The Fatigue Assessment Scale (FAS) is a 10-item self-report scale evaluating symptoms of chronic fatigue. The FAS treats fatigue as a unidimensional construct and does not separate its measurement into different factors. However, in order to ensure that the scale evaluates all aspects of fatigue, it measures both physical and mental symptoms.

Fatigue is a major problem in a wide range of (chronic) diseases and is the most frequently described symptom and is globally recognised as a disabling symptom. Fatigue is defined as “an experience of tiredness, dislike of present activity, and unwillingness to continue”, or as a “disinclination to continue performing the task at hand and a progressive withdrawal of attention” from environmental demands.

As a gradual and cumulative process, fatigue reflects vigilance decrement and decreased capacity to perform, along with subjective states that are associated with this decreased performance. It is a general psychophysiological phenomenon that diminishes the ability of the individual to perform a particular task by altering alertness and vigilance, together with the motivational and subjective states that occur during this transition. Consequently, there is reduced competence and willingness to develop or maintain goal directed behaviour aimed at adequate performance.

This scale can be useful in tracking fatigue over time in the context of psychiatric conditions, physical illness or chronic fatigue syndrome.

Psychometric Properties

The FAS has an internal consistency of .90 (Michielsen, De Vries, & Van Heck, 2003). Results on the scale also correlated highly with the fatigue-related subscales of other measures like the Checklist Individual Strength (Vercoulen et al., 1999).

For 351 adults between the ages of 21 and 65 who worked 20 or more hours per week, the mean score was 19.26 (SD = 6.52) (Michielsen et al., 2003).

Scoring and Interpretation 

The total score ranges from 10 to 50, with a higher score indicating more severe fatigue.

A normative percentile for the total score is calculated based on an adult sample (Michielsen et al., 2003), indicating how the respondent scored in relation to a typical pattern of responding for adults. For example, a percentile of 90 indicates the individual has more fatigue than 90 percent of the normal population.

Scores above 22 represent significant fatigue (De Vries et al., 2004), which corresponds to a normative percentile of 65. A horizontal dotted line is indicated on the Total Percentile graph for this cutoff score.

A description of the fatigue experienced is presented for the total score where:

• less than 22 indicates “normal” (i.e. healthy) levels of fatigue
• between 22 and 34 indicates mild-to-moderate fatigue
• 35 or more indicates severe fatigue (Hendricks et al., 2018).

There are two subscales:

1. Mental fatigue (sum of items 3, 6, 7, 8, and 9) – a measure of the cognitive impacts of fatigue for the client (e.g. lack of motivation, problems beginning tasks, problems thinking).
2. Physical fatigue (sum of items 1, 2, 4, 5 and 10) – a measure of the physical impacts of fatigue for the client (e.g. physical exhaustion, lack of energy).

Developer

Michielsen, H. J., De Vries, J., & Van Heck, G. L. (2003). Psychometric qualities of a brief self-rated fatigue measure the fatigue assessment scale. Journal of Psychosomatic Research, 54, 345–352.

References

De Vries, Michielsen H, Van Heck GL, Drent M. Measuring fatigue in sarcoidosis: the Fatigue Assessment Scale (FAS). Br J Health Psychol 2004; 9: 279-91. http://www.ncbi.nlm.nih.gov/pubmed/15296678

Hendriks, C., Drent, M., Elfferich, M., & De Vries, J. (2018). The Fatigue Assessment Scale: quality and availability in sarcoidosis and other diseases. Current Opinion in Pulmonary Medicine, 24(5), 495–503. https://doi.org/10.1097/MCP.0000000000000496

Vercoulen J. H. M. M., Alberts, M., & Bleijenberg, G. (1999). De checklist individual strength (CIS). Gedragstherapie, 32, 131-136.

The Adverse Childhood Experiences Questionnaire (ACE-Q) is a 10-item measure to quantify instances of adverse or traumatic experiences that the client has had before the age of 18. The ACE-Q checks for the client’s exposure to childhood psychological, physical, and sexual abuse as well as household dysfunction including domestic violence, substance use, and incarceration.

The ACE-Q can be administered in a self-report manner (for adults or teenagers) or can be reported by parents to indicate the experiences of their child. Given some of the questions may be triggering for trauma clients, some clinicians opt to read the questions to the client and answer the ACE-Q in a collaborative way rather than request self-report.

Clinically, the ACE-Q can be used to help inform treatment because of the connection between adverse childhood experiences, social issues, and adult mental and physical health. The ACE-Q can also help those who have a high score become more informed about their increased risk factor for health issues as well as validate their experiences. People with high scores are likely to benefit from interventions that support their mental health and promote the development of adaptive behaviours.

The ACE-Q was used in the Adverse Childhood Experiences (ACE) Study (Felitti et al., 1998), which found that the ACE-Q score is correlated with later life mental health challenges as well as health risk behaviours (including substance abuse) and serious health problems. These include increased risk for depression, suicide attempts, alcoholism, drug abuse, smoking, 50 or more sexual partners, physical inactivity, severe obesity, sexually transmitted disease, increased risk for broken bones, heart disease, lung disease, liver disease, and multiple types of cancer (Felitti et al., 1998).

Psychometric Properties

The ACE Study was completed on over 9,500 individual adults ranging in age from 19 to 92 years of age (Felitti et al., 1998). The ACE Study found that the higher someone’s ACE-Q score – the more types of childhood adversity a person experienced – the higher their risk of chronic disease, mental illness, violence, being a victim of violence and several other consequences.

A graded dose-response association has been found between ACE-Q score and risk for depression, risk for PTSD, relationship problems, emotional distress, worker performance, financial problems, current family problems, high stress, and inability to control anger (Anda et al., 2004; Hillis et al., 2004; Nurius, Logan-Greene, & Green, 2012; Ramiro et al., 2010). High ACE-Q scores also predict risk for homelessness which is especially prevalent in individuals with comorbid substance use disorders and mental illness (Patterson, Moniruzzaman, & Somers, 2014). Findings also suggest that people cannot merely “age out” of the mental health effects of ACEs; adults over the age of 65 with higher ACEs have increased odds of mood and personality disorders (Raposo, Mackenzie, Henriksen, & Afifi, 2014). Compared to people with an ACE-Q score of 0, people with an ACE-Q score of 6 are more likely to have a shorter lifespan by 20 years.

Scoring and Interpretation 

A response of Yes for each question is summed to provide an overall ACE-Q score (out of 10). The higher the score, the more adverse childhood experiences the client has had and the higher the risk for social, mental, or other wellbeing problems. The majority of all adults (52%–75%) score one or higher on the ACE-Q (CDC, 2010; Edwards et al., 2007; Ford et al., 2011; Ramiro et al., 2010; Rothman, Bernstein, & Strunin, 2010).

Scores of 4 or more are considered clinically significant. A minority (5%–10%) of the general population score 4 or more, where the general long-term health consequences become most pronounced (Hughes et al., 2017).

Compared with people who have an ACE-Q score of 0, people with an ACE-Q score of 4 are twice as likely to be smokers, 5 times more likely to have depression, 7 times more likely to be alcoholic, 10 times more likely to take illicit drugs, and 12 times more likely to attempt suicide.

Developer

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8

References

Anda, R. F., Fleisher, V. I., Felitti, V. J., Edwards, V. J.,Whitfield, C. L., Dube, S. R., & Williamson, D. F. (2004).Childhood abuse, household dysfunction, and indicators of impaired adult worker performance. The Permanente Journal, 8(1), 30–38.

CDC.(2010). Adverse childhood experiences reported by adults—Five states, 2009. MMWR. Morbidity and Mortality Weekly Report, 59(49), 1609–1613.

