Pediatric Anesthesia 2006 16: 10191027 doi:10.1111/j.1460-9592.2006.01914.

Distraction with a hand-held video game reduces

pediatric preoperative anxiety
A N U R A D H A P A T E L M D D A F R C A , T H O M A S S C H I E B LE
MD MBA, M E L I S S A D A V ID S O N M D , M IN H C . J. T R A N M D ,
C A T H E R I N E S C H O E N B E R G R N B S N , E L LI S E D EL P H I N
M D M P H A N D H EN R Y B E N N E T T P h D
Department of Anesthesiology and Perioperative Medicine, New Jersey Medical School,
University of Medicine and Dentistry of New Jersey, Newark, NJ, USA

Summary
Background: Video games have received widespread application in
health care for distraction and behavior modification therapy. Studies
on the effect of cognitive distraction during the preoperative period are
lacking. We evaluated the efficacy of an interactive distraction, a hand-
held video game (VG) in reducing preoperative anxiety in children.
Methods: In a randomized, prospective study of 112 children aged
412 years undergoing outpatient surgery, anxiety was assessed after
admission and again at mask induction of anesthesia, using the
modified Yale Preoperative Anxiety Scale (mYPAS). Postoperative
behavior changes were assessed with the Posthospital Behavior
Questionnaire (PHBQ). Patients were randomly assigned to three
groups: parent presence (PP), PP + a hand-held VG, and
PP + 0.5 mgkg)1 oral midazolam (M) given >20 min prior to entering
the operating room.
Results: There was a statistically significant increase in anxiety
(P < 0.01) in groups M and PP at induction of anesthesia compared
with baseline, but not in VG group. VG patients demonstrated a
decrease in anxiety from baseline (median change in mYPAS )3), the
difference compared with PP (+11.8) was significant (P 0.04). The
change in anxiety in the M group (+7.3) was not statistically different
from other groups. Sixty-three percent of patients in VG group had no
change or decrease in anxiety after treatment, compared with 26% in
M group and 28% in PP group (P 0.01). There was no difference in
anxiety changes between female and male patients.
Conclusions: A hand-held VG can be offered to most children as a low
cost, easy to implement, portable, and effective method to reduce
anxiety in the preoperative area and during induction of anesthesia.
Distraction in a pleasurable and familiar activity provides anxiety
relief, probably through cognitive and motor absorption.

Keywords: video games; pediatric anxiety; distraction; midazolam;

parental presence; ambulatory surgery

Correspondence to: Dr Anuradha Patel, Department of Anesthesiology and Perioperative Medicine, New Jersey Medical School, UMDNJ,
Medical Science Building E-552, 185 South Orange Avenue, Newark, NJ 07101, USA (email: patelan@umdnj.edu).

