Revised FLACC Tool: Reliable Pain Assessment for Children with Cognitive Impairment

This study validates the revised FLACC tool as a reliable & valid measure of pain in children with cognitive impairment, improving pain assessment & management.

I. Introduction

Pain assessment is a crucial aspect of healthcare, allowing medical professionals to effectively manage and alleviate pain in their patients. This is particularly important for individuals who face challenges in communicating their pain, such as young children and those with cognitive impairment (CI). For these individuals, the inability to self-report pain presents a significant barrier to receiving adequate pain management, often leading to under-treatment and unnecessary suffering.

Several pain assessment tools have been developed to address this issue in children with CI. However, existing tools often suffer from limitations. Some are lengthy and impractical for routine clinical use, while others lack consistent reliability in accurately measuring pain. This inconsistency is partly due to the diverse range of pain behaviors exhibited by individuals with CI, which can differ from those observed in typically developing children.

This study focuses on the Face Legs Activity Cry Consolability (FLACC) pain assessment tool, which has shown promise in previous research but also exhibited limitations in its reliability, particularly for the categories of leg movement and activity. To address these shortcomings, we revised the FLACC tool by incorporating specific pain behaviors commonly seen in children with CI and allowing for individualization based on each child’s unique pain expression.

The objectives of this study were twofold: (1) to revise the FLACC tool to be more comprehensive and sensitive to the pain behaviors of children with CI, and (2) to evaluate the validity and reliability of the revised tool in this population. Our hypothesis was that the revised FLACC tool would demonstrate strong validity and reliability as a measure of pain in children with CI.

Revised FLACC Tool: Reliable Pain Assessment for Children with Cognitive Impairment

II. Methods

This study employed a comprehensive approach to revise and evaluate the FLACC pain assessment tool for children with cognitive impairment (CI).

Revision Process

The initial phase focused on refining the FLACC tool to better capture the nuances of pain expression in children with CI. Researchers conducted a thorough review of existing literature, identifying common pain behaviors in this population, such as agitation, vocalizations, tremors, and altered muscle tone. Video recordings of children with CI experiencing post-surgical pain were analyzed to further understand the range and frequency of pain behaviors.

Based on these findings, the FLACC tool was revised. Specific behavioral descriptors were added to each of the five categories (Face, Legs, Activity, Cry, Consolability) to enhance the tool’s sensitivity to pain indicators in children with CI. Particular attention was given to expanding the descriptors within the Legs and Activity categories, as previous research identified these areas as having lower reliability.

Recognizing the individual variability in pain expression, the researchers incorporated an open-ended descriptor within each category, allowing parents or caregivers to document unique pain behaviors observed in their child. This individualized approach aimed to enhance the tool’s ability to capture the full spectrum of pain responses.

To ensure the revised FLACC tool’s content validity, it was presented to a panel of experts, including physicians and advanced practice nurses with expertise in pain assessment and management for children with CI. Their feedback further refined the tool and confirmed its suitability for the target population.

Study Design and Data Collection

Following the revision process, a study was conducted to evaluate the revised FLACC tool’s validity and reliability. Children with CI, aged 4-21 years and scheduled for elective surgery, were recruited with informed consent from parents and assent from children (when applicable).

Preoperative assessments were conducted to gather comprehensive data. This included collecting demographic information, conducting parent interviews to assess the child’s developmental level and communication skills, and evaluating the presence of motor impairments. The child’s ability to self-report pain was also assessed using standardized tests. If capable, children selected their preferred method for self-reporting pain postoperatively.

Parents reviewed the revised FLACC tool and provided information on any additional pain behaviors specific to their child. This information was used to create an individualized FLACC tool for each participant.

Postoperative pain assessments were conducted by two trained nurses, who independently observed and scored the child’s pain using the revised and individualized FLACC tool. Parents concurrently provided their own pain ratings using a VAS. These assessments occurred when the child was awake and, typically, in the presence of a parent or guardian. All observations were video-recorded.

