Measurement and Assessment of Pain In Children – A Review

Pain is a common experience during childhood. Despite the magnitude of effects that pain can have on a child, it is often inadequately assessed and treated. Numerous myths, insufficient knowledge among caregivers, and inadequate application of knowledge contribute to the lack of effective management. The pediatric pain experience involves the interaction of physiologic, psychologic, behavioral, developmental, and situational factors. Pain is an inherently subjective multifactorial experience and should be assessed and treated as such. Pediatric Dentists are responsible for eliminating or assuaging pain and suffering in children when possible. To accomplish this, we need to expand our knowledge, use appropriate assessment tools and techniques, anticipate painful experiences and intervene accordingly. As an assessment of pain which constitutes the foundation for all pain treatment, developing valid measures is both a clinical and research challenge. Clinicians and researchers should select measures with full knowledge of their psychometric strengths and weakness, as well as in keeping with their explicit conceptual model of pain. The purpose of this paper is to address potential sources of pain measurement, and responses to pain control and distractions based on the pediatric developmental stages.

Pain, Pain measurement, Pain assessment, Pain scales, Children

1. Fearon I, McGrath PJ, Achat H. Booboos: the study of everyday pain among young children. Pain, 68: 55–62, 1996.

2. Gilbert-MacLeod CA, Craig KD, Rocha EM, Mathias MD. Everyday pain responses in children with and without developmental delays. J Pediatr Psychol, 25: 301–308, 2000.

3. Cummings EA, Reid GJ, Finley GA, McGrath PJ, Ritchie JA. Prevalence and source of pain in pediatric inpatients. Pain, 68: 25–31, 1996.

4. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, Bahnen AM, van Suijlekom-Smit LW, Passchier J, van der Wouden JC. Pain in children and adolescents: a common experience. Pain, 87: 51–58, 2000.

5. Coderre TJ, Katz J. Peripheral and central hyperexcitability: differential signs and symptoms in persistent pain. Behav Brain Sci, 20: 404–419, 1997.

6. Melzack R, Coderre TJ, Katz J, Vaccarino AL. Central neuroplasticity and pathological pain. Ann N Y Acad Sci, 933: 157–174, 2001.

7. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science, 288: 1765–1769, 2000.

8. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med, 317: 1321–1329, 1987.

9. Fitzgerald M, Beggs S. The neurobiology of pain: developmental aspects. Neurosci, 7: 246–257, 2001.

10. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet, 345: 291–292, 1995.

11. Carr DB, Goudas LC. Acute pain. Lancet, 353: 2051–2058, 1999.

12. Mannion RJ, Woolf CJ. Pain mechanisms and management: a central perspective. Clin J Pain, 16(3): S144-156, 2000.

13. Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet, 353: 1959–1964, 1999.

14. Pain Assessment and Management: An Organizational Approach. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 2000.

15. Carr DB. The development of national guidelines for pain control: synopsis and commentary. Eur J Pain, 5(A): 91–98, 2001.

16. Broome ME, Richtsmeier A, Maikler V, Alexander M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage, 11: 312–320, 1996.

17. Forward SP, Brown TL, McGrath PJ. Mothers’ attitudes and behavior toward medicating children’s pain. Pain, 67: 469–474, 1996.

18. Manworren RC. Pediatric nurses’ knowledge and attitudes survey regarding pain. Pediatr Nurs, 26: 610–614, 2000.

19. McGrath PJ, Finley GA. Attitudes and beliefs about medication and pain management in children. J Palliat Care, 12: 46–50, 1996.

20. Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics, 100: 626–632, 1997.

21. Ready LB, Edwards WT, eds; The International Association for the Study of Pain (Task Force on Acute Pain). Management of Acute Pain: A Practical Guide. Seattle, Wash: IASP Publications; 1992. 22. Morton NS. “Pain assessment in children,” Paediatr Anaesth, 7(4): 267–272, 1997.

23. McGrath PJ, Frager G. Psychological barriers to optimal pain management in infants and children. Clin J Pain, 12(2): 135–141, 1996.

24. Cox TH. An evaluation of postoperative pain management in pediatricpatients at a university teaching hospital. Hosp Pharm, 30: 980–992, 1995.

