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Objectives: Assessing pain in young children requires astute judgment by observers. Multidimensional observational scales for pediatric pain contribute by providing behavioral cues believed to characterize pain in children; yet, few measurement items have undergone rigorous psychometric evaluation. This is the case with facial expression, which has been widely recognized as the most sensitive and specific nonverbal indicator of pain. The criteria for identifying facial expressions of pain differ substantially across scales and are frequently inconsistent with empirical descriptions., Materials and Methods: The present study compared observer ratings of children's (aged 1 to 6 y, inclusive) videotaped postoperative pain reactions using the facial activity items from 6 widely used pediatric pain assessment scales and an anatomically based and empirically validated measure, the Child Facial Coding System. We hypothesized that facial expression items that did not correspond to empirical descriptions would lead to less reliable and divergent pain estimates. Intercoder reliability, criterion validity (empirical and convergent), content validity, and face validity were examined., Results: Findings supported hypotheses and indicated that variation in cues proposed for assessing facial expression led to widely ranging scores that could be insensitive to differences in children's pain intensity., Discussion: The facial items varied considerably in coder judgment reliability as well as criterion (empirical and convergent), content, and face validity. Observational scales should provide behavioral cues that correspond to empirical descriptions of the facial expression of pain.

Objectives: Assessing pain in elderly persons, who have diminished capacity to communicate verbally, requires use of observational scales that focus upon nonverbal behavior. Facial expression has been recognized as providing the most specific and sensitive nonverbal cues for pain. This study examined the validity of facial expression components of 6 widely used pain assessment scales developed for elders with dementia. Descriptions of the facial expression of pain vary widely on these scales., Methods: The detailed, anatomically based, objectively coded, and validated Facial Action Coding System was used as a criterion index to provide a definitive description of the facial expression of pain. Thirty elderly inpatients with clinically significant pain in the back or hip, the majority of whom had cognitive impairments, provided videotaped reactions to physical activities. Participants' facial expressions were videotaped during 4 randomly ordered physical activities and coded by a qualified Facial Action Coding System coder. Three 6-second clips indicative of mild, moderate, and severe pain intensities were selected for study for each participant. The 90 clips were coded by 5 raters using the facial expression components of the following observational scales: Doloplus-2, Mahoney, Abbey, pain assessment checklist for seniors with limited ability to communicate, noncommunicative patient's Pain Assessment Instrument, and Pain Assessment in Advanced Dementia., Results: Overall, scales that provided specific descriptions using the empirically displayed facial actions associated with pain yielded greater sensitivity, interjudge reliability, and validity as indices of pain., Discussion: Facial expression items on observational scales for assessing pain in the elderly benefit from adherence to empirically derived descriptions. Those using the scales should receive specific direction concerning cues to be assessed. Observational scales that provide descriptors that correspond to how people actually display facial expressions of pain perform better at differentiating intensities of pain.

Pain assessment conventionally has been viewed hierarchically with self-report as its "gold-standard." Recent attempts to improve pain management have focused on the importance of assessment, for example, the initiative to include pain as the "fifth vital sign." We question the focus in the conceptualization of pain assessment upon a "vital sign," not in terms of the importance of assessment, but in terms of the application of self-report as a mechanistic index akin to a biologic measure such as heart rate and blood pressure. We synthesize current inclusive models of pain and pain assessment and propose a more comprehensive conceptualization of pain assessment as a transaction based on an organismic interplay between the patient and clinician.

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Objectives: Although self-reports are a commonly used means of assessing pain in clinical settings, little is understood about the nature of children's spontaneous verbal expressions of pain. The purpose of this study was to describe verbalizations of pain among children receiving a preschool immunization and to examine how pain verbalizations correspond to children's facial expressions and self-reports of pain intensity., Methods: Fifty-eight children between the ages of 4 years 8 months and 6 years 3 months (67% female) were videotaped while receiving their routine preschool immunization. Global ratings of facial expression and detailed transcription and coding of pain verbalizations were undertaken. Children provided self-reports of pain using a 7-point faces pain scale., Results: Fifty-three percent of children used verbalizations spontaneously to express their pain. The modal verbalization was the interjection "Ow!," which expressed negative affect and was specific to the experience of pain. Older children were less likely to use verbalizations to express their pain. Children who used verbalizations to express pain displayed greater facial reactions to pain and rated their pain experience as being more intense than children who did not use words to express their pain., Discussion: Results indicate that many young children do not spontaneously use verbalizations to express pain from immunization. When 5-year-olds use verbalizations to express pain, the verbalizations are most often brief statements that express negative affect and directly pertain to pain. Knowledge of how children verbalize pain may lead to an improved ability to assess and manage pediatric pain.

Objectives: Reduced pain sensitivity is widely reported to be a common feature of children with autism, yet this conclusion frequently has been based on anecdotal observations and questionable measures of pain. The aims of the study were to (1) characterize the behavioral response of children with autism experiencing a venepuncture using objective observational measures of pain and distress, (2) examine parents' assessments of pain behavior in children with and without autism, including comparison of the relationship of parental reports with behavioral measures, and (3) compare the behavioral reactions and parental assessments of children with autism with children without autism undergoing venepuncture., Methods: Pain reactions to the invasive procedure of venepuncture were videotaped, systematically described and compared in 21 children with autism (3-7 years old) and 22 nonimpaired children, the latter providing a chronological age and gender equivalent comparison group. Parents provided observer reports of pain, and facial activity was used as an objective behavioral measure of pain., Results: The children with autism displayed a significant facial pain reaction in response to the venepuncture procedure. There was a lack of concordance between parental reports of pain and observed pain responses for the children with autism. Behavioral responses of the children with autism were generally similar to the comparison group, except the substantial facial pain reactivity instigated by the venepuncture in the children with autism exceeded that displayed by the nonimpaired comparison children. Parent reports of pain severity did not differ between the autism and comparison groups. The degree of concordance between parental report and observed pain responses was consistently better for the comparison group., Discussion: The findings demonstrate that children with autism display a significant behavioral reaction in response to a painful stimulus, and these findings are in sharp contrast to the prevailing beliefs of pain insensitivity described in the literature to date. The findings also raise questions about the appropriateness of parental global report as an assessment tool for pain in children with autism.