Faces scales for the measurement of postoperative pain intensity in children following minor surgery

OBJECTIVES: Faces scales are commonly used to obtain self-reports of pain intensity from children. Previous research using hypothetical vignettes and pain following venepuncture has found differences in children's pain ratings as a function of the type of faces scale used. The purpose of the present study was to determine whether scales beginning with a smiling rather than neutral "no pain" face would produce higher ratings in the assessment of postoperative pain intensity in children and to compare ratings using different faces scales to those reported with an additional independent measure of pain intensity. METHODS: Participants were 78 children between the ages of 5 and 13 years undergoing surgery, one of their parents, and their postoperative care nurse. Following surgery, children were asked to provide a rating of their current pain intensity using a set of 5 successively administered faces scales and the Colored Analog Scale (CAS). Parents and nurses provided independent ratings using the same measures. RESULTS: Results showed that parents and nurses rated significantly more pain when using scales with a smiling rather than a neutral "no pain" face. This pattern was not as clear for the children's ratings, although their highest ratings were provided when using a smiling "no pain" faces scale. Children's and nurses' ratings on the CAS were generally more similar to their ratings using scales with neutral "no pain" faces, whereas parents' CAS ratings tended to fall in between ratings provided on the smiling and neutral "no pain" faces scales. Scale preference, age and sex differences in pain ratings, and child-parent-nurse agreement in pain ratings are also examined. DISCUSSION: Children's and parents' ratings of postoperative pain intensity are influenced by the presence of a smiling "no pain" face at the beginning of faces scales, with such scales producing significantly higher ratings than scales with neutral "no pain" faces. Ratings on the independent CAS measure were more comparable to those provided on faces scales with neutral "no pain" faces. Nurses are also susceptible to the influencing effect of a smiling face at the beginning of a faces scale.     

Strengthened estimates of individual pain trends in children following bone marrow transplantation.

Pre-transplant conditioning regimens for bone marrow transplantation often cause oral mucositis and severe pain. We evaluated the agreement of self- and parent reports of daily oral mucositis pain in children between the ages of 6 and 16 years. Child patients were asked to report their pain on visual analog scales (VAS) daily for 20 days following their transplants. Daily VAS ratings were also obtained from one of the parents. The analysis sample consisted of ten children aged 7-9, nine children aged 10-12, eight children aged 13-16, and their parents. We modeled individual child and parent reports as quadratic functions of the number of days post transplant. Empirical Bayes/restricted maximum-likelihood estimates were obtained of individual coefficients, treated as random effects, and age group coefficients, treated as fixed effects. Parents exhibited higher average pain curves than their children in each of the three age groups. The middle age group reported the highest average pain. Average within-person error variances representing unreliability were 692.2, 461.9, and 303.9 for young, middle, and old children, respectively; for parents, the corresponding error variances were 375.1, 413.3, and 252.4. These results challenge the presumption that children tend to over-report pain but are consistent with the contention that younger children may be less reliable reporters than adolescents and adults.     

Validity of Parent Ratings as Proxy Measures of Pain in Children with Cognitive Impairment

Parent-assigned pain scores have been used as proxy measures of pain for children, such as those with cognitive impairment (CI), who cannot self-report. However, the accuracy of parent-assigned pain ratings for children with CI has not been studied. This study evaluated the construct and criterion validity of parental pain scores of children with CI. Fifty-two children aged 4 to 19 years with CI and their parents/guardians were included in this observational study. Children were observed and assessed for pain by parents using the Faces, Legs, Activity, Cry, and Consolability (FLACC) observational tool and the 0 to 10 Numbers Scale, and simultaneously by nurses using the FLACC. Children who were cognitively able scored pain using simplified scales. Parent scores decreased after analgesic administration (6.4 +/- 2.5 vs. 3.1 +/- 2.3; p = .004), supporting their construct validity. Parents' FLACC and Numbers ratings correlated well with nurse ratings (intraclass correlation coefficient = 0.78 [confidence interval = 0.63-0.87] and intraclass correlation coefficient = 0.73 [confidence interval = 0.59-0.83], respectively). The parents' coded Numbers ratings correlated moderately with their child's ratings (rho = 0.57; p = .05) and agreed in 20% to 100% of cases (kappa = 0.388). There was better overall agreement between parents' FLACC scores and child ratings (33%-67% agreement; kappa = 0.43). The parent underestimated the child's pain with FLACC ratings in only one case (8%), but overestimated pain in three cases (25%). This study suggests that parents of children with CI provide reasonable estimates of their child's pain, particularly when using a structured pain tool. Parents may, however, tend to overestimate their child's pain during the early postoperative period.     

