Psychological aspects of pediatric anesthesia

“ Remember me and smile, for it’s better to forget than to remember me and cry. ” —Theodor Seuss Geisel (Dr. Seuss), 1904–1991

Introduction

Millions of children undergo surgery ever year in the United States, and a significant proportion of them will experience preoperative anxiety, fear, postoperative psychological distress, and maladaptive behaviors. It is apparent to most of us that these phenomena are not new; what is remarkable, however, are the uncanny observations and inferences of our esteemed anesthesiology colleagues from the 1940s and 1950s that are as accurate in current literature as they were in those days, albeit with a modern twist. In an article entitled “Psychic Trauma of Operations in Children, and a Note on Combat Neurosis,” published in 1945, Dr. David Levy from New York wrote: “Impressed by the number of cases in which fears, anxieties and other symptoms closely followed an operative procedure, I reviewed my records for some years past in order to determine how frequently such difficulties arose” ( ). Levy found that 20% of children had night terrors, temper tantrums, or were disobedient or destructive after surgical procedures. Eckenhoff described the relationship between a stormy induction and postoperative psychological complications ( ). Leigh and Belton recognized the advantages of premedication and the dangers of respiratory depression following premedication with a combination of an opiate and a barbiturate in young infants ( ). Freeman and Bachman studied combinations of 12 drugs for premedication in 292 children in a double-blind fashion, advocating for a combination of pentobarbital and scopolamine for its sedative and antisialagogue effects ( ). Jackson advocated a psychological approach to preoperative preparation in 1951, while recognizing that there were others who strongly advocated pharmacologic premedication to allay anxiety ( ). What is uncannily prescient about her approach, however, is the similarity it bears to many present-day efforts. Jackson’s plan for psychological preparation included assessment of the effect of any previous anesthesia experience; planned or unplanned preparation at home; simple, realistic descriptions of what the child will experience including the operating room suite and personnel; encouraging the child to handle the mask for familiarity; and, most importantly, doing and saying whatever is necessary for the child to gain the trust of the anesthesiologist without breaking any promises, however trivial. She was also a pragmatist, acknowledging that psychological preparation would not work for every child and may need to be combined with premedication ( ).

Identification of children at risk for preoperative anxiety

Preoperative anxiety is defined as a feeling of apprehension, nervousness, or fear that may be associated with heightened autonomic activity. Several factors interact in a complex fashion to produce or worsen preoperative anxiety. Identification of children at high risk for preoperative anxiety should be a priority for practitioners in every practice setting. Familiarity with these risk factors will enable early identification of children at highest risk for procedural anxiety and fear. Preoperative anxiety is a form of “state” anxiety related to the events surrounding anesthesia and surgery. This may be exacerbated by “trait” anxiety, which in young children would be described as having an anxious temperament. Anxiety-related behaviors may include a frightened appearance, agitation, crying, hyperventilating, clinging on to a parent, refusal to communicate or play, and attempts to run away from healthcare staff or the facility.

Anxiety throughout the pre- and postoperative continuum increases significantly prior to surgery, peaking at anesthetic induction, and decreases postoperatively and over the 2 weeks following surgery. Younger children between 1 and 5 years of age are at highest risk for anxiety, as are children with high trait anxiety, low social adaptability, a shy and inhibited personality, anxious parents, and those with a previous history of poor-quality medical encounters ( ; ). Significant anxiety occurs in over 80% of adolescents and is often subtle and hidden behind more casual behaviors that may not correlate well with physiologic indices indicative of anxiety ( ). This absence of observable anxiety may result in inadequate alleviation of anxiety, unless unearthed via a careful preoperative interview.

Identification by medical staff versus parents

Astute and experienced pediatric anesthesiologists who feel they are best equipped to identify children at high risk of anxiety prior to anesthesia appear to have evidence to support their claim; anesthesiologists practicing in a pediatric setting were shown to be the most accurate at predicting anxiety, and, surprisingly, were better than the children’s mothers ( ). Between parents, fathers’ predictions were found to be more accurate than mothers’ predictions of children’s anxiety at induction.

