Perioperative Care and Operating Room Management 24 (2021) 100203

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Perioperative Care and Operating Room Management

journal homepage: www.elsevier.com/locate/pcorm

Reduction of perioperative anxiety using a hand-held video game device: A

randomized study
Jeremy Teruel a, Grayson Stafford b, Jordan Brown c, Benjamin Jones d, Mark Hopkins e,
Allison Johnson f, Jessica Edenfield f, Alyssa Guo f, Christine Schammel g, *, Suzanne Renfro h,
Andrea Nisonson h
a
Medical University of South Carolina, Charleston, SC, United States
b
Auburn University, Auburn, AL, United States
c
University of North Carolina—Chapel Hill, Chapel Hill, NC, United States
d
Pediatric Psychology, Prisma Health Upstate, Greenville, SC, United States
e
Anesthesia Services, Patewood Outpatient Surgery Center, Prisma Health Upstate, Greenville, United States
f
University of South Carolina School of Medicine—Greenville, Greenville, SC, United States
g
Pathology Associates, Greenville, SC, United States
h
Department of Anesthesia, Prisma Health Upstsate, Greenville, SC, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Inadequately controlled anxiety during medical procedures is often remembered by children man­
Pediatric separation anxiety ifesting in distress, post-procedural behavior changes and overall angst. The use of distraction techniques during
Parental anxiety during pediatric outpatient medical procedures has been shown to reduce distress and overall anxiety. We sought to evaluate the anxiety of
surgery
children/parents with and without the use of a hand-held video game for distraction during transitions in the
Distraction techniques
Hand-held video game distraction
perioperative suite in a low risk outpatient pediatric surgical setting.
Methods: Children (n=108), between the ages of three and ten years undergoing low-risk outpatient surgical
procedures were randomized and evaluated for anxiety without (n=53) and with (n=55) the use of a handheld
video game in the preoperative suite. Clinical staff observed metrics associated with anxiety at three time points
up to induction. A self-reported questionnaire evaluating typical parental anxiety and their anxiety around their
child’s surgical procedure was completed by parents after separation. Post-operative behavioral changes were
queried 48 hours, 7-days and 14-days post-procedure through phone calls to parents.
Results: No significant differences in demographics or comorbidities between children that had the game for
distraction and those that did not were identified in our cohort. Only ADHD was found to be significantly
different between the randomized groups (no game; p=0.05). Overall, while not significant, a greater mean
anxiety was noted in the NG group (p=0.36); specifically, the NG group had greater mean anxiety for the sep­
aration/preoperative (p=0.05) surveys, particularly in the ‘activity’, ‘emotional expressivity’ categories. Overall,
separation was found to be significantly improved with hand held video game use; parental satisfaction was also
increased in the group in which games were used.
Conclusion: The use of hand-held games in perioperative settings are a low-cost, safe, easy to implement method
to mitigate pediatric/parental anxiety in an effort to improve overall satisfaction.

1. Introduction Inadequately controlled stress during medical procedures is often

The implications of perioperative anxiety in the pediatric population
are complex.1 In comparison to well-studied adult perioperative anxi­
ety,2 pediatric anxiety is complicated by separation from guardians and
enhanced by guardian anxiety during the preoperative period.
remembered by children and may cause changes in post-procedural
behaviour, contribute to anxiety during subsequent medical proced­
ures,3 and negatively influencing recovery.4 Post-procedural behaviours
such as agitation, crying, shivering, fighting and escape behaviour are
not eliminated by general aesthesia and the correlation with higher

* Corresponding author: Christine Schammel, Pathology Associates, 8 Memorial Medical Ct, Greenville, SC, 29605, United States.
E-mail address: Christine.schammel@prismahealth.org (C. Schammel).

