“Psychology Works” Fact Sheet: Pain Assessment in Children

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How do I know what type of pain my child is experiencing?

When assessing your child’s pain, it is important to distinguish between acute pain and chronic pain.

Acute pain describes pain that happens when body tissues are damaged by injuries, infections or painful procedures such as surgery or vaccinations. Acute pain usually comes on quickly and goes away after a few hours, days, or weeks. It is our body’s warning system to alert us that something is wrong. Typically, we can see acute pain with the naked eye such as swelling, a cut, an infected wound, a burn, or skin that is warm to the touch. We can respond to this type of pain using the “3P” approach: focusing on physical, psychological, and pharmacologic (medicines) strategies such as protecting the painful area, distracting ourselves, and taking pain medicines if necessary.

Chronic pain describes pain that is continuous or recurring, that lasts more than 3 months, and that continues even after an injury has healed. Chronic pain is different than acute pain in that it does not always signal that something is wrong. Chronic pain is often called an “invisible condition” – it is rare to see evidence of chronic pain with the naked eye and there are no blood tests or imaging (x ray, MRI) that show chronic pain. This is because chronic pain often occurs within the nervous system and requires the “3P” approach as part of pain management. Chronic pain can occur as part of a disease (e.g., arthritis) or can be a disease in its own right (e.g., chronic back pain).  Chronic pain is influenced by many factors such as one’s genetics, culture, temperament, parents’ responses to pain, and thoughts and feelings.

What are important considerations when assessing my child’s pain?

There are several factors to consider when assessing your child’s pain. The main way to assess pain is through self-report and through observing your child’s behaviour. Your child’s age and ability to communicate are important factors. Whenever possible, you should seek your child’s self-report of their pain. Pain is a subjective experience, and it is difficult to tell how much pain someone is experiencing just by looking at them. This means that it is generally best to ask the person in pain to tell you how much pain they are experiencing. Observers can be biased when assessing pain and tend to underestimate a child’s pain, so it is important to listen to and observe your child and believe their report.

Age:

Younger children have different ways of expressing pain than older children, and more likely to use words like “hurt” versus “pain”. For younger children (infants and toddlers) who cannot yet communicate their pain verbally, behaviours such as grimacing, flailing legs, irritability, and muscle tension can indicate pain. There is a tool called FLACC (Faces, Legs, Activity, Cry, Consolability) that can help you assess whether your baby or toddler is in pain. Typically developing children as young as 6 years old can use a pain scale to rate the intensity of their pain. For children and youth who have a good sense of numeracy, you can ask them to rate their pain on a scale of 0-10, with 0 being ‘no pain’, and 10 being ‘the worst pain imaginable’. This is called the 11-point Numeric Rating Scale. For children who don’t have a good sense of numeracy, you can also use a tool called the Faces Pain Scale-Revised. This tool shows five different faces that a child chooses from to help you understand how much pain they are feeling. When in doubt, onsider a preceding yes-no question about whether a child is hurt or in pain, and then supplement with observer assessment of pain behaviours.

Ability to Communicate:

Children who do not communicate verbally and/or are cognitively impaired often require different ways to assess pain versus their typically developing peers. If your child can report on their pain in their own way, it is best to use their self-report. If your child is not able to self-report, you are the best person to gauge your child’s pain, as you know them best. You can look for changes in vocal and social behaviour, facial expression, activity, and physical signs. The CPA has a fact sheet on pain in children with intellectual disabilities. You can also use FLACC for your child.

Gender:

Boys may be less likely to express their pain than girls. Even if your child does not express their pain verbally it is important to pay attention for any behavioural signs that your child may be uncomfortable (e.g., withdrawal from activities your child enjoys, changes in mood, holding the affected limb and/or grimacing).

Marginalized and/or racialized children:

Research shows that all children can feel the same amount of pain, but that healthcare professionals’ false beliefs and attitudes influence their assessment of pain in children who are marginalized and/or racialized in society (e.g., different race, culture, language, immigration status). Asking and believing the report of pain from the child who is experiencing it is best. Parents and/or caregivers are important advocates to make sure that a child’s pain is understood and treated.

Considering the whole pain experience:

Assessing your child’s pain should include more than just the location, severity, and frequency of their pain. Understanding the whole pain experience includes not only the biological, but also the psychological and social aspects of a child’s pain (called the ‘biopsychosocial model’). For instance, it is important to consider your child’s thoughts (e.g., viewing pain as a threat), emotions (e.g., anxiety, low mood), personality, and ability access to medical treatment. Reactions by their parents, family members, friends, and teachers to their pain can also influence how children feel. It is important to consider all these factors when assessing your child’s pain.

Where do I go for more information?

 You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to  https://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Danielle Ruskin. Elise Kammerer, and Kathryn Birnie in partnership with Solutions for Kids in Pain (SKIP), a national knowledge mobilization network whose mission is to improve children’s pain management by mobilizing evidence-based solutions through coordination and collaboration.

Date: October 2022

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