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Journal compilation  2006 Blackwell Publishing Ltd 1019
1 02 0 A. PATEL ET AL.
Introduction
Children may experience heightened anxiety in the
preoperative period and during induction of anesthe-
sia (1). Increased anxiety at induction of anesthesia
has been correlated with more distress in the imme-
diate postoperative period (2,3). The effects of fear,
distress and anxiety may extend beyond the immedi-
ate surgical period; postoperative maladaptive
behavior may be present in 3054% of children
during the first 2 weeks following surgery (4).
Behavioral and pharmacologic interventions are
utilized to treat preoperative anxiety, including par-
ental presence (PP), premedication and behavioral
preparation programs. Although the desirability of
treating preoperative anxiety is obvious, implemen-
tation of treatment modalities is restricted by time
constraints, undesirable side effects, increased health
care costs, or a combination of these. A recent survey
of anesthesiologists showed that sedative premedica-
tion was used in only 50% of all children undergoing
surgery (5). There are limitations with use of preme-
dication, including timing and amount of drug, side
effects, and economic issues. While there has been an
overall increase in parental presence (PP) during
induction of anesthesia (PPIA) over the past few
years, only 10% of survey respondents used PPIA in a
majority of cases (5). PPIA itself is controversial and
parental anxiety is believed to increase the childs
anxiety (6). Preoperative preparation programs are
not universally helpful in reducing anxiety and they
can be time consuming and expensive (7).
Distraction techniques such as music and toys
have been used with variable success to decrease
pain from intravenous cannulation (8,9), but their
effectiveness during the induction of anesthesia has
not been established (10,11). Anesthesiologists con-
tinue to search for a low cost, easy to administer, and
comprehensive method for anxiety reduction in the
pediatric surgical population.
Video game (VG) playing has become a ubiquitous
activity in society today. Children may be so
engrossed in playing VGs that they may become
oblivious to their surroundings or disregard verbal
and tactile stimuli. VGs have received widespread
application in health care, mainly for distraction and
behavior modification therapy (1214). There are no
studies documenting the effect of cognitive distrac-
tion during the preoperative period and the induction
Journal compilation  2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 10191027
of general anesthesia. The purpose of this investiga-
tion was to examine the efficacy of an interactive
distraction, the use of a hand-held VG to reduce
preoperative anxiety in children between the age of 4
and 12 years and to compare this intervention with
premedication with midazolam (M) and PP.
Methods
A prospective, randomized trial comparing two
interventions affecting preoperative anxiety to a
control group was conducted in 112 children under-
going general anesthesia for elective surgery in an
ambulatory surgery center. After Institutional Re-
view Board approval, parents or guardians were
approached and informed consent to participate was
obtained. Assent was obtained in children older than
7 years. Inclusion criteria were: children aged 4
12 years, American Society of Anesthesiologists
physical status I or II, and mask induction of general
anesthesia. Children requiring emergency surgery,
those with developmental disabilities or chronic
illnesses, those on psychoactive medications or
children having repeated surgery were excluded
from the study. Subjects were randomly assigned by
sealed envelopes to one of the three groups: PP;
PP + M (midazolam 0.5 mgkg)1 orally); or PP + an
active distraction, a hand-held VG.
A research nurse administered a structured inter-
view in the ambulatory surgery admitting area that
included demographic information and the Posthos-
pital Behavior Questionnaire (PHBQ) to establish a
baseline for comparison after surgery. The nurse
scored a baseline modified Yale Preoperative Anxi-
ety Scale (mYPAS) prior to randomization or any
intervention (T1). The child was informed of the
group assignment after randomization to minimize
patient expectations and/or disappointment (e.g.
anticipation of playing a VG and then being rand-
omized to another arm of the study). Children and
parents remained in private cubicles in the ambula-
tory surgery unit before transfer into the operating
room (OR). Parents were given a written and verbal
description of what to expect when they entered the
OR and were dressed in scrubs, hat and mask while
