Ability of 3- to 5-year-old children to use simplified self-report measures of pain intensity.

Little is known about self-report pain intensity scales best suited for young children. We tested the ability of preschool children to use two simplified scales (concrete ordinal and faces). Three- to 5-year-olds (n = 123) were asked to make binary discriminations ('less' vs 'more' pain) between response options using the Simplified Faces Pain Scale and Simplified Concrete Ordinal Scale and to complete a seriation task. Eighty participants were also asked to use the Simplified Concrete Ordinal Scale, with modified verbal anchors, to rate the loudness of tones and to assess practice effects. Binary discrimination accuracy and seriation ability improved with age. When using the Simplified Concrete Ordinal Scale to rate the loudness of tones, even the 3-year-olds performed significantly better than chance, and performance was better in 4- and 5-year-olds. Little evidence supported the ability of 3-year-olds to use either of the simplified tools in the pain context. The 4-year-olds demonstrated greater accuracy in using the Simplified Concrete Ordinal Scale than the Simplified Faces Pain Scale, suggesting that the Simplified Concrete Ordinal Scale may be more appropriate for this age group.

Changes in Pain Score Associated With Clinically Meaningful Outcomes in Children With Acute Pain.

BACKGROUND: Identifying changes in pain score associated with clinically meaningful outcomes is necessary when using self-report measures to assess pain in children. We aimed to determine the changes in pain score associated with a minimum clinically significant difference (MCSD), ideal clinically significant difference (ICSD), and patient-perceived adequate analgesia (PPAA) and to evaluate for differences based on initial pain intensity and patient characteristics. METHODS: This was a cross-sectional study of children 6 to 17 and 4 to 17 years old who were assessed using the Verbal Numerical Rating Scale (VNRS) and Faces Pain Scale-Revised (FPS-R), respectively. Children qualitatively described any endorsed change in pain score; those who received an analgesic were asked if they wanted additional analgesics to decrease their pain intensity. We used a receiver operating characteristic curve-based methodology to identify changes in pain score associated with "a little less" and "much less" pain (MCSD and ICSD, respectively) and patients declining additional analgesics because of adequate analgesia (PPAA). RESULTS: We enrolled 431 children with painful conditions. For the VNRS, raw change and percent reductions in pain scores associated with MCSD, ICSD, and PPAA were 2/10 and 20%, 3/10 and 44%, and 2/10 and 29%, respectively, and for the FPS-R, 2/10 and 33%, 4/10 and 60%, and 4/10 and 40%, respectively. Raw change in pain scores increased with increasing initial pain intensity, but percent reductions remained stable. There were no significant differences based on patient characteristics such as age, sex, and race/ethnicity. CONCLUSION: Our findings provide patient-centered outcomes in children that are suitable for designing trials and are generalizable across patient characteristics.

Pain in Child Health from 2002 to 2015: The early years of an international research training initiative.

Background: The 2018 Global Year for Excellence in Pain Education, an initiative of the International Association for the Study of Pain, brought worldwide attention to the need for education that crosses narrow disciplinary boundaries, addresses up-to-date research methods and findings, and encourages teamwork among trainees and mentors at different levels of training and with different perspectives. Aims: This commentary describes the development of Pain in Child Health (PICH), an interdisciplinary training program for researchers in pediatric pain at the undergraduate, graduate, and postdoctoral levels of training. Methods: Based on documentation of the structure, training processes, leadership, and membership of PICH, we outline its organization and its challenges and accomplishments over the first 12 years of its growth into a well-known international program. Results and Conclusions: Pain in Child Health began as a Strategic Training Initiative of the Canadian Institutes of Health Research in 2002 and developed into an international research training consortium featuring cross-site and cross-discipline mentorship and collaboration. PICH trainees and alumni have contributed extensively to the current scientific literature on children's pain. PICH could serve as a possible model for training and mentorship in other specialized health research domains within and outside thestudy of pain.

