An integrative review of literature examining psychometric properties of instruments measuring anxiety or fear in hospitalized children

A Review of Creative Play Interventions to Improve Children's Hospital Experience and Wellbeing

CONTEXT

Being in the hospital can be stressful for children and caregivers. Evidence-based play interventions to reduce this stress, such as play therapy or Child Life services, have been introduced in hospitals globally, with growing awareness of potential benefits.

OBJECTIVES

To evaluate the impact of nonmedical/illness-specific creative or play-based programs in hospital settings on children's (<18 years) and their caregivers' hospital experiences, wellbeing, and other health outcomes.

DATA SOURCES

PubMed, CINAHL, Google Scholar.

METHODS

We conducted a systematic review of original articles published since 2011, screening 2701 de-duplicated articles.

RESULTS

We identified 25 eligible articles, representing 1629 children (57% male), 422 caregivers, and 128 health professionals. Included studies most commonly evaluated professional children's entertainers (n = 8 studies), music therapy (n = 4), unstructured play (n = 3), and humanoid/animal robots (n = 3). Most studies evaluated the impact on the child's level of anxiety (n = 14/25), mostly supporting a reduction (n = 13/14 studies). Several studies provided evidence for a reduction in children's pain (n = 4/6), and negative emotional/behavioral outcomes (eg, sadness, anger, irritability; n = 5/6 studies). There was mixed evidence for the impact of the included interventions on physiologic outcomes (eg, systolic pressure, heart frequency; n = 3/5 studies) and fatigue (n = 1/2 studies). Evidence on caregiver outcomes and the impact on health care services was limited.

CONCLUSIONS

The findings of our review generally supported the value of play-based interventions on children's' wellbeing while in the hospital, particularly reducing anxiety and pain. Further evaluation of their impact on caregivers' outcomes and the health care system is needed.

Development of Hospital Perception Scale for Healthy Children (HPSHC) and Investigation of Its Psychometric Properties

(1) Aim: The aim of the study was to develop and analyze the psychometric properties of a hospital perception scale for healthy children aged 8 to 10 years. (2) Methods: A methodological design was employed. The scale's validity was investigated using the approaches of content validity, face validity, item analysis, and construct validity. The scale's reliability was evaluated utilizing the approaches of internal consistency reliability, measurer reliability, and measurement invariance. (3) Results: In total, 330 children took part in this study. The scale is composed of six factors. Factor loads range from 0.42 to 0.79. The item-total score correlation coefficients were 0.42 and 0.79, respectively, while the Cronbach alpha reliability coefficient was 0.87. (4) Conclusions: The HPSHC is a valid and reliable tool. It can be used to determine how healthy or sick children in their middle childhood are perceived when going to the hospital and being hospitalized.

The effects of goldfish on anxiety, fear, psychological and emotional well-being of hospitalized children: A randomized controlled study

AIM

This study aimed to determine the effect of goldfish intervention on anxiety, fear, psychological and emotional well-being of hospitalized children.

MATERIALS AND METHODS

Between November 2020 and August 2021, an open-label, single-center randomized controlled experimental study was conducted in Türkiye's Eastern Anatolia region. The study included 112 children aged 8 to 10 years old (56 in the study group and 56 in the control group). The study and control groups were randomly assigned to strata using a table of random numbers. The children in the study group observed after goldfish intervention for three days. As data collection tools, the State-Trait Anxiety Inventory for Children, Child Fear Scale, and the Stirling Children's Well-being Scale were used.

RESULTS

The mean state anxiety scores of the children in the study group who looked after goldfish intervention decreased significantly compared to the control group. When the two groups were compared, the difference between the post-test measurements were significant (p < 0.05). The mean score of the fear scale in the post-test measurements of the study group children was significantly lower than the control group (p < 0.05). Finally, the emotional, and psychological well-being post-test scale mean scores of the study group children were higher than the control group (p < 0.01).

CONCLUSION

Goldfish intervention was found to be effective in decreasing the state anxiety and fear levels and increasing the psychological and emotional well-being levels of the children in the study group.

Psychometric properties of a self-assessment fear scale in children aged 4 to 12 years. Scary Scale

BACKGROUND

Caregivers encounter difficulties differentiating fear and pain experienced by children and tend to interpret what children may feel, often resulting in inadequate pain management. While many pain self-assessment scales are available, there is no validated self-assessment fear scale for children.

