Illness perceptions and beliefs about medication: impact on health-related quality of life in adolescent kidney transplant recipients

Adolescents diagnosed with chronic kidney disease (CKD) who undergo kidney transplantation have to adjust to pervasive effects of chronic illness and life-long treatment maintenance, alongside normative developmental stressors. The way in which adolescent transplant recipients experience and think about their illness as well as their medication regimen can be a crucial factor impacting psychosocial outcomes. Participants were 26 adolescent kidney transplant recipients (μ = 16.8 years, σ = 1.69 years) who completed self-report surveys during a clinic visit. Multiple linear regressions were used to investigate whether adolescents' beliefs about medications and attitudes and perceptions of their illness are associated with their overall quality of life. Adolescents' negative illness perceptions contributed to lower transplant-specific health-related quality of life ratings (ΔR² =.305, p < .01). Additionally, adolescent beliefs about their specific medication regimens (ie, personal medication concerns) (ΔR² =.342, p < .01), and general beliefs about medication use (ie, harm, overuse) (ΔR² =.241, p < .05) also contribute significantly to the variance in their overall quality of life ratings. Adolescent transplant patients in older grades and those in special education endorsed lower quality of life. Cognitive components (eg, beliefs, perceptions) of an adolescent kidney transplant recipient's experience contribute to transplant-related quality of life outcomes. This highlights a point of intervention where cognitive change interventions may be utilized and efficacious in improving health outcomes.

Longitudinal Impact of Parental Catastrophizing on Child Functional Disability in Pediatric Amplified Pain

Objective

Children with amplified musculoskeletal pain (AMPS) experience significant functional disability, with impairment in their ability to participate in age-appropriate activities of daily living. Parental factors play an important role in a child’s pain symptoms and treatment outcomes, with parental pain catastrophizing and protective behaviors linked to several maladaptive outcomes for children. Aims of the current study were to examine how parental pain catastrophizing, child pain catastrophizing, and parental protective behaviors longitudinally impacted functional disability for children with AMPS.

Methods

Archival data were examined from parent-child dyads presenting to a tertiary pain clinic for treatment of AMPS. Over 1 year, parents completed measures assessing the level of pain catastrophizing, common behavioral responses to child pain, and child functional disability. Children completed measures of pain catastrophizing and functional disability. Measures were collected at initial evaluation, 6-months, and 12-months. Latent growth models (LGM) were conducted to examine how to study variables longitudinally impacted the rate of change in child functional disability.

Results

Examining a comprehensive LGM of study variables, parental catastrophizing emerged as the sole contributing factor to slower improvement in functional disability.

Conclusions

The strong influence of parental pain catastrophizing on functional disability may relate to parents limiting behaviors that promote adaptive coping in children with pain. As such, parents who catastrophize may benefit from specific interventions to increase their use of adaptive behavioral responses, such as redirecting children to complete functional activities and encouraging the use of positive coping skills for pain-related distress.

Association between day of the week and medication adherence among adolescent and young adult kidney transplant recipients

Disruption of usual routines may hinder adherence, increasing the risk of rejection. We aimed to compare weekend versus weekday medication adherence among adolescent and young adult kidney transplant recipients, hypothesizing poorer adherence on weekends. We examined data from the Teen Adherence in Kidney transplant Effectiveness of Intervention Trial (TAKE-IT). We assessed the 3-month run-in period (no intervention) and the 12-month intervention interval, considering a potential interaction between weekend/weekday and treatment group. Adherence was monitored using electronic pillboxes in participants 11-24 years followed in eight transplant centers in Canada and the United States. We used logistic regression with generalized estimating equations to estimate the association between weekends/weekdays and each of perfect taking (100% of prescribed doses taken) and timing (100% of prescribed doses taken on time) adherence. Taking (OR = 0.72 [95% CI 0.65-0.79]) and timing (OR = 0.66 [95% CI 0.59-0.74]) adherence were poorer on weekends than weekdays in the run-in (136 participants) and the intervention interval (taking OR = 0.74 [0.67-0.81] and timing OR = 0.71 [95% CI 0.65-0.77]). There was no interaction by treatment group (64 intervention and 74 control participants). Weekends represent a disruption of regular routines, posing a threat to adherence. Patients and families should be encouraged to develop strategies to maintain adherence when routines are disrupted. TAKE-IT registration number: Clinicaltrials.gov registration: NCT01356277 (May 17, 2011).