Contexte: En 2018, l'Année internationale pour l'excellence en éducation sur la douleur, une initiative de l'Association internationale pour l'étude de la douleur, a attiré l'attention partout dans le monde sur l'importance d'une éducation qui transcende les frontières étroites entre les disciplines, qui aborde les méthodes et les résultats de la recherche les plus actuels et qui encourage le travail d'équipe parmi les apprenants et les mentors à différents niveaux de formation et à partir de différentes perspectives.But: Ce commentaire décrit l'évolution de Pain in Child Heath (PICH), un programme de formation interdisciplinaire destiné aux chercheurs en douleur pédiatrique à tous les niveaux de formation : premier cycle, cycles supérieurs et postdoctoral.Méthodes: À partir de la documentation portant sur la structure, les processus de formation, le leadership et les caractéristiques des membres du PICH, nous décrivons son organisation, ses difficultés et ses accomplissements au cours de ses premiers douze ans, jusqu'à ce qu'il devienne un programme international de renom.Résultats et conclusions: À ses débuts, Pain in Child Health était une initiative de formation stratégique des Instituts de recherche en santé du Canada en 2002. Il s'est par la suite transformé en consortium international de formation à la recherche axé sur le mentorat et la collaboration entre différents sites et différentes disciplines. Les étudiants et les anciens du PICH ont largement contribué à la littérature scientifique sur la douleur pédiatrique. Le PICH pourrait possiblement servir de modèle en matière de formation et de mentorat dans d'autres domaines de recherche spécialisée en santé, que ce soit dans le contexte de l'étude de la douleur ou dans un autre contexte.

Boo-boos as the building blocks of pain expression: An observational examination of parental responses to everyday pain in toddlers.

BACKGROUND: Everyday pain experiences (minor bumps/scrapes) are common in early childhood and create frequent opportunities for socialization of pain behaviors. Nevertheless, everyday pain during the formative toddler period has been largely overlooked. AIMS: The aim of the current study was to describe the frequency and nature of toddlers' everyday pain experiences, child and parent responses, and the relationship between child characteristics (age, sex, temperament) and responses. METHODS: Fifty-two children aged 12-32 months and their parents were observed at an indoor play facility. Using an observational checklist, trained observers recorded children's everyday pain incidents and associated child and parent responses. RESULTS: Overall, 101 pain incidents were observed, the majority of which evoked low levels of pain and distress, which resolved after 1 min. Pain incidents occurred at a rate of 1.02 incidents/child/hour, with 81% of children experiencing at least one incident, which is higher than previous research with preschoolers and daycare staff. Common parent responses included a range of verbal (reassurance) and nonverbal (staying closer, hugging/kissing child) behaviors. Boys were more likely to not exhibit any protective behaviors. Parents were more likely to pick up older toddlers. CONCLUSIONS: Future research should examine the link between self-reported and observed parent responses to child pain in everyday and clinical contexts.

Contexte: Les expériences douloureuses quotidiennes (bosses et éraflures mineures), courantes chez les jeunes enfants, créent des occasions fréquentes de socialisation des comportements liés à la douleur. Néanmoins, la douleur de tous les jours pendant la période formative des tout-petits a été largement néligée.Buts: Le but de cette étude était de décrire la fréquence et la nature des expériences douloureuses de tous les jours chez les tout-petits, les réponses des enfants et des parents à ces expériences, ainsi que le lien entre les caractéristiques de l'enfant (âge, sexe, tempérament) et ces réponses.Méthodes: Cinquante-deux enfants âgés de 12 à 32 mois et leurs parents ont été observés dans un espace de jeu intérieur. À l'aide d'une grille d'observation, des observateurs dûment formés ont noté les incidents douloureux de tous les jours vécus par les enfants ainsi que les réponses des enfants et des parents à ces incidents.Résultats: Dans l'ensemble, 101 incidents douloureux ont été observés, dont la majorité a suscité des niveaux de douleur et de détresse faibles, résolus après une minute. Les incidents douloureux sont survenus à un rythme de 1,02 incident/enfant/heure et 81 % des enfants ont vécu au moins un incident, ce qui est plus élevé que les études antérieures portant sur des enfants d'âge préscolaire et le personnel de services de garde. Les réponses les plus courantes des parents comprenaient toute une gamme de comportements verbaux (rassurer) et non-verbaux (rester plus proche, étreindre ou embrasser l'enfant). Les garçons étaient plus suceptibles de ne pas démontrer de comportements de protection. Les parents étaient plus susceptibles de prendre les tout-petits plus âgés dans leurs bras.Conclusions: D'autres études devraient se pencher sur le lien entre les réponses auto-déclarées et les réponses observées des parents à la douleur de tous les jours chez les enfants ainsi qu'à la douleur dans un contaxte clinique.

Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain.

STUDY OBJECTIVE: The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity. It is unclear how the validity and reliability of the scale scores vary across children's ages. We aimed to determine the validity and reliability of the scale for children presenting to the emergency department across a comprehensive spectrum of age. METHODS: This was a cross-sectional study of children aged 4 to 17 years. Children self-reported their pain intensity, using the Verbal Numerical Rating Scale and Faces Pain Scale-Revised at 2 serial assessments. We evaluated convergent validity (strong validity defined as correlation coefficient ≥0.60), agreement (difference between concurrent Verbal Numerical Rating Scale and Faces Pain Scale-Revised scores), known-groups validity (difference in score between children with painful versus nonpainful conditions), responsivity (decrease in score after analgesic administration), and reliability (test-retest at 2 serial assessments) in the total sample and subgroups based on age. RESULTS: We enrolled 760 children; 27 did not understand the Verbal Numerical Rating Scale and were removed. Of the remainder, Pearson correlations were strong to very strong (0.62 to 0.96) in all years of age except 4 and 5 years, and agreement was strong for children aged 8 and older. Known-groups validity and responsivity were strong in all years of age. Reliability was strong in all age subgroups, including each year of age from 4 to 7 years. CONCLUSION: Convergent validity, known-groups validity, responsivity, and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years. Convergent validity was not strong for children aged 4 and 5 years. Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older, but not for those aged 4 and 5 years.

Defining No Pain, Mild, Moderate, and Severe Pain Based on the Faces Pain Scale-Revised and Color Analog Scale in Children With Acute Pain.

OBJECTIVES: The aims of this study were to define the Faces Pain Scale-Revised (FPS-R) and Color Analog Scale (CAS) scores associated with no pain, mild pain, moderate pain, and severe pain in children with acute pain, and to identify differences based on age, sex, and ethnicity. METHODS: We conducted a prospective observational study in 2 pediatric emergency departments of children aged 4 to 17 years with painful and nonpainful conditions. We assessed their pain intensity using the FPS-R, CAS, and qualitative measures. Pain score cut points that best differentiated adjacent categories of pain were identified using a receiver operating characteristic-based method. Cut points were compared within subgroups based on age, sex, and ethnicity. RESULTS: We enrolled 620 patients, of whom 314 had painful conditions. The mean age was 9.2 years; 315 (50.8%) were in the younger age group (aged 4-7 years); 291 (46.8%) were female; and 341 (55%) were Hispanic. The scores best representing categories of pain for the FPS-R were as follows: no pain, 0 and 2; mild pain, 4; moderate pain, 6; and severe pain, 8 and 10. For the CAS, these were 0 to 1, 1.25 to 2.75, 3 to 5.75, and 6 to 10, respectively. Children with no pain frequently reported nonzero pain scores. There was considerable overlap of scores associated with mild and moderate pain. There were no clinically meaningful differences of scores representing each category of pain based on age, ethnicity, and race. CONCLUSIONS: We defined pain scores for the FPS-R and CAS associated with categories of pain intensity in children with acute pain that are generalizable across subgroups based on patient characteristics. There were minor but potentially important differences in pain scores used to delineate categories of pain intensity compared to prior convention.

Systematic Review of Self-Report Measures of Pain Intensity in 3- and 4-Year-Old Children: Bridging a Period of Rapid Cognitive Development.

Claims are made for the validity of some self-report pain scales for 3- and 4-year-old children, but little is known about their ability to use such tools. This systematic review identified self-report pain intensity measures used with 3- and/or 4- year-old participants (3-4yo) and considered their reliability and validity within this age span. The search protocol identified research articles that included 3-4yo, reported use of any pain scale, and included self-reported pain intensity ratings. A total of 1,590 articles were screened and 617 articles met inclusion criteria. Of the included studies, 98% aggregated self-report data for 3-4yo with data for older children, leading to overestimates of the reliability and validity of self-report in the younger age group. In the 14 studies that provided nonaggregated data for 3-4yo, there was no evidence for 3-year-old and weak evidence for 4-year-old children being able to use published self-report pain intensity tools in a valid or reliable way. Preschool-age children have been reported to do better with fewer than the 6 response options offered on published faces scales. Simplified tools are being developed for young children; however, more research is needed before these are adopted. PERSPECTIVE: Some self-report pain scales have been promoted for use with 3- and 4-year-old children, but this is on the basis of studies that aggregated data for younger and older children, resulting in overestimates of reliability and validity for the preschool-age children. Scales with fewer response options show promise, at least for 4-year-old children.

