Self-reports of pain can be compared within individuals across time, but not between indivi duals. Th eir meaning is oft en idiosyn- cratic and may not agree with estimates of pain in tensity based on other sources, that is, observation of behavior and knowledge of the clini cal context. Th is chapter concludes with a structured proc- ess to follow when self-report s of pain or the absence of pain are not supported by information from other sources. Fanurik , D. , Koh , J. L. , Harrison , R. D. , Conrad , T. M. , and Tomerlin , C. ( 1998 ) . Pain assessment in children with cognitive impairment: an exploration of self-report skil ls . Clin Nurs Res , 7 , 103 \200\223124. Franck , L. S. , and Bruce , E. ( 2009 ). Putting pain assessment into practice: why is it so painful? Pain Res Manag , 14 , 13 \200\22320. Gelman , R. and Baillargeon , R. ( 2003 ). A review of some Piagetian concepts . In J. H. F lavell , and E. M. Markman (eds) Handbook of child psychology , pp. 167 \200\223230. 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New York : Cambridge University Press . Williams , A. C. , Davies , H. T. O. , and Chadury , Y. ( 2000 ). Simple pain rating von Baeyer , C. L. ( 2006 ). Children \200\231s self-reports of pain intensity: scale selec tion, limitations and interpretation . Pain Res Manage , 11 , 157 \200\223162. scales hide complex idiosyncratic meanings . Pain , 85 , 457 \200\223463. Wood , C. , von Baeyer , C. L. , Falinower , S. , Moyse , D. , Annequin , D. , and Legout , V. ( 2011 ). Electronic and paper versions of a faces pain intensity scale: concordance an d preference in hospitalized children . BMC Pediatr , 11 , 87 . von Baeyer , C. L. ( 2009 a). Children \200\231s self-report of pain intensity: what we know, where we are headed . Pain Res Manag , 14 , 39 \200\22345. CHAPTER 37 Behavioral measures of pain Jill MacLaren Chorney and C. Meghan McMurtry Introduction Measurement is the process of assigning numbers to things (Bakeman and Gottman , 1986 ) and can be as familiar as using a ruler to measure length and a scale to measure w eight. We also use measurement to characterize internal states and experiences. In the cont ext of pain, we can use numerical or facial expression scales to translate one \200\231s ow n or another \200\231s experience into a given value. Using behavioral tools, we seek to me asure, or assign num- bers to, observable behaviors. Behaviors that are measured may be mot oric (body movements), vocal (sounds), or verbal (words) and observed behaviors can be furt her characterized (e.g. tone of voice, intensity of movement). Background Why use behavior as a measure of pain? Given the subjective and personal nature of pain, self-report has generally been considered to be the gold standard of measure- ment . Despite the recognition of its importance, in some cases self-report may not be feasible, possible, or the best choice for measuring pain (Schiavenato and Craig, 2010 ). For exampl e, chil- dren who do not communicate verbally or who have cognitive impairments may have di ffi culty providing self-report. Children who are sedated or in severe distress may also ha ve diffi culty pro- viding self-report and behavioral observation is less intrusive. Even i n situations in which self-report is possible, other forms of measurement may be benefi cia l. For example, in some cases chil- dren may be motivated to under-report their pain to app ear brave or to avoid receiving needles. In these cases, observing behav- iour as a measure ment of pain may be helpful in determining whether the child is in need of further assessme nt or treatment. In fact, a child \200\231s behavior may be the fi rst signal to a caregive r that the child is in pain (McGrath, 1998 ). Observation of behav- iour is also particular ly useful when the goal is to examine inter- actions between individuals and understand the bidirectional relationships between the social context and experience of pain (Schiavenato and Craig, 2010 ). Th is chapter will review the current state of evidence on behav- ioural measures of pain i n children and adolescents including a brief discussion of future directions. To demonstrat e the utility of behavioral scales, we also include a clinical case example at the end of t his chapter. A few limits of coverage should be noted. First, although some of the measures included in this chapter may have been used for infants, we will not review measures that are only val- idated for infants as these measures are covered by Lee and Stevens (Chapter 35, this volume)). Second, given that there are no well- established behavioral measures of chronic pain, this chapter will focus on measures that are relevant