what helps when it hurts: children's views on pain relief

What helps when it hurts: children’s views onpain relief

L. S. Franck,*† A. Sheikh† and K. Oulton‡

*lnstitute of Child Health, University College London†University College London, and‡Great Ormond Street Hospital for Children NHS Trust, London, UK

Accepted for publication 8 October 2007

Keywordschildren’s views, healthbeliefs, pain

Correspondence:Linda S. Franck, PhD, RN,RGN, RSCN, FRCPCH,FAAN, Institute of ChildHealth & Great OrmondStreet Hospital forChildren NHS Trust, Level7, Old Building, GreatOrmond Street, LondonWC1N 3JH, UKE-mail:[email protected]

AbstractBackground Previous studies have focused on children’s views of sources of pain and only

secondarily explored their views on pain-relief strategies.

Methods An exploratory cross-sectional descriptive design and ‘draw and write’ technique were

used to investigate what children think helps them when they have pain.

Results The sample (n = 71) was comprised of 33% boys and 67% girls, with an age range of

4–16 years (mean � SD: 9.25 � 3.04). Four overarching themes were derived that were common to

both the texts and drawings: ‘People who help’, ‘What I do that helps’, ‘What other people do that

helps’ and ‘Things that help’. Children also described their emotional reactions to pain or pain relief.

Multiple themes were represented in most of the texts and drawings. There were few differences in

the themes present in the children’s texts and drawings based on developmental age and no

differences based on gender.

Conclusions Children across the three developmental age groups view themselves as active

agents in pain relief. Although less than half of the children described specific behaviours they had

taken, almost all children indicated their active role as the central figure in relation to use of objects

or the actions of others.

Introduction

The first investigations of children’s views about pain were con-

ducted in the 1970s and 1980s (Schultz 1971; Unruh et al. 1983;

Ross & Ross 1984; Gaffney & Dunne 1986; Hurley & Whelan

1988) showing that school-aged children understood the

concept of pain and could describe its causes and consequences,

and its sensory, cognitive and emotional characteristics. Two of

these studies had large school-based cohorts of 994 (Ross &

Ross 1984) and 680 (Gaffney & Dunne 1986) children, one of

which suggested that children’s understanding of the concept of

pain followed a developmental age trajectory consistent with

Piagetian stages (Gaffney & Dunne 1986) and the other did not

(Ross & Ross 1984). Some studies found a difference in the

descriptors used by boys and girls (Gaffney & Dunne 1986),

whereas others did not (Unruh et al. 1983; Ross & Ross 1984).

Later studies of healthy children’s understanding of and

responses to everyday and medical pain (Alex & Ritchie 1992;

Ely 1992; Harbeck & Peterson 1992; McGrath et al. 1997;

Kortesluoma & Nikkonen 2004) added support to the notion

that children’s concept of pain followed the stages of general

cognitive development and also revealed the importance of

influencing factors such as the child’s gender and type of pain.

In contrast to the body of research about how children per-

ceive pain, less is known about the views of children regarding

people, objects or actions that prevent or relieve pain. Previous

studies have focused primarily on children with post-operative

pain (Woodgate & Kristjanson 1995; Palermo & Lambert 1997;

Original Article doi:10.1111/j.1365-2214.2008.00812.x

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd430

Child: care, health and development

mailto:[email protected]

Polkki et al. 2003) and suggest that children may attempt basic

cognitive or physical actions aimed at reducing pain or anxiety.

Ely (1992) found that ‘bandaids’ (plasters) and medicine fea-

tured prominently in school-aged children’s drawings about

pain. However, because of the nature of the research questions

and samples used in previous studies, the findings tended to

emphasize the role of health professionals or parents in chil-

dren’s pain relief. Thus, the broad question of what helps chil-

dren when they have pain has never been directly posed. Greater

understanding of children’s general views on what constitutes

pain-relieving strategies and the factors that influence these

views is essential to ensuring that interventions are develop-

mentally appropriate and generalizable. This report provides

the first in depth analysis of children’s views when asked directly

what helps when they have pain, and provides the basis for

further research on influencing factors and effectiveness of

interventions.

