Development and validity of the Burns-Child Adult Medical Procedure Interaction Scale (B-CAMPIS) for young children

Abstract

Background:
Young children are at increased risk of burn injury and of procedural distress during the subsequent wound care. There are currently few observational measures validated for use with young children during medical procedures. The aim of this research was to adapt the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R) to assess parent-young child interactions during burn wound care by including nonverbal behavioral coding.

Method:
Eighty-seven families of children (1-6years old) were recruited at their first burn dressing change. Potential behaviors were identified through a literature review, consulting health professionals, and direct observation of parents and children during burn wound care. Nonverbal behaviors were coded live, and verbal behaviors were audio recorded for later assessment.

Results:
Inter-coder reliability was good to excellent for the Burns-CAMPIS (B-CAMPIS). The additional behaviors were correlated with the hypothesized coping, distress, coping-promoting and distress-promoting categories of the CAMPIS-R. Some behaviors differed in frequency across child age groups, with older children demonstrating more verbal behaviors. Convergent validity was demonstrated through correlations with previously validated observational parent-child behavior measures, and parent- and nurse- reported measures of child pain and anxiety. Univariate regression analyses demonstrated the child categories of the B-CAMPIS accounted for equal or more of the variance of parent- and nurse- reported child pain and anxiety, compared to the CAMPIS-R.

Conclusions:
The B-CAMPIS is a reliable and valid measure, for assessing coping and distress relationships in young children and their families. Pending further validation, the B-CAMPIS assists researchers and clinicians to recognize and target important behaviors to improve young child coping during pediatric burn wound care.

Full text

Development
and
validity
of
the
Burns-Child
Adult
Medical
Procedure
Interaction
Scale
(B-CAMPIS)
for
young
children
E.A.
Brown
a,b,
*,
A.
De
Young
a
,
R.
Kimble
a,c
,
J.
Kenardy
b
a
Centre
for
Children’s
Burn’s
and
Trauma
Research,
Centre
for
Children’s
Health
Research,
University
of
Queensland,
South
Brisbane,QLD,
Australia
b
School
of
Psychology,
University
of
Queensland,
St
Lucia,
QLD,
Australia
c
Pegg
Leditschke
Children’s
Burns
Centre,
Lady
Cilento
Children’s
Hospital,
Children’s
Health
Queensland,
South
Brisbane,
QLD,
Australia
a
b
s
t
r
a
c
t
Background:
Young
children
are
at
increased
risk
of
burn
injury
and
of
procedural
distress
during
the
subsequent
wound
care.
There
are
currently
few
observational
measures
validated
for
use
with
young
children
during
medical
procedures.
The
aim
of
this
research
was
to
adapt
the
Child–Adult
Medical
Procedure
Interaction
Scale-Revised
(CAMPIS-R)
to
assess
parent-young
child
interactions
during
burn
wound
care
by
including
nonverbal
behavioral
coding.
Method:
Eighty-seven
families
of
children
(1–6years
old)
were
recruited
at
their
first
burn
dressing
change.
Potential
behaviors
were
identified
through
a
literature
review,
consulting
health
professionals,
and
direct
observation
of
parents
and
children
during
burn
wound
care.
Nonverbal
behaviors
were
coded
live,
and
verbal
behaviors
were
audio
recorded
for
later
assessment.
Results:
Inter-coder
reliability
was
good
to
excellent
for
the
Burns-CAMPIS
(B-CAMPIS).
The
additional
behaviors
were
correlated
with
the
hypothesized
coping,
distress,
coping-
promoting
and
distress-promoting
categories
of
the
CAMPIS-R.
Some
behaviors
differed
in
frequency
across
child
age
groups,
with
older
children
demonstrating
more
verbal
behaviors.
Convergent
validity
was
demonstrated
through
correlations
with
previously
validated
observational
parent–child
behavior
measures,
and
parent–
and
nurse–
reported
measures
of
child
pain
and
anxiety.
Univariate
regression
analyses
demonstrated
the
child
categories
of
the
B-CAMPIS
accounted
for
equal
or
more
of
the
variance
of
parent–
and
nurse–
reported
child
pain
and
anxiety,
compared
to
the
CAMPIS-R.
Conclusions:
The
B-CAMPIS
is
a
reliable
and
valid
measure,
for
assessing
coping
and
distress
relationships
in
young
children
and
their
families.
Pending
further
validation,
the
B-CAMPIS
assists
researchers
and
clinicians
to
recognize
and
target
important
behaviors
to
improve
young
child
coping
during
pediatric
burn
wound
care.
©
2018
Elsevier
Ltd
and
ISBI.
All
rights
reserved.
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Accepted
17
August
2018
Keywords:
Observation
Pediatric
Parenting
Behavior
Procedural
pain
Anxiety
Coping
Distress
Psychometrics
Validity
Reliability
*
Corresponding
author
at:
C/o
CCBTR,
L7
CCHR,
62
Graham
St,
South
Brisbane,
Q
4107,
Australia.
E-mail
address:
erin.brown1@uqconnect.edu.au
(E.A.
Brown).
https://doi.org/10.1016/j.burns.2018.08.027
0305-4179/©
2018
Elsevier
Ltd
and
ISBI.
All
rights
reserved.
b
u
r
n
s
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5
(
2
0
1
9
)
7
6
–
8
7
Available
online
at
www.sciencedirect.com
ScienceDirect
jo
ur
n
al
ho
m
epag
e:
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ww.els
evier.c
o
m/lo
c
ate/b
ur
n
s

