Behavioral Analysis of Childrens Response to Induction

of Anesthesia
Jill MacLaren Chorney, PhD*
Zeev N. Kain, MD, MBA

BACKGROUND: It is documented that children experience distress at anesthesia

induction, but little is known about the prevalence of specific behaviors exhibited
by children.
METHOD: Digital audiovisual recordings of 293 children undergoing outpatient
elective surgery were coded using Observer XT software and the validated Revised
Perioperative Child-Adult Medical Procedure Interaction Scale. Multiple pass
second-by-second data recording was used to capture childrens behaviors across
phases of anesthesia induction.
RESULTS: More than 40% of children aged 210 yr displayed some distress behavior
during induction with 17% of these children displaying significant distress and
more than 30% of children resisting anesthesiologists during induction. Childrens
distress and nondistress behaviors displayed four profiles over the course of
anesthesia induction: Acute Distress, Anticipatory Distress, Early Regulating
Behaviors, and Engagement with Procedure. Older children had higher scores on
early regulating and engagement profiles whereas younger children had higher
scores on Acute Distress. There were no differences across age in childrens
Anticipatory Distress. Construct validity of behavior profiles was supported via
correlations of profile score (overall and on the walk to the operating room) with
a validated assessment of childrens anxiety at induction.
CONCLUSIONS: Children undergoing anesthesia display a range of distress and
nondistress behaviors. A group of behaviors was identified that, when displayed
on the walk to the operating room, is associated with less distress at anesthesia
induction. These data provide the first examination of potentially regulating
behaviors of children, but more detailed sequential analysis is required to validate
specific functions of these behaviors.
(Anesth Analg 2009;109:1434 40)

t is well documented that many children report fear

and become distressed with anesthesia induction by
mask,1,2 but little is known about the way in which
this distress is expressed. Previous research has demonstrated that children show a range of distress behaviors in response to medical procedures ranging
from verbalizations of fear, to vocal protests, and
attempts to escape.3 Understanding the different types
of behavior children exhibit has important implications for identifying and managing childrens distress
From the *Department of Anesthesiology, Dalhousie University
and the Division of Pediatric Anesthesiology, IWK Health Centre,
Halifax, Nova Scotia, Canada; Department of Anesthesiology and
Perioperative Care, University of California, Irvine, California;
Department of Pediatrics, Childrens Hospital of Orange County,
Orange, California; and Department of Psychiatry, Yale University,
New Haven, Connecticut.
Accepted for publication June 12, 2009.
Supported by the National Institutes of Health/National Institute
for Child Health and Development, R01HD048935, Bethesda, MD.
Address correspondence and reprint requests to Jill MacLaren
Chorney, PhD, Centre for Pediatric Pain Research, IWK Health
Centre, 8th floor (South), 5850 University Ave., PO Box 9700,
Halifax, NS, Canada B3K 6R8. Address e-mail to jemaclaren@
gmail.com.
Copyright 2009 International Anesthesia Research Society
DOI: 10.1213/ane.0b013e3181b412cf

1434

at anesthesia induction. For example, some children may

display distress by crying but may be compliant with the
procedure, whereas others may physically or verbally
resist anesthesiologists attempts to place the mask.
Although both of these types of distress behaviors are
important, their implications and management may be
very different. In addition to the topography of distress,
little is known about childrens distress across time.
Despite the preponderance of studies that have
examined childrens distress in some way, no study
has examined childrens nondistress behavior during
anesthesia induction. In a parallel body of literature on
childrens procedural pain, attention has been devoted
to both distress and nondistress behaviors. A range of
childrens behaviors during procedural pain has been
described including nonprocedural talk, using humor,
engaging in distraction, asking medically related
questions, and seeking emotional support. Based on
theoretical and empirical data, some authors have
hierarchically grouped childrens behaviors into distress, coping, and neutral behaviors.4 Behaviors
such as nonprocedural talk, using humor, and engaging with distracting stimuli have often been termed
coping behaviors because they are indicative of
childrens attention being deployed away from the
Vol. 109, No. 5, November 2009