https://doi.org/10.1016/j.pcorm.2021.100203
Received 20 February 2021; Received in revised form 2 July 2021; Accepted 19 July 2021
Available online 24 July 2021
2405-6030/© 2021 Elsevier Inc. All rights reserved.
J. Teruel et al.
pre-operative anxiety.5,6,7
To reduce patient anxiety, many institutions employ well supported
sedation prior to induction of anesthesia.8 However, sedation before
surgery in pediatric patients with chronic illnesses undergoing invasive
interventions has been shown to increase the risk of adverse outcomes,9
prompting minimization of pharmaceutical intervention and investiga­
tion of other methods to reduce anxiety. Methods such as play distrac­
tion, clowns, music and video games are comparable to premedication in
alleviating preoperative anxiety9,10 and reducing anxiety for subsequent
procedures, potentially acting as an alternative to medication.11,12
Since preoperative parental/guardian anxiety is a robust predictor of
child anxiety,13 distraction techniques may also calm the parent as they
observe their child’s cooperation, presuming a decrease in their child’s
anxiety. Specifically, distraction techniques such as virtual reality and
music therapy have resulted in parental self-reports of reduced worry
and anxiety during pediatric venipuncture and pre-anesthesia induc­
tion.11,14 A preoperative distraction study noted parents reported feeling
that their child was better cared for, resulting in reduced feelings of
worry, which concurrently reduced the child’s anxiety about the
procedure.14
Effective distraction techniques for pediatric patients must consider
age, developmental level, cognitive and communicative skills, previous
pain experiences, and associated beliefs.11,12 Additionally, the timing of
distraction during potentially traumatic transitions such as separation
from parents, movement to the operating suite and upon the introduc­
tion of anesthesia is essential.14
The goal of this study was to evaluate the anxiety of both children (as
observed by experienced clinical staff) and parents (self-reported) with
and without the use of an age-appropriate hand-held video game
distraction device during the three major transitions in the perioperative
suite in a low-risk outpatient pediatric surgical setting.
2. Methods
This study was approved by the Prisma Health Institutional Review
Board (IRB; eirb.healthsciencessc.org; protocol #Pro00057182) and was
registered with Clinicaltrials.gov (NCT04950088). Written informed
consent was obtained from all participants. A prospective randomized
analysis was completed at a single outpatient surgery center between
July 2016 and October 2016. The CONSORT guidelines for randomized
trials was followed (2010 checklist). Children, (ages 3–10 years) un­
dergoing low-risk outpatient surgical procedures, including, but not
limited to, tonsillectomies, adenoidectomies, etc., for which a masked
induction was planned, and their guardians were enrolled in the study.
Exclusion criteria included patients undergoing ear tube placement/
removal (due to the short duration of the procedure), patients requiring
premedication, patients with physical or mental disabilities rendering it
difficult to use the distraction device and non-English speaking care­
givers (due to the language barriers during the post-operative phone
calls). Demographic and clinicopathologic variables were collected on
each patient to include, but not be limited to, comorbidities (BMI,
ADHD, sleep apnea etc.), family/home structure (parents/guardians,
siblings etc.) and type of surgical procedure.
Randomization of hand-held video game (HHVG) use was completed
by assigning days as ‘game’ or ‘no game’. All patients were treated
identically on each day regardless of participation in the study. Staff
were notified of the status of any given day with a sign on the pre-
operative desk where patient/family access was limited.
The guardians of scheduled patients were contacted by phone prior
to the surgery date by the preassessment nurse per standard preopera­
tive protocol. Following registration, a standardized script was read
presenting the study and its goals. Guardians were queried about
possible participation. Those not interested were removed from a list of
participants; more information was given to those interested. Stickers,
red and green placed on the facesheet, delineated the groups.
Each day, a list of patients, the time of their surgical procedure and
2
Perioperative Care and Operating Room Management 24 (2021) 100203
participation status was at the check-in desk and pre-operative area for
reference by the clinical staff. Upon check in, those with green stickers
were queried regarding their desire to participate. Verification promp­
ted outlining the study again, providing a copy of the IRB approved
consent form (ICF), and answering questions/concerns. Of note was that
the study involved three calls following surgery regarding post-
operative behavior of the patient. Verification of involvement
commenced with signing the ICF, making a copy for the guardian and
attaching a folder containing the consent and anxiety surveys to the
patient chart which followed the patient throughout their stay.
The HHVG (Nintendo 2DS, Nintendo America, NY, NY) was a
handheld device with a variety of games targeted for children between
4–10. Factory installed gender neutral games that accompanied the
device were utilized for the study. The HHVG was utilized by the patient
for various lengths of time depending on the flow of work in the pre-
operative suite; however, patients/parents were escorted to the pre-
operative suite when pre-operative procedures could be initiated.
Thus, the HHVG was used by the patient for no more than 15 minutes.
Methods to quantify anxiety were chosen with the guidance and
mentorship of a board-certified pediatric psychologist. Each survey was
truncated to respect time constraints of the procedure and guardians
using previously truncated versions as guides. All truncated surveys
were evaluated for validity and modeled as reported by other studies.15
Any modifications were evaluated and approved by research psycholo­
gist familiar with using these surveys to evaluate anxiety in patients and
their families. Any questions that were included or excluded were done
so under this expertise. Final scoring of all anxiety surveys was
completed by students and consisted of adding up rankings from eval­
uating staff (mYPAS) and self-reporting parents (STAI and PHBQ).
The modified Yale Preoperative Anxiety Scale16 (mYPAS) objectively
rates pediatric anxiety by examination of patient ‘activity’ (A), ‘vocali­
zation’ (B), ‘emotion’ (C), and ‘state of arousal’(D). Qualitative de­
scriptors were ranked to allow quantification; higher anxiety correlated
to a higher score. The truncated mYPAS was completed by the nurses at
three time points-during their initial preoperative evaluation, upon pa­
tient separation from the parent/guardian and at the initiation of mask
induction. All three surveys were identical.
The Strait-Trait Anxiety Inventory (STAI)17 assessed self-reported
parental anxiety through a series of questions regarding current emo­
tions/anxiety compared to baseline. While not objective, the STAI does
not require an investigator to administer and can be completed in a
range of settings. The STAI was completed by the parent immediately
after separation in the waiting room. STAI consists of two parts: A
evaluates the parent’s perceived anxiety during the child’s perioperative
period and B evaluates the parent’s general state of anxiety. Differences
between these two metrics were used to indicate parental satisfaction
with their experience. Statements describing anxiety/calm were evalu­
ated by parents using the descriptors ‘not at all’, ‘somewhat’, ‘moder­
ately so’, and ‘very much so’ as previously published (STAI-6).17 Due to
the truncated nature of our survey, each answer was scored as follows.
For statements concerning calm or desirable feelings, ‘not at all’ was
given 1 point while ‘very much so’ was given 4 points. For statements
concerning anxiety or undesirable feelings, ‘not at all’ was given 4 points
and ‘very much so’ was given 1 point.
To evaluate overall satisfaction of parents with the pre-operative
process specifically, a final question was added to the STAI which
inquired if the parent/guardian thought that the experience of separa­
tion was better or worse than was expected. This question was scored
independently.
Post-procedural behavioral changes were evaluated using a trun­
cated and modified post-surgical parent evaluation of child anxiety
(PHBQ).18 The PHBQ queried parental evaluation of the patient‘s
behavior prior to and after the procedure. The timeline for postoperative
follow-ups using the PHBQ has been standardized; phone interviews at
48 hours, 7, 14 days post-surgery5,6,7 (PHBQ-1, -2, and -3) inquire about
new-onset negative behaviors manifesting post-surgery. Differences
J. Teruel et al. Perioperative Care and Operating Room Management 24 (2021) 100203

