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Reliability and Validity of the Brief

Behavioral Distress Scale: A Measure of

Children's Distress During Invasive
Medical Procedures
1. Cindy L. Tucker, PhD 1 , 2 ,
2. Keith J. Slifer, PhD 1 , 2 and
3. Lynnda M. Dahlquist, PhD 3
+ Author Affiliations

Kennedy Krieger Institute

Johns Hopkins University School of Medicine
University of Maryland Baltimore County

1. All correspondence should be sent to Cindy L. Tucker, Department of Behavioral

Psychology, The Kennedy Krieger Institute, 707 N. Broadway, Baltimore, Maryland
21205. E-mail: tuckerc@kennedykrieger.org .

Received June 30, 2000.

Revision received December 7, 2000.

Revision received March 15, 2001.

Accepted April 20, 2001.

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Objective: To evaluate the reliability and validity of a new observational measure of
children's procedure-related distress behaviors, the Brief Behavioral Distress Scale (BBDS),
to provide clinicians with an efficient, economical alternative measure that does not depend
on continuous interval coding.
Methods: Forty-eight randomly selected videotaped invasive medical procedures performed
on children (ages 2 to 10 years) with chronic illness were coded with the BBDS and the
Observation Scale of Behavioral Distress (OSBD). Reliability and validity analyses along
with item analysis were conducted.

Results: Total distress scores of the BBDS were highly correlated with six of seven
concurrent validity measures from multiple sources (i.e., OSBD, parent ratings, two nurse
ratings, child self-report, and a physiological arousal measure, heart rate) (range r =.57-.76, p
<.001-.0001). A robust association was found between the BBDS distress scores and OSBD
total distress scores (r =.72, p <.0001). For two concurrent validity measures, the BBDS
demonstrated stronger associations than did the OSBD. Interrater reliability was high for each
BBDS distress behavior category.
Conclusions: Based on the findings reported, the BBDS is a reliable and valid measure of
children's procedure-related distress with functional utility in both research and clinical

Key words

children's pain

procedure-related distress

rating scale

invasive medical procedures

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Children with chronic medical conditions are surviving in increasing numbers, yet their
quality of life may be diminished by the need for repeated invasive medical procedures
(Dahlquist, 1999; Wallander & Varni, 1992). Painful needle sticks can cause significant and
persistent conditioned fear and anxiety for children, with little reported evidence for
habituation over time (Jay, Ozolins, Elliott, & Caldwell, 1983). Procedure-related distress
often interferes with cooperation and jeopardizes the safe and timely delivery of essential
medical care. Medical personnel may choose to manage highly distressed children with
increased sedation, physical restraint, and, in some cases, general anesthesia, with its inherent
costs and risks and further disruption of daily life (Anderson, Zeltzer, & Fanurik, 1993). In a
recent review, Powers (1999) documented dramatic improvements in the treatment of
procedure-related distress in children over the past two decades. Concurrently, observational
assessment of children's procedure-related distress also has improved.
From the seminal efforts on the development of the Procedure Behavior Rating Scale (PBRS;
Katz, Kellerman, & Siegel, 1980) have emerged several related versions of observational
measures, including the Observation Scale of Behavioral Distress (OSBD; Jay et al., 1983;
Elliott, Jay, & Woody, 1987) and the Child-Adult Medical Procedures Interaction Scale
(CAMPIS, CAMPIS-R; Blount et al., 1989, 1997). The original version of the OSBD (Jay et
al.) remains the most commonly used outcome measure in procedure-related distress
treatment efficacy studies (Powers, 1999). The OSBD consists of 11 operationally defined
behaviors associated with the pediatric procedure-related distress constructs, anxiety and
pain, with severity assigned by expert-determined weights. The established strengths of the
OSBD have been widely reported.

The OSBD, however, is not without limitations. First, definitions of the phases of the medical
procedure (i.e., anticipatory, procedural, recovery) vary considerably across studies (Blount,
Sturges, & Powers, 1990). Even when procedural phases are consistently defined, differences
or delays in execution of the needle procedure, which often are independent of child
behavior, can alter procedure duration, thereby increasing or decreasing the number of
observation intervals and potentially deflating or inflating the resulting scores. Thus,
continuous interval coding systems using time-based phase definitions (Dahlquist, Power, &
Carlson, 1995; Jay et al., 1983) may result in comparisons of nonequivalent procedural events
across subjects or within subjects across observations. Children may be confronted with
varying quantities and types of demands, blurring potentially significant interactions relevant
to treatment design. Alternatively, one can focus on the essential demands for compliance
placed on the child and record the type and severity of distress exhibited in response to each
specific demand as a discrete step. Essential demands are the specific demands for
compliance sequentially placed on the child that are required for procedure completion.
Using this method, interventions aimed at distress reduction in response to the specific
demands of each step can be evaluated and refined. This is consistent with Blount et al.
(1990) and Katz et al., (1980), who examined steps specific to bone marrow aspiration
(BMA), and Manne, Bakeman, Jacobsen, and Redd (1993), who examined the steps of
venipunctures. Our research developed a measure that can be used across a variety of needle
stick procedures with a discrete-step format, which affords greater measurement efficiency
and more details on child behavior in relation to specific social and environmental
antecedents within the needle stick routine.
Finally, because OSBD scores are derived from summing across all 11 distress behaviors,
clinically relevant data about the type of distress being exhibited are lost. Conversely, as in
this study, distress behaviors can be sorted conceptually into functional topographies based
on the degree to which they affect procedure performance. Guided by the established OSBD
severity weights, we classified the 11 distress behaviors into three categories of increasing
intensity with respect to interference with medical procedures. Additional distress behaviors
were added to complement the intent of each category (e.g., moaning, flinching, disruption of
medical materials). A category for assessing children's coping responses during invasive
procedures, active coping responses, also was included.
This article presents preliminary reliability and validity analyses of the Brief Behavioral
Distress Scale (BBDS), a measure combining behavioral categories derived from the OSBD
and an essential demands approach as an alternative for measuring child procedure-related
distress and coping. We expected BBDS distress scores to be significantly positively
correlated with OSBD total distress scores and concurrent validity measures of child distress
(child pain ratings, parent ratings of child fear and pain, nurse ratings of child distress, and
heart rate) and significantly negatively correlated with nurse ratings of child cooperation.
Conversely, BBDS active coping responses scores were expected to correlate negatively with
concurrent measures of child distress and positively with nurse ratings of child cooperation.
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Participants and Setting

Participants were a consecutive sample of 40 children diagnosed with a chronic illness and
receiving repeated invasive medical procedures at a tertiary care pediatric hospital over a 2year period. All participants were part of an ongoing longitudinal study designed to compare
and evaluate the effects of different treatment approaches on children's procedure-related
distress (NICHD, HD#35528, Behavioral Medicine Approaches to Pediatric Acute Pain, K.
Slifer, P.I.). A member of the research team met with potential participants, explained the
study procedures, and obtained informed consent from the parent and assent from the child.
The 40 participants included 12 girls (30%) and 28 boys (70%) whose ages ranged from 2
years, 2 months to 10 years, 8 months (M = 6 years, 0 months). Sixty percent of the
participants were Caucasian, 35% were African American, 2.5% were Hispanic, and 2.5%
were Asian Indian. Twenty-one children receive one or more type of invasive procedure (i.e.,
implanted port access [PCA], venipuncture [IV], intramuscular injection [IM], subcutaneous
injections [SQ]) for treatment of childhood cancer, specifically for childhood leukemia (57%)
or solid tumor (43%). Nine children receive monthly chronic transfusions for treatment of a
hematological disorder (i.e., sickle cell anemia, thalasemia). The remaining nine children
receive an invasive procedure (i.e., PCA, IV, or SQ) for monitoring and treatment of a
chronic medical condition (e.g., idiopathic thrombocytopenia, growth hormone insufficiency,

We had an available archive of 360 observations videotaped over a 2-year period. The 40
participants were observed at scheduled clinic visits and followed from baseline, into nine
treatment sessions (if so randomized) and through a follow-up phase of approximately 6
months. The mean number of observations collected per participant was 9.47, ranging from 2
to 27. Videotaping began when the child entered the procedure room and continued for 3 to 4
minutes after the procedure. The filmer did not speak to the child once videotaping began.
The taped sessions were transcribed, coded, and scored according to the procedure described
by Jay et al. (1983) for one of the outcome measures, the OSBD. Procedure films ranged
from 3 to 22 minutes (M = 10.0 min., SD = 6.4); specifically, M = 6.3 min., SD = 2.9 for IMs
and SQs; M = 9.2 min., SD = 5.1 for PCAs; and M = 10.2 min., SD = 5.2 for IVs.
A random sample of 54 videotaped observations (15%) was selected for recoding with the
BBDS. Of the nine BBDS coders, two coders had prior OSBD training, three coders had
some familiarity with the OSBD and coding of pediatric invasive procedures, and four coders
were unfamiliar with the OSBD and inexperienced in procedural distress coding. Coders
were provided with approximately 1 hour of training on observational coding of pediatric
procedural distress along with a review of the behavioral categories and operational
definitions in the BBDS. As a group, coders reviewed three videotaped pediatric invasive
procedures, discussed discrepancies, determined decision rules, and clarified behavioral
definitions. A final version of the behavioral category definitions was provided to each coder
with instructions for independent coding. Each coder was assigned six videotaped
observations for recoding with the BBDS and given the following instructions: (1) view the
procedure and indicate the sequence of each step observed on the coding form; (2) write in
any additional steps observed and number as above; (3) during the duration of each observed
step, indicate the occurrence of each of the four behavioral categories with a check in the
appropriate box; and (4) if a step occurs more than once, combine multiple observations in
the row listing the step so that all occurrences of a behavior during any performance of the
step are included in the same box.