Can we screen young children for their ability to provide accurate self-reports of pain?

No validated screening tasks exist to distinguish children who can accurately use self-report pain measures from those who cannot. Children aged 3-7 years (n = 108), each with a parent, provided data before and after day surgery. Parents rated how well they thought their child could understand the Faces Pain Scale-Revised (FPS-R), and children completed 4 screening tasks in counterbalanced order, such as rating pain in vignettes and selecting a middle-sized cup. Parents and children used the FPS-R to rate the children’s pain intensity. Children’s FPS-R ratings were scored for accuracy based on the extent to which they conformed to expected pain trajectories (eg, pain increasing following surgery, decreasing following analgesia), and based on parent-child agreement. On average, parents rated the youngest age at which children could understand the FPS-R as 4.4 years (95% confidence interval 4.1-4.5). The youngest children provided inaccurate high pain ratings before surgery, but they became indistinguishable from the oldest in the accuracy of their pain ratings for the remainder of the 3-day study period, suggesting that direct experience with pain or with the rating task may improve accuracy. Although children’s performance on the screening tasks was significantly associated with self-report accuracy, no prediction was strong enough for clinical use (all r’s < 0.30). We failed to identify a screening tool that was better than chronological age in identifying which children could accurately self-report pain using the FPS-R. Future research should explore other screening tasks, training methods, and simplified approaches to pain assessment for young children.     

Facial expression of children receiving immunizations: a principal components analysis of the child facial coding system.

OBJECTIVE: To identify the structure of facial reaction to procedural pain and to determine the subset of facial actions that best describe the response. DESIGN: Observational. SETTING: Five rural and five urban physicians' offices. PATIENTS: One hundred twenty-three children aged 4 to 5 years undergoing routine diphtheria, pertussis, tetanus, and polio immunization. OUTCOME MEASURES: The Child Facial Coding System, comprising 13 discrete facial actions, was used to code each second of five 10-second phases from videotape: baseline, preneedle, needle, postneedle, and posthandling. Parents and a technician provided visual analog scale ratings of children's pain. Children provided a self-report using a Faces Pain Scale, and parents and nurses rated the children's pain and anxiety using visual analog scales. RESULTS: A "pain face" similar to that reported in adults emerged with the onset of pain. Principal component analyses revealed the frequency and intensity of facial action during the needle phase could be represented by components reflecting pain sensation, a "brave face," and the children's expectations for pain. Children's Faces Pain Scale and adult visual analog scale ratings were best predicted by components reflecting pain sensation and expectations of high pain. CONCLUSIONS: These results provide a preliminary indication that the Child Facial Coding System can be reduced to components that reflect several aspects of children's acute pain experience and predict self-reports and observer reports of children's pain.     

A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery.