Validity of Simplified Versus Standard Self-Report Measures of Pain Intensity in Preschool-Aged Children Undergoing Venipuncture.

There are inadequate age-specific data to support the use of current self-report pain scales in 3- and 4-year-old children. Most preschool-aged children also lack the necessary cognitive development to use standard scales. We aimed to evaluate the validity and feasibility of 2 novel simplified scales (Simplified Faces Pain Scale, S-FPS; Simplified Concrete Ordinal Scale, S-COS) for preschool-aged children. These simplified scales used a 2-step self-report method: children were first asked whether they have pain (yes/no); only if yes, then pain intensity was self-reported using a 3-point scale with visual aids signifying mild/moderate/severe. We recruited 180 3- to 6-year-old children undergoing routine blood collection. Each child was randomly assigned 2 of 3 scales-S-FPS, S-COS, Faces Pain Scale-Revised (FPS-R)-to self-report pain before venipuncture, immediately after, and 5 minutes later, using both scales at each time-point. Pain was also assessed using observation (Face Legs Activity Cry Consolability) at each time point. The ability to discriminate pain from no pain was improved with S-FPS and S-COS, compared with the FPS-R, among 4-year-olds, but not 3-year-olds. Correlation with Face Legs Activity Cry Consolability was moderate to strong and cooperation rates were similar for all self-report scales. The simplified scales can improve and simplify pain assessment for 4-year-olds. Quantitative pain rating remains challenging for 3-year-olds. PERSPECTIVE: This study evaluated 2 novel simplified pain assessment tools for preschool-aged children undergoing blood sampling. These scales demonstrated good validity and feasibility compared with the FPS-R, suggesting these simplified pain scales may have a role in clinical practice for children as young as 4 years.

Psychometric Properties of the Numerical Rating Scale to Assess Self-Reported Pain Intensity in Children and Adolescents: A Systematic Review.

OBJECTIVES: The Numerical Rating Scale-11 (NRS-11) is one of the most widely used scales to assess self-reported pain intensity in children, despite the limited information on its psychometric properties for assessing pain in pediatric populations. Recently, there has been an increase in published findings regarding the strengths and weaknesses of the NRS-11 as a measure of pain in youths. The purpose of this study was to review this research and summarize what is known regarding the reliability and validity of the NRS-11 as a self-report measure of pediatric pain intensity. METHODS: A literature search was conducted using PubMed, PsycINFO, CINAHL, and the Psychology and Behavioral Sciences Collection from their inception to February 2016. RESULTS: A total of 382 articles were retrieved, 301 were screened for evaluation, and 16 were included in the review. The findings of reviewed studies support the reliability and validity of the NRS-11 when used with children and adolescents. DISCUSSION: Additional research is needed to clarify some unresolved questions and issues, including (1) the minimum age that children should have to offer valid scores of pain intensity and (2) the development of consensus regarding administration instructions, in particular with respect to the descriptors used for the upper anchor. On the basis of available information, the NRS-11 can be considered to be a well-established measure for use with pediatric populations.

Optimizing Numeric Pain Rating Scale administration for children: The effects of verbal anchor phrases.

Background: The 0-10 Verbal Numeric Rating Scale (VNRS) is commonly used to obtain self-reports of pain intensity in school-age children, but there is no standard verbal descriptor to define the most severe pain. Aims: The aim of this study was to determine how verbal anchor phrases defining 10/10 on the VNRS are associated with children's reports of pain. Methods and Results: Study 1. Children (N = 131, age 6-11) rated hypothetical pain vignettes using six anchor phrases; scores were compared with criterion ratings. Though expected effects of age and vignette were found, no effects were found for variations in anchors. Study 2. Pediatric nurses (N = 102) were asked how they would instruct a child to use the VNRS. Common themes of "the worst hurt you could ever imagine" and "the worst hurt you have ever had" to define 10/10 were identified. Study 3. Children's hospital patients (N = 27, age 8-14) rated pain from a routine injection using four versions of the VNRS. Differences in ratings ranging from one to seven points on the scale occurred in the scores of 70% of children when the top anchor phrase was changed. Common themes in children's descriptions of 10/10 pain intensity were "hurts really bad" and "hurts very much." Discussion: This research supports attention to the details of instructions that health care professionals use when administering the VNRS. Use of the anchor phrase "the worst hurt you could ever imagine" is recommended for English-speaking, school-age children. Details of administration of the VNRS should be standardized and documented in research reports and in clinical use.

