Children who have negative or unpleasant pain memories are likely to have greater future pain intensity, fear, and distress. The development of these negative memories can lead to poor pain coping mechanisms, chronic pain and persistent problems with health-related quality of life.
All this to say, the impact of anxiety and pain can be significant and long lasting. The range of the repercussions vary from prolonged hospital stays and increased healthcare costs to significant behavioral issues and mistrust in the healthcare system. As anesthesiologists our goal should be, to the extent we can, create a stress-free environment for our patients and to do this we have to understand their anxiety better.
So- obviously having surgery would be a big stressor to anyone’s life. But let’s try to dissect it through the eyes of children at different ages. Young children, such as toddlers will not understand the practicalities of the procedure or even that they are going to have surgery at all. Their biggest stressors will likely be from being in a bright and unfamiliar new environment, feeling hungry, and being handled by many strangers. An early school aged child with some understanding of the process, may be terrified of being separated from their parents, or of perceived mutilation from being cut open. A teenager who will likely have a more comprehensive understanding of surgery may fear specific risks of surgery such as postoperative pain, awareness under anesthesia or the loss of control they will soon experience.
Similarly, anxiety related behavior and the coping skill set they will exhibit will be unique to their age and development, as well as to each individual child. In addition to age, there are multiple other factors contributing to a child’s coping mechanisms and behaviors, such as their language and socio-emotional development, their understanding and acceptance of new situations, parental behaviors, cultural influences and their lived experiences. We are going to dive into these factors in more detail.
Some of the well-defined contributors to a child’s coping ability are three traits that establish early in infancy. They are: A child’s cognitive development, A child’s temperament and, A child’s attachment.
Let’s take the first trait: cognitive development-this is based on a child’s age. Cognition defines the grasp and understanding of a situation, and the ability to articulate and talk about that situation. To quote Jean Piaget “A child is not less intelligent than an adult- they just think differently about the same things”. Piaget was a renowned psychologist of the 20th century and a pioneer in developmental child psychology, and he theorized that a child’s understanding of the world proceeds through four broad stages, with each stage demonstrating an increasingly sophisticated understanding of concepts. There are now many more developmental cognitive theories, but the general understanding is that a child’s fears, anxieties and their coping skills are closely linked to their cognitive development.
The first 2 years of life are described by Piaget as the “sensory motor” phase where development is focused on motor growth and when children learn simple cause-and-effect relationships. Children start to identify faces around the 4-6 months mark and at about 9 months there is a major milestone of infancy where children can distinctly recognize unfamiliar faces and develop the well-known “stranger anxiety”- this peaks at about 15 months, and often improves by about 2 years of age when a child has had more opportunities to socialize in multiple settings.
This phase overlaps with the second “preoperational phase” around age 18 months when children pass through the phases of phenomenalism from 1 -2 years – where everything tends to happen by “magic”. Children also now start to feel a range of emotions and they often have difficulty managing them- enter the age of tantrums! The magical phase soon transitions to the concrete logic of a 3- to 5-year-old with very literal understanding of concepts and a new ability to express and control some of their emotions. With this understanding, it is not surprising that the research shows that children ages 1 to 5 years have been found to experience the most perioperative anxiety secondary to their increased grasp of surroundings but as yet unlearned mechanisms for expression and self-regulating emotions.
From school age onwards - about the age of 7 -children advance to the “concrete operational” phase where they start controlling some of their social behaviors based on their social interactions, and from learning that displays of intense emotions are at times unacceptable. Logical thought, social awareness, problem-solving capacity and less reliance on parents mark this growth phase.
From the age of 11 or the onset of adolescence to adulthood Piaget describes his fourth and final phase as the “formal operational” phase where the older child establishes deductive reasoning and understanding of abstract concepts. This age group begins to establish their own personal identity and decision making and wants to establish boundaries- all this can precipitate conflict with caregivers. At this age there is a strong desire for social acceptance, so teenagers may alter their emotions to seem more mature or in control. Often, they have a lot of mixed emotions as they are more aware of the risks of surgery, and simultaneously are trying to be less dependent on their parents for support and trying to have complete control of their emotions. This conflict of emotions can precipitate atypical or inappropriate emotional responses in stressful situations.
The next trait that establishes in infancy is attachment.
By far, one of a child’s biggest fears is being separated from their parent or caregiver, and this is because they are “attached” to them. Attachment describes the reliance a child has on their caregiver, and this is built on a foundation of trust. This trait is influenced by the environment a child is raised in and at older ages the degree of socialization a child has been exposed to, such that the older a child gets they begin to be less attached to their parents. There are 4 different ways a child can be attached to their caregiver- and each has implications on their coping skills.
