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Behavioral Observation In Children
Behavioral observation is the primary assessment approach for preverbal and nonverbal children and is an adjunct to assessment for verbal children. Observations focus on vocalizations (e.g., crying, whining, or groaning), verbalizations, facial expressions, muscle tension and rigidity, ability to be consoled, guarding of body parts, temperament, activity, and general appearance. Adequate reliability and validity documentation is lacking for behavioral observations; consequently, most such observations offer only a second-best approximation of the child's experience, even though clinicians often attribute greater importance to nonverbal expression than to self-report.104 Changes in how a child looks and acts may indicate the onset of pain or its increase207 and warrant further investigation and documentation.
Observations are problematic in that the stimulus for behaviors or changes is not always clear. For example, children cry in response to pain, as well as fear, loneliness, and overstimulation. Clinicians may misinterpret behaviors such as sleeping, watching television, and using humor as the absence of pain when, in fact, the child is attempting to control pain. Moreover, behavioral responses may be absent or attenuated when vocalizations or movements cause or increase pain. Infants may become apathetic after only a few days of continuing severe pain, and suffering experienced by older children and adolescents with cancer may blunt behaviors and affect. Other factors that inhibit behavioral responses include incubation, use of paralyzing agents or sedatives, extreme illness, weakness, or depression. Therefore, the use of behavioral observation to guide analgesia requires close attention to the context. If caretakers are not sure whether a behavior indicates pain and if there is reason to suspect the presence of pain, a trial of analgesics can be diagnostic as well as therapeutic.
Most of the scales developed for measuring behaviors address postoperative pain or pain associated with invasive procedures.275 Given the nature of cancer-related pain, behavioral scales for the assessment of acute pain problems are unlikely to be sensitive in assessing the child with cancer pain. The Gustave-Roussy Child Pain Scale 174 is the only observation tool developed for children with cancer-pain.
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