in the holding area. Children in the M and VG
groups were then medicated (M) or given a VG. All
VGs were rated E for everyone and were self-
selected by the child from a variety of 10 games.
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 V I D E O GA M E S R EL I E V E P ED I A T R I C P R E O P E RA TI V E A N X I E TY
At least 20 min after the intervention (M, VG or
none), parent and patient were escorted into the OR
where standard preanesthesia procedures were car-
ried out prior to mask induction of general anesthe-
sia with oxygen, nitrous oxide, and sevoflurane.
Patients assigned to the VG group were allowed to
play through the introduction of the mask. A second
mYPAS was performed by an independent observer
during the period of monitor placement, introduc-
tion of the anesthesia mask, and induction of
anesthesia (T2).
Once the child was anesthetized, the parent or
guardian was escorted out of the OR by a nurse and
asked to complete a parent satisfaction survey.
Finally, between 7 and 10 days after surgery, a
telephone interview with the parent or guardian was
done to complete a follow-up PHBQ.
Dependent measures
Modified Yale Preoperative Anxiety Scale. This obser-
vational instrument contains 22 items in five categ-
ories qualifying anxiety in young children: activity,
emotional expressivity, state of arousal, vocalization,
and use of parents. The mYPAS has shown good to
excellent inter- and intraobserver reliability and
validity for measuring childrens anxiety in the
preoperative holding area, upon entrance to the
operating room, and during induction of anesthesia
for children aged 212 years. The score range is 23
100 (15).
Posthospitalization Behavior Questionnaire. This self-
report questionnaire for parents is designed to
evaluate maladaptive behavioral responses or devel-
opmental regression in children after hospitalization
or surgery. The PHBQ consists of 27 items grouped
into six categories: general anxiety, separation anxi-
ety, sleep anxiety, eating disturbances, aggression
against authority, and apathy/withdrawal. This
instrument shows acceptable test retest reliability
and good agreement with psychiatric interviews
with parents (16).
Statistical methods
One-way ANOVA was used to analyse the differences
of age and heart rate among different groups.
Nonparametric analytical methods were used, inclu-
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Journal compilation  2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 10191027
1 0 21
ding chi-squared test for distribution comparison,
KruskalWallis test for difference among groups,
and Wilcoxon signed ranks test for repeated meas-
ures. Some data are expressed as mean SEM, some
as median values and others in percentages. A
P-value <0.05 is considered significant.
Results
Demographic data were similar across groups and
are summarized in Table 1. The three groups were
comparable in age, gender, birth order, sibling
cohort, and prior hospitalization. Surgical proce-
dures were comparable across groups. The initial
mYPAS score was higher in the M group, the
difference was statistically significant (P 0.025).
To assess the effect of the interventions on
anxiety, comparing change from baseline (T1) to
induction scores (T2) on the mYPAS in three
groups served as the main dependent measure.
Wilcoxon-signed ranks test (a nonparametric meth-
od) was used to analyse the change of anxiety
after treatment, because the distribution of data
were not normal. There was a statistically signifi-
cant increase in anxiety (P < 0.01) in groups M and
PP at induction of anesthesia compared with
baseline, but not in VG group. Mean PHBQ scores
were largely unchanged from baseline across all
three groups.
Figure 1 shows anxiety scores (mYPAS) at induc-
tion (A) and within patient change from initial scores
(B) for PP, M and VG patients. The shaded box
represents the interquartile range from 25 to 75
percentile. Upper and lower whiskers indicate the
range of scores. A line within the box indicates the
median (50 percentile). The 0 to 75 percentiles of
mYPAS score changes in VG were lower than their
counterparts in PP and M. By plotting curves with
percentile to change of mYPAS score (T2T1) and
successful curve fitting (R2 > 0.98), an accurate
calculation of the median was obtained. The median
values obtained were )3.3 in VG, 7.3 in M, and 11.8
in PP groups, respectively. The change of anxiety in
the VG group at induction of anesthesia was less
than that in the PP group, the difference between the
two groups was significant (P 0.04, Kruskal
Wallis test). However, the increase of anxiety in the
M group was not statistically different from other
groups.
1 02 2 A. PATEL ET AL.

