Genuine, suppressed and faked facial expressions of pain in children

Children's efforts to hide or exaggerate facial expressions of pain were compared to their genuine expressions using the cold pressor task. Fifty healthy 8- to 12-year-olds (25 boys, 25 girls) submerged their hands in cold and warm water and were instructed about what to show on their faces. Cold 10 degrees C water was used for the genuine and suppressed conditions and warm 30 degrees C water was used for the faked condition. Facial activity was videotaped and coded using the Facial Action Coding System to provide objective, detailed accounts of facial expressions in each condition, as well as during a baseline condition. Parents were subsequently asked to correctly identify each of the four conditions by viewing each video clip twice. Faked expressions of pain in children were found to show more frequent and more intense facial actions compared to their genuine pain expression, indicating that children had some understanding but were not fully successful in faking expressions of pain. Children's suppressed expressions, however, showed no differences from baseline facial actions, indicating that they were able to successfully suppress their expressions of pain. Parents correctly identified the four conditions significantly more frequently than would be expected by chance. They were generally quite successful at detecting faked pain, but experienced difficulty differentiating among the other conditions. The results indicate that children are capable of controlling their facial expressions of pain when instructed to do so, but are better able to hide their pain than to fake it.     

Detecting deception in facial expressions of pain: accuracy and training

Clinicians tend to assign greater weight to nonverbal expression than to patient self-report when judging the location and severity of pain. However, patients can be successful at dissimulating facial expressions of pain, as posed expressions resemble genuine expressions in the frequency and intensity of pain-related facial actions. The present research examined individual differences in the ability to discriminate genuine and deceptive facial pain displays and whether different models of training in cues to deception would improve detection skills. Judges (60 male, 60 female) were randomly assigned to 1 of 4 experimental groups: 1) control; 2) corrective feedback; 3) deception training; and 4) deception training plus feedback. Judges were shown 4 videotaped facial expressions for each chronic pain patient: neutral expressions, genuine pain instigated by physiotherapy range of motion assessment, masked pain, and faked pain. For each condition, the participants rated pain intensity and unpleasantness, decided which category each of the 4 video clips represented, and described cues they used to arrive at decisions. There were significant individual differences in accuracy, with females more accurate than males, but accuracy was unrelated to past pain experience, empathy, or the number or type of facial cues used. Immediate corrective feedback led to significant improvements in participants' detection accuracy, whereas there was no support for the use of an information-based training program.     

Social modulation of facial pain display in high-catastrophizing children: an observational study in schoolchildren and their parents

The present study examined existing communal and operant accounts of children’s pain behavior by looking at the impact of parental presence and parental attention upon children’s pain expression as a function of child pain catastrophizing. Participants were 38 school children and 1 of their parents. Children completed a cold pressor pain task (CPT) twice, first when told that no one was observing (alone condition) and subsequently when told that they were being observed by their parent (parent-present condition). A 3-minute parent-child interaction occurred between the 2 CPT immersions, allowing measurement of parental attention to their child’s pain (ie, parental pain-attending talk vs non-pain-attending talk). Findings showed that child pain catastrophizing moderated the impact of parental presence upon facial displays of pain. Specifically, low-catastrophizing children expressed more pain in the presence of their parent, whereas high-catastrophizing children showed equally pronounced pain expression when alone or in the presence of a parent. Furthermore, children’s catastrophizing moderated the impact of parental attention upon facial displays and self-reports of pain; higher levels of parental nonpain talk were associated with increased facial expression and self-reports of pain among high-catastrophizing children; for low-catastrophizing children, facial and self-report of pain was independent of parental attention to pain. The findings are discussed in terms of possible mechanisms that may drive and maintain pain expression in high-catastrophizing children, as well as potential limitations of traditional theories in explaining pediatric pain expression.     

Detecting deception in pain expressions: the structure of genuine and deceptive facial displays

Clinicians tend to assign greater weight to non-verbal expression than to patients' self-report when judging the location and severity of pain. Judgments can misrepresent the actual experience because patients can successfully alter their pain expressions. The present research provides a basis for discriminating genuine and deceptive pain expressions by expanding detailed accounts of facial expressions to include previously unexamined variables, including study of temporal patterns and contiguity of facial actions as well as the occurrence of specific deception cues. Low back patients' facial expressions (n=40) were videotaped at rest and while undergoing a painful straight leg raise with instructions to: (1) genuinely express their pain, or (2) pretend that it did not hurt. As well, they were asked to fake pain without moving. The Facial Action Coding System was used to describe and quantify facial activity. The different types of expression were compared on the frequency, type, intensity, temporal pattern and contiguity of facial actions, as well as on the frequency of specific deception cues. Findings confirmed the difficulty of discriminating the facial expressions, but indicated that faked pain expressions show a greater number of pain-related and non-pain-related actions, have a longer peak intensity and overall duration, and the facial actions observed tend to be less temporally contiguous than are those in genuine pain expressions. The differences between masked pain and neutral expressions were subtle, with a greater frequency of mouth opening and residual eyebrow movement in masked pain expressions. Thus, there is an empirical basis for discriminating genuine and deceptive facial displays.     

