Boys don’t cry? The experience of pain in children

26 Jun 2015  |  Print

Boys don’t cry? The experience of pain in children

Pain, particularly chronic pain, is often considered to be an adult problem. This misconception may underlie the recent finding that only 5% of pain studies are dedicated to pediatric populations.[1] We need to reconsider this imbalance, not least because poorly managed pain in childhood can have long-term detrimental effects. Indeed, human and animal studies have linked pediatric pain with impaired brain development,[2] pain sensitization,[3] and progression to chronic pain in adulthood.[4]

Pain prevalence in children

Pediatric pain is a common occurrence. For example, in a study of almost 2,500 children aged 10-11 years who were followed up every 2 years until early adulthood, frequency rates of pain were consistently high throughout their adolescent years: 26.1-31.8% for headache, 13.5-22.2% for stomach ache, and 17.6-25.8% for backache.[5] Girls had higher rates than boys for all types of pain.[5] These findings are supported by the results of a recent systematic review examining data from 41 published studies of pain in children.[6] Not only did this analysis show high prevalence rates for various types of pain, it also found that pain prevalence was generally higher in girls than boys. Furthermore, prevalence increased with age for most pain types.[6]

Role of parents

There is a growing body of evidence suggesting that parents and other caregivers can have a substantial effect on children’s experiences of pain. In particular, ‘non-attending’ parental behaviors (such as non-procedure-related talk, humor and coping prompts) seem to reduce the levels of pain reported by children.[7] By contrast, ‘attending’ verbal responses among caregivers appear to increase their children’s pain – and this includes both predictably negative parental behaviors like criticism, as well as some surprising ones like apologies, empathy and reassurance.[7] However, when this phenomenon was examined more closely in a laboratory-based model of cold pressor pain in children, ‘attending’ parental behaviors increased the intensity of reported pain in girls but not in boys.[7] Hence, there may be important differences between boys and girls in their responsiveness to parental cues. Furthermore, this study only included mothers, so does the same hold true with fathers? It seems so: a follow-up study showed that, as was the case with mothers, attending behaviors among fathers increased their children’s perceptions of pain.[8] Interestingly, in the cold pressor pain model, levels of attending and non-attending verbal behaviors did not differ significantly between mothers and fathers.[8] However, perceptions of their children’s pain do seem to differ between the two genders. Perhaps surprisingly, it turns out that fathers may be better judges of their children’s pain than mothers,[9] although several studies have suggested that parents – whether male or female – often underestimate levels of pain in their children.[10,11]

Gender differences in children’s pain perception

So far, we have seen that pain is more common in girls than boys, and that parental behavior can have a substantial impact on how it is perceived. This raises the question: do girls experience pain differently from boys, and if so, which types of pain? Many pain studies in children have failed to find any gender-based differences, although that may often have been because the studies themselves were flawed – either they were not specifically designed to examine this question, or they were underpowered to do so. It does not necessarily mean that no gender differences actually exist. A recent meta-analysis set out to provide a more definitive answer.[12] A total of 33 studies were included, examining experimentally-induced pain in more than 2,000 healthy boys and girls aged ≤18 years. A key finding was that girls reported significantly higher cold pressor pain intensity compared with boys in studies in which the mean age of participants was >12 years.[12] This suggests that gender-related differences may only emerge later in development. For heat pain, there were no gender differences in intensity, but boys had significantly greater tolerance and threshold for this type of pain.[12]


Pain in children is an under-recognized issue that should be given more attention both in experimental settings and in normal clinical practice. There are important differences between girls and boys in pain prevalence and perception, and these may be greater in adolescents than younger children. Parents often underestimate pain in their children, and frequently display ‘attending’ behaviors that have the opposite effect to what was intended – by increasing the child’s perception of pain. Clinicians therefore need to consider both the child and their caregivers when assessing pediatric pain. More work is required to better understand the developmental trajectory of gender differences in childhood pain, and the mechanisms that underlie such differences. If we can answer these questions, we will be better able to tailor our pain management strategies in pediatric patients.


  1. 1. Mogil JS, Simmonds K, Simmonds MJ. Pain research from 1975 to 2007: a categorical and bibliometric meta-trend analysis of every Research Paper published in the journal, Pain. Pain 2009;142:48-58.
  2. 2. Brummelte S, Grunau RE, Chau V, et al. Procedural pain and brain development in premature newborns. Ann Neurol 2012;71:385-396.
  3. 3. Beggs S, Currie G, Salter MW, Fitzgerald M, Walker SM. Priming of adult pain responses by neonatal pain experience: maintenance by central neuroimmune activity. Brain 2012;135:404-417.
  4. 4. Walker LS, Sherman AL, Bruehl S, Garber J, Smith CA. Functional abdominal pain patient subtypes in childhood predict functional gastrointestinal disorders with chronic pain and psychiatric comorbidities in adolescence and adulthood. Pain 2012;153:1798-1806.
  5. 5. Stanford EA, Chambers CT, Biesanz JC, Chen E. The frequency, trajectories and predictors of adolescent recurrent pain: a population-based approach. Pain 2008;138:11-21.
  6. 6. King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain 2011;152:2729-2738.
  7. 7. Chambers CT, Craig KD, Bennett SM. The impact of maternal behavior on children’s pain experiences: an experimental analysis. J Pediatr Psychol 2002;27:293-301.
  8. 8. Moon EC, Chambers CT, McGrath PJ. “He says, she says”: a comparison of fathers’ and mothers’ verbal behavior during child cold pressor pain. J Pain 2011;12:1174-1181.
  9. 9. Moon EC, Chambers CT, Larochette AC, et al. Sex differences in parent and child pain ratings during an experimental child pain task. Pain Res Manag 2008;13:225-230.
  10. 10. St-Laurent-Gagnon T, Bernard-Bonnin AC, Villeneuve E. Pain evaluation in preschool children and by their parents. Acta Paediatr 1999;88:422-427.
  11. 11. Kelly AM, Powell CV, Williams A. Parent visual analogue scale ratings of children’s pain do not reliably reflect pain reported by child. Pediatr Emerg Care 2002;18:159-162.
  12. 12. Boerner KE, Birnie KA, Caes L, Schinkel M, Chambers CT. Sex differences in experimental pain among healthy children: a systematic review and meta-analysis. Pain 2014;155:983-993.