Journal of Pediatric Psychology, Vol. 27, No. 7, 2002, pp. 553-563
© 2002 Society of Pediatric Psychology
The Influence of Appraisals in Understanding Children's Experiences With Medical Procedures
1 Duke University Medical Center, 2 Peabody College of Vanderbilt University, 3 Vanderbilt University School of Medicine
Address all correspondence to Robyn Lewis Claar, Duke University Medical Center, Department of Psychiatry and Behavioral Science, DUMC-3119, Durham, North Carolina 27710.
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Abstract |
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Objective: To examine the influence of cognitive appraisals on anticipatory anxiety, procedural distress, and postprocedural evaluations in 100 children (ages 8-17) undergoing esophagogastroduodenoscopy (EGD).
Method: Children's knowledge about the procedure, appraisals of the procedure's aversiveness, coping ability, and state anxiety prior to the procedure were assessed by self-report. Distress during the EGD was assessed by observer ratings. Postprocedural evaluations were assessed by self-report 1 hour after the procedure.
Results: Structural equation modeling indicated that children who knew more about the EGD appraised it as less threatening, and, in turn, children who appraised the procedure as less threatening experienced less anxiety. Decreased anxiety was associated with decreased distress, which, in turn, was associated with decreased pain, evaluations of less aversiveness, and less negative attitudes toward future procedures.
Conclusions: This study has implications for how children are prepared for EGDs and supports the utility of an appraisal-based model in understanding children's experiences with medical procedures.
Key words: appraisals; pediatric medical procedures; preparation; anxiety; pain; endoscopy.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Over 5 million children in the United States undergo diagnostic medical procedures each year (Melamed, 1998
). These procedures often are associated with anxiety, pain,
and distress (e.g., Carpenter,
1992; Hubert, Jay, Saltoun,
& Hayes, 1988). Preparatory interventions designed to decrease
children's anxiety include modeling (e.g.,
Faust & Melamed, 1984),
distraction and relaxation (e.g., Dahlquist
et al., 1986), and combinations of these techniques (e.g.,
Melamed, 1998). Provision of
information is the most common preparatory intervention
(Jay, 1988) and typically
includes information about procedural events and sensory encounters.
Although the efficacy of preparatory techniques in reducing anxiety has
been documented (e.g., Suls & Wan,
1989), the mechanism accounting for efficacy is not well
understood. Janis's (1958)
theory of psychological preparation, "the work of worrying,"
postulates that preparatory information results in greater fear, which prompts
patients to engage in the "work of worrying," defined as the
rehearsal of thoughts and images of the threatening situation prior to its
occurrence. Thus, the function of preparatory information is to increase
anxiety initially, prompting patients to worry, and ultimately resulting in
less anxiety before the procedure. Janis's framework, however, does not
account for the observation that preparation does not reduce anxiety for all
patients (e.g., Dahlquist et al.,
1986, Faust & Melamed,
1984; Hubert et al.,
1988).
Other researchers (e.g., Carpenter,
1992; Faust & Melamed,
1984; Jay, 1988)
propose a direct relation between preparation and anxiety. In contrast to
Janis, who asserted that preparation first provokes greater anxiety that
lessens only after worrying, later studies hypothesized that preparation
provides patients with reasonable expectations that provoke less anxiety than
the unknown. Hodgins and Lander
(1997) found that 27% of
children lacking formal preparation who were undergoing venipuncture reported
anxiety due to the unknown aspects of the procedure. In addition, Drossman et
al. (1996) found that
"fear of the unknown" was a prominent fear in adult patients
undergoing endoscopy who received no formal preparation.
A stress, appraisal, and emotion model, advocated by Lazarus and colleagues
(e.g., Lazarus & Folkman,
1984; Smith & Lazarus,
1990), provides a more explicit framework for understanding how
preparation influences anxiety. The appraisal framework specifically addresses
some of the limitations of past theoretical approaches. For example, this
model accounts for individual differences in responses to a medical procedure.
Lazarus and Folkman (1984)
assert that to understand individual differences in response to a stressor,
appraisals of that stressor's significance and impact on well-being must be
examined. It is not the stressor itself that determines emotions but
interpretation of its relevance and desirability
(Smith & Lazarus,
1990).
According to the appraisal model, a patient's response to a medical
procedure can be evaluated in terms of primary appraisals, secondary
appraisals, and emotions resulting from the interplay among appraisals.
Primary appraisals address what is at stake. Patients are likely to appraise
upcoming medical procedures as stressful because procedures often entail
unknown events, pain, and discomfort. Patients' secondary appraisals address
available coping resources, as well as whether these resources can be
effectively implemented. Anxiety regarding procedures results from appraisals
of threat, defined as a combination of primary stress appraisals and secondary
appraisals of limited coping potential (cf.
Smith & Lazarus,
1990).
