1.5 HOURS CE Continuing Education Assessing a Child’s Pain A review of tools to help evaluate pain in children of all ages and levels of cognitive development. ABSTRACT: Effective pain assessment is a necessary component of successful pain management and the pursuit of optimal health outcomes for patients of all ages. In the case of children, accurate pain assessment is particularly important, because children exposed to prolonged or repeated acute pain, including proce- dural pain, are at elevated risk for such adverse outcomes as subsequent medical traumatic stress, more in- tense response to subsequent pain, and development of chronic pain. As with adults, a child’s self-report of pain is considered the most accurate and reliable measure of pain. But the assessment of pain in children is challenging, because presentation is influenced by developmental factors, and children’s responses to certain features of pain assessment tools are unlike those commonly observed in adults. The authors describe the three types of assessment used to measure pain intensity in children and the tools developed to address the unique needs of children that employ each. Such tools take into account the child’s age as well as special circumstances or conditions, such as ventilation requirements, cognitive impair- ment, and developmental delay. The authors also discuss the importance of proxy pain reporting by the par- ent or caregiver and how nurses can improve communication between the child, caregiver, and health care providers, thereby promoting favorable patient outcomes. Keywords: assessment tools, children, pain assessment, pain measurement, pediatric pain ain is a common symptom seen in patients of in children who undergo “posttraumatic growth” all ages and in all health care settings. In chil- and emerge from traumatic experiences with in- dren, however, pain assessment may be hin- creased resilience and a feeling that the world is a P 7 dered both by developmental factors and by the way safe place. certain features of pain assessment tools uniquely Optimal pain management and patient outcomes affect a child’s response. Inaccurate pain assessment require the use of valid and reliable pain assessments. leaves a child vulnerable to prolonged or repeated As a result of the multidimensional nature of pain, its acute pain, including procedural pain, and to such assessment is complex, and pediatric pain assessment associated sequelae as subsequent medical traumatic may be particularly challenging, depending on the stress, more intense response to subsequent pain, child’s level of cognitive development, ability to com- and development of chronic pain, resulting in in- municate, and prior experiences of pain.8 This article terference with sleep as well as with academic, so- discusses the factors that can influence a child’s report cial, household, and extracurricular activities.1-6 In of pain, describes components of a comprehensive comparison, children whose acute or procedural pediatric pain assessment, reviews appropriate pain pain is sufficiently relieved may be more likely to assessment scales for children of different ages and experience the type of enhanced development seen levels of cognitive development, and underscores 34 AJN ▼ May 2019 ▼ Vol. 119, No. 5 ajnonline.com By Debra Freund, DNP, ARNP, PPCNP-BC, CPNP-AC, and Beth N. Bolick, DNP, APRN, PPCNP-BC, CPNP-AC, FAAN A nurse uses the Wong–Baker FACES Pain Rating Scale to help assess her patient’s pain. Photo by Gerry Melendez / The State / MCT via Getty Images. the potential benefits nurses can reap from partner- understand pain, but they certainly experience it, dem- ing with the child’s parent or caregiver. onstrate memory of painful experiences, and respond to parental anxiety.10 It’s important that infants in this INFLUENCES ON A CHILD’S REPORT OF PAIN age range receive optimal pain management to prevent To appropriately assess a child’s pain, it’s necessary to adverse psychological and emotional responses to fu- understand the biological, psychological, and socio- ture painful events. At ages two years and older, chil- cultural factors that affect a child’s experience and dren’s understanding of pain evolves. expression of pain, as presented in George Engel’s An eight-year-old girl recovering from an appendec- biopsychosocial model.9 Viewing pain through this tomy may, when asked, report that she’s not in pain, lens allows nurses to tailor pain assessment specifi- though she’s lying on her side holding her flexed knees cally to each child. In addition to physical health, the against her abdomen. Her age places her in Piaget’s biopsychosocial model takes into account such fac- concrete operational stage, meaning that she has an tors as the child’s age and level of cognitive develop- increased awareness of her pain and can specify its lo- ment, temperament, fear, and previous experiences cation, but she also fears bodily harm and death. She with pain. All of these factors shape a child’s under- may not understand what her surgery entailed and standing of pain, how they describe their pain, and may perceive her pain as signaling impending death. how they respond to and cope with pain. It is impor- The nurse can provide reassurance and calm her fears tant to note that these influences are not static but by providing an age-appropriate explanation of her dynamic, changing both as the child develops and surgery, her pain, and its treatment. over the course of a discrete painful experience. Fear and prior painful experiences greatly affect Level of cognitive development, which deter- a child’s perception of painful events and are the pri- mines how children perceive the causes and effects mary influential factors in this model. Previous expe- of pain, may best be understood through the develop- riences with pain affect how children react to future mental stages defined by Jean Piaget (see Table 110, 11). events that are painful or potentially painful. Higher For example, infants ages zero to 12 months (de- levels of fear in children have been correlated with fined by Piaget as in the sensorimotor stage) do not higher levels of reported pain, anxiety, persistence of [email protected] AJN ▼ May 2019 ▼ Vol. 119, No. 5 35 pain, disability, and avoidance behaviors.12, 13 The ef- son’s ability to acknowledge, report, and effectively fects of fear based on prior painful experiences are of- cope with pain. ten observed in toddlers presenting to an urgent care Given the child’s age, which puts him at Piaget’s center shortly after vaccine administration. When a preoperational stage of cognitive development, in nurse approaches a recently vaccinated 18-month-old which children often perceive pain as punishment, he to clean and dress a superficial laceration, the toddler may plead with his mother, “Don’t make me get a may withdraw or cry, remembering the pain associ- shot. I promise I won’t get sick again.” The nurse ated with the shots and anticipating similar pain. In administering his injections can then guide the child’s this situation, the nurse should ask the parent whether mother in distraction techniques that can calm the the toddler had any recent painful experiences in a child’s fears and offer him reassurance that shots are health care setting, explaining that even having re- not a punishment for being sick but a way to help ceived a vaccination over the past few days may influ- him stay healthy and feeling well. ence a child’s response to subsequent health care visits. Anchor effects occur when the “anchors” (the ex- The nurse can then help the parent comfort and reas- tremes of a scale) influence the severity of a child’s self- sure the toddler both before and while providing nec- reported pain. For example, scales that use a smiling essary wound care. face to depict the bottom anchor (“no pain”) or a sad Societal expectations, stereotypical assumptions, face with tears to depict the top anchor (“most pain”) and familial cultural norms. Children learn how to may lead to false-negative or false-positive reports of experience, cope with, and report pain by observing pain, because children who feel happy are not neces- their parents’ and caregivers’ responses—and those sarily pain-free and children in no pain are not neces- responses are influenced by societal expectations and sarily happy.15 Furthermore, pain assessment tools that stereotypes. This is particularly evident in the way anchor the pain experience as “no pain” versus “most that sex-role socialization occurs within the family, pain” are often difficult for young children to under- with boys who receive parental cues that it is unac- stand, because the concept of “most” is abstract and ceptable to express pain tending to be less likely to re- relative, depending largely on the child’s previous ex- port pain.14 For example, a four-year-old boy recently periences with pain. Numeric or color anchors can hospitalized for surgery may fear needles and start to also evoke a child’s bias, as young children may not cry when taken to the office of his primary care pro- understand the quantitative significance of numbers, vider for immunization boosters. If his mother says, even if they know how to count, and color scales are “You’re a big boy now, and boys don’t cry,” she rein- not well researched.16 A child may be inclined to pick forces a stereotypical assumption about male behavior their favorite color or number rather than the color or that may reinforce sex-role expectations and affect her number that best corresponds with