to acute and procedura l pain and will also not cover other pain-related outcome measures (e.g. func- tional disab ility, quality of life). Finally, multidimensional compos- ite scales containing behavioral and physiological items will not be reviewed (e.g. COMFORT; Ambuel et al., 1992 ). Th ere are recent, good quality reviews published in the area of behavioral meas- ures of pain (Co hen et al., 2008 ; von Baeyer and Spagrud, 2007 ). As with any assessment tool, the psychom etrics of behavioral meas- ures are critical; thus, tools deemed well established or approa ching well established in these reviews will be included. Coverage of tools that are not we ll established can be found in the relevant reviews (Cohen et al., 2008 ; von Baeyer and Sp agrud, 2007 ). We make one notable exception: the existing reviews did not specifi cally id entify measures that are relevant to children with developmental delays or cognitive impair ments. We see measures for this population as particularly important and therefore include a brief review here. Characteristics of behavioral measures Behavioral measures may vary on several dimensions, includ- ing the level of granularity with which they capture observations. At one end are g lobal measures of pain such as numerical rating scales or visual analog scales. Th ese scal es are clinically-feasible, but individual behaviors determining the score may not be well understood and children demonstrating very diff erent behaviors may be given the same ratin g (von Baeyer and Spagrud, 2007 ). In contrast to global measures are those that characteri ze behaviors at a very precise level such as the Child \200\223Adult Medical Procedure Inte raction Scale (Blount et al., 1989 ). Th ese systems are useful, but are time consuming to administer and generally require high-qual- ity video recordings of behaviors. SECTION 5 measurement of pain 380 Behavioral measures also vary based on whether they charac- terize the intensity and/or fre quency of behaviors. Measures can be categorized as dichotomous (present/absent), ordinal ( more, less), and interval (frequency over time). Although easiest to col- lect, dichotomous checklists are limited in the extent to which they capture gradations of behavior and infe r intensity from number of behaviors endorsed in a given time period. Rating scales are mor e specifi c with scores usually considered on Likert-type scales (e.g. none/absent, a littl e, frequently). Interval scales generally capture data over time and can vary in their leve l of specifi city. 5 sec observation period and a 25 sec recording period (McGrath et al., 1985 ). In some pro tocols, this sampling procedure has been repeated four times over a 2 min period and an ave rage of scores has been used (Beyer et al., 1990 ). Th e CHEOPS consists of six items each rated on a three-point scale (e.g. cry ranges from 1 = no cry to 3 = scream), with total sc ores ranging from 4 to 13 points for each period. Although the initial validation of the sc ale did not provide descriptors for ranges of scores, subsequent researchers have done so. For example, Disma and colleagues ( 2009 ) described scores between 4 and 6 as minimal pain , 7 to 9 as mild pain, and 10 to 13 as severe pain. Th e CHEOPS was designed to be clinical ly feasible and can be completed relatively quickly. Time sampling may also vary. Some measures are designed to record behaviors at one point in time, but in this way capture only a snapshot of a child \200\231s behavior. Other measure s defi ne an observation interval that may be based on time (e.g. 15 sec, 24 h) or event (e .g. phase of procedure). Th is method captures a longer sample of children \200\231s behavi or but risks distortion. For example, in a 24 h observation interval, a child who cries for only 30 min receives the same score as a child who cries for the entire period. Continuous recording is also sometimes used. In this method of recording, observers note any instance when a behavior occurs; this coding allows various metrics including proportions of behav- iours (e.g. target behavior/total behaviors), proportions of time (e.g. behaviors/time int erval), or rates (e.g. behaviors/minute) of behaviors. Continuous recording can also be use d to report infor- mation on timing of when behaviors occurred (time-sequential) or simply the order of behaviors (event-sequential). Continuous recording provides the most represent ative data, but is time inten- sive to collect, although this has been made easier with rec ent advances in computer recording. Th e CHEOPS was developed using nurses \200\231 reports of common behaviors exhibited by po st-surgical children (McGrath et al., 1985 ). Aft er