Due to scheduling conflicts, four coders completed only five observations. Two observations
could not be coded because of film quality. This resulted in a set of 48 recoded procedures
that reflected the distribution of procedures in the overall sample: 20 IVs, 20 PCAs, 5 IMs,
and 3 SQs. The final set of 48 observations included procedures from 87.5% (35) of the total
40 participants, with multiple observations (across phases) randomly selected from 13 (37%)
of the 35 participants in the sample. Thirty-one of the procedures occurred during baseline,
12 during treatment, and 5 during follow-up. The participants had been randomly assigned to
either a distraction (Pringle et al., in press), counter-conditioning (Slifer, Babbitt, & Cataldo,
1995), or nondirective attention control intervention group. During each of the nine treatment
sessions, participants and their caregivers met with a therapist for 20 minutes prior to
scheduled invasive procedures.
A topical cream mixture of lidocaine and prilocaine, eutectic mixture of local anesthetics,
(EMLA, Astra Pharmaceutical Products, Inc., Westborough, MA 01581) was used to numb
the needle site prior to 30 procedures. Intradermal lidocaine was used prior to two of the IV
procedures. The remaining 16 procedures were performed without the use of any
pharmacological agent.

Brief Behavioral Distress Scale
The BBDS was adapted from the behavioral observation method described by Slifer et al.
(1995), who used it to measure children's cooperation and procedure-related distress with
discrete component steps involved in several types of invasive medical procedures. By
breaking a procedure into discrete steps, one can make observations relative to the specific
demands for compliance sequentially placed on the child during the procedure. These steps
constitute the essential demands of the invasive procedure (Blount et al., 1990). A variety of
needle stick procedures was observed and analyzed into a series of steps essential to
procedure completion. Twelve possible steps were identified. Steps were defined by their
onset and offset, without regard to sequence or duration. Observers recorded the occurrence
or nonoccurrence of the target behaviors during each step of the procedure. Descriptions and
operational definitions of target behaviors for each category are presented below.
Noninterfering Distress Behaviors. This category includes behaviors indicative of mild or
partially regulated procedural distress. The child displays behaviors that do not delay or
interfere with the performance of the procedure such as crying, whining, groaning, moaning,
negative vocalizations (i.e., Stop, I don't want it, Wait, I'm not ready yet) that are not
above conversational level, or seeking physical comfort from another person or object.
Potentially Interfering Distress Behaviors. These behaviors indicate moderate intensity
distress that is being less well regulated by the child and that do not necessarily disrupt
performance of the procedure but may delay, lengthen, or make it more difficult to perform.
This category includes behaviors such as screaming, yelling, shouting, negative vocalizations
(i.e., Stop, I don't want it, Wait, I'm not ready yet) that are above conversational level,
obvious tensing of muscles, facial contortions, jaw clenching, tooth grinding or gritting,
tightly clenched fists (not in response to being told to make a fist), or flinching.
Interfering Distress Behaviors. These behaviors result in the procedure being halted, delayed,
or performed using physical restraint and reflect a severe degree of distress and protest with

little to no ability (or effort) by the child to regulate his or her behavior. This category
includes attempted or completed behaviors such as escape or avoidance (i.e., getting up from
seat, leaving room, leaning or pulling away from nurse, resisting or moving out of position,
hiding, or blocking the procedure site), disruptions of medical materials, or physical
Active Coping Response Without Verbal Delay. When a health care provider attempts to
perform a step in an invasive procedure, the child engages in an observable coping response
such as playing with a toy or activity by pressing buttons, pointing to, or verbalizing about it;
counting aloud; singing; using focused breathing or relaxation strategies; audible praying;
initiating or engaging in a nonmedical conversation (beyond single-word responses); viewing
a preferred videotape; making positive coping statements (i.e.; It will be over soon, It
didn't hurt); asking questions about the procedure (e.g., What are you doing? When will
it be done?); or holding, stroking, or patting an object (i.e., blanket, Teddy, pacifier) or
person. Active coping response is not scored for any step in which the behavior is
accompanied by a verbal delay statement, such as, Don't do it yet, I need to pray first, or
Wait until I am ready to count. Otherwise, active coping may be scored simultaneously
with any distress behavior.
Asking questions about the procedure was included based on findings that information
seeking has been significantly negatively correlated with high procedural anxiety or distress
by some investigators (Katz et al., 1980; Manne et al., 1993; Peterson & Toler, 1986). This is
a departure from the OSBD and the CAMPIS scales, both of which include information
seeking as a distress behavior (Blount et al., 1989; Jay et al., 1983). Notwithstanding this
disagreement in the literature, asking questions was included here as an observable though
not necessarily effective effort by the child to cope, unless accompanied by a verbal delay
The total number of steps occurring during each procedure was noted (M = 9 steps, range =
6-12). The number of steps in which a behavior occurred was summed and divided by the
total number of steps, then multiplied by 100 to yield percentage of steps with occurrence
scores for each behavioral category. The number of steps in which behaviors from any of the
three distress behavior categories occurred (i.e.; noninterfering, potentially interfering, and
interfering) was summed and divided by the total number of steps multiplied by three
(number of distress categories), then multiplied by 100 to obtain the Total Distress Score. Use
of percentage scores allowed for a common metric for comparing scores from procedures
with different number of steps. The Active Coping Response Score was treated as a separate
subscale. Coding of the four behavioral categories of the BBDS generally took 10 to 15
minutes per observation, with coding being completed in one or, infrequently, two passes of
the videotaped procedure.
Observational Scale of Behavioral Distress (OSBD)
Overt child distress was measured using the OSBD (Jay et al., 1983). Written transcripts of
all vocalizations occurring during the filmed procedure were produced to improve interrater
reliability. From the videotape and transcription, observers coded for the presence or absence
of 11 child distress behaviors (e.g., crying, verbalizing fear) during 15-second continuous
intervals. Distress scores were calculated by summing the number of 15-second intervals
during which each distress behavior occurred and multiplying that number by an expertdetermined intensity weight from 1 to 4 reflecting the severity of the behavior. A Total

Distress Score was calculated by summing the weighted distress scores and dividing by the
total number of 15-second intervals for the procedure. Transcription of videotapes took
approximately 2 hours to produce. Coding of the OSBD usually took 30 to 45 minutes,
generally requiring three to four passes of the videotape. For this study, 18% of the 360
videotaped sessions were independently coded by a second observer, yielding a mean kappa
coefficient of.76.
Interrater reliabilities reported in the literature for the OSBD are uniformly good. Percentage
agreement scores range from 72% to 99% for total distress (Jay et al., 1983), and kappa
coefficients of.90 and.87 have been reported respectively for the procedural and recovery
phases (Gonzalez et al., 1989). OSBD distress scores have been significantly correlated with
other indices of children's procedural pain and distress, such as parent and nurse ratings of
child distress, children's ratings of fear, and physiological measures of distress (Elliott et al.,
1987; Jay et al., 1983; Jay, Elliott, Katz, & Siegel, 1987). The OSBD also has been shown to
be sensitive to changes in children's procedural distress after psychological intervention (e.g.,
Dahlquist, 1992; Jay et al., 1987; Pringle et al., in press).
Child Self-Report Ratings of Pain or Discomfort
Immediately after the invasive procedure, children were asked by research staff to indicate
the degree to which they experienced discomfort. Three- and 4-year-olds were assessed by
means of the Oucher Scale (Beyers, Villarruel, & Denyes, 1992), a posterlike instrument that
produces ordinal data ranging from 0 to 5 when only the photographic scale is used. These
six photographs are available in Caucasian, African American, and Hispanic versions. Studies
of the convergent, discriminant, and construct validity of the Oucher indicate good to
excellent validity (e.g., r =.70-.98) and test-retest reliability at a moderate level (e.g., r
=.54-.72). As directed in the manual, a Piagetian seriation task was performed prior to use of
the Oucher with 3- and 4-year-olds to determine adequate cognitive understanding and
maturity for task completion. No self-report ratings of discomfort were obtained for children
under the age of 3 years (n = 3) or aged 3 or 4 years who failed the cognitive screening test (n
= 2).
Children who were 5 years old or older were assessed using the Coloured Analogue Scale
(CAS; McGrath et al., 1996). The CAS assesses children's degree of subjective discomfort by
adjusting a sliding plastic marker along a visual analogue continuum that ranges from most
pain to no pain and varies in color, area, and length. McGrath et al. (1996) reported
adequate content and construct validity as well as test-retest reliability with children 5 to 16
years of age. In order to make the Oucher data comparable to the ordinal data obtained with
the CAS, which range from 0 to 10, we transformed the Oucher data by multiplying each
rating by 2. The transformation does not guarantee equivalency from a psychometric
standpoint, but does allow for assessment of children in the younger age group.
Eight children (M = 66 months, range = 39-106), did not respond when asked to rate their
discomfort. These children were observed to remain distressed and withdrawn from clinic
staff and researchers following the procedure, thereby likely accounting for their lack of
response. In total, self-report data for 35 children ages 38 to 119 months (M = 73) were
available for analysis.
Parent Ratings of Child Fear and Pain

