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. Postoperative pain Parents \200\231 Postoperative Pain Measure (PPPM) Th e PPPM (Chambers e t al., 1996b ) was developed to be completed by parents for their children at home followin g surgery and has been recommended for this use (von Baeyer and Spagrud, 2007 ). Th e PPPM is a 15-item dichotomous checklist designed to be easy to complete with minimal training. T h e majority of items ask par- ents to compare current to typical behavior of the child. Ex ample items include: whine or complain more than usual, play less than usual, hold sore par t of body, and want to be close to parent more than usual. A cut-off score of 6 out of 15 h as been shown to have excellent sensitivity and specifi city (>80% each for day 1 and day 2 in Chambers et al., 1996b ). Th e checklist uses an observation inter- val tied to daytime routines (i.e. between breakfast and lunch, lunch and supper, or supper and bedtime). Th e fi rst study with the PBRS included children with cancer undergoing bone marrow aspira tions (Katz et al., 1980 ). Interrater reliability was high across procedural phases (95% a greement; cor- relations ranged from r = 0.88 to 0.91 with a grand total score cor- relatio n of r = 0.94) and scores revealed a pattern consistent with mounting pre-procedural anxiet y that peaked during the procedure and reduced somewhat during recovery. Nurses \200\231 ra tings of child anxiety showed moderate to strong positive correlations with PBRS phase and total scores (ranging from r = 0.36 to 0.69; Katz et al., 1982 ). Younger children received higher scores than older children. Subsequent research has used the original and modifi ed versions of the PBRS to capture child distress during a variety of painful pro- cedures in cluding lumbar punctures (Katz et al., 1982 ), burn treat- ments (Tarnowski et al., 1987 ), venepunctures and immunizations (Schechter et al., 1991 ). Th e PPPM was designed from the results of Reid et al. ( 1995 ) who asked parents for the c ues they used to assess children \200\231s post- operative pain following surgery. In the o riginal validation study (Chambers et al., 1996b ) a 29-item version was reduced to 15 item s using item correlations and factor analysis. Good construct validity was demonstrated thr ough relatively high correlations with child self-report of pain ( r = 0.61 day 1 and 2), m oderate correlations with child self-report of emotional distress ( r = 0.39 and 0.27 day 1 and 2), and decreases in scores from postoperative day 1 one to day 2. Internal consistenc y was also very good (Cronbach \200\231s alpha coef- fi cients for day 1: 0.88 and day 2: 0 .87) (Chambers et al., 1996b ). Additional validation of the measure by Finley et al. ( 200 3 ) further supported the tool \200\231s construct validity. Th e PPPM has also been Procedure Behavior Checklist (PBCL) Th e PBCL (LeBaron and Zeltzer, 1984 ) was designed for use with children and adolescents undergoing bone marrow aspirations. Th e PBCL has been c ategorized as an approaching well-established assessment measure for distress and pain-rela ted fear (von Baeyer and Spagrud, 2007 ), a well-established observational measure of pain and behavioral distress (Cohen et al., 2008 ), and has been recommended as an outcome measu re of procedural distress in CHAPTER 37 behavioral measures of pain 385 pediatric pain clinical trials (McGrath et al., 2008 ). Th e PBCL includes eight operationa lly defi ned behaviors which parallel the items on the PBRS (Katz et al., 1980 ). Each beha vior is rated from 1 (very mild) to 5 (extremely intense) during each of three procedural p hases (preprocedure, procedure, recovery) (LeBaron et al., 1984 ). In general, there are tw o forms of the scale used most commonly: the original eight-item scale (Heden et al., 2011 ) and a modifi ed version including ten items (addition of groaning and fl inching) (Liossi et al., 2007 ). Th e two additional behaviors were captured and reported by LeBaron and Ze ltzer ( 1984 ) in their origi- nal paper but not formally as part of the PBCL. anxiety during the clinic visit and anxiety symptoms in the preced- ing 24 h (both at r = 0 .38) (Jay et al., 1983 ). However, child state anxiety was not signifi cantly related to OS BD scores (Jay et al., 1983 ). Th ere were no reliable overall sex diff erences; however, s imi- lar to research with the PBRS, overall scores of the OSBD decreased with age ( r = \210\2220.76). Th e OSBD and revised versions have shown sensitivity to both pharmacologica l and non-pharmacological pain interventions (Dahlquist et al., 1985 ; Jay et al., 1987 ). Versions of the OSBD have been used in a wide range of medical contexts including venepunct ures (Dahlquist et al., 1985 ), dressing changes (Kanagasundaram et al., 2001 ), and fractu re reduction (Kennedy et al., 1998 ). In the original study, interrater reliability was adequate to good (ranged from r = 0.64 to 