Parents need education about pain so they can support their hospitalized child and manage their child's pain at home. The purpose of this study was to examine the effectiveness of a pain booklet on parental pain support to children experiencing postoperative pain. A randomized, repeated measures, experimental design using a pain education booklet and a standard care comparison group was used to study parents of 51 children (3 to 16 years of age) having cardiac surgery. Measurement techniques used to assess differences in parental pain management included: attitudes about pain medication, child and parent pain ratings (Oucher), opioids used, recovery, satisfaction, and comfort in communication. Results indicate that children do report moderate levels of pain postoperatively. Parents who were exposed to the pain assessment and management for parents education booklet preoperatively significantly increased their knowledge and attitudes toward pain medication scores from pre- to post-test, whereas those in the control group remained stable. Post-test scores were not significantly different between groups. Child and parent pain ratings were significantly and positively correlated. Practice implications include the use of an educational booklet about pain with parents before surgery to increase their knowledge about and attitudes toward pain management. Additionally, a parent may provide an alternative pain report when a child is unable to or unwilling to self-report their pain.     

Preliminary validation of a self-efficacy scale for child functioning despite chronic pain (child and parent versions)

Despite frequent targeting of health beliefs in pediatric chronic pain treatment interventions, there are currently no reliable and valid self-efficacy measures for children with chronic pain and their parents. The current study examined the psychometric properties of parent and child versions of a self-efficacy measure related to the child functioning normally when in pain. Pediatric pain patients, 9-18 years of age, and a caregiver completed questionnaires before an initial tertiary care clinic appointment. The 67 patients in our sample had an average of 1.7 pain locations, including abdominal pain (43.3%), headaches (50.7%), body pain (25.4%), back pain (23.9%), limb pain (20.9%), and/or chest pain (9.0%). Reliability for the new measures was excellent; the Cronbach's alpha was .89 for the 7 child items and .90 for the 7 parent items. Strong evidence for construct validity was also obtained as 23 of the 27 hypothesized correlations were confirmed. As predicted, parent and child ratings of increased self-efficacy for the child functioning normally when in pain were significantly correlated with each other, and to parent reports of fewer problems functioning due to physical or emotional problems; parent reports of fewer somatic, behavioral or emotional symptoms; parent reports of increased self-esteem, and unrelated to child pain, age and gender. Additionally, child ratings of increased self-efficacy were significantly correlated with child reports of increased self-esteem and fewer somatic symptoms. Replication with a larger sample size, more complex modeling, and prospective studies are indicated.     

Parents' support and satisfaction with their child's postoperative care

It is recognized that parents' presence during their child's hospitalization is of benefit to the parents and the child. However, the level of parental involvement in their child's care may be influenced by many factors, such as the amount of support nurses provide for parents. This article reports on two themes from the findings of a larger study on parental involvement in children's postoperative pain management - parental support and parents' satisfaction with their child's postoperative pain management. The aim of the larger study was to explore both nurses' and parents' perceptions of parental involvement in their child's postoperative pain management. The methods used were both qualitative and quantitative. The qualitative method of phenomenology was used to guide 20 nurse and 20 parent interviews. Quantitative methods involved surveying the nurses and parents on their perceptions of how supportive the nurses were towards the parents. The charts of 20 children were reviewed for pain-related data. This article reports on the issues of parent support from the results of the survey, and on satisfaction relating to their child's postoperative pain management from the parent interviews. The findings demonstrated that nurses perceived that parents were receiving more support from them than that which parents felt they were receiving. Parents were more satisfied with their child's pain management and children received more analgesia when they were cared for by a lower grade nurse.     

Association between self-report pain ratings of child and parent, child and nurse and parent and nurse dyads: meta-analysis

