Sage Journals: Discover world-class research

Abstract

Objective

To investigate the effects of sociodemographic factors and maternal anxiety levels on behaviour in children undergoing surgery.

Methods

This study included children aged 3–12 years who were scheduled for surgery, and their respective mothers. Each mother completed a questionnaire concerning sociodemographic and economic characteristics. Maternal anxiety was assessed using the State-Trait Anxiety Inventory (STAI) form Tx-1, following transfer of the child to the operating room. An anaesthesiologist rated preoperative anxiety in each child using the Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT).

Results

One hundred children (mean ± SD age 7 ± 2.7 years) who received dental (47%), plastic (39%) or urological (14%) surgery, and 100 mothers (mean ± SD age 34 ± 6.6 years) were included. A statistically significant difference between maternal STAI Tx-1 scores and children’s VPT scores was revealed. There was no significant difference between maternal STAI Tx-1 scores and children’s FBRS scores. Maternal education level and socioeconomic status had no effect on FBRS, VPT and STAI Tx-1 scores.

Conclusion

Maternal knowledge and experience of anaesthesia, and high levels of maternal anxiety, may be related to increased anxiety in children undergoing surgery.

Keywords

Maternal anxiety preoperative anxiety in children paediatric surgery

Introduction

Surgical procedures are a major cause of anxiety (defined as feelings of worry, discomfort and fear in response to a perceived or real threat) in children and their parents.¹ In the preoperative period, parents may experience increased anxiety relating to the efficacy of surgery, risk of complications (including death or disability of the child), lack of knowledge and social and economic concerns:² they also may have feelings of helplessness and guilt. In contrast, children predominantly experience fear, anger and guilt in the preoperative period.³ Anxiety in paediatric patients may result in negative postoperative behaviours such as nightmares, parental separation anxiety, eating disorders and enuresis.⁴ Concepts relating to preoperative anxiety, postoperative behaviours and parental anxiety are becoming increasingly important.⁵ The main targets in improving these interrelated factors should be to maintain the parent–child relationship, to alleviate fear resulting from lack of knowledge and to provide psychological support for the parents.¹

The purpose of the present study was to investigate the effects of maternal sociodemographic factors and anxiety levels on the behaviour of children undergoing surgery.

Patients and methods

Study population

Patients aged between 3 and 12 years, scheduled for a surgical procedure (namely, dental, plastic or urological surgery) at the Faculty of Medicine, Ege University, Izmir, Turkey, between March 2012 and December 2012, and their respective mothers, were consecutively included in the study. Mothers who were illiterate, who rejected to fill out the questionnaire, or who had a previous history of psychiatric disorders were excluded. Preoperative sedatives such as midazolam were not permitted. The study was approved by the Ege University Clinical Research Ethics Committee. Written informed consent was obtained from the mothers of the children prior to the procedure.

Study questionnaires

Immediately after each child was taken to the operating room, two questionnaires were given to each mother to complete in privacy and without any pressure. The first maternal questionnaire comprised three groups of questions. The first group related to the following: age, sex and sibling status of the child; maternal education level (1, elementary school; 2, middle school; 3, high school); socioeconomic status (1,<1000 Turkish lira/month; 2, 1000–2000 Turkish lira/month; 3, > 2000 Turkish lira/month); maternal knowledge and experience of anaesthesia; child’s experience of anaesthesia; history of anaesthesia-related problems in the family or child. The second group of questions related to the level of maternal concern regarding: preoperative fasting; surgical procedure; anaesthesia; postoperative treatment; pain; hospitalization of the child. The mother was asked to rate her level of anxiety on a scale between 1 and 4 (1, not concerned; 2, a little concerned; 3, concerned; 4, very concerned). In the third group of questions the mother was asked ‘Which of the following will help to decrease your anxiety?’. She was asked to choose among the following options by checking the ‘yes’ or ‘no’ box: ‘more information from the doctors’; ‘talking to mothers whose children had previous experience of anaesthesia’; ‘audiovisual information on anaesthesia’; ‘accompanying the child to the operating room’; ‘being present during the induction of anaesthesia’.

