A systematic review of technology-based preoperative preparation interventions for child and parent anxiety

  • Jinsoo Kim
  • Natasha Chiesa
  • Mateen Raazi
  • Kristi D. WrightEmail author
Review Article/Brief Review



The purpose of this systematic review was to examine the effect of technology-based preoperative preparation interventions on children’s and parents’ anxiety.


PsycINFO, Cochrane, Science Direct, Taylor and Francis, and Pubmed MEDLINE databases were searched. Studies were restricted to those reporting on technology-based preoperative preparation interventions for pediatric patients (0–18 yr old) receiving elective surgery under general anesthesia.

Principal findings

Thirty-eight studies that provided level II or level III evidence were included (33 randomized-controlled trials and five non-randomized-controlled studies). Of the 38 studies, preoperative anxiety (measured by various indices of anxiety) was significantly reduced in children and parents in 25 and 11 studies, respectively. For children, tablet and handheld devices with interactive components were the most encouraging strategies. Video preparation alone may provide sufficient information to manage preoperative anxiety in parents.


The available literature is extremely heterogeneous and limits the ability to make definitive conclusions about the efficacy of technology-based preoperative preparation interventions. The available literature suggests that, for children, tablet and handheld devices with interactive capacity may represent a viable option to address preoperative anxiety. The findings are more mixed for parents, with video preparation a possible option. Execution of well-designed, methodologically sound studies is required to facilitate a better understanding of the efficacy of technology-based preoperative preparation.

Revue systématique de l’impact des interventions de préparation préopératoire fondées sur la technologie sur l’anxiété chez l’enfant et ses parents



L’objectif de cette revue systématique était d’examiner l’impact des interventions de préparation préopératoire fondées sur la technologie sur l’anxiété des enfants et de leurs parents.


Les bases de données PsycINFO, Cochrane, Science Direct, Taylor and Francis et Pubmed MEDLINE ont été passées en revue. Les études retenues se sont limitées à celles rapportant des interventions de préparation préopératoire fondées sur la technologie pour les patients pédiatriques (0-18 ans) recevant une chirurgie non urgente sous anesthésie générale.

Constatations principales

Trente-huit études présentant des données probantes de niveau II ou III ont été incluses (33 études randomisées contrôlées et cinq études non randomisées contrôlées). Parmi les 38 études, l’anxiété préopératoire (telle que mesurée par divers indices d’anxiété) a été significativement réduite chez l’enfant et les parents dans 25 et 11 études, respectivement. Pour les enfants, les tablettes et les appareils portatifs comprenant des composantes interactives constituaient les stratégies donnant les résultats les plus encourageants. La préparation sur vidéo seule pourrait offrir suffisamment d’informations pour prendre en charge l’anxiété préopératoire des parents.


La littérature existante est extrêmement hétérogène et limite notre capacité d’émettre des conclusions définitives quant à l’efficacité des interventions de préparation préopératoire fondées sur la technologie. La littérature disponible suggère que, pour l’enfant, les tablettes et appareils portatifs disposant de capacités interactives pourraient constituer une option viable pour prendre en charge l’anxiété préopératoire. Les résultats sont plus mitigés pour les parents, la préparation par vidéo constituant potentiellement une option. L’exécution d’études bien conçues et rigoureuses d’un point de vue méthodologique est nécessaire afin de mieux comprendre l’efficacité des interventions de préparation préopératoire fondées sur la technologie.



The views expressed in this article are the authors’ own and not an official position of the institution or funder.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Associate Editor, Associate Editor, Canadian Journal of Anesthesia.

Author contributions

Jinsoo Kim contributed to acquisition of the data, analysis of the data, interpretation of the data, and design of the manuscript. Natasha Chiesa contributed to the acquisition of the data. Mateen Raazi contributed to the conception and design of the manuscriptstudy. Kristi D. Wright contributed to all aspects of this manuscriptstudy, including conception and design; acquisition, analysis, and interpretation of data; and drafting the article.

Source of support

This research was conducted with financial support from a research scholarship supported through funding from the Jim Pattinson Children’s Hospital Foundation (#96000024).


