Journal of Pediatric Psychology Advance Access originally published online on September 21, 2005
Journal of Pediatric Psychology 2006 31(5):522-527; doi:10.1093/jpepsy/jsj081
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Brief Report: Optimizing Children’s Memory and Management of an Invasive Medical Procedure: The Influence of Procedural Narration and Distraction
1 University of New South Wales, 2 Sydney Children’s and Prince of Wales Hospitals, 3 School of Psychology, University of New South Wales, and 4 Department of Medical Imaging and Nephrology, Sydney Children’s and Prince of Wales Hospitals
All correspondence concerning this article should be addressed to Karen Salmon, School of Psychology, University of New South Wales, Sydney, New South Wales 2052, Australia. E-mail: k.salmon{at}unsw.edu.au.
Received February 17, 2005; revisions received April 26, 2005 and July 28, 2005; accepted August 28, 2005
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Abstract |
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Objective To evaluate the influence of two interventions on children’s memory of and distress during a voiding cysto-urethrogram (VCUG, X-ray of the kidneys). Methods Sixty-two children (aged 2.5–7.5 years) were allocated to one of three conditions. In one (CI + D), they received complete procedural information during the VCUG, with a cartoon video. In a second (PI + D), children received limited procedural information, with a cartoon video. In a third (standard care, PI), they received limited procedural information. VCUGs were videotaped and distress was coded using the CAMPIS-R. To assess memory, children were interviewed 1 week later. Results Relative to the PI condition, children in the CI + D condition recalled more information, appraised the VCUG as less painful, and were less distressed. There were no differences between the PI + D and PI conditions. Conclusions An inexpensive, theoretically driven intervention can enhance children’s memory and reduce distress during an invasive procedure.
Key words: children; distraction; distress; medical procedure; memory; procedural information.
How children remember a stressful medical procedure has implications for their management of future medical encounters. Forming a coherent and verbally reportable memory of the experience may enable retelling, potentially facilitating coping with any emotional sequelae (e.g., Bar-Haim, Fox, VanMeenen, & Marshall, 2004
; Pennebaker & Seagal, 1999). In contrast, inaccurate and impoverished memory can be associated with increased distress during subsequent medical procedures. For example, Chen, Zeltzer, Craske, and Katz (2000) found that when pediatric oncology patients aged 3- to 18 years were interviewed 1 week after a lumbar puncture (LP), exaggerations in their memory for the negative aspects of the LP were associated with their level of distress during the procedure. Importantly, negatively exaggerated memory was, in turn, associated with greater distress during the following LP. These findings extend research showing, first, that memory errors can occur in the context of procedural distress (e.g., Salmon, Price, & Pereira, 2002), and second, that across the childhood years, memories of pain and distress can influence subsequent anxiety, distress, and/or coping during medical procedures (Ornstein, Manning, & Pelphrey, 1999; von Baeyer, Marche, Rocha, & Salmon, 2004; see for reviews).
In this study, we evaluated the relative effectiveness of two interventions aiming to optimize memory and reduce distress for young children aged 2.5–7.5 years undergoing the VCUG (voiding cysto-urethrogram), a radiological assessment of the urinary tract requiring catheterization. In both interventions, the children watched a cartoon video. Cartoon distraction has been found to reduce young children’s distress during procedures of relatively short duration such as immunization (Cohen, Blount, & Panopoulos, 1997) and venipuncture (McLaren & Cohen, 2005), and movie distraction has also been shown to prevent negative distortions in 8- to 11-year-olds’ recall of the pain of recurrent injections (Cohen et al., 2001). It is possible, however, that cartoon or movie distraction will be less effective in the context of prolonged, invasive, and often unfamiliar procedures such as the VCUG.
In addition to the cartoon video, the children in the two intervention conditions were provided with differing amounts of procedural information during the VCUG. In one (partial information + distraction, PI + D condition), the children received only the limited information typically provided in standard care to ensure compliance. In the second, the children were provided with complete procedural narration as the VCUG unfolded (complete information with distraction, CI + D condition). Theories of memory development underscoring the influence of adult–child discussion suggest that by providing labels for equipment and highlighting links between the VCUG components, procedural narration could compensate for poor understanding, with benefits to recall (e.g., Nelson & Fivush, 2004; Ornstein, Haden, & Hedrick, 2004). Further, distress may be reduced because the unpredictability of the VCUG is minimized (Steward, 1993). Thus, complete procedural information may boost the impact of distraction by lowering procedural distress and improving recall, despite the apparently counter-active nature of these two strategies. A standard care condition, with limited information and without the cartoon video, provided a comparison (partial information; PI condition). To assess memory, all children were interviewed about the VCUG 1 week later.