Parental catastrophizing about children's pain and selective attention to varying levels of facial expression of pain in children: a dot-probe study

The attentional demand of pain has primarily been investigated within an intrapersonal context. Little is known about observers’ attentional processing of another’s pain. The present study investigated, within a sample of parents (n = 65; 51 mothers, 14 fathers) of school children, parental selective attention to children’s facial display of pain and the moderating role of child’s facial expressiveness of pain and parental catastrophizing about their child’s pain. Parents performed a dot-probe task in which child facial display of pain (of varying pain expressiveness) were presented. Findings provided evidence of parental selective attention to child pain displays. Low facial displays of pain appeared sufficiently and also, as compared with higher facial displays of pain, equally capable of engaging parents’ attention to the location of threat. Severity of facial displays of pain had a nonspatial effect on attention; that is, there was increased interference (ie, delayed responding) with increasing facial expressiveness. This interference effect was particularly pronounced for high-catastrophizing parents, suggesting that being confronted with increasing child pain displays becomes particularly demanding for high-catastrophizing parents. Finally, parents with higher levels of catastrophizing increasingly attended away from low pain expressions, whereas selective attention to high-pain expressions did not differ between high-catastrophizing and low-catastrophizing parents. Theoretical implications and further research directions are discussed.     

Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections

Objective

The aim of the study was to determine the efficacy of ShotBlocker (Bionix, Toledo, Ohio) in reducing pediatric pain with intramuscular (IM) injections.

Methods

A prospective randomized controlled trial was conducted in children aged 2 months to 17 years who required an IM injection. Children were randomized to the no-intervention group or the ShotBlocker group. Demographic data and the number of IM injections were recorded. Perceived pain scores were obtained from nurses and caregivers using a 6-point Likert-type scale. Baker Wong Faces scale was used in children 36 months or older. Difficulty using the device was also rated by nurses on a 6-point scale.

Results

One hundred sixty-five children were enrolled with 80 in the no-intervention arm and 85 in the ShotBlocker arm. The mean age of children was 45 months and 56% were male. Perceived pain scores by nurses were higher for the no-intervention group (2.6 vs 1.8, P < .001) as well as by caregivers (2.6 vs 2.1, P = .04). Children aged 36 months and older (n = 64) did not report a difference in pain scores (1.5 vs 1.3, P = .6); however, in a subgroup of children 72 months or older, pain scores trended higher in the no-intervention group (1.3 vs 0.5, P = .051). Nurse-perceived difficulty of ShotBlocker use was low 1.39 (±1.1).

Conclusions

Nurses and caregivers noted lower pain scores in children assigned to the ShotBlocker group. These differences were not as evident when children rated their own pain.     

The faces of Moebius syndrome: recognition and anticipatory guidance

Moebius syndrome is a rare congenital disorder characterized mainly by the inability to move the eyes laterally or produce facial expressions such as smiling. Moebius syndrome creates physical problems for the affected individual that may, in some cases, lead to emotional or social adjustment issues, yet the syndrome is relatively unknown among healthcare professionals. Because early recognition of Moebius syndrome can lead to early diagnosis and treatment, education of nurses in perinatal, pediatric, midwifery, and neonatal specialties is crucial. Through early recognition, maternal-child nurses can offer anticipatory guidance and provide or recommend resources to parents of children with this neurological condition.     

