Pain Research and Management

Pain Research and Management / 2017 / Article

Review Article | Open Access

Volume 2017 |Article ID 7603758 | 17 pages | https://doi.org/10.1155/2017/7603758

Chronic Pain Assessments in Children and Adolescents: A Systematic Literature Review of the Selection, Administration, Interpretation, and Reporting of Unidimensional Pain Intensity Scales

Academic Editor: Frauke Musial
Received31 Jan 2017
Revised12 Apr 2017
Accepted10 Jul 2017
Published21 Aug 2017

Abstract

Background. Advances in pain assessment approaches now indicate which measures should be used to capture chronic pain experiences in children and adolescents. However, there is little guidance on how these tools should best be administered and reported, such as which time frames to use or how pain scores are categorised as mild, moderate, or severe. Objective. To synthesise current evidence on unidimensional, single-item pain intensity scale selection, administration, interpretation, and reporting. Methods. Databases were searched (inception: 18 January 2016) for studies in which unidimensional pain intensity assessments were used with children and adolescents with chronic pain. Ten quality criteria were developed by modifying existing recommendations to evaluate the quality of administration of pain scales most commonly used with children. Results. Forty-six studies met the inclusion criteria. The highest score achieved was 7 out of a possible 10 (median: 5; IQR: 4–6). Usage of scales varied markedly in administrator/completer, highest anchors, number of successive assessments, and time referent periods used. Conclusions. Findings suggest these scales are selected, administered, and interpreted inconsistently, even in studies of the same type. Furthermore, methods of administration are rarely reported or justified making it impossible to compare findings across studies. This article concludes by recommending criteria for the future reporting of paediatric chronic pain assessments in studies.

1. Introduction

Chronic pain is frequently defined as pain that persists beyond the normal tissue healing time, lasting for three or more months [1], and is estimated to affect between 4 and 40% of children [2]. Changes in reported pain guide treatment decision-making [3] and accurate measurement of pain is associated with improved outcomes in those with long-term chronic conditions [4, 5]. A number of publications recommend that the primary source of information on pain should be the children themselves in paediatric settings [68]. However, the developmental changes which occur during childhood and adolescence make the measurement of paediatric pain particularly challenging [6, 9]. The cognitive and metacognitive skills required for a child to give reliable self-reports of pain (such as the ability to rank-order objects, consider numerous options simultaneously, and retain and manipulate information) change significantly during childhood and adolescence [10].

Although assessment of pain in children is complex, there are many single-item pain measures used with this group [11] and unidimensional pain scales are most often used to routinely assess paediatric chronic pain [12]. Whilst they may only provide assessment of one component of pain, these scales are often combined or included in multidimensional and composite pain measurement scales [9]. Some of the most commonly used unidimensional pain scales include visual analogue scales (VASs), numerical rating scales (NRSs), and faces pain scales (FPSs).

Recent attempts to standardise the assessment of pain in children and adolescents with chronic pain include the PedIMMPACT (Paediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) groups [13] identification of core outcome domains and measures to be used in clinical treatment trials. Other moves towards the standardisation of pain assessment have been made by PROMIS (Patient-Reported Outcomes Measurement Information System) investigators [14] who developed a suite of patient-reported measures to assess a range of chronic conditions, including pain. Whilst these groups’ recommendations have been influential in establishing which measures are best to use with children and adolescents with chronic pain, they do not provide corresponding recommendations or advice for how to use and administer pain measures. The lack of standardisation of the approach to pain assessment suggests that methods of measurement may be very different between researchers ostensibly using the same unidimensional pain intensity scales.

King et al. [2] alerted researchers to the problem that inconsistent measurement approaches and reporting pose when establishing the epidemiology of chronic pain in children and adolescents. Other authors have also highlighted that significant bias is created through the different measurement approaches used in paediatric pain research [15, 16]. Research attention has not been given to the variation in the administration of single-item pain assessments or the extent to which inconsistency in measurement approaches may be a problem.

Differences in administration are not the only cause for concern. There is uncertainty about interpretation of pain assessments, particularly when scores are used to classify chronic pain in children and adolescents [17]. The three classifications most commonly used for categorising facets of pain are mild, moderate, and severe. Systems to aid categorisation of pain scores into these classifications have not been well defined in children and few attempts have been made to standardise classification boundaries. Recently, attempts to do this in acute emergency care have been instigated by Tsze et al. [18], who defined ranges of pain scores associated with mild, moderate, and severe pain categories (as measured by the FPS-R and the colour analogue scale (CAS)) in children presenting at emergency departments. Currently, there is no consensus on the points at which pain intensity changes classifications from mild to moderate or from moderate to severe in paediatric chronic pain [17].

To address these issues, a systematic literature review was undertaken to identify, describe, and evaluate current research practices on the selection, administration, interpretation, and reporting of unidimensional chronic pain assessments in paediatric research. The unidimensional pain assessments most commonly used with children and adolescents were reviewed to explore the extent to which differences in research practice exist. From our findings, we develop recommendations for the future use and reporting of chronic pain assessments with children and adolescents.

2. Methods

The systematic review is reported according to preferred reporting items for systematic reviews and meta-analyses [19].

2.1. Data Sources

Databases searched included Medline (1946–28 December 2015), CINAHL (1937–18 January 2016), Embase (1974–18 January 2016), and PsycInfo (1966–18 January 2016). The date of the last search attempt was 18 January 2016. In addition to database searching, articles were identified through other sources (reference lists of articles and direct contact with authors when articles were irretrievable from databases). Search terms used for the current study included MeSH headings and keywords associated with the following terms: “chronic pain”, “child”, “”, “pain scale” (as well as specific names of pain measures such as “visual analogue ”) and “classification” (see Appendix for full search strategy). After these search terms were entered, articles were restricted to English language only. Reference sections of the included studies and review articles were screened for further eligible papers and retrieved where appropriate. One author (RL) conducted the systematic literature search and preliminary screening of article titles/abstracts and identified full-text papers of potential relevance. Two authors (RL and AR) independently reviewed full-text articles for inclusion/exclusion.

2.2. Inclusion/Exclusion Criteria

Articles were included if they were studies reporting on the use of a unidimensional pain assessment in children and adolescents experiencing a chronic pain condition (including diagnoses of more specific chronic illness conditions in which pain is a recurring feature, e.g., cancer, headache, and juvenile arthritis), providing that at least one of the primary or secondary outcomes was to assess pain intensity. Studies were included if the children and adolescents in the study sample were between 5 and 18 years of age, similarly to other recent systematic reviews of pain measures used with children and adolescents [20, 21]. Only published peer-reviewed English language, quantitative studies were considered for inclusion. Reviews, commentaries, published abstracts, and qualitative articles were excluded. Studies were excluded if participants who did not have a chronic pain condition formed part of the sample. The purpose of the current review was to explore how pain is assessed in children with existing chronic pain conditions, not how pain assessment tools might be used to screen and identify chronic pain diagnoses (e.g., in community-based epidemiological studies). Where data on children with chronic pain were reported separately, then studies were included.

The unidimensional pain assessments evaluated in the current review include VASs, NRSs, and FPSs as these are the most commonly used with children [22, 23]. VASs are generally considered appropriate for use with children above 7 [24], NRSs for children aged 8 and over [25], and FPSs for children above 4 [26]. Single-item scales used as part of larger multidimensional pain assessments were included and reviewed separately where details were available. However, studies using composite measures were excluded if information on the administration and interpretation of each of the single-item unidimensional scales used within these was not available separately.

