Table 2. Selected Outcome Summary of 23 Studies in the Systematic Review.
| Source; Country | Temperament Style | Temperament Scale | Temperament Assessment Time Point | Anxiety Scale | Anxiety Assessment Time Point | Outcome Summary |
|---|---|---|---|---|---|---|
| Carson et al,29 1991; United States | Activity level, predictability, approach-withdrawal, adaptability to change, intensity of reaction, threshold of responsiveness, quality of mood, distractibility, and attention span/persistence; scores allowed for the creation of 4 subgroups: easy, difficult, slow to warm up, and intermediate (undifferentiated) | BSQ, MCTQ | 7-10 d before surgery | PPRS | Soon after surgery | Higher predictability (r = −0.43), approach-withdrawal (r = −0.54), adaptability to change (r = −0.42), distractibility (r = 0.60), lower negative mood (r = −0.42), and lower response threshold (r = 0.50) were significantly associated with less distress during hospital procedures and better in-hospital adjustment; intensity of reaction was positively associated with in-hospital adjustment (F = 11.48; R2 = .14; P < .001; β = 0.42; t = 3.14; P < .01) |
| Chow et al,48 2017; Canada | Shyness, sociability, emotionality, activity, attention span/persistence, and soothability | CCTI | Preoperative clinic visit approximately 1 wk before surgery | CPMAS | Preoperative clinic visit approximately 1 wk before surgery and same-day surgery holding area immediately before surgery | Temperamental shyness was associated with lower preoperative anxiety at clinical visit (β = −10.78; P = .03) and in same-day surgery holding area (β = −12.31; P = .03) |
| Davidson et al,53 2006; Australia | Easy or difficult temperament | STST, SATI | Day of surgery | mYPAS | Immediately before anesthetic induction | No association of temperament style with anxiety |
| Fernandes and Arriaga,30 2010; Portugal | Emotionality, activity, sociability, and shyness | EAS-TS | Day of surgery | CSWQ, SAM | Preoperative holding area (CSWQ, SAM) and postoperative (SAM) | Higher emotionality was significantly associated with greater worries about surgery (r = 0.25); more sociable patients were significantly associated with higher preoperative positive affect (r = 0.29) |
| Fernandes et al,31 2014; Portugal | Emotionality, activity, sociability, and shyness | EAS-P | Day of surgery | CSWQ (global preoperative worries only), SAM | Preintervention (SAM), postintervention (SAM, CSWQ), after surgery (SAM) | Emotionality was significantly associated with global worries (r = 0.21); other temperament dimensions were not significantly associated with preoperative worry: shyness (r = 0.08), activity (r = −0.10), and sociability (r = −0.01) |
| Fernandes et al,32 2015; Portugal | Emotionality, activity, sociability, and shyness | EAS-P | Day of surgery | CSWQ, SAM | Preintervention (SAM), postintervention (CSWQ, SAM) | Lower activity was significantly associated with global worries (r = −0.28); increased emotionality, lower shyness, and lower activity were significantly associated with higher hospitalization worries (emotionality: r = 0.25; shyness: r = −0.24; activity: r = −0.44); higher emotionality and lower activity were significantly associated with greater illness worries (emotionality: r = 0.27; activity: r = −0.21); activity levels were significantly associated with worries about surgery (β = −0.231; t = −3.042; P = .003) |
| Finley et al,33 2006; Canada | Emotionality, activity, sociability, and impulsivity | EASI | 1 wk before surgery | mYPAS without parent rating | Predrug administration (90 min before surgery), 20 min after drug administration (40 min before surgery), and at anesthetic induction | In midazolam group, there was a significant positive association of anxiety at anesthetic induction with the impulsivity dimension (r = 0.42) |
| Fortier et al,52 2009; United States | Emotionality, activity, sociability, impulsivity, and avoidant temperament | EASI, CDI (avoidant temperament) | Day of surgery | STAI-CH | Preoperative holding area | Association of EASI with anxiety not investigated; association of avoidance with anxiety was not significant; bivariate correlations showed that state anxiety was negatively correlated with avoidance (r = −0.22; P = .02); however, analysis of variance of patients who were highly avoidant (ie, upper 25%) and not avoidant (ie, lower 25%) showed that mean differences for state anxiety between the 2 groups was not significant (F1,116 = 2.96; P = .08) |
