Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children (2024)

Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children (1)

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J Pediatr Psychol. 2016 Mar; 41(2): 159–181.

Published online 2015 Sep 3. doi:10.1093/jpepsy/jsv076

PMCID: PMC4884904

PMID: 26338981

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Abstract

Objective To conduct a systematic review of the factors predicting anticipatory distress to painful medical procedures in children. Methods A systematic search was conducted to identify studies with factors related to anticipatory distress to painful medical procedures in children aged 0–18 years. The search retrieved 7,088 articles to review against inclusion criteria. A total of 77 studies were included in the review. Results 31 factors were found to predict anticipatory distress to painful medical procedures in children. A narrative synthesis of the evidence was conducted, and a summary figure is presented. Conclusions Many factors were elucidated that contribute to the occurrence of anticipatory distress to painful medical procedures. The factors that appear to increase anticipatory distress are child psychopathology, difficult child temperament, parent distress promoting behaviors, parent situational distress, previous pain events, parent anticipation of distress, and parent anxious predisposition. Longitudinal and experimental research is needed to further elucidate these factors.

Keywords: anxiety, children, infancy, pain, parents, systematic review

Introduction

Healthy children experience frequent medical procedures such as immunization and blood draws (Public Health Agency of Canada, 2006). Many young children experience high levels of pain and distress during these procedures, and adequate pain management strategies are seldom used (). Many children also experience distress and anxiety before the procedure even begins (). This is called anticipatory distress. Anticipatory distress has been identified as occurring as early as infancy. Newborn infants who have been exposed to several painful procedures can learn to anticipate pain and exhibit more intense pain responses (). Anticipatory distress and fear of medical procedures have also been identified as concerns in preschool and school-aged children. One study found that 22% of 4–6-year-old children experience serious distress during the preparatory phase of an immunization (Jacobson etal., 2001). Another recent study found that more than half of children under the age of 8 years have needle fear (Taddio etal., 2012). This finding is particularly concerning as anticipatory distress has been associated with several negative sequelae (; ; Tsao etal., 2004; ). These negative outcomes could lead to avoidance of painful medical procedures and reduced compliance with preventative medical care (Taddio etal., 2012). Despite the important implications of anticipatory distress to painful medical procedures for children, little empirical work has investigated the factors that lead to its development.

Several models in the developmental literature have outlined the pathways that lead to the development of maladaptive anxiety and anxiety-related problems (; Rachman, 1977; ). Within the pediatric pain literature, some work has examined the preprocedural child factors that impact a child’s pain response (; Young, 2005); however, these models focus on pain responses rather than anxiety and anticipatory distress. Previous models share a common emphasis on the transactional and developmental nature of anxiety or fear over time and highlight the dynamic interaction between the individual child and his/her environment. The four “Ps” of case formulation (predisposing, precipitating, perpetuating, and protective factors) also provide a useful framework for organizing the factors that may contribute to the development of anticipatory distress (Barker, 1988; Carr, 1999; ). Predisposing factors are those that put a child at risk of developing a problem (in this case, high anticipatory distress). These may include genetics, life events, or temperament. Precipitating factors refer to a specific event or trigger to the onset of the current problem. Perpetuating factors are those that maintain the problem once it has become established. Finally, protective factors are strengths of the child or reduce the severity of problems and promote healthy and adaptive functioning. Another “P” that can be relevant in case formulation are “present” factors, that is, those that are operating during the time of the event-eliciting distress. Present factors are relevant due to the emphasis on “procedure” or context in the literature. Additionally, factors that are considered protective can be collapsed within predisposing, perpetuating, and present factors.

The objective of this review is to summarize the findings of studies that examine factors that predict anticipatory distress to painful medical procedures in children. This systematic review is a qualitative synthesis and summarizes the findings from the search in a summary figure. The goal of the summary figure (Figure 2) is to provide an overview for researchers and clinicians of the current literature as well as highlight gaps in the literature. Based on the developmental psychopathology perspective, factors in this review were hypothesized to fall under the four Ps of case formulation: predisposing (e.g., genetics and temperament), precipitating (e.g., negative pain experiences), perpetuating (e.g., parent behavior, parent anxiety, child behavior, and child cognitions), and present factors (e.g., health care professional behavior). This review also evaluated the included studies for risk of bias and identified methodological limitations of current studies. Promising directions for future research in this area are outlined.

Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children (3)

Summary figure of results. FS = findings synthesis; ROB = risk of bias; + = factor has a positive relationship with anticipatory distress; − = factor has a negative relationship with anticipatory distress; ∅ = no effect or significant relationship; ? = inconclusive results; U = unclear risk of bias; L = low risk of bias; H = high risk of bias; # = number of studies.

Method

Criteria for Considering Studies for This Review

Types of Studies

Studies examining factors that are related to or predict anticipatory distress (anxiety, fear, distress) to painful medical procedures that were published in peer-reviewed journals were considered for inclusion. Although the goal of the study was to examine anticipatory distress, not pain, pain studies that measured anticipatory distress, anxiety or fear were included in the review. Given the study of fear and anxiety is a bourgeoning area in the field of pediatric pain and the goal was not to summarize treatment efficacy, nonrandomized studies were included in this review and formed the preponderance of the literature base. Nonrandomized studies were included following guidelines of the Cochrane Collaboration that a systematic review should include the best available study designs with the least risk of bias (). Randomized controlled trials were included when appropriate; however, the variables predicting anticipatory distress were the focus, not the treatment effect. Pharmacological (e.g., sedatives) and physical (e.g., needle type) predictors of anticipatory distress were not examined in this review. All studies were examined for potential sources of bias.

Types of Participants

To be considered in the review, the study had to examine a painful procedure in children from birth through 18 years of age. The study also had to measure anticipatory distress (including anxiety/fear rated before or after the procedure or in some cases pain scores prior to the application of pain) to a painful medical procedure or operation (laboratory pain tasks were excluded from the review). Exclusion criteria for studies were: no painful medical procedure, incorrect age (i.e., not children 0 to 18 years), and studies where no factor was analyzed for its relationship to anticipatory distress.

Types of Measures of Anticipatory Distress

Studies that used an objective behavioral measure, observer reported (e.g., parent, nurse, physician, and research assistant), or self-report measure of distress prior to a painful medical procedure or operation were included in this review. In addition to distress prior to painful medical procedures, for the purpose of this review, the term anticipatory distress was operationalized to be an umbrella term that also included ratings of fear or anxiety about a procedure provided after the procedure or operation as well as a retrospective report of anxiety/fear about a procedure. In circumstances where more than one measure of anticipatory distress was provided, self-report measures of anxiety, fear, and distress were prioritized. Behavioral measures and observer report measures were used when self-report was not available or was not developmentally appropriate. Additionally, measures that were most specific to anxiety and fear were used. For example, using the State Trait Anxiety Inventory over a general distress measure. Measures of anticipatory distress most proximal to the painful medical procedure were used. For preoperative studies, ratings in holding areas or during induction were used rather than during separation from parents as not to confound fear and distress of the medical procedure with fear and distress from separation.

Search Methods for Identification of Studies

A review protocol was not registered for this review. A librarian from a tertiary hospital with specialized training in conducting systematic reviews conducted a systematic search in MEDLINE, EMBASE, and EBM Reviews—Cochrane Central Register of Controlled Trials and PsycINFO to include articles indexed as of November 20, 2013. Separate search strategies and terms were developed for each of the databases. Search results were limited to publication years (1946+) and age group (children 0–18 years). Search terms related to anticipatory distress, medical procedures, pain procedures, and children were systematically paired (see Supplementary Appendix 1). A manual database search was also conducted for new articles published after 2013 to update the search in November 2014. Prior meta-analyses and reference lists from identified studies were also reviewed. Authors of studies that could not be found were contacted.

Data Collection and Analysis

Selection of Studies

Three authors (N.R., R.P.R., A.T.) and the librarian from a tertiary hospital identified studies through database searching as described above, and duplicates were removed using reference management software (Endnote X7). Two review authors (N.R. and R.P.R.) initially screened 1,000 abstracts to pilot the initial search strategy. Five review authors (N.R., R.P.R., P.T., M.C., and M.K.) screened titles and abstracts of studies from the final database searches for inclusion in the review based on predetermined inclusion and exclusion criteria listed above. Figure 1 provides the preferred reporting items for systematic reviews and meta-analyses (PRISMA) () chart outlining the flow of study selection.

Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children (4)

Included study flow chart following PRISMA guidelines.

