Evidence-based Assessment of Pediatric Pain

Lindsey L. Cohen, PhD; Kathleen Lemanek, PhD; Ronald L. Blount, PhD; Lynnda M. Dahlquist, PhD; Crystal S. Lim, MA; Tonya M. Palermo, PhD; Kristine D. McKenna, MS; Karen E. Weiss, MS


J Pediatr Psychol. 2008;33(9):939-955. 

In This Article

Abstract and Introduction


Objective: To conduct an evidence-based review of pediatric pain measures.
Methods: Seventeen measures were examined, spanning pain intensity self-report, questionnaires and diaries, and behavioral observations. Measures were classified as "Well-established," "Approaching well-established," or "Promising" according to established criteria. Information was highlighted to help professionals evaluate the instruments for particular purposes (e.g., research, clinical work).
Results: Eleven measures met criteria for "Well-established," six "Approaching well-established," and zero were classified as "Promising."
Conclusions: There are a number of strong measures for assessing children's pain, which allows professionals options to meet their particular needs. Future directions in pain assessment are identified, such as highlighting culture and the impact of pain on functioning. This review examines the research and characteristics of some of the commonly used pain tools in hopes that the reader will be able to use this evidence-based approach and the information in future selection of assessment devices for pediatric pain.


Pain is the most common reason people present for health care, pain costs to society are exorbitant, and pain can have a widespread impact on all aspects of life (Stewart, Ricci, Chee, Morganstein, & Lipton, 2003). The importance of attending to pain is highlighted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; Phillips, 2000) directives that it be considered the "fifth vital sign" to monitor in medical care. However, it is not readily evident how pain should be monitored.

Pain is both a sensory and emotional personal experience, making assessment complex (Melzack & Wall, 1965). Further, pain occurs across a spectrum of conditions including acute injuries and medical events, recurrent or chronic pain, and pain related to chronic disease. Acute pain is typically brief, ending around the time of the healing of an injury, or the termination of the stretching, contraction, or impingement of some part of the body (Cohen, MacLaren, & Lim, 2007). Chronic pain, on the other hand, may or may not be symptomatic of underlying, ongoing tissue damage or chronic disease. It can persist long after an initial injury has healed or other event has occurred (typically longer than 3 months) (Cohen, MacLaren, & Lim, 2007). Clearly, evaluating pain is complicated both by the personal nature of the experience and the variety of forms in which it can exist.

The assessment of children's pain is especially problematic as younger children or those with developmental delays often do not have the language or cognitive sophistication to describe their pain. Unfortunately, pain is a frequent and vivid part of childhood, whether as part of routine care (e.g., immunization injections) or a symptom of a chronic illness (e.g., chronic sickle cell disease pain). Outside of the medical arena, children experience frequent bumps, bruises, and injuries as they acquire coordination and adapt to their quickly developing body.

Accurate assessment of children's pain is needed to diagnose conditions and to guide pain management interventions; especially given the accumulating research suggesting that untreated pain may have long-term negative and permanent repercussions on pain sensitivity, immune functioning, neurophysiology, attitudes, and health care behavior (for a review, see Young, 2005). Instruments measuring pain intensity, location, and affect are typically used to assess acute pain of relatively brief duration. Measurement of recurrent and chronic pain requires tools that also measure the frequency, duration, time course, and activity interference due to pain.

Over the past 15 years, significant research attention has been devoted to developing instruments to quantify children's pain. Whereas there are descriptions and summaries of measures (Finley & McGrath, 1998; O’Rourke, 2004), there are only a few critical evaluations and comparisons of pain measures. Recently, the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (Ped-IMMPACT) commissioned reviews to identify measures to use in pediatric pain clinical research trials. The Ped-IMMPACT papers have included one on self-report (Stinson, Kavanagh, Yamada, Gill, & Stevens, 2006) and one on observational measures (von Baeyer & Spagrud, 2007). These two reviews and the current report have similarities, for example, both used the same Society of Pediatric Psychology Assessment Task Force criteria (Cohen, La Greca, Blount, et al., 2007). In addition, where the groups overlapped, there are generally consistent recommendations. For example, all measures that were included in both the Ped-IMMPACT and current reports were rated as "well-established."