One benefit of an appraisal model is that by specifying the cognitive
evaluations (appraisals) hypothesized to be directly responsible for
procedure-related anxiety, the appraisal model provides clear targets around
which to design maximally effective interventions. Children's appraisals of
medical procedures have been largely unexplored
(Rudolph, Dennig, & Weisz,
1995), although researchers occasionally mention the influence of
children's appraisals on medical procedures (e.g.,
Jay, 1988;
Peterson, 1989). In reviewing
the literature, Rudolph et al.
(1995) found no empirical data
directly assessing the role of appraisals in children's experiences with
medical procedures. Recently, however, Waibel-Duncan and Sandler
(2001) provided some of the
first empirical evidence that appraisals predicted children's emotions related
to an anogenital exam, a relatively noninvasive exam for children who may have
been sexually abused.
The purpose of this study was to examine an appraisal-based model (see
Figure 1) of children's
experiences with an invasive medical procedure. This model was examined in
patients undergoing an esophagogastroduodenoscopy (EGD), a common diagnostic
procedure in which a flexible tube is inserted by mouth to examine the
esophagus, stomach, and duodenum. EGDs are commonly performed to assess tissue
damage and structural abnormalities in patients with unexplained weight loss,
vomiting, or recurrent abdominal pain. Patients' experiences with EGDs have
been examined in adults (e.g., Drossman et
al., 1996; Shipley, Butt,
Horwitz, & Farbry, 1978) but have rarely been examined in
children. Schnee (1995) noted
that his dissertation was the first to examine children's experiences with
EGDs. Mahajan and colleagues
(1998) presented the first
published study of the effects of preparation on children's experiences with
EGDs. Neither study assessed the role of appraisals in children's experiences
with EGDs.
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The proposed model sought to examine both direct and mediated effects as
outlined by Holmbeck (1997).
The model posits that appraisals mediate (or account for) the direct relation
between knowledge and anxiety. The first path in the model indicates that
children's preprocedural knowledge will affect their appraisals. Greater
knowledge is expected to be associated with lower threat. The second path
proposes a relation between children's appraisals and their anxiety. Children
with appraisals of greater threat are predicted to experience greater anxiety.
The third path examines whether children's appraisals mediate the direct
relation between knowledge and anxiety. It is not patients' knowledge but
their appraisals that supposedly predict their anxiety. Patients with the same
knowledge may differ in their anxiety as a result of their appraisals. In
addition, patients' knowledge may differ due to the amount of parental
preparation. An additional path examines the influence of parental
preparation; parents often prepare their children for procedures either
informally or with materials provided by health professionals (cf.
Bush, Melamed, Sheras, & Greenbaum,
1986; Jay, Ozolins, Elliott,
& Caldwell, 1983).
The next path in the model represents the hypothesized effect of
anticipatory anxiety on children's procedural distress. Several studies have
documented the influence of anticipatory anxiety on patients' distress during
medical procedures (e.g., Hubert et al.,
1988; Miller, Sherman, Combs,
& Kruus, 1992). Consistent with previous literature, patients
who are more anxious prior to the procedure likely will be more distressed
during the procedure.
The model also includes the influence of children's age on their procedural
distress. Previous research has demonstrated higher levels of observed
distress in younger children than in older children (e.g.,
Jay et al., 1983;
Katz, Kellerman, & Siegel,
1980). It is expected that younger patients will display greater
procedural distress than older patients.
The final path represents the effect of procedural distress on children's
postprocedural evaluations in terms of how painful the procedure was, how
aversive it was, and how they would feel if they were to undergo it again.
Several studies have examined the influence of distress on patients' pain
(e.g., Carpenter, 1992;
Hubert et al., 1988). Previous
research has demonstrated a relation between greater distress and more
negative evaluations (e.g., Mahajan et
al., 1998).
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Method |
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Participants
Participants were 100 patients, ages 8 to 17, who underwent an EGD at Vanderbilt University Medical Center. Patients' parents or primary caretakers also participated; 92.0% were mothers. Patients met the following criteria: (1) between the ages of 8 to 18, (2) no cognitive disability (as determined by a review of the medical chart and through discussion with the family), and (3) living with a parent or primary caretaker who also was willing to participate. Of the 118 families contacted, three (2.5%) were ineligible, and five (4.2%) declined. Of the 110 families who agreed to participate, two (1.8%) lacked time because their procedures began earlier than scheduled. Six (5.5%) families canceled their appointments. Two (1.8%) patients completed the initial questionnaires but later became ineligible: one patient (0.9%) had an additional procedure after the EGD, and one patient (0.9%) did not have his EGD due to lack of symptoms. The final sample of 100 was primarily Caucasian (92.0%) and female (55.0%). The mean age was 11.57 (SD=2.54). The social class distribution, based on the Hollingshead Index of Social Status (1975
), ranged from unskilled
laborers to professionals (scores ranged from 14 to 66 respectively,
M = 42.42, SD = 12.42). Fifteen of the 100 patients had
previously undergone an EGD.
