Psychological Assessment © 2016 American Psychological Association

2016, Vol. 28, No. 9, 1101–1109 1040-3590/16/$12.00 http://dx.doi.org/10.1037/pas0000318

Children’s Perioperative Multidimensional Anxiety Scale (CPMAS):

Development and Validation

Cheryl H. T. Chow, Ryan J. Van Lieshout, Norman Buckley, and Louis A. Schmidt
McMaster University

Up to 5 million children are affected by perioperative anxiety in North America each year. High
perioperative anxiety is predictive of numerous adverse emotional and behavioral outcomes in youth. We
developed the Children’s Perioperative Multidimensional Anxiety Scale (CPMAS) to address the need
for a simple, age-appropriate self-report measure of pediatric perioperative anxiety in busy hospital
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

settings. The CPMAS is a visual analog scale composed of 5 items, each of which is scored from 0 –100.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

The objective of this study was to assess the psychometric properties of the CPMAS in children
undergoing surgery. Eighty children aged 7 to 13 years who were undergoing elective surgery at a
university-affiliated children’s hospital were recruited. Children self-completed the CPMAS and the
Screen for Childhood Anxiety Related Disorders (SCARED-C) at 3 time points: at preoperative
assessment (T1), on the day of the operation (T2), and 1 month postoperatively (T3). Internal consis-
tency, test–retest reliability, and the convergent validity of the CPMAS were assessed across all 3 visits.
The CPMAS demonstrated good internal consistency (Cronbach’s alpha ⱖ .80) and stability (ICC ⫽
0.71) across all 3 visits. CPMAS scores were moderately correlated with total SCARED-C scores (r
values ⫽ .35 to .54, p values ⬍ .05 to .01) and SCARED-C state-related anxiety scores (r values ⫽ .29
to .71, p values ⬍ .05 to .01) at all 3 time points, suggesting the CPMAS and SCARED-C measures tap
similar but not identical phenomena. These results suggest that the CPMAS has the potential to be a
useful tool for evaluating perioperative anxiety in children undergoing surgery.

Keywords: anxiety, children, perioperative period, psychometrics, surgery

Of the nearly 5 million children who undergo surgical proce- 2006; Kain, Mayes, O’Connor, & Cicchetti, 1996; Wollin et al.,
dures in North America annually, up to 75% will develop elevated 2004). In fact, nearly 50% of youth with preoperative anxiety
pre- and postoperative anxiety (Perry, Hooper, & Masiongale, exhibit postoperative behavioral changes, including aggression
2012). Children with heightened preoperative anxiety are three and toward authority figures, feeding problems, insomnia, and noctur-
a half times more likely to develop a range of adverse postopera- nal enuresis (Fortier et al., 2010; Kain et al., 2004, 2006; Kain et
tive outcomes, including separation anxiety, maladaptive behav- al., 1996; Kain, Wang, Mayes, Caramico, & Hofstadter, 1999;
ioral patterns, and increased distress in surgical recovery (Ahmed, Litke, Pikulska, & Wegner, 2012). Kain et al. (1996) reported that
Farrell, Parrish, & Karla, 2011; Fortier, Del Rosario, Martin, & 54% of these children continued to experience negative behavioral
Kain, 2010; Kain, Mayes, Caldwell-Andrews, Karas, & McClain, changes up to 2 weeks after surgery, 20% up to 6 months later, and
7.3% 1 year after their procedures.
In addition to these adverse emotional and behavioral reactions,
children with higher levels of preoperative anxiety often have a
Cheryl H. T. Chow, MiNDS Neuroscience Graduate Program, McMas- more complicated operative and postoperative course, including
ter University; Ryan J. Van Lieshout, Department of Psychiatry and prolonged anesthesia induction, poorer postoperative recovery,
Behavioural Neurosciences, McMaster University; Norman Buckley, De-
higher doses of postoperative analgesia requirements, and postop-
partment of Anesthesia, McMaster University; Louis A. Schmidt, Depart-
ment of Psychology, Neuroscience and Behaviour, McMaster University. erative delirium (Kain et al., 2006; Maranets & Kain, 1999). These
This study was supported by a graduate scholarship from Ontario Grad- children also have a longer postoperative course of recovery with
uate Scholarship (Daley Fellowship) awarded to Cheryl H. T. Chow and elevated levels of complications and prolonged wound healing
grants from the Social Sciences and Humanities Research Council, the (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006; McCann &
Natural Sciences and Engineering Research Council of Canada (NSERC), Kain, 2001). Finally, children with greater preoperative anxiety are
and the Canadian Institutes of Health Research (CIHR) awarded to Louis three times more likely to exhibit postoperative anxiety and ele-
A. Schmidt. We thank the many children and families who participated in vated levels of postoperative pain (Caumo et al., 2000). These
the study, Eliza Pope, Pauline Leung, Stephanie Wan, and Mark Hwang adverse outcomes can have both transient and long-term detrimen-
who assisted with data collection and data entry, and the Child Life
tal effects on a child’s health and development (Chow, Van
Specialists and Program at the McMaster Children’s Hospital, and Dr.
Charles Cunningham who helped with scale development.
Lieshout, Schmidt, Dobson, & Buckley, 2016). In order to prop-
Correspondence concerning this article should be addressed to Cheryl erly describe and understand the precursors and sequelae of peri-
H. T. Chow, MiNDS Neuroscience Graduate Program, McMaster Univer- operative anxiety, brief, objective, reliable, and valid tools need to
sity, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4L8. E-mail: be developed that can accurately measure perioperative anxiety in
[email protected] busy and complex clinical settings.
1101
 1102 CHOW, VAN LIESHOUT, BUCKLEY, AND SCHMIDT