0.86 across the three time periods, with percent agreement ranging from 72% to 94% and ove rall agreement of 84%; LeBaron and Zeltzer, 1984 ). No sex diff erences emerged but younger children were more likely to score higher on the PBCL during the procedure due to an incre ase in demonstrative distress behaviors compared to older children. Th e pattern of relatio n- ships between ratings on the PBCL with observer and self-report ratings of pain indicate d that the PBCL related more strongly to anxiety (versus pain) and to observer (versus self -report) ratings. For example, the relationships between the PBCL and child self- report of pain were: pre-procedure r = 0.26, procedure r = 0.44, and postprocedure r = \210\2220.09 . Th e parallel correlations between the PBCL and child self-reported anxiety were: pre-pro cedure r = 0.49, procedure r = 0.53, and post-procedure r = 0.21. Observer ratings of child anxiety were moderately to highly correlated with PBCL scores across time points ( r range d from 0.59 to 0.74). Observer ratings of child pain were moderately related to PBCL scores across time points ( r ranged from 0.42 to 0.65) (LeBaron and Zeltzer 1984 ). Use of the P BCL to assess pain and distress behaviors has continued in a broad age range of children (F reyer et al., 1997 ), in a number of diff erent medical contexts, and by researchers in a v ariety of countries. Th e major limitation with the OSBD and its versions, as with sev- eral other scales of a s imilar nature, is the length of time required for training and coding. In addition, many st udies using the OSBD have diff ered in their defi nitions and timing of phases. Some author s have pointed out that the length of phase may have little to do with child behavior but m ay change the overall score of the measure (Tucker et al., 2001 ). Child Adult Medical Procedure Interaction Scale (CAMPIS) Partially based on the OSBD (Jay e t al., 1983 ), the CAMPIS (Blount et al., 1989 ) was designed to capture adult behavior and the full spectrum of child behavior including coping. Cohen and col- leagues ( 2008 ) cate gorized the CAMPIS and its revisions as well established in measuring pain and behavioral d istress. Th e original version of the CAMPIS has 35 operationally-defi ned verbalizations b y children (16 codes) and adults (19 codes), and is administered using a continuous recordi ng strategy. (Additional information including manuals can be accessed at: < http://psychol ogy.uga. edu/people/bios/faculty/BlountDoc/Blount-CAMPIS%20&%20 CAMPIS-R%20no%20aff ect.pdf >.) Although the CAMPIS manual includes a Likert-type scale of vocal aff ect coding, this has not typi- cally been used in published studies. Overall interrater reliabilities were e xcellent for child and adult behaviors (kappas of 0.92 and 0.80 respectively; Blount et al. , 1989 ). Observation Scale of Behavioral Distress (OSBD) According to Jay et al. ( 1983 ), the OSBD is a revised version of the PBRS (Katz et al., 1980 ). Deemed a well-established measure by Cohen et al. ( 2008 ), the original version of OSBD contained 11 behaviors consistent with distress (pain and anxiety). A later revi- sion of the measure eliminated three items that were infrequent or negatively related to total distress scores, leaving an eight-item scal e (Elliott et al., 1987 ). Each behavior is operationally-defi ned and the medical procedur e is divided into four phases. In contrast to the PBRS procedural phases, behaviors are rec orded on the OSBD as present or absent in 15 sec intervals. Each category of behavior is al so assigned an intensity weighting (e.g. screaming is weighted 4.0 whereas nervous behavior is weighted 1.0). Th ese intensity weightings were derived based on the average ratings pr ovided by three health care professionals familiar with the procedure on which the measure was validated (bone marrow aspirations). Th e CAMPIS was later revised to group adult and child behav- iours on empirical and concep tual bases (Blount et al., 1990 ). Note, however, that validation of this revision was on t he same sample as the original tool (Blount et al., 1989 ). In the CAMPIS-R, the original 3 5 codes are collapsed into six categories: child distress, child coping, child neutral, adu lt distress promoting, adult coping promoting, and adult neutral. Continuous or interval co ding can be used. In a paper exploring the validity of the CAMPIS-R, inter- rater reliabili ty was good to excellent for each of the behavior cat- egories (e.g. child coping; kappas r anged from 0.65 to 0.92; Blount et al., 1992 ). Supporting construct validity, the code gro upings showed most of the expected relationships with observational, self- report, and adul t report measures of child fear and pain (Blount et al., 1997 ). For example, child coping was positively related to staff ratings of child cooperation ( r = 0.37) and inversely rela ted to child distress on the OSBD ( r = \210\2220.49) and child