Procedure
After the experiments received approval from the institutional review board
(IRB), parents of patients scheduled to undergo an EGD were contacted by
telephone prior to their child's appointment. Families were screened for
eligibility, provided with information about the study, and asked to arrive 15
minutes prior to the EGD if they were interested in participating in the
study. After we obtained informed consent from parents and assent from
children, parents completed their questionnaires in the waiting room while an
interviewer read children's questionnaires to them privately. After completing
their questionnaires, children underwent the EGD. Each procedure entailed the
following components. First, a nurse inserted an IV. A blood pressure monitor
was attached to the arm that did not have the IV. A pulse oximetry monitor (to
measure heart and breathing rates) was attached to the child's finger. Topical
pharyngeal anesthesia using Cetacaine (14% benzocaine, 2% butyl aminobenzoate,
and 2% tetracaine hydrochloride) to numb the back of the throat was typically
provided prior to administration of IV sedation. All physicians used
intravenous midazolam and fentanyl to provide conscious sedation. Typical
doses began at 0.05 to 0.1 mg/kg for midazolam and 1 mcg/kg for fentanyl. If
the desired sedative effect was not achieved, titration with additional
midazolam and/or fentanyl was performed. A bite plate was inserted in the
child's mouth to protect his or her teeth and to protect the endoscope from
damage. The child's eyes were lightly covered with a washcloth to protect them
from any gastrointestinal fluids that could spray from the endoscope. The
physician then inserted the endoscope and told the patient to swallow it.
Next, he or she examined and photographed the child's esophagus, stomach, and
duodenum and used forceps to take endoscopic grasp biopsies, which patients
could not feel, at each of the three sites. Oxygen saturation, pulse,
respiration, and blood pressure were monitored throughout the EGD. Trained
observers and nurses rated children's distress. Approximately 1 hour after the
EGD, children completed the pain and postendoscopy measures.
Measures
Endoscopy Knowledge. A 29-item multiple-choice measure was
developed to assess children's preprocedural knowledge of the EGD. This
measure was developed after observing each component of the EGD and consulting
the preparatory information sheet given to families (the standard preparation
in this hospital). In addition, three physicians who regularly performed EGDs
reviewed the questionnaire.
Children were told that they would be asked a series of questions, some true and some untrue of their procedure. Sample items include "Will the needle or IV...a) take blood or b) give medicine?"; "Will the doctor take a picture of your insides? a) Yes b) No c) Don't know." Because the purpose of the measure was to assess current knowledge rather than to impart additional knowledge, children were not asked follow-up questions if they reported no knowledge of an aspect of the procedure. Total scores could range from 0 to 29 and were computed by summing the correct items. Higher scores indicated greater knowledge of the EGD.
Parent Preparation. A 26-item, self-report, multiple-choice measure was developed to assess parent preparation regarding the EGD. Parents were told to indicate whether they had told their children about each component of the procedure. They were reassured that parents tell their children different things about the EGD, that there were no right or wrong answers, and that we did not expect that they had told their children all of the information on the questionnaire. Sample items include "Did you tell your child about the needle or IV?" and "Did you tell your child there will be a tube?" Parent preparation scores were computed by summing the positively endorsed items. Each endorsed item was scored 1, and each unendorsed item was scored 0. Total scores could range from 0 to 22 (4 of the 26 items refer to parents' reasons for not telling their children about specific aspects of the procedure). Higher scores indicated higher levels of preparation.
In addition, if parents reported that they did not tell their child about the IV, the throat spray, the medication, or the endoscope, they were asked to provide their reasons for doing so by responding to multiple choice questions. A sample item is "If you did not tell your child about the IV (needle) was it because... a. you did not know about the IV (needle)?, b. you did not think it would be helpful for your child to know about the IV (needle)?, c. you thought your child would be upset if you told him/her about the IV?, d. your child already knew about the IV (needle)?, or e. other (please explain)."
EGD Appraisals. A 32-item self-report measure was developed to
assess children's appraisals of the EGD. The item format for this measure
paralleled the Pain Beliefs Questionnaire
(Van Slyke, Smith, Walker, & Garber,
1997), which assesses children's beliefs and appraisals of their
abdominal pain. Aversiveness of the EGD was assessed by items tapping the
procedure's significance, expected pain, and expected duration. Sample items
include "Swallowing the endoscope is no big deal" (significance);
"Swallowing the endoscope will hurt a lot" (expected pain); and
"Swallowing the endoscope will be over quickly" (expected
duration). Items were targeted toward each component of the EGD: inserting the
IV, administering the medication, swallowing the endoscope, and having the
endoscope in the stomach. Patients used a 5-point scale from "not at all
true" (0) to "very true" (4) to indicate how true each
statement was about their EGD. Total scores were computed by averaging
standardized item ratings after reverse coding eight items; higher scores
indicated greater aversiveness. Alpha reliability for this scale was .65.
Patients' appraisals of their ability to cope with each component of the EGD also were assessed. Sample items include "I don't think I'll be able to stand swallowing the endoscope" and "I can deal okay with the IV (needle)." Items were targeted toward each EGD component, and the rating scale described above was used. After we reverse coded 12 items, total scores were computed by averaging standardized item ratings. Higher scores indicated greater coping potential. Alpha reliability was .89.