between the results at the different time points were indicative of Table 1
improvement/worsening behavior. Three attempts were made to gather Patient demographics.
survey information for each timepoint; if a parent could not be reached, Overall No Game Game p-value
data collection for that patient was truncated and no other attempts n=108 53 (49.07%) 55 (50.93%)
were made. Within 48 hours of the surgery, the consented guardian was
contacted for the PHBQ survey. Answers were recorded in an excel Age
spreadsheet. At the conclusion of the first phone survey, the parent was Mean 6.32 6.40 6.27 0.75
reminded that they would receive phone surveys on day seven and 14 Range 3–10 4–10 3–10
3–5 47 (43.5%) 23 (43.4%) 24 (43.6%)
post procedure. Each of the three follow-up calls were completed uti­ 6–8 41 (38%) 19 (35.85%) 22 (40%)
lizing the same protocol. 9–10 19 (17.59%) 10 (18.87%) 9 (16.4%)
The HHVG was given to the patients on ‘HHVG day’ upon arrival into Not Recorded 1 (0.93%) 1 (1.89%) 0
the pre-operative suite. As the HHVG was the property of medical center, Gender 0.40
Male 61 (56.48%) 32 (60.38%) 29 (52.7%)
the use of the game was limited to the pre-operative suite and removed
Female 47 (43.52%) 21 (39.62%) 26 (47.3%)
after induction. No other use of the HHVG was allowed. Race
Data were analyzed using Fisher’s T-tests and ANOVA where White 77 (71.3%) 41 (77.36%) 36 (65.5%)
appropriate. Where applicable (PHBQ), small sample size was consid­ Black 25 (23.15%) 11 (20.75%) 14 (25.5%)
ered in all analyses. An alpha level of 0.05 was used for all calculations. Hispanic 5 (4.63%) 2 (3.77%) 3 (5.5%)
Asian 1 (0.93%) 0 1 (1.8%)
Insurance 0.12
3. Results None 2 (1.85%) 1 (1.89%) 1 (1.8%)
Private 53 (49.07%) 30 (56.60%) 23 (41.8%)
Overall, 108 patients were enrolled in the study: 53 no game patients Government 52 (48.15%) 21 (39.62%) 31 (56.4%)
Undocumented 1 (0.93%) 1 (1.89%) 0
(NG; 49%) and 55 game patients (G; 51%). The average age was 6.32
Family Structure 0.48
years, (NG=6.4/G 6.3; Table 1; p=0.75), with 38% of the cohort be­ Mother and Father 49 (45.37%) 24 (45.28%) 25(45.5%)
tween three and five years, 38% six to eight years and 18% nine and ten Mother & Stepdad 5 (4.63%) 2 (3.77%) 3 (5.5%)
years. Males represented 56.5% of the group, female 43.5% (p=0.40). Mother only 21 (19.44%) 9 (16.98%) 12 (21.8%)
Demographically, 71% of the patients were White, 23% Black, 5% Father only 2 (1.85%) 2 (3.77%) 0
Grandparents 4 (3.7%) 1 (1.89%) 3 (5.5%)
Hispanic and 1% other (p=0.56). In terms of documented family Guardian 4 (3.7%) 1 (1.89%) 3 (5.5%)
structure, 45% of the group had a two-parent home, with 22% being Not Recorded 23 (21.3%) 14 (26.42%) 9 (16.4%)
from a single parent home (mother only or father only; Table 1); 21% did Siblings 0.98
not designate family structure. Most of the group and each cohort had 0 siblings 12 (11.11%) 7 (13.21%) 5 (9.1%)
1–2 siblings 48 (44.44%) 20 (37.74%) 28 (50.1%)
other siblings at home (1–2; 44% overall; 38% NG and 50% G; p=0.98).
3 or more 6 (5.56%) 3 (5.66%) 3 (5.5%)
Over 50% of the entire group and each cohort attended school (p=0.75). Not Recorded 42 (38.89%) 23 (43.4%) 19 (34.5%)
In evaluating the home environment, most of the patients were in Adoption 0.62
smoke-free homes (45% overall; 53% NG and 38% G; p=0.08) and did Pt adopted 3 (2.78%) 2 (3.77%) 1 (1.8%)
not have pets (22%); however, more NG homes had dogs (23%) Schooling 0.75
Attends school 57 (52.78%) 27 (50.94%) 30 (54.55%)
compared to G homes, which had more no pets (29%; p=0.98). No school 5 (4.63%) 2 (3.77%) 3 (5.5%)
When considering comorbidities, 17% were born prematurely Not Recorded 46 (42.59%) 24 (45.28%) 22 (40%)
(Table 2; p=0.95), 6% had a history of heart murmurs, 4% were diag­ Cigarette Smoke 0.08
nosed as autistic, 26% experienced sleep apnea, 15% had sleep disor­ Around Smoke 17 (15.74%) 5 (9.43%) 12 (21.8%)
No Smoke 49 (45.37%) 28 (52.83%) 21 (38.2)
dered breathing (SDB), 4% had insomnia, 32% allergic rhinitis and 12%
No Response 43 (39.81%) 21 (39.62%) 22 (40%)
had asthma; none of these were significantly different. ADHD was Pets (n¼56) 0.98
identified in 14% of the total cohort, with 21% of NG and 7% of G having No Pets 24 (22.22%) 8 (15.09%) 16 (29.1%)
ADHD (p=0.05). This difference was reflected in patients that were on Dog 17 (15.74%) 12 (22.64%) 5 (9.1%)
medication for their ADHD (87% of the total cohort), with 100% of the Cat 4 (3.7%) 2 (3.77%) 2 (3.6%)
Both 8 (7.4%) 2 (3.77%) 6 (10.1%)
NG and 50% of the G group reporting medication. Psychological issues Unspecified Pet 2 (1.85%) 1 (1.89%) 1 (1.8%)
were significantly different between the cohorts: 15% in NG and 4% in
the G group (p=0.05; Table 2), which correlated with patients on anti-
depressants (NG 4%; G=0) and the utilization of counseling (NG 6%
and G 2%; p=0.44). induction/preoperative (p=0.91) surveys when compared to the G
As anxiety could be attributed to the type of surgical procedure, with cohort; however, the mean difference between induction and separation
54% of the group having previous surgical experience (NG 57%; G 50.9; for NG was lower than that for the G group (p=0.23). The effect of the
p=0.50; data not shown). HHVG could be evaluated more specifically concerning ‘activity’ (A),
The m-YPAS differences measuring the patient anxiety at the three ‘vocalization’ (B), ‘emotional expressivity’ (C) and ‘state of arousal’ (D)
time points (pre-operative, separation from guardian, induction) with when looking at the individual section differences (Table 3). The overall
and without the HHVG was evaluated (higher numbers indicating mean difference between survey 2 and 1 was greatest for B and D;
increased anxiety; Table 3). The mean mYPAS for the first timepoint was however, these were not significantly different when the data was
the lowest of the three (4.84) with increasing means for the second stratified. Categories A and C were both significantly different when
timepoint (5.6) and third (6.9). This was reflected in the stratified comparing NG/G (0.04 and 0.02, respectively) with the G cohort
groups (NG and G) with more mean anxiety noted in the NG group over exhibiting much less anxiety during separation. The same analysis when
the G group (p=0.36). When evaluating the difference between the comparing induction/preoperative anxiety levels revealed no significant
means for each timepoint, there was a smaller difference between differences between the cohorts for any section, as was also seen for the
overall mYPAS 2 and 1 (0.73), with the largest anxiety difference be­ differences between induction/separation; however, the differences
tween 3 and 1 (2.03; induction and preoperative, respectively). An in­ between induction/separation were greater between the NG/G groups
termediate difference (1.3) was seen between induction and separation (Table 3).
(3–2; Table 3). In observing the stratified groups, the NG group had In evaluating the means for each section of the mYPAS (Table 4), NG
greater mean anxiety for both the separation/preoperative (p=0.05) and patients showed more anxiety across all sections and all timepoints.

