RESEARCH UPDATE REVIEW

This series of 10-year updates in child and adolescent psychiatry began in July 1996. Topics are selected in
consultation with the AACAP Committee on Recertification, both for the importance of new research and
its clinical or developmental significance. The authors have been asked to place an asterisk before the five
or six most seminal references.

Ten-Year Review of Rating Scales. I: Overview of Scale

Functioning, Psychometric Properties, and Selection
KATHLEEN MYERS, M.D., M.P.H., M.S., AND NANCY C. WINTERS, M.D.

ABSTRACT
Objective: As part of the Journal’s 10-year Research Update Reviews, a series of articles will be presented on the role
of rating scales in child and adolescent psychiatry. The first article in the series summarizes principles underlying scale
functioning. Method: Sources were reviewed regarding testing theory, scale development, variability in scale function-
ing, psychometric properties, and scale selection. The extracted information was adapted to issues in child and adoles-
cent psychiatry. Results: Rating scales can make major contributions to understanding youths’ needs. They provide easy
and efficient measurement of psychopathology and quantify underlying constructs for comparison across youths, time,
and applications. Although multiple factors may affect a scale’s functioning, these factors can be understood and man-
aged by considering the goals of measurement and basic psychometric principles. Conclusions: Potential users of rat-
ing scales should not blindly assume that a well-known scale will meet the measurement needs for a particular application.
Rather, they can relatively easily educate themselves regarding the appropriate use of rating scales. This article pro-
vides the background information needed to evaluate scales for intended applications. It will also assist in reviewing the
individual scales presented in subsequent articles in this series. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(2):114–122.
Key Words: rating scales, psychometrics, measurement.

This article is the first in a series of 10-year updates on
the contributions of rating scales to child and adolescent
psychiatry. The topic is broad, and the literature address-
ing it is rich. To adequately cover the wealth of informa-
tion while remaining within the scope of the Journal’s
10-year updates, we have grouped the rating scales into
several areas for sequential publication: overview, inter-
nalizing disorders, psychosocial scales, externalizing dis-
orders, and miscellaneous scales. Within the four groupings,
we have emphasized scales most relevant to practice in
child and adolescent psychiatry. This means the exclu-
sion of some interesting scales widely used in related pro-
Accepted September 4, 2001.
Dr. Myers was Associate Professor and Director of Outpatient Child and
Adolescent Psychiatry and Dr. Winters is Assistant Professor and Director of
Training, both at Oregon Health Sciences University, Portland.
Correspondence to Dr. Myers, Division of Child Psychiatry CH-13, Children’s
Hospital and Regional Medical Center, Box 5371, 4800 Sand Point Way, N.E.,
Seattle WA 98105.
0890-8567/02/4102–0114䉷2002 by the American Academy of Child and
Adolescent Psychiatry.
fessional fields, but with limited relevance for child and
adolescent psychiatry.
The scales reviewed in this series of articles were cho-
sen according to several guidelines. In keeping with the
current practice of child and adolescent psychiatry, we
chose scales predominantly relating to diagnosis, such as
major depressive disorder, obsessive-compulsive disorder
(OCD), and attention-deficit/hyperactivity disorder
(ADHD), or alternatively relating to specific constructs,
such as self-esteem and aggression. Older scales were
included if they had long track records in research or
practice, established psychometric properties, and con-
tinued citations in the literature. Newer scales cannot
meet these criteria. Rather, we selected newer scales that
have promising initial psychometric properties and that
also improve upon older scales or fill a special niche. To
determine which scales meet these criteria, we sampled
articles on various diagnostic categories published over
the past 25 years and selected scales with good represen-
tation or special applications. We reviewed the proper-

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ties of these scales. We then included those with adequate
psychometric properties or wide use. Finally, to deter-
mine their current applications, we examined studies over
the past decade that used these scales. Specifically not
included in these reviews are broad-band scales and per-
sonality inventories.
Subsequent articles will present specific scales along
with their relevant psychometric properties, strengths and
weaknesses, and current use. This article reviews princi-
ples underlying the successful use of these rating scales,
including variability in scales’ functioning, psychomet-
ric properties, and successful scale selection.
DEFINITIONS AND CHARACTERISTICS
Rating scales gained popularity in the second half of
the 20th century as a response to the declining interest
in projective measures, along with an increasing focus on
scientific measurement, refinements in diagnostic nomen-
clature, development of new models of juvenile psycho-
pathology, need for outcome measures in clinical trials,
and the recognition of internalizing disorders in youths.
The term rating scale is broad and encompasses multiple
types of measurement, including checklists, question-
naires, inventories, self-reports, other-reports, indices,
and other measures. In this series, rating scale refers to
any type of measure that provides relatively rapid assess-
ment of a specific construct with an easily derived numer-
ical score which is readily interpreted, whether completed
by the youth or someone else, regardless of the response
format and irrespective of application. Traditionally, self-
report methodology has been used to assess internalizing
disorders and emotional functioning, while other-report
methodology from parents and teachers has been used to
assess externalizing disorders and behavior. However,
newer scales have incorporated multiple informants into
rating scales across disorders and related constructs.