Edwards, V. J., Anda, R. F., Gu, D., Dube, S. R., & Felitti, V. J.(2007). Adverse childhood experiences and smoking persistence in adults with smoking-related symptoms and illness. The Permanente Journal, 11(2), 5–13.

Ford, E. S., Anda, R. F., Edwards, V. J., Perry, G. S., Zhao, G.,Li, C., & Croft, J. B. (2011).Adverse childhood experiences and smoking status in five states. Preventive Medicine, 53(3), 188–193. https://doi.org/10.1016/j.ypmed.2011.06.015

Hillis, S. D., Anda, R. F., Dube, S. R., Felitti, V. J.,Marchbanks, P. A., & Marks, J. S. (2004). The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial con-sequences, and fetal death. Pediatrics, 113(2),320–327.

Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D.,Butchart, A., Mikton, C.,…Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health,2(8), e356–e366. https://doi.org/10.1016/S2468-2667(17)30118-4

Nurius, P. S., Logan-Greene, P., & Green, S. (2012). Adverse childhood experiences (ACE) within a social disadvantage framework: Distinguishing unique, cumulative, and moderated contributions to adult mental health. Journal of Prevention & Intervention in theCommunity, 40(4), 278–290. https://doi.org/10.1080/10852352.2012.707443

Patterson,M. L., Moniruzzaman, A., & Somers, J. M. (2014).Setting the stage for chronic health problems:Cumulative childhood adversity among homeless adults with mental illness in Vancouver, British Columbia. BMC Public Health, 14, 350. https://doi.org/10.1186/1471-2458-14-350

Ramiro, L. S., Madrid, B. J., & Brown, D. W. (2010). Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child Abuse & Neglect, 34(11), 842–855. https://doi.org/10.1016/j.chiabu.2010.02.012

Raposo, S. M., Mackenzie, C. S., Henriksen, C. A., &Afifi, T. O. (2014). Time does not heal all wounds:Older adults who experienced childhood adversities have higher odds of mood, anxiety, and personality disorders. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 22(11),1241–1250. https://doi.org/10.1016/j.jagp.2013.04.009

Rothman, E. F., Bernstein, J., & Strunin, L. (2010). Why might adverse childhood experiences lead to under-age drinking among US youth? Findings from an emergency department-based qualitative pilot study. Substance Use & Misuse,45(13), 2281–2290. https://doi.org/10.3109/10826084.2010.482369

The Compassion Motivation and Action Scales (CMAS) encompass two dimensions assessing self-compassion (CMAS-self) and compassion to others (CMAS-other; Steindl et al., 2021). In clinical practice it can be helpful to use the CMAS as an aid for formulation, given that compassionate motivation has been found to be associated with many benefits for wellbeing, including physiologically (Kim et al., 2020; Klimecki et al., 2014; Matos et al., 2017), psychologically (Kirby, 2016; MacBeth & Gumley, 2012), and relationally (Crocker & Canevello, 2012; Kirby & Laczko, 2017; Seppala et al., 2012).

The CMAS-other has three subscales:

1. compassion intention – measuring the intent to be compassionate towards others
2. compassion distress tolerance – measuring the ability to tolerate distress when others are experiencing suffering
3. compassionate action – measuring compassionate actions and behaviours towards others

Psychometric Properties

The CMAS-other was developed by Steindl et al. (2021) using an initial item pool that was generated on the basis of a review of existing measures in combination with the dimensions of motivational language in motivational interviewing. The initial item pool was disseminated to international experts in compassion and/or motivational interviewing literature for feedback and to ensure that wording and content were culturally relevant. Following this process, the initial pool of items was evaluated via exploratory and confirmatory factor analysis to reduce the items further.

There was very good internal consistency present for the CMAS-other with an overall Chronbach’s alpha of 0.88 and subscale consistencies of 0.87 (Intention), 0.88 (Distress tolerance), and 0.96 (Action).

For 621 adults from Australia, USA, UK, and New Zealand, the mean score was 61.16 (SD = 10.22) for the CMAS-other, 17.19 (SD = 3.24) for the Intention subscale, 17.08 (SD = 3.27) for the Distress Tolerance subscale, and 26.90 (SD = 7.43) for the Action subscale (Steindl et al., 2021).

Scoring and Interpretation 

All items are summed to provide an overall score, with higher scores indicative of more self-compassion. Subscale scores are also provided to enable a comparison between subscales:

1. compassion intention (items 1, 2, 3) – measuring the intent to be compassionate towards others
2. compassion distress tolerance (items 4, 5, 6) – measuring the ability to tolerate distress when others are experiencing suffering
3. compassionate action (items 7, 8, 9, 10, 11, 12) – measuring compassionate actions and behaviours

A normative percentile for the total score and subscales are calculated based on a normative sample (Steindl et al., 2021), indicating how the respondent scored in relation to a typical pattern of responding for adults. For example, a percentile of 83 or less indicates the individual has more self-compassion than 83 percent of the normal population.

Results are presented in a graph, which indicates the percentile for total compassion and sub-scales compared to the normative sample, with a dotted line at 50 indicating average compassion towards others.

Developer

Steindl, S. R., Tellegen, C. L., Filus, A., Seppälä, E., Doty, J. R., & Kirby, J. N. (2021). The Compassion Motivation and Action Scales: a self-report measure of compassionate and self-compassionate behaviours. Australian Psychologist, 56(2), 93–110. https://doi.org/10.1080/00050067.2021.1893110  

The Camouflaging Autistic Traits Questionnaire (CAT-Q) is a 25-item self-report measure of social camouflaging behaviours for individuals of age 16 and above. It is used to identify individuals who compensate for or mask autistic characteristics during social interactions and who might not immediately present with autistic traits due to their ability to mask. This can be especially relevant for women with autism.

The CAT-Q measures the degree of use of camouflaging strategies among people with autism. The more an individual can camouflage, the more of their autistic inclinations they are likely able to suppress. As such, a high camouflaging score can also account for lower scores on standard autism psychometric scales.

Importantly, there are significant differences between males and females, so interpretation of scores should be considered in light of gender factors.

The CAT-Q measures camouflaging in general, as well as three subscales:

1. Compensation
2. Masking
3. Assimilation

Psychometric Properties

Research shows robust psychometric support for the CAT-Q. High internal consistency was found for the total scale (Cronbach’s alpha = 0.94), and the Compensation (0.91), Masking (0.85), and Assimilation (0.92) factors (Hull et al., 2019).

Test–retest reliability was good for the total scale (0.77) and no significant differences were found between scores at both times (3 months apart; Hull et al., 2019). The stability was good for the Compensation factor (0.78), while moderate stability was found for the Masking (0.70) and Assimilation factors (0.73; Hull et al., 2019).

The CAT-Q was validated on 306 autistic and 472 non-autistic individuals between the ages of 16 and 82 years of age (Hull et al., 2020). The means and standard deviations are as follows and are used to calculate percentiles:

• Autistic Individuals (Mean (SD)):
  • Total Score (Female 124.35 (23.27); Male 109.64 (26.50))
  • Compensation (Female 41.85 (11.11); Male 36.81 (12.14))
  • Masking (Female 37.87 (10.54); Male 32.90 (10.57)
  • Assimilation (Female 44.63 (7.82); Male 39.93 (11.26))
• Neurotypical Individuals (Mean (SD)):
  • Total Score (Female 90.87 (27.67); Male 96.89 (24.22))
  • Compensation (Female 27.18 (11.5); Male 30.06 (10.92))
  • Masking (Female 34.69 (9.05); Male 36.34 (8.13))
  • Assimilation (Female 29.00 (11.73); Male 30.48 (10.33))

Scoring and Interpretation 

The total score ranges from 25–175 with higher scores reflecting greater camouflaging.