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J. Teruel et al. Perioperative Care and Operating Room Management 24 (2021) 100203

Table 2 Table 4
Comorbidities identified in patients in our cohort. mYPAS section values for observed anxiety†.
Study No Game Game p-value Study No Game Game p-value
n=108 n=53 n=55 n=108 n=53 n=55

Pre-maturity 18 (16.67%) 9 (16.98%) 9 (16.4%) 0.95 Section A

Heart murmur 6 (5.56%) 3 (5.66%) 3 (5.5%) 0.84 Initial Mean 1.215 1.300 1.135 0.125
Autism 4 (3.7%) 3(5.66%) 1 (1.8%) 0.32 Separation Mean 1.354 1.591 1.120 0.001
Sleep apnea 28 (25.92%) 17 (32.08%) 11 (20%) 0.10 Induction Mean 1.5 1.571 1.429 0.452
SDBy 16 (14.81%) 8 (15.09%) 8 (14.5%) 0.73 Section B
Insomnia 4 (3.7%) 3 (5.66%) 1 (1.8%) 0.28 Initial Mean 1.284 1.420 1.154 0.057
Allergic Rhinitis 36 (32.41%) 21 (39.62%) 15 (27.3%) 0.17 Separation Mean 1.495 1.816 1.180 0.003
Asthma 13 (12.03%) 7 (13.21%) 6 (10.1%) 0.65 Induction Mean 1.888 2.041 1.734 0.308
Known Anxiety 4 (3.7%) 3 (5.66%) 1 (1.8%) 0.50 Section C
ADHD 15 (13.89%) 11 (20.75%) 4 (7.3%) 0.05 Initial Mean 2.529 1.340 1.154 0.102
on meds‡ 13 (86.7%) 11 (100%) 2 (50%) Separation Mean 1.414 1.694 1.14 0.001
Psych Issues 10 (9.26%) 8 (15.09%) 2 (3.6%) 0.05 Induction Mean 1.816 1.918 1.714 0.329
anti-depressant 2 (1.85%) 2 (3.77%) 0 Section D
Counseling 4 (3.7%) 3 (5.66%) 1 (1.8%) 0.44 Initial Mean 1.098 1.160 1.034 0.043
Separation Mean 1.333 1.490 1.18 0.053
Induction Mean 1.704 1.796 1.612 0.425
ySleep Disordered Breathing; no overlap with sleep apnea or insomnia; ‡ADHD
mediations identified: Focalin, Vyvanse Adderall XR, Concerta, Intuniv, Ritalin.
†further analysis of mYPAS to determine where HHVG had the largest effect.

