Journal of Pediatric Psychology, Vol. 25, No. 5, 2000, pp. 301-308
© 2000 Society of Pediatric Psychology
Everyday Pain Responses in Children With and Without Developmental Delays
1 University of British Columbia, 2 University of Northern British Columbia
All correspondence should be sent to Kenneth Craig, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, British Columbia V6T 1Z4. E-mail : kcraig{at}cortex.psych.ubc.ca
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Objective : To examine whether children with developmental delays respond to painful events differently than nondelayed children.
Methods : Sixty families participated. Children between the ages of 2 and 6 years were observed at daycare centers while engaged in usual daily activities, such as free play. Spontaneous painful incidents and the child's responses were recorded using an observational measure (Dalhousie Everyday Pain Scale) designed to capture pain behavior.
Results : Children with developmental delays (n = 24) displayed a less intense distress response to an equivocal pain event than nondelayed children (n = 36). Children with developmental delays were more likely to display no reaction following a pain event, whereas children without delays cried more often. Further, children with developmental delays engaged in fewer help-seeking behaviors and were less likely to display a social response following a pain event than nondelayed children.
Conclusions : Children with developmental delays appear to react in a different manner to pain events than nondelayed children do ; we discuss a possible socio-communicative deficit.
Key words: developmental delays; pain response; communication deficits.
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Introduction |
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The ability to communicate distress (e.g., hunger, pain, anger) appears to be present at birth (Izard, 1994
), may dictate a child's survival, and is an important
foundation for communication and language development
(Wetherby & Prizant,
1993). Even though the specific source of distress often may be
obscure to the observer, painful experiences appear to have salient and
discriminable overt features (Anand &
Craig, 1996).
Detailed description of the manner in which nondelayed infants and children
communicate pain has been a focus of interest for some time. Although there
are developmental changes in how children behave when in pain—older
children are less likely to cry (Craig,
Grunau, & Branson, 1988)—young children respond to
painful stimuli in a consistent manner. Fine-grained, nonverbal measurement
scales of pain indicate that infants and young children display a relatively
stereotypic facial reaction when confronted with invasive procedural pain
(e.g., Craig, Hadjistavropoulos, Grunau,
& Whitfield, 1994 ;
Gilbert et al., 1999 ;
Lilley, Craig, & Grunau,
1997). Multidimensional pain assessment measures also support the
observation of a consistent pain response. Children reacting to acute pain
situations predictably display muscular rigidity, verbal distress, crying,
flailing, and agitated behavior (Jay,
Ozolins, Elliott, & Caldwell, 1983). Similarly, recent
research examining how children respond to everyday pain incidents found that
they typically responded to a painful event with changes in facial expression,
verbal complaints (e.g., "ouch"), crying, and screaming
(Fearon, McGrath, & Achat,
1996 ; von Baeyer,
Baskerville, & McGrath, 1998).
The presence of a "stereotyped, temporally integrated pattern of
response to pain" (Craig et al.,
1988), which occurs across age groups, is no longer a point of
contention. The adaptive value of a consistent, recognizable expression
appears self-evident ; if infants and children are to persevere despite
physical harm, displaying a discernible reaction to provoke assistance
increases one's chances of survival
(Huebner & Izard, 1988)
and fosters closer interpersonal ties
(Craig, 1998 ;
Fridlund, 1991). However, we
have yet to determine what, if anything, happens to the pain expression when
there is neurological impairment.
To date, few investigations have studied the impact of developmental delays
on children's pain responses. Two studies by Biersdorff
(1991,
1994) proposed that adults with
developmental delays have a significantly elevated pain threshold and that
they display signs of pain indifference or pain insensitivity. A more recent
study (Oberlander, Gilbert, Chambers,
& Craig, 1999) demonstrated diminished facial activity during
a flu-shot in adolescents with severe neurological impairment. Like the
Biersdorff studies, the Oberlander et al. study also found little evidence of
a physiological response (i.e., heart rate).
Given the frequency at which children experience bumps and bruises,
approximately 0.33 incidents per hour per child
(Fearon et al., 1996),
everyday pain is an ideal subject to begin to investigate differences in how
children with and without developmental disabilities respond to painful
events. This study was a first step in examining whether there would be
notable differences in how children with and without developmental delays
respond to everyday pain events. We hypothesized that children with
developmental delays would display less intense pain reactions in response to
comparable pain events and would seek less social comfort.
