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1 Observational Measures of Parent-Child Interactions During Painful Procedures: A Systematic Review Jinbing Bai, PhD(c), MSN, RN Sheila J. Santacroce, PhD, RN, CPNP, FAANP The University of North Carolina Chapel Hill School of Nursing Kristen M. Swanson, PhD, RN, FAAN Seattle University College of Nursing Conflict of Interest Disclosure Authors Conflicts of Interest None of the authors have conflict of interest to declare IRB is not applicable for this review 2 Learning Objectives Outline the missing part of parent-child interactions in painful procedures Review the observational measures of parentchild interactions Compare the observational measures of parentchild interactions Evaluate the observational measures of parentchild interactions 3 1

2 Definition Coding System that can be used to transform qualitative data into numerical data that can be entered into a computer file that can classify field notes into categories (Wikipedia, 2015) The worth of a scientific system lies in its usefulness and economy Skinner (1983, p. 127) 4 Definition Systematic Review...a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data (Green et al 2005) Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results (Green et al 2005) 5 Background Cancer is the second most common cause of death in children and adolescents (Siegel, Naishadham, & Jemal, 2013) Children with cancer experience different painful procedures Children reported that treatment-related procedures can be more traumatic than cancer itself (Ljungman, Gordh, Sorensen, & Kreuger, 1999) 6 2

3 Background cont d Parental presence plays importance roles to help children go through these procedures A recent shift has been made to understand parent-child behavioral interactions during procedures (Caldwell-Andrews, Blount, Mayes, & Kain, 2005; Chorney, Tan, & Kain, 2013) 7 Background cont d Frank et al found that mother behaviors could account for 53% of the variance in child distress in immunizations (Frank et al, 1995) Blount et al categorized parent-child interacting behaviors into parent coping promoting behaviors and parent distress promoting behaviors during LPs and BMAs (Blount et al., 1989, 2001) 8 Background cont d Mixed findings were continuously reported for parent verbal behaviors, i.e., reassurance and empathy (Cline et al., 2006; McMurtry et al., 2006, 2007) Most of these studies depended on correlational analysis rather than new methods (Chorney, Tan, & Kain, 2013) Cassatt, M 9 3

4 Background cont d Clinical applications and research require ways to categorize parent-child interactions Different observational coding systems have been used to quantify parent-child interacting behaviors Two types of observational coding systems: cure systems (i.e. task-focused) vs. care systems (i.e. emotional-based) (Bensing, 1991; Ong, De Haes, Hoos, & Lammes, 1995) 10 Background cont d Other criteria: the population, clinical relevance, observation strategy, reliability and validity, channels of communicative behavior (Ong et al., 1995) Compared with the adult population, the use of extant parent-child interactions coding system is still unknown 11 What is Missing? Study mixed finding in parent-child interactions (Bai, 2015) Explore Longitudinal trajectories of parent-child interactions (Bai, 2015) Use new methods, e.g. time-window sequential analysis (Chorney et al 2013) Review and evaluate of extant coding system systematically (Bai, 2015) 12 4

5 Importance/Significance Examine the strengths and limitations of the extant observational measures Provide solid directions for the future study Give clinicians reliable and valid tools Develop new tools to capture parent-child interactions 13 Purpose Purpose Systematically review and evaluate observational parent-child interaction analysis systems (IASs) during procedures Guideline The PRISMA statement (Moher et al & The PRISMA Group, 2009) 1 Identifying 2 Screening 3 Eligibility 4 Inclusion 14 PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses Search Process Methodology Database PubMed, CINAHL, PsycINFO, Health & Psychosocial Instruments Search Date From inception to Jan 2015 Key Terms (parent-child interaction OR adult-child interaction OR parent-child communication) AND (procedure*) AND (scale OR assessment OR measure OR coding) Key Authors Blount R, Penner L, Caldwell-Andrews AA 15 5

