- Email: [email protected]
Pain behaviors: Postsurgical responses of children and adolescents
Pain Behaviors: Postsurgical Responses of Children and Adolescents Mary D. Tesler, RN, MS William L. Holzemer, RN, PhD, FAAN Marilyn C. Savedra, RN, DNS, FAAN There is scant data identifying the range and variety of pain behaviors associated with ongoing, short-term acute pain of older children and adolescents. The purposes of this study were to identify and record pain behaviors manifested by children and adolescents during the first 3 days after surgery and examine the relationship between behaviors and self-report of pain intensity. Data were collected from 37 multi-ethnic children and adolescents using the Word Graphic Rating Scale for self-report of pain intensity and the Pediatric Pain Behavior List to record pain behaviors. The five most frequently observed behaviors were calm, maintaining one position, flexing limbs, eyes shut, and knees drawn up. All children reported pain on the first 2 days postsurgery. Many children who were lying in one position with a calm expression, at the same time, reported moderate to severe pain.
Copyright9 1998 by W.B. SaundersCompany
p
AIN IS CUSTOMARILY assessed by evaluating the individual's verbal reports and the behaviors observed. Verbal reports are used more widely and are considered the "gold standard" against which other measures are weighed (McGrath, Unruh & Finley, 1995). Yet behaviors, the instinctive responses to pain, are considered to be more objective. Craig and Perkachin (1983) reported that behaviors and the autonomic reactions are the first responses to a painful stimuli and are less subject to intervening factors than verbal reports. While pain behaviors have been described and categorized, there is scant data identifying the range and variety of pain behaviors associated with ongoing, short-term, acute pain of older children and adolescents. Most behavioral responses to pain have been documented in the procedural literature. That literature identifies a variety of factors that influence children's behavioral responses and little on postoperative responses has been reported. The purposes of this study were to (1) identify and record pain behaviors manifest by children and adolescents during the first 3 days after surgery, (2) document the reported pain intensities, and (3) examine the relationship between behaviors manifest and pain scores reported.
REVIEW OF THE LITERATURE Early research on children's pain behaviors focused on identifying and evaluating behaviors associated with the sharp, intense, short-term pain Journalof PediatricNursing,Vol 13, No 1 (February),1998
of discrete diagnostic procedures. The behaviors evidenced included crying, screaming, stoic silences, and muscular rigidity. The most frequent behaviors observed were categorized in instruments used to assess infants' and children's facial and body movement behaviors associated with these painful encounters (Katz, Kellerman, and Siegel, 1980; Craig and Perkachin, 1983; Jay, Ozolins, Elliott, and Caldwell, 1983; Craig, McMahon, Morison and Zaskow, 1984; Jay and Elliott, 1984; LeBaron & Zelter, 1984). Among the instruments developed was the Procedure Behavior Rating Scale (PBRS) (Katz, Kellerman, and Siegel, 1980) that identified 13 behavioral responses of children undergoing bone marrow aspirations. The tool, designed to evaluate pain and anxiety, was used to assess the children's behaviors across the four stages of the procedure. Children evidenced the greatest number of behaviors during the actual procedure and scores decreased for the older children. Older children tended to demonstrate increased muscle tension and behavioral withdrawal compared with the more physical and From the Department of Family Health Care Nursing, and the Department of Communi~' Health Systems, University of California at San Francisco, San Francisco, CA. This study was supported by funding from the National Institute for Nursing research (RO1 NRO1045 03). Address reprint requests to Mar)' D. Tesler, RN, MS, 46 Atalaya Terrace, San Francisco, CA 9411Z Copyright 9 1998 by W.B. Saunders Company 0882-5963/98/1301-000553.00/0
41
42
emotional responses of the younger children. The behavioral scores, however, could not differentiate between pain and anxiety. Later, researchers built on this work and developed additional measures with reduced numbers of behaviors and stronger psychometric properties which also focused on acute episodic pain (Jay, Ozolins, Elliott, and Caldwell, 1983; Lebaron & Zeltzer, 1984). These studies were followed by investigations and identification of the more subtle behavior manifestations of on-going postoperative pain. A number of tools to assess the most commonly exhibited behaviors of on-going pain were developed and included (1) Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) (McGrath, Johnson, Goodman, Schillinger, Dunn, and Chapman, 1985), (2) Gustave-Roussy Child Pain Scale (Gauvain-Piquard, Rodary, Rezvani, and Lemerle (1987); and (3) the Toddler-Preschooler Postoperative Pain Scale (TPPS) (Tarbell, Cohen, and Marsh 1992). The CHEOPS (McGrath et al., 1985) is the best known. Designed for use with 1- to 7-year-old children, it has been used and tested with children 1- to 12-years old and rates six categories of behaviors: cry, facial expression, verbal responses, torso position, touch, and limb movements. Each of the 28 behaviors is scored from 0 to 3 depending on the intensity exhibited. Beyer, McGrath, and Berde (1990) found that unlike the verbal reports of pain, the behavior scores of postoperative population did not vary over time. The children showed few behavioral responses and these did not correlate with the verbal reports of pain. However, in a subsequent study, Tyler, Tu, Douthit, and Chapman (1993) found that on postoperative Day 1 the CHEOPS scores did correlate with other behavior scales and the self-report Oucher Scale (Beyer, Denyes, and Villarruel, 1992). In a recent descriptive study of postoperative pain (Chambers, Reid, McGrath, and Finley (1995), mothers reported their children's pain cues they identified and used to determine their child's pain during the first 3 postoperative days. The 29 behavioral cues were categorized as (1) changes in normal behavior (appetite, sleep, activity, alertness, and emotional state), (2) illness behaviors: verbal reports, visible-audible discomfort, physiological observations, protective behavior, regressive behaviors, and requests for or refusal of medication; and (3) cues lacking behavioral information (looks more pale, flushed, or swollen than usual). The number of cues reported by mothers decreased from M = 2.4 on Day 1 to 2.3 on Day 2 and 1.8 on
TESLER,HOLZEMER,AND SAVEDRA
the Day 3. Changes in appetite, sleep quality, activity level, alertness, and emotional state were the most reported cues on Day 1 and activity level on Days 2 and 3. Illness behaviors such as holding sore body parts, refusing or taking medication also decreased over the 3 days. The work to date that has examined acute pain behaviors in children has focused primarily on procedural pain, pain of short-term duration. Examination of postoperative pain behaviors in children with subsequent development of the CHEOPS and TPPS has focused on the early school age and younger child. The current study examined the pain behaviors in older children and adolescents, a population that has received little attention.