The combination of beliefs regarding aversiveness and coping potential can
serve as an index of the extent to which patients perceived well-being to be
threatened by the procedure. In line with Van Slyke et al.'s
(1997) work, a summary score
indexing the degree of perceived procedure-related threat was computed by
averaging the aversiveness and coping potential scores. Higher scores
indicated greater threat. Alpha reliability was .86.
Anxiety. Children completed the State-Trait Anxiety Inventory for
Children (STAIC; Spielberger, Edwards,
Montuori, & Luschene, 1983). The STAIC, State Form, is a
20-item measure designed to assess state anxiety. Children selected one of
three words or phrases that best described how they felt prior to the
procedure. Each item was scored on a 3-point scale. Total scores, computed by
summing the items, could range from 0 to 40. Higher scores indicated greater
anxiety. Alpha reliability was .88.
Distress. A 32-item measure based on the Observation Scale of
Behavioral Distress-Revised (OSBD-R; Jay
& Elliott, 1986) was developed to assess distress. The OSBD-R
is an observational measure of behavioral distress for children undergoing
medical procedures. It assesses eight operationally defined behaviors
(information seeking, cry, scream, restraint, verbal resistance, requests
emotional support, verbal pain, and flail). Schnee
(1995) adapted the OSBD-R to
three phases for EGDs: (1) IV insertion, (2) throat spraying, and (3)
endoscopic exam. Schnee reported an interrater reliability of 98.3%.
The measure used in this study included the eight OSBD-R distress
categories with ratings on a three-point scale ("none,"
"some," "a lot"). Ratings were completed for each
phase of the EGD according to Schnee's procedure. However, in this study,
distress was assessed across four phases rather than three. Schnee's Phase 3
was broken down into two phases (Phases 3 and 4) as this phase includes two
events: swallowing the endoscope and having the endoscope in the stomach. A
trained observer recorded distress ratings during the procedure. A second
trained observer assessed distress for 25.0% of the procedures. High levels of
interrater reliability were achieved with 97.0% agreement (
=.92). Total
scores were created by computing the mean of the items. Higher scores
indicated greater distress.
In addition, the attending nurse completed a four-item measure that assessed child distress across the four phases of the procedure (e.g., "How upset was this child when the IV was inserted?"). The four items were rated on a three-point scale ("not at all," "some," "a whole lot"), and the mean of the items served as a total score. Higher scores indicated greater distress.
Because the ratings provided by the nurse and the observer were significantly correlated (r = .87, p < .0001), the two sets of distress ratings were standardized and combined to compute a composite distress index. Alpha reliability for the composite distress index was .93.
Pain. Children used the Faces Pain Scale
(Bieri, Reeve, Champion, Addicoat, &
Ziegler, 1990) to rate the painfulness of five aspects of the
procedure (IV insertion, throat spraying, medication administration, endoscope
insertion, endoscope in the stomach). This scale contains seven drawings of
faces ranging from "no pain" (0) to "the most pain
possible" (6). Each child pointed to the face that shows how much pain
he or she felt. Responses were summed to compute total scores, which could
range from 0 to 30. Higher scores indicated greater pain. Bieri et al.
(1990) reported adequate
validity and reliability. Alpha reliability in this study was .71.
Procedural Aversiveness and Attitude Toward Future EGDs.
Evaluations of the EGD were assessed with a modified version of the
Post-Endoscopy Patient Questionnaire
(Mahajan et al., 1998). Items
were rated on a five-point scale from "not at all" (1) to "a
whole lot" (5). Six items assessing how bothered the child was by each
component of the procedure were averaged to compute a total aversiveness
score. Higher scores indicated greater aversiveness. Alpha reliability was
.60. Two items assessing the child's attitude toward future procedures (in
terms of how upset and how scared or worried he or she would be) were averaged
to compute a total score. Higher scores indicated a more negative attitude
toward future EGDs. Alpha reliability was .85.
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Results |
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Children's Knowledge of EGD
A majority of children reported knowledge of the IV (82%) and the endoscope (96%). In contrast, only 48% of children knew that they would swallow the endoscope. Forty-four percent of children did not know that they would be able to hear the doctor during the procedure. In addition, only 17% of children knew that they would be able to wear their own clothes rather than a hospital gown (a concern spontaneously reported by many children undergoing the EGD). However, most children knew which medical events (e.g., stitches, cast, tube in the ear) would not occur during the EGD.
Frequency analyses indicated that most parents told their children about the major aspects of the procedure (73.0% of parents told their children about the IV; 75.0% told their children about the medication; 83.0% told their children about the endoscope; 55.0% told their children that they would swallow the endoscope). The most common reason parents gave for not telling their children about procedural components was that they thought that their children already had knowledge of the component. Only 2% of parents reported that they did not tell their children about some aspect of the procedure because they thought that it would upset their children.