Although there are consistencies, the current review and the Ped-IMMPACT reviews differ in a number of ways. One distinction is that the current review spans a broad focus on pain intensity, distress behaviors, and caregiver behaviors using self-report, questionnaire, diary, and observational instruments, as well as infants through adolescents. The Ped-IMMPACT reviews focus on children and adolescents 3–18 years of age and focus on self-report (Stinson) and observational (von Baeyer & Spagrud) measures. The most distinguishing aspect of the current review is its purpose. Specifically, we sought to apply an evidence-based framework for evaluating a number of popular and diverse pain tools that are used by pediatric psychologists. We present the strengths and limitations of measures used in the field of pediatric psychology to assess pain. Thus, interested parties can make informed decisions in critiquing and selecting measures for their particular purpose, population, and situation (e.g., clinical work, randomized clinical trials). In other words, whereas the Ped-IMMPACT reviews take a more nomothetic approach to establish broad recommendations or guidelines for clinical trials, the current review adopts an idiographic perspective to help professionals identify measures to answer their unique questions. Given that both groups relied on a combination of objective and systematic as well as expert opinion or subjective methods in the selection and evaluation of measures, there were measures distinct to Ped-IMMPACT or the current review. For example, the current review did not include the FLACC (Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997) or the Post-operative Pain at Home Scale (PPPM; Chambers, Reid, McGrath, & Finley, 1996), which were included by von Baeyer & Spagrud. Likewise, a number of measures included in the current review were omitted in the Ped-IMMPACT papers. The various differences between the Ped-IMMPACT and this review may be attributed to the differences in the purpose, process, methodology, and decisions of the reviewing committees.


The American Psychological Association (APA), Division 54, Society of Pediatric Psychology (SPP) Assessment Task Force commissioned this review to provide evidence-based assessment of pediatric pain. We adopted the APA definition of evidence-based practice, which states that "Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences" (APA Presidential Task Force on Evidence-based Practice, 2006). For the purposes of our review, along with "patient," we have included "research participant," "research sample," "setting," and other relevant situational variables. From this approach, we acknowledge that selection of a pain measure will depend on a number of factors including the research base (e.g., psychometrics, prior findings), patient/situation characteristics (e.g., age, culture, time available for assessment), and clinical expertise (e.g., weighing particular research findings and situational aspects; experience needed to perform, score, or interpret the measure). In our review of measures, we highlight some of the research base and relevant patient/situation characteristics. Where pertinent, we identify aspects of the measure related to needed expertise.

Measure Selection

Selection of measures was conducted in multiple stages. First, in 2002, a list of assessment measures was generated by the SPP Assessment Task Force in broad areas of interest, one of which was pain. Second, the survey was distributed via the Internet to the SPP listserv. Eighty-seven respondents completed the survey. These respondents identified an additional three pain measures not initially included in the survey. Third, we discussed the responses, surveyed the literature, and consulted other pain measure review sources. This process occurred during 2005–2006. Based on this search and evaluation, we selected a pool of measures seen as those that are commonly used by pediatric psychologists across self-report, interviews and questionnaire, observational, and diary formats. We selected instruments that represented a range of type of measure (e.g., self-report, observational) and are popular in the pediatric psychology literature. In 2007, another literature search was conducted specifically to identify additional studies using the measures included in our review. This review was not intended to be exhaustive or comprehensive. Given that the best measures will depend on the questions being asked, and that the pain assessment research literature is evergrowing; we did not attempt to detail a list of the "best" measures, but rather, we adopted an evidence-based approach in evaluating popular pediatric pain measures. The final list of 17 measures consisted of five pain intensity self-reports, four questionnaire and diary, and eight observational instruments ( Table I ). When making the decision of which measures to highlight in our review, we aimed for presenting a range of measures and ones that are commonly used by pediatric psychologists. We acknowledge that the review is not comprehensive, and that the available research base for pain measure is ever-changing.

Assessment Criteria for Research Base

As detailed in the lead article in this series, assessment criteria were developed to apply to the measures reviewed (Cohen, La Greca, Blount, et al., 2007), in order to establish some of the research base supporting the measure. Accordingly, the instruments were classified as "Well-established assessment" (e.g., at least two research teams have published, sufficient information available to evaluate the measure, good psychometric properties), "Approaching well-established" (e.g., presented in at least two articles, sufficient detail available, moderate or vague psychometrics presented), or "Promising assessment" (e.g., at least one peer-reviewed article, sufficient detail available, moderate or vague psychometrics). Although interpretation and application of these criteria were left to the workgroup authors, the SPP Assessment Task Force circulated documents detailing considerations for interpreting the validity and reliability of a variety of measures. Inter-rater agreement was assessed to evaluate the reliability of our ratings of the pain measures. Specifically, a detailed summary of each measure was developed and was sent along with the task force criteria to a pain researcher who was not an author or collaborator on the current review. The authors’ ratings and those of the outside rater showed high agreement with only one instance of disagreement, which resulted in a κ of.87 and a weighted κ of.89.

We should note that the criteria used by this committee highlight the quality of the research base for a given measure, but do not provide an evaluation of the overall quality of a measure. In order to truly critique a measure and deem it the best one in a particular situation, it is necessary to know the questions being asked, the particular personal and contextual circumstances in which it will be used, and the expertise of the individual administering the instrument.


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