distressing event.4 6 Behaviors typically associated

with the procedure, such as medically related talk,
were termed neutral behaviors. Childrens behaviors termed distress included crying, verbal resistance, verbal fear, seeking information, and seeking
emotional support.7
Current scoring methodologies of childrens distress have precluded an in-depth analysis of childrens
perioperative behavior. The exact prevalences of different types of distress behaviors are unknown; there
are no strong data on how many children resist
anesthesiologists during induction or how many report fear. Furthermore, little is known about other
behaviors exhibited by children in the perioperative
process. What children do during nondistress time
points (i.e., on the walk to the operating room [OR]),
may help to identify those behaviors that would be
adaptive if used to a greater extent during stressful
timepoints.
The purpose of the current report is to use detailed behavior analytic methods to characterize
childrens behavior from a large-scale project examining adult-child interactions in the perioperative
environment. Second-to-second coding of discrete
behaviors using computerized coding technology provided data on both the topography and the proportionality of childrens behavior. In this way, the
current report examines the number of children displaying specific behaviors and the proportion of time
children spend engaging in these behaviors across
phases of anesthesia induction. A large age range of
children allowed the examination of childrens behavior profiles across age.

METHODS
Participants
Participants in this study were children with ASA
physical status I or II who were a part of the National
Institute of Health funded Behavioral InteractionsPerioperative (BIP) study. The BIP study is a largescale multi-year project assessing the main effects and
moderators of adult behaviors on childrens perioperative distress. Children recruited for the BIP study
were aged 210 yr undergoing outpatient surgery
with general anesthesia. Exclusion criteria included
children with chronic illness, children with developmental delay, and children with parents who did not
speak English. This current report includes 293 children who were part of the BIP study. Forty-eight
percent of these children were female, and most were
non-Hispanic Caucasian (85.7%). Thirty-five percent
of children had previous experience with surgery. The
most common surgical procedures were tonsillectomy
and/or adenoidectomy (n 96), followed by pressureequalizing tube placement (n 47), endoscopy (n 40),
urological procedures (n 28), hernia repairs (n 21),
and dermatological procedures (n 14).
Vol. 109, No. 5, November 2009

Measures
Yale Preoperative Anxiety Scale (mYPAS) (Child)1
This observational measure of preoperative anxiety
was developed and validated in previous investigations. The mYPAS consists of 27 items in five categories of behavior indicating anxiety in young children
(Activity, Emotional expressivity, State of arousal, and
Vocalization). Using kappa statistics, all mYPAS categories have good to excellent interobserver and intraobserver reliability (0.73 0.91), and when validated
against other global behavioral measures of anxiety,
the mYPAS had good validity (r 0.64). The mYPAS
score ranges from 22.5 to 100 with higher scores
indicating greater anxiety. Since its development, this
scale has been used in multiple investigations.8 11

Behavioral Coding System

Description of Coding System: Revised
Perioperative Child-Adult Medical Procedure
Interaction Scale (R-PCAMPIS)
The R-PCAMPIS is an observational behavioral coding system designed to capture childrens and adults
behaviors in the perioperative setting. Based on the
originally validated PCAMPIS,12 the R-PCAMPIS
includes 44 operationally defined verbal and nonverbal behavioral codes. Modifications to the original PCAMPIS were made to facilitate the interface
between the coding system and a behavioral collection
computer system, Observer XT (Noldus, The Netherlands). Codes were subdivided into 1) state codes:
those behaviors of which duration was a meaningful
metric (e.g., cry) and 2) event codes: those in which
frequency, not duration, was a meaningful metric
(e.g., verbalizing negative emotion). Event codes are
typically representative of verbalizations; in this way,
whether a verbalization of Im Scared takes 1 or 3 s
to utter is of less interest than how many times an
utterance like this is used. Although behavioral data
on all individuals in the perioperative environment
(i.e., physician, nurse, parent, and child) were collected for the BIP study, because of the extremely large
amount of data, only child codes are described in this
report. Child behaviors are listed in Table 1. Operational definitions and coding manual are available
from the authors upon request.
Training of Raters
Two bachelors level and one masters level researchers completed the behavioral coding. All coders
underwent a 3-mo training protocol under the direction of the first author (JMC). This training process
included two phases. First, coders were familiarized
with the technological coding interface, Observer XT,
via administration of a simplified set of behavioral
codes. Second, coding of study-independent training
videos was accomplished. Multiple raters coded each
training video and met, at length, with the first author
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Table 1. Descriptive Data on Childrens Display of Behaviors

Code

Type

No. displaying
behavior
(% of sample)