METHODS Design. A descriptive-correlational design was used to identify the postsurgical behaviors in older children and adolescents and to examine the relationship between the observed pain behaviors and the self-report of pain. Sample. The self-selected multiethnic sample (N = 37), 18 boys and 19 girls 8 to 17 years old, had undergone surgery in a major West coast medical center. All patients who met the inclusion criteria from the same surgical unit were invited to participate. Forty-nine percent of the sample was between 8- to l 1-years old. The ethnicity of the children/adolescents was distributed as follows: 59% Caucasian, 19% Hispanic, 8% AfricanAmerican, and 14% other. The surgical procedures included 19% orthopedic, 16% thoracic, 13% genitourinary, 13% gastro-intestinal, and 38% other surgeries. Instruments. Data were collected using the children's/adolescents' medical records, the Word Graphic Rating Scale (WGRS) (Tesler et al., 1991) and the Pediatric Pain Behavior List (PPBL), a tool designed for this study. The Word Graphic Rating Scale, designed to measure pain intensity, is a 100 mm line anchored by two descriptors, "no pain" at the far left or zero point and "worst possible pain" at the far right. Three other descriptors, "little pain," "medium pain," and "large pain" appear equidistant along the line. Construct validity was determined in a repeated measure design examining the postoperative pain of children and adolescents on days 1 to 5 following surgery (Tesler, Saverdra, Holzemer, Wilkie, & Paul, 1991). Pain decreased over time with a statistically significant difference between days 2 and days 4 and 5 (P = .002). When six intensity scales, including two Word Graphic Rating Scales, were used by
PAIN BEHAVIORS
children/adolescents to report their pain, correlations among the pairs of scores from the scales ranged from .68 to .97 (M = .84) supporting convergent validity of the scales. Test-retest reliability between the WGRS scores was .91 supporting strong test-retest reliability (Tesler et al., 1991). The PPBL was investigator-designed for this study and was patterned after Wilkie's (1992) adaptation of the Behavior Observation Manual (Keefe and Block, 1982). The PPBL consists of 47 behaviors, divided among seven categories: Torso (8 behaviors), Limb (9), and Touch (3); Facial (7), Crying (6), Verbal (7), and Affective (7). In addition, autonomic responses (pulse, respirations and blood pressure) are recorded. The list of behaviors was compiled from an extensive review of the literature, consultation with expert clinicians and the investigators' own experience in children's and adolescents' pain assessment. Definitions of behaviors were derived from dictionaries and pain scales, then reviewed for the clearest description by the entire research team and nurse clinicians. Each behavior was evaluated individually for clarity and explicitness and was retained only if 100% agreement could be achieved on its clarity and distinction from other behaviors. Research assistants then tested the behaviors in the clinical setting and additional clarifications and testing were made twice again until there again was 100% agreement on all behaviors. Face validity was assured by the panel of expert nurses who evaluated the behaviors. Procedure. Training of research assistants, primarily graduate nursing students, in the use of the PPBL was conducted until they reached 100% agreement. Patient behaviors were assessed three times every 2 hours between 8 a.m. and 8 p.m. on days 1 through 3 following surgery. Each assessment consisted of a 30-second observation for evidence of individual behaviors. Each 30-second observation was followed by a 30-second period for scoring the behaviors that had been exhibited. This procedure was repeated twice with a oneminute waiting period prior to the second and third assessments. Eighteen potential samples of each behavior were able to be obtained over the 12-hour period on each of the 3 days, providing a potential total of 54 incidents of each behavior for each child. Pain intensity was measured after the behaviors had been recorded. The children reported pain intensity by marking its location on the Word Graphic Rating Scale (WGRS). Pain scores were determined by measuring with a micrometer the
43
distance on the WGRS from 0 to the point marked by the child/adolescent. Inter-rater reliability for data collected on Days 1 and 2 varied from 24% to 100%. On Day 1, the highest scores (77% and 100%) were in the morning and the lowest score (24%) in the afternoon. Percentage of agreement on Day 2 were 76, 73, 41, 70, 90, and 92% (M = 74%) for the six data sets. Agreement was higher if both raters were frequent evaluators.
FINDINGS Data Analysis. Data were analyzed using descriptive statistics for means, standard deviations, ranges and t tests and Pearson correlations. Findings are reported for (a) behaviors observed and recorded, (b) pain scores reported and (c) correlations between them. Behaviors also were examined by (1) their evidenced frequency over the 3 days, (2) category classification, (3) patient diagnostic group, and (4) the child/adolescent age and gender. Manifested Frequency of Behavior. Every behavior except torso thrashing, was exhibited by one or more child/adolescent. A total of 6,224 behaviors were observed and recorded, 2116 on Day 1, 2309 on Day 2, and 1799 on Day 3. The difference between the number of behaviors exhibited between Days 2 and 3 was significant (P--.025). Three behaviors, calm, maintaining one position, and flexing limbs were manifest by 100% of the children. The two most frequently exhibited behaviors, calm (N = 1274) and maintains one position (N = 1206) accounted for 40% of the behaviors exhibited. Fourteen behaviors: calm, maintaining one position, flexing limbs, eyes shut, asleep, knees drawn up, bites/purses lips, shifting torso, massage/ rubbing, frown, wincing, moves protectively, sad, and clutching limbs were manifest by 59% or more of the children. (See Table 1 for the list of behaviors with rank order and percentages of their manifestation.) The means for the five most frequently observed behaviors for the 3 days were calm 35.34 (SD = 8.2), maintaining one position, 33.09 (SD = 9.1), flexing limbs 19.14 (SD = 8.0), eyes shut 13 (SD = 8.9), and knees drawn up 10.25 (SD = 8.5). The mean number of behaviors per child varied over the three days: 56.9 (SD = 27.3) were tallied for Day 1, 62.24 (SD = 23) on Day 2, and 50.68 (SD = 24.9) on Day 3. The number of behaviors manifest by individual children over the 3 days ranged from 73 displayed by a child who had undergone ureteral reconstruction to 313 by an adolescent after a scoliosis repair.
44
TESLER, HOLZEMER, AND SAVEDRA
Table i, Rank Order of Percentage of Children Wilh Observed Behaviors N = 37 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47.
Calm Maintaining one position Flexing limbs Eyesshut Asleep Knees drawn up Bites or purses lips Shifting torso Massage, rubbing Frown Wincing (Brief Pain Facies) Moves protectively--limbs Sad Clutching limbs Rigid torso Squirming Tense~limbs Jaw clench, grits teeth Grimace prolonged pain facies Rigid limbs Restlesstorso Dazed Whimpering Lack of interest in surroundings Appeals for relief Stoic silence Sighing Immobile torso Pain ratings Scared Grasping pain Eyeswide open Hunched over Pain complaints Groaning Angry Pain Cry Moaning Monotonous, mumbled words Resisting movement, handling Asks to be left alone Kicking Hysterical Flinging arms, limbs Screaming Avoids Touching Thrashing
100% 100% 100% 95% 92% 86% 84% 84% 78% 78% 73% 70% 62% 59% 47% 43% 41% 41% 38% 38% 35% 35% 32% 30% 30% 30% 30% 27% 27% 27% 24% 24% 22% 16% 16% 16% 16% 14% 14% 8% 5% 5% 3% 3% 3% 3% 0%
The least frequently evidenced eight behaviors shown by 8% or less of the children/adolescents were: resisting movement, asks to be left alone, kicking, hysterical, flinging limbs, screaming, avoids touching, and thrashing (see Table 1).