Effect of morphine in needle procedures in children with cancer

Background: The aim was to investigate whether children experience less fear, distress, and/or pain when they receive oral morphine vs. placebo before a needle is inserted in a subcutaneously implanted intravenous port when combined with topical anesthesia. Method: Fifty children 1–18 years of age who were treated in a pediatric oncology and hematology setting were included consecutively when undergoing routine needle insertion into an intravenous port. All children were subjected to one needle insertion following topical anesthetic (EMLA) application in this randomized, triple‐blind, placebo‐controlled study comparing orally administered morphine (n= 26) 0.25 mg/kg body weight with placebo (n= 24). The patients’ fear, distress, and pain were reported by parents, nurses and the children themselves (if ≥7 years of age) on 0–100 mm Visual Analogue Scales. In addition, observational methods were used to measure distress and procedure pain. Results: No differences between the morphine and the placebo group were found with respect to age, weight, height, physical status, sex, weeks from diagnosis, or weeks from latest needle insertion. According to, parents, nurses, and children, oral morphine at a dose of 0.25 mg/kg body weight did not reduce fear, distress or pain compared with placebo. Conclusion: We could not reject the null hypothesis that there is no difference between the oral morphine and placebo groups assuming an effect size of 15 mm on VAS. Therefore it seems that oral morphine at 0.25 mg/kg does not give any additional reduction of fear, distress or pain compared with placebo when combined with topical anesthesia in pediatric patients undergoing subcutaneous port needle insertion, and would not be expected to be of any advantage for similar procedures such as venipuncture and venous cannulation when topical anesthesia is used.     

When “don’t worry” communicates fear: Children’s perceptions of parental reassurance and distraction during a painful medical procedure

Children’s distress during painful medical procedures is strongly influenced by adult behavior. Adult reassurance (e.g., “it’s okay”) is associated with increased child distress whereas distraction is associated with increased child coping. It is unknown why reassurance shows this counterintuitive relationship with child distress. The present research investigated whether children perceive their parents as fearful when they reassure using complementary observational and experimental methodologies. One hundred children (40 boys, 60 girls) 5–10 years old (M = 8.02, SD = 1.69) and their parents (86 mothers, 14 fathers) participated. First, spontaneous parent–child interactions during pediatric venipuncture were captured and used for a video-mediated recall task in which the children viewed instances of parental reassurance and distraction and rated their parents’ fear and happiness. Second, the children were asked to rate the intensity of parental fear and happiness for 12 video vignettes showing an actor posing as a parent during venipuncture. To determine whether the children’s perceptions varied with the qualities of the behavior, the vignettes manipulated: facial expression (happy vs. fearful), vocal tone (rising vs. falling), and content (informative reassurance vs. uninformative reassurance vs. distraction). For both tasks, the children provided higher ratings of fear during reassurance than distraction. In response to the vignettes, the children gave higher ratings of parental fear for a fearful facial expression, but the influence of vocal tone differed with the verbal content of the utterance. The results provide insight into the complexity of adult reassurance and highlight the important role of parental facial expression, tone, and verbal content during painful medical procedures.     

Gender effects in pain detection: Speed and accuracy in decoding female and male pain expressions

The ability to detect facial expressions of pain is crucial in eliciting prosocial behaviors towards the individual experiencing pain. Previous studies have shown that the sufferers' gender can affect the observers' explicit judgment of the pain face, thus suggesting its possible influence on pain decoding. The present study investigates whether the sufferer's gender affects the observer's reflexive or implicit detection of facial expression of pain. More specifically, we used implicit measures to test whether observers detect pained expression more quickly or accurately on male or female faces. In three experimental studies, we devised a set of stimuli using computer‐generated faces. In Experiment 1, prototypical female and male avatars with different facial expressions (pain, anger, disgust, and neutral) were displayed, while subjects' (N =34) accuracy and speed at identifying the expressions were recorded. In Experiment 2, participants (N =56) watched videos of the avatars displaying dynamic expressions and had to quickly and accurately identify each expression. In Experiment 3, participants (N =38) were shown an androgynous avatar face showing different expressions and were asked to identify the face as either female or male. Overall, we found that the target's gender affected the observer's reflexive decoding of the facial expression of pain. Specifically, the results showed that participants, regardless of their gender, were slower and less accurate in recognizing pain expressions (but not other expressions) on female faces. Furthermore, androgynous faces displaying pained expressions were more likely to be categorized as male than female. Several potential explanations are discussed.     

护士指导家长减轻患儿注射疼痛认知的调查研究

目的 :描述护士在指导家长减轻患儿注射疼痛方面的认知情况。方法 :采用方便抽样法 ,抽取西安市 3所三级甲等医院护士 15 5名 ,以调查问卷的形式进行。结果 :护士未能经常给予患儿家长有关注射方面的知识 ,包括如何参与减轻患儿的注射疼痛。结论 :建议护士多提供给家长相关知识 ,帮助家长更好地参与患儿的护理 ,更有效地减轻患儿的注射疼痛。     

Pain and related suffering reduce attention toward others

Background

It has been proposed that the expression of pain-related suffering may lead to an enhanced focus on oneself and reduced attention toward the external world. This study aimed at investigating whether experimentally induced painrelated suffering may lead persons to withdraw into themselves, causing a reduced focus on external stimuli as reflected by impaired performance in a facial recognition task and heightened perception of internal stimuli measured by interoceptive awareness.

