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Revista Brasileira de Anestesiologia

Print version ISSN 0034-7094On-line version ISSN 1806-907X

Rev. Bras. Anestesiol. vol.56 no.6 Campinas Nov./Dec. 2006 



A transversal study on preoperative anxiety in children: use of the modified Yale Scale*


Estudio transversal de ansiedad preoperatoria en niños: utilización de la Escala de Yale modificada



Álvaro Antônio Guaratini, TSAI; José Álvaro Marques MarcolinoII; Ayrton Bentes Teixeira, TSAI; Ricardo Caio BernardisI; Maria Lúcia Bastos PassarelliIII; Lígia Andrade da Silva Telles Mathias, TSAIV

IMestre em Medicina, Doutorando da FCM-ISCMSP, Médico Assistente, Hospital Central da ISCMSP
IIMédico Assistente, Hospital Central da ISCMSP, Professor Adjunto de Psiquiatria da FCM-ISCMSP
IIIDiretora do Departamento de Pediatria da ISCMSP, Professora Doutora em Pediatria pela FCMSCSP
IVDiretora do Serviço e Disciplina de Anestesiologia da FCM-ISCMSP; Professora Adjunta de Anestesiologia; Responsável pelo CET/SBA, ISCMSP

Correspondence to




BACKGROUND AND OBJECTIVES: Scales can be useful to recognize anxiety states and to indicate ways to prevent complications due to elevated levels of anxiety. The modified Yale Preoperative Anxiety Scale (YPAS-m) was developed to evaluate anxiety in preschool children at the time of the anesthetic induction. It is an observational scale, being applied and completed in a short period of time. Studies on anxiety in children in the preoperative period do not mention anxiety at the preanesthetic evaluation. This transversal study tried to evaluate the level and prevalence of anxiety at the preanesthetic evaluation and in the clinical evaluation using the YPAS-m in preschool children.
METHODS: One hundred children, physical status ASA I and II were evaluated; GPED = 50 children undergoing clinical evaluation; GPEC = 50 children undergoing preanesthetic evaluation for surgery. The study was conducted at the pediatric clinic and preanesthetic evaluation waiting-room while the children waited for their appointment. Two observers applied the YPAS-m independently. Parameters analyzed included the demographic data; and median and percentage of patients with anxiety (YPAS-m > 30). Statistical analysis considered a p < 0.05 significant.
RESULTS: The groups were homogenous regarding the socio-demographic data. The mean ages were: GPED 4.25 and GPEC 4.67 years. There was a significant difference in the median of the YPAS-m (GPED 23.4 and GPEC 50.0) and on the prevalence of anxiety between both groups (GPED 16.7% and GPEC 81.6%).
CONCLUSIONS: In children between 2 and 7 years the levels and prevalence of anxiety, evaluated by the YPAS-m, at the time of the outpatient preanesthetic evaluation are higher than at the time of the clinical evaluation.

Key Words: PRE-ANESTHETIC EVALUATION: psychological status; SURGERY: pediatric; EVALUATION TECHNIQUES: anxiety scale.


JUSTIFICATIVA Y OBJETIVOS: La utilización de escalas puede ser útil en el reconocimiento de los estados de ansiedad, dirigido a medidas que prevengan complicaciones provenientes de niveles elevados de ansiedad. La Escala de Ansiedad Preoperatoria de Yale modificada (EAPY-m) fue desarrollada para la evaluación de la ansiedad en niños en la edad preescolar al momento de la inducción de la anestesia. Esa escala posee un carácter de observación y es muy fácil para ser completada. Los estudios sobre ansiedad en niños en el período preoperatorio no mencionan la ansiedad al momento de la evaluación preanestésica ambulatorial (APA). Este estudio transversal buscó evaluar el nivel y la prevalencia de la ansiedad al momento de la APA y de la consulta clínica utilizando la escala EAPY-m, en niños en edad preescolar.
MÉTODO: Se seleccionaron 100 Niños, estado físico ASA I y II: GPED = 50 niños a ser sometidos a la evaluación clínica; GAPA = 50 niños a ser sometidos a la APA para programación quirúrgica. El estudio se desarrolló en la sala de espera de los ambulatorios de pediatría y de APA mientras los niños esperaban sus respectivas consultas. Dos observadores aplicaron la escala EAPY-m de forma independiente. Las variables analizadas fueron datos socio demográficos; promedio y porcentaje de pacientes con ansiedad (EAPY-m > 30). Se realizó el análisis estadístico considerando significativo p < 0,05.
RESULTADOS: Los grupos fueron homogéneos con relación a los datos socio demográficos. Los promedios de edad fueron: GPED 4,25 y GAPA 4,67 años. Se observó la diferencia significativa del promedio de la EAPY-m (GPED 23,4 y GAPA 50,0) y de la prevalencia de ansiedad entre los dos grupos (GPED 16,7% y GAPA 81,6%).
CONCLUSIONES: En niños con edad entre 2 y 7 años, los niveles y as prevalencias de ansiedad, evaluados a través de la EAPY-m, al momento de la evaluación preanestésica ambulatorial, so mayores que al momento de la consulta clínica.