Rating scales are diverse (Corcoran and Fischer, 2000a;
Piacentini, 1993). They may measure global constructs,
such as anxiety or hostility; or specific behavioral quan-
tities, such as types of phobias or number of fights. They
may measure a construct broadly, such as thinking style;
or narrowly, such as negative cognitions. Some scales mea-
sure trait characteristics, such as temperament, while oth-
ers measure state functioning, such as fearfulness. Regardless
of their focus, all good scales include both generic and
specific aspects of a problem in order to represent the
range of symptoms. For example, ADHD scales cover
both hyperactivity and fidgeting, or disorganization and
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RATING SCALES, I: OVERVIEW
losing items. Scales may be unidimensional or multidi-
mensional. The former may be more time-efficient, but
the latter provide more information. Also, rating scales
may be completed by various individuals, with each pro-
viding a unique perspective. Youths describe their own
perceptions, which often surprise even those adults clos-
est to them. Parents provide the most comprehensive
knowledge as they observe variations in behavior across
multiple situations. Teachers best note deviations from
peers in the normalized setting of school. Some scales use
peer ratings to gain a perspective of youths in their own
world. Clinicians draw upon their experience in assess-
ing youths’ problems and functioning. The relevance of
others’ reports may vary across youths’ development, e.g.,
parents’ importance may wane while teachers’ impor-
tance may increase and then decline as youths mature.
The best informants are those who initiate referral, pro-
vide feedback during treatment, and are most familiar
with the youth.
Finally, rating scales are standardized. They have uni-
form items, scoring, and administration procedures that
do not change over youths, users, applications, adminis-
trations, or time. Their developers are obliged to provide
information that allows the user to assess the scale’s rele-
vance for an application. Unfortunately, optimal infor-
mation is often not available.
ADVANTAGES AND DISADVANTAGES OF
RATING SCALES
The value of rating scales may be best indicated by
their inclusion in the evaluation and treatment of youths
as recommended in the practice parameters published by
the American Academy of Child and Adolescent Psychiatry.
They have multiple applications (Corcoran and Fischer,
2000a; Piacentini, 1993). Rating scales are used to screen
groups in normative settings such as school or the com-
munity, to monitor the emergence of symptoms in high-
risk youths, to ensure selection of homogeneous subjects
for research, to evaluate intervention effects, and to deter-
mine treatment outcomes. Rating scales can ensure sys-
tematic coverage of behaviors, thereby reducing variability
in data collection. They provide quantifiable informa-
tion regarding the presence, frequency, and severity of
behavior and symptoms. They allow comparisons with
self across multiple administrations, with peers in simi-
lar circumstances, and with the overall population of
other youths. Early in treatment, they may allow youths
to more easily endorse distressing symptoms that they are
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reluctant to discuss, such as hallucinations or deviant
behaviors. They may also reveal difficult-to-observe behav-
iors, such as compulsions or stealing. Rating scales are
easy to score and to interpret. They are efficient and eco-
nomical in time, cost, and personnel. Of great relevance
for outcome-based treatments is the increased account-
ability provided by these quantifiable indicators. Finally,
a major advantage is that specialized training is not needed
to use most rating scales. They do not require advanced
training in psychological testing, knowledge of testing
theory, or even in-depth understanding of psychomet-
rics. This is not to say that no training is needed. Some
understanding of scale construction, developmental rel-
evance, informer variance, and limitations helps the clin-
ician to better select and implement a scale. Also, the
examiner must provide standardized instruction to youths
completing the scales. For venues using clinician-rated
scales with multiple raters, these raters must be trained
to high interrater agreement.
Rating scales are not without disadvantages (Corcoran
and Fischer, 2000c). These relate predominantly to youths’
self-reporting abilities, examiners’ goals for the scale, and
psychometric properties. During their earliest years of
use, many juvenile scales represented downward modifi-
cations of adult scales and thus were not developmen-
tally appropriate; this compromised their functioning.
Newer scales developed specifically for youths addressed
this shortcoming. However, concerns then arose regard-
ing youths’ competence as reporters of their feelings and
behaviors. Although adolescents have generally been con-
sidered competent self-reporters, factors such as reading
level, learning disabilities, psychological maturity, and
experience may attenuate their competence. Children’s
competence is even less clear. In addition to the factors
affecting adolescents’ competence, children may also have
limitations in their linguistic skills, self-reflection, emo-
tional awareness, and the ability to monitor their behav-
iors, thoughts, and feelings. They may also tend to respond
in a socially desirable manner. Despite these concerns,
research over two decades has shown that both adoles-
cents and children can be reliable and valid self-reporters.
Nevertheless, caution is still warranted to ensure that
there is an appropriate match between a particular scale
and the youths completing it.