We predicted that, relative to the PI condition, children in the CI + D but not the PI + D condition would provide more comprehensive memory reports with fewer errors and would appraise the VCUG more positively and further, that this advantage would be particularly evident in free (unprompted) recall. We expected free recall to be most sensitive for two reasons. First, narration during the event is likely to benefit the child’s ability to verbally encode and therefore retrieve and report the VCUG under conditions of minimal cuing (e.g., Ornstein et al., 2004); second, children’s memory performance improves with the additional prompts provided in cued recall, and differences between conditions are likely to be reduced (e.g., Salmon, Bidrose, & Pipe, 1995). Additionally, we expected that, relative to the PI condition, children in the CI + D but not the PI + D condition would manifest less distress during the VCUG.
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Method |
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Participants
Eligible children were referred to a hospital in Sydney, Australia, for a VCUG between July, 2001 and March, 2003. Inclusion criteria were as follows: Older than 2.5 and younger than 7.5 years (>30, < 96 months); no chronic medical condition; developmentally appropriate language. The age range was selected because we wanted to ensure that the participating children were likely to have some facility with language. Further, relatively few children undergo the VCUG after age 7.5 years. Twelve children did not meet criteria (M age = 34.97, SD = 12.76 months; 5 males, 7 females). Rate of consent was 87%; 10 parents declined (M age = 54.50, SD = 21.79 months; two males, eight females). The final sample was 62 children (M age = 53.20, SD = 16.59 months; 20 males, 42 females), of mixed ethnicity and socioeconomic backgrounds. There was no significant difference in age between the children whose parents consented and those whose parents did not, t(70) = –.22, p > .5. Due to scheduling difficulties, seven children did not participate in the memory interview (M age = 49.43, SD = 10.06 months; three males, four females).
Assessments
Child–Adult Medical Procedure Interaction Scale–Revised
The Child–Adult Medical Procedure Interaction Scale–Revised (CAMPIS-R) (Blount et al., 1997) is a standardized rating scale that codes videotaped verbal interactions in the pediatric treatment room. Concurrent validity and interrater reliability of between 89 and 94% are reported (e.g., Blount et al., 1997). We report data for the two Child Distress behavioral categories: Apprehensive Distress (seeking emotional support, information seeking and verbal fear) and Demonstrative Distress (crying, screaming, expressing verbal emotion, verbal pain, and verbal resistance) (Blount et al., 1997). Child and staff video-verbalizations, child attention to the video, and staff procedural information were also coded. To establish reliability of the assignment of CAMPIS-R categories from procedural transcripts, approximately 28% of the transcripts were coded independently. Reliability, [agreements/(agreements + disagreements)], was 90% (range; 83–98%) for child behaviors and 94% (range; 85–100%) for staff behaviors. Behavioral categories are reported in terms of rate/minute.
Expressive Vocabulary Test
Expressive Vocabulary Test (EVT) (Williams, 1997). The EVT was administered to establish that there were no differences in language skill between conditions. Thirty-eight (of 190) items require a label for a picture and 152 items require a synonym for words presented in a picture.
Procedure
Nurse Training
All four nurses in the study were highly experienced in relation to the VCUG. The four nurses received three 1-hour training sessions focusing on: (1) directing children’s attention toward the cartoon using prompts and questions and (2) providing procedural information. Nurses received a written script and practice involved role-plays and feedback. All nurses implemented all conditions.
Interventions
Ethical approval was obtained from relevant committees. Allocation to conditions, conducted by a research assistant who was not a principal investigator, was random, stratified for age, gender, and nursing staff. On the day of the VCUG, consent forms were signed. The video camera was in a corner of the treatment room, and to ensure treatment fidelity, prompt cards were displayed for the nurses. The VCUG components were as follows: The child’s genital area was washed and lubricating jelly applied, a catheter was inserted through the urethra into the bladder, dye was infused, and the child was asked to urinate on the table or into a bottle as X-ray pictures were taken. The catheter came out during urination or was removed, and further X-rays were taken. Videotaping began when the child entered the treatment room until following removal of the catheter. The mean duration was 30.54 minutes (SD = 19.23). Children were given a card medal as a cue for the interview.