1.
Introduction
Young
children
are
at
risk
of
increased
pain-related
distress
during
medical
procedures
because
they
have
an
underdevel-
oped
cognitive
capacity
and
thus
difficulty
rationalizing
procedural
pain
as
necessary,
helpful
and
temporary
[1,2].
Research
on
child
pain-related
distress
during
medical
procedures
has
predominantly
been
conducted
on
children
undergoing
oncology
[3],
perioperative
anesthetic
induction
[4],
and
immunization
procedures
[5].
The
majority
of
children
who
are
hospitalized
due
to
injury
(e.g.
drowning,
poisoning,
falls,
and
burns),
are
under
5-years-old
[6].
Monitoring
child
behavior
during
all
types
of
medical
procedures
is
valuable,
because
behavior
is
often
indicative
of
pain
and
distress
[7].
Medical
procedures
relating
to
injuries
might
be
particularly
distressing
for
children,
as
it
can
serve
as
a
reminder
of
the
injury
itself,
and
has
been
implicated
in
posttraumatic
stress
development
[8].
Considering
the
prevalence
of
injuries
in
young
children,
there
is
a
unique
need
for
an
observational
tool
to
assess
young
child
(1–6-years-old)
procedural
distress,
and
for
it
to
be
validated
for
use
in
a
variety
of
injury-related
medical
procedures.
One
important
yet
understudied
cohort
is
families
under-
going
pediatric
burn
wound
care.
Burn
wound
care
(debride-
ment
and
dressing
change)
is
often
painful
and
distressing,
and
is
repeated
until
re-epithelialization
(wound
healing).
Understanding
the
young
child’s
experience
during
burn
wound
care
is
particularly
relevant
because
the
procedure
can
be
especially
painful
due
to
physiological
changes
can
interfere
with
the
provision
of
adequate
pharmacological
pain
management
[9].
Also,
burn
injuries
are
related
to
more
frequent
posttraumatic
stress
symptoms
compared
to
other
injuries
[10].
Posttraumatic
stress
symptomology
(avoidance,
hyper-arousal,
intrusive
thoughts,
negative
mood)
can
be
especially
prevalent
and
affect
a
child’s
behavior
during
burn
wound
care.
Observational
research
in
young
child
burn
wound
care
is
important
because
increased
pain
and
anxiety
during
pediatric
burn
wound
care
has
been
associated
with
delayed
re-epithelialization
[11,12]
as
well
as
ongoing
psycho-
logical
distress
[13].
In
addition
to
pharmacological
intervention,
non-pharma-
cological
pain
management
interventions
are
available
for
school-aged
children
undergoing
burn
wound
care.
Children
4years
and
older
are
commonly
offered
the
Ditto
TM
device
(an
evidence-based
electronic
preparation
and
distraction
device,
and
is
available
through
Diversionary
Therapy
Technologies,
Queensland,
Australia)
[11].
Other
work
has
recognized
the
benefits
of
virtual
reality,
which
is
suitable
for
children
6-
years-old
and
older
[14].
The
availability
of
these
interventions
rely
on
uptake
by
the
particular
burns
center.
Burns
centers
may
also
employ
psychologists
and
child
life
therapists
to
assist
with
procedural
distress.
However,
there
are
currently
no
non-pharmacological
pain
management
interventions
available
for
young
children,
despite
their
high
risk
for
experiencing
procedural
distress.
Understanding
a
young
child’s
experience
during
burn
wound
care
is
necessary
to
inform
interventions
for
improving
care.
Parenting
behavior
is
a
key
factor
in
child
coping
and
distress
behaviors
during
medical
procedures
[15].
A
medical
procedure
can
be
highly
distressing
for
young
children
[16],
and
children
are
particularly
attentive
to
their
parents’
reactions
during
a
stressful
event
[17,18].
A
parent
engaging
in
emotion
co-regulation
(appropriately
assisting
the
child
to
regulate
their
emotional
responses)
[19–21]
will
likely
result
in
a
calmer
procedure.
However,
parenting
behavior
during
a
child’s
burn
wound
care
may
be
impacted
by
the
additional
stress
of
witnessing
their
child
in
pain,
the
shock
of
seeing
the
wound,
ongoing
worry
about
the
injury
severity,
need
for
grafting,
and
the
potential
for
scarring
[22–24].
Key
parent–child
behaviors
have
been
previously
identified
and
validated.
Child
distress
behaviors
include
crying,
screaming,
flailing,
requiring
restraint,
resisting,
fear,
pain,
negative
emotion,
seeking
emotional
support
and
information
[3,25].
Behaviors
that
indicate
child
coping
include
making
a
coping
statement,
non-procedural
talk,
deep
breathing,
play-
ing,
and
looking
at
their
parent
[3,5,25].
For
parents,
distress-
promoting
behaviors
include
criticism,
reassurance,
giving
the
child
control,
apologizing,
and
empathy
[3,4].
Finally,
parent
coping-promoting
behaviors
include
humor,
non-procedural
talk,
command
to
engage
in
a
coping
strategy,
playing,
offering
soothing
item,
and
demonstrating
what
to
do
[3,5,25].
A
common
observational
measure
used
for
interpreting
parent
and
child
(4–13-years-old)
behavior
during
medical
procedures
is
the
Child–Adult
Medical
Procedure
Interaction
Scale-Revised
(CAMPIS-R)
[3,26].
The
CAMPIS-R
identifies
35
verbal
behaviors
that
are
grouped
into
three
child
behavior
categories
(coping,
neutral,
and
distress),
as
well
as
three
adult
behavior
categories
(coping-promoting,
neutral,
and
distress-promot-
ing).
The
CAMPIS-R
was
initially
developed
using
a
sample
of
children
undergoing
bone
marrow
aspiration/lumbar
punc-
ture
procedures
as
part
of
cancer
treatment
[26].
To
date,
no
studies
have
observed
parent–child
interactions
during
burn
wound
care.
A
variety
of
observational
instru-
ments
have
been
utilized
to
assess
child
distress
behavior
during
burn
wound
care.
Studies
investigating
child
distress
behavior
during
burn
wound
care
have
used
the
Observational
Scale
of
Behavioral
Distress
(OSBD)
measure
[27–29],
Children’s
Hospital
of
Eastern
Ontario
Pain
Scale
(CHEOPS)
[30],
COMFORT
behavior
scale
(COMFORT-B)
[31],
Pain
Observation
Scale
for
Young
Children
(POCIS)
[32],
or
the
Face,
Legs,
Arms,
Cry,
Consolability
(FLACC)
measure
[12,33].
The
OSBD
and
CHEOPS
require
videoing,
while
the
FLACC,
POCIS,
and
COMFORT-B
can
be
coded
live.
Five
of
the
studies
assessed
young
children
with
mean
ages
between
2–4-years-old
[28,30–33],
and
three
studies
assessed
older
children
with
mean
ages
between
6–8-years-old
[12,27,29].
These
measures
do
not
code
child
coping
behaviors
or
adult
behaviors,
which
are
important
for
identifying
the
parent’s
influence
(i.e.
emotion
co-regulation)
on
their
child’s
behavior
[15].
In
comparison,
the
CAMPIS-R
does
code
child
coping
behavior
and
adult
behavior,
however
it
is
not
able
to
be
used
with
preverbal
children.
Further
work
is
required
to
create
a
valid
and
reliable
measure
for
specifically
assessing
parent–young
child
interactions
during
burn
wound
care.
In
order
to
expand
the
CAMPIS-R
to
be
relevant
for
use
with
families
of
young
children
undergoing
burn
wound
care,
the
measure
must
include
child
and
parent
nonverbal
behavior.
Adding
nonverbal
coding
to
the
measure
is
important
because
young
children
(1–3-years-old)
primarily
communicate
emo-
tion
through
nonverbal
behavior
[34,35].
With
regards
to
77