Instruments to measure preoperative anxiety

Several validated instruments exist to measure anxiety in children and parents in the perioperative period. The modified Yale Preoperative Anxiety Scale (mYPAS) ( ), the State-Trait Anxiety Inventory for children (STAIC) ( ), the Numeric Rating Scale (NRS) ( ), and visual analog scales (VASs) are commonly used to measure perioperative anxiety. The mYPAS was specifically developed for anxiety measurement at anesthetic induction, and is an appropriate tool for these measurements ( ) (see Box 15.e1 , available online). In addition, measures of child behavior and temperament such as the EASI (Emotionality, Activity, Sociability, and Impulsivity) instrument ( ), the Child Behavior Checklist (CBCL) ( ), and the Post Hospitalization Behavioral Questionnaire (PHBQ) ( ) have been validated to accurately assess emotionality and changes in behavior during the perioperative period. This list is by no means exhaustive, and many other instruments exist with varying degrees of validity and reliability.

BOX 15.e1

Modified from Kain, Z. N., Mayes, L. C., Cicchetti, D. V., Bagnall, A. L., Finley, J. D., and Hofstadter, M. B. (1997). The Yale Preoperative Anxiety Scale: How does it compare with a “gold standard”? Anesthesia and Analgesia, 85 (4), 783–788.

Modified Yale Preoperative Anxiety Score (mYPAS)

Activity

1.
Looking around, curious, playing with toys, reading (or other age-appropriate behavior); moves around holding area/treatment room to get toys or to go to parent; may move toward operating room equipment
2.
Not exploring or playing, may look down, fidget with hands, or suck thumb (blanket); may sit close to parent while waiting, or play has a definite manic quality
3.
Moving from toy to parent in unfocused manner, non-activity-derived movements; frenetic/frenzied movement or play; squirming, moving on table; may push mask away or cling to parent
4.
Actively trying to get away, pushes with feet and arms, may move whole body; in waiting room, running around unfocused, not looking at toys, will not separate from parent, desperate clinging

Vocalizations

1.
Reading (nonvocalizing appropriate to activity), asking questions, making comments, babbling, laughing, readily answers questions but may be generally quiet; child too young to talk in social situations or too engrossed in play to respond
2.
Responding to adults but whispers, “baby talk,” only head nodding
3.
Quiet, no sounds or responses to adults
4.
Whimpering, moaning, groaning, silently crying
5.
Crying or may be screaming “no”
6.
Crying, screaming loudly, sustained (audible through mask)

Emotional expressivity

1.
Manifestly happy, smiling, or concentrating on play
2.
Neutral, no visible expression on face
3.
Worried (sad) to frightened; sad, worried, or tearful eyes
4.
Distressed, crying, extreme upset, may have wide eyes

State of apparent arousal

1.
Alert, looks around occasionally, notices or watches what anesthesiologist does (could be relaxed)
2.
Withdrawn, sitting still and quiet, may be sucking on thumb or have face turned to adult
3.
Vigilant, looking quickly all around, may startle to sounds, eyes wide, body tense
4.
Panicked whimpering, may be crying or pushing others away, turns away

Use of parents

1.
Busy playing, sitting idle, or engaged in age-appropriate behavior and doesn’t need parent; may interact with parent if parent initiates the interaction
2.
Reaches out to parent (approaches parent and speaks to otherwise silent parent), seeks and accepts comfort, may lean against parent
3.
Looks to parent quietly, apparently watches actions, doesn’t seek contact or comfort, accepts it if offered or clings to parent
4.
Keeps parent at distance or may actively withdraw from parent, may push parent away or desperately cling to parent and not let parent go

A score is calculated by dividing each item rating by the highest possible rating (i.e., 6 for the “vocalizations” item and 4 for all other items), adding all of the produced values, dividing by 5, and multiplying by 100. This calculation produces a score ranging from 23.33 to 100, with higher values indicating higher anxiety. Typically a score of 30 functions as a threshold for anxiety.

Risk factors

Preparation for anesthesia and surgery is a very stressful experience, with the potential to cause significant and lasting psychological distress. However, pediatric anesthesiologists have the opportunity to reduce psychological stress and hopefully even make the experience fun for our patients. The ability to identify specific risk factors in our patients allows us to tailor our interactions, language, pharmacologic interventions, environment, and overall experience for each patient and family.

Developmental factors

A basic understanding of the developmental psychology of children is crucial for the pediatric anesthesiologist. Based on the age of the patient, a pediatric anesthesiologist should be able to anticipate where the child is in terms of their cognitive, social, and emotional development. This should guide their preoperative strategy and possible interventions. Major milestones in the domains of cognitive, physical, social/emotional, and language development are outlined in Table 15.1 .

