Validation of the Individualized Numeric Rating Scale (INRS): A pain assessment tool for nonverbal children with intellectual disability

Abstract

Clinical observations suggest that nonverbal children with severe intellectual disability exhibit pain in a wide variety yet uniquely individual ways. Here, we investigate the feasibility and describe the initial psychometrics properties of the Individualized Numeric Rating Scale (INRS), a personalized pain assessment tool for nonverbal children with intellectual disability based on the parent's knowledge of the child. Parents of 50 nonverbal children with severe intellectual disability scheduled for surgery were able to complete the task of describing then rank ordering their child's usual and pain indicators. The parent, bedside nurse and research assistant (RA) triad then simultaneously yet independently scored the patient's post-operative pain using the INRS for a maximum of two sets of pre/post paired observations. A total of 170 triad assessments were completed before (n=85) and after (n=85) an intervention to manage the child's pain. INRS inter-rater agreement between the parents and research nurse was high (ICC 0.82-0.87) across all ratings. Parent and bedside nurse agreement (ICC 0.65-0.74) and bedside nurse and research nurse agreement (ICC 0.74-0.80) also suggest good reliability. A moderate to strong correlation (0.63-0.73) between INRS ratings and NCCPC-PV total scores provides evidence of convergent validity. These results provide preliminary data that the INRS is a valid and reliable tool for assessing pain in nonverbal children with severe intellectual disability in an acute care setting.

The revised FLACC score: Reliability and validation for pain assessment in children with cerebral palsy

“…The Bland-Altman plots for both reliability measures illustrates that the differences of measurements are concentrated around the mean difference, though with a rather large interval of agreement for especially inter-rater reliability. This is in accordance to other studies testing the psychometric properties of pain assessment scales, where the range of ICCs for inter-rater reliability for the INRS was 0.65-0.87 [10], for the NCCPC-PV 0.78-0.82 [11] and for the PPP 0.74-0.89 [13]. This suggests that even though intra-rater reliability is established, the most exact pain assessment during hospitalization of a child with CP is performed using only one rater continuously for each child.…”

“…Nevertheless, in medical science, reproducibility parameters are more commonly used. Present study opted to calculate and report reproducibility by use of ICC similar to Solodiuk et al [10] and in accordance to the COSMIN guideline. Opposite, Malviya et al [4] calculates both kappa agreement and ICC reproducibility, making comparisons between the two studies difficult.…”

“…Other pain assessment tools for children with CP validated for postoperative pain assessment include the Individualized Numeric Rating Scale (INRS) [10] with established construct validity and inter-rater reliability and the Noncommunicating Childrens's Pain Checklist-Postoperative Version (NCCPC-PV) [11,12] with established construct validity, inter-rater reliability and internal consistency. Good psychometric properties were found for the Paediatric Pain Profile (PPP) [13] for assessment of everyday pain with established content and construct validity, inter-rater reliability and internal consistency and for the Echelle Douleur Enfant San Salvador (DESS) [14] for procedural pain assessment with established construct validity [15].…”

Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems

“…In general, the approaches to medication use for pain and anxiety should hold true for children with developmental disabilities; some children, however, show altered sensitivity to medications and may be taking medications that interact with common pain medications. 219 …”

Clinical Research: Together, Stronger, Bolder

“…With Jean Solodiuk, we developed and tested the Individualized Numeric Rating Scale to help pediatric nurses observe, consistently document, and communicate the unique pain behaviors of intubated, nonverbal, children. 23,24 With Karen Fraser and Rita Johnson, we developed and tested the State Behavioral Scale to help describe the sedation-agitation spectrum in intubated children. 25 With Linda Franck (University of California, San Francisco) and Sion Kim Harris (psychometrician), we developed and tested the Withdrawal Assessment Tool-version 1 to describe iatrogenic opiate and benzodiazepine withdrawal in pediatric patients.…”