Release of The World Health Organisation Disability Assessment Schedule (WHODAS 2.0)

NovoPsych’s assessment library has been updated with the gold-standard measure for the impact disability is having on a person’s daily functioning. The World Health Organisation Disability Assessment Schedule (WHODAS 2.0) may be especially helpful in the context of assessments related to the National Disability Insurance Scheme (NDIS), and can provide a comprehensive measure of functional impacts. The WHODAS is a practical, generic assessment instrument that can measure health and disability at population level or in clinical practice. 

There are three versions of the WHODAS included in the NovoPsych test library: 

  1. The self-report version, which can be completed by individuals 18 years of age and over.
  2. The proxy version, which can be completed by a relative, carer, or friend.
  3. The interviewer version, which can be completed by a clinician.

WHODAS captures the level of functioning in six domains of life:

  1. Cognition – understanding and communicating
  2. Mobility – moving and getting around
  3. Self-care – attending to one’s hygiene, dressing, eating and staying alone
  4. Getting along – interacting with other people
  5. Life activities – domestic responsibilities, leisure, work and school
  6. Participation – joining in community activities, participating in society

Disability is a major health issue. When global assessments are made for burden of disease, more than half of the burden of premature mortality is due to overall disability. People generally seek psychological services because a disease makes it difficult for them to do what they used to do beforehand (i.e. because they are disabled) rather than because they have a disease. As outlined by the World Health Organisation (WHO, 2010), diagnosis and assessment of disability is valuable because it can predict the factors that medical diagnosis alone fails to predict; these include:

  • service needs – What are the patient’s needs?
  • level of care – Should the patient be in primary care, specialty care, rehabilitation or another setting?
  • outcome of the condition – What will the prognosis be?
  • length of hospitalisation – How long will the patient stay as an inpatient?
  • receipt of disability benefits – Will the patient receive any funding?
  • work performance – Will the patient return to work and perform as before?
  • social integration – Will the patient return to the community and perform as before?

Disability assessment is thus useful for client care, especially in the context of NDIS funding applications, in terms of:

  • identifying needs
  • matching treatments and interventions
  • measuring outcomes and effectiveness
  • setting priorities
  • allocating resources

WHODAS provides a common metric of the impact of any health condition in terms of functioning. Being a generic measure, the instrument does not target a specific disease – it can thus be used to compare disability due to different diseases. WHODAS also makes it possible to design and monitor the impact of health and health-related interventions. The instrument has proven useful for assessing health and disability levels in the general population and in specific groups (e.g. people with a range of different mental and physical conditions). Furthermore, WHODAS makes it easier to design health and health related interventions, and to monitor their impact.

Cognitive Flexibility Inventory (CFI)

March 25, 2022

The Cognitive Flexibility Inventory (CFI) is a 20-item self-report measure to monitor how often individuals engaged in cognitive behavioural thought challenging interventions (Dennis & Vander Wal, 2010). Cognitive flexibility enables individuals to think adaptively when encountering stressful life events, and is a core skill that helps individuals avoid becoming stuck in maladaptive patterns of thinking. The CFI measures two aspects of cognitive flexibility:

  1. Alternatives – the adaptive ability to perceive multiple alternative explanations for life occurrences and the ability to generate multiple alternative solutions to difficult situations.
  2. Control – having an internal locus of control, or the tendency to perceive difficult situations as somewhat controllable.

Individuals with high cognitive flexibility are more likely to react adaptively in response to difficult life experiences, while cognitively inflexible individuals are more susceptible to experiencing pathological reactions. The CFI has been shown to differentiate between a clinical group (anxiety and depression) and a non-clinical sample (Johnco, Wuthrich, & Rapee, 2014), with a clinical group showing significantly lower CFI total and subscale scores than the non-clinical group.

When administered multiple times during a course of cognitive behavioural therapy the scale can be useful in indicating treatment response.

Psychometric Properties

The 20-item CFI showed high test-retest reliability for the full score (r = .81), Alternatives subscale (r = .75), and Control subscale (r = .77; Dennis & Vander Wal, 2010). Cronbach’s alpha ranged from good to excellent, for the Alternatives subscale (alpha = .91), Control subscale (alpha = .86), and the full score (alpha = .90; Dennis & Vander Wal, 2010). Furthermore, evidence was obtained for the convergent construct validity of the CFI and its two subscales via their associations with other measures of cognitive flexibility, depressive symptomatology, and coping (Dennis & Vander Wal, 2010).