Title.  Association between self-report pain ratings of child and parent, child and nurse and parent and nurse dyads: meta-analysis.
Aim.  This paper is a report of a meta-analysis to investigate the association between self-report pain ratings for the dyads of child and parent, child and nurse and parent and nurse.
Background.  Existing research has shown conflicting results with regard to agreements of self-report pain ratings between the three dyads.
Data sources.  The CINAHL, Medline, Ovid and PsycINFO databases were searched using keyword, such as 'children/adolescents', 'parents/nurses', 'pain assessment', 'pain ratings', 'association' and 'agreement'. Studies published in English in or after 1990 were included.
Methods.  Meta-analysis methodology was applied to 12 pain assessment studies published between 1990 and 2007 which met the inclusion criteria. In the 12 studies a common effect size was estimated using the Pearson's correlation coefficient. Therefore, a fixed-effects model was chosen for this meta-analysis.
Results.  We found moderate summary effect sizes between self-reported pain ratings for the dyad of child and parent ( r  = 0·64) and the child and nurse dyad ( r  = 0·58) and a weak summary effect size of r  = 0·49 for the dyad of parent and nurse. The summarized effect sizes for each of the three dyads varied across the studies. A test of homogeneity ( Q -statistic) indicated that all effect size estimates were not homogeneous.
Conclusion.  Parents' and nurses' perceptions of children's pain should only be considered as estimates rather than expressions of the pain experienced, and not the same as children's self-reports. There is a need for education on selection of appropriate pain assessment scales in relation to the age and development of the child.     

Parent Pain Responses as Predictors of Daily Activities and Mood in Children with Juvenile Idiopathic Arthritis: The Utility of Electronic Diaries

The present study used electronic diaries to examine how parent responses to their child's pain predict daily adjustment of children with juvenile idiopathic arthritis (JIA). Nine school-aged children with JIA along with one of their parents completed thrice-daily assessments of pain-related variables, activity participation, and mood using handheld computers (Palm® pilots) for 14 days, yielding a potential of 42 child and parent assessments for each dyad. Children provided information on current pain level, mood, and participation in social, physical, and school activities. Parents independently rated their own mood as well as their behavioral responses to their child's pain at the same time points using a separate handheld computer. Results of multilevel modeling analyses demonstrated that use of “protective” pain responses by parents significantly predicted decreases in child activity and positive mood, with an even stronger inverse relationship between protective pain response and positive mood observed in children with higher than average disease severity. Protective pain responses were not found to be significantly predictive of daily negative mood in children. The use of “distracting” responses by parents significantly predicted less child activity restrictions but only in children having higher disease severity. There also was an unexpected trend in which parent use of more distracting pain responses tended to be associated with lower child positive mood. These preliminary findings suggest the importance of the parent in influencing adjustment in children with JIA and lend support to the incorporation of parents into comprehensive pain management approaches. The potential benefits of using electronic daily diaries as a strategy to examine pain and adjustment in children with JIA pain are discussed.     

Factors Influencing Agreement between Parent and Child Reports of Anxiety Symptoms among Children with High-Functioning Autism Spectrum Disorders

Challenges with identifying and measuring anxiety in children and young people with an Autism Spectrum Disorder (ASD) have prompted studies examining the reliability of and agreement between different informants. In this study, agreement and factors influencing agreement (caregivers’ educational level and stress; child’s age, gender, verbal and performance IQ) between parent and child reports of anxiety symptoms was examined in a sample of 70 children with an ASD (66 boys; 9–16 years; mean age = 11.21, SD = 1.79 years). The participants completed the Spence Children’s Anxiety Scale (SCAS) - Child Version, while their parents completed the SCAS - Parent Version and the Parenting Stress Index. Children rated themselves as having significantly more anxiety symptoms compared to parental ratings of children’s anxiety. Parent and child reports of anxiety were significantly positively correlated for separation, social and generalized anxiety and for total anxiety scores with mostly medium effect sizes, but not for panic attack or obsessive-compulsive subscale scores. Higher parent-child agreement was found for anxiety symptoms associated with clearly observable behaviours. More agreement was associated with higher child verbal IQ and lower levels of parenting stress. Specifically, increased parental stress was associated with more discrepant caregiver-child reports of social anxiety symptoms. Our findings support the need for multi-informant data in order to capture a more comprehensive clinical picture of anxiety symptoms in children with an ASD and to consider the informants’ own stress and anxiety levels when obtaining caregivers’ perspectives.     