self-report of pain ( r = \210\2220.22). Similarly, child distress behavior was positively related to OSBD distress scores ( r = 0.57), child self-report of pain ( r = 0.34), and parent ratings of child pain ( r = 0.25). Adult behav- iour categories showed most of the expected relationships. Paren t distress promoting behavior was related to increased child self- report of pain ( r = 0.2 1), OSBD distress ( r = 0.64), and inversely to staff ratings of child cooperation ( r = \210\2220.43). Parent coping In the original study of the OSBD, interrater reliability was gen- erally high ( r ranged 0 .72 to 0.99 over the phases, with the total r = 0.99; percent agreements similarly ranged f rom 80% to 91% with a total agreement of 84%; Jay et al., 1983 ). Construct validity was su pported through a variety of signifi cant positive correlations with related constructs inc luding children \200\231s trait anxiety ( r = 0.63), children \200\231s anticipated and exp erienced levels of procedural pain ( r = 0.76 and 0.62, respectively), as well as parental ratings of child SECTION 5 measurement of pain 386 promoting behaviors were only weakly related to staff ratings of child cooperation ( r = 0. 22) and were not signifi cantly related to child self-report of pain, fear, or OSBD distres s (Blount et al., 1997 ). Of note, adult \200\230neutral \200\231 behaviors were weakly re lated to some outcomes. For example, parent neutral behaviors were inversely related to OSB D distress ( r = \210\2220.37; Blount et al., 1997 ). consistent (Chronbach \200\231s alpha = 0.93) and showed good concur- rent validity with pa rent-rated numerical rating scales ( r = 0.46) (Breau et al., 2002 ). A cut-off of 7 was fo und to have the best bal- ance of sensitivity (84%) and specifi city (68%). Th e observatio n time for administering the NCCPC-R is somewhat unclear. In the validation studies, caregi vers reported on painful events that lasted from 1 min to 24 h and presumably provided rati ngs on the basis of the entire event. Th e CAMPIS-R has demonstrated sensitivity to changes in parent and/or child behavior follo wing intervention (Blount et al., 1992 ). Use of the CAMPIS and its revised version can pro vide exception- ally rich interactional data and description for research; these data are a chieved through extensive eff ort however, including recording the interactions, followed b y detailed post hoc transcription and coding, making the burden likely too high for clinica l use. A postoperative version of the NCCPC (NCCPC-Post opera- tive; NCCPC-PO) retains the ordinal ratings of the NCCPC-R, but removes the eating/sleeping subscale (Breau et al., 2002 ). In an attempt to examine whether individuals other than pri- mary caregivers could provide va lid ratings using this scale, the measure was administered by both primary caregivers and r esearch assistants. Th is scale further improved on the NCCPC-R by specifying an observatio n interval of 10 min. Similar to the NCCPC-R, the postoperative version showed good interna l con- sistency and convergent validity (Breau et al., 2002 ). Excellent interrater reliabi lity was found between caregivers and research assistants (ICC = 0.82 pre-surgery and 0.79 post-surgery), and research assistant NCCPC scores showed good convergent valid- ity with v isual analog scale (VAS) ratings of pain ( r = 0.72 between NCCPC and caregiver VAS). A cut -off of 11 was deemed to be the best balance of sensitivity (88%) and specifi city (81%) on the NCCPC-PO. Since its original publication, the NCCPC has been translated and validated in several other languages includ- ing French (Zabalia et al., 2011 ) and Swedish (Johansso n et al., 2010 ). Further discussion of pain assessment and management in children with dis abilities can be found in Chapter 16 (Belew et al., this volume). Th e CAMPIS-short form (CAMPIS-SF; Blount et al., 2001 ) was designed to be an alternative to the CAMPIS-R that can be admin- istered in real-time. Th e CAMPIS-SF removes the neutral codes and retains the child and adult distress (promoting) and coping (promoting) groups. For each phase of the procedure, behavior groups are scored on a fi ve-point Likert scale ( e.g. 1 = none/one, 5 = maximum or nearly continuous). Initial training takes approx- imatel y 1.5 to 2 days, following which videos can be coded in real time. In the initial study, go od to excellent interrater reliability was achieved (kappas ranged from 0.74 to 1.0) (Bloun t et al., 2001 ). Correlations between CAMPIS-SF child behaviors and other measures of chil d distress were in the expected directions (e.g. CAMPIS-SF child distress was positively co rrelated with OSBD distress, r = 0.84, child coping was negatively correlated with OSBD dis tress, r = \210\2220.40). In addition to its development for lumbar punctures and bone marrow aspirations (Blount et al., 1989 ), the CAMPIS has been used in various forms in many procedural settings includin