Social Problem Solving and Posttraumatic Growth New Possibilities in Postoperative Breast Cancer Survivors

The purpose of this study was to examine whether social problem solving (SPS) would relate to posttraumatic growth (PTG), particularly new life possibilities in breast cancer survivors. Participants included 85 women who had undergone surgical intervention for breast cancer at least 6 months prior to study participation. Participant ages ranged from 29 to 88 years. The majority of the sample was White (86%), married (58%), and had received at least some postsecondary education (73%), and all participants spoke English. This IRB-approved cross-sectional study was part of a larger study examining psychosocial protective and risk factors in breast cancer survivors at a university-affiliated private hospital. We hypothesized that better SPS ability would relate to PTG new possibilities above and beyond age, annual income, and time since surgery. Results from this study indicate that a positive problem orientation and lack of impulsive/careless problem-solving style appear to play a role in posttraumatic growth among breast cancer survivors, particularly in developing beliefs about one's ability to positively change one's life. Given the established benefits of active/approach coping in cancer populations, it makes sense that similar interventions such as problem-solving therapy, a cognitive-behavioral therapy that includes challenging and reframing negative beliefs about self and situation, may promote new possibility beliefs in this population.

Examining Uncertainty in Illness in Parents and Children With Chronic Kidney Disease and Systemic Lupus Erythematosus: A Mediational Model of Internalizing Symptoms and Health-Related Quality of Life

To examine if parent illness uncertainty is indirectly associated with child depression, anxiety, and HRQOL in the CKD/SLE population. Parent-child dyads (N = 31) from outpatient rheumatology and nephrology clinics included children (ages 9-18) diagnosed with CKD (Stage 1, 2, or nephrotic syndrome) or SLE. Parents completed demographic and uncertainty measures and children completed uncertainty, depression, anxiety, and HRQOL measures. This cross-sectional study examined mediational models using the percentile bootstrapping method. Parent uncertainty had an indirect effect on child depression, anxiety, and HRQOL through the mediator, child uncertainty. In other words, parents' illness uncertainty regarding their child's condition correlates to the child's illness uncertainty, which then is associated with the child's mental health and wellbeing. Reverse mediations illustrated that parent uncertainty did not mediate child uncertainty and outcome variables. Results extend previous research by examining parent and child illness uncertainty in understudied conditions (CKD/SLE) and the relationship to outcome variables commonly related to depression (e.g., anxiety and HRQOL). Findings allow health psychologists and medical personnel to understand the impact of uncertainty on the child's wellbeing and HRQOL. Clinical implications, including using specialized interventions to address illness uncertainty, are discussed.

Medication adherence in pediatric renal transplant patients: The role of family functioning and parent health locus of control

Children and adolescents with renal disease experience daily social, emotional, and medical challenges. Renal transplantation can help to improve quality of life but requires a lifelong regimen of immunosuppressant medication to maintain health. Adherence to a daily complex regimen can be difficult, particularly for adolescents who are beginning to develop autonomy from caregivers and are faced with a unique set of socio-emotional challenges. This study examines two factors that have shown to influence adherence in other pediatric populations, namely family functioning and parent health locus of control, from mothers' perspectives, in predicting medication non-adherence for adolescents (ages 12-19 years) 1 year post-transplant. Non-adherence was defined as the percentage of missed doses and late doses of the weekly immunosuppressant doses prescribed. Regression results demonstrated that mothers' perceptions of poorer overall family functioning predicted missed medication doses (ΔR²  = 0.383, F(7, 21) = 2.570, P = 0.044) with significant contributions in the domains of problem-solving (β = -0.795, t(21) = -2.927, P = 0.008) and affective involvement (β = 0.872, t(21) = 3.370, P = 0.003). Moreover, mothers who perceived that their adolescent had control over his/her health also predicted more missed medication doses (ΔR²  = 0.133, F(1, 27) = 5.155, P = 0.031). Important implications for these findings include implementation of family-based interventions that promote developmentally appropriate skills for adolescents and cultivate emotional involvement within the family.

A Randomized Trial of a Multicomponent Intervention to Promote Medication Adherence: The Teen Adherence in Kidney Transplant Effectiveness of Intervention Trial (TAKE-IT)

BACKGROUND

Poor adherence to immunosuppressive medications is a major cause of premature graft loss among children and young adults. Multicomponent interventions have shown promise but have not been fully evaluated.