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Method |
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Participants
A total of 60 children between the ages of 2 and 6 years (developmentally delayed and nondelayed) and one of their parents participated. There were 36 children in the nondelayed group and 24 in the developmentally delayed group. There were no significant group differences in any of the demographic variables as demonstrated by t tests (child age, parent age, socioeconomic status) and chisquare tests for the categorical variables (gender, ethnicity, marital status ; see Table I). Ninety-three percent of parents completing the questionnaires were mothers. Parents completing the questionnaires were asked to indicate if they were the primary caregiver. In both groups, all but one parent labeled themselves as such and all the fathers who completed the questionnaires indicated they were the principle caregivers. Therefore, data from fathers and mothers was combined for the analyses.
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The developmentally delayed group included children with a variety of developmental disorders including : autism (n = 1), down syndrome (n = 3), cerebral palsy (n = 3), spina bifida (n = 1), Apert's syndrome (n = 1), expressive language disorders (n = 8), and general developmental delays (n = 7). As all children were in Ministry for Children and Families supported daycare positions, children had at least two areas of documented delay with a minimum of six months to one year discrepancy between age expectations and performance. However, no further testing was completed to determine current cognitive abilities or areas of delay. Children who were severely delayed or physically impaired (confined to a wheel chair) were excluded. All families spoke English.
Procedure
This study was approved by the university human subjects review committee.
A list of the citywide daycares with Ministry for Children and Families
supported placements for children who were developmentally delayed was
obtained. Thirteen daycares had such places, and each daycare was contacted by
telephone to arrange an appointment to describe the study in more detail. All
daycares agreed to participate.
All families within the age range at each daycare were given a letter describing the purpose of the study and asking for permission to contact them at home. A total of 74 families returned the form. A research assistant contacted these families and asked to speak with the child's principal caregiver. The study was then described in more detail and a brief interview was conducted to determine group assignment for the participating child, nondelayed or developmentally delayed. Assignment to the developmentally delayed group was verified with the daycare director. Verbal consent was obtained and a package of questionnaires and a written consent form was left at the daycare the following business day for the participating parent to complete. Parents were given a copy of the consent form for their own purposes and asked to complete the questionnaires and return them to the daycare at their earliest convenience. Of the 74 families contacted, 5 did not return the consent forms. Also, data from 4 of the 13 daycares were not used because no children who were developmentally delayed were observed. This yielded the final total of 60 children and their parents who were included in the study.
Observations took place both in and outside the daycare facility for a
maximum of 3 hours per visit. The time limit was to ensure that the observers
remained vigilant. A total of six observers (five undergraduate students who
volunteered in the lab and the first author) collected all the data using a
variation of the focal sampling method described in
Altmann's 1974 paper on
observational studies of behavior. Focal sampling entails recording all
occurrences of a specified (inter)action of an individual, or specified group
of individuals during each sampling period
(Altmann, 1974). If daycares
were equipped with one-way mirrors, observations were conducted through them
according to the daycare director's wishes. There was a ratio of one observer
to every six children during all observation sessions, with a maximum of 12
children watched at one time. In general, two observers were present at each
session, each watching separate areas of the daycare. It was explained to the
children that the observers were there to do "homework." All
observations were conducted in as unobtrusive a manner as possible. No outward
contact was made with children ; however, due to the curious nature of
children, on some occasions an interaction could not be avoided. When a
potentially painful event occurred, the observer completed the Dalhousie
Everyday Pain Scale (Fearon et al.,
1996). An event was defined as potentially painful when either (1)
the observer judged it was appropriate to use a rating of 1 or more on the
perceived severity of hurt scale, or (2) the child responded to an incident
with distress or engaged in protective behaviors (e.g., holding the injured
area).
Measures
Demographic/Past History Questionnaires.
Parents completed a standard demographic information form (e.g., age,
gender, ethnic identity) and reported on their child's past medical history.
This measure asked for the number of visits to the doctor and dentist, number
of times the child had throat cultures or bloodwork done, and the number of
hospitalizations. Parents rated their child's reaction to each of type of
experience on a 7-point Likert scale (negative, neutral, or positive). This
measure is the same used in a study by Dalhquist et al.
(1986).