Data Extraction and Management

Four authors conducted data extraction independently for all included studies using a data extraction form created by the lead author designed for this review, which was approved by the senior author (R.P.R.). The lead author conducted training sessions with the review authors to explicitly outline the exclusion criteria and how to use the data extraction form. Decision-making reliability for study inclusion was evaluated for 20% of all studies screened. Percent agreement, calculated as the percentage of studies that were agreed upon between two authors, ranged from 0.83 to 0.95 indicating strong inter-rater agreement.

Assessment of Risk of Bias

A nuanced approach was necessary as the purpose of this review was not to evaluate treatment outcomes or to make recommendations about practice. The state of the literature in the area of anticipatory distress is such that the preponderance of research is observational, not experimental, in nature. However, assessment of risk of bias within observational studies was deemed necessary despite the lack of randomization. Risk of bias was assessed for the 77 included studies using the Cochrane Collaboration methodology for systematic reviews (). The majority of the studies included in the review (70 studies) were not randomized controlled trials. In the Risk of Bias tool created by the Cochrane Collaboration, the first three criteria (random sequence generation, allocation concealment, and blinding of participants) are only relevant for randomized controlled trials. As such, for observational and retrospective studies, only the last four criteria were used to make judgments: blinding of outcome assessment, incomplete outcome data, selective reporting, and other sources of bias. This adaptation was based on the decision not to penalize nonrandomized observational studies for being evaluated against criteria for randomization. The Cochrane collaboration recently launched a risk of bias tool for nonrandomized studies of interventions (); however, at the time of this manuscript, trainings were only beginning to be offered and the tool was not yet widely used. Established tools to evaluate risk of bias in nonrandomized studies were also considered (e.g., ). However, given the number of studies in the review, an abbreviated tool was selected. Two authors evaluated risk of bias and consensus decisions were made where authors disagreed. All studies were classified as high, unclear, or low risk of bias. If one of the criteria was rated as “high,” the overall study rating was considered to be high risk. “Unclear risk of bias” was indicated when one of the four criteria was missing, not mentioned, or did not meet the criteria for low or high risk of bias. To be evaluated as low risk of bias, all the criteria had to be rated as low.

Data Synthesis

Because of the diversity of medical procedures, outcome measures used, and participant ages included in the studies, a meta-analysis was not deemed appropriate for this review and, rather, a narrative synthesis framework (Popay etal., 2005) was applied. Influenced by developmental psychopathology theory and by the four Ps for case conceptualization (; ), this review categorized factors related to anticipatory distress to painful medical procedures as predisposing, precipitating, perpetuating, or present factors. Present factors were chosen (instead of protective factors) due to the emphasis on “procedure” or contextual factors in the literature. Additionally, factors that could be considered protective factors were collapsed within predisposing, perpetuating, and present factors as it made more conceptual sense based on how these factors were operationalized in the medical literature. For the purposes of this review, predisposing factors were operationalized as inherent variables that increase the child’s risk for anticipatory distress, for example, preexisting aspects of the child such as age, gender, or temperament as well as socio-demographic variables of the parent or environment. Precipitating factors were conceptualized as factors that lead to the onset of anticipatory distress to painful medical procedures such as a negative pain event or previous experience with pain. Perpetuating or maintaining factors (Carr, 1999) were factors that likely extend or preserve the problem such as parent behavior that maintains the child’s distress both inside and outside the medical procedure. Finally, present factors were variables that occurred at the time of the procedure and could positively or negatively influence the child’s anticipatory distress. It should be noted that predisposing, precipitating, perpetuating, and present factors are not mutually exclusive categories as some factors may apply to multiple categories. These factors may also interact to compound anticipatory distress. For the purposes of the review, the lead author and senior author categorized each factor for parsimony and ease of interpretation.

Results

Results of the Search

The search strategy retrieved 7,088 abstracts to review against the inclusion criteria. Four individuals screened the initial 7,088 abstracts against inclusion criteria. Based on these criteria, the full article was retrieved for 159 studies. Eighty-two articles for which the full text was retrieved were excluded from the review. A total of 77 full-text studies were included in the review. The review process followed the PRISMA guidelines (Moher etal., 2009; Figure 1). Tables I–IV provide detailed overviews of the included studies including age range, sample size, country of origin, procedure, design, and risk of bias rating. In summary, most included studies were observational, from North America, encompassed a broad age range, and were based on surgical or needle-related procedures. The most common procedures included surgery or operative procedures (29), immunizations/injections (13), dental procedures (11), and venipuncture procedures (8). A total of 15,106 participants were included in the review.

Table I.