There are three subscales:

1. Compensation — (items 1, 4, 5, 8, 11, 14, 17, 20, and 23)
   Strategies used to actively compensate for difficulties in social situations. Examples: copying body language and facial expressions, learning social cues from movies and books.
2. Masking — (items 2, 6, 9, 12, 15, 18, 21, and 24)
   Strategies used to hide autistic characteristics or portray a non-autistic persona. Examples: adjusting face and body to appear confident and/or relaxed, forcing eye contact.
3. Assimilation — (items 3, 7, 10, 13, 16, 19, 22, and 25)
   Strategies used to try to fit in with others in social situations. Examples: Putting on an act, avoiding or forcing interactions with others.

Percentiles are calculated, comparing scores against neurotypical and ASD males, females, or combined males/females (if your client’s gender is not specified; Hull et al., 2020), indicating how the respondent scored in relation to a typical pattern of responding for neurotypical and autistic adults.

For example, a clinical percentile of 50 for females indicates the individual has typical Camouflaging compared to the ASD population, which corresponds to an approximate 89th percentile compared with a normative population i.e., what is “normal” for someone with autism is unusual compared to people without autism.

Below are some considerations relevant for interpreting scores:

• High total scores correlate with social anxiety in both individuals with autism and neurotypicals. Therefore, high percentile scores relative to the normative sample (i.e. above 84) indicates either neurotypical social anxiety or camouflaging of autistic traits.
• Autistic females demonstrate higher total camouflaging scores than autistic males, but there is no camouflaging gender difference for non-autistic people.
• Autistic males score lower on Masking than their neurotypical counterparts, but do score higher in Compensation and Assimilation.
• In individuals with autism, the total score and the Assimilation score negatively correlate with well-being.
• In neurotypical people, all scores negatively correlate with well-being.
• In individuals with autism, all scores were correlated with depression and generalised anxiety.

Developer

Hull, L., Mandy, W., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., & Petrides, K. V. (2019). Development and Validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). Journal of Autism and Developmental Disorders, 49(3), 819–833. https://doi.org/10.1007/s10803-018-3792-6

References

Hull, L., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., Petrides, K. V., & Mandy, W. (2020). Gender differences in self-reported camouflaging in autistic and non-autistic adults. Autism: The International Journal of Research and Practice, 24(2), 352–363. https://doi.org/10.1177/1362361319864804

The Compassion Motivation and Action Scales (CMAS) encompass two dimensions assessing self-compassion (CMAS-self) and compassion to others (CMAS-other). This is the CMAS-self, which is an 18-item self-report measure designed to assess compassion for oneself (Steindl et al., 2021).

The CMAS-self has three subscales:

1. self-compassion intention – measuring the intent to be compassionate towards oneself
2. self-compassion distress tolerance – measuring the ability to tolerate distress by oneself when experiencing suffering
3. self-compassionate action – measuring self-compassionate actions and behaviours

Psychometric Properties

The CMAS-self was developed using an initial item pool that was generated on the basis of a review of existing measures in combination with the dimensions of motivational language in motivational interviewing. The initial item pool was disseminated to six international experts who were researchers and clinicians each with over 20 years experience in the compassion and/or motivational interviewing literature for feedback and to ensure that wording and content were culturally relevant. Following the development and consultation process, the initial pool of items was evaluated via exploratory and confirmatory factor analysis to reduce the items further.

There was very good internal consistency present for the CMAS-self with an overall Chronbach’s alpha of 0.94 and subscale consistencies of 0.92 (Intention), 0.95 (Distress tolerance), and 0.94 (Action).

For 621 adults from Australia, USA, UK, and New Zealand, the mean score was 90.79 (SD = 17.52) for the CMAS-self, 30.95 (SD = 4.72) for the Intention subscale, 34.13 (SD = 9.14) for the Distress Tolerance subscale, and 25.70 (SD = 8.38) for the Action subscale (Steindl et al., 2021).

Scoring and Interpretation 

All items are summed to provide an overall score, with higher scores indicative of more self-compassion. Subscale scores are also provided to enable a comparison between subscales:

1. self-compassion intention (items 1, 2, 3, 4, 5) – measuring the intent to be compassionate towards oneself
2. self-compassion distress tolerance (items 6, 7, 8, 9, 10, 11, 12) – measuring the ability to tolerate distress by oneself when experiencing suffering
3. self-compassionate action (items 13, 14, 15, 16, 17, 18) – measuring self-compassionate actions and behaviours

A normative percentile for the total score and subscales are calculated based on a sample from Australia, USA, UK, and New Zealand (Steindl et al., 2021), indicating how the respondent scored in relation to a typical pattern of responding for adults. For example, a percentile of 83 or less indicates the individual has more self-compassion than 83 percent of the normal population.

Results are presented in a graph, which indicates the percentile for total self-compassion and sub-scales compared to a normative sample, with a dotted line at 50 indicating average self-compassion..

Developer

Steindl, S. R., Tellegen, C. L., Filus, A., Seppälä, E., Doty, J. R., & Kirby, J. N. (2021). The Compassion Motivation and Action Scales: a self-report measure of compassionate and self-compassionate behaviours. Australian Psychologist, 56(2), 93–110. https://doi.org/10.1080/00050067.2021.1893110  

The Vanderbilt ADHD Diagnostic Parent Rating Scale is used to help in the diagnostic process of Attention Deficit/Hyperactivity Disorder (ADHD) in children between the ages of 6 and 12. It has a total of 55 questions, includes all 18 of the DSM-IV criteria for ADHD and should be completed by a parent of the child. As well as identifying inattentive, hyperactive/impulsive, or combined subtypes of ADHD, it can also be used to identify symptoms of frequent comorbidities, including oppositional defiance, conduct disorder, anxiety and depression.  

Psychometric Properties

Concurrent validity has been established through comparing parent rating with teacher ratings and those independently diagnosed with ADHD (Mark et al., 2003). Confirmatory factor analysis confirmed four factors that fitted with the theoretical formulation of inattention, hyperactivity/impulsivity, ODD-CD, and anxiety-depression subscales.

Becker et al. (2011) validated the subscales but reformulated the scoring method for the comorbid sub-scales by using the total sum of scores. In this scoring system the total sum of the subscales (rather than when a parents rates either 2 or 3 on the Likert scale), ODD is ruled out at <10, CD at <4, Anxiety at <5 and Depression at <5. Nevertheless, the overall scale was validated and found to have high reliability and clinical utility.  

Scoring and Interpretation 

Scores are presented for the three subtypes of ADHD:

• Predominately Inattentive Subtype. A child meets the diagnostic criteria if they have six or more “Often” or “Very Often” on items 1 to 9, plus a performance problem (scores of 1 or 2) on questions 48 to 55.
• Predominately Hyperactive/Impulsive Subtype. A child meets diagnostic criteria if they have six or more “Often” or “Very Often” on items 10 through 18, plus a performance problem (scores of 1 or 2) on questions 48 to 55.
• Combined Subtype. A child meets the diagnostic criteria if they meet the above criteria for both Inattentive and Hyperactive/Impulsive subtypes.

In addition to the ADHD scales, scores are presented for frequently comorbid difficulties. Children with scores below the clinical cutoff are highly unlikely to meet the diagnostic criteria for that disorder. Children above the cutoff on the ODD, CD, Anxiety/Depression sub-scales should be further evaluated, as these sub-scales are only designed as a cursory screening measure for such problems.

