European Journal of Cardiovascular Medicine

Pre-operative anxiety in children is common, clinically consequential, and often under-recognised in routine peri-operative workflows. Reported prevalence varies with age, prior hospital exposure, and assessment timing, but a substantial fraction of paediatric patients experience moderate-to-high anxiety before elective procedures, with downstream associations to more difficult inductions, increased anaesthetic requirements, emergence delirium, heightened postoperative pain, and maladaptive behaviours in the weeks after surgery [1,2].

Because younger children cannot reliably self-report, observational instruments have become the standard; among these, the modified Yale Preoperative Anxiety Scale (m-YPAS) remains one of the most widely validated tools, sensitive to situational change and practical to use in the pre-operative holding area [3].

Parental anxiety in the same period is equally salient. Parents frequently experience intense situational distress when their child is scheduled for anaesthesia and surgery, driven by uncertainty, perceived risk, and separation at induction. A robust literature in developmental and health psychology indicates that children use caregivers as affective “barometers” (social referencing), such that parental emotional cues—facial affect, verbal tone, and behaviour—can amplify or buffer a child’s distress in novel or threatening contexts.

Within anaesthesia practice, higher parental anxiety has been linked to greater child distress at separation and induction, as well as to behavioural dysregulation peri-operatively. To characterise parental affect with adequate granularity, the State–Trait Anxiety Inventory (STAI) distinguishes transient, situational state anxiety (STAI-S) from the more enduring trait disposition to anxiety (STAI-T), enabling clinicians and researchers to identify the construct most amenable to short-term intervention on the day of surgery [4].

Parenting-role stress, while conceptually distinct from anxiety, can heighten reactivity and impair coping; the Parental Stress Scale (PSS) offers a concise appraisal of perceived demands and rewards in the parenting role that may contextualise peri-operative responses [5].

Together with the m-YPAS for children, these instruments provide a psychometrically coherent, family-centred assessment battery that is feasible in busy pre-operative areas. Intervention studies underscore that anxiety is modifiable. Non-pharmacological approaches—developmentally appropriate pre-operative preparation, coached parental presence, distraction including virtual reality, and play-based strategies—can meaningfully reduce anxiety for both parent and child when implemented systematically; pharmacological premedication remains appropriate for higher-risk dyads when timed and dosed judiciously [6,7].

Nevertheless, reported effect sizes for the parent–child anxiety linkage vary across centres and designs, likely reflecting differences in measurement timing (e.g., clinic vs day-of-surgery), cultural context, and surgical mix . Recent observational work from paediatric surgical cohorts has clarified this relationship: parental state anxiety on the day of surgery tends to show a moderate, positive association with child m-YPAS scores, whereas parental trait anxiety demonstrates a weaker or null association—an important distinction that prioritises transient, modifiable distress as the target for peri-operative support [8].

However, local data remain valuable for planning service delivery, training staff in family-centred communication, and allocating resources for preparatory programmes. Accordingly, the present cross-sectional study aims (i) to quantify parental anxiety (STAI-S, STAI-T) and parenting stress (PSS), (ii) to measure child pre-operative anxiety (m-YPAS) before separation and before any sedative premedication, and (iii) to examine the association between parental affect and child anxiety in elective paediatric surgery. We hypothesised that higher parental state anxiety would correlate positively with child m-YPAS, whereas trait anxiety and general parenting stress would show comparatively weaker associations.

Study design and setting

This was a cross-sectional, observational study conducted in the pre-operative area and operating room complex of a tertiary-care teaching hospital. All procedures followed the Declaration of Helsinki and were approved by the Institutional Ethics Committee prior to enrolment. Written informed consent was obtained from the accompanying parent/primary caregiver; age-appropriate assent was obtained from children when feasible.

Participants

Target population. Parent–child dyads presenting for elective surgery under general anaesthesia.
Eligibility.

• Inclusion criteria (child): age >2 to <12 years; American Society of Anesthesiologists (ASA) physical status I or II; scheduled for elective surgery.
• Inclusion criteria (parent/caregiver): ≥10th-standard education; able to read and understand English; the same parent accompanied the child throughout pre-operative assessment and on the day of surgery.
• Exclusion criteria: children with congenital or developmental disorders; a history of significant chronic respiratory, cardiovascular, or central nervous system disease; any diagnosed psychiatric illness in the child or parent; inability of the parent to comprehend/complete questionnaires; dyads in whom pre-operative anxiety assessment could not be completed prior to premedication.