Parental preparation was not significantly correlated with children's procedural knowledge (r=-.10, p = ns). One explanation is that some children may have obtained information from sources other than their parents or may not have understood or attended to the information provided by their parents. Alternatively, the nonsignificant relation between preparation and knowledge may be accounted for by the 15 children in this study who had previously undergone an EGD and therefore were not prepared by their parents for the current procedure. When these parents and children were excluded from the correlational analyses, a significant relation emerged between the level of parental preparation and children's level of knowledge (r=.21, p < .05).
Preliminary Analyses
Prior to using structural equation modeling (SEM) to perform a path
analysis of the hypothesized model, bivariate correlations among all variables
in the conceptual model were examined (see
Table I). Many of the relations
hypothesized in the model were in the predicted directions and will be
described below in conjunction with each hypothesis. It was determined a
priori that variables not significantly correlated with their respective
outcomes would be eliminated from further analyses. Because the correlation
between parental preparation and children's knowledge was -.10 (p =
ns), parental preparation was not included in further analyses. The
correlation between knowledge and anxiety was -.09 (p = ns).
Therefore, the direct path from knowledge to anxiety was not included when
testing the hypothesized model. Instead, the indirect effects (from knowledge
to appraisals and from appraisals to anxiety) were assessed.
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Structural Equation Modeling
SEM is preferred over regression analyses, because it simultaneously
examines all paths and provides a global index of fit for the data
(Holmbeck, 1997). We employed
path analysis using the EQS structural equation modeling program (version 5.4)
(Bentler, 1995). The goal of
SEM is to determine the degree to which the hypothesized model fits the data.
If the hypothesized model fits the data well, the 
2 for the
null model should be high while the 2 for the hypothesized
model should be low with a high probability of occurrence (p values
greater than .05). In addition to the 2 statistics, two
indices of fit, the Comparative Fit Index (CFI) and the Root Mean Square Error
of Approximation (RMSEA), are reported for each model. The CFI is a goodness
of fit criterion that is described as the index of choice and does not
penalize for smaller sample sizes (Byrne,
1994). CFI values range from 0.00 to 1.00. Values greater than or
equal to .90 indicate acceptable fit
(Byrne, 1994). The RMSEA is a
fit index that follows an alternate, noncentral 2
distribution. RMSEA values begin at zero and have no upper limit. Confidence
intervals provide the following information: an RMSEA less than or equal to
.05 indicates a very good fit, an RMSEA greater than or equal to .05 but less
than or equal to .09 indicates reasonable fit, and an RMSEA greater than .10
indicates poor fit (Browne & Cudeck,
1993).
SEM analyses require large sample sizes to provide stable estimates. This
study's sample size of 100 is considered by some researchers to be the lower
bound for using SEM (see Tanaka,
1987). Due to the small sample size, SEM was used to represent
constructs with observed indicators and was not used to model latent
constructs.
Figure 2 depicts the SEM analysis examining the hypothesized model. Independent variables are indicated by shaded squares and dependent variables are indicated by unshaded squares. Regression coefficients are represented by unidirectional arrows. Residual error variance is denoted by "E." The error terms associated with each variable were fixed at 1.0. The variances of each error term and the covariances for the error terms associated with the outcome variables (i.e., pain, aversiveness, and attitude toward future procedures) were freely estimated parameters.
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The model depicts paths from knowledge to threat, from threat to anxiety, from anxiety to distress, from age to distress, and from distress to each post-procedural evaluation: pain, evaluations of the EGD's aversiveness, and attitude toward future EGDs. The model also includes correlations among the error terms associated with each of the postprocedural evaluations; these variables were highly correlated with one another and likely represent a unitary construct.
The standardized parameter estimates associated with each of the model
paths were significant in the expected direction. Increased knowledge was
associated with decreased threat, which, in turn, was associated with
decreased anxiety. Decreased anxiety was associated with decreased distress,
which, in turn, was associated with less pain, evaluations of less
aversiveness, and a less negative attitude towards future procedures. Younger
children were observed to experience greater distress than older children. The
fit of the null model was 2 (28) = 226.01, while the fit of
the hypothesized model was 2 (18) = 25.97, p <
.10. The CFI = .96, and the RMSEA was .07 with a 90% confidence interval (.00
< RMSEA < .12). These results indicated that the model fit the data
well. No respecification was needed.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Results of this study support an appraisal-based approach to understanding children's experiences with medical procedures. The appraisal framework appears to be an improvement upon Janis's (1958
) theoretical model of
the "work of worrying" and later frameworks that propose a direct
relation between preparation and anxiety. Past theories do not address why
preparation may not be effective for all patients. An appraisal-based model,
however, asserts that the perception of the stressor, rather than the stressor
itself, predicts individual responses. Thus, preparatory knowledge affects
anxiety through its relation to appraisals.