Table 3
Clinical evaluation of child anxiety (mYPAS)†. Table 5
Self-reported parent anxiety (STAI) and parent/child separation†.
Study n=108 No Game n=53 Game n=55 p-
value Study No Game Game p-
n=108 n=53 n=55 value

n¼102 n¼50 n¼52

mYPAS 1 mean‡ 4.84314 5.22 4.480769 0.36 STAI A‡(Avg) 2 1.88 2.11111 0.23
n¼99 n¼49 n¼50 STAI B¶ (Avg) 1.76923 0.54 1.51852 0.001
mYPAS 2 mean 5.596 6.591837 4.62 0.21 (STAI B –A) -0.23077 -1.34 -0.59259 0.006
n¼98 n¼49 n¼49 Separation 91 (84%) 43 (81.1%) 48 87.2%) 0.451
mYPAS 3 mean 6.90816 7.326531 6.489796 0.83 Experience
Survey Differences§ n¼91 n¼43 n¼48
mYPAS 2–1 Mean 0.72727 1.346939 0.12 0.05 Better than expected 80(87.9%) 37(86.1%) 43(90%) 0.344
mYPAS 3–1 Mean 2.030612 2.081633 1.979592 0.91 Worse than expected 11(12%) 6(14%) 5(10%) 0.677
mYPAS 3–2 Mean 1.278351 0.979167 1.857143 0.23
Section
Differences¶
†Larger numbers indicate less anxiety and greater calm. ‡parent self-reported
mYPAS 2–1 means n¼99 n¼49 n¼50 anxiety during the surgery (while the parent was in the waiting room);
Section A, 2–1 0.131313 0.285714 -0.02 0.04 ¶parent self-reported generalized anxiety.
Section B, 2–1 0.20202 0.387755 0.02 0.11
Section C, 2–1 0.16162 0.346939 -0.02 0.02
Table 5 with higher scores indicative of lower levels of anxiety. The
Section D, 2–1 0.23232 0.326531 0.14 0.21
mYPAS 3–1 means n¼98 n¼49 n¼49 average overall score for the procedural section (A) was 2, with NG
Section A, 3–1 0.27551 0.265306 0.285714 0.92 parents reporting higher anxiety (1.88 and 2.11, respectively; p=0.23).
Section B, 3–1 0.591837 0.612245 0.571429 0.89 As expected, the mean for the B section (1.8; generalized anxiety) was
Section C, 3–1 0.561224 0.571429 0.55102 0.93 lower than the A. When evaluating the stratified cohorts, B anxiety in NG
Section D, 3–1 0.602041 0.632653 0.571429 0.80
mYPAS 3–2 means n¼97 n¼48 n¼49
was significantly higher (0.54) than the G group (1.52; p=0.001).
Section A, 3–2 0.14433 -0.02083 0.306122 0.11 Likewise, when the B score was subtracted from the A score, the NG
Section B, 3–2 0.391753 0.229167 0.55102 0.34 cohort reported a significantly greater difference (p=0.006). Regarding
Section C, 3–2 0.402062 0.229167 0.571429 0.15 the perception of the separation experience, 88% of the NG cohort and
Section D, 3–2 0.340206 0.25 0.428571 0.51
90% of the G group reported that the experience was better than ex­
pected (p=0.344); a higher percentage of NG parents ranked the expe­
†Truncated mYPAS is noted in Figure 3; ‡averages represent the average mYPAS rience worse than expected (n=6;14%); however, this was not
score across all three time points for the cohort with mYPAS 1 preoperative, significantly different (p=0.677).
mYPAS 2 separation, mYPAS 3 induction; §highlights the mean differences be­
The evaluation of anxiety on post-operative behavior was evaluated
tween the different timepoint mYPAS assessements; ¶highlights the differences
in three phone surveys using a truncated PHBQ (Table 6) and evaluating
between the individual sections in surveys for the timepoints: section A ‘activ­
behavior as improved, no change or worse. While all parents that con­
ity’, section B ‘vocalization’, section C ‘emotional expressivity’, section D ‘state
of apparent arousal’. sented agreed to answer phone questions, only 49% (n=53) answered
PHBQ 1. Of those, 36 answered PHBQ 2 (33%) and 22% (n=24)
answered PHBQ3. For the NG cohort, 27% (n=29) answered the PHBQ1
When comparing the stratified cohorts, the mean anxiety for the pre­
while 22% of G parents (n=24) participated. Overall, 31% of parents
operative evaluation (initial) was not significantly different for any of
reported that their child’s behavior was improved after surgery (NG
the observed anxiety metrics except for the ‘state of apparent arousal’
32%; G 29%), with most parents indicating that the behavior change at
(NG 1.16 versus G 1.034; p=0.043). The difference between game co­
time points one and two were unchanged (67%; NG 53%; G 71%). Only
horts during separation for all anxiety metrics evaluated was significant
one parent reported worse behavior (NG cohort; Table 5). Similarly,
(A 0.001; B 0.003; C 0.001) except for D (p=0.053); none were signifi­
average change in behavior scores improved when considering the dif­
cantly different during induction.
ference between PHBQ3–1 and PHBQ3–2; however, these changes were
STAI self-reporting evaluation of parental anxiety is outlined in

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J. Teruel et al. Perioperative Care and Operating Room Management 24 (2021) 100203

