Pain expression in children with an intellectual disability

Pain care for children with cognitive impairment: A parent-nurse partnership

PURPOSE

To explore nurses' experiences of establishing partnerships with parents for pain care of hospitalized children with cognitive impairment (CI) and identify related facilitators and barriers.

DESIGN AND METHODS

In this qualitative, interpretive descriptive study, individual semi-structured interviews were conducted via videoconferencing with pediatric nurses from inpatient wards in a Canadian pediatric quaternary hospital. Verbatim transcripts were analyzed using an inductive, data-driven thematic analysis approach.

RESULTS

Eleven nurses were interviewed. The overarching theme was Assessing Pain as an Outsider: "A Complete Guessing Game". Seven major themes were identified.: Relying on Parent Expertise for Pain Assessment, Brainstorming with Parents for Pain Treatment, Supporting Parents as Advocates for Pain Care, Individualizing Pain Care with Parents, Involving the Child in Pain Care: A Spectrum, Barriers to Partnership in Pain Care and Facilitators to Partnership in Pain Care.

CONCLUSIONS

Nurses described the many ways they involve parents as partners in pain care. However, nurses shared strong feelings of uncertainty associated with pain care in children with CI. Consequently, nurses felt the need to rely on parents for appropriately assessing and treating pain in children with CI. Findings highlighted the practice and education gaps that may contribute to nurses' uncertainty and reliance on parents.

PRACTICE IMPLICATIONS

By identifying related practice and education gaps, healthcare organizations can implement strategies to further support nurses in establishing partnerships and potentially optimize pain care practices.

Individualized Numeric Rating Scale to Assess Pain in Critically Ill Children With Neurodevelopmental Disabilities

BACKGROUND

Pain is a significant burden for children with neurodevelopmental disabilities but is difficult for clinicians to identify. No pain assessment tools for children with neurodevelopmental disabilities have been validated for use in pediatric intensive care units. The Individualized Numeric Rating Scale (INRS) is an adapted 0-to-10 rating that includes parents' input on their child's pain indicators.

OBJECTIVES

To evaluate the reliability, validity, and feasibility and acceptability of use of the INRS for assessing pain in critically ill children with neurodevelopmental disabilities.

METHODS

This observational study enrolled critically ill patients with neurodevelopmental disabilities aged 3 to 17 years in 2 pediatric intensive care units at a children's hospital using a prospective repeated-measures cohort design. Structured parent interviews were used to populate each patient's INRS. Bedside nurses assessed pain using the INRS throughout the study. The research team completed independent INRS ratings using video clips. Participating parents and nurses completed feasibility and acceptability surveys. Psychometric properties of the INRS and survey responses were evaluated with appropriate statistical methods.

RESULTS

For 481 paired INRS pain ratings in 34 patients, interrater reliability between nurse and research team ratings was moderate (weighted κ = 0.56). Parents said that creating the INRS was easy, made them feel more involved in care, and helped them communicate with nurses.

CONCLUSIONS

The INRS has adequate measurement properties for assessing pain in critically ill children with neurodevelopmental disabilities. It furthers goals of patient- and family-centered care but may have implementation barriers.

Perspectives on pain in Down syndrome

Down syndrome (DS) or trisomy 21 is a genetic condition often accompanied by chronic pain caused by congenital abnormalities and/or conditions, such as osteoarthritis, recurrent infections, and leukemia. Although DS patients are more susceptible to chronic pain as compared to the general population, the pain experience in these individuals may vary, attributed to the heterogenous structural and functional differences in the central nervous system, which might result in abnormal pain sensory information transduction, transmission, modulation, and perception. We tried to elaborate on some key questions and possible explanations in this review. Further clarification of the mechanisms underlying such abnormal conditions induced by the structural and functional differences is needed to help pain management in DS patients.

Pain research and children and adolescents with severe intellectual disability: ethical challenges and imperatives

Children with severe intellectual disabilities encounter inequities in pain-related care, yet little pain research involves this population. A considerable issue with pain research in this population is its ethical complexity. This Viewpoint delineates the ethical challenges of pain research involving children (aged 2-12 years) and adolescents (aged 13-21 years) with severe intellectual disabilities. There are two main issues. First, some of the standard methods for assessing pain and pain sensitivity are not suitable for individuals with severe intellectual disability, who are often non-verbal and unable to understand or follow instructions. Second, children and adolescents with severe intellectual disability cannot provide informed consent or assent to participate in pain research, and their dissent is not always recognised. The existing ethical guidelines for pain research by the International Association for the Study of Pain provide helpful, but general, guidance. This Viewpoint supplements these guidelines and uses a well established framework for assessing the ethics of clinical research to highlight points relevant to designing, doing, reviewing, and evaluating research involving children and adolescents with severe intellectual disability, focusing on issues that are unaddressed in existing guidance.

