Journal of Pediatric Psychology Advance Access published online on June 23, 2008
Journal of Pediatric Psychology, doi:10.1093/jpepsy/jsn066
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Infants’ and Toddlers’ Remembering and Forgetting of a Stressful Medical Procedure
1Department of Psychology, Stockholm University, 2Center for Clinical Research, Uppsala University, 3Department of Neurosurgery, UmeåUniversity Hospital, 4Department of Women and Child Health, Karolinska Institute and Astrid Lindgren Children's Hospital, Karolinska University Hospital, and 5Stress Research Institute, Stockholm University
All correspondence concerning this article should be addressed to Dr Torun Lindholm, Department of Psychology, Stockholm University, 10691 Stockholm, Sweden. E-mail: tlm{at}psychology.su.se
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Abstract |
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Objective To examine whether a distressing medical procedure leaves lasting impressions in young children's memories. Methods Children 12- to 78-weeks old (N = 172) received inhalation treatment through a face mask or underwent other interventions at a pediatric emergency department. They were randomized to be presented with neutral cues and cues from the inhalation 1 week or 6 months after the target event. Children's reactions at cue presentation were scored from videotapes. Results Across the age span tested, children treated with inhalation showed higher distress than controls when presented with cues from inhalation 1 week, but not 6 months after target treatment. Conclusions Stress during medical procedures in preverbal children may develop as a result of prior experience of such procedures. These memories typically seem to fade within 6 months.
Key words: memory; preverbal children; stressful medical procedure.
Management of children's distress is one of the most central issues in clinical pediatrics. This may be illustrated by clinical trials of aerosol inhalation in infants in which typically large numbers of children are excluded because of signs of distress (Amirav & Newhouse, 2001
; Noble, Ruggins, Everard, & Milner, 1992). Such distress is known to significantly decrease aerosol deposition in lungs both because of changes in breathing patterns and because of difficulties in maintaining a closed seal between mask and face (Amirav & Newhouse, 2001; Iles, Lister, & Edmunds, 1999).
Memories of prior experiences of stressful medical procedures (Cohen et al., 2001; Ornstein, Manning, & Pelphrey, 1999; Sjöberg & Lindholm, 2005) are likely to play an important role for pediatric stress reactions in verbal children (Everard, 2003). However, when it comes to the fate and durability of younger children's memories of such experiences, research findings are less clear. On the one hand, experimental studies imply that infants’ and toddlers’ memories for neutral and positive procedures, such as interacting with a toy, are typically extinguished within weeks or at most a couple of months, depending on the age of the child (Bauer, 2006; Hartshorn et al., 1998). On the other hand, memories of briefly experienced painful stimuli may suffice to create an enhanced pain sensitivity in infants that will typically last for several months, and possibly longer (Fitzgerald, Millard, & McIntosh, 1989; Hermann, Hohmeister, Derimakca, Zohzel, & Flor, 2006; Taddio, Katz, Ilersich, & Koren, 1997). The fact that the latter effects can be remedied with analgesic agents may be taken to suggest that these findings apply to pain rather than stress per se, but may also be seen as a result of the fact that the procedures studied were not perceived as stressful under analgesia.
A number of case reports and anecdotal data (Terr, 1988; Watson & Reyner, 1920) suggest that memories (at least in the very basic form of conditioned responses) can be evoked by a single, stressful event that does not directly involve pain. One classical example of this is the classical study of "little Albert," written in the tradition of behaviorism, in which Watson and Reyner (1920) created a conditioned emotional reaction to furry objects in an infant by associating the presence of such objects with a loud scary sound. However, due to a lack of systematic documentation of such effects in controlled experimental studies this conclusion can presently at best be considered tentative.
An increased understanding of whether not only pain, but also other forms of stressful medical procedures leave lasting impression in the minds of infants and toddlers is of considerable interest for the development of adequate management of children's distress in routine pediatric medical interventions. The purpose of the present study was to address these questions by studying young children's memories for one single experience of salbutamol inhalation through a face mask.