Categoriesof Behaviors Twelve of the top 16 behaviors were from three categories: Facial, Limb, and Torso. Facial actions most frequently seen were: eyes shut, bites/purses lips, frowning and wincing. These behaviors were
exhibited by 73% or more of the children/ adolescents. Most common Limb group movements: flexing limbs, knees drawn up, moves limbs protectively, were shown by 70% or more. High ranking Torso behaviors included maintaining one position (100%) evidenced by the total sample and shifting (84%). Two other high-ranking behaviors were massage from the Touch category and asleep from the Verbal group. Calm from the Affective group was one of the behaviors shown by the total group. In each category the behaviors manifested most frequently by 59% or more of the children were ones indicating withdrawal or protective action. No Facial group behaviors were among the least frequently observed behaviors.
Age and GenderDifferences The number of behaviors displayed by the two age groups did not differ greatly, 3002 behaviors were manifested by the 8- to ll-year-olds, and 3222 behaviors by the 12- to 17-year-olds. Girls exhibited 347l behaviors compared to 2753 by boys. No gender differences were evident among the 15 most frequently observed behaviors. However, the entire list of behaviors showed definite gender differences. Girls manifested 10 behaviors significantly more than boys and boys demonstrated three behaviors significantly more than girls (see Table 2).
Difference by DiagnosticGroups The diagnostic groups varied both in the number and range of behaviors evidenced over the 3 days. The orthopedic group demonstrated the highest mean numbers of behaviors over the three days 206 (SD = 75.5). The genitourinary group demonstrated the lowest, 146 (SD = 56). However, only one group reached statistical difference, the genitourinary group was greater than the thoracic on Day
Table 2. Significant BehaviorsManifest by Gender Girls More Than Boys (N = 19) Eyesshut (P = <.0049) Asleep (P = <0.015) Immobile (P = 0.0172) Dazed (P = <0.000) Tense(P = <0.0096) Pain ratings/Iocalizations (P = <0.000) Pain complaints (P = <0.000) Scared (P = <0.000) Monotonous, mumbled words (P = <0.000) Pain cry (P = <0.00090.) BoysMore Than Girls (N = 18) Stoic silence (P = <0.000) Eyeswide open (P = <0.000) Grasping pain sites (P = <0.000)
PAIN BEHAVIORS
2 (P = <0.0214). The mean number of behaviors shown by the groups differed more on Days 1 and 3 but ranged from 59 to 67 behaviors for all groups on Day 2. The orthopedic and "other surgery" group each demonstrated the widest range of behaviors. They showed between 31 and 36 different behaviors, 70% to 75% of the total list of behaviors, on all 3 days. In addition to the top ranking behaviors these patients also evidenced immobile, pain ratings and complaints, dazed, and moves protectively. The gastrointestinal group demonstrated the most restricted range of behaviors, 18, 20, 29, on each of the 3 days. This restricted pattern also was demonstrated by the thoracic group for Days 2 and 3 when 25 and 26 different behaviors were shown and by the genitourinary group with 27 different behaviors on Days 1 and 3.
45
total numbers of behaviors. Nine correlations for each of the two categories showed a negative relationship. Three correlations in the unambiguous group and six in the total behavior groups were significant (see Table 3).
DISCUSSION The list of behaviors studied was a global representation of behaviors usually associated with painful encounters and all 47 behaviors except thrashing were manifest at least once. Three behaviors were evidenced by 100% of the children and 14 were manifest by 59%. The finding that maintaining one position, remaining calm, and flexing limbs were the most universally seen behaviors is not surprising. Bonica (1980) points out that after the anesthesia has worn off, pain producing substances continue to be released. These reduce highthreshold nociceptor action and what would other-
Children's Reportsof Pain Children experienced the complete range of pain intensities during the 3 days. All children reported pain on the first 2 days, but five from the thoracic and gastrointestinal groups reported no pain on Day 3. Almost half (46%) reported mild pain on Day 1, 22% on Day 2, and 11% on Day 3. However, almost one fourth of the children, 22% on Day 1 and 19% on Day 2 reported severe pain. This number had decreased to less than 5% by Day 3. Two orthopedic patients reported severe (60 to 100) pain all 3 days. Two others, one orthopedic, and one thoracic patient reported moderate (40 to 60) pain, 16 reported mild pain (0 to 40) on all 3 days. Others reported a mixture of all pain intensities. Mean pain scores decreased over the 3 days, 42.9 (SD = 20.7) on Day 1, 36.2 (SD = 25) on Day 2, and 22.86 (SD = 19.2) on Day 3. The pain scores ranged from 0.50 to 88 on Day 1, 0.40 to 99.3 on Day 2, and 0 to 72.2 on Day 3. Pain scores also varied by surgical procedure. The highest scores were reported by the orthopedic surgery patients (M = 54.1) on Day 1 and (M = 45) on Day 3, and by the genitourinary patients on Day 2 (M = 65.6).
Frequency of Manifest Behaviors and Pain Scores The list of 47 behaviors was reviewed by a panel of pain management nurses who selected nine that were unambiguous pain behaviors: moves protectively, grasping pain, massage, grimacing, wincing, pain cry, pain complaints, appeals for relief and pain ratings. Pearson correlations were calculated using each patient's daily pain scores and (1) the nine identified unambiguous pain behaviors and (2)
Table 3. Correlations Belween Pain Scoresand Discre~ and Total Behaviors Obs
N
I:$Corr
PBP
PTBCorr
PTBP
1 2 3 4 5 6 7 8 9 I0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
14 12 16 8 14 11 9 9 8 15 12 10 10 4 10 10 13 15 13 15 13 11 8 13 12 9 7 12 9 5 10 10 12 7 12 10 14
-0.1203 0.2048 0.3996 0.9313* 0.7515" -0.0983 -0.2084 0.2277 -0.2198 0.4671 O.1262 0.1220 0.1350 0.6473 -0.1941 0.5265 -0.2167 0.3463 -0.3545 0.6056* 0.3852 0.1109 -0.0943 0.5668 0.5216 0.5609 0.1599 --0.5487 0.5042 0.3321 0.4798 0.5068 0.3156 -0.3829 0.4843
0.6822 0.5232 O.1 2 5 2 0.0008 0.0019 0.7738 0.5905 0.5558 0.6009 0.0792 0.6959 0.7371 0.7100 0.3527 0.5911 0.1180 -0.4378 0.2464 0.1948 0.0283 0.2420 0.7938 0.7593 0.0546 0.1498 0.1902 0.6195 -0.3382 0.1373 0.3486 0.114A 0.2457 0.31 77 0.2748 0.0793
-0.5447" 0.3203 0.5327' 0.8883" 0.3632 -0.2664 -0.0021 0.1913 0.2692 0.0599 -0.0089 -0.3311 0.2766 0.9614 -0.0742 0.4422 -0.0617 0.6235* 0.3798 0.6418* 0.3283 0.2015 0.1850 0.0758 0.4418 0.2004 0.4344 -0.2814 -0.1098 -0.4354 0.0553 0.4470 0.2861 0.7970* 0.0364 0.3425 0.4896
0.0440 3.31 O0 0.0336 0.0032 0.2018 0.4285 0.9958 0.6221 0.5190 0.8320 0.9782 0.3500 0.4392 0.0386 0.8385 0.2007 0.8414 0.0130 0.2005 0.0099 0.2734 0.5524 0.6610 0.8057 0.1504 0.6051 0.3301 0.3756 0.7785 0.4637 0.8795 0.1953 0.3673 0.0319 0.9106 0.3327 0.0756
*Significant <0.05.
