Journal of Pediatric Psychology, Vol. 27, No. 3, 2002, pp. 227-233
© 2002 Society of Pediatric Psychology
Predicting Children's Response to an Invasive Medical Investigation: The Influence of Effortful Control and Parent Behavior
1 School of Psychology, University of New South Wales, 2 Sydney Children's and Prince of Wales Hospitals
All correspondence should be sent to Karen Salmon, School of Psychology, University of New South Wales, Sydney 2052, Australia. E-mail: K.Salmon{at}unsw.edu.au
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Abstract |
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Objective: To investigate the relative contributions of effortful control (reflecting the child's ability to shift and refocus attention) and parental coping- and distress-promoting behaviors to children's coping and distress during the voiding cystourethrogram (VCUG, X-ray of the kidneys).
Method: Thirty-two children between ages 2 and 7 years were
videotaped undergoing the VCUG. Parent and child behaviors were coded
according to the CAMPIS-R (Blount et al.,
1997
), and parents completed a temperament inventory assessing
effortful control across a range of everyday situations.
Results: Children manifested relatively high rates of distress and low rates of coping. Their coping attempts were not associated with reduced rates of distress. The most frequent child coping behavior was distraction. Both effortful control and parent coping-promoting behavior (particularly talk about topics other than the VCUG) made independent contributions to child coping behavior. Parent distress-promoting behavior (particularly reassurance) made a strong contribution to child distress behavior.
Conclusions: Factors relating to the child (effortful control) and parent (coping and distress-promoting behaviors) both contribute to children's response to an aversive medical procedure. Interventions that facilitate parent coping and promoting behavior, reduce their distress-promoting behavior, and compensate for children's infrequent and ineffective use of coping strategies (such as distraction) may be optimal for young children, particularly those low in effortful control.
Key words: child distress; child coping; parents; emotion regulation; voiding cystourethrogram.
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Introduction |
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Children differ in their coping and distress responses during stressful and invasive medical procedures. Age is important (e.g., preschool children show less adaptive coping and greater distress than older children; Rudolph, Dennig, & Weisz, 1995
), but it is not the only factor contributing to individual
differences in children's responses. Theories of children's coping highlight
the association between coping and emotion regulation
(Eisenberg, Fabes, & Guthrie,
1997). Effortful control, a dimension of temperament reflecting
voluntary and willful regulation of attention and behavior
(Rothbart, Ahadi, & Evans,
2000), is potentially of particular relevance to children's coping
and distress in medical contexts. Research findings show that higher effortful
control is associated with the modulation of emotion, including less
discomfort, fear, and frustration in infants and less intense negative affect
in pre-school children (Kochanska, Murray,
& Harlan, 2000; Rothbart
et al., 2000). Effortful control and children's coping have not
been investigated in the context of a relatively severe real-world stressor,
however. The first aim of this study was to investigate the association
between effortful control and children's coping and distress during a
stressful and invasive medical procedure, the VCUG (voiding cystourethrogram,
X-ray of kidneys). We expected that higher effortful control would be
associated with more child coping and less distress during the VCUG.
Children's coping is influenced also by the context in which it occurs
(Eisenberg et al., 1997).
Parental presence can be either a positive or a negative influence, depending
on the parental behaviors (Frank, Blount,
Smith, Manimala, & Martin, 1995;
Peterson, Oliver, & Saldana,
1997). Analyses of parent and child behaviors during aversive
medical procedures have yielded information about specific parent behaviors
that precede children's distress and coping. Parental prompting of coping
behaviors, such as distraction, is associated with increased coping by the
child; other parent behaviors, such as empathic comments, criticism, and
excessive reassurance, are associated with increased child distress
(Manimala, Blount, & Cohen,
2000). The second aim of this study was to investigate the
relative contributions of effortful control and parent behaviors in the
prediction of children's coping and distress during the VCUG. We expected that
parental encouragement of coping would lead to children's coping and that
parental encouragement of distress would lead to children's distress. We
expected also that effortful control would make a significant contribution to
both coping and distress.