More specifically, we decided to test the hypotheses that preverbal children may recognize and react aversively to stimuli that they have been exposed to during stressful medical interventions and that the strength of such effects would be dependent on age and the time between exposure and testing. Our conceptualization of psychological distress follows the tradition of Katz et al. (1980, 1981), who defined distress as an organism's response to aversive stimuli which may include discomfort, anxiety, fear, and at the extreme, pain. The organism's response may be expressed through three components: Behavioral (agitation, movement, grimacing, crying, avoidance, etc.), Physiologic (increased muscle tension, heart rate, hormonal response, etc.), and Phenomenological (self-reports of anxiety, fear etc.). Because self-reports are not applicable in the cases of infants and toddlers, and physiological measurement (such as attaching a pulse oximeter on the child's finger or toe) per se often causes distress in young children, the current study focused on the behavioral component.
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Methods |
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Participants
Participants in this prospective cohort study were recruited from children between 12- and 78-weeks old who were admitted to the pediatric emergency department (ED) at a university hospital (Astrid Lindgren Children's Hospital, Karolinska University Hospital) between October 2003 and April 2005. This age range was chosen to allow the study of possible age differences in preverbal children capable of interacting with researchers in a way that would make testing meaningful. Demographic data for the final sample are summarized in Table I. The study was approved by the local ethics board, and written consent was obtained from parents of all participating children. The study group included children with indications of virosis (i.e., fever) and breathing difficulties who received inhalation treatment at the ED for their condition. The control group was children with virosis without breathing complications who underwent other, routine medical interventions (e.g., blood sampling, urinary bladder puncture). In order to assure that we consistently studied the effects of one single inhalation experience children who had received inhalation treatment at the ED before the target visit or between the target visit and the memory test were excluded from the study and children were only tested once (after 1 week or 6 months). We also excluded children with chronic diseases. A flowchart presenting participant selection and assignment procedure and the resulting number of participants in each category is presented as Fig. 1.
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Procedure
Nurses at the ED asked parents of potential study participants whether they were willing to be contacted by an investigator for possible participation in the study. Consenting parents gave their contact information to the nurse, and the nurse then assessed the child's distress during the medical procedure on a Visual Analogue Distress Scale (VAS). Scores were measured on an unmarked 100 mm ruler, with verbal anchors at the endpoints (0 = no distress; 100 = worst possible distress). A total of 34 nurses were involved in assessing distress at the ED. These nurses are used to applying such ratings as a part of day to day practice. We were unable to detect any systematic difference in use of the VAS scale depending on the rater.
When a potential participant had been recruited, the child was randomized to be tested for his/her memory either about a week (M = 7 days, range 5–9 days), or 6 months (M = 25 weeks, range 24–28 weeks) after the target visit at the ED.
An investigator telephoned or emailed the parents 4–6 days (children tested after 1 week), or 2–3 weeks (children tested after 6 months) before the planned date of the memory test to determine eligibility and, for eligible children, to decide on details of the upcoming appointment. Of the 397 children whose parents consented to be contacted, 172 (43%) completed the study. Of those who did not complete the study, 125 (56%) were not eligible either because the child had received inhalations after the target visit to the ED or was too ill to participate, 59 (26%) declined, and 41 (18%) could not be reached within the given time frame (Fig. 1). There were no significant differences between children who were contacted versus completers in age (M = 38.80 weeks, SD = 17.99 vs. M = 41.16 weeks, SD = 19.37) or gender (64% vs. 55% males).
The setting for the memory test was a clinic at the hospital where the child had been admitted to the ED. Because of a lack of available space at the clinic due to a high clinical caseload at certain times a minority of the children (n = 15, or 9% of the final sample) were tested in a neutral room at the university. An investigator met the parent(s) and the child at the test site. The memory testing was standardized. Parents were asked to sit with their child on the lap such that the child came face to face with the investigator. The investigator explained that she was going to present a series of objects to the child. To standardize observations, the procedure was divided into four phases. After having established contact with the child, the investigator presented the child with an age-appropriate toy. This first phase constituted baseline. If the child showed interest in the toy, the investigator gently invited the child to touch and hold it. In the first critical phase, the investigator then presented an inhalation mask attached to a nebulisator. As in the baseline phase, the child was invited to touch and hold the mask if showing interest in it. If a child showed a strong negative reaction when presented with the mask, the investigator kept it resting on her lap. In the second critical phase, while still presenting the mask, the investigator turned on an oxygen tube attached to the nebulisator, such that the distinct sound from the inhalation treatment was emitted. In the final phase, a new toy was presented to the child. Each phase lasted for at least 20 s. After this period, the experimenter showed the child a new object. When this object had attracted the attention of the child a new phase was considered initiated. The child was videotaped for the entire procedure. Before parents were debriefed and thanked for their participation, the investigator asked them background questions regarding their child's medication, previous hospital admissions, etc.
