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Children's coping during invasive medical procedures
BEHAVIORTI-I~RAPY24, 143-158, 1993
Children's Coping During Invasive Medical Procedures SHARON L. MANNE Memorial SIoan-Kettering Cancer Center ROGER BAKEMAN
Georgia State University PAUL JACOBSEN
WILLIAM H. REDD Memorial Sloan-Kettering Cancer Center The study examined the impact of three coping behaviors (non-procedure-related statements and behaviors, information seeking, and requests for modifications in the procedure) exhibited during stressful medical procedures performed on 45 children undergoing cancer treatment. Using videotaped recordings of venipunctures, the relations among the three coping behaviors and the relations between coping and distress were investigated. Because age was associated with both distress and coping, age was partialled out when computing correlations. Coping behaviors were independent (i.e., not correlated). A pattern of consistent, weak-to-moderate associations was noted between non-procedure-related behaviors and reductions in both concurrent and subsequent distress. The role of developmental differences in the study of children's coping are discussed.
There are few childhood events that are more stressful and that challenge both the child's and the parent's ability to cope more than invasive medical procedures (Jacobsen, Manne, Gorfinkle, Schorr, Rapkin, & Redd, 1990; Jay, 1988; Jay, Ozolins, Elliott, & Caldwell, 1983). Such stressors can reach crisis level when they occur in the context of a life-threatening illness such as cancer. This research was supported by a grant from the American Cancer Society (PBR #17E and F) to William H. Redd and Sharon L. Manne, an American Cancer Society Junior Faculty Research Award to Sharon L. Manne (JFRA #357), and a NIMH Research Scientist Development Award to William H. Redd (K02-MH00882). We would like to thank Donna Bernstein, Ken Gorfinkle, Fern Gerstein, Diana Morrobel, and Tanner Freeman for their assistance in data collection and coding. We also would like to thank the patients, their parents, and the medical staff at Memorial Sloan-Kettering Cancer Center for their cooperation. Correspondence should be directed to Sharon L. Manne, Psychiatry, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.
143 0005-7894/93/0143-015851.00/0 Copyright 1993 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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Unfortunately, our understanding of the factors that affect a child's ability to handle stressors is primitive. Although theories have been offered to account for how adults cope with medical events (e.g., Miller, 1980), the conceptualization of children's coping during medical procedures has lagged behind. One reason why this research has not progressed as quickly is that children's varying developmental levels have made investigation using traditional methodologies such as paper-and-pencil rating scales difficult. How to define coping is a major issue in child health psychology. For example, some researchers have defined children's assertions to medical staff regarding how the procedure is to proceed as coping (Peterson & Toler, 1986), while others either have not included this behavior or have categorized it as a "neutral" behavior (Blount, Corbin, Sturges, Wolfe, Prater, & James, 1989). The identical problem exists regarding the categorization of information seeking. Although most researchers define it as a coping strategy (e.g., Peterson & Toler, 1986), others categorize it as a distress behavior (Elliott, Jay, & Woody, 1987). Indeed, it appears that researchers in the area do not agree on what behaviors actually constitute coping. This inconsistency in how coping has been defined may be due to the fact that researchers developed their definitions of coping without functional criteria. That is, coping has been defined on an a priori basis rather than being defined in terms of behaviors that are observed to be associated with an actual reduction in behavioral distress. Another aspect of the problem of how to define children's coping is the time frame for assessment. Most studies have examined anticipatory coping, focusing on coping in preparation for impending hospitalization or surgery (e.g., La Montagne, 1984, 1987; Peterson & Toler, 1986) or in anticipation of routine medical examinations (Bush, Melamed, Sheras, & Greenbaum, 1986). Although this approach is appropriate when the child is anesthetized during the stressful event (e.g., surgery), it is not adequate for understanding situations in which the child is alert during the stressful event. In these situations, it is important to observe how the child behaves (i.e., copes) during the event and to determine the relation between specific coping behaviors and changes in levels of behavioral distress. It should be noted that the impact of coping behaviors may differ depending upon when they occur over the course of the procedure. The present study used this functional approach to examine child behaviors that are associated with distress during an invasive medical procedure (i.e., venipuncture). Can a cluster of behaviors be identified that are associated with reduced distress? Our selection of three behaviors for study (information seeking, children's directives regarding how they would like the procedure to proceed, and non-procedure-related statements and behaviors) was guided by the conceptualization of children's characteristic style of coping along the active/avoidant dimension (Peterson, 1989; Peterson & Toler, 1986; Siegel, 1981). Information seeking prior to the onset of the procedure is generally regarded as an active form of coping. This behavior has been studied frequently in prior work and has generally been found to be associated with less distress (e.g., Siegel, 1981; Peterson & Toler, 1986). A second behavior that has been studied, children's directives regarding how the procedure should proceed (assertive procedure vocalizations), can also be categorized as an active coping strategy.
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This behavior has been studied by Blount and his colleagues (Blount et al., 1989; Blount, Sturges, & Powers, 1990) in their research on children's distress during bone marrow aspirations and lumbar punctures, and has not been associated with distress. A third coping behavior that has been studied frequently is non-procedure-related statements and behaviors. The categorization of this behavior along the active/avoidant dimension is complex. On one hand, this behavior could be considered an avoidant coping strategy if the child is not addressing the procedure (in fact, this behavior is often labeled "distraction"). On the other hand, a child who is talking about toys rather than the procedure may be attempting to actively cope with the procedure (Peterson, 1989). One aspect which influences categorization is the intent behind the behavior, and this is strongly influenced by the timing or phase of coping in which the behavior occurs. These three behaviors- information seeking, attempts to direct how the procedure is to proceed, and non-procedure-related statements and behaviors (distraction)-were examined in several ways. First, we examined whether these behaviors naturally occurred (i.e., without specialized training) and how these behaviors related to each other. Our goal was to determine whether these behaviors should be categorized as separate behaviors or as a group of coping behaviors. Second, we studied the association of these behaviors with children's distress and crying to determine whether the behaviors met the functional definition of coping (a reduced level of distress). To address the issue of time frame in coping assessment, we examined these behaviors in the context of the performance of the medical procedure (venipuncture). For the purpose of this research, venipuncture was divided into phases so that we could determine whether the timing of the behavior had a bearing upon its impact. Third, we analyzed the effect of the child's age upon the relationship between coping and distress. Prior research has indicated that age may play an important role in both coping and distress during invasive procedures (e.g., Peterson & Toler, 1986).
Method Subjects Forty-five children with cancer and their parents participated. The sample included 24 boys and 21 girls between the ages of 36 months and 112 months (mean = 64 months or approximately 5 ½ years). Criteria for inclusion were: (a) outpatient at the Pediatric Day Hospital, (b) patient scheduled for performance of venipuncture, (c) parent present for outpatient treatment, (d) parent and child English-speaking, and (e) child between 3 and 10 years of age. Fiftyfour parents were approached and asked to participate. Three parents stated they did not wish to be videotaped, and two parents stated their children were not sufficiently distressed during the venipuncture to participate in the study. Of the 49 parents who consented to participate, four subjects were not videotaped because of equipment malfunction or nonavailability of equipment. Medical diagnoses included acute leukemia (18), lymphoma (1), Kostman's syndrome (4), neuroblastoma (6), embryonic rhabdomyosarcoma (4), solid
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tumor (2), aplastic anemia (1), hepatoblastoma (1), Wilm's tumor (2), Wiscott Aldrich syndrome (3), myelodysplastic syndrome (1), glioma (1), and agranulocytosis (1). The average amount of time since diagnosis was 28 months (SD -- 24, range = 1-95 months). Average number of prior venipunctures was 54 (SD = 79, range = 1-400), which is a higher level of previous experience with venipuncture than most prior studies of pediatric cancer patients undergoing invasive medical procedures (e.g., BIount et al., 1989; Jay, Elliot, Katz, & Siegel, 1987). Overall, the children were physically functional as rated by the Lansky Play Performance Inventory (median = 90, range = 50-100). Seventy-three percent of the children were White, 11070were Black, and 16°70 were Hispanic. In 29 cases, the mother was present during the procedure, in 6 cases both parents were present, in 4 cases the father was present, and in 6 cases the mother and another relative were present. Mean parent age was 35 years (SD = 9 years, range = 22-47 years).