Methods

Thirty-two participants had to recognize different emotional facial expressions (neutral, sad, angry, happy), or neutral geometrical figures under conditions of no pain, low, and high prolonged pain intensities. Interoceptive accuracy was measured using a heartbeat-detection task prior to and following the pain protocol.

Results

Males but not females were slower to recognize facial expressions under the condition of high painful stimulation compared to the condition of no pain. In both, male and female participants, the difficulty in recognizing another person's emotions from a facial expression was directly related to the level of suffering and unpleasantness experienced during pain. Interoceptive accuracy was higher after the pain experiment. However, neither the initial interoceptive accuracy nor the change were significantly related to the pain ratings.

Conclusions

Our results suggest that long-lasting and intense painful stimuli, which induce suffering, lead to attentional shifts leading to withdrawal from others. These findings contribute to a better understanding of the social dynamics of pain and pain-related suffering.     

EVENDOL, a new behavioral pain scale for children ages 0 to 7 years in the emergency department: design and validation

Numerous behavioral pain measures have been validated for young children, but none is appropriate to assess pain in emergency departments (EDs), where caregivers need a simple, easily completed scale. Our objective was to elaborate and validate a tool, relevant in any painful situation, with agitation or prostration, and for any age under 7 years. Five items (scored 0 to 3) were developed by pediatric pain and emergency caregivers. The new scale, called EVENDOL, was tested at children's arrival and after analgesics, at rest, and during mobilization. The validation study included 291 children from birth to 7 years old in 4 French EDs, and independent observations by the ED nurse and a researcher. The Cronbach coefficient was excellent (0.83 to 0.92). Construct validity was demonstrated by a decrease in scores after nalbuphine: 8.14 to 3.62 of 15 at rest (P<.0001), 11.87 to 6.65 at mobilization (P = .0011); by good correlations between EVENDOL and nurse or researcher numerical scores: 0.79 to 0.92 (P<.0001); by good correlations between children's self-assessment scores and EVENDOL in children ages 4 to 7 (0.64 to 0.93). Discriminant validity with tiredness, anxiety, and hunger was good. Interrater reliability was excellent between nurses and researcher (weighted kappa 0.7 to 0.9), and in a group of 6 nurses (simultaneous assessment of 122 videos). The treatment threshold was determined at 4 of 15. EVENDOL has excellent validity and can be used for all children under age 7 in EDs, for any age and any pain, acute as well as more prolonged.     

Attention effects on vicarious modulation of nociception and pain

The observation of others’ facial expressions of pain has been shown to facilitate the observer’s nociceptive responses and to increase pain perception. We investigated how this vicarious facilitation effect is modulated by directing the observer’s attention toward the meaning of pain expression or the facial movements. In separate trials, participants were instructed to assess the “intensity of the pain expression”(meaning) or to “discriminate the facial movements” in the upper vs lower part of the face shown in 1-second dynamic clips displaying mild, moderate, or strong pain expressions or a neutral control. In 50% of the trials, participants received a painful electrical stimulation to the sural nerve immediately after the presentation of the expression. Low-level nociceptive reactivity was measured with the RIII-response, and pain perception was assessed using pain ratings. Pain induced by the electrical stimulation increased after viewing stronger pain expressions in both tasks, but the RIII-response showed this vicarious facilitation effect only in the movement discrimination task at the strongest expression intensity. These findings are consistent with the notion that vicarious processes facilitate self-pain and may prime automatic nociceptive responses. However, this priming effect is influenced by top-down attentional processes. These results provide another case of dissociation between reflexive and perceptual processes, consistent with the involvement of partly separate brain networks in the regulation of cortical and lower-level nociceptive responses. Combined with previous results, these findings suggest that vicarious pain facilitation is an automatic process that may be diminished by top-down attentional processes directed at the meaning of the expression.     