Both parents were present during testing for 16% of the children, only mothers were present for 68%, and only fathers were present for 16%. The child was brought to testing by another parent than the one accompanying the child to the ED in nine (5%) cases.
Measures
The children's distress was scored from videotapes using four behavioral measures. One trained research assistant scored all children on all four measures. A second assistant scored a sub-sample (55%) of the children on a VAS, and a reduced COMFORT scale and a third assistant scored a sub-sample (25%) on two new behavioral measures. All three assistants were blind to child group and retention interval.
The VAS
First, distress was rated using a global VAS, based on global facial expressions and other observable signs of distress such as body movement and crying. VAS distress scores were measured on an unmarked 100 mm ruler, where 0 was no distress and 100 was the worst possible distress. The VAS was scored based on children's overall behavior in the first 20 s of each phase of the procedure. The rational for using VAS in this study was the fact that it is an extensively used measure of pediatric pain and distress in clinical practise. While global rating scales, like the VAS, may be subject to various observer biases in the absence of objective criteria, these measures may be used as a criterion for validation of more complex measurement scales as was the case in this study (von Baeyer & Spagrud, 2007). Inter-rater reliability was assessed for the VAS scores in each phase; mean intraclass correlation (ICC) value was.65, which is substantial (Landis & Koch, 1977).
The Reduced COMFORT Scale
Distress was also measured with a reduced version of the COMFORT scale (Ambuel, Hamlett, Marx, & Blumer, 1992). The COMFORT scale is a well-studied instrument that has been shown to have desirable psychometric properties with distributions that accommodate extremes of both high and low distress, high internal consistency and is highly correlated with clinical judgements of children's distress (von Baeyer & Spagrud, 2007). The scale was originally developed to measure postoperative distress and pain in children, and for the current study only two of the behavioral distress variables from the scale were applicable. These variables were Calmness and Facial tension, both rated on a verbally anchored scale from 1 (calm/facial muscles totally relaxed) to 5 (panicky/facial muscles contorted and grimacing). On this scale, the summed score ranged between 2 and 10. For the reduced COMFORT-scale scores, mean ICC-value for the two raters was.76.
In addition, distress was rated on a new behavioral measures with two subscales: an Avoidance/Fear scale and an Approach/Contact scale (for detailed descriptions see below).
A New Measure of Children's Behavioral Distress
No existing scales have been constructed to meet the specific needs of assessing psychological distress in the absence of pain in children under the age of 1 year. To develop a scale suitable for children up to 3-years old, potential scale variables were first identified by reviewing the behavioral science and medical literature on assessments of pediatric pain and distress (Ambuel et al., 1992; American Academy of Pediatrics, 2001; Humphrey, Boon, Van Linden, van den Heuvell, & van de Wiel, 1992; Jay, Elliott, Ozolins, Olson, & Pruitt, 1985; Katz et al., 1980, 1981; McGrath, 1998; von Baeyer & Spagrud, 2007). Moreover, informal interviews were conducted with experienced pediatric nurses to identify the behaviors they use to assess patient distress. As described in the introduction, the current study focused on the behavioral component of children's responses to aversive stimuli (agitated, movement, grimacing, crying, avoidance, etc.). However, based on the literature review and the interviews, we hypothesized that children's distress may not only be indicated by behaviors directly signaling fear or avoidance, but also by behaviors indicating a "shutdown of activity" (McGrath, 1998). That is, a lack of contact with and approach towards the environment which has been repeatedly described as a reaction to distress and pain in infants similar in its behavioral manifestations to depression (Bowlby, 1951; McGrath, 1998).
Thirteen behavioral variables were tentatively selected to cover the two behavioral categories: Avoidance and fear (AF) behaviors—turning head away, pressing backwards, climbing backwards, climbing to get down, grimacing, and crying; Approach and contact (AC) behaviors—turning head forward, eye contact, smiling, reaching for object, touching object, holding object, and manipulating object. The thirteen behaviors were coded as present or absent for every other second during the first 20 s of each phase of the procedure. Preliminary analyses showed that three of the AF behaviors (pressing backwards, climbing backwards, and climbing down), and two of the AC behaviors (turning head forward and reaching for object) did not produce enough variability to calculate inter-rater agreement (for the three AF behaviors too few children exhibited the target behaviors and for the AC behaviors too many children did), and hence these behaviors were dropped from the measures. The remaining eight behaviors were summed to construct two indices. Scores ranged between 0 and 30 on the AF index, and between 0 and 50 on the AC index.
