Pain assessment in intellectually disabled people: non-verbal indicators


  • Sandra M.G. Zwakhalen RN MSN,

  • Katinka A.J. Van Dongen RN MSN,

  • Jan P.H. Hamers PhD RN,

  • Huda Huijer Abu-Saad PhD RN

Sandra Zwakhalen, Department of Health Care Studies, Section of Nursing Science, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.


Background.  Although important progress has been made during the past decade, research on pain in people with intellectual disabilities is still scarce. Pain assessment in people with intellectual disabilities is a frequent and difficult problem, especially for nurses working with people with intellectual disabilities on a daily basis. Gathering more information about pain in people with intellectual disabilities is of major importance and relevance for nursing, and adds to the developing body of knowledge.

Objective.  To investigate the nature and relative importance of non-verbal indicators used by nurses to assess pain in people with a severe or profound intellectual disability.

Methods.  A questionnaire consisting of 158 indicators of pain was used. A total of 135 nurses from nine institutions specializing in the care of people with intellectual disability were asked to rate each indicator on a scale of 1–10 to show which non-verbal expressions they considered important in diagnosing pain.

Results.  A total of 109 nurses responded. All 158 indicators were mentioned as being important to indicate pain. All except four had a range of 9. Seven (moaning during manipulation, crying during manipulation, painful facial expression during manipulation, swelling, screaming during manipulation, not using (affected) body part, and moving the body in a specific way of behaving) were reported as ‘very important’ by more than 50% of nurses. The lowest score (median 5·5; minimum 1, maximum 10) was given to the indicator ‘waving arm movements’. The pain of people with severe intellectual disability appeared to be assessed differently from that of people with profound intellectual disability. Indicators belonging to the ‘physiological’ category scored relatively higher in the group of nurses specializing in profound disability. In contrast, indicators belonging to the ‘social-emotional’ category were scored relatively higher by nurses specializing in severe disability.

Conclusion.  Nurses used a wide range of indicators to assess pain in people with intellectual disability. Functional abilities and level of disability seem to influence the indicators used.