The “securely attached” child can separate easily from their caregivers because they have a strong trust in them and believe that they will see them again soon. They may be calm with separation, and easily reassured when reunited with them. Children with less healthy attachment styles such as the “anxious”, “disorganized” or “avoidant” may experience a more intense separation anxiety or may even appear emotionally withdrawn.
The third trait is temperament. Temperament refers to a child’s emotionality and sociability and is a genetic predisposition- which means you can try, but you can’t really change this about them! It defines their individual capacity for regulating their emotions, affect and anxiety. It explains why some children may be more stoic and be considered to have better coping skills, some more friendly, some shy, or others more emotionally labile or moody. It has been shown that children who are more social and have an ability to regulate their emotions and affect tend to have less anxiety development. And those who tend to have more withdrawn emotional and social behaviors find it harder to adapt to new environments and tend to be more distressed.
These three traits- cognition, temperament, and attachment- will be different in patients who may have developmental delays, disabilities, fall on the autism spectrum or have issues such as attention deficit disorder or mental health issues. For these patients their caregivers will be critical in helping us understand the needs of the child and provide us with the best assessment of these three traits.
Apart from these three traits a child’s behavioral response is also based on other known factors.
- Children with a previous experience with medical procedures or illnesses tend to have more anxiety especially if they have had a prior unpleasant experience. Remember- the experience doesn’t have to be from a hospitalization or surgery- a prior stressful experience during a vaccination, PCP or dentist visit can also contribute.
- Parental anxiety is also important as it has been established that children of anxious parents are more likely to experience high levels of preoperative anxiety. I will add to this that parents are also critical for influencing a child’s experience around pain and the pain memories they form- particularly in early childhood. Physiologically we should remember that pain does require our attention because it alerts us to a threat to our body. But if attention to pain is repeatedly emphasized, it can cause negative pain memory biases. If parents repeatedly attend to and reinforce their child’s pain-related fear, they can contribute to the development of pain-related fear or pain catastrophizing behaviors and this in turn can lead to children who have increased pain intensity, poor pain coping skills and delayed postoperative recovery from pain. And as we mentioned earlier, this can potentially also lead to lifelong issues with their health-care quality of life.
- And one of the last contributing factors I would like to mention, is a child’s lived experiences which will undoubtedly have an impact on their handling of new stressors. Abandonment, displacement, and/or abuse will have tremendous influences on a child’s coping skills.
So far, we have covered the impact of perioperative anxiety and the importance of helping children cope, as well as factors that can contribute to their anxiety and coping mechanisms. It’s equally important to talk about how we recognize and then help children who are in distress.
So- what does an anxious child look like or what should we be looking for? Anxious children will often have a frightened appearance, will be crying, clinging to their parent, reluctant to make eye contact or communicate with the health- care provider and sometimes even refuse care and run away. Older children may be very quiet or may be asking a lot of questions, deferring eye contact and may cope by distracting themselves with their phone or simply staring at their feet! At times it may seem like the questioning child, or the quiet teenager is coping but remember- they may be pushing themselves to be emotionally restrained and can later have unpredictable behavior. There are multiple opportunities to assess a patients anxiety starting from the surgical and preanesthetic clinic or the preoperative nurse evaluation- and a team-based approach of communicating these concerns should be adopted.
So how can we help? There are well established interventions that have been studied to help with a child’s coping skills. These interventions can be categorized into behavioral, educational, pharmacological, and complimentary approaches. Let’s take a look at each one:
Behavioral interventions: This includes the preoperative anesthesia interview, parental presence during induction and/or emergence, utilization of child life specialists and distraction techniques.
Firstly, let’s talk about the anesthesia interview- we have a unique position of meeting patients at the time of their peak stress, and we must have the ability to recognize and mitigate this. From the moment we meet a child and their family the anesthesiologist should “read the room”. It is important that the anesthesiologist builds a rapport and establishes trust with the patient, engages in some form of communication with the child even if that is just simple play. Younger children are sometimes more open to strangers only if they see their parents comfortable with the new people and so it is crucial to build trust with the parents and allay their anxiety too. Conversations with the children should be age appropriate and that can range from engaging in play and humor for younger kids to risk/benefit discussions with teenagers when prompted.
Parents and children can often come in with misunderstood concepts of anesthesia and be focused on certain risks. It is important to have a well- informed conversation that can help break down misconceptions and put risks into better perspective. Providing a clear description of what to expect in terms of the room description, monitoring, and where they will be in recovery often helps the anxiety of the unknown. Reassurance of an anesthesiologist’s continual presence to ensure a child stays asleep and wakes up safely is also very helpful. Parents are often good guides as to how anxious their children are, and the anesthesiologist should heed prompts to limit discussions of procedural details and/or risks in front of them. If the child appears very fearful, try to find out what is making them the most afraid. Giving the child space to speak and ask questions may help with their emotional turmoil.
