Perioperative Behavioral Stress in Children

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, Werner ) 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 phenomenalism (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.

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. 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 and therefore are at unique and disparate risk for perioperative stress.

Attachment

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 inevitable and necessary for a child's normal, healthy development. 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. 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. 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. 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. 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 children 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” children are more easily distressed by even brief separations and spend more time trying to stay close to their parents.

Temperament

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) that appear in infancy and are thought to be primarily genetic in nature. Three main dimensions have been proposed to classify infant temperament: emotionality, activity, and sociability. 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. In long-term studies, infants who are inhibited in the face of novelty continue to be so through early school age. 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 relating 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 and postoperative behavioral outcomes, such as emergence delirium, sleep, and other maladaptive behavioral changes.

Risk Factors

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 ).

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 brief outpatient procedures (<30 minutes) 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:

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  Age and developmental maturity

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  Previous experience with medical procedures and illness

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  Individual capacity for affect regulation and trait (baseline) anxiety

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  Parental state (situational) and trait anxiety

Previous studies that examined the behavioral responses to induction of anesthesia in children did so in terms of these four domains. 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 5 years can more easily cope with new situations. A history of previous stressful medical encounters, such as 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.

Parental characteristics also have a strong influence on a child's behavior. 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. 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 fathers ), the child's age (<1 year), children with repeated hospital admissions, and the child's temperament are all predictors of increased parental preoperative anxiety. 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.