Accurate classification of pain experiences using wearable electroencephalography in adolescents with and without chronic musculoskeletal pain

Objective

We assessed the potential of using EEG to detect cold thermal pain in adolescents with and without chronic musculoskeletal pain.

Methods

Thirty-nine healthy controls (15.2 ± 2.1 years, 18 females) and 121 chronic pain participants (15.0 ± 2.0 years, 100 females, 85 experiencing pain ≥12-months) had 19-channel EEG recorded at rest and throughout a cold-pressor task (CPT). Permutation entropy, directed phase lag index, peak frequency, and binary graph theory features were calculated across 10-second EEG epochs (Healthy: 292 baseline / 273 CPT epochs; Pain: 1039 baseline / 755 CPT epochs). Support vector machine (SVM) and logistic regression models were trained to classify between baseline and CPT conditions separately for control and pain participants.

Results

SVM models significantly distinguished between baseline and CPT conditions in chronic pain (75.2% accuracy, 95% CI: 71.4%–77.1%; p < 0.0001) and control (74.8% accuracy, 95% CI: 66.3%–77.6%; p < 0.0001) participants. Logistic regression models performed similar to the SVM (Pain: 75.8% accuracy, 95% CI: 69.5%–76.6%, p < 0.0001; Controls: 72.0% accuracy, 95% CI: 64.5%–78.5%, p < 0.0001). Permutation entropy features in the theta frequency band were the largest contributor to model accuracy for both groups.

Conclusions

Our results demonstrate that subjective pain experiences can accurately be detected from electrophysiological data, and represent the first step towards the development of a point-of-care system to detect pain in the absence of self-report.

The influence of contextual factors on children's communication of pain during pediatric Haematopoietic Stem Cell Transplantation: A qualitative case study

PURPOSE

The aim of this study was to describe how contextual factors related to the clinical setting of a pediatric HSCT unit influenced children's communication of pain to their health-care providers and parents during hospitalization.

DESIGN AND METHODS

A qualitative case study design was conducted in two-phases in a tertiary level pediatric HSCT unit. The Social Communication Model of Pain provided the conceptual framework for the study. In phase one participants were parents and phase two participants were health-care providers and children in a pediatric HSCT unit. Parents participated in semi-structured interviews at 30- and 90-days post-transplantation regarding their child's communication of pain. Naturalistic observations of children receiving clinical care were conducted and health-care providers participated in semi-structured interviews.

RESULTS

Children extensively denied pain to their parents and health-care providers. When children did communicate pain, they were motivated by a need to seek interventions for their pain. Children's willingness to communicate pain was influenced by the physiological impact of HSCT therapy, their previous experiences of pain, their relationship with parents and health-care providers and parents and an environment of fear and uncertainty.

CONCLUSIONS

There is a pressing need for child-centric approaches to support children to communicate their pain experiences to overcome the limitations imposed by the complexity of their medical treatment and the clinical environment in which they receive healthcare.

PRACTICE IMPLICATIONS

In the context of HSCT therapy children may not communicate pain until pain is severe, and no longer bearable, or outright deny the presence of pain.

Detection and assessment of postoperative pain in children with cognitive impairment: A systematic literature review and meta-analysis

Background and Objective

Children with cognitive impairment (CI) are at risk of experiencing pain. Several specific pain rating scales have been developed to date. Thus, the aim of this meta‐analysis was to estimate the degree of reliability of different pain assessment scales for the postoperative pain in children with CI.

Databases and Data Treatment

PubMed, Scopus and Web of Science databases were approached: all studies validating and/or using pain assessment tool in children (0–20 years) with CI published in English from the 1st of January 2000 to the 1st of January 2022 were included. Only studies reporting the interclass correlation coefficient (ICC) to evaluate the concordance between caregivers’ and external researchers’ scores were eligible.

Results

Twelve studies were included (586 children with CI, 60% males; weighted mean age 9.9 years – range 2–20). Five of them evaluated the Non‐Communicating Children's Pain Checklist‐Postoperative Version (NCCPC‐PV) scale whereas four the original and revised Face, Legs, Activity, Cry, Consolability (FLACC) scale. The analysis showed an overall ICC value of 0.76 (0.74–0.78) for the NCCPC‐PV scale, with a high heterogeneity index (I² = 97%) and 0.87 (0.84–0.90) for the FLACC scale, with a discrete I² index (59%).

Conclusions

The NCCPC‐PV and FLACC pain rating scales showed the strongest evidence for validity and reliability for assessing postoperative pain in children with CI. However, due to the high heterogeneity of the studies available, these results should not be considered conclusive.

Significance

This review is focused on the assessment of pain in children with CI in the postoperative period. Simplified observation‐based pain assessment tools that rely on evaluating non‐verbal expressions of pain should be recommended for children with difficulties to communicate their feelings. Even if there is a high degree of heterogeneity in clinical presentations among youth with CI, two tools (NCCPC‐PV and FLACC) have emerged as reliable and valid in this population.