Predisposing Factors of Anticipatory Anxiety

StudyAge (years)NCountryProcedureDesignRisk of biasResultSummary of biasResults summary
Child predisposing factors
1. Age (43 studies; N = 9,890)
Bevan etal. (1990)2–10134CanadaPreopEUnclearUnclear (25 low, 8 high, 10 unclear)Inconclusive
Broome and Hellier (1987)5–1184USAMedicalRLow
Caldwell-Andrews, Kain, Mayes, Kerns, and Ng (2005)2–12289USAPreopOUnclear
Carpenter (1992)4–1873USAVenipunctureOLow
Chen, Craske, Katz, Schwartz, and Zeltzer (2000)3–1855USALPRCTHigh
2–10293USAPreopOLow
Chorney, Torry, McLaren, Chen, and Kain (2009)2–10293USAPreopOUnclear
Dahlquist, Power, Cox, and Fernbach (1994)2–763USABMAOLow
8–17
Dahlquist etal. (2001)5–1545USAIntramuscular injection and LPOLow
Dahlquist and Pendley (2005)2.4–5.129USAImmunizationRCTHigh
Davidson etal. (2006)3–121,250AustraliaPreopOLow
Fukuchi etal. (2005)2–1278BrazilPreopOUnclear
Hatava, Olsson, and Lagerkranser (2000)2–10160SwedenPreopEUnclear
Holm-Knudsen, Carlin, and McKenzie (1998)0–142,122AustraliaPreopOUnclear
Hosey etal. (2006)2–14407UKDentalOLow
Howe etal. (2011)4.9–16.223USAInjection, Finger sticksOUnclear
Kain, Mayes, Weisman, and Hofstadter (2000)3–1060USAPreopOHigh
Lilley, Craig, and Grunau (1997)0.17–1.575CanadaImmunizationOLow
Mahoney, Ayers, and Seddon (2010)7–1650UKVenipunctureOLow
Melamed, Meyer, Gee, and Soule (1993)4–1246USAPreopOLow
Olak etal. (2013)8–10344EstoniaDentalRLow
Taddio etal. (2012)6–171,024CanadaImmunizationRHigh
Tyc etal. (2002)2–780USARadiation TherapyOLow
Kain, Mayes, O'Connor, and Cicchetti (1996)2–10163USAPreopOLow+
Tickle etal. (2009)5–9799UKDentalOHigh+
Al-Jundi and Mahmood (2010)2–12118JordanDentalOHigh
Bijttebier and Vertommen (1998)2.75–12.7547BelgiumVenipunctureOHigh
Carr, Lemanek, and Armstrong (1998)3–1262USAAllergy skin testingOLow
Claar, Walker, and Smith (2002)8–18100USAEGDOLow
deVos etal. (2012)M = 3.118USAImmunotherapy InjectionsOHigh
Field, Alpert, Vega-Lahr, Goldstein, and Perry (1988)4–1056USAPreopOLow
Fox and Newton (2006)5–1738UKDentalRCTLow
Goodenough, Champion, Laubreaux, Tabah, and Kampel (1998)3–17117AustraliaVenipunctureOUnclear
Jacobson etal. (2001)1–6150USAImmunizationOLow
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow
Ortiz etal. (2014)8–16437MexicoDentalOUnclear
McMurtry, Noel, Chambers, and McGrath (2011)5–10100CanadaVenipunctureOLow
Mekarski and Richardson (1997)2.5–13324CanadaDentalOLow
Messeri, Caprilli, and Busoni (2004)2–1439ItalyPreopOLow
Siaw, Stephens, and Holmes (1986)3.5–12.830USAPreopOUnclear
Thompson (1994)8–1243USAPreopOLow
Wright, Stewart, and Finley (2010)3–661CanadaPreopELow
Wright, Stewart, and Finley (2013)3–661CanadaPreopOLow
2. Gender (26 studies; N = 6,483)
Al-Jundi and Mahmood (2010)2–12118JordanDentalOHighUnclear (18 low, 6 high, 2 unclear)No effect
Bearden, Feinstein, and Cohen (2012)3–590USAImmunizationOLow
Bijttebier and Vertommen (1998)2.75–12.7547BelgiumVenipunctureOHigh
Carr, Lemanek, and Armstrong (1998)3–1262USAAllergy testOLow
Colares, Franca, Ferreira, Amorim Filho, and Oliverira (2013)5–12970BrazilDentalRLow
Dahlquist etal. (2001)5–1545USAIntramuscular injection and LPOLow
Davidson etal. (2006)3–121,250AustraliaPreopOLow
Fortier, Martin, MacLaren Chorney, Mayes, and Kain (2011)11–1859USAPreopOLow
Fox and Newton (2006)5–1738UKDentalRCTLow
Gazal and Mackie (2007)2–12201UKDentalOLow
Goodenough etal. (1998)3–17117AustraliaVenipunctureOUnclear
Hanas etal. (2002)1–1541SwedenInsulin injectionRCTHigh
Horton etal. (2015)1–1.5130CanadaImmunizationOLow
Jacobson etal. (2001)1–6150USAImmunizationOLow
Kain etal. (2000)3–1060USAPreopOHigh
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow
Ortiz etal. (2014)8–16437MexicoDentalOUnclear
Thompson (1994)8–1243USAPreopOLow
Wright, Stewart, and Finley (2010)3–661CanadaPreopELow
Wright, Stewart, and Finley (2013)3–661CanadaPreopOLow
Broome and Hellier (1987)5–1184USAMedicalOLow+Girls
Logan and Rose (2004)12–18102USAPreopOLow+Girls
McMurtry etal. (2011)5–10100CanadaVenipunctureOLow+Girls
Olak etal. (2013)8–10344EstoniaDentalRLow+Girls
Taddio etal. (2012)6–171,024CanadaImmunizationRHigh+Girls
Tickle etal. (2009)5–9799UKDentalOHigh+Girls
3. Child psychopathology (8 studies; N = 2,053)
Davidson etal. (2006)3–121,250AustraliaPreopOLow+Unclear (6 low, 2 high)Positively predicts anticipatory distress.
Ericsson, Wadsby, and Hultcrantz (2006)5–1592SwedenPreopRCTHigh+
Fortier etal. (2011)11–1859USAPreopOLow+
Hosey etal. (2006)2–14407UKDentalOLow+
Kain etal. (2000)3–1060USAPreopOHigh+
Wright, Stewart, and Finley (2013)3–661CanadaPreopOLow+
Kiley and Polillio (1997)School age74USAImmunizationELow
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow
4. Temperament (11 studies; N = 2,235)
Arnrup, Broberg, Berggren, and Bodin (2003)4–1286SwedenDentalEHigh+Unclear (7 low, 3 high, 1 unclear)Positively predicts anticipatory distress.
Chen etal. (2000)3–1855USALPRCTHigh+
Cropper etal. (2011)4–784UKGA (Cochlear Implant)OLow+
Fortier etal. (2011)11–1859USAPreopOLow+
Jacobson etal. (2001)1–6150USAImmunizationOLow+
Kain etal. (1996)2–10163USAPreopOLow+
Kain etal. (2000)3–1060USAPreopOHigh+
Lee and White-Traut (1996)3–7137USAVenipunctureOUnclear+
Davidson etal. (2006)3–121,250AustraliaPreopOLow
Horton etal. (2015)1–1.5130CanadaImmunizationOLow
Wright, Stewart, and Finley (2013)3–661CanadaPreopOLow
5. Race (4 studies; N = 296)
Broome and Hellier (1987)3–15140USAMedicalRLowUnclear (3 low, 1 high)No effect
Kain etal. (2000)3–1060USAPreopOHigh
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow
Melamed etal. (1993)4–1246USAPreopOLow+
6. Birth order (3 studies; N = 1,352)
Davidson etal. (2006)3–121,250AustraliaPreopOLowLow (3 low)No effect
Fortier etal. (2011)11–1859USAPreopOLow
Thompson (1994)8–1243USAPreopOLow
7. Number of siblings/sibling order (3 studies; N = 1,369)
Davidson etal. (2006)3–121,250AustraliaPreopOLowUnclear (2 low, 1 high)No effect
Fortier etal. (2011)11–1859USAPreopOLow
Kain etal. (2000)3–1060USAPreopOHigh
8. Child illness (1 study; N = 80)
Tyc etal. (2002)2–780USARadiation TherapyOLow+LowCNS disease positively predicts.
9. Attachment (2 studies; N = 180)
Horton etal. (2015)1–1.5130CanadaImmunizationOLowLowInconclusive
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow
10. Intelligence (1 study; N = 60)
Kain etal. (2000)3–1060USAPreopOHigh+HighPositively predicts anticipatory distress.
Parent predisposing factors
1. Anxious predisposition (4 studies; N = 1,532)
Davidson etal. (2006)3–121,250AustraliaPreopOLow+LowPositively predicts anticipatory distress.
Kain etal. (1996)2–10163USAPreopOLow+
Messeri, Caprilli, and Busoni (2004)2–1439ItalyPreopOLow+
Tyc etal. (2002)2–780USARadiation TherapyOLow
2. Beliefs about coping and coping style (2 studies; N = 349)
Caldwell-Andrews etal. (2005)2–12289USAPreopOUnclearUnclearInconclusive.
Kain etal. (2000)3–1060USAPreopOHigh+
3. Pain experience and fear of pain (3 studies; N = 1,185)
Ellerton and Merriam (1994)3–1575CanadaPreopRUnclear+High (1 unclear, 2 high)Positively predicts anticipatory distress.
Arnup (2003)4–1286SwedenDentalEHigh
Taddio etal. (2012)6–171,024CanadaImmunizationRHigh+
4. Parental education (2 studies; N = 1,029)
Colares etal. (2013)5–12970BrazilDentalRLow+Low (2 low)Inconclusive
Fortier etal. (2011)11–1859USAPreopOLow
5. Parent gender (1 study; N = 437)
Ortiz etal. (2014)8–16437MexicoDentalOUnclear+UnclearMothers associated with more anticipatory distress.
Contextual predisposing factors
1. Previous hospitalization of child or sibling (5 studies; N = 1,451)
Broome and Hellier (1987)5–1184USAMedicalRLowUnclear (4 low, 1 high)No effect of previous hospitalization.
Field etal. (1988)4–1056USAPreopOLow
deVos etal. (2012)M = 3.118USAImmunotherapy InjectionsOHigh
Thompson (1994)8–1243USAPreopOLow
Broome and Hellier (1987)5–1184USAMedicalRLow+(sibling)
Davidson etal. (2006)3–121,250AustraliaPreopOLow+
2. Other contextual factors (4 studies; N = 3,079)
Colares etal. (2013)5–12970BrazilDentalRLow+ (no visits)Unclear (2 low, 2 high)No/irregular dental visits positively predict.
Davidson etal. (2006)3–121,250AustraliaPreopOLow∅ (SES)
Kain etal. (2000)3–1060USAPreopOHigh∅(demographics)
Tickle etal. (2009)5–9799UKDentalOHigh+ (visits)

Note. + Factor has a positive relationship with anticipatory distress; − Factor has a negative relationship with anticipatory distress; ∅ = no effect or significant relationship; O = observational study; E = experimental study; R = retrospective study; RCT = randomized controlled trial; Preop = preoperative; LP = lumbar puncture; BMA = bone marrow aspiration; CNS = central nervous system.

Table II.