developing
a
measure
that
assesses
all
young
children,
it
is
expected
that
children
who
are
1years
of
age
will
show
the
lowest
rates
of
verbal
behavior,
children
who
are
2-years-old
will
show
an
increase
in
verbal
behavior,
and
comparatively
children
aged
between
3–6years
will
show
the
highest
rates
of
verbal
behavior.
Only
coding
verbal
behavior
would
miss
the
majority
of
interactions
between
young
children
and
their
parents.
There
may
also
be
additional
important
parenting
behaviors
specific
to
burn
wound
care.
Considering
the
unique
burden
of
witnessing
burn
wound
care
[22,23],
it
is
possible
there
are
other
parenting
behaviors
that
are
unique
to
burn
wound
care
that
are
related
to
child
coping
or
distress.
It
is
expected
that
including
these
additional
behaviors
will
improve
the
measure’s
validity.
A
new
observational
measure
should
show
convergent
validity
with
alternative
measures,
regarding
the
parent,
child,
and
associations
between
parent
and
child
behaviors.
Previous
research
has
established
varying
degrees
of
convergent
validity
in
parent–child
observational
measures.
Relevant
measures
include
the
CAMPIS-SF
[25],
Measure
of
Adult
and
Infant
Soothing
and
Distress
(MAISD)
[5],
and
Perioperative-
CAMPIS
(P-CAMPIS)
[4].
Parental
behavior
was
validated
during
the
development
of
the
CAMPIS-SF,
but
not
the
P-CAMPIS
or
MAISD.
In
comparison,
child
behavior
has
been
validated
with
various
alternative
observational,
parent-report,
nurse-report,
and
child
self-report
measures.
Specifically,
child
coping
behavior
and
child
distress
behavior
was
validated
in
the
development
of
the
CAMPIS-SF,
however
only
child
distress
behavior
was
validated
in
the
development
of
the
P-CAMPIS
and
MAISD.
To
more
effectively
validate
our
new
measure,
we
aim
to
analyze
the
convergent
validity
of
parental
behavior
and
child
behavior
(coping
and
distress)
with
a
range
of
alternative
measures.
Beyond
testing
for
convergent
validity,
it
is
recommended
that
other
types
of
validity
be
evaluated
[36].
For
the
current
study,
we
will
modify
an
existing
measure
(the
CAMPIS-R)
to
a
specific
population
(i.e.
burn
wound
care
for
young
children),
and
as
such
incremental
validity
(the
value
of
the
new
measure
compared
to
the
original
measure
in
assessing
a
construct)
should
also
be
demonstrated.
Therefore,
upon
developing
a
new
measure,
the
purposes
of
this
paper
are
to
1)
report
inter-
coder
reliability;
2)
confirm
the
nature
of
additionally
identi-
fied
behaviors
in
relation
to
existing
validated
behaviors
(used
in
other
instruments);
3)
assess
behavioral
differences
in
children
of
different
ages,
and;
4)
test
whether
the
modified
measure
is
valid
for
assessing
parent
and
child
behavior,
using
convergent
and
incremental
tests
of
validity.
2.
Materials
and
methods
2.1.
Participants
Parents
of
children
aged
1–6-years-old
who
had
sustained
an
unintentional
burn
injury,
were
recruited
at
the
child’s
first
burn
wound
care
appointment,
at
the
Pegg
Leditschke
Child-
ren’s
Burns
Centre,
Lady
Cilento
Children’s
Hospital,
Brisbane,
Australia,
during
September
2015–July
2016.
A
pilot
sample
was
recruited
to
refine
the
measure
and
reach
inter-coder
reliability
before
the
main
sample
was
recruited
to
assess
validity.
To
test
for
coder
drift,
inter-coder
reliability
was
also
assessed
in
20%
of
the
main
sample.
All
recruited
children
were
given
pharmacological
pain
relief
prior
to
the
dressing
removal;
however
sedative
medication
was
not
administered
to
any
child
in
this
study.
Exclusion
criteria
specified
1)
if
the
dressing
had
been
changed
prior
to
this
appointment;
2)
if
the
number
of
days
since
the
injury
exceeded
7days
(to
exclude
delayed
presentations);
3)
if
the
child
had
a
diagnosed
developmental
disorder,
or;
4)
comorbid
head
injury;
5)
the
injury
was
suspected
abuse
or
neglect;
6)
the
primary
care
giver
was
absent,
or;
7)
the
family
spoke
insufficient
English
for
questionnaire
completion
and
verbal
behavior
coding.
The
University
of
Queensland
Human
Research
Ethics
(approval
number
2015000623)
and
the
Children’s
Health
Queensland
Hospital
and
Health
Service
Human
Research
Ethics
Commit-
tee
(approval
number
HREC/15/QRCH/27)
approved
this
study.
Participating
parents
provided
written
informed
consent.
Participating
children
were
not
required
to
give
assent
as
all
children
were
under
the
age
of
7-years-old.
2.2.
Procedure
Potential
participants
were
approached
upon
arrival
to
the
centre.
Prior
to
the
dressing
removal
and
debridement,
parents
were
asked
to
report
on
demographic
information,
including
items
regarding
ages,
ethnicity,
gender,
education,
and
annual
family
income.
The
nonverbal
behavior
of
the
child
and
parent
was
coded
before,
during
and
after
dressing
removal
and
debridement.
Given
the
small
examination
rooms
often
held
all
attending
family
members
(i.e.,
both
parent/s,
grandparent/
s,
and
sibling/s)
and
at
least
one
nurse,
the
raters
stood
in
close
proximity
whilst
not
intruding
or
potentially
interfering
with
the
procedure,
in
an
attempt
to
observe
the
same
behaviors
while
under
instruction
to
ignore
the
other
rater’s
coding
behavior.
Audio
recordings
were
made
concurrently,
and
subsequently
transcribed
for
coding
verbal
behavior.
Consis-
tent
with
previous
research
[5],
coding
initiated
when
the
nurse
began
to
remove
the
dressing,
and
completed
2min
after
debridement
(the
washing
and
cleaning
of
the
wound),
unless
the
child
left
the
room
earlier.
Following
coding,
the
coder
asked
the
parent
to
report
the
child’s
procedural
pain
and
anxiety
retrospectively,
and
the
nurse
reported
the
child’s
pain-related
distress
behavior.
2.3.
Measures
2.3.1.
Development
of
the
Burns-CAMPIS
(B-CAMPIS)
The
B-CAMPIS
was
developed
under
the
recently
published
guidelines
for
pediatric
behavioral
coding
[36].
A
pool
of
potential
behaviors
were
identified
through
a
literature
search,
consulting
health
professionals,
and
direct
observa-
tions.
Firstly,
verbal
behaviors
were
identified
from
the
CAMPIS-R
measure
[3],
and
nonverbal
behaviors
were
identi-
fied
from
the
MAISD
[5],
CAMPIS-SF
[25],
and
P-CAMPIS
[4]
measures.
Additionally,
nonverbal
behaviors
specific
to
burn
wound
care
were
identified
through
consultations
with
a
range
of
pediatric
burns
healthcare
professionals
(doctors,
nurses,
occupational
therapists,
social
workers,
psychologists,
and
physiotherapists)
and
the
researcher
observed
a
large
number
of
burn
wound
care
procedures
prior
to
commencing
78