25. Ellis JA, O’Connor BV, Cappelli M, Goodman JT, Blouin R, Reid CW. Pain in hospitalized pediatric patients: how are we doing? Clin J Pain, 18: 262–269, 2002.

26. Finley GA, McGrath PJ, Forward SP, McNeill G, Fitzgerald P. Parents management of children’s pain following “minor” surgery. Pain, 64: 83–87, 1996.

27. Gauthier JC, Finley GA, McGrath PJ. Children’s self-report of postoperative pain intensity and treatment threshold: determining the adequacy of medication. Clin J Pain, 14: 116–120, 1998.28. Hamers JP, Abu-Saad HH. Children’s pain at home following (adeno) tonsillectomy. Eur J Pain, 6: 213–219, 2002.

29. Johnston CC, Abbott FV, Gray-Donald K, Jeans ME. A survey of pain in hospitalized patients aged 4–14 years. Clin J Pain, 8: 154–163, 1992.

30. McGrath PJ, Unruh AM. “Measurement and assessment of paediatric pain,” in Textbook of Pain, P. D. Wall and R. Melzack, Eds., pp. 371–384, Churchill Livingstone, New York, NY, USA, 4th edition, 1999.

31. World health organization, international association for study of pain. Pain in children with cancer. WHO – IASP Guidelines. http://www.whocancerpain. wisc. edu/?q¼node/236 (2008, accessed July 2010)

32. International Association for the Study of Pain. IASP pain terminology. http://www.iasppain.org/AM/Template.cfm?Section¼Pain_Definitions&- Template¼/CM/HTMLDisplay.cfm&ContentID¼1728 (2008, accessed July 2010).

33. American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics, 108: 793–7, 2001.

34. Anand KJ. International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med, 155: 173–80, 2001.

35. Watt Watson JH, Clark AJ, Finley A, Watson CP. Canadian Pain Society position statement on pain relief. Pain Res Manag, 4(2): 75–8, 1999.

36. Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. J Am Med Assoc, 284: 428–9, 2000.

37. Walco GA, Cassidy RC, Schechter NL. Pain, hurt, and harm – the ethics of pain control in infants and children. N Engl J Med, 331: 541–4, 1994.

38. Craig KD, Korol CT. Developmental issues in understanding, assessing, and managing pediatric pain. In: Walco G, Goldschnieder K. (eds.). Pediatric Pain Management in Primary Care: A Practical Guide. Totowa, New Jersy (USA): The Humana Press Inc, 2008.

39. Johnston CC. Psychometric issues in the measurement of pain. In: Finley GA, McGrath PJ, eds. Measurement of Pain in Infants and Children. Seattle, Wash: IASP Press; 1998: 5–20.

40. Kirshner B, Guyatt G. A methodological framework for assessing health indices. J Chronic Dis, 38: 27–36, 1985.

41. Franck LS, Greenberg CS, Stevens B. Pain assessment in infants and chil-dren. Pediatr Clin North Am, 47: 487–512, 2000.

42. Merkel S, Malviya S. Pediatric pain, tools, and assessment. J Perianesth Nurs, 15: 408–414, 2000.

43. Stevens BJ, Franck LS. Assessment and management of pain in neonates. Paediatr Drugs, 3: 539–558, 2001.

44. McGrath PA, Gillespie J. Pain assessment in children and adolescents. In: Turk DC, Melzack R, eds. Handbook of Pain Assessment. 2nd ed. New York, NY: Guilford Press, 97–118, 2001.

45. Finley GA, McGrath PJ, eds. Measurement of Pain in Infants and Children. Seattle, Wash: IASP Press; 1998.

46. McGrath PA. Pain in Children: Nature, Assessment, and Treatment. New York, NY: Guilford Press; 1990.

47. Schechter NL, Berde CB, Yaster M, eds. Pain in Infants, Children, and Adolescents. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003.

48. Van Hulle Vincent C. Nurses’ perceptions of children’s pain: a pilot study of cognitive representations. J Pain Symptom Manage, 33: 290–301, 2007.

49. McGrath PA. An assessment of children’s pain: a review of behavioral, phys-iological and direct scaling techniques. Pain, 31: 147–76, 1987.

