Item
Behavioral
Definition
Score
Cry
No cry
1
Child is not crying
Moaning
2
Child is moaning or quietly vocalizing silent cry
Crying
2
Child is crying, but the cry is gentle or whimpering
Scream
3
Child is in a full-lunged cry; sobbing; may be scored with complaint or without complaint
Facial
Composed
1
Neutral facial expression
Grimace
2
Score only if definite negative facial expression
Smiling
0
Score only if definite positive facial expression
Child verbal
None
1
Child not talking
Other complaints
1
Child complains, but not about pain, e.g., “I want to see mommy” or “I am thirsty”
Pain complaints
2
Child complains about pain
Both complaints
2
Child complains about pain and about other things, e.g., “It hurts. I want my mommy”
Positive
0
Child makes any positive statement or talks about other things without complaint
Torso
Neutral
1
Body (not limbs) is at rest; torso is inactive
Shifting
2
Body is in motion in a shifting or serpentine fashion
Tense
2
Body is arched or rigid
Shivering
2
Body is shuddering or shaking involuntarily
Upright
2
Child is in a vertical or upright position
Restrained
2
Body is restrained
Touching
Not touching
1
Child is not touching or grabbing at wound
Reach
2
Child is reaching for but not touching wound
Touch
2
Child is gently touching wound or wound area
Grab
2
Child is grabbing vigorously at wound
Restrained
2
Child’s arms are restrained
Legs
Neutral
1
Legs may be in any position but are relaxed; includes gentle swimming or separate-like movements
Squirm/kicking
2
Definitive uneasy or restless movements in the legs and/or striking out with foot or feet
Drawn up/tensed
2
Legs tensed and/or pulled up tightly to body and kept there
Standing
2
Standing, crouching, or kneeling
Restrained
2
Child’s legs are being held down
4.
That some measures (e.g., those requiring training, additional personnel, video recording, coding of data) may be more appropriate to research and less suitable for a clinical setting. A clinical situation can change rapidly and measures may not be sufficiently flexible to detect sudden changes.
The following are some illustrative examples of measures that can be used in various clinical situations.
To assess procedural and brief episodes of pain:
1.
Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
Originally developed as a measure of postoperative pain, this is now an established measure of behaviors during brief episodes of pain in infants and children up to 18 years, and can be used to measure the outcomes of interventions to alleviate pain. The measure comprises six items of behavior—cry, facial, child verbal, torso, touch, and legs—each item being given a score of 1–3 from which a total pain score can be derived (see Table 34.1). The CHEOPS has been used extensively in many countries and contexts for venipunctures, immunizations, and surgery. However, some consider it to be complicated to score and less practical compared to other observational scales.
2.
Face, Legs, Activity, Cry, and Consolability Scale (FLACC) [27]
This scale measures both procedural and postoperative pain, originally designed for children up to 7 years but subsequently modified for use up to late adulthood, with five indicators—face, legs, activity, cry, and consolability—each rated on a three-point scale (0–2) (see Table 34.2). This scale is used for a large variety of procedures, including venipuncture, catheterization, laceration repair, and chest drain removal. It is a low burden scale, translated for use in many countries.
Category | Scoring | ||
|---|---|---|---|
0 | 1 | 2 | |
Face | No particular expression or smile | Occasional grimace or frown | Frequent to constant quivering chin |
Withdrawn | Clenched jaw | ||
Disinterested | |||
Legs | Normal position or relaxed | Uneasy | Kicking or legs drawn up |
Restless | |||
Tense | |||
Activity | Lying quietly | Squirming | Arched, rigid, or jerking |
Normal position | Shifting back and forth | ||
Moves easily | Tense | ||
Cry | No cry (awake or asleep) | Moans or whimpers | Crying steadily |
Occasional complaint | Screams or sobs | ||
Frequent complaints | |||
Consolability | Content | Reassured by occasional touching, hugging, or being talked to | Difficult to console |
Relaxed | Distractable | ||
To assess procedural distress and interactions:
1.
Procedure (or Procedural) Behavioral Rating Scale (PBRS) [28]
This scale for children from 8 months to 18 years records the presence or absence of 11 distress-related behaviors for three phases of the procedure—pre-procedure, procedure, and recovery—producing summated scores for each phase of the procedure and across the three phases (see Table 34.3). The measure can be scored relatively quickly to obtain a gross overall score for each phase and has been used to record distress during venipunctures, lumbar punctures, immunizations, and treatments for burns.