METHODS

The aim of this prospective study was to validate, in children aged 4 to 12 years, the psychometric properties of our scale. In a first part, in a school setting, five exercises were given to 484 children in order to validate the expression of fear, grade the intensity of the faces, the ability to discriminate the faces and the equality of the intervals. The scale's reproducibility was studied by assessing the children's fear in everyday situations at two different time points. In a second part, in a hospital setting, the aim was to test the scale's feasibility. Sixty children admitted to one emergency care department self-assessed their fear with the Scary Scale.

FINDINGS

The expression of fear was validated by 57.64% (p < 0.0001) of the children in comparison with three other emotions (pain, surprise, sadness).The 7-9 year-olds validated the other properties (gradation, discrimination, equality, reproducibility). The 4-6 year-olds failed to validate the gradation exercise, but succeeded with the others. In the hospital, 95% of children self-assessed their fear using the scale.

DISCUSSION

Our self-assessment fear scale was validated in children aged 7-12 years specifically and was readily feasible in the hospital. We recommend its use in that age group in every care situation triggering fear.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02675504.

Hypnotherapy for procedural pain, itch, and state anxiety in children with acute burns: a feasibility and acceptability study protocol

Background

Burns and related procedures are painful and distressing for children, exposing them to acute and chronic sequelae that can negatively affect their physiological, psychological, and social functions. Non-pharmacological interventions such as distraction techniques are beneficial adjuncts to pharmacological agents for procedural pain, state anxiety, and itch in children with burns but have limitations (e.g. lack of research on burn-related itch, tailoring, and consensus on optimal treatment). Hypnotherapy is a non-pharmacological intervention that can be tailored for varied settings and populations with evidence of benefit for itch and superior effectiveness in comparison to other non-pharmacological interventions for children’s procedural pain and state anxiety. Thus, children with burns can benefit from hypnotherapy as an adjunct to pharmacological agents. Yet, in paediatric burns, rigorous studies of effectiveness are limited and no studies have been identified that screen for hypnotic suggestibility, an important predictor of hypnotherapy outcomes. Considering potential barriers to the delivery of hypnotherapy in paediatric burns, the proposed study will examine the feasibility and acceptability of hypnotic suggestibility screening followed by hypnotherapy for procedural pain, state anxiety, and itch in children with acute burns.

Methods

An observational mixed-methods feasibility and acceptability study will be conducted over 15 weeks. Eligible children (N = 30) aged 4 to 16 years presenting to a paediatric burns outpatient centre in a metropolitan children’s hospital in Australia with acute burns requiring dressing changes will be included. Eligible parents of children (N = up to 30) and clinicians who perform dressing changes (N = up to 20) will also be included. Child participants screened as having medium to high suggestibility as assessed by behavioural measures will receive hypnotherapy during dressing changes. A process evaluation will target feasibility and acceptability as primary outcomes and implementation (i.e. fidelity in delivery), reach, potential effectiveness, and adoption of evaluation procedures and intervention as secondary outcomes.

Discussion

Ethical approval was obtained from the Queensland Children’s Hospital and Health Service ethics committee. Results will be published in peer-reviewed publications and conference proceedings.

The findings will guide the design of future trials on the effectiveness of hypnotherapy and inform the development of child-centred hypnotic interventions in children with burns.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12620000988954

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01017-z.

The Use of a Dental Storybook as a Dental Anxiety Reduction Medium among Pediatric Patients: A Randomized Controlled Clinical Trial

This randomized clinical trial aimed to evaluate the effectiveness of a specially designed dental storybook in reducing dental anxiety among children. Eighty-eight children (6−8 years old) were randomly divided into two groups: the intervention group (received the storybook) and the control group (did not receive the storybook). Three dental visits (screening, examination and cleaning, and treatment) were provided for each child. Anxiety was assessed following each visit using the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) and the Venham clinical anxiety scale (VCAS). The behavior was assessed using the Frankl’s Behavior Rating Scale (FBRS). The intervention group showed significantly lower anxiety and more cooperative behavior during treatment than the control group (p < 0.0001). The intervention group showed a significant decrease in anxiety scores and more cooperative behavior across time according to the CFSS-DS (p = 0.001) and Frankl behavior scale OR = 3.22, 95% CI 1.18−8.76. Multivariate models found that using the storybook was a significant independent factor in reducing anxiety and improving behavior after controlling for sex, previous visits, family income, and mother’s education. In conclusion, the dental storybook can decrease children’s dental anxiety and improve their behavior during dental treatment.