g immu- nizations (Blount et al., 1992 ; Cohen et al., 1999 ), venepunctures (McMurtry et a l., 2010 ), and voiding cystourethrograms (Salmon and Pereira, 2002 ). Th e CAMPIS has also been translated into Portuguese (Pedro et al., 2010 ). Face, Legs, Activity, Cry, Consolability scale \200\223Revised (FLACC \200\223R) Th e FLACC scale has been used in its original form and has also been revised to measure pain behavio r in children with cognitive impairment. In the fi rst study using the FLACC with this popu la- tion (Voepel-Lewis et al., 2002 ), nurses administered the FLACC postoperatively using an observation interval of 2 to 3 min before and aft er analgesic administration. FLACC sco res were signifi cantly correlated with parent global ratings of children \200\231s pain ( r = 0.65) and the FLACC was responsive to analgesic administration (5.3 2.8 before analg esic, 2.0 1.4 aft er analgesic). Intraclass correlations between independent raters were signifi cant (range 0.51 \200\2230.78), but more stringent interrater reliability analyzes (exact agreement, kappa) showed some evidence of lower reliability, especially in the Legs and Activity categories (range 0.27 \200\2230.50). In a follow-up study, Malviya et al. ( 2006 ) revised the FLACC scale by adding additional behavioral descriptors within each cate gory. Similar to the origi- nal scale, FLACC \200\223R scores were signifi cantly correlate d with par- ent global ratings of children \200\231s pain ( r = 0.74). An improvement on in ter-rater reliability was evident with the revised scale; intraclass correlations (range 0. 75 \200\2230.90) and kappa values (0.44 \200\2230.57) were higher than those reported with the original tool. Behavioral measures of pain in children with intellectual disabilities Children with intell ectual disabilities are a population for whom behavioral measurement may be particularly be nefi cial. Although children in this group who are higher functioning may be able to provid e some degree of self-report, observation is oft en relied upon as a standard of measuremen t. A full systematic review and syn- thesis is beyond the scope of this chapter, but we rev iew two scales that have been the most consistently used and demonstrate good psychometric properties with this population. Non-communicating Children \200\231s Pain Checklist (NCCPC) Th e most widely validated beha vioral tool for assessing pain in children with intellectual disabilities is the NCCPC. Th e original checklist included 30 dichotomous items grouped into seven sub- scales and was c ompleted by primary caregivers (McGrath, 2008 ). Th e checklist showed good internal consis tency, test \200\223retest reli- ability, and convergent and divergent validity (Breau et a l., 2000 ). A revised version was published and, although the measure con- tinues to be cal led a checklist, the use of ordinal ratings (zero to three) results in this new measure now being better described as a rating scale (Breau et al., 2002 ). Th e new scale (range of 0 \200\22390), still completed by primary caregivers, continued to be internally In addition to the two scales described here, a number of other tools have been proposed to assess pain in children with cogni- tive impairment including the recently published Indiv idualized Numerical Rating Scale (Solodiuk et al., 2010 ). Facial expression has also been suggested to evaluate pain in specifi c populations (e.g. children with autism; Messmer et al., 2008 ). CHAPTER 37 behavioral measures of pain 387 Areas of special consideration Cross cultural considerations Several of the scales reviewed have been used by researchers around the world (e.g. FLACC, CHEOPS). However, the vast maj ority of behavioral measures of pain have been developed and validated in English speaking populations within largely Western cultures. Although some may argue that pain behaviors sh ould be univer- sal, the utility of behavioral measures has recently been questioned in gro ups that speak languages other than English or have diff erent cultural backgrounds (Finley et al., 2009 ). Th is argument is sup- ported by a small body of research examining some d iff erences in pain behavior across infants from diff erent cultural groups (Lewis et al., 1993 ; Rosmus et al., 2000 ). Literature on cultural considera- tions in behavioral measure ment of pain in older children is lim- ited. One study used the CAMPIS-R (Blount et al., 19 90 ) to study behavioral interactions in 3- to 6-year-old Portuguese children receiving imm unizations (Pedro et al., 2010 ). Th is study found that new adult behaviors were important to add in this population (e.g. intimidation, reward promise, rationalization). Literature on cul- tural diff erences in children \200\231s pain behavior is limited, but suggests th at caution be used in applying currently available measures out- side of the population in which they were developed. Sweeping con- clusions on the