In children, elevated anxiety levels in the preoperative period can be associated with negative medical, psychological, and social consequences. The main medical consequences include a stormy anesthetic induction, reduced defense against infections, and increased need for anesthetics in the intraoperative period and of analgesics in the postoperative period. The psychological consequences include recurrence of enuresis, difficulty to eat, apathy, continuous anxiety, irritability, and sleep disorders. The social consequences include indiscipline and lack of cooperation with health care professionals 1-10.

Factors that predict increased anxiety in the preoperative period include: the child's prior mood, decreased sociability, adaptive behavior, emotional liability, impulsivity, prior surgical experience, hospitalization, misbehaves at pediatricians' offices, and anxious family members 11-17.

On evaluating anxiety in children it is paramount to use methods developed specifically for this age Group, and that may include psychiatric evaluation, clinical evaluation, self-evaluation or observational scales, and evaluations conducted by family members 18,19.

A great variety of scales, designed to be used by physicians, parents, teachers, or children, have been developed to evaluate the presence of anxiety in children 20,21. However, most of them are not appropriate to evaluate the presence of anxiety in preschoolers in the preoperative period.

For children younger than 5 years, Kain et al. 22,23 developed an observational scale called YPAS (Yale Preoperative Anxiety Scale), which was later modified – YPAS-m (Yale Preoperative Anxiety Scale Modified) (Chart I), to be used in children in the immediate preanesthetic period and at the moment of the anesthetic induction. The YPAS-m includes the observation of five domains that contemplate the child's relationship with its environment (activity and state of arousal), vocalization, expression of emotions, and interaction with family members.

Since studies about anxiety in children in the preoperative period do not mention anxiety at the moment of the outpatient preanesthetic evaluation, we decided to undertake this study to assess the presence of anxiety at that moment, using the translated version of the YPAS-m scale.



After approval by the Ethics Committee on Research of the Irmandade da Santa Casa de Misericórdia de São Paulo, this transversal study was initiated. It consisted of using the YPAS-m in two groups of pediatric patients in order to compare the results between them.

One hundred children, physical status ASA I and II, with ages between 2 and 7 years that were going to be evaluated at the pediatric clinic or the preanesthetic evaluation clinic (PEC) were selected, forming two groups:

  • GPED = 50 children that were to be evaluated at the pediatric clinic;
  • GPEC = 50 children from the preanesthetic evaluation clinic, scheduled to undergo surgical procedures in the near future (between 1 and 2 weeks).

Exclusion criteria included: neuropsychomotor deficit; use of psychoactive drugs; presence of disease that was not under control; family members with clinically diagnosed mental disease or disorder; presence of severe family problems; prior surgery; and those who were accompanied by someone other than a family member.

The study was undertaken in the waiting-room of the pediatric and preanesthetic evaluation clinics, while the children were waiting their turn to be seen. Two observers (named Observer 1 and Observer 2), anesthesiologists, wearing normal clothes, applied independently the YPAS-m. Family members were informed about the reason for the evaluation, the method used, and requested to sign an informed consent.

There was no communication among the observers and the children and between the observers. Before beginning the procedures, the observers underwent training sessions.

The YPAS-m total score was calculated as proposed originally 22. Each domain received a partial score based on the punctuation observed divided by the number of categories of that domain (Table I). The score of each domain is added to the others and multiplied by 20.



The scores considered "cut points" to determine whether a patient had/had not anxiety were 23:

  • Without anxiety: 23.4 e 30;
  • With anxiety: greater than 30.

Results were presented in descriptive tables using the non-paired test t Student, Fisher Exact test, and Mann-Whitney test. A p < 0.05 was considered statistically significant.



