Child temperament and maternal behavior

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Child temperament and maternal behavior effects on children's behavior during anesthesia induction
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Abeles, Linda A., 1959-
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Maternal Behavior   ( mesh )
Anesthetics -- administration & dosage   ( mesh )
Child Behavior -- drug effects   ( mesh )
Clinical and Health Psychology thesis Ph.D   ( mesh )
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Thesis:
Thesis (Ph.D.)--University of Florida, 1987.
Bibliography:
Bibliography: leaves 90-95.
Statement of Responsibility:
by Linda A. Abeles.
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Typescript.
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Vita.

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CHILD TEMPERAMENT AND MATERNAL BEHAVIOR:
EFFECTS ON CHILDREN'S BEHAVIOR DURING ANESTHESIA INDUCTION



By

LINDA A. ABELES


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1987















ACKNOWLEDGEMENTS

I wish to express my gratitude to Dr. James H. Johnson

and Dr. Barbara Melamed for their direction in the

completion of this dissertation. Their support and

encouragement are greatly appreciated. Drs. Andrew

Bradlyn, Sheila Eyberg, Nancy Norvell and Marjorie White

served with Drs. Johnson and Melamed on my dissertation

committee and I thank them for their time and helpful

comments. The assistance of Mark Lumley in the

implementation and statistical analyses of this study was

invaluable. I would also like to thank Dr. Marc Zola for

his advice regarding the statistical analyses.

There are a great number of people without whom this

dissertation would not have been possible. The

encouragement and support of my parents Jeanette and Norman

Abeles, Betty Lee and Richard Bensen, Hugh Davis, Marilyn

Sokolof, Leslie Cleaver and Karen Bronk Froming are much

appreciated. Finally, I would like to give special thanks

to Peter Lee Bensen, who provided encouragement, support

and advice during the completion of this dissertation.















TABLE OF CONTENTS


PAGE
ACKNOWLEDGEMENTS ........................................ ii

LIST OF TABLES .......................................... v

LIST OF FIGURES ......................................... vi

ABSTRACT ...............................................vii

CHAPTER

I INTRODUCTION................................. 1

Temperament.................................. 2
Relationship of Parent Variables and
Child Temperament ......................... 14
Goodness of Fit............................. 20
Temperament and Hospitalization............. 22
Predictions................................. 24

II METHODS..................................... 27

Subjects .................................... 27
Measures.................................... 27
Background Information Interview Form.....27
Parent Temperament Questionnaire ..........28
Dyadic Prestressor Interaction Scale......29
Operating Room Behavior Rating Scale...... 32
Heart Rate ................................ 32
Procedure................................... 33

III RESULTS..................................... 35

Demographic and Questionnaire Measures......35
Reliability of observational measures.....39
DPIS intercorrelations .................... 41
ORBRS-R and heart rate intercorrelations..46
Tests of Hypotheses ......................... 46
Relationships between temperament,
maternal characteristics, and
children's behavior during anesthesia
induction............................... 48


-iii-









PAGE
Phase 1 of Anesthesia Induction............. 49
Direct relationships between children's
temperament and outcome measures ........ 49
Direct relationships between maternal
behavior and outcome measures...........51
Phase 2 of Anesthesia Induction............. 52
Phase 3 of Anesthesia Induction............. 52
Direct relationships between children's
temperament and outcome measures ........52
Relationships between maternal behavior
and outcome measures.................... 54
Influence of maternal and child
variables on heart rate levels.......... 55

IV. DISCUSSION .................................. 67

Children's Temperament and Behavior
During Anesthesia Induction............... 68
Goodness of Fit.................. ......... 69
Maternal Patterns of Behavior ...............71
Situational Components ...................... 73
Child Temperament and
Maternal Involvement ...................... 75
Limitations................................. 77
Conclusions................................. 79

APPENDICES

A BACKGROUND INFORMATION INTERVIEW FORM....... 82

B OPERATING ROOM BEHAVIOR RATING SCALE--
REVISED ................................... 83

C SAMPLE CHARACTERISTICS:
PARENT TEMPERAMENT QUESTIONNAIRE..........86

D SIGNIFICANT MULTIPLE REGRESSION MODELS ...... 87

REFERENCES .............................................. 90

BIOGRAPHICAL SKETCH..................................... 96


-iv-














LIST OF TABLES
TABLE PAGE


1 Demographic Characteristics ................ 36

2 DPIS Inter-rater Reliability
Pearson Product Coefficients ............... 40

3 ORBRS-R Inter-rater Reliability
Pearson Product Coefficients ............... 42

4 Intercorrelations Among DPIS
Parent Behavior Categories ................. 43

5 Intercorrelations Among DPIS
Child Behavior Categories .................. 45

6 Intercorrelations Among ORBRS-R Ratings....47














LIST OF FIGURES


FIGURE PAGE

3-1 Regression Lines Indicating the
Relationship Between Children's
Tendency Towards Approach/
Withdrawal and Maternal Use of
Distraction as Predicting Number
of Distress Behaviors ...................... 53

3-2 Regression Lines Indicating the
Relationship Between Children's
Tendency Towards Approach/
Withdrawal and Maternal Use of
Distraction as Predicting Number
of Distress Behaviors ...................... 56

3-3 Regression Lines Indicating the
Relationships Between Children's
Temperament and Maternal Ignoring
as Predicting Heart Rate Levels ............ 58

3-4 Regression Lines Indicating the
Relationship Between Children's
Tendency Towards Approach/
Withdrawal and Maternal Ignoring
as Predicting Heart Rate Levels............ 60

3-5 Regression Lines Indicating the
Relationship Between Children's
Temperament and Maternal Ignoring
as Predicting Heart Rate Levels............ 62

3-6 Regression Lines Indicating the
Relationship Between Children's
Temperament and Maternal Restraint
as Predicting Heart Rate Levels............ 64

3-7 Regression Lines Indicating the
Relationship Between Children's
Temperament and Maternal Agitation
as Predicting Heart Rate Levels............ 66


-vi-














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

CHILD TEMPERAMENT AND MATERNAL BEHAVIOR:
EFFECTS ON CHILDREN'S BEHAVIOR DURING ANESTHESIA INDUCTION

By

LINDA A. ABELES

December 1987
Chairman: James H. Johnson, Ph.D.
Major Department: Clinical and Health Psychology

This study explored children's adjustment to anesthesia

induction and how this is related to temperament factors.

Additionally, the relationship between maternal

characteristics and children's behavioral adjustment to

anesthesia induction was investigated.

Sixty mother-child dyads were interviewed in the Ear,

Nose, Throat Clinic waiting room at the J. Hillis Miller

Health Center, Gainesville, Florida. Mothers completed the

Parent Temperament Questionnaire regarding their child's

temperament. Mothers and children were then escorted to a

clinic examination room. A videotape recording was made of

the waiting period before the doctor entered the

examination room. Videotapes were subsequently scored

using the Dyadic Prestressor Interaction Scale. On the day

of surgery an observer met the child and parent in the

-vii-








pre-operative holding room. The observers used the

Operating Room Behavior Rating Scale-Revised to rate the

number of distress behaviors and level of cooperation

during the anesthesia induction procedure. Children's

heart rate was recorded as soon as the electrodes were

attached.

Only a limited number of temperament factors and

maternal behaviors were directly related to children's

adjustment to anesthesia induction. Instead, temperament

variables including approach/withdrawal, and the overall

temperament score in interaction with the maternal

behaviors of ignoring, restraint, reassuring, agitation and

distraction were the best predictors of children's behavior

during anesthesia induction. Both difficult and easy

temperament children displayed a higher number of distress

behaviors and had higher heart rate levels depending on

maternal behavior. The difficult child was adversely

affected by less ignoring, restraint and agitation, more

reassurance and varying amounts of distraction. In

contrast, the easy child was adversely affected by high

rates of ignoring, restraint and agitation, less

reassurance and varying amounts of distraction. These

findings support the view that maternal behaviors cannot be

judged as either "good" or "bad." Rather it appears that a

"goodness of fit" or poornesss of fit" exists between dyads

in different situations. Implications of these results

-viii-










with regard to possible interventions are discussed.


-ix-














CHAPTER I
INTRODUCTION

Every year millions of children undergo medical and

dental procedures (Melamed & Siegel, 1984). In the

hospital a child, who may have previously functioned

adequately may become anxious in response to medical

procedures so that normal coping behaviors are ineffective.

Following a hospital stay, as many as one third of all

children show some evidence of long-term psychological

adjustment problems (Davies, Butler, & Goldstein, 1972).

For some children, however, the hospital experience can be

viewed in some respects as a positive one and approximately

one quarter of all children are rated as behaviorally

improved after hospitalization (Vernon, Foley & Schulman,

1967). While there is little information regarding factors

that predict coping versus maladaptive behavior in the

medical setting, there is reason to suspect that

temperament characteristics may be of importance as

temperament has been found to be a significant predictor of

behaviors problems (Thomas & Chess, 1977). At present,

however, the relationship of child temperament

characteristics to children's adjustment to a hospital

experience has yet to be researched. This study proposes

to explore children's temperament, its relationship to

1








2

adjustment to a medical experience, and the extent to which

this relationship is influenced by maternal behaviors

exhibited in the medical setting.

Temperament

The concept of temperament dates to medieval times when

it was used to refer to an individual's mental disposition,

as constituted by the combination of the four cardinal

humours (Rutter, 1982). Today, the general consensus is

that temperament involves style rather than content; that

is the how rather than the what or why of behavior (Plomin,

1982).

There has been, however, much confusion regarding the

difference between the terms "temperament" and

"personality." While Goldsmith and Campos (1981) state

that there is no clear-cut distinction between temperament

and personality, Allport (1937) has suggested that

temperament includes those stylistic aspects of personality

that are stable and are influenced by heredity. Kagan

(1982) reflects the prevailing view of most temperament

theorists stating that any quality which has persisted for

more than two years is to be considered a temperament

trait. In its current usage temperament is considered a ".

. rubric for a group of related traits and not a trait

itself" (Goldsmith, Buss, Plomin, Rothbart, Thomas, Chess,

Hinde and McCall, 1987 p. 506). The temperamental rubric

encompasses phenomena such as irritability, activity level










and fearfulness. Goldsmith et al. (1987) outlines several

general points of convergence among contemporary approaches

to temperament. One is that temperamental dimensions

reflect behavioral tendencies and may not correspond

directly to discrete behavioral acts. Other points of

convergence include emphases on biological underpinnings,

continuity relative to other aspects of behavior, and

consensus that temperament refers to individual differences

rather than species general differences. Existing research

literature, however, has not always clearly supported these

positions and questions remain regarding both the

constitutional basis and stability of temperament

characteristics.

Temperament research in the United States began in the

1950s with the New York Longitudinal Study (NYLS) by

Thomas, Chess and Birch (Thomas & Chess, 1977). The goals

of the NYLS included (a) the development of a method for

classifying behavioral individuality in early infancy in

terms of objectively describable and reliably rated

categories of temperament; (b) the study of consistencies

and inconsistencies of these early characteristics in the

course of development; (c) the analysis of the pertinence

of early temperament to later psychological development;

(d) the dynamic of temperament in the mastery of








4
environmental demands and expectations at meeting age

appropriate tasks of development; (e) the identification of

those children who develop behavior disorders, and the

analysis of the etiology and course of these disorders in

terms of a continuously evolving child-environment

interactional process.

The first intensely studied group by Thomas, Chess and

Birch was comprised of 141 children from 85 families.

Sample collection was begun in 1956 when the children were

from 2-3 months of age and completed in 1963. As of 1984,

133 children were still being followed by the researchers.

These children and their parents were of middle- to upper-

middle class background and most of the parents were born

in the United States.