Cry
Scream
Nonverbal resistance
Verbal resistance
Negative verbal emotion
Request support
Information seeking
Coping statement
Positive affect
Informing status
Medical play
Nonprocedural talk
Medical talk
Humor

S
S
S
E
E
E
E
E
E
E
E
E
E
E

76 (26.0)
7 (2.1)
98 (33.6)
64 (19.6)
28 (8.6)
42 (12.9)
59 (18.1)
22 (7.5)
17 (5.2)
85 (26.1)
151 (46.3)
93 (28.5)
76 (23.3)
66 (22.6)

Median proportion of
observation behavior
was displayed (range)
18.1 (1.357.5)
7.7 (1.720.9)
13.4 (0.658.3)

Median rate of
behavior
per minute (range)a

0.50 (0.225.73)
0.32 (0.172.82)
0.34 (0.162.32)
0.34 (0.172.05)
0.29 (0.132.69)
0.26 (0.190.50)
0.31 (0.161.51)
0.47 (0.153.43)
0.55 (0.133.08)
0.30 (0.131.22)
0.33 (0.162.94)

S state (duration) behavior; E event (frequency) behavior.

a
Rate calculated as no. of seconds with observed behavior displayed/total number of seconds.

to discuss reliability statistics and disagreements. Raters were considered trained when they met a kappa
criterion of 0.80 with the first author on training tapes.
Coding Process
Administration of the R-PCAMPIS was facilitated
by using Observer XT (Noldus), a behavioranalysis software package with the capabilities to
code behaviors of one individual, or the interactions
of many. This system allows for the linking of
particular behaviors (e.g., nonverbal resistance) to
the subject who initiated the behavior (e.g., child).
In addition, the system allows each behavior coded
to be linked to the subject to whom the behavior was
directed (e.g., toward anesthesiologist). Data coding
was accomplished in passes, with each behavior
coded in a separate pass. Coding data in passes
ensured that behaviors that were not mutually exclusive (i.e., cry and nonverbal resistance) were
independently coded for duration. Real-time secondto-second data coding was used with onsets and
offsets of state behaviors and onsets of event behaviors recorded. Although this methodology is time
consuming, it ensures maximum reliability and validity of coding. Coding required approximately 4 h
per participant.
Behaviors were coded into four phases: 1) behaviors occurring from the time the child left the
holding room until they arrived at the OR door
(walk to OR), 2) behaviors occurring from the time
the child enters the OR to the time the mask is
introduced (OR entry), 3) behaviors occurring from
the time the child is notified of the mask to the time
the mask is placed and remains in place (mask
notification), and 4) behaviors occurring from the
time the mask is placed to the time the child makes
their last conscious movement (mask placement).
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Childrens Behavior During Induction

Data obtained from the R-PCAMPIS include duration of state behaviors and frequency of event
behaviors across phase.
Data Exporting and Compiling
Data were exported from Observer XT into text files
and were then imported into a computer program,
General Sequential Analysis Querier (GSEQ) for compilation. GSEQ was used to calculate summary data
on the frequency, duration, and rate of behaviors
across phases. Summary data were then imported into
SPSS 17 for further analysis (for details on analyses
conducted, see Statistical Analysis section).
Reliability Assessment
Interrater reliability of individual behavioral codes
was assessed by having two research assistants overlap on 10% of participants. Timed-event kappa coefficients were in the good-to-excellent range (range
0.771.0). Reliability assessment and discussion was a
process repeated weekly throughout coding. One reliability subject was coded per week; once kappa
values were calculated, coders met with the first
author to discuss disagreements. Decisions on valid
placement of behaviors into codes were incorporated
into the final version of the observational records.

Procedure
All procedures were approved by the Yale Human
Investigation Committee (New Haven, CT). Participants were recruited by phone between 1 wk and 1
day before surgery or on the morning of surgery.
Parents provided written informed consent, and children provided written assent as age appropriate (i.e.,
children older than 7 yr). After giving informed consent, parents completed a demographic questionnaire
and measures relevant to the larger BIP study. All
children were accompanied to the OR by one parent
and no child received any sedative premedication. A
ANESTHESIA & ANALGESIA

trained research assistant rated anxiety using the

mYPAS at the point of induction. Anesthesia was
induced in a standardized manner; upon arrival in the
OR, a Spo2 probe was placed on childs finger and a
scented anesthesia mask was presented to the child.
O2/N2O was introduced in a ratio of 3/7 L flow for 2
min, and sevoflurane was started in a concentration of
0.5% then increased every three breaths to a maximum
of 6%. All inductions were accomplished by pediatric
anesthesiologists.
A trained research assistant using a hand-held
digital video camera (Sony Handycam DCR-HC21)
videotaped all children from the time the child left the
holding area until anesthesia was induced. Digital
video files were converted to .mpg files and imported
into Observer XT software (Noldus) for coding, compiling, and analysis.

