Adult-Child Interactions in the Post Anesthesia Care Unit: Behavior Matters

Abstract

Background

Many children experience significant distress before and after surgery. Previous studies indicate that healthcare providers’ and parents’ behaviors may influence children’s outcomes. This study examines the influence of adults’ behaviors on children’s distress and coping in the post anesthesia care unit.

Methods

Children aged 2–10 years old were videotaped during their post anesthesia care unit stay (n=146). Adult and child behaviors were coded from video including the onset, duration, and order of behaviors. Correlations were used to examine relations between behaviors, and time-window sequential statistical analyses were used to examine whether adult behaviors cued or followed children’s distress and coping.

Results

Sequential analysis demonstrated that children were significantly less likely to become distressed after an adult used empathy, distraction, or coping/assurance talk than they were at any other time. Conversely, if a child was already distressed, children were significantly more likely to remain distressed if an adult used reassurance or empathy than they were at any other time. Children were more likely to display coping behavior (distraction, nonprocedural talk) after an adult used this behavior.

Conclusions

Adults can influence children’s distress and coping in the post anesthesia care unit. Empathy, distraction and assurance talk may be helpful in keeping a child from becoming distressed and nonprocedural talk and distraction may cue children to cope. Reassurance should be avoided when a child is already distressed.

Introduction

Family centered care has garnered attention over the past few years and has been promoted by organizations such as the Institute of Medicine and the National Institutes of Health. Within the context of pediatric perioperative care, a growing body of research has examined the role of parents in the Post Anesthesia Care Unit (PACU) ^1–2. Reports of effects of parental presence in the PACU on anxiety and pain in children are mixed, and while some studies report decreased crying and fewer postoperative behavioral changes in children whose parents were present in the PACU, other studies have found no change ^3–7. These contradictory results parallel earlier studies in parental presence during induction of anesthesia ^3–7. Research on parental presence during induction of anesthesia benefited significantly from a shift from studying the mere impact of parental presence, to an understanding how adults and children behaviorally interact during induction of anesthesia ^8–9. We suggest that the area of research of parental presence in the PACU may benefit from a similar change in the conceptual framework to focus on child-adult interactions.

Within the larger context of general adult-child interactions, it has long been established that adults have the ability to influence children’s behaviors, especially in new and stressful situations including illness and medical procedures ^10–13. For instance, mothers that attend to children’s symptoms tend to have children that express greater responses to these symptoms^14–16. In medical procedures, adult behaviors such as giving control to the child, reassurance, apologies, criticisms and empathy have been associated with greater child distress ^{9, 17}, whereas distraction, talk about procedurally unrelated topics and using humor have been associated with lower child distress^14–20. Similar results have been found in studies involving induction of anesthesia in children.^{9, 18}

In addition to the limited experimental work, the majority of research on adult-child interactions has relied on correlational analyses. Alternatively, newer methods such as sequential analyses consider how interactions occur over time and can therefore comment on whether children’s behaviors follow or precede adult behaviors. ¹⁹ For example, rather than asking if adult reassurance is related to child distress (a correlational question), we can ask if a child is more likely to start to display distress following adult reassurance than they are at any other time. Although causation can still not necessarily be concluded, sequential analysis answers questions on order of behaviors and how behaviors are related over time.

This study examines the relations between adult and child behaviors in the PACU using both correlational and sequential analyses. Although behaviors such as distraction and humor have clear benefits for children in the procedural setting,²⁰ it is unclear how these behaviors will function in the unfamiliar and prolonged exposure environment of the PACU. Learning more about the PACU will contribute to literature outside of periopererative care environment including children’s responses to medical symptoms in general. Based on previous findings it is hypothesized that emotion-focused behaviors (e.g., reassurance) will lead to children becoming distressed; whereas, distracting behaviors and non-emotion focused behaviors (e.g., non-procedural talk, humor) will lead to children showing non-distress behaviors.