Table 1
VG M PP Demographic data and baseline
(n 38) (n 38) (n 36) P-value scores
Gender
Male 24 23 22 0.97a
Female 14 15 14
Age (years) 7.0 0.4 6.9 0.4 6.6 0.4 0.75b
Previous hospitalization
No 27 25 23 0.79a
Yes 11 13 13
Baseline heart rate (min)1) 85.9 1.7 89.2 2.4 87.8 1.7 0.49b
mYPAS 37.4 2.3 45.2 3.1* 34.3 2.0 0.025c
Baseline PHBQ 5.5 0.5 6.4 0.7 5.7 0.4 0.62c

Values are expressed as mean SEM.

VG, video game; M, midazolam; PP, parent presence; mYPAS, modified Yale Preoperative Anxiety
Scale; PHBQ, Posthospital Behavior Questionnaire.
a
Two-sided chi-squared test; btwo-sided one-way ANOVA; ctwo-sided KruskalWallis test.
*P < 0.05, compared with other groups.

We compared the percentage of patients with no
change or decrease in anxiety in the three groups.
Table 2 shows that 63% patients in VG group had no
change or decrease in anxiety after treatment as
measured by mYPAS scores compared with 26% in
M group and 28% in PP group (v2 9.26, d.f. 2,
P 0.01, chi-squared test).
The percentage of patients with no change or
decrease in anxiety in the three groups in different
age subgroups was also compared. As shown in
Table 2, in the 45 years subgroup, the percentage of
patients with no change or a decrease in mYPAS
score after treatment is greater in the VG (50%) than
the M (12%) and the PP (18%) group (P 0.04, chi-
squared test). In 69 years subgroup, no change or a
decrease in the VG group (78%) was higher than
that in the M (40%) and the PP (43%) group
(P 0.05). In 1012 years subgroup, no change or
a decrease in the VG (50%) was higher than in the M
(33%) and the PP group (25%) without statistical
significance (P 0.54).
In Figure 2, the median change of mYPAS score in
different ages is shown. In the 45 years group, the
increase in anxiety in VG group was the lowest,
while it was the highest in the PP group. In the 6
9 years group, the increase in anxiety was low in the
PP and M groups, but anxiety was reduced in
the VG group. The 10 to 12-year-old patients had the
most increase in anxiety across all three groups. The
anxiety changes in the age subgroups were not
statistically different.
The effect of gender and different treatments was
also compared (Figure 3). In each group of patients,
there was no difference in median mYPAS score
changes between female (median: VG, 0; M, 6.7; PP,
15) and male patients (median: VG, 0; M, 8.4; PP,
14.2).
Limitations of the study
Observer bias is a limitation of studies that utilize an
observer tool for anxiety measurement with inter-
ventions such as PPIA and distraction techniques
(1719). The nurse/observer could not be blinded to
treatment group for obvious reasons. The parent
only group could have received placebo medication
in order to blind the observer to the M group. The
PHBQ is a self-report measure and can be biased by
parents perception of their childs behavior (19).
The VG intervention might be considered an
unexpected gift which children find pleasurable,
thus, decreasing anxiety. Yet, without the active
distraction and mental and motor participation, it is
unlikely that a gift alone would provide anxiolysis
as a study using distraction with novel toys, books,
and bubble blowing was not any more effective than
PP (10).
Discussion
This study was undertaken to assess the efficacy of
distraction with a VG in reducing anxiety in children
during the preoperative period and induction of
anesthesia. Under the conditions of our prospective,
randomized controlled trial, we found that children
412 years who played with a hand-held VG had

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 V I D E O GA M E S R EL I E V E P ED I A T R I C P R E O P E RA TI V E A N X I E TY 1 0 23

(a) 120 20

PPIA
100
15 M
Induction mYPAS score

80

Change of mYPAS score

VG

60 10

40
5
20

0 0
PP M VG
Group
5
(b) 80 45 69 10
* Age
60
*
Change of mYPAS score

Figure 2
40 The median change of modified Yale Preoperative Anxiety Scale
(T2T1) in patients of different ages in parent presence, midazo-
20 lam, and video game groups.

0
less anxiety at induction of anesthesia compared
20 with children who had only their parents present.
Although the median change in anxiety in the VG
40
patients was less than those premedicated with M,
60 this was not statistically significant. Based on be-
PP M VG havioral and physiologic data, it has been shown
Group that introduction of the anesthesia mask is possibly
Figure 1 the most stressful procedure a child experiences
Anxiety scores at (a) induction (T1) and within-patient change (b) during the perioperative period and this is the time
from initial scores (T2T1) for parent presence, midazolam, and when anxiety of the child escalates (1,11,17). This is
video game patients. Shaded box represents the interquartile
range from 25 to 75 percentile. Upper and lower whiskers indicate
the reason, why most studies on preoperative
range of scores. A line within the box indicates the median. anxiety compare anxiety at anesthesia induction
Asterisk indicates significant differences. with a prior baseline anxiety (1719). The median

