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The biasing effect of pain sensitivity information and the impact of facial activity on observers' judgments of pain intensity of children with autism were examined. Observers received information that pain experience in children with autism is either the same as, more intense than, or less intense than children without autism. After viewing six video clips of children with autism undergoing venepuncture, observers estimated pain intensity using a visual analogue scale. Facial activity as coded by Chambers et al. (Child Facial Action Coding System Revised Manual, 1996) had a significant impact on observers' estimates of pain intensity; pain sensitivity information did not. These results have important implications for the assessment and management of pain in children with autism.

The current study examined youths' and their parents' perceptions concerning participation in an investigation of spontaneous and induced pain during recovery from laparoscopic appendectomy. Youth (age range 5-17 years) and their parents independently completed surveys about their study participation. On a 0 (very negative) -to-10 (very positive) scale, both parents 9.4(1.3) [mean(SD)] and youth 7.9(2.4) rated their experience as positive. Among youth, experience ratings did not differ by pain severity and survey responses did not differ by age. Most youth (83%) reported they would tell another youth to participate. Ethical issues regarding instigation of pain in youth for research purposes are examined.

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A letter to the editor is presented in response to the letter "Bridging the Gap Between Pain Assessment and Treatment: Time for a New Theoretical Approach?" by T. Voepel-Lewis.

Abstract: Recent developments in clinical, cognitive, and behavioral sciences as well as in social neuroscience can provide new perspectives on our understanding of different forms of pain expression and the social reactions of observers to various types of pain expression. Studies indicate that pain expression is governed by both automatic (unintentional, reflexive) and controlled (intentional, purposive) neuroregulatory systems. Reciprocal mechanisms in observers responsible for automatic (unintentional, reflexive) and controlled (intentional, reflective) reactions also are important. Observers appear more likely to display immediate “visceral” emotional reactions to unintentional, reflexive expression, whereas controlled expression characterized by purposive behavior appears more likely to elicit reflection on the nature and origins of the person''s pain. This review summarizes research within the context of a theoretical model for understanding how pain is perceived in others. Perspective: People attempting to understand another person''s pain may have access to the person''s spontaneous behavioral reaction as well as verbal report and other purposive communications. The former instigates reflexive and emotional reactions, whereas the latter tends to be perceived as confounding expression of experience with response to situational demands. [Copyright &y& Elsevier]

Objective: To provide an experimental investigation of the impact of maternal behavior on children's pain experiences.Method: Participants were 120 healthy children (60 boys, 60 girls) between the ages of 8 and 12 years and their mothers. Mothers were randomly assigned and trained to interact with their children in one of three ways while the children were exposed to lab-induced cold pressor pain: (1) a pain-promoting interaction, (2) a pain-reducing interaction, and (3) a no training control group. Training was based on behaviors presumed to have the expected impact, as based on correlational studies reported in the literature. Children's pain experiences during the cold pressor were assessed using self-reports of intensity and affect, coding of facial activity, tolerance, and heart rate responsiveness.Results: Girls whose mothers interacted with them in the pain-promoting manner reported more pain than daughters of mothers in the control group, who in turn reported more pain than girls whose mothers interacted with them in the pain-reducing manner. This effect was not significant for boys. Maternal interaction type had no effect on children's pain affect, facial activity, tolerance, or heart rate.Conclusions: Results indicate that maternal behavior can have a direct impact on their daughters' subjective reports of pain. These data support the importance of social learning factors in influencing children's pain experiences. [ABSTRACT FROM AUTHOR]

Abstract: Facial expressions provide a primary source of inference about a child’s pain. Although facial expressions typically appear spontaneous, children have some capacity to fake or suppress displays of pain, thereby potentially misleading caregiver judgments. The present study was designed to compare accuracy of different groups of caregivers in detecting deception in children’s facial expressions of pain when voluntarily controlled. Caregivers (15 pediatricians, 15 pediatric nurses, and 15 parents) viewed 48 video clips of children, 12 in each of 4 conditions (genuine pain, faked pain, suppressed pain, neutral baseline), and judged which condition was apparent to them. A 3 (group: pediatrician vs pediatric nurse vs parent)×4 (condition: genuine vs faked vs suppressed vs neutral) mixed analysis of variance (ANOVA) of judgment accuracies revealed a significant main effect of group, with nurses demonstrating higher overall accuracy scores than parents, and pediatricians not differing from either group. As well, all caregivers, regardless of group, demonstrated the lowest accuracy when viewing the genuine condition, relative to the faked and suppressed conditions, with accuracy for the neutral condition not differing significantly from the other conditions. Overall, caregivers were more successful at identifying faked and suppressed than genuine expressions of pain in children, and pediatric nurses fared better overall in judgment accuracy than parents. [Copyright &y& Elsevier]