50. Harbeck C, Peterson L. Elephants dancing in my head: a developmental approach to children’s concepts of specific pains. Child Dev, 63: 138–149, 1992.

51. Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale–Revised: toward a common metric in pediatric pain measurement. Pain, 93: 173–183, 2001.

52. Hunter M, McDowell L, Hennessy R, Cassey J. An evaluation of the Faces Pain Scale with young children. J Pain Symptom Manage, 20: 122–129, 2000.

53. Champion GD, Goodenough B, von Baeyer C, Thomas W. Measurement of pain by self-report. In: Finley GA, McGrath PJ, eds. Measurement of Pain in Infants and Children. Seattle, Wash: IASP Press; 1998: 123–160.

54. Goodenough B, Addicoat L, Champion GD. Pain in 4- to 6-year-old children receiving intramuscular injections: a comparison of the Faces Pain Scale with other self-report and behavioral measures. Clin J Pain, 13: 60–73, 1997.

55. McGrath PA, deVeber LL, Hearn MJ. Multidimensional pain assessment in children. In: Fields H, Dubner R, Cervero F, eds. Proceedings of the Fourth World Congress on Pain. New York, NY: Raven Press; Advances in Pain Research and Therapy, 9: 387–393, 1985.

56. Shih AR, von Baeyer CL. Preschool children’s seriation of pain faces and happy faces in the Affective Facial Scale. Psychol Rep, 74: 659–665, 1994.

57. St-Laurent-Gagnon T, Bernard-Bonnin AC, Villeneuve E. Pain evaluation in preschool children and by their parents. Acta Paediatr, 88: 422–427, 1999.

58. Savedra MC, Holzemer WL, Tesler MD, Wilkie DJ. Assessment of postop-eration pain in children and adolescents using the adolescent pediatric pain tool. Nurs Res, 42: 5–9, 1993.

59. Beyer JE. The Oucher: A User’s Manual and Technical Report. Evanston, Ill: Hospital Play Equipment; 1984.

60. Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain, 41: 139–150, 1990.

61. Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs, 14: 9–17, 1988.

62. Mather L, Mackie J. The incidence of postoperative pain in children. Pain, 15: 271–82, 1983.

63. Hamers JP, Abu-Saad HH, van den Hout MA, Halfens RJG. Are children given insufficient pain-relieving medication postoperatively? J Adv Nurs, 27: 37–44, 1998.

64. Gaffney A, Dunne EA. Children’s understanding of the causality of pain. Pain, 29: 91–104, 1987.

65. Lindeke L, Nakai M, Johnson L. Capturing children’s voices for quality improvement. MCN Am J Matern Child Nurs, 31: 290–5; quiz 296–7, 2006.

66. Humphrey GB, Boon CM, Van Linden van den Heuvell GF, Van de Wiel HB. The occurrence of high levels of acute behavioral distress in children and adolescents undergoing routine venipunctures. Pediatrics, 90: 87–91, 1992.

67. Van Hulle Vincent C, Denyes MJ. Relieving children’s pain: nurses’ abilities and analgesic administration practices. J Pediatr Nurs, 19: 40–9, 2004.

68. Boughton K, Blower C, Chartrand C, Dircks P, Stone T, Youwe G, Hagen

B. Impact of research on paediatric pain assessment and outcomes. Pediatr Nurs, 24(1): 31–5, 62, 1998.

69. McGrath PJ, Rosmus C, Canfield C, Campbell MA, Hennigar A. Behaviours caregivers use to determine pain in non-verbal, cognitively impaired individ-uals. Dev Med Child Neurol, 40: 340–343, 1998.

70. Abu-Saad HH. Challenge of pain in the cognitively impaired. Lancet, 356: 1867–1868, 2000.

71. Hadjistavropoulos T, von Baeyer C, Craig KD. Pain assessment in persons with limited communication. In: Turk DC, Melzack R, eds. Handbook of Pain Assessment. 2nd ed. New York, NY: Guilford Press; 2001: 134–149.

72. LaChapelle DL, Hadjistavropoulos T, Craig KD. Pain measurement in persons with intellectual disabilities. Clin J Pain, 15: 13–23, 1999.