In a sample of 196 university students (Dennis & Vander Wal, 2010), the mean scores where as follows:

  • CFI total – 102.98 (SD = 13.91)
  • Alternatives Subscale – 67.59 (SD = 9.41)
  • Control Subscale 35.35 (SD = 7.02)

Scoring and Interpretation 

Scores consist of a total CFI score and two subscale scores. The total score ranges between 20 and 140, where higher scores indicate more cognitive flexibility.

A normative percentile for the total score and subscales are calculated, comparing the respondents scores to a sample of university students (Dennis & Vander Wal, 2010). Percentiles help contextualise how the respondent scored in relation to a typical pattern of responding. For example, a percentile of 50 indicates the individual has more cognitive flexibility than 50 percent of the normal population. i.e. is average.

Percentiles below approximately 25 represent clinically significant inflexibility, which would be important to target within cognitive behavioural therapy (CBT). According to the CBT framework, cognitive inflexibility underpins the development and maintenance of depression and anxiety.

A graph is presented of average scores (between 1 and 7), indicating the typical response on the likert scale and normalising scores between subscales.

The two subscales measuring important aspects of cognitive flexibility are:

  • Alternatives: measuring the ability to perceive multiple alternative explanations for life occurrences and human behaviour and the ability to generate multiple alternative solutions to difficult situations.
    Range = 13 to 91
    Sum items 1, 3, 5, 6, 8, 10, 12, 13, 14, 16,18, 19, 20
  • Control: measuring the tendency to perceive difficult situations as controllable.
    Range = 7 to 49
    Sum items 2, 4, 7, 9, 11, 15, 17

Note that items 2, 4, 7, 9, 11, & 17 are reverse scored.

Developer

Dennis, J. P., & Vander Wal, J. S. (2010). The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cognitive Therapy and Research, 34(3), 241–253. https://doi.org/10.1007/s10608-009-9276-4

References

Johnco, C., Wuthrich, V. M., & Rapee, R. M. (2014). Reliability and validity of two self-report measures of cognitive flexibility. Psychological Assessment, 26(4), 1381–1387. https://doi.org/10.1037/a0038009

Automatic Thoughts Questionnaire – Believability (ATQ-B)

March 25, 2022

The Automatic Thoughts Questionnaire – Believability (ATQ-B-15) (Netemeyer et al., 2002) is a 15-item self-report measure designed to assess the degree of believability of cognitions associated with depression. The scale does not measure the frequency of unhelpful thoughts, but rather measures the extent to which the client believes the thoughts to be true.

The ATQ-B is a frequently used tool in Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). Consistent with the ACT concept of fusion, the ATQ-B asks how much the client believed a thought when they felt depressed/sad. Given that changes in believability of unhelpful thoughts occur independently of reductions in their frequency (Zettle & Hayes, 1986), the believability and fusion of thoughts is an important aspect to target in therapy (Zettle, Rains & Hayes, 2011).

The scale can also be integrated into treatment using Cognitive Behaviour Therapy.

The ATQ has been found to be a reliable measure of cognitive change in depression in response to ACT and can therefore be a useful measure of progress in therapy (Zettle et al., 2011).

Psychometric Properties

Psychometric evaluation of the ATQ-B 30-item version showed that it had good internal stability in both clinical (n = 177) and nonclinical (n = 249) populations (Cronbach’s alpha = .95 and .97, respectively; Zettle, 2010, as cited in Zettle et al., 2011). Test–retest reliability for the ATQ-B over 3 months with a non-clinical sample was .85 and it correlated significantly with the BDI for both populations (r = .53 and .58, respectively), providing evidence of the measure’s construct validity.

The ATQ-15 was developed by Netemeyer et al. (2002) from the original 30-item version (Hollon & Kendall, 1980). Netemeyer et al. (2002) assessed the ATQ-15 using two samples (N=434 and N=419) and found that it had a single factor, with an alpha of .96. Two additional cross-validation samples (N=163 and N=91) also showed support for the 15-item reduced version (Netemeyer et al.,2002).

The ATQ-15 was found to be negatively correlated with self-esteem (r = -.63) and childhood wellbeing (r = -.38) and positively correlated to social anxiety (r = .56), neurotic / obsessive thoughts (r = .70) , and pathological gambling (r = .46; Netemeyer et al., 2002).