Children in the PI (standard care) condition were provided with limited procedural information: To ensure compliance, they were informed of the key aspects of the VCUG (lying still, "weeing") and given general praise. Children in the PI + D condition were provided with limited procedural information and were prompted to attend to a cartoon video selected (from three; Winnie the Pooh, Goofy, and Donald Duck) by the child and parent. In selecting these cartoons, we wanted to maximize the likelihood that the cartoons would not have been familiar to the child, and we therefore avoided the most popular current cartoons for young children. Following Cohen et al. (1997), the nurse used comments and questions to encourage attention to the cartoon, with additional prompting at catheterization, voiding, as distress increased. For children in the CI + D condition, the cartoon was shown and the nurses (1) provided a preprocedural summary (e.g., "These are the cameras. They make noises and come down near you, but they won’t touch you"); (2) described the VCUG as it unfolded (e.g., "The Dr is putting the little tube in the hole where your (child’s word for urinating) come out. The tube is smaller than the hole"); (3) highlighted neutral physical sensations (e.g., "The Dr is washing you. It might feel cold"); (4) provided specific praise (e.g., "I like how you are lying so still").
Memory Interview
One week later (M = 8.43 days, SD = 2.11), at the child’s home, a second researcher administered the EVT and interviewed the child following a standardized protocol. The interview protocol was based on one used in previous investigating memory of the VCUG, conducted by these researchers (e.g., Salmon et al., 2002). The memory interviews were conducted by the second author, who has considerable experience conducting memory interviews with young children in both research and clinical contexts (e.g., McGuigan & Salmon, 2004, 2005). Free recall began: "A while ago, you had a special test at the hospital, where you got a medal. I wasn’t there, so I’d like you to tell me everything about that time." When the child could report no further information, 12 semispecific prompts were given (e.g., "Tell me what happened with a little tube"). Thereafter, the child rated the VCUG in terms of how "scary" it was and how much it "hurt" on two three-point Faces scales (e.g., "not at all, a little bit, a lot") (e.g., Champion, Goodenough, von Baeyer, & Thomas, 1998; see also Goodenough et al., 1997), and parents estimated the number of VCUG discussions during the week (<2, <5, <10, >10). Transcribed audiotapes were coded following Salmon et al. (2002); children were credited with a correct item for mention of an item of equipment (e.g., tube), a body part (tummy), a person (mummy), an action (lie), or a detail ("white gown"). Reference to the cartoon was coded as one item. One error was given for distortions ("washed my tummy") and extra-event information ("I got medicine"). To establish reliability, approximately 26% of the transcripts were selected randomly from within each condition and coded independently. Reliability, [agreements/(agreements + disagreements)], was 91% (range; 84–100%).
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Results |
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Preliminary Analyses
One-way ANOVAs established that there were no differences between conditions with respect to age, EVT, prior VCUGs, and postprocedural discussions (all Fs < 1.48, all ps > .11). Interventions were implemented as intended (Table I). Specifically, there was no difference between the PI + D and CI + D conditions in the rate/minute of staff video-related talk, t(39) = .65, p > .5 nor in the rate/minute of child attention to the video, t(39) = –.59, p > .5. The rate/minute of staff provision of procedural information was higher for children in the CI + D than the PI + D and PI conditions, who did not differ, F(2, 59) = 14.71, p < .000.
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Impact of Intervention on Memory
Correct Recall
A priori hypotheses were tested via planned comparisons (Tabachnick & Fidell, 1996
) (Table I). For free recall, calculated as the correct items (equipment, body parts, people, actions, details, summed) reported in the unprompted interview phase, children in the CI + D condition reported more correct items than those in the PI condition, t(52) = -2.07, p < .05. The difference between children in the PI + D and PI conditions was not significant, t(52) = -.49, p > .5. For total recall, calculated as the correct items summed across phases (free, prompted recall, direct questions), the difference between children in the CI + D and PI conditions approached significance, t(52) = –1.85, < .07. The difference between children in the PI + D and PI conditions was not significant, t(52) = –.12, p > .5.