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Method |
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Participants
Thirty-two children between 2 and 7 years old (15 boys, 17 girls, M age = 45.47 months, SD = 15.33 months; 24 children were of European descent, 4 of Middle Eastern descent, 3 of Asian descent; one of Pacific Island descent) constituted the final sample; this was 82% of 39 parents contacted to request their and their child's participation over a 15-month period. All children had been referred to a major inner-city hospital in Sydney, Australia, for a VCUG. Children with significant medical difficulties (e.g., chronic illnesses) were excluded. Eleven children had experienced no prior VCUGs, seven had experienced one, four had experienced two; five had experienced three or more VCUGs; data regarding previous VCUGs were unavailable for five children. Of the parents present, 21 were mothers, 8 were fathers, and in 3 instances both parents were present. Neither the parents nor the children received prior training in coping with the VCUG.
Measures
Children's Behavior Questionnaire (CBQ)
(Rothbart, Ahadi, Hershey, & Fisher,
2001). The CBQ is a parent-report measure of child
temperament. Parents are provided with statements about their child's typical
reactions in a number of situations and are asked to rate each on a 7-point
scale (1 = "extremely untrue," 7 = "extremely true").
There is also a "not applicable" response option. The factor
structure of the CBQ has been reliably similar in parent-report samples from
different sites in the United States, China, and Japan and has shown high
levels of temporal stability across a 2-year period. Further, the CBQ has been
demonstrated to have moderate to high levels of parent agreement in multiple
samples (Rothbart et al.,
2000).
The effortful control (self-regulation) factor is associated with the
child's voluntary and willful regulation of attention and behavior
(Rothbart et al., 2000). This
factor includes 47 of the total 195 items and is defined by the scales of
Inhibitory Control (capacity to plan and to suppress inappropriate action);
Attentional Focusing (tendency to maintain attention on tasks); Perceptual
Sensitivity (detection of slight or low intensity stimuli from the external
environment); and Low-Intensity Pleasure (pleasure derived from situations
involving low-intensity stimuli). Effortful control has relationships with
behavioral (e.g., ability to focus attention, lower voice, slow down motor
activity, delay gratification; and less violation of maternal prohibitions)
and socioemotional (e.g., modulation of emotions such as anger, fear, and joy,
internalization of rules) variables. These variables have in common the
requirement that the child use attention to suppress a dominant emotional or
behavioral response and perform a modulated or different response
(Kochanska et al., 2000;
Rothbart et al., 2000).
Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R;
Blount et al., 1997). This
is a standardized rating scale developed to code verbal interactions in the
pediatric treatment room. Child vocalizations during the medical procedure are
coded into three superordinate categories (child coping, child distress, child
neutral). As neutral child behaviors were not included in the hypotheses and
were not the focus of analyses, these are not described here. Child
coping behaviors are verbal coping (nonprocedural talk, humor by child,
making coping statements) and audible deep breathing. Child distress
behaviors are apprehensive distress (seeking emotional support, information
seeking, and verbal fear) and demonstrative distress (crying, screaming,
expressing verbal emotion, verbal pain, and verbal resistance). Adult
vocalizations are also coded into three categories (coping-promoting,
distress-promoting, neutral). As neutral adult behaviors were not included in
the hypotheses and were not the focus of analyses, these are not described
here. Coping-promoting behaviors are nonprocedural talk to child,
humor to child, command to use coping strategy. Distress-promoting
behaviors are reassuring comments, criticism, apology, giving control to
child, empathy. The CAMPIS-R has strong concurrent validity relating to
subjective and objective measures of children's fear, distress, pain, and
approach/avoidance (Blount et al.,
1997).
Videotapes of child and parent verbal behavior during the VCUG were
transcribed and coded according to the criteria recommended by Blount et al.
(1997), with the exception that
behaviors were coded across the entire procedure rather than for each phase.
