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Face, Legs, Activity, Cry, Consolability Scale (FLACC)
Please visit this website for more information about the instrument: Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale
Revised FLACC (rFLACC)
Exploratory: Cerebral Palsy (CP)
Short Description of Instrument
The Face, Legs, Activity, Cry, Consolability scale (FLACC) is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to self-report their level of pain (Merkel et al., 1997).
A revised version (rFLACC) includes behaviors specific to children with cognitive impairments (Malviya et al., 2006; Fox et al., 2019).
Comments/Special Instructions
The FLACC is used in target populations that include children with mild to severe cognitive impairments, developmental delay, and cerebral palsy. It has also been used in elderly patients with dementia, although it is not a useful tool to assess pain in elderly patients that are cognitively impaired.
CP-specific Pain Category: Pain Behavior
CP-specific ICF Domains: Body Structure, Body Functions, Activities (World Health Organization, 2001).
Scoring and Psychometric Properties
Scoring: The FLACC scale scores pain intensity by rating 5 behaviors: F: face, L: legs, A: activity, C: cry and C: consolability, each equally weighted from 0 to 2. The scale is scored in a range of 0-10 with 0 representing no pain.
Category/Description; Score
0 = No particular expression or smile; Score = 0
1 = Occasional grimace/frown, withdrawn or disinterested; Score = 1
2 = Frequent/constant quivering chin, clenched jaw; Score = 2
0 = Normal position or relaxed; Score = 0
1 = Uneasy, restless, tense; Score = 1
2 = Kicking or legs drawn up; Score =2
0 = Lying quietly, normal position, moves easily; Score = 0
1 = Squirming, shifting back and forth, tense; Score = 1
2 = Arched, rigid or jerking; Score = 2
0 = No cry; Score = 0
1 = Moans or whimpers, occasional complaint; Score = 1
2 = Crying steadily, screams or sobs, frequent complaints; Score = 2
0 = Content and relaxed; Score = 0
1 = Reassured by occasional touching, hugging or being talked to, distractable; Score = 1
2 = Difficult to console or comfort; Score = 2
Psychometric Properties:
FLACC has been most widely used and studied for procedural pain in young children. Systematic review of the use of the FLACC found wide variation in validity and reliability (Crellin et al, 2015).
In spastic CP, r-FLACC scores showed moderate agreement between raters but low agreement between participants and raters (Fox, 2018).
Current validity testes with Objective Pain Scale (r = 0.80, n = 89, p< .001) (Merkel et al, 1997; Rahu et al., 2015)
The FLACC can be completed quickly in just a few minutes by observing for indicators of pain in children.
It is an observational tool that is reliable and valid for measuring postoperative pain in children with mild to severe cognitive impairment (Voepel et al., 2002).
The revised version includes additional descriptors that improve the reliability of the tool and allows for patient-specific description provided by those who know them best.
There is insufficient data to support the  measurement properties of the scale to assess postoperative pain infants younger than 2months of age (i.e., neonates) (Crellin et al., 2015)
It is difficult to distinguish actual pain from distress, fear, or anxiety (Crellin et al., 2015), and the facial expressions may be more sensitive indicators than the whole scale (Fox, 2018).  
Key References:
Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006 Mar;16(3):258-265.
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997 May-Jun;23(3):293-297.
Additional References:
Babl FE, Crellin D, Cheng J, Sullivan TP, O'Sullivan R, Hutchinson A. The use of the faces, legs, activity, cry and consolability scale to assess procedural pain and distress in young children. Pediatr Emerg Care 2012;28:1281-1296.
Crellin DJ, Harrison D, Santamaria N, Babl FE. Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use? Pain. 2015 Nov;156(11):2132-2151.
Fox MA, Ayyangar R, Parten R, Haapala HJ, Schilling SG, Kalpakjian CZ. Self-report of pain in young people and adults with spastic cerebral palsy: interrater reliability of the revised Face, Legs, Activity, Cry, and Consolability (r-FLACC) scale ratings. Dev Med Child Neurol. 2019 Jan;61(1):69-74.
Manworren RC, Hynan LS. Clinical validation of FLACC: preverbal patient pain scale. Pediatr Nurs. 2003 Mar-Apr;29(2):140-146.
Merkel S, Voepel-Lewis T, Malviya S. Pain assessment in infants and young children: the FLACC scale. Am J Nurs. 2002 Oct;102(10):55-58.
Rahu MA, Grap MJ, Ferguson P, Joseph P, Sherman S, Elswick RK Jr. Validity and sensitivity of 6 pain scales in critically ill, intubated adults. Am J Crit Care. 2015 Nov;24(6):514-523.
Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-1229.
Voepel-Lewis T, Malviya S, Tait AR. Validity of parent ratings as proxy measures of pain in children with cognitive impairment. Pain Manag Nurs. 2005 Dec;6(4):168-174.
Voepel-Lewis T, Malviya S, Tait AR, Merkel S, Foster R, Krane EJ, Davis PJ. A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anesth Analg. 2008 Jan;106(1):72-78
Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel S. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care. 2010 Jan;19(1):55-61.
Willis MH, Merkel SI, Voepel-Lewis T, Malviya S. FLACC Behavioral Pain Assessment Scale: a comparison with the child's self-report. Pediatr Nurs. 2003 May-Jun;29(3):195-198.
World health Organization (2001). International Classification of Functioning, Disability and Health (ICF) Retrieved 19August2021
Document last updated August 2023