Representation of Pain and Injury in Children's Picture Books—A Content Analysis

ABSTRACT

Background

Pain and injury experiences are common throughout childhood (e.g., minor injuries, vaccine injections) and provide important and frequent opportunities for children to learn about pain. Sociocultural contexts, such as reading picture books, may also provide critical opportunities for children to learn about pain/injury. This study aimed to investigate the representation of pain and injury in children's literature.

Methods

We systematically screened for pain/injury representations in children's picture books, freely available from public libraries in South Australia. A content analysis of pain/injury representations was conducted on all included books.

Results

Two hundred and fifty‐four picture books were screened until 50 books with pain/injury representations were identified. There were 63 pain (i.e., subjective experience) and 43 injury (i.e., associated with tissue damage) representations. ‘Minor’ pains/injuries were frequently represented (n = 69; 86%), whereas ‘procedural’ (e.g., vaccine injections) (n = 1; 1%) and ‘chronic’ pain (n = 2; 3%) were not. Gender differences were observed where boy characters experienced more pain/injury incidents (n = 42; 53%) than girl characters (n = 23; 28.8%). Behavioural responses to pain/injury also differed, with girl characters being portrayed to experience more emotional responses (e.g., crying; n = 7; 77.8%) than boy characters (n = 2; 22.2%). Other characters present during pain/injury experiences were more likely to be passive bystanders (i.e., did not respond; n = 109; 59.6%) than active responders (n = 51; 27.6%) to characters experiencing pain.

Conclusions

While the type of pain/injury representations in picture books seem consistent with young children's everyday pain/injury experiences (i.e., ‘minor’ pains/injuries), gendered stereotypes and dominant societal perspectives around pain and injury appear to be reinforced.

Significance Statement

Shared reading of children's picture books provides an important sociocultural context for children to learn about pain and injury. In this study, we investigated how pain and injury are represented in children's picture books. We found that pain/injury incidents were consistent with young children's common pain/injury experiences; however, observing characters often lacked prosocial behaviours (e.g., helping, providing comfort) and gendered stereotypes were common. These findings have similarities to pain representations in children's popular TV/movies, speaking to the pervasiveness of these messages across children's media.

1. Introduction

Pain is common during childhood and might include ‘everyday’ pains (e.g., bumps/scrapes), procedural pains (e.g., vaccinations), significant injuries (e.g., bone fractures) and chronic idiopathic or disease‐related pain (> 3 months) (Baeyer et al. 1998; Baker et al. 2016; Chambers et al. 2024). Children's pain experiences are often socially situated (i.e., caregiver/educator/healthcare practitioner present), thus serve as frequently occurring and important sociocultural learning opportunities that could inform children's fundamental beliefs about pain (Noel et al. 2018), and how to empathise with and respond to others. Building recognition on how one conceptualises pain, its underlying biology and its multifactorial (bio‐psycho‐social‐societal) nature points to the potentially critical role that socialisation of pain/injury in childhood may have in resilience or vulnerability to chronic pain in later life (Moseley et al. 2023).

Children's popular media (television/movies) is one sociocultural context in which children are exposed to learnings about pain/injury. Research investigating pain depictions in children's media found that injury and violent pain were the most frequently portrayed types of pain, and characters who were depicted experiencing pain demonstrated minimal help‐seeking behaviours (Mueri et al. 2021). Gender disparities were also prevalent, with boy characters depicted to experience more violent pain/injury than girl characters and girls displaying more empathetic behaviours towards characters experiencing pain (Mueri et al. 2021). Children's media appears to emphasise maladaptive pain behaviours, does not role‐model empathy for pain, and under‐represents common childhood pain experiences (e.g., grazes/scrapes) (Mueri et al. 2021).

Children's picture books provide another sociocultural context through which children might learn about pain, pain expression and pain responding. Social representation theory (Kugelmann et al. 2019) suggests that the medium of information delivery can shape both the delivery and reception of the message. In the case of children's picture books, messages can be delivered through both the transference of information within the book, as well as how these messages are engaged with during shared reading (i.e., between child and caregiver). Children's engagement with picture books has been shown to help children's vocabulary development, adopt new behaviours such as altruism from stories about sharing, and transfer information from illustrations to real‐world contexts, demonstrating that children can be influenced by media from an early age (Flack et al. 2018; Keates et al. 2014; Larsen et al. 2018). Picture books may promote the building of pain beliefs and vocabulary through character experiences and words such as ‘hurt’ or ‘ouch’ and through exposing children to illustrations depicting injury (e.g., grazed knee). On the other hand, shared reading of picture books provides a unique opportunity for parents/caregivers and educators to discuss and make meaning of narratives and character experiences, and to build children's learning of real‐world concepts (Cohen et al. 2012; Huebner and Payne 2010; Shoghi et al. 2013). Some picture books intentionally focus on health and social issues to promote such conversations (e.g., bibliotherapy; the use of books for therapeutic purposes) (Montgomery and Maunders 2015; Tympa and Karavida 2021). Our recent work demonstrated that shared reading of picture books that have pain/injury content prompted caregiver‐child discussions of pain/injury through the context of character experiences, addressed management, reminisced about their own pain/injury experiences, and promoted children's emotional literacy and empathy for pain (Wallwork, Nichols, et al. 2024). Shared reading at home is common in early childhood, occurring three or more times per‐week (Phillips and Lonigan 2009), making this a potentially powerful context for building children's understanding, expression and response to pain/injury.

How pain and injury are represented in children's picture books is important to understand because it provides the basis for understanding what pain‐ and injury‐related information is transferred to children, as well as the context for which shared reading interactions take place. Pain and injury may or may not co‐exist. In recognition of the contemporary understanding of pain (Ryan et al. 2024), whereby tissue injury is not sufficient for pain and that pain is not a direct marker of tissue injury, we believe it is important to explore pain and injury as distinct and related concepts. Therefore, in this study we aimed to investigate how pain and injury are represented in children's picture books. Specifically, we examined (a) the characteristics of pain/injury representations in children's picture books; (b) character, passive bystander and responder reactions to pain/injury; (c) gendered differences in representations of pain/injury; and (d) differences in representations of ‘pain’ (subjective experience) versus ‘injury’ (tissue damage).