Illness Encouragement Questionnaire.
Parents also completed the Illness Behavior Encouragement Scale (IBES ;
Walker & Zeman, 1992). The
IBES assesses the manner in which parents react to their child's hurt or pain,
that is, do they encourage or discourage pain responses. A total of 11
questions were rated on 5-point Likert scales (0 = never do this ; 4 = always
do this). An example of an IBES question is "How often do you bring your
child special treats, or little gifts when he/she is hurt or in
pain."
Observational Measure.
The Dalhousie Everday Pain Scale
(Fearon et al., 1996) was used
to record children's responses to pain events. This measure has been used in
several studies (e.g., Fearon et al.,
1996 ; von Baeyer et al.,
1998) and has been shown to have excellent interrater reliability,
and the validity of the measure is well supported. Observers in these studies
demonstrated reliability levels (kappa) between.67 and.95 for the different
checklist items. Reliabilities for pain situation description items (e.g.,
body location, activity level) ranged between.67 and.93, whereas reliabilities
for ratings of perceived severity and the child's reactions (e.g., intensity
of distress, intensity of anger) were all above.75. A comprehensive manual is
available (cf. Fearon et al.,
1996), which describes, in detail, scoring criteria for each item
on the checklist. The first author was trained by the original investigators
in the use of the tool and demonstrated reliability with them. Subsequently
she trained the other five observers who helped gathered data. Accounts of all
observed events and recorded responses were reviewed by the first author.
The checklist contains items to be either noted (e.g., gender of the child, location of the event) or rated by the observer (e.g., behavioral context in which the event took place, description of the incident, child's response, adult's response). There are four sections to the pain scale. The first is behavioral context, which includes ratings on a 5-point scale for the child's level of activity (low to high), his or her tone (calm to agitated), and the level of personal control (high to low). In addition, the number of participants in each event is recorded. The second section is description of incident and includes body location, proximity to adult (less than 1 meter ; 1-2 meters ; more than 2 meters), hurt caused by self, other child, adult, or object, and perceived severity of hurt. This rating requires a subjective judgment by the observers as to how much hurt or pain they believed the incident would cause on a 5-point scale, where 0 = no hurt and 4 = severe hurt, independent of the child's actual reaction. Third, in subject's response, observers provided qualitative information on the intensity of distress, that is, did the child do nothing, make a face, cry, or scream. Duration of distress is recorded. If the child engaged in an anger response (e.g., hitting the child who caused the hurt), it was also noted. Protective behaviors (holding, favoring, reduction of activity) and their duration were also recorded as was the child's social response (withdrawal, neutral, help-seeking). Fourth, the type of adult response (generally from a daycare employee) was recorded, if it occurred at all.
Statistical Analyses
First, possible group differences on the questionaire data were
investigated. Second, we evaluated similarities between pain-instigating
events across the two groups (e.g., severity of hurt, cause of hurt, activity
level). Third, differences in intensity and duration of distress, intensity of
anger displayed, use and duration of protective behaviors, and social response
were assessed across children with and without developmental delays using
independent t tests or chi-square nonparametric tests. If there was a
significant difference, follow-up analyses compared the frequency of different
types of responses. Fourth, age and gender differences were examined.
A power analysis using the information gathered from the 60 children and
parents who participated in the study supported the assumption that we had
significant power to reject the null hypothesis (d =.5 ; 
=.05
; 
=.88).
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Results |
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Questionnaire Data
Thirty-one of 36 parents of nondelayed children and all parents of the 24 children with developmental delays returned completed questionnaires. Parent ratings of past medical experiences indicated that children with developmental delays had more medical experiences than nondelayed children, t = -3.79 ; p <.001. In addition, children with developmental delays were described as more likely to have had a negative reaction to these experiences than nondelayed children, t = 2.84 ; p <.01. Parent ratings on the IBES indicated no significant differences in parental interactions between children with and without developmental delays. Child gender did not vary with parent responding.
Description of the Pain Event
Children were observed for a maximum of 30 hours. One child in each of the
two groups did not experience a codable pain event. The mean number of hours
nondelayed children and those with developmental delays were observed was
18.72 and 14.15, respectively. This was a significant difference, t =
3.89 ; p<.001. The mean number of pain events was 3.97 (range =
1-11) for the nondelayed group and 3.44 (range = 1-9) for the developmentally
delayed group, a nonsignificant difference (p >.10). Given the
significant difference in total hours observed, the rate at which pain events
occurred was calculated. Both nondelayed children and those with developmental
delays injured themselves at rates (.22 and.25 events per hour) that did not
differ significantly. Thus, all children were likely to hurt themselves at
least once in 4 hours.
