Table of Contents Author Guidelines Submit a Manuscript
Pain Research and Management
Volume 2017, Article ID 3017837, 10 pages
Research Article

Children’s Behavioral Pain Cues: Implicit Automaticity and Control Dimensions in Observational Measures

1School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
2Department of Psychology, York University, Toronto, ON, Canada
3Mississauga Academy of Medicine, University of Toronto, Toronto, ON, Canada
4Department of Computer Sciences, University of British Columbia, Vancouver, BC, Canada
5Department of Psychology, University of British Columbia, Vancouver, BC, Canada

Correspondence should be addressed to Kenneth D. Craig; ac.cbu.hcysp@giarck

Received 28 March 2016; Revised 16 December 2016; Accepted 24 January 2017; Published 21 February 2017

Academic Editor: Filippo Brighina

Copyright © 2017 Kamal Kaur Sekhon et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Some pain behaviors appear to be automatic, reflexive manifestations of pain, whereas others present as voluntarily controlled. This project examined whether this distinction would characterize pain cues used in observational pain measures for children aged 4–12. To develop a comprehensive list of cues, a systematic literature search of studies describing development of children’s observational pain assessment tools was conducted using MEDLINE, PsycINFO, and Web of Science. Twenty-one articles satisfied the criteria. A total of 66 nonredundant pain behavior items were identified. To determine whether items would be perceived as automatic or controlled, 277 research participants rated each on multiple scales associated with the distinction. Factor analyses yielded three major factors: the “Automatic” factor included items related to facial expression, paralinguistics, and consolability; the “Controlled” factor included items related to intentional movements, verbalizations, and social actions; and the “Ambiguous” factor included items related to voluntary facial expressions. Pain behaviors in observational pain scales for children can be characterized as automatic, controlled, and ambiguous, supporting a dual-processing, neuroregulatory model of pain expression. These dimensions would be expected to influence judgments of the nature and severity of pain being experienced and the extent to which the child is attempting to control the social environment.