Precipitating Factors of Anticipatory Anxiety

StudyAge (years)NCountryProcedureDesignRisk of biasResultSummary of biasResults summary
Child precipitating factors
1. General and specific negative pain events (33 studies; N = 5,186)
Al-Jundi and Mahmood (2010)2–12118JordanDentalOHigh+Unclear (20 low, 7 high, 6 unclear)Positively predicts anticipatory distress.
Bijttebier and Vertommen (1998)2.75–12.7547BelgiumVenipunctureOHigh+
Caes etal. (2014)0.6–1528CanadaBMA or LPOUnclear+
Carillo-Diaz, Crego, Armfield, and Romero (2013)8–18179SpainDentalRUnclear+
Colares etal. (2013)5–12970BrazilDentalRLow+
Cropper etal. (2011)4–784UKPreopOLow+
Ellerton and Merriam (1994)3–1575CanadaPreopRUnclear+
Hatava, Olsson, and Lagerkranser (2000)2–10160SwedenPreopEUnclear+
Jacobson etal. (2001)1–6150USAImmunizationOLow+
Kain etal. (1996)2–10163USAPreopOLow+
Lee and White-Traut (1996)3–7137USAVenipunctureOUnclear+
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow+ (quality)
Noel, McMurtry, Chambers, and McGrath (2010)5–1048CanadaVenipunctureOLow+
Olak etal. (2013)8–10344EstoniaDentalRLow+
Pillai Riddell etal. (2011)0–1731CanadaImmunizationOLow+
Taddio etal. (2002)Newborns (>1 month)66CanadaVenipuncture, Vitamin K injectionsOLow+
Tickle etal. (2009)5–9799UKDentalOHigh+
Arnrup etal. (2003)4–1286SwedenDentalEHigh
Broome, Lillis, McGahee, and Bates (1994)3–1514USALPOLow
Carr, Lemanek, and Armstrong (1998)3–1262USAAllergy testingOLow
2–10293USAPreopOLow
Ericcson, Wadsby, and Hultcrantz (2006)5–1592SwedenPreopRCTHigh
Dahlquist etal. (2001)5–1545USAIntramuscular injection and LPOLow
Fortier etal. (2011)11–1859USAPreopOLow
Goubet, Clifton, and Shah (2001)0–0.0412USAHeel-lanceOLow
Owens and Todt (1984)Newborns (>1 month)20USAHeel-lanceOLow
McMurtry etal. (2011)5–10100CanadaVenipunctureOLow
Wright, Stewart, and Finley (2010)3–661CanadaPreopELow
Wright, Stewart, and Finley (2013)3–661CanadaPreopELow
Mahoney, Ayers, and Seddon (2010)7–1650UKVenipunctureOLow
deVos etal. (2012)M = 3.118USAImmunotherapy InjectionsOHigh
Howe etal. (2011)4.9–16.223USAInsulin injection and Finger sticksOUnclear
Hanas etal. (2002)1–1541SwedenInsulin injectionRCTHigh
2. Previous pain behavior (5 studies; N = 3,681)
Holm-Knudsen, Carlin, and McKenzie (1998)0–142,122AustraliaPreopOUnclear+Unclear (4 low, 1 unclear)Positively predicts anticipatory distress.
Davidson etal. (2006)3–121,250AustraliaPreopOLow+
Jacobson etal. (2001)1–6150USAImmunizationOLow+
McMurtry etal. (2011)5–10100CanadaVenipunctureOLow+
Fortier etal. (2011)11–1859USAPreopOLow

Note. + Factor has a positive relationship with anticipatory distress; − Factor has a negative relationship with anticipatory distress; ∅, no effect or significant relationship; O = observational study; E = experimental study; R = retrospective study; RCT = randomized controlled trial; Preop = preoperative; LP = lumbar puncture; BMA = bone marrow aspiration.

Table III.

Perpetuating Factors of Anticipatory Anxiety

StudyAge (years)NCountryProcedureDesignRisk of biasResultSummary of biasResults summary
Child perpetuating factors
1. Child knowledge (7 studies; N = 1,850)
Claar, Walker, and Barnard (2002)8–17100USAEGDOLowUnclear (5 low, 2 unclear)Inconclusive
Crandall, Lammers, Senders, Braun, and Savedra (2008)7–1360USAPreopELow
Jacobson etal. (2001)1–6150USAImmunizationOLow
Claar, Walker, and Smith (2002)8–18100USAEGDOLow
Davidson etal. (2006)3–121,250AustraliaPreopOLow
Hatava, Olsson, and Lagerkranser (2000)2–10160SwedenPreopEUnclear
Siaw, Stephens, and Holmes (1986)3.5–12.830USAPreopOUnclear
2. Child coping style (4 studies; N = 174)
Bijttebier and Vertommen (1998)2.75–12.7547BelgiumVenipunctureOHigh+Unclear (1 high, 3 low)Inconclusive
Field etal. (1988)4–1056USAPreopOLow
Smith, Ackerson, and Blotcky (1989)6–1828USABMA and LPOLow
Thompson (1994)8–1243USAPreopOLow
3. Other child behaviors (2 studies; N = 368)
2–10293USAPreopOLow+Unclear (1 low, 1 unclear)More research needed.
Kain etal. (1998)2–1275USAPreopRCTUnclear
4. Child cognitions (3 studies; N = 352)
Carillo-Diaz et al. (2013)8–18179SpainDentalRUnclear + (expectancy)Unclear (2 low, 1 unclear)Negative child cognitions positively predict child anticipatory distress.
Claar, Walker, and Smith (2002)8–18100USAEGDOLow+
Carpenter (1992)4–1873USAVenipunctureOLow_
Carillo-Diaz etal. (2013)8–18179SpainDentalRUnclear+ (appraisal)
Parent perpetuating factors
1. Parent behavior (7 studies; N = 1,962)
Blount, Sturges, and Powers (1990)5–1322USABMA or LPOUnclear+Unclear (5 low, 2 unclear)Parent behaviour is associated with anticipatory distress. Direction dependent on type of behavior.
Chorney et al. (2009)2–10293USAPreopOUnclear+, − (distraction)
Dahlquist Power, Cox, and Fernbach (1994)2–7, 8–1763USABMAOLow+
Dahlquist etal. (2001)5–1545USAIntramuscular injection and LPOLow+
Lisi etal. (2013)0–1760CanadaImmunizationOLow+
Noel etal. (2010)5–1048CanadaVenipunctureOLow+
Pillai Riddell etal. (2011)0–1731CanadaImmunizationOLow
2. Parent situational distress (19 studies; N = 4,998)
Arnrup etal. (2003)4–1286SwedenDentalEHigh+Unclear (7 high, 9 low, 3 unclear)Positively predicts anticipatory distress.
Bearden etal. (2012)3–590USAImmunizationOLow+
Bevan etal. (1990)2–10134CanadaPreopEUnclear+
Caes etal. (2014)0.6–1528CanadaBMA or LPOUnclear+
Colares etal. (2013)5–12970BrazilDentalRLow+
Dahlquist Power, Cox, and Fernbach (1994)2–7, 8–1763USABMAOLow+
Davidson etal. (2006)3–121,250AustraliaPreopOLow+
Gazal and Mackie (2007)2–12201UKDentalOLow+
Hatava, Olsson, and Lagerkranser (2000)2–10160SwedenPreopEUnclear+
Kain etal. (2000)3–1060USAPreopOHigh+
LaMontagne, Hepworth, Johnson, and Cohen (1996)8–1790USAPreopOHigh+
Messeri, Caprilli, and Busoni (2004)2–1439ItalyPreopOLow+
Olak etal. (2013)8–10344EstoniaDentalRLow+
Tickle etal. (2009)5–9799UKDentalOHigh+
Tourigny (1992)2–1050CanadaPreopOHigh+
Al-Jundi and Mahmood (2010)2–12118JordanDentalOHigh
Dahlquist and Pendley (2005)2.4–5.129USAImmunizationRCTHigh
Hosey etal. (2006)2–14407UKDentalOLow
Tyc etal. (2002)2–780USARadiation TherapyOLow
3. Parent anticipation of child distress (5 studies; N = 742)
Jacobson etal. (2001)1–6150USAImmunizationOLow+Unclear (1 unclear, 4 low)Positively predicts anticipatory distress.
Ortiz etal. (2014)8–16437MexicoDentalOUnclear+
Lumley, Melamed, and Abeles (1993)4–1050USAPreopOLow+
Tyc etal. (2002)2–780USARadiation TherapyOLow+
Srivastava, Betts, Rosenberg, and Kainer (2001)0–6.525AustraliaMicturating cystourethrogramOLow
4. Parent self-efficacy/attitude toward procedure (2 studies; N = 236)
Arnrup etal. (2003)4–1286SwedenDentalEHighUnclearMore research is needed.
Jacobson etal. (2001)1–6150USAImmunizationOLow

Note. + Factor has a positive relationship with anticipatory distress; − Factor has a negative relationship with anticipatory distress; ∅, no effect or significant relationship; O = observational study; E = experimental study; R = retrospective study; RCT = randomized controlled trial; Preop = preoperative; LP = lumbar puncture; BMA = bone marrow aspiration; EGD = esophagogastroduodenoscopy.

Table IV.