For children requiring analgesics, pain assessments were repeated 30 minutes after administration using the same methods as the initial assessment.

The video recordings were then randomized and reviewed by four nurses experienced in pediatric pain assessment. Blinded to analgesic administration and previous pain scores, these nurses independently scored the children’s pain using the revised FLACC tool for half of the videos and the NAPI tool for the remaining half.

To evaluate test-retest reliability, two of the blinded reviewers independently rescored a random sample of 20 video segments after a period of 3-4 weeks.

Statistical Analysis

The collected data was analyzed using various statistical methods. Spearman’s rho and ICCs were calculated to assess the strength of association and agreement between different pain scores. Bias between parent and nurse scores was determined and presented as mean (bias) and standard deviation (precision). Percentage agreement and kappa statistics were used to evaluate exact agreement between FLACC scores. Wilcoxon signed-rank tests compared pain scores before and after analgesic administration.

Revised FLACC Tool: Reliable Pain Assessment for Children with Cognitive Impairment

III. Results

The study enrolled 52 children with CI, resulting in a total of 80 pain observations. The children ranged in age from 4 to 19 years, with a mean age of 11.3 years. Diagnoses included cerebral palsy (51%), syndromes with CI (18%), autism (16%), and other conditions (15%). The degree of impairment varied, with 31% classified as mildly impaired, 23% moderately impaired, and 46% severely impaired. A significant portion of the children (61%) exhibited spasticity, with quadriplegia being the most common form (49%).

Individualized Pain Behaviors

While most parents confirmed that the revised FLACC tool’s behavioral descriptors accurately reflected their child’s pain expression, 21 parents identified additional, unique behaviors indicative of pain in their children. These individualized behaviors included specific facial expressions, body movements (including self-stimulatory behaviors), vocalizations, and responses to comforting techniques. Interestingly, several parents noted that a lack of expression, crying, or responsiveness was a key indicator of pain in their child. The inclusion of these individualized pain behaviors alongside the revised FLACC descriptors aimed to provide a more comprehensive and personalized approach to pain assessment.

Interrater Reliability

The study found strong evidence supporting the interrater reliability of the revised FLACC tool. Analysis revealed excellent ICCs for all FLACC categories (Face, Legs, Activity, Cry, Consolability) and the total FLACC score. The agreement between observers was also deemed acceptable, indicating consistency in how different raters interpreted and scored pain behaviors using the revised tool.

To assess the tool’s reliability across varying pain intensities, FLACC scores were categorized as mild (0-3), moderate (4-6), or severe (7-10) based on established clinical standards. Interrater agreement for these categorized scores was found to be good to excellent, demonstrating the tool’s reliability across different levels of pain severity.

Comparisons were also made between children with and without spasticity to determine if spasticity impacted the reliability of the motor-related components of the FLACC tool (Legs and Activity categories). The results showed comparable levels of agreement between observers for both groups, suggesting that the revised FLACC tool maintains its reliability even in the presence of spasticity.

Test-Retest Reliability

To assess the revised FLACC tool’s stability over time, a subset of video recordings was reviewed and scored by two independent observers on two separate occasions, spaced 3-4 weeks apart. The analysis revealed an excellent ICC for the repeated FLACC scores, indicating high test-retest reliability and demonstrating that the tool yields consistent results even when used by the same rater at different time points.

Criterion Validity

The study assessed the criterion validity of the revised FLACC tool by comparing its scores to other measures of pain, including parent-reported pain ratings, NAPI scores assigned by blinded observers, and, when available, the child’s self-reported pain scores. The analysis demonstrated moderate to high correlations between the FLACC scores and these other pain measures, providing support for the tool’s validity in accurately assessing pain. It’s worth noting that parent-assigned pain scores tended to be slightly higher than those assigned by nurses and observers using the FLACC tool, suggesting a potential tendency for parents to rate their child’s pain as more severe.