As shown in Table II, rater agreement is demonstrated by the high ICC-values for the total AF score (ICC =.80), and for the total AC score (ICC =.98). Some individual scale dimensions have lower, but significant inter-rater correlations (ICC =.62–.99, n = 43, p <.001). Internal consistency for both scores is high.78 and.72, respectively. However, on the AC scale, two of the items, eye contact and smiling, stand out as having low correlations with the adjusted total score.
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Regarding validity, total AF score correlated significantly in all four phases with the global VAS score (r =.56–.90, p <.001) and with the reduced COMFORT score (r =.24–.63, p <.01). In all four phases, total AC score was negatively related to global VAS score (r = –.18 to –.34, p <.05), and to the reduced COMFORT score (r = –.20–.43, p <.05).
A principal component analysis of the Avoidance/Fear behaviors showed that all three loaded highly on one single factor (turning away =.79, grimacing =.90, crying =.87). Eigenvalue for this factor was 2.20, and it accounted for 73% of the total variance. Factor analysis of the Approach/Contact behaviors revealed a two-factor structure (Eigenvalues 2.90 and 1.19, respectively) that together accounted for 82% of the variance. The first factor, approach behaviors, included touching, holding, and manipulating object (factor loadings =.98.97.95, respectively). The second factor, contact behaviors, included eye contact and smiling (factor loadings =.81 and.72, respectively).
Statistical analyses
Demographic data were compared between groups with 
2-analyses (categorical data) and t-tests (continuous data). The main analyses compared difference scores (scores in mask phase, mask + oxygen phase, and toy phase, baseline values substracted from each test phase score, respectively) in the four distress measures (VAS, reduced COMFORT, AF, and AC scores) as a function of child group, test phase, retention interval, and child age. Preliminary analyses including the variables distress during treatment, nurse during treatment, child gender, and parent gender as covariates showed no significant effects of these factors on any of the dependant measures, and they were hence dropped from subsequent analyses. Furthermore, an analysis of variance (ANOVA) showed that there were no significant differences in initial distress between different types of control treatments.
Following the recommendations of several authors (Cohen & Cohen, 1983; Gully, 1994; Hollenbeck, Ilgen, & Sego, 1994) regarding analyses with mixed (both between and within factors) designs with a continuous predictor in the model (age in the current study), the present data were analyzed with a method that divides the total variance into within and between components while maintaining regression's advantages of allowing a continuous predictor variable. As a first step in the analysis, a repeated measures ANOVA was conducted for each of the four distress measures. In this analysis, child group and retention interval were entered as between-subject factors, difference scores for each test phase (mask, mask + oxygen, toy) were entered as a repeated measure, and child age as a covariate. Custom models were then built to produce all possible interaction terms between variables. Child age was centered before the interaction terms were built to avoid artificial multicollinearity (Aiken & West, 1991). Significant interactions were followed by simple slopes regression analyses. Only interaction effects involving child group are reported.
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Results |
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Demographic data for the 172 children who completed the study are summarized in Table I. There were no differences between children in the inhalation versus control group with respect to age, gender, or distress at treatment, all p >.10. Children tested 1 week versus 6 months after admission to the ED were also similar with respect to gender and distress at treatment, all p >.10. There was a difference between children tested after 1 week versus 6 months in age at treatment, p <.05. Follow-up analyses showed that children treated with inhalation and tested after 6 months were slightly younger than the control group tested after 1 week, p <.05, while age was comparable across all other groups, p >.10.
Raw scores and difference scores on the four measures for children in the different groups are presented in Table III. The repeated measures ANOVAs revealed significant main effects of child group on the reduced COMFORT scale scores [F(1,164) = 9.92, p =.002, 
=.06], on the VAS scores, [F(1,164) = 10.67, p =.001, =.06], and on the AF scores [F(1,164) = 5.53, p =.02, =.03]. On all four scores there was a main effect of test phase; COMFORT [F(2,328) = 44.74, p <.001, =.21], VAS [F(2,328) = 21.36, p <.001, =.12], AF [F(2,328) = 7.13, p =.001, =.04], and A/C [F(2,328) = 39.06, p <.001, =.19]. There was also a main effect of child age on the VAS [F(1,164) = 7.77, p =.006, =.04], and on the A/F scores [F(1,164) = 11.68, p =.001, =.07].