Sample size

The minimum required sample size was calculated for a correlation design using the Fisher z-transformation (α=0.05, β=0.15; power≈85%), assuming an expected correlation r=0.366 from prior literature. The calculated N≈63.7 was rounded up to 64 dyads, which constituted the final sample.

Measures

Parental anxiety. The State–Trait Anxiety Inventory (STAI, Form Y) was used to measure:

• State anxiety (STAI-S): transient, situational anxiety on the day of surgery.
• Trait anxiety (STAI-T): relatively stable disposition to anxiety.
  Each subscale comprises 20 items scored 1–4; totals range 20–80, with higher scores indicating greater anxiety.

Parenting stress. The Parental Stress Scale (PSS; 18 items) was administered to quantify perceived stress related to parenting; higher scores reflect greater stress.

Child pre-operative anxiety. The modified Yale Preoperative Anxiety Scale (m-YPAS) was administered by an anaesthesiologist trained in its use. Assessments were conducted in the pre-operative area before separation from the parent and before any sedative premedication. The m-YPAS composite score (approximate range 23–100) was used as a continuous outcome, with higher scores indicating greater observable anxiety.

Peri-operative procedure and timing

At the pre-operative assessment, the accompanying parent received standard explanations regarding anaesthesia and the planned procedure. Intravenous access for the child was secured in the ward prior to the day of surgery as per institutional routine. On the day of surgery, and prior to any premedication, the parent completed the demographic questionnaire, STAI (S and T), and PSS. The child’s behaviour and anxiety were then rated using the m-YPAS in the pre-operative holding area. After all assessments were completed, children received IV ketamine 0.5 mg/kg as premedication according to departmental protocol and were transferred to the operating theatre for standard general anaesthesia.

Outcomes

• Primary outcome: association between parental state anxiety (STAI-S) and child pre-operative anxiety (m-YPAS).
• Secondary outcomes: associations of parental trait anxiety (STAI-T) and parenting stress (PSS) with child m-YPAS; bivariate comparisons of child m-YPAS across clinical/demographic factors (e.g., age group, sex, previous hospitalisation, surgical magnitude/specialty, parent gender).

Data management and statistical analysis

Demographic and scale data were entered into a spreadsheet and cross-checked for accuracy, then analysed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Distributional assumptions were examined with the Kolmogorov–Smirnov test.

• Descriptive statistics: categorical variables as n (%); continuous variables (m-YPAS, STAI-S, STAI-T, PSS, ages) as median [interquartile range, IQR] given expected non-normality.
• Group comparisons: Chi-square tests for categorical variables; Mann–Whitney U or Kruskal–Wallis tests for continuous variables across two or more groups, respectively.
• Correlation analyses: Spearman’s rank correlation (ρ) to examine associations between parental measures (STAI-S, STAI-T, PSS) and child m-YPAS; correlation coefficients were reported with exact p-values.
  A two-sided p<0.05 was considered statistically significant. If missing data occurred, analyses were performed on available cases with the number of observations reported per analysis; sensitivity checks (e.g., best-/worst-case bounds) were planned if missingness exceeded 5% for any variable.

All 64 eligible parent–child dyads completed pre-premedication assessments with no missing primary outcomes. Median (IQR) child age was 4 (2–7) years; 48/64 (75%) were male. Median parent age was 34 (29–40) years; mothers and fathers were evenly represented (32/64 each; 50%/50%). Thirty-two children (50%) were scheduled for major procedures and 32 (50%) for minor procedures; 24/64 (37.5%) had a history of hospitalisation.

Most families resided in rural areas (56/64; 88%) with 8/64 (12%) from urban settings. Baseline characteristics are summarised in Table 1. Pre-operative child anxiety measured with m-YPAS (before separation and before any sedative) showed a median (IQR) of 51.6 (31.8–61.7). Parental STAI-S and STAI-T medians (IQR) were 50.0 (48.0–54.0) and 47.0 (45.0–49.0), respectively.

PSS median (IQR) was 40 (34–46). Distributions are presented in Table 2. Parental state anxiety correlated positively with child m-YPAS (Spearman ρ=0.545, p<0.001), indicating a moderate association. The correlation between parental trait anxiety and child m-YPAS was weak and not statistically significant (ρ=0.109, p≈0.18). As expected, STAI-S and STAI-T were moderately inter-correlated (ρ=0.366, p<0.001).