Table 2
The effect of age and intervention on the rate of anxiety relief

45 years 69 years 10 years Total

Group mYPAS score n % n % n % n %

VG No increase 6 50* 14 78* 4 50 24 63**

Increase 6 50* 4 22* 4 50 14 37
M No increase 2 12 6 40 2 33 10 26
Increase 15 88 9 60 4 67 28 74
PP No increase 3 18 6 43 1 20 10 28
Increase 14 82 8 57 4 80 26 72
P-value 0.044 0.05 0.54 0.01

VG, video game; M, midazolam; PP, parent presence; mYPAS, modified Yale Preoperative Anxiety Scale.
Two-sided chi-squared test; *P < 0.05, **P < 0.01, compared with M and PP group in the same age group.

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1 02 4 A. PATEL ET AL.
80
Change of mYPAS score from baseline
60
40
20
0 informed about their group assignment after a
20
Female
40
Male
60
PP
Group
Figure 3
The change of modified Yale Preoperative Anxiety Scale in female
and male patients at induction compared with baseline. The box
represents the interquartile range from 25 to 75 percentile. The
whiskers are lines that extend from the box to the highest and
lowest values. A line across the box indicates the median.
change in mYPAS score of )3 for the VG group
suggests that the normal rise in anxiety upon entry
to the operating room and induction of anesthesia
can be ameliorated if the child is playing with a
hand-held VG.
The first documentation of distraction during
anesthesia induction was by Robson in 1925 who
wrote, Ask the child to blow through the mask. It
gives the little patient something to occupy his
attention (20). Music-assisted relaxation seemed to
have a significant reduction in preoperative anxiety
in a small sample of children (21). Preparation of
parents by a play specialist for events in the
anesthetic room and methods of distraction em-
ployed during induction using novel toys, books or
blowing bubbles did not reduce anxiety compared
with PP alone (10). Kain et al. found that interactive
music therapy by a group of musicians playing to
children during the preoperative period until induc-
tion of anesthesia was effective in alleviating anxiety
on separation from parents and entry into the
operating room, but not during induction of an-
esthesia. This intervention was also quite expensive.
Their opinion was that children often perceive the
induction of anesthesia as a direct threat, and the
anxiety that results from this stimulus is of a
different quality and intensity than the previous
preoperative anxiety (11).
Although baseline mYPAS scores in M group
were high, by comparing change scores we are able
to demonstrate the effect of different treatments on
anxiety. The reason for the elevated baseline anxiety
score in the M group is not clear, as the child was
baseline mYPAS assessment was done. It can be
seen from Table 3 that the increase in anxiety in the
M and PP groups was significantly higher at
anesthesia induction compared with baseline
(P < .01). A similar increase was not seen in VG
patients.
M VG A significant number of patients had no change or
a decrease in their anxiety in the VG group com-
pared with patients in the M and PP groups
(P < 0.01). Sixty-three percent patients in the VG
group were less anxious upon induction of anesthe-
sia compared with their arrival in the preoperative
area (T2T1). Reduction in mYPAS scores at an-
esthesia induction has been reported in only one
prior study (19), whereas most studies have reported
a comparatively lesser increase in anxiety as a result
of interventions (17,18).
When we examined the median change of mYPAS
scores in different age subgroups, the findings were
a little surprising. Children in the 45 years sub-
group in the VG group had the lowest change in
median mYPAS scores compared with M and PP
groups (Figure 2). Patients in the subgroup 6
9 years showed the least overall increase in anxiety
across all three groups with median mYPAS change
scores for the VG group being negative ()3). Patients
in the 1012 years subgroup showed the least overall
Table 3
Anxiety and behavior scores in different groups
Video game Midazolam Parent presence
(n 38) (n 38) (n 36)
Modified Yale Preoperative Anxiety Scale
Baseline 37.4 2.3 45.2 3.1 34.3 2.0
Induction 41.7 4.1 53.9 2.7** 51.5 4.0**
Posthospital Behavior Questionnaire
Baseline 5.5 0.5 6.4 0.7 5.7 0.4
Postsurgery 6.1 0.9 6.6 0.6 5.7 0.6
Values are expressed as mean SEM.
Two-sided Wilcoxon-signed ranks test; **P < 0.01 compared with
baseline.
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 V I D E O GA M E S R EL I E V E P ED I A T R I C P R E O P E RA TI V E A N X I E TY
