Preschoolers’ Cognitive Limitations Affect Ability to Rate Pain

Preschool children may be confused by scales designed for older children, and their responses may be idiosyncratic and hard to interpret.

For most adults and older children, rating pain on a scale of 1 to 10 is a simple concept. Preschool-aged children, however, generally lack the cognitive skills to accurately report their pain, according to research published in PAIN.

“Using a scale to estimate and report pain intensity is a complex mental process and is often challenging for children under the age of 5 or 6,” Jenny Yun-Chen Chan, graduate student at the University of Minnesota-Twin Cities, and Carl L. von Baeyer, PhD, of the University of Manitoba, Winnipeg, wrote in the report.  “Preschool children may be confused by scales designed for older children; their responses may be idiosyncratic and hard to interpret.”

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The researchers discuss intellectual development issues that hinder children’s ability to rate their pain, as well as possible modifications to create more developmentally appropriate pain assessment scales for this age group.

In order to accurately rank their pain on a scale, children must make use of a number of skills: seriation, which makes use of cognitive flexibility; working memory; and inhibition — knowledge of magnitude, symbolic processing, and explicit memory. Many of these skills do not develop until the age of 5 or 6.


Seriation tasks test the ability to put objects in a particular order based on a dimension, such as size. An example of a seriation task would be rating expressions of pain according to the Facial Affective Scale. These kinds of tests require children to make use of cognitive flexibility, the skill of shifting attention between tasks, and of considering multiple options simultaneously (such as being able to recognize that a medium-sized cup is small compared with a big cup, but at the same time is big compared with a small cup). Children tend to not be able to incorporate multiple comparisons until about 4 or 5 years old.

Seriation tasks also require children to be able to hold enough information in their working memory to complete the task, and that they are able to inhibit irrelevant information (such as color, if the task requires ordering by size). Many young children have difficulty with these skills.