Procedure The procedure used in this study was the same as methods employed in a prior study (Manne, Bakeman, Jacobsen, Gorfinkle, Bernstein, & Redd, 1992). The present study differs from our prior study in that an expanded data base is used and the focus is on the children's behavior. After each child underwent a finger stick (small puncture of a finger) upon arrival at the clinic, informed consent and permission to videotape were obtained from parents and assent was obtained from the child. In this study, venipuncture was conducted in order to obtain blood samples only (44°7o), to obtain blood samples and to administer chemotherapy (13 °70), to administer chemotherapy only (7°70), to administer anesthesia (7o70), to administer hydration (2o70), to take blood and administer hydration (7o70), to take blood and administer anesthesia (9o70), and for three or more of the above reasons (11070). Videorecording (from a camera mounted on the wall of the treatment room) began as soon as the child entered the treatment room and ended when the child left the treatment room. Coding scheme. Videotapes were coded using a scale developed by the first author (S.M.). This scale was based in part on a scale employed in our prior work (Procedure Behavior Rating Scale-Venipuncture Version; Jacobsen et al., 1990) and on the Child-Adult Medical Procedure Interaction Scale (CAMPIS; Blount et al., 1989). Child behaviors included in the coping coding system are shown in Table 1. Distress behaviors are also included. For most codes, only the onset time was recorded (these categories are referred to as "momentary" codes). For two categories that could last for more than several seconds (child cry/scream, child non-procedure-related statements and behaviors), the offset time was also recorded, yielding information about duration. For the current study, information seeking was defined as questions about the medical procedure which could occur at any point during the procedure. Such questions typically involve ascertaining information about what will be done during the venipuncture tasks (e.g., "What type of needle are you going to use?", "How many tubes are you going to take?", "Why did you take the needle out?", or "Why did you put tape all over my arm?". Questions ascer-
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TABLE 1 CHILD COPING AND DISTRESS ]~EHAVIORS Behavior Category
Operational Definition
Coping Behaviors
Non-procedure-related statements and behaviors* Information seeking Assertive procedural vocalizations
Non-procedure-, non-disease-relatedtalk (i.e., talking about school or leisuretopics); non-verbalbehaviorsinclude deep breathing, looking around the room, playing with a toy. Attempts to obtain information about the procedure. Must take the form of questions (i.e., "What is the butterflyneedle for?") Statement of preferenceregarding how child wants the procedure to proceed (i.e., "Put the needle in this hand.")
Distress Behaviors
Momentary distress Cry/scream*
Any of the following behaviors: pain/fear, request termination, refuse position, support/cling, non-compliance,muscular rigidity. Tears in eyes or running down face, screaming.
* Duration Code: Onset and offset times are recorded.
taining how much pain is involved (e.g., "Will it hurt?") were coded as pain/fear rather than information seeking. Behaviors such as looking at the needle during insertion or discussion of the medical procedure that does not involve asking questions (i.e., "That is a butterfly needle") were not coded as information seeking. Three undergraduate observers completed a training program prior to coding tapes used in the data analyses. The training program is described in detail in a previous study (Manne et al., 1992). Data reduction. The child distress category was formed by collapsing several codes. The momentary child distress behaviors of pain/fear, request termination, refuse position, support/cling, noncompliance, and muscular rigidity were combined to form the category of momentary child distress. Our previous research (Jacobsen et al., 1990; Manne, Redd, Jacobsen, Gorfinkle, Schorr, & Rapkin, 1990) indicated a relatively high degree of internal consistency among these child distress behaviors. Child cry/scream was retained as a separate category from momentary distress for several reasons, It could and often did continue uninterrupted for relatively long periods of time and may be interpreted as a sign of more severe upset. If we lumped cry/scream with momentary distress codes on a frequency basis for the analyses, then the impact of the duration of cry/scream would be lost. If we combined the overall duration of cry/scream and momentary distress, then the combination category would become dominated by cry/scream. As a result, we decided to retain the two categories. A more detailed discussion of this issue is outlined in our prior study (Manne et al., 1992).
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As noted, durations were recorded for two of the behaviors (child cry/scream and non-procedure-related statements and behavior); the descriptive statistic used for these durations was the number of seconds within the phase coded for the behavior divided by the number of seconds in the phase, expressed as a percentage. Frequency of occurrence was recorded for the other behaviors; the descriptive statistic used for these behaviors was the rate, defined as the number of occurrences per minute. Observer agreement. In order to assess inter-rater reliability, one randomly selected quarter from each of 28 videotapes was coded both by the criterion coder (S.M.) and by the trained observers. Each second o f the protocol was checked for agreement, and agreement was tallied if both observers coded the same behavior within the same or an adjacent second. Kappa coefficients were as follows: momentary distress category = .96, cry/scream = .88, nonprocedure-related statements and behavior = .92, assertive procedural vocalizations = .96, information seeking = .99.
Approach to Data Analyses Phase definition. Because we were interested in examining whether the effects of coping differed across phases of the medical procedure, venipuncture was divided into three nonoverlapping phases: preparation, needle insertion, and completion. Preparation began when the parent and child entered the videoscreen area in the IV room. During preparation the nurse collected the necessary equipment and the child was positioned. Preparation concluded when the tourniquet was tied around the child's arm. During needle insertion, the nurse examined the child's arm to locate a suitable vein, cleaned the site with alcohol, and then inserted the needle. Insertion concluded as soon as blood was observed returning from the needle site. This phase had a longer duration if the nurse had difficulty accessing the vein or if additional attempts at needle insertion were required prior to successful access to the vein. During completion, the nurse performed the prescribed tasks of obtaining blood samples, administering chemotherapy, and/or leaving the IV line in place for other treatment procedures. Completion ended when the parent and child left the room. The mean times for each phase were as follows: preparation = 3.0 minutes, (SD = 4.2, range = .28-4.2 minutes), insertion = 3.1 minutes (SD = 3.75, range = .41-18.8 minutes), and completion = 4.2 minutes (SD = 2.56, range = .67-11.8 minutes). As can be seen from these figures, there was considerable variability in phase times. Procedures were divided into phases at these time points because the nature of the stressor posed changed at these points. Preparation can be viewed as the anticipatory period, where no painful stimulus has been presented. Needle insertion can be viewed as the most painful time o f the procedure, and we expected more distress to be exhibited during this phase. It should be noted that the procedures carried out during the completion phase differed. For example, some children were being administered chemotherapy during completion, whereas some children were going on to have a bone marrow aspiration under anesthesia. In fact, the majority of children had a needle inserted into one arm for part o f the completion phase, as blood
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was being drawn into tubes. Thus, the completion phase is not a true "recovery" phase, as procedures were still going on. Statistical significance and magnitude of effects. In the present study we asked whether or not the three coping behaviors intercorrelated, whether or not they correlated with two distress behaviors, and the effect of age of child and phase of procedure on these behaviors. In the process, a number of statistical tests are performed. The alpha level for individual tests is conventionally set to .05. However, when many tests are made, the study-wise alpha level can greatly exceed this. Consequently, some strategy was needed to protect against Type I error. One common strategy would be to use the Bonferroni correction. For example, if alpha is set to .05 divided by the number of tests, then the study wise alpha level will be .05. The Bonferroni correction can protect against incorrectly accepting the null hypothesis, but it can also be unduly restrictive. Moreover, defining the number of tests can be somewhat arbitrary. One alternative is to emphasize patterns of results rather than individual results, especially when patterns are identified with prior questions. A second choice is to emphasize the magnitude of results rather than the statistical significance of results. For example, correlation coefficients of .1 to .3 are commonly regarded as weak, .3 to .5 as moderate, and above .5 as strong (Cohen, 1977). This approach recognizes the arbitrary nature of statistical significance and its relation to sample size (Cohen, 1990). Indeed, even small effects become significant if the sample size is large enough. For the present paper, we use a combination of these approaches. Within each analysis (i.e., table), a Bonferroni alpha was applied. Within the results section, consistent patterns of results are noted. Near-zero correlations (less than .1 absolute) are not tabled; otherwise, correlations are identified as weak, moderate, or strong (greater than .1, .3, or .5). For discussion purposes, moderate and strong correlations are not ignored but are interpreted as suggestive.
Results We will first describe the prevalence of the three coping behaviors and examine whether there were differences in their rate of occurrence over the course of the procedure. Then, we will examine the effects of child age and previous experience with venipuncture upon children's coping. The relations among coping behaviors will be examined. Finally, relations between coping and both concurrent and later distress will be examined.
Descriptive Statistics and Interphase Differences For each behavior and for each phase, means, standard deviations, and the number of children who were observed engaging in the behavior at least once during the phase are given in Table 2. For comparison purposes, the same calculations were performed for the distress behavior categories. If fewer than half of the children engaged in the behavior during a phase, then the data for that behavior in that phase were transformed into binary data (child did
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M.ANNE TABLE 2 DESCRIPTIVE STATISTICSFOR COPING AND DISTRESS BEHAVIORS Preparation
Behavior
#
M
Insertion SD
#
M
Completion SD
#
M
SD
Coping Non-proc. related Info. seek Asst. voc.
33 9 18
9.5°70 .14 .53
(18.9) (.36) (.98)
30 14 22
5.7070 .37 .60
(8.2) (.86) (.93)
35 15 25
8.0070 .33 .51
(11.6) (.69) (.65)
Distress Momentary distress Cry/scream
31 19
1.8 19.4070
(2.1) (33.8)
38 35
3.4 44.6070
(3.6) (42.0)
32 19
1.5 26.8070
(2.6) (34.7)
Note.