The Spanish Version of the Child Medical Fear Questionnaire: Cross-Cultural Adaptation and Validation

Having valid and reliable tools that help health professionals to assess fear in children undergoing medical procedures is essential to offer humanised and quality of care in the paediatric population. The aim of this study was to develop the cross-cultural adaptation and the evaluation of the psychometric properties of the Spanish version of the "Child Medical Fear Scale" in its shortened version (CMFS-R). The design consisted of two phases: first, of cross-cultural adaptation and second, of the psychometric validation of the CMFS-R with a sample of 262 children from Spain, applying a cross-sectional design. Confirmatory factor analysis was conducted to assess construct validity and the Cronbach's alpha and the adjusted item-total score correlation coefficients were performed to study reliability. The results confirmed internal consistency and construct validity of the Spanish version of the CMFS-R, indicating that the scale has an acceptable level of validity and reliability. Therefore, this study brings a new version of the scale to assess fear related to medical procedures for use in the Spanish paediatric population.

A Systematic Review of Self-Report Instruments for the Measurement of Anxiety in Hospitalized Children with Cancer

Anxiety has been identified as one of the most severe and long-lasting symptoms experienced by hospitalized children with cancer. Self-reports are especially important for documenting emotional and abstract concepts, such as anxiety. Children may not always be able to communicate their symptoms due to language difficulties, a lack of developmental language skills, or the severity of their illness. Instruments with sufficient psychometric quality and pictorial support may address this communication challenge. The purpose of this review was to systematically search the published literature and identify validated and reliable self-report instruments available for children aged 5–18 years to use in the assessment of their anxiety to ensure they receive appropriate anxiety-relief intervention in hospital. What validated self-report instruments can children with cancer use to self-report anxiety in the hospital setting? Which of these instruments offer pictorial support? Eight instruments were identified, but most of the instruments lacked pictorial support. The Visual Analogue Scale (VAS) and Pediatric Quality of Life (PedsQL™) 3.0 Brain Tumor Module and Cancer Module proved to be useful in hospitalized children with cancer, as they provide pictorial support. It is recommended that faces or symbols be used along with the VAS, as pictures are easily understood by younger children. Future studies could include the adaptation of existing instruments in digital e-health tools.

Pre-operative Anxiety in Pediatric Surgery Patients: Multiple Case Study Analysis with Literature Review

Pre-operative anxiety affects millions of pediatric surgery patients each year and can have both short and long-term adverse effects in the post-operative period. As a result, it is particularly important for healthcare providers and others involved in the child's care, such as the parents, to be aware of interventions that can be used to reduce the onset of pre-operative anxiety and, thus, the likelihood of negative post-operative changes. The purpose of this paper is to familiarize the reader with the issue of pre-operative anxiety through a review of the literature and analysis of case studies. First, the paper looks at the causes of pre-operative anxiety and its effect on the development of maladaptive behavioral, emotional, and physiological changes. It then discusses the ways pre-operative anxiety can be measured and current methods for reducing the post-operative adverse outcomes associated with it. After doing so, it proposes the need for additional research and the use of precision medicine by physicians.

Exploring the use of Immersive Virtual Reality to enhance Psychological Well-Being in Pediatric Oncology: A pilot randomized controlled trial

PURPOSE

To investigate whether Immersive Virtual Reality (VR) has a greater positive influence on oncology patients' physical and emotional mood states when compared to an iPad attentional control condition. Our secondary objective was to understand what factors influenced VR effectiveness.

METHOD

Participants were 90 oncology inpatients, aged 7-19 years, and their primary parent caregiver. Using a randomized controlled study design patients were allocated to VR (three content groups) or an iPad control condition. Pre-post-intervention self-report state measures were collected using visual analogue scales and an objective measure of physiological arousal (pulse rate). Post-intervention, patients reported on level of immersion, enjoyment and simulator sickness.

RESULTS

Patients benefited from both Immersive VR and novel iPad intervention with no statistically significant differences found between conditions on child outcomes. However, patients accessing Immersive VR consistently reported greater positive shifts in mood state and reductions in negative symptoms when compared with iPad. No change was observed in physiological arousal levels (pulse rate) in either condition before, during or immediately after intervention. Moderation analysis showed that the degree of child illness (PedsQL), sex, age, and level of immersion were important in influencing the magnitude of differences between the VR and iPad conditions on mood, anxiety and pain.