The parent present during the observed invasive medical procedure was asked just prior to the
procedure to rate his or her child's degree of fear about the impending procedure using a
Visual Analogue Scale (VAS). End-points of the 10-centimeter scale were labeled Not Afraid
and Very Afraid. Immediately following the procedure, the parent was asked to rate the
degree to which his or her child experienced pain during the invasive procedure. The
endpoints of this 10-centimeter VAS were labeled No Pain and Most Pain (Powers, Blount,
Bachanas, Cotter, & Swan, 1993).
Nurse Ratings of Child Distress and Cooperation
The nurse or other health care provider performing the invasive medical procedure was asked
to use a VAS to rate the child's degree of observed distress and degree of cooperation during
the just completed procedure. The end-points of the 10 centimeter scale for distress were
labeled Not Distressed and Very Distressed, and for cooperation, Not Cooperative and Very
Cooperative (Powers et al., 1993).
Autonomic Physical Arousal Measure
To obtain an indicator of autonomic nervous system arousal, the child's heart rate (HR) was
measured using a portable electrocardiogram (ECG) quality event recorder (Heart Access
Plus, Paceart Associates, L. P., Fairfield, NJ 07004) attached to the child's chest via two
neonatal-sized adhesive electrodes, (e.g., Huggables). A 10-second ECG recording was
obtained by depressing the activator button on the device at five predetermined sampling
points during each observed procedure. Mean HRs across three of those time sampling points
were analyzed for this study: specifically, (1) anticipatory HR, when the injection site is
cleansed or covering tape or dressing is removed; (2) procedural HR, when the needle first
enters the skin; and (3) recovery HR, 30 seconds after the needle exits the skin or tape is
applied to secure the needle at the insertion site. ECG recordings then were downloaded to a
computer database where they were stored and analyzed for HR readings (in beats per
minute). HR data were missing for 13 (27%) cases due to high levels of artifact on the ECG
recordings or child or parent refusal.
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Interrater Reliability
For 20 randomly selected observations, two observers independently recorded the occurrence
of target behaviors for each step of the procedure. Pearson product-moment correlation
analyses conducted between the pairs of observers' BBDS scores yielded an r (19) of.87
(range across categories =.85-.93). Percent agreement scores (agreement/ agreement plus
disagreement 100) for BBDS total distress scores ranged from 65% to 100%, (M = 87%,
SD = 9.75). Percent agreement scores for individual behavioral categories were as follows:
93% (SD = 11.26) for interfering distress, 85% (SD = 17.07) for potentially interfering
distress, 84% (SD = 14.93) for noninterfering distress, and 86% (SD = 21.05) for active
coping responses. Kappa coefficients were.87 for interfering distress,.68 for potentially
interfering distress,.68 for noninterfering distress,.74 for BBDS total distress, and.72 for
active coping responses.

Item Analysis
We conducted an item analysis on the four behavioral categories comprising the BBDS.
Criteria for retaining a behavioral category were (1) occurrence of behaviors in at least 10%
of the sample, (2) correlation coefficients of +.3 or greater between each distress category and
the total distress score, (3) correlation coefficients of +.3 or greater with at least one other
distress category, and (4) kappa coefficients of at least.6 (Elliott et al., 1987; Nunnally, 1978).
Interfering distress behaviors occurred in 27 (56.3%) of 48 procedures and correlated
significantly with BBDS total distress (r [47] =.79, p <.0001) and potentially interfering
distress (r [47] =.71, p <.0001). Behaviors from the potentially interfering distress category
occurred in 36 (75%) of the procedures and correlated significantly with BBDS total distress
(r [47] =.90, p <.0001) and non-interfering distress (r [47] =.41, p <.004). Noninterfering
distress behaviors were coded for 42 (88%) of the procedures and correlated significantly
with BBDS total distress (r [47] =.69, p <.0001). No significant correlation was found
between interfering and noninterfering distress behaviors (r [47] = -.225, p =.125).
Cronbach's coefficient alpha test of internal consistency revealed a coefficient of.71 for
BBDS total distress. This is comparable with the coefficient alpha of.72 reported for the
OSBD by Elliott et al. (1987).
The behavioral category, active coping responses, was coded for 30 (62.5%) of the
procedures. Coping responses correlated with BBDS total distress scores in the expected
direction (r [47] = -.29, p <.046) but did not produce significant correlations with any of the
three distress behavior categories (range r = -.20 to -.27, p <.173 to.063). Given the lack of
significant negative correlation with any of the three BBDS distress behavior category scores,
the active coping responses category was not retained as part of the BBDS.

Comparisons were performed to determine the construct and concurrent validity of the BBDS
as compared to the frequently used and well-established measure of child behavioral distress,
the OSBD. Table I displays the Pearson product-moment correlation coefficients between
concurrent validity measures and both BBDS and OSBD total distress scores as well as
BBDS distress behavior scores. Bonferroni corrections (.05/11 = p <.005) were used to set
alpha levels for significance to reduce the risk of Type I error. Results indicate that BBDS
distress scores were significantly positively correlated with OSBD total distress. Both BBDS
and OSBD total distress scores were significantly associated with all concurrent validity
measures with one exception, the parent rating of child's fear of procedure.
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Table I.
Correlation Coefficients Between BBDS and OSBD Distress Scores and Concurrent Validity

Interfering distress behaviors were significantly positively correlated with three of five
concurrent validity measures of child distress. Potentially interfering distress behaviors were
significantly positively correlated with four of five concurrent validity measures of child
distress. Noninterfering distress behaviors were significantly positively correlated with two of
five concurrent validity measures of child distress. All three distress behaviors were
significantly negatively correlated with nurse reports of child cooperation.
When the correlation coefficients for BBDS and OSBD total distress scores with the
concurrent validity measures were compared (see Table I), individual r to z transformations
indicated that BBDS total distress scores were more strongly related to nurse ratings of both
child distress and cooperation than were OSBD total distress scores (z [0,1] = 2.39, p <.008; z
[0,1] = 2.14, p <.016, respectively). Correlation coefficients for the four remaining validity
measures (i.e., child self-report rating of pain, parent rating of child's fear, parent rating of
child's pain, mean heart rate) were essentially identical.
A Pearson product-moment correlation coefficient revealed no association between child's
age and observed distress as measured by BBDS total distress scores (r [30] = -.19, p <.302).
This finding is in contrast to the significant age effects typically found using the OSBD and
other similar observational measures of child procedure-related distress (e.g., Blount,
Landolf-Frische, Powers, & Sturges, 1991; Jay et al., 1983; Katz et al., 1980).