2.3. Quality Criteria for Pain Scale Selection, Administration, Interpretation, and Reporting

The quality criteria used to assess the selected papers were created by modifying two sets of published recommendations. The first set addressed the issues of selection, administration, and interpretation of pain scales with children and adolescents [8] and the second set addressed clinical practice, education, and research [6]. These sources were chosen as the basis for the development of quality criteria because they were specific to the use of pain assessment tools with children and were not confined to any particular scale or type of pain. A series of three consensus meetings were held by three of the authors prior to the independent critical appraisal of studies to discuss which of these practical points and recommendations would be appropriate to adapt to review the studies included. Authors also discussed the importance of adding quality criteria about the reporting of pain assessments with this group. The more detailed specifications which would need to be met for each criterion to be satisfied were developed, expanded, and agreed on during these meetings (see Table 1 for criteria used and specifications for satisfying the criteria. Criteria which were excluded with corresponding justification are provided in Supplementary Table available online at https://doi.org/10.1155/2017/7603758).


Requirements to satisfy this criterion: satisfied if

Quality of measure selection
(i) Is the tool age appropriate?(i) VAS used for children 7 and above
(ii) NRS used for children 8 and above
(iii) FPS used for children 4 and above

(ii) Were children screened for developmental delay or was a measure of competency conducted prior to pain assessment?(i) Studies commented upon completing an assessment for delay prior to conducting the study
(ii) They excluded children with developmental delay (assumed they had assessed for this in order to do so)

Quality of measure administration
(i) Did the child have a chance to become familiar with the pain scale used, for example, by rating hypothetical scenarios?(i) Authors commented upon conducting an assessment of pain prior to the assessment used in the final analysis
(ii) Authors explicitly commented upon children and adolescents having time to practice or become familiar with the assessment

(ii) Did authors identify whether pain measurement captured provoked pain levels or pain levels at rest?(i) Authors specify the nature of the pain measurement captured; for example, do authors comment upon whether pain assessment encompasses pain levels in provoked situations (activity) or unprovoked ones (at rest)?

(iii) Was the child the main reporter of pain at assessment?(i) Authors explicitly stated that children completed the scale or questionnaire independently
(ii) Pain information was gathered as part of a clinical interview with the child or adolescent

(iv) Were successive pain ratings observed?(i) Authors described taking more than one assessment of pain

(v) Were consistent verbal anchors used across patients in the same study?(i) Authors described the anchors used

Quality of measure interpretation
(i) Was a narrative explanation of pain scores also obtained, at least at the first data collection point?(i) Authors explicitly stated that a narrative was gained as part of the pain assessment
(ii) Pain assessment was conducted as part of a clinical interview

Quality of measure reporting
(i) Was the temporal frame for pain ratings reported?(i) Authors state the time scale used to frame pain assessments

(ii) Were the authors clear about which type of pain was measured?(i) Authors describe the type of pain reported, for example, worst, least, and most pain

2.4. Data Extraction

All the included studies were critically appraised independently by two reviewers against the ten modified quality criteria. In addition to evaluation against quality criteria, a descriptive summary of each of the studies was produced using a systematic approach to data extraction. The summary provided information on each of the following: age range of children included; administrator of the pain assessment; the person completing the pain assessment; anchor points; numbers of successive pain ratings; time/referent period used in the assessment; and classification of pain level produced by the assessment.

3. Results

3.1. Description of Studies

The search returned a total of 628 articles for review (after excluding 90 duplicates) and another 16 articles were identified through other sources (see Figure 1). Based on titles and abstracts alone, 526 articles were excluded. For articles of relevance, full-text versions were located and reviewed further. Full-text review of 118 studies resulted in 72 articles being excluded by both reviewers (see Table 2 for justifications). Forty-six papers were included in the final analysis (see Figure 1). Three papers commented on the use of more than one scale [2729]; hence a total of 49 scales were reviewed. Results reported below are described in relation to either the total number of reported studies (46) or the total number of different scales administered (49).


ReasonNumber of studies

Not in the defined age bracket (or does not describe age of children/adolescents)30
Not chronic pain21
No measure of pain6
Review or prevalence study9
Pain assessment tool not described3
Qualitative study1
Duplicate2

3.2. Excluded Articles

Thirty articles were excluded because they included some study participants who were outside of the specified age range of 5–18. For these studies, it was not possible to identify individual data as it was not reported separately by age. Some of these studies were also excluded because the age range of participants included in the study was not stated, despite the use of the terms “children” or “adolescent” pain assessment in the study title and/or abstract. On closer inspection, the samples included in some of these studies were possibly misclassified as either children or adolescents with some articles including young children aged 3 years and under [30, 31] and young adults up to 22 years old [32].

3.3. Quality Criteria

Ten quality criteria were used to evaluate the selection, administration, interpretation, and reporting of pain scales meaning each study review resulted in a score of between zero and ten. Two reviewers (RL and AR) read and evaluated the selected studies independently against the quality criteria. On first reading, reviewers achieved consensus on 19 (38.8%). At this point, it was recognised that the main area of disagreement was different interpretations of criterion 2. This was then reassessed and agreement reached on a further 26 studies increasing agreement to over 90%. A third author (LC) independently reviewed the four remaining studies (LC) [15, 17, 33, 34] (see Figure 2).

The maximum score using the quality criteria achieved by the reviewed studies was seven out of a possible ten (median score: 5; IQR: 4–6; see Table 3). The criteria against which most studies scored poorly were conducting developmental screening (19 out of 49 scales), familiarising children with the pain scale (0 out of 49 scales), identification of the nature of the pain measurement taken (provoked or unprovoked) (0 out of 49 scales), conduct of successive ratings of chronic pain (17 out of 49 scales), and gaining a narrative account whilst administering pain assessments (7 out of 49 scales).


ToolAuthor and yearChronic pain conditionMean age (years)SD (years)Female RangeQuality score
/10