effect of intervention amongst the three treatment
groups, although it is difficult to draw conclusions
based on the small number of patients in this age
subgroup (n 19). Although the VG seemed to
outperform M and PP in all age subgroups, the
results were not statistically significant when broken
down by age. A larger study with more patients in
each age subgroup may demonstrate a difference.
We assumed that older patients may benefit the
most from active and absorbing play with VGs than
younger patients. These patients also do not rou-
tinely receive premedication in clinical practice
because of the large doses of medication needed. It
is possible that video games are novel for younger
patients (49 years), whereas older patients are
accustomed to playing complicated and advanced
VGs, and may not find simple hand-held games
absorbing enough. It is well known that children at
different developmental stages respond to stress
with different defense mechanisms and with differ-
ent coping strategies (22).
The effectiveness of VG playing in reducing
anxiety was not influenced by the gender of the
child. Although, the general impression seems to be
that boys are more interested in VGs, we found that
girls were usually as engrossed in playing as the
boys. We ensured availability of games that girls
would find interesting.
As video and computer games have become an
integral part of the culture of children and adoles-
cents, they have received widespread application in
health care, mainly for distraction and behavior
modification therapy. VGs have been used as cog-
nitive and attentional distraction devices in cancer
patients to decondition the response of anticipatory
nausea before chemotherapy sessions (12). Cancer
patients also demonstrated less distress playing VGs
during chemotherapy, which was comparable with
relaxation therapy (23). Studies have also described
the successful use of VGs for psychotherapy and
behavior management, as well as to assist brain-
injured patients in regaining lost function (13,14,24).
VG playing engages an individuals active attention
through cognitive, visual and motor involvement.
The effects of VG playing on anxiety reduction may
be due to a decrease in arousal through escape or
recreation. In addition, most VGs increase perceived
challenges with increasing playtime to achieve sus-
tained play. The observations of typical VG group
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1 0 25
patients were of active visual and motor engagement
up to loss of consciousness, with most children
accepting application of monitors and introduction
of the mask while continuing use of the device.
Koepp et al. found that endogenous dopamine is
released and bound to receptors in the human
striatum during a goal-directed motor task like VG
playing. Dopaminergic neurotransmission may be
involved in learning reinforcement of behavior,
attention, and sensorimotor integration (25).
While PPIA is standard practice in our hospital,
the practice itself is controversial. Some studies with
PPIA found that children who were accompanied by
a parent or caregiver during induction of anesthesia
were less anxious than those who did not have
parents (26,27). Other randomized controlled trials
in ambulatory surgery patients have shown no
beneficial effect of PPIA over controls (6,17). Poten-
tial benefits of PPIA include reducing the need for
preoperative sedatives and avoiding the fear and
anxiety that may occur on separation to the OR.
There are several concerns with PPIA, including
disruption of the OR routine, increased time and
cost, and a possible adverse reaction of parents.
Parental anxiety is believed to increase the childs
anxiety (6), although no increase in anxiety in the
PPIA group was found compared with control in
one study (17). Parental satisfaction is reported to be
higher when parents are allowed to accompany their
child to the OR and most parents prefer to be present
during induction of anesthesia (18,28). In our study,
more than 80% of parents reported that they felt
their presence was helpful to the child.
The efficacy and safety of oral midazolam in doses
ranging from 0.2 to 0.7 mgkg)1 has been shown in
multiple studies with few reported complications
(29,30). Serious complications like respiratory
depression and hypoxia are rare after oral adminis-
tration. Paradoxical reactions include restlessness,
agitation, hiccoughs, violent behavior, and acts of
self-injury. The incidence of paradoxical reactions or
dysphoria ranges from 1.4% to 3.4%. Reactions