piloting and refi nement, the scale sh owed excellent ini- tial interrater reliability (average per cent agreement ranged from 90% to 99.5%) and good internal consistency (inter-correlations among items ranged from 0.35 t o 0.81). Convergent validity was demonstrated with moderate to high correlations with nurse and researcher-completed (unblinded) visual analog scale ratings (total score correlations of 0.81 and 0.86 respectively) (McGrath et al., 1985 ). CHEOPS scores were also responsive to analgesic intervention (although ratings were unblinded). Subsequently, comparison of t he CHEOPS with two self-report measures of pain demonstrated that scores on the CHEOPS tend to underesti- mate pain over time aft er surgery (Beyer et al., 1990 ). To date, the CHEOP S has been used extensively in a variety of painful contexts (e.g. surgery, immunizations, venepunctures, fracture reduction) and countries. An understanding of diff erences between behavioral measures is critical and the previous l ist of characteristics (e.g. granularity, time sampling) is intended to be illustrative rat her than exhaustive. Th ere is no measure that is perfect for all situations; each type of measure has its own strengths and weaknesses and these are impor- tant to acknowledge and u nderstand when choosing a scale to use and interpreting resulting data. Face, Legs, Activity, Cry, and Consolability scale (FLACC) Th e FLACC (Merkel et al., 1997 ), originally developed for post- operative pain, has been classifi ed as a well-establishe d measure for both postoperative and brief pain episodes (von Baeyer and Spagrud, 2007 ). A lthough based in part on behaviors contained in the CHEOPS, each of the fi ve behaviors on this scale is scored on a consistent 0 to 2 metric, yielding a total score between 0 and 10 with higher scores indicating greater pain. Th e FLACC is used as a point assessment, alth ough the observation period has not been specifi ed. It was designed to be clinically-feasi ble with low burden. Despite the 0 to 10 metric, it should be noted that, as the interval p roperties of the tool have not been fi rmly established, the score cannot be considered equ ivalent to a 0 to 10 self-report scale (von Baeyer and Spagrud, 2007 ). Behavioral measures of pain in children Measures reviewed are organized based on the contex t in which they have been typically used (e.g. procedures, postoperative). Consideration is given to the time and equipment requirements for each of these measures. For example, seve ral of the measures require video recording, training, and detailed coding and, although th ey off er important information for research, they may not be practical in clinical setting s due to high burden. Alternatively, some measures can be administered in the moment while behavior is occurring and therefore are more feasible in clinical settings. Further discus- sion is also provided regarding the type of rater who administers these scales. Tables 37. 1 and 37.2 provide an overview of reviewed measures including original reference and contex t. Th e original study of the FLACC (Merkel et al., 1997 ) showed adequate interrater reliabil ity (average r = 0.94 for 30 children at three separate time periods; kappa values for each FLACC cat- egory were acceptable and ranged from 0.52 to 0.82). Supporting convergent vali dity, a moderate correlation ( r = 0.41) was found between the FLACC scores and a global nu rse rating of pain and a strong positive correlation ( r = 0.80) was found with another mea s- ure of pain (Objective Pain Scale). Th e FLACC also demonstrated responsiveness to analg esic intervention (albeit with unblinded raters) (Merkel et al., 1997 ). Subsequent researc h has continued to support the interrater reliability, construct validity, internal con- si stency, specifi city and sensitivity of the FLACC (Voepel-Lewis et al., 2010 ). Since its d evelopment, the FLACC has been used in a variety of diff erent acute pain contexts (Bable e t al., 2009 ) and age ranges (Marmo and Fowler, 2010 ). Several language translations Procedural or brief pain episodes Children \200\231s Hospital of Eastern Ontario Pain Scale (CHEOPS) Th e CHEOPS (McGrath et al., 1985 ), originally developed to meas- ure postoperat ive pain, has been used in a variety of painful con- texts and is now considered a well-est ablished measure of brief pain episodes (Cohen et al., 2008 ; von Baeyer and Spagrud, 2007 ). Th e CHEOPS is administered using a time-sampling procedure with a CHAPTER 37 behavioral measures of pain 381 Table 37.1 Review of behavioral measures of pain Measure Rater Number and format of items Behaviors included Scoring method Scoring details 6 items with various