Biobehavioral Measures for Pain in the Pediatric Patient

Mamoona Arif-Rahu, RN, PhD, CCRN; Deborah Fisher, RN, MS, CS, CPON; Yui Matsuda, RN, BSN


Pain Manag Nurs. 2012;13(3):157-168. 

In This Article

Abstract and Introduction


Pain is a complex biobehavioral phenomenon. The quantification of pain involves the incorporation of many factors, including physiologic, behavioral, and psychologic factors. Recognition of pain relies heavily on the expression of the patient as well as the interpretation of the caregiver. There are many studies published on biobehavioral pain assessment tools, such as neuroimaging, neuromuscular, biomarker, and behavioral pain assessment scales. These tools present a clinical challenge to appropriately assess and manage pain in the noncommunicative pediatric patients, such as infants, preverbal toddlers, and intubated and/or unconscious or cognitively impaired patients. Pain is a combination of physiologic, behavioral, and psychologic interactions. Any tool that incorporates the measurement of only one of those domains is inherently incomplete in the assessment of pain. Therefore, the purpose of this literature review was to provide a comprehensive overview of these biobehavioral pain assessment tools used in pain assessment in the noncommunicative pediatric population.


Pain is a complex biobehavioral phenomenon still not fully understood by researchers and clinicians alike. The goal of objectifying a highly subjective phenomenon in a noncommunicative pediatric population continues to perplex many researchers. For the nonverbal population, the American Society for Pain Management Nursing (ASPMN) recommends using multidimensional instruments that are characterized by both behavioral and physiologic indicators of pain (Herr, Coyne, Key, Manworren, McCaffery, Merkel, Pelosi-Kelly, & Wild, 2006). There are several studies that have addressed the need for a pain assessment tool that uses multimodal variables (Buttner and Finke, 2000, Gregg, 1998, Labus et al., 2003, Ramelet et al., 2004). The three approaches to pain assessment include cognitive (self-report), behavioral (cry, posture, and facial expression), and physiologic (heart rate variability, blood pressure fluctuations, decreases in oxygen saturation, and metabolic and endocrine increases). Of all of these options, self-report is still the gold standard in pain assessment. Unfortunately, when children cannot express themselves, self-report is not possible; further investigations and observations are needed for accurate pain assessment. Over the past 2 decades, there have been an increasing number of studies published on biobehavioral assessment tools such as neuroimaging, neuromuscular, biomarker, and behavioral pain assessment scales.


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