Behavior rating scales are one of the oldest assessment tools used in mental health, education, and research. These scales typically assess problem behaviors, social skills, and emotional functioning; are widely employed in the assessment of personality development, adaptive behavior, and social-emotional functioning; and aid in diagnostic decision making and in planning treatment and education. These well-proven scales are easy to administer, score, and interpret and have become an integral part of the clinical and school assessment of children and adolescents.
A variety of behavior rating scales are available for use in clinical practice and research. The majority of behavior rating scales are intended for use with children, though a handful can be used with adults. The use of behavior rating scales in the evaluation of adult clients is gaining popularity. There are a number of advantages of using behavior rating scales: They quantify and systematically organize client information, administration and scoring is generally quick and easy, most allow for comparison of ratings across respondents and/or settings, and because these are norm-referenced instruments, the client’s symptoms and behaviors can be compared with those of his or her peers.
Behavior rating scales help clinicians obtain information from parents, teachers, and others about a client’s symptoms and functioning in various settings, which is necessary for an appropriate assessment for a number of disorders as well as for treatment monitoring. Such instruments are generally only one component of a comprehensive evaluation, which commonly includes direct observation of the client, objective and projective measures, and interviews. Most behavior rating scales are normed using nationally representative samples, but they also often include clinical norms as well, which allows for a variety of behavior comparisons. Ideally, the rating scale used should be normed to similar client populations, so results indicate if a client’s skill, behavior, or emotional status is typical or significantly different from that of peer groups.
Uses of Behavior Rating Scales
The most common use of behavior rating scales is in the diagnosis of mental and behavioral disorders. The content of behavior rating scales often conforms to Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria, though it often differs in the way the symptoms are quantified as well as in the way the symptoms are combined. In the educational setting, these scales are also used to help determine eligibility for special education and other programs. In addition, they are used to plan interventions and to monitor symptoms and behavior during and following treatment.
There is ample empirical support for the validity of using behavior rating scales for diagnostic and placement decision making. However, the use of these scales in planning interventions and monitoring client progress has not yet been adequately validated. Because of this, behavior rating scales should never be the sole method used to monitor response to treatment, though behavior rating scales do have a place as one piece of a multimodal method. For example, direct observations and rating scales are considered the best methods to evaluate the effects of medication trials on a child’s behavior. When used in conjunction with direct observations, behavior rating scales may give an indication of differences in behavior across settings or differences in the perception of the client’s behavior by significant others in his or her life. It is always important to ensure that the scale is appropriate for this use. If a behavior rating scale is used to monitor a behavioral intervention, care should be taken to make sure the scale aligns with this goal. Many scales monitor reductions in negative behaviors, but most lack items that measure positive replacement behaviors.
Behavior rating scales typically quantify the severity of the behaviors or symptoms on Likert scales (e.g., 0-not present to 4—severe) or the frequency that the behavior or symptom is observed (e.g., 0-never to 4-almost always). Scores on the scale or subscales are then summed and converted to a standard score such as a T score, which allows for comparison of the frequency of a variety of behaviors to norms for a client’s gender and/or age group. These data are critical for determining the clinical significance of the client’s symptoms and behaviors.
Types of Behavior Rating Scales
Many of the newer behavior rating scales use a comprehensive, multidimensional approach to the assessment of behavior. For example, many scales include observer/informant and self-report forms. In addition, clinicians can choose from global scales that assess multiple domains of functioning or scales that focus on a specific dimension of behavior.
Significant others, such as parents and teachers, can provide valuable information about a client’s behavior that would otherwise be unavailable to the clinician. This information can be extremely helpful as part of case conceptualization, especially with child clients. Informant scales assess the degree or frequency of certain behaviors or skills based on the respondent’s perceptions. The rater must be very familiar with the client to provide useful information, and using multiple raters helps reduce biased perceptions. The psychologist’s report should note who provided the ratings and describe his or her relationship to the client.
Older child clients and adults are often asked to provide ratings of their own behavior, feelings, and skills. These measures are similar, or even identical, to other rating scales and are often used in conjunction with teacher or parent ratings. It can be helpful to compare how clients perceive themselves relative to how others perceive them. However, it is important to note that in psychiatric disorders where either the client’s verbal capacity (e.g., autism, dementia) or insight (e.g., psychotic conditions) is compromised, self-rating scales have very little value.
Single Domain Scales
Scales that assess one specific area allow for focused, in-depth evaluation of a behavior or particular area of functioning. Focusing on a single dimension of behavior may be warranted when the referral question is limited to a specific concern. Most of these scales are intended to assess attention deficit hyperactivity disorder (AD/HD), social skills, or conduct problems. These measures are often used subsequent to the use of multidomain scales that have identified one or more areas of concern.
Multidomain behavior rating scales assess a broad array of social, emotional, and behavioral functioning. The use of these scales has increased dramatically in popularity due to research findings that many individuals, particularly children, tend to have difficulties in multiple areas. For example, research in developmental psychopathology suggests a high degree of comorbidity among the social, emotional, and behavioral domains. Thus, multidomain behavior rating scales allow the clinician to obtain information about a variety of areas of functioning with one tool.
Widely Used Behavior Rating Scales
There are many different behavior rating scales available to clinicians. The most commonly used scales are the Achenbach Scales, the Behavior Assessment System for Children (BASC-2), the Connors instruments, the Attention Deficit Disorders Evaluation Scale (ADDES), the ADD-H Comprehensive Teacher Rating Scale (ACTeRS), the ADHD Rating Scale-IV, the Behavior Rating Profile (BRP-2), the Burk’s Behavior Rating Scales (BBRS), and the Social-Emotional Dimension Scale (SEDS-2). One other behavior rating scale that is quickly gaining popularity is the Behavior Rating Scale of Executive Function (BRIEF). Although this list does not cover the full range of available behavior rating scales, it is a good representation of scales that are widely or typically used, as determined by surveys of practitioners.
The Achenbach System of Empirically Based Assessment (ASEBA) offers a comprehensive approach to assessing adaptive and maladaptive functioning. These multidomain instruments allow for multi-informant assessment across the age span (1.5 to 90 years). ASEBA instruments allow for documentation of clients’ functioning in terms of both quantitative scores and individualized descriptions in respondents’ own words. Descriptions include what concerns respondents most about the client, the best things about the client, and details of competencies and problems that are not captured by quantitative scores alone. Evidence of adequate psychometrics of the Achenbach scales is provided in the test manual. In addition, numerous studies have demonstrated significant associations between ASEBA scores and both diagnostic and special education categories.
ASEBA behavior rating scales include the Child Behavior Checklist (CBCL), the Caregiver-Teacher Report Form (C-TRF), the Teacher Report Form (TRF), the Youth Self-Report (YSR), the Adult Behavior Checklist (ABCL), the Adult Self-Report (ASR), the Older Adult Behavior Checklist (OABCL), and the Older Adult Self-Report (OASR). The ASEBA informant scales generally take 15 to 20 minutes to complete, while the self-report scales take 20 to 30 minutes. Forms can be hand- or computer-scored.
The CBCL/6-18 obtains reports from parents, other close relatives, and/or guardians regarding children’s competencies and behavioral or emotional difficulties. The CBCL/6-18 has 112 items that describe specific behavioral and emotional problems, plus two open-ended items for reporting additional problems. Parents rate their child for how true each item is using a 3-point scale from 0 (not true) to 2 (very true or often true). Parents also provide information for 20 competence items covering their child’s activities, social relations, and school performance.
The CBCL/6-18 scoring profile provides T scores and percentiles for three competence scales (Activities, Social, and School), Total Competence, eight syndromes, six ASSM-oriented scales, and Internalizing, Externalizing, and Total Problems. The syndrome scales include Aggressive Behavior, Anxious/Depressed, Attention Problems, Rule-Breaking Behavior, Social Problems, Somatic Complaints, Thought Problems, and Withdrawn/Depressed. The six ASSM-oriented scales are Affective Problems, Anxiety Problems, Somatic Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problems.
The CBCL for preschool-age children (CBCL/P/2-5) is used to obtain parents’ reports of their 1//- to 5-year-old child’s competencies and problems. It obtains ratings of 99 problem items, plus descriptions of problems, disabilities, what concerns parents most about their child, and the best things about the child. Items combine to form the following scales: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Attention Problems, Aggressive Behavior, and Sleep Problems. Scores on Internalizing, Externalizing, and Total Problems composite scales are also provided.
Like the CBCL/6-18, the preschool profile features ASSM-oriented scales in addition to the empirically based scales. Scales were constructed for the following five ASM-oriented categories: Affective Problems, Anxiety Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Pervasive Developmental Problems. The CBCL/U/-5 also includes the Language Development Survey (LDS), which uses parents’ reports to assess children’s expressive vocabularies and word combinations as well as risk factors for language delays. The LDS indicates whether a child’s vocabulary and word combinations are delayed relative to norms for children ages 18 to 35 months. The LDS can also be completed for language-delayed older children.
TRF and C-TRF/1-5
The TRF is designed to obtain teachers’ reports of children’s academic performance, adaptive functioning, and behavioral or emotional problems. The scale has 118 problem items, of which 93 have counterparts on the CBCL/6-18. The remaining items concern school behaviors that parents would not observe, such as difficulty following directions and or disturbance of other pupils. Teachers rate the child for how true each item is using the same 3-point response scale used on the CBCL/6-18.
Scores for Academic Performance, Total Adaptive Functioning, the eight cross-informant syndrome scales, and the six ASM-oriented scales can be obtained. Like the CBCL, the TRF also provides Internalizing, Externalizing, and Total Problems composite scores.
For 1/- to 5-year-olds, preschool teachers and day care providers can complete the Caregiver-Teacher Report Form for Ages 1/-5 (C-TRF/1/-5). The C-TRF consists of 99 items, plus descriptions of problems, disabilities, what concerns the respondent most about the child, and the best things about the child.
The YSR is a self-report scale that can be completed by youths who have fifth grade reading skills, or it can be administered orally. Its competence and problem items generally parallel those of the CBCL/6-18; plus it contains items covering physical problems, concerns, and strengths that require open-ended responses. In addition, the YSR has 14 socially desirable items that most youths endorse about themselves. The YSR scoring profile includes two competence scales (Activities and Social), Total Competence, the eight cross-informant syndrome scales, and the six ASM-oriented scales that are also scored on the CBCL and TRF, and Internalizing, Externalizing, and Total Problems scales.
The ASEBA is one of the few assessment systems with a behavior rating scale intended for use with adults. The ABCL is for clients ages 18 to 59. The client’s spouse or partner typically serves as the respondent, but any adult who is close to the client can complete the ABCL. The profiles of the ABCL include scales for Adaptive Functioning, Empirically Based Syndromes, Substance Use, Internalizing, Externalizing, and Total Problems. The ABCL profiles also feature new ASM-oriented scales and a Critical Items scale consisting of items of particular concern to clinicians.
The following cross-informant syndromes were derived for the ABCL: Anxious/Depressed, Withdrawn, Somatic Complaints, Thought Problems, Attention Problems, Aggressive Behavior, Rule-Breaking Behavior, and Intrusive. The ABCL and ASR have parallel Substance Use, Critical Items, Internalizing, Externalizing, and Total Problems scales. The ASM-oriented scales are Depressive Problems, Anxiety Problems, Somatic Problems, Avoidant Personality Problems, Attention Deficit/Hyperactivity Problems, and Antisocial Personality Problems. For older clients (ages 60-90+), clinicians can use the OABCL.
The Adult Self-Report (ASR) is normed for clients 18 to 59 years. Like the YSR, the ASR profiles include scores for Adaptive Functioning, cross-informant empirically based syndromes, Substance Use, Internalizing, Externalizing, and Total Problems. In addition, the ASR profiles feature the DSM-oriented scales that are scored on the ABCL and a Critical Items scale. Older clients (60-90+ years) can complete the OASR.
The BASC-2 system is a set of tools that assess the behaviors and emotions of preschool- through college-age individuals and is respected for its developmental sensitivity. The scales of the BASC-2 were first defined conceptually and then confirmed via factor analysis. In addition to evaluating personality and behavioral problems and emotional disturbances, the instruments identify positive attributes that can be capitalized on in the treatment process.
The BASC-2 system enables assessment from three vantage points: self, teacher, and parent or caregiver. Thus, information from multiple sources can be compared using instruments with overlapping norms to help achieve reliable and accurate diagnoses. The system provides an extensive view of adaptive and maladaptive behavior and measures areas important for both Individuals with Disabilities Education Act and DSM-IV classifications. Various types of validity checks are incorporated into the BASC-2 to help the clinician detect careless or untruthful responding, misunderstanding, or other threats to validity.
The BASC-2 Parent Rating Scales (PRS) and Teacher Rating Scales (TRS) are normed for individuals ages 2 years to 21 years, 11 months. These scales can typically be completed in 10 to 20 minutes. The Self-Report Scale (SRP) can be completed by individuals 8 years through college-age and takes about 30 minutes to complete.
T scores and percentiles for both general population and clinical norms can be obtained for all measures, and computer scoring and interpretation programs are available. Reliability and validity evidence is supportive of this measure.
The PRS assesses numerous aspects of behavior, including both adaptive (healthy) and clinical (problem) behaviors in the community and home settings. Parents or caregivers can complete forms for one of three age levels—preschool (ages 2 to 5), child (ages 6 to 11), and adolescent (ages 12 to 21)—in 10 to 20 minutes. The PRS contains 134 to 160 items that describe specific behaviors that are rated on a 4-point scale of frequency, ranging from never to almost always. The PRS clinical scales include Hyperactivity, Attention Problems, Aggression, Conduct Problems, Atypicality, Anxiety, Somatization, Withdrawal, and Depression. The adaptive scales are Activities of Daily Living, Adaptability, Social Skills, Functional Communication, and Leadership.
The clinical scales on the PRS combine to form three composite scales: Internalizing Problems, Externalizing Problems, and a Behavioral Symptoms Index. An Adaptive Skills Composite score is formed from scores on the adaptive scales. Validity and response set indexes used to help judge the quality of completed forms are also available. One additional tool is a list of Critical Items that may have clinical importance of their own. Some of these items are included solely for this singular attention and are not part of any scale (e.g., “Has a hearing problem”) while others have special significance such as “Says, ‘I wish I were dead.'”
Like the PRS, the TRS includes forms for three age levels and uses a four-choice response format for the 100+ items. Teachers or other qualified observers provide information about adaptive and problem behaviors in the preschool or school setting. Clinical scales on the TRS parallel those on the PRS but also include a Learning Problems scale for those between 6 and 21 years of age. The TRS adaptive scales are also identical to those on the PRS except for a Study Skills scale that is substituted for the Activities of Daily Living scale. The following composite scores are reported on the TRS profile: Internalizing Problems, Externalizing Problems, School Problems, Behavioral Symptoms Index, and Adaptive Skills.
The SRP helps provide insight into an individual’s thoughts and feelings. It contains 139 to 185 true/false and multiple choice (never to always) items and measures the following clinical areas: Attitude to School, Attitude to Teachers, Sensation Seeking (ages 12 to 21 only), Atypicality, Locus of Control, Social Stress, Anxiety, Depression, Sense of Inadequacy, Somatization, Attention Problems, and Hyperactivity. Positive psychological adjustment is measured via the adaptive scales (Relations with Parents, Interpersonal Relations, Self-Esteem, and Self-Reliance). Four composite scores are provided on the profile: School Problems, Internalizing Problems, Externalizing Problems, and Personal Adjustment.
First published in 1989, the Conners Rating Scales (CRS) is one of the most popular tools for assessing ADHD and other disruptive disorders in children and adolescents. The 1997 revised edition, the CRS-R, is linked to the DSM-IV and allows for multimodal evaluation of problem behaviors. There are long and short versions of each type of scale (parent, teacher, and self-report) that use a 4-point scale: not at all to very much. The short scales take 5 to 10 minutes to administer and the long scales take 15 to 20 minutes. Both the parent and teacher rating scales are used to characterize the behaviors of children and adolescents ages 3 to 17, while the self-report scales can be completed by 12- to 17-year-olds. The Conners manuals provide evidence of adequate psychometric properties of these measures.
The 10 scales scored on the long parent and teacher forms are Oppositional, Cognitive Problems/ Inattention, Hyperactivity, Anxious-Shy, Perfectionism, Social Problems, Psychosomatic, DSM-IV Symptom Subscales, Global Index (formerly the Hyperactivity Index), and AD/HD Index. The short forms offer scores on four scales: Oppositional, Cognitive Problems/ Inattention, Hyperactivity, and AD/HD Index.
The Adolescent Self Report long form has 87 items and 8 scales: Family, Emotional, Conduct, Cognitive, Anger Control Problems, Hyperactivity, AD/HD Index, and DSM-IV Symptoms Subscales, while the short self-report form has four scales: Conduct Problems, Cognitive Problems, Hyperactivity/Impulsive, and AD/HD Index.
The Conners Adult AD/HD Rating Scales (CAARS) is used to assess AD/HD in adults. It can be used with individuals 18 years and older and includes both observer and self-report forms. The CAARS quantitatively measures AD/HD symptoms across clinically significant domains while examining the manifestations of AD/HD in adults based on scientific literature and the authors’ clinical experience.
The self-report (CAARS-S) and observer forms (CAARS-O) address the same behaviors and contain identical scales, subscales, and indexes. T scores are produced for each scale, subscale, and index. Separate norms are available by gender and age-group intervals (18-29, 30-39, 40—19, and 50+ years).
Like the CRS, the CAARS has both long and short versions. The long versions comprise 66 items that assess a broad range of problem behaviors. They include a variety of factor-derived and DSM-derived subscales as well as three DSM-IV symptom measures (Inattentive, Hyperactive-Impulsive, and Total ADHD Symptoms), a 12-item AD/HD Index, and an Inconsistency Index for identifying random or careless responding. The short self-report (CAARS-S: S) and observer (CAARS-O: S) forms contain 26 items that are abbreviated versions of the factor-derived subscales that appear in the long versions. The AD/HD Index and the Inconsistency Index are also incorporated.
BRP-2, BBRS, and SEDS-2
Although the BRP-2, the BBRS, and the SEDS-2 still rank among the most frequently used behavior rating scales, they are being used with much less regularity than in the past. These scales are all multidimensional scales designed to be used with children. The BRP-2 has parent, teacher, and self-report forms; the BBRS has a single form that can be administered to parents and teachers, and the SEDS uses a teacher form only.
Although each of these scales can provide some helpful information, they all have limitations that the Achenbach, BASC-2, and Conners scales do not. For example, the BBRS has fairly weak psychometric properties, and the authors used a rather narrow standardization sample when norming the instrument. The BRP-2’s item content is limited, and the items lack behavioral specificity. Finally, the T scores on the SEDS-2 cannot be compared across scales, limiting the scale’s usefulness.
Measures for Assessment of ADHD
The most widely used measures of symptoms of AD/HD—the ADDES, ACTeRS and ADHD Rating Scale-IV—all use parent and teacher forms. The respondents rate the child client on characteristics typically associated with attention deficit disorders: inattention, impulsivity, and hyperactivity. All of these scales are generally easy to administer and score and provide helpful information that can contribute to the diagnostic process. However, considering the complexity of AD/HD, as well as the literature on comorbidity, it is wise to consider using a multidimensional instrument such as the CBCL or the BASC, either of which is more likely to detect evidence of commonly comorbid conditions such as a learning disability, oppositional defiant disorder, conduct disorder, obsessive-compulsive disorder, or depression.
Unlike other behavior rating scales, the BRIEF is designed specifically to assess impairment of executive function. According to the user manual, executive functions are those processes responsible for purposeful, goal-directed, and problem-solving behavior. The BRIEF uses parent and teacher forms that can be used with children ages 5 to 18. Both forms have 86 items and take 10 to 15 minutes to administer. Scoring by hand takes 15 to 20 minutes, and computer scoring software is available.
The BRIEF comprises two validity scales (Negativity and Inconsistency of Responses) and eight nonoverlapping theoretically and empirically derived clinical scales that measure various aspects of executive functioning. The clinical scales include Inhibit (control impulses, stop behavior), Shift (move freely from one activity or situation to another; problem-solve flexibly), Emotional Control (modulate emotional responses appropriately), Initiate (begin activity, generate ideas), Working Memory (hold information in mind to complete a task), Plan/Organize (anticipate future events, set goals, develop steps), and Monitor (check work, assess own performance). These scales form two broader indexes, Behavioral Regulation and Metacognition, as well as a Global Executive Composite score.
The family of BRIEF rating scales includes a preschool version for ages 3 to 5 years (BRIEF-P), a self-report form for adolescents ages 13 to 18 years (BRIEF-SR), and adult observer and self-report forms for individuals 18 to 90 years of age (BRIEF-A). Each of these scales parallels the original BRIEF in terms of format and conceptual framework. The BRIEF is useful in evaluating individuals with a wide spectrum of developmental and acquired neurological conditions and psychiatric disorders such as learning disabilities, AD/HD, Tourette’s disorder, traumatic brain injury, pervasive developmental disorders or autism, lead exposure, multiple sclerosis, dementias, and schizophrenia.
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