VASAbu-Saad and Uiterwijk (1995) [35]Juvenile rheumatoid arthritis3372.3%7–165
VASAstfalck et al. (2010) [36]Chronic low back pain2815.550.550%14–161
VASChan et al. (2009) [37]Chronic daily headache1214–182
VASCohen et al. (2010) [38]Chronic pain22214.81.974.6%10–185
VASde Oliveira et al. (2011) [39]Juvenile idiopathic arthritis8011.642%8–142
VASEccleston et al. (2004) [40]Chronic pain8014.451.5571.25%11–175
VASGold et al. (2009) [41]Chronic pain8013.892.5772.5%8–185
VASGragg et al. (1996) [42]Rheumatic disease10012.22.4968%8–165
VASGuite et al. (2011) [27]Chronic pain25915.101.6477.6%12–185
VASHunfeld et al. (2002) [43]Chronic pain4214.51.612–187
VASHunfeld et al. (2002) [44]Chronic pain858.42.2565.88%5–115
VASJacob et al. (2012) [45]Sickle cell disease3113.42.451.6%10–176
VASKashikar-Zuck et al. (2011) [28]Chronic pain130014.22.476%8–185
VASKashikar-Zuck et al. (2012) [46]Juvenile fibromyalgia114151.892.1%11–184
VASKonijnenberg et al. (2005) [47]Chronic pain14911.873%8–185
VASLogan et al. (2006) [48]Chronic pain11215.31.379.46%13–183
VASLynch et al. (2006) [49]Chronic back pain6514.92.680%8–186
VASSchanberg et al. (2003) [50]Polyarticular arthritis4112.32.959%8–175
VASStinson et al. (2008) [51]Juvenile idiopathic arthritis112132.458–176
VASStinson et al. (2013) [52]Cancer4713.49–186
VASSwain et al. (2005) [53]Juvenile fibromyalgia2215.621.33100%13–175
VASVarni et al. (1987) [54]Juvenile rheumatoid arthritis259.53.1776%5–157
VASVervoort et al. (2008) [34]Chronic pain7113.332.8357.38%8–184
VASVetter et al. (2014) [55]Chronic Pain9913.22.471%8–175
NRSClaar et al. (2008) [56]Chronic pain25414.691.4976.8%12–176
NRSCornelissen et al. (2014) [57]Juvenile idiopathic arthritis601373%7–175
NRSGuite et al. (2011) [27]Chronic pain25915.101.6477.6%12–185
NRSHainsworth et al. (2007) [58]Chronic pain6014.02.781.7%8–185
NRSHainsworth et al. (2009) [59]Chronic pain31913.42.771%8–184
NRSHechler et al. (2014) [29]Chronic pain87143.474.66%9–176
NRSHicks et al. (2006) [60]Chronic pain4711.72.163.839–164
NRSHirschfeld et al. (2013) [61]Chronic pain16714.11.9162%11–186
NRSHirschfeld et al. (2013) [17]Chronic pain224912.452.9361%2
NRSJastrowski et al. (2013) [62]Chronic pain61512–174
NRSLogan et al. (2008) [63]Chronic pain41414.71.675.6%12–174
NRSLogan et al. (2013) [64]Chronic pain61413.8874.73%7–185
NRSPalermo et al. (2008) [65]Chronic pain15514.312.4558.06%8–185
NRSRuskin et al. (2014) [15]Chronic pain14314.12.472%8–176
NRSRuskin et al. (2015) [66]Chronic pain1615.751.00100%13–175
NRSSimons et al. (2010) [67]Chronic pain126151.582.5%12–175
NRSSimons et al. (2015) [68]Chronic pain32113.732.4774.8%8–185
NRSSmith et al. (2015) [69]Chronic pain31013.802.6975.2%8–175
NRSVowles et al. (2010) [70]Chronic pain20914.81.974.6%10–185
FPSClaar and Walker (2006) [71]Chronic abdominal pain59611.592.4561%8–175
FPSPalermo et al. (2004) [72]Chronic pain18912.42.560%8–164
FPSPalermo and Kiska (2005) [73]Chronic pain8614.7567%13–164
FPS-revisedHechler et al. (2014) [29]Chronic pain87143.474.66%9–176
FPS-revisedKashikar-Zuck et al. (2011) [28]Chronic pain130014.22.476%8–186
FPS-revisedRamstad et al. (2011) [33]Cerebral palsy15314.272.8847.06%8–187

Highest score achieved7

Mean score4.86

Standard deviation1.26

Median score5

Interquartile range46

3.4. Types of Scales

Of the 49 scales, 24 used a VAS, 19 used a NRS, and six used a FPS (3 original, 3 revised versions) (see Tables 4, 5, and 6 for details of administration, interpretation, and reporting information provided in articles).


VAS study authorsAge range (mean)
Children completed assessment Completed with clinician Parents completed assessmentPerson completing not describedHighest anchorClassification details providedSuccessive ratings gainedReference time period

Abu-Saad and Uiterwijk (1995) [35]7–16I have very severe painXNoPresent and worst pain
Astfalck et al. (2010) [36]14–16 (15.55)XXXXCurrent pain
Chan et al. (2009) [37]14–18XXXYesX
Cohen et al. (2010) [38]10–18 (14.8)Worst pain possibleXNoTypical pain over the past week
de Oliveira et al. (2011) [39]8–14
(11.6)
Very severe painXNoX
Eccleston et al. (2004) [40]11–17 (14.45)Worst pain possibleXNoAverage pain intensity over the previous week
Gold et al. (2009) [41]8–18 (13.89)Worst pain imaginableXNoPain over the past month
Gragg et al. (1996) [42]8–16Hurting a whole lot or
severe pain
XYesPresent and worst pain intensity for the previous week
Guite et al. (2011) [27]12–18 (15.10)Unbearable painXYesMost, usual, and least pain
Hunfeld et al. (2002) [43]12–18 (14.5)Worst pain imaginableXYesPain at that moment
Hunfeld et al. (2002) [44]5–11
(8.4)
Worst pain imaginableXYesPain at that moment
Jacob et al. (2012) [45]10–17
(13.4)
XWorst painXNoCurrent, worst, and least pain in the last 12 hours
Kashikar-Zuck et al. (2011) [28]8–18
(14.2)
Worst imaginable painXNoHighest, lowest, and average pain
Kashikar-Zuck et al. (2012) [46]11–18
(15)
XWorst possible painXYesAverage pain severity
Konijnenberg et al. (2005)8–18
(11.8)
XWorst pain possibleXNoCurrent pain level and highest pain in days preceding
Logan et al. (2006) [48]13–18
(15.3)
XXXMost, usual, and least pain
Lynch et al. (2006) [49]8–18
(14.9)
Worst imaginable painXNoHighest, lowest, and average in the last two weeks
Schanberg et al. (2003) [50]8–17
(12.3)
Hurting a whole lot or
severe pain or very uncomfortable
XYesDaily pain intensity
Stinson et al. (2008) [51]8–17
(13)
Very much painXYesCurrent, least, average, and worst pain intensity
Stinson et al. (2013) [52]9–18Worst possible painXYesHow much pain you have right now
Swain et al. (2005) [53]13–17
(15.62)
✓ (psychologist)Worst imaginable painXNoHighest, lowest, and average in the last two weeks
Varni et al. (1987) [54]5–15 (9.5)✓ (paediatric rheumatologist)Hurting a whole lot or
severe pain
XNoPresent pain and worst pain intensity for the previous week
Vervoort et al. (2008) [34]8–18
(13.33)
✓ (psychologist)A lot of painXNoMost severe and present pain
Vetter et al. (2014) [55]8–17Hurting a whole lot or
Severe pain or very uncomfortable
XNoPain at the present time and at its worst in the past week

Note. “X” signifies details not reported.

NRS study authorsAge range (mean)Children completed assessment Completed with clinician Parents completed assessmentPerson completing not describedHighest anchorClassification details providedSuccessive ratings gainedReference time period

Claar et al. (2008) [56]12–17 (14.69)✓ (psychologist)Most pain possibleXNoCurrent pain rating
Cornelissen et al. (2014) [57]7–17Worst pain imaginableXNoOn the day of the study
Guite et al. (2011) [27]12–18 (15.10)Worst pain imaginableXNoCurrent, most, usual, and least pain
Hainsworth et al. (2007) [58]8–18 (14.0)Worst pain experiencedXNoIntensity of pain over the past two weeks
Hainsworth et al. (2009) [59]8–18
(13.4)
Worst pain experiencedXNoBest, worst, and usual pain
Hechler et al. (2014) [29]9–17
(14)
XXYesAverage of the last seven days
Hicks et al. (2006) [60]9–16
(11.7)
Worst painXYesX
Hirschfeld et al. (2013) [61]11–18 (14.1)Maximal painYesMean intensity in the past seven days
Hirschfeld et al. (2013) [17]Range not given
(12.45)
XXNoMaximal pain during the past four weeks
Jastrowski et al. (2013) [62]12–17XWorst painXYesPain over the prior two weeks
Logan et al. (2008) [63]12–17 (14.7)✓ (psychologist)Most pain possibleXNoCurrent, lowest, and highest pain ratings
Logan et al. (2013) [64]7–18 (13.88)✓ (psychologist)Most pain possibleXNoCurrent pain at rest
Palermo et al. (2008) [65]8–18 (14.31)Worst pain everXNoAverage or usual pain
Ruskin et al. (2014) [15]8–17
(14.1)
✓ (anaesthesiologist)The strongest or worst pain you can imagineXNoCurrent, usual, lowest, and strongest
Ruskin et al. (2015) [66]13–17 (15.75)Worst pain imaginableXNoAverage, worst, and lowest pain
Simons et al. (2010) [67]12–17 (14.8)✓ (type of clinician unclear)Most pain possibleXNoCurrent pain rating
Simons et al. (2015) [68]8–18
(13.73)
✓ (psychologist)Most pain possibleXNoAverage pain rating
Smith et al. (2015) [74]8–17 (range not given)✓ (psychologist)Most pain possibleXNoAverage daily pain rating
Vowles et al. (2010) [70]10–18 (14.8)Worst possible painXNoAverage/usual pain over the last week

Note. “X” signifies details not reported.