Materials & Methods

Data presented in this manuscript are from a subset of children that participated in a National Institute of Health funded Behavioral Interaction-Perioperative Study that was aimed at assessing the influence of adult behaviors on children’s perioperative distress. Results of Behavioral Interaction-Perioperative Study focusing on the preoperative period and validation of children’s postoperative behavioral coding are reported elsewhere^{9, 21–22}. Of the original 836 potential participants approached, 485 families chose not to participate. Most potential participants did not provide reasons for declining, but those who did noted that they found the study to involve too much paperwork. Of the 351 participants who enrolled, postoperative data was available for the 146 participants included in this report. Postoperative data was not available for remaining participants because of children/families withdrawing from the study (n = 10), equipment malfunction (n = 30), children not being placed in recorded PACU bed or going home too soon (n = 38), or inability to code behavioral data (e.g., no sound, too muffled, n = 137).

Participants

Participants in this study included 2–10 year old healthy children (American Society of Anesthesiologists physical status I or II) who were undergoing general anesthesia and surgery at Yale-New Haven Children Hospital and their accompanying parents. Children with American Society of Anesthesiologists physical status of III or higher and children with autism or diagnosed developmental delay or who did not speak English were excluded from this study. Parents who accompanied their children on the day of surgery were also included in this study (the only exclusion criterion for parents was not speaking English). In addition to children and parents, nurses who cared for children in the recovery room were also included as participants in this study. All participants (children, parents, and nurses) provided informed consent or assent for participation.

Measures

Child Behavior Checklist-PACU²²

The Child Behavior Checklist-PACU is an observational coding system that captures children’s behaviors in the PACU setting. The coding system has previously demonstrated excellent reliability and evidence of validity²². The Child Behavior Checklist-PACU contains 23 operationally defined verbal and non-verbal child behaviors that are further combined into empirically derived composites representing non-verbal distress (i.e., guarding, non-verbal resistance, non-verbal request for help, crying), verbal distress (e.g., verbal resistance, verbal pain, verbal request for help, negative verbal emotion) and non-distress behaviors (e.g., information seeking, distraction, medical talk). The Child Behavior Checklist-PACU also includes operationally defined adult behaviors that have been identified and defined from the procedural pain and preoperative anxiety research^{8–9, 17, 23–27}. Relevant behaviors and operational definitions from existing measures were generally retained with modifications to include behaviors identified in study-independent observations of adults in the PACU. Appendix 1 lists the PACU-specific adult behaviors and corresponding operational definitions and examples.

Appendix 1.

Adult behavior codes and operational definitions

Code	Definition
Verbal Codes
Apologies	Any statement child relating a sense of sorrow or a sense of responsibility for the procedure.
Cope/Assurance Talk	Talk about or instructions to engage in coping behavior (other than distraction). Also includes assurance comments that make tangible suggestions that the child’s state will improve “if” they do a stated behavior.
Criticism	A direct or indirect negative evaluation that expresses judgment of a behavior, which may include hostility.
Empathy	Statements to the parent or child that express understanding of or identification with their feelings.
Verbal Engage in Distraction	Comments that direct attention towards or refer to objects of distraction (e.g., talking about the TV show, book, toys).
Non Procedural Talk	Any conversation or statements pertaining to activities outside the surgery center. Distracting with talk rather than by directing attention towards an object.
Reassurance	Any statement that seeks to improve the child’s emotional state.
Non-Verbal Codes
Non-Verbal Distraction	Adult is engaged in activities that can distract child from their situation (e.g., watching TV, reading books, playing games).

Procedures

Parents were recruited 1 to 7 days prior to their child’s surgery and provided written informed consent. Children provided written assent as age appropriate. No child received sedative premedication while all children underwent a mask induction with nitrous oxide and sevoflurane, we did not control for the anesthetic protocol or the postoperative pain management. This was intentional as the purpose of the study was to result in a population of children with different levels of pain and anxiety in the PACU. Videotaping started when the child entered the PACU and continued throughout their entire stay. In order to efficiently capture the variability in PACU behaviors, three 5-minute segments (total 15 minutes) were selected and coded. The three, 5-minute segments were: (1) the first 5 minutes children were awake and coherent (no emergence delirium as defined clinically), (2) a five minute segment revolving around the IV removal event (2 minutes prior to the removal and 3 minutes after the removal), and (3) an additional 5 minute segment selected to capture the child when they were distressed. Selectively identifying times in the video in which the child was distressed allowed for examination of interactions around children’s distress behavior. The third segment was identified in the following way: a random number generator was used to identify a time point in the video. The video was then played forward until the first distress behavior was identified. Once the behavior was identified, a coding segment was defined that started 2 minutes before the onset of distress and continued until 3 minutes after. This procedure allowed us to examine the onset and potential offset of distress. If no distress behavior was shown on the video, the 5-minute segment was started at the time identified by the random number generator. Each segment was reviewed multiple times in order to be coded. Coders watched each video once (i.e., one pass) for each behavior they were coding.