Pain Behavior of People with Intellectual and Developmental Disabilities Coded with the New PAIC-15 and Validation of Its Arabic Translation

Pain management necessitates assessment of pain; the gold standard being self-report. Among individuals with intellectual and developmental disabilities (IDD), self-report may be limited and therefore indirect methods for pain assessment are required. A new, internationally agreed upon and user-friendly observational tool was recently published—the Pain Assessment in Impaired Cognition (PAIC-15). The current study’s aims were: to test the use of the PAIC-15 in assessing pain among people with IDD and to translate the PAIC-15 into Arabic for dissemination among Arabic-speaking professionals. Pain behavior following experimental pressure stimuli was analyzed among 30 individuals with IDD and 15 typically developing controls (TDCs). Translation of the PAIC followed the forward–backward approach; and reliability between the two versions and between raters was calculated. Observational scores with the PAIC-15 exhibited a stimulus–response relationship with pressure stimulation. Those of the IDD group were greater than those of the TDC group. The overall agreement between the English and Arabic versions was high (ICC = 0.89); single items exhibited moderate to high agreement levels. Inter-rater reliability was high (ICC = 0.92). Both versions of the PAIC-15 are feasible and reliable tools to record pain behavior in individuals with IDD. Future studies using these tools in clinical settings are warranted.

Can the Vocal Expression of Intellectually Disabled Individuals Be Used as a Pain Indicator? Initial Findings Supporting a Possible Novice Assessment Method

Pain is difficult to assess in non-verbal populations such as individuals with intellectual and developmental disability (IDD). Due to scarce research in this area, pain assessment for individuals with IDD is still lacking, leading to maltreatment. To improve medical care for individuals with IDD, immediate, reliable, easy to use pain detection methods should be developed. The goal of this preliminary study was to examine the sensitivity of acoustic features of vocal expressions in identifying pain for adults with IDD, assessing their feasibility as a pain detection indicator for those individuals. Such unique pain related vocal characteristics may be used to develop objective pain detection means. Adults with severe-profound IDD level (N = 9) were recorded in daily activities associated with pain (during diaper changes), or without pain (at rest). Spontaneous vocal expressions were acoustically analyzed to assess several voice characteristics. Analyzing the data revealed that pain related vocal expressions were characterized by significantly higher number of pulses and higher shimmer values relative to no-pain vocal expressions. Pain related productions were also characterized by longer duration, higher jitter and Cepstral Peak Prominence values, lower Harmonic-Noise Ratio, lower difference between the amplitude of the 1st and 2nd harmonic (corrected for vocal tract influence; H1H2c), and higher mean and standard deviation of voice fundamental frequency relative to no-pain related vocal productions, yet these findings were not statistically significant, possibly due to the small and heterogeneous sample. These initial results may prompt further research to explore the possibility to use pain related vocal output as an objective and easily identifiable indicator of pain in this population.

Pain interventions in adults with intellectual disability: A scoping review and pharmacological considerations

BACKGROUND AND OBJECTIVE

Having to deal on a daily routine with prescriptions in adults with intellectual disability (ID), we systematically reviewed the literature on the specificities of pain interventions in that population, focusing on medication and trying to gather practical information on appropriate pain treatments. Given the scarcity of the literature on the topic, we also discussed the pharmacological considerations to be taken into account when prescribing analgesic drugs in that vulnerable population.

DATABASES AND DATA TREATMENT

Articles on pain and ID were searched in the Medline and Google scholar electronic databases using the key words "Intellectual Disability," "Developmental Disability" and specific keywords for pharmacological and non-pharmacological pain interventions. Preset outcomes about pharmacological treatment specificity, efficacy and safety were then collected.

RESULTS

One hundred and fifty-two articles were found and 16 were retained based on our inclusion and exclusion criteria. Of the 16 articles, five were topical reviews. Among the 11 remaining articles, five discussed pharmacological interventions, four considered non-pharmacological interventions and two discussed both. As anticipated, the literature matching our specific outcomes about the pharmacological treatment of pain was scarce and for the most part not designed to answer the questions of specificity, efficacy and safety of pain treatment in adults with ID.

CONCLUSION

The specificity of analgesic treatments in adults with ID is a totally unexplored domain. In the absence of clinical guidelines, pharmacological facts-such as inter-individual variability in drug response, pharmacokinetic and pharmacodynamic interactions, frequent co-morbidities and ease of administration-must be systematically integrated, when prescribing in the population of adults with ID.

SIGNIFICANCE

This review synthesizes the state of research on pain interventions in adults with ID and is one of the rare articles addressing the specificities of analgesic prescriptions in this population.

Cancer Pain in People With Intellectual Disabilities: Systematic Review and Survey of Health Care Professionals

CONTEXT

Owing to life expectancy improvements for people with intellectual disabilities, their risk of developing cancer is increasing. Pain is an inevitable aspect of cancerous diseases. However, as pain experience and expression can be atypical in people with intellectual disabilities, this population is vulnerable to late diagnosis of cancer and undertreatment of cancer pain.

