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PEDIATRIC ANESTHESIOLOGY

Initial Validation of a Numeric Zero to Ten Scale to Measure Children's State Anxiety

Margie Crandall, RN, PhD^*, Cathy Lammers, MD, Craig Senders, MD, Marilyn Savedra, DNS, and Jerome V. Braun, PhD^||

From the Department of *Patient Care Services, Anesthesiology and Pain Medicine, Otolaryngology, University of California, Davis, Health System; Department of Family Health Nursing, University of California, San Francisco; and ||Department of Statistics, University of California, Davis.

Address correspondence to Margie Crandall, RN, PhD, University of California, Davis, Health System, The Center for Advancing Nursing Research and Clinical Practice, N-4 Nursing Administration, 2315 Stockton Blvd., Sacramento, CA 95817. Address e-mail to margie.Crandall{at}ucdmc.ucdavis.edu.

Abstract

BACKGROUND: Although children experience physical and behavioral consequences from anxiety in many health care settings, anxiety assessment and subsequent management is not often performed because of the lack of clinically useful subjective scales. Current state anxiety scales are either observational or multidimensional self-report measures requiring significant clinician and patient time. Because anxiety is subjective, in this pilot study, we evaluated the validity of a self-report numeric 0–10 anxiety scale that is easy to administer to children in the clinical setting.

METHODS: A descriptive correlation research design was used to determine the concurrent validity for a numeric 0–10 anxiety scale with the state portion of the State-Trait Anxiety Inventory for Children (STAIC). During clinic preoperative visits, 60 children, 7–13 yr, provided anxiety scores for the 0–10 scale and the STAIC pre- and posteducation. Simple linear regression and Pearson correlation were performed to determine the strength of the relationship.

RESULTS: STAIC was associated with the anxiety scale both preeducation (ß = 1.20, SE[ß] = 0.34, F[1,58] = 12.74, P = 0.0007) and posteducation (ß = 1.97, SE[ß]) = 0.31, F[1,58] = 40.11, P < 0.0001). Correlations were moderate for pre-education (r = 0.424) and posteducation (r = 0.639).

CONCLUSIONS: This initial study supports the validity of the numeric 0–10 anxiety self-report scale to assess state anxiety in children as young as 7 yr.

Anxiety is a common symptom that children experience in the health care setting. Yet, despite the physical and behavioral consequences that anxiety may cause, it is not often assessed, and subsequently undertreated. A major factor affecting clinicians' assessment of children's anxiety and management is the lack of clinically useful scales. In this study, children's anxiety is defined as state anxiety and refers to a transitory emotional state of anxiety that a child feels at a particular moment that is normally evoked in children experiencing stressful situations (1).

Previous studies suggest that there are numerous causes for children's heightened anxiety in various health care settings (e.g., clinic, emergency department, and various hospital environments), supporting the need for a clinical tool to assess children's anxiety in these settings. Causes for children's heightened anxiety include their anticipation of pain, experience of intense pain, fear of the unknown, loss of control, perceived stressful environments, gender, separation from parents and family, parenting style, and/or parental anxiety (2–5).

Assessment of a child's anxiety and subsequent symptom management alleviates the physical and behavioral costs that children experience as a consequence of their anxiety, including perceptions of higher pain intensity, greater analgesic use, poor quality of sleep, higher incidence of emergence delirium, difficult procedural sedation, postoperative behavioral changes, and caregivers' perceptions of inferior quality of care (3,6–8). Therefore, assessing a child's anxiety preprocedure provides clinicians additional information for individualizing a child's pharmacologic and nonpharmacologic symptom management (e.g., anxiolytics, presence of family and friends, distraction, imagery).

Because anxiety is subjective, whenever possible, a clinician's assessment of a child's self-report of anxiety is preferred (9). Current children's state anxiety scales include observational measures (10) or self-report scales composed of multiple response items (11) that require significant patient and/or clinician time to administer in the clinical setting. Therefore, the purpose of this pilot study was to evaluate the validity of a self-report numeric 0–10 anxiety scale that is easy to administer to children in various clinical settings. Reports from this study are part of a larger unpublished study investigating the clinical outcomes of preoperative pain education for children that included anxiety measurements pre- and posteducation.

