Review of a Parent’s Influence on Pediatric Procedural Distress and Recovery

Understanding how parents influence their child’s medical procedures can inform future work to reduce pediatric procedural distress and improve recovery outcomes. Following a pediatric injury or illness diagnosis, the associated medical procedures can be potentially traumatic events that are often painful and distressing and can lead to the child experiencing long-term physical and psychological problems. Children under 6 years old are particularly at risk of illness or injury, yet their pain-related distress during medical procedures is often difficult to manage because of their young developmental level. Parents can also experience ongoing psychological distress following a child’s injury or illness diagnosis. The parent and parenting behavior is one of many risk factors for increased pediatric procedural distress. The impact of parents on pediatric procedural distress is an important yet not well-understood phenomenon. There is some evidence to indicate parents influence their child through their own psychological distress and through parenting behavior. This paper has three purposes: (1) review current empirical research on parent-related risk factors for distressing pediatric medical procedures, and longer-term recovery outcomes; (2) consider and develop existing theories to present a new model for understanding the parent–child distress relationship during medical procedures; and (3) review and make recommendations regarding current assessment tools and developing parenting behavior interventions for reducing pediatric procedural distress.     

Preparing children for medical examinations: the importance of previous medical experience

The relationship between past medical experience and children's response to preparation for medical examinations was investigated in 79 pediatric outpatients aged 3 to 12 years. Children were randomly assigned to one of five preparation conditions prior to receiving a medical examination and a throat culture: sensory information about the exam, training in coping skills (deep breathing and positive self-talk), combined sensory information and coping skills training, attention control, and no-treatment control. The results indicated that children with previous negative medical experiences demonstrated more behavioral distress during a throat culture examination that did children with previous positive or neutral medical experiences. In addition, the attention control condition appeared to increase the distress of children with previous negative medical experiences. Amount of past exposure to the specific medical procedure was not related to observed distress. The implications of these findings for the preparation of children for medical procedures are discussed.     

Video Intervention for Child and Caregiver Distress Related to the Child Sexual Abuse Medical Examination: A Randomized Controlled Pilot Study

Children who disclose child sexual abuse are often referred for a comprehensive medical exam to ensure physical well-being and gather evidence. This study examined a brief, developmentally appropriate, psychoeducational video designed to instruct children and caregivers about the exam procedures and coping strategies to be used during the exam. Sixty-nine children ages 4–15 and their caregivers were randomly assigned to view the psychoeducational video (n = 35) or to receive standard practice (n = 34). Distress before, during, and after the exam was assessed in both children and caregiver, as were measures of satisfaction and knowledge about the investigation process and coping strategies. Consistent with hypotheses, results indicated that the video intervention was well-received by families, increased caregiver knowledge, and decreased stress during the examination. Caregiver and child distress decreased from pre to post examination across both conditions, and, unexpectedly, there were no significant differences in these decreases between groups. Overall results from this pilot study are promising in supporting a cost-effective and brief early intervention approach at the time of the medical examination for child sexual abuse for children and their caregivers.     

Maternal coping strategies and emotional distress: results of an early intervention program for low birth weight young children

Several questions were examined with Infant Health and Development Program (IHDP) data (N = 843). Are effects of intervention services found for maternal emotional distress and coping strategies, and are these effects different for different groups of mothers? Do maternal distress, coping, and life events moderate (or mediate) the intervention effects reported earlier for children's test scores and behavior problems (IHDP, 1990)? The intervention reduced maternal distress, especially for women with less than a high school education. Maternal distress did not moderate or mediate the influence of the intervention on child outcomes. Maternal coping was not influenced by the intervention and did not moderate the influence of the intervention on child outcomes. Life events moderated the influence of the intervention on children's test scores; the intervention was more effective for children whose mothers had fewer life events.     

Sequential treatment of a feeding problem using a pacifier and flipped spoon

Parents may be reluctant to treat the feeding disorder of a chronically ill child who exhibits distressed behavior during feeding. In this study, we identified a child with chronic medical problems and a feeding disorder who cried during feedings. We introduced treatment components sequentially to address parental concerns about crying. First, we used a pacifier to reduce crying, and then we used a flipped spoon to increase mouth clean. The results showed that a sequential approach to treatment can be effective for children with complex medical and behavioral problems.     

