August 12, 2014 is International Youth Day, a day that celebrates the hard work and determination of those young people who strive to better themselves. The theme of this year’s day is “Mental Health Matters.” This recognizes the important role that mental health plays for youth around the world and the complex factors that help keep kids (and adults) mentally healthy.

Young people who experience mental health issues can be discriminated against by their peers and, sometimes, their parents.

If a child is also experiencing a condition or injury that causes chronic pain, that stigma can increase and result in the worsening of both conditions. Chronic pain and depression often go hand in hand, and youth with both conditions are at a higher risk for suicide.

Scientists are actually studying the link between pain and depression, and some believe that the bridge between them may be inflammation. People with depression have higher levels of a type of protein called cytokines. These proteins trigger an immune response in the body. This immune response includes inflammation. Although inflammation after an injury is helpful to cushion and protect the area from further harm, extended inflammation is often a source of pain.

A major reason this link between mental health and chronic pain is so complex is that young people may have difficulty communicating the level of their pain. Pediatric pain patients are often seen in a heightened state of distress and anxiety. If there is a history of mental health issues, including anxiety, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), or even attention deficit hyperactivity disorder (ADHD), it may be difficult to gauge the level of pain being experienced.

Because of this, pain in youth is generally unidentified and under-treated.

Children who experience long-term chronic pain or experience pain at a young age show changes in their pain perception that can also be difficult to track and diagnose. For this reason, a number of age-specific pain diagnostics have been created.

Neonates and infants

Age-specific pain diagnostic tests for neonates and infants include the following.

  • Neonatal Facial Coding System (NFCS): This system looks for indications of pain on an infant’s face. Healthcare professionals will specifically watch for 8 distinct indicators of pain that include eye squeezing, brow bulging, a deeper crease in the area between the nose and upper lip, a stretched mouth, pursed lips, a quivering chin, or a taut tongue. Some of the facial actions are present at all times, and others are present in less than 50% of painful situations, so this scale is helpful only as a general tool.
  • Neonatal Infant Pain Scale (NIPS): This scale takes pain measurements at 1-minute intervals before, during, and after a painful procedure. Pain indicators such as breathing patterns, crying, tension in the arms and legs, and facial expressions are examined to place pain on a scale from 0 (no pain) to 2 (highest level of pain) and then added up for each indicator. A score of 7 overall indicates a high level of pain. This scale is a good measurement of acute painful incidents.

Other pain indicators for infants are the Premature Infant Pain Profile (PIPP), Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES), and Maximally Discriminate Facial Movement Coding System (MAX).


Pain reporting is still difficult as infants grow into toddlers because language is not always accurate and is present at inconsistent rates. To that end, physicians look at non-verbal indicators, such as facial expression, movement, crying, and grasping to diagnose pain.

The Observational Pain Scale (OPS) remains 1 of the most widely used scales to assess pain that is either short- or long-term. This scale measures 7 areas and uses a simple 0-1 scale for each area for a maximum total score of 7, where 7 is the most extreme state of pain.

Other pain scales for toddlers include the Observational Scale of Behavioral Distress (OSBD), the Toddler-Preschooler Postoperative Pain Scale (TPPPS), and the COMFORT scale.


Preschoolers are able to express pain verbally but their reactions can still be limited, so these scales utilize pictures and self-reporting in addition to observation.

  • Poker chip tool: The poker chip tool helps to assess pain intensity and asks children to indicate how many “pieces of hurt” (poker chips) they are experiencing. This tool has also been used with success for adolescents.
  • Faces Pain Scale: The Faces Pain Scale asks children to indicate which faces on a chart accurately depict their level of pain. The physician will initially describe the level of pain and then ask the child to choose. Charts with faces that are neither tearful nor smiling have been proven most accurate, as children could be influenced by those types of faces.

School-age children and adolescents

Although this age group has some positives when it comes to accurately reporting pain, there are some difficulties at this level also. Doctors can rely more heavily on self-reporting levels of pain as children get older, but once they reach adolescence, children may minimize or under-report pain, especially in front of peers.

Additionally, mental health issues and challenges may begin to develop as kids get older, and more active kids in year-round athletics or other pursuits such as dance or gymnastics may also have complicating chronic pain from a repetitive injury. So although teens can report their pain, their issues may be made more complex by their developing brains and neurochemicals, in conjunction with social and peer issues.

Mental health and chronic pain affect all children. International Youth Day seeks to empower youth around the world to make positive changes and contributions to the world around them.

Use this toolkit to participate in International Youth Day 2014!

Image by Tetyana Pryymak via Flickr


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