Two independent research assistants coded data in this study; a primary coder coded all data and a secondary independent coder coded approximately 10% of data to check inter-rater reliability. Coders underwent a rigorous training protocol with the lead trainer, in which they were familiarized with the technological coding interface, Observer XT (Noldus Inc, Wageningen, The Netherlands) and the behavioral codes. Raters met to discuss coding and disagreements daily during the training period and weekly when coding study data. Coders were considered “trained” only after they met a kappa criterion of .80 with the lead trainer’s codes. Data was coded using Observer XT software. Raters reviewed each segment multiple times (reviewed one time for each adult behavior). Coders were blinded to study hypotheses.

Statistical Analysis

Data were analyzed using SPSS 18.1 (SPSS Inc, Chicago, IL) and General Sequential Querier Software (GSEQ^*28). Preliminary analyses were conducted to examine inter-rater reliability on study data. Time and event-based Kappa coefficients are reported ²⁹ In order to account for slight variations in lengths of segments, rates were calculated by dividing the seconds in which the behavior occurs by the number of minutes in the observation. Correlations were used to examine the relations between adult and child behaviors. In order to control for heterogeneity in the sample, partial correlations are reported controlling for child age, previous surgery (yes/no) and type of procedure (painful/not painful).

Significant correlations were followed-up using time-window sequential analysis.¹⁹ Whereas correlations examine overall relations between adult and child behavior across observations, time-window sequential analysis examines how adult and child behaviors are related over time in each observation. Time-window sequential analyses ask whether a child behavior is more likely to follow an adult behavior within a specified time window than at any other time. In this way, sequential analysis provides more information on contingencies between behaviors than do correlations. Although there is some statistical guidance on the analysis of antecedent and target behavior duration ³⁰, the current recommendation for defining how long a time window should be is to use durations that make sense given the nature of the data ²⁸. The rate at which behavior is occurring in the data, and in our case the rate at which the participants are interacting, was relevant in choosing a relatively short (5 second) duration for the window in this study.

Time-window sequential analysis was conducted first at the individual dyad-level; each adult-child dyad received a score that represented the strength of the temporal contingency between behaviors for that dyad. The score (Yule’s Q) was based on the number of child behaviors that occur within the defined time window (i.e., 5-seconds following the adult behavior) and the number of child behaviors that occur outside the defined time window. Yule’s Q ranges from −1 to +1 and can be interpreted much like a correlation coefficient with scores closer to +1 indicating stronger positive relations and scores closer to −1 indicating stronger negative relations. Yule’s Qs of each dyad was then analyzed using standard statistical techniques to represent the sample of all dyads. Because Yule’s Q were not normally distributed in this sample, non-parametric statistics were used. Mean Yule’s Q are reported for descriptive purposes and Binomial tests are used to examine whether the distribution of positive and negative Yule’s Q significantly differs from the distribution that would be expected by chance.

Two sets of sequential analyses were conducted in this study. The first set of analyses examines whether children are more likely to start behaviors (distress, distraction, nonprocedural talk) within 5-seconds following adult behaviors (reassurance, empathy, distraction, etc) than they are at any other time. For example, we ask if children are more likely to start crying (nonverbal distress) within 5-seconds of adults’ reassurance than they are at any other time. Positive results of this type of analysis suggest that adult behaviors cue children’s behaviors. Because the duration of nonverbal behaviors are coded, the second set of analyses examines the co-occurrence of adult behavior during children’s nonverbal behaviors. For example, we ask if adults are more likely to use reassurance while children are crying (nonverbal distress) than at any other time. Positive results of this type of analysis suggest that adults may be responding to children’s behaviors, rather than cueing children’s behaviors.