Methods

Design

We used a descriptive, mixed methods design to investigate

what children think helps them when they have pain. The ‘draw

and write’ technique (Bradding & Horstman 1999; Horstman &

Bradding 2002) was used to ascertain children’s views in a child-

friendly manner, with as little adult influence as possible.

Sample and setting

The sample was recruited from children visiting Great Ormond

Street Hospital NHS Trust during the study period as part of a

programme of events to highlight the Global Day against Chil-

dren’s Pain initiated by the IASP, 2005–2006 (http://www.iasp-

pain.org/GlobalDay-2005.htm). Inpatients and outpatients,

as well as siblings or friends of the patients, were all actively

encouraged to take part. Children were eligible to participate if

they were able to draw pictures or write about the topic.

Instruments

The ‘draw and write’ technique gives children the opportunity

to answer the research question themselves without any

prompting or interference from an interviewer. It is often a

better choice of instrument than structured interviews or ques-

tionnaires as it is not intimidating and does not presuppose the

children’s answers, increasing response validity. Internal validity

is also strengthened because there are two within-subject

sources of data, drawings and text. The task involves children

drawing pictures in response to a question or theme as well as

writing their thoughts about the topic. The ‘draw and write’

technique has been used extensively to elicit children’s views

of health and health services (Pridmore & Bendelow 1995;

Pridmore & Lansdown 1997; Bradding & Horstman 1999;

Horstman & Bradding 2002). Drawings have also been used to

explore children’s views about pain (Unruh et al. 1983; Liossi

2000; Stafstrom et al. 2002).

Procedures

Children visiting hospital during the study period were in-

vited to enter a competition. Announcements were displayed

throughout the wards, in the lobby and near the outpatients

department. Nurses and play specialists encouraged participa-

tion of all children regardless of health status.

The competition entry form was an A3 folded sheet with two

large boxes, one for drawing and one for writing. At the top of

each sheet was the incomplete phrase ‘When I hurt the things

that help me are . . . ’. Children were asked to complete the

sentence by drawing or writing something (Fig. 1). They were

asked to give their age and gender. No other personal or clinical

data were obtained. Children could submit their entries to a

member of staff, deposit them in collection boxes or post them.

Children received a box of coloured pencils with the entry form

and those who submitted entry forms were eligible for prize

drawings in one of two age groups, under 8 years and over

8 years of age.

We are trying to find out more about what helps children when they are hurt. Can you help us by drawing or writing about the things that help YOU when you are hurt. If you agree, we would like to display your picture or writing in the hospital or on the hospital website so that other children and adults can learn more about what helps children when they hurt.

Figure 1. ‘Draw and write’ template.

Children’s views on pain relief 431

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 4, 430–438

http://www.iasp-pain.org/GlobalDay-2005.htm



A Research Ethics Committee reviewed the project outline

and determined that it was exempt from review because no

medical or personally identifying data were collected. Parents

and children gave written consent for the anonymized drawings

and text to be displayed.

Data analysis

Thematic content analysis (Boyatzis 1998) was used to derive

the major themes and subthemes represented in the children’s

drawing and writings separately. This methodology is a process

for systematically and objectively encoding qualitative data into

categorical data, extracting patterns, and describing or organiz-

ing observations. The units of analysis were the message char-

acteristics encoded within the texts and drawings. Data were

initially organized by one investigator (AS) using open coding,

without regard for relative importance. In this way, the breadth

of conceptual possibilities was appreciated. Conceptual catego-

ries that were salient across participants were created and vali-

dated by the second investigator (LF). Coding and conceptual

categories were defined precisely, and illustrated with verbatim

quotes to ensure completeness, inter-rater reliability and

validity.

Descriptive statistics were computed for the demographic

variables (age and gender) and for the major thematic catego-

ries. Non-parametric tests were used for all comparisons, and

P-values of less than 0.05 were considered significant.

