Analysing a family-centred preoperative intervention programme: a dismantling approach.

BACKGROUND: The goal of this project was to identify key effective components of ADVANCE, a family-centred preoperative intervention programme, through the use of a dismantling approach. ADVANCE was previously demonstrated to be more effective than parental presence and just as effective as midazolam in reducing children's preoperative anxiety. The total programme, however, may be difficult to implement in hospitals across the country. METHODS: Subjects in this follow-up dismantling report were 96 children aged 2-10 who were part of the original study and who underwent anaesthesia and surgery. Baseline characteristics, parental adherence to the components of ADVANCE, and child and parent anxiety were assessed. RESULTS: We found that greater parental adherence to the ADVANCE intervention was associated with lower child anxiety before surgery. The two components of ADVANCE that emerged as having a significant impact on children's anxiety were practising with the anaesthesia mask at home and parental planning and use of distraction in the preoperative holding area. In fact, not only did children experience significantly less preoperative anxiety when their parents were adherent to mask practise and use of distraction, their anxiety tended to remain stable and relatively low throughout the preoperative period. CONCLUSIONS: Shaping and exposure (i.e. practise with the anaesthesia mask) and parental use of distraction in the surgical setting are two beneficial components that could be included in preoperative preparation programmes that will be designed in the future.

Primary parental preoccupation: circuits, genes, and the crucial role of the environment.

Parental caregiving includes a set of highly conserved behaviors and mental states that may reflect both an individual's genetic endowment and the early experience of being cared for as a child. This review first examines the mental and behavioral elements of early parental caregiving in humans. Second, we consider what is known about the neurobiological substrates of maternal behaviors in mammalian species including some limited human data. Third, we briefly review the evidence that specific genes encode proteins that are crucial for the development of the neural substrates that underlie specific features of maternal behavior. Fourth, we review the emerging literature on the "programming" role of the intrauterine environment and postnatal caregiving environment in shaping subsequent maternal behavior. We conclude that there are critical developmental windows during which the genetically determined microcircuitry of key limbic-hypothalamic-midbrain structures are susceptible to early environmental influences and that these influences powerfully shape an individual's responsivity to psychosocial stressors and their resiliency or vulnerability to various forms of human psychopathology later in life.

Perceptions and attitudes toward prenatal cocaine exposure in young children.

OBJECTIVE: This paper investigated perceptions and attitudes toward young children believed to be prenatally exposed to cocaine. METHOD: 37 college students watched a videotape of eight children doing the same task and rated each child's performance after being told if the child had, might have been, or had not been prenatally exposed to cocaine. RESULTS: Multiple analysis of variance confirmed that when a child was labeled prenatally exposed to cocaine, the participants generally scored the child lower and less positively than it the child was thought to be possibly exposed or not exposed at all. Ethnicity and gender differences were also found. Participants rated males higher than females and African-American children higher than Caucasian children. CONCLUSIONS: Individuals who believe a child is exposed prenatally to cocaine hold more negative perceptions regarding that child's developmental abilities. These negative perceptions of a child labeled prenatally exposed to cocaine may diminish expectations for that child's developmental potential.

Sensory stimuli and anxiety in children undergoing surgery: a randomized, controlled trial.

UNLABELLED: We assessed the effectiveness of a behavioral intervention aimed at reducing the anxiety of children undergoing anesthesia and surgery. The intervention consisted of dimmed operating room (OR) lights (200 Lx) and soft background music (Bach's "Air on a G String," 50-60 dB). Only one person, the attending anesthesiologist, interacted with the child during the induction of anesthesia. Children undergoing anesthesia and surgery were randomly assigned either to a low sensory stimulation group (LSSG, n = 33) or to control group (n = 37). By using validated behavioral measures of anxiety (mYPAS) and compliance (ICC), children were evaluated at the preoperative holding area and during the induction of anesthesia. On postoperative Days 1, 2, 3, 7, and 14, the behavioral recovery of the children was assessed by using the Post Hospitalization Behavior Questionnaire. We found that the LSSG was significantly less anxious compared with the control group on entrance to the OR (P = 0.03) and on the introduction of the anesthesia mask (P = 0.003). Also, the compliance during the induction of anesthesia was significantly better in children assigned to the LSSG (P = 0.02). The incidence of postoperative behavioral changes, however, did not differ significantly between the two groups (P = ns). We conclude that children who are exposed to low-level sensory stimuli during the induction of anesthesia and who are exposed to background music exhibit lower levels of anxiety and increased compliance. IMPLICATIONS: Children are less anxious and show increased compliance during induction when exposed to a single care-provider in a dimmed, quiet operating room with background music.