This alteration was made for two reasons. First, we wished to reduce the
variables included in analyses because of constraints on statistical power
imposed by the small sample. Second, other research findings show relatively
high levels of distress across all phases of the VCUG
(Zelikovsky, Rodrigue, Gidycz, &
Davis, 2000), in part because, once triggered, distress tends to
continue (Manimala et al.,
2000). Where both parents were present, behavior was coded for
each and combined. As crying is continuous rather than discrete, we adjusted
the coding of crying such that longer episodes were awarded a greater number
of occurrences than shorter episodes, (one occurrence of crying equating to
approximately one child verbal utterance). Nine (28%) of the videotapes,
selected randomly, were coded independently by two raters. Cohen's kappa for
judgments of child and adult verbalizations across the 9 participants
was.87.
Rates of child coping and distress behavior and parent coping- and distress-promoting behaviors were calculated as (number of instances of each behavior) ÷ (duration of the procedure in minutes). For example, the rate of child coping behavior was calculated as number of instances of child coping (summed across coping categories) divided by the duration of the procedure in minutes. Proportions of total behavior comprised by child coping and distress behavior and parent coping- and distress-promoting behavior were calculated as (number of instances of each behavior) ÷ (total number of behaviors, summed across coping, distress, and neutral categories). For example, the proportion of total child behavior constituted by child coping was calculated as the number of instances of child coping (summed across coping categories) divided by the total number of child behaviors.
Procedure
Ethical approval had been received from both the hospital and university
ethics committees. Prior to the VCUG, parents were sent written information
about the study and this was followed by a telephone call to clarify
questions. Only those children who had written parental consent participated.
At the time of the VCUG, the parent who was present was provided with the CBQ
and asked to complete and return the questionnaire after the procedure; a
stamped addressed envelope was provided. Twenty-eight (of 32) questionnaires
were returned. The time delay between the CBQ completion and the VCUG
procedure ranged between 1 week and 2 months; we did not regard this as
problematic because, as noted earlier, the CBQ has been shown to have
stability across time and to have moderate to high levels of parental
agreement (Rothbart et al.,
2000).
Videotaping of the VCUG commenced when the child was brought into the examination room and continued until the procedure was complete. The VCUG procedure involved the following steps: The child was undressed by the parent, dressed in a hospital gown and asked to lie down on the bed. After the genital area had been washed and lubricating jelly applied, a urinary catheter was inserted through the urethra and into the bladder. Dye was infused into the bladder and the child was requested to urinate on the table while X-ray pictures were taken. The catheter came out during urination or was removed. The mean duration was 24.09 minutes (SD = 9.45 minutes).
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Results |
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Preliminary correlational analyses showed that the number of prior VCUGs was not associated with the rate of child coping, (r[27] =.09, p >.1) or child distress (r[27] = -.21, p >.1). Accordingly, the number of prior VCUGs was excluded from analyses. Because our sample included equal numbers of boys and girls whereas a higher rate of urinary tract infections is typically reported in girls (Zelikovsky et al., 2000
), we
conducted preliminary ANOVAs to establish whether child and parent behaviors
during the VCUG were influenced by child gender. There were no significant
differences in rates of child coping and distress behaviors and parent coping-
and distress-promoting behaviors, all Fs <.57, all ps
>.38.1
Child and Parent Behaviors
Table I shows the mean rates
and proportions (and standard deviations) of child and parent behaviors during
the VCUG. Child distress behaviors constituted a high proportion of all child
behaviors (summed across coping, distress, and neutral) and occurred at the
greatest rate per minute. Crying constituted approximately half of all child
distress behaviors (M =.56, SD =.29). Child coping behaviors
constituted a relatively small proportion of all child behaviors and occurred
at a relatively low rate per minute. Nonprocedural talk (i.e., talk about
topics other than the VCUG) constituted a high proportion of child coping
behavior (M =.91, SD =.20). Both parent distress- and parent
coping-promoting behaviors constituted a relatively small proportion of parent
behaviors and occurred at similar rates per minute. Reassuring comments
constituted a high proportion of all parent distress-promoting behaviors
(M =.88, SD =.16). Nonprocedural talk to the child
constituted a high proportion of all parent coping-promoting behaviors
(M =.73, SD =.23).