Results

The sample (n = 71) was comprised of 33% boys and 67% girls,

with an age range of 4–16 years (mean � SD: 9.25 � 3.04).

According to Piagetian developmental stages (Meadows 2006),

24% of the children were preoperational (less than 7 years of

age), 49% of them were concrete operational (7–11 years of age)

and 27% were formal operational (12 years and older). Three

boys (aged 9, 9 and 6 years) provided drawings only. All other

children provided texts and drawings.

Four overarching themes were derived that were common

to both the texts and drawings: ‘People who help’, ‘What I do

that helps’, ‘What other people do that helps’ and ‘Things

that help’. Children also described their emotional reactions

to pain or pain relief. Multiple themes were represented in

most of the texts and drawings. Examples illustrating these

themes across the three developmental ages are shown in

Figs 2–4. More examples can be viewed on the Children’s First

for Health website, Kid, Creative Corner (http://www.

childrenfirstforhealth.org).

People who help when I hurt

Table 1 shows the percentages of children who wrote or drew

about people who helped them when they hurt. Almost all of

the children wrote about people (n = 64; 94.1%) who help to

make their pain better. Fewer children (n = 50; 70.4%) drew

pictures of people who helped them when they hurt. Most of the

children mentioned themselves as the central figure in dealing

with pain and about half as many children drew pictures of this.

Parents were the next most frequent person to appear in the

texts and drawings. More children identified their mother

or both parents as helping them. Other family members who

helped included siblings and grandparents and significant

others such as friends, pets and teachers. Hospital staff were

described, specifically doctors and nurses, play specialists, hos-

pital clowns and the chemist. In 10 cases, the persons drawn

were not identifiable from the drawings or from the accompa-

nying text.

What I do that helps when I hurt

Over half of the children (n = 43; 63.2%) wrote about behav-

iours or actions they initiated themselves to provide pain relief.

Slightly fewer children (n = 38; 53.5%) drew pictures of these

actions. The self-initiated strategies were varied and included

limiting activity by resting or sleeping, engaging in visual dis-

traction by concentrating on an object in front of them (e.g.

the fish on the cubicle curtain fabric), cognitive distraction by

thinking of ‘nice things’ or by physical actions such as counting

to 10, holding someone’s hand or taking deep breaths (Table 1).

Many of the children wrote about their active role in taking

medication or about how they decided when medication was

indicated. They notably did not use words or phrases indicating

a passive role (e.g. ‘mummy gave me’ or ‘I was given’).

What others do that helps when I hurt

Children described in writing (n = 39; 57.3%) or drew (n = 11;

15.5%) the actions of other people that helped them when they

hurt. The most common were hugs, cuddles and kisses from

parents and other actions by parents, such as giving gifts to

children. Fewer children wrote or drew about the actions of

hospital staff, and the actions described were predominantly

entertainment provided by play specialists or clowns, doctors

making children laugh and nurses talking to them (Table 1).

Things that help when I hurt

Many children described in their writing (n = 56; 82.3%) and

drawing (n = 54; 76.1%) objects such as medicine (tablets

432 L.S. Franck et al.


http://www.childrenfirstforhealth.org

http://www.childrenfirstforhealth.org

and/or syrups) or plasters and bandages that provided pain

relief. Needles and intravenous lines featured in the texts and

drawings as sources of pain requiring pain relief. Children

described and drew about entertainment objects that distracted

them from thinking about their pain or helped them relax,

specifically music and television, favourite stuffed toys and

games such as Play Station or sporting activities. Children also

commented about food and drink that made them feel better.

Several children wrote about the positive effects of nature. Some

children also wrote or drew about hospitals although they did

not specify how hospitals help them (Table 2).