Results

Participants

Participants included 146 parents of children undergoing general anesthesia and elective surgery. Children in this study ranged in age from 2 to 10 and were on average 4.8 ±2.3 years of age. Gender of children was relatively evenly distributed (49.6% male). Mothers (n = 146) and fathers recruited for this study (n = 134) were of similar age (37.2 ± 5.8 years and 39.6 ± 8.0 years respectively). Forty-five of the children had previously undegone surgery, 69 children had not undergone previous surgery, and no previous surgery data was available for 32 children. Children underwent a variety of procedures. Fifty-three underwent ear, nose and throat procedures (tonsillectomy and/or adenoidectomy, turbinectomy), 16 underwent genito/urologicial procedures (circumcision, orchidopexy, meatotomy, hyrdocele), 8 underwent orthopedic procedures (tendon release), 8 underwent plastic procedures (lesion excision), and 5 underwent ophthalmological procedure (strabismus). Of note, 30 children underwent procedures that typically don’t generate high levels of postoperative pain (endoscopy, myringotomy).

Health care providers studied in the PACU included a group of 14 nurses who interacted with these families throughout the study. As is the usual practice, physicians were not present for the overwhelming majority of the time children spent in the PACU and were therefore excluded from analyses.

Preliminary Analyses: Inter-rater reliability

Two research assistants independently coded 16 (10.9%) child participants and their accompanying adults. Kappa coefficients for adult behaviors fell in good to excellent range. ³¹ Criticism had the highest Kappa (Time-unit = 1.0, Event-sequence = 1.0), followed by Reassurance (Time-unit = 0.95, Event-sequence = 0.72). Kappas for Verbal distraction (Time-unit = 0.89, Event sequence = 0.64), Empathy (Time-unit = 0.86, Event-sequence = 0.64), Coping/assurance talk (Time-unit = 0.87, Event-sequence = 0.67), and Nonprocedural talk (Time-unit = 0.85, Event-sequence = 0.60) were similar. Nonverbal distraction had the lowest Kappa (Time-unit = 0.79, Event-sequence = 0.56).

Descriptive Analyses

Table 1 shows the number of adults displaying each behavior of interest during the analysis period. Eighty-five percent of mothers, 88% of nurses, and 67% of fathers used verbal distraction, while 86% of mothers, 95% of nurses, and 57% of fathers used reassurance. Criticism was shown by the least number of adults with 2% of fathers, 7% of mothers and no nurses used criticism. Seventeen percent of the nurses, 4.8% of mothers and no fathers used apologies during the period studied.

Table 1.

Adult Behaviors shown in the post anesthesia care unit

	Mother (n = 146)			Father (n = 134)			Nurse (n = 14, 146 observations)**
Behavior	Number using behavior	Median Rate per hour*	25th/75th percentile	Number using behavior	Median Rate per hour*	25th/75th percentile	Number using behavior	Median Rate per hour*	25th/75th percentile
Apology	7	3.84	3.67/5.66	0	n/a	n/a	25	4.2	3.90/8.08
Coping/Assurance Talk	63	5.54	3.96/16.21	32	4.28	3.95/7.83	63	4.16	3.71/8.27
Criticism	11	4.10	2.86/6.12	3	3.63	1.99/5.72	0	n/a	n/a
Empathy	49	4.60	4.01/10.92	22	4.20	3.90/11.32	47	4.11	3.87/10.20
Non Procedural Talk	68	5.70	3.87/11.72	17	4.02	3.90/11.32	53	8.06	4.00/16.46
Reassurance	125	15.63	5.91/36.78	77	8.17	3.93/20.76	138	16.84	7.91/32.80
Verbal Distraction	124	19.47	7.54/36.30	90	16.34	4.5/31.20	129	15.09	7.28/26.89
Non-Verbal Distraction	80	7.89	3.88/18.55	57	8.20	3.95/18.39	9	4.0	3.53/4.08

^*Median of those displaying behavior,

^**Nurses may have been observed more than once.

Overall rates of adults’ use of studied behaviors during the analysis period were relatively low. Within those adults who displayed a specific behavior, rates of verbal distraction were highest (0.32/minute for mothers, 0.27/minute for fathers, 0.25/minute for nurses), followed by reassurance (0.26/minute for mothers, 0.13/minute for fathers, 0.28/minute for nurses). Although fewer fathers displayed studied behaviors, when behaviors were displayed, fathers used them at similar rates to mothers and nurses.