6 Methodology cont d Inclusion and Exclusion Criteria Included Examining reliability/validity or the use of IASs during procedures; targeting at the pediatric population; in English Excluded Review articles; not English; full texts not available 16 Methodology cont d Data Screening and Extraction Screen Include Extract Evaluation Criterion SPP-ATF Criterion (Blount et al., 2008) SPP-ATF, Society of Pediatric Psychology, assembled the Assessment Task Force 17 SPP-ATF Criterion Measure Level Well-established Approaching well-established Promising I II III I II III I II III Specific Criteria Two peer-reviewed articles Allow critical evaluation and replication Good validity and reliability Two peer-reviewed articles Allow critical evaluation and replication Validity and reliability information One peer-reviewed article Validity and reliability information Allow critical evaluation and replication Permission to use this criterion will be obtained from Blount et al. (2008). 18 6

7 Results Included Eligibility Screening Identification Database searching (n = 3379 ) Screened (n = 3380) Records remove duplicates (n = 32 ) Full-text for eligibility (n = 15) Included (n = 15) Included in meta-analysis (NA ) Other sources (n = 1 ) Excluded (n = 3306 ) Excluded (n = 17) 19 PUB YEAR AUTHORS MEASURE 1983 Jay et al OSBD 1986 Bush et al DPIS 1988/1996 Hubert et al; Bachanas et al BAADS 1989/1997 Blount et al CAMPIS/ 1997 Blount et al CAMPIS-R 2001 Blount et al CAMPIS-SF 2005 Caldwell-Andrews et al P-CAMPIS 2005 Cohen et al MAISD 2006 Walker et al Modified CAMPIS-R 2006 Cline et al Parent Communication Typology 2007 Peterson et al Distance and Touch Behaviors 2008 Blount et al CAMPIS-IV 2009 Wolff et al GRIDS 2010 Sadhasivam et al PACBIS 2012 Chorney et al CBCS-P 20 Study Demographics 21 7

8 Scale Demographics 22 Coding Systems Matrix, Variable (#) Measure Age (YR) Theory Channel Target 1 MAISD (Infant) 2 CAMPIS-IV (Infant) < 3 (3) 3 GRIDS (Infant) 4 DPIS (Premedical) BOTH (7) 5 CAMPIS-SF NO (10) 6 P-CAMPIS (Perioperative) 3-12 (6) 7 PACBIS (PACU) V & NV (11) 8 BAADS (Child) 9 CBCS-P (Child) CHILD (3) 10 OSBD (Child) > 12 (1) 11 Parent Communication Typology YES (2) PARENT (2) 12 Distance and Touch NV (1) 3-12 (4) 13 CAMPIS 14 CAMPIS-R NO (3) V (3) BOTH (3) 15 Modified CAMPIS-R (Chronic) >12 (1) 23 Specific Measures-CAMPIS/CAMPIS-R Child behaviors (16), adult behaviors (19) 6 domains Frequency of behaviors Kappa for child, for adults Predictive/concurrent validity Sensitive changes Clinical implication Long items No theory support No information for motoric behaviors No nonverbal codes CAMPIS, Child-Adult Medical Procedure Interaction Scale 24 8

9 Specific Measures-CAMPIS-SF Rating items (6) 5-point global anchors Sum score Kappa for child, for parents, nurses Convergent/construct validity Economy to use Limited validity info Much info loss No theory support Low sensitivity Lack of implications CAMPIS-SF, Child-Adult Medical Procedure Interaction Scale-Short Form 25 Specific Measures-DPIS Child behaviors (4) Parent behaviors (6) Kappa for Premedical child, for procedures parent Limited to dyadic Sensitive to interaction (mother-child) DPIS, Dyadic Prestressor Interaction Scale 26 Specific Measures-BAADS Approach- Avoidance, Distress 5-point anchored rating No parent behavior No theory support Measure the coping quantity Avoidance as one way of distress Limited clinical application BAADS, Behavioral Approach-Avoidance and Distress Scale 27 9

