26 August 2004

Pain in children

I just came across this online article on assessing pain in children with cancer. Both sad and interesting.

While the whole article is worth reading, here's something I was unaware of:
The first question on the Pain Experience History [ed:see next quote]addresses whether the child understands the word pain. This question evolved from two studies (42,43) documenting that hospitalized children often do not understand what pain is. The preferred word for many children under 12 years is hurt (49). The child's response to ``Tell me what pain is'' provides the health care provider with the word to use when discussing pain with the child. For example, a 12-year-old boy with Burkitt's lymphoma said pain was ``real hard throbbing'' (52). This child seemed to understand the word pain. In contrast, a 7-year-old boy with more than 20 previous surgeries denied knowing what the word pain meant (42). He did, however, understand the word hurt.

This seems to be another phenomenon which points to the fact that we must learn what pains are and their place in our lives (i.e., they are evils to be avoided). This conclusion is important for understanding what pains are.*

For just one example, simple hedonic theories of value are traditionally threatened by the fact that pleasures and pains come in myriad forms. This makes it unclear why some things are pains and others are not. Such theories therefore verge on trivial. The fact that we must learn our conceptions of pain thus suggests that the class of pains has few natural boundaries. Losing pain as a fundamental or innate concept twists the knife for these views.

Whether you buy this connection or not, the material here is at least thought provoking.

Here's a bit of the Pain Experience History questionairre

Child form (C) Parent Form (P)
(C1) Tell me what pain is.
(P1)What word(s) does your child use in regard to pain?
(C2)Tell me about the hurt you have had before.
(P2)Describe the pain experiences your child has had before.

C3)Do you tell others when you hurt? If yes, who?
P3)Does your child tell you or others when he or she is hurting?

(C4)What do you do for yourself when you are hurting?
(P4)How do you know when your child is in pain?

(C5) What do you want others to do for you when you hurt?
(P5)How does your child usually react to pain?

(C6)What don't you want others to do for you when you hurt?
(P6)What do you do for your child when he or she is hurting?

(C7)What helps the most to take your hurt away?
(P7)What does your child do for him- or herself when he or she is hurting?

(C8)Is there anything special that you want me to know about you when you hurt? (If yes, have child describe.)
(P9)What works best to decrease or take away your child's pain? Is there anything special that you would like me to know about your child and pain? (If yes, describe.)

And two, depressing but philosophically interesting, cases
Other questions focus on the child's prior pain experiences, how the child communicates about pain, and the child's preferences for management. A 5-year-old boy with Burkitt's lymphoma said ``spinal taps'' in response to the inquiry about prior pain experiences; he described his bone marrow aspiration as ``bow and arrow'' (52). A response like this provides the health care professional with important information about the child's understanding of a bone marrow aspiration. The child placed the concept of the bone marrow aspiration into the context of something more familiar-a bow and arrow.

A 9-year-old girl with osteosarcoma and severe mucositis said she told others when she hurt, but with the mucositis, she had to communicate by writing (52). She wanted to hold her mother's hand when she hurt and described back rubs, conversation, quiet distraction, and a quiet room as helpful in relieving her pain. She did not want others to surprise her by ``moving her sore leg.'' This child's responses would be extremely helpful in planning care to identify, prevent, and treat pain.

I suppose I'm alone in being impressed by the fact that the boy describes how his pain felt via an inference about what it would feel like to be shot with an arrow (though he might mean that the pain is both sharp and tight; I'm drawing my reading from the fact that the cause is having his bones drilled).

*There's a bunch of literature on how we learn pain. The references for this article are here. And you must know the classic McGill dog study if you are to impress your friends and intimidate your enemies is. I can scrounge up more references on request.

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