Clinical Interview

In addition to soliciting a careful description of the patient's pain, the clinical interview should review factors that are related to pain perception and disability. The Piagetian stages of cognitive development provide a helpful context for understanding a child's or adolescent's experience of pain (Gaffney et al. 2003) (see Table 9-3).

Table 9-2. Pain assessment tools

Type of measure Name of measure

Description of measure

Child/adolescent self-report measures

Parent observational (behavioral) measures

Clinician observational (behavioral) measures

Poker Chip Tool (Hester 1979; Hester et al. 1990)

Faces Pain Scale-Revised (Hicks et al. 2001)

Visual analog scale

Pain diaries

Parents' Postoperative Pain Measure (Chambers et al. 1996)

FLACC (Merkel et al. 1997)

Children's Hospital of Eastern Ontario Pain Scale (McGrath et al. 1985)

COMFORT Scale (Ambuel et al. 1992)

For children ages 3-7 years. This tool, scored from 0 to 4, consists of a set of four red plastic poker chips, each reflecting a "piece of hurt." The child is asked to use the poker chips to show "how many pieces of hurt" he or she has right now.

For children ages 4-16 years. This scale consists of six gender-neutral line drawings of faces depicting different intensities of pain. The child points to the face that shows how much he or she hurts.

For ages 3 years to adulthood. A visual analog scale is a line with descriptive or numerical anchors on a continuum of pain intensity, anchored at one end by no pain (0) and at the other by worst pain imaginable (10). The child rates his or her current pain by making a mark across the line.

For children ages 6 years and older (ideal age range unknown). Pain diaries are typically used to assess recurrent or chronic pain, correlates of pain symptoms, and/or response to treatment. They might include rating scales and questions related to pain intensity, disability, perceived triggers, coping strategies used, consequences, medications used, and medication efficacy.

For children in acute pain who are age 1 year and older. Using the 15-item scale, parents observe and report changes from their children's usual behavior.

For children in the hospital with procedural or postoperative pain who are ages 1 year and older. Similar to the APGAR, FLACC is a 5-item scale with scores from 0 to 2 for each item—Face, Legs, Activity, Cry, and Consolability; item scores are combined for a total score ranging from 0 to 10.

For children in the hospital with procedural or postoperative pain who are age 1 year and older. Using the 6-item scale, raters choose a score anchored by a behavioral description of the following: crying, facial expression, verbal expression, torso position, touch, and leg position.

For children in critical care who are ages 1 year and older. Distress is assessed based on the child's alertness, calmness/agitation, respiration, physical movement, blood pressure change, heart rate change, muscle tone, and facial tension.

Table 9-3. Piagetian stages of cognitive development and the experience of pain

Developmental stage Typical implications related to pain

Sensorimotor (birth to Children at this stage are mostly preverbal, without capacity to create narratives about 2 years old) to explain their experiences.

They are most likely to demonstrate pain by social withdrawal or changes in patterns of sleep, eating, and level of activity.

By age 18 months, most typically developing children make efforts to localize pain and seek reassurance from adults. By age 2 years, children are often able to use specific words to indicate the presence of pain.

Preoperational (about 2-7 Children at this stage use words and understand basic concepts of cause and years old) effect. However, they tend to erroneously see events that are temporally related as causally related.

They may view pain as a punishment for the real or imagined transgression of rules.

They are not able to use self-generated coping strategies and tend to rely on their environment (e.g., the support of adults).

They have difficulty using rating scales. They also have difficulty differentiating pain from anxiety or fear.

Concrete operational Children at this stage can apply logic to their perceptions in a more integrative

(about 7-11 years old) manner. However, the logic is literal (concrete) and allows for only one cause for an effect.

Interventions that are concrete make more sense to children at this stage. For example, applying a topical anesthetic to a painful part makes more sense to them than pain relief via oral or intravenous medication.

They are likely to be able to use a rating scale for pain assessment, and they have an increased ability to use self-initiated coping strategies such as distraction or guided imagery.

Formal operational Children at this stage can use abstract reasoning to discuss body systems and can

(11+ years old) conceptualize multiple causes of pain.

They are potentially more aware of the psychological aspects of pain and better able to understand a biopsychosocial model.

Their greater ability to focus on future events may lead to greater worries and concerns about the pain.

Not all adolescents (or parents) can use abstract reasoning. Most adults engage in abstract reasoning only in areas of their own expertise, if at all. In addition, many children tend to regress in stressful situations.

For pain treatment recommendations to make sense, the clinician often needs to provide biopsy-chosocial pain education before, during, and/or after the assessment. The clinician should avoid the dichotomy between a medical and a psychiatric etiology for the pain, explain that all pain has biological and psychological aspects to it, and present the goal of optimal pain management by addressing all contributing factors. Providing examples of the bio-psychosocial model applied to other medical conditions is sometimes helpful. To reinforce the bio-psychosocial approach, medical and psychiatric evaluations should be conducted concurrently when feasible, regardless of presumed etiology for the pain.

Individuals experiencing pain have significant variations in pain sensitivity and the consequent need for analgesics. Distress and pain severity are not always linearly related among those with either acute or chronic pain. Also, pain-related disability is related to many factors in addition to pain severity and distress. Regardless of the type of pain, the following domains are helpful to assess: current pain and pain history, other physical symptoms, pain beliefs, coping strategies and consequences, physical functioning, emotional and cognitive functioning, and family functioning. For children with recurrent, uncontrolled, or chronic pain, the clinician should also carefully assess behaviors outside the hospital setting, such as social functioning and academic functioning. Table 9-4 provides a summary of topics to cover in these domains.

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