FPS study authorsAge range (mean)Children completed assessment Completed with clinician Parents completed assessmentPerson completing not describedHighest anchorClassification details providedSuccessive ratings gainedReference time period

Original Faces Pain Scale (Bieri et al., 1990) [75]
Claar and Walker (2006) [71]8–17 (11.59)XXNoUsual level
Palermo et al. (2004) [72]8–16
(12.4)
Worst painXNoOver the previous four weeks
Palermo and Kiska (2005) [73]13–16 (14.75)Worst pain everXNoPain during the previous four weeks

Faces Pain Scale Revised (Hicks et al., 2001) [26]
Hechler et al. (2014) [29]9–17
(14)
XXYesAverage of the last seven days
Kashikar-Zuck et al. (2011) [28]8–18
(14.2)
XXNoMaximum intensity over the last month
Ramstad et al.
(2011) [33]
8–18 (14.27)✓ (paediatrician or physiotherapist)XXNoMaximum intensity over the last month

Note. “X” signifies details not reported.
3.5. Administrators of Pain Scales

This section reports the findings from the analysis of 49 scales as reported in 46 studies. Twenty-six of the 40 reports on scales explicitly reported that children and/or adolescents completed the scale themselves [27, 29, 35, 4043, 4852, 54, 55, 5759, 61, 65, 66, 7072]. Data include that from two in which more than one scale was used [27, 29]. Eleven studies from the included 46 (23.91%) stated that pain measurements were completed with a healthcare professional: seven with psychologists [34, 53, 56, 63, 64, 68, 69], one with a paediatric rheumatologist [54], one with an anaesthesiologist [15], one with a paediatrician or physiotherapist [33], and one not stating which healthcare professional [67].

In ten studies (21.74%) parents completed pain measures in addition to their child’s report [29, 35, 40, 42, 48, 54, 55, 58, 59, 72]. These studies reported on the use of nine scales (one study reported the use of more than one scale used with parents and CYP [29]). In two of the included studies (5.71%), only parents reported pain (without an accompanying child report) [39, 44]. In eleven of the included studies (reporting the use of a total of 12 scales) the administrators and completers of assessment were not described at all or reports were ambiguous (23.91%) [17, 28, 3638, 4547, 60, 62, 73].

3.6. Scale Anchors

Thirty-five studies (76.09%) labelled the “0” anchor as “No Pain” [15, 27, 28, 34, 3844, 46, 47, 4954, 5665, 68, 70]. Three authors described the use of more than one lowest anchor for scales with some using “not hurting,” “no hurt at all,” or “no discomfort” [42, 50, 55]. Other lowest anchors used included “I have no pain” [35] and “none” [45]. Seven studies did not report what “0” signified on the scales used [17, 28, 29, 36, 37, 48, 71]. Eight studies (17.39%) covering nine uses of scales did not report on the highest upper verbal anchor used as an anchor [17, 28, 29, 33, 36, 37, 48, 71]. One of these studies reported two different scale uses [29]. In the remaining articles which did describe highest anchor points, there were 16 variations in wording, namely, “Worst pain” [45, 60, 62, 72], “Worst pain possible” [38, 40, 47, 52, 70], “Very severe pain” [39, 46], “Worst pain imaginable” [27, 28, 41, 43, 44, 49, 53, 57, 66], “Unbearable pain” [27], “A lot of pain” [34], “Most pain possible” [56, 63, 64, 6769], “Worst pain experienced” [58, 59], “Maximal pain” [61], “Worst pain ever” [65, 73], “I have very severe pain” [35], “Hurting a whole lot” [42, 50, 54, 55], “Severe pain” [42, 50, 54, 55], “Very uncomfortable” [50, 55], “Very much pain” [51], and “The strongest or worst pain you can imagine” [15].

The FPS [75] and the FPS-R [26] have standardised instructions for highest anchor points. For the original FPS, it is recommended that there should not be any written or verbal anchors given to children other than the faces themselves. Two studies in the review discussed the use of top interpretative anchors for children who indicated pain using the highest pain face: “worst pain” [72] and “worst pain ever” [73]. These top anchors were implemented despite no guidance on the interpretation of meaning of pain faces in standardised instructions for this scale. None of the studies which used the FPS-R described the use of written or verbal top anchors although it is suggested by the scale’s authors that the top anchor should be verbally described to children as “very much pain.”

3.7. Number of Records Kept

Two studies (4.35%) omitted information on the number of successive pain measurements completed [36, 48]. Of the studies that did report this, only 13 studies (28.26%) completed successive ratings of pain [27, 29, 37, 4244, 46, 5052, 6062]. These 13 studies included the use of 15 scales as two studies included the use of two scales [27, 29]. Thirty-two studies (69.57%) explicitly reported taking only one measurement of pain [15, 17, 27, 28, 3336, 3841, 45, 47, 49, 5359, 6368, 7073]. These 26 studies reported on the use of 27 scales, with one article reporting only one measurement of pain taken with more than one pain scale [28]. One author described taking successive ratings of pain with a VAS scale but only a one-off assessment with an NRS [27].

3.8. Reference Time Frame Captured by Assessments

There were extremely wide variations in the time periods for which participants were due to report on pain. Three studies did not provide details on the reference time given to frame the assessment period [10, 39, 60]. In the remaining 43 studies that did, over 32 different variations were used. Some gave a specific time frame such as “Current pain” [36, 56, 67], “Present pain” [35], “Pain over the past month” [41], “Pain at that moment” [43, 44], “Today” [57], “Daily pain intensity” [50], “How much pain you have right now” [52], “Intensity of pain over the past two weeks” [58], “Pain over the prior two weeks” [62], and “Over the previous four weeks” [72, 73].

Other time frames depended on recollection of specific pain (i.e., worst pain) without a specified time frame: “Average pain” [46, 68], “Usual pain” [71] “Average or usual pain” [65], “Highest, lowest, average pain” [28], “Average, worst, lowest pain” [66], “Most, usual and least pain” [27, 48], “Current pain level and highest pain in the days preceding” [47], “Current, least, average and worst pain intensity” [51], and “Current, lowest and highest pain ratings” [15, 63].

Only 35% (17) of the scales reviewed specified both time frames and specific pain recall: “Typical pain over the past week” [38], “Current pain at rest” [64], “Average daily pain” [69], “Average pain intensity over the previous week” [40, 70], “Most severe and persistent pain” [34], “Mean intensity in the past seven days” [29, 61], “Average of the last seven days” [29], “Best, worst and usual pain” [59], “Maximal pain during the past four weeks” [17], “Present and worst pain intensity for the previous week” [42], “Current, worst and least pain in the last 12 hours” [45], “Present pain and worst pain intensity for the previous week” [54, 55], and “Maximum intensity over the last month” [28, 33].

3.9. Classification Details Given in Studies

Only two studies (4.35%) provided information about the classification systems used to categorise pain into mild, moderate, and severe pain categories [17, 61]. This means that 95.65% of articles (44 studies) failed to describe pain classification methods. The two studies which provided information were NRS studies from the same research team [17, 61].

4. Discussion

Despite recent attempts to standardise assessment of chronic pain in children and adolescents, little advice exists about how to use and interpret pain measures within paediatric research. Other authors have highlighted how pain is poorly operationalised and approaches to its assessment are inadequately reported across research studies [2, 15, 16, 74] but, to date, there has been no attempt to synthesise evidence from existing pain research studies about how far this problem extends. We conducted a systematic literature review in order to identify, describe, and evaluate paediatric pain assessment research practices with regard to the selection, administration, interpretation, and reporting of chronic pain. The review demonstrates marked variation in the administration of paediatric pain assessments including the administrator and completer of assessments, the anchor points, number of records collected, time/referent periods used to frame assessments, and reported systems for scoring and classification of pain into mild, moderate, and severe pain categories.