As hypothesized, children with less knowledge about the EGD appraised it as
more threatening. In addition, children with higher threat appraisals reported
greater anxiety. However, contrary to previous studies that found a direct
relation between preparation and anxiety (e.g.,
Carpenter, 1992;
Faust & Melamed, 1984;
Melamed et al., 1983; Shipley et al.,
1978), this study found an indirect relation. Children with
greater knowledge reported significantly lower threat, and, in turn, children
with lower threat reported significantly less anxiety.
The absence of a relation between knowledge and anxiety may be due in part
to the type of knowledge children had of the procedure. Families were given a
one-page typed explanation regarding the procedural events during the EGD.
There was no sensory information nor was there an intervention component to
the preparation (e.g., modeling, coping skills training, a tour of the
procedure rooms). Previous research demonstrates that the most effective
preparations include both sensory and procedural information and
combine preparatory information with other interventions (e.g.,
Suls & Wan, 1989). Thus,
the provision of sensory information or an intervention component may have
increased the likelihood of a direct relation between knowledge and anxiety,
as found in previous studies.
According to the appraisal perspective, the provision of information about
sensory aspects of the procedure and about coping strategies should reduce
anxiety to the extent to which it affects patients' threat-related primary and
secondary appraisals. For example, rather than simply telling patients that
they will swallow the endoscope, telling them what the sensation of swallowing
the endoscope will feel like may be helpful (e.g., it is like swallowing a
large bite of hot dog [an analogy used by one physician in this hospital] or a
"really long piece of licorice about the thickness of a pinkie
finger" [an analogy used by Schnee
(1995) on p. 11]). Providing
sensory information about the IV also may be helpful; some nurses at this
medical center used the analogy of a tiny bee sting. The description of such
sensory details using benign analogies might well serve to make the procedure
seem less aversive and serious (primary appraisals) than what the child might
be imagining in the absence of such information. In a similar manner,
appraised threat could also be reduced by teaching patients coping strategies
that would strengthen their secondary appraisals of coping potential. Thus,
they might be taught to use distraction or deep breathing to reduce IV-related
distress (e.g., Fanurik, Koh, &
Schmitz, 2000), just as they might be taught how to breathe during
the endoscope insertion (many patients report that they cannot breathe with
the endoscope in place). In short, the appraisal perspective argues that
interventions providing knowledge of sensory information and effective coping
strategies should result in reduced anxiety to the extent to which such
knowledge is effective in reducing threat-related appraisals. A recent study
demonstrated that children who underwent an intervention to decrease
threatening appraisals of an upcoming procedure experienced less anticipatory
anxiety, procedural distress, and pain than children receiving an information
based preparation only (Chen, Zeltzer,
Craske, & Katz, 1999).
Along the same lines, patients may appraise the EGD as less threatening if
they know that they will receive additional medication. Administration of a
eutetic mixture of local anesthetics (EMLA), a topical anesthetic cream, may
help to decrease distress, as EMLA reduces the experience of pain during IV
insertion (Fanurik et al.,
2000). Recent research by Fanurik et al. demonstrated the
effectiveness of combining EMLA with distraction in reducing distress before,
during, and after IV insertion in pediatric patients scheduled to
undergo an EGD. Although not assessed, perhaps the decrease in IV-related
distress resulted in decreased distress during endoscope insertion. Including
a simple intervention during the IV may effectively decrease distress across
later phases of the EGD, especially for younger children who exhibited higher
levels of distress than older children.
An intervention similar to the one used by Mahajan et al.
(1998) may reduce patients'
threat appraisals. In addition to procedural information, children were
provided with a demonstration of materials to be used during the procedure;
practice with a doll; a book showing photographs of a child entering the
clinic, undergoing the EGD, and recovering; and time with a child life
specialist who answered families' questions. These interventions may have
helped patients formulate less threatening appraisals of the EGD by providing
them with more information about what to expect. For example, some children in
this study were concerned about the size of the IV. Children in the Mahajan et
al. study saw the size of the IV prior to the procedure, which may
have helped them form more realistic appraisals and ultimately experience less
anxiety.
Results also indicated that children with greater anxiety demonstrated
greater distress. These findings are consistent with previous studies (e.g.,
Hubert et al., 1988;
Miller et al., 1992). Children
with greater distress during the EGD reported the procedure to be more painful
and aversive than children with lesser distress. Children with greater
distress also reported that they would be more anxious if they were to undergo
future EGDs. These procedures are often repeated for children with chronic
gastrointestinal symptoms that are difficult to diagnose. Anxious children may
be at risk for increased distress during future EGDs. Thus, providing children
with a more positive experience has implications for their current as well as
future medical experiences.
Future studies may incorporate family members as coaches to reduce
patients' threat appraisals, anxiety, and distress. Previous research has
demonstrated a significant decrease in children's procedural distress when
they engage in deep breathing or guided imagery as coached by their parents
(e.g., Blount et al., 1992;
Kazak et al., 1996). When
provided an opportunity to practice these techniques with a family member
prior to the procedure, patients may appraise the procedure as less
threatening, ultimately resulting in less anxiety and distress.