In general, the circumstances provoking pain were relatively similar for children with and without developmental delays. The pain events were similar in respect to activity level, tone, number of participants, perceived level of personal control, cause of the hurt, and, most important, perceived severity of hurt. Chi-square analyses demonstrated significant differences between nondelayed children and those with developmental delays for the following variables only : proximity to adult, X2 (1, N = 60) = 11.57, p <.01, and whether the pain event took place inside or outdoors, X2 (1, N = 60) = 18.73, p <.01.
Follow-up analyses using the procedure developed by Marascuilo
(1996) for multiple
comparisons among proportions demonstrated that a higher proportion of
children with developmental disabilities (46.5% vs. 26.1%) were within less
than one meter of an adult caregiver during the painful event. Nondelayed
children were more often two or more meters away (40.8% vs. 24.4%). Finally,
nondelayed children experienced more pain events outside (81% vs. 48%). This
is likely an artifact as the daycare where the majority of the children with
developmental delays were observed had only 15 minutes of the morning or
afternoon scheduled for outside play.
Children's Response to the Painful Event
Independent sample t tests indicated notable differences in how
children with developmental delays responded to a painful stimulus as compared
to nondelayed children (see Table
II). First, children with developmental delays displayed a less
intense distress response ; t = 3.13 ; p <.01. Given the
significant overall t test, follow-up chi-square analyses on the
frequency of each level of distress response (no response, facial action,
verbal comment, crying, screaming) were performed. More children with
developmental delays engaged in no response to a painful event than nondelayed
children, X2 (1, N = 60) = 15.57 ; p <.001,
and a greater proportion of nondelayed children engaged in crying,
X2 (1, N = 60) = 6.43 ; p <.01, and/or
screaming behaviors, X2 (1, N = 60) = 16.79 ; p
<.001, than children who were developmentally delayed.
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The type of social response children in each group displayed was also significantly different, X2 (1, N = 60) = 7.22 ; p <.05. More children without a developmental delay (22.8% vs. 9.3%) engaged in help-seeking behavior after a painful incident than children with a developmental delay.
There were no significant differences between groups in : the duration of distress response, the use of protective behaviors, duration of protective behaviors, or anger response.
Age and Gender Differences in Response Styles
Independent sample t tests examining gender differences within the
pain response variables revealed only one difference. Within the
developmentally delayed group, boys used self-protective behaviors more often
than girls, t = 2.14 ; p <.05.
Correlational analyses between pain response variables (e.g., use of protective behaviors, distress behaviors) and child age suggested a positive relationship between age and the use of anger only for the developmentally delayed group (r =.43 ; p<.05).
Correlation analyses between pain response variables, amount of medical experience, and quality of reaction indicated no significant relationships for either children with or without developmental delays.
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Discussion |
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Children with developmental delays, in contrast to children without delays, displayed less vigorous responses to comparable pain events, and these events instigated fewer social responses, even though they were in closer proximity to adults. It appears that children with developmental delays (1) exhibit a moderated response to the everyday bumps and bruises they endure, and (2) do not seek attention to the same degree when hurt as do children without developmental delays.
As proposed by Biersdorff
(1991,
1994) the unconventional pain
response described here could reflect basic biophysical differences between
the two populations, but we have no direct evidence of this. Perhaps
interpreting the altered response as being due, at least in part, to a
socio-communicative deficit may be more parsimonious.
A socio-communicative deficit has been documented in children with
developmental delays for positive interactions. For example, children with
developmental delays were shown to express less positive affect during social
interactions (Kopp, Baker, & Brown,
1992). Bufkin and Altman
(1995) also ascertained that
children with developmental delays often display inappropriate facial actions
during positive social interactions (e.g., a game). Finally, it seems that
social signaling behaviors (e.g., making eye contact, vocalizing, pointing to
an object) are less developed and effective in children with developmental
delays (Berger & Cunningham,
1981).
