Assessment and Questionnaires for Children with Pain

Original Editor - Robin Tacchetti based on the course by Tracy Prowse

Top Contributors - Robin Tacchetti, Jess Bell, Naomi O'Reilly, Kim Jackson, Ewa Jaraczewska and Tarina van der Stockt

Chronic Pain

Pain that occurs for longer than three months is considered chronic and often involves multiple systems. Children who have chronic pain may experience disruptions in social, recreational and school activities causing functional and emotional distress. They may also experience changes in sleep, mood and anxiety levels in response to chronic pain.

Factors Affecting Pain

The most reliable and accurate measure of pain in children is self-reporting, but it is not without its challenges. Pain is shaped by developmental factors and the sociocultural, psychological and biological attributes of the child need to be understood. Utilising the biopsychosocial model helps clinicians to appreciate a child’s understanding of pain, how they describe it and how they manage their pain. These attributes are always changing and are not static as the child grows and develops.

When assessing a child’s report on their pain, Freund et al. listed four factors to take into account:

1. Level of cognitive development: Determines how a child perceives the causes and effects of pain. Very young infants do not understand pain, but can experience it and remember it. As they age, their understanding of pain matures.
2. Fear and prior painful experiences: A child's previous pain experiences can influence how they respond to future painful / potentially painful events. Increased fear levels in children correspond with higher levels of reported pain, the persistence of pain, anxiety, avoidance behaviours and disability.
3. Societal expectations, stereotypical assumptions, and familial cultural norms: Children learn how to experience, manage and describe pain by observing their parents’ response. Parental and caregiver responses are guided by societal stereotypes and expectations.
4. Anchor effects: These "occur when the “anchors” (the extremes of a scale) influence the severity of a child's self-reported pain." For example, scales may use different numbers, colours, pictures etc to describe states such as pain or no pain. A child may not readily understand these abstract scales. Thus, they tend to choose based on previous experiences, which can lead to false-positive or false-negative results. For example:
   1. Smiley face vs sad face - a child may be in pain, but feels happy and, therefore, chooses the smile; or the child may have no pain, but feels sad, and therefore, chooses the sad face
   2. High number vs low number - a child may choose their favourite number
   3. One colour that depicts pain vs another colour depicting no pain - a child may choose their favourite colour

Assessment

Pain questionnaires can be used to get a holistic view of the child and to gain an understanding of what they are experiencing. Ideally, getting a history from the child and parent will create a more in-depth picture of the child's life experiences. Effective assessment tools are necessary to help guide successful treatment.

Pain Questionnaires

Fear of Pain Questionnaire Child and Parent (FOPQ-C and FOPQ-P):

• Fear of pain increases pain perception and decreases functionality. Alternatively, the absence of pain-related fear enables the child to continue with routine daily activities and decreases the likelihood of emotional side effects. This specific tool allows the clinician to identify symptoms that may be related to avoidance and fear of pain.

Pittsburgh Sleep Quality Index (PSQI):

• This self-measured tool looks at a child's overall sleep quality. The use of open-ended questions serves to identify the possible causes of sleep issues and to guide treatment.

Central Sensitisation Inventory (CSI):

• This tool is used to determine how sensitive the nervous system is. When the central nervous system is on high alert, it can increase a child's sensitivity to various things in their everyday routine like bright lights or strong smells. This questionnaire aims to find areas where the child might be sensitive, but that they might not have associated with their pain.

Hospital Anxiety and Depression Scale (HADS):

• Depression often follows anxiety. This questionnaire measures depression and anxiety and is a fast, simple and easy tool to use.

Revised Child and Anxiety Scale (RCADS):

• This self-reported questionnaire is another tool to measure depression and anxiety in children and adolescents.

Adverse Childhood Questionnaire:

• This is a freely available tool that identifies if there has been any trauma or traumatic experiences influencing a child's pain.

Resilience Questionnaire:

• Resilience describes the ability to cope with adversity. This questionnaire looks at resilience in the face of stressors in various arenas including self, peer, school, family and community.

Highly Sensitive Child Questionnaire:

• When the nervous system is over-protective it can be overly sensitive. This quality can be a positive as it tunes children in to the world around them. However, this quality needs to stay in check so that it does not make them hypersensitive to the environment. This questionnaire asks questions to help the child identify if they are innately a highly sensitive person.

Physical Assessment

After reviewing the questionnaires and the past medical history, a physical assessment including range of motion, strength, sensation and functional mobility are performed. Additionally, it is important to inquire whether there is a condition or disease that may be contributing to the pain such as juvenile idiopathic arthritis, lupus, benign joint hypermobility syndrome or any kind of spondyloarthropathy. When limitations are noted, it is important to find out what activities the child would like to return to and what skills or activities they would like to do. Using the child’s value system for goal setting and treatment planning helps increase the likelihood of success during their rehabilitation.

Resources

• International Association for the Study of Pain
• Who Guidelines for the Management of Chronic Pain in Children
• New WHO Guideline for Treating Chronic Pain in Children