While several measures are currently used to assess anxiety in assessing perioperative anxiety in clinical settings. Ideally, a useful
pediatric surgical settings, existing scales have limitations and perioperative tool should be reliable, valid, short, and informative;
have led to their relatively inconsistent use in studies of perioper- utilize self-report; and be age-appropriate, as well as specific to
ative anxiety. For example, the modified Yale Preoperative Anx- perioperative settings. Existing gaps in this area have led us to
iety Scale (mYPAS; Kain et al., 1997) consists of 5 items that develop the CPMAS, a tool that uniquely measures state anxiety in
assess a child’s activity, vocalizations, emotional expressivity, the surgical context.
state of arousal, and utilization of their parent preoperatively. It The phenomenon of anxiety contains multiple components and
takes approximately 5 min to complete (Kain et al., 1997) and has emotions, with cognitive/affective, behavioral, and physiological
been shown to have good internal reliability (Jenkins, Fortier, manifestations. Anxiety is also composed of the constructs of
Kaplan, Mayes, & Kain, 2014). Despite these strengths, this worry and fear. Worry is a cognitive construct and a normal
observer-rated scale is susceptible to bias (i.e., interobserver vari- adaptive negative emotion associated with the anticipation of
ability) and requires that health care staff and research assistants be future threat (e.g., thinking about bad things that could happen
trained on its administration at multiple assessment points (Wright, during surgery). Fear, on the other hand, is defined as the normal
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Stewart, & Finley, 2013). Unfortunately, from a practical stand- adaptive biological reaction to an immediate real or perceived
This document is copyrighted by the American Psychological Association or one of its allied publishers.

point, the busy hospital setting offers very limited observation time threat (e.g., fears of needles and pain associated with surgery).
for health care and study staff to fully and accurately assess Heightened anxiety about surgery may lead to distress and chronic
preoperative anxiety (Jenkins et al., 2014). Another disadvantage avoidance of the source (e.g., high preoperative anxiety leads to
of the mYPAS is that it also does not allow for the assessment of avoidance of future surgeries; McMurtry et al., 2015). In order to
postoperative anxiety. properly capture the richness of the phenomenon of anxiety, we
Other scales such as the Visual Analog Scale (VAS; DeLoach, have included items such as “worried,” “scared,” and “nervous-
Higgins, Caplan, & Stiff, 1998) and Wong-Baker FACES ness,” as they allow for a more comprehensive assessment of the
(FACES) scale (Wong & Baker, 1988) have been applied in this multidimensional nature of the anxiety construct (Barlow, 1988;
setting. The VAS is a single 100-mm wide horizontal line with “no Chorpita & Barlow, 1998; Silverman, La Greca, & Wasserstein,
pain” and “worst possible pain” anchors at each end (DeLoach et 1995). These interrelated but different aspects of anxiety are sub-
al., 1998). Similarly, FACES is a one-item scale comprised of 6 jective and are likely best measured via self-report in the surgical
cartoon faces ranging from happy to sad to crying (Wong & Baker, context. It is particularly challenging for pediatric health care
1988). However, both the VAS and FACES are primarily used to providers to assess children’s fear and anxiety in medical settings,
assess children’s pain. As the construct of pain and anxiety are and so it is vital that a proper measure be utilized (i.e., CPMAS)
conceptually different, more research is required to determine the that allows for children to communicate how they feel briefly and
psychometric properties of these scales in the assessment of chil- accurately (Foster & Park, 2012).
dren’s anxiety. These one-item scales provide very limited infor- The CPMAS is a brief, age-appropriate self-report scale that is
mation and may lack the accuracy and comprehensiveness re- designed to evaluate pediatric perioperative anxiety in busy hos-
quired to adequately describe and measure perioperative anxiety. pital settings. The measure is a five-item visual analog scale that
Moreover, the reliability of these single-item scales is also unclear quantifies perioperative anxiety numerically from 0 to 500. Chil-
as internal consistency cannot be assessed for one-item measures dren as young as 3 years are able to self-report on anxiety (Wright,
(Lee & Kieckhefer, 1989; Wewers & Lowe, 1990). However, a Eisner, Stewart, & Finley, 2010), and as long as they have the
multi-item VAS that combines several related constructs could ability to comprehend space, numbers, and distance, they are able
allow for a more accurate assessment of a complex phenomenon to correctly self-report on their anxiety levels using VAS scales
such as anxiety or fear (Foster & Park, 2012; Gift, 1989). (Foster & Park, 2012). By age 7, concrete operations emerge:
Two other self-report measures that have been used to assess children develop an understanding of their mental operations, and
children’s anxiety in the clinical setting are the State–Trait Anxiety so the majority of children older than 7 are capable of reporting
Inventory-Children (STAI-C; Spielberger, Edwards, Lushene, their feelings accurately. A number of other studies have also
Monturoi, & Platzek, 1973), and the Screen for Child Anxiety demonstrated the validity of numeric visual analog self-report
Related Emotional Disorders–Child Version (SCARED-C; Birma- scale to measure preoperative anxiety and/or pain in children
her et al., 1997). The STAI-C is a 40-item scale that measures both between 7 and 13 years of age (Bringuier et al., 2009; Crandall,
stable (trait) and situational (state) anxiety (Spielberger et al., Lammers, Senders, Savedra, & Braun, 2007; Garra, Singer, Do-
1973), and the SCARED-C is a 41-item screening instrument that mingo, & Thode, 2013).
measures childhood anxiety disorders (Birmaher et al., 1997). The The objective of the present study was to assess the psychomet-
SCARED-C is a “gold” standard that encompasses many facets of ric properties of the CPMAS in 7- to 13-year-old children under-
childhood anxiety. Both of these scales take approximately 10 –15 going surgery. We aimed to test the reliability of CPMAS scores
min to complete and were designed primarily to assess anxiety by examining the internal consistency at three time points and
outside of hospital and other medical settings. While both have test–retest reliability across all three perioperative visits. The con-
demonstrated good validity and reliability outside of the surgical vergent validity of CPMAS scores (using the SCARED-C) was
context, their length and lack of specificity in this medical envi- also examined. We hypothesized that CPMAS would demonstrate
ronment makes these scales cumbersome to administer, particu- good internal consistency and test–retest reliability at all three time
larly in busy operative areas (Birmaher et al., 1997; Papay & Hedl, points. CPMAS scores were also predicted to be moderately cor-
1978). related with overall SCARED-C scores at all three time points,
At present, the limitations associated with existing children’s given that the two measures tap similar, but not identical features
anxiety measures may prevent us from rapidly and accurately of anxiety.
 PSYCHOMETRIC PROPERTIES OF CPMAS 1103