10 Measures-Parent Communication Typology Communication styles (4) Present/absent for each pattern Kappa 0.81, 100% agreement Symbolic interactionism Resemblance to the attachment styles Limited validity info No healthcare provider s behaviors Lack of clinical effects from interventions 28 Specific Measures-Distance and Touch Distance (5) Touch (3) Continuous code in real time Distance based on Hall s typology of interactional distances Kappa 0.83 for distance, 0.82 for touch No theory support for touch Limited validity info No clinical application 29 Specific Measures-P-CAMPIS Verbal and nonverbal (40) Adult-to-Adult, Adult-Child, Child Vocalizations, Nonverbal Kappa 0.87 for adult verbal, 0.92 for child verbal, 0.88 for nonverbal Convergent validity No theory support Low sensitivity Perioperative environment No real-time interventions P-CAMPIS, Perioperative Child-Adult Medical Procedure Interaction Scale 30 10

11 Specific Measures-Modified CAMPIS-R Parental verbal attending talk Parental distracting talk Uncodeable talk Child utterance ICC 0.95 to 0.99 Divergent validity Easy to use No theory support No nonverbal coding for parents CAMPIS-R, Child-Adult Medical Procedure Interaction Scale-Revised 31 Specific Measures-MAISD Parent (11), nurses (6) verbal and nonverbal behaviors Infant behaviors (9) Kappa Concurrent validity Verbal and nonverbal behaviors Limited external validity Infants No theory support Not comprehensively identifying adult behaviors No specific body positions MAISD, Measure of Adult and Infant Soothing and Distress 32 Specific Measures-CAMPIS-IV Adult coping promoting behaviors (5) Adult distresspromoting behaviors (7) Neutral behaviors Two infant codes Kappa for adult vocalizations, for adult motoric behaviors, 0.77 to 1.00 for child codes Adult nonverbal No theory support Limited validity info Infants CAMPIS-IV, Child-Adult Medical Procedure Interaction Scale-Infant Version 33 11

12 Specific Measures-CBCS-P Child nonverbal distress, verbal distress, and nondistress behaviors Kappa Concurrent validity Verbal and Nonverbal behaviors PACU No theory support No parent behavior CBCS-P, Child Behavior Coding System-PACU 34 Specific Measures-OSBD Child verbal, nonverbal behaviors (11) Each item weighted with intensity Agreement Convergent validity No theory support Only child behavior Not child coping No real-time instrument directed intervention OSBD, Observational Scale of Behavioral Distress 35 Specific Measures-PACBIS Child Coping/Distress Parent Positive/Negative Rating score 0, 1, or 2 Kappa Coping, Distress, Positive, Negative Concurrent/Predictive validity Convergent/Divergent validity Instrument directed interventions Simple, real time use PACBIS, Perioperative Adult Child Behavioral Interaction Scale Perioperative care No theory support 36 12

13 Specific Measures-GRIDS Parental behaviors (13) Child behaviors (14) Coded as present/absent ICC Convergent validity Verbal, nonverbal behavior GRIDS, Generation R Infant Distress Scale Based on previous instruments Infants No clear domains Limited external validity 37 Evaluation of Measures Measure Level Wellestablished Promising I II III I II III I II III Specific Criteria # Two peer-reviewed articles Allow critical evaluation and replication Good validity and reliability Two peer-reviewed articles Allow critical evaluation and replication Validity and reliability information One peer-reviewed article Validity and reliability information Allow critical evaluation and replication Approaching wellestablished OSBD DPIS Well- CAMPIS Established CAMPIS-R Approaching Well- Established Promising BAADS CAMPIS-SF MAISD P-CAMPIS Modified CAMPIS PACBIS CBCS-P Parent Communication Typology Parent Distance and Touch CAMPIS-IV GRIDS 39 13