73. Oberlander TF, O’Donnell ME, Montgomery CJ. Pain in children with signif-icant neurological impairment. J Dev Behav Pediatr, 20: 235–243, 1999.

74. Breau LM, McGrath PJ, Camfield C, Rosmus C, Finley GA. Preliminary validation of an observational pain checklist for persons with cognitive impairments and inability to communicate verbally. Dev Med Child Neurol, 42: 609–616, 2000.

75. Fanurik D, Koh JL, Schmitz ML, Harrison RD, Conrad TM. Children with cognitive impairment: parent report of pain and coping. J Dev Behav Pediatr, 20: 228–234, 1999.

76. Giusiano B, Jimeno MT, Collignon P, Chau Y. Utilization of neural network in the elaboration of an evaluation scale for pain in cerebral palsy. Methods Inf Med, 34: 498–502, 1995.

77. Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviors. Pain, 99: 281–288, 2002.

78. Stallard P, Williams L, Velleman R, Lenton S, McGrath PJ. Brief report: behaviors identified by caregivers to detect pain in noncommunicating chil-dren. J Pediatr Psychol, 27: 209–214, 2002.

79. Breau LM, Camfield C, McGrath PJ, Rosmus C, Finley GA. Measuring pain accurately in children with cognitive impairments: refinement of a caregiver scale. J Pediatr, 138: 721–727, 2001.

80. Breau LM, Finley GA, McGrath PJ, Camfield CS. Validation of the Non-communicating Children’s Pain Checklist–Postoperative Version. Anesthesiol, 96: 528–535, 2002.

81. Breau LM, McGrath PJ, Camfield CS, Finley GA. Psychometric properties of the Non-communicating Children’s Pain Checklist–Revised. Pain, 99: 349–357, 2002.

82. Sweet SD, McGrath PJ. Physiological measures of pain. In: Finley GA, McGrath PJ, eds. Measurement of Pain in Infants and Children. Seattle, Wash: IASP Press; 1998: 59–81.

83. Anand KJ, Aynsley-Green A. Measuring the severity of surgical stress in newborn infants. J Pediatr Surg, 23: 297–305, 1988.

84. Stevens B. Composite measures of pain. In: Finley GA, McGrath PJ, eds. Measurement of Pain in Infants and Children. Seattle, Wash: IASP Press; 1998: 161–178.

85. Stevens B, Johnston C, Petryshen P, Taddio A. Premature Infant Pain Profile: development and initial validation. Clin J Pain, 12: 13–22, 1996.

86. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw, 12: 59–66, 1993.

87. Murtomaa H, Milgrom P, Weinstein P, Vuopio T. Dentists’ perceptions and management of pain experienced by children during treatment: a survey of groups of dentists in the USA and Finland. Int J Paediatr Dent, 6: 25-30, 1996.

88. Fitzgerald M, Beggs S. The neurobiology of pain: developmental aspects. Neurosci, 7(3): 246– 257, 2001.

89. Grunau RV, Craig KD. Pain expression in neonates: facial action and cry. Pain, 28(3): 395–410, 1987.

90. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med, 41(5): 617–622, 2003.

91. Stevens BJ, Johnston CC, Horton L. Multidimensional pain assessment in premature neonates: a pilot study. J Obstet Gynecol Neonatal Nurs, 22(6): 531–541, 1993.

92. Hadjistavropoulos HD, Craig HD, Grunau RV, Johnston CC. Judging pain in newborns: facial and cry determinants. J Pediatr Psychol, 19(4): 485–491, 1994.

93. Grunau RV, Craig KD. “Facial activity as a measure of neonatal pain expres-sion,” in Advances in Pain Research and Therapy, D. C. Tyler and E. J. Krane, Eds., vol. 15, pp. 147–155, Raven Press, New York, NY, USA, 1990.

94. Grunau RE, Oberlander T, Holsti L, Whitfield MF. Bedside application of the neonatal facial coding system in pain assessment of premature neonates. Pain, 76(3): 277–286, 1998.

95. Kohut SA, Riddell RP. Does the neonatal facial coding system differentiate between infants experiencing pain-related and non-pain-related distress? J Pain, 10(2): 214–220, 2009.