The twin poles of order and chaos. Development as a dynamic, self-ordering system.

The diversity of theories regarding children's development is commensurate with the enormity of the task of seeking ordering designs for explaining behavioral and psychic ontogeny in infants, children, and adults. The purpose of this paper is to look at these developmental theories as epigenetic stages themselves. I shall suggest that the next stage in the epigenesis of theories of development is to see variability and disorder on a continuum with order and stability, as a constant dialectic that moves development along, whether at the level of the cell or at the level of fantasy. I shall explore four questions that are implicitly about development as an ordering process and about theories of development as methods for bringing order to what is an inherently messy, even chaotic. The first two questions--what does it mean to take a developmental perspective, and what does any theory of development need to explain--set the stage for the consideration of some different perspectives for thinking about development. These other perspectives, borrowed from general systems theory, focus on the interplay of order-stability and variability-instability in psychological development. The third question, asks what does a more detailed consideration of the variability or noise in development add to our current developmental perspectives? Exploring dynamic systems and self-ordering processes will lead to several fields not explicitly clinical, psychological, or even psychoanalytic, but I shall circle back to apply these ideas to psychoanalytic perspectives on development, change, and adaptation in the fourth and concluding question. What can these cross-disciplinary attitudes offer to the psychoanalytic developmental perspective, whether in the form of our theories or our work with patients?

Midazolam: effects on amnesia and anxiety in children.

BACKGROUND: The minimum time interval between administration of oral midazolam and separation of children from their parents that ensures good anterograde amnesia has not been previously determined. This is of particular importance in a busy operating room setting where schedule delays secondary to midazolam administration may not be tolerated. METHODS: Children (n = 113) undergoing general anesthesia and surgery completed preoperative baseline memory testing using a validated series of picture cards and were randomly assigned to one of three midazolam groups or a control group. Exactly, 5, 10, or 20 min after receiving oral midazolam (0.5 mg/kg) or 15 min after receiving placebo, children were administered a second memory test that used pictures. Anxiety of children was assessed during induction of anesthesia with use of a validated anxiety measurement tool. Postoperatively, recall and recognition for picture cards seen during baseline testing and postintervention testing were assessed. RESULTS: Postoperatively, recall and recognition of pictures presented to patients after drug administration (anterograde amnesia) showed significant group differences (P = 0.0001), with recall impaired in the 10- (P = 0.004) and 20-min groups (P = 0.0001). Similarly, recognition memory was impaired in the 5- (P = 0.0008), 10- (P = 0.0001) and 20-min (P = 0.0001) groups. Significant anxiolytic effects of midazolam were observed as early as 15 +/- 4 min after midazolam administration (P = 0.02). CONCLUSIONS: Midazolam administered orally produces significant anterograde amnesia when given as early as 10 min before a surgical procedure.

A developmental perspective on the regulation of arousal states.

Arousal regulation is an organizing construct for describing the relations between stimulation, stress, and cortical activity and performance. It describes a dynamic process of cortical activation and behavior in response to varying levels of stimulation. Contemporary neurobiological perspectives provide evidence that the concept of arousal regulation involves complex interactions among different neurochemical systems in the pontine and midbrain reticular formation. These interactive arousal systems serve as multilevel gates that both protect cortex from excessive stimulation and facilitate coordination between attentional, executive, and sensory cortical systems. The coordination between these systems emerges over the course of development with increasing balance of inhibitory and excitatory processes. The threshold for switching between more executive and more automatic modes of functioning also changes with development and may be particularly sensitive to early stressful and/or traumatic experiences.

The mother-child dyad facing trauma: a developmental outlook.

The effects of trauma in children are amply documented. This paper investigated the relationship between children's age and posttraumatic clusters of symptoms 30 months after the end of the Gulf War and the mother's reaction to the trauma 6 and 30 months after the war. Fifty-one children aged 6 to 8 years (3 to 5 years during the war) and their mothers were interviewed. Results showed no age differences in the various posttraumatic symptoms of the children. Correlations between the children's posttraumatic symptoms and both the general and the specific posttraumatic symptoms of their mothers were positive and significant in the 6-year-olds, positive and nonsignificant in the 7-year-olds, and nonsignificant and mostly negative in the 8-year-olds. These findings may reflect the developmental changes that render the older child more autonomous and the younger child rigidly attached to the mother after a traumatic event.