1. Right now, how worried are you? Summing the responses to the CPMAS items produces a score
Not at all Very ranging from 0 to 500, with higher values indicating greater
worried worried anxiety. Item 4 was only applicable during preoperative periods,
2. Right now, how scared are you?
and so this item was eliminated at the postoperative assessment.
Scale development of the CPMAS. The CPMAS was created
Not at all Very
scared scared by a team of experts from various disciplines, including a devel-
opmental personality psychologist with over 20 years of experi-
3. Right now, how nervous are you? ence in studying children’s anxiety, an anesthesiologist with over
Not at all Very 20 years in pediatric anesthesiology, a psychiatrist, and a child
nervous nervous
clinical psychologist with over 40 years of clinical experience with
4. Right now, I feel scared that this might hurt.* children’s anxiety. During the planning/construction phase, the
Not at all Very expert panel created dozens of preliminary question items using
scared scared theoretical and empirical domains of child anxiety from the extant
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

literature and based on their practical and research experience

This document is copyrighted by the American Psychological Association or one of its allied publishers.

5. Right now, I feel worried that something bad might happen.

(Birmaher et al., 1997; La Greca & Stone, 1993; Reynolds &
Not at all Very
worried worried Richmond, 1978). During pilot testing, the panel reviewed prelim-
inary item tryouts, edited items, and reduced the number of items
to only include appropriate and relevant contents manifested dur-
Figure 1. Children’s Preoperative Multidimensional Anxiety Scale. Item
ing the perioperative periods. The original CPMAS had a total of
4 is only applicable during preoperative periods.
6 items. Data were collected on all 6 items at all three study time
points. Preliminary analysis showed that Item #2, “Right now, how
Method happy are you?” had low inter-item correlations (range from .131
to .404), and the stability of the scale was improved when this item
Participants was removed (as shown by an increase in Cronbach’s alpha from
.85 to .89). As a result, the team agreed that the “happy” item/
Eighty children (50 boys, 30 girls) with a mean age of 9.8 ⫾ 0.18 construct was theoretically different from the “anxiety” construct.
years (range 7 to 13) who were scheduled to undergo elective outpa- Accordingly, the decision was made to remove it from the scale.
tient surgical procedures (i.e., tonsillectomy, adenoidectomy, and her- We also removed item #5, “Right now, I feel scared that this might
niorraphy) at a single university-affiliated children’s hospital were hurt” from the postoperative visit because it did not apply postop-
recruited during their preoperative clinic visits. Informed assent and eratively. Therefore, this item was eliminated for T3 follow-ups
parental consent were obtained prior to enrollment in the study. only. The CPMAS panel had agreed on the final version of the
Enrollment took place between September 2013 and February 2015. five-item CPMAS used preoperatively in this study.
Children diagnosed with neurodevelopmental disorders (e.g., autism SCARED-C. The SCARED-C is a 41-item self-report scale
spectrum disorders, visual and/or hearing impairment, etc.) and whose that screens for common pediatric anxiety disorders in children
families were unable to comprehend the study process (i.e., enroll- aged 8 to 18 years (Birmaher et al., 1997). It contains subscales
ment, completing measures, receiving telephone calls, the right to for social anxiety disorder (SAD), panic disorder (PD), or
withdraw from the study at anytime etc.) or to provide consent due to significant somatic symptoms, generalized anxiety disorder
language barriers were not eligible to participate. (GAD), separation anxiety disorder (SpD), and significant
school avoidance (SSA). Scores on each item range from 0 (not
Measures true) to 2 (very true). A total overall scale score of ⱖ25
suggests the presence of an anxiety disorder. The SCARED-C
CPMAS. The CPMAS is a five-item visual analog scale that has demonstrated excellent reliability with an internal consis-
quantifies perioperative anxiety numerically. Each question directly tency of ␣ ⫽ .74 to .93 and test–retest reliability (intraclass
asks about how the child feels under/during various perioperative correlation coefficients ⫽ .70 to .90), as well as concurrent
settings. validity with anxiety and other mental disorders), and moderate
During the administration of the CPMAS, children were told to parent– child agreement (r ⫽ .20 to .47, p ⬍ .001, all correla-
respond to questions in a way that reflected exactly how they feel tions). It is important to note that the SCARED-C measures
about the surgery at that moment. In particular, they were asked symptoms of various anxiety disorders.
each CPMAS question individually as they were shown the visual Two state-related items within the Generalized Anxiety Sub-
analog scale. Children were told to draw a line on the number that scale (i.e., Q7—“I am nervous,” and also Q33—“I worry about
was closest to how they felt with 0 representing not at all X and what is going to happen in the future”) were selected for further
100 representing very X for that item. At all three time points, analyses. These two items were selected and used to examine
children were reminded of the fact that they were answering convergent validity with the CPMAS.
questions about their surgery while completing the scale. For
example, children were asked
Procedure and Data Collection
Right now, how worried are you? Please answer by drawing a line on
the number that is closest to how you are feeling about the surgery, Data were collected at three time points: at preoperative assess-
from a scale of 0 to 100 with 0 meaning not at all worried, 100 ment (T1), immediately preoperatively on the day of surgery (T2),
meaning very worried or any numbers in between (see Figure 1). and 1 month postoperatively (T3). Children completed two self-
 1104 CHOW, VAN LIESHOUT, BUCKLEY, AND SCHMIDT