96. Ballantyne M, Stevens B, McAllister M, Dionne K, Jack A. Validation of the premature infant pain profile in the clinical setting. Clin J Pain, 15(4):297–303, 1999.

97. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measure-ment score. Initial testing of validity and reliability. Paediatr Anaesth, 5(1): 53–61, 1995.

98. Izard CE. The Maximally Discriminative Facial Movement Coding System (MAX)-Manual, University of Delaware Resource Centre, Newark, NJ, USA, 1979.

99. Izard CE. The Maximally Discriminative Facial Movement Coding System, Academic Computing Services and University Media Services, University of Delaware, Newark, Canada, Revised edition, 1983.

100. Fridlund AJ. Human Facial Expression: An Evolutionary View, Academic Press, San Diego, California, USA, 1994.

101. Russell JA. Is there universal recognition of emotion from facial expression?A review of the cross-cultural studies. Psychol Bulletin, 115(1): 102–141, 1994.

102. Moore RJ, Paice JA. Behavioural Approaches to Pain, Springer, New York, NY, USA, 2009.

103. O’Rourke D. The measurement of pain in infants, children, and adolescents: from policy to practice. Physical Therapy, 84(6): 560–570, 2004.

104. Beyer JE, Wells N. The assessment of pain in children. Pediatr Clin North Am, 36(4): 837–854, 1989.

105. McGrath PJ, Johnston G, Goodman JT, Schillinger J, Dunn J, Chapman J. CHEOPS: a behavioral scale for rating postoperative pain in children. In Fields HL, Dubner R, Cervero F (eds.), Proceeding of the 4th World Congress on Pain: Advances in Pain Research and Therapy, vol. 9, Raven Press, New York, 1985, pp 395–401.

106. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behav-ioral scale for scoring postoperative pain in young children. Pediatr Nurs, 23(3): 293– 297, 1997.

107. Merkel S, Voepel-Lewis T, Malviya S. Pain assessment in infants and young children: the FLACC scalex. Am J Nurs, 102(10): 55–68, 2002.

108. Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pedi-atric intensive care environments: the COMFORT scale. J Pediatr Psychol, 17(1): 95–109, 1992.

109. Wielenga JM, De Vos R, De Leeuw R, De Haan RJ. COMFORT scale: a reli-able and valid method to measure the amount of stress of ventilated preterm infants. Neonat Netw, 23(2): 39–44, 2004.

110. Powers SW. Empirically supported treatments in pediatric psychology: procedure- related pain. J Pediatr Psychol, 24(2): 131–145, 1999.

111. Elliot CH, Jay SM, Woody P. An observational scale for measuring children’s distress during medical procedures. J Pediatr Psychol, 12(4): 543–551, 1987.

112. Tucker CL, Slifer KJ, Dahlquist LM. Reliability and validity of the brief behavioral distress scale: a measure of children’s distress during invasive medical procedures. J Pediatr Psychol, 26(8): 513–523, 2001.

113. Blount RL, Sturges JW, Powers SW. Analysis of child and adult behavioral variations by phase of medical procedure. Behavior Therap, 21(1): 33–48, 1990.

114. Hesselgard K, Larsson S, Romner B, Stromblad LG, Reinstrup P. Validity and reliability of the behavioural observational pain scale for postoperative pain measurement in children 1–7 years of age. Pediatr Crit Care Med, 8(2): 102–108, 2007.

115. Boelen-van der Loo WJC, Scheffer E, de Haan RJ, de Groot CJ. Clinimetric evaluation of the pain observation scale for young children in children aged between 1 and 4 years after ear, nose, and throat surgery. J Dev Behav Pediatr, 20(4): 222–227, 1999.

116. de Jong AE, Bremer M, Schouten M, Tuinebreijer WE, Faber AW. Reliability and validity of the pain observation scale for young children and the visual analogue scale in children with burns. Burns, 31(20): 198–204, 2005.

117. Tarbell SE, Cohen IT, Marsh JL. The toddler-preschooler postoperative pain scale: an observational scale for measuring postoperative pain in children aged 1–5. Preliminary report. Pain, 50(3): 273–280, 1992.