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The main effects were moderated by significant two-way interactions between child group and test phase on three of the distress measures; COMFORT scores [F(2,328) = 3.28, p =.04,
=.02], VAS scores [F(2,328) = 6.52, p =.002, =.04], and A/F scores [F(2,328) = 5.43, p =.005, =.03]. In addition, there were significant interactions between child group and retention; COMFORT [F(1,164) = 5.53, p =.02, =.03], VAS [F(1,164) = 7.70, p =.006, =.04], and A/F [F(1,164) = 8.11, p =.005, =.05]. Effects on these three scores were further qualified by three-way interactions between child group, test phase and retention; COMFORT scores [F(2,328) = 3.37, p =.04, =.02], VAS scores [F(2,328) = 4.16, p =.02, =.02], and A/F scores [F(2,328) = 4.23, p =.02, =.02]. These main and interaction effects revealed that children treated with inhalation had higher distress levels relative to baseline than children in the control group, that this difference between groups occurred when the children were presented with the mask, and with the mask + oxygen, but not when they were presented with a toy. Moreover, the difference between children in the inhalation and control group in the two critical phases occurred only when the children were tested 1 week but not 6 months after their treatment at the ED.
On two of the distress measures, there was also a significant four-way interaction, indicating that the difference obtained after a retention interval of 1 week between children in the inhalation and the control group when presented with stimulus cues from the inhalation treatment occurred for older, but not for younger children; VAS scores [F(2,328) = 3.49, p =.03, =.02] and A/F scores [F(2,328) = 4.57, p =.01, =.03].
Using the procedures described by Aiken & West (1991), the interactions were decomposed by using simple slopes analyses. These analyses tested the simple slopes representing the effect of child group in each test phase within each retention interval and evaluated separately for children aged 78, 60, 40, 30, 20, and 12 weeks at the target visit to the ED, respectively. The results of the simple slopes analyses are summarized in Table IV. Predicted values of difference scores at presentation of the mask and oxygen for children in the two groups as a function of age and retention interval are presented in Fig. 2a–c.
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One-week Retention
As can be seen in Table IV, children treated with inhalation a week before the test exhibited higher distress scores relative to baseline than the control group on the reduced COMFORT scale when presented with the mask and/or with the mask + oxygen, regardless of age at treatment. In the final toy phase, there were no differences between the groups on this scale at any treatment age. On the VAS, the children treated with inhalation had higher distress difference scores than the controls in both critical phases, but also in the last toy phase, when the treatment age was 78, 60, and 40 weeks. On this scale, there was also a tendency towards higher distress scores in the critical phases for the treated children among those with a treatment age of 30 weeks. Children younger than 30 weeks, when treated with inhalation did not differ from controls in distress level on this scale. On the A/F scale, children treated with inhalation scored higher in distress than controls in both critical phases when they were 78, 60, and 40 weeks at treatment, whereas no difference between groups was found for younger children on this scale. In the final, toy phase, there were no differences between the groups on this scale at any treatment age.
Six-month Retention
The simple slopes analyses revealed no differences between the control group and children treated with inhalation on any of the distress scales at any age or in any test phase.
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Discussion |
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In this study, children's memory for the target event of inhalation of salbutamol through a face mask was assessed by blinded raters who used different distress measures to describe children's reactions when later exposed to the face mask and the sound of an oxygen tube turned on. The results suggest that preverbal children may recognize and react aversively to stimuli that they have been exposed to previously during stressful medical interventions. They also suggest that the strength of such effects are dependent on age and that effects decline with time between exposure and testing.
During recent decades a number of laboratory studies have demonstrated that preverbal children do have an ability to learn and understand the logic of complex novel situations (Bauer, 2005, 2006; Hartshorn et al., 1998; Hayne, Boniface, & Barr, 2000; Rovee-Collier, 1997). This study provides a link between these laboratory paradigms and the clinical situation by offering systematic evidence that participation in a nonpainful but stressful medical procedure such as inhalation also involves learning. The results should challenge researchers and clinicians to develop knowledge and skills necessary to use this learning to the advantage of the patient. For instance, one clinically important issue would be to investigate whether repeated inhalation will further increase the distress perceived by the child or if the child will learn to accommodate to the situation.