impact of culture on these measure s will likely not be useful; instead, it will be important to consider individual diff er- ences in socialization and history of pain in order to best interpret pain behavior. A deta iled discussion of culture, communication and pain can be found in Chapter 11 (Clemente, th is volume). where investigators have added or removed behaviors from the measure (Caldwell-Andrews et a l., 2005 ; Chorney et al., 2012 ). Although this process is not necessarily problematic, it is impor- tant that modifi cations are well described and further psychometric testing is completed. Conclusion Although self-report is oft en considered the gold standard of pain measurement, authors have recently pointed out the limita- tions of this approach (Schiavenato and Crai g, 2010 ). Young chil- dren and those with signifi cant cognitive impairments may not be ab le to provide self-report and even in older children, self-report may not always be reliabl e. Contextual factors can infl uence chil- dren \200\231s reports of pain and may result in children over or under- reporting their experience. Measures to quantify overt behavior ar e an important addition to a thorough pain assessment. Several well-validated measures are available for acute pain including pro- cedural and postoperative contexts. One measure is available for parents as raters, but the majority of measures are designed to be administer ed by healthcare professionals or researchers. Some measures can be administered at the bed side, whereas others need to be administered using video recordings. Th ere are currently t wo well-validated behavioral measures of pain in children with devel- opmental delays, one of which can be administered by parents. Although data on behavioral pain measurement are strong, a few limitations should be noted. First, most of the studies have been completed in English-speaking populations from Wester n cultures and the applicability of these scales outside the population in which they were originally validated is questionable. Second, although all of these scales include behavior s that have been identifi ed by con- sensus and validation to be related to painful stimuli , it is important to note that none of these behaviors are specifi c to pain. Children may cry, grimace, or show physical tension with a range of other negative emotions. Pain versus distress It is important to note that not all of the behaviors included in the scales previously discussed are necessarily specifi c to pain. In fact, there have been que stions about the utility of diff erentiating pain from other negative emotions especially a round acute pro- cedures (Blount and Loiselle, 2009 ). For example, cry is a com- mon behav ior included on many pain measures, but this same behavior can be indicative of a range of emotions including fear, anxiety, sadness, or anger. Th is is particularly evident in studi es of invasive procedures in which the same scale is used to measure anticipatory distress/ fear/anxiety and procedural pain. Th ere is an implied assumption that behaviors displayed before the proce- dure are indicative of distress and those displayed during and aft er the procedure are indicative of pain, but there are clear similarities in behaviors across all phases. However, distinguishing between pain and other negative emotions such as fear may be important for appropriate intervention; the ability of children, caregivers, and researc hers to accurately tease apart these constructs has implica- tions for our understanding of the pain context, accurate measure- ment, and targeted intervention and should be explored in future research (Bird and McMurtry, 2012 ). Despite these limitations, behavioral measurement of pain is an integral part of thorough p ain assessment and, in some cases, may be the most valid measure available. Th e availabili ty of measures of pain behavior and accompanying adult behavior opens new doors to examine contextual infl uences on children \200\231s pain and dis- tress. Future work in this area needs to continue to consider clini- cal utility and develop decision metrics around the us e of these scales, particularly around decisions to treat. It is also important to acknowle dge individual diff erences and contextual infl uences on pain expression and consider thes e in treatment decisions. Finally, given the relatively high prevalence and burden of recur rent/ chronic pain in children and adolescents (King et al., 2011 ) further development of the understanding of the role of behavioral meas- urement in this area is critical. Case example Modi \201 cation of scales It is clear that many scales that were developed and validated in one context have subsequently been used in other contexts. For example, the CHEOPS was o riginally developed for postoperative pain but has since been used in other painful procedu res. In some cases, use of a measure in another context requires modifi