Statistical Analyses
Statistical analyses were performed in a series of
steps. First, descriptive data on the proportion of
children displaying individual behaviors are reported.
The varying length of observation was accounted for
by dividing the duration of state behaviors by total
observation time and multiplying by 100; therefore
resulting in a statistic of the proportion of observation
time during which a child displayed a particular state
code. Frequency of event codes was divided by number of seconds in the observation and multiplied by 60
to obtain a rate of code display per minute. Descriptive data on the relevant statistic for each code are
presented. Next, patterns of childrens behaviors
across phases of induction were examined using repeated measures analyses of variance for each behavior. Bonferroni corrected P values were used to control
for familywise error. Visual inspection was used to
group behaviors that showed similar phase profiles,
and a summary score for each profile was calculated
for each child (sum of rate or proportion of codes in
that profile). The relation between age and behavior
profile was examined using one-way analysis of variance to compare mean profile scores across age group
(23 yr, 4 6 yr, and 710 yr). Construct validity of
behavior profiles was examined using correlations
and hierarchical regression controlling for child age.
Data compilation and summarization were accomplished using GSEQ for Windows (Bakeman and
Quera, Atlanta, GA) and was analyzed using SPSS 17
(SPSS, Chicago, IL).

RESULTS
Overall Prevalence of Childrens Behaviors
The proportion of children displaying each behavior is shown in Table 1. The highest proportion of
children displayed engagement in medical play which
was usually indicative of children being involved in
medical play with anesthesiologists (e.g., playing astronaut with the mask). The next most common
Vol. 109, No. 5, November 2009

Figure 1. Number of distress behaviors displayed by

children.

behavior was nonverbally resisting the procedure. The

proportion of observation time spent engaging in state
behaviors and rate per minute of event behaviors are
also shown in Table 1. Children cried and resisted up
to 57.5% of the observation time. The most common
event behavior was verbal resistance, and the least
common event behavior was verbalizing positive affect about the procedure (e.g., This is cool). Notably,
there were no differences in proportions of any displayed behavior between children who had previous
experience with surgery and those who did not on any
behavior(2s range from 0.02 to 1.01, all Ps 0.05).
To better describe the prevalence of childrens
distress, childrens display of the five clear distress
behaviors (cry, scream, nonverbal resistance, verbal
resistance, and negative verbal emotion) was examined further. Forty-two percent of all children displayed at least one of the five distress behaviors (Fig.
1) and 16.7% of all children displayed significant
distress, characterized by at least three distress behaviors. Of children showing distress, the most common
display was cry, verbal resistance, and nonverbal
resistance together (23.8%), followed by nonverbal
resistance alone (17.2%), and nonverbal resistance and
cry together (16.4%). A significantly higher proportion
of 2- and 3-yr-old children showed any distress behavior than 4 6-yr-old children, 2 (1) 21.4, P 0.001,
and 710-yr-old children, 2 (1) 22.4, P 0.001.
There was no significant difference in the proportions
of 4 6- and 710-yr-old children showing distress, 2
(1) 0.36, P 0.05.