Frequency of Occurrences of Distress Behaviors During Essential Procedural

Table II displays the frequency of occurrence of each procedural step along with the
distribution of occurrence of distress behaviors from each category. Interfering distress
behaviors occurred most frequently during positioning of the child and exposing the injection
site, needle manipulation, and needle insertion. Potentially interfering distress behaviors
occurred most frequently during needle insertion and manipulation. Noninterfering distress
behaviors occurred most frequently during needle manipulation, securing the needle with
tape, and positioning and exposing the site. The steps, gauze or bandage application,
replacement of clothing, and needle removal produced the fewest occurrences of behavioral
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Table II.
Frequency Occurrence of BBDS Behaviors During Steps of Procedures
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Based on the results of this initial study, we found the BBDS to be a reliable and valid
measure of children's observable procedure-related distress with some unique features in
relation to a well-established children's distress measure, the OSBD. BBDS total distress
scores were highly correlated with six of seven concurrent validity measures from multiple
sources. A robust association was found between BBDS and OSBD total distress scores.
For two concurrent validity measures, nurse ratings of child cooperation and distress during
procedures, the BBDS demonstrated stronger associations than did the OSBD. Improved
validity with nurse ratings may be related to the conceptual distress categories employed by
the BBDS. These categories specifically relate to the degree to which the child's distress
behavior may interfere with completion of a necessary medical procedure. The ability to
complete a procedure without delays or physical restraint is a highly salient feature for
nurses, which the BBDS distress categories are uniquely designed to measure.
Validity for the three BBDS distress behavior categories was supported with all significant
correlations in the expected direction. BBDS distress behaviors were most strongly associated
with OSBD total distress scores and nurse reports of child distress and cooperation. Neither
BBDS total distress scores nor any of the distress behavior scores were significantly
associated with parent reports of children's fear prior to the procedure. This is consistent with
lower associations between parent ratings and observed distress reported by Manne,
Jacobsen, and Redd (1992). Overall, the more overt distress behaviors, interfering and
potentially interfering, were more strongly associated with a greater number of concurrent
validity measures as compared to non-interfering distress behaviors, which may reflect
behaviors considered by raters to be nondisruptive, justifiable expressions of discomfort or
protest (Slifer et al., 1995). The physical nature of the escape behaviors comprising the
interfering distress category likely accounts for the particularly strong association found with
the physiological marker, heart rate.
No significant correlations were found between the category, active coping responses, and the
OSBD or other concurrent validity measures. The operational definition of this category was
purposely broad to account for all observable efforts employed by children to cope with
procedural distress. Blount et al. (1997) discussed this approach in contrast to their own more
conservative definition of coping behaviors as only those inversely correlated with distress.
The dilemma revolves around the logical paradox in which distress produces the need for
coping, while simultaneously coping implies alleviation of distress. Broader definitions
including attempts to cope that may or may not successfully ameliorate distress are by
definition more likely to result in no or positive associations with observed distress (Manne et
al., 1993; Siegel & Smith, 1991). In this study, the behavioral category, active coping, was
determined by item analysis not to meet the criteria for retention in the BBDS. The lack of
significant association with validity measures further supports this decision. In future studies,
this positive behavioral category could be redefined to include performance of responses on
which the child has received specific training, thereby serving as a measure of treatment
integrity rather than of child coping, which is better assessed by measures specifically
designed to assess child coping and its associated factors, such as the CAMPIS-R (Blount et
al., 1997).
No association was found between child's age and degree of observed procedure-related
distress in contrast to the findings of other studies (e.g., Blount et al., 1991; Jay et al., 1983;
Katz et al., 1980). Carr, Lemanek, and Armstrong (1998) attributed reported age difference in
observed distress, in part, to the overrepresentation of behaviors typical of younger children

(e.g., crying, screaming, flailing) (p. 305) in observational distress measures rather than to
actual differences in experienced distress. By adding two types of distress behaviors more
commonly observed in older children, flinch and groan, LaBaron and Zeltzer (1984) found
that age differences were eliminated. The distress categories of the BBDS, which include
these behaviors, may work to reduce the age bias typically reported for other observational
The use of an essential demands approach for measuring child distress offers the BBDS some
advantages compared to continuous interval coding of observations. In clinical practice,
analysis of distress in response to essential procedural demands allows clinicians to examine
areas of particular difficulty for individual children, targeting interventions to the specific
social and medical stimuli associated with each discrete procedural step. For instance, the
broadest and most disruptive distress behaviors among this sample were observed during
positioning for the procedure and exposure of the injection site. This essential demand has
not been identified previously as a particularly distressing demand for young children
undergoing invasive procedures. Yet, it likely represents a stimulus that, for many children,
signals the impending aversive procedure. This step may be missed as a focus for specific
intervention due to the practice of defining the anticipatory phase by a standard number of
intervals prior to site cleaning or some other specified antecedent event. An unforeseen delay
between positioning or site exposure and the event defining the start of the procedural phase
would result in the loss of clinically important observational data related to these often
distressing antecedent demands.
Blount et al. (1990) examined distress and coping in response to the steps of a BMA and
found that quantity and type of distress behavior differed significantly across phases of the
procedure. In this study, similar peaks and decreases in distress behavior appeared at
corresponding steps in the procedures. These results, combined with previous reports
revealing demand-specific variations in the levels and types of child distress observed,
suggest continuing research to evaluate interventions specific to distress at these predictably
critical points in needle stick procedures.
The BBDS is offered as a potential alternative to more complex continuous interval coding
systems. Further, we propose that the BBDS should be useful as a coding system during the
actual performance of the procedure. To test this proposition, validity and reliability analyses
of the BBDS must be performed in real time as well as on videotaped observations and the
data compared. Should the findings of this study not be replicated in future research with in
vivo coding, the time savings of coding the BBDS from videotape would nevertheless be
significant in daily practice. In this study, coding a procedure from videotape using the BBDS
took approximately one-third to one-quarter the amount of time required to code the same
procedure with the OSBD (10 to 15 minutes vs. 30 to 45 minutes, respectively). When
including time for transcribing vocalizations from the videotapes, the time savings of using
the BBDS increase appreciably from 150 minutes (2 hours for transcribing plus 30 to 45
minutes for coding) for OSBD coding to 10 to 15 minutes for BBDS coding, a tenfold
reduction. All of the OSBD coders and half of the BBDS coders in this study were
moderately to well-experienced in the observation and/or coding of pediatric invasive
procedures. This fact may limit the generalizability of these time savings for the BBDS when
used by inexperienced coders in a clinical setting.
Although providing support for the reliability and concurrent validity of the BBDS, this
preliminary investigation has several limitations. First, all the children studied received

treatment at the same medical facility, albeit from personnel staffing five different pediatric
specialty clinics. Child participants were diagnosed with a variety of chronic conditions
ranging from mild and nonlethal to serious and life-threatening. The procedures studied did
not include those typically reported to cause the greatest discomfort for children, BMAs and
lumbar punctures. Children from ages 2 to 10 years were included, spanning several
cognitive stages of development. It is uncertain if the findings here would be replicated if
children from different medical facilities, with more homogeneous chronic conditions,
receiving other procedures, and from different age ranges were studied. Several additional
studies with improved methodology and larger samples will add to information on the
potential utility of the BBDS. For instance, future validity research should avoid the use of
repeated procedures and focus on procedures occurring during only one condition (i.e.,
baseline). Hypotheses regarding coder experience and ease of use should be tested.
Operational definition revision, and reliability and validity testing of the coping responses
category are needed prior to further use.
The OSBD continues to be the most frequently used outcome measure in the procedurerelated distress literature (Powers, 1999). However, it is costly in terms of time, staffing, and
training, with a complicated coding and scoring system heavily reliant on vocalization
content and subtle indices of distress. As the developers state, the OSBD may be most useful
for researchers who are well-funded with access to ample resources (e.g., staff and equipment
for intensive analyses of videotapes) and interested in detecting subtle differences in
individual distress behaviors (Elliott et al., 1987). The same holds true for the continuousinterval coded CAMPIS-R that allows for complex sequential analyses of staff- and parentchild interactions in terms of distress and coping promotion (Blount et al., 1997). However,
for researchers with modest resources or clinicians who wish to use session-by-session data
to evaluate treatment effectiveness, the BBDS appears to afford an effective and economical
alternative for measuring children's procedure-related distress based on these preliminary
reliability and validity findings.
Previous SectionNext Section

We thank the parents and children who agreed to participate in this study, the staff of the
Johns Hopkins Pediatric Oncology, Hematology, Endocrine, and Immunology services for
allowing us to work with their patients; Michael F. Cataldo, PhD, for his administrative
support, and Adrianna Amari for her helpful comments on an earlier draft of this manuscript.
We thank Lisa Hilley, Wendy Sulc, and the other research assistants of the Pediatric
Psychology Lab at the University of Maryland Baltimore County for OSBD coding, and
Adrianna Amari, Melissa Beck, Suzanne Busby, Tanya Diver, Stephanie Eischen, Alana
Kane, Sharon McDonnell, Christopher Sarampote, and Ana Sobel for their assistance with
data collection and coding. This study was supported in part by the National Institute of Child
Health and Human Development, Grant#HD 35528, K. Slifer, P.I.

Society of Pediatric Psychology

Previous Section

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health (pp. 279-298). New York: Guilford.

Keandalan dan Validitas Brief Perilaku Skala Distress: Sebuah Ukur Distress Anak
Selama Prosedur Medis Invasif
Cindy L. Tucker, PhD 1, 2,
Keith J. Slifer, PhD 1, 2 dan
Lynnda M. Dahlquist, PhD 3
+ Penulis Afiliasi
1 Kennedy Krieger Institute
2 Johns Hopkins University School of Medicine
3 Universitas Maryland Baltimore County
Semua korespondensi harus dikirim ke Cindy L. Tucker, Departemen Psikologi
Perilaku, The Kennedy Krieger Institute, 707 N. Broadway, Baltimore, Maryland
21205. E-mail: tuckerc@kennedykrieger.org.
Menerima 30 Juni 2000.
Revisi menerima 7 Desember 2000.
Revisi menerima 15 Maret 2001.
Diterima April 20, 2001.