Emotional reactions to pain or pain relief

One-quarter of the children wrote about how they felt when in

pain, of which 12 (18%) described being happy when they had

coped with pain either on their own or with the help of

someone else. Others (7.4%) described feeling sad because of

Girl, Age 5

Boy, Age 6

Figure 2. Younger children’s drawings and texts.



pain or needing medical attention. Description of emotional

reactions was more prominent in the children’s drawings

(36.2%), with 30.4% of children drawing themselves in a happy

mood and 10.1% drawing sad faces or tears.

Influence of developmental age and gender

There were few differences in the themes present in the children’s

texts and drawings based on developmental age (Table 3). More

children in the preoperational age group wrote or drew hospital

staff (c2 6.42, P = 0.04) and favourite toys (c2 8.23, P = 0.02)

compared with the other developmental age groups. There were

no differences in thematic content based on gender.

Discussion

This study is the first in-depth examination of children’s views

of what helps when they hurt. Previous studies have focused

on children’s views of sources of pain and only secondarily

explored their views on pain-relief strategies. We used the well-

established developmentally appropriate ‘draw and write’ tech-

nique to elicit children’s views and the children responded

enthusiastically, providing detailed responses in both modali-

Boy, Age 9

Girl, Age 10

Figure 3. Middle-age children’s drawings and texts.



ties. The children’s written descriptions were generally easier to

analyse and consistent with the content represented in the draw-

ings. However, some children preferred drawing to writing, and

emotions in relation to pain or pain relief were more often

expressed in the drawings. Thus, both modalities should be

offered in future studies.

Our main finding is that children across the three develop-

mental age groups view themselves as active agents in pain

relief. Although less than half of the children described specific

behaviours they had taken, almost all children indicated their

active role as the central figure in relation to use of objects or the

actions of others. This finding is in contrast to previous research

that found only a few simple self-initiated pain-coping strate-

gies used by school children (Ross & Ross 1984), but is consis-

tent with previous research with children with recurrent pain

(Unruh et al. 1983) and hospitalized children (Woodgate &

Kristjanson 1995; Palermo & Lambert 1997; Polkki et al. 2003)

or those who have received injections (Haines et al. 2005).

However, in the present study, children’s views of themselves as

active agents in pain relief were more prominent than in any

previous studies.

We also found that children valued the actions of other

people, primarily parents. Parental presence and positive physi-

cal contact were important sources of comfort for children of all

Girl, Age 14

Boy, Age 14

Figure 4. Older children’s drawings and texts.



ages and types of pain, consistent with previous research (Polkki

et al. 2003). Interestingly, hospital staff were valued for their

social actions rather than for delivering health care, with chil-

dren finding the staff entertainment, humour and kindness

most helpful to them. Children also viewed other family

members, friends and pets as important.

Unsurprisingly, medicines and bandages feature prominently

in children’s writing and drawings (Ely 1992). Interestingly,

children saw themselves as active agents rather than passive

recipients of medication. Furthermore, entertainment or

attachment objects were mentioned more frequently than

medication as providing distraction and comfort, and children

were also cognizant of the importance of general comfort

strategies and the environment. These findings indicate a

greater level of awareness and sophistication in children’s

understanding of the influence of relationships and environ-

mental factors on pain experience than pervious research. All of

the children’s ideas were reasonable and none were overtly mal-

adaptive, as has been previously suggested (Brown et al. 1986).

However, as Ross & Ross (1984) pointed out in 1984, children

could benefit from learning more about coping with everyday

pain and anxiety in the school curriculum.

We found little evidence of developmental changes in chil-

dren’s descriptions of what helped when they hurt. The finding

that younger children more frequently mentioned hospital staff

may have been related to the hospital setting in which the study

took place and will need to be examined in future studies. There

were differences in the types of objects (e.g. cuddly toys vs.