The findings of this study should be qualified by a few limitations. First, the sample size of 100 may have lacked the statistical power to detect certain effects. However, the SEM model used observed indicators only and did not attempt to model latent constructs. Although this decision sacrificed a strength of structural equation modeling, it minimized the number of parameters to be estimated and allowed reliable estimates to be derived from the relatively small sample. Second, being in this study may have decreased some families' anxiety and may have changed the way in which they prepared their children. When contacted about the study, some parents remarked that participation would be helpful for their children. They were informed that the purpose of the study was to learn more about what EGDs were like for children, not that the study itself was designed to help their children. However, after participating in this study, some parents reported that they thought it was helpful for their children to talk with the interviewer. In addition, some parents reported that they felt more comfortable knowing that the interviewer would be present during the EGD, since parents were not permitted to observe. Therefore, families who participated in this study may have had a more positive experience with their visits to the hospital. Participation also may have altered parents' preparation; some parents may have provided more information because they knew that their children would be speaking with an interviewer. However, patients' experiences with the EGD itself are likely comparable to those of other children who did not participate in the study. Finally, results of this study may be limited by participant characteristics. Replication with a more ethnically diverse population is needed; this sample was primarily Caucasian, as is typical of the pediatric gastroenterology patients at this medical center.
This study provides one of the first accounts of children's experiences with EGDs and offers new information for designing interventions for patients who are expected to experience high levels of distress. In addition, it presents one of the first applications of an appraisal framework for understanding the way in which appraisals function in the relations among preprocedural knowledge, anticipatory anxiety, procedural distress, and postprocedural evaluations.
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Acknowledgments |
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This study was based on a dissertation by Robyn Lewis Claar. Thanks to Tricia Lipani for her assistance with coding children's distress and to the pediatric patients and families who participated in this study. We also thank the physicians and nurses in the Pediatric Gastroenterology Clinic at Vanderbilt University Medical Center: Catherine E. Arthur, MD, John A. Barnard, MD, Karen D. Crissinger, MD, Cheryl A. Little, MD, Brent Polk, MD, P. Paulette Cole, RN, Kim Eisenberg, RN, and Stan McQuistin, RN.
Received June 27, 2001; revision received October 5, 2001; accepted October 24, 2001
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TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Bentler, P. M. (1995). EQS structural equations program manual. Encino, CA: Multivariate Software.
Bieri, D., Reeve, R. A., Champion, G. D., Addicoat, L., & Ziegler, J. B. (1990). The faces pain scale for the self-assessment of the severity of pain experienced by children: Development, initial validation, and preliminary investigation for ratio scale properties. Pain, 41, 139-150.[Web of Science][Medline]
Blount, R. L., Bachanas, P. J., Powers, S. W., Cotter, M. C., Franklin, A., Chaplin, W., Mayfield, J., Henderson, M., & Blount, S. D. (1992). Training children to cope and parents to coach them during routine immunizations: Effects on child, parent, and staff behaviors. Behavior Therapy, 23, 689-705.[Web of Science]
Browne, M. W., & Cudeck, T. (1993). Alternative ways of assessing model fit. In K. A. Bollen & J. S. Long (Eds.), Testing structural equation models (pp. 136-162). Newbury Park, CA: Sage.
Bush, J. P., Melamed, B. G., Sheras, P. L., & Greenbaum, P. E. (1986). Mother-child patterns of coping with anticipatory medical stress. Health Psychology, 5, 137-157.[Web of Science][Medline]
Byrne, B. M. (1994). Structural equation modeling with EQS and EQS/Windows: Basic concepts, applications, and programming. Thousand Oaks, CA: Sage.
Carpenter, P.J. (1992). Perceived control as a
predictor of distress in children undergoing invasive medical procedures.
Journal of Pediatric Psychology,
17, 757-773.
Chen, E., Zeltzer, L. K., Craske, M. G., & Katz, E. R. (1999). Alteration of memory in the reduction of children's distress during repeated aversive medical procedures. Journal of Clinical and Consulting Psychology, 67, 481-490.
Dahlquist, L. M., Gil, K. M., Armstrong, F. D., DeLawyer, D. D., Greene, P., & Wuori, D. (1986). Preparing children for medical examinations: The importance of previous medical experience. Health Psychology, 5, 249-259.[Web of Science][Medline]
Drossman, D. A., Brandt, L. J., Sears, C., Li, Z., Nat, J., & Bozymski, E. M. (1996). A preliminary study of patients' concerns related to GI endoscopy. American Journal of Gastroenterology, 91, 287-291.[Web of Science][Medline]
Fanurik, D., Koh, J. L., & Schmitz, M. L. (2000). Distraction techniques combined with EMLA: Effects of IV insertion pain and distress in children. Children's Health Care, 29, 87-101.
Faust, J., & Melamed, B. G. (1984). Influence of arousal, previous experience, and age on surgery preparation of same day of surgery and in-hospital pediatric patients. Journal of Consulting and Clinical Psychology, 52, 359-365.[Web of Science][Medline]
Hodgins, M. J., & Lander, J. (1997). Children's coping with venipuncture. Journal of Pain and Symptom Management, 13, 274-285.[Web of Science][Medline]
Hollingshead, A. B. (1975). Four factor index of social status. Working paper. New Haven, CT: Yale University, Department of Sociology.
