Awareness Questionnaire

Last Updated

November 27, 2012

Purpose

The AQ measures impaired self-awareness after acquired brain injury.

Link to Instrument

Instrument Details

Acronym AQ

Cost

Free

Diagnosis/Conditions

Brain Injury Recovery

Brain Injury

The self and family versions of the AQ consist of 17 items, a clinician version consists of 18 items.
Each item is rated 5-point scale from “much worse” to “much better”, comparing pre- and post- injury. A score of 3 is “about the same” as pre-injury.
Scoring occurs by comparing family or clinician scores to the self-rated scores completed by the person with the brain injury. The total score for family or clinician is subtracted from the total score for the patient. A larger difference indicates greater impairment.
Scoring for the additional clinician rating scale (item 18) is a 1-5 rating of severity of awareness deficit (none, minimal, moderate, severe, or complete lack of awareness of deficits).

Number of Items

10 minutes

Required Training

No Training

Instrument Reviewers

Initially reviewed by Karen McCulloch, PT, PhD, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 6/2012

ICF Domain

Activity
Participation

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
LS / UR	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	LS	LS	LS	NR

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
TBI EDGE	No	No	Yes	Not reported

Considerations

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Cut-Off Scores

Traumatic Brain Injury: (Evans et al, 2005; n=96; median age 33; admitted to inpatient TBI rehabilitation)

Scores range from 17-85 on the AQ, with a 51 estimating “about the same as before injury”.
Difference scores (clinician or family subtracted from patient ratings) range from -68 to 68, with higher scores associated with the patient rating him/herself higher.
A score of >20 in the difference score has been suggested as indicating clinically significant impairment of self-awareness.

Test/Retest Reliability

Traumatic Brain Injury: (Hellebrekers et. al; 2017; n=105; avg age 41.7(12.1); avg years post injury 7.5 (8.5))

Patient Test-Retest:

	T₀-T₁
Variables	R (Spearman’s correlation coefficient)	Cronbach’s α
Awareness Questionnaire (AQ)	.80**	.80
AQ_Cognition	.67**
AQ_Behavior	.74**
AQ_Senso/Motor	.59**

*Correlation is significant at the 0.01 level (2-tailed)

Relative Test-Retest

	T₀-T₁
Variables	R (Spearman’s correlation coefficient)	Cronbach’s α
Awareness Questionnaire (AQ)	.66**	.82
AQ_Cognition	.82**
AQ_Behavior	.74**
AQ_Senso/Motor	.61**

*Correlation is significant at the 0.01 level (2-tailed)

Internal Consistency

Traumatic Brain Injury:(Sherer et al, 1998a; n=126; mean age 32.3(12.4); average time post injury 10.2 months (21.3))

Excellent internal consistency for patient and family ratings alpha=.88

Traumatic Brain Injury: (Hellebrekers et al., 2017)

Excellent internal consistency among Patients (Cronbach’s α =.80)
Excellent internal consistency among Relatives (Cronbach’s α =.82)
After removing items 4, 10, 15, 17 internal consistency still adequate (α=.71 )

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Traumatic brain injury:(Sherer et al, 1998b; n=66; mean age 31.7(12.2) years, mean time post injury= 8.5 (19.7); mean clinician rating of moderate awareness deficits)

Difference in patient and family ratings were significantly associated with employment status 30.2 (22.2) months after injury using a regression model.
Differences in ratings between family and patient and single item clinician rating of accuracy of self-awareness predicts productivity outcome. (31% of variance).