Bagian berikutnya
Tujuan: Untuk mengevaluasi keandalan dan validitas ukuran observasional baru
perilaku distress prosedur terkait anak-anak, Brief Skala Distress Perilaku (BBDS),
untuk memberikan dokter dengan efisien, ukuran alternatif ekonomis yang tidak
bergantung pada selang terus menerus coding.
Metode: Empat puluh delapan yang dipilih secara acak direkam prosedur medis
invasif dilakukan pada anak-anak (usia 2-10 tahun) dengan penyakit kronis diberi
kode dengan BBDS dan Skala Pengamatan Distress Perilaku (OSBD). Reliabilitas
dan validitas analisis bersama dengan analisis item dilakukan.
Hasil: Jumlah skor distress dari BBDS tersebut sangat terkait dengan enam dari

tujuh langkah bersamaan validitas dari berbagai sumber (yaitu, OSBD, peringkat
orangtua, dua peringkat perawat, laporan diri anak, dan ukuran gairah fisiologis,
denyut jantung) (kisaran r = 0,57-0,76, p <0,001-0,0001). Sebuah asosiasi yang
kuat ditemukan antara skor distress BBDS dan OSBD skor total distress (r = 0,72,
p <0,0001). Untuk dua ukuran validitas bersamaan, BBDS menunjukkan asosiasi
kuat dari melakukan OSBD. Keandalan interrater tinggi untuk setiap kategori
BBDS perilaku tertekan.
Kesimpulan: Berdasarkan temuan yang dilaporkan, yang BBDS adalah ukuran
yang dapat diandalkan dan valid distress prosedur terkait anak-anak dengan
utilitas fungsional di kedua penelitian dan pengaturan klinis.
Kata kunci
nyeri anak-anak
distress prosedur terkait
skala penilaian
prosedur medis invasif
Bagian SectionNext Sebelumnya
Anak-anak dengan kondisi medis kronis bertahan dalam jumlah meningkat,
namun kualitas hidup mereka dapat berkurang oleh kebutuhan untuk prosedur
medis invasif berulang (Dahlquist, 1999; Wallander & Varni, 1992). Jarum suntik
yang menyakitkan dapat menyebabkan ketakutan yang signifikan dan terusmenerus dikondisikan dan kecemasan bagi anak-anak, dengan bukti dilaporkan
sedikit untuk habituasi dari waktu ke waktu (Jay, Ozolins, Elliott, & Caldwell,
1983). Distress prosedur terkait sering mengganggu kerjasama dan
membahayakan pengiriman aman dan tepat waktu perawatan medis penting.
Tenaga medis dapat memilih untuk mengelola anak-anak yang sangat tertekan
dengan peningkatan sedasi, pengekangan fisik, dan, dalam beberapa kasus,
anestesi umum, dengan biaya yang melekat dan risiko dan gangguan lebih lanjut
dari kehidupan sehari-hari (Anderson, Zeltzer, & Fanurik, 1993). Dalam sebuah
tinjauan terbaru, Powers (1999) didokumentasikan perbaikan dramatis dalam
pengobatan tekanan prosedur terkait pada anak-anak selama dua dekade
terakhir. Bersamaan, penilaian pengamatan tertekan prosedur terkait anak-anak
juga telah meningkat.
Dari upaya mani pada pengembangan Perilaku Prosedur Rating Scale (PBRs;
Katz, Kellerman, & Siegel, 1980) telah muncul beberapa versi terkait tindakan
observasional, termasuk Skala Pengamatan Perilaku Distress (OSBD;. Jay et al,
1983 ; Elliott, Jay, & Woody, 1987) dan Anak-Dewasa Prosedur Medis Skala
Interaksi (CAMPIS, CAMPIS-R; Blount et al, 1989, 1997).. Versi asli dari OSBD (Jay
et al.) Tetap yang paling umum digunakan hasil pengukuran dalam studi
prosedur terkait khasiat pengobatan distress (Powers, 1999). The OSBD terdiri
dari 11 perilaku didefinisikan secara operasional berhubungan dengan anakprosedur terkait distress konstruksi, kecemasan dan rasa sakit, dengan tingkat
keparahan yang diberikan oleh ahli-ditentukan bobot. Kekuatan didirikan dari

OSBD telah banyak dilaporkan.

The OSBD, bagaimanapun, bukan tanpa keterbatasan. Pertama, definisi dari fase
prosedur medis (yaitu, antisipatif, prosedural, pemulihan) bervariasi di seluruh
studi (Blount, Sturges, & Powers, 1990). Bahkan ketika fase prosedural
didefinisikan secara konsisten, perbedaan atau keterlambatan dalam
pelaksanaan prosedur jarum, yang sering independen dari perilaku anak, dapat
mengubah durasi prosedur, sehingga meningkatkan atau menurunkan jumlah
interval observasi dan berpotensi mengempis atau menggembungkan nilai yang
dihasilkan. Dengan demikian, selang terus menerus coding sistem yang
menggunakan berbasis waktu fase definisi (Dahlquist, Power, & Carlson, 1995;.
Jay et al, 1983) dapat mengakibatkan perbandingan peristiwa prosedural
nonequivalent seluruh mata pelajaran atau dalam mata pelajaran di observasi.
Anak-anak dapat dihadapkan dengan berbagai jumlah dan jenis tuntutan,
mengaburkan interaksi berpotensi signifikan relevan dengan desain pengobatan.
Atau, satu dapat fokus pada tuntutan penting untuk kepatuhan ditempatkan
pada anak dan merekam jenis dan tingkat keparahan kesusahan dipamerkan
dalam menanggapi setiap permintaan khusus sebagai langkah diskrit. Tuntutan
penting adalah tuntutan spesifik untuk memenuhi berurutan ditempatkan pada
anak yang diperlukan untuk prosedur penyelesaian. Dengan menggunakan
metode ini, intervensi yang bertujuan mengurangi tekanan dalam menanggapi
tuntutan spesifik dari setiap langkah dapat dievaluasi dan disempurnakan. Hal ini
konsisten dengan Blount et al. (1990) dan Katz et al., (1980), yang meneliti
langkah-langkah khusus untuk sumsum tulang aspirasi (BMA), dan Manne,
Bakeman, Jacobsen, dan Redd (1993), yang meneliti langkah-langkah
venipunctures. Penelitian kami mengembangkan ukuran yang dapat digunakan
di berbagai prosedur jarum suntik dengan format diskrit-langkah, yang
memberikan efisiensi pengukuran yang lebih besar dan detail lebih lanjut
tentang perilaku anak dalam hubungannya dengan anteseden sosial dan
lingkungan tertentu dalam rutinitas jarum suntik.
Akhirnya, karena skor OSBD berasal dari menjumlahkan seluruh 11 perilaku
distress, data klinis yang relevan tentang jenis marabahaya yang dipamerkan
hilang. Sebaliknya, seperti dalam penelitian ini, perilaku distress dapat diurutkan
secara konseptual dalam topografi fungsional berdasarkan sejauh mana mereka
mempengaruhi kinerja prosedur. Dipandu oleh OSBD keparahan bobot didirikan,
kami mengklasifikasikan perilaku distress 11 dalam tiga kategori meningkatkan
intensitas sehubungan dengan gangguan prosedur medis. Perilaku distress
tambahan yang ditambahkan untuk maksud dari masing-masing kategori
(misalnya, mengerang, mengernyit, gangguan bahan medis). Sebuah kategori
untuk menilai respon koping anak-anak selama prosedur invasif, tanggapan
mengatasi aktif, juga disertakan.
Artikel ini menyajikan keandalan awal dan validitas analisis Brief Skala Perilaku
Distress (BBDS), ukuran menggabungkan kategori perilaku yang berasal dari
OSBD dan pendekatan tuntutan penting sebagai alternatif untuk mengukur
prosedur terkait distress anak dan mengatasi. Kami harapkan BBDS skor distress