METHODS

Once the study received approval from the hospital's IRB, parental consents and child assents were obtained. Children, 7–13 yr, scheduled for tonsillectomy and/or adenoidectomy were recruited at a university children's hospital ENT clinic. Inclusion criteria were that the child was able to speak and read English, and had no history of neurological impairments (i.e., developmental delay, hearing or visual impairments). Demographic information was provided by the parent.

Children completed both the state anxiety portion of Spielberger's State-Trait Anxiety Inventory for Children (STAIC) (1) and a numeric 0–10 anxiety scale before and after their preoperative education. STAIC is a standardized self-report scale used to measure state and trait anxiety levels in children and is appropriate for children kindergarten through sixth grade (12). Only the 20 item "How I feel right now" state anxiety scale was used to measure situational anxiety. Scores range from 1 to 3 for each of the 20 scale items. Therefore, total continuous scores range from a minimum of 20 to a maximum of 60. Higher scores indicate increasing levels of anxiety. Evidence of reliability and validity are reported (1).

Because children as young as 5 yr can provide self-reports of pain intensity using a numeric pain scale (13), and numeric pain scales are commonly used in clinical practice to measure pain intensity, a numeric 0–10 anxiety scale was developed. The scale comprises numbers from 0 to 10 with word anchors, 10 cm long, aligned horizontally (Fig. 1). Word anchors on the anxiety scale were modeled after a pediatric word graphic pain rating scale (14). Words describe different levels of anxiety or nervousness with "0" for not at all, "2" for a little, "5" medium, "8" a lot, and "10" worst imaginable.

View larger version (4K): [in this window] [in a new window]   Figure 1. Numeric 0–10 State Anxiety Scale.

Anxiety scores were obtained before and after preoperative education. All children received standard preoperative education that included a general description of the location of their tonsils and adenoids, the reason for their surgery, appearances of clinicians involved in their care, and what to expect before and after surgery. As part of a larger unpublished study to measure the effects of preoperative pain education on children's clinical outcomes, 30 children were randomly assigned to receive additional preoperative pain education.

Anxiety scores were first obtained using the numeric 0–10 scale, followed by the state version of the STAIC. Using the numeric 0–10 anxiety scale, children were instructed to circle the number that best describes how anxious or nervous they felt. Following directions for the STAIC, for each of the 20-scale items, children were instructed to placed an X in front of the word or phrase, which best describes how they felt. The pre- and posteducation anxiety measures were taken approximately 20 min apart. All children stated they understood the numeric anxiety scale without difficulty. STAIC scoring was done according to recommended standards (1).

Using simple linear regression and Pearson correlation, the association of the STAIC with the numeric 0–10 anxiety scale was assessed. Goodness of fit was evaluated both graphically and by the Shapiro-Wilks test for normality of residuals. Equality of slopes pre- and posteducation was assessed using mixed model of covariance with a random effect for subjects. The Spearman rank correlations were also calculated in each case as a nonparametric alternative. Because pre- and posteducation anxiety measurements were taken under differing circumstances (i.e., standard preoperative education and randomized pain education) and state anxiety is transient, reliability test–retest are not reported.

RESULTS

Sixty children with a mean age of 10.13 ± 2.08 yr were recruited. Gender representation was equal. Although participants represented diverse ethnic groups, including Latino, African American, Asian, and of mixed race, the majority were Caucasian (57%).

For both testing times, children's numeric anxiety scores ranged from 0 to 10, with a mean of 3.4 ± 2.69 and 2.93 ± 2.8, respectively. Preinstruction Speilberger anxiety scores ranged from 22 to 56, with a mean of 32.68 ± 7.60. Postinstruction anxiety scores ranged from 20 to 59, with a mean of 31.95 ± 8.54.

STAIC was associated with the anxiety scale both pre-education (ß = 1.20, SE[ß] = 0.34, F[1,58] = 12.74, P = 0.0007) and posteducation (ß = 1.97, SE[ß] = 0.31, F[1,58] = 40.11, P < 0.0001). Figures 2 and 3 summarize the association of STAIC with the numeric 0–10 state anxiety scale, as well as showing the results of the pre- and posteducation simple linear regressions. Fit of the regression model was good for posteducation; the fit was reasonable though not as good for pre-education. However, a formal test for difference in slopes was not significant (F[1,57] = 0.17, P = 0.68). Parametric results were corroborated by nonparametric results for both preeducation (r = 0.424, = 0.515) and posteducation (r = 0.639, = 0.580).

