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Cognitive functioning self-assessment scale (CFSS): Preliminary

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Cognitive functioning self-assessment

scale (CFSS): Preliminary psychometric
data
a a a b
M. A. Annunziata , B. Muzzatti , L. Giovannini & G. Lucchini
a
Unit of Oncological Psychology, IRCCS Centro di Riferimento
Oncologico, National Cancer Institute, Aviano (PN), Italy
b
General Medical Practice, Health Local Service 6 Friuli
Occidentale, Aviano (PN), Italy

Available online: 21 Jul 2011

To cite this article: M. A. Annunziata, B. Muzzatti, L. Giovannini & G. Lucchini (2012): Cognitive
functioning self-assessment scale (CFSS): Preliminary psychometric data, Psychology, Health &
Medicine, 17:2, 207-212

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 Psychology, Health & Medicine
Vol. 17, No. 2, March 2012, 207–212

Cognitive functioning self-assessment scale (CFSS): Preliminary

psychometric data
M.A. Annunziataa*, B. Muzzattia, L. Giovanninia and G. Lucchinib
a
Unit of Oncological Psychology, IRCCS Centro di Riferimento Oncologico, National Cancer
Institute, Aviano (PN), Italy; bGeneral Medical Practice, Health Local Service 6 Friuli
Occidentale, Aviano (PN), Italy
(Received 7 February 2011; final version received 7 June 2011)
Downloaded by [University of Milan] at 01:47 08 March 2012

The cognitive functioning is included in the concept of quality of life. Many times
well-being remains incomplete because of cognitive difficulties, that people are
not always able to properly recognize and explain. Nonetheless, only few
instruments, specifically thought for non-clinical neurologic populations, are
available to measure them. The present study is an attempt at providing a self-
report instrument – cognitive functioning self-assessment scale (CFSS) – to
measure the individual cognitive functioning in general population. The CFSS is
itemized into 18 questions to which participants answer on a five-point scale. Two
hundred and eighty-two patients in a General Practitioner study have filled-in the
CFSS together with a clinical and socio-demographic data form. Explorative
factor analysis, using principal component analysis, suggests the consideration
of the CFSS as one-dimensional; internal reliability ¼ 0.856. Non-parametric
tests have shown that women report a worse cognitive functioning than men,
while no differences emerged in relation to age, manual prevalence, presence of an
illness or being in pharmacological treatment. Although further verifications are
necessary, the CFSS seems to be a promising self-report cognitive functioning
measure.
Keywords: cognitive functioning; general population; psychometrics; self-
assessment; quality of life

Introduction
The cognitive functioning, i.e. a series of mental processes including memory,
attention, executive functions, language, and perception, plays a fundamental role in
people’s life, in particular in social and work independence.
Cognitive assessments aim to detect difficulties in patients who present central
nervous system damage of different etiology and it is conducted by means of a series
of neuropsychological tests and by specialized staff (Lezak, Howieson, & Loring,
2004). Despite this general practice, cognitive impairment can also occur as a
consequence of mood disorders or of psycho-emotional distress (Chamberlain &
Sahakian, 2006; Gotlib & Joormann, 2010; Marazziti, Consoli, Picchetti, Carlini, &
Faravelli, 2010).

*Corresponding author. Email: annunziata@cro.it

ISSN 1354-8506 print/ISSN 1465-3966 online

Ó 2012 Taylor & Francis
http://dx.doi.org/10.1080/13548506.2011.596552
http://www.tandfonline.com
 208 M.A. Annunziata et al.

Moreover, the change in perspective – from health as the absence of disease to

overall bio-psycho-social well-being – promoted by the World Health Organization
(WHO) and welcome in clinical practice and research lead to include cognitive
functioning among the concepts of quality of life (QoL). Thus, it is possible to
broaden the interests and applications of the cognitive assessment outside the
restricted field of neurologic disease, including people with psycho-emotional
disorders, persistent or reactive at different degrees, as well as the well-being and
QoL of different populations.
However, such broadening of views was not followed by an improvement of
registration and assessment approaches. Indeed, the employment of neuropsycho-
logical instruments, such as screenings of the general population without
neurological impairments, is not always handy, neither effective nor economic for
people reporting generic disorders, such as memory failure. In these situations,
evaluating cognitive functioning by means of a self-report instrument could be more
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responsive. Furthermore, the employment of such an instrument offers a different

point of view – the patients’ one, and a self perception of their own functioning – and
it is complementary to the more objective neuropsychological tests. In addition, it
represents some sort of a first level screening in the identification of patients who
would really benefit from a more specific and sensitive exam, which is burdensome in
terms of costs and timing.
Not many self-report instruments are available in literature. The Cognitive
Failure Questionnaire (CFQ; Broadbent, Cooper, Fitzgerald, & Parkes, 1982) has
been often employed, although its construct validity was not univocally described
(e.g. Matthews, Coyle, & Craig, 1990; Pollina, Greene, Tunick, & Pukett, 1992; Rast,
Zimprich, Van Boxtel, & Jolles, 2009; Stratta, Rinaldi, Daniluzzo, & Rossi, 2006;
Wallace, 2004). In alternative, the multiple ability self-report questionnaire (MASQ;
Seidenberg, Haltiner, Taylor, Hermann, & Wyler, 1994) has been used, which
includes 38 questions aimed at evaluating five cognitive domains: language skills,
attention/concentration, visual-perceptual function, visual memory, and verbal
memory. Additional questionnaires were born within the context of specific
neurologic illnesses, for instance, the multiple sclerosis neuropsychological screening
questionnaire (MSNQ).
Despite the different components of QoL, the related questionnaires do not
always consider inherent items to cognitive functioning. Some of these instruments
ignore it completely [e.g. Nottingham Health Profile (Hunt, McEwen, & McKenna,
1986); Short Form-36 Health Survey (McHorney, Ware, & Raczek, 1993);
WHOQoL (WHO, 1993)], others summarise it by means of few items concerning
the several, possible cognitive domains [e.g. European Organization of Research on
Treatment of Cancer QoL Core 30 (Aaronson et al., 1993); Functional Assessment
of Cancer Therapy – Bone Marrow Transplant Scale (McQuellon et al., 1997)].
The present study is an attempt at providing a receptive instrument for self-
report of cognitive functioning. The cognitive functioning, together with emotional
states, social support, physical health, contributes to the self-perception of well-being
(Pessoa, 2010), and it is included in the concept of QoL. However, not many QoL
instruments (not specifically thought for clinical neurological population) measure
cognitive functioning. Measuring the self-perception of cognitive functioning is,
thus, useful from a clinical perspective. Moreover, this information could represent
an important completion of more objective data collected, for instance, by means of
neuropsychological assessment.
 Psychology, Health & Medicine 209

Methods
Participants
Three hundred and one adults took part in the study; they were all patients attending
the same General Practice Study in a small town in north-east Italy. From the initial
301 participants, three were excluded from the analysis because they declared
suffering from psychological distress, 14 did not complete the questionnaire (i.e.
more than 10% of the required answers were missing), and two gave incomplete
socio-demographic data.
The analyzed dataset included data on 282 participants of whom, 38.1% males
and 61.9% females; the median age was 45 years (range: 18–87). 61.1% of the sample
declared to be married, 26.8% single, the remaining 12.1% separated/divorced,
widowed or withheld this information. 69.3% were employed and 30.7% were
retired people, housewives or students. 91.1% of the sample declared right-hand
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dominance, 8.1% left-hand dominance, whereas 0.8% was ambidexter. 37.2% of

the subjects declared a chronic health problem that did not seem to affect their
cognitive functioning, whereas 29.8% were in pharmacological treatments; people
in psychotropic drug treatment were a priori excluded from the study.

Material and procedure

Participants were individually recruited in the waiting room of a General
Practitioner’s study. The Researcher, conducting the survey, briefly explained the
program emphasizing the research objectives, anonymous conditions, and the
approval of the General Practitioner who gave permission to the study taking place
in his practice. Each subject received a covering letter, describing the study and its
aims, a questionnaire, and an anonymous form eliciting demographic information
such as age, gender, marital status, occupation, hand dominance, ongoing diseases,
and/or drug treatments.
The ‘‘cognitive functioning self-assessment scale’’ (CFSS) questionnaire included
18 statements (e.g. ‘‘I find it difficult to concentrate’’); participants were required to
estimate, on a five-point scale anchored ‘‘never-always’’, the frequency of each
described situation in the past 12 months. The contents of CFSS items are
summarized in Table 1.

Results and discussion

Table 1 shows the median, mean, and standard deviation of patients’ answers for
each of the 18 items contained in the CFSS.
To verify the questionnaire factorial structure, an exploratory factor analysis
(EFA) was performed by the principal component analysis using the scree plot analysis
as criterion for factor extraction. Before performing the analysis, the suitability of
the data for factoring was assessed. Inspection of the correlation matrix revealed the
presence of many coefficients of 0.30 and above. The Kaiser–Meyer–Oklin value was
0.88, and Bartlett’s test of sphericity reached statistical significance, supporting the
factorability of the correlation matrix (Bartlett, 1954; Kaiser, 1974). EFA suggested
using the instrument as mono-factorial, as the first factor alone explained more
than 31% of the entire variance and all 18 items strongly loaded (40.40) with it. In
addition, the internal consistency of the entire scale was high (¼0.856).
 210 M.A. Annunziata et al.

Table 1. Median, mean and standard deviation of patients’ (N ¼ 282) answers for each of the
18 items contained in the CFSS questionnaire.

Stand.
Item Min Max Median Mean Dev
Lack of concentration 1 5 2 2.31 0.81
Absent-mindedness 1 5 2 2.41 0.84
Difficulty in performing two tasks simultaneously 1 5 1 1.61 0.82
Difficulty in performing mental calculation 1 5 2 1.78 0.87
Tip of the tongue phenomenon 1 5 3 2.72 0.70
Absent-mindedness during intellectual/cognitive 1 4 3 2.57 0.77
activities
Difficulty in organizing extra-routine activities 1 5 2 1.80 0.90
Difficulty in recalling recent information 1 5 3 2.46 0.96
Difficulty in recalling old information 1 5 3 2.54 0.91
Difficulty in recalling autobiographical events 1 4 2 1.90 0.82
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Forgetfulness 1 4 2 2.38 0.79

Lack of concentration while reading 1 5 3 2.41 0.86
Lack of motor coordination 1 4 1 1.59 0.75
Slowness in the execution of movements 1 4 2 1.80 0.90
Difficulty in finding the appropriate words 1 5 3 2.45 0.75
Use of periphrases or generic terms instead 1 5 3 2.52 0.80
of specific words
Difficulty in spatial orientation 1 5 2 1.81 0.87
Difficulty in temporal orientation 1 5 2 1.83 0.88

To ease comprehension of CFSS data, the CFSS total score was calculated as
mean of the 18 items: this procedure allowed maintaining the total score within the
same score range of each item (1–5).
Non-parametric data analyses were performed to verify whether CFSS score
changed according to gender, age, hand dominance, ongoing disease, or drug
treatments. Women (M ¼ 2.21) reported cognitive functioning impairments more
frequently than men (M ¼ 2.08) (z ¼ 72.19, p ¼ 0.027). Conversely, no differences
in cognitive functioning were found according to age, obtained comparing scores of
18–40-year age subgroup (36.2%), 41–50-year age subgroup (28%) and 51–87-year
age subgroup (35.8%) [chi2(2) ¼ 0.85, p ¼ 0.654], hand dominance [chi2(2) ¼ 0.22,
p ¼ 0.900], presence of illnesses (z ¼ 70.92, p ¼ 0.358) or being in pharmacological
therapy (z ¼ 71.23, p ¼ 0.220).
Table 2 shows the cumulative percentages, differentiated for males and females,
associated to CFSS total scores.
Cognitive functioning takes part in the individual’s perception of well-being and
it is included in the concept of QoL; however, not many instruments dedicated to the
assessment of QoL in general populations take it into consideration. A cognitive
impairment – even a mild one – of verbal expression and comprehension, perception
or attention, can limit a person’s work and relational abilities; consequently, it alters
their independence and, in turn, substantially affects QoL. The assessment of an
individual’s self-perception of cognitive functioning is thus useful from a clinical
point of view. Moreover, this information could represent an important completion
of objective data collected, for instance, by means of neuropsychological assessment.
Indeed, self-perception of cognitive functioning below the average leads to two
hypotheses: (1) the awareness of changes in cognitive status, which can be considered
 Psychology, Health & Medicine 211

Table 2. Cumulative parentages of CFSS scores according to gender (N ¼ 282).

Score Males (N ¼ 107) Females (N ¼ 175)

1.0 0.9 1.1
1.2 2.8 2.3
1.4 4.7 6.3
1.6 16.8 10.3
1.8 29.0 19.0
2.0 41.1 35.1
2.2 64.5 56.3
2.4 72.9 64.4
2.6 89.7 81.0
2.8 94.4 89.1
3.0 99.1 98.3
3.2 100.0 99.4
3.4 – 100.0
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a useful resource in an eventual rehabilitation plan; and (2) an underestimation

of self cognitive abilities, which can be valued as a first screening in a psychological
evaluation. In both cases, a neuropsychological examination will direct the
psychologist towards neuropsychological or psychological supportive care. Likewise,
an overestimate of the cognitive functioning still requires psychological examination.
Maybe it would be useful for further steps of assessment, administering the CSFF
with scales detecting emotional states in order to achieve a more accurate diagnosis;
in fact, in clinical practice cognitive symptoms may also be the consequence of mood
disorders.
This work is a contribution to the validation of an instrument specifically
designed for the self-report of cognitive functioning. When tested in a sample of
subjects extracted from the general population, the CFSS reported the following:
good instrument comprehension and acceptance (i.e. less than 5% of the completed
questionnaires had 10% of missing); mono-factorial structure; and good internal
reliability. Furthermore, our study provides the first reference data (i.e. mean,
median, minimum, maximum, standard deviation, and cumulative percentages)
related to the general population. Once further studies have demonstrated its test–
retest reliability, discriminant validity (for instance, by administration to a clinical
population with brain damage), and content validity (for instance, by studying
the correlation of the score with the CFSS and with a set of neuro-cognitive
instruments), the CFSS could be a promising candidate to fill the aforementioned
gap in the instrument set available to health professionals and researchers who wish
to study the self-perception of cognitive functioning.

Acknowledgement
The authors thank Mrs. Luigina Mei for editorial assistance.

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