1. Developmental aspects of peri-operative anxiety Daniela Hearst Consultant Clinical Psychologist Great Ormond Street Hospital for Children, London May 21 ‘09

2. Pre-operative Anxiety why does it matter? children’s concepts of illness and procedures - developmental changes interventions to reduce anxiety

3. Anaesthesia 4 million children per year undergo anaesthesia and surgery in USA 40-60% experience anxiety 25% needed physical restraint Non compliance: 16 - 48% for intravenous induction Non compliance: 8 - 58% for inhalation induction Kain & Caldwell-Andrews ’05, Kain & Mayes ’96, Lumley et al ’93, Meyer&Lakheera ’02, Proczkowska-Bjorklund &Svedin ‘04

4. Why does it matter? immediate post-operative effects - more painful, slower recovery - increased use of pain medication - more post-operative delirium and agitation - increased sleep difficulties behavioural changes - 54% children (Kain et al, 1994)

5. Behavioural changes anger, aggression, disobedience nightmares separation anxiety eating problems, enuresis fear and distrust of doctors lack of cooperation with subsequent procedures (Kain et al, 1999)

6. Why does it matter? high parental anxiety staff distress delays to surgical lists potential waste of resources child and family’s quality of life

7. What do children get anxious about? anticipated separation from parents pain unpleasant smells, tastes, sensations loss of control, death, waking up during procedure procedure as intrusive/an assault damage to body environment, equipment Kain et al, 2000

8. Children It does not get better with time

9. Children Children do not usually develop coping strategies by themselves

10. Developmental Perspective child’s age at diagnosis can inform us of: - developmental skills acquired before onset of illness - how long family life was free of illness-related anxieties - have parents had time to develop confidence in their parenting skills?

11. Adaptation to Illness dealing with pain, discomfort and incapacity dealing with hospital and relationships with staff preserving a positive self-image preserving a normal life preparing for an uncertain future

12. Children’s Concept of Illness 0-2 years little understanding 3 - 5 years magic or punishment 6– 11 years germs (contagion) 11-15 years malfunction 16 + psychological stress/complex contributing factors

13. Concept of illness: 0-2 yrs probably little understanding baby responds to parent’s anxiety, sadness, anger illness symptoms experienced as caused from outside, in the here and now unfamiliar adults can provoke anxiety baby can develop fear reaction in response to painful procedure

14. Interventions comforting soothing distraction supporting parents transitional object – blanket, teddy 0-2 years:

15. Concept of illness : 3-5 yrs concrete thinking based on direct experience, illogical, magical thoughts very egocentric health and illness seen as separate entities pain attributed to external causes can’t distinguish illness from side effects of treatment threat of pain can feel overwhelming, little concept of future time immediate physical sensations can generalise to fear of painful situations

16. How anxiety is expressed 3-5yrs elevated distress even before procedure begins agitation, withdrawal, panic, tantrums resistance – be prepared for kicks

17. Interventions brief, non-technical explanations concrete: where, how, when sensory information: see, hear, taste, smell,feel play, use of dolls, teddy 3-5 years :

18. Concept of illness: 6-10 yrs more sophisticated thinking but still concrete and literal health still perceived as mainly under the control of others illness viewed as multiple symptoms caused by germs or dirt – contagion theory death seen as irreversible, personalised

19. How anxiety is expressed 6-10yrs may regress to earlier more egocentric thinking tantrums, separation anxiety high distress, loss of self–esteem self consciousness, embarrassment, frightening fantasies of damage

20. Interventions understanding reasons for procedure enhancing feelings of control coping strategies: distraction, relaxation positive self-talk specified goals and rewards play preparation, story books, photos 6-10 years:

21. Concept of illness: 11-16 yrs mature, adult comprehension, logical reasoning understanding of multiple causes, exacerbated by emotions and stress illness has an end-point still egocentric, assumes everyone sees things their way

22. How anxiety is expressed: 11-16yrs anger, defiance, confrontational behaviour desire to have central role in decision- making shyness and embarrassment about physical examination or exposure of body

23. Interventions maximise privacy- physical and emotional enhance sense of control and self- efficacy participation in decision-making teach coping skills 11-16+ years

24. Interventions sedative premedication parental presence during induction preparation programmes music therapy acupuncture hypnotherapy

25. Parental presence Parents’ behaviour accounts for up to 53% of child’s behaviour/distress for infants and toddlers for older children with CALM parents who reinforce coping strategies (Caldwell-Andrews et al ’05, Kain et al ’06)

26. Parental presence Helpful: Non-procedural talk, humour, support, encouragement with coping strategies Unhelpful: apologising, criticising, bargaining, bribery, giving explanations during procedure

27. Predicting distress 4-7 yrs No. previous GAs EAS Emotionality scale 8-11yrs Age CSWQ predict difficulty with induction Cropper et al (in preparation)

28. Induction type For both age groups Statistically significant difference: Induction by inhalation associated with higher levels of distress

29. Things to consider involvement of ward play specialist preoperative clinics protocols of care developmentally appropriate explanations and communication

30. Protocol: Adapted from RCPU, Duff, ‘03

31. Children :

32. What works procedural information sensory information teaching coping strategies, refocusing attention presence of CALM parents who play an active role

33. What you can do use of questionnaires at pre-op clinics to identify those children most likely to have a difficult induction. FIND OUT WHAT CHILD KNOWS ASK THE CHILD targeted play preparation and teaching coping strategies

34. What you can do remove frightening equipment give info at developmentally appropriate level one person at a time should speak to the child use a quiet tone with slow delivery of speech

35. What you can do be aware of how anxiety can be provoked be aware of non verbal cues conveying impatience, frustration eg frowning, crossing arms tell child what he/she can do, not what they can’t

36. What you can do increase child's sense of control by giving choice offer child opportunity to handle equipment record behaviour at induction and management