Preoperative anxiety and postoperative pain in women undergoing hysterectomy. A repeated-measures design.

OBJECTIVES: To determine whether psychological variables such as preoperative anxiety can serve as predictors for the postoperative pain response. METHODS: The study sample included women who underwent elective abdominal hysterectomy (n=53). Two weeks prior to surgery, characteristics such as trait anxiety, coping style, and perceived stress were evaluated. Throughout the perioperative period, state anxiety, pain, as well as analgesic consumption were assessed at multiple time points. The anesthetic and surgical management were carefully controlled for and postoperative pain management was standardized. RESULTS: Path analysis demonstrated that there are both direct and indirect effects of preoperative state anxiety on postoperative pain. Preoperative state anxiety is a significant positive predictor of the immediate postoperative pain (beta=0.30), which, in turn, is a positive predictor of pain on the wards (beta=0.54). Pain on the ward, in turn, is predictive for pain at home (beta=0.30). CONCLUSION: The results of this study indicate that preoperative anxiety may have a critical role in the chain-of-events that controls the postoperative pain response.

Social adaptability, cognitive abilities, and other predictors for children's reactions to surgery.

STUDY OBJECTIVE: To examine the relationship between social adaptability, cognitive abilities, and other personality characteristics to perioperative anxiety. STUDY DESIGN: Prospective cohort investigation. PATIENTS: 60 children ASA physical status I and II, age 3 to 10 years. SETTING: Tertiary care children's hospital. MEASUREMENTS: Temperament (EASI), cognitive abilities (KABC), and adaptive behavior (Vineland) were evaluated in a group of children undergoing surgery. Parental coping style (MBBS) and parental state (STAI-S) and trait (STAI-T) anxiety were assessed as well. On the day of surgery, anxiety of the child was measured at the preoperative holding area and during induction of anesthesia (m-YPAS). MAIN RESULTS: Univariate correlational analysis demonstrated that young age (r = -0.27), poor social adaptability (Vineland) (r = -0.38), shy and inhibited personality (EASI; temperament) (r = -0.33), higher intelligence (KABC) (r = 0.29), increased parental anxiety (r = 0.44), and parental high-monitoring coping style (r = -0.25) are all associated with higher levels of perioperative anxiety. Stepwise multivariate regression analysis has demonstrated that controlling for the variables above, parental anxiety (p = 0.004), child's social adaptive capabilities (p = 0.04), and child's temperament (sociability) (p = 0.04) are independent predictors for increased perioperative anxiety (R(2) = 0.38, F = 5.5, p = 0.003). CONCLUSIONS: Anesthesiologists need to pay close attention to the families of pediatric surgical children who are socially maladjusted, shy and inhibited, and have anxious parents.

Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study.

BACKGROUND: Although some anesthesiologists use oral sedatives or parental presence during induction of anesthesia (PPIA) to treat preoperative anxiety in children, others may use these interventions simultaneously (e.g., sedatives and PPIA). The purpose of this investigation was to determine whether this approach has advantages over treating children with sedatives alone. METHODS: The child's and the parental anxiety throughout the perioperative period was the primary endpoint of the study. Parental satisfaction was the secondary endpoint. Subjects (n = 103) were assigned randomly to one of two groups: a sedative group (0.5 mg/kg oral midazolam) or a sedative and PPIA group. Using standardized measures of anxiety and satisfaction, the effects of the interventions on the children and parents were assessed. Statistical analysis (varimax rotation) of the satisfaction questionnaire items resulted in two factors that described satisfaction of the separation process and satisfaction of the overall care provided. RESULTS: Anxiety in the holding area, at entrance to the operating room, and at introduction of the anesthesia mask did not differ significantly between the two groups (F[2,192] = 1.26, P = 0.28). Parental anxiety after separation, however, was significantly lower in the sedative and PPIA group (F[2,93] = 4.46, P = 0.037). Parental satisfaction with the overall care provided (-0.28 +/- 1.2 vs. 0.43 +/- 0.26, P = 0.046) and with the separation process (-0.30 +/- 1.2 vs. 0.47 +/- 0.20, P = 0.03) was significantly higher among the sedative and PPIA group compared with the sedative group. CONCLUSIONS: PPIA in addition to 0.5 mg/kg oral midazolam has no additive effects in terms of reducing a child's anxiety. Parents who accompanied their children to the operating room, however, were less anxious and more satisfied.

Early parental preoccupations and behaviors and their possible relationship to the symptoms of obsessive-compulsive disorder.