rating scales (e.g. 0 to 2, 1 to 3, 1 to 2) Range: 4 \200\22313 CHEOPS \227\206 Health care professional \227\206 Researcher \227\206 Interval scoring \227\206 5-sec interval (one time) One scale (Cry, Facial, Child verbal, Torso, Touch, Legs) Range: 0 \200\22310 \227\206 Health care professional \227\206 Researcher \227\206 Point scoring \227\206 Interval time not de \201 ned Five items all rated 0 to 2 One scale (Face, Legs, Activity, Cry, Consolability) FLACC CFCS Researcher 13 items: 10 ratings and 3 dichotomously scored Scoring methods has varied. Often mean intensity, mean frequency, or total intensity \227\206 Interval scoring \227\206 1- to 2-sec interval Th ree subscales: \227\206 Eyes (e.g. brow furrow) \227\206 Nose (e.g. nasiolabial furrow ) \227\206 Mouth (e.g. mouth stretch) (repeated) \227\206 Interval scoring \227\206 Interval based on daytime events (breakfast to lunch, lunch to supper, supper to bed time) Range: 0 \200\22315 PPPM Parent 15 items all dichotomously scored One scale (e.g. Cry more easily than usual, Refuse to eat, Eat less than usual, Groan or mo an more than usual) Range: 0 \200\22313 (or 0 \200\22311 for revised) for each procedural phase. Add to derive total score \227\206 Health care professional \227\206 Researcher \227\206 Interval scoring \227\206 Intervals based on 13 items (later revised to 11) all dichotomously scored PBRS One scale (e.g. Cry, Cling, Fear verbal, Pain verbal, Flail, Muscular rigidity) procedural events (e.g. preprocedure, procedure, recovery) Eight items all rated 1 to 5 One scale (e.g. Muscle tension, Screaming, Crying, Restraint used, Pain verbalized) \227\206 Interval scoring \227\206 Intervals based on \227\206 Health care professional \227\206 Researcher Range: 8 \200\22340 for each procedural phase. Add to derive total score. PBCL procedural events (e.g. pre-procedure, procedure, recovery) 11 items (later revised to 8 items)all dichotomously scored \227\206 Each item is assigned a weight between 1and 4 (e.g. Scream weighted as 4.0, Cry w eighted as 1.5) \227\206 Range 0 \200\22328 for 11 item version \227\206 Health care professional \227\206 Researcher \227\206 Interval scoring \227\206 15-sec interval (repeated over 4 procedural phases) One scale (e.g. Information seeking, Cry, Scream, Verbal pain, Flail) OSBD Continuous event scoring Rates (behavior/ minute) or proportions (behavior/total behaviors) CAMPIS Researcher 35 items all dichotomously scored Four subscales: \227\206 Adult to adult (e.g. procedural talk, humor) \227\206 Adult to child (e.g. reassuring comment to child; non-procedural talk) \227\206 Child distress (e.g. crying) \227\206 Child coping (e.g. humor) \227\206 Continuous or interval Rates (behavior/ minute) or proportions (behavior/total behaviors) interval CAMPIS-R Researcher Six items (item represents category of behavior) all dichotomously scored Six items/subscales: \227\206 Adult neutral, Adult coping-promoting, Adult distress-promot ing, Child distress, Child coping, Child neutral scoring \227\206 Intervals based on procedural events \227\206 Interval scoring \227\206 Intervals based on Range 1 \200\2235 for each item/subscale for each interval CAMPIS-SF Researcher Four items (item represents category of behavior) all rated 1 to 5 Four items/subscales \227\206 Adult coping promoting \227\206 Adult distress promoting \227\206 Child coping \227\206 Child distress procedural events (e.g. preprocedure, procedure, recovery) (Continued) SECTION 5 measurement of pain 382 Table 37.1 (Continued) Measure Rater Number and format of items Behaviors included Scoring method Scoring details \227\206 Interval scoring \227\206 Interval time not de \201 ned Range: 0 \200\22330 NCCPC \227\206 Primary caregiver \227\206 30 items all Seven subscales: \227\206 Vocal Behavior (e.g. whining) \227\206 Social (e.g. withdrawn) \227\206 Facial Expression (e.g. grimacing) \227\206 Activity (e.g. less active) \227 \206 Body and Limbs (e.g. sti \200 , spastic) \227\206 Physical signs (e.g. change in col or) \227\206 Eating/Sleeping (e.g. increase in sleep) dichotomously scored Range 0 \200\22390 \227\206 Interval scoring \227\206 Interval time not de \201 ned NCCPC- Revised Primary caregiver 30 items all rated 0 to 3 Same as original NCCPC Range 0 \200\22360 \227\206 Interval scoring \227\206 10-min interval NCCPC- Postoperative Primary caregiver or researcher 6 subscales with items rated 0 \200\2233 each Same as original NCCPC with Eating/ Sleeping scale removed Table 37.2 Review of original references for behavioral measures of pain Measure Primary reference Population Context CHEOPS McGrath et al. (1985) Original: 1 \200\2237-year-old Canadian children Original: post-surgical (variety of surgeries) Subsequent: Age range has included 4 months \200\22318 years Subsequent contexts have included: perioperative (anesthesia induction, post-surgical); var ious medical procedures (acupuncture, venepuncture, intramuscular injections, immunizations , fracture reductions, dental, bone marrow aspirations, laceration repair); severe pain fro m fractures or sickle cell disease Samples have included: American, Canadian, Chinese, Czech, Dutch, French, Indian, Iranian, Italian, Korean, Scottish, Singaporean, Spanish, Swedish, Turkish, Th ai, and Trinidadian c hildren and adolescents FLACC Merkel et al. (1997) Original: 2-month \200\2237-year-old American children Original: post-surgical in the PACU Subsequent: Age range has included 15 days to adults over 80 years Subsequent contexts have included: perioperative (including post-dental surgery); criticall y ill, ventilated and minimally conscious individuals; various medical procedures (e.g. imm unizations, urethral catheterization, temperature assessment, nasogastric tube insertion, v enepunctures or subcutaneous venous port access, laceration repair, chest drain removal, fr acture reduction) Samples have included: American, Austrian, Australian, Belgian, Brazilian, British, Canadia n, Egyptian, Finnish, French, Indian, Iranian, Israeli, Italian, Korean, Swedish, Taiwanese , Th ai, and Turkish children and adults Has been modi \201 ed for children with cognitive impairment CFCS Chambers et al. (1996a) Original: 13 \200\22374-month old Canadian infants and children Original: post-surgical (variety of surgeries) Gilbert et al. (1999) Subsequent: Age range has included : 4 \200\22314 years Subsequent contexts have included: immunizations; stretching exercises; experimental pain Has been used in children with cerebral palsy and signi \201 cant neurological impairment PPPM Chambers et al. (1996b) Original: 7 \200\22312-year-old Canadian children Original: post-surgical (variety of surgeries) Subsequent: Age range has included 6 months \200\22318 years Subsequent contexts have included: everyday pains; post fracture reductions; chronic pain; burn injuries (Continued) CHAPTER 37 behavioral measures of pain 383 Table 37.2 (Continued) Measure Primary reference Population Context Samples have included: American, British, Dutch, Finnish, German, Indian, and Korean childr en and adolescents PBRS Katz et al. (1980) Original: 8 month \200\22317-year-old American children and adolescents Original: bone marrow aspirations Revised: Katz et al. (1987) Subsequent: Age range has included 8 months \200\22318 years Subsequent contexts have included: perioperative; various medical procedures (lumbar punctu res, immunizations, venepunctures, burn injury treatment, chemotherapy, and others) Samples have included: American, Canadian, and Dutch children and adolescents PBCL LeBaron and Zeltzer (1984) Original: 6 \200\22317-year-old American children and adolescents Original : bone marrow aspirations Subsequent: Age range has included 0.1 \200\22319 years Subsequent: various medical procedures (intravenous port access, lumbar punctures, bone mar row aspirations, nasendoscopy, venepuncture, fracture reductions, laceration repairs, VCUG, pediatric assessments) Samples have included American, Australian, Canadian, French, Greek, Italian, New Zealander , and Swedish children and adolescents OSBD Original: Jay et al. (1983) Original: 2 \200\22320-year-old American children and adolescents Original: bone marrow aspirations Revised: Elliott et al. (1987) Subsequent: Age range has included 1 \200\22318 years Subsequent: perioperative; medical examinations and other examinations/procedures (bone mar row aspirations, lumbar punctures, immunizations, venepunctures, venous cannulations, dress ing changes, exercise and play for children with burn injuries, fracture reduction, lacerat ion repair) Samples have included American, Australian, British, Italian, and New Zealander children CAMPIS Blount et al. (1989) Original: 5 \200\22313-year-old American children Original: bone marrow aspirations and lumbar punctures CAMPIS-R Blount et al. (1990) CAMPIS-SF Blount et al. (2001) Subsequent: Age range has included 2 \200\22318 years Subsequent: various medical procedures (immunizations, bone marrow aspirations, lumbar punc tures, venepunctures, intramuscular injections, venous cannulations, stretching during phys iotherapy, voiding cystourethrograms); cold pressor task. Samples have included American, Australian, Canadian, British, and Portuguese children and adolescents. Modi \201 ed versions have been used with Australian and Austrian samples Revised versions have also been used in other laboratory