the
study.
Identified
additional
nonverbal
child
behaviors
included
gaze
to
injury,
using
the
Ditto
TM
device,
watching
television,
and
aggressive
behavior
(i.e.
intentionally
kicking
or
hitting
someone).
Identified
additional
nonverbal
parent
behaviors
included
crying
and
unengaged
distress.
A
parent
demonstrated
unengaged
distress
when
they
did
not
initiate
or
respond
to
their
child
because
they
were
distressed
themselves.
All
behaviors
were
operationalized
in
terms
of
behavior
examples
and
how
to
score
each
behavior.
2.3.1.1.
Scoring.
The
frequency
of
each
discrete
behavior
was
calculated.
The
frequency
of
continuous
behavior
(i.e.
playing)
was
coded
in
10-s
time
blocks,
similar
to
previous
methods
[3,5].
For
example,
a
child
who
looked
at
the
television
screen
for
1s
(discrete
behavior),
looked
away
for
2s,
then
reengaged
with
the
screen
for
2s
(discrete
behavior),
was
represented
by
a
frequency
score
of
2.
In
comparison,
a
child
who
looked
at
the
television
screen
for
11s
(continuous
behavior)
is
also
represented
by
a
frequency
score
of
2.
The
frequencies
of
behaviors
relating
to
each
CAMPIS-R
category
(child
coping,
child
distress,
parent
coping-promoting,
parent
distress-
promoting)
were
summed
then
divided
by
the
procedure
duration
to
give
a
proportion
of
behavior,
as
recommended
previously
[36].
2.3.1.2.
Coder
training
and
inter-coder
reliability.
Two
coders
were
trained
on
the
first
version
of
the
B-CAMPIS
to
establish
reliability.
A
pilot
sample
of
parents
of
15
children
aged
1–6-
years-old
presenting
for
burn
dressing
changes
was
recruited
for
reliability
training
and
refinement
of
the
B-CAMPIS
measure.
Children
were
predominantly
male
(n=11,
73%),
with
a
mean
age
of
2.45years
old
(SD= 1.53).
Data
from
the
pilot
study
was
not
included
in
the
main
study
sample.
For
coding
verbal
behavior,
the
coders
reviewed
the
CAMPIS-R
manual.
The
coders
discussed
reasons
for
coding
discrepancies
after
coding
each
transcript
for
verbal
behavior.
Inter-coder
reliability
was
assessed
using
intra-class
correlations
(ICCs)
rather
than
Kappa
because
the
data
is
ordinal
in
nature
(i.e.
2
instances
of
reassurance
is
larger
than
1
instance)
and
Kappa
analyses
are
appropriate
for
data
that
is
nominal
in
nature
[37].
Additionally,
ICCs
consider
the
magnitude
rather
than
abso-
lute
disagreement,
and
this
is
valuable
because
of
the
difficulty
in
attaining
absolute
reliability
when
scoring
in
vivo
data
that
is
expected
to
occur
at
a
low
frequency
(i.e.
Coder
#1
recording
2
instances
of
a
behavior,
and
Coder
#2
observing
1
instance)
[37].
After
coding
the
verbal
behavior
of
10
families,
ICCs
reached
excellent
agreement
for
parent
(ICCs
.98–1.00)
and
child
(ICCs
.99–1.00)
behaviors.
For
coding
nonverbal
behavior,
the
coders
reviewed
the
operationalized
definitions
and
examples.
The
coders
dis-
cussed
reasons
for
coding
discrepancies
after
coding
each
dressing
removal
and
debridement
for
nonverbal
behavior.
Closer
examination
of
inter-coder
reliability
data
from
the
pilot
study
revealed
certain
behavior
codes
could
be
collapsed.
For
example,
it
was
common
to
observe
a
parent
demonstrat-
ing
to
their
young
child
how
to
play
with
a
toy.
Because
of
how
young
the
children
were,
this
behavior
could
be
easily
interpreted
as
‘engaging
in
play’
‘action
example’
and/or
‘offering
a
soothing
item’.
These
codes
were
merged
into
the
single
adult
nonverbal
coping-promoting
behavior,
entitled
‘distract’.
After
coding
nonverbal
behavior
of
15
families,
ICCs
reached
good
to
excellent
agreement
for
parent
behaviors
(ICCs
.74–.90),
and
fair
to
excellent
agreement
for
child
behaviors
(ICCs
.52–1.00).
Familiarization
of
the
codes,
recruit-
ing
and
training
for
nonverbal
coding
during
outpatient
clinics,
and
verbal
coding
from
transcripts
was
completed
in
approxi-
mately
5days.
Although
agreement
was
lower
than
preferred,
this
rate
is
similar
to
agreement
rates
on
previous
nonverbal
behavioral
measures
[5].
Lower
reliability
rates
have
been
associated
with
low
base
behavior
frequencies
[38],
which
was
the
case
in
the
pilot
sample.
Greater
variability
is
also
to
be
expected
when
coding
behavior
live
because
there
is
increased
potential
to
overlook
behaviors.
Only
child
nonverbal
behavior
‘requiring
restraint’
failed
to
attain
at
least
good
agreement
in
the
pilot
sample
(i.e.
an
ICC
of
.60).
In
addition,
a
number
of
parent
behaviors
(criticism,
apology,
empathy,
command
to
engage
in
a
coping
strategy,
crying,
unengaged
distress)
and
child
behaviors
(scream,
seeking
emotional
support,
verbal
fear,
verbal
emotion,
information
seeking,
making
a
coping
statement,
non-procedural
talk,
humor,
breathing,
reading,
aggression)
were
not
observed
in
the
pilot
sample.
These
behaviors
will
be
tested
for
inter-coder
reliability
in
the
main
sample.
2.3.1.3.
Subsequently
identified
parent
behavior.
When
review-
ing
transcripts
from
the
main
sample,
there
were
three
additional
verbal
adult
behaviors
that
were
not
present
in
the
pilot
sample,
but
seemed
to
represent
important
informa-
tion
parents
communicated
to
their
child
during
burn
wound
care.
Additional
verbal
parenting
behaviors
included
‘prompt-
ing
disclosure
of
pain’,
‘threat
to
remove
coping
strategy’,
and
‘negative
evaluation
of
the
wound’.
Parents
prompted
the
child
to
disclose
pain,
such
as
“That
looks
painful,
does
it
hurt
a
lot?”
Parents
also
threatened
the
child
to
remove
a
coping
strategy
(i.e.
a
distracting
toy)
in
an
attempt
to
control
behavior,
such
as
“I’ll
take
away
the
iPad
if
you
can’t
play
quietly”.
Finally,
burn
wounds
are
uniquely
graphic
compared
to
other
pediatric
medical
procedures,
and
parents
reacted
with
negative
evaluations
of
the
wound
such
as
“That
looks
disgusting!”.
These
behaviors
were
added
to
the
B-CAMPIS.
2.3.2.
Validity
measures
for
child
behavior
2.3.2.1.
Parent-reported
child
pain.
Parents
rated
their
child’s
procedural
pain
score
using
the
Numerical
Pain
Rating
Scale
[39].
The
11-point
scale
was
used
to
identify
the
parent’s
report
of
the
“worst
pain
your
child
has
experienced
during
this
medical
treatment”.
The
left
anchor
was
titled
no
pain,
and
the
right
anchor
was
titled
worst
imaginable
pain.
Parent-reported
procedural
pain
scales
have
been
positively
correlated
with
child
self-reported
pain
[40].
2.3.2.2.
Parent-reported
child
anxiety.
Parents
reported
their
child’s
procedural
anxiety
using
the
Visual
Analogue
Scale-
Anxiety
(VAS-A)
[41].
The
VAS-A
is
a
single
item
measure
of
state
anxiety
consisting
of
a
continuous
line
10cm
in
length.
The
left
anchor
is
no
anxiety
or
fear
and
the
right
anchor
is
worst
possible
anxiety
or
fear.
The
VAS-A
was
developed
to
be
a
self-report
tool,
but
has
been
also
used
as
a
proxy-report
tool
79

for
pediatric
medical
procedures
[42].
Parent-reported
child
anxiety
has
been
validated
against
child
self-reported
anxiety
[42].
2.3.2.3.
Child
behavior
The
child
behavior
scales
in
the
CAMPIS-SF
[25]
were
used
to
assess
construct
validity
for
child
behavior
in
the
B-CAMPIS.
An
observer
gives
overall
scores
for
child
coping
behavior
and
child
distress
behavior
on
two
validated
5-point
Likert
scales
(none/one
to
maximum/continuous),
based
on
the
child’s
verbal
and
nonverbal
behaviors.
The
CAMPIS-SF
has
good
reliability
(ßs>0.88),
and
validity
against
other
child
distress
measures
(rs>.39,
ps<.001).
For
the
current
study,
good
to
excellent
reliability
was
established
(coping
ICC= .63,
distress
ICC= .82).
2.3.2.4.
Nurse-reported
child
pain-related
distress
behavior
A
nurse
rated
the
child’s
procedural
pain-related
distress
behavior
using
the
FLACC
[43].
The
FLACC
is
an
additive
observational
measure
with
five
subscales.
Each
subscale
(Faces,
Legs,
Arms,
Consolability,
Cry)
can
score
0–2,
for
a
total
score
of
0–10
(0
represents
no
distress,
10
represents
highest
distress
possible).
The
FLACC
has
excellent
responsiveness,
reliability,
and
validity
[44],
and
is
recommended
for
nurse-
reported
young
child
distress
across
a
range
of
hospital
departments
[45].
2.3.3.
Validity
measures
for
parent
behavior
2.3.3.1.
Parenting
behavior.
The
CAMPIS-SF
[25]
and
the
CAMPIS-
R
[3]
were
used
to
validate
parenting
behavior.
As
for
the
child,
the
CAMPIS-SF
has
two
5-point
Likert
scales
to
give
overall
scores
for
parental
coping-promoting
behavior
and
distress-promoting
behavior.
The
CAMPIS-SF
has
good
reliability
(ßs>0.74)
and
validity
for
parental
coping-promoting
and
distress-promoting
behavior
against
the
CAMPIS-R
parenting
behavior
categories
(rs>.75)
[25].
For
the
current
study,
good
to
excellent
inter-coder
reliability
was
obtained
(coping-promoting
ICC= .81,
distress-
promoting
ICC= .70).
The
CAMPIS-R
consists
of
three
coping-
promoting behaviors (nonprocedural talk to the child, humor to the
child,
commands
to
use
coping
strategy),
and
five
distress-
promoting
behaviors
(verbal
reassurance,
apologies,
empathy,
giving
control
to
the
child,
criticism).
The
CAMPIS-R
has
strong
reliability
(ßs>0.78)
and
validity
for
parental
coping-promoting
and
distress-promoting
behavior
against
child
distress
behaviors
(rs>.33)
[3].
For
the
current
study,
excellent
inter-coder
reliability
was
obtained
(coping-promoting
ICCs>.99,
distress-promoting
ICCs>.99).
2.4.
Statistical
analyses
Descriptive
statistics
were
presented
using
medians
and
inter-
quartile
ranges
(IQR)
for
non-normally
distributed
data.
Categorical
variables
were
presented
using
frequencies
and
percentages.
Inter-coder
reliability
of
the
pilot
and
final
versions
of
the
B-CAMPIS
were
assessed
between
the
two
coders
using
ICC
analyses
in
SPSS
24
for
Windows.
All
ICCs
were
calculated
using
ordinal
measure,
two-way
mixed
effect,
absolute
agreement,
and
averages
[37].
ICCs
were
rated
in
accordance
with
Cicchetti’s
values
of
poor
(0.00–0.39),
fair
(0.40–
0.59),
good
(0.60–0.79)
and
excellent
(0.80–1.00)
[46].
Due
to
the
non-normality
of
the
data,
Spearman’s
Rho
correlation
analyses
were
used
to
assess
the
relationship
between
raw
frequencies
of
additional
identified
behaviors
with
raw
frequencies
of
previously
validated
behaviors.
Table
1
–
B-CAMPIS
behaviors
for
child
and
parent.
Child
Parent
Coping
Distress
Coping-promoting
Distress-promoting
Verbal
behavior
Making
a
coping
statement
Cry
Humor
directed
to
the
child
Criticism
Non-procedure
related
talk
by
child
Scream
Non-procedure
related
talk
to
child
Verbal
reassurance
Audible
deep
breathing
Verbal
resistance
Command
child
to
engage
in
a
coping
strategy
Giving
child
control
Seek
emotional
support
Apologizing
Verbal
fear
Empathizing
Verbal
pain
Prompt
disclosure
of
pain
Verbal
emotion
Negative
evaluation
of
the
wound
Information
seeking
Threat
to
remove
coping
strategy
Nonverbal
behavior
Play
Flail
Point
to
distract
Distract
(play,
action
example,
offer)
Reassuring
contact
a
Point
to
décor
Requires
restraint
Parent
Cry
Self-soothing
Aggression
Unengaged
distress
Gaze
to
parent
Gaze
to
injury
Using
the
Ditto
device
Watch
television
a
Classified
as
distress-promoting
in
the
P-CAMPIS.
Italicized
behaviors
not
previously
included
in
observational
measures.
80