View larger version (7K): [in this window] [in a new window]   Figure 2. Preeducation linear regression scatterplot and line of best fit comparing State-Trait Anxiety Inventory for Children (STAIC) with numeric 0–10 anxiety scale.

View larger version (8K): [in this window] [in a new window]   Figure 3. Posteducation linear regression scatterplot with line of best fit comparing State-Trait Anxiety Inventory for Children (STAIC) with the numerical 0–10 anxiety scale.

Although completing the STAIC, six children, between 7 and 12 yr, identified words from the list that they did not understand. The words were jittery (n = 5), satisfy (n = 4), pleasant (n = 2), and troubled (n = 1). Unlike the STAIC, children stated they understood all of the words on the numeric 0–10 anxiety scale. The numeric anxiety scale was completed within a minute or less, whereas the STAIC required approximately 5 min to complete.

DISCUSSION

Using both the numeric 0–10 anxiety scale and the STAIC, children reported varying intensities of anxiety during their preprocedural visit. Although the correlation between the numeric 0–10 anxiety scale and the STAIC increased slightly pre- and posteducation, this may be explained by the children's increased familiarity with the measures or to changes in the testing condition. Compared with the single-item numeric 0–10 anxiety scale, as expected, children's anxiety scales that capture multiple domains of anxiety report stronger correlations with the STAIC (10). However, the numeric 0–10 anxiety scale is clinically useful for several reasons.

Compared with other self-report anxiety scales (1,11), the numeric 0–10 anxiety scale is easy to administer in the clinical setting to quickly quantify 7–13-year-old children's levels of anxiety or changes in anxiety. Clinicians are familiar with numeric 0–10 scales, facilitating consistent interpretable communication between caregivers. The numeric scale was easily understood by children and completed quickly. In addition, this scale is modeled after the numeric 0–10 and word graphic scales, which children identified as the two most preferred single-dimensional pain scales (14).

The increased administration time of the STAIC, compared with the numeric 0–10 scale, was due to the scale's multiple response items and children's lack of understanding of specific words. In this study, the words "jittery," "satisfied," and "pleasant" were the most common words that children did not understand and is consistent with previous findings from hospitalized children (15). Although chronological age appeared not to contribute to lack of word understanding, possible explanations are children's lack of familiarity with specific words or the use of outdated words. Therefore, considering children's developing social and cognitive skills, their understanding of numbers and the use of a numeric 0–10 scale is preferred. Numbers, unlike words, are less likely to be influenced by environmental or historical factors.

In addition, this initial study suggests that the clinical use of an easy to administer numeric anxiety scale may benefit clinicians, children, and their families in a variety of settings where children encounter procedures and/or anticipate pain. Anxiety screening identifies children who are highly anxious and who benefit most from a clinician's specific symptom interventions (e.g., supportive behaviors, preparation, relaxation, imagery training). Thus, clinicians can promote children's coping and self-control (16). Clinicians' interventions that diminish children's anxiety may subsequently improve their procedural sedation and postoperative outcomes (e.g., pain, sleep, and behavioral changes).

The numeric 0–10 anxiety scale was evaluated with a small sample of children, between 7 and 13 years, in the clinic setting during their preoperative appointments. However, further testing with hospitalized children with a wider age range who experience multiple caregivers, potential and actual separation of parents and friends, and pain is warranted. In addition, the use of the self-report numeric 0–10 anxiety measure is dependent on children's cognitive development and may be less sensitive to changes or interpretability when compared with multidimensional anxiety scales. Because a written, not a verbal, 0–10 numeric anxiety scale was validated, it is not technically valid to administer the scale verbally to children. Nonetheless, the numeric 0–10 scale provides clinicians a familiar, easy, and quick assessment of children's subjective state anxiety and may be appropriate for multiple health care settings.

Footnotes

Accepted for publication July 19, 2007.

Supported by University of California, Davis, Innovative Pilot Project.

Reprints will not be available from author.

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