Treatment expectations for CAM interventions in pediatric chronic pain patients and their parents

Patient expectations regarding complementary and alternative medicine (CAM) interventions have important implications for treatment adherence, attrition and clinical outcome. Little is known, however, about parent and child treatment expectations regarding CAM approaches for pediatric chronic pain problems. The present study examined ratings of the expected benefits of CAM (i.e. hypnosis, massage, acupuncture, yoga and relaxation) and conventional medicine (i.e. medications, surgery) interventions in 45 children (32 girls; mean age = 13.8 years +/- 2.5) and parents (39 mothers) presenting for treatment at a specialty clinic for chronic pediatric pain. Among children, medications and relaxation were expected to be significantly more helpful than the remaining approaches (P < 0.01). However, children expected the three lowest rated interventions, acupuncture, surgery and hypnosis, to be of equal benefit. Results among parents were similar to those found in children but there were fewer significant differences between ratings of the various interventions. Only surgery was expected by parents to be significantly less helpful than the other approaches (P < 0.01). When parent and child perceptions were compared, parents expected hypnosis, acupuncture and yoga, to be more beneficial than did children, whereas children expected surgery to be more helpful than did parents (P < 0.01). Overall, children expected the benefits of CAM to be fairly low with parents' expectations only somewhat more positive. The current findings suggest that educational efforts directed at enhancing treatment expectations regarding CAM, particularly among children with chronic pain, are warranted.     

Agreements and disagreements between children and their parents in health-related assessments

Purpose: To systematically review research concerning parent–child agreement in health-related assessments to reveal overall agreement, directions of agreement, and the factors that affect agreement in ratings.

Method: The Uni-Search and five additional databases were searched. Children’s health issues were grouped into psychosocial issues including autism and ADHD, and physical and performance issues including pain. Measures used for comparison were those addressing (a) psychosocial functioning, (b) physical and performance functioning, and (c) health-related quality of life.

Results: Totally, 39 studies met the inclusion criteria, comprising 44 analyses in all since four studies contained more than one analyses. Moderate child–parent agreement was demonstrated in 23 analyses and poor agreement in 20 analyses. Several analyses found more agreement on observable/external than on non-observable/internal domains. Overall, parents considered their children had more difficulties than did the children themselves, although there were indications that for children with physical performance issues, parents may underreport their children’s difficulties in emotional functioning and pain. There were no consistencies in differences between children’s and parent’s ratings on levels of agreement with respect to the children’s health issue, age or gender.

Conclusions: Discrepancies between child and parent reports seem to reflect their different perspectives and not merely inaccuracy or bias.

• Implications for Rehabilitation

• In general, parents consider their children to have more difficulties – or more extensive difficulties – than the children themselves think they have.

• The perspectives of the child and his or her parents should be sought whenever possible since both constitute important information concerning the child´s health and well-being.

• Children with physical and performance issues reported more difficulties than their parents concerning the children’s emotional functioning and pain.

• Clinicians should prioritize obtaining children’s views on subjective aspects such as emotional issues as well as on pain.

     

Comparison of ventilator-dependent child reports of health-related quality of life with parent reports and normative populations

AIMS: This paper is a report of the first study of ventilator-dependent child and parent ratings of health-related quality of life using a validated instrument, which was undertaken as part of a case study of costs and consequences. BACKGROUND: Advances in medical care and technologies such as the ventilator have extended childhood illness trajectories beyond our current range of knowledge and experience. These advances and their effects reinforce the need for further research to determine health-related quality of life as an outcome of ventilator-dependency in childhood. METHODS: The KINDL was administered to ventilator-dependent children aged 4-18 years and parents as part of an in-depth case study. Twenty-seven parents and 17 children (including 17 child-parent pairs) completed questionnaires. Data were collected between 2001 and 2004. Findings were compared with normative values derived from a representative sample of children of a similar age in the general population. RESULTS: Ventilator-dependent children reported significantly lower overall health-related quality of life, and significantly lower scores on all domains except about their friends, compared with school children, and chronically ill children in respect of their disease. Parents and children rated children's overall health-related quality of life the same but parents reported significantly lower scores for their child's disease and relationships with friends. There was a positive correlation between children and parents in all areas apart from self-esteem and school. CONCLUSIONS: Both child and parent perspectives are needed to understand the impact of ventilator-dependency and associated co-morbidity on the child. As new interventions and models of service delivery emerge it will be important for nurses to understand the impact on the child by evaluating physical, emotional and social consequences.     