The
data
retained
non-normality
when
the
proportion
of
behavioral
frequency
per
minute
was
calculated.
Therefore,
the
effect
of
child’s
age
group
on
rates
of
displayed
behavior
was
analyzed
using
Kruskal–Wallis
tests.
Based
on
the
increase
in
language
acquisition
from
2-years-old
[47],
we
divided
the
cohort
into
three
groups
of
children
aged
1.0–1.9,
2.0–2.9,
and
3.0–6.9years
old.
Significant
findings
were
followed
up
using
the
one-tailed
Jonckheere–Terpstra
test
to
test
for
potential
trends
in
rates
of
behavior
by
age.
In
addition
to
the
J
test-
statistic,
we
reported
the
z
score
(a
z
score
of>1.65
indicates
a
significant
trend,
and
a
positive
z
score
indicates
the
rate
of
behavior
is
increasing
as
the
child’s
age
increases),
and
the
effect
size
of
the
trend,
r.
Analyses
were
performed
to
test
convergent
and
incre-
mental
validity.
Convergent
validity
was
tested
using
Spear-
man’s
Rho
correlations
for
the
B-CAMPIS
proportion
scores
against
the
CAMPIS-SF
scales
and
the
CAMPIS-R
proportion
scores.
Incremental
validity
was
examined
using
univariate
linear
regression
analyses.
This
served
to
compare
the
variance
accounted
for
by
the
B-CAMPIS
child
categories
to
the
CAMPIS-R
child
categories
in
predicting
parent-reported
child
procedural
pain
and
anxiety,
and
nurse-reported
child
pain-related
distress
behavior.
The
proportion
of
variance
in
the
outcome
explained
by
each
model
(B-CAMPIS
and
CAMPIS-
R)
was
presented
using
the
R
2
value.
All
analyses
were
performed
using
SPSS
24
for
Windows
[48]
and
p-values
with
p<.05
were
considered
statistically
significant.
3.
Results
Three
previously
reported
child
coping
behaviors
(reading,
humor
by
child,
nodding)
remained
unobserved
in
the
final
sample,
and
were
therefore
omitted
from
the
final
B-CAMPIS
measure.
These
behaviors
were
likely
unobserved
because
of
the
young
age
of
the
children.
Child
B-CAMPIS
codes
not
previously
found
in
the
CAMPIS-R
include
gaze
to
injury,
using
the
Ditto
TM
device,
watching
television,
and
aggression.
Parent
B-CAMPIS
codes
not
previously
found
in
the
CAMPIS-R
include
prompt
disclosure
of
pain,
negative
evaluation
of
the
wound,
threat
to
remove
coping
strategy,
parent
cry,
and
unengaged
distress.
These
behavior
codes
were
hypothesized
to
relate
to
the
indicated
categories,
as
reported
in
Table
1.
The
manual
and
coding
sheets
for
the
final
version
of
the
B-CAMPIS
can
be
obtained
from
the
corresponding
author.
3.1.
Demographics
Of
the
recruited
92
families,
3
families
were
excluded
due
to
speaking
a
language
other
than
English
during
the
dressing
removal
and
debridement,
one
child’s
injury
was
superficial
in
depth,
and
for
one
child
the
wound
mechanism
was
an
infection
rather
than
due
to
a
thermal
cause.
The
remaining
sample
consisted
of
87
parent–child
dyads.
See
Table
2
for
the
sample
characteristics.
3.2.
Inter-coder
reliability
The
primary
coder
coded
all
87
medical
procedures,
and
the
secondary
rater
coded
18
(20%)
transcripts,
and
a
further
15
(17%)
nonverbal
live
observations.
Table
3
reports
the
inter-
coder
reliabilities
for
parent
and
child
behavior
in
the
main
sample.
Inter-coder
reliability
was
good
to
excellent.
The
average
ICC
for
verbal
child
behavior
was
.90,
and
for
nonverbal
child
behavior
was
.85.
The
average
ICC
for
verbal
parenting
behavior
was
.87,
and
for
nonverbal
parenting
behavior
was
.83.
Although
nonverbal
behaviors
aggression
(child)
and
unengaged
distress
(parent)
were
not
observed
during
the
15
selected
live
observations,
it
was
observed
by
the
primary
coder
during
other
observa-
tions
and
therefore
retained
in
the
final
version
of
the
B-
CAMPIS.
Table
2
–
Sample
characteristics.
Sample
characteristics
N=87
Child
Age,
meanSD
(range),
years
2.401.12,
(1.04–6.94)
Sex,
n
(%)
Male
50
(57)
Female
37
(43)
Ethnicity,
n
(%)
n=76
Anglo/European
60
(69)
Pacific
Islander
8
(9)
Asian
5
(6)
African
2
(2)
Aboriginal/Torres
Strait
Islander
1
(1)
Parent
Sex,
n
(%)
Mothers
73
(84)
Fathers
14
(16)
Age,
meanSD
(range),
years,
n=75
32.375.31
(21–43)
Education,
n=73,
n
(%)
High
school
education
or
less
21
(22)
Technical
training
20
(27)
University
degree
32
(44)
Annual
family
income,
n=69,
n
(%),
$AUD
Less
than
$40,000
9
(10)
$40,000–80,000
19
(22)
$80,000–120,000
21
(24)
More
than
$120,000
20
(23)
Injury
Burn
depth,
n
(%)
Superficial-partial
63
(72)
Deep-partial
21
(24)
Full-thickness
3
(4)
%TBSA,
meanSD
(range)
1.902.10
(0.50–12.00)
Injury
mechanism,
n
(%)
Scald
42
(48)
Contact
42
(48)
Friction
2
(3)
Radiant
Heat
(sunburn)
1
(1)
Number
of
days
following
injury
when
procedure
was
observed,
meanSD
(range)
3.240.99
(1–6)
Procedure
duration,
meanSD
(range),
min:sec
12:283:33
(5:57–23:25)
Number
of
pharmacological
intervention,
meanSD
(range)
1.980.63
(1–4)
SD= Standard
deviation;
$AUD= Australian
dollars;
%TBSA= Per-
centage
of
total
body
surface
area
burned.
81

