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From the *Center of the Advancement of Perioperative Health® and the Departments of Anesthesiology, Pediatrics, and Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut and the Depatment of Anesthesiology, University of California Irvine, Irvine, California.
Address correspondence and reprint requests to Zeev N. Kain, MD, MBA, Department of Anesthesiology, University of California Irvine, 101 The City Drive South, Orange, CA 92868. Address e-mail to kain{at}perioperativehealth.org.
Abstract
We compared anxiety in mothers of children undergoing ambulatory surgery with female patients undergoing surgery themselves. We found that mothers were as anxious as patients undergoing major abdominal surgery and more anxious than patients undergoing minor surgery. Predictors of maternal anxiety were child age and maternal monitoring coping.
High parental preoperative anxiety is associated with high perioperative anxiety in children undergoing surgery.1,2 Given that high preoperative anxiety in children is associated with multiple adverse outcomes, such as emergence delirium, maladaptive behavioral changes, and increased postoperative pain,3,4 there is a clear need to address parents' perioperative anxiety as its own entity. Indeed, one randomized controlled trial has documented that reduction of parental perioperative anxiety can result in reduction of children's perioperative anxiety.5
Despite its link with child anxiety, little is known about the degree to which parents experience anxiety before their children's surgery. For example, it is unknown whether parents are as anxious when their child undergoes surgery as they would be if they were undergoing surgery themselves. Given that this question cannot be answered using typical randomized experimental methods, we used a cohort-controlled design to examine the magnitude of anxiety of mothers whose children were undergoing surgery compared with adult females undergoing surgery themselves. As a secondary aim, we examined predictors for parental anxiety. Although previous studies have evaluated this issue, none has used multivariate regression models to identify independent contributors.6–8
METHODS
Over the past several years members of the Center for the Advancement of Perioperative Health (CAPH) have conducted a number of studies related to perioperative anxiety in children, parents, and adults undergoing surgery. The Yale IRB approved all studies, and informed consent was obtained from all participants. Data from these studies are combined in a central database that is updated weekly and that now contains several thousand subjects. The present investigation includes only mothers and female adults to avoid gender as a potential confound. All subjects in this report were ASA physical status I or II and had no history of chronic illness, psychiatric illness, or developmental delay. Based on these criteria, data from 12 present and previous studies conducted by our laboratory are included.4,9–17 All children in the studies underwent outpatient minor surgery (e.g., herniorrhaphy, tonsillectomy) and adults underwent either outpatient minor surgery (e.g., herniorrhaphy, tonsillectomy) or inpatient major surgery (abdominal hysterectomy).
Data were collected about 1 h before surgery in the preoperative holding area. Adult patients and mothers completed demographic information and measures of anxiety. Mothers also completed measures of child temperament and adult copying style. The same research team administrated all the psychological instruments ensuring consistency across pediatric and adult studies. None of the adult patients or mothers received anxiolytic interventions before surgery and none underwent a preoperative preparation program. The following instruments were given to the subjects to complete: EASI instrument of child temperament,18 this parental report instrument assesses four child temperament categories, emotionality, activity, sociability, and impulsivity. State trait anxiety inventory,19 this self-report anxiety behavioral instrument consists of two separate 20-item subscales that measure trait (baseline) and state (situational anxiety). The state trait anxiety inventory shows excellent validity and reliability. This tool is considered the "gold standard" in the assessment of adult anxiety in clinical settings. Miller behavior style scale (MBSS),20 this standardized instrument assesses coping style in adults using responses to four scenarios of stressful situations. Eight potential responses to each situation are presented and adults are asked to endorse which one or more of these strategies they would use in response to the situation. Four responses to each situation are monitoring responses. These responses are indicative of a coping style in which an individual seeks information about the stressful situation and attends to threatening cues in the situation. For example, in response to a feared dental situation, adults might respond that they would "watch all the dentist's movements and listen for the sound of the drill." Four responses to each situation are blunting responses. These responses are indicative of a coping style in which individuals attempt to distract themselves from or avoid information associated with the situation. In the dentist example, an individual might respond that they would "try to sleep" or "think about pleasant memories." The MBSS provides two scores: total monitoring score and total blunting score. The MBSS has been widely used in studies of coping in medical situations and has been found to be related to perception of threat in ovarian cancer screening,21 regret after breast reconstruction,22 and response to cancer rehabilitation.23
Continuous data are reported as means and standard deviations and are analyzed using Pearson correlations, t-tests, and analyses of variance (ANOVA). Where appropriate, covariates were included in ANOVA, and Tukey honestly significant difference (HSD) tests were used to follow-up significant ANOVA results. This post hoc procedure controls for family-wise error by "fixing the error rate at 
for all possible null hypotheses, not simply the one being tested."24,p377 Nominal and ordinal data are reported as frequencies and are analyzed using 
2.