Table 6 this was not significantly different. These data suggest that the HHVG
Post-surgical parent evaluation of child behavior (PHBQ)†‡§. allows for the patients to be distracted and engaged such that separation
Study from the parent, typically traumatic especially in a medical setting,5,6,7
can be minimized. Interestingly, for ‘state of apparent arousal’, the
n=53 No Game
n=29 Game initial mean was significantly different between NG/G (Table 4) sug­
n=24 p-value gesting that the game reduced the anxiety of the patients even in the
presence of the parents and further illustrating the power of this
PHBQ 2–1 n=36 n=19 n=17 distraction tool.
Mean ¶ -0.5 -0.421 -0.588 0.915
Improved n=11 n=6 n=5
When children undergo surgery, many parents, become protective of
Mean ¶ -1.909 -1.8333 -2 their child and manifest anxious behavior which may or may not be
No change n=22 n=10 n=12 perceived by the child.13,22 This anxiety, which may be present before,
Mean ¶ 0 0 0 during, and after their child’s surgery, is focused on the child’s
Worse n=3 n=3 n=0
well-being (side effects, anesthesia, pain, comfort, outcomes)13,23;
Mean ¶ 1 1 0
PHBQ 3–1 n=24 n=12 n=12 however, this anxiety often produces anxiety in the child, manifesting
Mean ¶ -0.4166 -0.166 -0.667 0.487 potentially aberrant behaviors.24 In our study, parents self-reported less
Improved n=9 n=5 n=4 anxiety immediately after separation in the G cohort more often than the
Mean ¶ 1.5555 -1.2 -2 NG group, indicating that the HHVG not only reduced anxiety in the
No change n=14 n=6 n=8
Mean ¶ 0 0 0
child, but also the parent (Table 5; p=0.23). Interestingly, the parent
Worse n=1 n=1 n=0 self-reported generalized anxiety (in comparison to the anxiety felt in
Mean ¶ 4 4 0 the waiting room) was significantly less in the G cohort (p=0.001).
PHBQ 3–2 n=24 n=12 n=12 Whether this is an accurate assessment of parental normal anxiety, the
Mean ¶ -0.4166 -0.166 0.08333 0.621
perception of G parents was that they typically are not anxious, with NG
Improved n=5 n=3 n=2
Mean ¶ -1.6 -2 -1 parents reporting higher levels of generalized anxiety. Given this, the
No Change n=16 n=8 n=8 difference of the two parental anxiety timepoints illustrate a signifi­
Mean ¶ 0 0 0 cantly larger difference in anxiety states for NG parents versus the G
Worse n=3 n=1 n=2 group (p=0.006). The actual meaning of this difference is complex as
Mean ¶ 2.3333 4 1.5
parents/guardians were evaluating their generalized anxiety in an
stressful environment (child having surgery), and there were no pa­
†while all parents that consented to be part of the study agreed to answer rameters regarding timing of survey completion. All surveys were simply
questions by phone post-operatively, only 49% of parents answered PHBQ1 collected when the patient was discharged. It is possible that paren­
(n=53). Of those, 36 answered PHBQ 2 (68%) and 45% (n=24) answered
ts/guardians in the G cohort felt less anxious after separation from their
PHBQ3. Overall, only 22% of the original cohort answered all three surveysl
child which is reflected in reporting lower generalized anxiety; those in
‡24–48 hours post-op (PHBQ 1), 7 days post-op (PHBQ 2), and 14 days post-op
(PHBQ 3); ¶the scale was -2 (best behavior) to +2 (worst behavior) and 0 indi­ the NG cohort felt more anxious on separation and thus reflected a
cating no change; §mean change from one survey time point to the other. higher generalized anxiety. Definitive determination of anxiety of par­
ents in this environment is beyond the scope of this study. However, the
much smaller than those seen between PHBQ2–1. None of the changes sentiment of the benefit of HHVG to the children upon separation and
noted were significant (PHBQ3–1 p=0.487; PHBQ3–2 p=0.621).There the effect on the parent can maybe be best noted in the last question of
were no significant difference between the parents in the NG or G co­ the STAI which asked if the separation experience was better or worse
horts that responded to the PHBQs. than expected. While not significantly different, G parents reported a
slightly higher satisfaction with the separation experience than NG
4. Discussion parents overall (90% better versus 86%).
The patient and parent data presented here correlates to other
Treating anxiety around medical procedures is part of the medical studies utilizing other forms of distraction such as music therapy,14
management 19 with unaddressed anxiety resulting in decreased patient which also found significantly reduced levels of anxiety in patients and
cooperation and satisfaction.4,6,13 Anxiety in children is challenging as parents, utilizing the mYPAS and STAI, respectively. Other studies noted
developmental levels limit cognitive communication, manifesting as that smartphones and incentive-based games on those devices were
aberrant behavior such as aggression, withdrawal and lack of coopera­ effective distraction techniques in alleviating anxiety in the
tion.12 This is especially true in the outpatient setting where procedures pre-operative setting for pediatric patients.25 Our larger study produced
are often short with minimal pharmacologic assistance. similar results, further supporting that HHVG interventions alleviate
Virtual reality has been a proven effective form of distraction, anxiety prior to induction of anesthesia.
particularly in the pediatric population.6,7 Virtual reality games in While most mYPAS and STAI surveys were completed, the post-
young children break the chain of pain and anxiety by drawing the operative PHBQ data was harder to obtain. While all consenting par­
patient’s attention to the visual, auditory, and tactile stimuli of the ents agreed to participate in the short phone surveys, only 49% partic­
virtual world,11,20,21 promoting patient cooperation and preventing ipated in the first survey(n=53), 68% in the second (n=36), and 24
post-procedural behavioral changes.1 parents completed the final assessment. Of these, the number of parents
Our randomized investigation of HHVG as a distraction technique for participating in the study was similar from both the NG and G groups
children ages 3–10 years undergoing outpatient surgical procedures (Table 6). Differences between PHBQ surveys revealed that none of the
revealed, like other studies, that the mean patient anxiety was dimin­ behavioral change metrics were significantly different between the NG/
ished in patient separation (mYPAS 2–1; Table 3); significant differences G groups (Table 6). However, while similar numbers of NG and G par­
were noted in the ‘activity’ (section 1) and ‘emotional expressivity’ ents reported improved behavior for the 48 hour and 7-day timepoints
(section 3) sections. Comparison of the raw clinical scores revealed (NG n=6; G n=5), most reported no change in the behavior of their child
significantly less anxiety during separation in the G cohort when eval­ post-procedure for all time points. More NG parents indicated worse
uating ‘activity’ (section 1), ‘vocalizations’ (section 2), and ‘emotional behavior post-surgery (PHBQ 2–1 n=3; PHBQ3–1 n=1) than the G group
expressivity’ (section 3; Table 4); while the anxiety of the G cohort was (n=0 for both). Interestingly, the mean difference for the PHBQ 3–2
less than NG during separation for ‘state of apparent arousal’ (section 4), indicated worsening behavior in the G cohort; further investigation
revealed two children had markedly improved behavior immediately