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Correlations Among Predictor Variables
The predictor variables of interest were age, effortful control, and rates
of parent coping- and distress-promoting behaviors. A positive correlation was
obtained between age and effortful control (r[28] =.42, p
<.05); 28 (of 32) children were included in this analysis due to missing
CBQ data for 4 children. Older rather than younger children were higher in
effortful control. A positive correlation was found between the rates of
parent coping- and distress-promoting behavior (r[32] =.54,
p <.01). Parents who engaged in higher rates of distress-promoting
behavior also engaged in higher rates of coping-promoting behavior. There were
no other significant correlations, all ps >.1.
Correlations between the predictor and the two criterion variables (rate of child coping and distress behavior) were established. Child coping behavior was correlated positively with effortful control, (r[28] =.43, p <.05) and with parent coping-promoting behavior (r[32] =.59, p <.01). Child distress behavior was correlated positively with parent distress-promoting behavior (r[32] =.76, p <.01). Child distress behavior was correlated negatively with age (r[32] = -.35, p <.05), indicating that younger rather than older children engaged in higher rates of distress behavior. Child distress behavior was not correlated significantly with effortful control (r[28] = -.20, p >.1). Further, rates of child coping and distress behavior were not correlated with each other (r[32] = -.02, p >.1).
Prediction of Children's Rates of Coping and Distress
To delineate the variables that predict child coping and distress behavior,
two hierarchical multiple regression analyses were conducted (see
Table II). These analyses were
exploratory because of the small number of participants; 28 (of 32)
participants were included in each analysis due to missing CBQ data for 4
children. With respect to the prediction of the rate of child coping, age was
entered at Step 1, effortful control at Step 2, and rate of parent
coping-promoting behavior at Step 3. Age was not significant at Step 1, but
effortful control was significant at Step 2, accounting for an additional 18%
of the variance. Effortful control remained significant when parent
coping-promoting behavior was included at Step 3, accounting for an additional
24% of the variance. With respect to the prediction of child distress, neither
age nor effortful control was significant at Steps 1 and 2. At Step 3, rate of
parent distress-promoting behavior was significant, accounting for an
additional 58% of the variance. At Step 3, also, with the influence of parent
distress-promoting behavior and age controlled, the influence of effortful
control approached significance (p <.051).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Children with higher scores on effortful control demonstrated a higher rate and a greater proportion of coping behavior during the VCUG. Whereas age had no significant influence, effortful control predicted the rate of children's coping. The most frequently occurring coping behavior was distraction in the form of talk about topics other than the VCUG. This finding is consistent with the proposal of Derryberry and Rothbart (1997
) that children higher in
effortful control, rather than lower, are more able to disengage their
attention from threat. More generally, theorists of children's coping have
highlighted the role of the effortful management of attention (e.g., attention
shifting and focusing, distraction) as a means of achieving emotion regulation
(Eisenberg, Fabes, Guthrie, & Reiser,
2000).
Nonetheless, children's coping attempts were few and bore no consistent
relation to their level of distress; this highlights the distinction between a
coping response and its outcome (Rudolph
et al., 1995). Further, the association between effortful control
and children's distress was modest and occurred only in the context of parent
distress-promoting behaviors. According to Kochanska et al.
(2000), effortful control is
evident as a system of temperament at the end of the first year of life, is
increasingly coherent during early childhood, and later becomes a salient
personality variable. It is possible that, when confronted with a prolonged,
invasive, and severe stressor, children as young as those in this study, even
when higher in effortful control, are limited developmentally in their ability
to use attention to regulate their emotional response
(Eisenberg et al., 1997).
Parental factors were also associated with children's response to the VCUG.
Effortful control and parent coping-promoting behavior made independent
contributions to children's coping. In other words, effortful control
influenced children's coping behavior, particularly their use of distraction,
which was influenced also by (and possibly influenced) parent coping-promoting
behavior, particularly talk about topics other than the VCUG. The association
between children's distress and parent behavior was especially marked;
however; the addition of parent distress-promoting behaviors added almost 60%
of explained variance to the influence of age and effortful control. The
greatest proportion of parental distress-promoting behavior was reassurance.