OBJECTIVES

The objective of this study was to investigate what is currently known about cancer pain in people with intellectual disabilities and provide specific recommendations to improve this knowledge.

METHODS

A systematic review using PubMed, PsycINFO, and CINAHL and an anonymous online survey of Dutch health care professionals were conducted.

RESULTS

From 10,146 publications, with intellectual disabilities in the title, and pain or cancer in the title or abstract, 11 articles underwent qualitative synthesis. Discussions within these articles were predominantly unspecific and brief, frequently indicating challenges in symptom presentation, communication, as well as assessment and treatment of cancer pain. The survey received 102 responses. The 63 health care professionals experienced with cancer in people with intellectual disabilities indicated challenges recognizing, assessing, and treating their cancer pain.

CONCLUSION

Cancer pain in people with intellectual disabilities is a topic lacking specific and comprehensive research within scientific literature. We suggest this is due to inherent difficulties regarding the complex interplay of comorbidities and communication issues in people with intellectual disabilities.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Pain in Children With Developmental Disabilities: Development and Preliminary Effectiveness of a Pain Training Workshop for Respite Workers

INTRODUCTION

Pain in children with intellectual disabilities (ID) is common and complex, yet there is no standard pain training for their secondary caregivers (ie, respite staff).

OBJECTIVES

Determine perceived pain training needs/preferences of children's respite staff (phase 1) and, use this information combined with extant research and guidelines to develop and pilot a training (phase 2).

METHODS

In phase 1, 22 participants responded to questionnaires and engaged in individual interviews/focus groups about their experiences with pain in children with ID, and perceived training needs/preferences. In phase 2, 50 participants completed knowledge measures and rated the feasibility of, and their own confidence and skill in, pain assessment and management for children with ID immediately before and after completing a pain training. They also completed a training evaluation.

RESULTS

Participants viewed pain training as beneficial. Their ideal training involved a half-day, multifaceted in-person program with a relatively small group of trainees incorporating a variety of learning activities, and an emphasis on active learning. Phase 2 results suggested that completion of the 3 to 3.5-hour pain training significantly increased respite workers' pain-related knowledge (effect sizes: r=0.81 to 0.88), as well as their ratings of the feasibility of, and their own confidence and skill in, pain assessment and management in children with ID (effect sizes: r=0.41 to 0.70). The training was rated favorably.

DISCUSSION

Training can positively impact respite workers' knowledge and perceptions about pain assessment and management. As such, they may be better equipped to care for children with ID in this area.

Interventions in pain management for persons with an intellectual disability

Pain is a multidimensional and subjective experience, and an ideal pain management regime needs to be comprehensive, integrative and involve all relevant persons. Multimodal interventions may include pharmacological, physical, social, psychological and spiritual approaches in order to address pain management at a molecular, functional, behavioural, cognitive and affective levels. Pain management interventions will vary according to pain aetiology, patient characteristics and preferences. In keeping with best practice guidelines for effective pain management, a structured approach incorporating an effective assessment of pain by the healthcare professional, identification of the source and type of pain and accurate documentation is essential. This article focuses on pharmacological and non-pharmacological pain management for individuals with intellectual disability.

Voiceless disability: A worth case of bilateral infrainguinal testicular torsion in a patient with cerebropalsy

Introduction

A fast surgical treatment is the gold standard when a testicular torsion is diagnosed.

However, an early diagnosis of torsion may not be feasible in case of torsion associated with undescended testis in the patients affected by cerebropalsy.

Case presentation

A Bolivian 16 year old male with acquired cerebropalsy and spastic neuromuscular disease was admitted to our Institute for a right inguinal swelling observed by the father in the morning. Indeed, the father had reported that the swelling had may be started two days before without pain or any other symptoms apparently. Two episodes of vomiting were only reported. At the general examination the patient, apparently, seemed to laugh repeatedly and a spastic movements increase were observed. The child had an infrainguinal bilateral cryptorchidism. An urgent left infrainguinal orchyectomy had been performed in the past and controlateral cryptorchidism was not corrected. At the right inguinal exploration, a complete twist of the spermatic chord was observed and a right orchyectomy was then performed.

Discussion

Testicular torsion in the inguinal canal is a rare reported condition that usually can involve patients with spastic neuromuscular disease. Processing, communication and verbalization of a chronic or acute pain seems to be different in a child with or without intellectual disability. It could be a lot more difficult to correct pain interpretation, with an important repercussion on pain accurate assessment and management.

Conclusion

In the patients with intellectual disability, a control of the testicles, it should always be done, mostly in case of atypical behaviour.

•

An early diagnosis of a testicular torsion may not be feasible in case of torsion associated with undescended testis in the patients affected by intellectual disability.

•

Processing, communication and verbalization of a chronic or acute pain seems to be different in a child with or without intellectual disability.

•

Atypical behaviour could be present in the children without capacity to verbalize the pain.