reports, the CPMAS and the SCARED-C, at these time points. traclass correlations (ICC) across all three visits. Inter-item corre-
Demographics such as sex, age, previous hospitalization, preoper- lations were also examined. Finally, the total SCARED-C and
ative preparation with a ChildLife Specialist, parental sex, and state-related items of the SCARED-C were administered simulta-
parental age were also collected at T1. neously with the CPMAS during all three visits to assess the
This study and all procedures were approved by the local convergent validity, using the Pearson product–moment correla-
university Hospital Research Ethics Board. Written informed as- tion coefficient (r). Item analyses were also conducted on two
sent and consent were obtained from children and parents. selected state-related items within the Generalized Anxiety Sub-
scale (i.e., Q7—“I am nervous,” and also Q33—“I worry about
Pilot Testing what is going to happen in the future”) as our outcomes.
Sensitivity to change was assessed using the Standardized Re-
The present study was completed in three phases. The first sponse Mean (SRM) change coefficient. We defined the magni-
phase was conducted to assess the psychometric properties of the
tude of the change using Cohen’s d, where an effect size (ES) of
CPMAS, to determine if our recruitment procedures were feasible,
less than 0.20 is trivial, ⱖ 0.20 to ⬍0.50 is small, ⱖ 0.50 to ⬍0.80
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

and if CPMAS scores were stable across preoperative visits (i.e.,

is moderate and ⱖ0.80 is large (Stratford & Riddle, 2005).
T1 and T2). We demonstrated that participant recruitment (n ⫽ 30)
This document is copyrighted by the American Psychological Association or one of its allied publishers.

A post hoc power analysis for the correlation of CPMAS scores

and anxiety assessment were feasible at these time points. How-
between time points was conducted based on our pilot data and
ever, in this phase, we identified the issue of reduced study
revealed that a minimum of 80 participants would be required to
retention during postoperative visits. This was due to the fact that
achieve 80% (␤ ⫽ 0.2) statistical power with a significance level
many outpatient surgical patients did not return to the clinic for
of 0.05 (␣ ⫽ .05) to detect a correlation coefficient of r ⫽ .31.
follow-up and/or were not recommended to return to the follow-up
Additionally, a power analysis for a one-group paired samples t
clinic. In our second phase, we recruited another 30 children and
test was also conducted using CPMAS scores and revealed a mean
followed up via telephone protocol. In the last phase, we recruited
difference of 37 and a standard deviation of 24 between T1 and T2
another 20 participants and administered the revised five-item
and a mean difference of 136 and a standard deviation of 25
CPMAS scale using the refined protocol.
between T2 and T3. A minimum of 6 participants would be
required to achieve 80% (␤ ⫽ 0.2) statistical power to detect a
Statistical Analysis significance difference (␣ ⫽ .05) between the 2 groups at these
Descriptive analyses were conducted to report on all demo- time points. Furthermore, a power analysis for Cronbach’s alpha
graphic and anxiety outcomes. The Pearson product–moment cor- with 5 items was conducted and revealed a minimum of 10
relation coefficient (r) was used to determine the strength of the participants to achieve 80% (␤ ⫽ 0.2) statistical power with a
associations between CPMAS administration between time points. significance level of 0.05 (␣ ⫽ .05).
Paired samples t tests were performed to determine construct To account for attrition, sensitivity analyses using independent
validity by comparing the differences of CPMAS scores between samples t test and chi-square tests were conducted to compare the
the preoperative (T1 and T2) and postoperative (T3) groups. baseline characteristics between those who remained in the study and
Internal consistency was evaluated using Cronbach’s alpha those who did not complete all of the assessments (see Table 1). A
(Cronbach’s alpha). Test–retest reliability was assessed using in- sensitivity analysis was also conducted to compare the results be-

Table 1
Demographic Characteristics of Children and Family (N ⫽ 80)

Characteristics Complete Incomplete (T2) Incomplete (T3)