Our review identified 46 usable studies which covered 49 reports on the use of unidimensional pain intensity assessments in children and adolescents with chronic pain or conditions in which chronic pain was a feature. Studies were evaluated using a new set of quality criteria devised by the authors which took account of von Baeyer’s [6, 8] practical advice on the selection, administration, and interpretation of pain scales and recommendations for clinical practice, education, and research. None of the studies met all ten of the quality criteria. The highest number of criteria met was seven out of ten achieved by only three studies. This highlights the fact that there are currently no guidelines for reporting research use of pain scales with children and adolescents with chronic pain. Importantly, this limits our ability to compare pain outcomes in this patient population. None of the researchers provided evidence that the children were sufficiently familiar with the scale process prior to assessment. Nor did they make it clear whether the children were reporting levels of pain when at rest or when provoked by activity. Studies were marginally better but still poor at recording whether they had conducted developmental screening or collected successive ratings of pain.

In the field of adult pain assessment in analgesic trials, Smith and colleagues found that pain data collection was far from standardised. They concluded that differences in pain assessment methods influenced the inferences drawn in the studies they reviewed [74]. In line with this and other recent commentaries about adult pain assessment [2, 15, 16], the overall picture formed from our analysis is one of tremendous variation in the ways in which researchers assess pain with young individuals with chronic pain. There was no consensus on any aspect of pain assessment administration and interpretation. This review highlights additional issues relating to the administration of pain scales. A significant proportion of studies did not clearly describe either the person administering the assessment or the person completing it. It was difficult to ascertain the degree to which parents were involved in pain reporting in the assessed studies. Around a quarter of all assessments were completed by a parent but still badged as “self-report.” A similar proportion of studies indicated that healthcare professionals were directly involved in the administration of pain assessments to children. Little is currently known about the effect on pain measurement of the presence of a healthcare professional. In most of the studies, pain scales were given to children for independent completion without reference to the degree of cognitive demand involved or to whether it corresponded with the current cognitive capacity of the child [10].

The wide variation in the anchor points used to frame pain assessment is a further source of inconsistency between studies. Even where standardised guidance is available regarding top anchors [75], these recommendations were not always followed [72, 73]. Anchor points can influence pain ratings and currently the potential influence of upper anchors in particular is in need of further study [22]. There was little consensus with some studies using the upper boundary “worst imaginable” pain, whereas others used “worst pain experienced.” A recent editorial advises caution in using worst imaginable pain as an anchor because of the inherent ambiguity for individuals when imagining the “worst possible” pain [76]. Furthermore, the limits of “imagined” pain may be very different depending upon previous pain experiences leading to artificially low pain scores.

Another concern rising from the findings of the current review was the number of studies which based conclusions about children and adolescents with chronic pain upon one-off assessments of the pain episode. Given that this review was based on studies of children with chronic pain (lasting three or more months [1]) and captures pain for children with conditions such as juvenile idiopathic arthritis (which is characterised by intermittent and fluctuating pain episodes [50]), it was a surprise that so many studies limited pain measurement to such a small fragment of the chronic pain experience [8].

A further issue related to timing aspects of pain assessment was that the studies applied widely differing time referent points in their scales. This included different timings on scales of the same type such as VAS or NRS scales. This aspect of pain measure administration highlighted the biggest discrepancy between pain researchers and there was no evidence to support that any one of the referent points was more widely accepted over others. There has been very little exploration of the impact of different time reference points [77] and what the cognitive challenges may be in asking a child or young person to summarize a month’s worth of pain experiences into a single response. The complexities involved increase when we take into account the developmental cognitive changes that occur between the ages of five and eighteen years.

In the reviewed studies, pain classification information was rarely presented. Almost all studies failed to report how pain was classified and categorised or what scores were defined as mild, moderate, and severe pain. Many of the studies referred to mild, moderate, and severe pain categories without describing the cut points used to define each category. This has significant implications for consistency and comparability between studies. Scores reported by some authors as indicating moderate pain actually constituted mild or severe pain in others. Overall, results indicate confusion about pain scoring systems [78] which may be in part due to the lack of information reported.

By attempting to collate specific methodological information from studies reporting paediatric pain assessments, the degree of poor or incomplete reporting of the use of pain scales became clear. The majority of studies failed to report basic aspects of measurement procedures and interpretation of pain scores. It was therefore difficult to ascertain whether the use of pain assessments with this population was poor, whether it was good but poorly reported, or both. This review evaluated a wide range of study types from observational to clinical trials and therefore some differences in administrative methods would be expected. However, the extent to which differences occurred within studies of the same nature is problematic. Justifications for differences in selection, administration, or interpretation of pain scales in studies of the same type were not provided. Most importantly, the current situation makes comparisons across pain studies in paediatric research virtually impossible [2, 74].

5. Future Directions

Transparent reporting of the use of pain assessments should lead to improvements in the interpretation, reliability, replicability, and comparability of research findings [74]. As a starting point for improving pain assessment administration and reporting in children and adolescents with chronic pain, we suggest that the quality criteria developed for this systematic review are used as guidelines for the reporting of pain assessment tools. These guidelines cover three broad areas: (1) measurement selection, (2) measurement administration, and (3) measurement interpretation. In addition to the modified quality criteria, presentation and interpretation of pain classification information should be provided.

At this stage, there is limited research evidence to suggest that any particular administrative or interpretative methods are better than others. However, we argue that, at the very least by using these criteria and reporting guidelines, researchers will be able to examine and report the differential impacts of methods of pain scale selection, administration, and interpretation. This will enable pain researchers to identify and justify optimal approaches to pain assessment to address their specified research aims. The standardisation of pain assessment methods has been identified as a research priority for reducing bias in pain reports [16, 17]. Standardisation of assessment refers to how measures are used as well as which ones are selected. Our guidelines for the reporting of pain assessments with children and adolescents with chronic pain will go some way towards achieving this aim.

6. Conclusions

This systematic review found that the selection, administration, interpretation, and reporting of chronic pain assessments with children and adolescents are inconsistent and poor, and the approaches used are rarely justified. The results of this review provide evidence to suggest that, in paediatric pain assessment, researchers gather information through distinctively different approaches meaning that it is hard to compare and interpret data from different studies. This also demonstrates that there is a weak evidence base on which to base administrative and interpretative decisions about new developing tools. The implications of the findings from this review include the adoption of guidelines for reporting the use of pain assessments with children and adolescents with chronic pain.

Appendix

Full Search Strategy Used in Review

(1)(2)ediatric(3)(4)Juvenile(5)1 or 2 or 3 or 4(6)(7)(8)Pain scale(9)Visual analogue scale(10)Faces pain scale(11)Numerical rating scale(12)Verbal rating scale(13)VAS(14)NRS(15)VRS(16)6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15(17)Chronic pain(18)Musculoskeletal pain(19)Recurrent pain(20)17 or 18 or 19(21)(22)Classification(23)Mild(24)Moderate(25)Severe(26)(27)21 or 22 or 23 or 24 or 25 or 26(28)5 AND 16 AND 20 AND 27(29)Limit to article (for Embase or journal article in Medline)(30)Limit to English

Disclosure

The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Acknowledgments

This work was supported by Arthritis Research UK Grant no. 20380 and by the NIHR Manchester Biomedical Research Centre. This article includes independent research funded by the National Institute for Health Research Biomedical Research Unit Funding Scheme. The authors would like to thank Carl von Baeyer for valuable advice about recommendations for pain assessment tool administration and their development of these into a quality assessment tool for the current review.