Given these findings in positive social situations, it is conceivable that
the children with developmental delays in this study may have exhibited an
altered pain response also because of social-communicative deficits. Rather
than assume that children with developmental delays are relatively pain
indifferent or insensitive, as suggested by Biersdorff
(1991,
1994), we propose that these
children process information and communicate distress in a different manner.
However, further research needs to examine this in more detail.
There were limitations to the study. Because developmental delays are often
visually identifiable, observers could not be kept wholly blind to group
assignment. Trained observers were aware if a child had a developmental delay
and were also aware of the purpose of the study. Although this could have
yielded biased results, it was unlikely as the rate of painful behaviors did
not differ between groups despite significant differences between groups in
time observed. Second, the diagnoses for children with developmental delays
were somewhat heterogeneous ; however, all children were delayed by at least 1
year and no children were classified as severely delayed. The heterogeneous
sample was seen as advantageous as this was an initial study with children who
had intellectual deficits and generalizability was an issue. In addition,
combining all developmentally delayed children into one group was a
conservative move ; children with moderately severe developmental delays
(e.g., Down syndrome) might be expected to have more communicative
difficulties than those with less severe (e.g., expressive language
disorders), so if a difference was still evident between nondelayed children
and those in this sample with developmental delays, our findings would be
strengthened. Nonetheless, it is important that future research refine these
broad categorizations to identify specific cognitive, motor, linguistic, and
other possible differences that might be clearly linked to the pain response
(Craig, Lilley, & Gilbert,
1996). Future research may with to examine the cognitive
functioning of all children, both those with and without developmental delays
as we were unable to ensure that children in the nondelayed group in this
study did not have unidentified delays.
Finally, in choosing to engage in an investigation of spontaneous behavior in a natural environment, one trades external validity for lack of control ever events having an impact on the children. That is, the events instigating pain in this study could not be standardized to ensure that the pain events in the two groups were comparable in frequency, intensity, and character. Nevertheless, given that the events were judged comparable on a number of variables by trained observers, there is little reason to attribute the differences in the children's responses to event differences.
There are several important implications of this research. Given the apparent differences in how children with and without developmental delays respond to painful incidents (children with developmental delays display a less intense response and are less likely to seek social support), health care practitioners and caregivers need to take care when assessing pain states in this population, particularly as it may affect delivery of appropriate care to these children. For instance, health care workers may underestimate the prevalence of pain, because these children do not display the pain with the same vigor as can be expected from children without cognitive deficits. Familiarizing health care professionals with how children with developmental delays respond to pain may help to avoid untreated and unnecessary pain. Similar logic applies to parents and daycare workers, as the majority of a child's painful experiences do not occur in the health care system. Untreated pain at home or in the daycare has as many adverse consequences at that experienced in a hospital environment.
To continue to effectively educate people working with this population of children, future research needs to examine more fine-grained behaviors, such as facial actions, and determine more specifically those psychological parameters that affect pain expression, such as level of cognitive impairment. Furthermore, determining whether these children, over time, develop a response to pain similar to those of children without developmental delays, or if they acquire a unique way of expressing pain, is also essential. This study provided preliminary information about age effects in that age was not associated with the development of a similar response to painful events. In fact, age was related only to the use of an anger response ; older developmentally delayed children engaged in more anger responses when hurt or in pain. Perhaps these children are developing an ability to signal pain, but they use different behaviors to do so ; however, more extensive research needs to be completed before we can make this assertion.
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Acknowledgments |
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This study was supported, in part, by a Social Science & Humanities Research Council Grant to Kenneth Craig. Cheryl Gilbert-MacLeod was supported by a Social Science & Humanities Research Council Studentship. We thank all the families and daycares who participated in the study and Deborah Sandbrand and Tina Wang for their invaluable assistance in data collection.
Received July 24, 1998; revision received December 1, 1998; revision received May 7, 1999; accepted August 10, 1999
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References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Altmann, J. (1974). Observational study of behavior : Sampling methods. Behaviour, 499, 227-267.
Anand, K. J. S., & Craig, K. D. (1996). Editorial : New perspectives in the definition of pain. Pain, 67, 3-6.[Web of Science][Medline]
Berger, J., & Cunningham, C. C. (1981). The development of eye contact between mothers and normal versus Down's syndrome infants. Developmental Psychology, 17, 678-689.