Abstract: Children’s efforts to hide or exaggerate facial expressions of pain were compared to their genuine expressions using the cold pressor task. Fifty healthy 8- to 12-year-olds (25 boys, 25 girls) submerged their hands in cold and warm water and were instructed about what to show on their faces. Cold 10°C water was used for the genuine and suppressed conditions and warm 30°C water was used for the faked condition. Facial activity was videotaped and coded using the Facial Action Coding System to provide objective, detailed accounts of facial expressions in each condition, as well as during a baseline condition. Parents were subsequently asked to correctly identify each of the four conditions by viewing each video clip twice. Faked expressions of pain in children were found to show more frequent and more intense facial actions compared to their genuine pain expression, indicating that children had some understanding but were not fully successful in faking expressions of pain. Children’s suppressed expressions, however, showed no differences from baseline facial actions, indicating that they were able to successfully suppress their expressions of pain. Parents correctly identified the four conditions significantly more frequently than would be expected by chance. They were generally quite successful at detecting faked pain, but experienced difficulty differentiating among the other conditions. The results indicate that children are capable of controlling their facial expressions of pain when instructed to do so, but are better able to hide their pain than to fake it. [Copyright &y& Elsevier]

Abstract: Accurate pain assessment is the foundation for effective pain management in children. At present, there is no clear consensus regarding the age at which young children are able to appropriately use self-report scales for pain. This study examined young children''s ability to use the Faces Pain Scale-Revised; (FPS-R; [Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001; 93: 173–83]) for pain in response to vignettes and investigated the role of developmental factors in predicting their ability to use the scale. One hundred and twelve healthy children (3–6 years old) were assessed for their ability to accurately use a common faces scale to rate pain in hypothetical vignettes depicting pain scenarios common in childhood. Accuracy was determined by considering whether children''s judgements of pain severity matched the pain severity depicted in the various vignettes. Children were also administered measures of numerical reasoning, language, and overall cognitive development. Results indicated that 5- and 6-year-old children were significantly more accurate in their use of the FPS-R in response to the vignettes than 4-year-old children, who in turn were significantly more accurate than 3-year-old children. However, over half of the 6-year-olds demonstrated difficulties using the FPS-R in response to the vignettes. Child age was the only significant predictor of children''s ability to use the scale in response to the vignettes. Thus, a substantial number of young children experienced difficulties using the FPS-R when rating pain in hypothetical vignettes, although the ability to use the scale did improve with age. [Copyright &y& Elsevier]

Abstract: Effective verbalization of pain requires progressive cognitive development and acquisition of social communication skills. Use of self-report in pediatric pain assessment assumes children have acquired a capacity to understand and use common words to describe pain. The current investigation documented the language most commonly used by young children to describe pain and the age of onset of use of these words. Two complementary research methodologies were employed. Study 1 used the CHILDES database, an aggregated transcript database of multiple research studies examining spontaneous speech development across childhood. Transcripts of 14 randomly selected studies, yielding a total of 245 child participants ranging in age from 1 to 9 years, were searched for seven English primary pain word-stems: ‘ache’, ‘boo–boo’, ‘hurt’, ‘ouch’, ‘ow’, ‘pain’, and ‘sore’. Study 2 surveyed 111 parents of children aged 3 to 6 years old concerning words the children commonly used for pain. Parents rated their children''s frequency and age of first use of the seven pain word-stems. Both studies indicated that the most frequently used word-stems were ‘hurt’, ‘ouch’, and ‘ow’. These words first emerged in children''s vocabularies as early as 18 months of age. The word-stem ‘pain’ was used relatively infrequently and gradually emerged in children''s vocabularies. The findings indicate that young children rely on a select number of words to describe pain, with these words appearing in children''s vocabularies at an early age. These results have implications for developmentally appropriate pain assessment in young children. [Copyright &y& Elsevier]

Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials. [ABSTRACT FROM AUTHOR]