Supplementary Materials

Supplementary Table 1: Criteria which were excluded with corresponding justification.

  1. Supplementary Material

References

  1. IASP, Classification of Chronic Pain: Descriptions of chronic pain syndromes and definitions of pain terms, IASP Press, Seattle, Wash, USA, 1994.
  2. S. King, C. T. Chambers, A. Huguet et al., “The epidemiology of chronic pain in children and adolescents revisited: a systematic review,” Pain, vol. 152, no. 12, pp. 2729–2738, 2011. View at: Publisher Site | Google Scholar
  3. G. Hirschfeld, “Clinically meaningful changes in pain ratings: why we need special cut points in children and adolescents,” Pain management, vol. 4, no. 2, pp. 81–83, 2014. View at: Publisher Site | Google Scholar
  4. L. S. Franck, C. S. Greenberg, and B. Stevens, “Pain assessment in infants and children,” Pediatric Clinics of North America, vol. 47, no. 3, pp. 487–512, 2000. View at: Publisher Site | Google Scholar
  5. M. J. Treadwell, L. S. Franck, and E. Vichinsky, “Using quality improvement strategies to enhance pediatric pain assessment,” International Journal for Quality in Health Care, vol. 14, no. 1, pp. 39–47, 2002. View at: Publisher Site | Google Scholar
  6. C. L. von Baeyer, “Self-report: the primary source in assessment after infancy,” in Oxford Textbook of Paediatric Pain, P. J. McGrath, B. J. Stevens, S. Walker, and W. Zempsky, Eds., pp. 370–380, Oxford University Press, Oxford, UK, 2014. View at: Google Scholar
  7. A. Twycross, T. Voepel-Lewis, C. Vincent, L. S. Franck, and C. L. Von Baeyer, “A Debate on the Proposition that Self-report is the Gold Standard in Assessment of Pediatric Pain Intensity,” Clinical Journal of Pain, vol. 31, no. 8, pp. 707–712, 2015. View at: Publisher Site | Google Scholar
  8. C. L. von Baeyer, “Children's self-reports of pain intensity: scale selection, limitations and interpretation,” Pain Research and Management, vol. 11, no. 3, pp. 157–162, 2006. View at: Publisher Site | Google Scholar
  9. R. F. Howard and C. Liossi, “Pain assessment in children,” Archives of Disease in Childhood: Education and Practice Edition, vol. 99, no. 12, pp. 1123-1124, 2014. View at: Publisher Site | Google Scholar
  10. J. Y.-C. Chan and C. L. Von Baeyer, “Cognitive developmental influences on the ability of preschool-aged children to self-report their pain intensity,” Pain, vol. 157, no. 5, pp. 997–1001, 2016. View at: Publisher Site | Google Scholar
  11. J. N. Stinson, “Improving the assessment of pediatric chronic pain: harnessing the potential of electronic diaries,” Pain Research and Management, vol. 14, no. 1, pp. 59–64, 2009. View at: Publisher Site | Google Scholar
  12. N. Adib, K. Hyrich, J. Thornton et al., “Association between duration of symptoms and severity of disease at first presentation to paediatric rheumatology: results from the Childhood Arthritis Prospective Study,” Rheumatology, vol. 47, no. 7, pp. 991–995, 2008. View at: Publisher Site | Google Scholar
  13. P. J. McGrath, G. A. Walco, D. C. Turk et al., “Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations,” Pain, vol. 9, no. 9, pp. 771–783, 2008. View at: Publisher Site | Google Scholar
  14. C. J. Jacobson, S. Kashikar-Zuck, J. Farrell et al., “Qualitative Evaluation of Pediatric Pain Behavior, Quality, and Intensity Item Candidates and the PROMIS Pain Domain Framework in Children with Chronic Pain,” Journal of Pain, vol. 16, no. 12, pp. 1243–1255, 2015. View at: Publisher Site | Google Scholar
  15. D. Ruskin, C. Lalloo, K. Amaria et al., “Assessing pain intensity in children with chronic pain: convergent and discriminant validity of the 0 to 10 numerical rating scale in clinical practice,” Pain Research and Management, vol. 19, no. 3, pp. 141–148, 2014. View at: Publisher Site | Google Scholar
  16. M. Schiavenato and K. D. Craig, “Pain assessment as a social transaction: Beyond the ‘gold standard’,” Clinical Journal of Pain, vol. 26, no. 8, pp. 667–676, 2010. View at: Publisher Site | Google Scholar
  17. G. Hirschfeld and B. Zernikow, “Variability of ‘optimal’ cut points for mild, moderate and severe pain: neglected problems when comparing groups,” Pain, vol. 154, no. 1, pp. 154–159, 2013. View at: Publisher Site | Google Scholar
  18. D. S. Tsze, G. Hirschfeld, P. S. Dayan, B. Bulloch, and C. L. von Baeyer, “Defining No Pain, Mild, Moderate, and Severe Pain Based on the Faces Pain Scale–Revised and Color Analog Scale in Children With Acute Pain,” Pediatric Emergency Care, 2016. View at: Publisher Site | Google Scholar
  19. D. Moher, A. Liberati, J. Tetzlaff, and D. Altman, “Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement,” Annals of Internal Medicine, vol. 151, pp. 264–267, 2009. View at: Google Scholar
  20. J. N. Stinson, T. Kavanagh, J. Yamada, N. Gill, and B. Stevens, “Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents,” Pain, vol. 125, no. 1-2, pp. 143–157, 2006. View at: Publisher Site | Google Scholar
  21. C. L. von Baeyer and L. J. Spagrud, “Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years,” Pain, vol. 127, no. 1-2, pp. 140–150, 2007. View at: Publisher Site | Google Scholar
  22. C. L. von Baeyer, “Children's self-report of pain intensity: what we know, where we are headed,” Pain Research and Management, vol. 14, no. 1, pp. 39–45, 2009. View at: Publisher Site | Google Scholar
  23. E. Castarlenas, M. P. Jensen, C. L. Von Baeyer, and J. Miró, “Psychometric properties of the numerical rating scale to assess self-reported pain intensity in children and adolescents,” Clinical Journal of Pain, vol. 33, no. 4, pp. 376–383, 2017. View at: Publisher Site | Google Scholar
  24. B. J. Shields, T. M. Palermo, J. D. Powers, S. D. Grewe, and G. A. Smith, “Predictors of a child's ability to use a visual analogue scale,” Child: Care, Health and Development, vol. 29, no. 4, pp. 281–290, 2003. View at: Publisher Site | Google Scholar
  25. C. L. von Baeyer, L. J. Spagrud, J. C. McCormick, E. Choo, K. Neville, and M. A. Connelly, “Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children's self-reports of pain intensity,” Pain, vol. 143, no. 3, pp. 223–227, 2009. View at: Publisher Site | Google Scholar
  26. C. L. Hicks, C. L. von Baeyer, P. A. Spafford, I. van Korlaar, and B. Goodenough, “The Faces Pain Scale—Revised: toward a common metric in pediatric pain measurement,” Pain, vol. 93, no. 2, pp. 173–183, 2001. View at: Publisher Site | Google Scholar
  27. J. W. Guite, D. E. Logan, L. E. Simons, E. A. Blood, and R. D. Kerns, “Readiness to change in pediatric chronic pain: Initial validation of adolescent and parent versions of the Pain Stages of Change Questionnaire,” Pain, vol. 152, no. 10, pp. 2301–2311, 2011. View at: Publisher Site | Google Scholar
  28. S. Kashikar-Zuck, S. R. Flowers, R. L. Claar et al., “Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain,” Pain, vol. 152, no. 7, pp. 1600–1607, 2011. View at: Publisher Site | Google Scholar