2. Methods

This study adhered to the recommendations set out in the Standards for Reporting Qualitative Research (O'Brien et al. 2014). Following recommended practice for pain research in promoting replicable and reproducible research (Lee et al. 2018), a proposal was developed prior to data collection, which is available on Open Science Framework (https://osf.io/fps6b). The public were not involved in the conceptualisation, design or conduct of the study.

2.1. Research Design

A content analysis (using inductive and deductive coding) of pain and injury representation in children's picture books was sourced through a systematic screening process. This research design facilitated a systematic, in‐depth exploration and contextual understanding of the representations of pain and injury in children's picture books (Korstjens and Moser 2017).

2.2. Data Collection

Prior to data collection, we conducted a pilot trial with two researchers (DNM and SBW) at one library site to identify 10 picture books with representations of pain/injury. This ensured that a comprehensive capture of pain/injury was included for analysis, as the researchers compared and discussed their interpretations of pain/injury representations to agree on definitions, the inclusion/exclusion criteria and generate a priori codes. The generation of a priori codes involved identifying recurring patterns in how pain/injury was depicted across the pilot books (e.g., coding types of pain/injury, observer responses to pain/injury). Through an iterative and collaborative process, an initial set of codes was developed to capture these patterns. These codes were then tested on the pilot sample of books, with adjustments made to ensure clarity and consistency in capturing pain/injury representation. This also allowed us to review and refine our protocol prior to lodging it on Open Science Framework.

Fifty children's picture‐books were then sought for analysis (see Figure 1). A sample of 50 books was chosen to capture broad pain/injury representations and was based on similar works and methodologies (Axell and Boström 2021; Kim and Wee 2020; Price et al. 2016). Picture books were sourced from local public libraries in Adelaide, South Australia, to ensure representation of readily available books to the public that could be easily taken off the shelf and read to children. After completion of the pilot trial, the primary researcher (DNM) visited public libraries in person and systematically screened the available books on the shelves in the children's section of the library. This involved scanning in alphabetical order, based on author surname, starting at ‘A’ through to ‘Z’, taking four books at a time. That is, four books were taken from ‘A’, then four from ‘B’ and so on, until we reached ‘Z’ and then we returned to ‘A’ and screened the next four books, and so on until 50 picture books with pain/injury representations were identified. Books were included if they were in the English language, were aimed at children, and had a representation of pain/injury in the text and/or illustrations; acknowledging that pain and injury could be present solely in the text, the illustration or both (Martinez and Harmon 2012; Wolfenbarger and Sipe 2007). We recognised that pain and injury may not co‐exist, as depictions of pain may be present with no injury or tissue‐based cause, and depictions of injury may be present with no reference to an experience of pain. With this understanding, representations could include in‐text references and/or illustrations portraying tissue‐based injuries (e.g., grazed knee, plaster/band‐aid), an expression of pain (e.g., words such as ‘ouch’, facial or bodily expression), and reference to pain experiences (e.g., stomach‐ache, sore throat). Books were excluded if they were not aimed at children, were written in a language other than English, were levelled readers (books specifically developed to assist children learning to read) or information books, and had no pain/injury representations. Both fiction and non‐fiction books were included. Return visits were made to the libraries so that we could access and screen books that were not available on the library shelves at the time of the first visit (e.g., loaned out or otherwise unavailable). Librarians were not consulted, and the library catalogue was not searched. Two public libraries were visited (both suburban Adelaide, location of convenience) with a total of seven visits to complete data collection.

FIGURE 1.

Flow chart of data collection process.

When identifying pain/injury depictions in picture books, we acknowledged that pain/injury events may not always be central (i.e., integral and the driving force of the plot), but may be consequential (i.e., having some notable effects, without being central to the plot), or incidental (i.e., without any subsequent development in the narrative) to the narrative. For example, pain/injury may be consequential if a child experiences stomach‐pain causing them to rest, however the next day is able continue with their day as normal. Alternatively, pain/injury may be incidental if a child is shown with a band‐aid on their hand, however no further reference is made to its presence.

2.3. Data Extraction

We extracted basic book details (e.g., title, author, illustrator) from all screened picture books using Microsoft Excel (Microsoft Excel for Microsoft 365 MSO—Version 2302, Microsoft Corporation, Redmond, Washington). This information assisted us in capturing how common pain/injury was represented in children's picture books and allowed us to identify possible duplication of books. Picture books that had no pain or injury representations were then excluded from further analysis. For each picture book that included a representation of pain/injury, the following details were recorded: title; author and illustrator; publication date; genre (fiction or non‐fiction); whether pain/injury was central, incidental or coincidental to the plot; page number/s of pain/injury representation; characteristic of character experiencing pain/injury (gender, age group, human or non‐human). If a book had multiple pain/injury representations, each representation was coded separately. See Supporting Information for details of the 50 included picture books.

All included picture books were scanned digitally to facilitate off‐site (i.e., library) analysis, while adhering to copyright parameters (only pages with pain/injury related content were scanned) (Australian Government 2022). For picture books that required analysis of > 10% of a book's content and could therefore not be digitally scanned for copyright reasons, the researcher (DNM) based themselves at the library and coded on‐site.

2.4. Data Analysis

We conducted a content analysis on all included picture books (n = 50). This involved examining all text and illustrations for pain and injury representations and coding each representation using inductive and deductive approaches. That is, deductively starting with a set of codes that aligned with our research aims (i.e., a priori codes) and inductively identifying new codes during the analysis process (Azungah 2018). Categories were generated under each code during analysis, with detailed definitions for each category, which provided a systematic process for analysis and classification of pain/injury incidents, enabling a comprehensive and detailed examination of the dataset (Azungah 2018; Thomas 2006). We recognised that pain and injury may or may not co‐exist, and therefore were not treated as mutually exclusive in our analysis. If an incident involved both pain and injury, it was analysed twice (i.e., under both ‘pain’ and ‘injury’) to avoid overlooking any significant data (Graneheim et al. 2017). This nuanced approach to the analysis of pain and injury enabled us to explore differences in how ‘pain’ and ‘injury’ are represented and responded to. It is also consistent with the contemporary understanding of pain in the wider literature (Ryan et al. 2024).

