Comparative Prospective Evaluation of the Responsiveness of Single-Item Pediatric Pain-Intensity Self-Report Scales and Their Uniqueness From Negative Affect in a Hospital Setting

  • Mark Connelly
    Address reprint requests to Mark Connelly, PhD, Assistant Professor of Pediatrics, Pain Management Program, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108.
    Section of Developmental and Behavioral Sciences, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
    Search for articles by this author
  • Kathleen Neville
    Section of Pediatric Clinical Pharmacology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
    Search for articles by this author


      Evaluating pain in verbal children in the hospital setting is done primarily through serial assessments of pain intensity using single-item measures. However, little remains known about intensity scales' relative responsiveness and uniqueness from negative affect in this clinical setting. In the present study, a total of 411 assessments using 3 common pediatric pain intensity measures (the Faces Pain Scale-Revised, a verbally presented numeric rating scale, and a visual analog scale) were obtained over a period of 3 days from 29 children ages 9 to 18 years following a relatively standardized surgical procedure. Hierarchical linear models were used to compare the 3 scales on responsiveness over postoperative recovery time, invariance across baseline variables (age, sex, and baseline mood), and distinctiveness from changes in negative affect. Results showed that all 3 pain-intensity measures were highly interrelated, varied similarly with age and baseline state anxiety, and were comparably related to contemporaneous changes in affect. However, patients tended to rate pain intensity higher on the Numerical Rating Scale, and only this scale failed to reflect a decreasing trend in pain scores with elapsed surgical recovery time. Potential implications for clinical practice are discussed.