usually occur when midazolam is given via rectal or
intravenous routes (31,32), but they have been
reported after oral administration as well (31).
There are other issues that may discourage the use
of premedication in a busy ambulatory surgery
center. The minimum time interval for successfully
separating children premedicated with midazolam
1 02 6 A. PATEL ET AL.
from their parents is 10 min; the peak sedative effect
occurs 2030 min later and wanes after 4560 min
(30,33). In busy surgery centers where the turnover
of cases is quick and unpredictable, the timing of
premedication may be difficult to anticipate. Addi-
tional staff may be required to administer premedi-
cation and monitor the patient. Oral midazolam has
a bitter taste, which is difficult to mask. Many
parents may not want the child to receive sedative
premedication, and in fact, this was the only reason
parents refused to participate in our study. Delay in
emergence and recovery after oral premedication
has also been reported (34,35). A recent editorial
argues that midazolams sedative and amnestic
qualities are not necessarily beneficial to children
(36). Distraction with a hand-held VG is free from all
of these constraints; children can play for an exten-
ded period of time if they must wait or are delayed
for surgery. A longer waiting time between admis-
sion to the hospital and induction of anesthesia was
found to be one factor associated with increased
levels of anxiety in 5 to 12-year-old children (37).
Children are usually eager to play VGs and offering
them to the child serves to build rapport. The
importance of establishing rapport with children
leading to successful inductions has been empha-
sized (22). A choice of games may aid in preventing
boredom and keep attentional processes engaged.
Seizures have been reported in individuals with
epilepsy while playing VGs, although in the vast
majority of cases they occur in photosensitive per-
sons. Games and programs with a bright back-
ground or flashing images are specifically
provocative and playing on a 50 Hz television was
more provocative than a 100 Hz set (38). Another
study concluded that seizures during VG play in the
majority of patients without visual sensitivity are a
chance occurrence and are not more likely to happen
compared with other leisure pursuits (39). Hand-
held VGs have not been implicated in provoking
seizure activity in prone individuals, but caution
should be exercised when offering one to a patient
with photosensitive epilepsy.
The incidence of maladaptive behavior following
ambulatory surgery in pediatric patients is reported
to be about 30% (4). In Thompson and Vernons (40)
meta-analysis on childrens behavior after hospital-
ization and surgery, a 65% increase in separation
anxiety behaviors was noted especially in children
Journal compilation  2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 10191027
6 months to 4 years of age. One of the reasons for the
low incidence of negative behavior changes seen in
our study may be the older age of our patients. Our
practice is to allow parents to accompany their
children into the OR so our patients may be
experiencing less separation anxiety. This has been
suggested as a reason for the low incidence of
behavioral changes seen in other studies (41,42).
In summary, in an unfamiliar and stressful
environment, children cannot easily inhibit behav-
ior and methods to urge quiescence are often
ineffective. Similarly, engagement in passive activ-
ities like watching TV, or even mildly active tasks
(e.g. blowing bubbles, listening to music or a
story) do not engage the attentional focus of
children whereas other tasks such as active play
may completely absorb the child. Distraction in a
pleasurable and familiar activity permits cognitive
and motor absorption during an otherwise stress-
ful period while avoiding psychotropic medication.
We have shown that a hand-held VG can be
offered to most children as a low cost, easy to
implement, portable, and effective method to
reduce anxiety in the preoperative area and during
induction of anesthesia. Future work will examine
whether emergence from anesthesia is affected
when this distraction activity is used for preoper-
ative anxiolysis.
Acknowledgements
We would like to thank Cheng Xiao PhD for his
assistance with data analysis and Rex Ponnundurai
MD, FRCA for reviewing the manuscript. Thanks to
Susan Walsh CRNA for the idea of using video
games to reduce pediatric anxiety.
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Accepted 17 January 2006