We used the Narrative and Rhetorical Processing Framework which examines how narratives influence beliefs, attitudes and behaviours. This approach enabled us to examine illustrations for visual and/or narrative cues which may function to shape the reader's perception of pain/injury incidents. These cues include visual signs of a character's emotional response to pain/injury. A thorough analysis of the illustrations, text, narrative tone and plot was used to identify cues that convey characters' emotions and reactions to pain/injury incidents (Sanford and Emmott 2012). This allowed us to analyse the visual cues (e.g., facial expressions, body language) alongside narrative elements (e.g., tone) that may guide the reader's emotional engagement with these incidents. We employed the Structural Narrative Analysis Framework (i.e., a methodological approach that dissects narratives into their constituent parts, to understand their underlying structure and significance), which ensured deep and contextualised coding of the picture book interactions, by examining: (1) narrative orientation, which establishes the setting, characters and initial situation; (2) complication, which is the central conflict or challenge in the story; and (3) resolution, which is the outcome of the complication (James 2023). Together these frameworks facilitated an in‐depth exploration of the depictions and meaning of pain and injury incidents across picture book narratives (Graneheim et al. 2017; James 2023).

Data coding and analysis were undertaken by the primary researcher (DNM), and any uncertainty was resolved through discussion with researchers SBW and SN. To ensure consistency, prior to full data coding and analysis, researchers DNM and SBW independently analysed features from five books (see Supporting Information) and compared results. Any differences were resolved through discussion. The coding definitions and excel spreadsheets containing coding and analysis were shared with the broader research team to check for accuracy, consistency and adherence to qualitative reporting guidelines (O'Brien et al. 2014).

3. Results

Two hundred fifty‐four picture books were screened until our a priori quota of 50 picture books with pain/injury representations were identified (19.7%) (see Figure 1 for flow chart of data collection process). Across the 50 picture books, 63 pain representations and 43 injury representations were identified (including 17 ‘injury only’, 37 ‘pain only’ and 26 ‘pain with injury’). Pain/injury representations were central to the narrative in 21 books (42%), consequential in 14 books (28%) and incidental in 15 books (30%). All 50 picture books were fiction.

3.1. Characteristics of Pain and Injury Representations

The characteristics of pain/injury representations are presented in Figure 2 and Table 1. Pain and injury were depicted to be experienced by several character types including animals (n = 37; 48%), humans (n = 34; 44%) and fantasy creatures (n = 6; 9%). Overall, boy characters (n = 42; 53%) experienced more pain/injury incidents than girl characters (n = 23; 29%) or gender‐unspecified characters (i.e., no clear gendered appearance and/or use of they/them pronouns; n = 15; 19%). The most represented type of pain/injury was ‘minor’ (n = 69; 86%) (e.g., incidents resulting in scrapes, bruises, swelling) (Figure 2). ‘Chronic’ (n = 2; 3%) and ‘procedural’ (n = 1; 1%) pain/injury types were only represented in girl characters. ‘Physical trauma’ pain/injury type was represented more commonly in boy characters (n = 4; 67%) than in girl characters (n = 1; 17%) or gender‐unspecified (n = 1; 17%) characters. Pain/injury appeared to be most often unintentionally caused (n = 38; 47%) rather than intentionally caused (n = 15; 19%) and resulted mostly from accidents or play (n = 26; 33%). Boy characters (n = 8; 44%) were more likely to experience pain/injury from impulsive or aggressive behaviour than girl characters were (n = 3; 17%).

FIGURE 2.

Types of pain/injury represented in childrens picture books. This figure illustrates the distribution of types of pain/injury represented in the 50 children's picture books. The total number of representations of each type of pain has been presented and a percentage has been given. The percentages in this figure have been rounded, therefore may present a deviation from a cumulative total of 100%. The category ‘not applicable*’ refers to incidents where the cause of pain/injury was mentioned but did not occur, rendering the specific type indeterminable. The number of representations of each pain/injury type has then been presented by gender; green represents boy characters, blue represents girl characters and pink represent gender‐unspecified characters.

TABLE 1.

Characteristics of pain and injury representations in children's picture books.

Items (%)	Pain/injury				Pain only	Injury only	Pain and Injury
	Total characters	Boy characters	Girl characters	Unspecified gender	Total characters	Total characters	Total characters
Character‐types
Animals	38 (47.5)	17 (21.3)	9 (11.3)	12 (15)	17 (44.7)	8 (21.2)	13 (34.2)
Humans	35 (43.8)	20 (25)	14 (17.5)	1 (1.3)	16 (45.7)	9 (25.7)	10 (28.6)
Fantasy creatures	7 (8.8)	5 (6.3)	0 (0)	2 (2.5)	4 (57.1)	0 (0)	3 (42.9)
Causes of pain/injury
Accidental/play	26 (32.5)	13 (50)	8 (30.8)	5 (19.2)	10 (38.5)	7 (26.9)	9 (34.6)
Impulsive/aggression a	18 (22.5)	8 (44.4)	3 (16.7)	7 (38.9)	12 (42.9)	0 (0)	6 (21.4)
Unknown	15 (18.8)	8 (53.3)	6 (40)	1 (6.7)	1 (6.7)	9 (60)	5 (33.3)
Other	11 (13.8)	8 (72.7)	2 (18.2)	1 (9.1)	7 (63.6)	0 (0)	4 (36.4)
Medical	4 (5)	1 (25)	3 (75)	0 (0)	3 (75)	0 (0)	1 (25)
Hunting	3 (3.8)	2 (66.7)	0 (0)	1 (33.3)	1 (33.3)	1 (33.3)	1 (33.3)
Deliberate b	3 (3.8)	2 (66.7)	1 (33.3)	0 (0)	3 (100)	0 (0)	0 (0)
Self‐protective behaviour
No self‐protective behaviours	51 (63)	27 (52.9)	15 (29.4)	9 (17.6)	24 (47.1)	13 (25.5)	14 (27.5)
Total self‐protective behaviours	28 (34.6)	16 (57.1)	8 (28.6)	4 (14.3)	—	—	—
Touching/holding	9 (11.1)	4 (44.4)	2 (22.2)	3 (33.3)	3 (33.3)	0 (0)	6 (66.7)
Activity reduction	9 (11.1)	5 (55.6)	4 (44.4)	0 (0)	5 (55.6)	2 (22.2)	2 (22.2)
Avoiding pain/injury source	5 (6.2)	4 (80)	1 (20)	0 (0)	2 (40)	0 (0)	3 (60)
Guarding	2 (2.5)	1 (50)	0 (0)	1 (50)	1 (50)	1 (50)	0 (0)
Favours pain/injury	2 (2.5)	1 (50)	1 (50)	0 (0)	2 (100)	0 (0)	0 (0)
Not applicable (pain/injury was mentioned but did not occur)	2 (2.5)	0 (0)	0 (0)	2 (100)	1 (50)	1 (50)	0 (0)
Pacing	1 (1.2)	1 (100)	0 (0)	0 (0)	0 (0)	0 (0)	1 (100)
Character causing pain/injury
Self (unintentional)	26 (32.1)	18 (69.2)	5 (19.2)	3 (11.5)	13 (50)	4 (15.4)	9 (34.6)
Unknown	15 (18.5)	0 (0)	0 (0)	0 (0)	1 (6.7)	9 (60)	5 (33.3)
Another character (unintentional)	12 (14.8)	7 (58.3)	0 (0)	5 (41.7)	7 (58.3)	2 (16.7)	3 (25)
Another character (intentional)	12 (14.8)	3 (25)	0 (0)	9 (75)	7 (58.3)	1 (8.3)	4 (33.3)
No one c	13 (16)	0 (0)	0 (0)	0 (0)	7 (53.8)	1 (7.7)	5 (38.5)
Self (intentional)	3 (3.7)	1 (33.3)	2 (66.7)	0 (0)	3 (100)	0 (0)	0 (0)