5
J. Teruel et al.
following surgery and had returned to ‘normal’ which was a decrease in
improved behavior. As many parents did not participant in the post-
operative behavioral assessments, the characteristics of participating
families were evaluated (data not shown). No demographic variable was
different between the NG and G groups, indicating other factors besides
HHVG and satisfaction motivated full participation. A more robust
analysis could have been achieved with greater participation.
Of interest was that while there were no differences between the NG
and G cohorts in terms of demographics (Table 1), and despite the
randomization of the study, the NG group had a significantly greater
number of patients with ADHD (21% of the cohort) and psychological
issues (9% of the cohort; Table 2). However, all ADHD patients were
medicated, suggesting control. Similarly, patients with psychological
issues reported use of medication and counseling to mitigate the con­
ditions. While these issues could have resulted in higher anxiety in NG
patients, the numbers affected would not have been enough to influence
the mYPAS clinically observed anxiety evaluations.
Further studies to examine the efficacy of distraction by HHVG in the
outpatient surgical pediatric population could benefit from a larger
sample size allowing for better matched control analysis. Hilly et al. had
a robust recruitment system that allowed each patient in the interven­
tion group to be matched with a patient with similar criteria in terms of
type of surgery, surgery date, within a one-year age difference,5 elimi­
nating potentially confounding variables. Lastly, while our sample size
(n = 108) is larger than similar studies, future larger sample sizes may
provide additional insight into benefits of distraction techniques
contributing to widespread usage.
In lieu of potentially dangerous pharmacological interventions to
reduce anxiety, video distractions allow children’s attentions to be
attuned to an imaginary world while being oblivious to the unfamiliar
environment of the preoperative room.6,25 As children have lower
prevalence and level of anxiety in waiting rooms,25 this may be the
optimal setting in which to introduce distraction games to help children
feel comfortable in unfamiliar settings.
CRediT Author Statement
Teruel: investigation, writing (original and editing); Stafford:
methodology, investigation, writing original; Brown: methodology,
statistical analysis; Jones: conceptualization, methodology; Hopkins:
resources, supervision, administration; Johnson: data curation; Eden­
field: data curation; Guo: editing; Schammel: conceptualization,
methodology, investigation, data curation, editing, review, visualiza­
tion, supervision, administration; Renfro: conceptualization, supervi­
sion, administration; Nisonson: conceptualization, methodology,
validation, supervision, administration.
Declaration of Competing Interest
Teruel none; Stafford none; Brown none; Jones none; Hopkins none;
Johnson none; Edenfield none; Guo none; Schammel none; Renfro none;
Nisonson none.
Funding
No funding was received for this study.
Acknowledgements
Justin Collins assisted in initial development of the research idea;
Kelly Price, Heather Crawford RN, Shelley Bridges RN and Susan Martin
RN assisted with coordination of the facility and staff for execution of
the study; numerous nurses and staff at Patewood Outpatient Surgery
Center who assisted in clinical evaluations of patients and made the
disruption of the study as minimal as possible.
6
Perioperative Care and Operating Room Management 24 (2021) 100203
IRB approval
This study achieved IRB approval Pro00057182 from Health Sci­
ences SC prior to initiation; last continuing review was 7/2017.
Clinical Implications
Based on our study results, we propose the use of hand-held games,
to alleviate both pediatric and parental anxiety in perioperative settings,
as they are low-cost, safe to use, easy to implement, and can be given to
all patients who choose to participate.
References
1 Beringer RM, Segar P, Pearson A, Greamspet M, Kilpatrick N. Observational study of
perioperative behavior changes in children having teeth extracted under general
anesthesia. Pediatc Anesth. 2014;24:499–504, 10.111/pan12362.
2 Kühlmann AYR, de Rooij A, Kroese LF, van Dijk M, Hunink MGM, Jeekel J. Meta-
analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg.
2018;105:773–783. https://doi.org/10.1002/bjs.10853.
3 Schockey DP, Menzies V, Glick DF, Taylor AG, Boitnott A, Rovnyak V. Preprocedural
distress in children with cancer: An intervention using biofeedback and relaxation.
J Pediat Oncol Nurs. 2013;30:129–138, 10.1177/1043454213479035.
4 Sadeghi A, Khaleghnejad Tabari A, Mahdavi A, Salarian S, Razavi SS. Impact of
parental presence during induction of anesthesia on anxiety level among pediatric
patients and their parents: a randomized clinical trial. Neuropsychiatr Dis Treat. 2017;
12:3237–3241, 10.2147/NDT.S119208.
5 Hilly J, Hörlin AL, Kinderf J, Ghez C, Menrath S, Delivet H, Brasher C, Nivoche Y,