The results further offer systematic support for the widespread clinical intuition that stressful life experiences in preverbal children may cause discernable behavioral reactions when the child is later exposed to similar stressful stimuli. Variants of this idea has historically been proposed within a number of widely different theoretical frameworks such as behaviorism (Watson & Rayner, 1920), attachment theory (Bowlby, 1951), and cognitive psychology (Howe, Courage, & Peterson, 1994) but has relied mainly on anecdotal evidence. At the same time, our finding that the effects seem to fade over time seems inconsistent with some of the more extreme claims made within these traditions.
Two of the main outcome variables in the present study showed significant effects of age: younger children demonstrated weaker effects of prior exposure to inhalation on subsequent exposure to the inhalation device than older ones. This finding is consistent with previous observations based on clinical experience (Everard, 2003). Similar age differences for various aspects of memory performance have furthermore, with som notable exceptions (Brainerd, Reyna, & Ceci, 2008) been a fairly consistent finding across a number of studies in both verbal and nonverbal children (Bauer, 2005, 2006; Ceci & Bruck, 1993; Courage & Howe, 2004; Hartshorn et al., 1998; Hayne, Boniface, & Barr, 2000; Lindholm, 2005; Rovee-Collier, 1997; Sjöberg, 1995).
From a theoretical point of view, it should be noted that our findings of age-related differences in memory performance and loss of the memory after a 6-month retention interval are reminiscent of findings made in studies of declarative memories for nonstressful events in infants and toddlers (Bauer, 2005; 2006; Courage & Howe, 2004; Hayne, Boniface, & Barr, 2000; Rovee-Collier, 1997). This suggests the possibility that stressful preverbal memories unlike memory for pain may be categorically similar to nonstressful declarative memories.
In this study, mean distress score at the initial treatment for children in the inhalation group was 44 on a 100 point scale, confirming previous observations of inhalation as a potentially stressful medical procedure for young children (Amirav & Newhouse, 2001; Noble, Ruggins, Everard, & Milner, 1992). Preliminary analyses revealed no effects of distress level at initial inhalation episode on subsequent reactions to inhalation related stimuli. However, this study was primarily designed to detect effects of exposure versus nonexposure to inhalation. Detection of dose response relationships may require more variation in initial stress exposure than the stimuli chosen in the present study had to offer.
This study has several strengths, such as its controlled and prospective design and the relatively large sample size. Furthermore, the risk of influencing memory by reinforcement was controlled for by testing each child only once even though the design covered a period of 6 months. Raters of the independent variables were blind to the children's group. However, for obvious ethical reasons it was not possible to blind the parents who were also present while the children were tested. One potential subject for future studies may be to include measurements of parental distress and how that may relate to child behavior.
In this study, we chose to study children's memories at 1 week and 6 months after the target procedure, respectively. The 6-month follow-up was chosen because similar intervals have frequently been used in high profile studies on infant pain (Taddio et al., 1997). Even though this study did not directly compare memories for pain with memories for distress, the use of similar retention intervals might facilitate fruitful discussions of parallels and differences between these kinds of studies. The 1 week retention interval was decided on since evidence of memories for neutral events in infants over this period of time exists (Hartshorn et al., 1998). Additional follow-ups between the 1-week and 6-month period could have been interesting, but not possible due to limitations of resources
When the present study was designed we found that there was a lack of validated behavioral instruments for measuring children's distress. The VAS that was used by nurses for measurement of distress is very common in clinical use, but lacks solid psychometric validation. We also designed an instrument for measurement of behavioral distress that proved useful and reliable from a psychometric perspective. However, this instrument will need further exploration in future studies. In addition, it should be noted that until standardized reference values on the measures used are available for different age groups, there is always a possibility that age-related differences detected by these measures may reflect different sensitivity of the measures on different age groups.
In sum, the present study demonstrates that distress during medical procedures in infants and toddlers may be influenced by prior experiences of nonpainful, but potentially stressful medical procedures, although these effects seem more pronounced in children at least 6-months old. The findings highlight the importance of clinicians being aware of the potential psychological impact of a medical intervention even in young children who have not yet developed the ability to speak.
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Acknowledgment |
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This research was supported by Grant F0612/2001 from the Swedish Research Council to T.L.
Conflicts of interest: None declared.
Received November 13, 2007; revision received May 24, 2008; accepted May 31, 2008
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