  1. 1.
    Davidson A, McKenzie I. Distress at induction: prevention and consequences. Cur Opin Anaesthesiol 2011; 24: 301-6.CrossRefGoogle Scholar
  2. 2.
    Kain ZN, Mayes L, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med 1996; 150: 1238-45.Google Scholar
  3. 3.
    Kain ZN, Caramico LA, Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcome. Anesth Analg 1999; 88: 1042-7.CrossRefPubMedGoogle Scholar
  4. 4.
    Kain ZN, Mayes LC, Caldwell-Andres AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioural recovery in young children undergoing surgery. Pediatrics 2006; 118: 651-8.CrossRefPubMedGoogle Scholar
  5. 5.
    McCann ME, Kain ZN. The management of preoperative anxiety in children: an update. Anesth Analg 2001; 93: 98-105.CrossRefPubMedGoogle Scholar
  6. 6.
    Caumo W, Broenstrub JC, Fialho L, et al. Risk factors for postoperative anxiety in children. Acta Anaesthesiol Scand 2000; 44: 782-9.CrossRefPubMedGoogle Scholar
  7. 7.
    Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg 2004; 99: 1648-54.CrossRefPubMedGoogle Scholar
  8. 8.
    Wright KD, Stewart SH, Finley GA, Buffett-Jerrott SE. Prevention and intervention strategies to alleviate preoperative anxiety in children: a critical review. Behav Modif 2007; 31: 52-79.CrossRefPubMedGoogle Scholar
  9. 9.
    Kain ZN, Wang SM, Caldwell-Andrews AA, Smith G, Saadat H. Pre-surgical preparation programs for children undergoing outpatient surgery: current status. Anesthesiology 2006; 105: A955 (abstract).Google Scholar
  10. 10.
    Vernon DT, Bailey WC. The use of motion pictures in the psychological preparation of children for induction of anesthesia. Anesthesiology 1974; 40: 68-72.CrossRefPubMedGoogle Scholar
  11. 11.
    Melamed BG, Siegel LJ. Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. J Consult Clin Psychol 1975; 43: 511-21.CrossRefPubMedGoogle Scholar
  12. 12.
    Ferguson B. Preparing young children for hospitalization: a comparison of two methods. J Am Acad Child Psychiatry 1980; 19: 540-1.CrossRefGoogle Scholar
  13. 13.
    Abrams L. Resistance behaviors and teaching media for children in day surgery. AORN J 1982; 35: 244-58.CrossRefPubMedGoogle Scholar
  14. 14.
    Peterson L, Schultheis K, Ridley-Johnson R, Miller DJ, Tracy K. Comparison of three modeling procedures on the presurgical and postsurgical reactions of children. Behav Ther 1984; 15: 197-203.CrossRefGoogle Scholar
  15. 15.
    Pinto PR, Hollandsworth JG Jr. Using videotape modeling to prepare children psychologically for surgery: influence of parents and costs versus benefits of providing preparation services. Health Psychol 1989; 8: 79-95.CrossRefPubMedGoogle Scholar
  16. 16.
    Durst LM. Preoperative teaching videotape. The effect on children’s behavior. AORN J 1990; 52: 576-84.Google Scholar
  17. 17.
    Faust J, Olson R, Rodriguez H. Same-day surgery preparation: reduction of pediatric patient arousal and distress through participant modeling. J Consult Clinc Psychol 1991; 59: 475-8.CrossRefGoogle Scholar
  18. 18.
    Cassady JF Jr, Wysocki T, Miller KM, Cancel DD, Izenberg N. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesth Analg 1999; 43: 246-50.Google Scholar
  19. 19.
    Zuwala R, Barber KR. Reducing anxiety in parents before and during pediatric anesthesia induction. AANA J 2001; 69: 21-5.PubMedGoogle Scholar
  20. 20.
    McEwen A, Moorthy C, Quantock C, Rose H, Kavanagh R. The effect of videotaped preoperative information on parental anxiety during anesthesia induction for elective pediatric procedures. Paediatr Anaesth 2007; 17: 534-9.CrossRefPubMedGoogle Scholar
  21. 21.