In 1961, a second longitudinal study was initiated by

Thomas, Chess and Birch (1968). This study involved 95

children of working class Puerto Rican parents; of this

sample 86% lived in low-income public housing projects.

This study was begun so as to research a population of

contrasting socio-economic background, as compared to the

original group. Additionally, Thomas, Chess and Birch

began longitudinally researching two samples of deviant

children. One sample included 68 children born prematurely

with low birth weights--approximately 40% of these children

had clinical evidence of neurological impairment at age

five years. This group was followed from birth. The









5

second group was comprised of 52 children with mildly

retarded intellectual levels but without evidence of motor

dysfunction or body stigmata. This group has been followed

since when they were between 5- and 11-years-old. A

special population of 243 children with congenital rubella

was also studied in a cross-sectional experimental design

at 2- to 4-years of age, and during a follow-up four years

later.

For all of subjects the parents were the primary source

of information on the child's behavior in infancy. As the

child grew older, behavioral data were obtained through

teacher interviews in nursery and elementary school, direct

observations in the school setting and psychometric testing

at ages 3, 6 and 9 and direct interview with each youngster

and parent separately age 16-17 years. Academic

achievement scores were gathered from school records.

Additionally, whenever anyone in contact with the child

suspected that there was a behavioral disturbance, a

complete clinical evaluation was completed.

For each phase of data collection different individuals

assessed each child. Thomas and Chess (1977) report that

the intra- and interscorer reliability was at the 90% level

of agreement.

The nine categories of temperament, their definitions

and the three point scoring scales are as follows:









6

(1) Activity level is defined as the extent to which a

motor component is present when a child is engaged in

bathing, eating, playing, dressing, being handled,

sleeping, reaching, crawling and walking (high, medium,

low).

(2) Rhythmicity is defined as the predictability and/or

unpredictability in time of any function. It can be

analyzed in relation to the sleep-wake cycle, hunger,

feeding patterns and elimination schedules (regular,

variable, irregular).

(3) Approach or withdrawal is defined as the nature of

the child's response to a new stimulus, whether it is a new

food, toy or person (approach, variable, withdrawal).

(4) Adaptability is defined as the responses to a new

or altered situation over time. In contrast to the

approach-withdrawal dimension, the concern in this case is

the ease which the responses are modified in the desired

directions (adaptive, variable, non-adaptive).

(5) Threshold of responsiveness is defined as the

intensity level of stimulation necessary to evoke an

observable response from the child (high, medium, low).

(6) Intensity of reaction is defined as the energy

level of the response (positive, variable, negative)

(7) Quality of Mood is defined as the amount of

pleasant, joyful, and friendly behavior as contrasted with









7
unpleasant, crying and unfriendly behavior (positive,

variable, negative).

(8) Distractibility is defined as the extent to which

the environmental stimuli changes an ongoing behavior

(distractible, variable, non-distractible).

(9) Attention span and persistence concerns the length

of time an activity is pursued by the child and the

continuation of an activity in the face of obstacles

(persistent, variable, non-persistent).

Qualitative and factor analyses of these nine

dimensions by Thomas and Chess (1977) yielded three

temperament constellations of functional significance: the

most common pattern, the easy child, was seen in about 40%

of the children. It is characterized by regularity,

positive approach, high adaptability and mild or moderately

intense mood which is mostly positive. An opposite pattern

is seen in the difficult child. This child has been found

to have an irregularity in biological functions, negative

withdrawal responses to new stimuli, non- or slow-

adaptability to change, and intense and negative mood.

This pattern was found in approximately 10% of children.

The third constellation has been termed the slow-to-warm-up

child and was seen in 15% of the sample. These children

were active, withdrawing, low in adaptability, tended to

have a negative mood and a low intensity of reaction level.








8

Thomas, Chess and Birch (1968) found that 70% of

children classified as "difficult" developed behavior

problems, whereas only 18% of those children identified as

"easy" developed such difficulties.

Graham, Rutter and George (1973) attempted to replicate

the findings of the NYLS on a population of children all of

whom who had a mentally ill parent. Subjects were obtained

through an outpatient clinic of a London psychiatric

facility. For an unspecified time period, all parents of

children between the ages of 3.0 and 7.11 years who

attended the clinic were included in this study. After an

initial appointment to explain the purposes of the study,

parents were interviewed both separately and together.

Ratings were made at this time regarding the quality of the

parental marriage and the amount of criticism expressed by

the mother towards the child. Additionally, mothers were

asked to complete a behavior questionnaire, on which a

judgment of "psychiatric abnormality" was made, and a

"temperamental characteristics" interview about the child.

This interview regarding the child's temperament was

divided into three sections. In the first section the

mother was asked to describe the child's behavior over a

wide range of routine situations including behavior at

breakfast and while watching television. During the second

section, the mother was asked for details of the child's

regularity in areas such as sleep patterns, appetite and








9

bowel function. Finally the mother was questioned about

the child's behavior in various non-routine situations.

From this interview each child was rated on seven

categories of behavior: mood, intensity of emotional

expression, activity, regularity, malleability,

fastidiousness, and approach/withdrawal to new people.

Five of these categories including mood, intensity,

activity, regularity and approach/withdrawal directly

corresponded with Thomas, Chess and Birch's (1967) Parent

Temperament Questionnaire. One year later the mother again

completed the behavior questionnaire on her child.

Results indicated that those children judged as

"psychiatrically abnormal" at the first administration of

the behavior questionnaire were more likely to be intense

in their emotional expression than those judged as

psychiatrically normal. One year later, the

psychiatrically abnormal children were found to have been

characterized at the onset of the study as negative in mood

and irregular in their biological functioning than those

children judged as normal.

While these results support the hypothesis that

temperament factors affect children's adjustment, several

important issues are raised concerning this study. The

first concerns the validity of the parental reports of the

behavior and temperament of their children. Bates (1980)

has questioned the validity of parent reports and has








10

suggested that "difficult temperament" is a parental

perception. This may be especially relevant as one of the

children's parents in this study was presumably

psychiatrically ill. Additionally Graham et al. (1973)

assume that temperament is a relatively constant trait.

This has not been totally supported by the literature

(Hooker, Nesselroade, Nesselroade & Lerner, 1987).

In a study which sought to identify antecedent

characteristics of children that best predicted behavioral

problems in young children, Bates, Maslin and Frankel

(1985) found that a difficult temperament, as perceived by

parents and secondary care givers, predicted behavior

problems as measured by the Preschool Behavior

Questionnaire. Specifically, those children with the

difficult temperament traits of negative emotion,

unadaptability/unsociability and high activity level were

rated by their mothers as higher in anxiety, hostility and

hyperactivity. These results, however, must be interpreted

cautiously as they might be reflective of bias in mothers'

report. Only one temperament dimension--unadaptability--

was found to correlate significantly with one child

behavior problem--anxiety. Furthermore, Bates et al.

(1985) writes that correlations between difficult

temperament, child and mother self-reported anxiety,

defensiveness and social desirability, reflect that anxious

mothers are more likely to have anxious children, and that








11

these children may express their proneness to anxiety via a

difficult temperament.

Weber, Levitt and Clark (1986) investigated temperament

and its affect on children's attachment to their mothers.

Previous research has found that differences in children's

temperament and qualitative differences in children's

attachment are associated with different behavioral

outcomes (Ainsworth, Blehar, Waters and Wall 1978).

Temperament and attachment data were collected on 36

mother-child dyads. Temperament was assessed with the

Dimensions of Temperament Survey (DOTS) (Lerner, Palermo,

Spiro & Nesselroade, 1982) The dimensions of the DOTS are

conceptually similar to those identified by Thomas and

Chess (1977) except some of the Thomas and Chess categories

were combined and the quality of mood dimension was

eliminated. The DOTS dimensions include activity level,

attention span, adaptability, rhythmicity, and reactivity.

Attachment was assessed via the strange situation

(Ainsworth et al., 1978). The strange situation is divided

into eight 3 minute episodes. The situation begins with

the mother and child alone in a room. A female stranger

enters the room, sits quietly at first, then talks to the

mother and attempts to play with the child. The mother

then leaves the room leaving the child with the stranger.

After 3 minutes, the mother returns and the stranger

leaves. The mother settles her child if necessary and









12

encourages the child to play with toys. The mother exits

again, leaving the child alone. After 3 minutes the

stranger returns. In the final episode the stranger departs

and mother and child are reunited. Based on the strange

situation children were classified as avoidant, resistant

or secure in their attachment relationship to their mother.

The results of this study indicated that child

temperament showed little relation to behavior directed

toward the mother but was related to behavior to the

stranger. The dimension of temperament that showed the

strongest association with strange situation behavior was

adaptability. Children rated as more adaptable experienced

less negative and more positive interactions with the

stranger. Summary ratings of child difficult temperament,

however, correlated with resistant behaviors towards both

the mother and stranger. These results suggest that

children's temperament characteristics do in fact

contribute to their social development.

Although the literature has indicated an association

between temperament and school performance (Carey, Fox &

McDevitt, 1977; Thomas & Chess, 1977), the actual process

variables through which variation in temperament has not

been identified. Paget, Nagle and Martin (1984)

investigated the relationships between child temperament

characteristics and first-grade teacher-student

interactions. Teachers of 105 first grade children









13

completed the Teacher Temperament Questionnaire (Thomas &

Chess, 1977). This questionnaire is based on the Parent

Temperament Questionnaire (Thomas & Chess, 1977) and

contains seven sub-scales including (a) activity level, (b)

adaptability, (c) approach-withdrawal, (d) sensory

threshold, (e) intensity, (f) distractibility, and (g)

persistence. Shortly after the questionnaires were

completed, videotapes were made of classroom interactions.

For each child a total of 5 hours of observation data was

collected. These videotapes were rated by the Brophy and

Good (1969) observation system. This observation system was

teacher-student interactions rated as falling into one of

three general categories: Response Opportunities, Child-

Initiated Contacts, and Teacher-Initiated Contacts. A

response opportunity occurred when a child publicly

attempted to answer a question posed by the teacher, or

when the child read aloud; child initiated contacts were of

two types: work contacts occurred when a child asked a

teacher for help with work and procedure contacts occurred

when the child asked to engage in an activity such as

sharpening a pencil, or asked what work he or she should

begin to work on; teacher-initiated contacts were also of

two types: work contacts in which the teacher helped a

child with work without being asked, and behavior contacts

which involved questions of discipline or classroom control








14

when the teacher commented on a child's nonacademic

behavior.

Paget, Nagle and Martin (1984) found that children's

temperament characteristics predicted teacher-student

interactions. The findings suggested that the most

adaptable and attentive children were the least likely to

receive contact for their behavior, particularly contact

involving praise. These results were explained in terms of

a reinforcement cycle being in effect. That is, more

praise is given to withdrawn children as they are more

responsive to praise than more extroverted children.

Taken together this selective overview suggests that

children's temperament characteristics influence their

behavior in a variety of environments, and furthermore

temperament characteristics may influence other

individuals' responses.

Relationship of Parent Variables and Child Temperament

One factor affecting the child's psychological

functioning within various environments may be the parent-

child relationship including parent-child interaction

characteristics. Webster-Stratton and Eyberg (1982)

assessed 35 children between the ages of 3 and 5 years-old

and their mothers on variables including child temperament,

child behavior problems and mother-child interaction.

Temperament was assessed by the Colorado Childhood

Temperament Inventory (CCTI) (Rowe & Plomin, 1977). This is










a parental rating instrument for children 1 through 6 years

of age. The CCTI was derived from the joint factor

analyses of the Parent Temperament Questionnaire (Thomas et

al., 1968) and Buss and Plomin's (1975) temperament

questionnaire. Mothers also completed the Eyberg Child

Behavior Inventory (ECBI) (Eyberg, 1980) on their children.