Childrens Behavior by Phase of Induction

Figures 2a d shows profiles of childrens behavior
across phase of induction. To simplify presentation,
codes demonstrating similar profiles across time are
shown in separate graphs. The first profile included
state behaviors that showed a pattern of steady increase across phase of procedure. This profile was
termed Acute Distress and included cry, scream, and
nonverbal resistance. The main effects of phase on cry
and nonverbal resistance were significant (Fs 94.3
and 72.7, respectively, P 0.001). Although the
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Figure 2. Profiles of child behavior across phase of induction. a, Acute Distress profile. b, Anticipatory Distress profile. c, Early
Regulating profile. d, Procedure Engage profile.
F-value for phase on Scream was large, it was statistically nonsignificant, likely because of the small
sample size F (1,2) 15.4, P 0.056. The second
profile included event behaviors that showed a peak
at mask notification and a sharp decrease at mask
placement. These behaviors were in two conceptual
groups: those that were termed Procedural Engagement including medical talk, informing on status,
and positive affect about the procedure and those that
were termed Anticipatory Distress including requesting support, negative verbal emotion, and verbal
resistance. Medical talk, positive affect, and verbal
resistance demonstrated significant quadratic patterns, Fquad 6.46, 6.47, and 12.22, respectively, P
0.05 for all behaviors. Quadratic trends across phase
for informing status, requesting support, and negative
verbal emotion were not statistically significant. The
final profile of behaviors included those that peaked
early in the phases, either on the walk to the OR or on
OR entry. This profile was termed Early Regulatory
Behaviors and included information seeking, nonprocedural talk, humor, and coping statements. Linear
trends were significant for information seeking and
nonprocedural talk, Fs 8.73 and 3.88, respectively,
P 0.01 for all behaviors. Results were nonsignificant
for humor and coping statements. Medical play
showed a pattern that was between Early Regulatory
and Procedural Engagement with peaks on the walk
to the OR and at mask notification. Notably, the
1438

Childrens Behavior During Induction

highest peak was on the walk, and the linear trend

was significant, F (1,109) 9.62, P 0.001, so Medical
play was deemed to be more similar to the Early
Regulatory profile.

Behavior Profiles by Child Age

Profile scores were calculated for each child by
summing the rates of codes that were found to have
significant repeated measures findings within each
profile: Early Behaviors (sum of rate of Nonprocedural
Talk and Information Seeking), Anticipatory Distress
(rate of Verbal Resistance), Engaging with Procedure
(sum of Medical Talk and Positive Affect about Procedure), and Acute Distress (sum of proportion of Cry
and Nonverbal Resistance). Results are shown in
Figure 3. Older children displayed more Early Regulating Behaviors, F (2,281) 7.8, P 0.001 and
Procedural Engagement, F (2,281) 20.08, P 0.001.
Younger children displayed more Acute Distress, F
(2,281) 17.5, P 0.001. There were no statistically
significant differences across age in Anticipatory Distress, F (2,281) 2.24, P 0.05.

Construct Validity of Behavior Profiles

Preliminary construct validity of behavior profiles
was examined by assessing the relations between
profiles and mYPAS scores, a validated measure of
childrens anxiety at induction. Correlations were in
the expected directions. Scores on the Acute and
ANESTHESIA & ANALGESIA

Figure 3. Behavior profiles by child age.

Anticipatory Distress were both significantly positively correlated with mYPAS scores, rs 0.778 and
0.453, respectively, Ps 0.001. Scores on the Early
Behavior and Procedure Engagement profiles were
significantly negatively correlated with mYPAS
scores, rs 0.218 and 0.186, respectively, Ps
0.01. Given that behavior profiles differed by age, a
hierarchical regression was conducted to control for
age. Child age was entered in Block 1 of the model,
and the four behavior profiles were entered simultaneously in Block 2. The four profiles accounted for
significant variance in mYPAS scores above and
beyond child age, r2 change 0.513, P 0.001. The
Acute and Anticipatory Distress and Early Regulatory Behaviors profiles had significant standardized
coefficients at the P 0.05 level. The standardized
coefficient for the Procedural Engagement profile
was nonsignificant.
To further explore the utility of these behavior
profiles in identifying children at risk for anxiety, we
examined the relations between behaviors exhibited
on the walk to the OR and childrens distress at
induction as assessed by the mYPAS. Similar to overall findings, there was a significant positive correlation
between Acute and Anticipatory Distress behaviors
on the walk to the OR and childrens anxiety at
anesthesia induction, rs 0.146 and 0.197, respectively, P 0.01. Childrens display of Early Regulatory Behaviors was significantly negatively correlated
with childrens anxiety at induction, r 0.123, P
0.05. There was no significant association between
Procedural Engagement on the walk and childrens
anxiety at induction.