14 Discussion and Implications Multiple observational measures of parentchild interactions were identified Most of these measures have good psychometric properties These measures were widely reported in Western countries 40 Discussion/Implications cont d A small number of these measures were identified as well-established Interventions based on these measures should be further tested Healthcare providers should use these measures to guide clinical practice 41 Future Directions Theory-based measures including verbal and nonverbal behaviors should be further developed and tested Parent emotional indicators should be further explored during the parent-child interactions The longitudinal patterns of parent-child interactions should be explored using newer methods 42 14

15 Conclusion Most extant parent-child IASs are not theorybased The widely used measures rarely consider nonverbal behaviors A small number of IASs are well-established 43 Conclusion Further testing of approaching wellestablished and promising parent-child IASs is needed The development of a theory-based parentchild IAS that considers nonverbal behaviors is promising 44 Questions? 45 15

16 References Bensing, J. M. (1991). Doctor-patient communication and the quality of care. An observation study into affective and instrumental behavior in general practice. Dissertation. NIVEL, Utrecht. Blount, R. L., Bunke, V. L., Cohen, L. L., & Forbes, C. J. (2001). The Child-Adult Medical Procedure Interaction Scale- Short Form (CAMPIS-SF): Validation of a rating scale for children s and adults behaviors during painful medical procedures. Journal of Pain and Symptom Management, 22(1), Blount, R. L., Corbin, S. M., Sturges, J. W., Wolfe, V. V., Prater, J. M., & James, L. D. (1989). The relationship between adults behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20(4), Blount, R. L., Simons, L. E., Devine, K. A., Jaaniste, T., Cohen, L. L., Chambers, C. T., & Hayutin, L. G. (2008). Evidence-based assessment of coping and stress in pediatric psychology. Journal of Pediatric Psychology, 33(9), Caldwell-Andrews, A. A., Blount, R. L., Mayes, L. C., & Kain, Z. N. (2005). Behavioral interactions in the perioperative environment: a new conceptual framework and the development of the perioperative child-adult medical procedure interaction scale. Anesthesiology, 103(6), Chorney, J. M., Tan, E. T., & Kain, Z. N. (2013). Adult-child interactions in the postanesthesia care unit: Behavior matters. Anesthesiology, 118(4), Cline, R. J., Harper, F. W., Penner, L. A., Peterson, A. M., Taub, J. W., & Albrecht, T. L. (2006). Parent communication and child pain and distress during painful pediatric cancer treatments. Social Science & Medicine. 63(4), References cont d Frank, N. C., Blount, R. L., Smith, A. J., Manimala, M. R., & Martin, J. K. (1995). Parent and staff behavior, previous child medical experience, and maternal anxiety as they relate to child procedural distress and coping. Journal of Pediatric Psychology, 20(3), Green S, Higgins J, eds (2005) Glossary. Cochrane handbook for systematic reviews of interventions The Cochrane Collaboration. Available: Accessed 19 May Ljungman, G., Gordh, T., Sorensen, S., & Kreuger, A. (1999). Pain in paediatric oncology: Interviews with children, adolescents and their parents. Acta Paediatrica (Oslo, Norway: 1992), 88(6), doi: /j tb00011.x. McMurtry, C., McGrath, P., & Chambers, C. (2006). Reassurance can hurt: Parental behavior and painful medical procedures. The Journal of Pediatrics, 148(4), McMurtry, C. M., McGrath, P. J., Asp, E., & Chambers, C. T. (2007). Parental reassurance and pediatric procedural pain: A linguistic description. The Journal of Pain, 8(2), Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., & The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicne, 6(6), e Ong, L. M. L., De Haes, J. C. J. M., Hoos, A. M., & Lammes, F. B. (1995). Doctor-patient communication: A review of the literature. Social Science & Medicine, 40(7), Siegel, R., Naishadham, D., & Jemal, A. (2013). Cancer statistics, CA: A Cancer Journal for Clinicians, 63(1), doi: /caac Skinner, B.F. (1983). Notebooks. Englewood Cliffs, NJ: Prentice Hall. 47 Thank you! Jinbing Bai The University of North Carolina at Chapel Hill jbai7@ .unc.edu 16