Note: The percentages in this table have been rounded, therefore may present a deviation from a cumulative total of 100%. The ‘total characters’ and ‘boys’, ‘girls’ and ‘unspecified’ gender categories refers to the gender of the character experiencing pain/injury.

^a Impulsive/aggression refers to pain/injury caused by actions that were driven by frustration, hunger, anger or immediate desires to themselves or others, often without consideration of consequences.

^b Deliberate refers to pain/injury caused by intentional actions, often out of curiosity or purpose to themselves or others.

^c No one refers to pain/injury caused form various uncategorisable reasons (e.g., make‐believe injuries for play).

3.2. Character, Bystander and Responder Reactions to Pain and Injury

The reactions of the characters experiencing pain/injury are presented in Table 1 and Table 2. Boy characters were more likely to respond to experiences of pain/injury (n = 42; 50%) than girl characters (n = 27; 32%). Boys displayed higher rates of vocal expression for pain/injury (n = 11; 48%) than girls (n = 4; 17%), while girls displayed more crying (n = 7; 78%) than boys (n = 2; 22%). Self‐protective behaviours (e.g., holding the area of pain/injury) were identified in 35% (n = 28) of incidents. Help‐seeking and medical response behaviours were more common in response to injury (n = 20; 61%) than they were in response to pain (n = 13; 39%), and characters had greater vocal expressions (e.g., saying ‘ouch!’) in response to pain (n = 23; 82%) than they did in response to injury (n = 5; 18%). Characters were more likely to rest if they experienced pain (n = 6; 75%) than if they experienced injury (n = 2; 25%) and were more likely to show no response to pain (n = 11; 58%) than they were to show no response to injury (n = 8; 42%).

TABLE 2.

Character response to experiencing pain/injury in children's picture books.

Response (%)	Pain/injury				Pain only				Injury only
	Total characters	Boy characters	Girl characters	Unspecified gender	Total characters	Boy characters	Girl characters	Unspecified gender	Total characters	Boy characters	Girl characters	Unspecified gender
Help‐seeking/medical attention	23 (25.3)	11 (47.8)	10 (43.5)	2 (8.7)	13 (39.4)	5 (38.5)	8 (61.5)	0 (0)	20 (60.6)	10 (50)	8 (40)	2 (10)
Vocal expression	23 (25.3)	11 (47.8)	4 (17.4)	8 (34.8)	23 (82.1)	11 (47.8)	4 (17.4)	8 (34.8)	5 (17.9)	2 (40)	1 (20)	2 (40)
No response	14 (15.4)	9 (64.3)	4 (28.6)	1 (7.1)	11 (57.9)	8 (72.7)	2 (18.2)	1 (9.1)	8 (42.1)	4 (50)	4 (50)	0 (0)
Crying	9 (9.9)	2 (22.2)	7 (77.8)	0 (0)	9 (56.3)	2 (22.2)	7 (77.8)	0 (0)	7 (43.8)	1 (14.3)	6 (85.7)	0 (0)
Resting	7 (7.7)	5 (71.4)	2 (28.6)	0 (0)	6 (75)	4 (66.7)	2 (33.3)	0 (0)	2 (25)	1 (50)	1 (50)	0 (0)
Not applicable a	7 (7.7)	2 (28.6)	2 (28.6)	3 (42.9)	4 (50)	2 (50)	1 (25)	1 (25)	4 (50)	1 (25)	1 (25)	2 (50)
Avoidance	3 (3.3)	3 (100)	0 (0)	0 (0)	3 (60)	3 (100)	0 (0)	0 (0)	2 (40)	2 (100)	0 (0)	0 (0)
Revenge	3 (3.3)	0 (0)	0 (0)	3 (100)	3 (100)	0 (0)	0 (0)	3 (100)	0 (0)	0 (0)	0 (0)	0 (0)
Anger/Confrontation	2 (2.2)	1 (50)	0 (0)	1 (50)	2 (66.7)	1 (50)	0 (0)	1 (50)	1 (33.3)	1 (100)	0 (0)	0 (0)
Total response reactions b	84 (94.4)	42 (50)	27 (32.1)	15 (17.9)	70 (83.3)	34 (40.5)	23 (27.4)	13 (15.5)	45 (53.6)	21 (25)	20 (23.8)	4 (4.8)

Note: The percentages in this table have been rounded, therefore may present a deviation from a cumulative total of 100%. Each character reaction stands alone in comparison of pain versus injury and has not been compared to the other character reactions present in the table.

^a Not applicable refers to incidents where pain/injury cause was mentioned but did not occur.

^b Total response reactions, excludes the category of ‘not applicable’ in calculation, as no reaction was depicted.

Bystander (i.e., non‐assisting character) and responder (i.e., assisting character) character reactions to pain and injury are presented in Table 3. There were more passive bystanders (n = 109; 60%) than responders (n = 51; 28%). Responders were more likely to respond to those with pain (n = 38; 52%) than to those with injury (n = 35; 48%). Most responders helped the characters experiencing pain/injury through physical actions such as applying a band‐aid/plaster (n = 22; 43%). Boy responders were depicted to provide more verbal advice than girl responders were (n = 3; 75% vs. n = 1; 25%), while girl characters were more likely to offer physical comfort, such as embracing (n = 8; 50%) than boy characters were (n = 3; 19%). Bystanders were more likely to notice characters experiencing pain (n = 34; 69%) than characters experiencing injury (n = 15; 31%).

