Childhood Pain

Juvenile arthritis is one of the most prevalent chronic diseases in children in the United States. While arthritis pain has been the focus of much research in adults, there is an increasing awareness of the need to focus on pain in children. Children with juvenile arthritis may have pain that can be intense and disabling, and comprehensive treatment optimizes their ability to fully participate in school and social activities.1

Children with arthritis may experience pain until their disease is adequately treated and controlled, and during disease flares. Pain may significantly interfere with a child’s daily activities. When children do not want to talk about their pain, it is difficult for parents, health care professionals, and teachers to determine how much pain a child is experiencing.

A child’s self report of pain is the most valid and reliable assessment of a child’s pain intensity and location.2 Children are sometimes reluctant to complain of pain,3 and may deny or under report pain because they:

  • fear it will result in additional unpleasant procedures or treatments
  • do not understand the pain can be treated
  • wish to protect their parents from the reality of their disease
  • desire to please others.

A Body Outline can assist a child in communicating the location and intensity of their pain. Children over the age of 4 years can use crayons or colored markers to indicate the part of the body which has pain, and how much the pain hurts.

Body Outline

Reprinted with permission of J.M. Eland from McCaffery and Beebe, 1989. May be duplicated.
McCaffery M, Beebe A. Pain: clinical manual for nursing practice. St. Louis: CV Mosby Co.; 1989.

After discussing with the child several things that have hurt the child in the past: Present eight crayons or markers to the child. Suggested colors are yellow, orange, red, green, blue, purple, brown, and black. Ask the following questions, and after the child has answered, mark the appropriate square on the tool (e.g., severe pain, worst hurt), and put that color away from the others. For convenience, the word hurt is used here, but whatever term the child uses should be substituted. Ask the child these questions:

  1. "Of these colors, which color is most like the worst hurt you have ever had, (using whatever example the child has given) or the worst hurt anybody could ever have?" Which phrase is chosen will depend on the child's experience and what the child is able to understand. Some children may be able to imagine much worse pain than they have ever had, while other children can only understand what they have experienced. Of course, some children may have experienced the worst pain they can imagine.
  2. "Which color is almost as much hurt as the worst hurt (or, use example given above, if any), but not quite as bad?"
  3. "Which color is like something that hurts just a little?"
  4. "Which color is like no hurt at all?

"Show the four colors (marked boxes, crayons, or markers) to the child in the order he has chosen them, from the color chosen for the worst hurt to the color chosen for no hurt.  Ask the child to color the body outlines where he hurts, using the colors he has chosen to show how much it hurts.  When the child finishes, ask the child if this is a picture of how he hurts now or how he hurt earlier. Be specific about what earlier means by relating the time to an event, e.g., at lunch or in the playroom.

Download the Body Outline.


1. Schanberg L, Anthony K, Gil K, and Maurin E. Daily pain and symptoms in children with polyarticular arthritis. Arthritis and Rheumatism, 2003; 48(5):1390-97.
2. Ross DM, Ross SA. Childhood pain: current issues, research, and management. Baltimore: Urban & Schwarzenberg; 1988.
3. McGrath PA, editor. Pain in children: nature, assessment, and treatment. New York: The Guilford Press; 1990b.
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