This study focuses on early parental preoccupations and behaviors (EPPB) surrounding the birth of a new family member. An interview instrument was developed to assess EPPB at eight months prepartum and two weeks and three months postpartum. Measures with adequate psychometric and conceptual properties were used to assess the overall level of parental preoccupations and associated actions as well as three content domains: caregiving (CARE), relationship building (RELATIONSHIP), and anxious intrusive thoughts associated with harm avoidant behaviors (AITHAB). The hypothesis that preoccupations and behaviors would peak for both parents close to the birth of the child was confirmed. Measures of EPPB were distinguished from symptoms of depression and generalized anxiety. Consistent with our a priori hypothesis the content and character of the AITHAB was found to resemble the symptoms of obsessive-compulsive disorder (OCD). The study findings suggest the potential adaptive significance of EPPB and the possible evolutionary origins of OCD.

Preoccupations and behaviors associated with romantic and parental love. Perspectives on the origin of obsessive-compulsive disorder.

This article first examines the hypothesis that the early phases of romantic love and early parental love share phenomenologically an overlapping set of mental states and behaviors. Second, the authors consider what is known of the neurobiologic substrates of these behaviors. Third, the authors evaluate the hypothesis that these highly conserved behavioral and neural systems and the genetic messages that guide their development are intimately involved in the pathogenesis of OCD.

Distress during the induction of anesthesia and postoperative behavioral outcomes.

UNLABELLED: We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process. Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority. IMPLICATIONS: Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes.

Addressing mental health needs of infants and young children.

Work with infants and young children is a subspecialty of child psychiatry. Special areas of expertise and clinical skills are required for work in this area and even traditional areas of clinical skills--evaluating mental and developmental competency, collaborations with other professionals, synthesizing information for parents--have an added valence when applied to work with very young children. Furthermore, in the last three decades, there has been a remarkable increase in knowledge about the first years of life. Most recently, understanding about early brain development and the complex interactions among biology, environment, and experience in shaping early development has highlighted the critical nature of psychological interventions in the first years of life. Providing mental health services for very young children requires a multidisciplinary approach, and the field has evolved simultaneously in the disciplines of child psychiatry, pediatrics, psychology, social work, neurology, early childhood education, and nursing. With that range of theoretic and professional background, the resulting evaluative approaches and services are also quite diverse. The agenda for the next decade of work is to bring together these multiple viewpoints around critical areas for the development of the field, including improved diagnostic nosology, a better understanding of the number of young children needing services, pathways for accessing those services, and more explicit descriptions of the important features of a mental health intervention for very young children and their families.

Postoperative behavioral outcomes in children: effects of sedative premedication.

BACKGROUND: Although multiple studies document the effect of sedative premedication on preoperative anxiety in children, there is a paucity of data regarding its effect on postoperative behavioral outcomes. METHODS: After screening for recent stressful life events, children undergoing anesthesia and surgery were assigned randomly to receive either 0.5 mg/kg midazolam in 15 mg/kg acetaminophen orally (n = 43) or 15 mg/kg acetaminophen orally (n = 43). Using validated measures of anxiety, children were evaluated before and after administration of the intervention and during induction of anesthesia. On postoperative days 1, 2, 3, 7, and 14, the behavioral recovery of the children was assessed using the Post Hospitalization Behavior Questionnaire. RESULTS: The intervention group demonstrated significantly lower anxiety levels compared with the placebo group on separation to the operating room and during induction of anesthesia (F[1,77] = 3.95, P = 0.041). Using a multivariate logistic regression model, the authors found that the presence or absence of postoperative behavioral changes was dependent on the group assignment (R = 0.18, P = 0.0001) and days after operation (R = -0.20, P = 0.0001). Post hoc analysis demonstrated that during postoperative days 1-7, a significantly smaller number of children in the midazolam group manifested negative behavioral changes. At week 2 postoperatively, however, there were no significant differences between the midazolam and placebo groups. CONCLUSIONS: Children who are premedicated with midazolam before surgery have fewer negative behavioral changes during the first postoperative week.

Clocks, engines, and quarks--love, dreams, and genes. What makes development happen?