• Oppositional Defiant Disorder = items 19 to 26. To be above the clinical cutoff score of 2 or 3 on 4(or more) out of 8 behaviors on questions 19–26 AND score a 1 or 2 on any of the performance questions 48–55.
• Conduct Disorder = items 27 to 40. To be above the clinical cutoff scores a 2 or 3 on 3(or more) out of 14 behaviors on questions 27–40 AND score a 1 or 2 on any of the performance questions 48–55
• Anxiety/ Depression = items 41 to 47. To be above the clinical cutoff scores a 2 or 3 on 3(or more) out of 7 behaviors on questions 41–47 AND score a 1 or 2 on any of the performance questions 48–55.  

Developer

Wolraich, M. L., Hannah, J. N., Baumgaertel, A., & Feurer, I. D. (1998). Examination of DSM-IV critieria for attention deficit/hyperactivity disorder in a county-wide sample. Journal of Developmental and Behavioral Pediatrics, 19, 162– 168. https://doi.org/10.1097/00004703-199806000-00003 

References

Wolraich, M, Lambert, W., Doffing, M., Bickman, L., Simmons, T., Worley, K., (2003). Psychometric Properties of the Vanderbilt ADHD Diagnostic Parent Rating Scale in a Referred Population, Journal of Pediatric Psychology, Volume 28, Issue 8, 1, Pages 559–568. https://doi.org/10.1093/jpepsy/jsg046

Becker, S. P., Langberg, J. M., Vaughn, A. J., & Epstein, J. N. (2012). Clinical utility of the Vanderbilt ADHD diagnostic parent rating scale comorbidity screening scales. Journal of Developmental and Behavioral Pediatrics, 33(3), 221. https://doi.org/10.1097/dbp.0b013e318245615b

The Mood Disorder Questionnaire (MDQ) is a 15-item self-report screening instrument that can be used to identify clients most likely to have bipolar disorder. The MDQ assists in identifying bipolar disorder and distinguishing it from other mood disturbances in clinical populations.

Past research has found that MDQ total scores are associated with anxiety, trauma-related, substance use, eating, and impulse control disorders, in addition to BD (Paterniti & Bisserbe, 2018; Zimmerman et al., 2011). As a result, there have been two subscales identified (Carpenter et al., 2020):

• Positive Activation: increased energy/activity, grandiosity, and decreased need for sleep. This subscale is specific to BD.
• Negative Activation: irritability, racing thoughts, levels of negative affectivity, and distractibility. This subscale is more broadly related to emotion dysregulation and transdiagnostic personality traits.

Research indicates that effective treatment of bipolar disorder (BD) differs significantly from that of other related disorders, such as unipolar depression (Carpenter et al., 2020). This underscores the importance of screening for bipolar disorder (BD) in patients who present to mental health services so that they can receive an effective intervention. For example, the use of antidepressants in BD treatment is controversial (Sidor & MacQueen, 2011) and psychotherapy treatment more often involves addressing issues such as unrealistic goal-setting and impulsivity in patients with BD than in others (Geddes & Miklowitz, 2013; Miklowitz & Johnson, 2006). As BD is associated robustly with significant psychosocial impairment (e.g., poor work and relationship functioning), failing to detect cases of BD can lead to suboptimal treatment approaches and, thereby, exacerbate personal and societal costs associated with BD (Conus, Macneil, & McGorry, 2014).  

Psychometric Properties

The internal reliability for the MDQ is strong (Cronbach’s alpha = 0.88; Stanton & Watson, 2017).

Traditionally, a positive screen on the MDQ requires endorsement of (a) 7 or more of 13 symptom items, (b) multiple symptoms occurring at the same time, and (c) symptoms causing notable psychosocial impairment (Hirschfeld et al., 2000). The first thirteen questions on the MDQ are based upon bipolar symptoms and a score of 7 or more is the optimal cutoff, as it provides good sensitivity (73%) and very good specificity for a diagnosis of BD (90%; Hirschfeld et al., 2000). However, results from a number of studies suggest that the MDQ is not unidimensional (Ruggero et al., 2014; Stanton & Watson, 2017).

Carpenter et al. (2020) and Stanton and Watson (2017) investigated the structure of the MDQ’s 13 symptom items and found that the MDQ was best represented by two factors, which they termed Positive Activation (e.g., “had much more energy”; “was much more confident”) and Negative Activation (e.g., “thoughts raced”; “felt very irritable”) symptom dimensions. Three of the MDQ symptoms (items 5, 10, and 11) loaded highly onto both Positive and Negative Activation factors and were removed from the final model. Carpenter et al. (2020) found that Positive Activation was uniquely associated with BD diagnosis, whereas Negative Activation was associated with a range of diagnoses. Thus, a 4-item Positive Activation subscale (α = .82) and a 6-item Negative Activation subscale (α = .73) was created.  

Scoring and Interpretation 

A total score is calculated for questions 1-13 where a “Yes” provides a score of 1 and “No” is 0. The percentage of items endorsed (raw score / number of items multiplied by 100) is included to provide an indication of the proportion of symptoms identified with by the respondent.

In order to meet the threshold for bipolar disorder the traditional scoring method is as follows:

• A score of 7 or more for questions 1-13 (53% of items endorsed) AND
• Check “yes” for the item asking if the symptoms clustered in the same time period (question 14) AND
• Symptoms caused either “moderate” or “serious” problems (question 15).

Subscale scores were also developed (Carpenter et al., 2020, Stanton & Watson, 2017) using 10 of the 13 items in the symptom questions:

• Positive Activation (items 3, 4, 8, 9): assesses increased energy/activity, grandiosity, and decreased need for sleep. Individuals endorsing symptoms defining Positive Activation are not likely to report significant levels of negative affect and are likely to be energetic and extraverted. Individuals scoring high on Positive Activation may be less likely to rate their symptoms as impairing given that increased levels of energy and activity may be experienced as advantageous to some degree, especially if they are mild in nature. This factor is strongly associated with a BD diagnosis.
• Negative Activation (items 1, 2, 6, 7, 12, 13): assesses irritability, racing thoughts, levels of negative affectivity, and distractibility. This factor is strongly associated with BD as well as a a range of other disorders, many of them (e.g. depressive disorders, PDs, PTSD, GAD, substance use disorders) characterised by emotion dysregulation and/or transdiagnostic personality traits such as neuroticism and disinhibition. Clients high in Negative Activation may be at risk for engaging in impulsive behavior in emotional situations.

Clinical percentiles are also presented for the two subscales as developed by Carpenter et al. (2020) on over 1,700 outpatients (for a variety of diagnoses). A percentile of 50 means that the client has scored at the average level compared with the clinical group for that subscale.  

Developer

Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr, Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. The American Journal of Psychiatry, 157(11), 1873–1875. https://doi.org/10.1176/appi.ajp.157.11.1873  

References

Carpenter, R. W., Stanton, K., Emery, N. N., & Zimmerman, M. (2020). Positive and Negative Activation in the Mood Disorder Questionnaire: Associations With Psychopathology and Emotion Dysregulation in a Clinical Sample. Assessment, 27(2), 219–231. https://doi.org/10.1177/1073191119851574

Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr, Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. The American Journal of Psychiatry, 157(11), 1873–1875. https://doi.org/10.1176/appi.ajp.157.11.1873 

Stanton, K., & Watson, D. (2017). Explicating the structure and relations of the Mood Disorder Questionnaire: Implications for screening for bipolar and related disorders. Journal of Affective Disorders, 220, 72–78. https://doi.org/10.1016/j.jad.2017.05.046  

The Borderline Symptom List – Short Version (BSL-23) is a 23-item self-rating instrument for specific assessment of borderline personality disorder (BPD) symptomatology in adults (18+). The scale assesses DSM BPD diagnostic criteria (e.g., affective instability, recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour, and transient dissociative symptoms) in addition to items that are based on borderline-typical empirical findings regarding self-criticism, problems with trust, emotional vulnerability, and proneness to shame, self-disgust, loneliness, and helplessness (Kleindienst et al., 2020).