This measure surveys a wide variety of parental concerns

regarding child conduct problems. Finally, behavioral

observations were obtained by videotaping each mother-child

dyad for 30 minutes in a play room through a one-way

mirror. The videotapes were then rated using the

Interpersonal Behavior Construct Scale (IBCS) (Kogan &

Gordon, 1975). Dimensions included on this scale are

positive affect behavior, negative affect behavior, non-

acceptance behavior, dominance, and submissiveness.

Webster-Stratton and Eyberg's (1982) findings suggested

that children with high levels of activity and low

attention span tended to be negative, non-accepting, and

noncompliant in their interactions with their mothers.

Additionally, children described by their mothers as more

social in temperament were judged as non-accepting in their

interactions with their mothers. With regard to the

interaction of the mother-child relationship with child

temperament, mothers of highly active, low attention span

children were observed to be more negative in affect, more

non-accepting and more submissive with their children.











Furthermore, mother positive affect was found to be

negatively correlated with child sociability.

Two observational studies examined the relationships of

maternal characteristics and child temperament. Stevenson-

Hinde and Simpson (1982) investigated the relationship

between mother's mood and child temperament. Subjects

included 26 boys and 21 girls from families composed of

both parents and one sibling. Maternal mood was assessed

by a self-report inventory developed by Snaith,

Constantopoulous, Vardne and McGuffin (1982; cited in

Stevenson-Hinde & Simpson, 1982) which provided summary

ratings for depression, anxiety, inward irritability and

outward irritability. Child temperament was assessed

twice, once at 3 1/2 years of age, and again eight months

later by the Temperamental Characteristics Interview. This

structured interview was based on the interview schedule

developed by Garside, Birch, and Scott (1982; cited in

Stevenson-Hinde & Simpson, 1982). Dimensions assessed by

the Temperamental Characteristics Interview included

activity level, shyness, dependency, moodiness, intensity,

malleability, irregularity, assertiveness and attention

span. Stevenson-Hinde and Simpson (1982) found that the

more temperamentally difficult the child (composed of the

dimensions of moodiness, intensity, unmalleability,

irregularity, assertive and decreased attention span) the

more anxious and irritable (inwardly and outwardly) was the








17

mother. The findings of this study state the authors,

raise the broader issue of how mothers influence and are

influenced by children's characteristics.

Hinde, Easton, Meller and Tamplin (1982) studied the

interaction of child temperament with maternal behavior.

Data were collected from 21 girls and 24 boys at 42 (n=45)

and 50 months of age (n=37) Children's temperament was

assessed with the Temperamental Characteristics Interview

(Garside et al., 1982 cited in Hinde et al., 1982), and

maternal behavior was rated with an observational scale

during an interaction with their children. Dimensions

included on this observational scale included physical

friendliness, verbal friendliness, expression of pleasure,

types of speech, types of questions, types of controls,

non-compliance, hospitality and excitement. Hinde et al.

(1982) found that moody children, especially girls, were

the recipients of maternal hostility and more physical

responses and fewer verbally friendly responses.

In a study of infant temperament, maternal level of

depression and child behavior problems, Wolkind and De

Salis (1982) found that children assessed at 4 months of

age as temperamentally difficult tended to have more

behavior problems than other children when again assessed

at 42 months of age. Additionally, the researchers found

that maternal depression was positively associated with

child behavior problems when the child was in the extreme









18

quartiles of either end of the dimensions of temperament,

i.e., extremely easy or extremely difficult. Wolkind and

De Sallis (1982) explain these somewhat curious results by

stating that perhaps totally different mechanisms operate

for these two groups of children. That is, at the

"difficult" end there may be a group of children who are

objectively difficult. These children could put stress on

a mother and cause her to be depressed. On the opposite

end of the spectrum there exists a group of "easy"

children. It may well be the case that these children are

truly easy, but their mothers may lack the capacity to cope

with any stresses which arise.

In addition to investigating child temperament and the

prediction of behavior problems, other studies have

examined the interaction of child temperament, parental

behavior and child behavior problems. Cameron (1977, 1978)

utilized the data from the NYLS for his research. Parents

were interviewed and completed the Parent Temperament

Questionnaire on their child at various intervals during

the child's life. Near the child's third birthday parents

were also administered a focused interview which included

such topics as the degree of parent conflict and tension,

the degree of warmth, protectiveness and permissiveness

directed toward the child, and the degree and forms of

discipline used. Cameron (1978) found that first year

temperament scores predicted later child behavior problems.











Parental psychopathology was related to behavior problems

in both male and female children; additionally, for male

children, behavior problems were also related to negative

temperament changes over time. Furthermore, these negative

temperament changes were associated with parental

intolerance, inconsistency and conflict (Cameron, 1977).

This study suggests that while child behavior problems may

be related to a difficult temperament, other variables

including parent characteristics may affect children's

behavioral adjustment.

Lee and Bates (1985) examined mother-child interaction

as a possible mediating process between early child

temperament and later behavior problems. Temperament was

assessed on 111 children at the ages of 6, 13, and 24

months old via mother ratings on age appropriate forms of

the Infants Characteristics Questionnaire. Additionally,

each mother-child dyad was observed at home during two 2-3

hour observational periods several days apart. These

observational periods were coded by observers, who

continuously entered behavior codes on electronic event

recorders. The behavior coding system used for the mother-

child interaction sequences consisted of 65 descriptors of

parent and child behaviors. The major categories of the

codes included affection, maturity demands, communication,

interpersonal control and child trouble behaviors. Child

problem behavior was described in terms of conflict








20

sequence variables. Specifically the sequence variable

consisted of a child trouble behavior, a mother control

response and a child's response to the mother's control

attempt.

Lee and Bates (1985) found that children perceived as

difficult in temperament were more likely to have

conflictual interactions with their mother than

temperamentally easy children. The "difficult" child was

observed to be more negative or resistent in response to

mothers' control attempts and the mothers of such children

were likely to use more intrusive control strategies

including restraint of the child and a demand for maturity.

Lee and Bates conclude that the data presented support the

hypotheses that the quality of mother-child interaction can

be considered a mediating process between a difficult

temperament and later behavior disorders.

Goodness of Fit

Thomas and Chess (1977) state that "temperament is

never considered by itself, but always in its relationship

to, or in interaction with the individual's abilities,

motives, external environmental stresses and opportunities"

(p.1). Thus, temperament is to be considered within the

context of the environment. This interactionist approach

requires that information on an individual's behavior style

be considered within the specific context in which it has

occurred. That is, an individual's temperament cannot be








21
understood without a knowledge of the environmental

situation within which the behavior was demonstrated.

Additionally, a parent's response to a child and the

parents' accompanying child-rearing characteristics cannot

be assessed without a simultaneous consideration of the

child's temperament and their influence on the parent.

From this interactionist approach to temperament,

Thomas and Chess (1977) have used the concept of "goodness

of fit" and poornesss of fit." The "goodness of fit" model

postulates that favorable psychological adjustment and

development will be possible if environmental demands and

expectations are congruent with the individual's

capacities, abilities, motivations and temperament.

Similarly, if environmental demands and expectations are

not congruent with an individual's capacities, abilities,

motivations and temperament, a poornesss of fit" will exist

and unfavorable psychological adjustment and development

will be the results (Lerner, 1984).

The goodness of fit model is a contextual one which

stresses that psycho-social functioning can best be

predicted when one places the individual within a specific

context. From this mode, neither adaptive psychological

nor social functioning derive directly from either the

individual's characteristics or the demands of the

individual's environment. Goodness of fit is the extent to

which an individual's characteristics are congruent with








22

the demands of the environment. Therefore, those

individuals whose characteristics are not congruent with

the environmental demands may have difficulties in adapting

in that environment (Lerner, Lerner, Windle, & Hooker,

1985).

Temperament and Hospitalization

Children's responses to new places and procedures are

strongly influenced by their temperament characteristics

(Thomas and Chess, 1977). One situation which often

includes new or unfamiliar surroundings and procedures is

coming to the hospital, a situation that can be very

stressful for some children (Melamed and Siegel, 1984).

The stress of hospitalization for a child includes the

distress of unfamiliar surroundings, the actual physical

discomfort of surgery or recovery from illness and the

loneliness precipitated by isolation from peers and school

(Melamed, Robbins & Fernandez, 1982). Many children suffer

behavior problems during the hospital stay. Not all

children, however, are equally vulnerable to the effects of

the hospital experience. Vernon et al. (1967) investigated

the effects of hospital admissions and anesthesia induction

on children between the ages of 2 and 6-years-old. They

found that when the level of potential stress is low, as

during the admission procedures to the hospital,

differences in the children's responses are "primarily a

matter of personality" (p.173). It is only those children









23
who are unusually sensitive to the situation who become

upset. Most of the children are not upset. Furthermore,

for some children, hospitalization may have a beneficial

effect, as 25% of the children were rated by their mothers

as behaviorally improved after a hospitalization experience

(Vernon et al., 1967).

Thomas and Chess (1977) describe some of the ways

children's temperament may influence their responses to

physical symptoms, the physician and the medical setting.

For example, the child who is brought to a medical setting

is confronted with an unfamiliar place, a number of

unfamiliar persons, unusual sounds and is subjected to a

physical examination and procedures which may be

discomforting and sometimes painful. Thomas and Chess

(1977) write that depending on the child's temperament, the

child may fuss quietly and briefly squirm a bit and then be

immediately cheerful once the procedures are completed. Or

the child may howl loudly from the moment he or she enters

the physicians' office, struggle violently during the

physical examination and inoculation, take up to several

hours to subside, and then start up again with even more

intensity at the next visit. The child with the low

activity level will sit quietly in the waiting room. The

high activity youngsters, by contrast, will fidget, jump

around, try to poke into drawers and closer and make a









24
nuisance of themselves, if they have to wait a long time

before the doctor sees them.

The purpose of this study was to investigate children's

adjustment to a surgical experience and how it is related

to temperament factors. Additionally, the mediational

effect that maternal characteristics have on children's

behavioral adjustment to the surgical experience was

investigated. The literature has indicated the importance

of temperament in influencing children's reactions to

different stressors; however, individual differences in

children's adjustment to a surgical experience as prompted

by temperament factors had yet to be investigated.

Additionally, children's temperament was to be considered

in relationship to the parent and could not be assessed

without the simultaneous consideration of the parent's

response to the child.

Predictions
Predictions regarding children's temperament, their

behavioral adjustment to the surgical experience and the

mediational effect that parent-child interaction had on

children's behaviors in the hospital were as follows:

(1) Children with a "Difficult" temperament make up

would more frequently display the behaviors of "Distress"

and "Exploration" as measured by the Dyadic Prestressor

Interaction Scale during a pre-operative visit to the

clinic, as compared to children with an "Easy" temperament.









25

(2) Children's behavioral adjustment to anesthesia

induction would vary depending on the child's temperament.

That is, difficult temperament children would display more

problematic behaviors and would be rated by observers and

anesthesiologists as less cooperative during anesthesia

induction than those children with an easy temperament.

(a) Specifically, children who tended to have negative

withdrawal responses to new stimuli and/or non- or slow

adaptability to change would be rated by observers and

anesthesiologists as displaying more disruptive behaviors

and less cooperative during anesthesia induction as

compared to those children who tended to approach new

stimuli and/or tended to adapt to change.

(3) Children whose parents used distraction,

reassurance, and information provision during the pre-

operative visit to the clinic would display fewer distress

behaviors and be rated by observers and anesthesiologists

as more cooperative during anesthesia induction as compared

to those children whose parents demonstrated ignoring,

agitation and restraint during the pre-operative visit.