The second maternal questionnaire comprised the 20-item State-Trait Anxiety Inventory (STAI) form, which was used to measure maternal anxiety symptoms.⁶ For each statement in the questionnaire, the participant was asked to choose from the options ‘almost never’, ‘sometimes’, ‘often’ and ‘almost always’. Items numbered 3, 4, 6, 7, 9, 12, 13, 14, 17 and 18 were scored positively; items numbered 1, 2, 5, 8, 10, 11, 15, 16, 19 and 20 were scored negatively. Scoring was performed manually. During the assessment, each item (depending on its negative or positive value) was scored between 1 (or −1) and 4 (or −4),and an extra 50 points were added to the total score. The highest and lowest scores were 80 and 20, respectively. Mothers were allowed to answer the questions in privacy and without any pressure.

Preoperative anxiety in children was measured by an anaesthesiologist using the Frankl Behaviour Rating Scale (FBRS)⁷ and the Venham Picture Test (VPT).⁸ The FBRS was used to assess and evaluate the behaviour of the child by observation, and behaviour was divided into four categories (ratings): 1, definitely negative; 2, negative; 3, positive; 4, definitely positive. The VPT comprised eight cards with two figures on each card. Eight pairs of pictures depicted cartoon boys in contrasting moods (one anxious figure and one nonanxious figure); children were asked to choose the picture from each card that they most felt like at that time. The anxious figure was scored 1 and the nonanxious figure was scored 0. The total score was calculated by adding the number of times the anxious figure was chosen (minimum score 0, maximum score 8).

Statistical analyses

Statistical analyses were performed with the SPSS® software package, version 13.0 (SPSS Inc., Chicago, IL, USA) for Windows®. Spearman’s rank correlation coefficient analysis was performed between maternal STAI Tx-1 scores, and children’s VPT and FBRS scores. Mann–Whitney U-test was used to analyse the mother’s and child’s knowledge of anaesthesia and family history of problems with anaesthesia and child’s VPT, FBRS scores and maternal STAI scores. Data relating to maternal education level or socio-economic status, child’s age, sex or type of surgery, overall maternal STAI Tx-1 scores and children’s VPT and FBRS scores were assessed using Kruskal–Wallis test. A P-value <0.05 was considered statistically significant.

Results

A total of 100 children and their mothers (n = 100) were included in this study; sociodemographic characteristics are given in Table 1. Maternal education level and socio-economic status had no statistically significant effect on maternal STAI TX-1 scores, or children’s FBRS and VPT scores (Table 2). Age and sex of the children had no effect on the children’s FBRS and VPT scores, or on maternal STAI Tx-1 scores (Table 3).

Table 1.

Sociodemographic characteristics of children (n = 100) aged 3–12 years, scheduled for surgery, and their mothers (n = 100).

Characteristic	Participant group
Age of child, years	7 ± 2.7
Sex of child, female/male	37/63
Sibling status, present/absent	80/20
Maternal education level
1. Elementary school	50
2. Middle school	38
3. High school	12
Maternal socioeconomic status
1. <1000 TL	12
2. 1000–2000 TL	63
3. >2000 TL	25

Data presented as mean ± SD or % of participants.

TL, Turkish lira/month.

Table 2.

Effect of maternal education level and socioeconomic status on Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT) scores of children aged 3–12 years, scheduled for surgery (n = 100), and maternal (n = 100) State-Trait Anxiety Inventory (STAI) Tx-1 scores.

Characteristic	Incidence	Behaviour/Anxiety rating
Characteristic	Incidence	Children’s FBRS	Children’s VPT	Maternal STAI Tx-1
Maternal education level
1. Elementary school	50	2.34 ± 0.98	3.05 ± 1.86	44.64 ± 6.56
2. Middle school	38	2.05 ± 1.05	3.21 ± 1.83	47.0 ± 6.69
3. High school	12	2.25 ± 0.86	3.17 ± 1.85	45.0 ± 4.91
Maternal socioeconomic status
1. <1000 TL	12	2.42 ± 1.08	3.58 ± 1.67	44.17 ± 10.54
2. 1000–2000 TL	63	2.19 ± 1.01	3.43 ± 1.87	45.35 ± 5.50
3. >2000 TL	25	2.20 ± 1.0	3.04 ± 1.85	45.40 ± 6.53

Data presented as n of mothers or mean ± SD scores.