    Karabulut N, Arikan D. The effect of different training programs applied prior to surgical operation on anxiety levels. New/Yeni Symposium Journal 2009; 47: 64-9.Google Scholar
  22. 22.
    Berghmans J, Weber F, van Akoleyen C, et al. Audiovisual aid viewing immediately before pediatric induction moderates the accompanying parents’ anxiety. Paediatr Anaesth 2011; 22: 386-92.CrossRefPubMedGoogle Scholar
  23. 23.
    de Armendi AJ, Gillaspy SR, Martinez M, Cure JA, Butt AL, Boekman LM. Effect of informational Spanish anesthesia video on the level of anxiety and uncertainty with Native Spanish speaking parents. A pilot study. J Okla State Med Assoc 2014; 107: 331-4.Google Scholar
  24. 24.
    Fernandes S, Arriaga P, Esteves F. Providing preoperative information for children undergoing surgery: a randomized study testing different types of educational material to reduce children’s preoperative worries. Health Educ Res 2014; 29: 1058-76.CrossRefPubMedGoogle Scholar
  25. 25.
    Zastowny TR, Kirschenbaum DS, Meng AL. Coping skills training for children: effects of distress before, during, and after hospitalization for surgery. Health Psychol 1986; 5: 231-47.CrossRefPubMedGoogle Scholar
  26. 26.
    Robinson P, Kobayashi K. Development and evaluation of a presurgical preparation program. J Pediatr Psychol 1991; 16: 193-212.CrossRefPubMedGoogle Scholar
  27. 27.
    Ellerton M, Merriam C. Preparing children and families psychologically for day surgery: an evaluation. J Adv Nurs 1994; 19: 1057-62.CrossRefPubMedGoogle Scholar
  28. 28.
    Kain ZN, Caramico LA, Mayes LC, Genevro JL, Bornstein MH, Hofstadter MB. Preoperative preparation programs in children: a comparative examination. Anesth Analg 1998; 87: 1249-55.PubMedGoogle Scholar
  29. 29.
    Huth M, Broome M, Good M. Imagery reduces childrenʼs post-operative pain. Pain 2004; 110: 439-48.CrossRefPubMedGoogle Scholar
  30. 30.
    Kain ZN, Caldwell-Andrews A, Mayes LC, et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007; 106: 65-74.CrossRefPubMedGoogle Scholar
  31. 31.
    Wakimizu R, Kamagata S, Kuwabara T, Kamibeppu K. A randomized controlled trial of an at-home preparation programme for Japanese preschool children: effects on children’s and caregivers’ anxiety associated with surgery. J Eval Clin Pract 2009; 15: 393-401.CrossRefPubMedGoogle Scholar
  32. 32.
    Wright K, Raazi M, Walker KL. Internet-delivered, preoperative, preparation program (I-PPP): development and examination of effectiveness. J Clin Anesth 2017; 39: 45-52.CrossRefPubMedGoogle Scholar
  33. 33.
    Palermo TM, Wilson AC, Peters M, Lewandowski A, Somhegyi H. Randomized controlled trial of an internet-delivered family cognitive-behavioral therapy intervention for children and adolescents with chronic pain. Pain 2009; 146: 205-13.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Yip P, Middleton P, Cyna AM, Carlyle AV. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev 2009; 6(CD006447): 71-134.Google Scholar
  35. 35.
    Chow CH, Van Lieshout RJ, Schmidt LA, Dobson KG, Buckley N. Systematic review: Audiovisual interventions for reducing preoperative anxiety in children undergoing elective surgery. J Pediatr Psychol 2016; 41: 182-203.CrossRefPubMedGoogle Scholar
  36. 36.
    Chow CH, Wan S, Pope E, et al. Audiovisual interventions for parental preoperative anxiety: a systematic review and meta-analysis. Health Psychol 2018; 37: 746-58.CrossRefPubMedGoogle Scholar
  37. 37.
    Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151: 264-9.Google Scholar
  38. 38.
    Vernon DT, Schulman JL, Foley JM. Changes in children’s behavior after hospitalization. Some dimensions and their correlates. Am J Dis Child 1966; 111: 581-93.Google Scholar
  39. 39.
    Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am 2003; 85-A: 1-3.Google Scholar
  40. 40.
    Patel A, Schieble T, Davidson M, et al. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatr Anaesth 2006; 16: 1019-27.CrossRefPubMedGoogle Scholar
  41. 41.
    Mifflin K, Hackmann T, Chorney JM. Streamed video clips to reduce anxiety in children during inhaled induction of anesthesia. Anesth Analg 2012; 115: 1162-7.CrossRefPubMedGoogle Scholar
  42. 42.
    Lee J, Lee J, Lim H, et al. Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesth Analg 2012; 115: 1168-73.CrossRefPubMedGoogle Scholar
  43. 43.
    Lee JH, Jung HK, Lee GG, Kim HY, Park SG, Woo SC. Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients. Korean J Anesthesiol 2013; 65: 508-18.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Seiden S, McMullan S, Sequera-Ramos L, et al. Tablet-based Interactive Distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: a noninferiority randomized trial. Paediatr Anaesth 2014; 24: 1217-23.CrossRefPubMedGoogle Scholar
  45. 45.
    Bailey KM, Bird SJ, McGrath PJ, Chorney JE. Preparing parents to be present for their child’s anesthesia induction: a randomized controlled trial. Anesth Analg 2015; 121: 1001-10.CrossRefPubMedGoogle Scholar
  46. 46.
    Fernandes S, Arriaga P, Esteves F. Using an educational multimedia application to prepare children for outpatient surgeries. J Health Commun 2015; 30: 1190-200.CrossRefGoogle Scholar
  47. 47.
    Kim H, Jung SM, Yu H, Park SJ. Video distraction and parental presence for the management of preoperative anxiety and postoperative behavioural disturbance in children: a randomized controlled trial. Anesth Analg 2015; 121: 778-84.CrossRefPubMedGoogle Scholar
  48. 48.
    Liguori S, Stacchini M, Ciofi D, Olivini N, Bisogni S, Festini F. Effectiveness of an app for reducing preoperative anxiety in children: a randomized clinical trial. JAMA Pediatr 2016; 170: e160533.CrossRefPubMedGoogle Scholar
  49. 49.
    Chow CH, Van Lieshout RJ, Schmidt L, Buckley N. Tablet-based intervention for reducing childrenʼs preoperative anxiety: a pilot study. J Dev Behav Pediatr 2017; 38: 409-16.CrossRefPubMedGoogle Scholar
  50. 50.
    Cumino DO, Vieira JE, Lima LC, Stievano LP, Silva RA, Matthias LA. Smartphone-based behavioural intervention alleviates children’s anxiety during anaesthesia induction: a randomized controlled trial. Eur J Anaesthesiol 2017; 34: 169-75.PubMedGoogle Scholar
  51. 51.
    Marechal C, Berthiller J, Tosetti S, et al. Children and parental anxiolysis in paediatric ambulatory surgery: a randomized controlled study comparing 0.3 mg kg−1midazolam to tablet computer based interactive distraction. Br J Anaesth 2017; 118: 247-53.Google Scholar
  52. 52.
    Campbell C, Hosey MT, McHugh S. Facilitating coping behavior in children prior to dental general anesthesia: a randomized controlled trial. Paediatr Anaesth 2005; 15: 831-8.CrossRefPubMedGoogle Scholar
  53. 53.
    O’Conner-Von S. Preparation of adolescents for outpatient surgery: using an internet program. AORN J 2008; 87: 374-98.CrossRefPubMedGoogle Scholar
  54. 54.
    Fortier M, Bunzli E, Walthall J, et al. Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): formative evaluation randomized controlled trial. Anesth Analg 2015; 120: 915-22.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Kerimoglu B, Neuman A, Paul J, Stefanov DG, Twersky R. Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children. Anesth Analg 2013; 117: 1373-9.CrossRefPubMedGoogle Scholar
  56. 56.
    Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain 1990; 41: 139-50.CrossRefPubMedGoogle Scholar
  57. 57.
    Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs 1988; 14: 9-17.Google Scholar