•

In the patients with intellectual disability, a control of the testicles should always be carried out, mostly in case of atypical behaviour.

Self-Reported Presence and Experience of Pain in Adults with Down Syndrome

Objective

The aim was to examine whether the presence of pain (based on physical conditions and participants' report) and self-reported pain experience in adults with Down syndrome (DS) differ from general population controls.

Design

Cross-sectional study of 224 adults with DS (mean age = 38.1 years, mild-severe intellectual disabilities) and 142 age-matched controls (median age = 40.5 years, mean estimated IQ = 105.7) in the Netherlands.

Methods

File-based medical information was evaluated. Self-reported presence and experience of pain were assessed in rest and after movement during a test session (affect with facial affective scale (FAS: 0.04-0.97), intensity assessed with numeric rating scale (NRS: 0-10).

Results

Compared with controls, more DS participants had physical conditions that may cause pain and/or discomfort ( p  = .004, 50% vs 35%), but fewer DS participants reported pain during the test session ( p  = .003, 58% vs 73%). Of the participants who indicated pain and comprehended self-reporting scales ( n  = 198 FAS, n  = 161 NRS), the DS group reported a higher pain affect and intensity than the controls ( p  < .001, FAS: 0.75-0.85 vs 0.50-0.59, NRS: 6.00-7.94 vs 2.00-3.73).

Conclusions

Not all adults with DS and painful/discomforting physical conditions reported pain. Those who did indicated a higher pain experience than adults from the general population. Research into spontaneous self-report of pain, repeated pain assessment, and acute pain is needed in people with DS for more insight into pain experience and mismatches between self-report and medical information.

Physiological and Behavioral Responses to Calibrated Noxious Stimuli Among Individuals with Cerebral Palsy and Intellectual Disability

Objective

As individuals with intellectual disability (ID) due to cerebral palsy (CP) are at high risk of experiencing pain, measuring their pain is crucial for adequate treatment. While verbal reports are the gold standard in pain measurements, they may not be sufficient in ID. The aim was to detect behavioral/autonomic responses that may indicate the presence and intensity of pain in individuals with CP and ID, using calibrated stimuli, here for the first time.

Subjects

Thirteen adults with CP and ID (CPID), 15 healthy controls (HC), and 5 adults with CP with no ID (CPNID).

Methods

Subjects received pressure stimuli of various intensities. Self-reports (using a pyramid scale), facial expressions (retrospectively analyzed with Facial Action Coding System = FACS), and autonomic function (heart rate, heart rate variability, pulse, galvanic skin response) were analyzed.

Results

Self-reports and facial expressions but not the autonomic function exhibited stimulus-response relationship to pressure stimulation among all groups. The CPID group had increased pain ratings and facial expressions compared with controls. In addition, the increase in facial expressions along the increase in noxious stimulation was larger than in controls. Freezing in response to pain was frequent in CPID.

Conclusions

1) Individuals with CP and ID have increased responses to pain; 2) facial expressions and self-reports, but not autonomic variables can reliably indicate their pain intensity; 3) the pyramid scale is suitable for self-report in this population. Although facial expressions may replace verbal reports, increased facial expressions at rest among these individuals may mask pain, especially at lower intensities.

Caring for children with intellectual disabilities part 2: Detailed analyses of factors involved in respite workers' reported assessment and care decisions

Respite workers (RW) commonly care for children with intellectual disabilities (ID), and pain is common for these children. Little is known about factors which inform RW pain assessment and management-related decisions.

OBJECTIVES

To describe/determine the following in response to a series of pain-related scenarios (e.g., headache, falling): (1) factors considered important by RW when assessing children with ID's pain; (2) whether children's verbal ability impacts pain assessment factors considered; (3) RW assessment and management approach.

PARTICIPANTS

Fifty-six RW (18-67 years, M_age=33.37, 46 female).

PROCEDURE/MEASURES

In an online survey, participants read and responded to six vignettes manipulating child verbal ability (verbal, nonverbal) and pain source.

RESULTS

The factors most frequently considered when assessing pain were child behavior (range: 20-57.4%), and history (e.g., pain, general; 3.7-38.9%). Factors did not vary by child's verbal ability. RW indicated varied assessment and management-related actions (range: 1-11) for each scenario.

DISCUSSION

Findings suggest: a) factors informing pain assessment did not depend on whether or not the child was verbal and b) a degree of flexibility in RW response to pain across situations. While these findings are encouraging, ensuring RW have adequate pain assessment and management knowledge specific to children with ID is critical.

Pain in children with intellectual disabilities: a randomized controlled trial evaluating caregiver knowledge measures

Inadequate knowledge has contributed to inaccurate pain assessment and treatment for children with intellectual disabilities.

AIM

Develop and evaluate pain knowledge measures and accompanying self-report ratings; determine their sensitivity to change.