Across a range of medical procedures, research findings show that parental
reassurance is associated with either the maintenance of or an increase in
children's distress (Gonzales, Routh,
& Armstrong, 1993; Kleiber
& McCarthy, 1999; Manimala
et al., 2000; Sweet &
McGrath, 1998).
The practical implications of our findings are twofold. First, they
highlight that young children require help to use distraction, which is a key
strategy for preschoolers, given their difficulty mastering the skills
involved in muscle relaxation, imagery, and self-talk
(Blount, Schaen, & Cohen,
1999; Dahlquist,
1999). Providing a compelling distractor during an aversive
procedure may help to compensate for children's limitations
(Blount et al., 1999). Various
examples of distractors have been reported (e.g., a party blower, toys, a
cartoon video), although their relative efficacy and interaction with other
components of intervention (e.g., provision of information, role-playing,
modeling) have not yet been tested (Cohen, Blount, & Panapolous, 1997;
Manimala et al., 2000;
Zelikovsky et al., 2000). The
effortful control factor of the CBQ may be useful in identifying children
needing particular help in this area. The findings also underscore the
importance of interventions that facilitate parental coping-promoting
behaviors, particularly in light of the low spontaneous rates in this study.
In other words, although the parents and children in our study engaged
spontaneously in few coping and coping-promoting behaviors, reduced distress
and increased coping would likely be found with appropriate training. Cohen et
al. (1997) reported, for
example, that, during immunization, staff training to prompt the child's
attending to a cartoon video distraction was associated with enhanced child
coping, reduced distress, and increased parent coping-promoting behavior.
Interventions such as these, that compensate for the developmental limitations
of young children and facilitate constructive parent behaviors, are likely to
be effective.
Our study was exploratory, particularly given the relatively small numbers
of participants. With greater numbers in future research, it may be possible
to investigate the associations between effortful control and children's
coping and distress during the distinct phases of the VCUG and the influence
of parent gender on children's response. Another useful focus of future
research may be the association between children's coping and distress
response to the VCUG and the nature of their prior VCUG experiences;
we suspect that this, rather than the number of previous VCUGs, is likely to
have a stronger association with children's coping and distress (see also
Chen, Zeltzer, Craske, & Katz,
1999; Zelikovsky et al.,
2000). Further, we obtained limited information about the
participants who refused to take part in the study, and this limits the
generalizability of our results. Nonetheless, we believe that the findings
underscore the important interactions between parent and child in a stressful
medical situation and provide clear guidance for systematic research into the
developmental and contextual factors that mediate optimal coping in response
to childhood stressors.
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Acknowledgments |
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We thank those who helped in this research, including the children and parents; the staff from the Departments of Medical Imaging and Nephrology at Sydney Children's Hospital, in particular, the booking staff, nursing staff including Sandra Nerichow and Madeline Cogswell, Drs. Miriam van Roojen, Geoffrey Peretz, Andrew Rosenberg, and Gad Kainer; the research assistants and students who helped with the data collection and coding, in particular Melinda Price, David Rouen, Maria Kangas, and Kathy Veljaca; and Kevin McConkey and three anonymous reviewers for comments on earlier drafts.
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Notes |
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1 One-way ANOVAs, conducted to investigate the influence of parent gender (excluding the three instances when both parents were present) on the rates of child coping and distress behaviors and parent coping-and distress-promoting behaviors revealed no significant differences, all Fs < 1.03, all ps >.32. To establish whether the presence of both parents, rather than one, influenced the pattern of findings, we reran the regression analyses excluding the three children for whom both parents were present. The pattern of findings was not altered; that is, rate of child coping was significantly predicted by effortful control, (ß =.48, p <.01), and rate of child distress was significantly predicted by parent distress-promoting behavior (ß =.79, p =.00).
Received October 18, 2000; revision received April 12, 2001; revision received June 7, 2001; accepted June 29, 2001
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