TABLE 15.1

Major Developmental Milestones of Childhood

Age	Cognitive	Physical	Social/Emotional	Language
0–6 months	Sensation	Rolling to sitting unassisted	Bonding Smiles Recognizes familiar faces	Laugh Babble
6–12 months	Further environment exploration Object permanence	Crawling to walking	Stranger anxiety Peek-a-boo Parallel play	Repetitive sounds Gestures 4–6 words by 1 year
1–2 years	Use of symbols Concrete object use Simple cause-and-effect understanding	Walks up and down stairs	Self-centered Imitates others Tantrums, difficulty managing emotions	50–75 words by 2 years Pronouns
3–4 years	Literal thinking Give reasons for actions Frequent opinion changes	Ride a tricycle Toilet trained	Identifies some emotions Manages emotions better Coordinates social play	Many words Tells stories Compound sentences
5–10 years	Logical thought Organize and classify objects	Increased coordination	Increased social awareness, less egocentricity Understands others feelings	Shift from egocentric to social speech Major vocabulary expansion
11+ years	Abstract/flexible thought Understands hypotheticals	Growth spurt Sexual maturation	Strong desire for social acceptance Establishes personal identity	Personal speech patterns

Cognitive development

Children are not “little adults” who simply know less. The process by which they acquire, construct, and use knowledge involves a progressive reorganization of mental processes resulting from biological maturation and environmental experience. The most well-known theory of how the process of cognitive development occurs throughout childhood was introduced by Jean Piaget in the 1940s to 1950s and continues to be the most comprehensive framework for this process ( ). Familiarity with the periods of cognitive development as described by Piaget can help the pediatric anesthesiologist recognize how typically developing children will understand and respond to their environment based on their level of cognitive development.

The first 2 years of life are referred to as the “sensory motor” period, when children learn and understand basic things about their environment, such as the concept that objects exist apart from themselves and continue to exist when they do not perceive them ( ). They also learn simple cause-and-effect relationships and spatial relationships. Motor skills develop rapidly at this age, as children quickly progress from crawling, to walking, to running, and this allows them to experience the world around them. Language skills are more limited during this period, and communication remains mostly nonverbal, relying on gestures and pointing ( ).

The period from 2 to 7 years of age is the “preoperational” period and is subcategorized into the “preconceptual” (ages 2 to 4) and the “intuitive” (ages 4 to 7) substages. In the “preconceptual” substage, children are able to represent one thing with another so that they are able to use language symbols and represent objects by drawing them. In the “intuitive” substage, children can give reasons for their actions and beliefs. However, this is limited by some misunderstandings such as attributing causation to something that happens sequentially, as well as by frequent changes in opinion and egocentricity ( ). “Preoperational” thinking can be very literal, but these children may also use “magical thinking” or fantasy to understand the world or to explain confusing or stressful situations ( ). For example, with literal thought the child may wonder where you put their blood pressure when you say, “I’m going to take your blood pressure now” but they may also show patterns of magical thinking such as “I’m going to breathe the special sleepy air!” at the beginning of a mask induction.

From age seven to adolescence is the period of “concrete operations” during which children are able to internalize the properties of objects, meaning they are able to classify or organize them in their mind. Thinking also becomes less egocentric in this period. Children at this stage cannot truly think abstractly and desire increased explanation as well as the opportunity to participate ( ). For example, it would be appropriate to include them in the preoperative interview, allowing them to answer some of your questions or giving them the option of decorating their mask with stickers in the preoperative area. Children at this age begin thinking more logically, have an appreciation for rules and for right and wrong, and are able to understand other people’s feelings.

Adolescence is the period of “formal operations” during which children develop a much more flexible type of thinking, the main features of which are the ability to accept assumptions for the sake of argument, to make hypotheses and test them, and to look for general properties and laws in symbolic material ( ). They begin to understand consequences. Adolescents in this period will respond better to the anesthesiologist who is attentive and nonjudgmental. They should have clear explanations and assurances while also being offered increased independence and the ability to have some decision-making power ( ). Adolescents are increasingly body conscious, and the clinician must respect their need for privacy in order to gain their trust. Examples of this include keeping them covered when placing ECG leads or offering them privacy from their family during a physical examination. At this age, the focus of the preoperative conversation must be directed toward to the patient, as this will validate their role in the decision-making process.