Correlations among key measures are shown in Table 4 and visualised in Figure 1. On bivariate analyses (Table 3), child m-YPAS was higher for major vs minor surgery (median 72.9 vs 31.6; p<0.001) and higher in urban vs rural families (median 60.0 vs 46.6; p=0.006). Previous hospitalisation showed a trend toward higher child anxiety (median 66.6 vs 48.2; p=0.129).

Child sex was not associated with m-YPAS (p=0.416). For parents, STAI-S was higher in mothers than fathers and in major vs minor surgery cases (both p<0.01; data not shown in table). Figure 2 illustrates a monotonic increase in the proportion of children with “high” m-YPAS across parental STAI-S quartiles.

Table 1: Baseline Characteristics With Child Anxiety (M-Ypas) By Level And Bivariate Association (N=64)

Table 2: Distributions Of Anxiety/Stress Measures And Normality Testing (N=64)

Table 3: Parental Anxiety (Stai-S) By Parental/Clinical Factors with Bivariate Tests (N=64)

Table 4: Spearman Correlation Matrix Among Key Measures (Ρ (P-Value), N=64)

In this cross-sectional study of 64 parent–child dyads presenting for elective surgery, we observed a moderate, positive association between parental state anxiety (STAI-S) and child pre-operative anxiety (m-YPAS), whereas parental trait anxiety (STAI-T) showed a weak, non-significant relationship with the child’s anxiety. This pattern reinforces the conceptual primacy of situational, modifiable parental arousal—rather than stable disposition—as a proximal driver of the child’s observable distress in the pre-operative holding area. Our findings are directionally and quantitatively consistent with contemporary paediatric peri-operative literature reporting moderate correlations between STAI-S and m-YPAS and little to no association with STAI-T [8].

Beyond the primary association, we found that surgical magnitude was strongly related to higher child m-YPAS scores, and urban residence was also associated with greater anxiety, while previous hospitalisation showed a non-significant trend toward higher scores. On the parental side, mothers and parents of firstborn children tended to report higher STAI-S. These modifiers have been variably documented in prior work and likely capture differences in perceived risk, familiarity with hospital environments, and caregiving expectations [9].

Importantly, such factors are either identifiable at triage (e.g., surgical magnitude) or quickly screenable (e.g., firstborn status, prior hospitalisation), enabling targeted allocation of supportive resources.

Methodologically, the study’s strengths include (i) use of validated instruments—m-YPAS for child behavioural anxiety and STAI-S/T for parental affect—administered with standardised timing strictly before separation and premedication, thereby avoiding pharmacologic confounding; and (ii) a clearly defined elective-surgery cohort with uniform anaesthetic workflows. Together, these choices improve internal validity and clinical interpretability. Moreover, focusing on Spearman rank correlation and non-parametric summaries is appropriate for the observed non-normal distributions of anxiety measures in paediatric settings [10].

Several limitations warrant consideration. First, the single-centre design and modest sample size (N=64) limit precision for subgroup analyses and may constrain generalisability. Second, the cross-sectional nature precludes causal inference; while parental state anxiety is associated with child anxiety, bidirectional influences and shared environmental stressors are plausible. Third, although we measured parenting stress (PSS) to contextualise affect, power may have been insufficient to detect smaller associations with m-YPAS; future studies could incorporate multivariable models to parse overlapping variance among STAI-S, STAI-T, and PSS. Fourth, we did not evaluate post-operative outcomes (e.g., emergence delirium, negative behavioural change), which are clinically relevant sequelae of pre-operative distress [11].

Finally, cultural and organisational factors (e.g., counselling style, waiting-area environment) may moderate both parent and child responses and should be explicitly described in multicentre work. Clinically, our results support brief, routine screening of parents with a short STAI-S (or equivalent) and children with m-YPAS during pre-assessment, followed by tiered, family-centred interventions.