TABLE 3.

Bystander and responder character response to pain/injury in children's picture books.

Response (%)	Pain/injury				Pain only				Injury only
	Total characters	Boy characters	Girl characters	Unspecified gender	Total characters	Boy characters	Girl characters	Unspecified gender	Total characters	Boy characters	Girl characters	Unspecified gender
Bystander (%)	109 (59.6)	46 (42.2)	35 (32.1)	28 (25.7)	64 (50.4)	30 (46.9)	13 (20.3)	21 (32.8)	63 (49.6)	20 (31.7)	26 (41.3)	17 (27)
Responder (%)	51 (27.6)	22 (43.1)	19 (37.3)	10 (19.6)	38 (52.1)	17 (44.7)	15 (39.5)	6 (15.8)	35 (47.9)	14 (40)	13 (37.1)	8 (22.9)
No bystander/responder (%)	25 (13.7)	0 (0)	0 (0)	0 (0)	13 (52)	0 (0)	0 (0)	0 (0)	12 (48)	0 (0)	0 (0)	0 (0)
Responder (%)
Helps (e.g., applies band‐aid)	22 (43.1)	10 (45.5)	9 (40.9)	3 (13.6)	13 (44.8)	7 (53.8)	6 (46.2)	0 (0)	16 (55.2)	7 (43.8)	6 (37.5)	3 (18.8)
Embraces character	16 (31.4)	3 (18.8)	8 (50)	5 (31.3)	14 (51.9)	3 (21.4)	7 (50)	4 (28.6)	13 (48.1)	2 (15.4)	6 (46.2)	5 (38.5)
Sympathises with character	3 (5.9)	2 (66.7)	0 (0)	1 (33.3)	2 (66.7)	1 (50)	0 (0)	1 (50)	1 (33.3)	1 (100)	0 (0)	0 (0)
Gives verbal advice	4 (7.8)	3 (75)	1 (25)	0 (0)	4 (100)	3 (75)	1 (25)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Checks in or reassures character	4 (7.8)	3 (75)	1 (25)	0 (0)	4 (50)	3 (75)	1 (25)	0 (0)	4 (50)	3 (75)	1 (25)	0 (0)
Apologises to character	2 (3.9)	1 (50)	0 (0)	1 (50)	1 (50)	0 (0)	(0)	1 (100)	1 (50)	1 (100)	0 (0)	0 (0)
Bystander (%)
Notices pain/injury but does not act	35 (32.1)	12 (34.3)	9 (25.7)	14 (40)	34 (69.4)	12 (35.3)	9 (26.5)	13 (38.2)	15 (30.6)	3 (20)	4 (26.7)	8 (53.3)
Does not notice pain/injury	74 (67.9)	34 (45.9)	26 (35.1)	14 (18.9)	30 (38.5)	18 (60)	4 (13.3)	8 (26.7)	48 (61.5)	17 (35.4)	22 (45.8)	9 (18.8)

Note: The percentages in this table have been rounded, therefore may present a deviation from a cumulative total of 100%. The ‘boy’, ‘girl’ and ‘unspecified’ gender categories refers to the gender of the bystander or responder character. Each bystander or responder reaction stands alone in comparison of pain versus injury and has not been compared to the other bystander or responder reactions present in the table.

3.3. Linguistic Text Representing Pain and Injury

The use of linguist text in picture books to depict pain and injury are provided in Table 4. Descriptive vocabularies that were categorised into signs and symptoms (i.e., words providing information about the pain/injury event and experience, e.g., ‘sore’, ‘swollen’) were more commonly used to depict pain and injury (n = 75; 72%), than exclamations (i.e., single words or sound effects marking the moment pain/injury occurred, e.g., ‘ouch’) (n = 29; 28%). Common signs included ‘bruise’ (n = 5; 6.7%), words for swelling (e.g., ‘swollen’, ‘puffy’) (n = 3; 4%), and words to express a burn (e.g., ‘covered in crackling flames’) (n = 3; 4%). Symptoms were categorised into sensory descriptive (i.e., sensations experienced by an individual, providing detail about the sensory qualities of the experience; e.g., ‘sore’) and affective motivational/behavioural (i.e., emotional and behavioural responses elicited by an individual's pain/injury experience; e.g., ‘cry’). They included ‘hurt’ and ‘pain’ (n = 14; 18.7%), ‘sore’ or ‘ache’ (n = 9; 12%), words to express hot sensations (e.g., ‘burning sun’) (n = 6; 8%) and words to express crying (e.g., ‘wail’, ‘tears’) (n = 7; 9.3%). Girl characters were more frequently depicted to use affective motivational/behavioural responses (n = 7; 9.3%) than boy characters (n = 4; 5.3%), whereas boy characters were more frequently depicted to use sensory descriptives (n = 17; 22.7%) compared to girls (12; 16%). Common exclamations included variations of the ‘ow’ sound (n = 11; 37%) and ‘ouch’ (n = 10; 33%). Linguistic text was more likely to be used to depict pain (n = 98; 56%) than injury (n = 76; 43%).

TABLE 4.

Linguistic text used to represent pain/injury in children's picture books.