Behavioral Item | Operational Definition |
|---|---|
Cry | Tears in eyes or running down face |
Cling | Physically holds on to parent, significant other, or nurse |
Fear verbal | Says “I’m scared,” “I’m afraid,” etc. |
Pain verbal | Says “Ow,” “Ouch,” “It hurts,” “You’re hurting me,” etc. |
Scream | No tears, raises voice, verbal or nonverbal |
Stall | Verbal expression of delay (“Wait a minute,” “I’m not ready yet,” etc.) or behavioral delay (ignores nurse’s instructions) |
Carry | Has to be physically carried into or out of room or placed on table, not because of physical inability to do so on his or her own |
Flail | Random gross movements of arms or legs, but no intention to make aggressive contact |
Refusal position | Does not follow instructions with regard to body placement on treatment table |
Restrain | Has to be held down due to lack of cooperation |
Muscular rigidity | Any of following behaviors: clenched fists, white knuckles, gritted teeth, clenched jaw, wrinkled brow, eyes clenched shut, contracted limbs, body stiffness |
Emotional support | Verbal or nonverbal solicitation of hugs, physical comfort, or expression of empathy from parent, significant other, or nurse |
Requests termination | Verbally asks/pleads that procedure be stopped |
The following items were subsequently eliminated from the original list: | |
Groan | Nonverbal, vocal expression of pain or discomfort |
Laugh | Smiling with a chuckling sound |
Stoic silence | Child does not respond to questions or remarks of others. May appear “trancelike” |
Nausea verbal | Says “I’m sick,” “I feel nauseous,” “My stomach feels like I’m going to throw up” |
Vomit | Includes retching, dry heaves |
Urinate/defecate | Soils or wets self |
Kick | Intentional aggressive movement of leg(s) to make physical contact |
Hit | Intentional aggressive movement of arm(s) or hand(s) to make physical contact |
Bite | Intentional aggressive closing of jaw to make physical contact |
Verbal hostility | Says “I hate you,” “You’re mean,” etc. |
Curse | Utters profanity |
Questions | Nondelay, information-seeking verbal behavior (“What are you doing now?” “Is it over yet?” etc.) |
2.
Pediatric Behavior Checklist (PBCL) [29]
This measure, originally designed for children and young people undergoing bone marrow aspiration, has been modified to rate ten behaviors on a 1–5 scale, before, during, and after the procedure, akin to the PBRS described previously (see Table 34.4). It can be used for a variety of medical procedures and has been recommended as an outcome measure of procedural distress in pediatric pain clinical trials [30].
Behavioral item | Operational definition |
|---|---|
Muscle tension | Displays any of the following behaviors: eyes tightly shut, clenched jaw, stiff body, clenched fists, gritted teeth (contraction of any observable body part) |
Screaming | Raises voice or yells (can be with or without words) |
Crying | Tears or sobs |
Restraint | Has to be held down |
Pain verbalized | Says “Ow,” “Ouch,” or “You’re hurting me,” etc. |
Anxiety verbalized | Says “I’m scared” or “I’m afraid” |
Verbal stalling | Expresses verbal delay such as “Stop,” “I’m not ready,” or “I want to tell you something” |
Physical resistance | Moves around, will not stay in position, or tries to climb off table |
3.
Child-Adult Medical Procedure Interaction Scale-short form (CAMPIS-SF) [31]
This scale measures categories of behavior—child distress, child coping, adult distress promoting, and adult coping promoting—with scoring on a five-point scale (see Table 34.5). The scale requires a training period of 1–2 days, but videos can then be coded in real time. It can be used for venipunctures, bone marrow aspirations, immunizations, and voiding cystourethrograms.
Table 34.5
CAMPIS-SF codes and descriptive statistics
Mean | Standard deviations | Minimum range | Maximum range | |
|---|---|---|---|---|
CAMPIS-SF codes | ||||
Child coping | 6.0 | 2.7 | 3 | 13 |
Child distress | 6.8 | 3.3 | 3 | 14 |
Parent coping promoting | 6.4 | 2.9 | 3 | 14 |
Parent distress promoting | 4.3 | 1.5 | 3 | 8 |
Nurse coping promoting | 5.3 | 1.8 | 3 | 10 |
Nurse distress promoting | 4.2 | 1.1 | 5 | 8 |
Proportions of CAMPIS-R codes | ||||
Child coping | 0.42 | 0.28 | 0 | 1.00 |
Child distress | 0.49 | 0.31 | 0 | 1.00 |
Parent coping promoting | 0.26 | 0.14 | 0 | 0.58 |
Parent distress promoting | 0.15 | 0.13 | 0 | 0.46 |
Nurse coping promoting | 0.25 | 0.13 | 0.03 | 0.52 |
Nurse distress promoting | 0.12 | 0.07 | 0.02 | 0.33 |
Validity measures | ||||
OSBD distress | 13.2 | 17.3 | 0 | 76.8 |
BAADS approach/avoidance | 15.6 | 3.3 | 6 | 22 |
BAADS distress | 10.2 | 7.7 | 5 | 60 |
Parent fear | 41.3 | 27.8 | 0 | 100 |
Parent pain | 52.7 | 27.4 | 2 | 100 |
Nurse distress | 20.3 | 29.3 | 0 | 100 |
Nurse cooperation | 81.1 | 31.7 | 0 | 100 |
Child fear | 2.4 | 1.7 | 1 | 5 |
Child pain | 3.4 | 1.6 | 1 | 5 |
To assess perioperative behavior and distress:
1.