cation of the scale . Th is is particularly evident in studies using the CAMPIS Molly is a 7-year-old girl who is on the medical surgical ward of a tertiary care children \200\231s hospital following an emergency appen- dectomy. Molly had surgery yesterday and t oday her nurse, Tim, has noticed that she seems to be quiet and tearful. Molly has around the clock dosing of analgesics, but Tim suspects that she might still be h aving pain. Tim is aware that children in this age range can usually provide self-report of their SECTION 5 measurement of pain 388 validation of a rating scale for children \200\231s and adults \200\231 behaviors during pa inful medical procedures . J Pain Symptom Manage , 22 , 591 \200\223599. Blount , R. L. , Cohen , L. L. , Frank , N. C. , Bachanas , P. J. , Smith , A. J. , Manimala , M. R. , et al . ( 1997 ). Th e Child-Adult Medical Procedure Interaction Scale \200\224Revised: an asses sment of validity . J Pediatr Psychol . 22 , 77 \200\22388. Blount , R. L. , Corbin , S. M . , Sturges , J. W. , Wolfe , V. V. , Prater , J. M. , and James , L. D. ( 1989 ). Th e rel ationship between adults \200\231 behavior and child coping and distresss during BMA/LP pro cedures: a sequential analysis . Behav Th er , 20 , 585 \200\223601. pain, and uses a validated tool (the Faces Pain Scale \200\223Revised) to ask Molly to rate her pain. Molly does not talk or make eye contact with Tim when he is explaining the scale and reaches for her mother. Her mother encourages Molly to use the scale and Molly quickly points to the fi rst face (indicating no pain). Tim and Molly \200\231s mother explain the scale again and remind Molly to point to the face that matches how she feels. Molly again points to the fi rst face on the scale. Blount , R. L. , and Loiselle , K. A. ( 2009 ). Behavioral assessment of pediatric Outside the room, Molly \200\231s mother tells Tim that she believes Molly is having pain. She says that Molly doesn \200\231t like to take medicine and she wonders if Molly is ratin g her pain as very low to avoid taking medication. Tim agrees that this is possible and sug gests that they use some additional ways of assessing Molly \200\231s pain. Tim knows that he will be in Molly \200\231s room for a short period of time, so wants a scale that he can administer based on a short observation. He chooses the FLACC because this scale has been validated for children in Molly \200\231s age range and in postoperative pain. Using this s cale, Tim observes that Molly \200\231s face is grimaced and her jaw is clenched, her legs are tensed and restless and she is squirming in her bed, she is whimpering, but is consoled by her mother sitting in her bed with her. Using FLACC scoring, Molly scores a six out of ten. Tim takes this as additional evi- dence that Molly is experiencing pain. He pages the physician on call who recommends titrating Molly \200\231s medication on the basis of Tim \200\231s information. Tim discusses this plan with Molly and her mother and addresses Moll y \200\231s potential concerns about taking more medication (she was worried that she would need to get another needle). He also off ers to get a movie for Molly so she can be distra cted. About a half hour later, Tim again assesses Molly \200\231s pain using the FLACC. Her score has decreased to one out of ten. Molly appears generally relaxed, but shift s in her bed once while Tim is observing. Tim discusses this score with Molly and her mother and Ti m again asks Molly to rate her pain using the FPS \200\223R. Molly chooses the fi rst face of the FPS \200\223R and Molly \200\231s mother reports that she feels Molly \200\231s pain is now well managed. Tim remind Molly and her mother to call if they feel Molly \200\231s pain is increasing again and notes that he will be back to check on them in a few hours. pain . Pain Res Manag , 14 , 47 \200\22352. Blount , R. L. , Sturges , J. W. , and Powers , S. W. ( 1990 ). Analysis of child and adult behavioral variations by phase of medical procedure . Behav Th er , 21 , 33 \200\22348. Breau , L. M. , McGrath , P. J. , Camfi eld , C. , Rosmus , C. , and Finley , G. A. ( 2000 ). Preliminary validation of an observational pain checklist for persons with cognitive imp airments and inability to communicate verbally . Dev Med Child Neurol , 42 , 609 \200\2236 16. Breau , L. M. , McGrath , P. J. , Camfi eld , C. S. , and Finley , G. A. ( 2002 ) Psychomet ric properties of the non-communicating children \200\231s pain checklist-revised . Pain , 99 , 349 \200\223357. Breau , L. M. , McGrath , P. J. , Craig , K. D. , Santor , D. , Cassidy , K. , and Reid , G . J. ( 2001 ). Facial expression of children receiving immunizations: a principal component s Analysis of the Child Facial Coding System . Clin J Pain , 17 , 178 \200\223186. Caldwell-Andrews , A. A. , Blount , R. L. , Mayes , L. C. , and Kain , Z. N. ( 2005 ). 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