CONCLUSIONS

These preliminary findings support the use of Immersive VR in clinical oncology settings to improve patient well-being. Further studies examining the application of Immersive VR in supporting children adjusting to hospitalization and cancer treatment are therefore warranted. Factors found to moderate VR effectiveness provide important clinical implications.

Investigation of the Fear of 7-18-Year-Old Hospitalized Children for Illness and Hospital

Illness and hospitalization are conditions leading to negative effects in children's lives regardless of their age. This study was performed descriptively in order to examine the fears of hospitalized children for illness and hospital. The study was descriptive and sectional and performed in Karabük University (Turkey) Training and Research Hospital between February 1 and May 1, 2015. Sample of the study was composed of 144 children who were hospitalized due to an acute illness and their parents who approved to participate in the study. Participant information form and an information form that was prepared to evaluate the fears of children for illness and hospital were used as data collection tools. Data were collected by face-to-face interview technique. Statistical analyses were used to assess data. It was found that 56.2% of children in the study were males and were between 7 and 10 years of age; 42.4% were scared of getting illness. 39.5% of 86 children who were previously hospitalized have stated that they experienced fear due to hospitalization; injections were in the first place among causes of fear by 64.7%. When the causes of children's fear for illness and hospital were examined, it was determined that "undergoing an operation (3.21 ± 1.13)," "staying away from the family during hospitalization (3.11 ± 0.96)" and "worrying the family when he/she gets an illness (3.02 ± 1.05)" were in the first three ones. When the relationship between some characteristics of the children and their parents and children's status of fear for illness was investigated, it was detected that there was a significant difference between their previous fear of hospitalization and their current status of fear for getting illness (p = 0.003). It was observed that children in the study experienced fear for illness and hospitalization and the percentage of children with fears was found to be high. It was also determined that undergoing an operation, staying away from the family during hospitalization and worrying the family when he/she gets an illness were among the first causes of their fears.

Level and predictors of anxiety in patients undergoing diagnostic bronchoscopy

AIMS:

Flexible bronchoscopy is a common procedure performed in pulmonary medicine, critical care, and thoracic surgery. In this study, we aimed to assess the prevalence and predictors of anxiety in patients undergoing diagnostic bronchoscopy.

METHODS:

This is a prospective study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. All patients undergoing diagnostic bronchoscopy filled the State-Trait Anxiety Inventory questionnaire before the procedure. Bronchoscopy was performed either through the mouth or the nose, based on the bronchoscopist preference. Lidocaine (1%–2%) spray was used for administering topical anesthesia. Results were collected, and statistical analysis was performed using t-test to measure statistically significant (P < 0.05).

RESULTS:

A total of 117 patients participated in this study. High anxiety score was found in 45% of the patients. Older patients significantly showed higher anxiety score than younger patients (53 years vs. 46 years, P = 0.034). Similarly, patients with higher body mass index (BMI) showed a statistically significant increase in anxiety score (28 vs. 25, P = 0.041). Premedication with pethidine significantly reduced the anxiety levels (26.9% vs. 73.1%, P = 0.031). Logistic regression demonstrated that old age and outpatient settings were significant predictors of higher anxiety scores.

CONCLUSION:

Diagnostic bronchoscopy can cause high anxiety in many patients. Prebronchoscopy anxiety assessment can help bronchoscopists to anticipate the anxiety levels of patients, and then further use it to tailor sedation requirements. Special attention should be given to older patients, patients with high BMI, and the ones undergoing bronchoscopy in outpatient settings.

Efficacy of Non-pharmacological Methods of Pain Management in Children Undergoing Venipuncture in a Pediatric Outpatient Clinic: A Randomized Controlled Trial of Audiovisual Distraction and External Cold and Vibration

PURPOSE

Venipuncture generates anxiety and pain in children. The primary aim of the study was to evaluate two non-pharmacological techniques, vibration combined with cryotherapeutic topical analgesia by means of the Buzzy® device and animated cartoons, in terms of pain and anxiety relief during venipuncture in children.