No statistically significant between-group differences (maternal education level or socioeconomic status versus children’s FBRS or VPT scores or maternal STAI scores; P ≥ 0.05, Kruskal–Wallis test).

TL, Turkish lira/month.

Table 3.

Effect of children’s age, sex and type of surgery on Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT) scores of children aged 3–12 years scheduled for surgery (n = 100), and maternal (n = 100) State-Trait Anxiety Inventory (STAI) Tx-1 scores.

Characteristic	Incidence	Behaviour/Anxiety rating
Characteristic	Incidence	Children’s FBRS	Children’s VPT	Maternal STAI Tx-1
Age, years
≤6	49	2.06 ± 1.00	2.98 ± 1.75	44.90 ± 6.28
≥7	51	2.37 ± 0.97	3.70 ± 1.86	46.20 ± 6.67
Sex
Female	37	2.19 ± 0.93	3.30 ± 1.98	44.50 ± 6.49
Male	63	2.24 ± 1.05	3.38 ± 1.76	46.16 ± 6.46
Type of surgery
Dental	47	2.04 ± 0.97	3.04 ± 1.69	44.02 ± 5.34
Plastic	39	2.33 ± 1.03	3.38 ± 2.06	47.05 ± 7.14
Urological	14	2.50 ± 1.01	4.29 ± 1.38	46.71 ± 7.29

Data presented as n of children or mean ± SD.

No statistically significant between-group differences (child’s age, sex or type of surgery versus child’s FBRS or VPT scores or maternal STAI Tx-1 scores; P ≥ 0.05, Kruskal–Wallis test).

Of the types of surgery included in the present study, 47% of the patients underwent dental surgery, 39% underwent plastic surgery and 14% underwent urological surgery. There were no statistically significant differences in children’s FBRS and VPT scores and maternal STAI Tx-1 scores between the different types of surgical procedure (Table 3).

A statistically significant difference was noted between overall maternal STAI Tx-1 scores (45.5 ± 6.4) and VPT scores (3.3 ± 1.8) in children (P = 0.003) but not in maternal STAI Tx-1 scores and children’s FBRS scores (2.2 ± 1.0); Spearman’s rank correlation test.

Analysis of the first maternal questionnaire revealed that there was a statistically significant difference between children’s VPT scores in relation to the mother’s knowledge and experience of anaesthesia (P = 0.001; Table 4; Mann-Whitney U -test). Maternal responses to questions relating to their anxiety levels about surgery, anaesthesia, preoperative fasting, postoperative treatment, postoperative pain and hospitalization are presented in Table 5. There was no statistically significant effect of maternal concern relating surgery, anaesthesia, preoperative fasting, postoperative treatment, postoperative pain and hospitalization, on children’s FBRS and VPT scores or on maternal STAI Tx-1 scores.

Table 4.

Effect of maternal and child’s knowledge and experience of anaesthesia, and family history of problems with anaesthesia, on Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT) scores in children aged 3–12 years, scheduled for surgery (n = 100), and maternal (n = 100) State-Trait Anxiety Inventory (STAI) Tx-1 scores.

Question	Response		Statistical significance
Question	Yes	No	Children’s FBRS	Children’s VPT	Maternal STAI Tx-1
Do you have knowledge and experience of anaesthesia?	54	46	NS	P = 0.001	NS
Has your child experienced any anaesthesia problems in the past?	7	93	NS	NS	NS
Do you have any family history of problems with anaesthesia?	3	97	NS	NS	NS

Data presented as % incidence of maternal response.

NS, no statistically significant differences (knowledge category versus child’s FBRS or VPT score, or maternal STAI score; P ≥ 0.05, Mann–Whitney U-test).

Table 5.