Children’s fears during the perioperative period are closely linked to their stage of cognitive development. The basis of these fears may be modified significantly by neurodevelopmental issues or previous unpleasant medical encounters; a summary of these fears and recommended approaches are outlined in Table 15.2 .

TABLE 15.2

Age-Specific Fears and Recommended Approaches

Concepts adapted from Holzman, R. S., Mancuso, T. J., & Polaner, D. M. (2015). A practical approach to pediatric anesthesia. Hagerstown, MD: Wolters Kluwer Health. Retrieved from http://ebookcentral.proquest.com/lib/ohsu/detail.action?docID=4786237 .

Age	Fear	Example Approach
Infant	Separation (from parents) and stranger anxiety	Premedication or behavioral distraction. Avoid masks prior to induction if possible.
Toddler	Loss of control (of environment)	Allow some participation—stickers on their mask or choosing a scent for it, picking a finger for the pulse oximeter.
Preschool	Injury/pain	If planning a mask induction—”No pokes or ‘owies’ while you are awake! We’ll just sing songs and breathe the sleepy air.”
School aged	Meeting expectations (of adults/authority)	Explain expectations simply and remain calm/friendly—”Once the mask is over your nose and mouth you must keep it there and then its ok to close your eyes and go to sleep.”
Adolescent	Death	Anticipate and reassure—”It may be hard to understand how, but trust that we will keep you safe, asleep, and comfortable during this procedure.”

Social/emotional development

The patterns of social and emotional development in children tend to follow a less predictable timeline than their cognitive development. There is also significant interdependency of emotional and social development so that it is difficult to describe one without the other, as emotion is greatly influenced by interpersonal interactions, and social interactions are often guided by emotional transactions.

The most important social and emotional developmental process of infants is the process of bonding with the parent. Through this attachment process, infants learn to trust their parent, and parents learn to interpret their infants’ cues. Infants learn to recognize familiar faces by 4 to 5 months of age. By 8 to 10 months of age the infant can recognize unfamiliar faces ( ). This is when “stranger anxiety,” the major social milestone of infancy, occurs. It usually begins by 9 months of age, peaks at about 15 months, and often improves by about 2 years of age when the child has had more routine socialization. This comes into play when it is time for the child to separate from the parent (i.e., to go back to the operating room or procedural suite). Separating a child younger than 9 months of age from their parent is usually straightforward, and the child does not typically show significant signs of distress. However, with the onset of “stranger anxiety,” separation of the child from their parent may be difficult without distraction, sedative premedication, or both.

Throughout the “preoperational” stages, children are learning how to manage emotions within interactions and social play. Processes inherent in succeeding at these tasks call for skills of emotional competence, such as the ability to resolve an argument to keep play going. Children begin to learn to avoid tantrums and to think about distressing situations. Emotion regulation becomes both necessary, due to increased social interactions and the overall complexity of their world, and also possible because of their increased comprehension and regulation of their emotions ( ). Compared with younger children, children at this stage become more autonomous and capable of cooperation. However, despite outward appearances that may give the unsuspecting clinician the impression of cooperation, most children in this age group will still experience significant anxiety in unfamiliar settings, such as the operating room.

As children progress to school age, which roughly correlates to the “concrete” operations period, they become more aware of their social networks, and their focus shifts to the desire for social acceptance. Managing emotions, such as how and when to show them, as well as whom to share emotional experiences or thoughts with, is fundamental to their development of emotional competence ( ). Children will increasingly use cognitive and problem-solving behavioral coping strategies to regulate their emotions and rely less on the support of their parents ( ). As they learn that goals are not always met by showing intense feelings, they begin to express their emotions less fervently and with thought given to their situation and company.

All of these skills related to emotional competence continue to be honed throughout adolescence as children place even more value on social acceptance and begin to understand emotions with greater nuance. However, even though adolescents have a greater understanding of increasingly complex emotions, they are still plagued by difficulty understanding mixed emotions and will often confuse them ( ). This can play out with adolescents who have seemingly very inappropriate or atypical emotional reactions, particularly when in stressful situations.

