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(Hicks et al, 2001). In scales anchored with smiling or tearful faces, pain may be confused with
other emotional states such as happiness, sadness or anxiety (Champion et al, 1998).
Between 7 and 10 years of age children develop skills with measurement, classification and
seriation (ie putting things in ascending or descending order). The upper end of the scale is
less static than in adults as it will change with the individual child’s ability to objectify, label
and remember previous pain experiences (Gaffney et al, 2003). It is not until 10 to 12 years of
age that children can clearly discriminate the sensory intensity and the affective emotional
components of pain and report them independently (McGrath et al, 1996). Verbally competent
children aged 12 years and above can understand and use the McGill Pain Questionnaire
(Gaffney et al, 2003).
Six self‐report tools have well‐established evidence of reliability and validity (Pieces of Hurt
tool; Faces Pain Scale and Faces Pain Scale‐Revised; Oucher; Wong‐Baker Faces; visual
analogue scale [VAS]) for acute pain assessment in children (over 3 years) and adolescents
(Stinson et al, 2006 Level I; McGrath et al, 2008 Level I). Although chronological age may not always
be an accurate indicator of developmental stage, the following general age ranges are
suggested (see also Howard et al, 2008):
• 3 to 4 years — Pieces of Hurt (Poker Chip) tool;
• 4 to 12 years — Faces Pain Scale‐Revised; and
• over 8 years — 0 to 100 VAS.
10.3.4 Children with cognitive impairment

In children with cognitive impairment and/or communication problems, assessment of pain
is difficult and can contribute to inadequate analgesia. Neonates at risk for neurological
impairment required more procedural interventions in intensive care, but received less
analgesia (Stevens et al, 2003) and may be perceived as being less responsive to painful stimuli
(Breau et al, 2006; Stevens, McGrath et al, 2007). A retrospective chart review of children who had
undergone spine fusion surgery, found that pain was assessed less frequently in cognitively
impaired children and that they received less analgesia (Malviya et al, 2001 Level IV). Another
group found that while cognitively impaired children received less analgesia during surgery,
they received comparable amounts and types of analgesics as cognitively intact children in the
postoperative period (Koh et al, 2004 Level III‐2).
Specific tools have been developed for cognitively impaired children (Howard et al, 2008).
Behaviours reported by caregivers to be associated with potentially painful stimuli and that
discriminate these from distressful or calm events, have been compiled in the revised Non‐ CHAPTER 10
Communicating Children’s Pain Checklist (NCCPC‐R) (Breau, McGrath et al, 2002), which also has
a postoperative version (NCCPC‐PV) (Breau, Finley et al, 2002). The Paediatric Pain Profile (PPP)
also rates 20 behaviours to assess pain in children with severe neurological disability (Hunt et
al, 2004). A revised FLACC scale, which incorporates specific descriptors and parent‐identified
behaviours for individual children, has also been developed for cognitively impaired children
(Malviya et al, 2006).

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