Contexte: L'échelle numérique verbale (ENV) de 0 à 10 est fréquemment utilisée pour l'auto-évaluation de l'intensité de la douleur chez les enfants d'âge scolaire, mais il n'existe pas de descripteur verbal pour définir la douleur la plus aiguë.But: Déterminer de quelle manière les énoncés définissant 10/10 sur l'ENV sont associés à la douleur rapportée par les enfants.Méthodes et résultats: Étude 1. Des enfants (N = 131, âgés de 6 à 11 ans) ont évalué des vignettes représentant une douleur hypothétique à l'aide de six énoncés; les scores obtenus ont été comparés aux évaluations de référence. Bien que les effets attendus en ce qui concerne l'âge et la vignette aient été observés, aucun effet n'a été observé pour les variations dans les énoncés. Étude 2. On a demandé à des infirmières pédiatriques (N = 102) de quelle manière elles enseigneraient à un enfant à utiliser l'ENV. Les thèmes communs de « la pire douleur que tu puisses imaginer ¼ et « la pire douleur que tu aies ressentie ¼ pour définir 10/10 ont été identifiés. Étude 3. Les patients d'un hôpital pour enfants (N = 27, âgés de 8 à 14 ans) ont évalué la douleur d'une injection de routine à l'aide de quatre versions de l'ENV. Des différences dans l'évaluation allant d'un à sept points sur l'échelle sont apparues dans les scores de 70 % des enfants lorsque l'énoncé relatif à la douleur la plus élevée a été modifié. Les thèmes communs dans les descriptions des enfants en ce qui concerne l'intensité de douleur 10/10 étaient « hurts really bad ¼ (fait vraiment mal) and « hurts very much ¼ (fait très mal).Discussion: Cette étude démontre l'importance de porter attention aux détails dans les instructions que les professionnels de la santé utilisent lorsqu'ils ont recours à l'ENV. L'utilisation de l'énoncé « the worst hurt you could ever imagine ¼ (la pire douleur que tu puisses imaginer) est recommandée pour les enfants d'âge scolaire anglophones. Les détails concernant l'utilisation de l'ENV devraient être uniformisés et documentés dans les rapports de recherche ainsi que dans le cadre de leur usage clinique.

Young children's ability to report on past, future, and hypothetical pain states: a cognitive-developmental perspective.

Children are at times asked by clinicians or researchers to rate their pain associated with their past, future, or hypothetical experiences. However, little consideration is typically given to the cognitive-developmental requirements of such pain reports. Consequently, these pain assessment tasks may exceed the abilities of some children, potentially resulting in biased or random responses. This could lead to the over- or under-treatment of children's pain. This review provides an overview of factors, and specifically the cognitive-developmental prerequisites, that may affect a child's ability to report on nonpresent pain states, such as past, future, or hypothetical pain experiences. Children's ability to report on past pains may be influenced by developmental (age, cognitive ability), contextual (mood state, language used by significant others), affective and pain-related factors. The ability to mentally construct and report on future painful experiences may be shaped by memory of past experiences, information provision and learning, contextual factors, knowledge about oneself, cognitive coping style, and cognitive development. Hypothetical pain reports are sometimes used in the development and validation of pain assessment scales, as a tool in assessing cognitive-developmental and social-developmental aspects of children's reports of pain, and for the purposes of training children to use self-report scales. Rating pain associated with hypothetical pain scenarios requires the ability to recognize pain in another person and depends on the child's experience with pain. Enhanced understanding of cognitive-developmental requirements of young children's pain reports could lead to improved understanding, assessment, and treatment of pediatric pain.

Children's Forgetting of Pain-Related Memories.