Construct Validity

Further support for the revised FLACC tool’s validity came from its ability to detect changes in pain following analgesic administration. The study found that FLACC scores decreased significantly after pain medication was given, as did parent-reported pain scores. This finding aligns with the expected outcome of effective pain management and provides evidence for the tool’s construct validity, meaning it accurately reflects the underlying concept it is intended to measure (i.e., pain).

Revised FLACC Tool: Reliable Pain Assessment for Children with Cognitive Impairment

IV. Discussion

Effectively managing pain in children with cognitive impairment (CI) hinges on the ability of healthcare providers to accurately assess and interpret their pain. However, the lack of a standardized and reliable pain assessment tool for this population has posed a significant challenge. Existing tools often fall short due to their length, complexity, or inconsistent reliability, particularly when considering the diverse range of pain behaviors exhibited by children with CI.

This study highlights the revised FLACC (Face Legs Activity Cry Consolability) tool as a promising solution to this challenge. The revised tool incorporates key features that address the limitations of previous pain assessment methods.

Advantages of the Revised FLACC Tool

  • Comprehensive Pain Behavior Coverage: The inclusion of specific behavioral descriptors relevant to children with CI, such as changes in muscle tone, vocalizations, and atypical responses, allows for a more nuanced and accurate understanding of pain expression in this population.
  • Individualized Approach: The addition of open-ended descriptors for each FLACC category enables parents or caregivers to document unique pain behaviors specific to their child, further enhancing the tool’s sensitivity and personalized approach.
  • Improved Reliability: Compared to the original FLACC tool, the revised version demonstrated significantly improved reliability across all categories and pain intensity levels. This enhanced reliability ensures greater consistency in pain assessment, regardless of who is using the tool or the child’s specific pain behaviors.
  • Ease of Use: The FLACC tool maintains its simple and straightforward structure, making it easy for healthcare providers to integrate into their clinical practice. Its user-friendly nature facilitates efficient and effective pain assessment, ultimately leading to more timely and appropriate pain management interventions.


While the revised FLACC tool demonstrates significant strengths, some limitations should be considered:

  • Generalizability: The study primarily focused on post-surgical pain, which may limit the generalizability of the findings to other pain contexts, such as chronic pain or pain associated with medical procedures. Further research is needed to explore the tool’s applicability and effectiveness in a broader range of pain settings.
  • Scoring Individualized Behaviors: The open-ended nature of the individualized pain behavior descriptors may present challenges in terms of standardization and interpretation. Ensuring consistent scoring across different raters may require additional training and guidance.

Future Directions

The revised FLACC tool offers a valuable contribution to the field of pain assessment for children with CI. Future research should focus on exploring its effectiveness in diverse pain contexts, refining the scoring of individualized behaviors, and developing training resources to support its widespread adoption in clinical practice. Additionally, investigating the tool’s use in conjunction with other pain assessment methods, such as physiological measures, could provide a more comprehensive understanding of pain experiences in this population.

V. Conclusion

The findings of this study provide compelling evidence for the revised FLACC tool as a reliable and valid instrument for assessing pain in children with cognitive impairment (CI). By incorporating specific behavioral descriptors relevant to this population and allowing for individualization based on each child’s unique pain expression, the revised FLACC tool overcomes many limitations of existing pain assessment methods.

The tool’s enhanced reliability ensures greater consistency in pain assessment across different raters and pain intensities, while its user-friendly design facilitates easy integration into clinical practice. Ultimately, the utilization of the revised FLACC tool has the potential to significantly improve pain management for children with CI, leading to better clinical outcomes and a reduction in unnecessary suffering. By providing healthcare professionals with a reliable and valid means of assessing pain in this vulnerable population, we can move closer to ensuring that every child receives appropriate and timely pain relief.

Malviya, S., Voepel-Lewis, T., Burke, C., Merkel, S., & Tait, A. R. (2006). The revised FLACC observational pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia, 16(3), 258-265.


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