STUDY DESIGN

Unblinded parallel-arm randomized trial to assess the efficacy of a clinic-based adherence-promoting intervention.

SETTING & PARTICIPANTS

Prevalent kidney transplant recipients 11 to 24 years of age and 3 or more months posttransplantation at 8 kidney transplantation centers in Canada and the United States (February 2012 to May 2016) were included.

INTERVENTION

Adherence was electronically monitored in all participants during a 3-month run-in, followed by a 12-month intervention. Participants assigned to the TAKE-IT intervention could choose to receive text message, e-mail, and/or visual cue dose reminders and met with a coach at 3-month intervals when adherence data from the prior 3 months were reviewed with the participant. "Action-Focused Problem Solving" was used to address adherence barriers selected as important by the participant. Participants assigned to the control group met with coaches at 3-month intervals but received no feedback about adherence data.

OUTCOMES

The primary outcomes were electronically measured "taking" adherence (the proportion of prescribed doses of immunosuppressive medications taken) and "timing" adherence (the proportion of doses of immunosuppressive medications taken between 1 hour before and 2 hours after the prescribed time of administration) on each day of observation. Secondary outcomes included the standard deviation of tacrolimus trough concentrations, self-reported adherence, acute rejection, and graft failure.

RESULTS

81 patients were assigned to intervention (median age, 15.5 years; 57% male) and 88 to the control group (median age, 15.8 years; 61% male). Electronic adherence data were available for 64 intervention and 74 control participants. Participants in the intervention group had significantly greater odds of taking prescribed medications (OR, 1.66; 95% CI, 1.15-2.39) and taking medications at or near the prescribed time (OR, 1.74; 95% CI, 1.21-2.50) than controls.

LIMITATIONS

Lack of electronic adherence data for some participants may have introduced bias. There was low statistical power for clinical outcomes.

CONCLUSIONS

The multicomponent TAKE-IT intervention resulted in significantly better medication adherence than the control condition. Better medication adherence may result in improved graft outcomes, but this will need to be demonstrated in larger studies.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT01356277.

Post-transplant adjustment--the later years

As survival rates for pediatric solid organ transplantation have continued to improve, researchers and healthcare providers have increasingly focused on understanding and enhancing the HRQOL and psychosocial functioning of their patients. This manuscript reviews the psychosocial functioning of pediatric transplant recipients during the "later years," defined as more than three yr post-transplant, and focuses on the day-to-day impact of living with a transplant after the immediate period of adjustment and early years after surgery. Key topics reviewed include HRQOL, cognitive functioning, impact on the family, regimen adherence, and transition of responsibility for self-management tasks. Overall, pediatric transplant recipients evidence impairment in HRQOL, neuropsychological outcomes, and family functioning as compared to non-transplant recipients. However, the degree of impairment is influenced by a variety of factors including, disease severity, age, solid organ type, and study methodologies. Studies are limited by small samples, cross-sectional design, and the lack of universal assessment battery to allow for comparisons across solid organ populations. Areas for future research are discussed.

Best practices in the pediatric pretransplant psychosocial evaluation

Assessment of psychosocial functioning is an often-included component of the pretransplant evaluation process. This study reviews several domains of assessment that have been related to post-transplant outcomes across solid organ transplant populations. These include evaluation of patient and family past adherence, knowledge about the transplantation process, and their neurocognitive, psychological, and family functioning. To date, few comprehensive pretransplant evaluation measures have been standardized for use with children; however, several assessment measures used to evaluate the aforementioned domains are reviewed throughout the study. Additionally, this article discusses some developmental, illness-specific, and cultural considerations in conducting the psychosocial evaluation. We also discuss ethical issues specific to the pediatric psychosocial evaluation. Recommendations are advanced to promote a comprehensive evaluation that identifies family strengths and risk factors as they begin the transplant journey.