Correlational Analyses

Based on previous studies¹⁷ and given that there is little theoretical basis to expect the function of behaviors to differ based on who displays the behavior, data from nurses, mothers and fathers were combined for analyses and will be referred to here as adults. Given the heterogeneity in our sample, partial correlations reported here controlling for child age, previous surgery (yes/no) and type of procedure (painful/non-painful). A bonferroni-corrected p value of 0.001 was used to correct for family-wise error.

Results of partial correlations are shown in Table 2. Results indicated that adults’ use of verbal distraction was positively correlated with child distraction, but was also positively correlated with child distress. Adults’ use of reassurance, empathy, and coping/assurance talk were significantly positively correlated with children’s distress and were not significantly correlated with children’s distraction or nonprocedural talk. Adults’ use of non-procedural talk was significantly positively correlated with children’s non-procedural talk and adults’ use of non-verbal distraction was significantly positively correlated with children’s non-verbal distraction. Adults’ use of apologies and criticism were not related to children’s distress, distraction, or nonprocedural talk. All of these analyses controlled for child age, previous surgery and type of procedure. Of note, correlations not controlling for these variables showed the same pattern of results.

Table 2.

Partial correlations between adult and child behaviors.

Adult Behavior	Child Behavior
	Verbal Distress (e.g., verbalizing pain or fear)	Nonverbal Distress (e.g., cry, physical resistance)	Non-verbal Distraction	Verbal Distraction	Non-procedural Talk
Verbal Distraction	0.26*	0.39*	0.28*	0.50*	−0.05
Reassurance	0.49*	0.57*	−0.03	0.02	−0.04
Empathy	0.49*	0.53*	0.03	0.19	−0.05
Coping/Assurance Talk	0.53*	0.30*	0.10	0.03	0.09
Non-procedural Talk	−0.02	0.01	0.18	0.21	0.72*
Non-verbal Distraction	−0.05	0.14	0.54*	0.21	−0.10
Apologies	0.14	0.19	0.11	0.12	0.11
Criticism	0.11	0.14	−0.12	−0.04	−0.07

Note: The first two columns represent negative child behaviors and the remaining three columns represent positive child behaviors. Correlations shown are partial correlations controlling for previous surgery (yes/no), child age, and type of procedure (painful/not painful)

^*Correlation significant at the 0.001 level

Time Window Sequential Analyses

As previously noted, time-window sequential analysis examines the temporal relations between behaviors. The first set of analyses examined the likelihood that children would start to display a distress or non-distress behavior within 5-seconds of an adult behavior.

Results displayed in Table 3 show similarly strong relations between adult and child behaviors, but in many cases in opposite directions to those found in correlations. A significant proportion of children were less likely to verbalize distress following adult coping/assurance talk, empathy, and verbal distraction than they were at any other time. Similarly, a significant proportion of children were less likely to begin to display nonverbal distress following adult coping/assurance talk and empathy than at any other time. (Table 3) In other words, adult use of coping/assurance talk, empathy, and verbal distraction reduced the likelihood that children would verbalize distress or become non-verbally distressed (e.g., cry). As predicted, a significant proportion of children were more likely to engage in verbal distraction following adult distraction and engage in nonprocedural talk following adult non-procedural talk than at any other time. Children were not found to be more likely to verbalize distress or begin to display nonverbal distress following reassurance.

Table 3.

Sequential analysis of children who are starting distress and adaptive behaviors following adult behaviors

Adult Behavior	Child Behavior (Mean Yule’s Q)
	Verbal Distress	Start Nonverbal Distress	Start Non-verbal Distraction	Verbal Distraction	Non-procedural Talk
Cope/Assurance Talk	−0.59 * n = 72	−0.57 * n = 42
Empathy	−0.53* n = 66	−0.69 * n = 41
Reassurance	−0.08 n = 92	−0.04 n = 49
Verbal Distraction	−0.86* n = 74	−0.25 n = 50	−0.39 n = 66	0.50* n = 26
Non-Verbal Distraction			−0.42 n = 67
Non-Procedural Talk					0.98* n = 7