(4) Children's behavioral adjustment to the surgical

experience would be mediated by parent characteristics

assessed during parent-child interaction characteristics.

Those children with a "Difficult" temperament and whose

parents demonstrated agitation, restraint, or ignoring

during the pre-operative clinic visit would have higher









26

heart rate levels and would be rated by observers and

anesthesiologists as displaying more distress behaviors and

less cooperative behavior during anesthesia induction than

children with an "easy" temperament and whose parents

demonstrated distraction, reassurance, or information

provision during the pre-operative clinic visit.
















CHAPTER II
METHODS

Subjects
Sixty children between the ages of 4- and 10-years-old

being seen at the Ear, Nose, Throat Outpatient Clinic at

Shands Teaching Hospital, J. Hillis Miller Health Center,

Gainesville, Florida for a scheduled preoperative

evaluation along with their mothers served as subjects.

Shands is a tertiary care hospital, and clinic patients are

usually referred from local pediatricians or general

practitioners. Children included in the study were

admitted for surgery usually one to two days following

their visit to the Ear, Nose, Throat Clinic. All subjects

in this study had elective surgery. Additional

characteristics of the sample will be discussed in some

detail in the Results section.

Measures
Background Information Interview Form (BIIF) (Appendix A)

This questionnaire provided data on factors that may

influence the child and parent's behavior in the medical

situation. Information obtained from this short,

structured interview form included age, sex and race of the

child. Brain and McClay (1968) found age to be an









28
influencing factor with regard to the child's response to

medical procedures. The parents also used a four-point

scale to indicate how their child had reacted to previous

medical experiences and how well they expected their child

to react to the hospitalization experience. Research has

demonstrated the importance of taking into consideration

the child's previous experiences (Melamed, Meyer, Gee &

Soule, 1976). Therefore, the experimental interviewer

ascertained the subjects' previous surgical experience.

Parent Temperament Questionnaire (PTQ)

The PTQ is a 72 item questionnaire developed by Thomas

and Chess (1977). The questions relate to a range of child

behaviors reflective of the nine temperament dimensions

discussed earlier with eight items pertaining to each

dimension. The parent is asked to rate each item on a

seven point scale (1=hardly ever occurs; 7=almost always

occurs). A mean score ranging from one to seven is

determined for each dimension. Five of these dimensions of

temperament including Mood, Adaptation,

Approach/Withdrawal, Intensity and Biological Rhythmicity

are used to calculate a child's standing on a continuous

scale of difficult-easy temperament.

Difficult temperament children were defined using

Thomas and Chess's (1982) specifications, i.e. negative

mood, slow adaptability to change, tendency to withdraw









29
from new situations, tendencies towards intense

expressiveness and irregularity of biological functions.

Katz-Newman and Johnson (1986) reported that both the

overall temperament score and the individual sub-scale

scores obtained on the Parent Temperament Questionnaire

showed adequate test-retest reliability over a two-week

period. Reliability for the overall score was .78. With

regard to the scales which comprised the "Easy"/"Difficult"

continuum Katz-Newman and Johnson (1986) reported the

following reliability coefficients: adaptability .73,

approach/withdrawal .92, intensity .64, mood .80, and

biological rhythmicity .64. Regarding the validity of the

measure, it can be noted that there is evidence from a

number of studies to indicate significant relationships

between ratings of difficult temperament via this measure

and later behavioral difficulties (Graham, Rutter & George,

1973; Maurer, Cadoret & Cain, 1980; Rutter, Birch, Thomas &

Chess, 1964; Thomas et al., 1968).

Dyadic Prestressor Interaction Scale (DPIS)

The DPIS was used to rate videotaped mother-child

interactions in the examination room prior to the beginning

of the physical examination. Observers rated the tapes

using the instantaneous scan method (Altmann, 1974) every

five seconds, to determine whether a behavior was occurring

at that moment.








30
This DPIS was constructed on the basis of related

literature and extensive narrative descriptive clinic

observations (Bush, 1982). The child categories on this

scale were chosen because of their theoretical relevance to

the attachment literature (Bretherton & Ainsworth, 1974)

and because recent studies (Arend, Gove, & Sroufe, 1979;

Sroufe, Fox, & Pancake, 1983) suggest that a continuity of

the quality of early mother-child interactions exists with

regard to older children's competence in problem solving.

The parent categories on the DPIS were selected based on

the empirical literature on parents' child management

styles as they relate to children's fear development and

independence (Bush, Melamed, Sheras & Greenbaum, 1986).

This scale consisted of four classes of functionally

similar child behaviors and six parent behaviors.

Within each class four specific behaviors were defined.

The child categories included attachment, distress,

exploration and social behavior. The parent categories

corresponded to dimensions of parent behavior which

previous research had found to be related to the child's

adjustment in the medical setting. The categories included

information provision, reassurance, ignoring, distraction,

agitation and restraint. Bush et al. (1986) established

the reliability for the DPIS in a stressful medical

situation. Inter-observer reliability for eight of the ten

behavior categories was above .90 with only distress (.77)









31

and restraint (.60) falling outside of this range. The

results of the Abeles (1984) study, which showed that those

parents who demonstrated informing in response to child

attachment had children who were less distressed in the

medical setting, support the importance of looking at

observational data on specific interactions between parents

and their children, as measured by the DPIS, in predicting

children's reactions to medical procedures.

For the purposes of the present investigation, inter-

rater reliability of the DPIS was assessed by comparing the

ratings made by two independent observers. In order to

estimate the reliability of these ratings, a Pearson

correlation coefficient was calculated for each DPIS

behavior for half (30 subjects) of the sample.

Operating Room Behavior Rating Scale--Revised (ORBRS-R)
(Appendix B)

This scale was developed by Lumley and Melamed (1986)

and was adapted from Meyer and Muravchick's (1977) measure

of the extent of cooperation with anesthesia induction

procedures. It consists of a checklist of disruptive

behaviors and a seven point cooperation scale (l=total

uncooperation; 7=total cooperation) across the three phases

of anesthesia induction. Phase one consisted of that time

period from the child's separation from the mother and

entry into the operating room until the child was

transferred to the operating room table; phase two included

that time from when the child was transferred to the










operating room table until the mask or needle was viewed by

the child; and phase three included that time from when the

child viewed the mask or needle, until complete anesthesia

induction.

At the completion of anesthesia induction,

anesthesiologists were asked to rate children's level of

cooperation on a seven point scale (1=total uncooperation;

7=total cooperation).

In the present study inter-rater reliability of ORBRS-R

was assessed by the ratings made by two independent

observers. In order to estimate the reliability of these

ratings, a Pearson correlation coefficient was calculated

for approximately 20% of the sample.

Heart Rate

Children's heart rate levels were recorded during

phases two and three of anesthesia induction. Heart rate

data were considered relevant to this study, as

accelerations in heart rate have been found to be

significantly associated with increased levels of fear

(Andreassi, 1980). After the child was placed on the

operating room table (phase 2), electrodes were attached to

the child which electronically monitored his or her heart

rate. Observers manually recorded initial heart rate and

changes in heart rate during the anesthesia induction

process. Due to the varied number of recordings during

each phase of anesthesia induction, mean heart rate levels











were computed for each phase. This was completed by

averaging the first, middle and final recording within each

phase of anesthesia induction..

Procedure

Subjects were initially approached in the clinic's

general waiting area by one of the experimenters. The

mothers and their children were asked to participate in a

study seeking to investigate how people handle coming to

the hospital. Informed consent was obtained from all

subjects. Approximately 95% of the mothers asked to

participate in this study agreed to do so.

At this time mothers were interviewed using the

structured format provided by the Background Information

Interview Form (BIIF) and completed the Parent Temperament

Questionnaire (PTQ). After this interview, children and

their mothers were sent to laboratory for a venipuncture as

part of the routine preoperative evaluation. After

returning from the laboratory, the child and the parent

were escorted to a clinic examination room where they were

to see a physician for the preoperative examination. A

videotape recording was made of the waiting period before

the doctor entered the examination room. These videotapes

were rated by observers using the Dyadic Prestressor

Interaction Scale (DPIS).

On the day of surgery, an observer met the child and

parent in the preoperative waiting room. After a time








34

period varying from 10 minutes to 1 hour the child was

taken to the operating room by the anesthesiologist. While

the child was in the operating room the mother usually

waited to be called by hospital staff in one of several

waiting rooms. The observer used the Operating Room

Behavior Rating Scale--Revised (ORBRS--R) to rate the

number of distress behaviors and level of cooperation

during the various phases of the anesthesia induction

procedure. Children's heart rate was recorded as soon as

the electrodes were attached. After anesthesia induction

was completed, anesthesiologists were asked to rate the

children's level of cooperation with the induction

procedure.

In order to address the major hypotheses of the study

several approaches to data analyses were taken. Initial

analyses involved computing means and standard deviations

for all measures used in this study. This was followed by

multiple regression analyses designed to examine both the

direct and interaction relationships between temperament,

parenting behaviors, and children's responses to anesthesia

induction as well as the combined effects of temperament

and parent variables.















CHAPTER III
RESULTS

This section will be organized as follows: first,

demographic information will be presented; then preliminary

data on measures will be presented; finally, data regarding

tests of hypotheses will be considered.

Demographic and Questionnaire Measures

Table 3-1 presents the demographic characteristics of

the sample of 60 mother-child dyads used in the data

analyses. As can be seen the sample was reasonably balanced

with respect to both age and sex. More than one half (55%)

of the children had some type of previous surgical

experience involving general anesthesia.

Means and standard deviations for subjects on all

questionnaire measures are presented in Appendix C. On the

Parent Temperament Questionnaire (PTQ) mothers used a seven

point scale to rate their children across nine dimensions

of temperament. As a group, the subjects were rated as

having an overall moderate temperament (M=4.77, SD=.57,

range=3.43-6.01). With regard to the specific dimensions

of temperament, mothers rated their children as having a

moderately positive mood (M=5.06, SD=.89, range=l.88-6.63)

and moderate levels of adaptability (M=5.16, SD=.96,

range=l.75-6.88). Mothers also rated their children as

35

















Table 3-1
Demographic Characteristics


Age years


4 5 6 7 8 9 10

7 11 12 10 8 11 1


Males (N)

36


Sex


Females (N)

24


(N)
Previous Surgical
Experience








Laser of
Papilloma


(N)


Experience (N)


Removal or
Insertion
of Tubes

(N)


No Experience


Tonsillectomy
and/or
Adenoidectomy

(N)


Surgical
Procedure


14 15


Other

(N)








37

being about moderate in terms of biological rhythmicity

(M=4.58, SD=.94, range=2.50-7.50), tendency to approach new

stimuli (M=4.60, SD=1.13, range=1.38-6.71) and low to

moderate in intensity of reactions (M=3.70, SD=1.00,

range=1.88-5.88).

The DPIS was used to rate videotaped mother-child

interactions. A time-date generator was used to

superimpose an elapsed-time digital clock onto the tapes

without obscuring the visibility of subjects. Observers

then used this clock to make instantaneous scan ratings

(Altmann, 1974) of the 10 DPIS categories every 5 seconds.

Every 5 seconds, observers rated whether each of the 10

behavior classes was being engaged in at that moment. The

5-second interval was chosen as it has been used

successfully in previous studies (Bush, Melamed, Sheras, &

Greenbaum, 1986; Abeles, 1984) and because this interval

minimized the frequency of scorable behaviors occurring but

not being scored due to onset and offset between

scanpoints. It is important to realize that each parent

behavior and each child behavior are rated independently;

therefore collectively, the DPIS behaviors will not sum to

100%.

