The Management of Procedure-Induced Anxiety in Children

Elizabeth C. Halloran, PhD

Fam Med. 2022;54(6):483-484.

DOI: 10.22454/FamMed.2022.197876

Book Title: The Management of Procedure-Induced Anxiety in Children

Author: Richard Martin

Publication Information: New York, Cambridge University Press, 2021, 89 pp., $25.99, paperback

Imagine bringing your child to the hospital. Your child is visibly anxious and behaviorally uncooperative. Physicians in one scenario neither engage, distract, nor calm your child. They use force to make your child comply with procedures. Physicians in another scenario make every effort to read your child’s body language, adjust how they interact with your child, use calming strategies, and succeed in eliciting cooperation without coercion. There is no question which situation is preferable.

While these images might seem exaggerated, the number of children suffering from procedure-induced anxiety is noteworthy. Approximately half of children experience anxiety at the induction of anesthesia; 24%-60 % have postoperative dysfunctional behavior 3 weeks to 3 months after surgery, and 4%-12% of children display problem behaviors for more than a year (p. 10). This thin textbook helps clinicians minimize such negative experiences. It describes the theory, research, and application of anxiety-reducing strategies for children undergoing medical procedures.

Dr Martin speaks from experience as a fellow of the Royal Academy of Anaesthetists and trained hypnotherapist. He is passionate about the topic and believes anxiety management skills should be a core competency for physicians. Furthermore, he advocates for a system that uses screening and triage to identify children at risk, has flexibility in the delivery of interventions, and requires follow up after discharge.

The most important thesis of Dr Martin’s text is the need to “broadcast an overwhelming message of non-threat” (p. 3) to pediatric patients. He highlights the importance of rapport, trust, and compassion, as well as the negative impact of coercion and restraint. When children are anxious, they are in a vulnerable state and more sensitive to both positive and negative influences. According to Dr Martin, this state provides opportunities for those with proper training, as well as risks when clinicians are unaware of the negative impact they could have.

In this manual, Dr Martin goes into specifics about nonverbal and verbal communication. He describes 20 strategies categorized into interventions that (1) disrupt an internal focus, (2) enhance rapport building, and/or (3) deliver a coping strategy. While specific tactics overlap in what they accomplish, examples of disrupting an internal focus include the clinician violating expectations (ie, doing something surprising), purposely being confusing, or doing a magic trick. Approaches that help build rapport include conversing about interests, validating the child’s thoughts and feelings, and backing off as needed. Strategies that promote coping include using humor and distraction, breaking things down so they are manageable, and using guided imagery, storytelling, or hypnosis.

The book is well organized, with sections numbered for easy reference. The information throughout is detailed and technical. While these aspects are helpful, they contribute to the book reading like an encyclopedia. Dr Martin describes interactions in a mechanistic way, and there are no cases described to pull the reader into the importance of the topic at a more personal level. This is particularly problematic when discussing some of the more covert strategies he promotes. Some approaches seem insensitive to children’s need to understand what is happening. Thus, illustrating the strategies used with actual cases would have put some of the covert tactics in perspective and humanized the whole process of working with these youngsters.

Missing from this book is a thorough discussion of the need for a developmental approach. Strategies used with a baby, a toddler, a preschooler, a school-aged child, or a teenager would look very different, but are not fully described. Furthermore, more focus on supporting the role of the parent/caregiver in helping the child manage anxiety is needed. Caregivers’ preprocedural anxiety has been linked to children’s procedural anxiety and pain.1 Finally, most people will not be able to use the hypnotherapeutic techniques without additional training or supervision, while many of the rapport-building techniques should already be in a physician’s armamentarium.

This book seems excessive for family physicians who are not typically involved in presurgical anesthesia. Family physicians can benefit from learning how to reduce medical-related anxiety in children, and there are other resources that may give family physicians enough of a glimpse into this topic to develop those skills. One such reseource is a 10-minute video by the New England Journal of Medicine.2 Another is an article focusing on the CARE process to manage health care-induced anxiety in children.3 These resources cover relevant information, use real faces and cases, and present information in a straightforward manner. If more detailed and technical information is desired, this book serves as a good reference volume.


  1. Bearden DJ, Feinstein A, Cohen LL. The influence of parent preprocedural anxiety on child procedural pain: mediation by child procedural anxiety. J Pediatr Psychol. 2012;37(6):680-686. doi:10.1093/jpepsy/jss041
  2. Krauss BS, Krauss BA, Green SM. VIDEOS IN CLINICAL MEDICINE. Managing Procedural Anxiety in Children. N Engl J Med. 2016;374(16):e19. Accessed November 30, 2021. doi:10.1056/NEJMvcm1411127
  3. Lerwick JL. Minimizing pediatric healthcare-induced anxiety and trauma. World J Clin Pediatr 2016; 5(2): 143-150. doi:10.5409/wjcp.v5.i2.143

Lead Author

Elizabeth C. Halloran, PhD

Affiliations: Mercy Health St. Vincent Family Medicine Residency Program, Toledo, OH

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