  58. 58.
    Münsterberg Koppitz E. Psychological Evaluation of Children’s Human Figure Drawings. NY: Grune and Stratton; 1968 .Google Scholar
  59. 59.
    Spielberger CD. Manual for the State Trait Anxiety Inventory for Children. Palo Alto, CA.: Consulting Psychologists Press; 1973.Google Scholar
  60. 60.
    Venham LL, Gaulin-Kremer E. A self-report measure of situational anxiety for young children. Pediatr Dent 1979; 1: 91-6.PubMedGoogle Scholar
  61. 61.
    Klinedinst JK. Relationship between Minnesota multiphasic personality inventory and personality inventory for children data from mothers of disturbed children [doctoral dissertation]. [Minneapolis (USA)]. University of Minnesota; 1971.Google Scholar
  62. 62.
    Scherer MW, Nakamura CY. A fear survey schedule for children (FSS-FC): a factor analytic comparison with manifest anxiety (CMAS). Behav Res Ther 1968; 6: 173-82.CrossRefPubMedGoogle Scholar
  63. 63.
    Chow CH, Van Lieshout RJ, Buckley N, Schmidt LA. Children’s Perioperative Multidimensional Anxiety Scale (CPMAS): development and validation. Psychol Assess 2016; 28: 1101-9.CrossRefPubMedGoogle Scholar
  64. 64.
    Quiles MJ, Ortigosa JM, Pedroche y Sira Mendez FX. The child surgery worries questionnaire (Spanish). Psicothema 1999; 11: 601-9.Google Scholar
  65. 65.
    Kain ZN, Mayes LC, Cicchetti DV, Vagnali AL, Finley JD, Hofstadter MB. The Yale preoperative anxiety scale: how does it compare with a” gold standard”? Anesth Analg 1997; 85: 783-8.CrossRefPubMedGoogle Scholar
  66. 66.
    Davey HM, Barratt AL, Butow PN, Deeks JJ. A one-item question with a likert or visual analog scale adequately measured current anxiety. J Clin Epidemiol 2007; 60: 356-60.CrossRefPubMedGoogle Scholar
  67. 67.
    Johnson JE, Dabbs JM Jr. Enumeration of active sweat glands: a simple physiological indicator of psychological changes. Nurs Res 1967; 16: 273.CrossRefGoogle Scholar
  68. 68.
    Kain ZM, Mayes LC, Cicchetti DV, et al. Measurement tool for preoperative anxiety in young children: the Yale Preoperative Anxiety Scale. Child Neuropsychol 1995; 1: 203-10.CrossRefGoogle Scholar
  69. 69.
    Moerman N, van Dam FS, Muller MJ, Oosting H. The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 1996; 82: 445-51.PubMedGoogle Scholar
  70. 70.
    Radloff R, Helmreich R. Groups Under Stress: Psychological Research in Sealab II. NY: Appleton-Century-Crofts; 1968 .Google Scholar
  71. 71.
    Doris J, McIntyre A, Kelsey C, Lehman E. Separation anxiety in nursery school children. Proceedings of the 79thAnnual Convention of APA. 1971; 79: 145-8.Google Scholar
  72. 72.
    Spielberger CD, Gorsuch R, Lushene RE. STAI Manual for the State-Trait Anxiety Inventory (“self-evaluation questionnaire”). Palo Alto, CA.: Consulting Psychologists Press; 1970.Google Scholar
  73. 73.
    Stewart SH, Buffett-Jerrott SE, Finley GA, Wright KD, Valois Gomez T. Effects of midazolam on explicit versus implicit memory in a pediatric surgery setting. Psychopharmacology (Berl) 2006; 188: 489-97.CrossRefGoogle Scholar
  74. 74.
    Statistics Canada. The Internet and Digital Technology. Release date: November 14, 2017. Available from URL: (accessed February 2019).

Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  • Jinsoo Kim
    • 1
  • Natasha Chiesa
    • 2
  • Mateen Raazi
    • 3
  • Kristi D. Wright
    • 1
    Email author
  1. 1.Department of PsychologyUniversity of ReginaReginaCanada
  2. 2.Department of PsychologyUniversity of SaskatchewanSaskatoonCanada
  3. 3.Department of Anesthesiology, Perioperative Medicine and Pain Management, College of MedicineUniversity of SaskatchewanSaskatoonCanada

Personalised recommendations