Modified Yale Preoperative Anxiety Scale (m-YPAS) [32]
This 27-item scale measures anxiety across five domains of behavior (activity, emotional expressivity, arousal state, vocalization, and dependence on parents) in children over 2 years of age, prior to induction of anesthesia (see Table 34.6). It is quick to administer and can track rapidly changing states in the child.
Activities |
1. The child looks around, is curious, plays with toys, reads (or other behavior that is appropriate for the age group); moves around the pre-anesthetic/treatment room to get toys or seeks family members; might move toward the equipment in the surgery room |
2. The child does not explore or play, may look down, plays with own hands, or sucks own thumb (blanket); may stay close to family while playing, or exhibits a manic quality while playing |
3. The child moves without concentration from toy to family members, movements are not connected to the activity; movements or play are frantic/agitated; twisting, moving on the table; may push the mask or grab family members |
4. Child tries to escape, pushes with arms and feet, may move entire body; in the waiting room, the child runs around without purpose, does not look at toys, does not want to be separated from family, clings on desperately |
Vocalization |
1. Reads (vocalization not adequate for the activity), asks questions, makes comments, stutters, laughs, answers questions promptly, but generally may be quiet; child is too young to speak in social situations or too absorbed in play to answer |
2. Answers adults, but whispers; uses “baby talk”; only responds with shaking or nodding of head |
3. Quiet, no sound or does not answer adults |
4. Weeping, moaning, grunting, silent crying |
5. Child cries, may scream “No” |
6. Crying—high pitched and sustained |
Expressing emotions |
1. Happy, smiling, concentrating on playing |
2. Neutral, no discernible facial expression |
3. From worried (sad) to frightened, sad, worried, or teary eyes |
4. Distressed, crying, extreme upset, eyes may be wide open |
State of arousal |
1. Alert, looks around occasionally, notices or watches the anesthesiologist’s actions (could be relaxed) |
2. Withdrawn, calm and silent, may suck thumb, or face turned into adult |
3. Attentive, quickly looks around, may be startled by sounds, eyes wide, body tense |
4. Panicked whining, may cry, may shun others, turns body away |
Interaction with family members |
1. Child concentrates on playing, sits idle, or shows age-appropriate behavior, does not need family members; may interact with parent if the parent initiates the interaction |
2. Seeks family members (moves close and speaks to otherwise silent parent), seeks and accepts comfort, may lean against family member |
3. Looks silently to family members, apparently observes their actions, does not seek contact or comfort, but will accept it if offered; or clings to parent |
4. Keeps family members at a distance or leaves area when family members appear, might push away parent or else desperately cling to parent and not let them go away |
2.
The Induction Compliance Checklist (ICC) [33]
This is an 11-point scale developed for use as an observational measure to quantify the level of compliance in a children aged 0–17 years undergoing induction of anesthesia by inhalation (see Table 34.7). Scores range from 0 to 10, where 0 is considered to be the ideal induction without anxiety or behavioral disturbance in the child, with a cut-off score of 6 for poor compliance with induction.
Check off all applicable behavior: | Score |
|---|---|
Perfect induction (does not exhibit negative behavior, fear, or anxiety) | Score 0 |
Crying, tears in eyes | |
Turns head away from mask | |
Verbal refusal, says “no” | |
Verbalizes fear or worry, such as “Where’s Mommy?” or “Will it hurt?” | |
Pushes mask away with hands, pushes away nurse/anesthetist with hands or feet | |
Covers mouth/nose with hands/arms or buries face | |
Hysterical crying, may scream | |
Kicks, flails legs/arms, arches back, or general struggling | |
Requires physical restraint | |
Completely passive, either rigid or limp | |
Total Score (number of items ticked) |
3.
Emotionality, Activity and Sociability Scale (EAS) [34]
This is a measure of child temperament containing 20 items, each item being rated by parents on a five-point scale, with a score obtained for each of the three temperaments (see Table 34.8). It is a useful measure to obtain preoperatively to predict a child’s distress at the time of anesthesia.