Effect of maternal responses to a questionnaire relating to anxiety levels regarding surgery, anaesthesia, preoperative fasting, postoperative treatment, postoperative pain, and hospitalization, on Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT) scores in children aged 3–12 years, scheduled for surgery (n = 100), and maternal (n = 100) State-Trait Anxiety Inventory (STAI) Tx-1 scores.

Anxiety Category	Statistical Significance
Anxiety Category	Children’s FBRS (2-tailed)	Children’s VPT (2-tailed)	Maternal STAI (2-tailed)
Surgery	NS	NS	NS
Anaesthesia	NS	NS	NS
Preoperative fasting	NS	NS	NS
Postoperative treatment	NS	NS	NS
Postoperative pain	NS	NS	NS
Hospitalization	NS	NS	NS

NS, no statistically significant differences (P ≥ 0.05, Spearman’s rank correlation coefficient).

In response to the third group of questions regarding what would help to decrease maternal anxiety relating to surgery, 86% of the mothers selected getting more information from the doctor, 28% selected talking to mothers whose children had previous experience of anaesthesia, 33% selected audiovisual information on anaesthesia, 37% selected accompanying the child to the operating room and 46% selected being present during the induction of anaesthesia.

Discussion

In the present study, high maternal anxiety, measured by overall maternal STAI scores, was found to be related to increased preoperative anxiety levels in children undergoing a surgical procedure. Maternal socio-economic and education level was not associated with preoperative anxiety levels in children. Other research has demonstrated that children of parents with high levels of anxiety are more fearful, nervous and worried, compared with children of parents who have low levels of anxiety.^9,10

Preoperative parental anxiety has been shown to lead to increased anxiety in children, not only during the surgical procedure but also in the postoperative period.^11,12 A study on dental anxiety in children emphasized the importance of the effects of immediate surroundings (and in particular the family) on children’s behaviours in the dental setting.¹³

A study of experimental pain responsivity in children suggested a significant association between the anxiety levels of the parent and pain responsivity in the children undergoing painful medical procedures.¹⁴ In other research, maternal verbal and nonverbal behaviour was reported to affect experimental pain responses in healthy children.^15,16 It has also been suggested that reducing parental anxiety prior to painful medical procedures would be of great help in reducing anxiety and pain levels in children.¹⁴ The present study showed that preoperative maternal anxiety levels (STAI Tx-1 scores, 45.5 ± 6.4) were significantly related to preoperative anxiety (VPT scores) in children (P = 0.003).

A study evaluating preoperative anxiety levels in the parents of children undergoing outpatient surgery determined an association between the maternal anxiety score and the child’s age: mothers of children <1 year old were more anxious than those of children >1 year old.¹⁷ In the present study, there was no significant relationship between maternal anxiety score and the child’s age. This finding may be attributed to the fact that the present study included children aged between 3 and 12 years.

A study of 1 250 children aged between 3 and 12 years demonstrated that the child’s sex had no effect on their anxiety levels during induction of anaesthesia, which was consistent with the findings in the present study.¹⁰ In the same study, maternal sociodemographic characteristics were also found to have no effect on children’s anxiety levels during induction of anaesthesia.¹⁰ One study reported that the maternal education level had no impact on anxiety,¹⁸ whereas another stated that the level of anxiety increased as the maternal education level increased.¹⁹ In the present study, maternal education level and family socio-economic status had no effect on the child’s anxiety status.

Patients with a history of surgery under anaesthesia ≥10 years previously have been reported to have lower levels of anaesthesia-related anxiety than patients who had undergone surgery within the previous 10 years.²⁰ Other studies have reported that previous anaesthesia experience had no effect on preoperative anxiety.^21,22 In the present study, previous experience of anaesthesia by mothers did not change the children’s VPT scores.

Parents may experience increased anxiety in the preoperative period regarding the surgical procedure, possible complications, risk of death or disability of the child, feelings of helplessness or guilt and lack of knowledge.^23,24 Anxiety relating to surgery and anaesthesia, fasting before surgery, postoperative treatment, and pain and hospitalization were assessed in the present study. The highest levels of anxiety related to surgery and anaesthesia. However, concerns about surgery and anaesthesia had no effect on the mothers’ and children’s levels of anxiety. In a similar study using the same questions as the present investigation,²⁵ parental anxiety levels were heightened regarding surgery, anaesthesia, postoperative treatment and pain, and hospitalization, whereas parents were not anxious about preoperative fasting.