46
wise be an innocuous action, such as moving, produces pain. Casual examination of the most frequently manifested behaviors, lying motionless in one position and having a calm expression, (the two behaviors that accounted for 405 of the total behaviors), might lead observers to believe that these children were comfortable. At the same time, however, many were reporting moderate to severe pain. This poses a major management problem for clinicians. These findings support those of Beyer, McGrath, and Berde (1990) who also found weak relationships between self-report scores and behavioral measures in a younger population of postsurgical patients. Findings that give ambiguous messages need to be examined. Are behaviors not usually associated with acute pain (i.e., passivity) reflective of how school age children and adolescents cope with pain? Do the more overt, active acute procedural pain behaviors inappropriately become a stereotype for postsurgical pain? The eight behaviors that were manifested by 8% or less are the typical responses of younger children or behaviors associated with shorter, acute procedural pain. These behaviors may be too energy and emotionally expensive to use during the ongoing acute pain experience, where immobility and rest are part of the recuperative process. These findings suggest that pain from procedures and postoperative pain are not comparable and perhaps assessment scales need to be different. Facial expressions, the most evident behaviors for assessing pain, were seen less frequently than motor behaviors. The number of these observations was reduced by the number of children/adolescents who were sleeping, watching television or playing video games. These children/adolescents were focused on the distraction and were almost expressionless and motionless. Another finding of interest was the higher mean self-report pain scores of the orthopedic group and "other surgery" patients who also showed a greater number and variety of behaviors. This finding is reflective of a vulnerable population that merits attention. While their behaviors may have been influenced by the paucity of analgesics administered to the orthopedic patients on Days 1 and 3, their pain behaviors and pain scores were still the highest on day 2 when they received the most analgesics. Another population that may present assessment problems was the gastrointestinal group who demonstrated so few behaviors that it would be difficult to make comprehensive assessments. The gender difference found in this study also
TESLER,HOLZEMER,AND SAVEDRA
supports the need to explore variables influencing overt behaviors and examine more subtle behaviors that distinguish the responses between genders. This supports the investigators' previous findings of differences in how boys and girls report and handle their pain (Savedra, Gibbons, Tesler, Ward, and Wegner, 1982). Cultural expectations regarding behaviors may be an influencing factor in these differences. The low number of significant correlations between pain scores and the numbers of observed behaviors requires further investigation. One third of the unambiguous pain behaviors were verbal reports, a category of behaviors this group used sparingly during observations. The number may not reflect the true frequency of this behavior. The issue of discrepant relationships between behaviors and verbal reports poses a major pain management dilemma for nurses and physicians. Walco and Dampier (1990) report that it is not surprising that such correlations are always very low. They emphasize the difficulty of an observer translating an individual's inner subjective experience by attributing specific meaning to observed actions. Craig and Perkachin (1983), however, stress the importance of studying behaviors because they are the evidence that cause health professionals to respond. The findings need to be evaluated in light of several limitations of this study. In some cases inter-rater reliability scores were low. This could be related to the fact that some data collectors were only occasionally involved in the study. Another data collection challenge related to securing a complete data set. While complete data were available for most of the children and adolescents, some children were off the unit or asleep and unable to provide self-reports of pain each time. Despite the limitations, this study adds to our knowledge of children's and adolescents' behaviors when they are in pain by identifying a panorama of discrete behaviors that manifest a response to postoperative pain. These behaviors have not been previously reported. Seventy-five percent of this group of children/adolescents manifested 30 different behaviors at discrete points during the 3 days following surgery. Further investigation of the most evident behaviors is indicated to determine if this smaller cadre of behaviors could be further refined to increase their correlation with verbal reports of pain.
ACKNOWLEDGEMENT Rani Eversley, PhD, was Project Director for this study and supervised data collection and entry.
PAIN BEHAVIORS
47
REFERENCES Beyer, J.E., McGrath, P.J. & Berde, C.B. (1990). Discordance between self report and behavior measures in children aged 3-7 years after surgery. Journal of Pain and Symptom Management, 5, 6, 350-356. Beyer, J.E., Denyes, M.J., & Villarruel, A.M. (1992). The creation, validation and continuing development of the Oucher: a measure of pain intensity in children. Journal of Pediatric Nursing, 7, (5) 335-46. Chambers, C.T., Reid, C.J., McGrath, P.J. & Finley, G.A. (1996). Development and preliminary validation of a postoperative pain measure for parents. Pain, 68, 307-313. Craig, K.D., McMahon, R.J., Morison, J.D. & Zaskow, C. (1984). Developmental changes in infant pain expression during immunization injections. Social Science Medicine, 19 (12), 1331-1337. Craig, K.D. & Prkachin, K.M. (1983). Nonverbal measures of pain. In R. Melzack, (Ed). Pain measurement and assessment, 173-179. New York: Raven Press. Gauvain-Piquard, A., Rodary, C., Rezvani, A., & Lemerie, J. (1987). Pain in children aged 2-6 years: a new observational rating scale elaborated in a pediatric oncology unit--preliminary report. Pain, 31, 177-188. Jay, S.M., Ozolins, M., Elliott, C.H., & Caldwell, S. (1983). Assessment of children's distress during painful medical procedures. Health Psychology, 2, 133-147. Jay, S.M. & and Elliott, C. (1984). Behavioral observation scales for measuring children's distress: the effects of increased methodological rigor. Journal of Consulting Clinical Psychology, 52, 6, 1106-1107. Katz, E.R., Kellerman, J. & Siegel, S.E. (1980). Behavioral distress in children with cancer undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48 (3), 356-365. Keefe, EJ. and Block, A.R. (1982). Development of an
observation method for assessing pain behavior in chronic low back patients. Behavior Therap), 13, 363-375. LeBaron, S. and Zeltzer, k (1984). Assessment of acute pain and anxiety in children and adolescent by self reports, observer reports and a behavior checklist. Journal of Consulting Clinical Psycholog); 52, 5,729-738. McGrath, P.J., Unruh, A.M., Finley, G.A. (1995). Pain measurement in children. Pain Clinical Update, ISAP, III, (2) 1-4. McGrath, P.J., Johnson, G., Goodman, J.T., Schillinger, J., Dunn, J., and Chapman, J. (1985) CHEOPS: A behavior scale for rating postoperative pain in children. Advances in Pain Research and Therapy, 9. H.L. Fields et al. (Eds. 1985, 395-402). Savedra, M., Gibbons, P., Tesler, M., Ward, J., Wegner, C. (1982). How do children describe pain? A tentative assessment. Pain, 14:95-104. Tarbell, S.E., Cohen, 1". & Marsh, J.L. (1992). The toddlerpreschooler postoperative pain scale: an observational scale for measuring postoperative pain in children aged 1-5. Preliminary report. Pain, 50, 273-280. Tesler, M.D., Savedra, M.C., Holzemer, W.L Wilkie, D.J., & Paul, S.M. (1991). The Word-Graphic Rating Scale as a measure of children's and adolescents' pain intensity. Research in Nursing and Health, 14, 361-371. Tyler, D.C., Tu, A., Douthit, J. & Chapman C.R. (1993). Toward validation of pain measurement tools for children: a pilot study. Pain, 52, 301-309. Walco, G.A. & Damper, C.D. (1990). Pain in children and adolescents with sickle cell disease: A descriptive study. Journal of Pediatric Psychology, 15, (5), 643-658. Wilkie, D.J., Keefe, EJ., Dodd, M.J. & Copp, L.A. (1992). Behavior of patients with lung cancer: description and associations with oncologic and pain variables. Pain, 51, 231-240.