118. Tarbell SE, March JL, Cohen ITC. Reliability and validity of the pain assessment scale for measuring postoperative pain in young children. J Pain Symptom Manage, 6: 196, 1991.

119. Suraseranivongse S, Santawat U, Kraiprasit K, Petcharatana S, Prakka-modom S, Muntraporn N. Cross-validation of a composite pain scale for preschool children within 24 hours of surgery. Br J Anaesth, 87(3): 400–405, 2001.

120. St-Laurent-Gagnon T, Bernard-Bonnin AC, Villeneuve E. Pain evaluation in preschool children and their parents. Acta Paediatr, 88(4): 422–427, 1999.

121. Chambers CT, Cassidy KL, McGrath PJ. Child Facial Coding System: A Manual, Dalhousie University, Halifax, Canada; University of British Columbia, Vancouver, Canada, 1996.

122. Gilbert CA, Lilley CM, Craig KD. McGrath PJ, Court CA, Bennett SM, Montgomery CJ. Postoperative pain expression in preschool children: vali-dation of the child facial coding system. Clin J Pain, 15(3): 192-200, 1999.

123. Hester NK. The preoperational child’s reaction to immunization. Nurs Res, 28(4): 250–255, 1979.

124. Hester NO, Foster RL, Kristensen K. “Measurement of pain in children: generalizability and validity of the pain ladder and poker chip tool,” in Advances in Pain Research and Therapy, Volume 15: Pediatric Plan, D. C. Tyler and E. J. Krane, Eds., pp. 79–84, Raven Press, New York, NY, USA, 1990.

125. Hester NO, Foster RL. “Scrutiny of the protocol for administration of the poker chip tool: phase I. Research study partially funded by RR03503,” National Institutes of Health, 1991-1992.

126. Chambers CT, Craig KD. An intrusive impact of anchors in children’s faces pain scales. Pain, 78(1): 27–37, 1998.

127. “The Oucher! TM A user’s manual and technical report,” January 2010, http://www.oucher.org/index.html.

128. Beyer JE, Aradine CR. Content validity of an instrument to measure young children’s perceptions of the intensity of their pain. J Pediatr Nurs, 1(6): 386–395, 1986.

129. Aradine CR, Beyer JE, Tompkins JM. Children’s pain perception before and after analgesia: a study of instrument construct validity and related issues. J Pediatr Nurs, 3(1): 11–23, 1988.

130. Beyer JE, Denyes MJ, Villarruel AM. The creation, validation, and continuing development of the oucher: a measure of pain intensity in children. J Pediatr Nurs, 7(5): 335–346, 1992.

131. Varni JW, Thompson KL, Hanson V. The Varni/Thompson pediatric pain questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis. Pain, 28(1): 27–38, 1987.

132. Savedra MC, Tesler MD, Holzemer WL, Ward JA. Adolescent Pediatric Pain Tool (APPT): Preliminary User’s Manual, University of California, San Francisco, Calif, USA, 1989.

133. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health, 13(4): 227–236, 1990.

134. Brinmaumer D. “Colour analogue scale, a reliable measure of pain in chil-dren,” J Acad Emerg Med, 16: 465, 2009.

135. Rapoff MA. Pediatric measures of pain: the pain behavior observation method, pain coping questionnaire, and pediatric pain questionnaire. Arthritis Care Res, 49(S5): S90–95, 2003.

136. Crandall M, Savedra M. Multidimensional assessment using the adolescent pediatric pain tool: a case report. J Spec Pediatr Nurs, 10(3): 115–123, 2005.

137. Savedra MC, Tesler MD, Holzemer WL, Wilkie DJ, Ward JA. Pain location: validity and reliability of body outline markings by hospitalized children and adolescents. Res Nurs Health, 12(5): 307–314, 1989.

138. Savedra MC, Tesler MD, Holzemer WL, Wilkie DJ, Ward JA. “Testing a tool to assess postoperative pediatric and adolescent pain,” in Advances in Pain Research and Therapy, Volume 15: Pediatric Pain, Tyler DC, Krane EJ, Eds., pp. 85–94, Raven, New York, NY, USA, 1990.

139. Melzack R, Torgerson WS. On the language of pain. Anesthesiol, 34(1): 50–59, 1971.

140. Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain, 1(3): 277–299, 1975.