Note: Yule’s Q represents the likelihood that the child behavior will follow the adult behavior within 5-seconds. Yule’s Q ranges from −1 to 1 (much like a correlation coefficient); positive values indicate that the child behavior is more likely to follow the adult behavior than any other time whereas negative values indicate that the child behavior is less likely to follow the adult behavior than at any other time. Because Yule’s Q’s were not normally distributed, binomial tests were conducted to determine whether the distribution of positive and negative Yule’s Q’s in the sample were significantly different from that expected by chance. Asterisks denote significant bionomial tests at p < .001. Participants must have displayed the child and adult behavior of interest in order to receive a Yule’s Q score, therefore, sample sizes are different for each analysis.

A second set of sequential analyses was used to further examine behaviors in the context of starting or ongoing behaviors. That is, whereas previously described analyses examined children starting to display nonverbal distress or starting to engage in nonverbal distraction, this set of analysis looked at adults’ behaviors while children were already displaying these behaviors. These analyses were generally consistent with correlational findings (see Table 4). As expected, a significant proportion of adults were more likely to reassure while a child was displaying nonverbal distress than at any other time. Similarly, adult nonverbal distraction was more likely to occur while a child was engaged in non-verbal distraction.

Table 4.

Sequential analysis of adult behaviors during children’s nonverbal behaviors

Adult Behavior	Child Behavior (Mean Yule’s Q)
	During Non-verbal Distress	During Non-verbal Distraction
Cope/Assurance Talk	0.26 n = 26
Empathy	0.54* n = 15
Reassurance	0.47* n = 97
Verbal Distraction	− 0.34* n = 81	− 0.14 n = 92
Non-Verbal Distraction		0.69* n = 82

Note: Yule’s Q represents the likelihood that the child behavior will follow the adult behavior within 5-seconds. Yule’s Q ranges from −1 to 1 (much like a correlation coefficient); positive values indicate that the child behavior is more likely occur with the adult behavior than any other time whereas negative values indicate that the child behavior is less likely to occur with the adult behavior than at any other time. Because Yule’s Q’s were not normally distributed, binomial tests were conducted to determine whether the distribution of positive and negative Yule’s Q’s in the sample were significantly different from that expected by chance. Asterisks denote significant bionomial tests at p < .001. Participants must have displayed the child and adult behavior of interest in order to receive a Yule’s Q score, therefore, sample sizes are different for each analysis.

Discussion

Under the conditions of this study, we demonstrated that not only was there a relationship between adult and child behaviors in the postoperative period, but that, in some cases, adult behaviors cued the onset of children’s behaviors. Adults’ use of distraction and coping/assurance talk seem to keep children from becoming distressed. Reassurance and empathy do not seem to be as harmful as earlier thought if children are calm, but if children are distressed, these behaviors seem to keep them from calming down. Not surprisingly, children tend to follow adults’ lead in using coping behaviors; children were more likely to display coping behavior (distraction, nonprocedural talk) after an adult used this behavior. Although previous studies have examined correlations between adult and child behaviors ^{9, 17, 21} this is the first study of its kind to examine how adults and children’s behavior influence each other over time in the perioperative period.

The findings of this study have both clinical and methodological implications. In terms of methodological contributions, it is important to note that our results were somewhat different between correlational and sequential findings. For example, although most correlational findings in this study were generally in line with hypotheses generated from previous literature on children’s procedural pain, ^{21, 25, 32–34} some findings were contradictory. For example, adults’ uses of verbal distraction and coping talk were positively correlated with children’s distress in this study, but previous literature in pediatric pain that suggests these behaviors are “coping promoting.” Because our findings are correlational, it is impossible to conclude whether these results are reflective of adults’ behavior promoting children’s distress, children’s distress cueing adults to try to help with distraction or some other third variable accounting for the effect. This is an important distinction for clinical recommendations. One interpretation would suggest that adults should refrain from using distraction whereas the other would simply describe what adults do in response to children’s distress. In this study, sequential analysis helped to explain why distraction and coping talk have been previously referred to as “coping promoting.” Despite positive correlations, when we looked at how behaviors were related in time, we found that children were less likely to become distressed following adults’ use of distraction and coping talk then they were at any other time. This suggests that these behaviors may indeed be distress reducing.