The Effect of Parental Modeling on Child Pain Responses: The Role of Parent and Child Sex

Social modeling is a process by which pain behaviors are learned, and research has found parents act as models for their children's behavior. Despite social learning theory predicting that same-sex models have greater effect, no experimental investigation to date has examined the role of sex of the model or observer in social learning of pediatric pain. The present study recruited 168 parent-child dyads (equal father-son, father-daughter, mother-son, and mother-daughter dyads) in which children were generally healthy and 6 to 8 years old. Unbeknownst to their child, parents were randomly assigned to exaggerate their expression of pain, minimize their expression of pain, or act naturally during the cold pressor task (CPT). Parents completed the CPT while their child observed, then children completed the CPT themselves. Children whose parents were in the exaggerate condition reported higher anxiety than children of parents in the minimize condition. Additionally, girls in the exaggerate condition rated their overall pain intensity during the CPT significantly higher than boys in the same condition. No child sex differences were observed in pain intensity for the control or minimize conditions. Parent expressions of pain affects children's anxiety, and sex-specific effects of parental exaggerated pain expression on children's own subsequent pain experience are present.

Observation of Emergency Room Nurses Managing Pediatric Pain: Care to Be Given… Care Given…

BackgroundAlthough pain undeniably has negative consequences, pain management often remains suboptimal, particularly in the pediatric population in the emergency room (ER).AimIn this observational study using qualitative and quantitative methods, we investigated everyday adherence to current nursing best-practice pediatric guidelines in the ER paying particular attention to the interaction between children, parents, and nurses.MethodsAn adapted version of the nursing observation tool for pain management was used to describe pediatric pain management provided by nurses caring for children (0-14 years old) admitted to the ER. We also assessed child–parent–nurse interactions. (The aim of the study was presented to the nurses as part of the survey on interactions without specifying the focus on pain management.)ResultsForty-seven children were included (91 painful episodes) during the observation period (112 hours). There was a screening for pain in 55% of cases, and pain scales were used in 10% of cases. Analgesic treatments were administered in 75% of cases (procedural or disease-related pain). Follow-up evaluations were performed in 19% of cases. Nonpharmacologic approaches were scarcely used. The use of both helpful and nonhelpful languages were noted during interactions with children and parents. Parents' collaboration was rarely requested to help relieve their child's pain.ConclusionsOur results show that pediatric pain management in the ER could be optimized. Parents are still not considerably involved in their child's pain management. Parents' involvement could contribute to improving pediatric pain management.     

Nurses' Views About the Barriers and Facilitators to Effective Management of Pediatric Pain

Children continue to experience moderate to severe pain during hospitalization. This paper presents data from two modified focus groups undertaken as part of a larger study exploring pediatric pain management practices in one hospital in the south of England. Thirty nurses took part in the focus groups and were asked questions about their views about the barriers and facilitators to effective pain management in the hospital. Participants identified a number of barriers which related to the staff, children and parents and the organization. Nurses indicated that they and the medical staff lacked knowledge about pain management. They also felt that staff shortages and a heavy workload detracted from the quality of the care they could provide. Several participants indicated that insufficient analgesic drugs were sometimes prescribed. Many of the barriers identified related to parents and children. It appears that nurses may not take as active a role as they could do in managing pediatric pain rather seeing it as the parents and child’s responsibility to let them know when they are experiencing pain. Nurses also felt that parents exaggerate their child’s pain and ask for analgesic drugs before their child needs them. There is a need to explore the interactions between nurses, children and parents in this context in more detail.     

Emotion regulatory function of parent attention to child pain and associated implications for parental pain control behaviour

We investigated the function of parental attention to child pain in regulating parental distress and pain control behaviour when observing their child performing a painful (cold pressor) task (CPT); we also studied the moderating role of parental state anxiety. Participants were 62 schoolchildren and one of their parents. Parental attention towards or away from child pain (ie, attend to pain vs avoid pain) was experimentally manipulated during a viewing task pairing unfamiliar children’s neutral and pain faces. Before and after the viewing task, parental distress regulation was assessed by heart rate (HR) and heart rate variability (HRV). In a subsequent phase, parents observed their own child perform a CPT task, allowing assessment of parental pain control behaviour (indexed by latency to stop their child’s CPT performance) and parental distress, which was assessed via self-report before and after observation of child CPT performance. Eye tracking during the viewing task and self-reported attention to own child’s pain confirmed successful attention manipulation. Further, findings indicated that the effect of attentional strategy on parental emotion regulation (indexed by HR, self-report) and pain control behaviour depended on parents’ state anxiety. Specifically, whereas low anxious parents reported more distress and demonstrated more pain control behaviour in the Attend to Pain condition, high anxious parents reported more distress and showed more pain control behaviour in the Avoid Pain condition. This inverse pattern was likewise apparent in physiological distress indices (HR) in response to the initial viewing task. Theoretical/clinical implications and further research directions are discussed.