Physical symptoms, perceived social support, and affect in adolescents with cancer

Treatment for cancer among adolescents is often more intense and lasts longer than treatment for older or younger patients. It typically causes pain, fatigue, and nausea and affects social and emotional well-being. This study examined the relationships among demographics, physical symptoms, perceived social support from friends and family, and affect (positive and negative) in 102 adolescents (age 13-19) with cancer using correlational analyses. Additionally, perceived social support was explored as a mediator and moderator of the relationship between physical symptoms and affect using regression. Females reported significantly lower friend support and higher negative affect compared to males. Minority participants were more likely to endorse physical symptoms and less negative affect compared to White respondents. Higher report of physical symptoms was significantly related to greater negative affect, whereas higher perceived social support from friends was related to higher positive affect. Adolescents consistently reported high levels of social support from family and friends. Additionally, adolescents tended to report average levels of positive affect and low levels of negative affect compared to healthy populations. No significant mediation or moderation effects were found. This research highlights that females and minorities, and those with greater physical symptoms, may be more vulnerable to poor adjustment to cancer during adolescence. However, overall this study lends support to the notion that adolescents with cancer are an especially resilient population, as these patients endorsed generally high levels of social support and positive affect, with low levels of negative affect.

The experience of secondary traumatic stress upon care providers working within a children's hospital

This study examined the impact of routine occupational exposure to traumatic aspects of child illness, injury, and medical treatment upon care providers working within a children's hospital. Three hundred fourteen providers completed a demographic data sheet and four questionnaires. Results suggested overall that the level of Compassion Fatigue in this sample was similar to a trauma worker comparison group. In addition, 39% of the sample was at moderately to extremely high risk for Compassion Fatigue, and 21% was at moderate to high risk for Burnout. Burnout and Compassion Fatigue were related to type of profession and length of employment. Various dimensions of empathy were related to both Burnout and Compassion Fatigue. Regression analyses indicated that years in direct care and greater blurring of caregiver boundaries were predictive of greater Burnout and Compassion Fatigue. There is a need to further refine the assessment of occupational exposure to potential traumatic aspects of care within pediatric hospital settings and link assessment to prevention and intervention efforts.

Perceived barriers to adherence among adolescent renal transplant candidates

Non-adherence to medical regimens is a ubiquitous hindrance to quality health care among adolescent transplant recipients. Identification of potentially modifiable barriers to adherence when patients are listed for organ transplant would help with early intervention efforts to prepare adolescents for the stringent medication regimen post-transplant. Fifty-six adolescents listed for a kidney transplant, mean age 14.27 (s.d. = 2.2; range 11-18 yr), 73.2% male, 62.5% Caucasian participated in a semi-structured interview, the Medical Adherence Measure, to assesses the patient's knowledge of the prescribed regimen, reported adherence (missed and late doses), the system used to organized medications, and who holds the primary responsibility over medication management. Better knowledge of the medication regimen was associated with fewer missed doses (r = -0.48, p < 0.001). Patients who perceived more barriers had more missed (r = 0.38, p = 0.004) and late (r = 0.47, p < 0.001) doses. Patients who endorsed "just forget," the most common barrier (56.4%), reported significantly more missed (z = -4.25, p < 0.001) and late (z = -2.2, p = 0.02) doses. Only one-third of the transplant candidates used a pillbox to organize medications but these patients had significantly better adherence, z = -2.2, p = 0.03. With regard to responsibility over managing the regimens, adolescents missed fewer doses when their parents were in charge than when they were solely responsible, z = -2.1, p = 0.04. Interventions developed to prepare transplant candidates for a stringent post-transplant regimen need to focus on ensuring accurate knowledge of as simple a regimen as possible. Use of an organized system such as a pillbox to establish a routine and facilitate tracking of medications is recommended with integration of reminders that may be appealing for this age group. Although individuation is developmentally normative at this age, parent involvement seems critical until the adolescent is able to manage the responsibility more independently.

Eliciting accurate reports of adherence in a clinical interview: development of the Medical Adherence Measure

Nonadherence is a major public health concern but reliable assessment methods are limited. The Medical Adherence Measure (MAM) was designed as a semi-structured clinical interview to elicit comprehensive and accurate responses from patients regarding adherence during the course of standard clinical care. The measure was developed in three phases and administered to 219 pediatric patients (ages 1.3-23) and/or their parents to assess the content, clinical utility, and ease of use. The MAM has three general regimen domains (medication, diet, clinic attendance) and several treatment specific modules. Items assess knowledge of the prescribed regimen, self-reported adherence, organizational system used to manage the regimen, and perceived barriers to optimal management. The MAM is a screening tool that assists providers in identifying patients at risk for adherence problems, assessing the extent of nonadherence, and targeting specific barriers to care in interventions. The interview emphasizes a supportive patient-provider relationship with the goal of improving patient care.