Items	Total representations (%)	Girl characters	Boy characters	Unspecified gender
Exclamations
Ow/Oooowwww/Hooowwwwllll/Yeeeoooow	11 (36.7)	2 (6.7)	3 (10)	6 (20)
Ouch	10 (33.3)	2 (6.7)	5 (16.7)	3 (10)
Donk/Bonk	2 (2.7)	1 (3.3)	1 (3.3)	0 (0)
Smack	2 (2.7)	1 (3.3)	1 (3.3)	0 (0)
Thud	2 (2.7)	0 (0)	2 (6.7)	0 (0)
Sob	1 (3.3)	1 (3.3)	0 (0)	0 (0)
Ooh	1 (3.3)	0 (0)	1 (3.3)	0 (0)
Oof	1 (3.3)	0 (0)	1 (3.3)	0 (0)
Descriptive vocabulary signs
Bruised/Bruises	5 (6.7)	1 (1.3)	4 (5.3)	0 (0)
Fell/Fall	4 (5.3)	3 (4.0)	1 (1.3)	0 (0)
Swollen/Puffy	3 (4)	0 (0)	3 (4.0)	0 (0)
Burns/Sunburned/Fur covered in crackling flames	3 (4)	1 (1.3)	2 (2.7)	0 (0)
Sting/Thorns stuck‐in‐his‐tushy/Pierced	3 (4)	0 (0)	3 (4.0)	0 (0)
Limp	3 (4)	3 (4.0)	0 (0)	0 (0)
Hit/Beat	3 (4)	1 (1.3)	2 (2.7)	0 (0)
Wound	2 (2.7)	0 (0)	2 (2.7)	0 (0)
Scraped	2 (2.7)	0 (0)	2 (2.7)	0 (0)
Bent antenna	1 (1.3)	1 (1.3)	0 (0)	0 (0)
Injured	1 (1.3)	0 (0)	0 (0)	1 (1.3)
Bumped	1 (1.3)	0 (0)	1 (1.3)	0 (0)
Blistered	1 (1.3)	0 (0)	1 (1.3)	0 (0)
Red is sour like unripe strawberries and as sweet as watermelon (metaphor referring to blood)	1 (1.3)	0 (0)	1 (1.3)	0 (0)
Symptoms—sensory discrimination
Hurt/Pain	14 (18.7)	6 (8.0)	7 (9.3)	1 (1.3)
Sore/Ache	9 (12)	3 (4.0)	5 (6.7)	1 (1.3)
Burn/Fire/Burning sun/Roast and sizzle	6 (8)	2 (2.7)	4 (5.3)	0 (0)
Throb/Thrumb	2 (2.7)	1 (1.3)	1 (1.3)	0 (0)
Symptoms—affective motivation/behavioural
Tears/Cry/Wail	7 (9.3)	4 (5.3)	3 (4.0)	0 (0)
Sharp Prickle/Spikes	3 (4)	2 (2.7)	1 (1.3)	0 (0)
Fell ill	1 (1.3)	1 (1.3)	0 (0)	0 (0)
Pain/injury incidents with no linguistic text	13 (16.3)
Pain/injury incidents with linguistic text	67 (83.8)
Linguistic text used for pain only	98 (56%)
Linguistic text used for injury only	76 (43%)

Note: The percentages in this table have been rounded, therefore may present a deviation from a cumulative total of 100%.

3.4. Illustrations Representing Pain and Injury

Details of illustration features used to represent pain and injury are presented in Table 5. Most pain/injury representations 91% (n = 81) used illustrations to depict pain/injury. Illustrations mostly used shapes to represent pain/injury (e.g., circle for a grazed knee or a band‐aid indicating a healing injury). Red was the most common colour used to represent pain and injury (n = 16; 20%), followed by black (n = 5; 6%). Common character expressions included wide or squinted eyes (n = 27; 33%) or a curled/slumped posture (n = 23; 28%). Impact illustrations (e.g., lines shooting from the location of pain/injury) were often used to represent pain/injury. Illustrations were more commonly used to depict pain (n = 65; 59%) than injury (n = 46; 41%).

TABLE 5.

Illustrations used to represent pain/injury.

Items	Total representations (%)
Shape of pain/injury
No shape	41 (50)
Band‐aid/plaster	15 (18.3)
Circle	8 (9.8)
Sharp object (e.g., thorn)	6 (7.3)
Bump/swelling	6 (7.3)
Fracture (e.g., broken leg x‐ray)	2 (2.4)
Fire	2 (2.4)
Smudge/scratch	2 (2.4)
Colour of pain/injury
No colour	57 (71.3)
Red	16 (20)
Black	5 (6.3)
Fire flame (red, orange, yellow)	2 (2.5)
Facial expression
Wide or squinted eyes (e.g., shock or discomfort)	27 (32.5)
Quivered or frowned expression (e.g., sadness)	11 (13.3)
Crying/tears (e.g., sad and pain)	11 (13.3)
Unaffected (either not noticed or has been treated)	10 (12)
Exhausted/tired (e.g., dropped eyes)	6 (7.2)
Comfort/reassured (e.g., a gentle smile)	6 (7.2)
Angry (e.g., furrowed brows or clenched jaw)	4 (4.8)
Nervous/worry (e.g., frowning)	4 (4.8)
No facial expression (e.g., face covered)	4 (4.8)
Body language
Curled up/sitting slumped (e.g., sad, pain and discomfort)	23 (28)
Body straighten up (e.g., in surprise or discomfort)	15 (18.3)
Fallen/falling	12 (14.6)
Unaffected (either not noticed or has been treated)	10 (12.2)
Allowing help/embrace	7 (8.5)
Worried (e.g., touching painful/injured area)	6 (7.3)
Avoidance (e.g., running away)	4 (4.9)
Anger (e.g., clenched fist and tensed body)	3 (3.7)
Limping (e.g., injury)	2 (2.4)
Impact illustration
No impact illustration	57 (67.9)
Spark lines	13 (15.5)
Spark bubble	5 (6)
Stars	4 (4.8)
Black smoke from area of burn	3 (3.6)
Lines to represent a graze	2 (2.4)
Pain/injury not depicted using illustrations	8 (9)
Pain/injury depicted using illustrations	81 (91)
Illustration used to depict pain only	65 (58.6%)
Illustration used to depict injury only	46 (41.4%)

Note: The percentages in this table have been rounded, therefore may present a deviation from a cumulative total of 100%.

4. Discussion

In investigating representations of pain and injury in children's picture books, we explored: (a) characteristics of pain/injury representations; (b) characters' reactions to pain/injury; (c) gendered differences in pain/injury representations; and (d) differences in representations of ‘pain’ versus ‘injury’. The most common representations were minor pains/injuries that were caused unintentionally. Passive bystander characters were more common than responder characters, and responses of characters experiencing pain differed between genders. Responses of observing characters differed between ‘pain’ and ‘injury’, with injury more likely to elicit a response than pain. Overall, pain/injury representations were frequent in children's picture books and provided opportunities for children to learn about pain and injury.

The finding that minor pains and injuries were most commonly represented is consistent with reports that 3–5‐year‐olds experience minor pains/injuries multiple times daily (Baeyer et al. 1998; Hagan Jr. et al. 2001). Accidental and play‐related causes of pain/injury were common in these representations, which is consistent with reports that accidental falls, such as from playground equipment, are a leading cause of injury in children aged 1–9 years (Australian Institute of Health and Welfare 2021). Procedural pain was less common, being represented in just over 1% of representations. While many children will receive approximately 13 vaccine injections before the age of five (Australian Institute of Health and Welfare 2022), other children will undergo regular painful procedures during healthcare investigations or procedures (Stevens et al. 2011). Chronic pain was represented in 3% of pain/injury instances. While chronic pain is less common in young children than it is in adolescents and adults, its representation in picture books could provide socialised learning opportunities about a condition that is poorly managed, highly prevalent and burdensome (Vos et al. 2020).