The first number in each column is the number of children who engaged in the behavior at least once during each phase. The second number is the mean for the descriptive statistic, and the third number is the standard deviation (in parentheses). The descriptive statistic is the percentage of time during the phase the behavior lasted (for child nonprocedure-related behavior and cry/scream, marked with a percent sign) or the rate (for all other behaviors, expressed in occurrences per minute).
or did not engage in the behavior). Other possible transformations (e.g., log transformation) yielded essentially similar results for correlations. Therefore, information seeking in all phases, assertive procedural vocalizations in the preparatory and insertion phases, and cry/screaming in the preparation and completion phases were transformed into dichotomous variables. These transformations were completed in order to avoid a highly skewed distribution. Assertive procedural vocalizations during completion, cry/scream during insertion, non-procedure-related statements and behaviors during all phases, and momentary distress during all phases were not transformed into binary data. As noted earlier, for 20 children venipuncture was performed to obtain blood samples, whereas for the remaining children, insertion was followed by other procedures (e.g., chemotherapy administration). In order to determine whether behavior during the completion phase was affected by the reason for performing venipuncture, t tests compared the two groups. No significant differences were found for the five child behaviors examined. Eight different nurses performed the venipunctures for the current study. In addition, two nurses were present during 24 procedures and three nurses were present during one procedure. In order to examine the possibility that different nurses may have elicited different child coping and distress behaviors, nonparametric analyses (Kruskal-Wallis one-way analyses of variance) were conducted to determine whether children's coping and distress differed across nurses. These analyses indicated no significant differences between nurses per-
CHILD COPING
151
forming venipunctures. In order to determine whether the number of nurses present influenced children's behavior, correlations between number of nurses present and children's coping and distress were conducted. Results indicated that children engaged in more assertive procedural vocalizations during the insertion phase (r = -.37, p > .05 with Bonferroni correction) and the completion phase (r = -.39, p > .05 with Bonferroni correction) when fewer nurses were present. No associations were found between number of nursing personnel and either non-procedure-related statements and behaviors or information seeking. An examination of distress behaviors suggests that children engaged in more crying during all three phases (r = .22, .47, and .34, respectively for three phases; only .47 was significant with Bonferroni correction) and less distress during all three phases (r = .16, .26, and .19, respectively, p > .05 with Bonferroni correction) when more nurses were present. One explanation for this finding is that additional nurses were brought in whenever a child required physical restraint (when the child's level of distress prevented him/her from keeping his/her arm still). In order to examine this possibility, t tests were conducted to examine whether more nurses were employed when physical restraint was used. Results support this hypothesis: During the insertion and completion phases, significantly more nurses were present when physical restraint was used than when it was not used. Of course, it is still possible that the introduction of additional personnel caused the child to behave in a different manner. In order to determine whether child behavior varied across phases, a repeated measures analysis of variance was conducted. Results indicated that the mean scores for the three coping behaviors did not differs significantly across phases. However, the frequency of distress behaviors differed across phases. Both momentary distress (F(2,88) = 6.5, p < .01) and cry/scream (F(2,88) = 10.3, p < .001) occurred more frequently during the needle insertion phase than in the other two phases.
The Effects of Age and Previous Experience with Venipuncture Correlations of children's age and number of previous venipunctures with coping and distress during each phase are presented in Table 3. Older children cried less. In addition, there were trends for older children to exhibit less momentary distress and engage in a greater number of coping behaviors. In particular, correlations between age and cry/scream during insertion and completion were significant (Bonferroni corrected). Across all phases, the three correlations of age with cry/scream were negative (moderate or strong), the three correlations of age with momentary distress were also negative (but weak), and the nine correlations of age with coping were positive (weak or moderate). Given the consistent effects of age on children's behavior, all subsequent correlations reported in this paper (except for the next paragraph) are partial correlations, controlling for age. Compared to age, the pattern for previous experience with venipuncture was less clear. No correlations between number of previous venipunctures and behavior were significant (Bonferroni corrected). Five of 6 correlations with
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TABLE 3 ASSOCIATIONS BETWEEN AGE AND PREVIOUS EXPERIENCE WITH VENIPUNCTURE AND COPING AND DISTRESS BEHAVIORS ACROSS PHASES OF THE PROCEDURE Age Behavior
Prep.
Insert.
.17 .16 .14
.33 .30 .28
- .20 - .56*
No. Prey. Venip. Compl.
Prep.
Insert.
.16 .21 .15
- .11 .13 .19
.
-.19 - .46*
- .20
Compl.
Coping Non-proc. related I n f o . seek A s s t . voc.
. .26 ..
.
. .23 .16
Distress Momentary distress Cry/scream
- .27 - .38
- .23 - .32
- .22 - .25
Note.
C o r r e l a t i o n s less t h a n .1 a b s o l u t e a r e i n d i c a t e d w i t h t w o d o t s . d f = 43, t h u s i n d i v i d u a l c o r r e l a t i o n s .3 o r g r e a t e r a r e s i g n i f i c a n t at the .05 level. * p < .05, B o n f e r r o n i c o r r e c t e d .
distress behaviors were negative (mainly weak), and 5 of 9 correlations with coping behaviors were positive (all weak) (see Table 3). However, older children had experienced more venipunctures (r = .44, p < .005), and thus even the weak relation between previous venipuncture and distress might be spurious. To examine this possibility, partial correlation coefficients were computed, controlling for age. The results were unchanged. The partial correlations between previous venipunctures and distress remained negative and weak. Associations Among Coping Behaviors and Among Distress Behaviors Non-procedure-related statements and behaviors, information seeking, and assertive vocalizations were not significantly intercorrelated. The 9 partial correlations between coping behaviors (3 for each phase, controlling for age) ranged from -.23 to .23; the second highest was .14 and the rest were uncorrelated or were weakly negative. Thus, there is no evidence that these three behaviors should be treated as manifestations of a single underlying construct. Momentary distress and cry/scream, however, were correlated (.54, .38, and .25, respectively for preparation, insertion, and completion). Associations Between Coping and Distress Within Phases Associations between coping and distress within phases are shown in Table 4. Partial correlations controlling for age are presented. There was a tendency for more coping to be associated with less crying, especially during the insertion phase. However, none of the correlations were significant after the Bonferroni correction was applied. Across all phases, 8 of 9 correlations between coping and crying were negative; two of these negative correlations (information seeking and non-procedure-related behavior with
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TABLE 4 CORRELATIONS BETWEEN COPING AND DISTRESS WITHIN PHASES, CONTROLLING FOR AGE Preparation
Behavior Non-proc. related Info. seek Asst. voc.
Insertion
Completion
Mo. Dist.
Cry/ Scream
Mo. Dist.
Cry/ Scream
Mo. Dist.
Cry/ Scream
- .22 -.23
- .23 -.13 .29
.. -.19 -.19
- .36 -.30 -.15
.. ..
-.16 -.29 -.18
Note.
Correlations less t h a n . 1 absolute are indicated with two dots. df = 42, thus individual correlations .3 or greater are significant at the .05 level. * p < .05, Bonferroni corrected.
crying during insertion) were moderately strong. Four of 9 correlations between coping and momentary distress were negative (all weak), all during preparation or insertion.
Associations Between Early Coping and Subsequent Distress To determine whether information seeking, assertive procedure vocalizations, and non-procedure-related statements and behaviors were associated with subsequent distress, two sets of correlations were examined: (1) the relation of the three coping behaviors exhibited during preparation to distress during the needle insertion phase, and (2) the relation of these three behaviors during needle insertion to distress during the completion phase. All correlations were computed as partial correlations, controlling for the effects of age. Partial correlations are shown in Table 5. Results indicated that there was little effect on coping in an earlier phase on distress in the next phase (see Table 5). None of these correlations were significant (Bonferroni corrected); 4 of 12 correlations were weakly negative and 2 were weakly positive.
Associations between Early Distress and Subsequent Coping Two sets of correlations were examined to determine whether early distress effected coping in the subsequent phase. There was a small effect of early distress upon later coping, but no correlations were significant after the Bonferroni correction was applied. Three correlations were weakly negatively correlated with later coping. All of these relations were between distress during preparation and coping during insertion; distress and crying during preparation were associated with less non-procedure-related behavior and information seeking in the insertion phase.
Discussion The findings of the current study suggest that child behaviors often defined by child researchers as coping do not form a single category of behavior. Un-
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TABLE 5 CORRELATIONS BETWEEN CHILDREN'S COPING AND DISTRESS IN SUBSEQUENT PHASES, CONTROLLING FOR AGE Moment a ry distress
Behavior
Cry/ scream
Preparation Coping with Insertion Distress Non-proc. related Info. seek Asst. voc.