Dahmani S. Preoperative preparation workshop reduces postoperative maladaptive
behavior in children. Paediatr Anaesth. 2015;25:990–998. https://doi.org/10.1111/
pan.12701.
6 Kim H, Jung SM, Yu H, Park SJ. Video distraction and parental presence for the
management of preoperative anxiety and postoperative behavioral disturbance in
children: a randomized controlled trial. Anesth Analg. 2015;121:778–784, 10.1213/
ANE.0000000000000839.
7 Ryu JH, Oh AY, Yoo HJ, Kim JH, Park JW, Han SH. The effect of an immersive virtual
reality tour of the operating theater on emergence delirium in children undergoing
general anesthesia: a randomized controlled trial. Paediatr Anaesth. 2019;29:98–105.
https://doi.org/10.1111/pan.13535.
8 Qiao H, Xie Z, Jia J. Pediatric premedication: a double-blind randomized trial of
dexmedetomidine or ketamine alone versus a combination of dexmedetomidine and
ketamine. BMC Anesthesiol. 2017;17:158. https://doi.org/10.1186/s12871-017-
0454-8.
9 Al-Yateem N, Brenner M, Shorrab AA, Docherty C. Play distraction versus
pharmacological treatment to reduce anxiety levels in children undergoing day
surgery: a randomized controlled non-inferiority trial. Child Care Health Dev. 2016;
42:572–581. https://doi.org/10.1111/cch.12343.
10 Seiden SC, McMullan S, Sequera-Ramos L, De Oliveira Jr GS, Roth A, Rosenblatt A,
Jesdale BM, Suresh S. Tablet-based Interactive Distraction (TBID) vs oral midazolam
to minimize perioperative anxiety in pediatric patients: a noninferiority randomized
trial. Paediatr Anaesth. 2014;24:1217–1223. https://doi.org/10.1111/pan.12475.
11 Gold JI, Kim SH, Kant AJ, Joseph MH, Rizzo A. Effectiveness of virtual reality for
pediatric pain distraction during IV placement. Cyberpsychol Behav. 2006;9:207–212.
https://doi.org/10.1089/cpb.2006.9.207.
12 Rodriguez ST, Jang O, Hernandez JM, George AJ, Caruso TJ, Simons LE. Varying
screen size for passive video distraction during induction of anesthesia in low-risk
children: A pilot randomized controlled trial. Paediatr Anaesth. 2019;29:648–655.
https://doi.org/10.1111/pan.13636.
13 Fisak B, Holderfield KG, Douglas-Osborn E, Cartwright-Hatton S. What do parents
worry about? examination of the construct of parent worry and the relation to parent
and child anxiety. Behav Cogn Psychoth. 2012;40:542–557. https://doi.org/10.1017/
S1352465812000410.
14 Millett CR, Gooding LF. Comparing Active and Passive Distraction-Based Music
Therapy Interventions on Preoperative Anxiety in Pediatric Patients and Their
Caregivers. J Music Ther. 2018;54:460–478. https://doi.org/10.1093/jmt/thx014.
15 Jenkins BN, Fortier MA, Kaplan SH, Mayes LC, Kain ZN. Development of a short
version of the Modified Yale Preoperative Anxiety Scale. Anesth Analg. 2014;119:
643–650. doi.org/10.1213/ANE.0000000000000350.
16 Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale
Preoperative Anxiety Scale: how does it compare with a "gold standard"? Anesth
Analg 1997;85:783–8. doi: 10.1097/00000539-199710000-00012.
17 Al-Yateem N, Maria Brenner M. Validation of the Short State Trait Anxiety Inventory
(Short STAI) Completed by Parents to Explore Anxiety Levels in Children. Compr
Child Adolesc Nurs. 2017;40(1):29–38. https://doi.org/10.1080/
24694193.2016.1241836.
18 Jenkins BN, Kain ZN, Kaplan SH, Stevenson RS, Mayes LC, Guadarrama J,
Fortier MA. Revisiting a measure of child postoperative recovery: development of the
post hospitalization behavior questionnaire for ambulatory surgery. Paediatr Anaesth.
2015;25:738–745. https://doi.org/10.1111/pan.12678.
19 House A, Stark D. Anxiety in medical patients. BMJ. 2002;325:207–209. https://doi.
org/10.1136/bmj.325.7357.207.
J. Teruel et al.
20 Tychsen L, Foeller P. Effects of Immersive Virtual Reality Headset Viewing on Young
Children: Visuomotor Function, Postural Stability, and Motion Sickness. Am J
Ophthalmol. 2020;209:151–159. https://doi.org/10.1016/j.ajo.2019.07.020.
21 Bement MH, Weyer A, Keller M, Harkins AL, Hunter SK. Anxiety and stress can
predict pain perception following a cognitive stress. Physiol Behav. 2010;101:87–92.
https://doi.org/10.1016/j.physbeh.2010.04.021.
22 Ben-Amitay G, Kosov I, Reiss A, Toren P, Yoran-Hegesh R, Kotler M, Mozes T. Is
elective surgery traumatic for children and their parents? J Paediatr Child Health.
2006;42:618–624. https://doi.org/10.1111/j.1440-1754.2006.00938.x.
Perioperative Care and Operating Room Management 24 (2021) 100203
23 Stone MB, Botto LD, Feldkamp ML, et al. Improving quality of life of children with
oral clefts: perspectives of parents. J Craniofac Surg. 2010;21(5):1358–1364.
24 Fliek L, Dibbets P, Roelofs J, Muris P. Cognitive bias as a mediator in the relation
between fear-enhancing parental behaviors and anxiety symptoms in children: a
cross-sectional study. Child Psychiatry Hum Dev. 2017;48:82–93. https://doi.org/
10.1007/s10578-016-0655-2.
25 Cumino DO, Vieira JE, Lima LC, Stievano LP, Silva RA, Mathias LA. Smartphone-
based behavioural intervention alleviates children’s anxiety during anaesthesia
induction: A randomised controlled trial. Eur J Anaesthesiol. 2017;34:169–175.
https://doi.org/10.1097/EJA.0000000000000589.