OBJECTIVE: Given that forgetting negative experiences can help children cope with these experiences, we examined their ability to forget negative aspects of painful events. METHODS: 86 children aged 7-15 years participated in a retrieval-induced forgetting task whereby they repeatedly retrieved positive details of a physically painful experience, and an experimental pain task (cold-pressor task). RESULTS: Repeatedly retrieving positive details of a prior pain experience produced forgetting of the negative aspects of that experience. Pain-related self-efficacy predicted retrieval-induced forgetting; children with a poorer belief in their ability to cope with pain experienced less forgetting. Children who had a more difficult time forgetting prior negative experiences were more anxious about the pain task and reported higher pain thresholds. CONCLUSIONS: Understanding children's memory for painful experiences may help improve their pain management and coping ability.

A smartphone version of the Faces Pain Scale-Revised and the Color Analog Scale for postoperative pain assessment in children.

BACKGROUND: Effective pain assessment is essential during postoperative recovery. Extensive validation data are published supporting the Faces Pain Scale-Revised (FPS-R) and the Color Analog Scale (CAS) in children. Panda is a smartphone-based application containing electronic versions of these scales. OBJECTIVES: To evaluate agreement between Panda and original paper/plastic versions of the FPS-R and CAS and to determine children's preference for either Panda or original versions of these scales. METHODS: ASA I-III children, 4-18 years, undergoing surgery were assessed using both Panda and original versions of either the FPS-R or CAS. Pain assessments were conducted within 10 min of waking from anesthesia and 30 min later. RESULTS: Sixty-two participants, median (range) age 7.5 (4-12) years, participated in the FPS-R trial; Panda scores correlated strongly with the original scores at both time points (Pearson's r > 0.93) with limits of agreement within clinical significance (80% CI). Sixty-six participants, age 13 (5-18) years, participated in the CAS trial. Panda scores correlated strongly with the original scores at both time points (Pearson's r > 0.87); mean pain scores were higher (up to +0.47 out of 10) with Panda than with the original tool, representing a small systematic bias, but limits of agreement were within clinical significance. Most participants who expressed a preference preferred Panda over the original tool (81% of FPS-R, 76% of CAS participants). CONCLUSION: The Panda smartphone application can be used in lieu of the original FPS-R and CAS for assessment of pain in children. Children's preference for Panda may translate to improved cooperation with self-report of pain.

Clinically significant differences in acute pain measured on self-report pain scales in children.

OBJECTIVES: The objective was to determine the minimum and ideal clinically significant differences (MCSD, ICSD) in pain intensity in children for the Faces Pain Scale-Revised (FPS-R) and the Color Analog Scale (CAS) and to identify any differences in these estimates based on patient characteristics. METHODS: This was a prospective study of children aged 4 to 17 years with acute pain presenting to two urban pediatric emergency departments. Participants self-reported their pain intensity using the FPS-R and CAS and qualitatively described their changes in pain. Changes in pain score reported using the FPS-R and CAS that were associated with "a little less" and "much less" pain (MCSD and ICSD, respectively) were identified using a receiver operating characteristic-based method and expressed as raw change score and percent reductions. Estimates of MCSD and ICSD were determined for each category of initial pain intensity (mild, moderate, and severe) and patient characteristics (age, sex, and ethnicity). Post hoc exploratory analyses evaluated categories of race, primary language, and etiology of pain. RESULTS: A total of 314 children with acute pain were enrolled; mean (±SD) age was 9.8 (±3.8) years. The FPS-R raw change score and percent reduction MCSD estimates were 2/10 and 25%, with ICSD estimates of 3/10 and 60%. For the CAS, raw change score and percent reduction MCSD estimates were 1/10 and 15%, with ICSD estimates of 2.75/10 and 52%. For both scales, raw change score and percent reduction estimates of the MCSD remained unchanged in children with either moderate or severe pain. For both scales, estimates of ICSD were not stable across categories of initial pain intensity. There was no difference in MCSD or ICSD based on age, sex, ethnicity, race, primary language, or etiology of pain. CONCLUSIONS: The MCSD estimates can be expressed as raw change score and percent reductions for the FPS-R and CAS. These estimates appear stable for children with moderate to severe pain, irrespective of age, sex, and ethnicity. Estimates of ICSD were not stable across different categories of initial pain intensity, therefore limiting their potential generalizability.

A debate on the proposition that self-report is the gold standard in assessment of pediatric pain intensity.