-.14 . .15
-.23 .
.
. .16
Insertion Coping with Completion Distress Non-proc. related Info. seek Asst. voc .
.
. -.12 .
.
.
.
. -.27
.
Note.
Correlations less t h a n . 1 absolute are indicated with two dots. df = 43, thus individual correlations .3 or greater are significant at the .05 level. * p < .05, Bonferroni corrected.
like children's distress behaviors, which correlate with one another and are frequently combined into a cluster of behaviors (e.g., Katz, Kellerman, & Siegel, 1980), the three behaviors studied were not significantly correlated. Future research should study the effects of coping behaviors individually rather than combining different coping behaviors to examine their effects. The current study also highlights the importance of considering the child's age when studying coping. Within the age range studied (3-10 years), older children engaged in more coping behaviors and fewer distress behaviors (particularly during the needle insertion phase). As a result, partial correlations controlling for age were reported. The comparable zero-order correlations al-
TABLE 6 CORRELATIONS BETWEEN CHILDRENJS DISTRESS AND COPING IN SUBSEQUENT PHASES, CONTROLLING FOR AGE
Distress behavior
Non-proc. related
Info. seek
Asst. voc.
- .26 ..
.13 .21
Preparation Distress with Insertion Coping Mo men tary distress Cry/scream
-.26 - .29
Insertion Distress with Completion Coping Momentary distress Cry/scream
Note.
.. - . 15
Correlations less t h a n . 1 absolute are indicated with two dots. df = 42, thus individual correlations .3 or greater are significant at the .05 level. * p < .05, Bonferroni corrected.
CHILD COPING
155
most always indicated stronger relations between coping and distress. However, it would have been misleading to report these correlations, because much of the variability can be explained by a third variable, age. An examination of the frequency and timing of naturally occurring coping behaviors yielded several patterns. First, these behaviors were not exhibited by many children and, when they did occur, the behaviors did not occur at a high rate (or proportion of time). Only half of the children (22/45) employed information seeking at any time while being assessed. Although non-procedurerelated statements and behaviors were used by the majority of children (43/45), children engaged in these behaviors for only a relatively small proportion of the time during each phase. Clearly, many children require specialized training in coping strategies in order to employ these behaviors. Second, the frequency of occurrence of coping over the course of venipuncture was not as predicted. Information seeking is usually conceptualized as obtaining information about the procedure prior to its onset, and therefore should occur most frequently during the preparation phase. This was not the case in the current study. Information seeking occurred more frequently during the needle insertion and completion phases than during the preparation phase. These data suggest that when the child is alert during the procedure, information seeking may continue throughout the procedure as long as the child continues to perceive threat. Indeed, examination of coded responses suggests that children asked questions during the completion phase regarding the numbers of tubes of blood to be taken, what type of arm board they were to receive, and why extra tubes of blood were being taken. In addition, none of the coping behaviors decreased during the completion phase. These results suggest that the completion phase of venipuncture only marks the completion of needle insertion. Some aversive aspects of treatment continue to occur during this time period, and the completion phase should not be considered a true "recovery" phase. The relations between coping behaviors and distress provide some preliminary information on whether these behaviors can be functionally defined as coping. The pattern of relationships for non-procedure-related behaviors suggests consistent, weak to moderate associations with both concurrent and subsequent distress. More non-procedure-related behaviors were consistently associated with less distress, even after age was partialled out. These results suggest that distraction has a positive impact on distress, and they support prior research which has incorporated distraction into pediatric behavioral interventions to reduce distress and other symptoms (e.g., Manne et al., 1990; Redd, Jacobsen, Die-Trill, Dermatis, McEvoy, & Holland, 1987). The pattern of relationships for information seeking was similar. Information seeking was associated with less concurrent distress, and this relationship was maintained across phases for those children who engaged in information seeking during the insertion phase and distress during the completion phase. The beneficial effect of information seeking is consistent with previous investigations (e.g., Siegel, 1981). Siegel (1981) found that children who sought out information and asked questions were less anxious and more cooperative than children who avoided information. Peterson and Toler (1986) also found that an information seeking disposition predicted less anticipatory distress (distress prior
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to the onset of the procedure) after accounting for age. However, an information seeking disposition did not predict distress during the blood test after accounting for age. The results of the current study are consistent with Peterson and Toler's (1986) findings, in that both studies found that information seeking during the anticipatory phase (preparation) did not predict distress during the insertion phase after controlling for age. However, in the current study the associations between non-procedure-related behavior and information seeking with distress were weak to moderate in magnitude, and these conclusions should be regarded as tentative. Our results regarding assertive vocalizations suggest that this behavior does not meet the functional definition of coping. In fact, the moderate, positive association between assertive procedural vocalizations and crying during preparation suggests that, at least during the anticipatory phase, this behavior may be a correlate of distress. Since assertive vocalizations have been categorized as a "neutral" behavior in a prior study (Blount et al., 1990), future studies should examine whether the function of assertive vocalizations varies across phases of the medical procedure. The pattern of relationships between distress exhibited during the preparation phase and subsequent coping suggests that when children are distressed at the beginning of the procedure, they are less likely to engage in coping behaviors (non-procedure-related behavior and information seeking) during the subsequent phase. These findings suggest that careful attention must be given to the introduction of intervention to increase coping behaviors early in the treatment session. Given the current study's sample size and the number of statistical tests performed, these conclusions should be considered only suggestive. Although the patterns of associations were consistent, all associations were weak to moderate in magnitude. Replication of the results using a larger sample would provide more conclusive evidence regarding coping and distress relationships. Two other limitations of the current study should be noted. First, our method of assessing coping was not without its problems. Because only observable behaviors were assessed, we were not able to examine cognitive coping strategies that were not verbalized. Although some authors (e.g., Hubert, Jay, Saltoun, & Hayes, 1988) have argued that the only valid measure of coping is observable behaviors, others have stated that coping is an internal strategy that is best assessed through self-report methods (La Montagne, 1984). Second, many of the patients in the current study had considerable prior experience with venipuncture. In contrast, pediatric patients studied while undergoing bone marrow aspirations (e.g., Hubert et al., 1988; Jay et al., 1987) and while awaiting elective surgery (e.g., Peterson & Toler, 1986) had less prior experience with these procedures. As a result, the generalizability of the current findings may be limited. In conclusion, the current study provides preliminary evidence to suggest that coping behaviors do not form a single category of coping and that nonprocedure-related behaviors and information seeking should be functionally defined as coping behaviors. Our results also illustrate that studies of children's coping should be sensitive to developmental issues. Indeed, age affected
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both coping and distress. Our findings also suggest the need to provide specialized training in coping skills during the early phases of medical procedures; many children in our study did not spontaneously use non-procedure-related behaviors or information seeking in their apparent attempts to cope.
References Blount, R., Corbin, S., Sturges, J., Wolfe, V., Prater, J., & James, L. (1989). The relationship between adults' behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20, 585-601. Blount, R., Sturges, J., & Powers, S. (1990). Analysis of child and adult behavioral variations by phase of medical procedure. Behavior Therapy, 21, 33-48. Bush, J., Melamed, B., Sheras, P., & Greenbaum, P. 0986). Mother-child patterns of coping with anticipatory medical stress. Health Psychology, 5, 137-157. Cohen, J. (1977). Statisticalpower analysis for the behavioralsciences. Hillsdale, N J: Erlbaum. Cohen, J. (1990). Things I have learned (so far). American Psychologist, 45, 1304-1312. Elliott, C., Jay, S., & Woody, P. (1987). An observation scale for measuring children's distress during medical procedures. Journal of Pediatric Psychology, 12, 543-551. Hubert, N., Jay, S., Saltoun, M., & Hayes, M. (1988). Approach-avoidance and distress in children undergoing preparation for painful medical procedures. Journal of Clinical ChildPsychology, 17, 194-202. Jacobsen, P., Manne, S., Gorfinkle, K., Schorr, O., Rapkin, B., & Redd, W. H. (1990). Analysis of child and parent activity during painful medical procedures. Health Psychology, 9, 559-576. Jay, S. 0988). Invasive medical procedures: Psychological intervention and assessment. In D. Routh (Ed.), Handbook of Pediatric Psychology (pp. 401-425). New York: Guilford. Jay, S., Elliott, C., Katz, E., & Siegel, S. (1987). Cognitive-behavioral and pharmacologic interventions for children's distress during painful medical procedures. Journal of Consulting and Clinical Psychology, 55, 860-865. Jay, S., Ozolins, M., Elliott, C., & Caldwell, S. (1983). Assessment of children's distress during painful medical procedures. Health Psychology, 2, 133-147. Katz, E., Kellerman, J., & Siegel, S. (1980). Behavioral distress in children undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48, 356-365. La Montagne, L. (1984). Children's locus of control beliefs as predictors of preoperative coping behavior. Nursing Research, 33, 76-85. La Montagne, L. (1987). Children's preoperative coping: Replication and extension. Nursing Research, 36, 63-167. Manne, S., Bakeman, R., Jacobsen, P., Gorfinkle, K., Bernstein, D., & Redd, W. (1992). Adult and child interaction during invasive medical procedures. Health Psychology, H (4), 241-249. Manne S., Redd, W. H., Jacobsen, P., Gorfinkle, K., Schorr, O., & Rapkin, B. (1990). Behavioral intervention to reduce child and parent distress during venipuncture. Journal of Consulting and Clinical Psychology, 58, 565-572. Miller, S. (1980). When is a little information a dangerous thing? Coping with stressful events by monitoring versus blunting. In S. Levine & H. Ursin (Eds.), Coping and Health (pp. 145-169). New York: Plenum. Petersen, L. (1989). Coping by children undergoing stressful medical procedures: Some conceptual, methodological, and therapeutic issues. Journal of Consulting and Clinical Psychology, 57, 380-387. Peterson, L., & Toler, S. (1986). An information seeking disposition in child surgery patients. Health Psychology, 5(4), 343-358.
