Can we screen young children for their ability to provide accurate self-reports of pain? Carl L. von Baeyer a,b,⇑ , Lindsay S. Uman c,d , Christine T. Chambers c,d,e , Adele Gouthro d a Department of Psychology, University of Saskatchewan, Saskatoon, SK, Canada b Department of Pediatrics, University of Saskatchewan, Saskatoon, SK, Canada c Department of Psychology, Dalhousie University, Halifax, NS, Canada d IWK Health Centre, Halifax, NS, Canada e Department of Pediatrics, Dalhousie University, Halifax, NS, Canada Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. article info Article history: Received 22 September 2010 Received in revised form 13 January 2011 Accepted 3 February 2011 Keywords: Screening Self-report Young child Pain intensity Pain scale Postoperative pain Parent abstract No validated screening tasks exist to distinguish children who can accurately use self-report pain mea- sures 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 chil- dren’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 anal- gesia), and based on parent-child agreement. On average, parents rated the youngest age at which chil- dren 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 chrono- logical 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. Ó 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. 1. Introduction Because pain is primarily a subjective experience, self-report, when available, is widely considered to be the primary source of information about pain intensity [16]. Most children develop the ability to provide accurate self-reports of pain intensity between 3 and 7 years of age [25]. Child age has emerged as the best predic- tor to date of accurate use of self-report measures [18–20]. How- ever, age is only a proxy for the underlying skills required to understand and provide accurate self-reports of pain [3], such as classification, seriation, or matching. These skills are typically not highly developed in preschool-aged children. Lacking these skills, preschoolers often provide pain ratings distorted by response biases such as choosing only the highest and lowest scores; these provide simpler strategies to answer questions that are cognitively complex [27]. It would be helpful if screening tasks could be used to deter- mine whether individual children are able to provide self-reports of pain with reasonable accuracy; for children failing such tasks, observational measures would be required. Various screening methods have been suggested, including tasks assessing verbal comprehension, matching figures, rating known quantities, rating pain in hypothetical vignettes, classification, counting, and seria- tion [3]. For example, Beyer and colleagues [5] recommend a task they call seriation, in which they have children pick the biggest of 6 cutout shapes, then the smallest, and then pick the biggest shape among those remaining until no shapes remain. Beyer et al. recommend that only children who successfully complete this task should be asked to rate pain intensity using the Oucher faces scale. Only one study [24] provides some support for this screening task: children (ages 3–7 years) who failed the screening task (14% of participants) were less accurate in sequencing the 0304-3959/$36.00 Ó 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2011.02.013 ⇑ Corresponding author at: Department of Psychology, University of Saskatche- wan, 9 Campus Drive, Saskatoon, SK, Canada S7N 5A5. Fax: +1 306 966 6630. E-mail address: carl.vonbaeyer@usask.ca (C.L. von Baeyer). PAIN Ò 152 (2011) 1327–1333 www.elsevier.com/locate/pain