DESIGNS AND METHODS

150 children undergoing venipuncture were randomized into four groups: the 'no method' group, the Buzzy® device group, the animated cartoon group and the combination of Buzzy® and an animated cartoon group. Children's pain and anxiety levels along with parents' and nurses' anxiety levels were evaluated by means of validated grading scales.

RESULTS

Overall children's pain increased less in the non-pharmacological intervention groups as compared to the group without intervention. Notably, the difference was statistically significant in the animated cartoon group for children's perception of pain. Children's anxiety and parents' anxiety decreased more in non-pharmacological interventions groups as compared to the group without intervention.

CONCLUSIONS

The study showed the effectiveness of non-pharmacological methods of pain management during venipuncture. Notably, distraction with animated cartoons was superior in terms of children's perception of pain when compared to Buzzy®, and to the combination of cartoons and Buzzy®. Buzzy® was significantly effective at the secondary analysis for children younger than 9. Children's and parents' anxiety is decreased by non-pharmacological methods. Furthermore, nurses' involvement in pediatric care can be enhanced.

PRACTICE IMPLICATIONS

Non-pharmacological methods of pain management during venipuncture represent an easy way to achieve an increased level of compliance among children and parents.

Gender differences in response to a school-based mindfulness training intervention for early adolescents

Mindfulness training has been used to improve emotional wellbeing in early adolescents. However, little is known about treatment outcome moderators, or individual differences that may differentially impact responses to treatment. The current study focused on gender as a potential moderator for affective outcomes in response to school-based mindfulness training. Sixth grade students (N = 100) were randomly assigned to either the six weeks of mindfulness meditation or the active control group as part of a history class curriculum. Participants in the mindfulness meditation group completed short mindfulness meditation sessions four to five times per week, in addition to didactic instruction (Asian history). The control group received matched experiential activity in addition to didactic instruction (African history) from the same teacher with no meditation component. Self-reported measures of emotional wellbeing/affect, mindfulness, and self-compassion were obtained at pre and post intervention. Meditators reported greater improvement in emotional wellbeing compared to those in the control group. Importantly, gender differences were detected, such that female meditators reported greater increases in positive affect compared to females in the control group, whereas male meditators and control males displayed equivalent gains. Uniquely among females but not males, increases in self-reported self-compassion were associated with improvements in affect. These findings support the efficacy of school-based mindfulness interventions, and interventions tailored to accommodate distinct developmental needs of female and male adolescents.

Experiences During a Psychoeducational Intervention Program Run in a Pediatric Ward: A Qualitative Study

Hospitalization, despite its duration, is likely to result in emotional, social, and academic costs to school-age children and adolescents. Developing adequate psychoeducational activities and assuring inpatients' own class teachers' collaboration, allows for the enhancement of their personal and emotional competences and the maintenance of a connection with school and academic life. These educational programs have been mainly designed for patients with long stays and/or chronic conditions, in the format of Hospital Schools, and typically in pediatric Hospitals. However, the negative effects of hospitalization can be felt in internments of any duration, and children hospitalized in smaller regional hospitals should have access to actions to maintain the connection with their daily life. Thus, this investigation aims to present a psychoeducational intervention program theoretically grounded within the self-regulated learning (SRL) framework, implemented along 1 year in a pediatric ward of a regional hospital to all its school-aged inpatients, regardless of the duration of their stay. The program counts with two facets: the psychoeducational accompaniment and the linkage to school. All the 798 school-aged inpatients (M_age = 11.7; SD_age = 3.71; M_{hospital stay} = 4 days) participated in pedagogical, leisure nature, and SRL activities designed to train transversal skills (e.g., goal-setting). Moreover, inpatients completed assigned study tasks resulting from the linkage between the students' own class teachers and the hospital teacher. The experiences reported by parents/caregivers and class teachers of the inpatients enrolling in the intervention allowed the researchers to reflect on the potential advantages of implementing a psychoeducational intervention to hospitalized children and adolescents that is: individually tailored, focused on leisure playful theoretically grounded activities that allow learning to naturally occur, and designed to facilitate school re-entry after hospital discharge. Parents/caregivers highlighted that the program helped in the preparation for surgery and facilitated the hospitalization process, aided in the distraction from the health condition, promoted SRL competences, and facilitated the communication and linkage with school life. Class teachers emphasized the relevance of the program, particularly in the liaison between hospital and school, in the academic and psycho-emotional and leisure-educational support provided, and in smoothing the school re-entry.