  29. T. Hechler, A.-K. Ruhe, P. Schmidt et al., “Inpatient-based intensive interdisciplinary pain treatment for highly impaired children with severe chronic pain: Randomized controlled trial of efficacy and economic effects,” Pain, vol. 155, no. 1, pp. 118–128, 2014. View at: Publisher Site | Google Scholar
  30. B. Zernikow, J. Wager, T. Hechler et al., “Characteristics of highly impaired children with severe chronic pain: a 5-year retrospective study on 2249 pediatric pain patients,” BMC Pediatrics, vol. 12, article 54, 2012. View at: Publisher Site | Google Scholar
  31. B. Taubman, P. Mamula, and D. D. Sherry, “Prevalence of asymptomatic celiac disease in children with fibromyalgia: A pilot study,” Pediatric Rheumatology, vol. 9, article no. 11, 2011. View at: Publisher Site | Google Scholar
  32. L. Kachko, S. Ben Ami, A. Lieberman, R. Shor, E. Tzeitlin, and R. Efrat, “Neuropathic pain other than CRPS in children and adolescents: incidence, referral, clinical characteristics, management, and clinical outcomes,” Paediatric Anaesthesia, vol. 24, no. 6, pp. 608–613, 2014. View at: Publisher Site | Google Scholar
  33. K. Ramstad, R. Jahnsen, O. H. Skjeldal, and T. H. Diseth, “Characteristics of recurrent musculoskeletal pain in children with cerebral palsy aged 8 to 18 years,” Developmental Medicine and Child Neurology, vol. 53, no. 11, pp. 1013–1018, 2011. View at: Publisher Site | Google Scholar
  34. T. Vervoort, K. D. Craig, L. Goubert et al., “Expressive dimensions of pain catastrophizing: A comparative analysis of school children and children with clinical pain,” Pain, vol. 134, no. 1-2, pp. 59–68, 2008. View at: Publisher Site | Google Scholar
  35. H. H. Abu-Saad and M. Uiterwijk, “Pain in children with juvenile rheumatoid arthritis: A descriptive study,” Pediatric Research, vol. 38, no. 2, pp. 194–197, 1995. View at: Publisher Site | Google Scholar
  36. R. G. Astfalck, P. B. O'Sullivan, L. M. Straker, and A. J. Smith, “A detailed characterisation of pain, disability, physical and psychological features of a small group of adolescents with non-specific chronic low back pain,” Manual Therapy, vol. 15, no. 3, pp. 240–247, 2010. View at: Publisher Site | Google Scholar
  37. V. W. Chan, E. J. Mccabe, and D. L. Macgregor, “Botox treatment for migraine and chronic daily headache in adolescents,” Journal of Neuroscience Nursing, vol. 41, no. 5, pp. 235–243, 2009. View at: Publisher Site | Google Scholar
  38. L. L. Cohen, K. E. Vowles, and C. Eccleston, “The impact of adolescent chronic pain on functioning: Disentangling the complex role of anxiety,” Journal of Pain, vol. 11, no. 11, pp. 1039–1046, 2010. View at: Publisher Site | Google Scholar
  39. S. J. de Oliveira, J. E. Corrente, and M. C. Saad, “Progression of articular and extraarticular damage in oligoarticular juvenile idiopathic arthritis,” Clinical and Experimental Rheumatology, vol. 29, no. 5, pp. 871–877, 2011. View at: Google Scholar
  40. C. Eccleston, G. Crombez, A. Scotford, J. Clinch, and H. Connell, “Adolescent chronic pain: Patterns and predictors of emotional distress in adolescents with chronic pain and their parents,” Pain, vol. 108, no. 3, pp. 221–229, 2004. View at: Publisher Site | Google Scholar
  41. J. I. Gold, N. E. Mahrer, J. Yee, and T. M. Palermo, “Pain, fatigue, and health-related quality of life in children and adolescents with chronic pain,” Clinical Journal of Pain, vol. 25, no. 5, pp. 407–412, 2009. View at: Publisher Site | Google Scholar
  42. R. A. Gragg, M. A. Rapoff, M. B. Danovsky et al., “Assessing chronic musculoskeletal pain associated with rheumatic disease: Further validation of the Pediatric Pain Questionnaire,” Journal of Pediatric Psychology, vol. 21, no. 2, pp. 237–250, 1996. View at: Publisher Site | Google Scholar
  43. J. A. M. Hunfeld, C. W. Perquin, W. Bertina et al., “Stability of pain parameters and pain-related quality of life in adolescents with persistent pain: A three-year follow-up,” Clinical Journal of Pain, vol. 18, no. 2, pp. 99–106, 2002. View at: Publisher Site | Google Scholar
  44. J. A. M. Hunfeld, C. W. Perquin, A. A. J. M. Hazebroek-Kampschreur, J. Passchier, L. W. A. Van Suijlekom-Smit, and J. C. Van der Wouden, “Physically unexplained chronic pain and its impact on children and their families: The mother's perception,” Psychology and Psychotherapy: Theory, Research and Practice, vol. 75, no. 3, pp. 251–260, 2002. View at: Publisher Site | Google Scholar
  45. E. Jacob, J. Stinson, J. Duran et al., “Usability testing of a smartphone for accessing a web-based e-diary for self-monitoring of pain and symptoms in sickle cell disease,” Journal of Pediatric Hematology/Oncology, vol. 34, no. 5, pp. 326–335, 2012. View at: Publisher Site | Google Scholar
  46. S. Kashikar-Zuck, T. V. Ting, L. M. Arnold et al., “Cognitive behavioral therapy for the treatment of juvenile fibromyalgia: a multisite, single-blind, randomized, controlled clinical trial,” Arthritis and Rheumatism, vol. 64, no. 1, pp. 297–305, 2012. View at: Publisher Site | Google Scholar
  47. A. Y. Konijnenberg, C. S. P. M. Uiterwaal, J. L. L. Kimpen, J. Van Der Hoeven, J. K. Buitelaar, and E. R. De Graeff-Meeder, “Children with unexplained chronic pain: substantial impairment in everyday life,” Archives of Disease in Childhood, vol. 90, no. 7, pp. 680–686, 2005. View at: Publisher Site | Google Scholar
  48. D. E. Logan, J. W. Guite, D. D. Sherry, and J. B. Rose, “Adolescent-parent relationships in the context of adolescent chronic pain conditions,” Clinical Journal of Pain, vol. 22, no. 6, pp. 576–583, 2006. View at: Publisher Site | Google Scholar
  49. A. M. Lynch, S. Kashikar-Zuck, K. R. Goldschneider, and B. A. Jones, “Psychosocial Risks for Disability in Children With Chronic Back Pain,” Journal of Pain, vol. 7, no. 4, pp. 244–251, 2006. View at: Publisher Site | Google Scholar
  50. L. E. Schanberg, K. K. Anthony, K. M. Gil, and E. C. Maurin, “Daily pain and symptoms in children with polyarticular arthritis,” Arthritis and Rheumatism, vol. 48, no. 5, pp. 1390–1397, 2003. View at: Publisher Site | Google Scholar
  51. J. N. Stinson, B. J. Stevens, B. M. Feldman et al., “Construct validity of a multidimensional electronic pain diary for adolescents with arthritis,” Pain, vol. 136, no. 3, pp. 281–292, 2008. View at: Publisher Site | Google Scholar
  52. J. N. Stinson, L. A. Jibb, C. Nguyen et al., “Development and testing of a multidimensional iphone pain assessment application for adolescents with cancer,” Journal of Medical Internet Research, vol. 15, no. 3, p. e51, 2013. View at: Publisher Site | Google Scholar
  53. N. F. Swain, S. Kashikar-Zuck, T. B. Graham, and S. Prahalad, “Tender point assessment in juvenile primary fibromyalgia syndrome,” Arthritis Care and Research, vol. 53, no. 5, pp. 785–787, 2005. View at: Publisher Site | Google Scholar