During the waiting period before the physician entered

the examination room, children were observed engaged in

social behaviors 51.33% of the time (range=0-100).

Attachment behaviors were the next most frequently










occurring at 36.02% of the time (range=1.8-100) Children

engaged in exploration 25.84% of the time (range=0-100) and

exhibited distress 19.11% (range=0-90.6) of the time.

Among the parent behaviors, distraction was the most

frequently occurring at 40.02% of the time (range=0-100).

Information provision was the next most frequently

occurring behavior at 21.08% of the time (range=0-97.30)

followed by reassurance at 14.97% (range=0-100). Mothers

were observed ignoring their children at an average of

13.27% of the time (range=0-75.60). Maternal agitation was

observed 7.68% of the time (range=0-60.00). Restraint was

the least frequently observed behavior occurring at 3.70%

of the time (range=0-33.90). These findings are similar to

those found by Bush et al. (1986).

Videotaped recordings of the mother-child interactions

ranged in length from 5 to 10 minutes. Correlational

analyses of the relationship of length of recording to

percent of each behavior displayed revealed that a higher

percentage of child attachment behaviors were displayed

when the recording period was shorter (r=-.27, p<.04), and

a higher percentage of maternal ignoring behaviors were

displayed when the recording period was longer (r=.39,

p<.003). No significant relationships were found between

the other DPIS behaviors and the length of the videotape

recording.










On the Operating Room Behavior Rating Scale-Revised

(ORBRS-R) the mean number of distress behaviors displayed

by children during entry into the operating room until

transfer to the operating room table (phase 1) was .66

(range=0-5, SD=1.09) Cooperation during this phase was

rated at a mean level of 6.05 (1=total uncooperation,

7=total cooperation) (range=l-7, SD=1.42) From the time

the child was transferred to the operating table until the

child viewed the mask or needle (phase 2) children

exhibited an average of 1.68 distress behaviors (range=0-6,

SD=1.5). The mean level of cooperation during phase 2 was

rated as 6.00 (range=2-7, SD=1.31). In the final phase of

anesthesia induction (phase 3--view of the mask or needle

until complete anesthesia induction) children displayed an

average of 2.22 distress behaviors (range=0-9, SD=2.39) and

were rated as having a mean cooperation level of 5.22

(range=1-7, SD=2.05). Anesthesiologists rated 44 children

as having a mean cooperation level of 5.55 (range=l-7,

SD=2.02) during the complete course of induction.

Reliability of Observational Measures

DPIS. Interobserver reliability of the DPIS was

evaluated by comparing the percentages of behaviors rated

as being present by two independent observers. DPIS

ratings were made by two raters on 50% of the dyads,

Pearson product moment correlations were obtained for the

DPIS and are presented in Table 3-2. A correlation









40







Table 3-2
DPIS Inter-Rater Reliability
Pearson Product Coefficients





Attachment .94

Distress .66

Exploration .75

Social .94

Ignoring .98

Reassuring .52

Distraction .83

Restraint .50

Informing .74

Agitation .89










coefficient was computed for each DPIS category. These

coefficients provided estimates of the reliability of the

DPIS total frequency scores within each DPIS category.

The DPIS was found to have adequate to high reliability

for observational measurement of mother-child interactions.

Good concordance was found for all categories except

distress, reassurance and restraint. Bush et al. (1986)

attributes the low reliability coefficient for restraint to

be due to the observed incidence and short duration of

restraining behaviors during videotaping.

ORBRS-R. Interobserver reliability of the ORBRS-R was

evaluated by comparing the number of distress behaviors and

level of cooperation as rated by two independent observers.

Pearson product moment correlations were obtained for the

ORBRS-R and are presented in Table 3-3. The distress

behavior scores and cooperation ratings showed adequate

interobserver reliability for all phases of anesthesia

induction.

DPIS Intercorrelations

Intercorrelations among parent behaviors. Correlation

coefficients between parent behaviors are presented in

Table 3-4. Parental ignoring was significantly related to

distracting, informing, and agitation. Ignoring is defined

so as to be the only behavior on the DPIS not able to co-

occur in any one interval with parental reassurance,

distraction, restraint or informing; however, ignoring can

















Table 3-3
ORBRS-R Inter-Rater Reliability
Pearson Product Coefficients





Phase 1 Distress Behaviors 1.00

Phase 1 Cooperation Level .73

Phase 2 Distress Behaviors .80

Phase 2 Cooperation Level .73

Phase 3 Distress Behaviors .98

Phase 3 Cooperation Level .72

















Table 3-4
Intercorrelations Among DPIS Parent Behavior Categories



Ignore Reassure Distract Restrain Inform


Ignore

Reassure -.05

Distract -.41* -.05

Restrain -.03 -.01 -.11

Inform -.37* -.01 -.46** .00

Agitation .39* .01 -.24 .00 -.11


* p < .005
** p < .0005










co-occur with agitation. Consistent with the operational

definitions of behaviors included on the DPIS, ignoring was

found to be inversely correlated with distraction and

informing, and positively related to parental agitation.

Parental distraction was found to be inversely correlated

with parental informing. This finding is reflective of the

definitions of distraction and informing. Distraction is

defined as engaging in play or conversation which is

unrelated to medicine, and informing is defined as the

parent giving information, exploring and answering

questions which are medically relevant. These findings

are consistent with previous research findings (Bush, et

al. 1986; Abeles, 1984).

Intercorrelations among child behaviors. Correlation

coefficients between child behaviors are presented in Table

3-5. In general, child behaviors were related to one

another. Social/affiliative behavior was found to be

inversely correlated with attachment, distress and

exploratory behaviors. Child attachment was positively

correlated with distress behavior. These results while not

discrepant with previous findings are somewhat different in

that Bush et al. (1986) report no relationships between

social/affiliative behavior and the other child behavior

categories.

















Table 3-5
Intercorrelations Among DPIS Child Behavior Categories




Attachment Distress Exploration

Attachment

Distress .33*

Exploration .16 .08

Social -.31** -.59*** -.72***





*p < .01

**p < .05

***p < .0001










ORBRS-R and Heart Rate Intercorrelations

Correlation coefficients between child distress

behaviors, ratings of cooperation and heart rate are

presented in Table 3-6. Amount of distress behavior was

related to ratings of cooperation and to children's heart

rate. Children who demonstrated many distress behaviors

were rated as less cooperative by observers and their

anesthesiologists across the three phases of anesthesia

induction. Ratings of cooperation by independent observers

and anesthesiologists were strongly positively correlated

especially in the third phase of anesthesia induction.

Analyses of physiological data indicated a positive

relationship between children's heart rate across phases of

anesthesia induction. Additionally, children who had a

high heart rate during the final phase of induction tended

to display more distress behaviors and were rated as less

cooperative by observers and anesthesiologists.

Tests of Hypotheses

Initial analyses were conducted to examine the

relationships between children's temperament

characteristics and their behavior as assessed by the DPIS

during the pre-operative visit to the clinic. No

significant relationship was found between children's

status on the overall composite measure of easy-difficult

temperament and their distress during the pre-operative

visit. When separate dimensions of temperament were









47







Table 3-6
Intercorrelations Among ORBRS-R Ratings


DST1 COOP1 DST2 COOP2 HR2


DST3 COOP3


-.49


.36*


-.37*


-.32 .86*

.24 -.26

.22 -.11


COOP39 -.16


-.53*


.16 -.14


.37*


.47* -.39*


-.31*

.68*


.09 -.07


-.03


.16 -.27 .63 .42*


.36** -.32** .62*


distress behaviors phase 1
cooperation ratings phase 1
Distress behaviors phase 2
cooperation ratings phase 2
heart rate levels phase 2
distress behaviors phase 3
cooperation ratings phase 3
"heart rate levels phase 3
'anesthesiologist ratings


-.14 -.71


DST1a

COOP1b

DST2c

COOP2d

HR2 e

DST3f


HR3


HR3h

ANES'


-.08


-.75


-.48


.87*


-.43*


**p<.01
p<.05








48

considered, contrary to predictions, children's tendency to

approach new stimuli was associated with higher rates of

distress behavior during the clinic visit (r=.27, p<.03)

No significant relationships between any of the other

dimensions of temperament and children's behavior in the

clinic were obtained.

Relationships Between Temperament, Maternal Characteristics

and Children's Behavior During Anesthesia Induction

Multiple regression analyses were completed in order to

examine any main and interaction effects between children's

temperament, maternal specific characteristics as assessed

by the DPIS, and children's behavior during the three

phases of anesthesia induction. Because previous

experience with medical procedures and the age of the child

have been found to be influencing factors with regard to

children's responses' to medical procedures (Melamed,

Meyer, Gee and Soule, 1976; Brain and McClay, 1968), the

multiple regression analyses also included these variables.

The overall easy-difficult temperament score comprised of

the five sub-scales of temperament, (mood, adaptability,

approach/withdrawal, biological rhythmicity and intensity)

and the individual sub-scale scores of approach/withdrawal

and adaptability were used in these analyses. DPIS

parenting variables were entered separately in each of the

analyses. Results of those analyses yielded a number of










significant findings and are presented in the following

sections.

Phase 1 of Anesthesia Induction

Direct relationships between children's temperament and

outcome measures

Multiple regression analyses of phase 1 data revealed

no significant findings regarding the overall temperament

score or adaptability sub-scale score. Significant

findings, however, were obtained when the

approach/withdrawal temperament dimension was used in the

equation.

Influence of child temperament on children's distress

levels. The multiple regression model which included the

variables of age, previous experience, children's tendency

to approach or withdraw from new stimuli, maternal

information provision, and an interaction of

approach/withdrawal and information provision as predicting

the number of distress behaviors displayed by children upon

entry into the operating room, was significant [F(5,49) =

2.40, p<.05]. Together these variables achieved a multiple

R of .44 accounting for approximately 20% of the variance.

When controlling for the other variables entered into the

equation, children's tendency to approach new stimuli was

negatively associated with the number of distress behaviors

displayed (F=4.33, p<.04). Children who were described by










their mothers as withdrawing from new stimuli tended to

display more distress behaviors.

No significant findings were obtained regarding the

interaction of approach withdrawal and maternal information

provision in predicting the number of distress behaviors

displayed by children during the first phase of anesthesia

induction.

Influence of child temperament upon children's

cooperation levels. The multiple regression model which

included the variables of children's tendency to approach

or withdraw from new stimuli, maternal information

provision and an interaction of approach/withdrawal and

information as predicting children's cooperation levels

during the first phase of anesthesia induction was

significant [F(3,51) = 3.13, p<.03]. Together these

variables achieved a multiple R of .39 which accounted for

approximately 15% of the variance. When controlling for

the other variables entered into the equation, children's

tendency to withdraw from new stimuli was positively

associated with ratings of cooperation (F=6.29, p<.02).

Children who were rated as withdrawing from new stimuli

were rated as less cooperative by observers during the

first phase of anesthesia induction.

No significant findings were obtained regarding the

interaction of approach/withdrawal and information








51

provision as predicting children's cooperation levels

during the first phase of anesthesia induction.

Direct relationships between maternal behaviors and outcome

measures

Multiple regression analyses revealed no significant

main effect findings regarding maternal ignoring,

reassurance, restraint, information provision or agitation.

Significant findings were obtained, however, when maternal

distraction was used in the equation.

The multiple regression model which included the

variables of age, previous experience, children's tendency

to approach or withdraw from new stimuli, maternal rates of

distraction and the interaction of approach/withdrawal and

distraction as predicting the number of distress behaviors

displayed by children during the first phase of anesthesia

induction was significant [F (5,49)=4.09, p<.004].