The challenges of using medication event monitoring technology with pediatric transplant patients

This study investigated the advantages and challenges of using Medication Electronic Monitoring System (MEMS) technology to examine adherence among pediatric kidney transplant patients. Twenty-nine patients participated in the study, with a mean age of 14.03 yr (SD = 3.34, range 8-19 yr). Patients were given a MEMS bottle and cap to be used with their primary immunosuppressant medication over a three-month period. Issues related to study eligibility, recruitment, and participant maintenance were recorded. Patients completed the Debriefing Form regarding their experiences with the MEMS. Many younger patients were on liquid medications affecting the feasibility of this technology across ages. Acceptance of this technology proved difficult, as many patients either declined upfront or dropped out because they did not want to use the MEMS. Of the final sample, 41% found transferring medication into the MEMS bottle difficult and 27.2% reported that the MEMS was a burden and/or difficult to transport. Another 22% of the patients reported that using the MEMS changed their routine, and 10.2% worried about missing their medications. Pediatric transplant centers should be cautious about solely relying on MEMS to examine adherence until more research is conducted on the feasibility, acceptance, and utility of this technology.

Psychosocial evaluation of candidates for living related kidney donation

Living kidney donation has raised practical and ethical questions since renal transplantation became possible 50 years ago. Nevertheless, living donors are a common source for badly needed organs in the pediatric population. The safety and well being of the living donor are important concerns. Among the risks of living donation are those of a psychological and social nature. To protect these donor interests, psychosocial evaluations of donors are done at some transplant centers, but there is a lack of consistency regarding standardization of the evaluation, the content of the evaluation, and the role of the interviewer. Goals of the overall living donor evaluation for kidney transplantation at The Children's Hospital of Philadelphia, and the components of the psychosocial evaluation protocol in particular, are presented. The protocol's strengths are discussed, including the standardization of evaluations for all potential donors; the broad spectrum of psychosocial domains assessed; the psychometric measures administered; the systematic handling of negative results and some donors' desire to opt out; and the protection of confidentiality. Future directions with regard to long-term psychosocial outcomes and research protocols are discussed.

An Integrative Model of Pediatric Medical Traumatic Stress

OBJECTIVE

To guide assessment and intervention for patients and families, a model for assessing and treating pediatric medical traumatic stress (PMTS) is presented that integrates the literature across pediatric conditions.

METHODS

A model with three general phases is outlined--I, peritrauma; II, early, ongoing, and evolving responses; and III, longer-term PMTS. Relevant literature for each is reviewed and discussed with respect to implications for intervention for patients and families.

RESULTS

Commonalities across conditions, the range of normative responses to potentially traumatic events (PTEs), the importance of preexisting psychological well-being, developmental considerations, and a social ecological orientation are highlighted.

CONCLUSIONS

Growing empirical support exists to guide the development of assessment and intervention related to PMTS for patients with pediatric illness and their parents. The need for interventions across the course of pediatric illness and injury that target patients, families, and/or healthcare teams is apparent. The model provides a basis for further development of evidence-based treatments.

Anemia and health-related quality of life in adolescents with chronic kidney disease

BACKGROUND

A number of studies of adults with chronic kidney disease (CKD) have shown a negative impact of anemia on several aspects of health-related quality of life (HRQOL). Although similar links have been suggested in adolescent dialysis populations, the relationship between anemia and HRQOL in children not requiring dialysis therapy has yet to be studied extensively in a large sample.

METHODS

We examined the association between anemia and HRQOL in baseline data collected on a prospective cohort of adolescents with CKD by using a generic HRQOL questionnaire completed by parents or caregivers (Child Health Questionnaire Parent Form [CHQ-PF50]). Our study population included guardians or caregivers of 105 adolescents (mean age, 14 +/- 2 years) with stages 1 to 5 CKD as defined by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative, including subjects with chronic renal insufficiency, patients with functioning kidney transplants, and dialysis patients.