3.3.
Nature
of
additionally
identified
behavior
3.3.1.
Child
behavior
Frequencies
of
using
the
Ditto
TM
device,
gaze
to
injury,
watching
television,
and
aggressive
behavior
were
associated
with
frequencies
of
previously
validated
child
behaviors.
Using
the
Ditto
TM
device
was
positively
associated
with
coping
behaviors
(making
a
coping
statement,
r
s
=.30,
p=.005;
non-
procedural
talk
by
the
child,
r
s
=.37,
p<.001),
and
negatively
associated
to
distress
behaviors
(crying,
r
s
=.26,
p=.016;
requiring
restraint,
r
s
=.24,
p=.027).
Gaze
to
injury
was
positively
related
to
one
coping
behavior
(making
a
coping
statement,
r
s
=.21,
p=.049),
and
negatively
associated
with
distress
behaviors
(crying,
r
s
=.37,
p<.001;
screaming,
r
s
=
.38,
p<.001;
flail,
r
s
=.34,
p=.001;
requiring
restraint,
r
s
=
.36,
p=.001).
Understandably,
watching
television
was
nega-
tively
associated
with
coping
behavior
(playing,
r
s
=.22,
p=.040),
however
watching
television
was
also
negatively
associated
with
distress
behaviors
(screaming,
r
s
=.23,
p=.031;
verbal
resistance,
r
s
=.23,
p=.031).
Aggressive
behav-
ior
was
only
negatively
associated
with
gaze
to
injury
(r
s
=.28,
p=.009).
Therefore,
the
additional
behaviors
using
the
Ditto
TM
device,
gaze
to
injury
and
watching
television
were
added
to
the
child
coping
category,
and
aggressive
behavior
was
added
to
the
child
distress
category.
3.3.2.
Parenting
behavior
Frequencies
of
negative
evaluation
of
the
wound,
prompting
disclosure
of
pain,
threatening
to
remove
coping
strategy,
crying,
and
unengaged
distress
were
associated
with
frequen-
cies
of
previously
validated
parenting
behaviors.
Negative
evaluation
of
the
wound
was
positively
associated
with
distress-promoting
behaviors
(empathy,
r
s
=.26,
p=.014;
threat
to
remove
coping
strategy,
r
s
=.31,
p=.003).
Prompting
disclo-
sure
of
pain
tended
to
be
associated
with
distress-promoting
behaviors
(giving
control
to
the
child,
r
s
=.19,
p=.085;
empathy,
r
s
=.19,
p=.077).
Surprisingly,
threat
to
remove
coping
strategy
was
positively
associated
with
one
coping-promoting
behavior
(command
to
engage
in
a
coping
strategy,
r
s
=.31,
p=.004),
but
it
was
also
associated
with
a
distress-promoting
behavior
(verbal
reassurance,
r
s
=.29,
p=.007).
Crying
was
negatively
associated
with
one
coping-promoting
behavior
(distract,
r
s
=.23,
p=.033).
Unengaged
distress
was
positively
associated
with
a
negative
evaluation
of
the
wound
(r
s
=.23,
p=.031),
and
threat
to
remove
coping
strategy
(r
s
=.29,
p=.007).
Therefore,
negative
evaluation
of
the
wound,
prompting
disclosure
of
pain,
threatening
to
remove
coping
strategy,
crying,
and
unengaged
distress
were
added
to
the
parental
distress-promoting
category.
The
nature
of
parental
reassuring
contact
required
addi-
tional
analyses
as
previous
measures
code
it
differently.
In
the
current
study,
reassuring
contact
was
positively
related
with
other
distress-promoting
behaviors
verbal
reassurance
(r
s
=.31,
p=.004),
and
giving
control
to
the
child
(r
s
=.24,
p=.023),
however
it
was
not
associated
with
any
coping-
promoting
behaviors.
Therefore,
reassuring
contact
was
added
to
the
parental
distress-promoting
category
in
the
B-
CAMPIS.
3.4.
Child
development
The
effect
of
child
development
on
displayed
behavior
was
assessed
by
categorizing
children
into
age
groups.
Table
4
demonstrates
the
median
proportion
of
child
behavioral
frequency
per
minute
by
child
age.
Kruskal–Wallis
tests
demonstrated
that
child
behavior
(making
a
coping
statement,
non-procedural
talk
by
child,
crying,
verbal
resistance,
seeking
emotional
support,
verbal
pain,
verbal
emotion,
information
seeking,
self-soothing,
requiring
restraint,
using
the
Ditto
TM
device,
and
gaze
to
injury)
was
significantly
affected
by
child
age,
(Hs(2)6.48,
ps.039).
Jonckheere’s
test
revealed
Table
3
–
Inter-coder
reliability
of
behavior.
Behavior
ICC
Ratings
of
agreements
a
Child
behavior
Child
verbal
behavior
(N=18)
Cry
.99
Excellent
Scream
.89
Excellent
Verbal
resistance
.92
Excellent
Emotional
support
.79
Good
Verbal
pain
.99
Excellent
Information
seeking
.90
Excellent
Non-procedural
talk
by
child
.89
Excellent
Verbal
fear
.99
Excellent
Verbal
emotion
.80
Excellent
Making
a
coping
statement
.80
Excellent
Breathing
.99
Excellent
Child
nonverbal
behavior
(N=15)
Play
.90
Excellent
Point
.60
Good
Requires
restraint
.79
Good
Flail
.79
Good
Self
soothe
.85
Excellent
Using
the
Ditto
device
.93
Excellent
Watching
television
.96
Excellent
Gaze
to
injury
.88
Excellent
Gaze
to
parent
.96
Excellent
Aggression
–
–
Parenting
verbal
behavior
(N=18)
Verbal
(N=18)
Criticism
.70
Good
Verbal
reassurance
.97
Excellent
Giving
control
to
the
child
.93
Excellent
Apology
.62
Good
Empathy
.91
Excellent
Humor
to
child
.99
Excellent
Nonprocedural
talk
to
child
.86
Excellent
Command
to
engage
in
coping
strategy
.93
Excellent
Prompting
disclosure
of
pain
.79
Good
Threat
to
remove
coping
strategy
.99
Excellent
Negative
evaluation
.88
Excellent
Parenting
nonverbal
behavior
(N=15)
Point
to
décor
.91
Excellent
Distract
(play,
action
example,
offer)
.78
Good
Reassuring
contact
.74
Good
Parent
cry
.88
Excellent
Unengaged
distress
–
–
a
According
to
Cicchetti’s
(1994)
interpretation.
82