Different psychometric properties of the Emotional Reaction Instrument-English (ERI-E) between hospitalized African American and Caucasian children

PURPOSE

To demonstrate the psychometric properties of the Emotional Reactions Instrument-English (ERI-E) between hospitalized African American and Caucasian children aged 7-12 years.

DESIGN AND METHOD

A methodological study was conducted to examine validity and reliability of the ERI-E with 230 hospitalized African American and Caucasian children. Data were collected with sociodemographic and clinical forms, and using the ERI-E, and the Facial Affective Scale (FAS).

RESULTS

Different factor structures were found between hospitalized African American and Caucasian children. In psychometric testing of the ERI-E with African American children, four items, alone, lonely, shy, and bored, were removed from the original 16-item ERI-E after exploratory factor analysis. Three factors, including Fear, Anxiety, and Distress, were identified explaining 60.71% of the total variance. Cronbach's alpha coefficient for the revised 12-item scale was 0.85. Six items, happy, sad, afraid, frightened, hurt, and uncomfortable, in the ERI-E were significantly correlated with the FAS (r = 0.20-0.59) as evidence of concurrent validity. In the sample with hospitalized Caucasian children, two items, bored and uncomfortable, were eliminated from the original ERI-E after exploratory factor analysis. Four factors including Fear, Anxiety, Distress, and Loneliness were extracted with 62.61% of total variance. Cronbach's alpha coefficient for the revised 14-item in the ERI-E was 0.84 for hospitalized Caucasian children. As evidence of concurrent validity, 10 items, happy, sad, afraid, frightened, bad, lonely, scary, bored, hurt, and uncomfortable, in the ERI-E were significantly correlated with the FAS (r = 0.20-0.69).

PRACTICE IMPLICATION

Because children with different cultural backgrounds understand or use words differently, healthcare providers should assess the cultural norms of pediatric patients and ensure steps have been taken to ensure clear, effective communication with pediatric patients. In addition, healthcare providers should evaluate the meanings of faces in the FAS before using it in a clinical setting because faces have different cultural connotations. The explosive growth of ethnic minority children in the United States makes it paramount for healthcare providers and researchers to consider the measurement equivalence of any measure to better serve different racial and cultural groups.

A Prospective Randomized Controlled Trial of Nonpharmacological Pain Management During Intravenous Cannulation in a Pediatric Emergency Department

OBJECTIVES

Intravenous (IV) cannulation is commonly performed in pediatric emergency departments (EDs). The busy ED environment is often not conducive to conventional nonpharmacological pain management. This study assessed the use of Ditto (Diversionary Therapy Technologies, Brisbane, Australia), a handheld electronic device which provides procedural preparation and distraction, as a means of managing pain and distress during IV cannulation performed in the pediatric ED.

METHODS

A randomized controlled trial with 98 participants, aged 3 to 12 years, was conducted in a pediatric ED. Participants were recruited and randomized into 5 intervention groups as follows: (1) Standard Distraction, (2) PlayStation Portable Distraction, (3) Ditto Distraction, (4) Ditto Procedural Preparation, and (5) Ditto Preparation and Distraction. Children's pain and distress levels were assessed via self-reports and observational reports by caregivers and nursing staff across the following 3 time points: (1) before, (2) during, and (3) after IV cannulation.

RESULTS

Caregivers and nursing staff reported significantly reduced pain and distress levels in children accessing the combined preparation and distraction Ditto protocol, as compared to standard distraction (P ≤ 0.01). This intervention also saw the greatest reduction in pain and distress as reported by the child.

CONCLUSIONS

Caregiver reports indicate that using the combined Ditto protocol was most effective in reducing children's pain experiences while undergoing IV cannulation in the ED. The use of Ditto offers a promising opportunity to negotiate barriers to the provision of nonpharmacological approaches encountered in the busy ED environment, and provide nonpharmacological pain-management interventions in pediatric EDs.

The Effect of Flexible Bronchoscopy on Anxiety in Children

OBJECTIVES

Flexible bronchoscopy (FB) is a semi-invasive diagnostic tool that allows direct visualization of the airways. The use for diagnostic and therapeutic purposes in children is incrasing with the developments in modern anesthesia. Irrespective of the type of the invasive diagnostic procedure, these interventions are known to cause anxiety in patients. The aim of our study was to evaluate the anxiety and depression status in children hospitalized for bronchoscopy and to investigate the effects of FB.