A Comparison of Distractors for Controlling Distress in Young Children During Medical Procedures

Distraction is a strategy that has been shown to be effective and safe in the control of pain and distress. We assessed the utility of two simple distraction procedures for reducing children's pain and distress. Three conditions, control, brief film, and short story, were delivered during repeated medical procedures in a randomized sequence to eight young children with cancer. Scores on the Observational Scale of Behavioral Distress (OSBD-R) as well as observer ratings of overall behavioral distress showed that the short story procedure was more effective than either the control condition or the cartoon film. These results argue for the utility of simple parent–child interactive distraction tasks to ameliorate children's procedural distress.     

Parental and family predictors of behavior problems in inner-city black children

Studied contributions of maternal psychological distress, family stress load, maternal and family risk factors, and family coping strategies in predicting behavior problems in 441 inner-city black primary-grade children. Results indicated maternal psychological distress and high family stress load were associated with high child behavior problems. Family coping strategies offered no protection against risk, while coping with life difficulties by reframing them was detrimental to child behavioral adjustment. Active help-seeking strategies (i.e., family mobilization, acquiring social supports) served to moderate the effects of maternal psychological distress and family risk attributes for boys, but exacerbated the effects of dysfunctional maternal social and psychiatric histories for girls. Implications for understanding vulnerability and resilience in inner-city black children and recommendations for future research are discussed.     

Psychological adjustment of children in the pretransplant phase of bone marrow transplantation: Relationships with parent distress,parent stress,and child coping

Families of 22 children preparing to undergo bone marrow transplantation (BMT) provided information concerning parent-reported major negative life stress, child coping strategies, parental psychological symptomatology, and child adjustment. Immediately prior to BMT, children and families are confronted with multiple stresses which challenge the child's coping and strain the parents' ability to assist the child with coping. Hence, stress, parental adjustment (distress), and child coping may be important factors affecting the child's overall psychological adjustment. Results showed that 15–25% of children and parents experienced clinically significant levels of psychological distress. Parent and child psychological distress were closely related. Major negative life stresses experienced by the parent and use of avoidant coping by the child significantly predicted child adjustment problems in the pretransplant period. Coping skills interventions targeting avoidant coping and management of parental stress/distress may reduce child psychosocial risk prior to BMT.     

Coping skills training for children: effects on distress before, during, and after hospitalization for surgery

Thirty-three parent-child dyads (children's mean age = 7.2 years, SD = 1.2) were randomly assigned to information, anxiety reduction, or coping skills presurgical preparatory interventions. All groups received the "information" procedure that described typical hospitalization and surgery experiences via a puppetry film viewed 1 week prior to hospital admission. In the anxiety reduction group, parents also learned procedures (e.g., relaxation) to help them reduce their own distress. Parents in the coping skills group learned how to help their children use coping self-talk and related techniques. The coping skills intervention was expected to assist children most effectively, although the anxiety reduction procedure was also expected to improve adaptation relative to the information condition. These hypotheses were generally supported. Anxiety reduction and coping skills groups, compared to the information group, reduced children's self-reported fearfulness and parents' reported distress. Furthermore, only the coping skills group, compared to the information group, exhibited fewer maladaptive behaviors during hospitalization (ratings by observers) and less problematic behavior in the preadmission week and second postdischarge week (daily parental diaries). Theoretical explanations for these results are discussed in light of the similar findings obtained by Peterson and Shigetomi (1981).     

Weinen, ein Bindungsverhalten

Crying is an age-independent behavior of attachment of the (at that moment) weaker part, who cannot cope with a special experience alone. To cry because of anxiety, anger and mourning expresses helplessness and at the same time is an appeal to others to give help and comfort. Crying creates the chance to show relatedness. The considerate other person perceives himself at that moment to be the stronger one when he sees and hears the crying and usually feels the need to comfort and care. The crying of a newborn baby expresses fear to be abandoned, not to be protected and looked after which means to have to die. With growing experience about the reactions to crying the infant quickly learns which behavior is apt to bring the protecting attachment person closer to him. Crying is synchronized with the expectations of others even at the end of the first year of life, especially with those of the attachment person. Whether a child or an adult cries in a manner appropriate to the situation, or surprisingly does not cry or cries in an exaggerated dramatic manner, very much depends on the experiences made in attachment relationships with crying. In the same way, how effective the comfort can be and whether the other wants to care at all, depends on the experiences of both persons concerning crying and comforting in preceding relationships. If those experiences were reassuring then as adults they can also cry or care and comfort, but if crying even aggravates painful experiences then the adult will have difficulties to desire and to accept comfort from others or offer comfort to others himself.     