significant
trends
in
the
data:
As
the
children
increased
in
age,
the
proportion
of
some
child
behaviors
(making
a
coping
statement,
non-procedural
talk
by
child,
verbal
resistance,
verbal
pain,
verbal
emotion,
information
seeking,
using
the
Ditto
TM
device)
increased
(Js1414.5,
zs2.47,
rs.27).
In
comparison,
the
proportion
of
other
child
behaviors
(crying,
self-soothing,
requiring
restraint)
decreased
as
the
children
increased
in
age
(Js1025.5,
zs2.03,
rs.22).
Significant
trends
were
not
found
across
child
age
for
seeking
emotional
support
and
gaze
to
injury.
One
difference
was
found
in
the
proportion
of
parental
behavioral
frequency
(empathy)
be-
tween
child
age
groups,
(H(2)= 6.52,
p=.038).
Jonckheere’s
test
revealed
that
as
the
children
increased
in
age,
parent
verbal
behavior
empathy
decreased
(J=1030.5,
z=1.86,
r=.20).
3.5.
Convergent
validity
Descriptive
statistics
for
each
category
of
the
B-CAMPIS
(behavioral
frequency
per
minute)
are
presented
in
Table
5.
Spearman’s
Rho
correlations
were
conducted
to
test
the
convergent
validity
of
the
B-CAMPIS
proportion
scores
against
the
CAMPIS-SF
scales
and
the
CAMPIS-R
proportion
scores.
Significant
positive
correlations
were
found
between
the
corresponding
B-CAMPIS
and
CAMPIS-SF
categories,
and
Table
4
–
Median
proportion
of
behavior
per
minute
and
interquartile
range
by
child’s
age.
Behavior
(N= 87)
1
year
old
(n= 33)
2years
old
(n= 23)
3–6years
old
(n= 31)
Median
IQR
Median
IQR
Median
IQR
Child
verbal
behavior
Verbal
Making
a
coping
statement
0.00
0.00–0.00
0.00
0.00–0.12
0.00
0.00–0.18
Non-procedural
talk
by
child
0.00
0.00–0.19
0.00
0.00–0.48
0.42
0.00–1.16
Breathing
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Cry
1.94
0.85–4.46
1.68
0.00–4.34
0.08
0.00–2.45
Scream
0.00
0.00–0.23
0.00
0.00–0.18
0.00
0.00–0.00
Verbal
resistance
0.00
0.00–0.00
0.00
0.00–0.14
0.00
0.00–0.21
Emotional
support
0.00
0.00–0.18
0.21
0.00–0.58
0.00
0.00–0.34
Verbal
fear
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Verbal
pain
0.00
0.00–0.17
0.17
0.00–0.31
0.41
0.00–1.41
Verbal
emotion
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Information
seeking
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Child
nonverbal
behavior
Self
soothe
0.00
0.00–0.33
0.13
0.00–0.68
0.00
0.00–0.00
Requires
restraint
0.35
0.05–0.77
0.18
0.00–0.54
0.00
0.00–0.07
Flail
0.21
0.00–0.70
0.13
0.00–0.34
0.00
0.00–0.24
Play
0.09
0.00–0.38
0.00
0.00–0.18
0.00
0.00–0.00
Point
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Gaze
to
parent
0.00
0.00–0.21
0.00
0.00–0.18
0.15
0.00–0.38
Watch
television
0.00
0.00–0.18
0.00
0.00–1.01
0.00
0.00–0.20
Using
the
Ditto
device
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.79
Gaze
to
injury
0.71
0.15–1.10
1.25
0.79–1.90
0.85
0.30–1.37
Aggression
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Parenting
verbal
behavior
Verbal
Criticism
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.16
Verbal
reassurance
0.23
0.57–1.85
0.40
0.00–0.94
0.34
0.00–1.05
Giving
control
to
the
child
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Apology
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Empathy
0.00
0.17–0.46
0.00
0.00–0.17
0.00
0.00–0.26
Humor
to
child
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Nonprocedural
talk
to
child
0.25
0.55–1.49
0.36
0.00–1.29
0.70
0.34–1.54
Command
to
engage
in
coping
strategy
0.00
0.28–0.86
0.27
0.00–1.01
0.24
0.09–0.94
Prompting
disclosure
of
pain
0.00
0.00–0.09
0.00
0.00–0.00
0.00
0.00–0.18
Threat
to
remove
coping
strategy
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Negative
evaluation
0.00
0.00–0.20
0.00
0.00–0.23
0.00
0.00–0.14
Parenting
nonverbal
behavior
Point
to
décor
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Distract
(play,
action
example,
offer)
0.00
0.30–0.68
0.12
0.00–0.38
0.15
0.00–0.29
Reassuring
Contact
0.06
0.81–1.15
0.34
0.13–0.73
0.61
0.18–1.02
Parent
cry
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
Unengaged
distress
0.00
0.00–0.00
0.00
0.00–0.00
0.00
0.00–0.00
IQR= interquartile
range.
83

between
the
corresponding
B-CAMPIS
and
CAMPIS-R
catego-
ries.
Table
5
also
demonstrates
that
associations
were
found
in
the
expected
directions:
B-CAMPIS
child
coping
was
negatively
associated
to
CAMPIS-SF
and
CAMPIS-R
child
coping,
and
B-
CAMPIS
child
distress
was
negatively
associated
to
CAMPIS-SF
and
CAMPIS-R
child
distress.
3.6.
Incremental
validity
Linear
regressions
were
conducted
to
assess
the
variance
accounted
for
by
the
B-CAMPIS
child
categories
compared
to
the
existing
CAMPIS-R
child
categories
on
nurse-report
pain-
related
behavioral
distress
score
(FLACC),
parent-report
child
procedural
pain
score,
and
parent-report
child
procedural
anxiety
score.
See
Table
6
for
results.
The
B-CAMPIS
child
distress
category
accounted
for
slightly
more
variance
in
the
variability
of
nurse-reported
child
behavioral
distress
(B-
CAMPIS= 46%,
CAMPIS-R= 44%),
and
equivalent
variability
in
parent-reported
child
procedural
pain
(B-CAMPIS= 26%,
CAM-
PIS-R= 26%)
and
parent-reported
child
procedural
anxiety
(B-
CAMPIS= 26%,
CAMPIS-R= 26%).
The
B-CAMPIS
child
coping
category
accounted
for
more
variability
in
nurse-reported
child
behavioral
distress
(B-CAMPIS=16%,
CAMPIS-R= 0%),
parent-reported
child
procedural
pain
(B-CAMPIS= 5%,
CAM-
PIS-R= 0%)
and
parent-reported
child
procedural
anxiety
(B-
CAMPIS= 17%,
CAMPIS-R= 4%)
scores.
4.
Discussion
The
aims
of
this
study
were
to
develop
and
test
the
reliability
and
validity
of
the
B-CAMPIS,
an
extension
of
the
CAMPIS-R
observational
measure.
There
was
a
gap
in
the
field
for
an
observational
measure
to
assess
parent–child
interactions
during
burn
wound
care,
and
particularly
for
young
children
(under
6-years-old)
who
are
commonly
at
greater
risk
of
procedural
distress,
as
well
as
sustaining
a
burn
injury.
Several
additional
child
and
parent
behaviors
were
identified
and
added
to
the
B-CAMPIS.
As
the
Ditto
TM
device
(currently
used
in
pediatric
burn
centers
across
the
UK,
USA,
and
Australia)
and
television
watching
are
common
methods
of
distraction
for
coping
[49],
it
was
important
to
include
these
behaviors.
In
comparison,
increased
gaze
to
injury
was
an
unexpected
child
coping
behavior,
despite
a
minority
of
children
who
displayed
increased
distress
at
the
sight
of
the
wound.
Preferred
coping
style
of
the
child
(i.e.
approach
vs.
avoidant
coping
style)
should
be
considered
before
encouraging
this
specific
coping
strategy
[50].
Parental
reassuring
contact
was
uniquely
associated
with
distress-promoting
behaviors
in
this
sample.
Research
on
infants
demonstrate
the
analgesic
benefits
of
contact
[51].
However,
for
young
children
it
appears
that
reassuring
contact
is
more
likely
to
be
present
with
other
distress-promoting
behaviors,
than
coping-promoting
behaviors.
Table
5
–
Spearman’s
Rho
correlations
between
B-CAMPIS,
CAMPIS-SF,
and
CAMPIS-R
child
categories
(frequency
of
behavior
per
minute).
B-CAMPIS
categories
Child
coping
behavior
Child
distress
behavior
Parent
coping-promoting
behavior
Parent
distress-promoting
behavior
Median
2.10
2.34
1.39
1.69
Range
0–12
0–20
0-13
0–15
B-CAMPIS
categories
Child
coping
behavior
–
.57
***
.25
*
.24
*
Child
distress
behavior
–
.07
.47
***
Parent
coping-promoting
behavior
–
.28
**
Parent
distress-promoting
behavior
–
CAMPIS-SF
categories
Child
coping
behavior
.63
***
.75
***
.18
.43
***
Child
distress
behavior
.52
***
.78
***
.06
.50
***
Parent
coping-promoting
behavior
.30
**
.36
**
.55
***
.07
Parent
distress-promoting
behavior
.29
**
.45
***
.03
.49
***
CAMPIS-R
categories
Child
coping
behavior
.67
***
.33
**
.12
.24
*
Child
distress
behavior
.50
***
.98
***
.09
.47
***
Parent
coping-promoting
behavior
.25
*
.07
.97
***
.32
**
Parent
distress-promoting
behavior
.22
*
.59
***
.26
*
.86
***
B-CAMPIS= Burns–Child–Adult-Medical
Procedure
Interaction
Scale;
CAMPIS-SF= Child–Adult-Medical
Procedure
Interaction
Scale;
CAMPIS-
R= Child–Adult-Medical
Procedure
Interaction
Scale-Revised.
***
p<.001,
**
p<.01,
*
p<.05.
Bolding
indicates
the
equivalent
category
on
previously
validated
measures.
84