MATERIAL AND METHODS

Thirty children hospitalized for FB and 30 controls, aged 7 to 16 years, were enrolled in this study. Anxiety was evaluated with the "Hospital anxiety and depression scale" (HADS)" besides other parameters recorded.

RESULTS

The mean HADS anxiety scores in the patient and control groups were respectively 10.1 (3.5) and 2.7 (1.3) (p= 0.001). The mean HADS depression scores were respectively 8.8 (3.7) and 2.2 (1.1) (p= 0.001). Among the patients, 50% had anxiety and 53.3% had findings while none in the control group showed signs of anxiety and depression. A positive correlation was found between the age and, anxiety and depression scores in patients' groups (respectively r₁= 0.257; p= 0.05 and r₂= 0.288; p= 0.02).

CONCLUSION

Anxiety was demonstrated in nearly half of the children hospitalized for bronchoscopy. It has been observed that behavioral and physical problems may be encountered in approximately 40-60% of children who feel generalized anxiety before anesthesia, during the preoperative, postoperative period, and subsequent periods. These results suggest that the detection of children with increased anxiety and indicate the individual requirements can be assisted pharmacological and psychological supports.

Adaptation of the State-Trait Inventory for Cognitive and Somatic Anxiety for Use in Children: A Preliminary Analysis

OBJECTIVE

Anxiety has both state/trait and cognitive/somatic dimensions, and these distinctions may be particularly relevant for children with medical problems. This two-part study adapted the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) and confirmed its factor structure in a sample of children in a primary care clinic.

METHODS

STICSA items were adapted for reading level and piloted in a small group of children. Next, 250 children (12.3 ± 2.7 years) completed the adapted version, the STICSA-C.

RESULTS

Separate confirmatory factor analyses conducted on the State and Trait forms of the STICSA-C confirmed the two-factor structure of the original measure (i.e., cognitive and somatic anxiety) and suggested an improved parsimonious model.

CONCLUSIONS

Support was found for use of the STICSA-C as a reasonably good internally consistent measure for assessing cognitive and somatic anxiety in pediatric samples. Further investigation of its reliability and validity with replication in pediatric populations is warranted.

Examining Validity and Reliability of the Emotional Reactions Checklist with Hospitalized Children

Fear, anxiety, and emotional upset are common experiences for hospitalized children. To identify and treat children's emotional reactions, health care professionals must be able to differentiate emotional reactions from pain and other symptoms. Clinical assessment of emotions requires the use of valid and reliable instruments in acute care settings. This study examined internal consistency, construct, and concurrent validity of the Emotional Reactions Checklist (ERC). A descriptive correlational design guided the psychometric approach. Children answered a sociodemographic questionnaire and responded to self-generated scenarios of pleasant and unpleasant events using two self-report scales of emotions. The convenience sample comprised 59 children admitted to an inpatient unit in a large children's hospital or to a community hospital emergency department. Construct validity was supported by significantly different ERC mean responses to recalled pleasant prehospitalization experiences and unpleasant hospitalization experiences (p < .001) for both ERC item responses and total scale scores. Children's explanations for seemingly inconsistent item responses further supported their ability to use the ERC to convey their emotions. Concurrent validity was supported by moderate (r = 0.32) to strong (r = 0.70) correlations between the Facial Affective Scale and ERC items and scale scores. Internal consistency was better supported for the recalled unpleasant experience (α = 0.77) than for the pleasant experience (α = 0.60). Results supported construct and concurrent validity and beginning internal consistency reliability for the ERC in an acute care setting. Further research is required to establish feasibility of repeated use with ill children.

Psychometric properties of the RCMAS-2 in pediatric cancer patients

PURPOSE OF THE RESEARCH

The Revised Children's Manifest Anxiety Scale, second edition (RCMAS-2) is widely used internationally to assess anxiety. However, there is little data regarding its validity for pediatric cancer patients. This study evaluated the psychometric properties of the RCMAS-2 in pediatric cancer patients.

METHODS AND SAMPLE

This cross-sectional study included 370 pediatric cancer patients (aged 6-19 years) that were recruited from three medical centers between August 2008 and March 2011 in Taiwan. Reliability was evaluated by internal consistency. Confirmatory factor analysis was performed to examine the factor structure. Construct validity was examined by known-groups analyses.