      This article presents data comparing the responsiveness over time and association with negative affect of 3 single-item pediatric pain-intensity scales commonly used in hospital settings. The results can help inform the selection of self-report measures when serially evaluating pain and treatment response in hospitalized children.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bailey B.
        • Daoust R.
        • Doyon-Trottier E.
        • Dauphin-Pierre S.
        • Gravel J.
        Validation and properties of the verbal numeric scale in children with acute pain.
        Pain. 2010 Feb 24; (2010 Feb 24; [Epub ahead of print])
        • Bailey B.
        • Bergeron S.
        • Gravel J.
        • Daoust R.
        Comparison of four pain scales in children with acute abdominal pain in a pediatric emergency department.
        Ann Emerg Med. 2007; 50: 379-383
        • Bulloch B.
        • Tenenbein M.
        Assessment of clinically significant changes in acute pain in children.
        Acad Emerg Med. 2002; 9: 199-202
        • Chambers C.T.
        • Craig K.D.
        An intrusive impact of anchors in children's faces pain scales.
        Pain. 1998; 78: 27-37
        • Chambers C.T.
        • Giesbrecht K.
        • Craig K.D.
        • Bennett S.M.
        • Huntsman E.
        A comparison of faces scales for the measurement of pediatric pain: Children's and parents' ratings.
        Pain. 1999; 83: 25-35
        • Chambers C.T.
        • Hardial J.
        • Craig K.D.
        • Court C.
        • Montgomery C.
        Faces scales for the measurement of postoperative pain intensity in children following minor surgery.
        Clin J Pain. 2005; 21: 277-285
        • Cohen L.L.
        • Lemanek K.
        • Blount R.L.
        • Dahlquist L.M.
        • Lim C.S.
        • Palermo T.M.
        • McKenna K.D.
        • Weiss K.E.
        Evidence based assessment of pediatric pain.
        J Pediatr Psychol. 2008; 33: 939-955
        • Faulstich M.E.
        • Carey M.P.
        • Ruggiero L.
        • Enyart P.
        • Gresham F.
        Assessment of depression in childhood and adolescence: An evaluation of the Center for Epidemiological Studies Depression Scale for Children (CES-DC).
        Am J Psychiatry. 1986; 143: 1024-1027
        • Gillies M.L.
        • Smith L.N.
        • Parry-Jones W.L.
        Postoperative pain assessment and management in adolescents.
        Pain. 1999; 79: 207-215
        • Goodenough B.
        • Thomas W.
        • Champion G.D.
        • Perrott D.
        • Taplin J.E.
        • von Baeyer C.L.
        • Ziegler J.B.
        Unravelling age effects and sex differences in needle pain: Ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents.
        Pain Headache. 1999; 80: 179-190
        • Goodenough B.
        • van Dongen K.
        • Brouwer N.
        • Abu-Saad H.H.
        • Champion G.D.
        A comparison of the Faces Pain Scale and the Facial Affective Scale for children's estimates of the intensity and unpleasantness of needle pain during blood sampling.
        Eur J Pain. 1999; 3: 301-315
        • Hicks C.L.
        • von Baeyer C.L.
        • Spafford P.A.
        • van Korlaar I.
        • Goodenough B.
        The Faces Pain Scale - Revised: Toward a common metric in pediatric pain measurement.
        Pain. 2001; 93: 173-183
        • Hollingshead A.B.
        Two-factor Index of Social Position.
        Yale University Press, New Haven, CT1957
        • Holmbeck G.N.
        • Thill A.W.
        • Bachanas P.
        • Garber J.
        • Miller K.B.
        • Abad M.
        • Bruno E.F.
        • Carter J.S.
        • David-Ferdon C.
        • Jandasek B.
        • Mennuti-Washburn J.E.
        • O'Mahar K.
        • Zukerman J.
        Evidence-based assessment in pediatric psychology: Measures of psychosocial adjustment and psychopathology.
        J Pediatr Psychol. 2008; 33: 958-980
        • Jacob E.
        • Puntillo K.A.
        A survey of nursing practice in the assessment and management of pain in children.
        Pediatr Nurs. 1999; 25: 278-286
        • Joint Commission on Accreditation of Healthcare Organizations
        Implementing the New Pain Management Standards.
        JCAHO, Oakbrook Terrace, IL2000
        • Laurent J.
        • Catanzaro S.J.
        • Rudolph K.D.
        • Lambert S.
        • Osborne L.
        • Gathright T.
        • Joiner T.E.
        • Potter K.I.
        A measure of positive and negative affect for children: Scale development and preliminary validation.
        Psychol Assess. 1999; 11: 326-338
        • Lonigan C.J.
        • Hooe E.S.
        • David C.F.
        • Kistner J.A.
        Positive and negative affectivity in children: Confirmatory factor analysis of a two-factor model and its relation to symptoms of anxiety and depression.
        J Consult Clin Psychol. 1999; 67: 374-386
        • Maciocia P.M.
        • Strachan E.M.
        • Akram A.R.
        • Hendrie R.E.
        • Kelly D.N.
        • Kemp A.
        • McLuckie A.M.
        • Smith L.M.
        • Beattie T.F.
        Pain assessment in the paediatric Emergency Department: Whose view counts?.
        Eur J Emerg Med. 2003; 10: 264-267
        • McGrath P.A.
        Pain in Children: Nature, Assessment and Treatment.
        Guilford Publications, New York, NY1990
        • McGrath P.A.
        • Seifert C.E.
        • Speechley K.
        • Booth J.
        • Stitt L.
        • Gibson M.
        A new analogue scale for assessing children's pain: An initial validation study.
        Pain. 1996; 64: 435-443
        • Miró J.
        • Castarlenas E.
        • Huguet A.
        Evidence for the use of a numerical rating scale to assess the intensity of pediatric pain.
        Eur J Pain. 2009; 13: 1089-1095
        • Moon E.C.
        • Chambers C.T.
        • Larochette A.C.
        • Hayton K.
        • Craig K.D.
        • McGrath P.J.
        Sex differences in parent and child pain ratings during an experimental child pain task.
        Pain Res Manag. 2008; 13: 225-230
        • Newman C.J.
        • Lolekha R.
        • Limkittikul K.
        • Luangxay K.
        • Chotpitayasunondh T.
        • Chanthavanich P.
        A comparison of pain scales in Thai children.
        Arch Dis Child. 2005; 90: 269-270
        • Nilsson S.
        • Finnström B.
        • Kokinsky E.
        The FLACC behavioral scale for procedural pain assessment in children aged 5-16 years.
        Paediatr Anaesth. 2008; 18: 767-774
        • Palermo T.M.
        • Drotar D.
        Prediction of children's postoperative pain: The role of presurgical expectations and anticipatory emotions.
        J Pediatr Psychol. 1996; 21: 683-698
        • Perrott D.A.
        • Goodenough B.
        • Champion G.D.
        Children's ratings of the intensity and unpleasantness of post-operative pain using facial expression scales.
        Eur J Pain. 2004; 8: 119-127
        • Powell C.V.
        • Kelly A.-M.
        • Williams A.
        Determining the minimum clinically significant difference in visual analog pain score for children.
        Ann Emerg Med. 2001; 37: 28-31
        • Price D.D.
        Central neural mechanisms that interrelate sensory and affective dimensions of pain.
        Mol Interv. 2002; 2: 392-403
        • Raudenbush S.W.
        • Bryk A.A.
        Hierarchical Linear Models: Applications and Data Analysis Methods.
        2nd ed. Sage Publications, Newbury Park, CA2002
        • Raudenbush S.W.
        • Bryk A.S.
        • Cheong Y.F.
        • Congdon R.T.
        HLM 6: Hierarchical Linear and Nonlinear Modeling.
        Scientific Software International Inc., Lincolnwood, IL2004
        • Spielberger C.D.
        Manual for the State-Trait Anxiety Inventory for Children (STAIC).
        Consulting Psychologists Press, Palo Alto, CA1973
        • Stinson J.N.
        • Kavanagh T.
        • Yamada J.
        Systematic review of the psychometric properties, interpretability, and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents.
        Pain. 2006; 125: 143-157
        • Subhashini L.
        • Vatsa M.
        • Lodha R.
        Comparison of two pain scales in Indian children.
        Indian J Pediatr. 2008; 75: 891-894
        • von Baeyer C.L.
        Numerical Rating Scale for self-report of pain intensity in children and adolescents: Recent progress and further questions.
        Eur J Pain. 2009; 13: 1005-1007
        • von Baeyer C.L.
        • Spagrud L.J.
        • McCormick J.C.
        • Choo E.
        • Neville K.
        • Connelly M.
        Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children's self-reports of pain intensity.
        Pain. 2009; 143: 223-227
        • von Baeyer C.L.
        Children's self-reports of pain intensity: Scale selection, limitations and interpretation.
        Pain Res Manag. 2006; 11: 157-162