title: Validity of parent ratings as proxy measures of pain in children with cognitive impairment.
abstract: 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.
authors.affiliation: University of Michigan Medical Center, Ann Arbor, 48109, USA. terriv@umich.edu
authors.forename: Terri
authors.initials: T
authors.lastname: Voepel-Lewis
authors.forename: Shobha
authors.initials: S
authors.lastname: Malviya
authors.forename: Alan R
authors.initials: AR
authors.lastname: Tait
mesh_terms: D000293:Adolescent; D001294:Attitude to Health; D015982:Bias; D002648:Child; D002652:Child Behavior; D002675:Child, Preschool; D003072:Cognition Disorders / Q000150:complications*; D003448:Crying; D005149:Facial Expression; D006801:Humans; D007697:Kinesics; D008824:Michigan; D009730:Nursing Assessment / Q000379:methods / Q000592:standards; D015403:Nursing Evaluation Research; D010147:Pain Measurement / Q000379:methods* / Q000451:nursing / Q000592:standards; D010149:Postoperative Pain / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000523:psychology; D010290:Parents / Q000523:psychology*; D019727:Proxy / Q000523:psychology*; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D013997:Time Factors