An information seeking disposition in child surgery patients

Several studies in the last decade have demonstrated the importance of considering an information seeking versus information avoiding coping dimension in adult medical patients. However, there have been few empirical demonstrations of such a dimension in children. The present study utilized the Coping Strategies Interview to assign an information seeking score to child elective surgery patients. This information seeking score was related to several parent-rated variables, including the child's historical success in coping with medical procedures, the child's typical preference for information acquisition, and the child's typically emitted coping behaviors. In addition, the information seeking score was related to question asking and discussion of medical procedures as rated by an objective observer during the blood test, by the nurse during anesthesia induction, and by the parent during recovery from surgery. It was strongly related to the information acquired prior to hospitalization. Information seeking was also related to stress responses, such that high information seeking scores predicted more adaptive behaviors prior to the blood test. This cross-rater and cross-situation validation suggests the existence of an information seeking dimension in children and the utility of considering this dimension in future research.     

Analysis of child and parent behavior during painful medical procedures

Examined (a) the impact of demographic, medical, and psychological factors on overall child distress during an invasive medical procedure required for pediatric cancer treatment and (b) the relationship of individual parent behaviors to child distress across phases of the procedure. Seventy 3- to 10-year-old pediatric cancer patients receiving outpatient venipuncture and their parents participated. Overall distress was greater in younger children who had fewer previous venipunctures and poorer venous access and whose parents rated them prior to the procedure as less likely to be cooperative. Providing explanations regarding the procedure was the parent behavior most clearly associated with child distress. The impact of parent explanation depended on when the explanation was given and on the child's level of distress at the time.     

Gender and individual differences in adult crying

This study reports on gender and individual differences in adult crying. A total of 105 subjects filled out a questionnaire on adult crying (Vingerhoets, 1995) and two personality inventories, the NEO Personality Inventory-Revised (NEO-PI-R) (Costa & McCrae, 1992) and the Five-factor Personality Inventory (FFPI) (Hendriks et al., 1995). The results showed that gender and personality substantially and independently contribute to the variance in weeping frequency. Women cry more often and perceive weeping more as a coping style. Neuroticism proved to be considerably correlated with weeping frequency and weeping as a coping style, even after partialling out the effects of gender and age. Extraversion was correlated with relief and positive feelings after crying. These results are discussed in the context of an ongoing international study on adult crying.     

Reducing Parent Distress and Increasing Parent Coping-Promoting Behavior During Children's Medical Procedure

The study investigated whether involving parents in their child's cognitive-behavioral intervention would effectively reduce parent distress during their child's medical procedure. Parents participating with their 3- to 7-year-old children prior to a voiding cystourethrogram were randomly assigned to an intervention (N = 20) or a standard care (N = 20) condition. The intervention included provision of information, coping skills training, and parent coaching. Parents participating in the intervention had a significant reduction in anxiety following the intervention relative to parents in standard care. Trained parents displayed fewer distress-promoting and more coping-promoting behaviors during the procedure, even though parents in both conditions reported similar levels of anxiety during the procedure. Involving parents in children's interventions is crucial to reduce parent distress and prepare parents to assist their child during the medical procedure.     

The Role of Family Processes and Coping Strategies in the Relationship Between Parental Chronic Illness and Childhood Internalizing Problems

Sixty-nine families (father, mother, and one child) in which the father had hemophilia, approximately half of whom were HIV positive, were assessed in an examination of the relationship between parental chronic illness, family functioning, child coping strategies, and child adjustment. Latent variable path analyses with partial least-squares estimation procedures (PLS) were used to test a model of the relationship between parental chronic illness, family process variables, child coping strategies, and child internalizing behavior problems. The severity of the father's illness predicted family process variables, which predicted the coping style of the child. The use of more avoidant coping strategies was associated with more internalizing problems.     

Family Coping During Hospitalization of Children with Chronic Illnesses

Information about family coping when a child with a chronic illness is hospitalized for procedures related to his or her illness is needed. The current research presents the results of two pilot studies designed to assess family resilience and coping, during a hospitalization for medical procedures for a child with a chronic condition. Sixty-one parents participated in the first study and reported on their child’s hospital experiences and completed a survey designed to assess family coping. Twelve mothers and one grandmother completed interviews examining their perceptions of their coping, siblings’ coping, and coping of the child with an illness for study two. Results of Study 1 indicated parents’ perceived the family as resilient. Cognitive strategies were used to see the hospital stay as positive for the child or to accept what had to occur as having the possibility of improving the child’s life. Some of the mothers mentioned financial stress as being difficult for the family. Results of Study 2 also supported resilient functioning for mothers, siblings, and children with illnesses. Mothers reported they stayed strong for their child. Siblings could serve as protectors, helpers, and companions and were described as adapting well. Children with illnesses used distraction (e.g., play, art, music) to facilitate their coping. Findings of this study indicated parents perceived the family as coping well and supporting the child with an illness. Future research will need to assess perceptions of siblings and fathers and assess family members’ perspectives at different times over the course of children’s illnesses.     