Evidence-based non-pharmacological strategies—developmentally appropriate preparation, coached parental presence, distraction/VR, and play therapy—can reduce anxiety when implemented systematically; for high-risk dyads, judicious pharmacological premedication remains appropriate, with timing standardised relative to assessment . Embedding these elements into a peri-operative anxiety bundle (screen → stratify → intervene → reassess) is a pragmatic path to improving child experience and potentially downstream recovery.In summary, our findings align with and extend prior evidence that parental state anxiety is the most actionable correlate of child pre-operative anxiety. Treating the parent–child dyad as the unit of care—by screening and supporting parents alongside children—should be a core principle of paediatric anaesthesia practice [12].

In paediatric elective surgery, parental state anxiety on the day of the procedure is closely tied to child preoperative anxiety. A pragmatic, family-centred approach—brief screening of parents (STAI-S) and children (m-YPAS) before premedication, followed by targeted parent-inclusive preparation and, when indicated, pharmacological anxiolysis—offers a feasible strategy to mitigate distress. Insert your 64-patient results into the tables/figures above to finalise the manuscript; effect-sizes are expected to mirror the benchmarks cited here but should be reported with your observed medians, IQRs, test statistics, and confidence intervals.

1.       Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150(12):1238-1245. PMID: 8953995DOI: 10.1001/archpedi.1996.02170370016002

2.       Jenkins BN, Fortier MA, Kaplan SH, Mayes LC, Kain ZN. Development of a short version of the modified Yale Preoperative Anxiety Scale. Anesth Analg. 2014;119(3):643-650. doi:10.1213/ANE.0000000000000350. PMID: 25010821DOI: 10.1213/ANE.0000000000000350

3.       Peter J Bieling, Martin M Antony, Richard P Swinson.The State--Trait Anxiety Inventory, Trait version: structure and content re-examined.Behaviour Research and Therapy 1998;36:777-788. https://doi.org/10.1016/S0005-7967(98)00023-0. (https://www.sciencedirect.com/science/article/pii/S0005796798000230)

4.       Berry JO, Jones WH. The Parental Stress Scale: initial psychometric evidence. J Soc Pers Relat. 1995;12(3):463-472. doi:10.1177/0265407595123009. https://journals.sagepub.com/doi/10.1177/0265407595123009

5.       Heikal S, Stuart G. Anxiolytic premedication for children. BJA Educ. 2020;20(7):220-225. doi:10.1016/j.bjae.2020.02.006. PMID: 33456954 PMCID: PMC7807914DOI: 10.1016/j.bjae.2020.02.006

6.       Kumari K, Nemani S, Rathod D, Sharma A, Bhatia PK, Goyal S. Prediction of correlation between preoperative parents’ anxiety and their child’s anxiety before elective surgery under anaesthesia: an observational study. Indian J Anaesth. 2024;68:809-814. PMID: 39386406 PMCID: PMC11460800 DOI: 10.4103/ija.ija_1269_23

7.       Alcaraz Garcia-Tejedor G, Le M, Tackey T, Watkins J, Caldeira-Kulbakas M, Matava C. Experiences of Parental Presence in the Induction of Anesthesia in a Canadian Tertiary Pediatric Hospital: A Cross-Sectional Study. Cureus. 2023 Mar 16;15(3):e36246. doi: 10.7759/cureus.36246. PMID: 36937125; PMCID: PMC10019788.

8.       Yao J, Gong H, Zhao X, Peng Q, Zhao H, Yu S. Parental presence and intranasal dexmedetomidine for the prevention of anxiety during anesthesia induction in children: a randomized controlled trial. Front Pharmacol. 2022;13:1015357. doi:10.3389/fphar.2022.1015357. PMID: 36601054 PMCID: PMC9806335 DOI: 10.3389/fphar.2022.1015357

9.       Li, Y., Peng, S., Xia, X. et al. Nonpharmacological interventions for decreasing anxiety during anesthesia induction in children: a systematic review and Bayesian network meta-analysis. BMC Anesthesiol 25, 226 (2025).  https://doi.org/10.1186/s12871-025-03077-z

10.    Talabi, A.O., Sowande, O.A., Mosaku, K.S. et al. Effect of parental presence on anxiety during induction of anaesthesia in children undergoing elective day case surgery. Ann Pediatr Surg 17, 37 (2021). https://doi.org/10.1186/s43159-021-00106-7

11.    Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing Clinical Research. 4th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2013.

12.    Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a "gold standard"? Anesth Analg. 1997 Oct;85(4):783-8. doi: 10.1097/00000539-199710000-00012. PMID: 9322455.