Children
Gender, % (boys/girls) 62.5/37.5 18.8/7.5 37.5/16.3
Age, M ⫾ SD 9.8 ⫾ 1.62 9.9 ⫾ 1.49 9.9 ⫾ 1.57
Baseline CPMAS scores, M ⫾ SD 146.09 ⫾ 128.72 123.57 ⫾ 96.84 140.65 ⫾ 128.09
Baseline SCARED-C scores, M ⫾ SD 24.71 ⫾ 15.25 23.44 ⫾ 16.25 22.25 ⫾ 14.55
Type of surgery, %
Otolaryngologic 57.5 13.8 27.5
Urologic 21.3 3.8 12.5
General pediatric 15 3.8 8.8
Opthamalogic 5 3.8 3.8
Dental 1.3 1.3 1.3
ChildLife specialist, % (yes/no) 98/2 25/1.3 25/1.3
Previous hospitalization, % (yes/no) 9/71 2.5/23.8 5/48.8
Parents
Mother/father/other, % (Mother/father/other) 73.8/21.3/5 20/3.8/2.5 48.8/11.3/2.5
Age, M ⫾ SD 40.43 ⫾ 7.57 39.24 ⫾ 7.25 39.28 ⫾ 6.49
Household income, Mdn $82,290 (Cdn)
Note. % ⫽ percentage; M ⫽ Mean; SD ⫽ standard deviation; Mdn ⫽ median; Cdn ⫽ Canadian dollars;
CPMAS ⫽ Children’s Perioperative Multidimensional Anxiety Scale; SCARED-C ⫽ Screen for Child Anxiety
Related Disorders-Child Version.
 PSYCHOMETRIC PROPERTIES OF CPMAS 1105

tween those who received preoperative preparation by ChildLife correlations, ranging from .44 to .72 at T1, .48 to .84 at T2, and .33
Specialist and those who did not, and to compare the anxiety mea- to .53 at T3 were found (see Table 4).
sures between those 8- to 13-year-old (the recommended age for
SCARED-C) and children who were 7 years old. Convergent Validity
Data were analyzed using Statistical Package for the Social
Sciences (SPSS; 22.0, SPSS Inc., Chicago, IL). p values ⬍ 0.05 The convergent validity of the CPMAS was assessed by com-
were considered statistically significant. paring the CPMAS with SCARED-C and selected state-related
anxiety items from the SCARED-C (i.e., SCARED-C Q7—ner-
vous and SCARED-C Q33—worry about future) across all three
Results visits. CPMAS scores moderately correlated with overall
Table 1 shows the demographic characteristics of the study SCARED-C scores at all three time points: at T1, r ⫽ .35, p ⬍ .05,
sample. Children’s baseline anxiety scores were assessed an aver- at T2, r ⫽ .46, p ⬍ .05, and at T3, r ⫽ .54, p ⬍ .05 (see Table 3).
age of 10 days before surgery (M ⫽ 10.05, SD ⫽ 10.08). The Furthermore, the CPMAS was moderately correlated with the
following SCARED-C subscales: PD, r ⫽ .34, p ⬍ .05, and GAD,
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majority of these children received otolaryngologic surgeries

r ⫽ .41, p ⬍ .05 at T1, PD, r ⫽ .55, p ⬍ .01, and SpD, r ⫽ .52,
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(57.5%) and urologic surgeries (21.3%). As part of the standard of

care routine at this hospital, most children (97.5%) received pre- p ⬍ .013 at T2, and PD, r ⫽ .47, p ⬍ .01, GAD, r ⫽ .53, p ⬍ .01,
operative preparation by a ChildLife Specialist during their pre- and SAD, r ⫽ .36, p ⬍ .05 at T3.
operative clinic visit. As preoperative preparation by ChildLife Our results also showed that SCARED-C Q7—nervous corre-
Specialists was available for only 4 hrs each day, two children who lated with 4 of 5 CPMAS items at T1 (r values ranged from .29
came in before or after these hours did not receive this preparation. to.71, p ⬍ .05 to p ⬍ .01, respectively, and T2 (r values ranged
Children of all ages in our sample were able to read and from .51 to .69, p ⬍ .01). SCARED-C Q7—nervous also corre-
understand the assent form and measures. A total of 5 children lated to 2 items at T3 (r values ranged from .49 to .58, p ⬍ .01).
were 7 years old at the time of testing. The results of our sensitivity Moreover, Q33—worry about future correlated with all CPMAS
analysis showed no significant differences between those who items at T1 (r values ranged from .39 to .58, p ⬍ .01), 1 CPMAS
were 8 to 13 years old and those who were 7 years old on any item at T2, r ⫽ .52, p ⬍ .05, and 2 CPMAS items at T3 (r values