The final study sample was composed of 97 children, 48 from the pediatric clinic (GPED) and 49 from the PEC clinic (GPEC). Two children were excluded from the GPEC and one from the GPED because they were not accompanied by family members.

There were no statistically significant differences between the groups regarding age, gender, presence of family members, and skin color (Table II).



Table III shows the median and the 25th and 75th percentil of the YPAS-m scores of both observers for the two groups, GPED and GPEC. There was a statistically significant difference (p < 0.001) between both groups when the YPAS-m scores of both observers were compared.

The results of observers 1 and 2, partial YPAS-m scores for Activity, Vocalization, Emotional expression, State of arousal, and Interaction with family members for both groups were compared using the Mann-Whitney test, showing a statistically significant difference (p < 0.001) for every domain and for both observers.

Tables IV and V show the distribution of patients in both groups, classified by the observers by category for each domain of the YPAS-m scale.

Table VI shows the total number and percentage of patients with and without anxiety in both groups according to the YPAS-m. The Fisher Exact test showed a statistically significant difference (p < 0.001) in the prevalence of anxiety between GPED and GPEC.



Anxiety is not part of the specific evaluation during PEC, receiving more attention when clinical studies are conducted about factors, conditions, or drugs that interfere with anxiety at the moment of the PEC or in the immediate preoperative period, such as those that evaluate whether there is change in anxiety when the PEC is done in different situations or with patients with specific morbidities 8,24-30, and those comparing the prevalence and levels of anxiety with the use of specific premedication, such as midazolam, clonidine, and ketamine 31-37. In these situations, since anxiety is the focus or object of the study, it is assessed distinctively. For such, clinical criteria, with scales approved by anesthesiologists, but that have not been submitted to validation or reliability studies, are used. Those that classify the patient's clinical status in four of five items, from sleeping and calm to agitated and anxious, mixing anxiety and sedation, are used most often. And frequently they are used indiscriminately for adults and children 26, 33-35, 37.

In Brazil, little has been published about preoperative anxiety in children 38,39.

The use of two observers was based on the original idea of Kain et al. 23. Data were gathered by the same two observers, always in a large waiting-room, and at the same time, in the morning, avoiding a long waiting period, which could cause irritation both in the child and in the family. Both observers evaluated the children independently and at the same time to eliminate possible interferences caused by evaluating the patients at different times, what could also lead to a difference in the data gathered, since the child could become anxious with time. The evaluation was done before informing family members of the research, so the observers would go unnoticed by the children, avoiding a change in behavior if they identified a stranger talking to their family. After explaining the objective of the study, if family members did not consent, the case would be excluded, but such did not happen.

In this study, the prevalence and the level of anxiety in children in GPEC and GPED were statistically different. Note the 81.6% prevalence of anxiety in the GPEC.

The data obtained in this study using the YPAS-m indicated that the prevalence of preoperative anxiety is already elevated at the time of the preanesthetic evaluation. Other studies using the YPAS-m to evaluate preoperative anxiety in children showed that the incidence was smaller. Kain et al. 23 studied children with a mean age of 8 years, in which 67% had a history of prior surgery, all of them were evaluated in the preoperative room; it demonstrated a 24% incidence of anxiety. Wollin et al. 40 used the YPAS-m to evaluate children aged 5 to 12, hospitalized, at a time close to the anesthetic induction, and 53% were considered anxious. Similar to the previous study, there was a difference among the groups regarding age and time of the evaluation. Besides, the data were collected in six different hospitals.

According to Caumo et al. 38, a history of prior surgery can be associated with a reduced anxiety level. When the age was analyzed as a factor that could influence the results, some authors found out that younger children tend to be more anxious, at the time of anesthetic induction, when compared with older children 41.

The present scale seems to be useful and reliable to diagnose preoperative anxiety in preschoolers, according to the results obtained from the observation. Once the presence of anxiety is confirmed, pharmacologic or non-pharmacologic measures can be used to reduce it, which is associated with serious behavioral changes in the operative and postoperative periods 3,4,7,41.

Further studies are necessary to define whether the levels of anxiety observed with this scale are modified by parameters such as age, temperament, anxious parents, and previous experiences.



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Correspondence to:
Dra. Lígia Andrade da Silva Telles Mathias
Alameda Campinas, 139/41
01404-000 São Paulo, SP

Submitted for publication 08 de fevereiro de 2006
Accepted for publication 25 de julho de 2006



* Received from Faculdade de Ciências Médicas da Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP

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