MATERIALS & METHODS

Young adults (n = 77; M_age = 18.89; standard deviation = 2.29; 67 females) were randomly assigned to one of two 'caring for children with intellectual disabilities' training programs (pain and visual supports). Participants completed pre-post-measures of pain knowledge and six self-report ratings of feasibility, confidence and perceived skill in pain assessment and treatment.

RESULTS

After controlling for pretraining scores, pain knowledge and self-report ratings were significantly higher following pain training versus visual support training.

CONCLUSION

These measures show promise for the evaluation of pain knowledge in secondary caregivers.

Daily living pain assessment in children with autism: Exploratory study

This study aims to broaden knowledge about pain expression and assessment in daily life situations in children with Autism Spectrum Disorder (ASD). The goals are to provide a description of the responses of the GED-DI, the French version of the NCCPC, and to test the internal structure validity of this scale. Thirty five children with ASD were included in this study (mean age=58months; mean developmental age=32months). The French version of the NCCPC was filled in by parents. Descriptive analysis of responses shows that children with ASD express pain through varied and common behaviours, related to different expressive markers (vocal, facial, activity, etc.). Behaviours more specific to the symptomology and disturbances of ASD are also displayed. A four-factor solution (negative emotional reaction, idiosyncratic expression, hyper-vigilance reaction, pain expression) emerges from an exploratory factor analysis that explains 54.4% of the total variance. Correlation coefficients show good psychometric qualities in terms of internal consistency, factorial validity and discriminant validity. This study provides new data about pain expression in daily life situations and shows that the French version of NCCPC adjusted to ASD children is relevant to assess pain in daily life situations.

Caring for children with intellectual disabilities part 1: Experience with the population, pain-related beliefs, and care decisions

Some children with intellectual disabilities (ID): experience pain more frequently than children without ID, express their pain differently, and are incapable of providing self-reports. No research has examined disability and pain-related beliefs of respite workers (RW) and their relations to pain assessment and management decisions for children with ID.

OBJECTIVES

(1) compare disability and pain-related beliefs between RW and a sample with little experience in ID; (2) determine whether individuals' beliefs and personal characteristics are related to pain assessment and management decisions.

PARTICIPANTS

Fifty-six RW (aged: 18-67 years, M_age=33.37, 46 female) and 141 emerging adults (aged: 18-31 years, M_age=19.67, 137 female).

PROCEDURE/MEASURES

In an online survey, participants responded to six vignettes depicting pain in children with ID, and completed measures of pain and disability-related beliefs.

RESULTS/DISCUSSION

Compared to those without experience, RW held more positive disability-related beliefs, t(192)=4.23, p<0.001. Participants' pain-related beliefs (e.g., sensitivity to pain) differed depending on severity of the child's ID and participant group. Participants' pain-related beliefs predicted care decisions. Results provide initial insight into RW pain-related beliefs about children with ID, and a basic understanding of the relations among pain beliefs, personal characteristics and pain-related decisions.

An Exploration of Comfort and Discomfort Amongst Children and Young People with Intellectual Disabilities Who Depend on Postural Management Equipment

BACKGROUND

The natural response to the intrusive bodily sensation is positional change. This study explored how children and young people (CYP) with intellectual disabilities had their comfort needs met when using adaptive positioning equipment.

METHODS

Thirteen qualitative case studies were undertaken. A parent, a teacher/key worker and a therapist for each CYP were interviewed, and daily routines were observed, with selective video recording. Single case and cross case analyses were undertaken.

RESULTS

Attentive caregivers read the behavioural expressions of the CYP and responded reassuringly, safeguarding them from discomforting experiences. Threats to comfort include the restrictive nature of some equipment accessories, positioning errors and procedural stretching.

CONCLUSIONS

The same item of equipment can be both comfortable and uncomfortable. Given the social and interactional world in which the CYP live and learn, it is others who must accept responsibility for ensuring their optimal level of comfort.

Eina! Ouch! Eish! Professionals' Perceptions of How Children with Cerebral Palsy Communicate About Pain in South African School Settings: Implications for the use of AAC

Most children with severe cerebral palsy experience daily pain that affects their school performance. School professionals need to assess pain in these children, who may also have communication difficulties, in order to pay attention to the pain and support the children's continued participation in school. In this study, South African school professionals' perceptions of how they observed pain in children with cerebral palsy, how they questioned them about it and how the children communicated their pain back to them were investigated. Thirty-eight school professionals participated in five focus groups. Their statements were categorized using qualitative content analysis. From the results it became clear that professionals observed children's pain communication through their bodily expressions, behavioral changes, and verbal and non-verbal messages. Augmentative and alternative communication (AAC) methods were rarely used. The necessity of considering pain-related vocabulary in a multilingual South African context, and of advocating for the use of AAC strategies to enable children with cerebral palsy to communicate their pain was highlighted in this study.

Pain Prevalence and Treatment Patterns in a US Children's Hospital

OBJECTIVE

Hospitalized children experience significant pain despite improvement efforts. This study was undertaken to better understand the epidemiology of acute pain in hospitalized children and the extent to which existing measures reveal targets for improving pain management.