outcome measures (p ⬎ .05). ranged from .37 to .44, p ⬍ .05; see Table 5). The pattern of
All 80 children completed the CPMAS at T1. Fifty-nine children correlations suggested that features of anxiety and worry were
completed the CPMAS at T2, and 37 children completed the differentially exhibited at different perioperative periods (e.g.,
CPMAS at T3. In Table 2, the descriptive statistics of the CPMAS preoperatively, day of, and postoperatively).
and SCARED-C scores are shown. The mean CPMAS score was Paired samples t tests revealed no statistically significant differ-
146.09 ⫾ 128.72 (range 0 –500) at T1, 182.71 ⫾ 135.01 (range ences between the CPMAS mean scores during the two preoper-
0 –500) at T2, and 46.24 ⫾ 69.61 (range 0 –230) at T3. In keeping ative visits (i.e., T1 and T2). Significant differences of mean
with general clinical experience, the mean CPMAS scores in- CPMAS scores were reported between T1 and T3, t(36) ⫽ 5.56,
creased from T1 to T2 (p ⬎ .05) and decreased from T2 to T3, with p ⬍ .01, and T2 and T3, t(35) ⫽ 7.05, p ⬍ .01. That CPMAS
the highest scores at T2 (immediately preoperatively). scores changed over time suggest that it can discriminate between
SCARED-C scores were available for 45 children at T1, 20 preoperative and postoperative visits.
children at T2, and 31 children at T3 (see Table 2). Only a portion
of recruited children were able to complete SCARED-C at T2 due Sensitivity to Change
to accommodations made for operating room schedule changes or Our results also suggest that the CPMAS was sensitive to
insufficient time in holding area for children to complete the entire change between preoperative (T1 or T2) and postoperative periods
SCARED-C scale. Overall SCARED-C scores were near the cutoff (T3), as demonstrated by their effect sizes. The SRM was 0.214
score of 25, which suggests the presence of anxiety symptoms at (small) between T1 and T2, large (⫺1.17) between T2 and T3 and
T1, and slightly below the cutoff score at T2 and T3. Most of the was also large (⫺0.91) between T1 and T3.
SCARED-C subscale scores were below individual scale cutoffs,
the exception being SpD. All children scored 5 or higher on SpD
Sensitivity Analyses
items across all three time points, suggesting that operative pro-
cedures might increase levels of SpD. Sensitivity analyses revealed no significant differences between
those who remained in the study and those who did not complete
all of the assessments on any baseline characteristics (p ⬎ .05).
Reliability
Moreover, no significant differences were found between the
The five-item CPMAS showed strong internal consistency at all groups who received preoperative preparation by ChildLife Spe-
three time points, with a reliability of .75 or higher. Cronbach’s cialist and those who did not on all outcomes (p ⬎ .05). When
alpha coefficients measured at three time points were 0.89 during children (n ⫽ 2) who did not receive preoperative preparation by
preoperative clinic visit (T1), 0.90 on the day of surgery (T2), and ChildLife Specialists were eliminated from analysis, the CPMAS
0.75 1 month postoperatively (T3). The test–retest reliability for continued to demonstrate good internal consistency (Cronbach’s
the five-item CPMAS demonstrated moderate stability (ICC ⫽ alpha ⫽ .80 or higher; i.e., 0.88 at T1, 0.90 at T2, and 0.75 at T3)
0.71) across all three visits. CPMAS scores were moderately and moderately stable (ICC ⫽ 0.69) across all three visits. CPMAS
correlated at T1 and T2, r ⫽ .52, p ⬍ .01, and at T1 and T3, r ⫽ scores also remained moderately correlated at T1 and T2, r ⫽ .52,
.47, p ⬍ .05 (see Table 3). In addition, moderate positive inter-item p ⬍ .01, and at T2 and T3, r ⫽ .47, p ⬍ .05.
 1106 CHOW, VAN LIESHOUT, BUCKLEY, AND SCHMIDT