Errors
Errors were too few to analyze statistically (range = .00 to .30).
Appraisals
Children in the CI + D condition appraised the procedure as hurting less than did those in the PI condition, t(49) = 2.69, p < .01 (Table I). The difference between children in the PI + D and PI conditions was not significant, t(49) = .43, p > .5. For appraisal of procedural fear, there was no significant difference between children in the CI + D and the PI conditions, t(49) = .43, p > .5 nor between those in the PI + D and PI conditions, t(49) = .65, p > .5.
Impact of Interventions on Distress
Children in the CI + D condition manifested a lower rate of Demonstrative Distress t(59) = 2.00, p < .05, than children in the PI condition, t(59) = 2.00, p < .05 (Table I). The difference between children in the PI + D and PI conditions was not significant, t(59) = .65, p > .5. There were no significant differences for Apprehensive Distress, both ps > .1
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Discussion |
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There were three major findings. First, complete information with distraction during the VCUG enhanced children’s memory, relative to standard care. As predicted by social interaction theories of memory development, procedural narration may have compensated for children’s limited language and poor understanding of the VCUG by highlighting the links between its components, drawing attention to its salient aspects, and labeling actions and equipment (Nelson & Fivush, 2004
; Ornstein et al., 2004). Indeed, our finding that the advantage of procedural information with distraction was in free recall suggests that the memory of children in the CI + D condition was better encoded and more accessible to minimal cuing. The children who received procedural information and distraction also appraised the VCUG as less painful 1 week later, providing further evidence of memorial benefit from the intervention relative to standard care. Interestingly, although memory for distressing and unfamiliar medical procedures is vulnerable to errors (Chen et al., 2000), almost no errors were made. As errors increase over time, the longer term impact of procedural information with distraction is a useful focus of future research (e.g., Cordon, Pipe, Sayfan, Melinder, & Goodman, 2004; Salmon et al., 2002).
Second, it was particularly noteworthy that the children who received procedural information and distraction manifested less demonstrative distress (e.g., crying and screaming, expressing resistance) during the VCUG; indeed, their rate of distress was almost half that demonstrated by the children who received standard care. These findings raise the possibility that factors associated with better memory, such as the increased predictability and comprehensibility of the VCUG, also contribute to lower distress (Steward, 1993).
Third, cartoon video distraction without complete information provided no significant benefit to children’s recall or their distress, relative to standard care. In the context of a long, invasive and complex procedure such as the VCUG, a cartoon—or at least those in this study—may not be sufficiently compelling to engage children’s attention. In contrast, an electronic toy involving multiple sensory modalities and requiring active motor and cognitive responses reduced 2- to 5-year old children’s distress during repeated chemotherapy injections, although its impact on memory was not assessed (Dahlquist, Pendley, Landthrip, Jones, & Steuber, 2002; but see McLaren & Cohen, 2005). It is unclear, however, whether distraction is a necessary addition to procedural information or whether procedural information alone can enhance children’s recall and reduce their distress.
Limitations of the study include the unavailability of parent appraisals of children’s pain and fear; this would have provided useful information about the convergence of parent–child perceptions (e.g., Klein, 1991). Additionally, the relatively small sample size spanning a large age range precluded analyses of age-related responses to the interventions and reduced power to detect significant differences. Indeed, some of our findings (e.g., total recall) approached but did not reach significance. In addition to considerations of sample size, however, the effectiveness of the intervention may be increased were brief procedural information to be provided before and after as well as during the VCUG (Chen, Zeltzer, Craske, & Katz, 1999; McGuigan & Salmon, 2004, 2005).
In closing, our findings indicate that, relative to standard care, procedural information with cartoon distraction, a theoretically driven and inexpensive intervention that is easily implemented in a busy pediatric setting, can shape young children’s memory of a prolonged and stressful medical procedure and reduce their distress.
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Acknowledgments |
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This study was supported by a grant from the Sydney Children’s Hospital Foundation. We are grateful to the children and parents who allowed us to videotape as they underwent the procedure and to conduct the memory interviews. Additionally, we thank radiology and nursing staff from the Department of Medical Imaging and Nephrology at Sydney Children’s Hospital, in particular, Margaret Allen, Madeline Cogswell, Lisa Dowdell, Diane Dunn, and Sandara Nerichow. Thanks also to Kay Pegg for help with data collection.
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References |
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