| Fortier et al,47 2010; United States | Emotionality, activity, sociability, impulsivity, internalizing problems, and externalizing problems | EASI, CBCL | 7-10 d before surgery | mYPAS, VAS, NRS | Preoperative holding area (mYPAS, VAS); parental separation (mYPAS, VAS); OR entrance (mYPAS, VAS); introduction to anesthesia mask (mYPAS, VAS); arrival to recovery (VAS); 6 h, 12 h, 18 h, and 24 h in recovery (VAS); 2 d, 3 d, 7 d, and 14 d after operation (NRS) | Low child sociability was significantly associated with perioperative anxiety (β = −0.57; SE, 0.21; odds ratio, 0.56; 95% CI, 0.37-0.85; P = .007); patients in the high-anxiety group (1 SD above mean perioperative anxiety score) were associated with lower sociability than patients in the low-anxiety group (high-anxiety group mean [SD] EASI sociability score, 18.1 [2.7]; low-anxiety group mean [SD] EASI sociability score, 19.6 [2.1]; P = .03) |
| Fortier et al,50 2011; United States | Activation/control, affiliation, attention, fear, frustration, inhibitory control, shyness, aggression, depressive mood, surgency, anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, aggressive behavior, internalizing problems, and externalizing problems | EATQ-R-P, CBCL/6-18 | In preoperative holding area or OR prior to surgery | VAS, ECG, SCL, BP | Preoperative holding area (VAS, BP, ECG, SCL), parental separation (VAS), introduction to anesthesia mask (VAS, BP, ECG, SCL) | High preoperative anxiety assessed by the VAS was associated with internalizing behavior (F1,47 = 4.5; P = .04), somatic complaints (F1,49 = 4.0; P = .05), and fear (F1,50 = 5.2; P = .03) |
| Glazebrook et al,21 1994; England | Activity level, predictability, approach-withdrawal, adaptability to change, intensity of reaction, threshold of responsiveness, quality of mood, distractibility, attention span/persistence, and normal vs extreme behavior | TS, BQ (normal vs extreme behavior) | Day before surgery | OSBD | OR | OSBD distress associated with extreme behavior (r = 0.88), intensity of reaction (r = 0.32), withdrawal (r = 0.28); intensity of reaction was associated with distress (R2 for model = 0.21; F2,47 = 6.2); patients in the high-distress group (scoring 4 or greater on OSBD distress scale) scored significantly higher on intensity of reaction (z = 2.47) and withdrawal (z = 2.22) |
| Kain et al,5 1996; United States | Emotionality, activity, sociability, and impulsivity | EASI | Day of surgery | CARS, VAS, VPT | Preoperative holding area (VPT, VAS), parental separation (VAS, CARS) | Low activity scores were significantly associated with high child anxiety (r = −0.37) in preoperative waiting room (R2 = 0.11; F = 6.1) and at separation to the OR (R2 = 0.18; F = 12.3) |
| Kain et al,22 1996; United States | Emotionality, activity, sociability, and impulsivity | EASI | 1 wk before surgery | VAS, YPAS, CARS, cortisol analysis | Preoperative holding area (VAS), OR entrance (YPAS, CARS), introduction of anesthesia mask (YPAS, CARS), after induction (cortisol analysis) | Activity dimension interacted with parental presence and was associated with child anxiety, as measured by serum cortisol (t = 2.54; P = .01; R2 = 0.15) |
| Kain et al,45 1996; United States | Emotionality, activity, sociability, and impulsivity | EASI | 1-2 d before surgery | VAS, VPT, CARS | Preoperative holding area (VAS, VPT), parental separation (VAS, CARS) | Activity was significantly associated with child anxiety in preoperative holding area; emotionally labile patients (upper quartile of EASI emotionality scale) who received a behavioral preparation program were associated with more anxiety than emotionally stable patients (lower quartile of EASI emotionality scale) in preoperative holding area (upper-quartile group mean [SD] VAS score, 51 [16]; lower-quartile group mean [SD] VAS score, 34 [19]; P = .03) and on separation to the OR (upper-quartile group mean [SD] VAS score, 41 [19]; lower-quartile group mean [SD] VAS score, 13 [8]; P = .01) |
| Kain et al,34 2000; United States | Emotionality, activity, sociability, and impulsivity | EASI | 1 wk prior to surgery | mYPAS | Preoperative holding area, OR entrance, introduction of anesthesia mask | Lower activity (r = −0.21) and lower sociability (r = −0.33) were significantly associated with high perioperative anxiety; child sociability was an independent risk factor for perioperative anxiety (R2 = 0.38; F = 5.5; P = .04) |
| Kain et al,7 2004; United States | Emotionality, activity, sociability, and impulsivity | EASI | NS | mYPAS | Preoperative holding area, OR entrance, introduction of anesthesia mask | Compared with children at low risk, children at high risk (those with emergence delirium and intense preoperative anxiety or postoperative maladaptive behaviors) were associated with higher emotionality (high-risk group mean [SD] EASI emotionality score, 11.5 [3.4]; low-risk group mean [SD] EASI emotionality score, 10.2 [3.6]; P = .03), more activity (high-risk group mean [SD] EASI activity score, 17.0 [4.5]; low-risk group mean [SD] EASI activity score, 15.2 [4.2]; P = .02), and less sociability (high-risk group mean [SD] EASI sociability score, 17.7 [3.4]; low-risk group mean [SD] EASI socialiability score, 18.8 [2.8]; P = .01) |