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Redd, W. H., Jacobsen, P. B., Die-Trill, M., Dermatis, H., McEvoy, M., & Holland, J. (1987). Cognitive-attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy. Journal of Consulting and ClinicalPsychology, 55, 391-395. Siegel, L. (1981, April). Naturalistic study of coping strategies in childrenfacing medicalprocedures. Paper presented at the meeting of the Southeastern Psychological Association, Atlanta. RECEIVED: February 28, 1992 FIN~ ACCEPTANCE:June 2, 1992
Children's Coping During Invasive Medical Procedures SHARON L. MANNE Memorial SIoan-Kettering Cancer Center ROGER BAKEMAN
Georgia State University PAUL JACOBSEN
WILLIAM H. REDD Memorial Sloan-Kettering Cancer Center The study examined the impact of three coping behaviors (non-procedure-related statements and behaviors, information seeking, and requests for modifications in the procedure) exhibited during stressful medical procedures performed on 45 children undergoing cancer treatment. Using videotaped recordings of venipunctures, the relations among the three coping behaviors and the relations between coping and distress were investigated. Because age was associated with both distress and coping, age was partialled out when computing correlations. Coping behaviors were independent (i.e., not correlated). A pattern of consistent, weak-to-moderate associations was noted between non-procedure-related behaviors and reductions in both concurrent and subsequent distress. The role of developmental differences in the study of children's coping are discussed.
There are few childhood events that are more stressful and that challenge both the child's and the parent's ability to cope more than invasive medical procedures (Jacobsen, Manne, Gorfinkle, Schorr, Rapkin, & Redd, 1990; Jay, 1988; Jay, Ozolins, Elliott, & Caldwell, 1983). Such stressors can reach crisis level when they occur in the context of a life-threatening illness such as cancer. This research was supported by a grant from the American Cancer Society (PBR #17E and F) to William H. Redd and Sharon L. Manne, an American Cancer Society Junior Faculty Research Award to Sharon L. Manne (JFRA #357), and a NIMH Research Scientist Development Award to William H. Redd (K02-MH00882). We would like to thank Donna Bernstein, Ken Gorfinkle, Fern Gerstein, Diana Morrobel, and Tanner Freeman for their assistance in data collection and coding. We also would like to thank the patients, their parents, and the medical staff at Memorial Sloan-Kettering Cancer Center for their cooperation. Correspondence should be directed to Sharon L. Manne, Psychiatry, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.
143 0005-7894/93/0143-015851.00/0 Copyright 1993 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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Unfortunately, our understanding of the factors that affect a child's ability to handle stressors is primitive. Although theories have been offered to account for how adults cope with medical events (e.g., Miller, 1980), the conceptualization of children's coping during medical procedures has lagged behind. One reason why this research has not progressed as quickly is that children's varying developmental levels have made investigation using traditional methodologies such as paper-and-pencil rating scales difficult. How to define coping is a major issue in child health psychology. For example, some researchers have defined children's assertions to medical staff regarding how the procedure is to proceed as coping (Peterson & Toler, 1986), while others either have not included this behavior or have categorized it as a "neutral" behavior (Blount, Corbin, Sturges, Wolfe, Prater, & James, 1989). The identical problem exists regarding the categorization of information seeking. Although most researchers define it as a coping strategy (e.g., Peterson & Toler, 1986), others categorize it as a distress behavior (Elliott, Jay, & Woody, 1987). Indeed, it appears that researchers in the area do not agree on what behaviors actually constitute coping. This inconsistency in how coping has been defined may be due to the fact that researchers developed their definitions of coping without functional criteria. That is, coping has been defined on an a priori basis rather than being defined in terms of behaviors that are observed to be associated with an actual reduction in behavioral distress. Another aspect of the problem of how to define children's coping is the time frame for assessment. Most studies have examined anticipatory coping, focusing on coping in preparation for impending hospitalization or surgery (e.g., La Montagne, 1984, 1987; Peterson & Toler, 1986) or in anticipation of routine medical examinations (Bush, Melamed, Sheras, & Greenbaum, 1986). Although this approach is appropriate when the child is anesthetized during the stressful event (e.g., surgery), it is not adequate for understanding situations in which the child is alert during the stressful event. In these situations, it is important to observe how the child behaves (i.e., copes) during the event and to determine the relation between specific coping behaviors and changes in levels of behavioral distress. It should be noted that the impact of coping behaviors may differ depending upon when they occur over the course of the procedure. The present study used this functional approach to examine child behaviors that are associated with distress during an invasive medical procedure (i.e., venipuncture). Can a cluster of behaviors be identified that are associated with reduced distress? Our selection of three behaviors for study (information seeking, children's directives regarding how they would like the procedure to proceed, and non-procedure-related statements and behaviors) was guided by the conceptualization of children's characteristic style of coping along the active/avoidant dimension (Peterson, 1989; Peterson & Toler, 1986; Siegel, 1981). Information seeking prior to the onset of the procedure is generally regarded as an active form of coping. This behavior has been studied frequently in prior work and has generally been found to be associated with less distress (e.g., Siegel, 1981; Peterson & Toler, 1986). A second behavior that has been studied, children's directives regarding how the procedure should proceed (assertive procedure vocalizations), can also be categorized as an active coping strategy.
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This behavior has been studied by Blount and his colleagues (Blount et al., 1989; Blount, Sturges, & Powers, 1990) in their research on children's distress during bone marrow aspirations and lumbar punctures, and has not been associated with distress. A third coping behavior that has been studied frequently is non-procedure-related statements and behaviors. The categorization of this behavior along the active/avoidant dimension is complex. On one hand, this behavior could be considered an avoidant coping strategy if the child is not addressing the procedure (in fact, this behavior is often labeled "distraction"). On the other hand, a child who is talking about toys rather than the procedure may be attempting to actively cope with the procedure (Peterson, 1989). One aspect which influences categorization is the intent behind the behavior, and this is strongly influenced by the timing or phase of coping in which the behavior occurs. These three behaviors- information seeking, attempts to direct how the procedure is to proceed, and non-procedure-related statements and behaviors (distraction)-were examined in several ways. First, we examined whether these behaviors naturally occurred (i.e., without specialized training) and how these behaviors related to each other. Our goal was to determine whether these behaviors should be categorized as separate behaviors or as a group of coping behaviors. Second, we studied the association of these behaviors with children's distress and crying to determine whether the behaviors met the functional definition of coping (a reduced level of distress). To address the issue of time frame in coping assessment, we examined these behaviors in the context of the performance of the medical procedure (venipuncture). For the purpose of this research, venipuncture was divided into phases so that we could determine whether the timing of the behavior had a bearing upon its impact. Third, we analyzed the effect of the child's age upon the relationship between coping and distress. Prior research has indicated that age may play an important role in both coping and distress during invasive procedures (e.g., Peterson & Toler, 1986).