KEY RESULTS

The internal consistency of the full scale was good (α = 0.90) but the scores of Physiological Anxiety subscale was low (α = 0.65). Using known-groups validity, significant differences in anxiety were observed between genders and between patients that were on and off treatment. The hypothesized three-factor model did not adequately fit (χ(2)/d.f = 2.4; p < 0.01, GFI = 0.80, CFI = 0.71, RMSEA = 0.06, SRMR = 0.01).

CONCLUSIONS

The RCMAS-2 demonstrated reliability and validity for use with pediatric cancer patients aged 6 and 19 years. Further structure evaluation of the RCMAS-2 in pediatric oncology population is needed, and the scores of the Physiological Anxiety subscale should be interpreted with caution.

[Validity of instrument development research in korean nursing research]

PURPOSE

This integrative review study was done to analyze methods used for validation studies in Korean nursing research.

METHODS

In this study, the literature on instrument development in nursing research from Research Information Sharing Service (RISS) and major nursing journal databases in Korea were examined. The MeSH search terms included 'nursing', 'instrument', 'instrument development', 'validation' and 189 articles were included in the review.

RESULTS

The most frequently reported validity type was content validity, followed by construct validity, and criterion validity. One third reported a single type of validity, and 15% of the studies demonstrated three kinds of validity at the same time. In about 40% of the studies, both content and construct validity were examined.

CONCLUSION

The results of the study indicate that it is necessary to provide a wider variety of evidence to establish whether instruments are valid enough to use in nursing research.

A randomized controlled pilot trial of classroom-based mindfulness meditation compared to an active control condition in sixth-grade children

The current study is a pilot trial to examine the effects of a nonelective, classroom-based, teacher-implemented, mindfulness meditation intervention on standard clinical measures of mental health and affect in middle school children. A total of 101 healthy sixth-grade students (55 boys, 46 girls) were randomized to either an Asian history course with daily mindfulness meditation practice (intervention group) or an African history course with a matched experiential activity (active control group). Self-reported measures included the Youth Self Report (YSR), a modified Spielberger State-Trait Anxiety Inventory, and the Cognitive and Affective Mindfulness Measure -Revised. Both groups decreased significantly on clinical syndrome subscales and affect but did not differ in the extent of their improvements. Meditators were significantly less likely to develop suicidal ideation or thoughts of self-harm than controls. These results suggest that mindfulness training may yield both unique and non-specific benefits that are shared by other novel activities.

Psychometric validation of Emotional Reaction Instrument-English to measure American children's emotional responses to hospitalisation

AIMS AND OBJECTIVES

The aim of this study was to test the initial psychometric properties of the Emotional Reactions Instrument-English with hospitalised American children, ages 7-12 years, in the USA.

BACKGROUND

Children's negative emotional responses have been a subject of concern for paediatric clinicians and researchers, especially because negative emotional responses following or during hospitalisation are associated with adverse patient outcomes. Existing self-report paediatric instruments have a number of limitations including lack of clinical feasibility and psychometric evidence.

DESIGN

A survey and psychometric approach was used to test initial reliability and validity of the Emotional Reactions Instrument-ENGLISH.

METHODS

Two hundred hospitalised American children, 7-12 years of age, who were admitted to a Children's Hospital in the USA were recruited for this study. The children were administered the Emotional Reactions Instrument-English, the Facial Affective Scale, and a demographic form.

RESULTS

Internal consistency was supported by a Cronbach's alpha of 0·83 for the total scale. Alpha coefficients for subscales ranged from 0·59-0·82. Construct validity was tested with exploratory factor analysis. Through principal component analysis, four factors were identified that explained 64% of the variance. Concurrent validity was supported by most items in the Emotional Reactions Instrument-English being significantly correlated with the Facial Affective Scale (r = 0·18-0·59). The instrument can be administered to hospitalised children in 5-10 minutes.

CONCLUSIONS

The results of this exploratory study provide initial support for the psychometric adequacy of the Emotional Reactions Instrument-English with hospitalised American children ages 7-12 years. Further testing of the Emotional Reactions Instrument-English is required to validate the subscales and evaluate the instrument's use with children of different ages, race and ethnicity.

RELEVANCE TO CLINICAL PRACTICE

This study introduces a new, clinically feasible instrument to measure children's diverse emotional responses to hospitalisation.