141. Melzack R. The short-form McGill pain questionnaire. Pain, 3(2): 191–197, 1987.

142. Tesler MD, Savedra MC, Holzemer WL, Wilkie DJ, Ward JA, Paul SM. The word-graphic rating scale as a measure of children’s and adolescents’ pain intensity. Res Nurs Health, 14: 361–371, 1991.

143.Wilkie DJ, Holzemer WL, Tesler MD, Ward JA, Paul SM, Savedra MC. Measuring pain quality: validity and reliability of children’s and adolescents’ pain language. Pain, 41: 151–159, 1990.

144. Breau LM, McGrath PJ, Craig KD, Santor D, Cassidy KL, Reid GJ. Facial expression of children receiving immunizations: a principal components analysis of the child facial coding system. Clin J Pain, 17: 178–186, 2001.

145. Cassidy KL, Reid GJ, McGrath PJ, Smith DJ, Brown TL, Finley GA. A randomized double-blind, placebo-controlled trial of the EMLA patch for the reduction of pain associated with intramuscular injection in four to six-year-old children. Acta Paediatr, 90: 1329–1336, 2001.

146.Tyler DC, Tu A, Douthit J, Chapman CR. Toward validation of pain measurement tools for children: a pilot study. Pain, 52: 301–309, 1993.

147. Stein PR. Indices of pain intensity: construct validity among preschoolers. Pediatr Nurs, 21: 119–123, 1995.

148. Taddio A, Nulman I, Koren BS, Stevens B, Koren G. A revised measure of acute pain in infants. J Pain Symptom Manage, 10: 456–463, 1995.

149. McGrath PA, Seifert CE, Speechley KN, Booth JC, Stitt L, Gibson MC. A new analogue scale for assessing children’s pain: an initial validation study. Pain, 64: 435–443, 1996.

150. Bulloch B, Tenenbein M. Validation of 2 pain scales for use in the pediatric emergency department. Pediatrics, 110(3): e33, 2002.

151. Bulloch B, Tenenbein M. Assessment of clinically significant changes in acute pain in children. Acad Emerg Med, 9: 199–202, 2002.

152. Sparshott M. The development of a clinical distress scale for ventilated newborns infants: Identification of pain and distress based on validated scores. J Neonatal Nurs, 2: 5-11, 1996.

153. Eland J and Anderson J. The experience of pain in children. In: A Jacox (ed.) A source book for nurses and other health professionals. Little, Brown and Co; boston, MA, 453-76, 1997.

154. Eland J. The child who is hurting. Semin Oncol Nurs, 1: 116-122, 1985.

155. Eland J. Pain in children. Nurs Clin North Am, 25: 871-874, 1990.

156. Kremer E, Atkinson J, Ignelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain, 10: 241–9, 1981.

157. Ferraz MB, Quaresma MR, Aquino LRL, Atra E, Tugwell P, Goldsmith CH. Reliability of pain scales in the assessment of literate and illiterate patient with rheumatoid arthritis. J Rheumatol, 17: 1022–4, 1990.

158. Guyatt GH, Townsend M, Berman LB, Keller JL. A comparison of Likert and visual analogue scales for measuring change in function. J Chronic Dis, 40: 1129–33, 1987.

159. Jaeschke R, Singer J, Guyatt GH. A comparison of seven-point and visual analogue scales: a randomised controlled trial. Control Clin Trials, 11: 43–51, 1990.

160. Paul-Dauphin A, Guillemin F, Virion JM, Briancon S. Bias and precision in Visual Analogue Scales: a randomised controlled trial. Am J Epidemiol, 150: 1117–27, 1999.

161. Demyttenaere S, Finley GA, Johnston CC, McGrath PJ. Pain treatment thresholds in children after major surgery. Clin J Pain, 17: 173–177, 2001.

162. Goodenough B, van Dongen K, Brouwer N, Abu-Saad HH, Champion GD. A comparison of the Faces Pain Scale and the Facial Affective Scale for children’s estimates of the intensity and unpleasantness of needle pain during blood sampling. Eur J Pain, 3: 301–315, 1999.

163. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg, 95: 1224–1229, 2002.