Table 2 ically selected two state-related items within the Generalized Anx-
Descriptive Statistics of the CPMAS and SCARED-C Scores iety Subscale of the SCARED-C (i.e., Q7—“I am nervous,” and
also Q33—“I worry about what is going to happen in the future”)
Anxiety scores N M ⫾ SD Range and used them as our outcomes in additional analyses. When using
CPMAS these two state-related items, our results showed that SCARED-C
Preoperative visit (T1) Q7 and Q33 correlated with CPMAS items across all three time
Boy 50 126.74 ⫾ 120.18 0–500 points. This finding supports the convergent validity of CPMAS
Girl 30 178.33 ⫾ 137.89 0–400 using state-related anxiety items of the SCARED-C.
Total 80 146.09 ⫾ 128.72 0–500
Day of surgery (T2) The five-item CPMAS showed strong internal consistency at all
Boy 35 170.57 ⫾ 136.81 0–500 three time points, with a reliability of .75 or higher. The Cron-
Girl 24 200.42 ⫾ 133.20 0–420 bach’s alpha coefficient was relatively high (␣ ⫽ .89) during the
Total 59 182.71 ⫾ 135.01 0–500 preoperative clinic visit. Since children received similar preoper-
1 month after surgery (T3)
ative preparation, it is possible that less variability in anxiety levels
Boy 20 38.50 ⫾ 71.25 0–230
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Girl 17 55.35 ⫾ 68.64 0–190 were found at T1. The Cronbach’s alpha coefficient was the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Total 37 46.24 ⫾ 69.61 0–230 highest on the day of surgery (␣ ⫽ .90), which could be due to the
SCARED-C fact that most children experience heightened anxiety at T2. How-
Preoperative visit (T1) ever, Cronbach’s alpha coefficient was lowest 1 month postoper-
PD 50 4.84 ⫾ 4.71
GAD 47 5.60 ⫾ 4.13 atively (␣ ⫽ .75). This may be due to the variability in postoper-
SpD 49 6.06 ⫾ 4.22 ative situations such as individual differences in recovery,
SAD 49 6.12 ⫾ 3.70 susceptibility to preoperative anxiety, and/or the ability to cope
SSA 50 2.04 ⫾ 1.73 with negative postoperative outcomes.
Total 45 24.71 ⫾ 15.53 4–67
Convergent validity was supported by the presence of statisti-
Day of surgery (T2)
PD 21 5.19 ⫾ 5.99 cally significant correlations between CPMAS scores and
GAD 20 5.15 ⫾ 4.70 SCARED-C scores at all three assessment points. Construct valid-
SpD 22 5.18 ⫾ 4.94 ity was also supported, and mean scores differed between these
SAD 21 4.43 ⫾ 3.94 preoperative (T1 and T2) and postoperative (T3) periods, suggest-
SSA 20 1.93 ⫾ 1.75
Total 20 21.53 ⫾ 18.95 2–74 ing that the CPMAS is sensitive to change in the surgical context.
1 month after surgery (T3) This finding is consistent with clinical experience and previous
PD 31 4.10 ⫾ 5.22
GAD 31 4.94 ⫾ 5.05
SpD 31 5.10 ⫾ 3.48 Table 3
SAD 31 6.19 ⫾ 3.57 Correlations of the CPMAS
SSA 31 1.68 ⫾ 1.60
Total 31 22.00 ⫾ 14.66 3–66 CPMAS CPMAS CPMAS
at T1 at T2 at T3
Note. CPMAS ⫽ Children’s Perioperative Multidimensional Anxiety
Scale; SCARED-C ⫽ Screen for Child Anxiety Related Disorders-Child CPMAS
Version; PD ⫽ panic disorder; GAD ⫽ generalized anxiety disorder; CPMAS at T1 .52ⴱⴱ .47ⴱⴱ
SpD ⫽ separation anxiety disorder; SAD ⫽ social anxiety disorder; SSA ⫽ CPMAS at T2 .31
significant school avoidance. A SCARED-C score of ⱖ25 may indicate the SCARED-C
presence of an anxiety disorder; PD score of ⱖ7 may indicate the presence SCARED-C at T1 .35ⴱ
of panic disorder; GAD score of ⱖ 9 may indicate the presence of PD .34ⴱ
generalized anxiety disorder; SpD score of ⱖ 5 may indicate the presence GAD .41ⴱⴱ
of separation anxiety disorder; SAD score of ⱖ 8 may indicate the presence SpD .22
of social anxiety disorder; SSA score of ⱖ 3 may indicate significant SAD .16
school avoidance. SSA .16
SCARED-C at T2 .16 .46ⴱ
PD .07 .55ⴱ
Discussion GAD .20 .29
SpD .25 .52ⴱ
The objectives of this study were to assess the psychometric SAD .13 .17
properties of the CPMAS in 7- to 13-year-old children undergoing SSA ⫺.07 .22
elective surgery and to examine the reliability and validity of SCARED-C at T3 .33 .18 .54ⴱ
PD .25 .21 .47ⴱ
CPMAS scale scores in a busy children’s hospital setting. The GAD .27 .06 .53ⴱⴱ
CPMAS scale scores demonstrated good reliability and strong SpD .30 .38ⴱ .27
internal consistency and stability. Moderate positive inter-item SAD .19 ⫺.09 .36ⴱ
correlations were also found. However, the tighter clustering of SSA .26 .09 .34
correlations at T2 may be due to the condition of elevated stress/ Note. CPMAS ⫽ Children’s Perioperative Multidimensional Anxiety
worry/anxiety that is present in the presurgical area and the oper- Scale; SCARED-C ⫽ Screen for Child Anxiety Related Disorders-Child
ating room on the day of surgery. It is possible that the T2 visit Version; PD ⫽ panic disorder; GAD ⫽ generalized anxiety disorder;
SpD ⫽ separation anxiety disorder; SAD ⫽ social anxiety disorder; SSA ⫽
(day of surgery) is a context in which anxiety is heightened, significant school avoidance. T1 ⫽ preoperative visit; T2 ⫽ day of surgery;
resulting in the clustering of items and/or more difficulty for T3 ⫽ 1 month after surgery.
ⴱ
children in distinguishing between items. Furthermore, we specif- p ⬍ .05. ⴱⴱ p ⬍ .01.
 PSYCHOMETRIC PROPERTIES OF CPMAS 1107