The psychometric characteristics of the preschool behavior questionnaire in preschoolers with developmental handicaps

Parents and teachers rated 34 preschoolers with developmental handicaps on the Preschool Behavior Questionnaire (PBQ) (Behar and Stringfield, 1974a); student assistants rated 11 children. Approximately four weeks later, parents and teachers rerated the children. Shortly after the first rating, 14 of the older subjects were assessed by direct observations for classroom behavior and were tested on a Continuous performance Task (CPT) and the Marble Dropping Task (Zigler, 1961). Interrater agreement was generally modest to moderately high for the disruptive subscales of the PBQ (Hostile-Aggressive and Hyperactive-Distractible), whereas agreement was usually unsatisfactory for the Anxious-Fearful subscale. Test-retest reliability was high for ratings by both parents and teachers. Data from the direct observations and from the CPT and Marble Dropping tasks failed to validate the parent ratings, whereas they provided moderate support for the validity of teacher ratings on the disruptive subscales. We concluded that parent ratings on the PBQ do have some utility but that extreme scores derived from parent ratings should be interpreted with caution. Reliability appears to be adequate to good on the disruptive behavior subscales for teacher ratings, and existing relationships with other measures support the validity of the subscales assessing disruptive behavior. The PBQ appears to be useful for assessing preschoolers with developmental handicaps, although our data suggest limitations as well.     

Unravelling age effects and sex differences in needle pain: ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents

Age and sex differences were investigated in children's self-report of venipuncture pain. Equal numbers of boys and girls aged 3-15 years (n = 110) made separate ratings of the intensity and unpleasantness of their needle pain, using a paired Visual Analogue Scale (VAS) technique. The parents of these children used the same method to give ratings of predicted pain and unpleasantness before the needle, as well as ratings based on observing their child during the needle. Results showed that, across age, children's intensity and unpleasantness scores were highly correlated (r = 0.78), and that both of these ratings decreased with increasing age. Analyses of covariance showed that, with the variance in the unpleasantness ratings accounted for, a significant age main effect persisted for the intensity ratings (scores decreasing with increasing age), with no effect of sex. In the corollary analysis, with intensity scores entered as a covariate, unpleasantness ratings showed no main effect of age, but a significant main effect of sex emerged: girls' ratings of pain unpleasantness, when averaged across age, were significantly higher than boys'. The interaction between age and sex was explored in analysis of the relative difference between intensity and unpleasantness ratings. The results indicated that, from approximately 8-years of age, children (especially girls) gave significantly higher ratings of unpleasantness than sensory intensity of needle pain. Prior to the age of 8 years, children tended to give equivalent ratings of intensity and unpleasantness, with no evidence of a sex difference. The agreement between parental and children's ratings was higher for parents' observed, as opposed to predicted, scores, especially for pain intensity, with no systematic influence of the child's age and sex. In conclusion, it is suggested that age effects in children's self-report of needle pain are predominantly manifest in ratings of sensory intensity, whilst sex effects are predominantly manifest in ratings of an affective (unpleasantness) dimension. It is argued that both age and sex differences are largely the function of pain reporting variables, rather than reflecting fundamental age or sex based variance in nociceptive processing.     