Present Factors of Anticipatory Anxiety

StudyAge (years)NCountryProcedureDesignRisk of biasResultSummary of biasResults summary
Child present factors
1. Idiosyncratic needs (1 study; N = 9)
Ameringer etal. (2013)13–189USAChemotherapyOLow + LowMore research is needed.
Parent present factors
1. Parent presence (6 studies; N = 2,159)
Al-Jundi and Mahmood (2010)2–12118JordanDentalOHighUnclear (3 low, 2 high, 1 unclear)Inconclusive
Bevan etal. (1990)2–10134CanadaPreopEUnclear
Davidson etal. (2006)3–121,250AustraliaPreopOLow
Tourigny (1992)2–1050CanadaPreopOHigh+
Messeri, Caprilli, and Busoni (2004)2–1439ItalyPreopOLow
Kain etal. (2006)2–12568USAPreopOLow−,+
Health care professional factors
1. Health professional behavior (3 studies; N = 386)
Noel etal. (2010)5–1048CanadaVenipunctureOLow+Unclear (2 low, 1 unclear)Distress promoting behaviour positively predicts child anticipatory distress.
Chorney et al. (2009)2–10293USAPreopOUnclear+
Dahlquist etal. (2001)5–1545USAIntramuscular injection and LPOLow+ (nurse)
∅ (MD)
Contextual present factors
1. Environmental factors (15 different studies; N = 4,926)
Davidson etal. (2006)3–121,250AustraliaPreopOLow− admission typeUnclear (9 low, 4 high, 2 unclear)More research needed.
Holm-Knudsen, Carlin, and McKenzie (1998)0–142,122AustraliaPreopOUnclear− induction location
Kain, Wang, Mayes, Krivutza, and Teague (2001)2–770USAPreopRCTHigh− reduced sensory stimulation
Mekarski and Richardson (1997)2.5–13324CanadaDentalOLow+ dental work severity
deVos etal. (2012)M = 3.118USAImmunotherapy InjectionsOHigh∅ injection personnel
Horton etal. (2015)1–1.5130CanadaImmunizationOLow∅ number of needles
Davidson etal. (2006)3–121,250AustraliaPreopOLow+ longer procedure
deVos etal. (2012)M = 3.118USAImmunotherapy InjectionsOHigh+ intervals between needles
Holm-Knudsen, Carlin, and McKenzie (1998)0–142,122AustraliaPreopOUnclear∅ fasting time
Al-Jundi and Mahmood (2010)2–12118JordanDentalOHigh+ referral reason
Dahlquist Power, Cox, and Fernbach (1994)2–7, 8–1763USABMAOLow∅ time since diagnosis
Dahlquist etal. (2001)5–1545USAIntramuscular injection and LPOLow∅ time since diagnosis
Tyc etal. (2002)2–780USARadiation TherapyOLow∅ time since diagnosis
Dahlquist and Pendley (2005)2.4–5.129USAImmunizationRCTHigh− time since diagnosis
Holm-Knudsen, Carlin, and McKenzie (1998)0–142,122AustraliaPreopOUnclear∅ type of case
Ortiz etal. (2014)8–16437MexicoDentalOUnclear∅ procedure
Wright, Stewart, and Finley (2010)3–661CanadaPreopELow∅ surgery type
Wollin etal. (2004)5–12120AustraliaPreopOLow+ various factors
deVos etal. (2012)M = 3.118USAImmunotherapy InjectionsOHigh∅ number of needles
Fortier etal. (2011)11–1859USAPreopOLow∅ preadmission visit

Note. +, factor has a positive relationship with anticipatory distress; −, factor has a negative relationship with anticipatory distress; ∅, no effect or significant relationship; O = observational study; E = experimental study; R = retrospective study; RCT = randomized controlled trial; Preop = preoperative; LP = lumbar puncture; BMA = bone marrow aspiration.

In terms of the types of outcome measures, 43 measured anxiety, 15 measured fear, 13 measured distress, and 6 measured baseline pain. The majority of outcome measures were self-report (35), while the remaining outcome measures were behavioral (11) or observer reported (31).

Risk of Bias

Risk of bias was assessed for the 77 studies included in the review using the Cochrane Collaboration methodology for systematic reviews. As all but 7 studies were nonrandomized controlled trials, 15 studies were evaluated to have high risk of bias, 16 studies had unclear risk of bias, and 46 studies had low risk of bias (Tables I–IV).

Factors Included in the Review

The list of factors that predict anticipatory distress to painful medical procedures can be found in the left-most column of Tables I–IV. Overall, there were 31 factors that were examined for their relationship to predict anticipatory distress.

Overall Findings

The overall goal of the review was to synthesize the literature on factors that predict anticipatory distress to painful medical procedures. Following data extraction, the lead and senior authors synthesized the results into the summary figure. The summary figure (Figure 2) includes most of the information from Tables I to IV and highlights the contribution of predisposing, precipitating, perpetuating, and present factors influencing the child’s anticipatory distress. Only factors with two studies or more that were similar in nature were included in Figure 2. Moreover, in the summary figure, factors were subcategorized according to child, parent, health care professional, and/or contextual domains. Finally, the risk of bias and overall findings synthesis have been presented in Tables I–IV as well as in Figure 2.

Predisposing Factors

Child

As seen in Table I, 10 variables were identified for child predisposing factors (Table I). Results suggest that the data regarding age were inconclusive with almost half the studies showing no age effect, and the majority of the other studies suggesting younger children have higher anticipatory distress. The overall risk of bias for age was unclear (Table I). For gender, although results were varied, most studies (20/26) reported there was no effect of gender on anticipatory distress in children, while six studies found that girls experienced more anticipatory distress than boys. The overall risk of bias for gender was unclear (Table I). Four studies examined the effect of race on anticipatory distress, with the majority suggesting no effect. The overall risk of bias was unclear (Table I). Birth order was not found to have an effect on child anticipatory distress as indicated by three studies. The effect of number of siblings and sibling order was investigated by three studies and was found to have no effect. Child illness and child intelligence were both investigated by one study and were both found to positively predict child anticipatory distress.

For child psychopathology, the overall findings (6/8) supported the positive relationship between preexisting child psychopathology and increased child anticipatory distress to painful medical procedures. The overall risk of bias rating was unclear (Table I). For child temperament, the overall findings (8/11 studies) support a positive relationship between difficult child temperament and increased child anticipatory distress. The overall risk of bias score for temperament was unclear (Table I). Finally, there were inconclusive results for child attachment from two low risk of bias studies. One study (Horton etal., 2015) indicated that infants with avoidant infant attachment had lower anticipatory distress where as another study () found no effect.

Parent

A total of 12 studies provided evidence for parent predisposing factors that are associated with child anticipatory distress to painful medical procedures. Results are found in Table I. Overall findings suggest that parent anxious predisposition, and pain experience or fear of pain were all associated with increased anticipatory distress. The results for parent education and coping style were found to be inconclusive.

Health Professional

No health professional factors were found under the predisposing domain.

Contextual

Two factors were identified as contextual predisposing factors: previous hospitalization of the child or sibling (five studies) and other contextual factors (four studies). For previous hospitalization, four of the five studies found no effect of previous hospitalization on child anticipatory distress; however, one study () found that hospitalization of a sibling (but not of self) was associated with higher anticipatory distress. The overall risk of bias for this factor was unclear. In terms of other contextual factors, the overall findings showed that having never visited a dentist and having irregular visits to the dentist are positively associated with child anticipatory distress. Other demographic variables had mixed results. The evidence for this factor was unclear.

Precipitating Factors

Child

Two broad factors were identified as precipitating factors that contributed to the onset of anticipatory distress to painful medical procedures (Table II). The first factor was general and specific negative pain events (33 studies). The results showed that 17 studies found that previous negative experiences positively predict child anticipatory distress, whereas 12 studies found no effect of previous painful events. Four studies indicated that history of painful procedures was in fact associated with decreased child anticipatory distress. Overall, the evidence points toward a positive relationship between previous pain events and child anticipatory distress based on unclear risk of bias.

The second precipitating child factor that was identified was previous child/adolescent behavior (five studies). Overall, results indicate that previous pain behavior positively predicts child anticipatory distress. The risk of bias was unclear.

Parent

No parent factors were found under the precipitating domain.

Health Professional

No health professional factors were found under the precipitating domain.

Contextual

No contextual factors were found under the precipitating domain.

Perpetuating Factors

Child

As listed in Table III, four factors were identified as child perpetuating factors: child knowledge (seven studies), child coping style (four studies), child cognitions (three studies), and other child behaviors (two studies). For child knowledge, the results were inconclusive. This was based on unclear evidence. The evidence for child coping style was inconclusive based on unclear risk of bias. For child cognitions (three studies), overall results suggest that child cognitions including high threat appraisal, lower perceived control, and high aversion to the procedure were all associated with higher child anticipatory distress, based on studies with unclear risk of bias. Finally, the evidence for other child behaviors (two studies) was inconclusive as studies highlighted different child behaviors associated with increased or decreased anticipatory distress.

Parent

Four factors were identified as parent perpetuating factors: parent behavior (7 studies), parent situational distress (19 studies), parent anticipation of child distress (5 studies), and parent self-efficacy/attitudes (2 studies) (Table III). Overall findings suggest that most parent behavior, parent situational distress, and parent anticipation of child distress were associated with increased anticipatory distress (Table III).

