Study Reviews Faces Scales for Reporting Pain in Kids

Fran Lowry

October 06, 2010

October 6, 2010 — There are no reasons to switch from one faces scale to another when one of the scales is in use in clinical practice, but for research purposes, the Faces Pain Scale-Revised is the one to use, according to a new study published online October 4 in Pediatrics.

"The assessment and measurement of pain in pediatric populations have been examined and debated in the literature for more than 2 decades," write Deborah Tomlinson, MN, from the Hospital for Sick Children, Toronto, Ontario, Canada, and colleagues. "Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference."

The aim of this study was to summarize and review the pain scales most commonly used for self-report of pain intensity in kids for their reliability and validity and to compare them for preference and usefulness.

From an analysis of 127 studies, the authors found 4 faces pain scales that had undergone extensive psychometric testing. These were the Faces Pain Scale (scored 0 - 6), the Faces Pain Scale-Revised (scored 0 - 10), the Oucher pain scale (scored 0 - 10), and the Wong-Baker Faces Pain Rating Scale (scored 0 - 10).

The researchers found that the Faces Pain Scale-Revised had the most data to support its reliability and validity for assessing pain intensity in children aged 4 to 12 years and that the scale showed excellent interscale agreement even in 4-year-old children.

The Faces Pain Scale-Revised has no smiling face and no tears, which may be advantageous in avoiding the confounding effect of affect and pain intensity. A limitation of the Faces Pain Scale-Revised is that it has shown low preference when kids and adults are given a choice among faces scales. However, this tool is recommended for use in clinical trials for optimal psychometric measurement, they note.

The Oucher scale has adequate psychometric properties in validity and reliability and can also be presented using photographed faces that match various ethnic and racial groups. However, it can be difficult to use, especially by younger children 3 to 7 years old.

It is also more expensive to reproduce because it requires printing of color photographs. The Oucher scale may be particularly useful for children older than 7 years and for studies that are restricted to certain ethnic groups, the study authors write.

The Wong-Baker Faces Pain Rating Scale is quick and easy to use and has adequate psychometric properties. It is also inexpensive to reproduce. Its greatest strength is its wide acceptability, being preferred to all other faces pain scales by children of all ages, parents, and practitioners.

The major concern with the Wong-Baker Faces Pain Rating Scale is the confounding of emotion with pain intensity as represented in the faces. "Children who do not cry with intense pain, especially older boys, may be reluctant to pick the face scored 10 of 10 because it shows tears," the study authors write. "If there are concerns regarding potential for confounding of pain intensity with affect, or regarding the possibility of overestimation of pain scores for a particular study or purpose, then this scale may not be optimal. If these are not major issues and patient and staff acceptance are critical, then the Wong-Baker Faces Pain Rating Scale may be suitable."

There is no reason to change from one scale to another in settings where one is currently in use because such a change may be disruptive and costly. However, when no faces scale has been adopted, the Faces Pain Scale-Revised scale is recommended for use in multicenter clinical trials in which standardized methods to assess pain are critical.

Self-report measures of pain intensity in younger children 3 to 5 years old and in older children with mild development delay need further research, they add.

"Research should continue, not on developing new scales for older children (because there are already so many), but on studying the use of existing scales in various clinical situations, in a consistent manner, and including disease-related or chronic pain, which have received minimal comparative self-report pain-scale testing to date," the study authors conclude.

The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 4, 2010.

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