Scoring and Interpretation 

The respondent is asked to rate how much he/she BELIEVED a given thought when they had it on a 5-point scale (1 = Not at all, to 5 = Totally). Scores are summed across the 15 items to form an ATQ-B index ranging from 15 to 75. A higher score indicates a higher level of cognitive fusion with depressive thoughts.

A descriptor is provided to give an overall indication of how ‘fused’ the client is to these thoughts. This descriptor is determined by the average response to the questions.

ATQ-B scores can be used to track progress in therapy over time. Successful therapy should see ATQ-B scores reduce over time, reflecting a reduction in fusion.

Based on ACT theory, a client’s ability to distance themselves from depressive thoughts would decrease the control exerted by these thoughts and result in a reduction of depression symptomatology.

Note that the ATQ-B does not measure the frequency of unhelpful thoughts, but rather the extent to which unhelpful thoughts are believed.

Developer

Netemeyer, R. G., Williamson, D. A., Burton, S., Biswas, D., Jindal, S., Landreth, S., Mills, G., & Primeaux, S. (2002). Psychometric properties of shortened versions of the automatic thoughts questionnaire. Educational and Psychological Measurement, 62(1), 111–129. https://doi.org/10.1177/0013164402062001008

References

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press. 

Hollon, S. D., & Kendall, P. C. (1980). Cognitive self-statements in depression: Development of an Automatic Thoughts Questionnaire.Cognitive Therapy and Research,4, 383-395.

Netemeyer, R. G., Williamson, D. A., Burton, S., Biswas, D., Jindal, S., Landreth, S., Mills, G., & Primeaux, S. (2002). Psychometric properties of shortened versions of the automatic thoughts questionnaire. Educational and Psychological Measurement, 62(1), 111–129. https://doi.org/10.1177/0013164402062001008

Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of reason-giving. The Analysis of Verbal Behavior, 4, 30–38. https://doi.org/10.1007/BF03392813

Zettle, R. D., Rains, J. C., & Hayes, S. C. (2011). Processes of change in acceptance and commitment therapy and cognitive therapy for depression: a mediation reanalysis of Zettle and Rains. Behavior Modification, 35(3), 265–283. https://doi.org/10.1177/0145445511398344

World Health Organisation Disability Assessment Schedule 2.0 – Interview (WHODAS-interview)

March 25, 2022

The World Health Organisation Disability Assessment Schedule (WHODAS 2.0) is a practical, generic assessment instrument that can measure health and disability at population level or in clinical practice (World Health Organisation (WHO), 2010). This is the interview version of the WHODAS 2.0, which can be completed by a clinician for interviewing individuals 18 years of age and over. There is also a proxy version, which can be completed by a relative, carer, or friend, or a self-report version.

WHODAS 2.0 captures the level of functioning in six domains of life:

  1. Cognition – understanding and communicating
  2. Mobility – moving and getting around
  3. Self-care – attending to one’s hygiene, dressing, eating and staying alone
  4. Getting along – interacting with other people
  5. Life activities – domestic responsibilities, leisure, work and school
  6. Participation – joining in community activities, participating in society.

WHODAS 2.0 provides a common metric of the impact of any health condition in terms of functioning. Being a generic measure, the instrument does not target a specific disease – it can thus be used to compare disability due to different diseases. WHODAS 2.0 also makes it possible to design and monitor the impact of health and health-related interventions. The instrument has proven useful for assessing health and disability levels in the general population and in specific groups (e.g. people with a range of different mental and physical conditions). Furthermore, WHODAS 2.0 makes it easier to design health and health related interventions, and to monitor their impact.

Disability is a major health issue. When global assessments are made for burden of disease, more than half of the burden of premature mortality is due to overall disability. People generally seek health services because a disease makes it difficult for them to do what they used to do beforehand (i.e. because they are disabled) rather than because they have a disease. Health-care providers consider a case to be clinically significant when it limits a person’s daily activities, and they use disability information as the basis of their evaluation and planning.

Psychometric Properties

WHODAS 2.0 has excellent psychometric properties. Test–retest studies of the 36-item scale in countries across the world found it to be highly reliable, with an intra-class coefficient of 0.69–0.89 at item level; 0.93– 0.96 at domain level; and 0.98 at overall level. Cronbach’s alpha levels were generally very high (0.94 – 0.96 for domains and 0.98 for total score; WHO, 2010).