Construct Validity

Traumatic Brain Injury: (Sherer et al., 2003; n= 129; avg age= 33)

Convergent Validity:

Adequate-Excellent convergent validity (Spearman's coefficient= 0.50-0.69)

Spearman correlation coefficients for PCRS and AQ scores

	PCRS Family	PCRS Clinician	AQ Patient	AQ Family	AQ Clinician
PCRS Patient	0.11	-0.02	0.50**	0.12	0.08
PCRS Family	-	0.36**	0.06	0.62--	0.35**
PCRS Clinician		-	0.06	0.21*	0.69**
AQ Patient			-	0.06	-0.06
AQ Family				-	0.44**

*p<0.05; p<0.01

Spearman correlation coefficient for ISA measures

	PCRS P-F	AQ P-C	AQ P-F
PCRS P-C	0.64*	0.61*	0.34*
PCRS P-F	-	0.37*	0.50*
AQ P-C		-	0.65*

*p<0.01

Traumatic Brain Injury: (Sherer et al, 1998c; n= 64; average age 28.8 (9.8) years; average 13.0 (20.8) months post injury)

Individuals with brain injury rate themselves as less impaired than do clinicians or family members.
Awareness of cognitive and behavioral function is more impaired than awareness of motor and sensory functioning.

Traumatic Brain Injury: (Evans et al, 2005)

Adequate correlation with clinician (0.34) and patient (0.39) AQ scores with Satisfaction with Life Scale.

Traumatic Brain Injury: (Hellebrekers et al., 2017)

A factor structure with 12 items accounts for 50.9% of the variance.

Items 4, 10, 15, and 17 can be excluded to retain a viable model

Items	Factor Loading
Factor 1: Cognitive functioning (α = .70)
5. How well can you do the things you want to do in life now as compared to before your injury?	0.62
11. How well can you concentrate now as compared to before your injury?	0.75
12. How well can you express your thoughts to others now as compared to before your injury?	0.58
13. How good is your memory for recent events now as compared to before your injury?	0.77
Factor 2: Behavioural functioning (α = .72)
1. How good is your ability to live independently now as compared to before your injury?	0.70
2. How good is your ability to manage money now as compared to before your injury?	0.60
3. How well do you get along with people now as compared to before your injury?	0.61
14. How good are you at planning things now as compared to before your injury?	0.71
16. How well can you keep your feelings in control now as compared to before your injury?	0.74
Factor 3: Senso/motor functioning (α = .62)
6. How well are you able to see now as compared to before your injury?	0.53
7. How well can you hear now as compared to before your injury?	0.51
8. How well can you move your arms and legs now as compared to before your injury?	0.78
9. How good is your coordination now as compared to before your injury?	0.79

Content Validity

Traumatic Brain Injury:(Sherer et al, 1998a)

A factor analysis demonstrated three factors: cognitive (7 items), behavioral/affective (6 items), and motor/sensory (4 items).

Floor/Ceiling Effects

Traumatic Brain Injury: (Hellebrekers et al., 2017)

No floor/ceiling effects found

Bibliography

Evans, C. C., Sherer, M., et al. (2005). "Early impaired self-awareness, depression, and subjective well-being following traumatic brain injury." Journal of Head Trauma Rehabilitation 20(6): 488-500. Find it on PubMed

Hellebrekers, D., Winkens, I., Kruiper, S., & Van Heugten, C. Psychometric properties of the awareness questionnaire, patient competency rating scale and dysexecutive questionnaire in patients with acquired brain injury. Brain Injury. 2017; 31(11), 1469-1478. Find it on PubMed

Sherer M., Hart T., & Nick T. G. Measurement of impaired self-awareness after traumatic brain injury: A comparison of the patient competency rating scale and the awareness questionnaire. Brain Injury. 2003; 17:25–37. Find it on PubMed

Sherer, M., Bergloff, P., et al. (1998). "The Awareness Questionnaire: factor structure and internal consistency." Brain Injury 12(1): 63-68. Find it on PubMed

Sherer, M., Bergloff, P., et al. (1998). "Impaired awareness and employment outcome after traumatic brain injury." J Head Trauma Rehabil 13(5): 52-61. Find it on PubMed

Sherer, M., Boake, C., et al. (1998). "Characteristics of impaired awareness after traumatic brain injury." J Int Neuropsychol Soc 4(4): 380-387. Find it on PubMed

Last Updated

Purpose

Link to Instrument

Cost

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Professional Association Recommendation

Considerations

Cut-Off Scores

Test/Retest Reliability

Internal Consistency

Criterion Validity (Predictive/Concurrent)

Construct Validity

Content Validity

Floor/Ceiling Effects

Bibliography

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