|Assessment tool||Description||Type of pain||Age group||Psychometric properties|
|Neonatal Facial Coding System (34,35)||Facial actions comprising the scale: brow bulge, eye squeeze, nasolabial furrow, open lips, mouth stretch (horizontal and vertical), lip purse, tongue tautening, and chin quiver. An action receives a score if it occurs.||Used during invasive procedures. Measures immediate response to cutaneous pain.||Neonates||Reliability: interrater estimated at 0.88 and 0.90
Validity: coding system was based on the adult Facial Action Coding System, providing some evidence for content validity. Associations between facial activity and injection were moderate in magnitude but were higher than associations between facial activity and noninvasive procedures. Consistent pattern of facial movement occurred with invasive stimuli. Variations in patterns occurred according to sleep state. Associations suggest that facial activity and cry are different response modes.
|Infant Pain Behavior Rating Scale (25)||This scale includes seven categories of behavior: vocal actions, nonvocal-face, nonvocal-torso, nonvocal-limbs, verbal actions to the child, verbal actions to another person, and nonverbal behavior. Scoring involves determining the occurrence of the behaviors.||Used during invasive procedures. Measures immediate response to cutaneous pain.||Infants and toddlers||Reliability: interrater estimates were greater than 0.70 for
only 4 of the 29 subcategories.
Validity: no published information.
|Clinical Scoring System for Measurement of Postoperative Pain (12,13)||This scoring system includes 10 criteria: sleep, facial expression, motor activity, excitability and responsiveness to stimulation, flexion of fingers and toes, sucking, tone, consolability, and sociability. Each criterion is scored on a 0-to-2 scale, with lower scores indicating higher amounts of pain. Range of scores is 0 to 20.||Used postoperatively. Measures established response to cutaneous pain.||Infants||Reliability: no published information.Validity: ratings of 15 to 20 were used as satisfactory postoperative analgesia but no evidence for the validity of this criteria. Scores for infants receiving fentanyl were significantly higher than control group, suggesting some evidence for construct validity.|
|Children's Hospital Eastern Ontario Pain Scale (CHEOPS) (72)||This scale includes six items: cry, facial, child verbal, torso, touch, and legs. Each item has several behavioral indicators. Each behavioral indicator is associated with a score between 0 and 3. Total scores range from 0 to 13, with higher scores indicating greater amounts of pain.||Used postoperatively. Measures established response to cutaneous pain.||Toddlers and preschool children||Reliability: average interrater reliability ranged from 0.90 to 0.99.Validity: recovery room nurses provided content for items based on their observations of postoperative be havior. Intercorrelations among items were moderate in magnitude. Correlations between nurses' ratings of pain on a visual analogue scale and the CHEOPS were moderate to high. Method for determining score for each behavioral indicator was not discussed. Recent work by Beyer et al. (18) raised issues about validity of tool when flat scores were obtained on 3- to 7-year-old children recovering from surgery. Whether these findings apply to children younger than 3 years has not been determined.|
|Gustave-Roussy Child Pain Scale (32; Gauvain-Piquard, 1991, personal communication||Original scale had 17 items pertaining to pain, depression, and anxiety. Current form of scale has 10 items related to pain. Items focus on the following: rest position, expressiveness, protection of painful areas, somatic complaints, antalgic behavior, lack of interest in surroundings, passive mobilization, child pointing out painful areas, reactions when examined, and slowness and infrequency of movements. Each item is scored on a 0-to-4 scale, with higher scores indicating pain.||Used on children with cancer. Measures visceral, deep somatic, or neuropathic pain.||Toddlers and preschool children||Psychometric properties have been published on original tool but not the current form.
Reliability: agreement among raters was low to moderate.
Validity: content for scale derived from health care provider's descriptions of children with cancer. Factor analysis supported a factor related to the expression of pain that accounted for 51% of the variance. Variability in scores across children suggests scale discriminates among pain levels.
|Pain/Discomfort Scale (20,37)||Six criteria comprise the scale: blood pressure, crying, movement, agitation, posture, and pain complaints. Each criteria is scored on a 0-to-2 scale. Range of scores is 0 to 12.||Used postoperatively. Measures established response to cutaneous pain.||Toddlers and preschool children||Reliability: no published information.