secara signifikan berkorelasi positif dengan OSBD skor keseluruhan distress dan
langkah-langkah validitas bersamaan tertekan anak (peringkat nyeri anak,
peringkat orang tua takut anak dan nyeri, peringkat perawat kesusahan anak,
dan denyut jantung) dan secara signifikan berkorelasi negatif dengan peringkat
perawat kerjasama anak. Sebaliknya, skor BBDS tanggapan mengatasi aktif
diharapkan berkorelasi negatif dengan tindakan bersamaan kesusahan anak dan
positif dengan penilaian perawat kerjasama anak.
Bagian SectionNext Sebelumnya
Peserta dan Pengaturan
Peserta sampel berturut-turut dari 40 anak didiagnosis dengan penyakit kronis
dan menerima prosedur medis invasif diulang di sebuah rumah sakit anak
perawatan tersier selama 2 tahun. Semua peserta adalah bagian dari studi
longitudinal yang sedang berlangsung dirancang untuk membandingkan dan
mengevaluasi efek dari pendekatan pengobatan yang berbeda pada prosedur
terkait distress anak-anak (NICHD, HD # 35528, Behavioral Medicine Pendekatan
untuk Pediatric Nyeri akut, K. Slifer, PI). Seorang anggota tim peneliti bertemu
dengan calon peserta, menjelaskan prosedur penelitian, dan memperoleh
persetujuan dari orang tua dan persetujuan dari anak. 40 peserta termasuk 12
anak perempuan (30%) dan 28 anak laki-laki (70%) yang usianya berkisar dari 2
tahun, 2 bulan sampai 10 tahun, 8 bulan (M = 6 tahun, 0 bulan). Enam puluh
persen dari peserta Kaukasia, 35% adalah Afrika Amerika, 2,5% Hispanik, dan
2,5% adalah Asia India. Dua puluh satu anak menerima satu atau jenis lebih dari
prosedur invasif (yaitu, ditanamkan akses pelabuhan [PCA], venipuncture [IV],
injeksi intramuskular [IM], suntikan subkutan [SQ]) untuk pengobatan kanker
anak, khusus untuk leukimia ( 57%) atau tumor padat (43%). Sembilan anakanak menerima transfusi kronis bulanan untuk pengobatan gangguan
hematologi (yaitu, anemia sel sabit, thalasemia). Sembilan anak yang tersisa
menerima prosedur invasif (yaitu, PCA, IV, atau SQ) untuk pemantauan dan
pengobatan kondisi medis yang kronis (misalnya, trombositopenia idiopatik,
insufisiensi hormon pertumbuhan, immunodeficiency).
Kami memiliki sebuah arsip yang tersedia dari 360 pengamatan direkam selama
2 tahun. 40 peserta yang diamati pada kunjungan klinik dijadwalkan dan diikuti
dari awal, menjadi sembilan sesi perawatan (jika demikian acak) dan melalui
fase tindak lanjut dari sekitar 6 bulan. Jumlah rata-rata pengamatan yang
dikumpulkan per peserta adalah 9,47, mulai dari 2 hingga 27. rekaman video
dimulai ketika anak memasuki ruang prosedur dan dilanjutkan selama 3-4 menit
setelah prosedur. Filmer tidak berbicara kepada anak sekali rekaman video
mulai. Sesi yang direkam yang ditranskrip, kode, dan mencetak sesuai dengan
prosedur yang dijelaskan oleh Jay et al. (1983) untuk salah satu ukuran hasil,
yang OSBD. Film prosedur berkisar 3-22 menit (M = 10,0 menit, SD = 6.4.);
khusus, M = 6.3 menit, SD = 2,9 untuk IM dan SQS.; M = 9.2 menit, SD = 5.1
untuk PCA.; dan M = 10,2 menit., SD = 5.2 untuk infus.

Sebuah sampel acak dari 54 pengamatan direkam (15%) dipilih untuk

pengodean ulang dengan BBDS. Dari sembilan coders BBDS, dua coders memiliki
pelatihan OSBD sebelumnya, tiga coders memiliki beberapa keakraban dengan
OSBD dan coding prosedur invasif anak, dan empat coders tidak terbiasa dengan
OSBD dan berpengalaman dalam kesulitan prosedural coding. Coders disediakan
dengan sekitar 1 jam dari pelatihan coding pengamatan dari marabahaya
prosedural anak bersama dengan review dari kategori perilaku dan definisi
operasional dalam BBDS. Sebagai kelompok, coders Ulasan tiga prosedur invasif
anak videotape, dibahas perbedaan, aturan keputusan ditentukan, dan definisi
perilaku diklarifikasi. Sebuah versi akhir dari definisi perilaku kategori diberikan
kepada setiap coder dengan instruksi untuk coding independen. Setiap coder
ditugaskan enam pengamatan videotape untuk pengodean ulang dengan BBDS
dan diberikan petunjuk berikut: (1) melihat prosedur dan menunjukkan urutan
setiap langkah yang diamati pada bentuk coding; (2) menulis dalam langkahlangkah tambahan diamati dan nomor seperti di atas; (3) selama durasi setiap
langkah diamati, menunjukkan terjadinya masing-masing dari empat kategori
perilaku dengan cek pada kotak yang sesuai; dan (4) jika langkah terjadi lebih
dari sekali, menggabungkan beberapa pengamatan di barisan daftar langkah
sehingga semua kejadian dari perilaku selama setiap kinerja langkah yang
termasuk dalam kotak yang sama.
Karena konflik penjadwalan, empat coders selesai hanya lima pengamatan. Dua
pengamatan tidak dapat dikodekan karena kualitas film yang. Hal ini
mengakibatkan satu set 48 prosedur recoded yang mencerminkan distribusi
prosedur dalam sampel keseluruhan: 20 infus, 20 PCA, 5 IM, dan 3 SQS. Set
terakhir dari 48 pengamatan termasuk prosedur dari 87,5% (35) dari total 40
peserta, dengan beberapa pengamatan (di fase) yang dipilih secara acak dari 13
(37%) dari 35 peserta dalam sampel. Tiga puluh satu dari prosedur terjadi
selama awal, 12 selama pengobatan, dan 5 selama masa tindak lanjut. Para
peserta telah acak ditunjuk untuk selingan (Pringle et al., Dalam pers), kontraconditioning (Slifer, Babbitt, & Cataldo, 1995), atau kontrol perhatian kelompok
intervensi nondirective. Selama masing-masing sembilan sesi perawatan,
peserta dan pengasuh mereka bertemu dengan seorang terapis selama 20 menit
sebelum prosedur invasif dijadwalkan.
Campuran krim topikal lidocaine dan prilocaine, campuran eutektik dari anestesi
lokal, (EMLA, Astra Produk Farmasi, Inc, Westborough, MA 01581) digunakan
untuk mematikan situs jarum sebelum 30 prosedur. Lidocaine intradermal
digunakan sebelum dua prosedur IV. Sisanya 16 prosedur dilakukan tanpa
menggunakan agen farmakologis setiap.
Singkat Perilaku Skala Distress
The BBDS diadaptasi dari metode pengamatan perilaku dijelaskan oleh Slifer
dkk. (1995), yang digunakan untuk mengukur kerjasama anak-anak dan
kesulitan prosedur terkait dengan langkah-langkah komponen diskrit terlibat
dalam beberapa jenis prosedur medis invasif. Dengan melanggar prosedur dalam

langkah diskrit, seseorang dapat melakukan pengamatan relatif terhadap

tuntutan spesifik untuk memenuhi berurutan ditempatkan pada anak selama
prosedur. Langkah-langkah ini merupakan tuntutan penting dari prosedur invasif
(Blount et al., 1990). Berbagai prosedur tongkat jarum diamati dan dianalisis
menjadi serangkaian langkah-langkah penting untuk prosedur penyelesaian. Dua
belas langkah yang mungkin diidentifikasi. Langkah yang didefinisikan oleh onset
dan offset, tanpa memperhatikan urutan atau durasi. Pengamat mencatat
terjadinya atau tidak terjadinya perilaku sasaran selama setiap langkah prosedur.
Deskripsi dan definisi operasional perilaku target untuk setiap kategori disajikan
di bawah ini.
Noninterfering Perilaku Distress. Kategori ini meliputi perilaku menunjukkan
distress prosedural ringan atau sebagian diatur. Anak menampilkan perilaku
yang tidak menunda atau mengganggu kinerja prosedur seperti menangis,
merengek, merintih, mengerang, vokalisasi negatif (yaitu, "Berhenti," "Aku tidak
ingin," "Tunggu, aku belum siap ") yang tidak di atas permukaan percakapan,
atau mencari kenyamanan fisik dari orang atau objek lain.
Berpotensi Mengganggu Perilaku Distress. Perilaku ini menunjukkan distress
intensitas sedang yang sedang diatur kurang baik oleh anak dan yang belum
tentu mengganggu kinerja prosedur tetapi dapat menunda, memperpanjang,
atau membuat lebih sulit untuk melakukan. Kategori ini meliputi perilaku seperti
menjerit, berteriak, berteriak, vokalisasi negatif (yaitu, "Berhenti," "Aku tidak
ingin," "Tunggu, aku belum siap") yang berada di atas tingkat percakapan,
menegang jelas otot, contortions wajah, rahang mengepalkan, gigi menggiling
atau mengertakkan, tinju terkepal erat (tidak menanggapi diberitahu untuk
"membuat kepalan"), atau berkedip.
Perilaku mengganggu Distress. Perilaku ini mengakibatkan prosedur yang
dihentikan, ditunda, atau dilakukan dengan menggunakan pengekangan fisik dan
mencerminkan tingkat parah tekanan dan protes dengan sedikit tidak
kemampuan (atau usaha) oleh anak untuk mengatur perilaku nya. Kategori ini
termasuk berusaha atau menyelesaikan perilaku seperti melarikan diri atau
menghindari (yaitu, bangun dari kursi, meninggalkan ruangan, bersandar atau
menarik diri dari perawat, menolak atau bergerak keluar dari posisi,
menyembunyikan, atau memblokir situs prosedur), gangguan dari bahan medis ,
atau agresi fisik.
Active Coping Response Tanpa Verbal Tunda. Ketika penyedia layanan kesehatan
mencoba untuk melakukan langkah tertentu dalam prosedur invasif, anak
terlibat dalam respon koping diamati seperti bermain dengan mainan atau
kegiatan dengan menekan tombol, menunjuk ke, atau verbalisasi tentang hal itu;
menghitung dengan suara keras; nyanyian; menggunakan pernapasan atau
relaksasi strategi yang terfokus; terdengar berdoa; memulai atau terlibat dalam
percakapan nonmedis (luar tanggapan single-kata); melihat rekaman video
disukai; membuat pernyataan koping positif (yaitu; "Ini akan segera berakhir,"
"Hal itu tidak sakit"); mengajukan pertanyaan tentang prosedur (misalnya, "Apa