Health Professional

No health professional factors were found under the perpetuating domain.

Contextual

No contextual factors were found under the perpetuating domain.

Present Factors

Child

As listed in Table IV, one factor was identified for child present factors: idiosyncratic needs. One study () showed that fatigue and nausea were positively associated with child anticipatory distress prior to chemotherapy with a low risk of bias.

Parent

One parent present factor was identified: parental presence during a painful medical procedure. The overall results for this factor are inconclusive (Table IV). The risk of bias for this factor was unclear.

Health Professional

One factor was identified as a health professional present factor: health professional behavior (three studies). Overall, evidence suggests that distress promoting behavior by health care professionals is associated with higher child anticipatory distress. The overall risk of bias was unclear.

Contextual

One broad factor, environmental factors, was identified for contextual present factors. Fifteen studies investigated the effects of various contextual factors on child anticipatory distress during the painful medical procedure (e.g., type of admission and severity of procedure). Results vary based on the study.

Discussion

The purpose of this review was to summarize the findings of studies that examine the factors that predict anticipatory distress to painful medical procedures in children. The overarching goal of this review was to qualitatively synthesize the literature on the factors that predict anticipatory distress to painful medical procedures into a summary figure using predisposing, precipitating, perpetuating, and present factors as a framework. The following paragraphs will discuss key findings and patterns from the summary figure (Figure 2) of the review in the context of methodological differences and risk of bias within studies. Only factors with two or more included studies of a similar nature that can be found in the summary figure will be discussed. Finally, clinical implications, areas for future research based on the summary figure and limitations of the review will be highlighted.

Predisposing Factors

Child

There were some interesting patterns among the child predisposing factors. First, there is clear evidence that child psychopathology and difficult, fearful, or shy child temperament are individual child factors that increase the risk of child anticipatory distress. This finding is in line with developmental literature suggesting that children who have internalizing or externalizing problems have more difficulty regulating their affect (Bradley, 2003). Preexisting psychopathology or difficult temperament may be important factors to screen for prior to a medical procedure or surgery to have an understanding of how a child might respond or cope with the procedure. The risk of bias subsuming this factor was generally unclear because there were 6 low and 2 high-rated studies included.

Second, gender does not appear to play an important role in predicting anticipatory distress. Although some studies did find that girls experience higher anticipatory distress to medical procedures, the majority of studies did not find an effect. The studies that found an effect for girls had participants closer to pubertal age, which may have played a role.

Some predisposing child factors yielded inconclusive results. Despite the large body of research (43 studies) that examined the effect of age on child anticipatory distress, the research on this factor does not seem to converge. Almost half the studies showed no effect of age, while the other half suggests younger children experience higher anticipatory distress. The type of medical procedure did not seem to systematically differ between the two groups. Although the studies that did not find an effect of age were more likely to have a low risk of bias, it is difficult to make conclusions based on this. Methodological factors may also have contributed to differences in results as the majority of studies did not examine a discrete age range but rather averaged over large age ranges of up to 15 years. Examining a restricted age range may also have contributed to the lack of an effect. At this point, the results on age remain largely inconclusive, although the results from this review point toward younger children experiencing more anticipatory distress than older children. This is in line with the literature that indicates that younger children are more likely to be fearful and distressed and that this fear may increase and decrease over the course of childhood (American Psychiatric Association, 2013). It may also be the case that the relationship between age and anticipatory distress is nonlinear or co-varies with other factors. Future longitudinal or cross-sectional studies could provide some insight into whether age is an important factor in predicting child anticipatory distress.

Parent

Two parent predisposing factors that emerged as predicting increased child anticipatory distress are parent anxious predisposition and previous parent pain experience. The fact that a parent’s own anxiety and fear/experiences with pain are related to the child’s anticipatory distress directly supports the transmission of anxiety from parent to child. Previous work has hypothesized the mechanisms by which this occurs, such as through modeling and information transmission (Rachman, 1977; ). It may be that parents are discussing or demonstrating their fear of pain as it relates to painful medical procedures, impacting the anticipatory distress of their children. Future experimental research could examine how transmission of fear of painful medical procedures occurs to develop targets for intervention. Risk of bias was variable across factors ranging the full gamut from low to unclear to high. Of note, the anxious predisposition has low risk of bias; thus, there is increased confidence in this finding.

Inconclusive results were found for the impact of parent education level on child anticipatory distress. The difference in finding may be due to the differences in education levels included in the studies. More research is needed in this area.

Context

Two contextual factors emerged under the predisposing domain. First, previous hospitalization was overall not found to have an effect on child anticipatory distress (only previous hospitalization of siblings did). It may be that hospitalization itself is not sufficient to lead to the development of fear but rather that negative experiences or vicarious fear are much more salient. The risk of bias for this factor was unclear as there was a mix of high and low rated studies. Few predisposing contextual factors have been examined and more research is needed.

Precipitating Factors

Child

Two broad factors were identified as factors that contributed to the onset of anticipatory distress to painful medical procedures. The first factor is general and specific negative pain events. Although the overall result is that previous negative pain events predict anticipatory distress, this was not uniformly the case across studies. Some reasons for this include risk of bias and sample size. The studies that found an effect of previous negative procedures largely had low risk of bias and large sample sizes. The studies that found a negative relationship between previous pain events and anticipatory distress were methodologically different in that they all involved short routine medical procedures such as insulin injections (Hanas etal., 2002; ) and immunotherapy injection (deVos etal., 2012). These types of procedures provide repeated exposure to the stimuli whereby eventually extinction of the fear occurs. Typically, developing children do not usually have daily exposure to needles or surgery to facilitate extinction, which may explain the difference in finding for the studies. Furthermore, previous work in child anxiety has demonstrated that direct conditioning is only one pathway to the development of anxiety problems in children (). According to retrospective reports of adults with phobia, modeling and information transmission were the most common modes of fear acquisition with a minority reporting direct conditioning experiences (). This highlights that, although direct conditioning of a general or specific negative pain event may precipitate anticipatory distress for some children, multiple factors are at play, including the frequency and severity of the painful medical procedure.

The second factor that was identified as a child precipitating factor is previous child/adolescent behavior (five studies). There is evidence that a child or adolescent’s previous behavior during a painful medical procedure will predict anticipatory distress at a future medical procedure. The risk of bias was rated as unclear due to one study with an unclear rating.

Perpetuating Factors

Child

Four child factors were identified as maintaining child anticipatory distress. First, child maladaptive cognitions were found to positively predict distress prior to a procedure with overall low risk of bias studies. Overall, children who perceived less control expected an aversive experience and appraised procedures as more threatening were more inclined to be distressed prior to those procedures. Given that child threat appraisal and perceived control predict child anticipatory distress, this highlights the importance of teaching children cognitive and behavioral coping strategies to manage their anticipatory distress. The overall risk of bias is unclear, reducing our confidence in these findings.

In terms of having more knowledge about the procedure, the overall results were inconclusive; however, three studies did show a decrease in anticipatory distress. The method, type of information, and developmental level of the knowledge provided may be important variables in whether the knowledge presented works. The overall risk of bias was unclear for this factor, reducing our confidence in the findings. There was inconclusive evidence for child coping style with unclear risk of bias, reducing confidence in these findings. There are specific child behaviors such as using nonprocedural talk, humor, and talking to a parent that were related to child coping before a procedure, while verbal resistance was found to be positively associated to child preoperative anxiety. The child behavior factor had an overall unclear risk of bias, reducing our confidence in these findings. More research on the child behaviors that are associated with coping before a painful medical procedure will help inform targets for intervention.

Parent

When examining the parent factors that perpetuate a child’s anticipatory distress to painful medical procedures, an important pattern emerges. Across three factors examined, there was evidence that parent factors play a key role in maintaining the distress of children during painful medical procedures. Parent behavior during the procedure, parent situational distress/state anxiety, and parent anticipation of child distress had overall results predictive of child anticipatory distress. Although the findings of the studies were not completely uniform, the majority of studies highlighted the role that parents play in continuing child anticipatory distress. It has been argued that, particularly for infants and young children, the caregiver is the most important context in the pediatric pain setting (). Parental responding (modeling, overprotection, reinforcement, and encouragement) plays a key role in the development of anxiety (). These results highlight the importance of engaging parents in interventions to help reduce child anticipatory distress. The risk of bias for the parent perpetuating factors was unclear, indicating reduced confidence in these findings.