Individuals with high scores on the BSL-23 are more likely to have BPD and associated challenges with managing emotions, self-image, relationship issues, and general functioning in everyday life.

Psychometric Properties

The BSL-23 items are based on criteria of the DSM-5, on the revised version of the Diagnostic Interview for Borderline Personality Disorder, and on the experiences of both clinical experts and input from BPD (Kleindienst et al., 2020). The BSL-23 has a single factor structure and has excellent psychometric properties, with high internal consistency with a Cronbach’s of 0.97 and test-retest reliability of 0.82 within 1 week (Bohus, 2009). These properties have been replicated in several studies that validated the translations of the BSL-23 into 18 foreign languages (Kleindienst et al., 2020). The BSL-23 also has strong convergent validity with correlations between the BSL-23 and depression as measured by the BDI (r = 0.87), as well as general severity of psychopathology as measured by the SCL-90-R GSI (r = 0.89; Bohus, 2009).

Kleindienst et al. (2020) tested the BSL-23 on over 1,000 adults and developed cut-off scores and severity levels (none or low, mild, moderate, high, very high, and extremely high) for clients with BPD. They found that individuals with a severity grade of “none or low” were virtually free from diagnostic BPD-criteria and had a high level of global functioning corresponding to few or no symptoms. Severity grades indicating “high” to “extremely high” levels of BPD symptoms were observed at a much higher rate in treatment-seeking patients (70.0%) than in a healthy control group with no prior psychopathology history (0.0%)

Scoring and Interpretation 

The average score of items (range 0 to 4, sum of scores divided by 23) is calculated, with a higher score indicating more impairment. Six grades of symptom severity were defined by Kleindienst et al. (2020) based upon the average score:

• None/Low: 0 – 0.3
• Mild: 0.3 – 0.7
• Moderate: 0.7 – 1.7
• High: 1.7 – 2.7
• Very High: 2.7 – 3.5
• Extremely High: 3.5 – 4

Scores of 1.50 or higher indicates the responses are consistent with BPD, with empirical data showing this cutoff score is able to discriminate between BPD patients and clients with other clinical psychopathology (e.g. anxiety disorders, major depressive disorders, schizophrenia, etc.; Kleindienst et al., 2020).

Percentiles are also presented comparing the respondents scores to a healthy group (n = 356; with no history of psychopathology) and a BPD group (n = 317; met DSM-V diagnostic criteria for BPD; Kleindienst et al. 2020). A percentile of 50 means that the client has scored at the typical level compared with the comparative group. An average score of 1.5 corresponds to a percentile of 17 compared to the BPD group, and a percentile of 99.9 compared to the healthy control group. These metrics indicate that a score of 1.5 is typical for someone with BPD but highly extreme compared to someone without a psychiatric diagnosis.

There is an additional question (24) that provides an indication of the client’s perspective on their overall well-being, but it is not included in the overall score. The rating on this last question (from 0 to 100) is strongly correlated with specific indicators of wellbeing for BPD patients, including self-perception, affect regulation, self-destruction, dysphoria, loneliness, intrusions, and hostility (Bohus, et al., 2007).  

Developer

Bohus, M., Kleindienst, N., Limberger, M. F., Stieglitz, R.-D., Domsalla, M., Chapman, A. L., Steil, R., Philipsen, A., & Wolf, M. (2009). The short version of the Borderline Symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology, 42(1), 32–39. https://doi.org/10.1159/000173701  

References

Bohus, M., Limberger, M. F., Frank, U., Chapman, A. L., Kühler, T., & Stieglitz, R.-D. (2007). Psychometric properties of the Borderline Symptom List (BSL). Psychopathology, 40(2), 126–132. https://doi.org/10.1159/000098493

Kleindienst, N., Jungkunz, M., & Bohus, M. (2020). A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). Borderline Personality Disorder and Emotion Dysregulation, 7, 11. https://doi.org/10.1186/s40479-020-00126-6  

The Ritvo Autism Asperger Diagnostic Scale – Revised (RAADS–R) is an 80-item self-report questionnaire designed to identify adults with ‘higher functioning’ autism spectrum disorders (ASD). The assessment is suitable for adult (age 18+) males and females with average or above-average intelligence (i.e. IQ above 80).

There are four symptom-areas assessed by the RAADS-R:

1. Social Relatedness Problems
2. Circumscribed Interests
3. Language
4. Sensory Motor

With high prevalence of ASD in mental health settings and the fact that adults are being referred for diagnosis with increasing frequency, this instrument is a useful clinical tool to assist clinicians with diagnosis (Ritvo et al., 2011).

The RAADS-R is best used in conjunction with clinical expertise and/or other assessment procedures to establish a diagnosis. The self-report nature of this assessment may mean that individuals with low reflective capacity score low on the RAADS-R despite having diagnosable ASD.  

Psychometric Properties

Questions on the original RAADS (Ritvo et al. 2008) assessed developmental pathology in three symptom areas: language, social relatedness, and sensory-motor. After critical review of the original RAADS and the results of a factor analysis, the revised 80-item RAADS-R was developed with the addition of a fourth symptom area (circumscribed interests), two questions, and several wording clarifications.

The RAADS–R is a valid and reliable instrument to assist the diagnosis of autistic adults. A validation study (Ritvo et al., 2011) with a sample of 201 adults with ASD and 578 non ASD (a.k.a neurotypical) adults from the USA and Australia (Ritvo et al., 2011) defined the optimum cutoff score of 65. At this level, no one without ASD scored above the autism threshold (specificity = 100%) and only 3% of the autistic group did not score over the cutoff score (sensitivity = 97%). Test–retest reliability was high (0.987) and it had high concurrent validity (96%) with the SRS-A.

The clinical norms which are used to calculate clinical percentiles are based on the validation study by Ritvo, et al. (2011). A sample of 201 individuals with a confirmed DSM-IV-TR diagnosis of Autism or Aspergers had a mean RAADS-R score of 133.81 (SD = 37.72). This combined ASD and Aspergers group had an average age of 31, IQ of 119 and were 28% female. The Autism group alone had a mean RAADS-R score of 138.46 (SD = 41.4), however the combined group was used in calculating percentiles given it is most representative of DSM-5-TR diagnostic criteria.

The normative percentile is based on a sample of 578 individuals who did not have a diagnosis of Autism, Aspergers or PDD NOS, however did include people with other high prevalence clinical diagnoses, making it representative of a neurotypical population. The sample had an average age of 42, IQ of 114 and 57% percent were female. The normative sample’s mean RAADS-R score was 25.95 (SD = 16.04) and is used to calculate the normative percentile.  

Scoring and Interpretation 

The total score of the RAADS-R ranges from 0 – 240, with a higher score more indicative of behaviours and symptoms consistent with Autism. Scores at or above 65 are consistent with ASD.

There is also a normative and clinical percentile calculated that compares the respondent’s score with a comparison control group of neurotypical adults (Mean = 25.95, SD = 16.04) and adults with an autism diagnosis (Mean = 133.81, SD = 37.72; Ritvo et al., 2011). The graph shows the respondent’s pattern of responding compared with the normative sample, with the 50th percentile marking the average response for someone without autism.

These percentiles can be helpful for interpretation as they contextualise scores in comparison to a typical pattern of responding for neurotypical adults and adults with autism. For example, a normative percentile of 80 indicates the individual scored higher than 80 percent of the neurotypical (normative) comparison group. The cutoff raw score of 65 is above the 99th percentile on the normative percentile, whereas this is at about the 3rd percentile for adults with autism.