Validity: no published information. A score of 7 on two occasions (5 min apart) was used for the administration of an opioid. No information on how this criteria was established.
|Toddler-Preschooler Postoperative Pain Scale (101)||Seven items comprise the scale: three focus on verbal expression of pain (e.g., verbal pain complaint, scream, groan), three focus on facial expression (e.g., open mouth, squint, furrow forehead), and two focus on bodily expression of pain (e.g., restless motor behavior, rub or touch painful area). Each item is scored a 1 if it occurs during a 5-min observation period and a 0 if not. Range of scores is from 0 to 7.||Used postoperatively. Measures estab lished response to cutaneous pain.||Toddlers and preschool children||Reliability: internal consistency for scale was high (0.88). Interrater re
liability was moderate to high.
Validity: associations between scale scores and pain ratings by parents and nurses were moderate. Sensitive to timing and type of analgesic regimen. Associations between scale score and intraoperative vital signs were zero to low; associations between scale score and postoperative vital signs were low.
|Behavioral Observation Tool (39)||Four categories comprise the scale: vocal (six rank- ordered vocal behaviors), verbal (five rank-ordered verbal behaviors), facial (three dichotomously scored items), and motor (two items, one with four rank-ordered behaviors and the other dichotomously scored). Range of scores is from 7 to 23.||Used with invasive procedures. Measures immediate response to cutaneous pain.||Preschool and young school-age children||Reliability: interrater
reliability was moderate to high.
Validity: scores on Poker Chip Tool were positively and moderately associated with verbal and vocal behaviors, suggesting some evidence for convergent validity. Scores on Poker Chip Tool were negatively and moderately associated facial and motor behaviors, suggesting some evidence for discriminant validity.
|Procedure Behavior Rating Scale (63)||Twenty-five items originally comprised the scale. Ten items that never or infrequently occurred during 115 bone marrow aspirations were eliminated. Two other items were eliminated due to statistical concerns. Thus 13 items comprise the scale. Each item is scored as a 1 when present. Scores range from 0 to 13.||Used with invasive procedures. Measures immediate response to cutaneous pain.||Infants through adolescents||Reliability: interrater
reliability and rater agreement were high.
Validity: concept measured is anxiety but it is unclear why ``Pain Verbal'' is included as an item, thus raising questions about construct validity. Scores are highest for younger children (8 months to 6.5 years); scores decrease for school-age children, more for older children and adolescents. Scores for oldest age group are extremely low, raising issues about the validity of the tool for this age group. Scores for all age groups are higher during invasive phase of bone marrow aspiration, suggesting evidence for discriminant validity but raising questions about what is being measured. Nurses' ratings of anxiety moderately related to behavioral scores.
|Procedure Behavior Checklist (68)||Eight items comprise this scale. Scale is a revision of the Procedure Behavior Rating Scale. Each item is rated on a 1-to-5 scale (very mild to extremely intense). Range of scores is from 8 to 40.||Used with invasive procedures. Measures immediate response to cutaneous pain.||Schoolage children and adolescents||Reliability: interrater reliability was moderate to high for behavior
checklist and anxiety but low to high for pain. Agreement between raters
Validity: concept of anxiety is being measured but some items suggest pain is being measured, raising issues about construct validity. Associations among behavior checklist, observed anxiety, and observed pain were moderate to high, suggesting convergent validity. Associations between behavior checklist and patient pain and patient anxiety were low to moderate, providing minimal support for convergent validity. Associations between patient and observer anxiety ratings were moderate to high, providing support for convergent validity. Associations between patient and observer pain ratings were low to moderate, providing minimal support for convergent validity.
|Observational Scale of Behavioral Distress (56,57,59)||Eleven behaviors related to pain and/or anxiety comprise this distress scale. This scale is a revision of the Procedure Behavior Rating Scale. Each item is associated with an intensity weight derived by averaging intensity scores from three clinic personnel. Item intensity weights range from 1 to 4.||Used for invasive procedures. Measures immediate response to cutaneous pain.||Toddlers through adolescents||Reliability: interrater reliability and agreement between raters were high.
Validity: concept of behavioral distress is being measured; it is operationalized as encompassing two other concepts-pain and anxiety. Evidence for convergent validity of the distress scale is shown through moderate relationships with anxiety, experienced pain, parent's rating of child's anxiety, and parent-reported anxiety symptoms; and a high relationship with anticipated pain. Age score differences raise the question of whether the tool is appropriate for older children and adolescents, as younger children exhibited more behavioral distress.