| Kain et al,46 2006; United States | Emotionality, activity, sociability, and impulsivity | EASI | 7-10 d before surgery | mYPAS | Preoperative holding area, introduction of anesthesia mask | No difference in temperament styles between the high-anxiety and low-anxiety groups |
| Kain et al,51 2006; United States | Emotionality, activity, sociability, and impulsivity | EASI | Day of surgery | mYPAS | Preoperative holding area, introduction of anesthesia mask | Compared with the low-anxiety group, the high-anxiety group (upper quartile of mYPAS score during induction) was associated with higher activity (high-anxiety group mean [SD] EASI activity score, 17.8 [3.9]; low-anxiety group mean [SD] EASI activity score, 15.6 [3.9]; P = .001) and impulsivity levels (high-anxiety group mean [SD] EASI impulsivity score, 13.9 [3.6]; low-anxiety group mean [SD] EASI impulsivity score, 12.5 [3.7]; P = .005); activity dimension was associated with anxiety at anesthetic induction while parent was present (R2 change = 0.016; P = .007) |
| Kain et al,35 2007; United States | Emotionality, activity, sociability, and impulsivity | EASI | Day before surgery | mYPAS | Preoperative holding area, separation to the OR, OR entrance, introduction of anesthesia mask | EASI emotionality was significantly associated with child anxiety at induction (ρ = 0.174); logistic regression model found emotionality to be a significant predictor of preoperative anxiety (β = 0.209; SE, 0.06; Wald χ2 = 11.89; P = .001); patients who did not respond to midazolam scored higher on the EASI emotionality subscale than patients who did respond (nonresponder mean [SD] EASI emotionality score, 13.6 [3.6]; responder mean [SD] EASI emotionality score, 11.3 [3.8]; P = .001) |
| MacLaren and Kain,36 2008; United States | Emotionality, activity, and sociability | EASI | 5-7 d Before surgery | mYPAS | Preoperative holding area, OR entrance | No correlation was found between child anxiety at induction and sociability (r = 0.09); association of other temperament dimensions and anxiety was not assessed |
| Quinonez et al,49 1997; Canada | Emotionality, activity, sociability, and shyness | EAS-TS | Prior to OR on day of surgery | MBPRS-R, Frankl Scale | Prior to OR (ie, in playroom), en route to OR, parental separation, postseparation/anesthetic induction | Shyness was significantly associated with state anxiety (disruptive behavior, as measured by MBPRS-R) during preseparation (R2 = 0.16; F = 9.23; P = .004) and separation of the child from the parent at the entry of the OR (R2 = 0.10; F = 5.12; P = .03) |
| Wight et al,23 2013; Canada | Emotionality, activity, sociability, impulsivity; anxiety-shyness, and hyperactivity-impulsivity | EASI; CPRS-R: L | Prior to day of surgery | mYPAS | Introduction of anesthesia mask | CPRS-R:L anxiety-shyness subscale was significantly associated with preoperative anxiety at anesthetic induction (r = 0.24) |
| Wright et al,37 2017; Canada | Emotionality, activity, sociability, and impulsivity | EASI | Prior to day of surgery | mYPAS | Admission, day surgery unit, OR entrance, introduction of anesthesia mask | No significant association of temperament dimensions and child preoperative anxiety |
Abbreviations: BP, blood pressure; BQ, Scaife and Campbell behavioral questionnaire; BSQ, Behavioral Style Questionnaire; CARS, Clinical Anxiety Rating Scale; CBCL, Child Behavior Checklist; CBCL/6-18, Child Behavior Checklist for Ages 6-18; CCTI, Colorado Child Temperament Inventory; CDI, children’s desire for information; CPMAS, Children’s Perioperative Multidimensional Anxiety Scale; CPRS-R:L, Conners Parent Rating Scale–Revised, long form; CSWQ, Child Surgery Worries Questionnaire; EASI, Emotionality Activity Sociability and Impulsivity inventory; EAS-P and EAS-TS, Emotionality Activity Sociability temperament survey; EATQ-R-P, Early Adolescent Temperament Questionnaire Revised–parent version; ECG, electrocardiography; MBPRS-R, Melamed Behavior Profile Rating Scale–Revised; MCTQ, Middle Childhood Temperament Questionnaire; mYPAS, modified Yale Preoperative Anxiety Scale; NRS, numeric rating scale; NS, not specified; OR, operating room; OSBD, Observational Scale Of Behavioral Distress; PPRS, Pediatric Patient Rating Scale; SAM, self-assessment mannequin; SATI, School Age Temperament Inventory; SCL, skin conductance level; STAI-CH, State Trait Anxiety Inventory for Children; STST, Short Temperament Scale for Toddlers; TS, temperament scale; VAS, visual analog scale; VPT, Venham Picture test; YPAS, Yale Preoperative Anxiety Scale.