Providing parents with information about the procedures, enabling communication with the doctors and allowing parents to talk to other parents in a similar situation reduce anxiety in the parents, and help them to support their children more effectively.^12,26 In the present study, with regard to factors that mothers thought would reduce maternal anxiety, 86% thought that getting more information from the doctor, 28% thought that talking to mothers whose children had previous experience of anaesthesia, 33% thought that providing audiovisual information on anaesthesia, 37% thought that accompanying the child to the operating room and 46% thought that being present during the induction of anaesthesia would reduce maternal anxiety. In a previous study,²⁵ consistent with the present findings, 89% of parents wanted to receive more information from the doctors and 44% wanted to accompany their children to the operating room.

Parental separation is reported to be one of the most significant causes of anaesthesia-related anxiety²⁷ and is suggested to be a major cause of stress, particularly in children >6 months of age. Studies indicate that children want parental presence during induction of anaesthesia, and that this also reduces parental anxiety.^28,29

In a study comparing two groups of parents whose children were scheduled to undergo surgery, one group received routine verbal instructions and the other was involved in an educational programme on anaesthesia.³⁰ The parents enrolled in the educational programme reported reduced levels of preoperative anxiety and increased levels of postoperative satisfaction, compared with the parents who received routine verbal instructions. In another study,³¹ one group of parents received an educational brochure explaining the events in the preoperative period while the other group viewed a 2-min video about anaesthesia induction, in addition to receiving an educational brochure. It was concluded that the levels of anxiety in parents who viewed the video on anaesthesia induction were significantly lower compared with the other group. The present study also found that the vast majority of mothers thought that receiving more information from the doctor would help to decrease maternal anxiety regarding the surgery, with one-third of mothers agreeing that receiving audiovisual information about anaesthesia would be beneficial. Providing emotional support to parents whose children are undergoing surgery appears to be important in reducing anxiety in parents and children, and suggests a necessity to arrange preoperative preparation programmes. Detailed qualitative and quantitative research into this area may help reduce the anaesthesia and surgery-related psychological trauma experienced by parents and children, which may help prevent future behavioural disorders in children. The role of hospital staff (including nurses) as team members who are capable of communicating effectively with healthy and diseased individuals and their families, and observing their psychological, social and economic problems, should be carefully considered.²³

The present study is limited by the fact that specific STAI scores were not analysed in relation to the children’s behaviour. The VPT was chosen as the measure of the children’s anxiety levels in the current study since this form is approved by the Ege University Clinical Research Ethics Committee.

In conclusion, the present study found that maternal knowledge and experience of anaesthesia and high levels of maternal anxiety may be related to increased anxiety levels in children undergoing surgery. The provision of quality training and support may reduce maternal anxiety levels, and as a consequence may reduce the anxiety levels in children scheduled for surgery.

Footnotes

Declaration of conflicting interest

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Litke

Pikulska

Wegner

. Management of perioperative stress in children and parents. Part I – the preoperative period. Anaesthesiol Intensive Ther 2012; 44: 165–169.

Turan

Acaroğlu

. The relationship between anxiety levels of adolescents who undergo surgical interventions and their parents and analysis of anxiety causes. Turk Klin J Med Sci 2012; 32: 308–315. [in Turkish, English abstract].

Justus

Wyles

Wilson

. Preparing children and families for surgery: Mount Sinai’s multidisciplinary perspective. Pediatr Nurs 2006; 32: 35–43.

Watson

Visram

. Children’s preoperative anxiety and postoperative behaviour. Paediatr Anaesth 2003; 13: 188–204.

McGraw

. Preparing children for the operating room: psychological issues. Can J Anaesth 1994; 41: 1094–1103.

Spielberger

. State-trait anxiety inventory: a comprehensive bibliography, Palo Alto, CA: Mind Garden, 1989.