yang kamu lakukan?" "Kapan itu dilakukan"?); atau memegang, membelai, atau
menepuk sebuah benda (yaitu, selimut, Teddy, dot) atau orang. Respon koping
aktif tidak mencetak gol untuk setiap langkah di mana perilaku yang disertai
dengan pernyataan penundaan verbal, seperti, "Jangan lakukan itu lagi, saya
harus berdoa dulu," atau "Tunggu sampai aku siap untuk menghitung." Jika tidak,
mengatasi aktif dapat mencetak bersamaan dengan perilaku tertekan.
Mengajukan pertanyaan tentang prosedur termasuk berdasarkan temuan bahwa
pencarian informasi telah secara signifikan berkorelasi negatif dengan
kecemasan tinggi prosedural atau tekanan oleh beberapa peneliti (Katz et al,
1980;.. Manne et al, 1993; Peterson & Toler, 1986). Ini adalah keberangkatan dari
OSBD dan CAMPIS skala, yang keduanya termasuk mencari informasi sebagai
perilaku distress (Blount et al, 1989;. Jay et al, 1983.). Meskipun perselisihan ini
dalam literatur, mengajukan pertanyaan termasuk di sini sebagai diamati
meskipun upaya belum tentu efektif dengan anak untuk mengatasi, kecuali
disertai dengan pernyataan penundaan verbal.
Jumlah langkah yang terjadi selama setiap prosedur tercatat (M = 9 langkah,
kisaran = 6-12). Jumlah langkah di mana perilaku yang terjadi itu dijumlahkan
dan dibagi dengan jumlah total langkah, kemudian dikalikan dengan 100 untuk
menghasilkan persentase langkah dengan skor kejadian untuk setiap kategori
perilaku. Jumlah langkah dalam perilaku apa dari salah satu dari tiga distress
kategori perilaku terjadi (yaitu; noninterfering, berpotensi mengganggu, dan
mengganggu) itu dijumlahkan dan dibagi dengan jumlah total langkah dikalikan
tiga (jumlah kategori distress), kemudian dikalikan dengan 100 untuk
mendapatkan Total Skor Distress. Penggunaan skor persentase diperbolehkan
untuk metrik umum untuk membandingkan skor dari prosedur dengan nomor
yang berbeda dari langkah-langkah. Active Coping Response Skor diperlakukan
sebagai subskala terpisah. Coding dari empat kategori perilaku dari BBDS
umumnya mengambil 10 sampai 15 menit per observasi, dengan coding yang
selesai dalam satu atau, jarang, dua melewati prosedur rekaman video.
Skala pengamatan Distress Perilaku (OSBD)
Menyusahkan anak terbuka diukur menggunakan OSBD (Jay et al., 1983).
Transkrip tertulis dari semua vokalisasi yang terjadi selama prosedur difilmkan
diproduksi untuk meningkatkan keandalan interrater. Dari rekaman video dan
transkripsi, pengamat kode untuk ada atau tidaknya perilaku distress 11 anak
(misalnya, menangis, verbalisasi takut) selama interval kontinyu 15 detik. Skor
Distress dihitung dengan menjumlahkan jumlah interval 15 detik selama mana
setiap perilaku distress terjadi dan mengalikan angka tersebut dengan berat
intensitas ahli-ditentukan 1-4 mencerminkan tingkat keparahan perilaku. Total
Skor Distress dihitung dengan menjumlahkan skor distress tertimbang dan
membaginya dengan jumlah total interval 15 detik untuk prosedur ini. Transkripsi
rekaman video mengambil sekitar 2 jam untuk menghasilkan. Pengkodean dari
OSBD biasanya mengambil 30 sampai 45 menit, umumnya membutuhkan 3-4
lewat rekaman videonya. Untuk studi ini, 18% dari 360 sesi direkam secara
independen kode oleh pengamat kedua, menghasilkan rata-rata koefisien kappa

Reliabilitas interrater dilaporkan dalam literatur untuk OSBD yang seragam baik.
Skor kesepakatan persentase berkisar dari 72% sampai 99% total distress (Jay et
al., 1983), dan koefisien kappa of.90 and.87 telah dilaporkan masing-masing
untuk prosedural dan pemulihan fase (Gonzalez et al., 1989). OSBD skor distress
telah secara signifikan berkorelasi dengan indeks lain dari anak-anak sakit
prosedural dan kesusahan, seperti orang tua dan perawat peringkat penderitaan
anak, peringkat anak-anak ketakutan, dan langkah-langkah fisiologis distress
(Elliott et al, 1987;.. Jay et al, 1983; Jay, Elliott, Katz, & Siegel, 1987). The OSBD
juga telah terbukti menjadi sensitif terhadap perubahan dalam kesulitan
prosedural anak-anak setelah intervensi psikologis (misalnya, Dahlquist, 1992;
Jay et al, 1987;.. Pringle et al, in press).
Anak Self-Laporan Penilaian of Pain atau Ketidaknyamanan
Segera setelah prosedur invasif, anak-anak diminta oleh staf penelitian untuk
menunjukkan sejauh mana mereka mengalami ketidaknyamanan. Tiga dan 4year-olds dinilai dengan cara Oucher Skala (Beyers, Villarruel, & Denyes, 1992),
instrumen posterlike yang menghasilkan data ordinal mulai dari 0 hingga 5
ketika hanya skala fotografi digunakan. Keenam foto yang tersedia di Kaukasia,
Afrika Amerika, Hispanik dan versi. Studi dari konvergen, diskriminan, dan
membangun validitas Oucher menunjukkan baik untuk validitas yang sangat baik
(misalnya, r = 0,70-0,98) dan keandalan tes-tes ulang pada tingkat yang
moderat (misalnya, r = 0,54-0,72). Seperti yang diarahkan dalam manual, tugas
seriation Piaget dilakukan sebelum menggunakan satu Oucher dengan 3 dan 4year-olds untuk menentukan pemahaman kognitif yang memadai dan
kematangan untuk penyelesaian tugas. Tidak ada peringkat laporan diri dari
ketidaknyamanan diperoleh untuk anak di bawah usia 3 tahun (n = 3) atau
berusia 3 atau 4 tahun yang gagal tes skrining kognitif (n = 2).
Anak-anak yang berusia 5 tahun atau lebih yang dinilai menggunakan Analog
Skala berwarna (CAS;. McGrath et al, 1996). CAS menilai tingkat anak-anak
ketidaknyamanan subjektif dengan menyesuaikan penanda plastik geser
sepanjang kontinum analog visual yang berkisar dari "yang paling sakit" untuk
"tidak sakit" dan bervariasi dalam warna, daerah, dan panjang. McGrath et al.
(1996) melaporkan konten yang memadai dan membangun validitas serta
reliabilitas test-retest dengan anak-anak 5 sampai 16 tahun. Agar data Oucher
dibandingkan dengan data ordinal diperoleh dengan CAS, yang berkisar dari 0
sampai 10, kita mengubah data Oucher dengan mengalikan masing-masing
wisatawan dengan 2. Transformasi tidak menjamin kesetaraan dari sudut
pandang psikometri, tetapi tidak memungkinkan untuk penilaian anak dalam
kelompok usia yang lebih muda.
Delapan anak (M = 66 bulan, kisaran 39-106 =), tidak menanggapi ketika
diminta untuk menilai ketidaknyamanan mereka. Anak-anak ini diamati untuk
tetap tertekan dan ditarik dari staf klinik dan peneliti mengikuti prosedur,
sehingga kemungkinan akuntansi untuk kurangnya respon. Secara total, data

