In 1981, Donna Wong, a pediatric nurse consultant, and Connie Morain Baker, a child life specialist, worked together in pediatrics and the burn center at Hillcrest Medical Center, Tulsa, OK. Frequently children appeared to be in pain, but assessing their pain proved challenging, leading to misunderstandings and ineffective pain management. Wong and Baker believed with the proper tools, children could participate in assessing their pain, leading to more success in managing their pain.
Reviewing the literature, with the assistance of Peggy Cook, the hospital librarian, took considerable time, as computers were quite the novelty. Wong and Baker found a few scales used with adults and some tools that had been developed for children, such as those using colors, chips, and one unpublished paper that had used 4 different faces. Adapting a few of the adult scales and using the existing pediatric tools, Wong and Baker began introducing the tools to patients. Initially the idea was simply to find an assessment tool that would be effective for pediatric patients in that hospital. Research was not a part of the initial plans. Young children had considerable difficulty using any scale with a number concept, a ranking concept, or unfamiliar words, and they did not know colors sufficiently well to create their own color scale. However, since children seemed to respond well to facial expressions, Wong and Baker considered using a series of faces, with numbers assigned to each face to quantify the pain assessment.
Stickers were very popular during the 1980’s, often used to reinforce cooperation during burn treatments or other phases of care. Many stickers came with facial expressions, including “smiley” faces. Wong and Baker began developing the faces idea by giving school-aged children six empty circles and having them create facial expressions to indicate no pain to worst pain. The faces received ratings from 0-5, with 0 for no pain and 1 to 5 for increasing intensities of pain. The rating would not be sensitive enough with too few faces and would be confusing to have too many faces.
Six choices were consistent with other scales used, which facilitated statistical comparison among the scales. Obviously, at this point, a research project was developing. Children from the burn unit and the general pediatric unit helped with the project of finding a way for children to better assess their pain. The children readily participated and often created elaborate faces and hairstyles to demonstrate the gradation from “no pain” to “worst pain they could ever imagine.” Although many children drew the sequence of no pain to worst pain faces from left to right, several also drew the sequence from right to left, as you can see in Figure 1. The left-to-right format was chosen because it is consistent with other scales and with English reading. Over 50 children participated in the pilot work.
Each child’s series of faces was unique, but a pattern soon developed in terms of the shape of the eyes, nose, and mouth. A composite of the most frequently drawn features became a part of a pilot introduction with a new group of over 25 children to evaluate their ability to use the faces. The preliminary results were very favorable. A professional artist used the same original faces scale and drew the final version currently used. The only additional detail was more differentiation to the eyes and eyebrows.
The majority of the “worst pain” faces drawn by children included tears; even though many of these hospitalized patients did not cry when undergoing painful procedures, such as burn dressing changes. Baker questioned the children about the tears and they adamantly explained tears were important because “you could feel this bad inside.” The tears stayed. Even after the professional rendering of the Wong-Baker FACES® Pain Rating Scale, Baker continued to give patients the opportunity to create their own scale, by drawing six circles on a piece of paper, which they proudly displayed at their bedside.
Over the years, various expert reviewers had different ideas about improvements of the scale. Some believed that having all of the scales in a horizontal left-to-right fashion might bias the children in the younger age group. A change in format to a circular style was suggested. The FACES scale was reformatted in a circular fashion for study but was confusing to children so the original left to right format was resumed.
To see if children could use the FACES to distinguish between different pain intensities, Baker asked children to mark their areas of pain on a human figure drawing and then rate each area using the scale. Since many of these children were burned, the researcher knew those areas likely to be least to most painful. The children were able to do this task very accurately. See Figure 2.
Most of the pilot work was done informally with children from preschool through young school age. Because teenagers could use any of the adult scales, few adolescent subjects participated in the early pilot study work. It was thought that the idea of using the faces to rate pain might be too juvenile to the Wong-Baker FACES® Pain Rating Scale has been used effectively with those of every age above two. Other investigators have used this scale with adults, especially the elderly, with successful results. The advantages of the cartoon type faces are that they avoid gender, age, and racial biases.
The initial series of systematic validity and reliability research of the Wong-Baker FACES® Pain Rating Scale took about 2 years to complete. In 1983, Wong and Baker began data collection, assisted by Lynn Clutter. The scale was assessed along with an adaptation of the visual analogue scale, and 4 other pain assessment instruments. When the data analysis was completed on the comparison of the 6 scales, children in all of the age groups preferred the Wong-Baker FACES® Pain Rating Scale. Other results of that study appear in the research section of the website.
The primary goal for creating the Wong-Baker FACES® Pain Rating Scale was to help children effectively communicate about their pain so staff and parents could more successfully provide pain relief. Initially, the numbers 0-5 were used to quantify the pain, but using the numbers 0-2-4-6-8-10 is easier as it is more consistent with the numeric scale of 0-10.
The original instructions included a more detailed script. On this website, you will find more abbreviated instructions now recommended and included in the format you may download.
Sadly, Dr. Donna Wong died in May of 2008, but her work lives on through the Wong-Baker FACES® Pain Rating Scale and her lifetime contribution in pediatric nursing, including the textbooks, Nursing Care of Infants and Children, Clinical Handbook of Pediatric Nursing, and Essentials of Pediatric Nursing. You can read more about Donna Wong in the Tribute section of this website.
Now, Connie Baker, Kristie Nix, Lynn Clutter, Pam Di Vito-Thomas, Betty Rozier, and David Wilson, all close friends of Dr. Wong’s, have joined together to create this foundation to continue promotion of excellence in pain assessment and management for people of all ages. You will find more information about our esteemed board of directors and the Wong-Baker FACES® Foundation on this website.
We would love to hear from you. Feel free to contact us through this website and let us know what you are doing that works. And stay tuned…as we raise money through the products in our store, licensing agreements, and private donations, we will be offering scholarships and grants for education and research in pain assessment and management.
Connie Morain Baker, MS