METHODS

A cross-sectional survey was used to audit pain assessment, intensity, prevalence, source, and treatment hospital-wide on a single day in 2011. Chart audits were performed on patients aged 0 to 21 years. All patients had the option to participate in a structured interview about their pain experience.

RESULTS

The audit included 112 children, 47 of whom were interviewed. Pain prevalence obtained by child/parent interview (72%) was more than twice that documented by nurses (30%). Infants, but not cognitively impaired children, had significantly lower rates of pain detection and analgesic ordering than older age groups. Procedural pain was the most frequently cited source of pain among interviewed patients and was poorly addressed in the medical record. Fifty percent of children with documented moderate-to-severe pain received scheduled pain medications. More than one-third of interviewed patients would have wanted more pain medication if it could have been safely given.

CONCLUSIONS

Specific gaps remain in the quality of pain management provided to hospitalized children. Focus on infant pain detection, assessment and management of procedural pain, and scheduled analgesic ordering are sensible targets for future process improvement efforts.

Pain perception in people with Down syndrome: a synthesis of clinical and experimental research

People with an intellectual disability experience both acute and chronic pain with at least the same frequency as the general population. However, considerably less is known about the pain perception of people with Down syndrome. In this review paper, we evaluated the available clinical and experimental evidence. Some experimental studies of acute pain have indicated that pain threshold was higher than normal but only when using a reaction time method to measure pain sensitivity. However, when reaction time is not part of the calculation of the pain threshold, pain sensitivity in people with Down syndrome is in fact lower than normal (more sensitive to pain). Clinical studies of chronic pain have shown that people with an intellectual disability experience chronic pain and within that population, people with Down syndrome also experience chronic pain, but the precise prevalence of chronic pain in Down syndrome has yet to be established. Taken together, the literature suggests that people with Down syndrome experience pain, both acute and chronic, with at least the same frequency as the rest of the population. Furthermore, the evidence suggests that although acute pain expression appears to be delayed, once pain is registered, there appears to be a magnified pain response. We conclude by proposing an agenda for future research in this area.

How do children with autism spectrum disorders express pain? A comparison with developmentally delayed and typically developing children

There is a lack of knowledge about pain reactions in children with autism spectrum disorders (ASD), who have often been considered as insensitive to pain. The objective of this study was to describe the facial, behavioral and physiological reactions of children with ASD during venipuncture and to compare them to the reactions of children with an intellectual disability and nonimpaired control children. We also examined the relation between developmental age and pain reactions. The sample included 35 children with ASD, 32 children with an intellectual disability, and 36 nonimpaired children. The children were videotaped during venipuncture and their heart rate was recorded. Facial reactions were assessed using the Child Facial Coding System (CFCS) and behavioral reactions were scored using the Noncommunicating Children's Pain Checklist (NCCPC). A linear mixed-effects model showed that children's reactions increased between baseline and venipuncture and decreased between the end of venipuncture and the recovery period. There was no significant difference between groups regarding the amount of facial, behavioral and physiological reactions. However, behavioral reactions seemed to remain high in children with ASD after the end of the venipuncture, in contrast with children in the 2 other groups. Moreover, we observed a significant decrease in pain expression with age in nonimpaired children, but no such effect was found regarding children with ASD. The data reveal that children with ASD displayed a significant pain reaction in this situation and tend to recover more slowly after the painful experience. Improvement in pain assessment and management in this population is necessary.

A review of pain measures for hospitalized children with cognitive impairment

PURPOSE

The aims of this review were to examine pain measures for hospitalized children with cognitive impairment who are unable to self-report and to describe the best available evidence for their clinical utility in acute care settings.

DESIGN AND METHODS

Electronic searches to identify published evidence were conducted and studies reviewed. Reported psychometrics and feasibility of the Non-Communicating Child's Pain Checklist-Postoperative Version, Individualized Numeric Rating scale, Pediatric Pain Profile, and revised Face, Leg, Activity, Cry, and Consolability scale were examined.

CONCLUSIONS

These four measures have established validity and reliability. However, clinical utility findings varied.

PRACTICE IMPLICATIONS

The revised Face, Leg, Activity, Cry, and Consolability scale has demonstrated feasibility in acute care settings related to ease of use, time requirements, and flexibility regarding caregiver input.

Cognitive behavioural therapy for chronic pain in people with an intellectual disability: a case series using components of the Feeling Better programme

BACKGROUND

Cognitive behavioural therapy (CBT) has been shown to be effective in assisting people to cope with chronic pain. However, this approach has not been systematically evaluated with people with an intellectual disability (ID). This pilot study sought to examine the feasibility and clinical utility of CBT for people with an ID, using elements of a manualised CBT pain management programme called Feeling Better.