Frank

Blount

Smith

. Parent and staff behavior, previous child medical experience, and maternal anxiety as they relate to child procedural distress and coping. J Pediatr Psychol 1995; 20: 277–289.

Buchanan

Niven

. Validation of a facial image scale to assess child dental anxiety. Int J Paediatr Dent 2002; 12: 47–52.

Dreger

Tremback

. Management of preoperative anxiety in children. AORN J 2006; 84: 778–780.

10.

Davidson

Shrivastava

Jamsen

. Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study. Pediatr Anesth 2006; 16: 919–927.

11.

Shirley

Thompson

Kenward

. Parental anxiety before elective surgery in children. A British perspective. Anaesthesia 1998; 53: 956–959.

12.

Kain

Mayes

O’Connor

. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med 1996; 150: 1238–1245.

13.

Freeman

. Dental anxiety: a multifactorial aetiology. Br Dent J 1985; 159: 406–408.

14.

Tsao

Myers

. Parent and child anxiety sensitivity: relationship to children’s experimental pain responsivity. J Pain 2006; 7: 319–326.

15.

Chambers

Craig

Bennett

. The impact of maternal behavior on children’s pain experiences:an experimental analysis. J Pediatr Psychol 2002; 27: 293–301.

16.

Goodman

McGrath

. Mother’s modeling influences children’s pain during a cold pressor task. Pain 2003; 104: 559–565.

17.

Litman

Berger

Chhibber

. An evaluation of preoperative anxiety in a population of parents of infants and children undergoing ambulatory surgery. Paediatr Anaesth 1996; 6: 443–447.

18.

Shevde

Panagopoulos

. A survey of 800 patients’ knowledge, attitudes and concerns regarding anesthesia. Anesth Analg 1991; 73: 190–198.

19.

Power

Howard

Wade

. Pain and behaviour changes in children following surgery. Arch Dis Child 2012; 97: 879–884.

20.

Ramsay

. A survey of pre-operative fear. Anaesthesia 1972; 27: 396–402.

21.

Jawaid

Mushtaq

Mukhtar

. Preoperative anxiety before elective surgery. Neurosciences (Riyadh) 2007; 12: 145–148.

22.

Mavridou

Dimitriou

Papadopoulou

. Effect of previous anesthesia experience on patients' knowledge and desire for information about anesthesia and the anesthesiologist: a 500 patients' survey from Greece. Acta Anaesthesiol Belg 2012; 63: 63–68.

23.

Smith

Callery

. Children’s accounts of their preoperative information needs. J Clin Nurs 2005; 14: 230–238.

24.

Zempsky

WT,

. and Cravero JP. American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2004; 114: 1348–1356.

25.

Thompson

Irwin

Gunawardene

. Pre-operative parental anxiety. Anaesthesia 1996; 51: 1008–1012.

26.

Cassady

JF Wysocki

Miller

. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesth Analg 1999; 88: 246–250.

27.

Messeri

Caprilli

Busoni

. Anaesthesia induction in children: a psychological evaluation of the efficiency of parents’ presence. Paediatr Anaesth 2004; 14: 551–556.

28.

Sobo

. Parent’s perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes? Soc Sci Med 2005; 60: 2341–2350.

29.

Kain

Mayes

Caramico

. Parental presence during induction of anesthesia. A randomized controlled trial. Anesthesiology 1996; 84: 1060–1067.

30.

Chan

Molassiotis

. The effects of an educational programme on the anxiety and satisfaction level of parents having parent present induction and visitation in a postanaesthesia care unit. Peadiatr Anaesth 2002; 12: 131–139.

31.

Zuwala

Barber

. Reducing anxiety in parents before and during pediatric anesthesia induction. AANA J 2001; 69: 21–25.

Effects of sociodemographic factors and maternal anxiety on preoperative anxiety in children

Abstract

Objective

Methods

Results

Conclusion

Keywords

Introduction

Patients and methods

Study population

Study questionnaires

Statistical analyses

Results

Discussion

Footnotes

Declaration of conflicting interest

Funding

References