Method Subjects Forty-five children with cancer and their parents participated. The sample included 24 boys and 21 girls between the ages of 36 months and 112 months (mean = 64 months or approximately 5 ½ years). Criteria for inclusion were: (a) outpatient at the Pediatric Day Hospital, (b) patient scheduled for performance of venipuncture, (c) parent present for outpatient treatment, (d) parent and child English-speaking, and (e) child between 3 and 10 years of age. Fiftyfour parents were approached and asked to participate. Three parents stated they did not wish to be videotaped, and two parents stated their children were not sufficiently distressed during the venipuncture to participate in the study. Of the 49 parents who consented to participate, four subjects were not videotaped because of equipment malfunction or nonavailability of equipment. Medical diagnoses included acute leukemia (18), lymphoma (1), Kostman's syndrome (4), neuroblastoma (6), embryonic rhabdomyosarcoma (4), solid
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tumor (2), aplastic anemia (1), hepatoblastoma (1), Wilm's tumor (2), Wiscott Aldrich syndrome (3), myelodysplastic syndrome (1), glioma (1), and agranulocytosis (1). The average amount of time since diagnosis was 28 months (SD -- 24, range = 1-95 months). Average number of prior venipunctures was 54 (SD = 79, range = 1-400), which is a higher level of previous experience with venipuncture than most prior studies of pediatric cancer patients undergoing invasive medical procedures (e.g., BIount et al., 1989; Jay, Elliot, Katz, & Siegel, 1987). Overall, the children were physically functional as rated by the Lansky Play Performance Inventory (median = 90, range = 50-100). Seventy-three percent of the children were White, 11070were Black, and 16°70 were Hispanic. In 29 cases, the mother was present during the procedure, in 6 cases both parents were present, in 4 cases the father was present, and in 6 cases the mother and another relative were present. Mean parent age was 35 years (SD = 9 years, range = 22-47 years).
Procedure The procedure used in this study was the same as methods employed in a prior study (Manne, Bakeman, Jacobsen, Gorfinkle, Bernstein, & Redd, 1992). The present study differs from our prior study in that an expanded data base is used and the focus is on the children's behavior. After each child underwent a finger stick (small puncture of a finger) upon arrival at the clinic, informed consent and permission to videotape were obtained from parents and assent was obtained from the child. In this study, venipuncture was conducted in order to obtain blood samples only (44°7o), to obtain blood samples and to administer chemotherapy (13 °70), to administer chemotherapy only (7°70), to administer anesthesia (7o70), to administer hydration (2o70), to take blood and administer hydration (7o70), to take blood and administer anesthesia (9o70), and for three or more of the above reasons (11070). Videorecording (from a camera mounted on the wall of the treatment room) began as soon as the child entered the treatment room and ended when the child left the treatment room. Coding scheme. Videotapes were coded using a scale developed by the first author (S.M.). This scale was based in part on a scale employed in our prior work (Procedure Behavior Rating Scale-Venipuncture Version; Jacobsen et al., 1990) and on the Child-Adult Medical Procedure Interaction Scale (CAMPIS; Blount et al., 1989). Child behaviors included in the coping coding system are shown in Table 1. Distress behaviors are also included. For most codes, only the onset time was recorded (these categories are referred to as "momentary" codes). For two categories that could last for more than several seconds (child cry/scream, child non-procedure-related statements and behaviors), the offset time was also recorded, yielding information about duration. For the current study, information seeking was defined as questions about the medical procedure which could occur at any point during the procedure. Such questions typically involve ascertaining information about what will be done during the venipuncture tasks (e.g., "What type of needle are you going to use?", "How many tubes are you going to take?", "Why did you take the needle out?", or "Why did you put tape all over my arm?". Questions ascer-
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TABLE 1 CHILD COPING AND DISTRESS ]~EHAVIORS Behavior Category
Operational Definition
Coping Behaviors
Non-procedure-related statements and behaviors* Information seeking Assertive procedural vocalizations
Non-procedure-, non-disease-relatedtalk (i.e., talking about school or leisuretopics); non-verbalbehaviorsinclude deep breathing, looking around the room, playing with a toy. Attempts to obtain information about the procedure. Must take the form of questions (i.e., "What is the butterflyneedle for?") Statement of preferenceregarding how child wants the procedure to proceed (i.e., "Put the needle in this hand.")
Distress Behaviors
Momentary distress Cry/scream*
Any of the following behaviors: pain/fear, request termination, refuse position, support/cling, non-compliance,muscular rigidity. Tears in eyes or running down face, screaming.
* Duration Code: Onset and offset times are recorded.
taining how much pain is involved (e.g., "Will it hurt?") were coded as pain/fear rather than information seeking. Behaviors such as looking at the needle during insertion or discussion of the medical procedure that does not involve asking questions (i.e., "That is a butterfly needle") were not coded as information seeking. Three undergraduate observers completed a training program prior to coding tapes used in the data analyses. The training program is described in detail in a previous study (Manne et al., 1992). Data reduction. The child distress category was formed by collapsing several codes. The momentary child distress behaviors of pain/fear, request termination, refuse position, support/cling, noncompliance, and muscular rigidity were combined to form the category of momentary child distress. Our previous research (Jacobsen et al., 1990; Manne, Redd, Jacobsen, Gorfinkle, Schorr, & Rapkin, 1990) indicated a relatively high degree of internal consistency among these child distress behaviors. Child cry/scream was retained as a separate category from momentary distress for several reasons, It could and often did continue uninterrupted for relatively long periods of time and may be interpreted as a sign of more severe upset. If we lumped cry/scream with momentary distress codes on a frequency basis for the analyses, then the impact of the duration of cry/scream would be lost. If we combined the overall duration of cry/scream and momentary distress, then the combination category would become dominated by cry/scream. As a result, we decided to retain the two categories. A more detailed discussion of this issue is outlined in our prior study (Manne et al., 1992).
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As noted, durations were recorded for two of the behaviors (child cry/scream and non-procedure-related statements and behavior); the descriptive statistic used for these durations was the number of seconds within the phase coded for the behavior divided by the number of seconds in the phase, expressed as a percentage. Frequency of occurrence was recorded for the other behaviors; the descriptive statistic used for these behaviors was the rate, defined as the number of occurrences per minute. Observer agreement. In order to assess inter-rater reliability, one randomly selected quarter from each of 28 videotapes was coded both by the criterion coder (S.M.) and by the trained observers. Each second o f the protocol was checked for agreement, and agreement was tallied if both observers coded the same behavior within the same or an adjacent second. Kappa coefficients were as follows: momentary distress category = .96, cry/scream = .88, nonprocedure-related statements and behavior = .92, assertive procedural vocalizations = .96, information seeking = .99.
Approach to Data Analyses Phase definition. Because we were interested in examining whether the effects of coping differed across phases of the medical procedure, venipuncture was divided into three nonoverlapping phases: preparation, needle insertion, and completion. Preparation began when the parent and child entered the videoscreen area in the IV room. During preparation the nurse collected the necessary equipment and the child was positioned. Preparation concluded when the tourniquet was tied around the child's arm. During needle insertion, the nurse examined the child's arm to locate a suitable vein, cleaned the site with alcohol, and then inserted the needle. Insertion concluded as soon as blood was observed returning from the needle site. This phase had a longer duration if the nurse had difficulty accessing the vein or if additional attempts at needle insertion were required prior to successful access to the vein. During completion, the nurse performed the prescribed tasks of obtaining blood samples, administering chemotherapy, and/or leaving the IV line in place for other treatment procedures. Completion ended when the parent and child left the room. The mean times for each phase were as follows: preparation = 3.0 minutes, (SD = 4.2, range = .28-4.2 minutes), insertion = 3.1 minutes (SD = 3.75, range = .41-18.8 minutes), and completion = 4.2 minutes (SD = 2.56, range = .67-11.8 minutes). As can be seen from these figures, there was considerable variability in phase times. Procedures were divided into phases at these time points because the nature of the stressor posed changed at these points. Preparation can be viewed as the anticipatory period, where no painful stimulus has been presented. Needle insertion can be viewed as the most painful time o f the procedure, and we expected more distress to be exhibited during this phase. It should be noted that the procedures carried out during the completion phase differed. For example, some children were being administered chemotherapy during completion, whereas some children were going on to have a bone marrow aspiration under anesthesia. In fact, the majority of children had a needle inserted into one arm for part o f the completion phase, as blood
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was being drawn into tubes. Thus, the completion phase is not a true "recovery" phase, as procedures were still going on. Statistical significance and magnitude of effects. In the present study we asked whether or not the three coping behaviors intercorrelated, whether or not they correlated with two distress behaviors, and the effect of age of child and phase of procedure on these behaviors. In the process, a number of statistical tests are performed. The alpha level for individual tests is conventionally set to .05. However, when many tests are made, the study-wise alpha level can greatly exceed this. Consequently, some strategy was needed to protect against Type I error. One common strategy would be to use the Bonferroni correction. For example, if alpha is set to .05 divided by the number of tests, then the study wise alpha level will be .05. The Bonferroni correction can protect against incorrectly accepting the null hypothesis, but it can also be unduly restrictive. Moreover, defining the number of tests can be somewhat arbitrary. One alternative is to emphasize patterns of results rather than individual results, especially when patterns are identified with prior questions. A second choice is to emphasize the magnitude of results rather than the statistical significance of results. For example, correlation coefficients of .1 to .3 are commonly regarded as weak, .3 to .5 as moderate, and above .5 as strong (Cohen, 1977). This approach recognizes the arbitrary nature of statistical significance and its relation to sample size (Cohen, 1990). Indeed, even small effects become significant if the sample size is large enough. For the present paper, we use a combination of these approaches. Within each analysis (i.e., table), a Bonferroni alpha was applied. Within the results section, consistent patterns of results are noted. Near-zero correlations (less than .1 absolute) are not tabled; otherwise, correlations are identified as weak, moderate, or strong (greater than .1, .3, or .5). For discussion purposes, moderate and strong correlations are not ignored but are interpreted as suggestive.