There are four subscales:

1. Social Relatedness Problems: how well the individual relates to others (e.g. sympathy, empathy, politeness, relationship skills). Scores above 30 are considered to be of clinical significance. 39 questions: 1, 3, 5, 6, 8, 11, 12, 14, 17, 18, 20, 21, 22, 23, 25, 26, 28, 31, 37, 38, 39, 43, 44, 45, 47, 48, 53, 54, 55, 60, 61, 64, 68, 69, 72, 76, 77, 79, 80
2. Circumscribed Interests: how broad-ranging the individual’s interests are and how much they talk about these interests. Scores above 14 are considered to be of clinical significance. 14 questions: 9, 13, 24, 30, 32, 40, 41, 50, 52, 56, 63, 70, 75, 78
3. Language: how often the individual uses words and phrases from movies or television in conversations and the ability to understand language nuances (e.g. metaphor). Scores above 3 are considered to be of clinical significance. 7 questions: 2, 7, 15, 27, 35, 58, 66
4. Sensory Motor: a measure of how much the individual struggles with sensory sensitivities, how often they engage in self-stimulatory behaviours, and the individual’s atypical speech patterns and tone of voice. Scores above 15 are considered to be of clinical significance. 20 questions: 4, 10, 16, 19, 29, 33, 34, 36, 46, 42, 49, 51, 57, 59, 62, 65, 67, 71, 73, 74

The self-report nature of this assessment may mean that individuals with low reflective capacity/insight score low on the RAADS-R despite having diagnosable ASD. It is therefore recommended that clinician’s inspect individual responses to items to judge the veracity of self-reported problems.  

Developer

Ritvo, R. A., Ritvo, E. R., Guthrie, D., Ritvo, M. J., Hufnagel, D. H., McMahon, W., Tonge, B., Mataix-Cols, D., Jassi, A., Attwood, T., & Eloff, J. (2011). The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R): a scale to assist the diagnosis of Autism Spectrum Disorder in adults: an international validation study. Journal of Autism and Developmental Disorders, 41(8), 1076–1089. https://doi.org/10.1007/s10803-010-1133-5  

References

Ritvo, R., Ritvo, E., Guthrie, D., Yuwiler, A., Ritvo, M., & Weisbender, L. (2008). A scale to assist the diagnosis of Autism and Asperger’s disorder in Adults (RAADS): A pilot study. Journal of Autism and Developmental Disorders, 38(2), 213–223.

The Multidimensional Assessment of Interoceptive Awareness – Version 2 (MAIA-2) is an 8-subscale state-trait self-report questionnaire to measure multiple dimensions of interoception (awareness of bodily sensations). The MAIA-2 is suitable for adults (18+) and has 37 items. There is a parallel youth version (MAIA-Y) for use with individuals 7 – 17 years of age.

Interoception refers to the sensation, interpretation, and integration of internal somatic signals (Eggart et al., 2021). There is compelling evidence demonstrating links between poor interoceptive awareness and difficulties with emotion awareness and emotion regulation (Price & Hooven, 2018). Interoception may be of clinical importance for individuals presenting with autism, eating disorders, alexithymia or chronic pain.

It can be beneficial to measure interoception in a therapeutic setting because effective emotion regulation involves the ability to accurately detect and evaluate cues related to physiological reactions to stressful events. The therapist and client can then work together on appropriate regulation strategies that temper and influence the emotional response.

The MAIA consists of 8 scales (addressing 5 dimensions of body awareness):

1. Noticing (Awareness of Body Sensations)
2. Not-Distracting (Emotional Reaction and Attentional Response to Sensations)
3. Not-Worrying (Emotional Reaction and Attentional Response to Sensations)
4. Attention Regulation (Capacity to Regulate Attention)
5. Emotional Awareness (Awareness of Mind-Body Integration)
6. Self-Regulation (Awareness of Mind-Body Integration)
7. Body Listening (Awareness of Mind-Body Integration)
8. Trust (Trusting Body Sensations)    

Psychometric Properties

The original MAIA (Mehling et al., 2012) was 32 questions and had some internal consistency weaknesses (Mehling et al., 2018). To improve upon the original the MAIA-2 added additional items (Mehling et al., 2018), yielding higher Cronbach alphas and improved psychometrics. Two subscales were below the standard Cronbach alpha criterion of 0.70 – Noticing (.64) and Not Worrying (.67). The eight MAIA-2 scales are sensitive to change and so can detect the effects of interventions aimed at improving interoception (Eggart et al., 2021).

A validation study by Mehling et al. (2018), based upon a convenience sample of 1,090 individuals between 18 and 69 years old, provided means and standard deviations for all 8 scales. The mean score (between 0 – 5) for each scale was: 1. Noticing (M = 3.34, SD = 0.90) 2. Not-Distracting (M = 2.06, SD = 0.80) 3. Not-Worrying (M = 2.52, SD = 0.85) 4. Attention Regulation (M = 2.84, SD = 0.86) 5. Emotional Awareness (M = 3.44, SD = 0.96) 6. Self-Regulation (M = 2.78, SD = 1.01) 7. Body Listening (M = 2.20, SD = 1.17) 8. Trust (M = 3.37, SD = 1.11)    

Scoring and Interpretation 

Scores are between 0 and 5, where higher score equates to more awareness of bodily sensation. A percentile is also calculated, indicating how the responded scored in comparison to a normative sample. Interpretation using percentiles helps contextualise scores. For example, percentile below 50 indicate that the individual scored below what is typical. Extreme percentile scores (below 10 or above 90) are of particular clinical significance.

The MAIA-2 consists of eight scales:

1. Noticing (Items 1-4): Awareness of uncomfortable, comfortable, and neutral body sensations
2. Not-Distracting (Items 5-10): Higher scores suggest a more tuned in relationship to unpleasant sensations, and is typically considered to be adaptive. Lower scores indicate the tendency to ignore or distract oneself from sensations of pain or discomfort.
3. Not-Worrying (Items 11-15): Higher scores indicate less rumination about discomfort. Low scores indicate emotional distress or worry with sensations of pain or discomfort
4. Attention Regulation (Items 16-22): Ability to sustain and control attention to body sensation
5. Emotional Awareness (Items 23-27): Awareness of the connection between body sensations and emotional states
6. Self-Regulation (Items 28-31): Ability to regulate psychological distress by attention to body sensations
7. Body Listening (Items 32-34): Actively listens to the body for insight
8. Trust (Items 35-37): Experiences one’s body as safe and trustworthy

The results from the MAIA-2 focus upon the individual scale scores as a total score is not meaningful (Mehling et al., 2012).   

Developer

Mehling WE, Acree M, Stewart A, Silas J, Jones A (2018) The Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2). PLoS ONE 13(12): e0208034. https://doi.org/10.1371/journal.pone.0208034

References

Eggart, M., Todd, J., & Valdés-Stauber, J. (2021). Validation of the Multidimensional Assessment of Interoceptive Awareness (MAIA-2) questionnaire in hospitalized patients with major depressive disorder. PloS One, 16(6), e0253913. https://doi.org/10.1371/journal.pone.0253913

Mehling, W. E., Price, C., Daubenmier, J. J., Acree, M., Bartmess, E., & Stewart, A. (2012). The Multidimensional Assessment of Interoceptive Awareness (MAIA). PloS One, 7(11), e48230. https://doi.org/10.1371/journal.pone.0048230

Price, C. J., & Hooven, C. (2018). Interoceptive Awareness Skills for Emotion Regulation: Theory and Approach of Mindful Awareness in Body-Oriented Therapy (MABT). Frontiers in psychology, 9, 798. https://doi.org/10.3389/fpsyg.2018.00798

The Multidimensional Assessment of Interoceptive Awareness – Youth Version (MAIA-Y) is an 8-scale state-trait questionnaire with 32 items to measure multiple dimensions of interoception (body awareness). The MAIA-Y is suitable for use with youths between 7 – 17 years of age. There is a parallel adult version (MAIA-2) for use with individuals 18+ years of age.

Interoception refers to the sensation, interpretation, and integration of internal somatic signals (Eggart et al., 2021). There is compelling evidence demonstrating links between poor interoceptive awareness and difficulties with emotion regulation (Price & Hooven, 2018). Therefore, it can be beneficial to measure interoception in a therapeutic setting because effective emotion regulation involves the ability to accurately detect and evaluate cues related to physiological reactions to stressful events. The therapist and client can then work together on appropriate regulation strategies that temper and influence the emotional response.

The MAIA consists of 8 scales (addressing 5 dimensions of body awareness):

1. Noticing (Awareness of Body Sensations)
2. Not-Distracting (Emotional Reaction and Attentional Response to Sensations)
3. Not-Worrying (Emotional Reaction and Attentional Response to Sensations)
4. Attention Regulation (Capacity to Regulate Attention)
5. Emotional Awareness (Awareness of Mind-Body Integration)
6. Self-Regulation (Awareness of Mind-Body Integration)
7. Body Listening (Awareness of Mind-Body Integration)
8. Trust (Trusting Body Sensations)     

Psychometric Properties

The MAIA-Y (Jones et al., 2020) is based on the original MAIA (Mehling et al., 2012), with modifications made to simplify the language of each statement. Cronbach’s alpha ranged from 0.36 – 0.78, with the Not-Distracting (0.36), Noticing (0.43), Not-Worrying (0.47), and Body Listening (0.69) scales being below 0.70 (Jones et al., 2020).

A validation study by Jones et al. (2020), based upon a convenience sample of children aged 7–10 years (n= 212) and adolescents aged 11–17 years (n= 217), provided means and standard deviations for all 8 scales for each age (7 – 15+). Age is an important component in the MAIA-Y as results from Jones et al. (2020) found a negative linear relationship between the trusting scale and age, suggesting that youths may lose trust in their body as they age.   

Scoring and Interpretation 

The results from the MAIA-Y focuses upon the individual scale scores (between 0 and 5), where higher score equates to more awareness of bodily sensation. A percentile is also calculated, indicating how the responded scored in comparison to an age related normative sample. Interpretation using percentiles helps contextualise scores. For example, percentile below 50 indicate that the individual scored below what is typical. Extreme percentile scores (below 10 or above 90) are of particular clinical significance.

The MAIA consists of eight scales:

1. Noticing (Items 1-4): Awareness of uncomfortable, comfortable, and neutral body sensations
2. Not-Distracting (Items 5-7): Higher scores suggest a more tuned in relationship to unpleasant sensations, and is typically considered to be adaptive. Lower scores indicate the tendency to ignore or distract oneself from sensations of pain or discomfort
3. Not-Worrying (Items 8-10): Higher scores indicate less rumination about discomfort. Low scores indicate emotional distress or worry with sensations of pain or discomfort
4. Attention Regulation (Items 11-17): Ability to sustain and control attention to body sensation
5. Emotional Awareness (Items 18-22): Awareness of the connection between body sensations and emotional states
6. Self-Regulation (Items 23-26): Ability to regulate psychological distress by attention to body sensations
7. Body Listening (Items 27-29): Actively listens to the body for insight
8. Trust (Items 30-32): Experiences one’s body as safe and trustworthy  

Developer

Jones, A., Silas, J., Todd, J., Stewart, A., Acree, M., Coulson, M., & Mehling, W. E. (2021). Exploring the Multidimensional Assessment of Interoceptive Awareness in youth aged 7-17 years. Journal of Clinical Psychology, 77(3), 661–682. https://doi.org/10.1002/jclp.23067

References

Eggart, M., Todd, J., & Valdés-Stauber, J. (2021). Validation of the Multidimensional Assessment of Interoceptive Awareness (MAIA-2) questionnaire in hospitalized patients with major depressive disorder. PloS One, 16(6), e0253913. https://doi.org/10.1371/journal.pone.0253913

Mehling, W. E., Price, C., Daubenmier, J. J., Acree, M., Bartmess, E., & Stewart, A. (2012). The Multidimensional Assessment of Interoceptive Awareness (MAIA). PloS One, 7(11), e48230. https://doi.org/10.1371/journal.pone.0048230

Price, C. J., & Hooven, C. (2018). Interoceptive Awareness Skills for Emotion Regulation: Theory and Approach of Mindful Awareness in Body-Oriented Therapy (MABT). Frontiers in psychology, 9, 798. https://doi.org/10.3389/fpsyg.2018.00798

The Tinnitus Handicap Inventory (THI; Newman et al., 1996) is a 25-item self-report measure to determine perceived tinnitus handicap severity. The THI is a useful measure for determining the efficacy of psychological treatment for tinnitus (Zeman et al., 2011).

The THI comprises 25 items grouped into three subscales:

1. Functional: this deals with limitations caused by tinnitus in the areas of mental, social, and physical functioning.
2. Emotional: concerns affective responses to tinnitus, e.g. anger, frustration, depression, anxiety.
3. Catastrophic: probes the most severe reactions to tinnitus, such as loss of control, inability to escape from tinnitus, and fear of having a terrible disease.    

Psychometric Properties

Studies concerning psychometric properties of THI report Cronbach’s alpha for the total score as very high, mostly above 0.90 (Gos et al., 2020). Alpha for the Functional and Emotional subscales ranged from 0.8 to 0.9, while for the Catastrophic subscale it was lower, about 0.6–0.7 (Gos et al., 2020). Although all three subscale scores are frequently used and reported, emphasis should be placed upon the total score (Gos et al., 2020).

In a validation study by Got et al. (2020), 1115 adult patients presenting at a tinnitus clinic (49.8% females, age range = 19 – 84; period of suffering tinnitus = 1 month – 50 years) were assessed using the THI and means (and standard deviations) were obtained:

1. Functional: Mean = 20.53 (11.71)
2. Emotional: Mean = 16.84 (10.30)
3. Catastrophic: Mean = 10.81 (5.17)
4. Total Score: Mean = 48.18 (25.27)

These means and standard deviations are used to calculate percentiles for the THI total score and subscale scores.   

Scoring and Interpretation 

The THI total score ranges from 0 to 100 where a higher score indicates more tinnitus handicap severity. In addition, a percentile is presented that shows the respondents scores in comparison to tinnitus patients. A percentile rank of 50 indicates that the individual has an average severity of tinnitus compared to other people suffering tinnitus.

Three three subscales are calculated:

1. Functional (items 1, 2, 4, 7, 9, 12, 13, 15, 18, 20, 24) – role limitations in the areas of mental, social/occupational, and physical functioning
2. Emotional (items 3, 6, 10, 14, 16, 17, 21, 22, 25) – affective reactions to tinnitus
3. Catastrophic (items 5, 8, 11, 19, 23) – catastrophic thinking about the symptoms of tinnitus, including a sense of lack of control

A grading system, as determined by the British Association of Otolaryngologists, Head and Neck Surgeons, is also used for the THI total score (McCombe et al., 2001):

• Very mild (score 0–16). Tinnitus is perceived only in silence and is easily masked. It does not interfere with sleep or with daily activities.
• Mild (score 18–36). Tinnitus is easily masked by environmental sounds and forgotten during daily activities. It can occasionally interfere with sleep but not with daily activities.
• Moderate (score 38–56). Tinnitus is perceived even in the presence of environmental sound; however, daily activities are not impaired. It is perceived less under concentration. Interference with sleep and relaxing activities is not infrequent.
• Severe (score 58–76). Tinnitus is continuously perceived and hardly masked by external noise. It alters the sleep cycle and can interfere with the subject’s daily activities. Relaxing activities are compromised. Subjects with this level of tinnitus often require medical consultations.
• Catastrophic (78–90). All side effects caused by tinnitus are present at a very severe level. The subject requires medical assistance very frequently, including neuropsychiatric help.

A change score of at least seven points has been considered to denote reliable clinically significant improvement on the THI (Zeman et al., 2011).  

Developer

Newman, C. W., Jacobson, G. P., & Spitzer, J. B. (1996). Development of the Tinnitus Handicap Inventory. Archives of Otolaryngology–Head & Neck Surgery, 122(2), 143–148. https://doi.org/10.1001/archotol.1996.01890140029007

References

McCombe, A., Baguley, D., Coles, R., McKenna, L., McKinney, C., Windle-Taylor, P., & British Association of Otolaryngologists, Head and Neck Surgeons. (2001). Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. Clinical Otolaryngology and Allied Sciences, 26(5), 388–393. https://doi.org/10.1046/j.1365-2273.2001.00490.x

Gos, E., Sagan, A., Skarzynski, P. H., & Skarzynski, H. (2020). Improved measurement of tinnitus severity: Study of the dimensionality and reliability of the Tinnitus Handicap Inventory. PloS One, 15(8), e0237778. https://doi.org/10.1371/journal.pone.0237778

Zeman, F., Koller, M., Figueiredo, R., Aazevedo, A., Rates, M., Coelho, C., Kleinjung, T., de Ridder, D., Langguth, B., & Landgrebe, M. (2011). Tinnitus handicap inventory for evaluating treatment effects: which changes are clinically relevant? Otolaryngology–Head and Neck Surgery, 145(2), 282–287. https://doi.org/10.1177/0194599811403882

The Equanimity Scale – 16 (ES-16) is a 16-item self-report mindfulness scale to assess the level by which a client is taking a non-reactive attitude to thoughts, feelings, and experiences. The ES-16 is for use with adults 18 years of age and older and can be useful in the therapeutic context to assess experiential avoidance and a client’s emotional reactivity – two factors that increase suffering (Grabovac et al. 2011, Hayes et al., 1996).

Equanimity is an attitude that is increasingly recognised as a component of mindfulness practice that is inseparable from experiential awareness (Eberth et al. 2019). Equanimity is “a balanced reaction to joy and misery, which protects one from emotional agitation” (Bodhi 2005, p. 154). Equanimity has also been conceptualised as an “even minded mental state or dispositional tendency towards all experiences or objects, regardless of their affective valence (pleasant, unpleasant or neutral) or source” (Desbordes et al. 2015, p. 357). Accordingly, “cultivating equanimity promotes one’s greater ability to regulate emotion and tolerate distress. In turn, greater coping ability resulting from increased equanimity improves one’s sense of self-efficacy in facing common stressors” (Cayoun et al., 2022, p. 752).

The ES-16 has two subscales:

1. Experiential Acceptance: where the client demonstrates an attitude which does not seek to resist or attach to the experience and involves acceptance of all internal experiences (thoughts, feelings, body sensations, etc.).
2. Non-Reactivity: where the client demonstrates non-reactivity to experiences preventing attachment or aversion to these experiences (e.g. thoughts, feelings) or where they have the ability to inhibit a previously learned response to these experiences.

Reactivity and acceptance are understood as both interrelated and different constructs. Acceptance has been shown to reduce reactivity (Lindsay et al. 2018), highlighting the interconnectedness of the two factors.

Psychometric Properties

For the construction of the ES-16, an initial 42-item instrument was selected from twenty existing self-report questionnaires measuring mindfulness and related constructs. These were chosen on the basis that some of their items were conceptually related to equanimity. After performing an EFA, the instrument was reduced to 16 items and in agreement with past research, the EFA revealed two underlying factors: Experiential Acceptance and Non-reactivity. The final 16-item measure showed good internal consistency (Cronbach’s alpha = .88), test-retest reliability (n =73; r =.87, p < .001) over 2–6 weeks and convergent and divergent validity, illustrated by significant correlations in the expected direction with the Nonattachment Scale, Depression Anxiety and Stress Scale, Satisfaction with Life Scale and Distress Tolerance Scale (Rogers et al., 2021).

In a validation study by Rogers et al. (2021), 223 adults from the general community (66.8% females and 33.2% males, age range = 18 – 75) were assessed using the ES-16 and means and standard deviations were obtained:

1. ES-16 Total Score: Mean 58.76 (SD 10.36)
2. Experiential Acceptance: Mean 29.59 (SD 5.71)
3. Non-Reactivity: Mean 29.17 (SD 5.99)

Scoring and Interpretation 

A total score is calculated in addition to subscale scores for Experiential Acceptance and Non-Reactivity, where a higher score indicates higher levels of equanimity – indicating that a client is engaged in experiential acceptance and is non-emotionally reactive.

A normative percentile is also calculated which compares the respondents score to a community sample. A percentile of 50 indicates an average level of equanimity in comparison to the normative comparison group. Interpretation using the percentile is useful because it contextualises responses in comparison to healthy peers.

The ES-16 consists of two subscales:

1. Experiential Acceptance (Items 1 – 8): where the client demonstrates an attitude which does not seek to resist or attach to the experience and involves acceptance of all internal experiences (thoughts, feelings, body sensations, etc.).
2. Non-Reactivity (Items 9 – 16): where the client demonstrates non-reactivity to experiences preventing attachment or aversion to these experiences (e.g. thoughts, feelings) or where they have the ability to inhibit a previously learned response to these experiences.

Developer

Rogers, H. T., Shires, A. G., & Cayoun, B. A. (2021). Development and Validation of the Equanimity Scale-16. Mindfulness, 12(1), 107–120. https://doi.org/10.1007/s12671-020-01503-6

References

Bodhi, B. (2005). In the Buddha’s words: an anthology of discourses from the Pali Canon. Wisdom Publications.

Cayoun, B., Elphinstone, B., Kasselis, N., Bilsborrow, G., & Skilbeck, C. (2022). Validation and Factor Structure of the Mindfulness-Based Self Efficacy Scale-Revised. Mindfulness, 13(3), 751–765. https://doi.org/10.1007/s12671-022-01834-6

Desbordes, G., Gard, T., Hoge, E. A., Hölzel, B. K., Kerr, C., Lazar, S. W., Olendzki, A., & Vago, D. R. (2015). Moving beyond mindful- ness: defining equanimity as an outcome measure in meditation and contemplative research. Mindfulness, 6(2), 356–372. https://doi.org/10.1007/s12671-013-0269-8.

Eberth, J., Sedlmeier, P., & Schafer, T. (2019). PROMISE: a model of insight and equanimity as the key effects of mindfulness meditation. Frontiers in Psychology, 10, 2389. https://doi.org/10.3389/fpsyg.2019.02389.

Grabovac, A. D., Lau, M. A., & Willett, B. R. (2011). Mechanisms of mindfulness: a Buddhist psychological model. Mindfulness, 2(3), 154–166. https://doi.org/10.1007/s12671-011-0054-5.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: a function- al dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168. https://doi.org/10.1037//0022-006x.64.6.1152.

Lindsay, E., Young, S., Smyth, J., Brown, K., & Creswell, D. (2018). Acceptance lowers stress reactivity: dismantling mindfulness train- ing in a randomized controlled trial. Psychoneuroendocrinology, 87, 63–73. https://doi.org/10.1016/j.psyneuen.2017.09.015.