Examiners may have unrealistic goals or poorly for-
mulated expectations for a scale and may not appreciate
alternative methods of ascertaining the same informa-
tion. A typical unrealistic goal is examiners’ use of cut-
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off scores for diagnostic determination. This is inappro-
priate. Rating scales are not diagnostic instruments and
should not substitute for diagnostic evaluation. When
examiners do not clearly formulate their expectations,
they may obtain interesting information about their
patients, but not information that helps to elucidate the
youths’ problem or answer their questions. Therefore, the
expectations for a scale and the information obtained
from it should be clear prior to scale selection. For exam-
ple, if the scale is hoped to easily render diagnostic clas-
sification in order to determine which youths will receive
pharmacotherapy, irrelevant data will be collected. On
the other hand, if the scale is intended to provide sever-
ity data during treatment, helpful monitoring may be
achieved. Rating scales should also be among the easiest
ways of obtaining information. Thus, if the examiner is
interested in whether a youth hallucinates, it may be eas-
ier to simply ask the youth.
Finally, examiners may use scales so frequently that
salient trends that take time to develop cannot be detected.
For example, weekly assessment of inattention during
stimulant treatment of a child with ADHD might yield
very helpful information. However, weekly assessment
of dissociation will not accurately depict effectiveness of
treatment.
Disadvantages regarding psychometric properties are
complex, but critical to a scale’s functioning. A summary
of psychometric properties is presented later. Relevant
here is the recognition that many rating scales do not have
sufficient psychometric information to allow optimal deci-
sions about their use. This is probably most frequently
noted in the lack of normative data that could be used to
interpret scores. Many scales lack validity data, which
makes it difficult to know whether the intended construct
has been measured. Compromises must then be made
regarding which psychometric properties are most impor-
tant to an intended task. A widely used scale cannot sim-
ply be assumed to possess the desired properties.
Perhaps the greatest empirical evidence of the disad-
vantages of rating scales is their poor functioning in recent
pharmacological trials (Ambrosini et al., 1999; Emslie
et al., 1997). In these studies, diagnosis-specific rating
scales have not adequately detected treatment effects when
global ratings have. The reasons are not clear, but they
may include suboptimal properties of the scales used,
study design, youths’ self-reporting, too short a study
period, or true medication nonresponse. There are obvi-
ous implications for any treatment monitoring.
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The main implication regarding these advantages and
disadvantages is that rating scales can be very useful in
the assessment and treatment of youths. However, exam-
iners must carefully consider what they want to learn,
decide whether a rating scale is the best way to ascertain
this information, and then familiarize themselves with a
scale’s functioning. Blind use of a scale is likely to bring
unanticipated, misleading, or invalid results.
VARIABILITY IN FUNCTIONING OF RATING SCALES
Although most scales highly discriminate clinically
referred from community youths, misclassification rates
up to 30% may occur. Misclassification may be an even
greater problem when clinical groups are compared. For
example, most anxiety rating scales will incorrectly include
depressed youths, and ADHD scales may pick up other
disruptive youths. Multiple factors affect a scale’s perfor-
mance (Piacentini, 1993; Reynolds, 1993).
Individual, Contextual, and Interpersonal Factors
The best-known individual factors include the associa-
tion of younger age with less reliable and valid ratings, and
female gender with higher internalizing scores (Angold
et al., 1987). Also, youths who seek social acceptance may
underreport symptoms, while those who feel overwhelmed
may overreport symptoms.
Rating scales generally fail to consider contextual fac-
tors. It is widely recognized that both children’s and adoles-
cents’ self-reports are situationally influenced. The behavior
and emotional functioning of young children are espe-
cially reactive to environmental factors. Youths also func-
tion differently across settings, such as between home and
school, or between the classroom and playground. It may
be difficult to decide whether measured problems reflect
underlying psychopathology or contextual issues. These
site factors are often addressed by using multiple infor-
mants in different relevant sites. However, scales rarely
address environmental stressors.
The poor concordance between different adult reporters
and between juvenile and adult reporters has been well
documented (Herjanic and Reich, 1982; Ines and Sacco,
1992; Welner et al., 1987). Four factors are particularly
salient regarding this poor concordance: contextual fac-
tors, the youth’s development, parental psychopathology,
and the type of symptom assessed.
Contextual issues were discussed above in relation to
youths’ differential functioning across settings. It is not
surprising that adults in the same settings demonstrate
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RATING SCALES, I: OVERVIEW
greater agreement than adults in different settings. For
example, a teacher will demonstrate greater agreement
with another teacher than with the youth’s parents. Even
mothers and fathers may differ. Generally, mothers tend
to rate their children’s symptoms higher than do fathers,
perhaps suggesting the different contexts youths experi-
ence with each parent.
Developmentally, the older the child, the better the
concordance between youths’ and adults’ reports. However,
it is unclear whether the improving concordance reflects
social-cognitive development, greater verbal abilities, or
other factors (Renouf and Kovacs, 1994). Furthermore,
concordance at all ages decreases when mothers are
depressed, since they then overreport depressive symp-
toms (Angold et al., 1987; Fergusson et al., 1993; Moretti
et al., 1985; Weissman et al., 1987) and possibly behav-
ior problems (Fergusson et al., 1993) in their children.