THE EFFECTS OF AN ENVIRONMENTAL “ENRICHMENT” PROGRAM ON THE BEHAVIOR OF INSTITUTIONALIZED PROFOUNDLY RETARDED CHILDREN

This study determined the effects of procedures designed to “enrich” the physical and social environment of an institutional ward on the “adaptive” and “maladaptive” child, adult, self, and object-directed behaviors of five profoundly retarded ambulatory females. Behavior observed in two treatment conditions, an environment “enriched” with toys and objects and an “enriched” environment coupled with differential reinforcement of adaptive behavior, was compared to behavior occurring in corresponding baseline or “austere” conditions and during a period of noncontingent reinforcement. The results generally revealed: (1) little change in adaptive and maladaptive child and adult-directed behavior across conditions, (2) an overall higher incidence of adaptive object-directed behavior and reduced self-directed maladaptive behavior in each treatment condition from that observed in corresponding control conditions, and (3) the use of an “enriched” environment and differential reinforcement of adaptive behavior resulted in maladaptive self-directed behavior being reduced and adaptive object-directed behavior being increased beyond that observed in the “enriched” environment alone. These behavioral gains were largely maintained during a follow-up condition by continuing the “enriched” environment and transferring the responsibility for differential reinforcement to direct-care staff.     

Colic and fussing in infancy,and sensory processing at 3 to 8 years of age

The purpose of this follow‐up study was to examine whether a group of 28 clinic‐referred infants with colic, excessive crying, or both at 4 to 12 weeks demonstrated sensory processing, coping, and behavioral/attention regulation difficulties at 3 to 8 years of age. Seventy‐five percent of the sample demonstrated atypical behavioral responses to sensory experiences. Hours of fussing during infancy significantly correlated with inattention, emotional reactivity, touch processing, environmental coping, and externalizing behavior at 3 to 8 years, but not hours of crying. The most striking result was that children with more hours of early fussing showed less efficient sensory processing, poorer coping with the environment, and more attention/hyperactivity problems compared to those with less hours of fussing. Results suggest that hours of fussing rather than crying could be an early marker for infants at risk.     

TEARS AND WEEPING AMONG PROFESSIONAL WOMEN: IN SEARCH OF NEW UNDERSTANDING

Crying among adult professional women is a phenomenon experienced far more often than it is studied or publicly discussed. Guided by Sherifs (1982) theoretical work on gender identity, socialization, reference groups, and power, the authors explore several factors central to the topic. Among them are: the origins of conflict between women's experience of emotional expression and "public" tears; gender-related differences in crying and responses to crying; the role of reference groups in conflicting attitudes toward crying; and power in the workplace as influencing the meaning of crying. The role of images and imagery during times of conflicted and heightened emotion is discussed. It is suggested that most imagery related to crying in adults derives from perceptions of crying in infancy and that most responses to adults who cry are linked to an understanding of appropriate responses to a crying infant or child. Lewin's construct of behavior as a person-environment transaction is employed as a means of exploring the images experienced by the crier and the observer when female crying occurs in a professional situation. New images to guide more productive approaches to emotional expression in the workplace are suggested.     

Distress of Japanese parents of children with intellectual disabilities: Correlations with age of parent and negative mood regulation expectancies

Parents caring for a child with an intellectual disability (ID) face many challenges. Few studies in Japan have focused on parents of children with an ID. We investigated the psychological factors that might help these parents maintain well‐being, in particular negative mood regulation expectancies (NMRE). NMRE are beliefs about one's ability to diminish one's negative moods. Research has shown NMRE to buffer the effects of stress: stronger NMRE are associated with less symptoms of distress, including depression and anxiety. We examined the associations of NMRE, coping, and severity of the child's ID with parental distress (somatization, depression, and anxiety) among 106 Japanese parents (mean age = 56.7 years) caring for at least one child with an ID. The age of the parent was negatively associated with parental distress, particularly anxiety. NMRE were also negatively related to distress, independent of the age of the parent and coping. The severity of the child's ID was not related to coping or parental distress. Stronger beliefs that they could control their negative moods and being older seemed to protect parents of an ID child from symptoms of distress.