That psychological growth and maturation throughout the lifespan involve progressive linear processes is an implicit assumption of all models of development. Within psychoanalysis, a particular focus has been those processes that hinder forward development and manifest themselves as regressions or fixations or in character structure. However, the implicit assumption of progressive, linear development leaves unexplored the central question of what are the processes that govern developmental progressions. What makes psychological development happen in more or less predictable ways and yet allows for considerable individual variability? And are those developmental progressions inevitably forwardly progressive? Questions regarding what regulates and integrates development are relevant not only for understanding the normal building up of the internal world and of childhood psychopathology but also for those times of dramatic mental reorganization in adulthood surrounding events such as pregnancy and aging and for issues of psychological change during and after an analysis. Clinical material from analyses with a child and an adult and from interviews with four- to five-year-old children is used to explore individual fantasies of how development and change happens. The central role of internalization and object relations in regulating psychological development is emphasized.

Developing brain and in utero cocaine exposure: effects on neural ontogeny.

Within the last decade, many investigators have focused on the physical, neurodevelopmental, and neuropsychological effects of prenatal cocaine exposure on infants and young children. Although inconclusive on many crucial issues, published studies reveal the beginnings of a profile of possible cocaine-related effects on neuropsychological functions subserving arousal and attention regulation. That profile is informed by preclinical studies in which important factors such as duration and type of exposure as well as environmental conditions may be more adequately controlled. In the developing brain, there are a number of candidate mechanisms that account for how prenatal cocaine exposure may interfere with neural ontogeny. This review focuses on the monoamine system, one of the primary sites of action of cocaine in the adult. In the developing organism, monoamines play critical trophic roles through all phases of central nervous system (CNS) ontogeny--cell proliferation, neural migration, growth, maturation, and synaptogenesis. Because of their trophic role in CNS ontogeny, cocaine effects on developing nervous system may be mediated in part through effects on monoamine system ontogeny. In turn, these effects may be expressed behaviorally in disrupted patterns of arousal and attention regulation given that these domains are connected intimately to monoaminergic systems.

Preoperative preparation programs in children: a comparative examination.

UNLABELLED: We sought to determine whether an extensive behavioral preparation program for children undergoing surgery is more effective than a limited behavioral program. The primary end point was child and parent anxiety during the preoperative period. Secondary end points included behavior of the child during the induction of anesthesia and the postoperative recovery period. Several days before surgery, children (n = 75) aged 2-12 yr randomly received either an information-based program (OR tour), an information + modeling-based program (OR tour + videotape), or an information + modeling + coping-based program (OR tour + videotape + child-life preparation). Using behavioral and physiological measures of anxiety, we found that children who received the extensive program exhibited less anxiety immediately after the intervention, in the holding area on the day of surgery, and on separation to the operating room. These findings, however, achieved statistical significance only in the holding area on the day of surgery (44[10-72] vs 32[8-50] vs 9[6-33]; P = 0.02). Similarly, parents in the extensive program were significantly less anxious on the day of surgery in the preoperative holding area, as assessed by behavioral (P = 0.015) and physiological measures (P = 0.01). In contrast, no differences were found among the groups during the induction of anesthesia, recovery room period, or 2 wk postoperatively. We conclude that children and parents who received the extensive preoperative preparation program exhibited lower levels of anxiety during the preoperative period, but not during the intraoperative or postoperative periods. IMPLICATIONS: The extensive behavioral preoperative program that we undertook had limited anxiolytic effects. These effects were localized to the preoperative period and did not extended to the induction of anesthesia or the postoperative recovery period.

Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective?

BACKGROUND: Both midazolam and parental presence during induction of anesthesia are routinely used to treat preoperative anxiety in children. The purpose of this investigation was to determine which of these two interventions is more effective. METHODS: Anxiety of the child during the perioperative period was the primary end point. Secondary end points included anxiety of the parent and compliance of the child during induction. Children (n = 88) were randomly assigned to one of three groups: (1) 0.5 mg/kg oral midazolam; (2) parental presence during induction of anesthesia; or (3) control (no parental presence or premedication). Using multiple behavioral measures of anxiety, the effect of the intervention on the children and their parents was assessed. RESULTS: Observed anxiety in the holding area (T1), entrance to the operating room (T2), and introduction of the anesthesia mask (T3) differed significantly among the three groups (P = 0.032). Post hoc analysis indicated that children in the midazolam group exhibited significantly less anxiety compared with the children in the parental-presence group or control group (P = 0.0171). Similarly, parental anxiety scores after separation were significantly less in the midazolam group compared with the parental-presence or control groups (P = 0.048). The percentage of inductions in which compliance of the child was poor was significantly greater in the control group compared with the parental-presence and midazolam groups (25% vs. 17% vs. 0%, P = 0.013). CONCLUSIONS: Under the conditions of this study, oral midazolam is more effective than either parental presence or no intervention for managing a child's and parent's anxiety during the preoperative period.