DISCUSSION
Results of this study indicated that more than 40%
of children displayed distress during the process of
anesthesia induction. Approximately 17% of children
showed significant distress characterized by at least
Vol. 109, No. 5, November 2009

three of the following: attempts to escape the procedure, verbal protestations, crying, screaming, or verbally communicating fear or sadness. Although
younger children were significantly more likely to
display distress than older children, almost 30% of
710-yr-old children indicated distress in some way.
The most common child behavior was nonverbal
resistance (i.e., tried to push mask away), with children doing so, on average, 18.4% of the entire observation period and 42% of the time in which the mask
was placed.
Two profiles of distress behaviors were identified
in our data. One profile, termed Acute Distress, contained behaviors that increased over phases of induction, peaking at the point at which the mask was
placed. These behaviors, especially nonverbal resistance, are those that are particularly problematic as
they could interfere with the induction being accomplished in a smooth manner. Not surprisingly,
younger children were higher on these types of behaviors. The second profile of distress behaviors
termed Anticipatory Distress contained behaviors
that peaked at mask notification including verbalizations of negative emotion and attempts to delay the
procedure. It is notable that Anticipatory Distress may
be artificially low at mask placement because the mask
limits verbalizations on the part of the child. For this
reason, attending to verbal distress behaviors earlier
in the induction (i.e., at mask notification) could be a
more accurate assessment of distress in older children
than looking for crying or other Acute Distress. It is
notable that there was a significant association between these behavior profiles on the walk to the OR
and childrens distress at induction; not surprisingly
children who show distress behavior early are more
likely to be distressed later in the induction. This
finding highlights the importance of addressing childrens distress early in the induction process. Important in and of themselves, the relations between these
behaviors and clinically-relevant recovery outcomes
should be examined.
A strength of this study is its attention to a wide
range of behaviors rather than being limited to only
the evaluation of distress. A focus on family-centered
care mandates attention not only to distress but also to
families overall experience in the health care setting.13
This study identified a profile of behaviors that are
common early in the induction process (when children
are less distressed), but sharply decrease at induction.
Behaviors in this profile, including distracting nonprocedural talk, have been identified in the procedural
pain literature as coping behaviors5 and may serve a
similar function during induction. Supporting the
importance of these behaviors, a negative association
was evidenced between childrens use of Early Regulatory Behaviors and distress. Children who displayed
more of these behaviors on the walk to the OR (as well
as throughout the induction period) showed less distress at anesthesia induction. Similar to the findings of
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the Acute Distress profiles, this finding highlights the

importance of early stages of induction. Similar to the
pattern demonstrated here, previous research has
demonstrated that children typically do not engage in
coping behaviors at times of stress unless they are
prompted by adults.14 Thus, future research will
examine how to prompt these potentially regulating
behaviors in children in later phases of the indication. Interestingly, information seeking has been
included as a distress behavior in procedural pain
contexts,5 but here it showed a similar profile to
regulating behaviors. Information seeking may not
be helpful in familiar environments (such as a
pediatricians office), but may be helpful in unfamiliar perioperative environments.
The final profile of behaviors was indicative of
children engaging with the medical procedure. This
profile followed a similar pattern to Anticipatory
Distress, but was indicative of children being involved
in the induction by talking about medical topics and
telling anesthesiologists how they were doing. This
profile also contained indications that children enjoyed at least part of this process. Further research will
examine what adults do to prompt these positive
assertions from children.
Several methodological issues should be highlighted. First, few studies in the perioperative area
have examined the nature of childrens distress, and
those that do generally use one-time measures or
composite measures of childrens distress behavior.
This study examines individual child behavior and
does so across phases of anesthesia induction. Furthermore, because this study used second-by-second data
coding, we were able to gain data on how much of
each behavior children displayed, rather than simple
presence/absence. Finally, this article is the first of its
kind to examine a range of child behaviors (rather
than simply distress) in the perioperative setting.
Identifying potential desirable behaviors provides additional targets for interventions that ameliorate childrens entire perioperative experience. In terms of
limitations, it is notable that all children included in
this study had their parents present at induction and
none received sedative premedication, thus the degree
to which these findings generalize to children without
parents present or to those who have been premeditated is unknown.

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Childrens Behavior During Induction

We conclude that a clinically significant proportion

of children display distress behaviors during anesthesia induction, with younger children displaying more
Acute Distress. A profile of Early Regulatory Behaviors was identified that could serve as a coping
mechanism if children were prompted to continue
these behaviors throughout induction.
ACKNOWLEDGMENTS
The authors thank Carrie Hammell, Megan Weinberg,
and Cristina Novoa for their assistance in data coding.
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