Development and assessment of an efficient pediatric affect and cooperation scale
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Updated: Oct 14, 2025
Psychophysiological Assessment of the Effectiveness of Emotion Regulation Strategies in Childhood
Published on: February 11, 2017
Kristin M Kennedy1, Ellen Wang2, Samuel T Rodriguez2
1Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA.
Insights
The HRAD± scale efficiently assesses pediatric preprocedural affect and cooperativity during anesthesia induction and IV placement. It correlates well with existing scales, offering a practical alternative for clinicians.
Area of Science:
- Pediatric Anesthesiology
- Patient Affect Assessment
- Procedural Sedation
Background:
- Evaluating pediatric patient affect and cooperativity during medical procedures is crucial for successful outcomes.
- Existing scales for assessing preprocedural affect can be time-consuming or complex.
- The HRAD± (Happy, Relaxed, Anxious, Distressed) scale was developed for rapid assessment.
Purpose of the Study:
- To compare the efficacy and reliability of the HRAD± scale against established pediatric affect and cooperativity scales.
- To determine the correlation between HRAD± scores and scores from the mYPAS, OSBD, and ICC.
- To assess the inter-rater and intra-rater reliability of the HRAD± scale.
Main Methods:
- An observational study involving video recordings of pediatric patients undergoing mask induction or peripheral intravenous (PIV) placement.
- HRAD± ratings were collected from anesthesiologists and perioperative providers.
- Scores from mYPAS, OSBD, and ICC were obtained by trained researchers for comparison.
Main Results:
- HRAD± scores showed strong correlations with mYPAS (r=0.846) and OSBD (r=0.723).
- Cooperativity scores correlated well with the ICC in both mask induction (r=-0.715) and PIV placement (r=-0.869) groups.
- Acceptable inter-rater and intra-rater reliability were observed for HRAD± and cooperativity ratings.
Conclusions:
- The HRAD± scale is an efficient and reliable tool for assessing pediatric affect and cooperativity.
- It serves as a practical and effective alternative to more complex scales.
- HRAD± facilitates quick evaluation during mask induction and PIV placement.
Study Objective:
HRAD± was developed to quickly evaluate pediatric preprocedural affect and cooperativity during mask induction of anesthesia and peripheral intravenous (PIV) placement. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to compare HRAD± to previously published scales.
Design:
We conducted an observational study.
Setting:
Videos of pediatric patients were collected in the perioperative environment.
Patients:
Twenty-four children, twenty-one pediatric anesthesiologists and twenty pediatric perioperative providers were included.
Interventions:
To assess the reliability of HRAD±, standard patient videos were created. Children underwent mask induction or PIV placement, and these interventions were video recorded. Mask induction and PIV placement videos were rated by pediatric anesthesiologists and perioperative non-physician providers respectively using HRAD±.
Measurements:
Two trained researchers provided the modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC) scores, and we calculated correlations to HRAD±, inter-rater reliability, and intra-rater reliability.
Main Results:
HRAD± scores strongly correlated with mYPAS (r = 0.846, p < 0.0001) and OSBD scores (r = 0.723, p < 0.0001). Cooperativity scores correlated strongly with ICC scores in the mask induction group (r = -0.715, p < 0.0001) and in the PIV group (r = -0.869, p < 0.0001). HRAD± inter-rater reliability for mask induction was 0.414 (p < 0.0001) and for PIV assessment was 0.378 (p < 0.0001). Inter-rater reliability for cooperativity on mask induction was 0.797 (p < 0.0001) and PIV assessment was 0.683 (p < 0.0001). Intra-rater reliability for mask induction was 0.675 and PIV assessments was 0.678. Intra-rater reliability for cooperativity for mask induction was 0.894 and for PIV assessments was 0.765.
Conclusions:
HRAD± is an efficient and reliable scale that serves as a practical alternative for measuring pediatric affect during mask induction and PIV placement. The results demonstrate strong correlation with commonly utilized yet more complex affect scales.
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