Prosocial behaviours, including helping, giving advice or providing comfort and aid, in response to characters' pain were not commonly depicted in picture books. Passive ‘bystander’ characters were more commonly portrayed than ‘responder’ characters who noticed and assisted the character experiencing pain/injury. In many instances, this may have been because the character experiencing pain/injury was already being assisted by a ‘responder’ character, whereby further assistance from supporting characters was deemed unnecessary to the storyline. In real‐life, this response is known as the ‘bystander effect’, which may also occur due to assumptions of shared responsibility or concerns for personal safety (Hortensius and de Gelder 2018; Latané and Nida 1981). Research has shown that picture books are sometimes used to convey societal values to children, which can influence children's behaviours in similar real‐life contexts (de Droog et al. 2017; Harrington 2016; Larsen et al. 2018). Thus, the portrayal of a passive bystander role, with a lack of support and comfort, may encourage children to avoid assisting others who are in pain or injured.

When characters did respond to pain/injury, the most common response was to provide physical assistance (e.g., applying a band‐aid/plaster). Boy characters were more commonly depicted offering advice, whereas girl characters provided physical comfort (e.g., hugging), reinforcing gendered stereotypes of girls being nurturing and boys being stoic (Adam and Harper 2023; Crisp and Hiller 2011). Depicting boys as stoic may be problematic, as it may encourage boys to conceal their pain, and this behaviour has been linked to an increased vulnerability to pain in later life (Mathews 2011), and the suppression of pain‐related emotions can reduce pain‐related emotion regulation skills (Emerson and Bursch 2020; Wallwork et al. 2022). Broader depictions of gender stereotypes are not uncommon in children's picture books, where research has shown that characters are often portrayed in traditional gender occupations (e.g., boy truck drivers, girl nurses), and girls are shown to be more nurturing than boy characters (Hamilton et al. 2006). Future research is needed to understand how these depictions might contribute to the socialisation of children's pain and prosocial responding.

There are similarities and differences in how pain/injury were represented across children's picture books and popular media (television/movies). Mueri et al. (2021) and Cormier et al. (2024) found that violent pain was the most common pain representation in North American popular children's and adolescents' television/movies, whereas in picture books, minor pain/injuries were most common and intentional infliction of pain was rare. This difference may be because picture books function as educational tools, while media function to entertain, which is associated with dramatic and humorous portrayals of pain/injury (Pavlova et al. 2022; Strouse et al. 2018; Zhang et al. 2016). Similar to North American popular media, prosocial behaviours such as helping and providing comfort in response to another character who was depicted to be in pain were not common in picture books. Pain‐related gender stereotypes were also common across television/movies and picture books, indicating that depictions of gender differences in behavioural responses persist across multiple sociocultural learning platforms (Mueri et al. 2021), and speaking to the pervasiveness of the stereotypes in the culture across North America and Australia. These socialisation tools may perpetuate societal constructs of gender‐specific norms and how children learn to respond to others in pain or injury.

Pain was commonly depicted to be attributed to an injury or tissue‐based cause, demonstrating that the representation of pain in children's picture books is aligned with the dominant societal understanding of pain, whereby pain and tissue pathology are thought to be directly related (Ryan et al. 2024). While pain and tissue pathology may bear a somewhat close relationship for several acute pain contexts (such as those depicted in the analysed picture books), contemporary understandings of pain emphasise its protective role and its dynamic and multifactorial biopsychosocial‐societal nature (Moseley et al. 2025). This distinction is likely to be important during the socialisation of pain because societal misconceptions, for example, that pain is always a direct marker of pathology, have been clearly associated with poor clinical outcomes and avoiding evidence‐based treatments that consider non‐tissue‐based contributions (Ryan et al. 2024). For many, particularly individuals with complex or persistent pain, treatments that focus only on finding and eradicating a tissue‐based pathology do not work. Reinforcing such misconceptions through pain messaging in picture books could be problematic, as they may contribute to the formation of unhelpful beliefs about pain at a critical developmental time period when children are establishing foundational beliefs about the world, including making sense of their bodies and how they work. Our work has shown that these messages are reinforced during shared reading of picture books (Wallwork, Nichols, et al. 2024), further perpetuating the formation of these lifelong and unhelpful misconceptions. This leaves open the opportunity to develop picture books that explicitly deliver evidence‐based pain messages and that directly address the complex nature of pain.

Character responses to ‘pain’ versus ‘injury’ often differed. Those experiencing pain were more responsive (e.g., vocal) than characters experiencing injury. Pain was more commonly expressed through vocalisations (e.g., ‘ouch’) whereas characters with an injury were more likely to seek help/medical attention. This may be because injuries can often be seen and therefore attended to (e.g., putting a band‐aid/plaster on a grazed knee), whereas pain is a personal experience that may otherwise go unnoticed (Wideman et al. 2019). Illustrations depicting pain were more common than illustrations depicting injury. Illustrators may have deliberately chosen to visually depict pain as a means of identifying pain in others (Bandstra et al. 2011), which is aligned with research showing that children more readily respond to visual elements than text (Evans and Saint‐Aubin 2005; Lin et al. 2018). Interestingly, observing characters were less likely to respond to pain than injury, which is consistent with reports from people with lived experience of chronic pain, who state that their pain is disbelieved/dismissed if there is no clearly identified pathology (Ojala et al. 2015).