RESULTS
Data from 353 mothers and 277 female patients were collected in the studies used above. Data were matched for age for use in this report (Table 1). Mothers and female patients were matched for age and did not differ significantly on years of education or trait anxiety. Significantly more mothers than female patients were married, thus marital status is used as a covariate in comparison analyses.
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Magnitude of Maternal Anxiety
Using a one-way ANCOVA with marital status as a covariate, there was no overall difference in the state anxiety of mothers of children undergoing surgery and women undergoing surgery themselves (43.9 ± 10.8 vs 43.3 ± 11.2, P = ns). The type of procedure was available for a subset of adult patients (n = 218). A one-way ANCOVA (with marital status included as a covariate) comparing anxiety levels of women undergoing minor surgery, major surgery, and mothers of children undergoing minor procedures was significant, [F(2,541) = 4.49, P < 0.02; Fig. 1]. Using this method, mothers of children undergoing minor surgery were significantly more anxious than women undergoing minor surgery, but did not differ from patients undergoing major surgery (P < 0.01).
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Predictors of Maternal Anxiety
Bivariate correlations were conducted between parent and child baseline and demographic variables and maternal preoperative anxiety. We found that younger mothers, mothers who scored higher on monitoring coping and mothers of younger children were more anxious (P < 0.05). There were no significant relations between maternal anxiety and any child temperament variable (emotionality, activity, sociability, or impulsivity). There were also no significant relations between maternal anxiety and child gender, child history of surgical experience or chronic illness, and maternal years of education.
A stepwise multiple regression was used to evaluate the relative contributions of the significant univariate predictors of state anxiety. Parent age, monitoring coping, and child age were entered into a model predicting parent state anxiety using a forward stepwise procedure with a probability of F to enter as 0.05. The final model included only child age and maternal monitoring coping style as predictors (P < 0.05).
DISCUSSION
We found that mothers of children undergoing minor outpatient surgery are more anxious than women undergoing minor surgery themselves, but equally as anxious as women undergoing major abdominal surgery. Hence, mothers appear to be more concerned with their children undergoing surgery than women undergoing surgery themselves. This finding is not unexpected, as our laboratory previously demonstrated that mothers desire significantly more perioperative information regarding their child's surgery than adult patients undergoing surgery themselves.25
Maternal preoperative anxiety is of particular importance for the anesthesiologist, as increased maternal anxiety has been shown to result in increased child anxiety1,2 and this increased anxiety is associated with multiple adverse outcomes, such as emergence delirium, maladaptive behavioral changes, and increased postoperative pain.3,4 Although a number of pharmacological and behavioral interventions are available to reduce children's anxiety, there is a paucity of interventions directed toward reduction of parental anxiety. Although preoperative preparation programs have been demonstrated to be effective in treatment of parental anxiety on the day of surgery,26 these programs can be very expensive and a recent report indicates that most children and parents undergoing day surgery do not receive preparation.27 Thus, there is a need for the development of inexpensive alternative treatment modalities, such as videotapes. Indeed, Cassady et al. reported that a preoperative educational videotape can improve parental knowledge and decrease parental anxiety before pediatric ambulatory surgery.28 We strongly advocate the use of interventions such as these for all parents of children undergoing surgery.
We also found predictors of mothers' anxiety; specifically, we found that mothers who were high on monitoring coping and mothers of younger children were more anxious before their child's surgery. The finding of maternal coping style has not been reported in the perioperative literature, but is in line with general findings that women who are frequent monitors are more medically anxious.29 In a clinical context, practitioners may be able to identify frequent monitoring mothers by their high degree of information-seeking behavior and thus may be able to specifically target these mothers for anxiety-reduction interventions. Anxiety-reduction interventions could include a higher degree of procedural information (in line with these mothers' coping styles), training in anxiety reduction strategies (relaxation, imagery), or targeted distraction strategies (availability of reading materials, television, etc).
Interestingly, previously reported predictors such as maternal age were not found to be independent predictors in this multiple regression. Further, children's prior surgery status (i.e., had prior surgery/did not have prior surgery) did not predict maternal anxiety. This lack of relation may have been due to the dichotomous nature of this variable. There may have been a relation between quality of past experience and maternal anxiety that could not be assessed here.
It is notable that all data used for this report were obtained from subjects who were part of various current and past studies conducted by the same investigators at CAPH. The data available across these studies allow for some comparison of the match between mothers and patients, although a full demographic comparison was beyond the scope of this study. Because of the similarity across methods used at CAPH we do not believe that the quality of the data is thereby hindered by combining data.
In conclusion, results of this study are indicative of the importance of addressing maternal anxiety in the pediatric perioperative context. Although there has recently been increased attention on interventions for children's perioperative anxiety,30 parent anxiety is generally treated as a secondary rather than primary outcome and more attention should be directed to this important outcome.28,31
Footnotes
Accepted for publication November 13, 2007.
Supported, in part, by the National Institutes of Health (R01-HD037007-04 and R0-1HD048935-01A1), Bethesda, MD.
REFERENCES
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