Results We will first describe the prevalence of the three coping behaviors and examine whether there were differences in their rate of occurrence over the course of the procedure. Then, we will examine the effects of child age and previous experience with venipuncture upon children's coping. The relations among coping behaviors will be examined. Finally, relations between coping and both concurrent and later distress will be examined.
Descriptive Statistics and Interphase Differences For each behavior and for each phase, means, standard deviations, and the number of children who were observed engaging in the behavior at least once during the phase are given in Table 2. For comparison purposes, the same calculations were performed for the distress behavior categories. If fewer than half of the children engaged in the behavior during a phase, then the data for that behavior in that phase were transformed into binary data (child did
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M.ANNE TABLE 2 DESCRIPTIVE STATISTICSFOR COPING AND DISTRESS BEHAVIORS Preparation
Behavior
#
M
Insertion SD
#
M
Completion SD
#
M
SD
Coping Non-proc. related Info. seek Asst. voc.
33 9 18
9.5°70 .14 .53
(18.9) (.36) (.98)
30 14 22
5.7070 .37 .60
(8.2) (.86) (.93)
35 15 25
8.0070 .33 .51
(11.6) (.69) (.65)
Distress Momentary distress Cry/scream
31 19
1.8 19.4070
(2.1) (33.8)
38 35
3.4 44.6070
(3.6) (42.0)
32 19
1.5 26.8070
(2.6) (34.7)
Note.
The first number in each column is the number of children who engaged in the behavior at least once during each phase. The second number is the mean for the descriptive statistic, and the third number is the standard deviation (in parentheses). The descriptive statistic is the percentage of time during the phase the behavior lasted (for child nonprocedure-related behavior and cry/scream, marked with a percent sign) or the rate (for all other behaviors, expressed in occurrences per minute).
or did not engage in the behavior). Other possible transformations (e.g., log transformation) yielded essentially similar results for correlations. Therefore, information seeking in all phases, assertive procedural vocalizations in the preparatory and insertion phases, and cry/screaming in the preparation and completion phases were transformed into dichotomous variables. These transformations were completed in order to avoid a highly skewed distribution. Assertive procedural vocalizations during completion, cry/scream during insertion, non-procedure-related statements and behaviors during all phases, and momentary distress during all phases were not transformed into binary data. As noted earlier, for 20 children venipuncture was performed to obtain blood samples, whereas for the remaining children, insertion was followed by other procedures (e.g., chemotherapy administration). In order to determine whether behavior during the completion phase was affected by the reason for performing venipuncture, t tests compared the two groups. No significant differences were found for the five child behaviors examined. Eight different nurses performed the venipunctures for the current study. In addition, two nurses were present during 24 procedures and three nurses were present during one procedure. In order to examine the possibility that different nurses may have elicited different child coping and distress behaviors, nonparametric analyses (Kruskal-Wallis one-way analyses of variance) were conducted to determine whether children's coping and distress differed across nurses. These analyses indicated no significant differences between nurses per-
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151
forming venipunctures. In order to determine whether the number of nurses present influenced children's behavior, correlations between number of nurses present and children's coping and distress were conducted. Results indicated that children engaged in more assertive procedural vocalizations during the insertion phase (r = -.37, p > .05 with Bonferroni correction) and the completion phase (r = -.39, p > .05 with Bonferroni correction) when fewer nurses were present. No associations were found between number of nursing personnel and either non-procedure-related statements and behaviors or information seeking. An examination of distress behaviors suggests that children engaged in more crying during all three phases (r = .22, .47, and .34, respectively for three phases; only .47 was significant with Bonferroni correction) and less distress during all three phases (r = .16, .26, and .19, respectively, p > .05 with Bonferroni correction) when more nurses were present. One explanation for this finding is that additional nurses were brought in whenever a child required physical restraint (when the child's level of distress prevented him/her from keeping his/her arm still). In order to examine this possibility, t tests were conducted to examine whether more nurses were employed when physical restraint was used. Results support this hypothesis: During the insertion and completion phases, significantly more nurses were present when physical restraint was used than when it was not used. Of course, it is still possible that the introduction of additional personnel caused the child to behave in a different manner. In order to determine whether child behavior varied across phases, a repeated measures analysis of variance was conducted. Results indicated that the mean scores for the three coping behaviors did not differs significantly across phases. However, the frequency of distress behaviors differed across phases. Both momentary distress (F(2,88) = 6.5, p < .01) and cry/scream (F(2,88) = 10.3, p < .001) occurred more frequently during the needle insertion phase than in the other two phases.
The Effects of Age and Previous Experience with Venipuncture Correlations of children's age and number of previous venipunctures with coping and distress during each phase are presented in Table 3. Older children cried less. In addition, there were trends for older children to exhibit less momentary distress and engage in a greater number of coping behaviors. In particular, correlations between age and cry/scream during insertion and completion were significant (Bonferroni corrected). Across all phases, the three correlations of age with cry/scream were negative (moderate or strong), the three correlations of age with momentary distress were also negative (but weak), and the nine correlations of age with coping were positive (weak or moderate). Given the consistent effects of age on children's behavior, all subsequent correlations reported in this paper (except for the next paragraph) are partial correlations, controlling for age. Compared to age, the pattern for previous experience with venipuncture was less clear. No correlations between number of previous venipunctures and behavior were significant (Bonferroni corrected). Five of 6 correlations with
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TABLE 3 ASSOCIATIONS BETWEEN AGE AND PREVIOUS EXPERIENCE WITH VENIPUNCTURE AND COPING AND DISTRESS BEHAVIORS ACROSS PHASES OF THE PROCEDURE Age Behavior
Prep.
Insert.
.17 .16 .14
.33 .30 .28
- .20 - .56*
No. Prey. Venip. Compl.
Prep.
Insert.
.16 .21 .15
- .11 .13 .19
.
-.19 - .46*
- .20
Compl.
Coping Non-proc. related I n f o . seek A s s t . voc.
. .26 ..
.
. .23 .16
Distress Momentary distress Cry/scream
- .27 - .38
- .23 - .32
- .22 - .25
Note.
C o r r e l a t i o n s less t h a n .1 a b s o l u t e a r e i n d i c a t e d w i t h t w o d o t s . d f = 43, t h u s i n d i v i d u a l c o r r e l a t i o n s .3 o r g r e a t e r a r e s i g n i f i c a n t at the .05 level. * p < .05, B o n f e r r o n i c o r r e c t e d .
distress behaviors were negative (mainly weak), and 5 of 9 correlations with coping behaviors were positive (all weak) (see Table 3). However, older children had experienced more venipunctures (r = .44, p < .005), and thus even the weak relation between previous venipuncture and distress might be spurious. To examine this possibility, partial correlation coefficients were computed, controlling for age. The results were unchanged. The partial correlations between previous venipunctures and distress remained negative and weak. Associations Among Coping Behaviors and Among Distress Behaviors Non-procedure-related statements and behaviors, information seeking, and assertive vocalizations were not significantly intercorrelated. The 9 partial correlations between coping behaviors (3 for each phase, controlling for age) ranged from -.23 to .23; the second highest was .14 and the rest were uncorrelated or were weakly negative. Thus, there is no evidence that these three behaviors should be treated as manifestations of a single underlying construct. Momentary distress and cry/scream, however, were correlated (.54, .38, and .25, respectively for preparation, insertion, and completion). Associations Between Coping and Distress Within Phases Associations between coping and distress within phases are shown in Table 4. Partial correlations controlling for age are presented. There was a tendency for more coping to be associated with less crying, especially during the insertion phase. However, none of the correlations were significant after the Bonferroni correction was applied. Across all phases, 8 of 9 correlations between coping and crying were negative; two of these negative correlations (information seeking and non-procedure-related behavior with
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TABLE 4 CORRELATIONS BETWEEN COPING AND DISTRESS WITHIN PHASES, CONTROLLING FOR AGE Preparation
Behavior Non-proc. related Info. seek Asst. voc.
Insertion
Completion
Mo. Dist.
Cry/ Scream
Mo. Dist.
Cry/ Scream
Mo. Dist.
Cry/ Scream
- .22 -.23
- .23 -.13 .29
.. -.19 -.19
- .36 -.30 -.15
.. ..
-.16 -.29 -.18
Note.
Correlations less t h a n . 1 absolute are indicated with two dots. df = 42, thus individual correlations .3 or greater are significant at the .05 level. * p < .05, Bonferroni corrected.
crying during insertion) were moderately strong. Four of 9 correlations between coping and momentary distress were negative (all weak), all during preparation or insertion.