Together these variables achieved a multiple R of .54

accounting for approximately 29% of the variance. When the

other variables in the equation were controlled for,

maternal distraction was positively associated with the

number of distress behaviors [F=8.65. p<.005]. High levels

of maternal distraction were associated with a high number

of distress behaviors during the first phase of anesthesia

induction. Additionally, the interaction of the

temperament characteristic approach/withdrawal and maternal

distraction was a significant predictor of distress









52
behaviors (F=5.88, p<.02). Figure 3-1 demonstrates the

nature of the interaction. Children who tended to withdraw

from new stimuli and whose mothers provided distraction at

low levels displayed fewer distress behaviors during phase

1 of anesthesia induction than did those withdrawing

children whose mothers provided distraction at higher

levels. Children who tended to approach new stimuli,

however, appeared not to be affected by different levels of

parental distraction. Overall, temperamentally withdrawing

children of parents who provided high levels of distraction

displayed the most number of distress behaviors, while

children who tended to approach new stimuli were unaffected

by different levels of parental distraction during phase 1

of anesthesia induction.

Phase 2 of Anesthesia Induction

Multiple regression analyses revealed no significant

findings regarding temperament or maternal behaviors as

predicting children's distress behavior, cooperation

ratings or heart rate levels during the second phase of

anesthesia induction.

Phase 3 of Anesthesia Induction

Direct relationships between children's temperament and

outcome measures

Multiple regression analyses revealed no significant

findings regarding the overall temperament score,

approach/withdrawal or adaptability sub-scale scores as






























0 2 4 6 8
Withdrawal Approach

-a- Hi Distraction
-- Avg Distraction
Low Distraction


Regression Lines Indicating the Rela-
tionship Between Children's Tendency
Towards Approach/Withdrawal and Mater-
nal Use of Distraction as Predicting
Number of Distress Behaviors.


Figure 3-1








54

predicting children's distress behaviors, cooperation

ratings or heart rate levels during the third phase of

anesthesia induction.

Relationships between maternal behavior and outcome

measures

Multiple regression analyses of phase 3 anesthesia

induction data revealed no significant findings regarding

the DPIS parent category of information provision.

Significant findings were obtained however, when the parent

behaviors of distraction, ignoring, reassurance, agitation

and restraint were entered into the models.

Influence of maternal distraction on children's

distress levels. The multiple regression model which

included the variables of age, previous experience, the

approach/withdrawal temperament dimension, maternal use of

distraction and an interaction of approach/withdrawal and

distraction as predicting the number of distress behaviors

displayed by children during the third phase of anesthesia

induction was significant [F (5,52)=2.39, p<.05]. Together

these variables achieved a multiple R of .43 accounting for

approximately 19% of the variance. Controlling for the

other variables entered into the equation, maternal

distraction was negatively associated with the number of

distress behaviors displayed by children (F=5.70, p<.02).

Less use of maternal distraction was associated with an

increased number of distress behaviors displayed by










children during the third phase of anesthesia induction.

Additionally, the interaction term of approach/withdrawal

and maternal distraction was a significant predictor of

children's distress behaviors (F=5.42, p<.02). As shown in

Figure 3-2, children who tended to withdraw from new

stimuli and whose mothers provided high rates of

distraction demonstrated fewer number of distress behaviors

than did the withdrawing child whose mother provided little

distraction. Average and low rates of maternal distraction

with the child who tended to approach new stimuli were

associated with a lowered number of distress behaviors, as

compared to the approaching child whose mother provided

high levels of distraction. Overall, withdrawing children

who had highly distracting mothers displayed the fewest

number of distress behaviors, while those children who

tended to approach stimuli and who had highly distracting

mothers displayed the highest number of distress behaviors.

Influence of maternal and child variables on heart rate

levels

Maternal ignoring and child temperament. The multiple

regression model which included the variables of age,

previous experience, overall temperament, maternal ignoring

and an interaction of temperament and ignoring variables as

predicting children's heart rate levels during the third

phase of anesthesia induction was significant [F

(5,40)=3.19, p<.02]. Together these variables achieved a











6-


5-




3



2-






0 2 4 6 8
Withdrawal Approach

-a- Low Distraction
-0- Hi Distraction
-W Avg Distraction


Regression Lines Indicating the Rela-
tionship Between Children's Tendency
Towards Approach/Withdrawal and Mater-
nal Use of Distraction as Predicting
Number of Distress Behaviors.


Figure 3-2








57

multiple R of .53 accounting for approximately 28% of the

variance. Maternal ignoring, when controlling for the

other variables entered into the equation, was negatively

associated with heart rate levels (F=6.29, p<.02). That

is, more ignoring was associated with lower heart rates.

Additionally, the interaction of maternal ignoring with

child temperament was significant (F=6.58, p<.01). As

shown on Figure 3-3, difficult temperament children whose

mothers showed a high degree of ignoring had lower heart

rates than did those difficult children whose mothers did

not ignore them. Easy temperament children whose mothers

did not ignore them had lower heart rates than those

children with easy temperaments whose mothers who ignored

them at high rates. Overall temperamentally difficult

children whose mothers ignored them at high levels had the

lowest heart rates, while temperamentally easy children

whose parents ignored them at high rates had the highest

heart rates.

Similar findings emerged when the temperament variable

approach/withdrawal was entered into the equation. The

multiple regression equation which included the variables

of age, previous experience, the approach/withdrawal

temperament characteristic, maternal ignoring and the

interaction of approach/withdrawal and ignoring as

predicting children's heart rate levels was significant [F

(5,40)=2.92, p<.02]. Together these variables achieved a











200-






(o

0 100-









0 | | |
0 2 4 6 8
Difficult Easy

-e- Low Ignoring
-+- Avg Ignoring
U Hi Ignoring


Regression Lines Indicating the Rela-
tionship Between Children's Tempera-
ment and Maternal Ignoring as Predict-
ing Heart Rate Levels.


Figure 3-3










multiple R of .52 accounting for approximately 27% of the

variance. Maternal ignoring, when controlling for the

other variables entered into equation, was negatively

associated with heart rate levels (F=4.14, p<.05). That

is, lowered rates of maternal ignoring were associated with

higher heart rates. Additionally, the interaction of the

approach/withdrawal temperament characteristic and maternal

ignoring was a significant predictor of heart rate levels

(F=4.58, p<.04). Figure 3-4 demonstrates the relationship

between heart rate levels and approach/withdrawal

characteristics at different levels of maternal ignoring.

Withdrawing children whose mothers ignored them at high

rates had lower heart rates than did those withdrawing

children whose mothers did not tend to ignore them. Those

children who tended to approach new stimuli and whose

mothers did not ignore them tended to have lower heart

rates than those withdrawing children whose mothers ignored

them at high rates. Overall, those children who tended to

withdraw from new stimuli and whose mothers tended to

ignore them at high rates had the lowest heart rates, while

those children who tended to approach new stimuli and whose

mothers tended to ignore at high rates had the highest

heart rates.

Maternal reassurance and child temperament. The

multiple regression model which the variables of age,

previous experience, overall temperament, maternal









60

160-


2 140-


2 120-


= 100-


80-


60 1 1 i
0 2 4 6 8
Withdrawal Approach

-.- Low Ignoring
-*- Avg Ignoring
-- High Ignoring



Regression Lines Indicating the Rela-
tionship Between Children's tendency
Towards Approach/Withdrawal and Mater-
nal Ignoring as Predicting Heart Rate
Levels.


Figure 3-4










reassurance and the interaction variable of temperament and

reassurance as predicting children's heart rate levels was

significant [F (5,40)=3.16, p<.02]. Together these

variables achieved a multiple R of .53 accounting for

approximately 28% of the variance. When the other

variables in the equation were controlled for, reassurance

was positively associated with heart rate levels (F=4.98,

p<.03). High levels of reassurance were associated with

high heart rate levels. Additionally, the interaction term

of temperament and reassurance significantly predicted

heart rate levels (F=4.36, p<.04). Figure 3-5 graphically

represents the nature of this interaction. Difficult

temperament children whose parents did not provide

reassurance had lower heart rates than did those difficult

children whose parents provided high amounts of

reassurance. Easy temperament children whose parents

provided high amounts of reassurance had lower heart rates

than did those easy children whose parents provided low

amounts of reassurance. Overall, the difficult temperament

child whose mother did not provide reassurance had the

lowest heart rate while the easy temperament child whose

mother provided low amounts of reassurance had the highest

heart rate.

Maternal restraint and child temperament. The

multiple regression model which included the variables of

age, previous experience, overall temperament, maternal









62


160-


) 140-


120-

(, 100-


S80-




40 ---
0 2 4 6 8
Difficult Easy

-0- Hi Reassurance
4- Avg Reassurance
+- Low Reassurance



Regression Lines Indicating the Rela-
tionship Between Children's Tempera-
ment and Reassurance as Predicting
Heart Rate Levels.


Figure 3-5










restraint and the interaction variable of overall

temperament and maternal restraint as predicting children's

heart rate levels was significant [F (5,40)=2.53, p<.04].

Together these variables achieved a multiple R of .49

accounting for approximately 24% of the variance. When the

other variables in the equation were controlled for,

maternal restraint was negatively associated with heart

rate levels (F=3.93, p<.05). Mothers who tended not use

restraint during the preoperative visit had children who

had higher heart rates during the final phase of anesthesia

induction. Additionally, the interaction of overall

temperament and maternal restraint significantly predicted

heart rate levels (F=3.93, p<.05). Figure 3-6 represents

the nature of this interaction. Difficult temperament

children whose mothers restrained them at high levels had

lower heart rates than did those temperamentally difficult

children whose parents did not use restraint. In contrast,

easy temperament children whose parents did not tend to be

restraining had lower heart rates than did those easy

temperament children whose parents used restraint at high

levels. Overall, difficult temperament children whose

mothers tended to be highly restraining had the lowest

heart rates, while easy temperament children whose mothers

tended to be highly restraining had the highest heart

rates.












200-




CD


| 100-









0 2 4 6 8
Difficult Easy

-B- Low Restraint
-+- Avg Restraint
Hi Restraint





Regression Lines Indicating the Rela-
tionship Between Children's Tempera-
ment and Maternal Restraint as Pre-
dicting Heart Rate Levels


Figure 3-6








65

Maternal agitation and child temperament. The

multiple regression model which included the variables of

age, previous experience, overall temperament, maternal

agitation, and the interaction variable of temperament and

agitation as predicting children's heart rate levels during

the third phase of anesthesia induction was significant [F

(5,40)=2.50, p<.05]. Together these variables achieved a

multiple R of .49 which accounted for approximately 24% of

the variance. When the other variables in the equation

were controlled, maternal agitation was somewhat related to

children's heart rate levels (F=3.80, p<.06). Mothers who

were less agitated had children with higher heart rates

during the third phase of anesthesia induction. Also, the

interaction of temperament and agitation was somewhat

predictive of children's heart rates (F=3.74, p<.06).

Figure 3-7 graphs the interaction. Temperamentally

difficult children with highly agitated mothers tended to

have lower heart rates than did those difficult children

with less agitated mothers. Temperamentally easy children

with highly agitated mothers had higher heart rates than

did those easy children with less agitated mothers.

Overall, temperamentally difficult children whose mothers

were highly agitated had the lowest heart rates, while

temperamentally easy children whose mothers were highly

agitated had the highest heart rates.












200-



0












O --I I El I

0 2 4 6 8
Difficult Easy
-a- Low Agitation
-- Avg Agitation
-- Hi Agitation




Regression Lines Indicating the Rela-
tionship Between Children's Tempera-
ment and Maternal Agitation as Pre-
dicting Heart Rate Levels.


Figure 3-7















CHAPTER IV
DISCUSSION

This study explored children's adjustment to anesthesia

induction and how this is related to temperament factors.