Present Factors

Parent

A trend toward family-centered care has led to the increase of parental presence within pediatric healthcare settings. Although parent presence during child hospital stays have been associated with positive outcomes (), parent presence during a painful medical procedure in this review had inconclusive results. However, two studies pointed to mechanisms that may underlie the effect of parental presence. Kain, Caldwell-Andrews, Maranets, Nelson, and Mayes (2006) found that the presence of a calm parent reduces preoperative anxiety, while the presence of an overly anxious parent does not. Given the transactional and individual factors that predict anticipatory distress, clinical recommendations for parental presence during a procedure should be based on characteristics of the parent and their ability to provide calm support rather than the blanket assumption that all parents should consistently be present or not present. More research should investigate the conditions under which parental presence is beneficial in reducing child anticipatory distress.

Health Professional

Our synthesis demonstrates that health care professional behavior does play an important role in predicting child anticipatory distress. Given the crucial role that healthcare professionals can play in the experience of children and families during painful medical procedures (), researchers should continue to examine distress reducing behaviors such as distraction that could be taught to health care professionals, as well as parents, as an intervention to reduce procedural distress prior to a painful medical procedure.

Contextual

Fifteen studies investigated the effects of various contextual factors on child anticipatory distress during the painful medical procedure. It is difficult to synthesize this research due to the varied contextual factors; however, some environmental factors (e.g., induction location and sensory stimulation) do seem to impact anticipatory distress. More research is needed to determine which contextual factors should be addressed in clinical practice.

Author’s Conclusions and Clinical Implications

As outlined in developmental psychopathology theory (), the development of anticipatory distress occurs through a dynamic interplay of factors, including individual child factors, parent factors, health professional factors, and their environment. There is no unique pathway that leads to the development of anticipatory distress but rather the interaction of predisposing, precipitating, perpetuating, and present factors over time leads to the onset and maintenance of distress.

In this review, we examined 31 factors that predict anticipatory distress. Children with preexisting anxiety and a difficult temperament were more likely to have anticipatory distress. Parents and children should examine patterns of past child behavior during painful procedures to better support and prepare children with these risk factors. Parent anxiety and parent’s previous experiences with pain are also important predictors of anticipatory distress. This suggests that parents need to be aware of their own subjective experience of medical procedures and how to manage their own anxiety in medical contexts. Past pain events and previous child behavior are indicators of future anticipatory distress. Using adequate pain management is of utmost importance in reducing the likelihood of conditioning fear and anxiety. Child and parent emotional and cognitive factors serve to maintain or fuel anticipatory distress. These areas will be important targets for interventions. Finally, health professionals should be wary of engaging in distress promoting behavior such as verbal reassurance and criticism and are encouraged to use coping promoting behavior such as talking about things other than the procedure and engaging in distraction.

Limitations and Implications for Research

This review highlights important gaps where additional research is needed. As shown in Figure 2, factors that are depicted with a question mark have inconclusive evidence. All of these areas would benefit from additional research to investigate their impact on anticipatory distress. Additionally, there is a need for longitudinal and more complex methodologies to investigate the transactional nature of these factors. Future studies should also examine the interaction of multiple factors (i.e., temperament, previous pain experience, and parent behavior) to determine the relative contribution of these factors. Furthermore, many of the studies included in the review were found to have high risk of bias often through biased outcome assessors or poor quality measures used. Many of the factors (e.g., child level of anxiety, age, gender, parent anxiety, and previous pain experiences) cannot be randomized to participants to improve the quality of the methodology to test these factors. However, the knowledge of these proposed factors should be incorporated in randomized trials that test the efficacy of treatments of anticipatory distress. Having large age ranges in studies and not controlling for factors such as psychopathology (parent/child), previous pain experiences (parent/child) and parent soothing behaviors/coping strategies will continue to limit the value of randomized controlled trials because they do not attempt to accommodate the inherent variability of pain responses and the causes for the variability (Pillai Riddell etal., 2013).

Supplementary Data

Supplementary data can be found at: http://www.jpepsy.oxfordjournals.org/.

Supplementary Data:

Acknowledgments

The authors thank Noam Bin-Noon for her contribution to this review in conducting some of the initial article screening, Elizabeth Uleryk for performing the data searches and Zhaodi Culbreath for assistance with figures.

Funding

This research was supported by awards to Dr. Pillai Riddell from the Canadian Institutes of Health Research (MOP 84511), the Ontario Ministry of Research and Innovation (ER05-08-219), the Canadian Foundation for Innovation, and the York Research Chairs Program. Ms. Racine received awards from the Canadian Institutes of Health Research, the Government of Ontario, the Lillian and Don Wright Foundation, and the Canadian Pain Society. Ms. Racine is also a trainee member of Pain in Child Health (PICH), a strategic research training initiative of the Canadian Institutes of Health Research.

Conflicts of interest: None declared.

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Articles from Journal of Pediatric Psychology are provided here courtesy of Oxford University Press

Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children (2024)

FAQs

What are the 4 P's predisposing precipitating? ›

The four “Ps” of case formulation (predisposing, precipitating, perpetuating, and protective factors) also provide a useful framework for organizing the factors that may contribute to the development of anticipatory distress (Barker, 1988; Carr, 1999; Winters, Hanson, & Stoyanova, 2007).

What are predisposing factors and precipitating factors? ›

Predisposing factors are those that put a child at risk of developing a problem (in this case, high anticipatory distress). These may include genetics, life events, or temperament. Precipitating factors refer to a specific event or trigger to the onset of the current problem.

What factors that put a child at risk of developing a problem and anticipatory distress? ›

The factors that appear to increase anticipatory distress are child psychopathology, difficult child temperament, parent distress promoting behaviors, parent situational distress, previous pain events, parent anticipation of distress, and parent anxious predisposition.

What are examples of predisposing factors? ›

Predisposing factors include demographic characteristics and socio-structural characteristics such as education level, race and ethnicity, and family size.

What is the 4 P model? ›

The 4Ps of marketing is a model for enhancing the components of your "marketing mix" – the way in which you take a new product or service to market. It helps you to define your marketing options in terms of price, product, promotion, and place so that your offering meets a specific customer need or demand.

What are precipitating factors of pain? ›

Psychological Risk Factors of Pain
  • Anxiety and depression.
  • Negative thoughts about illness and pain catastrophizing.
  • Fear of pain and avoidance.
  • Childhood trauma and pain.
  • Additional resources.

What are perpetuating factors factors? ›

Perpetuating factors: Factors that cause the young person's symptoms/problems to continue or to progressively get worse (e.g. conflict in home, low social support, poor coping strategies, bullying)

What does predisposing mean in medical terms? ›

(jeh-NEH-tik PREE-dih-spuh-ZIH-shun) An increased chance or likelihood of developing a particular disease based on the presence of one or more genetic variants and/or a family history suggestive of an increased risk of the disease. Having a genetic predisposition does not mean an individual will develop the disease.

What are the 4 types of protective factors? ›

Protective factor examples

Positive attitudes, values or beliefs. Conflict resolution skills. Good mental, physical, spiritual and emotional health.

What are the three 3 most common environmental factors that may put a child at risk for experiencing neglect? ›

Community Risk Factors
  • Communities with high rates of violence and crime.
  • Communities with high rates of poverty and limited educational and economic opportunities.
  • Communities with high unemployment rates.
  • Communities with easy access to drugs and alcohol.

What are the 5 protective factors? ›

Five Protective Factors are the foundation of the Strengthening Families Approach: parental resilience, social connections, concrete support in times of need, knowledge of parenting and child development, and social and emotional competence of children.

What is difference between risk factor and predisposing factor? ›

Predisposing factors are the risk factors that make a person more susceptible to developing a disease. It should not be confused with precipitating factors.

What is another name for predisposing factors? ›

Some common synonyms of predispose are bias, dispose, and incline. While all these words mean "to influence one to have or take an attitude toward something," predispose implies the operation of a disposing influence well in advance of the opportunity to manifest itself.

What are positive predisposing factors? ›

[29] Predisposing factors, which include knowledge, beliefs, values, attitudes, and self-efficacy, appeal to people's motives for behavior change. Enabling factors, which include health-related skills, and resources (e.g., training), facilitate a behavior's occurrence.

What are the 5 P's in psychology? ›

What should a formulation comprise? The 'Five P's' approach to formulation
  • Presenting problem. ...
  • Predisposing factors. ...
  • Precipitating factors. ...
  • Perpetuating factors. ...
  • Protective/positive factors.
Sep 27, 2012

What is considered predisposing factors for disease? ›

Some predisposing factors of contracting infectious diseases can be anatomical, genetic, general and disease specific. Climate and weather, and other environmental factors that are affected by them, can also predispose people to infectious agents.

What are the five Ps 5ps psychology? ›

They conceptualized a way to look at clients and their problems, systematically and holistically taking into consideration the (1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors.