Measuring the quality of children's postoperative pain management: initial validation of the child/parent Total Quality Pain Management (TQPM) instruments

Quality improvement measurement instruments for pediatric postoperative pain management are virtually nonexistent. Without standardized instruments to measure pediatric pain management outcomes, practitioners are hampered in their efforts to improve the quality of pain management for children. In this study, instruments for children (8--12 years) and parents were developed and tested to measure the quality of children's postoperative pain management. The child (Child TQPM) and parent (Parent TQPM) Total Quality Pain Management instruments were tested with 50 parent/child dyads across two large treatment centers. The pain rating scale modified for these instruments demonstrated good criterion validity with the well established Varni/Thompson Pediatric Pain Questionnaire Visual Analogue Scale. Parent--child agreement was described for responses across instruments. Construct validity was examined through selected inter-item relationships. Psychometric analyses support the initial measurement properties of the pediatric TQPM instruments.     

How many response levels do children distinguish on faces scales for pain assessment?

Faces scales are one of the most commonly used instruments to assess pain intensity in children. Most available faces scales present five to seven faces. The present research was conducted to investigate the ability of 4‐ to 7‐year‐old children to distinguish the response categories of different faces scales. In the first study, 121 children were asked to rate painful situations on a 3‐ and a 6‐level faces scale commencing with a smiling ‘no pain’ face. Children were divided into two age groups (4–5 and 6–7 years). Investigations of the category functioning were performed with a rating scale Rasch model for each age group. Results revealed the low performances of the 6‐level faces scale as compared to the 3‐level faces scale and also the difficulty children experienced in scoring the imaginary painfulness of items. Consequently, a second study was conducted. In this second study, 76 children were asked to rate pictures depicting painful situations on a 3‐level faces scale beginning with a neutral ‘no pain’ face. Results of this second study confirmed an improvement in the ability to distinguish the three response categories with age. The 4–5 year‐old children could only distinguish two response categories and the 6–7 year‐old children were able to discern the three levels of the 3‐level faces scale. In conclusion, young children do not distinguish as many faces as proposed by the majority of available faces scales. These results strongly recommend a reduction in the number of response levels of faces scales for pain assessment in children.     

Painful pricks and prickle pains: is there a relation between children's ratings of venipuncture pain and parental assessments of usual reaction to other pains?

OBJECTIVE: The objective of this study was to examine whether parental assessment of a child's usual behavioral reaction to common painful events predicts the child's ratings of needle pain intensity from routine venipuncture. DESIGN: Children aged 3 to 12 years (n = 88) used the Faces Pain Scale to rate how much venipuncture hurt and also indicated whether the pain was more, less, or the same as expected. The child's parent (mother) used the same scale to predict how much the needle would hurt the child as well as to rate the child's pain as observed at the time of venipuncture. Parents also estimated their child's usual reaction to six common painful events. An independent observer used a behavioral checklist to rate the child's pain response at the time of venipuncture as well as to assign a global pain rating on the Faces Pain Scale. OUTCOME MEASURES: The Faces Pain Scale and a behavioral checklist (scoring facial, vocal, motor, and verbal reactions) were used in this study. RESULTS AND CONCLUSIONS: Those children who reported venipuncture as hurting more than expected also gave the highest mean needle pain ratings and tended to have their pain underpredicted by their parents before venipuncture. For these children, parental estimates of reactions to other painful events proved to be a useful predictor of self-reported needle pain. Parent and child ratings of pain agreed more closely for those parents who indicated having relied on what their child "did" rather than "said." Additionally, and consistent with previous studies, independent observation of children's facial responses was the most useful indicator of needle pain severity. Preparation of children for venipuncture may be enhanced by asking a parent beforehand how the child usually responds to everyday pain. Specifically, reaction to other sharp time-limited pains (e.g., finger pinch, stepping on a prickle) may provide a useful guide to identifying which children will report experiencing greater pain than expected from venipuncture.