All items were selected on the basis of item-response theory and the instrument as a whole showed a robust factor structure that remained constant across cultures and different types of patient populations. Confirmatory factor analysis showed a rigorous association between the factor structure of the items and the domains, and between the domains and a general disability factor. These results support the unidimensionality of domains.The validation studies also showed that WHODAS 2.0 compared well with other measures of disability or health status, and with clinician and proxy ratings.

The WHODAS 2.0 shows sensitivity to change in people who have certain health conditions (e.g. cataract, hip or knee problems, depression, schizophrenia or alcohol problems), as it can pick up improvements in functioning following treatment.

Scoring and Interpretation 

There are three scoring methods used for the WHODAS 2.0:

  1. Simple score
  2. Complex score (and its percentile)
  3. Average score (and its descriptor)

In simple scoring, the scores assigned to each of the items (1-36) are simply added up without recoding or collapsing of response categories; thus, there is no weighting of individual items. Simple scoring of WHODAS is specific to the sample at hand and should not be assumed to be comparable across populations. The simple sum of the scores of the items across all domains constitutes a statistic that is sufficient to describe the degree of functional limitations. The domain scores provide more detailed information than the summary score and may be useful for comparing individuals or groups against one another or against population standards, and across time (e.g. before and after interventions or other comparisons).

The more complex method of scoring is called “item-response-theory” (IRT) based scoring; it takes into account multiple levels of difficulty for each WHODAS 2.0 item (1-36). This type of scoring for WHODAS 2.0 allows for more fine-grained analyses that make use of the full information of the response categories for comparative analysis across populations or subpopulations. It takes the coding for each item response as “none”, “mild”, “moderate”, “severe” and “extreme” separately, and then summarises the score by differentially weighting the items and the levels of severity. Converting the summary score into a metric ranging from 0 to 100 (where 0 = no disability; 100 = full disability). A percentile is provided that allows for a comparison to a large sample (n = 1,431) from a wide variety of populations (general population, populations with physical problems, populations with mental or emotional problems, populations with alcohol and drug use problems) from over 21 countries (WHO, 2010). A percentile of 50 indicates that an individual is experiencing an average level of disability when compared to other members of the sample.

The average scores are comparable to the WHODAS 5-point scale, which allows the clinician to think of the individual’s disability in terms of none (0-0.49), mild (0.5-1.49), moderate (1.5-2.49), severe (2.5-3.49), or extreme (3.5-4). The average domain and general disability scores were found to be reliable, easy to use, and clinically useful to the clinicians in the DSM-5 Field Trials (APA, 2021). The average domain score is calculated by dividing the raw domain score by the number of items in the domain (e.g., if all the items within the “understanding and communicating” domain are rated as being moderate then the average domain score would be 18/6 = 3, indicating moderate disability). The average general disability score is calculated by dividing the raw overall score by number of items in the measure (i.e., 36).

The three scoring methods are used for each of the 6 domains:

  1. Cognition – Assesses communication and thinking activities; specific areas assessed include concentrating, remembering, problem solving, learning and communicating.
  2. Mobility – Assesses activities such as standing, moving around inside the home, getting out of the home and walking a long distance.
  3. Self-care – Assesses hygiene, dressing, eating and staying alone.
  4. Getting along – Assesses interactions with other people and difficulties that might be encountered with this life domain due to a health condition; in this context, “other people” includes those known intimately or well (e.g. spouse or partner, family members or close friends) and those not known well (e.g. strangers).
  5. Life activities – Assesses difficulty with day-to-day activities (i.e. those that people do on most days, including those associated with domestic responsibilities, leisure, work and school).
  6. Participation – Assesses social dimensions, such as community activities; barriers and hindrances in the world around the respondent; and problems with other issues, such as maintaining personal dignity.

Developer

Ustun, T.B, Kostanjsek, N., Chatterji, S., Rehm, J (Ed.). (2010). Measuring health and disability : manual for WHO Disability Assessment Schedule (‎WHODAS 2.0)‎. World Health Organization. https://www.who.int/publications/i/item/measuring-health-and-disability-manual-for-who-disability-assessment-schedule-(-whodas-2.0)

References

American Psychiatric Association. Online Assessment Measures. (n.d.). Retrieved November 6, 2021, from https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_WHODAS-2-Self-Administered.pdf