Holmbeck, G. N. (1997). Toward terminological, conceptual, and statistical clarity in the study of mediators and moderators: Examples from the child-clinical and pediatric psychology literatures. Journal of Consulting and Clinical Psychology, 65, 599-610.[Web of Science][Medline]
Hubert, N. C., Jay, S. M., Saltoun, M., & Hayes, M. (1988). Approach-avoidance and distress in children undergoing preparation for painful medical procedures. Journal of Clinical Child Psychology, 17, 194-202.[Web of Science]
Janis, I. L. (1958). Psychological stress. New York: Wiley and Sons.
Jay, S. M. (1988). Invasive medical procedures: Psychological intervention and assessment. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp. 401-425). New York: Guilford Press.
Jay, S. M., & Elliott, C. H. (1986). Observation Scale of Behavioral Distress-Revised. Unpublished manuscript.
Jay, S. M., Ozolins, M., Elliott, C. H., & Caldwell, S. (1983). Assessment of children's distress during painful medical procedures. Health Psychology, 2, 133-147.
Katz, E. R., Kellerman, J., & Siegel, S. E. (1980). Behavioral distress in children with cancer undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48, 356-365.[Web of Science][Medline]
Kazak, A. E., Penati, B., Boyer, B. A., Himelstein, B., Brophy, P.,
Waibel, M. K., Blackhall, G. F., Daller, R., & Johnson, K.
(1996). A randomized controlled prospective outcome study of a
psychological and pharmacological intervention protocol for procedural
distress in pediatric leukemia. Journal of Pediatric
Psychology, 21,
615-631.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, & coping. New York: Springer-Verlag.
Mahajan, L., Wyllie, R., Steffen, R., Kay, M., Kitaoka, G., Dettorre, J., Sarigol, S., & McCue, K. (1998). The effects of a psychological preparation program on anxiety in children and adolescents undergoing gastrointestinal endoscopy. Journal of Pediatric Gastroenterology and Nutrition, 27, 161-165.[Web of Science][Medline]
Melamed, B. G. (1998). Preparation for medical procedures. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry Vol. 2: Disease, injury, and illness (pp. 16-30). Boston: Allyn & Bacon.
Miller, S. M., Sherman, H. D., Combs, C., & Kruus, L. (1992). Patterns of children's coping with short-term medical and dental stressors: Nature, implications and future directions. In A. M. La Greca, L. J. Siegel, J. L. Wallander, & C. E. Walker (Eds.), Stress and coping in child health (pp. 157-190). New York: Guilford Press.
Peterson, L. (1989). Coping by children undergoing stressful medical procedures: Some conceptual, methodological, and therapeutic issues. Journal of Consulting and Clinical Psychology 57, 380-387.[Web of Science][Medline]
Rudolph, K. D., Dennig, M. D., & Weisz, J. R. (1995). Determinants and consequences of children's coping in the medical setting: Conceptualization, review, and critique. Psychological Bulletin, 118, 328-357.[Web of Science][Medline]
Schnee, A. D. (1995). Effect of psychological preparation on reducing behavioral distress and morbidity in children undergoing endoscopy. Unpublished doctoral dissertation, Georgia State University.
Shipley, R. H., Butt, J. H., Horwitz, B., & Farbry, J. E. (1978). Preparation for a stressful medical procedure: Effect of amount of stimulus preexposure and coping style. Journal of Consulting and Clinical Psychology, 46, 499-507.[Web of Science][Medline]
Smith, C. A., & Lazarus, R. S. (1990). Emotion and adaptation. In L. A. Pervin (Ed.), Handbook of personality theory and research (pp. 609-637). New York: Guilford Press.
Spielberger, C. D., Edwards, C. D., Montuori, J., & Luschene, R. E. (1983). Manual for the State-Trait Anxiety Inventory for Children ("How I Feel Questionnaire"). Palo Alto, CA: Consulting Psychologists Press.
Suls, J., & Wan, C. K. (1989). Effects of sensory and procedural information on coping with stressful medical procedures and pain: A meta-analysis. Journal of Consulting and Clinical Psychology, 57, 372-379.[Web of Science][Medline]
Tanaka, J. S. (1987). "How big is big enough?": Sample size and goodness of fit in structural equation models with latent variables. Child Development, 59, 134-146.
Van Slyke, D. A., Smith, C. A., Walker, L. S., & Garber, J. (1997, April). Development and validation of the children's Pain Beliefs Questionnaire. Poster presented at the Sixth Florida Conference on Child Health Psychology, Gainesville, FL.
Waibel-Duncan, M. K., & Sandler, H. M. (2001).
Pediatric anogenital exam: A theory-driven exploration of anticipatory
appraisals and affects. Child Maltreatment,
6, 50-58.
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