164. Hester NO. The preoperational child’s reaction to immunization. Nurs Res, 28: 250–255, 1979.

165. Hester NO, Foster R, Kristensen, K. Measurement of pain in children: generalizability and validity of the pain ladder and the poker chip tool. In: Tyler DC, Krane EJ, eds. Pediatric Pain. New York, NY: Raven Press; 1990:179–198. Advances in Pain Research and Therapy; vol 15.

166. Johnston CC, Stevens B, Arbess G. The effect of the sight of blood and use of decorative adhesive bandages on pain intensity ratings by preschool children. J Pediatr Nurs, 8: 147–151, 1993.

167. Bray RJ, Woodhams AM, Vallis CJ, Kelly PJ, Ward-Platt MP. A double-blind comparison of morphine infusion and patient controlled analgesia in children. Paediatr Anaesth, 6: 121–127, 1996.

168. Melzack R, Katz J. The McGill Pain Questionnaire: appraisal and current status. In: Turk DC, Melzack R, eds. Handbook of Pain Assessment. 2nd ed. New York, NY: Guilford Press; 2001:35–52.

169. Johnston CC, Stevens B, Craig KD, Grunau RV. Developmental changes in pain expression in premature, full-term, two- and fourmonth- old infants. Pain, 52: 201–208, 1993.

170. Craig KD, Hadjistavropoulos HD, Grunau RV, Whitfield MF. A comparison of two measures of facial activity during pain in the newborn child. J Pediatr Psychol, 19: 305–318, 1994.

171. Hudson-Barr D, Capper-Michel B, Lambert S, Palermo TM, Morbeto K, Lombardo S. Validation of the Pain Assessment in Neonates (PAIN) scale with the Neonatal Infant Pain Scale (NIPS). Neonat Netw, 21: 15–21, 2002.

172. Beyer JE, Knott CB. Construct validity estimation for the African- American and Hispanic versions of the Oucher Scale. J Pediatr Nurs, 13: 20–31, 1998.

173. Gragg RA, Rapoff MA, Danovsky MB, Lindsley CB, Varni JW, Waldron SA, Bernstein BH. Assessing chronic musculoskeletal pain associated with rheumatic disease: further validation of the pediatric pain questionnaire. J Pediatr Psychol, 21: 237–250, 1996.

174. Johnston CC, Stremler R, Horton L, Friedman A. Effect of repeated doses of sucrose during heel stick procedure in preterm neonates. Biol Neonate, 75: 160–166, 1999.

175. Schade JG, Joyce BA, Gerkensmeyer J, Keck JF. Comparison of three preverbal scales for postoperative pain assessment in a diverse pediatric sample. J Pain Symptom Manage, 12(6): 670-676, 1996.

176. Choiniere M, Ansel R. A visual analogue thermometer for measuring pain intensity. J Pain Symptom Manage, 11: 299-311, 1996.

177. Soetenga D, Frank J, Pellino TA. Assessment of the validity and reliability of the University of Wisconsin Children’s Hospital pain scale for preverbal and nonverbal children. Pediatr Nurs, 25(6): 670-676, 1999.

178. Goodenough B, Thomas W, Champion GD, Perrott D, Taplin JE, von Baeyer CL, Ziegler JB. Unravelling age effects and sex differences in needle pain: ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents. Pain, 80:179–190, 1999.

179. Powell CV, Kelly AM, Williams A. Determining the minimum clinically significant difference in visual analog pain score for children. Ann Emerg Med, 37: 28–31, 2001.

180. Law M, King G, MacKinnon E, Murphy C, Russell D. All about outcomes. Thorofare, NJ: Slack Inc; 2000.

181. Deborah L, Olmstead DL, Scott SD, Austin WJ. Unresolved pain in children: A relational ethics perspective. Nurs Ethics, 17: 695, 2010.

182. Pasero C, McCaffery M. No self-report means no pain – intensity rating. Am J Nurs, 105(10): 50-55, 2005.

183. Benaim C, Froger J, Cazottes C, Gueben D, Porte M, Desnuelle C, Pelissier JY. Use of the faces pain scale by left and right hemispheric stroke patients. Pain, 128: 52-58, 2007.