Pain assessment in non-verbal children with neurocognitive impairment: a review on current tools, challenges, and clinical perspectives

Pain in non-verbal children with neurocognitive impairment (NCI) remains a complex and frequently under-recognized clinical challenge. Accurate pain assessment is essential for effective management, and is often hindered by non-verbal presentation, developmental adaptability, and the influence of sedation or illness. In response to these challenges, several observational tools have been developed to identify pain-related behaviors in non-verbal children. Among the most widely used tools is the Face, Legs, Activity, Cry, and Consolability (FLACC) scale, which was originally validated in young children and later adapted for use in children with communication barriers. Its revised version included additional behavioral descriptors tailored to children with cognitive impairments (CI). Similarly, the Non-Communicating Children's Pain (NCCP) Checklist was specifically developed for children with CI and provides a structured assessment across multiple behavioral domains. These tools have shown strong clinical utility and reliability, particularly in postoperative and critical care settings. Although both FLACC and the NCCP Checklists have proven effective, the latter is more designed to children with significant CI, suggesting a broader set of pain indicators. However, both tools require trained observers and clinical familiarity for optimal use. This review explores the strengths and limitations of these and other pain assessment tools, emphasizing the need for individualized approaches and validated instruments to ensure accurate pain recognition and treatment in pediatric populations, particularly those with NCI, including cases where critical illness further limits communication.