Description/Overview: Compared to other populations, children are among the most vulnerable to pain and the least likely to be adequately treated (Institute of Medicine, 2011). In this symposium, we will focus on the impact of pain on children exposed to multiple painful procedures and experiencing pain from tissue injury and trauma. While all children are at risk for untreated pain, there are some populations that may be at greater risk due to communication limitations such as children who are critically ill or those with autism spectrum disorder (ASD). Pain from needle related procedures, e.g. immunizations, blood draws and intravenous (IV) insertions, is a common experience for children beginning in infancy. When an infant or child is hospitalized the exposure to needle related procedures increases exponentially and psychological risk to children can range from increased anxiety to the extreme, but not uncommon, development of needle phobia. Procedural pain in children. By six years of age, most children have experienced over 20 painful procedures associated with routine immunizations (Pediatrics, 2014). Children who are sick, in accidents, or hospitalized may experience significantly more painful procedures including venipuncture and IV insertions. A recent Canadian study found in a 24 hour period 78.2% of hospitalized children required at least one painful procedure, experienced a mean 6.3 painful procedures, and less than a third had documented interventions for pain (Stevens et al., 2011). Likewise, in a US Emergency Department (ED), investigators found 13% (859/6545) of children encountered had an IV insertion or venipuncture, but less than 1% (7/859) had a topical anesthetic (TA), despite a mean 30 minutes between orders and the actual needle stick (MacLean, Obispo, & Young, 2007). Further complicating the problem is procedural anxiety and fear of needles. Fear of needles is reported by 24% of adult parents and 63% of children (Taddio et al., 2012). The significance of child pain and distress in response to a procedure is seen in multiple areas. The immediate responses of the body to pain such as increases in intracranial pressure, heart rate, respiratory rate, blood pressure, blood glucose, and stress hormones and decreases in oxygen saturation (Bouza, 2009; Mitchell & Boss, 2002; Peters et al., 2005) can have serious consequences in an already acutely ill child (Anand & Hickey, 1992; Anand, Sippell, & Aynsley-Green, 1987).In addition, the child and family often experience emotional sequelae. Inadequate management of pain (Jacob & Puntillo, 1999) can create an anticipatory fear or anxiety in the child and family for future medical encounters (Schechter, Altman, & Wiseman, 1990). Anxiety and fear may be manifested by difficulties in coping and in maladaptive behaviors (e.g., extreme noncompliance) during the procedure. Children have been shown to have accurate recall of pain intensity (Zonneveld, McGrath, Reid, & Sorbi, 1997), and the memory of painful experiences can affect children’s pain perceptions during subsequent procedures (Rocha, Marche, & von Baeyer, 2009; Weisman, Bernstein, & Schechter, 1998). Importantly, there is no evidence that young children habituate to repeated procedures or feel less pain or exhibit less behavioral distress over time (Dahlquist et al., 1986; Harris, Bradlyn, Ritchey, Olsen, & Pisaruk, 1994; Manne, Bakeman, Jacobsen, & Redd, 1993). For some children, maladaptive behaviors or treatment resistance is refractory to medical or psychological intervention (Burish & Carey, 1986). Healthcare providers and systems are also affected by children’s disruptive responses to painful procedures (Kennedy, Luhmann, & Zempsky, 2008). Procedures may be more costly, requiring more time and multiple providers to complete. Thus it is imperative that health care providers identify the most effective and least expensive interventions to decrease the pain and distress experienced by children undergoing painful procedures. Pain in the Pediatric Intensive Care Unit. Critically ill children experience more severe pain and six times as many painful procedures per day than children in general medical-surgical units (Groenewald, Rabbitts, Schroeder, & Harrison, 2012; Stevens et al., 2011; Stevens et al., 2012). Pain rated greater than 5 on a 10 point scale for more than 2 hours was the second most frequently occurring adverse event across 15 pediatric intensive care units (PICUs) in the United States; over 80% of these pain events were deemed preventable(Agarwal et al., 2010). Clearly, children in a PICU setting are at significant risk for untreated moderate to severe pain over time or through intermittent exposure to painful procedures. However, there is still much that is not well understood. The population of patients in the PICU is diverse (varying widely in age, cognitive development, diagnosis, and severity of illness) and complex, including patients with chronic medical conditions and long-term dependence on medical devices (Riley, Poss, & Wheeler, 2013). Additionally, PICUs can vary widely across organizations in patient volume, population, and severity of illness (Riley et al., 2013). Because of the high variability within and across PICUs, evidence-based interventions to improve pain management likely cannot be “one size fits all”. A better understanding of the variability of pain and the way it is assessed and treated in PICUs is needed. Pain in Children with Autism Spectrum Disorder (ASD). Children with ASD can have a spectrum of behavioral challenges along with poor interactive communication skills, putting them at great risk for unmanaged pain. Recognizing emotions through facial expressions and body language can be particularly difficult when a child has ASD, especially when the child is in a new and unfamiliar environment (Kennedy et al., 2008). This social communication deficit may explain why children with ASD seem to demonstrate less outward reaction to pain or pleasure. Limited interest in social reciprocity tempers otherwise recognizable displays of emotion in this population, including that of pain (Bandstra, Johnson, Filliter, & Chambers, 2012). However, the absence of discernible behaviors that typically indicate pain does not reflect an absence of pain perception. Consequently, children with ASD are often mistakenly thought to be stoic or even feel pain differently, when more likely they have an inability to exhibit "typical" pain behaviors. Pain behaviors are learned and reinforced thorough social interaction. Children with ASD have very poor social interactive skills, e.g. little to no eye contact and engagement with others. Pain assessment tools for children rely on the ability to assess pain behaviors as well as self-report. For children with ASD deficits limit accuracy of assessment leading to the need to explore alternative pain assessment methods.