Copyright9 1998 by W.B. SaundersCompany
p
AIN IS CUSTOMARILY assessed by evaluating the individual's verbal reports and the behaviors observed. Verbal reports are used more widely and are considered the "gold standard" against which other measures are weighed (McGrath, Unruh & Finley, 1995). Yet behaviors, the instinctive responses to pain, are considered to be more objective. Craig and Perkachin (1983) reported that behaviors and the autonomic reactions are the first responses to a painful stimuli and are less subject to intervening factors than verbal reports. While pain behaviors have been described and categorized, there is scant data identifying the range and variety of pain behaviors associated with ongoing, short-term, acute pain of older children and adolescents. Most behavioral responses to pain have been documented in the procedural literature. That literature identifies a variety of factors that influence children's behavioral responses and little on postoperative responses has been reported. The purposes of this study were to (1) identify and record pain behaviors manifest by children and adolescents during the first 3 days after surgery, (2) document the reported pain intensities, and (3) examine the relationship between behaviors manifest and pain scores reported.
REVIEW OF THE LITERATURE Early research on children's pain behaviors focused on identifying and evaluating behaviors associated with the sharp, intense, short-term pain Journalof PediatricNursing,Vol 13, No 1 (February),1998
of discrete diagnostic procedures. The behaviors evidenced included crying, screaming, stoic silences, and muscular rigidity. The most frequent behaviors observed were categorized in instruments used to assess infants' and children's facial and body movement behaviors associated with these painful encounters (Katz, Kellerman, and Siegel, 1980; Craig and Perkachin, 1983; Jay, Ozolins, Elliott, and Caldwell, 1983; Craig, McMahon, Morison and Zaskow, 1984; Jay and Elliott, 1984; LeBaron & Zelter, 1984). Among the instruments developed was the Procedure Behavior Rating Scale (PBRS) (Katz, Kellerman, and Siegel, 1980) that identified 13 behavioral responses of children undergoing bone marrow aspirations. The tool, designed to evaluate pain and anxiety, was used to assess the children's behaviors across the four stages of the procedure. Children evidenced the greatest number of behaviors during the actual procedure and scores decreased for the older children. Older children tended to demonstrate increased muscle tension and behavioral withdrawal compared with the more physical and From the Department of Family Health Care Nursing, and the Department of Communi~' Health Systems, University of California at San Francisco, San Francisco, CA. This study was supported by funding from the National Institute for Nursing research (RO1 NRO1045 03). Address reprint requests to Mar)' D. Tesler, RN, MS, 46 Atalaya Terrace, San Francisco, CA 9411Z Copyright 9 1998 by W.B. Saunders Company 0882-5963/98/1301-000553.00/0
41
42
emotional responses of the younger children. The behavioral scores, however, could not differentiate between pain and anxiety. Later, researchers built on this work and developed additional measures with reduced numbers of behaviors and stronger psychometric properties which also focused on acute episodic pain (Jay, Ozolins, Elliott, and Caldwell, 1983; Lebaron & Zeltzer, 1984). These studies were followed by investigations and identification of the more subtle behavior manifestations of on-going postoperative pain. A number of tools to assess the most commonly exhibited behaviors of on-going pain were developed and included (1) Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) (McGrath, Johnson, Goodman, Schillinger, Dunn, and Chapman, 1985), (2) Gustave-Roussy Child Pain Scale (Gauvain-Piquard, Rodary, Rezvani, and Lemerle (1987); and (3) the Toddler-Preschooler Postoperative Pain Scale (TPPS) (Tarbell, Cohen, and Marsh 1992). The CHEOPS (McGrath et al., 1985) is the best known. Designed for use with 1- to 7-year-old children, it has been used and tested with children 1- to 12-years old and rates six categories of behaviors: cry, facial expression, verbal responses, torso position, touch, and limb movements. Each of the 28 behaviors is scored from 0 to 3 depending on the intensity exhibited. Beyer, McGrath, and Berde (1990) found that unlike the verbal reports of pain, the behavior scores of postoperative population did not vary over time. The children showed few behavioral responses and these did not correlate with the verbal reports of pain. However, in a subsequent study, Tyler, Tu, Douthit, and Chapman (1993) found that on postoperative Day 1 the CHEOPS scores did correlate with other behavior scales and the self-report Oucher Scale (Beyer, Denyes, and Villarruel, 1992). In a recent descriptive study of postoperative pain (Chambers, Reid, McGrath, and Finley (1995), mothers reported their children's pain cues they identified and used to determine their child's pain during the first 3 postoperative days. The 29 behavioral cues were categorized as (1) changes in normal behavior (appetite, sleep, activity, alertness, and emotional state), (2) illness behaviors: verbal reports, visible-audible discomfort, physiological observations, protective behavior, regressive behaviors, and requests for or refusal of medication; and (3) cues lacking behavioral information (looks more pale, flushed, or swollen than usual). The number of cues reported by mothers decreased from M = 2.4 on Day 1 to 2.3 on Day 2 and 1.8 on
TESLER,HOLZEMER,AND SAVEDRA
the Day 3. Changes in appetite, sleep quality, activity level, alertness, and emotional state were the most reported cues on Day 1 and activity level on Days 2 and 3. Illness behaviors such as holding sore body parts, refusing or taking medication also decreased over the 3 days. The work to date that has examined acute pain behaviors in children has focused primarily on procedural pain, pain of short-term duration. Examination of postoperative pain behaviors in children with subsequent development of the CHEOPS and TPPS has focused on the early school age and younger child. The current study examined the pain behaviors in older children and adolescents, a population that has received little attention.
METHODS Design. A descriptive-correlational design was used to identify the postsurgical behaviors in older children and adolescents and to examine the relationship between the observed pain behaviors and the self-report of pain. Sample. The self-selected multiethnic sample (N = 37), 18 boys and 19 girls 8 to 17 years old, had undergone surgery in a major West coast medical center. All patients who met the inclusion criteria from the same surgical unit were invited to participate. Forty-nine percent of the sample was between 8- to l 1-years old. The ethnicity of the children/adolescents was distributed as follows: 59% Caucasian, 19% Hispanic, 8% AfricanAmerican, and 14% other. The surgical procedures included 19% orthopedic, 16% thoracic, 13% genitourinary, 13% gastro-intestinal, and 38% other surgeries. Instruments. Data were collected using the children's/adolescents' medical records, the Word Graphic Rating Scale (WGRS) (Tesler et al., 1991) and the Pediatric Pain Behavior List (PPBL), a tool designed for this study. The Word Graphic Rating Scale, designed to measure pain intensity, is a 100 mm line anchored by two descriptors, "no pain" at the far left or zero point and "worst possible pain" at the far right. Three other descriptors, "little pain," "medium pain," and "large pain" appear equidistant along the line. Construct validity was determined in a repeated measure design examining the postoperative pain of children and adolescents on days 1 to 5 following surgery (Tesler, Saverdra, Holzemer, Wilkie, & Paul, 1991). Pain decreased over time with a statistically significant difference between days 2 and days 4 and 5 (P = .002). When six intensity scales, including two Word Graphic Rating Scales, were used by
PAIN BEHAVIORS
children/adolescents to report their pain, correlations among the pairs of scores from the scales ranged from .68 to .97 (M = .84) supporting convergent validity of the scales. Test-retest reliability between the WGRS scores was .91 supporting strong test-retest reliability (Tesler et al., 1991). The PPBL was investigator-designed for this study and was patterned after Wilkie's (1992) adaptation of the Behavior Observation Manual (Keefe and Block, 1982). The PPBL consists of 47 behaviors, divided among seven categories: Torso (8 behaviors), Limb (9), and Touch (3); Facial (7), Crying (6), Verbal (7), and Affective (7). In addition, autonomic responses (pulse, respirations and blood pressure) are recorded. The list of behaviors was compiled from an extensive review of the literature, consultation with expert clinicians and the investigators' own experience in children's and adolescents' pain assessment. Definitions of behaviors were derived from dictionaries and pain scales, then reviewed for the clearest description by the entire research team and nurse clinicians. Each behavior was evaluated individually for clarity and explicitness and was retained only if 100% agreement could be achieved on its clarity and distinction from other behaviors. Research assistants then tested the behaviors in the clinical setting and additional clarifications and testing were made twice again until there again was 100% agreement on all behaviors. Face validity was assured by the panel of expert nurses who evaluated the behaviors. Procedure. Training of research assistants, primarily graduate nursing students, in the use of the PPBL was conducted until they reached 100% agreement. Patient behaviors were assessed three times every 2 hours between 8 a.m. and 8 p.m. on days 1 through 3 following surgery. Each assessment consisted of a 30-second observation for evidence of individual behaviors. Each 30-second observation was followed by a 30-second period for scoring the behaviors that had been exhibited. This procedure was repeated twice with a oneminute waiting period prior to the second and third assessments. Eighteen potential samples of each behavior were able to be obtained over the 12-hour period on each of the 3 days, providing a potential total of 54 incidents of each behavior for each child. Pain intensity was measured after the behaviors had been recorded. The children reported pain intensity by marking its location on the Word Graphic Rating Scale (WGRS). Pain scores were determined by measuring with a micrometer the
43
distance on the WGRS from 0 to the point marked by the child/adolescent. Inter-rater reliability for data collected on Days 1 and 2 varied from 24% to 100%. On Day 1, the highest scores (77% and 100%) were in the morning and the lowest score (24%) in the afternoon. Percentage of agreement on Day 2 were 76, 73, 41, 70, 90, and 92% (M = 74%) for the six data sets. Agreement was higher if both raters were frequent evaluators.
FINDINGS Data Analysis. Data were analyzed using descriptive statistics for means, standard deviations, ranges and t tests and Pearson correlations. Findings are reported for (a) behaviors observed and recorded, (b) pain scores reported and (c) correlations between them. Behaviors also were examined by (1) their evidenced frequency over the 3 days, (2) category classification, (3) patient diagnostic group, and (4) the child/adolescent age and gender. Manifested Frequency of Behavior. Every behavior except torso thrashing, was exhibited by one or more child/adolescent. A total of 6,224 behaviors were observed and recorded, 2116 on Day 1, 2309 on Day 2, and 1799 on Day 3. The difference between the number of behaviors exhibited between Days 2 and 3 was significant (P--.025). Three behaviors, calm, maintaining one position, and flexing limbs were manifest by 100% of the children. The two most frequently exhibited behaviors, calm (N = 1274) and maintains one position (N = 1206) accounted for 40% of the behaviors exhibited. Fourteen behaviors: calm, maintaining one position, flexing limbs, eyes shut, asleep, knees drawn up, bites/purses lips, shifting torso, massage/ rubbing, frown, wincing, moves protectively, sad, and clutching limbs were manifest by 59% or more of the children. (See Table 1 for the list of behaviors with rank order and percentages of their manifestation.) The means for the five most frequently observed behaviors for the 3 days were calm 35.34 (SD = 8.2), maintaining one position, 33.09 (SD = 9.1), flexing limbs 19.14 (SD = 8.0), eyes shut 13 (SD = 8.9), and knees drawn up 10.25 (SD = 8.5). The mean number of behaviors per child varied over the three days: 56.9 (SD = 27.3) were tallied for Day 1, 62.24 (SD = 23) on Day 2, and 50.68 (SD = 24.9) on Day 3. The number of behaviors manifest by individual children over the 3 days ranged from 73 displayed by a child who had undergone ureteral reconstruction to 313 by an adolescent after a scoliosis repair.
44
TESLER, HOLZEMER, AND SAVEDRA
Table i, Rank Order of Percentage of Children Wilh Observed Behaviors N = 37 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47.
Calm Maintaining one position Flexing limbs Eyesshut Asleep Knees drawn up Bites or purses lips Shifting torso Massage, rubbing Frown Wincing (Brief Pain Facies) Moves protectively--limbs Sad Clutching limbs Rigid torso Squirming Tense~limbs Jaw clench, grits teeth Grimace prolonged pain facies Rigid limbs Restlesstorso Dazed Whimpering Lack of interest in surroundings Appeals for relief Stoic silence Sighing Immobile torso Pain ratings Scared Grasping pain Eyeswide open Hunched over Pain complaints Groaning Angry Pain Cry Moaning Monotonous, mumbled words Resisting movement, handling Asks to be left alone Kicking Hysterical Flinging arms, limbs Screaming Avoids Touching Thrashing
100% 100% 100% 95% 92% 86% 84% 84% 78% 78% 73% 70% 62% 59% 47% 43% 41% 41% 38% 38% 35% 35% 32% 30% 30% 30% 30% 27% 27% 27% 24% 24% 22% 16% 16% 16% 16% 14% 14% 8% 5% 5% 3% 3% 3% 3% 0%
The least frequently evidenced eight behaviors shown by 8% or less of the children/adolescents were: resisting movement, asks to be left alone, kicking, hysterical, flinging limbs, screaming, avoids touching, and thrashing (see Table 1).
Categoriesof Behaviors Twelve of the top 16 behaviors were from three categories: Facial, Limb, and Torso. Facial actions most frequently seen were: eyes shut, bites/purses lips, frowning and wincing. These behaviors were
exhibited by 73% or more of the children/ adolescents. Most common Limb group movements: flexing limbs, knees drawn up, moves limbs protectively, were shown by 70% or more. High ranking Torso behaviors included maintaining one position (100%) evidenced by the total sample and shifting (84%). Two other high-ranking behaviors were massage from the Touch category and asleep from the Verbal group. Calm from the Affective group was one of the behaviors shown by the total group. In each category the behaviors manifested most frequently by 59% or more of the children were ones indicating withdrawal or protective action. No Facial group behaviors were among the least frequently observed behaviors.
Age and GenderDifferences The number of behaviors displayed by the two age groups did not differ greatly, 3002 behaviors were manifested by the 8- to ll-year-olds, and 3222 behaviors by the 12- to 17-year-olds. Girls exhibited 347l behaviors compared to 2753 by boys. No gender differences were evident among the 15 most frequently observed behaviors. However, the entire list of behaviors showed definite gender differences. Girls manifested 10 behaviors significantly more than boys and boys demonstrated three behaviors significantly more than girls (see Table 2).
Difference by DiagnosticGroups The diagnostic groups varied both in the number and range of behaviors evidenced over the 3 days. The orthopedic group demonstrated the highest mean numbers of behaviors over the three days 206 (SD = 75.5). The genitourinary group demonstrated the lowest, 146 (SD = 56). However, only one group reached statistical difference, the genitourinary group was greater than the thoracic on Day
Table 2. Significant BehaviorsManifest by Gender Girls More Than Boys (N = 19) Eyesshut (P = <.0049) Asleep (P = <0.015) Immobile (P = 0.0172) Dazed (P = <0.000) Tense(P = <0.0096) Pain ratings/Iocalizations (P = <0.000) Pain complaints (P = <0.000) Scared (P = <0.000) Monotonous, mumbled words (P = <0.000) Pain cry (P = <0.00090.) BoysMore Than Girls (N = 18) Stoic silence (P = <0.000) Eyeswide open (P = <0.000) Grasping pain sites (P = <0.000)
PAIN BEHAVIORS
2 (P = <0.0214). The mean number of behaviors shown by the groups differed more on Days 1 and 3 but ranged from 59 to 67 behaviors for all groups on Day 2. The orthopedic and "other surgery" group each demonstrated the widest range of behaviors. They showed between 31 and 36 different behaviors, 70% to 75% of the total list of behaviors, on all 3 days. In addition to the top ranking behaviors these patients also evidenced immobile, pain ratings and complaints, dazed, and moves protectively. The gastrointestinal group demonstrated the most restricted range of behaviors, 18, 20, 29, on each of the 3 days. This restricted pattern also was demonstrated by the thoracic group for Days 2 and 3 when 25 and 26 different behaviors were shown and by the genitourinary group with 27 different behaviors on Days 1 and 3.
45
total numbers of behaviors. Nine correlations for each of the two categories showed a negative relationship. Three correlations in the unambiguous group and six in the total behavior groups were significant (see Table 3).
DISCUSSION The list of behaviors studied was a global representation of behaviors usually associated with painful encounters and all 47 behaviors except thrashing were manifest at least once. Three behaviors were evidenced by 100% of the children and 14 were manifest by 59%. The finding that maintaining one position, remaining calm, and flexing limbs were the most universally seen behaviors is not surprising. Bonica (1980) points out that after the anesthesia has worn off, pain producing substances continue to be released. These reduce highthreshold nociceptor action and what would other-
Children's Reportsof Pain Children experienced the complete range of pain intensities during the 3 days. All children reported pain on the first 2 days, but five from the thoracic and gastrointestinal groups reported no pain on Day 3. Almost half (46%) reported mild pain on Day 1, 22% on Day 2, and 11% on Day 3. However, almost one fourth of the children, 22% on Day 1 and 19% on Day 2 reported severe pain. This number had decreased to less than 5% by Day 3. Two orthopedic patients reported severe (60 to 100) pain all 3 days. Two others, one orthopedic, and one thoracic patient reported moderate (40 to 60) pain, 16 reported mild pain (0 to 40) on all 3 days. Others reported a mixture of all pain intensities. Mean pain scores decreased over the 3 days, 42.9 (SD = 20.7) on Day 1, 36.2 (SD = 25) on Day 2, and 22.86 (SD = 19.2) on Day 3. The pain scores ranged from 0.50 to 88 on Day 1, 0.40 to 99.3 on Day 2, and 0 to 72.2 on Day 3. Pain scores also varied by surgical procedure. The highest scores were reported by the orthopedic surgery patients (M = 54.1) on Day 1 and (M = 45) on Day 3, and by the genitourinary patients on Day 2 (M = 65.6).
Frequency of Manifest Behaviors and Pain Scores The list of 47 behaviors was reviewed by a panel of pain management nurses who selected nine that were unambiguous pain behaviors: moves protectively, grasping pain, massage, grimacing, wincing, pain cry, pain complaints, appeals for relief and pain ratings. Pearson correlations were calculated using each patient's daily pain scores and (1) the nine identified unambiguous pain behaviors and (2)
Table 3. Correlations Belween Pain Scoresand Discre~ and Total Behaviors Obs
N
I:$Corr
PBP
PTBCorr
PTBP
1 2 3 4 5 6 7 8 9 I0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
14 12 16 8 14 11 9 9 8 15 12 10 10 4 10 10 13 15 13 15 13 11 8 13 12 9 7 12 9 5 10 10 12 7 12 10 14
-0.1203 0.2048 0.3996 0.9313* 0.7515" -0.0983 -0.2084 0.2277 -0.2198 0.4671 O.1262 0.1220 0.1350 0.6473 -0.1941 0.5265 -0.2167 0.3463 -0.3545 0.6056* 0.3852 0.1109 -0.0943 0.5668 0.5216 0.5609 0.1599 --0.5487 0.5042 0.3321 0.4798 0.5068 0.3156 -0.3829 0.4843
0.6822 0.5232 O.1 2 5 2 0.0008 0.0019 0.7738 0.5905 0.5558 0.6009 0.0792 0.6959 0.7371 0.7100 0.3527 0.5911 0.1180 -0.4378 0.2464 0.1948 0.0283 0.2420 0.7938 0.7593 0.0546 0.1498 0.1902 0.6195 -0.3382 0.1373 0.3486 0.114A 0.2457 0.31 77 0.2748 0.0793
-0.5447" 0.3203 0.5327' 0.8883" 0.3632 -0.2664 -0.0021 0.1913 0.2692 0.0599 -0.0089 -0.3311 0.2766 0.9614 -0.0742 0.4422 -0.0617 0.6235* 0.3798 0.6418* 0.3283 0.2015 0.1850 0.0758 0.4418 0.2004 0.4344 -0.2814 -0.1098 -0.4354 0.0553 0.4470 0.2861 0.7970* 0.0364 0.3425 0.4896
0.0440 3.31 O0 0.0336 0.0032 0.2018 0.4285 0.9958 0.6221 0.5190 0.8320 0.9782 0.3500 0.4392 0.0386 0.8385 0.2007 0.8414 0.0130 0.2005 0.0099 0.2734 0.5524 0.6610 0.8057 0.1504 0.6051 0.3301 0.3756 0.7785 0.4637 0.8795 0.1953 0.3673 0.0319 0.9106 0.3327 0.0756
*Significant <0.05.
46
wise be an innocuous action, such as moving, produces pain. Casual examination of the most frequently manifested behaviors, lying motionless in one position and having a calm expression, (the two behaviors that accounted for 405 of the total behaviors), might lead observers to believe that these children were comfortable. At the same time, however, many were reporting moderate to severe pain. This poses a major management problem for clinicians. These findings support those of Beyer, McGrath, and Berde (1990) who also found weak relationships between self-report scores and behavioral measures in a younger population of postsurgical patients. Findings that give ambiguous messages need to be examined. Are behaviors not usually associated with acute pain (i.e., passivity) reflective of how school age children and adolescents cope with pain? Do the more overt, active acute procedural pain behaviors inappropriately become a stereotype for postsurgical pain? The eight behaviors that were manifested by 8% or less are the typical responses of younger children or behaviors associated with shorter, acute procedural pain. These behaviors may be too energy and emotionally expensive to use during the ongoing acute pain experience, where immobility and rest are part of the recuperative process. These findings suggest that pain from procedures and postoperative pain are not comparable and perhaps assessment scales need to be different. Facial expressions, the most evident behaviors for assessing pain, were seen less frequently than motor behaviors. The number of these observations was reduced by the number of children/adolescents who were sleeping, watching television or playing video games. These children/adolescents were focused on the distraction and were almost expressionless and motionless. Another finding of interest was the higher mean self-report pain scores of the orthopedic group and "other surgery" patients who also showed a greater number and variety of behaviors. This finding is reflective of a vulnerable population that merits attention. While their behaviors may have been influenced by the paucity of analgesics administered to the orthopedic patients on Days 1 and 3, their pain behaviors and pain scores were still the highest on day 2 when they received the most analgesics. Another population that may present assessment problems was the gastrointestinal group who demonstrated so few behaviors that it would be difficult to make comprehensive assessments. The gender difference found in this study also
TESLER,HOLZEMER,AND SAVEDRA
supports the need to explore variables influencing overt behaviors and examine more subtle behaviors that distinguish the responses between genders. This supports the investigators' previous findings of differences in how boys and girls report and handle their pain (Savedra, Gibbons, Tesler, Ward, and Wegner, 1982). Cultural expectations regarding behaviors may be an influencing factor in these differences. The low number of significant correlations between pain scores and the numbers of observed behaviors requires further investigation. One third of the unambiguous pain behaviors were verbal reports, a category of behaviors this group used sparingly during observations. The number may not reflect the true frequency of this behavior. The issue of discrepant relationships between behaviors and verbal reports poses a major pain management dilemma for nurses and physicians. Walco and Dampier (1990) report that it is not surprising that such correlations are always very low. They emphasize the difficulty of an observer translating an individual's inner subjective experience by attributing specific meaning to observed actions. Craig and Perkachin (1983), however, stress the importance of studying behaviors because they are the evidence that cause health professionals to respond. The findings need to be evaluated in light of several limitations of this study. In some cases inter-rater reliability scores were low. This could be related to the fact that some data collectors were only occasionally involved in the study. Another data collection challenge related to securing a complete data set. While complete data were available for most of the children and adolescents, some children were off the unit or asleep and unable to provide self-reports of pain each time. Despite the limitations, this study adds to our knowledge of children's and adolescents' behaviors when they are in pain by identifying a panorama of discrete behaviors that manifest a response to postoperative pain. These behaviors have not been previously reported. Seventy-five percent of this group of children/adolescents manifested 30 different behaviors at discrete points during the 3 days following surgery. Further investigation of the most evident behaviors is indicated to determine if this smaller cadre of behaviors could be further refined to increase their correlation with verbal reports of pain.
ACKNOWLEDGEMENT Rani Eversley, PhD, was Project Director for this study and supervised data collection and entry.
PAIN BEHAVIORS
47
REFERENCES Beyer, J.E., McGrath, P.J. & Berde, C.B. (1990). Discordance between self report and behavior measures in children aged 3-7 years after surgery. Journal of Pain and Symptom Management, 5, 6, 350-356. Beyer, J.E., Denyes, M.J., & Villarruel, A.M. (1992). The creation, validation and continuing development of the Oucher: a measure of pain intensity in children. Journal of Pediatric Nursing, 7, (5) 335-46. Chambers, C.T., Reid, C.J., McGrath, P.J. & Finley, G.A. (1996). Development and preliminary validation of a postoperative pain measure for parents. Pain, 68, 307-313. Craig, K.D., McMahon, R.J., Morison, J.D. & Zaskow, C. (1984). Developmental changes in infant pain expression during immunization injections. Social Science Medicine, 19 (12), 1331-1337. Craig, K.D. & Prkachin, K.M. (1983). Nonverbal measures of pain. In R. Melzack, (Ed). Pain measurement and assessment, 173-179. New York: Raven Press. Gauvain-Piquard, A., Rodary, C., Rezvani, A., & Lemerie, J. (1987). Pain in children aged 2-6 years: a new observational rating scale elaborated in a pediatric oncology unit--preliminary report. Pain, 31, 177-188. Jay, S.M., Ozolins, M., Elliott, C.H., & Caldwell, S. (1983). Assessment of children's distress during painful medical procedures. Health Psychology, 2, 133-147. Jay, S.M. & and Elliott, C. (1984). Behavioral observation scales for measuring children's distress: the effects of increased methodological rigor. Journal of Consulting Clinical Psychology, 52, 6, 1106-1107. Katz, E.R., Kellerman, J. & Siegel, S.E. (1980). Behavioral distress in children with cancer undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48 (3), 356-365. Keefe, EJ. and Block, A.R. (1982). Development of an
observation method for assessing pain behavior in chronic low back patients. Behavior Therap), 13, 363-375. LeBaron, S. and Zeltzer, k (1984). Assessment of acute pain and anxiety in children and adolescent by self reports, observer reports and a behavior checklist. Journal of Consulting Clinical Psycholog); 52, 5,729-738. McGrath, P.J., Unruh, A.M., Finley, G.A. (1995). Pain measurement in children. Pain Clinical Update, ISAP, III, (2) 1-4. McGrath, P.J., Johnson, G., Goodman, J.T., Schillinger, J., Dunn, J., and Chapman, J. (1985) CHEOPS: A behavior scale for rating postoperative pain in children. Advances in Pain Research and Therapy, 9. H.L. Fields et al. (Eds. 1985, 395-402). Savedra, M., Gibbons, P., Tesler, M., Ward, J., Wegner, C. (1982). How do children describe pain? A tentative assessment. Pain, 14:95-104. Tarbell, S.E., Cohen, 1". & Marsh, J.L. (1992). The toddlerpreschooler postoperative pain scale: an observational scale for measuring postoperative pain in children aged 1-5. Preliminary report. Pain, 50, 273-280. Tesler, M.D., Savedra, M.C., Holzemer, W.L Wilkie, D.J., & Paul, S.M. (1991). The Word-Graphic Rating Scale as a measure of children's and adolescents' pain intensity. Research in Nursing and Health, 14, 361-371. Tyler, D.C., Tu, A., Douthit, J. & Chapman C.R. (1993). Toward validation of pain measurement tools for children: a pilot study. Pain, 52, 301-309. Walco, G.A. & Damper, C.D. (1990). Pain in children and adolescents with sickle cell disease: A descriptive study. Journal of Pediatric Psychology, 15, (5), 643-658. Wilkie, D.J., Keefe, EJ., Dodd, M.J. & Copp, L.A. (1992). Behavior of patients with lung cancer: description and associations with oncologic and pain variables. Pain, 51, 231-240.