MP3 players) mentioned by children of different ages, but no

differences in the frequency that objects were mentioned based

on developmental age. Some previous studies have suggested

that children’s cognition about pain develops in accordance with

developmental stages (Gaffney & Dunne 1986; Hurley & Whelan

1988; McGrath & Craig 1989; Harbeck & Peterson 1992), and

others have not (Ross & Ross 1984). However, our finding of only

minor variation in views about pain relief suggests that children’s

thinking about pain relief may be more related to their experi-

ence and learning than to stage of cognitive development. The

Piagetian stages of cognitive development have been criticized as

being too rigid and arbitrary. Alternative theories that propose

cognitive development mature differently for different domains

of knowledge or develop from the child’s active interactions

(Meadows 2006). These newer theories may provide more

appropriate to children’s understanding of pain and pain relief

development in childhood, but as yet remain untested.

Pain expression is commonly understood to differ by gender

(Zeman & Garber 2007), but we found no evidence of gender

differences in children’s views about what helps when they have

Table 1. People who help and what they do

People who help when I hurt Texts*(%) Drawings† (%)

Myself 86.8 43.7Other people 61.8 49.3

ParentsMother 36.8 22.5Father 1.5 1.4Both parents 23.5 5.6

Other family 14.7 4.2Significant others 19.1 8.5

Friends 11.8 4.2Pets 8.8 5.6Teachers 1.5 –

Healthcare staff 32.3 19.7Doctors 16.2 5.6Nurses 16.2 9.9Play specialists 7.4 4.2Hospital clowns 5.9 8.5Chemist 1.5 1.4

Unknown persons – 14.1What I do that helps when I hurtRest or sleep 13.2 11.3Visual distraction 2.9 4.2

Focusing on objectCognitive distraction 17.7 8.5

Thinking ‘nice thoughts’Physical actions 27.9 16.9

Counting, holding hands,Taking deep breaths

What others do that helps when I hurtParents give hugs, cuddles and kisses 25.0 9.9Parents do other things 27.9 8.5

Give presentsHospital staff 20.6 2.9

Play specialists entertainDoctors make me laughNurses talk to me

*Proportion of 68 texts submitted.†Proportion of 71 drawings submitted.

Table 2. Things that helps when I hurt

Texts* (%) Drawings† (%)

Medicine 32.4 21.1Tablets 8.8 7.0Syrups 1.5 9.6

Plasters/bandages 20.6 19.2Needles/intravenous lines (sources of pain) 7.4 12.7Entertainment 38.2 28.2

Music/television 19.1 11.3Toys 16.2 12.7Games 14.7 9.9

Food or drink 14.7 15.5Nature 5.9 –Home 1.5 –Hospital (how it helps not described) 10.3 17.4

*Proportion of 68 texts submitted.†Proportion of 71 drawings submitted.



pain. However, twice as many girls participated in this project

and we do not know if this was related to local demographics or

a gender-based preference for expressing views on the topic.

The findings from this study should be interpreted with

regard to the context of the acute care setting in which it took

place and the lack of detailed knowledge about the experience

of illness or pain of the children who participated. Particular

subgroups of children may have been over- or under-

represented and we cannot ensure that our results are represen-

tative of the general population. It is also possible that parents

or the incentive of a prize drawing may have had some influence

on the content of the children’s drawings or text. Furthermore,

chronological age is an imperfect estimation of developmental

age and there is wide individual variation. Nevertheless, we have

established that children have well-developed thoughts and feel-

ings about strategies for pain relief and that they can articulate

these ideas through drawing and writing. Further research is

warranted to understand how these ideas develop and how chil-

dren can be better engaged as active partners to achieve more

effective pain prevention and pain relief.

Acknowledgements

This research was supported by Great Ormond Street Hospital

for Children NHS Trust and the Institute of Child Health,

University College London. Research at these institutions ben-

efits from R & D funding received from the NHS Executive. The

views expressed in this publication are those of the authors and

are not necessarily those of the NHS Executive. The authors

wish to thank the Pain Control Service, Play Department,

nursing staff and Miss Razia Nuur for their assistance with this

project. We also thank the children and their parents for their

participation.

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• Children between 4–16 years of age have well-formed

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• Children see themselves as active agents in their own pain

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• Few differences were found in children’s views on pain

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differences in relation to gender.



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what helps when it hurts: children's views on pain relief

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