In terms of clinical recommendations, this study also adds to the literature. Although reassurance and empathy have previously been termed “distress promoting,” ^{23, 24, 33} our sequential analyses found that this was only the case if children were already distressed. In fact, when children are calm, adults using empathy seemed to buffer them becoming distressed. Previous studies have suggested that adults should stop using reassurance and empathic comments during painful procedures, but we suggest that these behaviors are not necessarily harmful, and may even be helpful if used skillfully.

This study adds to the previously published data from the Behavioral Interaction-Perioperative Study ^{9, 21} in several ways. Although some of previous results were consistent with the ones reported here (e.g., nonprocedural talk appears to be adaptive and reassurance appears not to be adaptive), there were different adult behaviors used in these settings. For example, the behavior of medical reinterpretation (reinterpreting medical equipment as less threatening/fun) was used commonly preoperatively and was effective in increasing children’s coping if used in the operating room ⁹. This behavior was not used postoperatively, but distraction via videos and toys was commonly used in the postoperative setting. Because of the differences in behaviors exhibited in these settings, it was important to develop separate coding schemes that were representative of the postoperative context ²².

Several methodological limitations with the current study should be mentioned. First, although we were able to identify important temporal relationships between adult behaviors and children’s non-distress and distress behaviors, these findings are still sequential-correlational in nature. Consequently, causation cannot be inferred with respect to these findings. However, given the findings from experimental studies on reassurance and pain,²⁵ it is likely that the finding between reassurance elicits children’s distress is plausible. It is also important to note that although in some cases sequential analyses did not yield significant results (e.g., reassurance), these analyses do not consider the larger dynamic of parent-child interactions. Although not significant at a micro-coding level, the correlation between reassurance and distress may be indicative of an overall pattern in interactions between parents and children. Secondly, the study did not examine how certain personal characteristics (e.g., age, temperament, previous surgical experience) or relational characteristics (e.g., parent-child relationship) can moderate the relationship between adult behaviors and children’s distress and non-distress behaviors. Presumably, parent-child relationships that are characterized by warmth and support may allow for a child to be soothed more easily than a relationship characterized by a lack of warmth and support. Future studies should examine potential moderators to these observed adult/child relationships in the PACU. Thirdly, there were a relatively substantial number of potential participants who declined participation. We have limited data on these potential participants, but some of the reasons provided (e.g., too stressed) suggest that we may have had some bias in sample selection. We also do not have data on the influences of other children in the PACU; it is possible that witnessing another child in distress may affect children as much, if not more, than adults. It is also possible that other nonverbal behaviors not coded here could influence results. Future research should consider child-child interactions in the PACU. Additionally, future studies should examine the causal nature of these relationships by experimentally manipulating these behaviors in their studies.

In conclusion, the present study examines the temporal relationship of adult and child behaviors in the PACU using two methodologies. Adult behaviors were related to the onset of children’s distress and coping behaviors and the function of these behaviors differ depending on whether children were already distressed. Future studies should design interventions to teach adults to increase desirable and decrease undesirable behaviors. These studies will be doubly beneficial; they will support the validity of conclusions reached via sequential analysis and they will establish an evidence-based intervention to decrease children’s distress. Notably, adults relatively infrequently used behaviors that were found to cue children’s coping and therefore should be encouraged through intervention to be more interactive in the PACU. Learning more about influences on children’s distress in the immediate perioperative period may also have implications for later recovery; behavioral patterns shown in the PACU may be indicative of patterns that will also be shown at home. In sum, adult behaviors represent important leverage points that can aid in the reduction of children’s distress and promote their coping and should be an important consideration in the perioperative period.

Summary Statement.

Using behavioral observations and sequential analysis, we found that adult behaviors influence whether children would become distressed, stay distressed or exhibit coping behavior in the post anesthesia care unit.

Final Box Summary.

What we know about this topic:

• Healthcare providers and parents behavior may influence how pediatric patients cope with recovery from surgery.

What this article tells us that is new:

• Children were less likely to become distressed after adults used empathy, distraction, and coping/assurance.

• Children who were already distressed were more likely to remain distressed when adults used reassurance or empathy than other approaches.

• Reassurance should be avoided when a postoperative child is already distressed.