The other main behavioral intervention is utilizing parental presence during induction of anesthesia. Parental presence is useful if the parent is calm but not as beneficial if they are anxious. This approach is particularly helpful in the 1-to-5-year age group extending to the elementary school age child where perioperative anxiety tends to peak and children remain quite attached to their parents, or in children with disabilities and neurodevelopmental issues. Parental presence is also equally comforting and helpful to these children in the recovery units postoperatively.
Child life specialists have been shown to be effective. A child life specialist is a provider who has a strong background in child development and can provide therapeutic play experiences and use developmentally appropriate language to normalize an unknown and stressful environment. Their expertise has also been found significantly helpful for procedural education, emotional support, coping skills, and pain management techniques.
Finally, to round of the behavioral interventions - play and distraction are very effective and easy to apply techniques. Using arts and crafts, the TV or technology including computer tablets and virtual reality are known to be extremely useful. There is now an even newer device that uses a patient’s breathing to control a video game that can be used to encourage calm breathing with induction.
Educational Interventions include age-appropriate preparation programs such as printed material or videos describing the perioperative experience or providing virtual operating room tours. When providing this information parents and providers should be cognizant of how well a child will cope with this information as some children may get overly sensitized to the information and develop anticipatory anxiety.
Pharmacological interventions include sedative medications such as midazolam, ketamine, and dexmedetomidine- which have been shown by multiple studies to effectively reduce anxiety and facilitate separation from parents. Discussing all pharmacological options is beyond the scope of this podcast, but since midazolam is the most commonly used perioperative anxiolytic, I would like to highlight it. It can be administered orally, intravenously, intranasally, or intramuscularly. Oral doses of 0.2 to 0.75 mg/kg have been shown to be effective, while nasal doses range from 0.1 to 0.3 mg/kg and IV doses range from 0.05 to 0.15 mg/kg. Oral midazolam has a bitter taste and is sometimes not well tolerated whereas intranasal midazolam can cause a burning sensation in the nasopharynx. It is often helpful to inform parents of this and then to elicit parental help in administering an oral or nasal premedication as many patients are more likely to trust and accept a medication being administered by their parent.
And finally, complimentary approaches including acupuncture, hypnosis, and music therapy -when available- can be helpful for some children.
All these interventions can be used interchangeably or simultaneously, and much research has gone into analyzing combinations of these techniques to find what works best. For example, Kain et al found that parental presence in addition to oral midazolam had no additive effects in terms of reducing a child's anxiety compared to midazolam alone. However, the parents themselves reported higher satisfaction scores and reduced anxiety.
Another interesting trial I’d like to highlight is the ADVANCE trial where ADVANCE stood for Anxiety reduction, Distraction on day of surgery, Video modelling and education, Adding parents to the surgical experience, No excessive reassurance, Coaching of parents, and Exposure via induction room mask practice. To quote from the paper: “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. Children spent less time in the recovery area and had reduced analgesic needs.” Interestingly, what they found to be the most effective strategies of their program were exposing children to the anesthesia mask and distraction on the day of surgery. Easy and cost-effective solutions we can all easily apply!
To conclude, we hope that this talk has given you some insight into the role perioperative anxiety plays in a child’s health and their long-term health-related quality of life. I also hope that it’s given you some tools for how to manage your next scared and tearful pediatric patient. If it’s a toddler, you may consider a pharmacological premedication but if you prefer to avoid one having the presence of a parent and engaging in a game of peek-a- boo may be as effective. In the early school age child bringing the anesthesia mask to the preop interview and mimicking in a playful way the act of breathing deeply may be very helpful, or you may be able to fascinate them with a magical story of what’s to come from parental separation to falling asleep. If that fails, screen time may do the trick as a great distractor! In adolescents and teenagers ensure you provide a safe space to have an age-appropriate conversation and hear their concerns with empathy and understanding. In the child with a language or cultural barrier or a prior poor healthcare experience consider reserving extra time to listen and learn about their fears and provide reassurance that you will individualize their anesthetic plan. In those affected by a disability, or neurodevelopmental disorder ensure the parent’s advocacy is heeded and you learn about measures to avoid triggering negative behaviors and how to soothe and comfort.
Do not forget how uniquely positioned we are as anesthesiologists to reduce psychological stress at a child’s most vulnerable moment, and the great opportunity we have to potentially even make their perioperative experience a fun one. I hope you have found this podcast helpful. Thanks for listening!
