What is the best approach the assessment of pain in a child? That is a big can of worms. We want to understand the pain so that we can treat both the pain and the underlying cause but much of what we do comes from adult practice. Rethinking our approach requires an understanding of what pain is to a child. Pain is a very different thing for a child and so our approach must also be different.
Pain is an abstract thing, and the younger the child, the less abstract
their thinking is.
The internet has plenty of comical examples of things that children have written or said that are reminiscent of the story of the Emperor’s New Clothes. In fact one of the most endearing things about children is the way that they often combine straight talking with unspeakable truths. The ability to think abstractly and interpret what someone means (rather than what they are saying) develops as children grow. We tend to develop what is needed for these situations based on experience of past events. To give you an example of adult thinking, I give you this excerpt, involving a word game, taken from a radio comedy with Benedict Cumberbatch and Roger Allam. I think that this is a great example of how adults use words in bizarre ways and still manage to make sense.
Why does this word play make sense to any of us? Years of having our minds messed with is the only answer that I can suggest. Expressing feelings like pain relies on similar processes to that of understanding complicated jokes.
In order to account for these difficulties, some people adopt a standardised approach that allows children to choose how they express the magnitude of their pain. I carry a card with the Wong-Baker faces (pictures of faces that go from smiley to sad) and, if appropriate, ask the child to use the faces, words or numbers to say how bad their pain is. My experience is that even this seemingly child friendly approach gives us the illusion that we are getting a meaningful answer because I am effectively speaking a different language.
When we are asking children about pain, how can we expect them to respond if they have not experienced that feeling before and lack the ability to describe it? Imagine a nine year old presenting with abdominal pain. All of the following questions are commonly asked of children in that assessment. The responses are all real as well. What I have taken the liberty to add is the internal response (I) that the child is having in their head.
When we are asking children about pain, how can we expect them to respond if they have not experienced that feeling before and lack the ability to describe it? Imagine a nine year old presenting with abdominal pain. All of the following questions are commonly asked of children in that assessment. The responses are all real as well. What I have taken the liberty to add is the internal response (I) that the child is having in their head.
Q. What does your pain feel like? Is it sharp, burning, aching or colicky?
I. It feels bad.
Burning feels bad. May be that’s
the right answer. Someone called it tummy ache.
That must be it. Aching. If I say aching, the doctor will stop looking
at me like that.
A. Aching I guess
Q. Does your pain come and go?
I. It hurts now. It
hurt yesterday. I’m not sure what the doctor means. Why is the doctor still looking at me?
A. (Shoulder shrug)
Q. How bad is your pain? We use these numbers and faces here
to help you chose an answer. (Shows Wong Baker Faces scale)
I. What is with all these questions? Bad is bad.
My tummy hurts and it feels bad.
That’s not one of the choices on the list. ‘Hurts more’ is there though and my tummy has
definitely got worse while I’ve been sat here.
A. Points to ‘Hurts a lot more’ (6/10 on Wong Baker scale)
So what should we be doing?
I am not saying that questions or pain assessment tools are unhelpful,
just that they should not be applied unthinkingly. The trouble is that the child wants to give
you an answer. I think that sometimes
they want to give an answer so much that they might give one for the sake of
giving an answer. I think that there are two simple things that do work really well
with children.
1. Just ask them what their pain is like.
A nice open question will tell you one of two things. Either the child will describe their pain in
a way that makes sense to them or they will make it obvious that they don’t
really understand how to describe their pain. Having no answer is better than a forced answer. If they seem able to begin to describe their
pain, you can progress to more closed questions and a scoring system perhaps.
2. Look at how they are behaving. A significant tummy pain will usually
manifest itself in some way in the child’s posture, activity or
interaction. A child who walks in and
plays but says they have severe pain may be proving my point about
understanding and describing pain.
Next time you see a child and want to know about their
pain. Ask them in a way that allows them to say what they want to say, in the way that they want to say it.