In all stages of cognitive and social/emotional development, it is important to bear in mind that all children may regress to a previous stage of development when presented with a stressful situation, such as the perioperative environment.

Personality/temperament

Temperament can be broadly defined as an individual’s characteristic nature or personality disposition, and it includes susceptibility to emotional stimulation, the strength and speed of response, the quality of the prevailing mood, the fluctuations and intensity of mood, and emotional regulation and reactivity ( ). It becomes apparent in early childhood, and temperament is generally accepted to be biologically based; however, over time it is influenced by maturation and experience ( ). Temperament can be viewed as the “core” of the ongoing personality development throughout childhood.

Previous research has found an association of temperament with anxiety in younger patients under stressful situations. Certain temperamental traits have been implicated as vulnerability factors for the development of psychological problems, such as anxiety. Behavioral inhibition, the tendency toward behavioral restraint and withdrawal in novel situations, as well as negative affectivity and neuroticism have been implicated as risk factors for the development of anxiety ( ). The ability to recognize these temperament qualities is an important skill for the pediatric anesthesiologist because it can provide insight into which children may not cope well in challenging or novel situations, such as those encountered in the perioperative period. Temperamental qualities such as these have also been shown to be independently associated with higher pain scores postoperatively, which is another important reason to identify these children preoperatively ( ).

In a recent systematic review and meta-analysis of the association of temperament with preoperative anxiety in pediatric patients, certain temperament styles were significantly associated with preoperative anxiety ( ). Specifically, emotionality, intensity of reaction, and withdrawal were found to be associated with increased preoperative anxiety, whereas activity level was associated with less anxiety. Patients who are behaviorally inhibited appear to be more rigid and inflexible in novel or stressful contexts, and this inability to adapt may predispose them to greater anxiety in an unfamiliar and stress-inducing environment, such as the surgical setting. Children who were more sociable were found to have less anxiety.

Family factors

Parents play an important role in the emotional state of the child presenting for anesthesia. These experienced adults have advanced knowledge of their children’s emotions and strategies for regulating them; thus they have the opportunity to promote the child’s emotional understanding and repertoire of emotional regulatory strategies. Parents are children’s primary attachment figures, and secure attachment promotes positive expressiveness and understanding of emotion. However, parents can also contribute negatively to children’s emotional competence. When a parent’s reactions or emotional expressions are misleading or idiosyncratic, children may develop a distorted understanding of emotions ( ).

Even parents with high emotional competence may experience anxiety in the perioperative setting, and parents who are more anxious have been demonstrated to have children who are more anxious as well ( ). This is likely related to an anxious parent being less available to respond to their child’s needs, and if the child becomes increasingly distressed, this may further compound the parent’s anxiety. Additionally, if a parent is anxious, there is a genetic predisposition toward anxiety in the child. It has also been noted that divorced parents, parents with lower educational levels, and parents of children who were not enrolled in a day care setting rate themselves as significantly more anxious preoperatively ( ).

Many parents express more anxiety around the administration of anesthesia than the surgery itself. Fear of anesthesia among parents originates largely from a lack of information regarding modern anesthetic practice rather than from a high probability of risk. It is often very effective for parents to engage in a discussion regarding the risks of an anesthetic for their child to help give them some perspective ( ). A description of monitoring equipment, the number of personnel in the operating room, systems for responding to emergencies, and a tailored description of anesthetic risks should be shared with the parent, because providing reassuring information typically allays some anxiety ( ).

Parents are also critical for influencing children’s memories for pain, particularly in early childhood. In fact, studies have shown that parental anxiety leads to children recalling higher levels of pain-related fear than initially stated ( ). Pain does require our attention because it is a threat; however, if it is repeatedly emphasized, it can cause negative pain memory biases. Therefore if parents repeatedly attend to and reinforce their child’s pain-related fear, they contribute to the development of pain-related fear and distress. In fact, parents who show a pattern of anxiety around their child’s pain, or pain catastrophizing, have been shown to have children who have increased intensity of pain and delayed postoperative recovery from pain ( ).

Neurodevelopmental disorders

The discussion throughout this chapter has focused on children with normal development. A thorough discussion of children with developmental delay and other neurodevelopmental pathology is beyond the scope of this chapter; however, the next section summarizes the most commonly encountered disorders: autism spectrum disorder, attention deficit disorder/attention deficit hyperactivity disorder, and Down syndrome.

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