OBJECTIVES AND METHODS: Self-report is often represented as "the gold standard" in assessment of pain intensity in children. We evaluate arguments for and against this claim and consider its implications for pain management. RESULTS: Those in the support of the proposition argue that, when children are able to self-report, treatment decisions should be made based on these scores in line with current evidence-based recommendations. Pain is a subjective phenomenon and can be assessed only via self-report. Treating self-report scores as the gold standard is the only valid way for health care professionals to decide on appropriate treatment.Those against the proposition contend that reliance on self-reported pain scores for analgesic treatment decisions is inappropriate as they oversimplify the pain experience, yield only marginal information on which to base treatment decisions, and potentially place children at significant risk for adverse events. Self-reports of pain intensity sometimes contradict well-founded estimates based on other evidence. Wide variation between children in the meaning of pain scores precludes easy interpretation. DISCUSSION: We conclude that self-report, when available, can be considered a primary source of evidence about pain intensity. However, it cannot be treated as an unquestioned gold standard. Instead, hierarchical or bundled approaches should be used, taking into account self-report as well as the many individual and contextual factors that influence pain including clinical history, patient preferences, and response to previous treatments. Alternate models are presented to guide further practice and research.

Training highly qualified health research personnel: the pain in Child Health consortium.

BACKGROUND AND OBJECTIVES: Pain in Child Health (PICH) is a transdisciplinary, international research training consortium. PICH has been funded since 2002 as a Strategic Training Initiative in Health Research of the Canadian Institutes of Health Research, with contributions from other funding partners and the founding participation of five Canadian universities. The goal of PICH has been to create a community of scholars in pediatric pain to improve child health outcomes. METHODS: Quantitative analyses enumerated PICH faculty, trainees, training activities and scientific outputs. Interviews with PICH stakeholders were analyzed using qualitative methods capturing perceptions of the program's strengths, limitations, and opportunities for development and sustainability. RESULTS: PICH has supported 218 trainee members from 2002 through 2013, from 14 countries and more than 16 disciplines. The faculty at the end of 2013 comprised nine co-principal investigators, 14 Canadian coinvestigators, and 28 Canadian and international collaborators. Trainee members published 697 peer-reviewed journal articles on pediatric pain through 2013, among other research dissemination activities including conference presentations and webinars. Networks have been established between new and established researchers across Canada and in 13 other countries. Perceptions from stakeholders commended PICH for its positive impact on the development of pediatric pain researchers. Stakeholders emphasized skills and abilities gained through PICH, the perceived impact of PICH training on this research field, and considerations for future training in developing researchers in pediatric pain. CONCLUSIONS: PICH has been successfully developing highly qualified health research personnel within a Canadian and international community of pediatric pain scholarship.

Validation of self-report pain scales in children.

BACKGROUND AND OBJECTIVES: The Faces Pain Scale-Revised (FPS-R) and Color Analog Scale (CAS) are self-report pain scales commonly used in children but insufficiently validated in the emergency department setting. Our objectives were to determine the psychometric properties (convergent validity, discriminative validity, responsivity, and reliability) of the FPS-R and CAS, and to determine whether degree of validity varied based on age, sex, and ethnicity. METHODS: We conducted a prospective, observational study of English- and Spanish-speaking children ages 4 to 17 years. Children with painful conditions indicated their pain severity on the FPS-R and CAS before and 30 minutes after analgesia. We assessed convergent validity (Pearson correlations, Bland-Altman method), discriminative validity (comparing pain scores in children with pain against those without pain), responsivity (comparing pain scores pre- and postanalgesia), and reliability (Pearson correlations, repeatability coefficient). RESULTS: Of 620 patients analyzed, mean age was 9.2 ± 3.8 years, 291(46.8%) children were girls, 341(55%) were Hispanic, and 313(50.5%) were in the younger age group (<8 years). Pearson correlation was 0.85, with higher correlation in older children and girls. Lower convergent validity was noted in children <7 years of age. All subgroups based on age, sex, and ethnicity demonstrated discriminative validity and responsivity for both scales. Reliability was acceptable for both the FPS-R and CAS. CONCLUSIONS: The FPS-R and CAS overall demonstrate strong psychometric properties in children ages 4 to 17 years, and between subgroups based on age, sex, and ethnicity. Convergent validity was questionable in children <7 years old.