Additionally, the relationship between maternal

characteristics and on children's behavioral adjustment to

anesthesia induction was investigated.

Temperament involves the style rather than content;

that is, the how rather than the what or why of behavior

(Plomin, 1982). Temperament is to be considered within the

context of the environment. This interactionist approach

necessitates the understanding of an individual's

temperament within the environmental situation within which

the behavior was demonstrated. Additionally, a parent's

response to a child and the parent's accompanying child-

rearing characteristics cannot be assessed without a

simultaneous consideration of the child's temperament and

their influence on the parent.

From this interactionist approach to temperament Thomas

and Chess (1977) has used the concept of "goodness of fit."

The goodness of fit model is a contextual one which

stresses that psychosocial functioning can best be

predicted when one places the individual within a specific

context. Goodness of fit is the extent to which an

67








68
individual's characteristics are congruent with the demands

of the environment. Therefore, those individuals whose

characteristics are not congruent with environmental

demands may have difficulties in adapting in various

situations (Lerner, Lerner, Windle & Hooker, 1985).

Results from this study were based on data obtained at

two different time points. Child temperament and mother-

child interaction data were collected directly prior to the

pre-operative clinic visit. One to two days later,

observers rated children's behavior during anesthesia

induction and recorded heart rate levels. Therefore, this

study does not assess the direct or interactive impact of

maternal behavior on child behaviors during anesthesia

induction. Instead, it appears that the interaction

between certain child temperament characteristics and

certain maternal characteristics, sampled during the pre-

operative assessment period, have implications for

subsequent child behaviors during the anesthesia induction

procedure in which the mother is not present.

Children's Temperament and Behavior
During Anesthesia Induction

In general, very few findings were obtained which would

indicate a direct relationship between child temperament

and their behavior during anesthesia induction. Consistent

with the existing literature, however, (Thomas & Chess,

1977) children's temperamental tendency to withdraw and

show negative emotional responses to new or novel








69
situations was associated with a higher number of distress

behaviors and being rated as less cooperative during the

introductory phase of anesthesia induction as compared to

children who show positive responses to new situations.

It is noteworthy that findings implicating a direct

relationship between temperament and behavior were found

only during the first phase of induction. Thomas and Chess

(1977) suggest that pure temperamental expression is likely

to be apparent only at those times when novel environmental

challenges render coping skills ineffective. The

temperamentally withdrawing child characteristically

demonstrates negative emotional responses to novel or

unfamiliar situations. The introductory phase of

anesthesia induction marked the beginning of such an

unfamiliar situation and it is postulated that a direct

expression of temperament would be found in this phase.

Thus, findings regarding children's negative withdrawal

responses and distress behaviors during the initial stage

of anesthesia induction would tend to support Thomas and

Chess's hypothesis.

Goodness of Fit

The paucity of findings indicating a direct

relationship between children's temperament and behavior

during anesthesia induction supports the necessity for

understanding a child's temperament within the context of

the environment (Goldsmith, Buss, Plomin, Rothbart, Thomas,









70

Chess, Hinde and McCall, 1987). Within each environmental

context there are behavioral demands. These demands may

take various forms (Lerner et al. 1985). First, the

demands may take the form of attitudes, values or

expectations held by others regarding the child's physical

or behavioral characteristics. Second, demands exist as a

consequence of the behavioral attributes of others in the

context with whom children must coordinate their behavioral

attributes for adaptive interactions to exist. And third,

the physical characteristics of a setting constitute

contextual demands (Lerner et al., 1984). Thus, from this

perspective, often termed the interactionist or "goodness

of fit model" (Lerner, 1984; Thomas, Birch, Chess and

Robbins, 1961) it is necessary to take into consideration

not only the child's characteristics but also other

individual's behaviors and the physical characteristics of

the environment.

It was hypothesized that maternal behaviors displayed

during the clinic visit would interact between children's

temperament characteristics and their behavior during

anesthesia induction. Findings from this study in fact,

indicated that maternal behaviors had relevance in

predicting children's reactions to anesthesia induction in

the context their view of children's temperament

characteristics. Some of the results included the findings

that children with a difficult temperament had higher heart









71

rate levels during the third phase of anesthesia induction

when their mothers displayed high rates of reassurance, low

rates of restraint and agitation, or did not ignore them.

For temperamentally easy children, low rates of maternal

reassurance and high rates of restraint, agitation or

ignoring were associated with higher heart rates during the

third phase of anesthesia induction.

These findings regarding difficult temperament children

may be considered counter intuitive. While the difficult

child would be expected to have difficulties in coping in

the medical setting (Thomas and Chess, 1977) previous

research has found the parental use of ignoring or

agitation to be associated with higher rates of child

distress behavior in the medical setting (Bush, Melamed,

Sheras and Greenbaum, 1986).

Maternal Patterns of Behavior

The findings from this study might be conceptualized

within a parental involvement-noninvolvement paradigm.

Here parental involvement would be seen as displaying high

rates of reassurance and low rates of agitation and

ignoring; and parental non-involvement would be defined as

displaying low rates of reassurance and high rates of

agitation and ignoring. For the easy temperament child

better outcomes during anesthesia induction were associated

with more maternal involvement; and for the difficult









72

temperament child better outcomes were associated with less

maternal involvement.

While it would be predicted that children with

components of a difficult temperament would have negative

responses in unfamiliar situations (Thomas and Chess,

1977), this was found to be true only during phase one of

anesthesia induction. No direct relationships between

temperament characteristics and behavior during phase three

of anesthesia induction were found. Thus, it becomes

necessary to consider other factors which influenced

children's behavior. As previously mentioned one

significant influence may be maternal behavior. Previous

research has examined maternal influences on children's

coping behaviors in the medical setting. Bush et al.

(1986) found that mothers who used high rates of

reassurance and infrequently ignored their children were

likely to have children who showed maladaptive responses

prior to being examined by a physician. Gutstein and

Tarnow (1983) investigated parenting behaviors as

facilitating children's preparation for elective surgery.

Parents of children between the ages of 6-9 who had a more

active style of guiding the child's activities were more

likely to interfere with the child's preparation for

surgery. The Bush et al. (1986) and Gutstein and Tarnow

(1983) studies provide data which indicate that parents do

influence children's behavior in the medical setting and,








73

moreover support a maternal involvement-noninvolvement

hypothesis. Specifically, both maternal reassurance and

infrequent ignoring (Bush et al., 1986) and active

parenting strategies (Gutstein and Tarnow, 1983) could be

conceptualized as maternal "involvement" which was

associated with less adaptive child outcomes. Results from

this study, however, indicated a significant interaction

between temperament and maternal behaviors as predicting

children's behavior during anesthesia induction. That is,

parenting behaviors led to different outcomes depending on

children's temperament. It may therefore be necessary to

examine another possible influencing factor on children's

behavior during anesthesia induction.

Situational Components

Findings from this study were based on data collected

in two different situations. Child temperament and mother-

child interaction data were collected in the outpatient

clinic, while ratings of children's behavior and recordings

of their heart rate levels were collected in the surgical

unit. One salient and important difference between these

two situations is that during the pre-operative visit

mothers were present, while during the anesthesia induction

procedure mothers were absent. Additionally, the clinic

visit contrasted with the anesthesia induction situation to

the extent that mothers were involved or not involved with

their children during the clinic visit. That is, difficult









74

temperament children of involved mothers might have been

expected to have adverse reactions to the induction

situation because of the marked contrast between the two

situations.

Typically, during anesthesia induction children do not

receive much reassurance and they are often restrained by

both nurses and physicians. Findings from this study

indicated that difficult temperament children whose mothers

did not use restraining behaviors, had higher heart rates

during the third phase of anesthesia induction. The

similarity of the preoperative visit and the anesthesia

induction situation would thus be heightened to the extent

that mothers were not involved with their children during

the preoperative visit. That is, mothers who were agitated

and displaying high rates of ignoring and restraint, and

low rates of reassurance may have served to increase the

similarity between the two situations.

Thus, for the difficult temperament child maternal

noninvolvement and maternal restraint behaviors may have

served a useful function as it resulted in increased

similarity between the two situations. In contrast,

temperamentally difficult children with involved mothers,

would have been expected to become more upset when placed

in an unfamiliar stressful situation without their mothers

(Shaw and Routh, 1982) due to the contrasting nature of the

two situations. Easy temperament children of non-involved








75

mothers might not have been adequately prepared for the

anesthesia induction situation. Previous research

(Melamed & Siegel, 1975) has demonstrated that preparing

children for a medical procedure can reduce children's

distress. Additionally, Gutstein and Tarnow (1983) found

that parents can facilitate this preparation. The easy

temperament child might have then benefitted from pre-

induction preparation from their mothers. For these easy

temperament children tending to show approach behaviors

towards new situations, one would not predict increased

levels of distress as a function of the contrasting nature

of the two situations and the newness associated with the

anesthesia induction context.

Child Attachment and Maternal Involvement

Some of the findings from this study seemed to be

contradictory. It was found that children who tended to

withdraw from new stimuli and whose mothers provided

distraction at high frequencies, displayed more distress

behaviors during phase 1 of anesthesia induction than did

those withdrawing children whose mother provided

distraction at lower frequencies. In contrast, during

phase 3 of anesthesia induction, those withdrawing children

whose mothers provided low rates of distraction,

demonstrated a higher number of distress behaviors than did

the withdrawing child whose mother distracted at a high

level. These findings may be explained within a maternal








76

involvement-noninvolvement framework, and with an

attachment theory paradigm (Ainsworth, Blehar, Waters, &

Wall, 1978; Sroufe, 1979).

Attachment relationships are thought to have important

effects on psychosocial development (Bowlby, 1969). The

accumulated clinical evidence and research findings

strongly support the hypothesis that qualitative

differences in child-mother attachment relationships are

associated with qualitative differences in antecedent

maternal behaviors and with different behavioral outcomes

in the case of the child (Ainsworth et al. 1978). Sroufe

(1979) writes that individual children elicit different

reactions from the environment. When placed in a

challenging situation children who are secure in their

relationship with their mothers seek more assistance from

their mothers. These mothers in turn maintain a high level

a support towards their children. Ainsworth (1979) also

reports that securely attached children are likely to

become distressed during separation.

This study did not directly examine the nature of

children's attachment to their mothers, however, as in the

attachment literature, child and mother characteristics,

and the associated child behavioral outcomes were

investigated. Previous research has indicated that mother-

child relationship characteristics can be considered a








77

mediating process between a difficult temperament and later

behavior problems (Weber, Levitt & Clark, 1986).

It may be the case that those temperamentally

withdrawing children whose mothers were involved with them

and provided high amounts of distraction, were likely to

become distressed when separated from their mothers. The

first phase of anesthesia induction was immediately

preceded by a separation of the child from the mother.

With the temperamentally withdrawing child, distress

displayed during the first phase of anesthesia induction

may be thought of as distress related to the change in

situations and as a separation protest. In contrast the

easy temperament child may able to more easily adjust to

the change in situations but be anxious about the

anesthesia induction procedure and display more distress

behaviors during the third phase of anesthesia induction.

Limitations

Despite the intriguing nature of the findings presented

here, there are several limitations of the present study.

One involves parents' provision of child temperament

ratings. Bates (1980) has suggested that parental ratings

of children's temperament may represent "perceptions"

rather than accurate reflections of behavior. From this

perspective one concern would be that a parent's own

characteristics may lead to bias reports of child

temperament characteristics. Doelling (1987) and Sheeber









78

(1987) collected child temperament data provided by both

mothers and teachers. While teacher and parental reports

of child temperament were only moderately correlated,

difference scores between the two reports indicated that

parental ratings had no systematic bias. Doelling (1987)

and Sheeber (1987) conclude that reports of child

temperament are not likely to be a function of parental

perceptions and are unlikely to represent a significant

limitation to the degree that allows meaningful conclusions

to be made regarding child temperament and outcome

measures.