METHOD

Five people with chronic pain who were functioning within the mild range of ID received a modified, individual eight-session cognitive behavioural intervention aimed at development of pain management skills. The participants' scores on a range of measures (pain management knowledge, pain self-efficacy, use of pain coping strategies and effectiveness of coping strategies) were compared pre-intervention, post-intervention and at 1-month follow-up.

RESULTS

The results indicated that participant scores on pain management knowledge, wellness-focused coping and effectiveness of coping increased following the intervention. However, these gains were generally not maintained at follow-up.

CONCLUSION

We concluded that CBT has potential utility for pain management in people with an ID, but that it requires a trial of a more intensive and prolonged intervention with the systematic involvement of care givers.

Pain in people with an intellectual disability

PURPOSE OF REVIEW

Pain is a near-universal experience and research suggests that chronic pain, defined as pain lasting longer than 3 months, affects around 20% of the general population. However, there is relatively little awareness of the problem of pain amongst people with an intellectual disability.

RECENT FINDINGS

Recent prevalence studies indicated that chronic pain affects around 15% of people with an intellectual disability. Although prevalence can be estimated based on third-party reports, there are methodological limitations that suggest this way of detecting pain may be unreliable. Other methods, such as structured behavioural observation, offer a reliable and valid alternative. Once pain has been recognized, however, there has been limited research to evaluate pain management interventions for people with an intellectual disability, especially in the area of self-management.

SUMMARY

There is good evidence to support behavioural observation methods for recognition of pain in people with limited ability to communicate about their pain. Psychological interventions for pain management are widely used in the general population and may also have a useful role in assisting people with an intellectual disability who are affected by persistent pain. However, there is an ongoing paucity of research in this area.

Qualitative evaluation of a pain intensity screen for children with severe neurodevelopmental disabilities

The population of individuals with severe and profound intellectual disabilities (ID) is extremely heterogeneous, and the unique pain-related behaviors of each individual might not be satisfactorily captured using a standardized checklist such as the Noncommunicating Children's Pain Checklist or the Revised Faces, Legs, Arms, Cry, and Consolability tools. There has been increasing appreciation of the importance of recognizing the idiosyncratic pain behaviors of these individuals. The investigators developed a tool, the Tailored Observational Pain Screen (TOPS), to facilitate recognition of pain in the individual who lacks verbal communication, based on caregivers' descriptions of the individual's unique pain-related behaviors. The aim of this study was to elicit caregivers' evaluations of this personalized pain screen, using qualitative analysis of semi-structured interviews. The participants were the primary caregivers of 13 children with severe or profound ID and ongoing pain issues who were interviewed after they had used the TOPS for 6 weeks. The investigators identified themes from the interviews, including: using the TOPS to recognize and evaluate pain; using the TOPS to facilitate communication; limitations of the TOPS; and recommendations for its improvement. For clinical purposes, the TOPS shows promise as a tool for helping caregivers to share with others the ways that pain of these children can be detected.

Physical conditions and challenging behaviour in people with intellectual disability: a systematic review

BACKGROUND

Challenging behaviour is a major problem among people with intellectual disabilities. Physical factors may be an important cause. The aim of the present systematic review was to determine the physical conditions associated with challenging behaviour.

METHODS

A literature search was conducted in PubMed and the Cochrane systematic review database for empirical studies published between 1990 and 2008. The quality of all the studies that met the inclusion criteria was assessed using the SIGN-50 methodology checklists.

RESULTS

The search identified 45 studies, which looked at general medical conditions, motor impairment, epilepsy, sensory impairment, gastrointestinal disease, sleep disorders, dementia and others. There were four high-quality observational studies, seven well-conducted observational studies, 21 observational studies of low methodological quality and 13 non-analytical studies. There were significant and independent associations between challenging behaviours and urinary incontinence, pain related to cerebral palsy and chronic sleep problems, and between self-injurious behaviour and visual impairment. No association was found with hearing impairment, bowel incontinence, mobility impairment or epilepsy. Many other physical conditions were not addressed at all.

CONCLUSION

Medical conditions can play a role in challenging behaviour, and this should be evaluated in the clinical setting. So far, the level of evidence is generally low, and longitudinal studies are completely lacking. We recommend a systematic approach to research examining the role of physical conditions in challenging behaviour, the ultimate aim being to establish a basis for the development of clinical guidelines.

[Autism and pain - a literature review]

The purpose of the present article was to assess the available literature concerning pain and autism. First, authors summarized the published articles on pain reactivity in people with autism. Second, the hypotheses envisaged to explain the presence of expressive particularities in people with autism spectrum disorders were reviewed; these included endogenous opioid excess theory, sensorial abnormalities and sociocommunicative deficit. Finally, the present review dealt with the tools available to assess and manage pain in people with autism. In conclusion, the authors revealed the need for more research to obtain more consensual data and provided some recommendations in this domain that were under exploited by the scientific community. From a clinical point of view, more knowledge about pain in people with autism should enable the development of specific assessment tools and, consequently, better pain management in daily care.