Objectives: To explore whether self-injurious behavior (SIB) alters pain expression in children with severe cognitive impairments and the relation between SIB and chronic pain. Study design: Caregivers of 101 nonverbal children 3 to 18 years of age (55% boys) completed the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R) retrospectively, and for all observed pain episode. Caregivers of children with SIB (n = 44) completed the Behavior Problems Inventory, the Self-Injury Grid, and the Self-Injury and Self-Restraint Checklist. Results: Multivariate analysis of variance indicated that NCCPC-R scores did not differ between children with and those without SIB. However, t tests indicated that children with chronic pain (n = 13) self-injured less body surface (P = .01) and fewer body sites (P = .04) than did children without (n = 31). Multiple Correspondence Analysis generated 2 dimensions (4996 variance), suggesting a distinction between two SIB forms: (1) high frequency of SIB to the head/hand and absence of chronic pain and (2) less frequent SIB near the site of pain. Conclusions: Children with severe cognitive impairments who display SIB do not have reduced pain expression, and chronic pain may influence the frequency, and location of SIB. Further research should examine the usefulness of these findings for management of SIB and pain.