Biersdorff, K. K. (1991). Pain insensitivity and indifference : Alternative explanations for some medical catastrophes. Mental Retardation, 29, 359-362.[Web of Science][Medline]
Biersdorff, K. K. (1994). Incidence of significantly altered pain experience among individuals with developmental disabilities. American Journal of Mental Retardation, 98, 619-631.
Bufkin, L. J., & Altman, R. (1995). A developmental study of nonverbal pragmatic communication in students with and without mild mental retardation. Education and Training in Mental Retardation and Developmental Disabilities, September, 199-207.
Craig, K. D. (1998). The facial display of pain. In G. A. Finley & P. J. McGrath (Eds.), Measurement of pain in infants and children (pp. 103-122). Seattle : IASP Press.
Craig, K. D., Grunau, R. V. E., & Branson, S. M. (1988). Age-related aspects of pain : Pain in children. In R. Dubner, G. F. Gebhart, & M. R. Bond (Eds.), Proceedings of the Vth World Congress on Pain (pp. 317-328). Amsterdam : Elsevier Science Publishers BV (Biomedical Division).
Craig, K. D., Hadjistavropoulos, H. D., Grunau, R. V. E., &
Whitfield, M. F. (1994). A comparison of two measures of facial
activity during pain in the newborn child. Journal of Pediatric
Psychology, 19,
305-318.
Craig, K. D., Lilley, C. M., & Gilbert, C. A. (1996). Social barriers to optimal pain management in infants and children. Clinical Journal of Pain, 17, 247-259.
Dahlquist, L. M., Gil, K. M., Armstrong, F. D., DeLawyer, D. D., Greene, P., & Wuori, D. (1986). Preparing children for medical examinations : Importance of previous medical experience. Health Psychology, 5, 249-259.[Web of Science][Medline]
Fearon, I., McGrath, P. J., & Achat, H. (1996). `Booboos' : The study of everyday pain among young children. Pain, 68, 55-62.[Web of Science][Medline]
Fridlund, A. J. (1991). Evolution and facial action in reflex, social motive, and paralanguage. Biological Psychology, 32, 3-100.[Web of Science][Medline]
Gilbert, C. A., Lilley, C. M., Craig, K. D., McGrath, P. J., Court, C., Bennett, S. M., & Montgomery, C. (1999). Postoperative pain expression in preschool children : Validation of the child facial coding system. Clinical Journal of Pain, 15, 192-200.
Hollingshead, A. B. (1965). Four factor index of social status. Unpublished manual.
Huebner, R. R., & Izard, C. E. (1988). Mothers' responses to infants' facial expressions of sadness, anger, and physical distress. Motivation and Emotion, 12, 185-197.
Izard, C. E. (1994). Innate and universal facial expression : Evidence from developmental and cross-cultural research. Psychological Bulletin, 115, 288-299.[Web of Science][Medline]
Jay, S. M., Ozolins, M., Elliott, C., & Caldwell, S. (1983). Assessment of children's distress during painful medical procedures. Journal of Health Psychology, 2, 133.
Kopp, C. B., Baker, B. L., & Brown, K. W. (1992). Social skills and their correlates : Preschoolers with developmental delays. American Journal of Mental Retardation, 96, 357-366.
Lilley, C. M., Craig, K. D., & Grunau, R. V. E. (1997). The expression of pain in infants and toddlers : Developmental changes in facial action. Pain, 72, 161-170.[Web of Science][Medline]
Marascuilo, L. A. (1966). Large-sample multiple comparisons. Psychological Bulletin, 65, 280-290.[Web of Science][Medline]
Oberlander, T. M., Gilbert, C. A., Chambers, C. T., O'Donnell, M. E., & Craig, K. D. (1999). Biobehavioral responses to acute pain in adolescents with a significant neurologic impairment. Clinical Journal of Pain, 15, 201-209.
von Baeyer, C. L., Baskerville, S., & McGrath, P. J. (1998). Everyday pain in 3-5 year old children in day care. Pain Research and Management, 3, 111-116.
Walker, L. S., & Zeman, J. L. (1992). Parental
response to child illness behavior. Journal of Pediatric
Psychology, 17,
49-71.
Wetherby, A. M., & Prizant, B. M. (1993). Profiling communication and symbolic abilities in young children. Journal of Childhood Communication Disorders, 15, 23-32.
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