Other factors distressing the mother may also influence
her perception of her children.
The type of symptom is also relevant. Parents and chil-
dren agree best on concrete and observable behaviors such
as school suspension or fighting, but poorly on psycho-
logical symptoms such as sadness or suicidality. In gen-
eral, parents are better reporters of externalizing behaviors
and youths are better reporters of internalizing symp-
toms (Welner et al., 1987; Yule, 1993).
Factors Relating to Characteristics of the Scale
Variability in rating scales partially reflects deficits in
scale construction. Rating scales are often not developed
with samples representative of the population, but with
specific groups such as urban black schoolchildren or chil-
dren in a single midwestern state. Application to other sam-
ples, such as rural Hispanic youths or incarcerated white
teenagers, may then produce suboptimal results. This is
because the distribution of the measured variable varies
according to development, culture, and situation (Riegelman
and Hirsch, 1989; Robson, 1988). Normative values, cut-
offs, and other properties will then vary with samples that
differ from the original sample. Thus it is important to
know the sample in which a scale was developed and to
decide whether it is sufficiently similar to the test sample
to ensure minimal variability in its functioning.
A particular concern is the degree to which a scale mea-
sures the range or complexities of a problem (Piacentini,
1993; Reynolds, 1993). The scope of a scale may be too
narrow to helpfully define clinical implications, or con-
versely, too broad to measure the construct of interest.
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While most scales focus on a particular problem, most
are too general to tap subtleties of that problem. Thus it
may not be possible to find a scale that provides helpful
information on specific aspects of a youth’s problem. As
an example, many depression-rating scales assess overall
depression severity, but few provide information on somatic
versus cognitive aspects of depression. Furthermore, even
when a scale is helpful in assessment, it may sensitize the
youth toward its content, i.e., the simple act of repeti-
tively completing the scale may influence how youths
endorse items. The scale would then not be invariant
across administrations, violating the standardization rules.
A scale may also not be appropriate to the type of symp-
tom assessed. Since many symptoms represent state con-
ditions, and thus wax and wane, changes measured over
time might not reflect the scale’s ability to detect treat-
ment effects, but may represent its variation with the nat-
ural course of the symptom. This may be more of an issue
for internalizing than for externalizing disorders. The
scale must be matched to the symptoms.
On a practical level, specifications for using a scale are
often not well delineated, especially the time frame for
reporting (Corcoran and Fischer, 2000b; Piacentini, 1993).
Most scales specify time frames between 1 week and 1
month, but many do not indicate any time frame. Thus
examiners must make their own decisions without sup-
porting data, producing variable results. Also, a scale may
not provide an optimal number of response options for
a stated purpose (Aman, 1993; Piacentini, 1993). For
example, dichotomous responses may be adequate for
detecting the presence of tics, but not for detecting their
decrease during treatment. Also, the type of response
options may be vague (e.g., never, sometimes, often) and
thus confuse youths, leading to increased response vari-
ability. On the other hand, if the response options are
too precise (e.g., never, weekly, monthly), reliability and
validity may be compromised. The length of the scale is
also important. Generally, a longer scale will demonstrate
better psychometric properties, but may decrease youths’
ability to maintain interest and respond accurately through-
out the scale administration. Also, if properties of a scale
have not been examined in a long time, changes in under-
standing a disorder, youths’ sophistication, goals of mea-
surement, and other factors may alter applicability of the
scale. Over such time periods, different versions of a scale
may emerge without reexamination of the psychometric
properties. Similarly, when scales are purchased by pub-
lishing companies and copyrighted, their formats and
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factor structures may be reevaluated. However, these newly
marketed versions may not be consistent with the origi-
nal scale’s structure and their relevance may not be clear.
Factors Relating to Psychometric Properties
Rating scales do not provide “the truth.” They repre-
sent measurement of a variable, e.g., of a construct such
as youths’ feelings or behavior. Measurement is the sys-
tematic process of assigning a number to this variable.
However, such measurement is subject to error, and thus
variability in functioning. Psychometric properties pro-
vide an estimate of this error, and thereby reveal how rel-
evant these scores might be for a selected application
(Sackett et al., 1991). Unfortunately, most scales do not
provide all of the psychometric data desired in selecting
the best scale; and even when such date are available, they
may not be optimal. The user must then decide which
properties best meet the needs of a particular application.
A major psychometric issue affecting variability is the
choice of a cutoff score. Cutoffs are useful for identify-
ing individuals for further clinical evaluation, but they
always represent a trade-off between sensitivity and speci-
ficity. A few points in either direction can greatly alter
who will be considered clinically relevant and who will
not receive further intervention. Conversion of raw scores
to T scores provides greater standardization as well as a
useful comparison in relation to all other examinees. T
scores greater than 70 represent 2 SD above the mean (T
score = 50) and are considered statistically significant, but
lower scores may be clinically significant. Strict adher-
ence to either raw score cutoffs or T scores to define clin-
ical relevance may miss youths in need of treatment.
Rather, it is important to examine the pattern of raw
scores or T scores and to consider these scores in relation
to the examiner’s overall practice population.
Because psychometric properties are so important to
understanding the variability of rating scales and their
appropriate use, and because many readers may be “rusty”
in their recollection of psychometric principles, follow-
ing is a brief review of the most relevant psychometric
properties. This information will complement future arti-
cles in this series that provide reliability and validity data
for the scales reviewed.
REVIEW OF PSYCHOMETRIC PROPERTIES
A good measure is both reliable and valid. Unfortunately,
no scale available for clinical practice is totally reliable
and/or totally valid. Lack of reliability and lack of valid-
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ity are referred to as random and systematic error, respec-
tively. Thus, higher reliability and higher validity increase
the user’s confidence that the scale is measuring what it
proposes to measure, with a minimum of error (Corcoran
and Fischer, 2000b; Piacentini, 1993; Sackett et al., 1991).
Reliability
Reliability refers to the consistency with which all of
a scale’s items measure the same construct, and the con-
sistency with which the total scale measures that con-
struct in the same way every time (Corcoran and Fischer,
2000c; Piacentini, 1993; Sackett et al., 1991). Stated in
another way, reliability reveals whether the scale performs
the same way every time it is administered across persons,
situations, and time. There are four approaches to relia-
bility: consistency of the items comprising a scale (inter-
nal reliability or internal consistency), stability of the scale
over time and measurements (test-retest reliability), agree-
ment between different raters using the scale (interrater
reliability), and concordance between similar forms of a
scale (parallel reliability).
Internal reliability, or internal consistency, measures
the homogeneity of the scale. It represents the degree to
which the individual items are consistent with each other,
and thus are tapping the same construct. Items that are
not internally consistent are likely measuring different
constructs and detract from the scale. Typically, an item
analysis is conducted during scale construction and those
items with poor internal consistency are dropped from
the final scale version. However, the author may elect to
retain some such items because of theoretical or clinical
appeal. Ultimately, they decrease the scale’s internal reli-
ability. Scales measuring a unitary construct are expected
to have high internal reliability. Multifactorial scales, or
those covering a wide variety of symptoms, have lower
internal reliability. In general, longer rating scales tend
to have higher internal consistency than shorter scales.
Internal consistency is usually measured and reported
in two ways. The most common is the Cronbach coeffi-
cient α, a measure of the average correlations among all
items. Another estimate of internal consistency is split-
half reliability. This approach correlates half of the items
with the other half. These two halves can be chosen in
various ways, e.g., the first half with the last half of items,
even numbers with odd numbers, or random selection
of items in each group. It should be noted that split-half
reliability underestimates internal consistency because
reliability is influenced by the total number of items in
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RATING SCALES, I: OVERVIEW
a scale, and split-half reliability effectively reduces the
number of items in each correlational assessment. This
underestimate may be corrected through a procedure
referred to as the Spearman-Brown formula. For either of
these types of internal reliability, coefficients exceeding
0.80 suggest that the scale is generally internally consis-
tent. However, a coefficient of 0.80 also means that 20%
of the scale’s score is due to random error. Thus, higher
reliability coefficients are more desirable and are com-
monly reported for newer scales.
Test-retest reliability, or stability, assesses whether a scale
is stable over time. If the variable measured has not changed,
then a scale’s scores should be similar over administrations,
and stability should be high. Test-retest reliability is espe-
cially important when a scale is used to assess the progress
of treatment. If a scale is not stable, then it is impossible
to determine whether measured change is real or repre-
sents random error in the scale. The construct measured
may affect the scale’s apparent stability. For example, a trait
measure, such as self-concept or inattentiveness, should
demonstrate high stability over 1 to 2 months; while a state
measure, such as loneliness or truancy, will have lower sta-
bility due to the natural history of the construct. A corre-
lation greater than 0.80 for two administrations of a scale
1 to 2 weeks apart suggests adequate stability. For admin-
istrations over a month, a correlation greater than 0.70 is
considered reasonable stability. The lower stability with
longer intervals has been posited to represent practice effects,
reactivity, the natural history of juvenile disorders, and sta-
tistical regression.
Interrater reliability represents the agreement, or con-
cordance, between different informants. Informants may
include lay informants, such as adults who are familiar
with the youth, but interrater reliability is most relevant
to clinician-rated scales requiring an interview format.
Considerable training may be needed to ensure that mul-
tiple raters are scoring items similarly, i.e., are using the
scale in a consistent manner. To assess their concordance,
correlations may be made between raters’ scores for the
total scale as well as for individual items. Again, correla-
tions greater than 0.80 are acceptable.
Parallel-forms reliability also assesses agreement between
different entities, but this time between two forms of a
scale. When such parallel forms of a scale exist, such as
parent and child versions or long and short versions, they
would tap the same construct and their scores should be
highly correlated. Correlations greater than 0.80 suggest
adequate parallel reliability.
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MYERS AND WINTERS
Validity
Validity pertains to whether the scale accurately assesses
what it was designed to assess (Corcoran and Fischer,
2000c; Piacentini, 1993; Sackett et al., 1991). This is a
serious concern for scales measuring juvenile psychopa-
thology due to the questionable validity of childhood diag-
noses, changing diagnostic criteria, and the natural history
of the course of juvenile disorders. Validity must be estab-
lished against multiple criteria, and it generally requires
several years to assess accurately. Thus newer scales do not
have optimal validity data available for the potential user
to review. Even older scales with wide applicability may
not have had their validity reevaluated since the initial
preliminary assessment. Caution is warranted in consid-
ering a scale’s validity. There are three major types of valid-
ity: content, criterion, and construct validity.
Content validity assesses whether the scale’s items rep-
resent the entity being measured. Adequate content valid-
ity is often ensured by deriving items from the diagnostic
criteria or clinical correlates of the disorder of interest or
by careful examination of youths with the disorder. There
are two basic approaches to content validity: face validity
and logical content validity. Face validity asks whether the
items appear on the surface to tap the content. It is deter-
mined by simple examination of the items and subjec-
tively judging whether they appear to be measuring the
content area. Logical content validity is more systematic.
It refers to the procedure the scale’s developer used to eval-
uate the content of the items, whether they cover the entire
content domain, and whether the items are representative
of all content areas that should be included. However, this
information is not always available.
Criterion validity offers greater depth than content valid-
ity. It is empirically based, assessed in relation to other scales
with established validity measuring the same construct.
Correlations with these established scales provide greater
confidence that the scale is measuring what it is supposed
to measure. There are two types of criterion validity: pre-
dictive validity and concurrent validity. Predictive validity
asks whether the scale is correlated with some event that
will occur in the future, e.g., a scale measuring strong
parental support may predict early hospital discharge.
Concurrent validity refers to a scale’s correlation with an
event that is assessed at the same time the scale is admin-
istered; for example, a scale of psychosis should correlate
with parents’ concerns about odd behaviors, or a conduct
disorder scale should correlate with incarceration. Two
types of concurrent validity are convergent validity and
120
discriminant validity. Convergent validity is the extent to
which the scale correlates with some theoretically relevant
variable with which it should correlate. For example, a
depression scale should correlate with a decrease in a youth’s
social activities. Discriminant validity, sometimes termed
known-groups validity, compares a scale’s scores for a group
that is known to have the problem with a group that is
known not to have the problem. If the scale is valid, then
these two groups should have different scores. For exam-
ple, scores on a drug abuse scale should differ for youths
in drug rehabilitation and those who abstain from drugs.
Construct validity examines whether the scale taps a
particular theoretical construct. To consider a scale as
having construct validity, it should be shown to have dis-
criminant and convergent validity. Thus construct valid-
ity shows that the scale converges with and diverges from
other appropriate variables.
Factorial validity is another approach to construct valid-
ity as it examines a scale’s convergent and discriminant valid-
ity using a statistical procedure known as factor analysis.
This derives groups of variables that measure separate aspects
of the problem, termed factors. If variables are similar, they
correlate with the same factor, demonstrating convergent
validity. Variables not associated with a particular factor sug-
gest discriminant validity. Alternatively, factorial validity is
determined by assessing whether individual items correlate
with the scale’s total score and do not correlate with unre-
lated variables. Factorial validity is complicated and often
not available. However, scales with reported subscales are
often described as multifactorial because these subscales
have been determined through factor analysis to demon-
strate some degree of discrimination from one another,
but good correlation with the overall score.
During scale construction reliability is determined first.
The scale’s ability to perform similarly each time must be
ensured in order to assess its ability to measure a construct.
In other words, random error must be minimized in order
to detect any systematic error in the scale. Thus, to be valid,
a scale must be somewhat reliable. The converse does not
apply. Thus, if only reliability is reported, caution is war-
ranted regarding validity. In addition, because validity is
determined over years as the scale is applied to various
groups, newer scales generally do not have sufficient valid-
ity data. Surprisingly, some scales with long track records
in child and adolescent psychiatry may not have estab-
lished validity. Also, no scale is completely reliable and
valid. Users will have to settle for some error in measure-
ment and be judicious in interpreting scores. Finally, users
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should be aware that authors often use inconsistently the
various terms relating to reliability and validity.
Normative Data
Normative data for a scale are important but often not
adequately addressed. Normative data provide informa-
tion on the representativeness of a scale’s functioning.
Normative data should be representative of the current
population and should be stratified on relevant variables
that show differences in scores, usually age and gender,
but often also ethnicity and geography. Separate norms
for these variables should then be provided. Normative
values are affected by base rates of the construct mea-
sured, as well as its distribution in the population. For
many clinical disorders and symptoms, self-report and
other-report measures are not normally distributed, but
are skewed. This can affect the determination of stan-
dard score norms developed from raw scores. Although
this problem is not generally addressed, it forms one basis
for the aforementioned caution about cutoff scores.
SELECTING A RATING SCALE
In choosing the best scale, several factors warrant con-
sideration (Corcoran and Fischer, 2000d; Riegelman and
Hirsch, 1989). Stability refers to what extent a scale per-
forms equally over repeated administrations. When con-
sidered from a psychometric perspective, this is called
test-retest reliability. However, in relation to scale selec-
tion, it can also refer to practical aspects, such as how well
the youth tolerates the scale with repeated administra-
tions. Utility represents the practical advantages the scale
offers and is influenced by how helpful the information
will be and by ease of use. For example, scales routinely
administered for entry to a clinic will likely demonstrate
low utility, inasmuch as they are not providing helpful
information on a specific issue. Also, if there is an easier
way to obtain desired information, then a rating scale will
have low utility. Suitability is an estimate of the scale’s
appropriateness to the youth’s abilities. A scale developed
for a teenager will not be suitable for a third grader with
a learning disability. Sensitivity estimates a scale’s ability
to detect change due to an intervention, rather than due
to other factors such as variability in the scale itself. This
is similar to the sensitivity described in the psychomet-
rics section, since in both cases sensitivity refers to the
scale’s ability to detect something “real.” In the case of
psychometric properties, it is the percentage of “real”
cases the scale detects, whereas in the case of scale selec-
tion, it is the amount of “real” change due to the inter-
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RATING SCALES, I: OVERVIEW
vention, not due to scale instability or error. By contrast,
reactivity refers to how the act of measuring something
may change it. This may be desirable for some interven-
tions in which measurement is intended to induce behav-
ioral change, such as dieting or smoking cessation. It is
not desirable with rating scales intended simply to mon-
itor change from the treatment. However, with repeated
administrations of the scale, youths can figure out what
is expected and may respond with a bias toward pleasing
the examiner. Directness refers to how the score reflects
the youth’s actual behavior, thoughts, or feelings. Behavioral
observations are relatively direct, whereas projective tests
are indirect, or symbolic. Direct measures best ensure reli-
ability and validity. Finally, appropriateness refers to how
compatible a scale is with the desired evaluation. The
most appropriate scales are valid, stable, and sensitive;
measure the problem in a direct and nonreactive man-
ner; have utility; and are suitable.
When selecting a scale, first address whether the scale
will be used for research or clinical purposes, as utility
will vary for investigators and clinicians who may have
different measurement goals. Define this problem in con-
crete, observable, and measurable terms. For example, if
the scale is to be used to follow response to cognitive-
behavioral therapy for OCD, scales may be needed to
measure a reduction in overall OCD severity, as well as
a change in time spent checking, possibly global func-
tioning, or even days tardy to school. Each focus for mea-
surement assesses a different domain and will require a
different scale or subscale. Next, determine whether the
youth will be a reliable and valid reporter, whether other
reporters will also be needed, and if so who would be the
most accurate reporter. When possible, use more than
one informant, usually a parent and a teacher, to obtain
various perspectives of the youth’s problem. Next, deter-
mine whether the youth’s behavior should be measured
in a specific setting or in multiple settings.
Only after deciding these aspects of the youth and the
problem should potentially relevant scales be reviewed.
These scales should be assessed regarding their suitabil-
ity for the youth’s age, reading level, and ability to com-
plete the scale. If the scale is suitable, review it for content,
determining whether each item is descriptive of the prob-
lem to be assessed. This will provide familiarity with the
scale, as well as estimate whether the scale might tap sub-
tleties of the problem. Next, address the purpose of mea-
surement in relation to psychometric properties. For
example, screening, severity of a diagnostic construct, or
treatment monitoring all require strong overall psycho-
121
MYERS AND WINTERS
metric properties, but each also has its own special needs.
A screening scale must have high sensitivity. Measuring
the intensity of a construct requires high construct valid-
ity and an appropriate response format. Monitoring treat-
ment effects requires high test-retest reliability, sensitivity,
nonreactivity, and appropriate response format.
Even when a scale has excellent psychometric proper-
ties, it is best to use more than one scale whenever pos-
sible. Different scales will tap somewhat different aspects
of the problem and will provide a more robust overall
assessment, perhaps closer to “the truth.” These scales
should demonstrate at least fair concurrent validity (>0.6),
although not so high (>0.95) that they are measuring
exactly the same aspects of the construct. Finally, be sure
that the response format is appropriate to the purpose of
the measurement. In general, a Likert-type format with
multiple responses is best because it will have greater
power and reliability. However, children may not be able
to understand expanded formats and may need only three
options or even a dichotomous yes/no format. Overall,
matching the scale to the problem and youth is crucial
to obtaining helpful information.
CONCLUSIONS
Rating scales assist in our evaluation and treatment of
children and adolescents. They enrich our understand-
ing of youths’ psychopathology and quantify their prob-
lems for comparison across individuals, situations, and
time. Their roles are adjunctive to careful psychiatric diag-
nosis and include screening, monitoring, and outcome
assessment. Among their many advantages is increased
accountability in clinical practice.
To obtain useful information, the potential user must
understand a scale’s functioning in relation to the pro-
posed application. This includes setting realistic goals for
the scale, conceptualizing the goals in measurable terms,
ensuring a developmental match between the youth and
a specific scale, and choosing a scale with the best psy-
chometric properties, utility, and appropriateness. Using
multiple scales can circumvent the limitations of any sin-
gle scale and can provide an estimation of the construct
measured in its various aspects. Similarly, the use of mul-
tiple informants can help to account for contextual issues.
The most important feature of the material presented
in this first article in this series is that potential users of rat-
ing scales should not simply assume that a particular scale,
even a widely used scale, will fulfill their measurement
needs. Otherwise invalid, and potentially damaging, results
may ensue. Rather, users can relatively easily educate them-
122
selves regarding the major factors in successful measure-
ment of child and adolescent psychopathology.
In subsequent articles in this series, we will review indi-
vidual scales relevant to specific diagnoses, such as OCD,
ADHD, and major depression, or specific problems, such
as suicidality, self-esteem, and aggression. The aforemen-
tioned principles will be incorporated into the discussion
of the utility of the individual scales to aid the reader in
selecting the most appropriate scale for an application.
REFERENCES
Aman MG (1993), Monitoring and measuring drug effects, II: behavioral,
emotional, and cognitive effects. In: Practitioner’s Guide to Psychoactive
Drugs for Children and Adolescents, Werry JR, Aman MG, eds. New York:
Plenum, pp 99–159
Ambrosini PJ, Wagner KD, Biederman J et al. (1999), Multicenter open-label
sertraline study in adolescent outpatients with major depression. J Am
Acad Child Adolesc Psychiatry 38:566–572
Angold A, Weisman MM, John K (1987), Parent and child reports of depres-
sive symptoms in children at low and high risk of depression. J Child
Psychol Psychiatry 28:901–915
*Corcoran K, Fischer J (2000a), Measures for Clinical Practice: A Sourcebook,
3rd ed, Vol I. New York: Free Press, pp 3–10
Corcoran K, Fischer J (2000b), Measures for Clinical Practice: A Sourcebook,
3rd ed, Vol I. New York: Free Press, pp 11–26
Corcoran K, Fischer J (2000c), Measures for Clinical Practice: A Sourcebook,
3rd ed, Vol I. New York: Free Press, pp 43–48
Corcoran K, Fischer J (2000d), Measures for Clinical Practice: A Sourcebook,
3rd ed, Vol I. New York: Free Press, pp 49–62
Emslie GJ, Rush AJ, Weinberg WA et al. (1997), A double-blind, random-
ized, placebo-controlled trial of fluoxetine in children and adolescents with
depression. Arch Gen Psychiatry 54:1031–1037
*Fergusson DM, Lynskey MT, Horwood LJ (1993), The effect of maternal
depression on maternal ratings of child behavior. J Abnorm Child Psychol
21:245–269
Herjanic B, Reich W (1982), Development of a structured psychiatric inter-
view for children: agreement between child and parent on individual symp-
toms. J Abnorm Child Psychol 10:307–324
*Ines TM, Sacco WP (1992), Factors related to correspondence between teacher
ratings of elementary student depression and student self-ratings. J Consult
Clin Psychol 60:140–142
Moretti M, Fine S, Haley G, Marriage K (1985), Childhood and adolescent
depression: child-report versus parent-report information. J Am Acad Child
Psychiatry 24:298–302
*Piacentini J (1993), Checklists and rating scales. In: Handbook of Child and
Adolescent Assessment, Vol 167, Ollendick TH, Hersen M, eds. Boston:
Allyn & Bacon, pp 82–97
*Renouf AG, Kovacs M (1994), Concordance between mothers’ reports and
children’s self-reports of depressive symptoms: a longitudinal study. J Am
Acad Child Adolesc Psychiatry 33:208–216
Reynolds WM (1993), Self-report methodology. In: Handbook of Child and
Adolescent Assessment, Vol 167, Ollendick TH, Hersen M, eds. Boston:
Allyn & Bacon, pp 98–123
*Riegelman RK, Hirsch RP (1989), Studying a Study and Testing a Test: How
to Read the Medical Literature. Boston: Little, Brown, pp 127–174
Robson PJ (1988), Self-esteem: a psychiatric view. Br J Psychiatry 153:6–15
Sackett DL, Haynes RB, Guyatt GH, Tugwell P (1991), Clinical Epidemiology:
A Basic Science for Clinical Medicine, 2nd ed. Boston: Little, Brown
Weissman MM, Wickramaratne P, Warner V (1987), Assessing psychiatric dis-
orders in children: discrepancies between mothers’ and children’s reports.
Arch Gen Psychiatry 44:747–753
Welner Z, Reich W, Herjanic B, Jung KG, Amado H (1987), Reliability, valid-
ity, and parent child agreement studies of the Diagnostic Interview for Children
and Adolescents (DICA). J Am Acad Child Adolesc Psychiatry 26:649–653
*Yule W (1993), Developmental considerations in child assessment. In:
Handbook of Child and Adolescent Assessment, Vol 167, Ollendick TH,
Hersen M, eds. Boston: Allyn & Bacon, pp 15–25
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 2 , F E B RU A RY 2 0 0 2