analogs of child pain and/or disco mfort NCCPC McGrath et al. (2008) Original NCCPC: 3 \200\22344-year-old Canadian individuals with severe to profound cognitiv e impairments Original NCCPC: Mixed pain episodes (every day or procedural pain) NCCPC- Revised Breau et al. (2002) Original NCCPC-PV: postsurgical Subsequent : postsurgical (NCCPC); every day pains; acute pain in hospital NCCPC- Post- operative Breau et al. (2002) Original NCPCC-PO: 3 \200\22319-year-old Canadian children and adolescents with cognitive i mpairments Subsequent: Age range has included: 40 months to adult Samples have included French, Swiss-German, and Swedish infants, children, and adults. SECTION 5 measurement of pain 384 are available (Voepel-Lewis et al., 2010 ) and the scale has been used in many countries ar ound the world. successfully modifi ed for everyday pains (Francke et al., 2010 ) and burn injuries (Patter son et al., 2002 ). Ten translated versions are reportedly available (von Baeyer et al., 20 11 ). Recently, a short- form version of the scale using the common 0 to 10 metric of pain intensity was developed by von Baeyer and colleagues (PPPM-SF; von Baeyer et al., 2011 ). T h e PPPM-SF is made up of two factors (functional interference, pain behaviors) and shows s trong con- sistency with the original scale ( r = 0.98), high internal consistency (Cronbac h \200\231s alpha = 0.85), and scores were unrelated to child sex or age. Promising constru ct validity of the total score was demon- strated through signifi cantly lower scores on th e second postop- erative day compared to the fi rst as well as moderate correlations with c hild self-report of pain intensity on both postoperative days ( r = 0.54 on day 1 and r = 0 .53 on day 2). Child Facial Coding System (CFCS) Th e CFCS (Chambers et al., 1996a ) is a measure of child ren \200\231s facial movements and was categorized as an approaching well-established measu re by Cohen et al. ( 2008 ). Th e CFCS assigns ratings to ten facial muscle movements and d ichotomous scoring to three others. All 13 movements are grouped into three categories (eye s, nose, mouth). A 1 or 2 sec interval coding system is used and each facial action is code d within each interval (Gilbert et al., 1999 ). Scoring metrics of mean intensity and frequ ency (Breau et al., 2001 ) and total intensity (Gilbert et al., 1999 ) have been used. Th e CFCS is a high-burden measure and thus is not feasible for clinical use. Th e CFCS is a modifi cation of the well-established Facial Action Coding System (Ekman et al., 2002 ) and Neonatal Facial Action Coding System (Grunau and Craig, 1987 ). Th e fi rst validation study of the CFCS examined pain in the recovery room following surgery in presc hool children (Gilbert et al., 1999 ). Results showed good concurrent validity; CFCS scores signifi cantly correlated with glo- bal observer visual analog ratings of pain over variou s 2 min time blocks ( r ranged from 0.33 to 0.73). Th ere was also a signifi cant negative correlation between CFCS score and time in the recovery room ( r = \210\2220.46). Two othe r studies examined responsivity of the CFCS to pain. Breau et al. ( 2001 ) found a change i n facial action fol- lowing an immunization. Cassidy et al. ( 2002 ) found no diff erence i n CFCS scores between distraction and standard care for children undergoing immunizations. It is unclear whether this intervention was not successful or whether the CFCS was not sens itive to this diff erence. Th e FLACC (described earlier) has been identifi ed as a well- established measure of in-ho spital postoperative pain (von Baeyer and Spagrud, 2007 ). Measures of procedural distress and interactions Procedure Behavioral Rating Scale (also re ferred to as the Procedural Behavior Rating Scale; PBRS) One of the fi rst observational me asures of child distress during painful medical procedures was the PBRS (Katz et al., 1980 ). Th e PBRS has been described as a promising assessment of distress and pain-related fear by von Baeyer and Spagrud ( 2007 ) and an approaching well-established assessment of pain and behavioral distress by Cohen et al. ( 2008 ). Th e PBRS originally included 13 operatio nally defi ned behaviors and was later revised to include 11 items (the two items removed w ere reportedly more indicative of anxiety) (Katz et al., 1987 ). Observers indicate the pre sence (or absence) of each of the behaviors for phases of the procedure (pre- procedure, pr ocedure, recovery); scores are the sum of behaviors displayed in each phase and across all phases. Th e PBRS (original or revised) is relatively fast to score, but the score does not capture frequency data beyond the gross level for each phase.