Associations Between Early Coping and Subsequent Distress To determine whether information seeking, assertive procedure vocalizations, and non-procedure-related statements and behaviors were associated with subsequent distress, two sets of correlations were examined: (1) the relation of the three coping behaviors exhibited during preparation to distress during the needle insertion phase, and (2) the relation of these three behaviors during needle insertion to distress during the completion phase. All correlations were computed as partial correlations, controlling for the effects of age. Partial correlations are shown in Table 5. Results indicated that there was little effect on coping in an earlier phase on distress in the next phase (see Table 5). None of these correlations were significant (Bonferroni corrected); 4 of 12 correlations were weakly negative and 2 were weakly positive.
Associations between Early Distress and Subsequent Coping Two sets of correlations were examined to determine whether early distress effected coping in the subsequent phase. There was a small effect of early distress upon later coping, but no correlations were significant after the Bonferroni correction was applied. Three correlations were weakly negatively correlated with later coping. All of these relations were between distress during preparation and coping during insertion; distress and crying during preparation were associated with less non-procedure-related behavior and information seeking in the insertion phase.
Discussion The findings of the current study suggest that child behaviors often defined by child researchers as coping do not form a single category of behavior. Un-
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TABLE 5 CORRELATIONS BETWEEN CHILDREN'S COPING AND DISTRESS IN SUBSEQUENT PHASES, CONTROLLING FOR AGE Moment a ry distress
Behavior
Cry/ scream
Preparation Coping with Insertion Distress Non-proc. related Info. seek Asst. voc.
-.14 . .15
-.23 .
.
. .16
Insertion Coping with Completion Distress Non-proc. related Info. seek Asst. voc .
.
. -.12 .
.
.
.
. -.27
.
Note.
Correlations less t h a n . 1 absolute are indicated with two dots. df = 43, thus individual correlations .3 or greater are significant at the .05 level. * p < .05, Bonferroni corrected.
like children's distress behaviors, which correlate with one another and are frequently combined into a cluster of behaviors (e.g., Katz, Kellerman, & Siegel, 1980), the three behaviors studied were not significantly correlated. Future research should study the effects of coping behaviors individually rather than combining different coping behaviors to examine their effects. The current study also highlights the importance of considering the child's age when studying coping. Within the age range studied (3-10 years), older children engaged in more coping behaviors and fewer distress behaviors (particularly during the needle insertion phase). As a result, partial correlations controlling for age were reported. The comparable zero-order correlations al-
TABLE 6 CORRELATIONS BETWEEN CHILDRENJS DISTRESS AND COPING IN SUBSEQUENT PHASES, CONTROLLING FOR AGE
Distress behavior
Non-proc. related
Info. seek
Asst. voc.
- .26 ..
.13 .21
Preparation Distress with Insertion Coping Mo men tary distress Cry/scream
-.26 - .29
Insertion Distress with Completion Coping Momentary distress Cry/scream
Note.
.. - . 15
Correlations less t h a n . 1 absolute are indicated with two dots. df = 42, thus individual correlations .3 or greater are significant at the .05 level. * p < .05, Bonferroni corrected.
CHILD COPING
155
most always indicated stronger relations between coping and distress. However, it would have been misleading to report these correlations, because much of the variability can be explained by a third variable, age. An examination of the frequency and timing of naturally occurring coping behaviors yielded several patterns. First, these behaviors were not exhibited by many children and, when they did occur, the behaviors did not occur at a high rate (or proportion of time). Only half of the children (22/45) employed information seeking at any time while being assessed. Although non-procedurerelated statements and behaviors were used by the majority of children (43/45), children engaged in these behaviors for only a relatively small proportion of the time during each phase. Clearly, many children require specialized training in coping strategies in order to employ these behaviors. Second, the frequency of occurrence of coping over the course of venipuncture was not as predicted. Information seeking is usually conceptualized as obtaining information about the procedure prior to its onset, and therefore should occur most frequently during the preparation phase. This was not the case in the current study. Information seeking occurred more frequently during the needle insertion and completion phases than during the preparation phase. These data suggest that when the child is alert during the procedure, information seeking may continue throughout the procedure as long as the child continues to perceive threat. Indeed, examination of coded responses suggests that children asked questions during the completion phase regarding the numbers of tubes of blood to be taken, what type of arm board they were to receive, and why extra tubes of blood were being taken. In addition, none of the coping behaviors decreased during the completion phase. These results suggest that the completion phase of venipuncture only marks the completion of needle insertion. Some aversive aspects of treatment continue to occur during this time period, and the completion phase should not be considered a true "recovery" phase. The relations between coping behaviors and distress provide some preliminary information on whether these behaviors can be functionally defined as coping. The pattern of relationships for non-procedure-related behaviors suggests consistent, weak to moderate associations with both concurrent and subsequent distress. More non-procedure-related behaviors were consistently associated with less distress, even after age was partialled out. These results suggest that distraction has a positive impact on distress, and they support prior research which has incorporated distraction into pediatric behavioral interventions to reduce distress and other symptoms (e.g., Manne et al., 1990; Redd, Jacobsen, Die-Trill, Dermatis, McEvoy, & Holland, 1987). The pattern of relationships for information seeking was similar. Information seeking was associated with less concurrent distress, and this relationship was maintained across phases for those children who engaged in information seeking during the insertion phase and distress during the completion phase. The beneficial effect of information seeking is consistent with previous investigations (e.g., Siegel, 1981). Siegel (1981) found that children who sought out information and asked questions were less anxious and more cooperative than children who avoided information. Peterson and Toler (1986) also found that an information seeking disposition predicted less anticipatory distress (distress prior
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to the onset of the procedure) after accounting for age. However, an information seeking disposition did not predict distress during the blood test after accounting for age. The results of the current study are consistent with Peterson and Toler's (1986) findings, in that both studies found that information seeking during the anticipatory phase (preparation) did not predict distress during the insertion phase after controlling for age. However, in the current study the associations between non-procedure-related behavior and information seeking with distress were weak to moderate in magnitude, and these conclusions should be regarded as tentative. Our results regarding assertive vocalizations suggest that this behavior does not meet the functional definition of coping. In fact, the moderate, positive association between assertive procedural vocalizations and crying during preparation suggests that, at least during the anticipatory phase, this behavior may be a correlate of distress. Since assertive vocalizations have been categorized as a "neutral" behavior in a prior study (Blount et al., 1990), future studies should examine whether the function of assertive vocalizations varies across phases of the medical procedure. The pattern of relationships between distress exhibited during the preparation phase and subsequent coping suggests that when children are distressed at the beginning of the procedure, they are less likely to engage in coping behaviors (non-procedure-related behavior and information seeking) during the subsequent phase. These findings suggest that careful attention must be given to the introduction of intervention to increase coping behaviors early in the treatment session. Given the current study's sample size and the number of statistical tests performed, these conclusions should be considered only suggestive. Although the patterns of associations were consistent, all associations were weak to moderate in magnitude. Replication of the results using a larger sample would provide more conclusive evidence regarding coping and distress relationships. Two other limitations of the current study should be noted. First, our method of assessing coping was not without its problems. Because only observable behaviors were assessed, we were not able to examine cognitive coping strategies that were not verbalized. Although some authors (e.g., Hubert, Jay, Saltoun, & Hayes, 1988) have argued that the only valid measure of coping is observable behaviors, others have stated that coping is an internal strategy that is best assessed through self-report methods (La Montagne, 1984). Second, many of the patients in the current study had considerable prior experience with venipuncture. In contrast, pediatric patients studied while undergoing bone marrow aspirations (e.g., Hubert et al., 1988; Jay et al., 1987) and while awaiting elective surgery (e.g., Peterson & Toler, 1986) had less prior experience with these procedures. As a result, the generalizability of the current findings may be limited. In conclusion, the current study provides preliminary evidence to suggest that coping behaviors do not form a single category of coping and that nonprocedure-related behaviors and information seeking should be functionally defined as coping behaviors. Our results also illustrate that studies of children's coping should be sensitive to developmental issues. Indeed, age affected
CHILD
COPING
157
both coping and distress. Our findings also suggest the need to provide specialized training in coping skills during the early phases of medical procedures; many children in our study did not spontaneously use non-procedure-related behaviors or information seeking in their apparent attempts to cope.
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Redd, W. H., Jacobsen, P. B., Die-Trill, M., Dermatis, H., McEvoy, M., & Holland, J. (1987). Cognitive-attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy. Journal of Consulting and ClinicalPsychology, 55, 391-395. Siegel, L. (1981, April). Naturalistic study of coping strategies in childrenfacing medicalprocedures. Paper presented at the meeting of the Southeastern Psychological Association, Atlanta. RECEIVED: February 28, 1992 FIN~ ACCEPTANCE:June 2, 1992