RESULTS

Seventy of 105 patients were classified in the study as anemic according to a hematocrit value of 36% or less. Compared with the group with higher hematocrit values and independent of sex, race, and estimated glomerular filtration rate, anemic patients reported greater limitations in CHQ-PF50 domains relating to (1) physical functioning, (2) limitations in schoolwork or activities with friends as a result of physical health, and (3) parental impact in time and family activities.

CONCLUSION

Anemia was associated with lower quality of life in adolescents across the spectrum of stages of CKD. Future studies should address the effect of interventions to improve anemia on HRQOL.

Creation of a novel hemodialysis bridge graft to extend the life of an adolescent

All conventional dialysis access options were exhausted in a 19-year-old girl with end-stage renal disease (ESRD). Her course was medically and psychosocially complicated. To save her life, a subclavian artery to right atrium hemodialysis bridge graft was created so that she could be dialyzed successfully. Adolescents and young adults confronted with the exhaustion of dialysis access and transplant options face extremely difficult management decisions. Attention to the multi-disciplinary needs of these patients and a combined effort by medical, surgical, psychological, and social work teams are necessary to address properly these dilemmas.

The Illness Management Survey: identifying adolescents' perceptions of barriers to adherence

OBJECTIVE

To develop a self-report measure of barriers to adherence and to evaluate its reliability and validity in a sample of adolescents with asthma.

METHODS

The Illness Management Survey (IMS) was developed through item generation, expert panel review, and focus group administration. Adolescents with asthma (N = 152) completed the measure. Participants reported on perceived drawbacks to medication, risk-taking behavior, and social desirability tendencies. Providers rated adolescents' illness severity and adherence. Reliability and validity of the IMS were assessed, and factor structure was examined.

RESULTS

The 27-item IMS shows high internal consistency (alpha =.87). Scores correlate with perceived medication drawbacks, risk taking, and self- and provider reports of adherence. Principal-components analysis indicates five domains of barriers, accounting for 52.4% of the variance: disease/regimen issues, cognitive difficulties, lack of social support/lack of self-efficacy, denial/distrust, and peer/family issues.

CONCLUSIONS

Preliminary data indicate that the IMS reliably and validly assesses perceived barriers to adherence within this sample of adolescents with asthma. It shows promise as a tool for identifying subgroups of nonadherent adolescents.

Poor metabolic control during menstruation and sexual abuse issues in an adolescent with diabetes

A case study is presented that describes the deterioration of a patient's diabetes control during her menstrual cycle in terms of her psychological functioning and family context. Therapeutic interventions pertinent toward improving diabetes control, resolving issues of abuse, and increasing family communication are addressed. The outcome of this case study supports the contention that psychological factors can impact diabetes control significantly during menstruation in young women.

Cognitive behavioral and behavioral interventions help young children cope during a voiding cystourethrogram

OBJECTIVE

To reduce young children's distress and increase coping behavior among children undergoing a voiding cystourethrogram (VCU).

METHODS

Three- to seven-year-old children were stratified based on prior VCU experience and randomly assigned to an intervention (n = 20) or a standard care (n = 20) condition. The intervention included provision of information, coping skills training, and parent coaching. We hypothesized that the intervention would reduce children's distress as assessed by child report, parent and technician ratings, and behavioral observations.

RESULTS

Children in the intervention displayed fewer distress behaviors and greater coping behaviors and were rated as more cooperative than children receiving standard care. Children's fear and pain ratings did not differ significantly between groups.

CONCLUSIONS

A cognitive-behavioral treatment package effectively reduced children's distress, increased coping, and increased cooperation during voiding cystourethrogram procedures. This type of an intervention should be integrated into routine pediatric radiological procedures.

Parental participation during induction stage of children's anesthetic procedures in Israel

Recognition of the long-term emotional effects on children being hospitalized for surgery and changes in the perception of children's rights have led to changes in nursing care on pediatric surgical wards and in staff attitudes. The tendency has been to involve the parents as much as possible in the pre-surgical procedure, thus decreasing anxiety and fear both in parents and children. The nursing staff at Schneider Children's Medical Center of Israel has implemented a new policy and procedure for admitting children to the operating room. Parents are permitted to accompany the child to the operating room and to stay until the child falls asleep. The parents' presence contributes to the child's mental and emotional health and increases the child's self-confidence. Our experience indicates that parental participation facilitates the anesthetic procedure and makes it less traumatic. We conclude that parents, participation during surgical induction plays an important role in helping the child cope with this traumatic experience.