Pain's impact on adaptive functioning.

BACKGROUND: Pain interferes with the functioning of typical children, but no study has examined its effect on children with pre-existing intellectual disabilities (ID). METHODS: Caregivers of 63 children observed their children for 2-h periods and recorded in 1-week diaries: pain presence, cause, intensity and duration. Caregivers also recorded the children's performance of pre-existing skills during each period. Proportion of skills displayed when pain was present and absent was compared. Fifty caregivers completed a second set of observations when pain was present and absent. RESULTS: Comparison of the first set of observations indicated children displayed significantly more abilities (64%) when pain-free (Pain-Free Day 1), than when pain was present (54%; Pain Day 1). Children displayed 64% of their possible abilities during Pain-Free Day 2, but only 53% during Pain Day 2. Pain impacted all areas of function (communication, daily living, social and motor skills). Children's physical and demographic characteristics did not moderate the impact of pain on function, but functioning of children with more severe ID was most impacted by pain. CONCLUSIONS: Children perform fewer adaptive skills when pain is present. This could affect long-term functioning as well, through reduced practice of skills.

Facial expression of children receiving immunizations: a principal components analysis of the child facial coding system.

OBJECTIVE: To identify the structure of facial reaction to procedural pain and to determine the subset of facial actions that best describe the response. DESIGN: Observational. SETTING: Five rural and five urban physicians' offices. PATIENTS: One hundred twenty-three children aged 4 to 5 years undergoing routine diphtheria, pertussis, tetanus, and polio immunization. OUTCOME MEASURES: The Child Facial Coding System, comprising 13 discrete facial actions, was used to code each second of five 10-second phases from videotape: baseline, preneedle, needle, postneedle, and posthandling. Parents and a technician provided visual analog scale ratings of children's pain. Children provided a self-report using a Faces Pain Scale, and parents and nurses rated the children's pain and anxiety using visual analog scales. RESULTS: A "pain face" similar to that reported in adults emerged with the onset of pain. Principal component analyses revealed the frequency and intensity of facial action during the needle phase could be represented by components reflecting pain sensation, a "brave face," and the children's expectations for pain. Children's Faces Pain Scale and adult visual analog scale ratings were best predicted by components reflecting pain sensation and expectations of high pain. CONCLUSIONS: These results provide a preliminary indication that the Child Facial Coding System can be reduced to components that reflect several aspects of children's acute pain experience and predict self-reports and observer reports of children's pain.

Measuring pain accurately in children with cognitive impairments: refinement of a caregiver scale.

OBJECTIVE: To examine whether typical pain behavior, as reported by caregivers, could be used prospectively to predict future pain behavior and to derive a subset of core items from the Non-Communicating Children's Pain Checklist. STUDY DESIGN: Caregivers (n = 33) of children with cognitive impairments completed the Non-Communicating Children's Pain Checklist retrospectively and immediately after subsequent episodes of pain and distress in their homes. Odds ratios were computed for checklist items, and multiple regressions were used to predict numerical pain and distress ratings with items that had significant odds ratios. A logistic regression was used to test whether the items found to predict pain could correctly classify the presence or absence of pain in a new cohort of 63 children with similar cognitive impairments. RESULTS: Seven of the checklist items had significant odds ratios: Cranky, Seeking Comfort, Change in Eyes, Less Active, Gesture to Part That Hurts, Tears, and Gasping. This subset of items significantly predicted numerical pain ratings by caregivers (multiple R =.70), but not distress ratings (multiple R =.31). In a second group of 63 children with cognitive impairments, this subset of items displayed 85% sensitivity and 89% specificity for pain. CONCLUSION: A subset of items from the Non-Communicating Children's Pain Checklist could predict pain in children with cognitive impairments. Caregivers' retrospective reports may be useful for clinicians making judgments about pain in these children.

Preliminary validation of an observational pain checklist for persons with cognitive impairments and inability to communicate verbally.

To obtain a preliminary validation of the Non-Communicating Children's Pain Checklist for individuals with an inability to communicate verbally, 32 caregivers of individuals with cognitive impairments aged 3 to 44 years retrospectively completed the Non-Communicating Children's Pain Checklist and rated item usefulness (0 to 10). In the second part of the study 33 caregivers completed the Checklist after two painful (e.g. burns, falls, surgery), one distressful (e.g. unwanted grooming, feared animal/noise), and one calm event (e.g. watching television). Checklist scores did not correlate with the age, sex, or physical limitations of individuals with an inability to communicate verbally. In the first part of the study Cronbach's alpha was 0.66; all mean usefulness ratings exceeded 5 out of 10. In the second part of the study after four items were removed, Cronbach's alpha was 0.79. Checklist scores during pain correlated with numerical ratings of pain intensity did not differ between the two pain events, and differed significantly from calm scores. Differences in Checklist scores during pain and distress were found for two subscales. The Checklist exhibits internal consistency, and preliminary evidence suggests it can detect pain and is reliable over time.

Review of juvenile primary fibromyalgia and chronic fatigue syndrome.

This article reviews the current literature on childhood fibromyalgia and chronic fatigue syndrome. In doing so, it questions assumptions about the presumed nature of the disorders-that they are distinct from each other and are duplicates of their adult counterparts. It also attempts to synthesize the available data to reach some preliminary judgments about these disorders: that fibromyalgia and chronic fatigue syndrome may be related in children and may not be duplicates of the adult disorders; that psychological and psychosocial factors are unlikely contributors to the etiology of these disorders; and that the evidence is increasingly pointing to a role for genetic factors in their etiology. A discussion of the research into treatments for childhood fibromyalgia and chronic fatigue syndrome highlights the lack of well-designed, controlled studies. Finally, directions for future research are offered where results of the current literature are unclear.

Facilitative and inhibitory effects of location and frequency cues: evidence of a modulation in perceptual sensitivity.

The possibility that facilitative and inhibitory effects of auditory cues result because of a modulation in perceptual sensitivity was examined. Listeners were presented with a cue followed by a target, with the time period between the two varied at stimulus onset asynchronies (SOAs) of 150, 450, or 750 msec. In two conditions, the cue and target were either the same or different in location or frequency. In both conditions, listeners were required to identify the rise time of the target. Whereas the cue was presented in isolation, the target was presented in a wide-band noise background such that the required discrimination was made relatively difficult. In both conditions, a facilitative effect was apparent at the 150-msec SOA and an inhibitory effect was apparent at the 750-msec SOA for both accuracy and response time measures of performance. That these results were apparent for a judgment unrelated to the manipulated cue-target relation suggests strongly that both location-based and frequency-based auditory inhibition of return result primarily because of changes in perceptual sensitivity.

Inhibitory processes in auditory selective attention: evidence of location-based and frequency-based inhibition of return.

The possibility that there is an inhibitory component to auditory covert orienting was addressed. Each trial consisted of a cue followed by a target, and listeners were required to detect, localize, or identify the frequency of the target. At 150-msec stimulus onset asynchrony (SOA), performance was best when stimuli sounded from the same location or were of the same frequency. However, at 750-msec SOA, performance was best when stimuli differed in location or were of different frequencies. These results document the existence of both location-based and frequency-based auditory inhibition of return.