FLACC behavioral pain assessment scale: a comparison with the child's self-report

Pediatric Nursing, May-June, 2003 by Martha H.W. Willis, Sandra I. Merkel, Terri Voepel-Lewis, Shobha Malviya

The difficulty quantifying and qualifying pain in young children may place this population at risk for inadequate pain control (Colwell, Clark, & Perkins, 1996). While self-report of pain should be obtained whenever possible, behavioral observation remains the primary method for pain assessment in children with limited verbal and cognitive skills. The Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Tool (see Table 1) was developed to provide a simple and consistent method for nurses to identify, document, and evaluate pain in children who have difficulty verbalizing the presence or intensity of pain (Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997). This study was designed to further validate the FLACC tool by comparing nurse assigned FLACC scores to the child's self-report of pain.

Review of the Literature

Self-report of pain remains the recommended method to assess pain intensity in both adults and children. However, young children often do not have the cognitive or verbal skills necessary to report and describe pain. Reliable use of a tool or scale that estimates or quantifies pain requires the cognitive ability to classify and communicate pain intensity. According to Piaget and Inhelder (1969), preoperational children do not have the cognitive ability to quantify and tend to choose extremes when presented with multiple response options. This theory was supported in a study of children aged 4-5 years undergoing immunization, where the majority of children rated their pain as 0, 1, or 5 on the 0-5 FACES scale (Stein, 1995). Yet, recent reports on developmental concepts and pain assessment suggest that the precise knowledge of numbers on a pain scale is not necessary in order to rank pain and that children older than 3 years of age can use pictures to self-report their pain (Keck, Gerkensmeyer, Joyce, & Schade, 1996). Furthermore, a large pain study in children birth to 17 years of age reported that if a child is willing and able to express pain using a self-report scale, his/her report can be trusted on the condition that the child has understood the use of the scale (Maunuksela, Olkkola, & Korpela, 1987). Several tools that incorporate symbols or pictures have been developed and validated to help children quantify their pain intensity. These include the Oucher (Beyer, Denyes, & Villarruel, 1992), Poker Chips (Hester, 1979), and Wong-Baker FACES scale (Wong & Baker, 1988). The FACES scale has been shown to be the preferred pain tool of children of various ages (Keck et al., 1996).

When children cannot speak or comprehend and use self-report pain measurement tools, behavior is the primary means by which they communicate their pain. Specific distress behaviors such as crying, facial grimaces, body posture, rigidity, changes in sleep, and consolability have been associated with pain in young children. Investigators and clinicians have incorporated these behaviors into behavioral pain scales to help with the objective measurement of pain when self-report is difficult (Buttner & Finke, 2000; McGrath et al., 1985; Norden et al., 1991; Soetenga, 1999; Tarbell, Cohen, & Marsh, 1992). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) was one of the earliest developed tools to systematically assess and document pain behaviors in young children and, as such, remains a gold standard for comparative purposes (McGrath et al., 1985). This tool incorporates six categories of behavior that are each scored individually (range of 0-2 or 1-3) and then totaled for a pain score ranging from 4-13. Its length and variable scoring system among categories make the CHEOPS somewhat complicated and impractical to use relative to other observational scales. The Children's and Infants' Postoperative Pain Scale (CHIPPS) was recently developed to include five behavioral items that were found to be consistently indicative of pain in both infants and young children in a series of studies (Buttner & Finke, 2000). These five items included crying, facial expression, posture of trunk, posture of legs, and motor restlessness. Buttner and Finke (2000) compared and summarized seven studies of behavioral observational tools and demonstrated the validity of several observational methods of pain assessment in detecting postoperative analgesic demand in infants and young children, but described the CHIPPS scale as being the easiest to use, learn, and implement.

While no single behavioral scale has been shown to be superior to others, some are difficult to integrate into routine clinical practice because of the length of time required for their administration and their complexity of scoring. The FLACC scale was developed to reduce these potential barriers by providing a simple framework for assessment, while facilitating a reliable and objective means of quantifying pain behaviors in children. This tool includes five categories of pain behaviors, including facial expression, leg movement, activity, cry, and consolability. These behaviors are consistent with those described by Buttner and Finke (2000) to be reliably associated with pain in young children. The acronym FLACC facilitates recall of these categories, each of which is scored from 0-2 to provide a total pain score ranging from 0-10. The FLACC tool was shown to have good interrater reliability and excellent validity as demonstrated by changes in pain scores from before to after analgesic administration and excellent correlation with the Objective Pain Scale (OPS) in a study of children aged 2-7 years (Merkel et al., 1997).