Inclusion
of
the
additional
child
behaviors
allowed
the
B-
CAMPIS
to
reflect
child
coping
and
child
distress
across
the
developmental
stages
of
children
1–6-years-old.
Previous
measures
have
not
reported
differences
across
age
groups
[4].
Older
children
displayed
higher
frequencies
of
verbal
behaviors
and
using
the
Ditto
TM
device,
and
this
was
expected
because
young
children
do
not
have
the
vocabu-
lary
and
metacognitive
skills
for
these
behaviors
[1,11].
Younger
children
showed
higher
frequencies
of
crying
and
required
more
physical
restraint,
which
also
aligns
with
the
literature
[2].
The
B-CAMPIS
was
found
to
be
a
valid
measure
of
parent
and
child
behavior
during
burn
wound
care.
Future
research
should
continue
to
disentangle
the
relationship
between
parenting
behavior
and
child
coping
outcomes.
The
B-CAMPIS
also
appeared
to
account
for
more
variability
in
parent–
and
nurse–
reported
child
distress
scores,
particularly
through
identifying
young
child
coping
behavior,
and
is
a
strength
of
the
measure.
4.1.
Clinical
and
research
applications
The
B-CAMPIS
can
be
used
in
a
variety
of
research
and
clinical
contexts.
Further
validation
is
required
to
ensure
the
B-
CAMPIS
is
acceptable
in
different
centers.
The
field
of
pediatric
burns
has
limited
evidence-based
resources
for
intervening
to
reduce
procedural
distress.
The
addition
of
the
B-CAMPIS
will
assist
researchers
to
design
studies
to
better
understand
and
support
the
important
role
parents
play
in
influencing
child
distress
during
pediatric
burn
wound
care.
Understanding
the
parents’
role
can
lead
to
the
development
of
parent-level
interventions,
for
example,
training
and
reinforcing
beneficial
behaviors
during
pediatric
burn
wound
care.
With
regards
to
clinical
application,
it
may
not
be
feasible
for
healthcare
professionals
to
code
frequency
of
behaviors.
However,
healthcare
professionals
can
still
be
aware
of
the
range
of
evidence-based
influential
behaviors,
in
terms
of
their
own
interactions
with
the
child,
as
well
as
the
behaviors
they
encourage
parents
to
use.
Concerns
have
been
raised
previously
regarding
the
potential
for
parental
distress
during
pediatric
burn
wound
care
[52],
however,
recent
research
has
highlighted
that
parents
generally
prefer
to
be
present
[53].
With
an
increasing
focus
towards
family-centered
care,
it
is
important
for
parents
to
feel
empowered
to
assist
their
child
during
wound
care,
and
providing
the
parents
with
an
explicit
role
such
as
distraction
may
be
extremely
helpful
for
the
child
as
well
as
the
parent.
4.2.
Limitations
and
future
directions
While
it
was
a
strength
of
the
current
study
to
test
multiple
types
of
validity,
and
validate
child
and
parent
behaviors,
there
were
also
some
limitations
to
report.
It
is
a
limitation
that
the
B-CAMPIS
was
not
compared
against
observational
procedural
distress
measures
separate
from
the
CAMPIS
coding
scheme
(i.e.
OSBD,
CHEOPS),
because
repeated
items
inflated
validity
scores.
However,
with
live
coding
nonverbal
behavior,
it
was
not
feasible
for
multiple
observational
measures
to
be
used.
Another
weakness
was
to
exclude
analyzing
healthcare
professional
behavior.
It
is
possible
that
parenting
behaviors
in
the
B-CAMPIS
can
be
applied
for
assessing
healthcare
professional
interactions
during
burn
wound
care.
Further
work
could
validate
healthcare
profes-
sional
behavior
within
a
burn
wound
care
context.
Addition-
ally,
the
current
research
has
built
on
the
existing
framework
of
the
CAMPIS-R,
which
was
designed
to
consist
of
four
categories.
Therefore
the
B-CAMPIS
was
designed
to
emulate
the
CAMPIS-R
constructs.
While
a
factor
analysis
would
be
beneficial
in
theory,
the
B-CAMPIS
scores
behaviors
that
have
a
broad
range
of
frequency
of
occurrence
and
also
the
frequency
of
behaviors
can
differ
significantly
across
the
age
groups
assessed
in
this
study.
As
such,
a
factor
analysis
is
not
recommended
in
this
case.
5.
Conclusions
Creating
the
B-CAMPIS
is
important
for
future
research
to
be
able
to
quantify
parent
and
child
interactions
during
pediatric
burn
wound
care.
Young
children
are
an
important
yet
under
studied
population
regarding
interventions
for
improving
coping
during
burn
wound
care.
Understanding
the
parents’
and
child’s
experiences
during
wound
care
can
inform
the
development
of
targeted
behavioral
interventions,
with
the
aim
to
reducing
distress
experienced
by
the
child
and
their
parents.
Table
6
–
Twelve
univariate
linear
regression
analyses
demonstrating
the
predictive
natures
of
the
B-CAMPIS
and
CAMPIS-R
child
categories
on
parent-
and
nurse-reported
measures
of
child
distress.
Predictor
Nurse-reported
pain-related
distress
behavior
N=87
Parent-reported
procedural
pain
N=85
Parent-reported
procedural
anxiety
N=85
F
b
p
R
2
F
b
p
R
2
F
b
p
R
2
Child
coping
behavior
CAMPIS-R
0.06
.03
.812
.00
0.00
.00
.996
.00
3.04
.20
.085
.04
B-CAMPIS
16.61
.40
<.001
.16
5.10
.24
.027
.05
15.92
.41
<.001
.17
Child
distress
behavior
CAMPIS-R
59.95
.66
<.001
.44
27.40
.51
<.001
.26
27.18
.51
<.001
.26
B-CAMPIS
65.81
.68
<.001
.46
27.57
.51
<.001
.26
26.90
.51
<.001
.26
B-CAMPIS= Burns–Child–Adult-Medical
Procedure
Interaction
Scale;
CAMPIS-R= Child–Adult-Medical
Procedure
Interaction
Scale-Revised.
85

Conflicts
of
interest
None.
Funding
sources
had
no
such
involvement
in
the
research.
Funding
E.A.B.
was
supported
by
the
Australian
Government
Research
Training
Program
Scholarship,
the
Children’s
Hospital
Foun-
dation,
and
is
a
trainee
member
of
Pain
in
Child
Health
(PICH),
a
Strategic
Training
Initiative
in
Health
Research
of
the
Canadi-
an
Institutes
of
Health
Research.
Acknowledgements
The
authors
would
like
to
acknowledge
Professor
Ronald
Blount
and
Dr.
Christine
Chambers
for
guidance
with
forward-
developing
the
CAMPIS-R
measure.
Furthermore,
the
authors
would
like
to
acknowledge
Krittika
Vongkiatkajorn
and
Gillian
Montague
for
assistance
with
data
collection,
and
Anne
Bernard
for
statistical
guidance.
We
would
also
like
to
acknowledge
the
families
involved
in
this
study,
and
the
clinical
staff
of
the
Pegg
Leditschke
Children’s
Burns
Centre
who
graciously
opened
their
workplace
to
our
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