laporan diri untuk 35 anak-anak usia 38-119 bulan (M = 73) tersedia untuk
Penilaian induk Anak Takut dan Sakit
Orang tua hadir selama prosedur medis invasif yang diamati diminta hanya
sebelum prosedur untuk menilai tingkat nya anak ketakutan tentang prosedur
yang akan datang menggunakan Skala Analog Visual (VAS). Akhir-poin dari skala
10-sentimeter diberi label Tidak Takut dan Sangat Takut. Segera setelah
prosedur, orang tua diminta untuk menilai sejauh mana anak nya mengalami
rasa sakit selama prosedur invasif. Endpoint ini 10-sentimeter VAS diberi label No
Pain dan Paling Sakit (Powers, Blount, Bachanas, Cotter, & Swan, 1993).
Penilaian perawat Distress Anak dan Kerjasama
Perawat atau penyedia perawatan kesehatan lainnya melakukan prosedur medis
invasif diminta untuk menggunakan VAS untuk menilai tingkat anak tertekan
diamati dan tingkat kerjasama selama prosedur saja menyelesaikan. The-titik
akhir dari skala 10 sentimeter untuk distress diberi label Tidak Tertekan dan
sangat Tertekan, dan kerjasama, Tidak Koperasi dan Koperasi Sangat (Powers et
al., 1993).
Otonom Fisik Gairah Ukur
Untuk mendapatkan indikator sistem saraf otonom gairah, detak jantung anak
(SDM) diukur dengan menggunakan elektrokardiogram portabel (EKG) perekam
acara berkualitas (Heart Access Plus , Paceart Associates, LP, Fairfield, NJ
07004) melekat dada anak melalui dua elektroda perekat neonatal berukuran,
(misalnya, Huggables). Sebuah rekaman EKG 10-kedua diperoleh dengan
menekan tombol pengaktif pada perangkat di lima titik sampel yang telah
ditentukan selama setiap prosedur yang diamati. HR rata di tiga dari mereka
waktu titik sampling dianalisis untuk penelitian ini: khusus, (1) HR antisipatif,
ketika situs injeksi dibersihkan atau menutup tape atau ganti dihapus; (2) HR
prosedural, ketika jarum pertama memasuki kulit; dan (3) pemulihan HR, 30
detik setelah jarum keluar kulit atau tape diterapkan untuk mengamankan jarum
di lokasi penyisipan. Rekaman EKG kemudian didownload ke database komputer
di mana mereka disimpan dan dianalisis untuk pembacaan HR (di denyut per
menit). Data HR yang hilang selama 13 (27%) kasus akibat tingginya tingkat
artefak pada rekaman EKG atau anak atau orang tua penolakan.
Bagian SectionNext Sebelumnya
Keandalan Interrater
Untuk 20 pengamatan yang dipilih secara acak, dua pengamat independen
mencatat terjadinya perilaku target untuk setiap langkah prosedur. Analisis
Pearson produk-moment korelasi dilakukan antara pasangan BBDS skor
pengamat 'menghasilkan sebuah r (19) of.87 (kisaran di kategori = 0,85-0,93).
Skor kesepakatan persen (perjanjian / kesepakatan ditambah ketidaksepakatan
100) untuk BBDS skor total distress berkisar antara 65% sampai 100%, (M =
87%, SD = 9,75). Skor perjanjian persen untuk kategori perilaku individu adalah

sebagai berikut: 93% (SD = 11,26) untuk campur distress, 85% (SD = 17,07)
untuk berpotensi mengganggu distress, 84% (SD = 14,93) untuk noninterfering
marabahaya, dan 86% (SD = 21,05) untuk respon koping aktif. Koefisien kappa
were.87 untuk campur distress, 0,68 untuk berpotensi mengganggu distress,
0,68 untuk noninterfering distress, 0,74 untuk BBDS jumlah distress, and.72
tanggapan mengatasi aktif.
Item Analisis
Kami melakukan analisis item pada empat kategori perilaku yang terdiri dari
BBDS. Kriteria untuk mempertahankan kategori perilaku adalah (1) terjadinya
perilaku dalam setidaknya 10% dari sampel, (2) koefisien korelasi +.3 atau lebih
besar antara masing-masing kategori distress dan total skor distress, (3)
koefisien korelasi + 0,3 atau lebih besar dengan setidaknya satu kategori lainnya
distress, dan (4) koefisien kappa di least.6 (Elliott et al, 1987;. Nunnally, 1978).
Perilaku distress campur terjadi di 27 (56,3%) dari 48 prosedur dan berkorelasi
secara signifikan dengan BBDS Total distress (r [47] = 0,79, p <0,0001) dan
berpotensi mengganggu distress (r [47] = 0,71, p <. 0001). Perilaku dari kategori
distress berpotensi mengganggu terjadi di 36 (75%) dari prosedur dan
berkorelasi secara signifikan dengan BBDS Total distress (r [47] = 0,90, p
<0,0001) dan non-campur distress (r [47] =. 41, p <0,004). Perilaku distress
Noninterfering diberi kode untuk 42 (88%) dari prosedur dan berkorelasi secara
signifikan dengan BBDS Total distress (r [47] = 0,69, p <0,0001). Tidak ada
hubungan yang signifikan yang ditemukan antara mengganggu dan
noninterfering perilaku distress (r [47] = -.225, p = 0,125). Uji koefisien alpha
Cronbach konsistensi internal mengungkapkan koefisien of.71 untuk BBDS
jumlah distress. Hal ini sebanding dengan koefisien alpha of.72 dilaporkan untuk
OSBD oleh Elliott et al. (1987).
Kategori perilaku, respon koping aktif, diberi kode 30 (62,5%) dari prosedur.
Mengatasi tanggapan berkorelasi dengan BBDS skor total kesusahan dalam arah
yang diharapkan (r [47] = -.29, p <0,046) tetapi tidak menghasilkan korelasi
yang signifikan dengan salah satu kategori perilaku tiga distress (kisaran r = -.20
ke - 0,27, p <0,173 to.063). Mengingat kurangnya korelasi negatif yang
signifikan dengan salah satu dari tiga BBDS distress skor kategori perilaku, aktif
kategori tanggapan koping tidak dipertahankan sebagai bagian dari BBDS.
Perbandingan dilakukan untuk menentukan konstruk dan validitas bersamaan
dari BBDS dibandingkan dengan ukuran yang sering digunakan dan mapan
perilaku menyusahkan anak, yang OSBD. Tabel I menampilkan Pearson momenproduk koefisien korelasi antara tindakan bersamaan validitas dan kedua BBDS
dan OSBD skor keseluruhan distress serta BBDS skor perilaku tertekan. Koreksi
Bonferroni (0,05 / 11 = p <0,005) yang digunakan untuk mengatur tingkat alpha
untuk signifikansi untuk mengurangi risiko Tipe I kesalahan. Hasil penelitian
menunjukkan bahwa BBDS skor distress secara signifikan berkorelasi positif
dengan OSBD jumlah kesusahan. Kedua BBDS dan OSBD skor keseluruhan

distress secara signifikan terkait dengan langkah-langkah validitas bersamaan

dengan satu pengecualian, rating orangtua takut anak dari prosedur.
Lihat tabel ini:
Dalam jendela ini
Di jendela baru
Tabel I.
Koefisien Korelasi Antara BBDS dan OSBD Distress Skor dan Tindakan Validitas
Perilaku distress mengganggu secara signifikan berkorelasi positif dengan tiga
dari lima langkah validitas konkuren tertekan anak. Berpotensi perilaku distress
mengganggu secara signifikan berkorelasi positif dengan empat dari lima
langkah validitas konkuren tertekan anak. Perilaku distress Noninterfering secara
signifikan berkorelasi positif dengan dua dari lima langkah validitas konkuren
tertekan anak. Ketiga perilaku distress secara signifikan berkorelasi negatif
dengan laporan perawat kerjasama anak.
Ketika koefisien korelasi untuk skor total distress BBDS dan OSBD dengan
langkah-langkah validitas konkuren dibandingkan (lihat Tabel I), r individu untuk
transformasi z menunjukkan bahwa BBDS skor keseluruhan distress yang lebih
kuat terkait dengan penilaian perawat dari kedua kesusahan dan kerjasama anak
dari yang OSBD skor total distress (z [0,1] = 2,39, p <0,008; z [0,1] = 2.14, p
<0,016, masing-masing). Koefisien korelasi untuk empat sisa langkah validitas
(yaitu, anak Peringkat laporan diri dari rasa sakit, Peringkat orangtua ketakutan
anak, orangtua Peringkat sakit anak, berarti denyut jantung) pada dasarnya
Sebuah Pearson momen-produk koefisien korelasi menunjukkan tidak ada
hubungan antara usia anak dan mengamati tekanan yang diukur dengan BBDS
skor total distress (r [30] = -.19, p <0,302). Temuan ini berbeda dengan efek usia
yang signifikan biasanya ditemukan menggunakan OSBD dan langkah-langkah
pengamatan serupa lainnya dari prosedur terkait distress anak (misalnya, Blount,
Landolf-Frische, Powers, & Sturges, 1991; Jay et al, 1983;. Katz et al., 1980).
Frekuensi Kemunculan dari Distress Perilaku Selama Tuntutan Prosedural Esensial
Tabel II menampilkan frekuensi terjadinya setiap langkah prosedural bersama
dengan distribusi terjadinya perilaku darurat dari masing-masing kategori.
Perilaku distress campur paling sering terjadi selama posisi anak dan
mengekspos tempat suntikan, manipulasi jarum, dan jarum penyisipan.
Berpotensi perilaku distress campur paling sering terjadi selama insersi jarum
dan manipulasi. Perilaku distress Noninterfering paling sering terjadi selama
manipulasi jarum, mengamankan jarum dengan pita, dan posisi dan mengekspos

Lihat tabel ini: