Can Parents Assess Dental Pain in Children with Cognitive Impairment?

It is often said that the "gold standard" for pain assessment in both children and adults is verbal report. This means that the individual is best at describing his or her pain experience. This however does not take into account individuals who lack the ability to communicate their feelings including those with cognitive immaturity such as infants and very young children, people with cognitive impairment and adults with dementia. This is even complicated by the fact that children who experience the most pain are those who are least able to verbally describe it; those with greater physical and cognitive disability. This paper reviews past and current beliefs on the experience and expression of pain in children with cognitive impairment and how parents can be used as useful tools in diagnosing their pain.

children, special health care needs, pain, cognitive impairment, parents

1. Merskey H. Classification of chronic pain: Description of chronic pain syndromes and definitions of pain terms. Pain supplement, 3, S1–S8, 1986.

2. Merskey H and Bogduk N. Classification of chronic pain: Description of chronic pain syndromes and definitions of pain terms. 2nd ed. WA:IASP Press, Seattle, 1994.

3. McIntosh N. Pain in the newborn, a possible new starting point. Eur J Pediatr, 156(3): 173–7, 1997.

4. Meinhart NT and McCaffery M. Pain, a Nursing Approach to Assess-ment and Analysis. Appleton & Lang, Norwalk, CTL, 1983.

5. Malviya S, Voepel-Lewis T, Tait AR, Merkel S, Lauer A, Munro H, Farely F. Pain management in children with & without cognitive impairment following spine fusion surgery. Paediatr Anaesth, 11: 453–8, 2001.

6. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. New Eng J Med, 317: 1321–9, 1987.

7. Galton F. Inquiries into human faculty and its development. 2nd ed.

J. M. Dent & Son, London, 1907.

8. Davenport CB. Heredity in relationship to eugenics. Henry Holt, New York, 1911.

9. Anthony JG and Michel H. Handbook of Pediatric and Adolescent Health Psychology. Allen & Bacon, Needham Heights, MA, 1999.

10. Luckasson R, Coulter DL, Polloway EA, Reiss S, Schalock RL, Snell M, Spitalnik D, Stark J. (Eds). Mental retardation: Definition, classifi-cation, and systems of supports. American Association on Mental Retardation, Washington, DC, 1992.

11. Centers for Disease Control and Prevention. Developmental disabili-ties. Available at: http://www.cdc.gov. Accessed April 23, 2008.

12. American psychiatric Association. Available at:http://www.psych.org. Accessed April 23, 2008.

13. Kliegman RM, Marcdante LJ, Jenson HB, Behrman RE. Nelson Essen-tials of Pediatrics. 5th ed. Elsevier Saunders, Philadelphia, PA, 2006.

14. Rubin IL. Health Care needs of adults with mental retardation. Ment Retard, 25: 201–6, 1987.

15. Lovaas OI, Schaeffer B, Simmons JQ. Experimental studies in child-hood schizophrenia: Building social behaviors in autistic children with electric shock. J Experiment Res Person, 1: 99–109, 1965.

16. Couston TA. Indifference to pain in low-grade mental detectives. Brit Med J, 1: 1128–9, 1954.

17. Breau LM, Camfield CS, McGrath PJ, Finley GA. The incidence of pain in children with severe cognitive impairments. Arch Pediatr Ado-lesc Med, 157: 1219–26, 2003.

18. Stallard P, Williams L, Lenton S, Velleman R. Pain in cognitively impaired, non-communicating children. Arch Dis Child, 85: 460–2, 2001.

19. Fanurik D, Koh JL, Schmitz ML, Harrison RD, Conrad TM. Children with cognitive impairment: Parent report of pain and coping. Dev Behav Pediatr, 20: 228–34, 1999.

20. Hadden KL, Von Baeyer CL. Pain in children with cerebral palsy: Common triggers and expressive behaviors. Pain, 99: 281–8, 2002.

21. Leland NL, Garrard J, Smith DK. Comparison of injuries to children with and without disabilities in a day-care center. J Dev Behav Pediatr, 15: 402–8, 1994.

22. Oberlander TF, O’Donnell ME, Montgomery CJ. Pain in children with significant neurological impairment. Dev Behav Pediatr, 20: 235–43, 1999.

23. Frank LS, Greenberg CS, Stevens B. Pain assessment in infants and children. Pediatr Clin North Am, 47: 487–512, 2000.

24. Fanurik D, Koh JL, Schmitz ML, Harrison RD, Conrad TM. Children with cognitive impairment: Parent report of pain and coping. J Dev Behav Pediatr, 20: 228–34, 1998.

25. Benini F, Trapanotto M, Gobber D, Agosto C, Carli G, Drigo P, et al. Evaluating pain induced by venepuncture in pediatric patients with developmental delay. Clin J Pain, 20: 156–63, 2004.

26. Breau LM, McGrath PJ, Craig KD, Santor D, Cassidy KL, Reid GJ. Facial expression of children receiving immunizations: A principal components analysis of the Child Facial Coding System. Clin J Pain, 17: 178–86, 2001.

27. Nader R, Oberlander TF, Chambers CT, Craig KD. Expression of pain in children with autism. Clin J Pain, 20: 88–97, 2004.

28. Stevens B, McGrath P, Yamada J, Gibbins S, Beyene J, Breau L, Cam-field C, Finley A, Franck L, Howlett A, Johnston C, McKeever P, O’Brien K, Ohlsson A. Identification of pain indicators for infants at risk for neurological impairment: A Delphi consensus study. BMC Pediatr. 2006; 6:1. Published online. 2006 February 2. doi:10.1186/1471-2431-6-1. Accessed April, 2008.

29. Reynell JK. Post-operative disturbances observed in children with cere-bral palsy. Dev Med Child Neurol, 7: 360–76, 1965.

30. Giusiano B, Jimeno MT, Collignon P, Chau Y. Utilization of Neural net-work in the elaboration of an evaluation scale for pain in cerebral palsy. Methods Inform Med, 34: 498–502, 1995.

31. Hunt A, Burne R. Medical and Nursing problems of children with neu-rodegenerative disease. Palliative Med, 9: 19–26, 1995.

32. Feldt KS, Ryden MB, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-frac-ture. J Am Geriatr Soc, 46: 1079–85, 1998.

33. Breau LM, McGrath PJ, Camfield C, Romus C, Finley GA. Prelimi-nary validation of an observational pain checklist of persons with cog-nitive impairment and inability to communicate verbally. Dev Med Child Neurol, 42: 609–16, 2000.

34. Hunt A, Mastroyannopoulou K, Goldman A, Seers K. Not-knowing the problem of pain in children with severe neurological impairment. Int J Nurse Studies, 40: 171–83, 2003.

35. Stallard P, Williams L, Velleman R, Lenton S, McGrath PG, Taylor G. The development and evaluation of the Pain Indicator for Communica-tively Impaired Children (PICIC). Pain, 98: 145–149, 2002.

36. Breau LM, MacLaren J, McGrath PJ, Camfield CS, Finley GA. Care-givers’ beliefs regarding pain in children with cognitive impairment: Relation between pain sensation and reaction increases with severity of impairment. Clin J Pain, 19: 335–44, 2003.

37. Fanurik D, Koh JL, Harrison RD, Conrad TM, Tomerlin C. Pain assess-ment in children with cognitive impairment: An exploration of self-report skills. Clin Nurse Res, 7: 103–24, 1998.

38. Nowak AJ. Dentistry for the handicapped patient. CV Mosby, St. Louis, 1974.

39. Desai M, Messer LB, Calache H. A study of the dental treatment needs of children with disabilities in Melbourne, Australia. Aust Dent J, 46(1): 41–50, 2001.

40. Pope JEC, Curzon MEJ. The dental status of cerebral palsied children. Pediatr Dent, 13: 156–62, 1991.

41. Ackerman A, Wiltshire WA. The occlusal status of disabled children. J Dent Assoc South Afr, 49: 447–51, 1994.

42. Milnes AR, Tate R, Perillo E. A survey of dentists and services they provide to disabled people in province of Manitoba. J Can Dent Assoc, 61: 149–58, 1995.

43. Hennequin M, Faulks D, Roux D. Accuracy of estimation of dental treatment need in special care patients. J Dent, 28: 131–6, 2000.