Table 4 experiencing lower state anxiety in the perioperative period. This

Inter-Item Correlations of the CPMAS result may indicate that the CPMAS and SCARED-C tap different
aspects of anxiety. Future research that examines individual dif-
Item #2 Item #3 Item #4 Item #5 ferences in trait anxiety in relation to the susceptibility to state
Preoperative visit (T1) anxiety within various contexts is needed.
Item #1 .674 .496 .614 .659
Item #2 .720 .613 .688 Limitations
Item #3 .437 .541
Item #4 .654 A few limitations should be mentioned that can help guide the
Item #5
future assessment of this measure. First, because this study was the
Day of surgery (T2)
Item #1 .772 .830 .594 .479 first of its kind to be conducted at this university-affiliated chil-
Item #2 .840 .591 .613 dren’s hospital, there were unforeseen challenges such as recruit-
Item #3 .691 .486 ment and follow-up during the early phases of testing
Item #4 .536
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Second, although the correlations of the CPMAS between visits

Item #5
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1 month after (T3) were significant, they were moderate at T1 and T2, and at T1 and
Item #1 .332 .447 N/A .379 T3. This may be due to the fact that the sample size was relatively
Item #2 .533 N/A .505 small particularly at T2 and T3. Other external factors (e.g., at
Item #3 N/A .483 school or at home) may also have affected our findings at T3 (i.e.,
Item #4 N/A
1 month after surgery). For example, the dynamics and interactions
Item #5 N/A
of each child with their peers, family, and/or teachers after surgery
Note. CPMAS ⫽ Children’s Perioperative Multidimensional Anxiety might vary due to differences in rate of recovery, pain levels,
Scale; Item #1 ⫽ “Right now, how worried are you?”; Item #2 ⫽ “Right
and/or medication dosages. Some children may recover faster and
now, how scared are you?”; Item #3 ⫽ “Right now, how nervous are
you?”; Item #4 ⫽ “Right now, I feel scared that this might hurt”; Item #5 ⫽ find it easier to get back to their normal routines than others who
“Right now, I feel worried that something bad might happen”; N/A ⫽ not took longer to heal. These factors need to be considered in future
applicable at this time point. studies.
Third, the correlations with the SCARED-C were statistically
significant, but ranged from r ⫽ .35 to .54, p ⬍ .05. Anastasi
research that showed that high anxiety is associated with the (1998) has suggested that a correlation of r ⫽ .5 to .7, with existing
anticipation of a stressful situation (e.g., anesthetic induction; scales, is considered acceptable when developing a new scale.
Davidson & McKenzie, 2011). Chorney and Kain reported that
more than 40% of children were anxious during anesthetic induc-
tion with 17% of these children displaying significant anxiety, and Table 5
more than 30% actively resisting induction (Chorney & Kain, Correlations of the CPMAS with SCARED-C Q7 and SCARED-C Q33
2009).
In addition to correlations with total SCARED-C scores, the SCARED-C Q7 Q1 SCARED-C Q33
CPMAS was moderately correlated with a few of the SCARED-C Preoperative visit (T1)
subscale scores across visits. Interestingly, the CPMAS was con- Item #1 .267 .386ⴱⴱ
sistently correlated with the PD subscale across all three visits, Item #2 .539ⴱⴱ .401ⴱⴱ
with GAD subscale at T1 and T3, with SpD subscale at T2 and Item #3 .713ⴱⴱ .415ⴱⴱ
with SAD subscale at T3. As expected, we found that symptoms of Item #4 .289ⴱ .385ⴱⴱ
Item #5 .362ⴱ .576ⴱⴱ
separation anxiety disorders were common throughout the periop- Day of surgery (T2)
erative process, and it is noteworthy that CPMAS scores correlated Item #1 .694ⴱⴱ .429
with this SCARED-C subscale at T2. This finding complements Item #2 .680ⴱⴱ .308
existing literature that suggests that elevated children’s anxiety is Item #3 .554ⴱⴱ .350
Item #4 .261 .345
present during separation from parents upon entry to the operating Item #5 .510ⴱ .519ⴱ
room (McCann & Kain, 2001). Moreover, it is likely that the 1 month after (T3)
generalized anxiety symptoms were trumped by symptoms of Item #1 .334 .373ⴱ
more salient concerns (e.g., panic and fear), as shown in the Item #2 .271 .441ⴱ
significant correlation between CPMAS and the SCARED-C PD Item #3 .492ⴱⴱ .220
Item #4 N/A N/A
subscale at T2. Furthermore, the association found between CP- Item #5 .575ⴱⴱ .239
MAS and the PD subscale at T3 may be due to some lingering
effects of the surgical experience. It is possible that certain aspects Note. CPMAS ⫽ Children’s Perioperative Multidimensional Anxiety
Scale; SCARED-C ⫽ Screen for Child Anxiety Related Disorders-Child
of PD symptoms emerge during the perioperative periods. Thus, if Version; Item #1 ⫽ “Right now, how worried are you?”; Item #2 ⫽ “Right
these preoperative PD symptoms are not properly managed, chil- now, how scared are you?”; Item #3 ⫽ “Right now, how nervous are
dren may continue to experience PD symptoms even after surgery you?”; Item #4 ⫽ “Right now, I feel scared that this might hurt”; Item #5 ⫽
is over. “Right now, I feel worried that something bad might happen”; N/A ⫽ not
applicable at this time point; SCARED-C Q7 ⫽ “I am nervous”;
Our finding that children scored lower on the CPMAS but SCARED-C Q33 ⫽ “I worry about what is going to happen in the future”;
relatively high on SCARED-C during all three time points sug- T1 ⫽ preoperative visit; T2 ⫽ day of surgery; T3 ⫽ 1 month after surgery.
ⴱ
gests that children may be exhibiting high trait anxiety while p ⬍ .05. ⴱⴱ p ⬍ .01.
 1108 CHOW, VAN LIESHOUT, BUCKLEY, AND SCHMIDT

These seemingly lower correlations could be due to attrition at T2 While demonstrating acceptable psychometric properties, our
and T3, which reduced the statistical power of our study and may findings need to be replicated in a larger sample on children over
leave it vulnerable to type II error (failure to detect an effect when a wider range of ages, and those who are scheduled to receive
it is present). As a result, this study may underestimate the con- different types of surgery. Additional research should focus on
vergent validity of the CPMAS with some of the SCARED-C establishing the appropriate cutoff score to differentiate low versus
subscales. Aside from the smaller sample size, these correlations high preoperative anxiety groups and to establish levels at which it
may not be higher because the SCARED-C taps a number of predicts clinically significant outcomes.
different anxiety-related phenomena, some of which may not
change in the perioperative period (e.g., significant school avoid- Conclusions
ance) or may not relate to the experience of anxiety during this This study provides empirical evidence to support the initial reli-
time. ability and validity of the CPMAS scores in assessing perioperative
While using a trait-like form such as SCARED-C is a limitation anxiety in children undergoing elective surgery. Future research is
to our study, we conducted further item analyses to examine the needed to confirm the psychometric properties of the scale in a larger
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

relation between state-related items with the CPMAS items. In so sample. Thus far, our results suggest that the CPMAS has the poten-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

doing, the pattern of correlations that emerged using selected state tial to be a useful and valid tool for the evaluation of anxiety in a
related items of the SCARED-C revealed points of further discus- surgical setting for children as young as 7 years old. This brief
sion. These correlations suggested that there might be differential five-item self-report can easily be utilized to accurately assess peri-
influences of perioperative timing (e.g., preoperatively, day of, and operative anxiety in routine clinical practice and research settings.
postoperatively) that might be differentially related to anxiety and
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