What are the 4Ps and what does each mean? ›

The four Ps are a “marketing mix” comprised of four key elements—product, price, place, and promotion—used when marketing a product or service. Typically, businesses consider the four Ps when creating marketing plans and strategies to effectively market to their target audience.

What is the 4 C's model? ›

The 4Cs (Clarity, Credibility, Consistency, Competitiveness) is most often used in marketing communications and was created by David Jobber and John Fahy in their book 'Foundations of Marketing' (2009).

What are the 4Ps of biopsychosocial model? ›

The VCE Psychology Study Design requires students undertaking Unit 4 to use a 4P factor model (predisposing, precipitating, perpetuating and protective factors) as a subset of a biopsychosocial approach to analyse mental health and the development and progression of mental health disorders.

What are the three main cognitive factors that influence the pain experience? ›

The cognitive factors attention, expectancy and appraisal can either increase or decrease pain experiences depending on their specific focus and content. Many brain regions are involved in nociceptive processing and bringing pain into awareness.

What situational factors influence pain? ›

Attention, understanding, control, expectations, and the aversive significance can affect pain perceptions.

What are the 4 process of pain? ›

There are four major processes: transduction, transmission, modulation, and perception. Transduction refers to the processes by which tissue-damaging stimuli activate nerve endings.

What is an example of precipitating event? ›

Precipitating Event

Sometimes a major life event moves a person from thinking about suicide to attempting suicide. Certain events may be insignificant to one person and very troubling to another.

What are precipitating stressors? ›

the particular factor, sometimes a traumatic or stressful experience, that is the immediate cause of a mental or physical disorder.

What are the predisposing factors of stress? ›

What kind of situations can cause stress?
  • Illness or injury.
  • Pregnancy and becoming a parent.
  • Infertility and problems having children.
  • Bereavement.
  • Experiencing abuse.
  • Experiencing crime and the justice system, such as being arrested, going to court or being a witness.
  • Organising a complicated event, like a holiday.

What does predispose mean for kids? ›

Kids Definition

predispose. verb. pre·​dis·​pose ˌprēd-is-ˈpōz. : to dispose in advance : make susceptible : incline.

What is an example of a predisposition to a medical condition? ›

There are a range of conditions and illnesses linked to a genetic predisposition. These include certain cancers, diabetes, obesity, heart disease, asthma, celiac disease, and more. Researchers have also linked mental illnesses, autism, and even addiction to genetics.

What does perpetuating mean in medical terms? ›

Definition. Factors or conditions that maintain the disabling symptoms in an individual.

What are the six areas of risk and protective factors in juvenile delinquency? ›

These factors include parenting, mal- treatment, family violence, divorce, parental psychopathology, familial anti- social behaviors, teenage parenthood, family structure, and family size. Inadequate parenting practices are among the most powerful predictors of early antisocial behavior (e.g., Hawkins et al., 1998).

Why are the 5 protective factors important? ›

Protective factors help ensure that children and youth function well at home, in school, at work, and in the community. They also can serve as safeguards, helping parents who otherwise might be at risk find resources, support, or coping strategies that allow them to parent effectively—even under stress.

What are 3 factors that may make individuals more vulnerable to abuse? ›

Risk factors for abuse

Lack of mental capacity. Increasing age. Being physically dependent on others. Low self-esteem.

What are the 3 main problems factors that threaten environmental health? ›

Climate change and natural disasters. Diseases caused by microbes. Lack of access to health care. Infrastructure issues.

What are the top key threats that will harm the health of a child? ›

Top 10 concerns of parents
  • Bullying/cyberbullying. Whether harassment takes place in person or online, the actions can have deep effects on a child's mental and physical health. ...
  • Internet safety. ...
  • Stress. ...
  • Motor vehicle accidents. ...
  • School violence. ...
  • Depression. ...
  • Unhealthy eating. ...
  • Not enough exercise.
Aug 21, 2017

What are the four types of child maltreatment? ›

Within the minimum standards set by CAPTA, each State is responsible for providing its own definitions of child abuse and neglect. Most States recognize four major types of maltreatment: physical abuse, neglect, sexual abuse, and emotional abuse.

What are protective factors for children's mental health? ›

Things that can help keep children and young people mentally well include:
  • being in good physical health, eating a balanced diet and getting regular exercise.
  • having time and freedom to play, indoors and outdoors.
  • being part of a family that gets along well most of the time.
Aug 12, 2021

What types of factors can mitigate risk and minimize the potential for child maltreatment? ›

Protective Factors
  • Parental Resilience. ...
  • Social and Emotional Competence of Children. ...
  • Parental Knowledge of Child Development and Parenting Skills. ...
  • Concrete Support for Parents. ...
  • Social Connections. ...
  • For More Information.

What are examples of predisposing and precipitating factors? ›

Based on the developmental psychopathology perspective, factors in this review were hypothesized to fall under the four Ps of case formulation: predisposing (e.g., genetics and temperament), precipitating (e.g., negative pain experiences), perpetuating (e.g., parent behavior, parent anxiety, child behavior, and child ...

What does predisposing mean in mental health? ›

n. 1. a susceptibility to developing a disorder or disease, the actual development of which may be initiated by the interaction of certain biological, psychological, or environmental factors. 2.

What are predisposing enabling and need factors? ›

Predisposing factors reflect the individuals' propensity to use health services, enabling factors are the resources that may facilitate access to services, and the need factors represent potential needs of health service use, such as self-perceived health, chronic conditions, and restricted activity [10].

What are the 4 types of risk factors? ›

In general, risk factors can be categorised into the following groups:
  • Behavioural.
  • Physiological.
  • Demographic.
  • Environmental.
  • Genetic.

What are the 4 Ps in the biopsychosocial model? ›

The VCE Psychology Study Design requires students undertaking Unit 4 to use a 4P factor model (predisposing, precipitating, perpetuating and protective factors) as a subset of a biopsychosocial approach to analyse mental health and the development and progression of mental health disorders.

Which of the 4 P's includes distribution? ›

Place – the third P of the marketing mix

The third P of marketing is about where you will sell your product or service. This encompasses both your distribution channels and your place in the market. Your distribution channels are the avenues through which you reach your target market.

What are predisposing factors in behavior? ›

[29] Predisposing factors, which include knowledge, beliefs, values, attitudes, and self-efficacy, appeal to people's motives for behavior change. Enabling factors, which include health-related skills, and resources (e.g., training), facilitate a behavior's occurrence.

What are precipitating factors in psychiatry? ›

Precipitating factors: Immediate issues or events that have caused the young person to present with or experience these problems or symptoms at this time (e.g. recent life experiences/stressors, bullying etc.)

What are the 4 P's in healthcare? ›

Similarly, “P4 Medicine” hopes to transform medicine by leveraging four interconnected strategies: Prevention, Prediction, Personalization, and Participation.

What are the 3 levels of the biopsychosocial approach? ›

The biopsychosocial perspective is an integrated approach to psychology that incorporates three different perspectives and types of analysis: biological, psychological, and social-cultural.

What are the 3 domains of the biopsychosocial model? ›

The Biopsychosocial (BPS) Model

The biopsychosocial model of wellness and medicine examines how the three aspects – biological, psychological and social – occupy roles in relative health or disease.

What is the most important out of the 4 Ps? ›

These are Promotion, Product, Place and Price. These 4 Ps play a major role in delivering the customer needs at the right time and the right place. Philip Kotler says, The most important thing is to predict where clients are going and stop right in front of them.

What are the 6 main distribution channels? ›

Here are eight distribution channels that can help consumers access products:
  • Direct sales. ...
  • Retailer. ...
  • Independent distributor. ...
  • Reseller. ...
  • Wholesaler. ...
  • Intensive distribution. ...
  • Exclusive distribution. ...
  • Selective distribution.

Which one of the following is not included in 4 Ps? ›

Detailed Solution:

The four Ps of marketing are Product, Price, Place and Promotion. Patience does not come under 4 Ps of marketing.

What are 5 factors that might influence a child's behavior? ›

External factors:
  • family relationships.
  • changes to family circumstances.
  • an event that has occurred in the community.
  • limited social experiences.
  • cultural expectations, experiences and child rearing practices.
  • exposure to drugs, alcohol.
  • the child's emotional development and temperament.

What are predisposing factors Andersen model? ›

Predisposing factors include age, sex, marital status, education, race/ethnicity, and occupation, as well as a set of beliefs (e.g., attitudes toward health services, knowledge about disease, and values).

What are the 5 Ps formulation? ›

The 5Ps highlight an approach that incorporates Presenting, Predisposing, Precipitating, Perpetuating, and Protective factors to a consumer's presentation.

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