  54. J. W. Varni, K. L. Thompson, and V. Hanson, “The Varni/Thompson Pediatrie Pain Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis,” Pain, vol. 28, no. 1, pp. 27–38, 1987. View at: Publisher Site | Google Scholar
  55. T. R. Vetter, C. L. Bridgewater, L. I. Ascherman, A. Madan-Swain, and G. L. McGwin Jr., “Patient versus parental perceptions about pain and disability in children and adolescents with a variety of chronic pain conditions,” Pain Research and Management, vol. 19, no. 1, pp. 7–14, 2014. View at: Publisher Site | Google Scholar
  56. R. L. Claar, K. F. Baber, L. E. Simons, D. E. Logan, and L. S. Walker, “Pain coping profiles in adolescents with chronic pain,” Pain, vol. 140, no. 2, pp. 368–375, 2008. View at: Publisher Site | Google Scholar
  57. L. Cornelissen, C. Donado, J. Kim et al., “Pain hypersensitivity in juvenile idiopathic arthritis: a quantitative sensory testing study,” Pediatric Rheumatology, vol. 12, no. 1, article 39, 2014. View at: Publisher Site | Google Scholar
  58. K. R. Hainsworth, W. H. Davies, K. A. Khan, and S. J. Weisman, “Development and Preliminary Validation of the Child Activity Limitations Questionnaire: Flexible and Efficient Assessment of Pain-Related Functional Disability,” Journal of Pain, vol. 8, no. 9, pp. 746–752, 2007. View at: Publisher Site | Google Scholar
  59. K. R. Hainsworth, W. H. Davies, K. A. Khan, and S. J. Weisman, “Co-occurring chronic pain and obesity in children and adolescents: The impact on health-related quality of life,” Clinical Journal of Pain, vol. 25, no. 8, pp. 715–721, 2009. View at: Publisher Site | Google Scholar
  60. C. L. Hicks, C. L. Von Baeyer, and P. J. McGrath, “Online psychological treatment for pediatric recurrent pain: A randomized evaluation,” Journal of Pediatric Psychology, vol. 31, no. 7, pp. 724–736, 2006. View at: Publisher Site | Google Scholar
  61. G. Hirschfeld, T. Hechler, M. Dobe et al., “Maintaining lasting improvements: One-year follow-up of children with severe chronic pain undergoing multimodal inpatient treatment,” Journal of Pediatric Psychology, vol. 38, no. 2, pp. 224–236, 2013. View at: Publisher Site | Google Scholar
  62. M. Jastrowski, K. S. Salamon, K. R. Hainsworth et al., “A randomized, controlled pilot study of mindfulness-based stress reduction for pediatric chronic pain,” Alternative Therapies in Health & Medicine, vol. 19, pp. 8–14, 2013. View at: Google Scholar
  63. D. E. Logan, R. L. Claar, and L. Scharff, “Social desirability response bias and self-report of psychological distress in pediatric chronic pain patients,” Pain, vol. 136, no. 3, pp. 366–372, 2008. View at: Publisher Site | Google Scholar
  64. D. E. Logan, S. E. Williams, V. P. Carullo, R. L. Claar, S. Bruehl, and C. B. Berde, “Children and adolescents with complex regional pain syndrome: More psychologically distressed than other children in pain?” Pain Research and Management, vol. 18, no. 2, pp. 87–93, 2013. View at: Publisher Site | Google Scholar
  65. T. M. Palermo, A. S. Lewandowski, A. C. Long, and C. J. Burant, “Validation of a self-report questionnaire version of the Child Activity Limitations Interview (CALI): The CALI-21,” Pain, vol. 139, no. 3, pp. 644–652, 2008. View at: Publisher Site | Google Scholar
  66. D. Ruskin, S. A. Kohut, and J. Stinson, “The development of a mindfulness-based stress reduction group for adolescents with chronic pain,” Journal of Pain Management, vol. 7, pp. 301–312, 2015. View at: Google Scholar
  67. L. E. Simons, D. E. Logan, L. Chastain, and M. Stein, “The relation of social functioning to school impairment among adolescents with chronic pain,” Clinical Journal of Pain, vol. 26, no. 1, pp. 16–22, 2010. View at: Publisher Site | Google Scholar
  68. L. E. Simons, A. Smith, C. Ibagon et al., “Pediatric pain screening tool: Rapid identification of risk in youth with pain complaints,” Pain, vol. 156, no. 8, pp. 1511–1518, 2015. View at: Publisher Site | Google Scholar
  69. A. M. Smith, C. B. Sieberg, S. Odell, E. Randall, and L. E. Simons, “Living life with my child's pain: the parent pain acceptance questionnaire (PPAQ),” Clinical Journal of Pain, vol. 31, no. 7, pp. 633–641, 2015. View at: Publisher Site | Google Scholar
  70. K. E. Vowles, A. Jordan, and C. Eccleston, “Toward a taxonomy of adolescents with chronic pain: Exploratory cluster and discriminant analyses of the bath adolescent pain questionnaire,” European Journal of Pain, vol. 14, no. 2, pp. 214–221, 2010. View at: Publisher Site | Google Scholar
  71. R. L. Claar and L. S. Walker, “Functional assessment of pediatric pain patients: Psychometric properties of the Functional Disability Inventory,” Pain, vol. 121, no. 1-2, pp. 77–84, 2006. View at: Publisher Site | Google Scholar
  72. T. M. Palermo, D. Witherspoon, D. Valenzuela, and D. D. Drotar, “Development and validation of the Child Activity Limitations Interview: A measure of pain-related functional impairment in school-age children and adolescents,” Pain, vol. 109, no. 3, pp. 461–470, 2004. View at: Publisher Site | Google Scholar
  73. T. M. Palermo and R. Kiska, “Subjective sleep disturbances in adolescents with chronic pain: Relationship to daily functioning and quality of life,” Journal of Pain, vol. 6, no. 3, pp. 201–207, 2005. View at: Publisher Site | Google Scholar
  74. S. M. Smith, M. Hunsinger, A. McKeown et al., “Quality of pain intensity assessment reporting: ACTTION systematic review and recommendations,” Journal of Pain, vol. 16, no. 4, pp. 299–305, 2015. View at: Publisher Site | Google Scholar
  75. D. Bieri, R. A. Reeve, G. D. Champion, L. Addicoat, and J. B. Ziegler, “The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties,” Pain, vol. 41, no. 2, pp. 139–150, 1990. View at: Publisher Site | Google Scholar
  76. S. Morley, “Bias and reliability in pain ratings,” Pain, vol. 157, no. 5, pp. 993-994, 2016. View at: Publisher Site | Google Scholar
  77. A. A. Stone, R. C. Kessler, and J. A. Haythomthwatte, “Measuring Daily Events and Experiences: Decisions for the Researcher,” Journal of Personality, vol. 59, no. 3, pp. 575–607, 1991. View at: Publisher Site | Google Scholar
  78. R. A. Moore, S. Straube, and D. Aldington, “Pain measures and cut-offs - 'no worse than mild pain' as a simple, universal outcome,” Anaesthesia, vol. 68, no. 4, pp. 400–412, 2013. View at: Publisher Site | Google Scholar

Copyright © 2017 Rebecca Rachael Lee 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.


More related articles

2400 Views | 608 Downloads | 6 Citations
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly and safely as possible. Any author submitting a COVID-19 paper should notify us at help@hindawi.com to ensure their research is fast-tracked and made available on a preprint server as soon as possible. We will be providing unlimited waivers of publication charges for accepted articles related to COVID-19. Sign up here as a reviewer to help fast-track new submissions.