Language and illustrations were commonly used to portray pain and injury. Words expressing pain/injury symptoms included ‘hurt’, ‘pain’, ‘sore’, ‘ache’ and ‘ouch’, which are similar to pain‐related vocabulary used by children (Stanford et al. 2005). The use of these expressions in picture books might contribute to children's socialisation of pain and injury‐related vocabulary, as well as reflecting terms familiar to readers. Boy characters were more likely to use sensory descriptors such as ‘sore’, whereas girl characters were more likely to display affective motivational or behavioural responses to pain (e.g., crying). This is consistent with work showing that society often endorses gendered emotional dramatisation stereotypes, whereby it is often believed that women are more likely to exaggerate and dramatise their pain, compared to men who are more likely to downplay their pain (Paganini et al. 2023). These portrayals may further reinforce gender stereotypes, promoting boys to conceal their pain and contributing to the common invalidation and disbelief of women's pain (Zhang et al. 2021). The colour red was commonly used to represent pain and injury. Red is often used to depict danger and warning, conveying the message that something is wrong or dangerous (Pravossoudovitch et al. 2014), and research has shown that exposure to the colour red can increase pain intensity reports during an experimental pain paradigm (Wiercioch‐Kuzianik and Bąbel 2019). Illustrations of fire and sharp lines may also help to reinforce concepts of danger due to their association with potential harm (Bar and Neta 2007; Jeong and Chiasson 2020). Associating pain and injury with colours and symbols that are commonly associated with danger may help children to identify signs of danger in real life. However, this messaging may also promote unhelpful behaviours associated with pain and fear.

Facial expressions consistent with shock and discomfort were frequently used to represent pain/injury. These expressions may serve to convey the intensity of pain/injury by creating a visual language that resonates with children's attraction to illustrations over text (Evans and Saint‐Aubin 2005). In line with this, Liu et al. (2019) found that cartoon facial features are often exaggerated to make them more engaging, and Kendall et al. (2016) suggest that exaggerating facial expressions enhances early perceptual processing, leading to more efficient extraction of emotional recognition in children. Thus, exaggerated pain‐related facial expressions in picture books may enhance reader engagement. Furthermore, sadness was commonly presented through facial illustrations of tears and quivered/frowned expressions following pain/injury incidents. Research shows that children develop empathy for sadness earlier than they develop empathy for pain (Bandstra et al. 2011) and parents reminisce with their children about past sad events in more adaptive ways than they do about past painful events (Pavlova et al. 2019). Perhaps then, depicting illustrations of pain using expressions of sadness may make it easier for children/caregivers to relate to.

4.1. Implications and Future Directions

This work has several clinical, research and societal implications. From a clinical perspective, reinforcing unhelpful misconceptions about pain (i.e., the belief that pain is a direct marker of tissue damage) through picture books from an early age may contribute to laying the foundations for unhelpful lifelong beliefs about pain. Such beliefs may lead children to seek future pain care that is not helpful or evidence‐based. From a research perspective, the portrayal of pain and injury depictions in picture books highlights the critical role that picture books likely play in the socialisation of pain messaging to children, alongside other types of media (Cormier et al. 2024; Mueri et al. 2021). From a societal perspective, this work has demonstrated how pervasive the portrayal of unhelpful pain‐related messages is across children's media, including gendered stereotypes and a lack of role‐modelling prosocial behaviours. However, if harnessed appropriately, picture books could play an important and influential role in challenging these beliefs and behaviours that are so deeply embedded across society.

This study has raised several directions for future work. While we now have an understanding of how pain/injury is depicted in picture books, and how these messages are engaged with during shared reading (Wallwork, Nichols, et al. 2024), future work should explore what key pain‐related learnings and concepts children take from engaging with picture books that depict pain/injury. This might include the exploration of cognitive, emotional, social and behavioural outcomes in children. In this study, we explored the depiction of pain‐related prosocial behaviours, such as helping and providing comfort; however, we did not explore concepts related to empathy or validation of another's pain. This may be particularly important given the role of validation of children's pain on future pain outcomes (Wallwork, Shenk, et al. 2024). Finally, future work could explore how picture books could be better harnessed to provide helpful messages about pain to young children.

4.2. Strengths and Limitations

This study has several strengths. We used a systematic, replicable approach to sampling, coding and analysis, with adherence to reporting standards and pre‐registration. We combined inductive and deductive coding with narrative analysis frameworks to facilitate a comprehensive understanding of how pain and injury are depicted within children's literature. This study also has limitations. These findings are culturally and linguistically bound as the books were sourced in South Australia in the English language. It is recognised that picture books lack representation of characters with diversity in cultural, ethnic and racialized identities (Caple and Tian 2022); therefore, children from minoritized and racialised backgrounds may not relate to, or may internalise messages that their pain experiences are less worthy, or that they should conform to experiences among white characters and people, potentially perpetuating inequities in pain/injury experiences (Mathur et al. 2022; Meints et al. 2019). We also do not understand how pain and injury are represented in picture books in other languages. Future research should target picture books from diverse cultures and languages. Finally, we did not code responders into adults and children, which limits our understanding of prosocial responding across these two groups.

5. Conclusion

We found that pain and injury are commonly represented in children's picture books and may be a powerful learning platform for children to learn about pain and injury. Similar to what has been observed in children's movies and television shows, prosocial responding (e.g., helping, providing comfort) to character's experiencing pain was uncommon, and gender stereotypes were frequent. Importantly, pain was often attributed to an injury or tissue‐based cause, potentially reinforcing and perpetuating unhelpful societal misconceptions about pain. Future work could investigate how picture books could be harnessed to promote a modern understanding of pain and prosocial behaviours and break down common and unhelpful pain gender stereotypes.

Author Contributions

S.B.W. and S.N. designed the study. D.‐E.‐N.M. and S.B.W. collected data. D.‐E.‐N.M., S.B.W. and S.N. analysed and interpreted results. D.‐E.‐N.M. had a primary role in preparing the manuscript. All authors discussed the results, commented on the manuscript and have approved the final version of the manuscript.

Conflicts of Interest

S.B.W. receives payments for lectures on pain and rehabilitation. G.L.M. has received support from: Reality Health, ConnectHealth UK, Institutes of Health California, AIA Australia, Workers' Compensation Boards and professional sporting organisations in Australia, Europe, South and North America. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain and pain education at scientific conferences/symposia. He has received speaker fees for lectures on pain, pain education and rehabilitation. He receives royalties for books on pain and pain education. He is non‐paid CEO of the non‐profit Pain Revolution and an unpaid Director of Painaustralia and the Australian Pain Solutions Research Alliance.

Supporting information

Data S1: ejp70102‐sup‐0001‐DataS1.docx.

Mehar, D.‐E.‐N. , Nichols S., Jordan A., Moseley G. L., Noel M., and Wallwork S. B.. 2025. “Representation of Pain and Injury in Children's Picture Books—A Content Analysis.” European Journal of Pain 29, no. 8: e70102. 10.1002/ejp.70102.