EAS Scales | Rating |
|---|---|
Shyness | |
Tends to be shy | |
Makes friends easily | |
Is very sociable | |
Takes a long time to warm up to strangers | |
Is very friendly with strangers | |
Sociability | |
Likes to be with people | |
Prefers playing with others rather than alone | |
Finds people more stimulating than anything else | |
Is somewhat of a loner | |
Activity | |
Is always on the go | |
When he moves about, he usually moves slowly | |
Is off and running as soon as he wakes up in the morning | |
Is very energetic | |
Prefers quiet, inactive games to more active ones | |
Emotionality | |
Cries easily | |
Tends to be somewhat emotional | |
Often fusses and cries | |
Gets upset easily | |
Reacts intensely when upset | |
When alone, he feels isolated |
4.
Post-hospital Behavioral Questionnaire (PHBQ) [35]
This questionnaire, completed by parents at home following discharge from hospital, assesses behavioral changes in the child. It consists of 27 items to assess general anxiety, separation anxiety, sleep disorders, eating difficulties, aggression, and apathy (see Table 34.9). The parent is asked to compare typical behavior in their child compared to behavior shown during the first week after hospitalization, using a five-point scale.
Questions: |
|---|
1. Do you have frequent headaches? |
2. Do you have lack of appetite? |
3. Do you have trouble sleeping? |
4. Do you get scared easily? |
5. Do you feel your hands shaking? |
6. Do you feel nervous, tense, or worried? |
7. Do you have digestion problems? |
8. Do you have trouble thinking clearly? |
9. Have you felt sad lately? |
10. Have you cried more than usual? |
11. Have you experienced difficulty in carrying out your daily activities with satisfaction? |
12. Do you find it difficult to make decisions? |
13. Do you have difficulties with your work? |
14. Are you unable to play a useful role in your life? |
15. Have you lost interest in things? |
16. Do you feel useless, not diligent? |
17. Have you thought about killing yourself? |
18. Do you feel tired all the time? |
19. Have you had unpleasant feelings in your stomach? |
20. Do you get tired easily? |
To assess pain in children with intellectual impairment:
1.
Non-communicating Children’s Pain Checklist (NCCPC) [36]
This is the most widely validated measure for assessing pain in children with cognitive impairments and is designed to be used by parents and caregivers (see Table 34.10). The checklist comprises 30 items rated 0–3 on seven subscales (vocal behavior, social, facial expression, active, body and limbs, physical signs, and eating/sleeping). A version of the NCCPC (NCCP-PO) is available to use postoperatively.
Table 34.10
Non-communicating Children’s Pain Checklist revised
Vocal subscale |
• Moaning, whining, or whimpering (fairly soft) |
• Crying (moderately loud) |
• Screaming or yelling (extremely loud) |
• A sound or word expressing pain |
Eating/sleeping subscale |
• Eating less, disinterested in food |
• Increased sleep |
• Decreased sleep |
Social subscale |
• Uncooperative, cranky, irritable, unhappy |
• Reduced social interaction, withdrawn |
• Seeking comfort or physical closeness |
• Difficult to distract, cannot be satisfied or pacified |
Facial subscale |
• Furrowed brow |
• A change in eyes, including squinting, eyes wide, eyes frowning |
• Mouth turned down into a frown, unsmiling |
• Lips puckered up, drawn tight, pouting, or quivering |
• Clenching or grinding teeth, chewing or thrusting out tongue |
Activity subscale |
• Unmoving, reduced activity, quiet |
• Jumps around, agitated, fidgety |
Body/limb subscale |
• Floppy body |
• Stiff, spastic, tense, rigid body |
• Points out or touches part of body that hurts |
• Protects, favors, or guards part of the body that hurts |
• Flinches or moves away body part, being sensitive to touch |
• Moving the body in specific way to show pain (e.g., head thrown back, arms down, body curled up) |
Physiological signs subscale |
• Shivering |
• Change in skin color, pallor |
• Sweating, perspiring |
• Tears |
• Sharp intake of breath, gasping |
• Breath holding |
2.
Face, Legs, Activity, Cry, and Consolability Scale-Revised (FLACC-R)
This is a revised version of the FLACC described previously for use with children with cognitive impairment (see Table 34.11).
Table 34.11
Revised FLACC Scale
Category | Scoring | ||
|---|---|---|---|
0 | 1 | 2 | |
Face | No particular expression or smile | Occasional grimace or frown | Frequent to constant quivering chin |
Withdrawn | Clenched jaw | ||
Disinterested | Distressed looking face | ||
Sad, appears worried | Expression of fright/panic | ||
Legs
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