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Psychological Issues in Paediatric Surgery 83

operative behaviour is with children between the ages of 2 and 6 years. styles in a clinical setting is to note those parents who exhibit high
Preoperative anxiety has also been linked to disturbances at recovery information-seeking behaviour or a high need to monitor the child’s
from the effects of anaesthesia. 10–12 Disturbances in the child’s postsur- progress. These parents are most likely adopting a problem-focused
gical behaviour have also been recorded; 13,14 for a small group of these approach and would benefit greatly from information about the
children, this problem can be long lasting. procedure and what the likely outcomes and potential side effects of
Other multiple adverse outcomes associated with the child’s the procedure may be.
anxiety include increased postoperative pain and delirium 15,16 as well MacLaren and Kain, in their comparative study of mothers of
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as postsurgical maladaptive behavioural changes. 17,18 Psychosocial children undergoing minor outpatient surgery and other women awaiting
adjustment problems are a major concern. 19–21 Notably, these changes surgery, found that the mothers of these children were more anxious
are not limited to those awaiting or having undergone an invasive than the women who themselves were undergoing minor operations, but
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procedure; as pointed out by Vernon, these changes are also evident equally as anxious as women awaiting major surgery. These findings
in children who have been hospitalised without necessarily undergoing lend credence to earlier studies, 14,15 which found that mothers of children
any surgical procedure. sought more preoperative information concerning their child’s surgery
An understanding of the effects that a child’s level of anxiety has than adult patients who were themselves awaiting surgery.
on postsurgical outcomes drives the need to direct efforts that would The focus on the parents’ anxiety in regard to the child’s surgical
attempt to reduce preoperative anxiety for these children. Reducing the procedure is important for several reasons. As pointed out by Piira
level of anxiety a child may have in regard to the process may help in et al., parents play a critical role in managing the child’s pain in the
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facilitating postsurgical recovery for that child. 23–25 aftermath of surgery; they are responsible for collaborating with health
Success in reducing the level of stress experienced, however, care professionals in making decisions and choices regarding the
depends on a number of factors. This would include the physician’s child’s health and would need to be competent and prepared to do so.
knowledge as well as skills in working with children or liaising with If the parents’ anxiety and distress are high, their understanding may
their parents in reducing surgery–related anxiety. Some parents may be hindered and their level of cooperation may be inadequate for the
need guidance in what to say to the child, how much detail to include, proper management of the child. Thus, parents should be adequately
the possible presences of a parent at anaesthetic induction, and so informed and in a frame of mind to give consent.
forth. Incorporating working with parents and their children to reduce A high level of parental anxiety during communication with
surgery-related anxiety into the routine clinical practice would help physicians may affect both their ability to communicate their
circumvent some postsurgical complications that may arise, reduce concerns and ask questions and their understanding of the physicians’
readmission rates, and shorten hospital contact days. explanations and prescriptions. This then runs the risk of poor
Parental Anxiety postsurgical management of the child. As pointed out by Montgomery
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As mentioned earlier, parents of children undergoing surgery often et al., there may be a need to engage parents identified as anxious in
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experience considerable stress themselves. Maligalig found that par- a different kind of information-sharing process.
ents were anxious about anaesthesia and associated risks, how the child Additionally, high parental preoperative anxiety is associated with
would respond to the surgical experience, and their own inadequacy in high preoperative anxiety in children undergoing surgery; 10,33–35 it would
taking care of the child when discharged from the hospital. The level of be correct to assume that a reduction in parental anxiety would lead to
anxiety experienced by parents, however, is affected by several factors. better outcomes for the children. Children have a tendency to evaluate
Mothers, for instance, experience a greater degree of anxiety than do and validate their experience based on the responses of the adults
fathers. 27,28 This may be due to maternal instinct or, as discussed later, around them; often, these are the child’s parents. This is seen in babies
the meaning and essence of the child in that family, and the apportion- just learning to walk: whether a fall is worthy of tears or they should
ing of blame when the child becomes ill. just pick themselves up and carry on with what they were engaged in
The anxiety experienced by parents and their ability to manage it has much to do with the response of the parent or the attending adult.
is also related to the coping style adopted. Coping loosely refers to a Where the adult response is shock and concern, it triggers a cry for
parent’s ability to see the problems as manageable, even in the face of help; where the adult response says pick yourself up, it often leads to
its being unpleasant. When faced with a problem, over time, there are less of a tragic response.
generally two response or coping behaviors—a problem-focused or For children who may be experiencing a particular event for the first
an emotion-focused strategy. Thus, responses may be predominantly time, which in this case is surgical, the cue to how to respond is to gather
problem-focused or predominantly emotion-focused. People who use from the adults in that environment their anxiety or fears about the event,
problem-focused strategies in coping are likely to be characterised as which is usually evident to the child, and to respond with a similar
exhibiting approach behaviours. These individuals would seek health- degree of anxiety. Because of this dependence on parents for guidance in
and procedure-related information about the surgery and they generally coping with new or stressful situations, the focus and the need to address
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would be more anxious prior to the procedure. In contrast, people parental anxiety in this situation is all the more pertinent.
who adopt emotion-focused strategies are characterised by avoidance Peculiar Stressors in Sub-Saharan Africa
of health-related information and denial of the stress. These individuals Conditions that are peculiar to sub-Saharan Africa contribute particular
are more likely to exhibit greater anxiety after the event than before it. stressors to people living in that region. These include the cost of surgi-
What this implies is that to help people cope with their anxieties, it cal operations, availability of surgical services, essence of children in
would be best to know how they predominantly respond to problems. the Nigerian cultures, and stigmatisation. These are discussed more
Once we can identify this, we can tailor interventions that are congruent elaborately in the following subsections.
with their response (coping) styles. Providing those who respond Cost of Procedure
with a problem-focused strategy with information and elaborating on
the medical equipment and procedure to be undertaken would help Cost is particularly stressful in the sub-Saharan region. This region is
alleviate some of these anxieties. This approach, however, would have characterised by difficult economic and health conditions: a low per
the opposite effect for those who respond with an emotion-focused capita gross domestic product, a negative economic growth rate, low
strategy. For those parents, it would be best to build in activities that life expectancy at birth, and catastrophic maternal and infant mortal-
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would enable deliberate avoidance or refocusing (distraction) from ity. These factors give insight to the stress that paediatric surgery
the procedure. A simple way to identify parents’ predominant coping poses for parents and children. First, the cost of a surgical procedure