Another limitation concerns the qualification of

children's prior experience with medical or surgical

procedures (so as to control for prior experience to some

degree). While data was collected regarding the number and

type of previous medical procedures, information was not

collected regarding the quality of these experiences.

Melamed, Dearborn and Hermecz (1983) found that the quality

of the child's prior experience was a significant factorin

predicting children's reactions to medical stressors. In

addition to temperament and mother-child interaction

factors, future research will need to address the issue of

the quality of the child's previous medical experiences.

Finally, in the course of this study many statistical

analyses were completed. It is possible that some of these

significant statistical results were spurious. The








79

consistent pattern of the findings, however, argue to some

extent against the possibility of these results reflecting

statistical artifacts.

Conclusions

The findings from this study are based on 60 parent-

child dyads. Important individual differences were

revealed in children's behavioral and physiological

responses to anesthesia induction. Furthermore, the

mothers' role as a mediator between temperament

characteristics and children's adjustment in a medical

situation was examined.

Only a limited number of temperament factors and

maternal behaviors were directly related to children's

adjustment to anesthesia induction. Instead, temperament

variables including approach/withdrawal, and the overall

temperament score in interaction with the maternal

behaviors of ignoring, restraint, reassuring, agitation,

and distraction were the best predictors of children's

behavior during anesthesia induction. Both difficult and

easy temperament children displayed a higher number of

distress behaviors and had higher heart rates levels

depending on maternal behavior. The difficult child was

adversely affected by less ignoring, restraint and

agitation, more reassurance and varying amounts of

distraction. The easy child, in contrast was adversely

affected by high rates of ignoring, restraint and









80

agitation, less reassurance and varying amounts of

distraction. These findings support the view that maternal

behaviors cannot be judged as either "good" or "bad."

Rather it appears that a "goodness of fit" or poornesss of

fit" exists between dyads in different situations. In this

study a "goodness of fit" appeared to have existed between

difficult temperament children and non-involved mothers,

and an easy temperament child and an involved mother. A

poornesss of fit" was present when temperamentally

difficult children interacted with involved mothers, and

when easy temperament children interacted with uninvolved

mothers.

Future research will need to make several

methodological improvements. Significant relationships

were found between children's temperament and mother child

interaction sequences 1 to 2 days prior to being admitted

for surgery, as predicting children's behavior during

anesthesia induction. It is postulated that these

relationships would have greater predictive validity if

mother-child interactions were recorded on the day of

surgery on the surgical unit.

The results from this study have various implications

with regard to possible interventions. One such

intervention may involve policy changes regarding parents'

presence in the operating room. At present, parents are

generally not allowed into the operating room unless the








81

child becomes extremely upset and disruptive during the

induction procedure. Hannallah and Rosales (1983) reported

findings regarding parents' presence during anesthesia

induction in children. Those children whose parents were

present during induction were rated as having more positive

mood scores during the pre-induction and induction periods.

Additionally, no major or minor complications or side

effects were attributed to the presence of parents in the

induction area. Interestingly, the parents who were

present with their children during anesthesia induction

were self-selected. It might be beneficial for some

children to have their parents accompany them into the

operating room. Another intervention indicated by the

findings from this study involves the institution of

surgery and anesthesia induction preparation programs for

children. Those children who would seem to especially

benefit from such a program might include the difficult

temperament child with the involved mother and the easy

temperament child with the uninvolved mother. The

difficult child would have the opportunity to become

somewhat familiar with the procedures and personnel present

in the operating room, and thereby possibly avert a

negative withdrawal response; and the easy temperament

child could have some of their anxiety allayed regarding

the induction procedures.















APPENDIX A
BACKGROUND INFORMATION INTERVIEW FORM

Child's Name Subject No.
Clinic Date_
Hospital No. Interviewer
Age and sex of siblings
Date of birth Sex Race
Accompanying parent Age
Father: Occupation Education Income
Mother: Occupation Education Income

Previous Medical Experience (reason and date):
1) Surgery
2) Other Hospitalizations
3) This clinic
4) Other clinic/outpatient
5) Siblings hospitalized
6) Parent's hospitalized

How do you think your child has reacted to past medical
procedures?
1. Very poorly 2. Moderately poorly 3. Moderately well
4. Very well

How do you think your child will react to this medical
visit?
1. Very poorly 2. Moderately poorly 3. Moderately well
4. Very well

How do you rate your child's anxiety (fear nervousness) at
this moment?
1. Very high 2. Moderately high 3. Moderately low
4. Very low

How would your rate your own anxiety (fear nervousness) at
this moment?
1. Very high 2. Moderately high 3. Moderately low
4. Very low

How stressful has it been for you to deal with your child's
current health problem--the reason you are here today?
1. High stress 2. Moderately high 3. Moderately low
4. Low stress















APPENDIX B
OPERATING ROOM BEHAVIOR RATING SCALE--REVISED
(Lumley & Melamed)

Subject name: Number: Date:

Anesthesiologist: Resident: Rater:

1. Leaving the child's parent to go to the operating room
until the child is to be transferred to the operating room
table.

crying
frowning
screaming
calling for parent (or other friend or guardian)
kicking
flinging arms
body tense and stiff
attempts to leave bed or doctor (if being walked)
repetitive movements (rocking leg or arm moving back
and forth, etc.)
does not answer questions or greetings

OPERATING ROOM COOPERATION RATING SCALE

1. TOTAL UNCOOPERATION: much restraint is needed, fights
the staff, much violent movement, tries to escape.
2. protests are loud and disruptive, restraint or force is
used by staff, much motor activity.
3. protests interfere with procedure, staff delays to calm
child, compliance achieved after a short period,
moderate motor activity.
4. protests occasionally, not attending to the requests of
the staff, some body movements.
5. protests a little, slight body movements, little
responsiveness, complies when requested but needs
prompting or help.
6. is quietly responsive, complies with requests, no extra
effort at being cooperative, no protestations.
7. TOTAL COOPERATION: very helpful, acts on own when
requested, no protestations, ideal working conditions.










Subject number:

2. Transfer to the operating room table until mask or
needle is viewed by child

crying
frowning
_ screaming, vocalizing
calling for parent (or other friend or guardian)
kicking
flinging arms
body tense and stiff
attempts to leave the table
repetitive movements (rocking, leg or arm moving back
and forth, etc.)
does not answer questions or greetings
resists the physiological hook-ups

OPERATING ROOM COOPERATION RATING SCALE

1. TOTAL UNCOOPERATION: much restraint is needed, fights
the staff, much violent movement, tries to escape.
2. protests are loud and disruptive, restraint or force is
used by staff, much motor activity.
3. protests interfere with procedure, staff delays to calm
child, compliance achieved after a short period,
moderate motor activity.
4. protests occasionally, not attending to the requests of
the staff, some body movements.
5. protests a little, slight body movements, little
responsiveness, complies when requested but needs
prompting or help
6. is quietly responsive, complies with requests, no extra
effort at being cooperative, no protestations.
7. TOTAL COOPERATION: very helpful, acts on own when
requested, no protestations, ideal working conditions.










Subject number:

3. View of the mask or needle until 30 seconds (15 seconds
for I.V.) after induction begins.

___crying
frowning
_ screaming, vocalizing
calling for parent (or other friend or guardian)
___kicking
flinging arms
body tense and stiff
attempts to leave the table
repetitive movements (rocking, leg or arm moving back
and forth, etc.)
does not answer questions or greetings
turns head away from mask/pulls arm away from needle
___ pushes away mask/needle
___ pulls at physiological hook-up wires

OPERATING ROOM COOPERATION RATING SCALE

1. TOTAL UNCOOPERATION: much restraint is needed, fight
the staff, much violent movement, tries to escape.
2. protests are loud and disruptive, restraint or force is
used by staff, much motor activity.
3. protests interfere with procedure, staff delays to calm
child, compliance achieved after a short period,
moderate motor activity.
4. protests occasionally, not attending to the requests of
the staff, some body movements.
5. protests a little, slight body movements, little
responsiveness, complies when requested but needs
prompting or help.
6. is quietly responsive, complies with requests, no extra
effort at being cooperative, no protestations.
7. TOTAL COOPERATION: very helpful, acts on own when
requested, no protestations, ideal working conditions.

Cooperation rating by anesthesiologist:


1 2 3 4 5 6 7
uncooperation cooperation















APPENDIX C
SAMPLE CHARACTERISTICS: PARENT TEMPERAMENT QUESTIONNAIRE


Mood
Distractability
Persistence
Activity
Rhythimicity
Adaptability
Approach/Withdrawal
Threshold
Intensity
Difficult Temperament


M
5.06
4.54
4.18
4.09
4.58
5.16
4 .60
3.40
3.70
4.77


SD
.89
1.03
.85
.98
.94
.96
1.13
.85
1.00
.57


Range
1.88-6.63
1.57-6.38
1.71-6.00
2.25-6.25
2.50-7.50
1.75-6.88
1.38-6.71
1.38-5.57
1.88-5.88
3.43-6.01

















APPENDIX D
SIGNIFICANT MULTIPLE REGRESSION MODELS



F P

Phase 1 of Anesthesia Induction
a. Distress Behaviors
F(5,49) = 2.40, p <.05, R2 = .20

Source
Age 2.19 .15
Previous Experience .14 .71
Approach/Withdrawal 4.33 .04
Information 1.03 .31
Approach/Withdrawal X Information .21 .65

b. Cooperation Level
F(3,51) = 3.13, p <.03, R2 = .16

Source
Approach/Withdrawal 6.29 .02
Information 3.56 .06
Approach/Withdrawal X Information 2.55 .12

c. Distress Behaviors
F(5,49) = 4.09, p <.004, R2 = .29

Source
Age 1.78 .19
Previous Experience .37 .54
Approach/Withdrawal .91 .34
Distraction 8.65 .005
Approach/Withdrawal X Distraction 5.88 .02










Phase 3 of Anesthesia Induction

a. Distress Behaviors
F(5,52) = 2.39, <.05, R2 = .19

Source
Age 2.07 .16
Previous Experience 4.60 .04
Approach/Withdrawal 1.71 .20
Distraction 5.70 .02
Approach/Withdrawal X Distraction 5.42 .02

b. Heart Rate Levels
F(5,40) = 3.19, p <.02, R2 = .28

Source
Age 5.11 .03
Previous Experience 1.59 .22
Overall Temperament .15 .70
Ignoring 6.29 .02
Temperament X Ignoring 6.58 .01

c. Heart Rate Levels
F(5,40) = 2.92, p <.02, R2 = .27

Source
Age 4.90 .03
Previous Experience 1.51 .23
Approach/Withdrawal .11 .74
Ignoring 4.14 .05
Approach/Withdrawal X Ignoring 4.58 .04

d. Heart Rate Levels
F(5,40) = 3.14, p <.02, R2 = .28

Source
Age 3.31 .08
Previous Experience 1.86 .18
Overall Temperament 6.41 .02
Reassurance 4.98 .03
Temperament X Reassurance 4.36 .04

e. Heart Rate Levels
F(5,40) = 2.53, p <.04, R2 = .24

Source
Age 7.86 .008
Previous Experience 2.70 .11
Overall Temperament .28 .60
Restraint 3.93 .05
Temperament X Restraint 3.93 .05








89

f. Heart Rate Levels
F(5,40) = 2.50, p <.05, R2 = .24

Source
Age 5.23 .03
Previous Experience 2.99 .12
Overall Temperament .05 .83
Agitation 3.80 .06
Temperament X Agitation 3.74 .06














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