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  2. Health of the Nation Outcome Scales for Children and Adolescents

Health of the Nation Outcome Scales for Children and Adolescents

Last Updated

Purpose

The Health of the Nation Outcome Scales for Children and Adolescents is a 15-item questionnaire used to measure the functioning levels of behavioral, impairment, symptomatic, and social domains for individuals aged 5-18 years. The self-rated version of the questionnaire can be used by individuals aged 13-18 years.

Link to Instrument

Self-reported HoNOSCA for individuals age 13-18 years

Acronym HoNOSCA

Area of Assessment

Behavior
Attention & Working Memory
Substance
Developmental
Social Support
Social Relationships
Activities of Daily Living
Psychosis
Occupational Performance
Incontinence
Infant & Child Development
Mental Health
General Health
Negative Affect

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Actual Cost

$0.00

Cost Description

Cost of equipment

CDE Status

Not a CDE--last searched 11/13/2023.

Populations

Mental Health

Key Descriptions

  • Item-level scores for items 1-13 range from 0-4
  • Items can be segregated into 4 section scores (Behavior, Impairment, Symptoms, and Social)
  • Item scores are summed, ranging from 0-52
  • Patient-reported version may be used by individuals aged 13-18 years
  • HoNOSCA parent rating form: https://www.corc.uk.net/media/1221/honosca_parentrated.pdf
  • HoNOSCA clinician scoresheet: https://www.corc.uk.net/media/1222/honosca_scoresheet.pdf

Number of Items

● 13 symptom or function items in section A
● 2 optional items on parents’ level of knowledge about services and difficulties in section B

Equipment Required

  • Paper & Pencil (or computer or tablet for electronic versions)

Time to Administer

10-20 minutes

One study reported average time to complete the assessment was 8.5 minutes with a range of 2 to 20 minutes.

Required Training

Training Course

Required Training Description

Should be performed by a trained clinician working in Child and Adolescent Mental Health Services. Training includes:
● Learning the reasons for creating HoNOSCA
● Understanding the current system of information collection
● Grasping the structure and scoring of HoNOSCA
● Learning the basic principles for rating
● Reviewing the systematic run through of the items
● Understanding the clinical uses (most important message)
● Performing aggregation and anonymisation and then using these data to make comparisons and assess targets
https://www.anq.ch/fileadmin/redaktion/deutsch/20131209_TRAINER.pdf

Age Ranges

Preschool Children age 5

5 +

years

Child

6 - 12

years

adolescents and young adults

13 - 18

years

Instrument Reviewers

Madison Blaydes, Najeeha Khan, Casey Salandra, and Saythala Thao, rehabilitation psychology students under the direction of Timothy Tansey, PhD, Rehabilitation Psychology and Special Education Dept., School of Education, University of Wisconsin-Madison

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living
Cognition
Emotion
General Health

Professional Association Recommendation

None found--last searched 11/13/2023.

Considerations

  • Age 5 to 18 for the parent and practitioner version of the Health of the Nation Outcome Scales for Children and Adolescent. 
  • Age 13 to 18 for the self-rated version. 

Mental Health

back to Populations

Standard Error of Measurement (SEM)

Varied symptoms and problems: (Hanssen-Bauer et al., 2007; n = 169 raters, rating 20 one page clinical vignettes of outpatients with mean age = 10.6 (4.26) years, age range = 4-17, male = 10; mean HoNOSCA total score = 18.34)

  • SEM for entire group = 3.51 points

 

Varied symptoms and problems: (Hanssen-Bauer et al., 2007; n = 3 raters, rating 20 one page clinical vignettes of outpatients with mean age = 10.6 (4.26) years, age range = 4-17, male = 10; mean HoNOSCA total score = 20.05 and sample of 30 consecutively referred patients at intake with mean age = 8.84 (2.24) years, age range = 4.1-12.5, male = 19 ; mean HoNOSCA total score = 18.67)

  • SEM for HoNOSCA total score of 30 outpatients at intake = 2.59
  • SEM for HoNOSCA total score of 20 clinical vignettes = 2.93 points

Cut-Off Scores

Inpatient Psychiatric Treatment: (Boon et al., 2019; n = 12,547, male = 7,700; mean age at admission = 11.35 (3.57) years, range = 6-18 years)

  • Mildly severe: (n = 2,079, calculated by initial total score of 1-31, mean (SD) = 6.86 (3.31) 
    • Cutoff point calculated to be 4, meaning if score increases by 4 they are classified as “deteriorated”, if the score decreases by 4 they are classified as “improved”, and if score stages within -3 and +3 of initial value then it is classified as “no reliable change”
  • Moderately severe (n = 3,821, calculated by initial total score of 3-34, mean (SD) = 9.47 (3.20)
    • Cutoff point calculated to be 4, meaning if score increases by 4 they are classified as “deteriorated”, if the score decreases by 4 they are classified as “improved”, and if score stages within -3 and +3 of initial value than it is classified as “no reliable change”
  • Very severe (n = 6,345, calculated by initial total score of 6-51, mean (SD) = 16.23 (5.47)
    • Cutoff point calculated to be 7, meaning if score increases by 7 they are classified as “deteriorated”, if the score decreases by 7 they are classified as “improved”, and if score stages within -6 and +6 of initial value than it is classified as “no reliable change”

Normative Data

Eating disorders (Anorexia Nervosa): (Gowers et al., 2002; n = 96 in-patients with mean age = 15.05 years (range = 13-18), female = 69; mean HoNOSCA scores over time; clinician-rated and self-report (HoNOSCA-SR) versions)

 

Mean clinician-rated and self-report HoNOSCA scores over time for in-patient cases in treatment for 18 weeks (n = 18)

Assessment

Self-report

Clinician

First assessment

16.22

20.17

Week 6

12.11

14.89

Week 12

10.72

11.94

Discharge/week 18

9.56

10.11

 

 

Inpatient Psychiatric Treatment: (Boon et al., 2019; n = 12,547)

  • Mean total score at admission = 12.37 (5.86)
  • Mean total score at discharge = 8.84 (6.21)
  • Moderate effect size of 0.59

 

Inpatient Psychiatric Treatment: (Harnett et al., 2005; n = 51 adolescent patients; mean age = 15.05 years (range = 12-17); female = 41%; HoNOSCA completed at intake and at 3- and 6-months following admission)

  • Mean score at admission = 15.86 (5.45, range = 5-28)

 

Eating disorders (Anorexia Nervosa): (Gowers et al., 2002; n = 54 out-patients with mean age = 15.6 years, all female; mean HoNOSCA scores over time; clinician-rated and self-report (HoNOSCA-SR) versions)

Mean clinician-rated and self-report HoNOSCA scores over time for out-patient cases in treatment for 18 weeks (n = 17)

Assessment

Self-report

Clinician

First assessment

15.00

18.00

Week 6

13.65

13.71

Week 12

10.53

11.06

Discharge/week 18

8.88

9.76

 

 

Outpatient/Day Patient Psychiatric Treatment: (Garralda et al., 2000; n = 203; children attending two or more times)

Scores on HoNOSCA in children attending two or more times

Score

Initial assessment (SD)

6-month follow-up (SD)

Clinical score*

11.40 (4.89)

7.79 (4.93)

Total score

12.95 (5.68)

8.60 (5.43)

*Clinical score = total score without the information subgroup.

 

Outpatient Psychiatric Treatment for Adolescents: (Mathiassen et al., 2012; n = 132, mean age = 11.5 (2.4) years; male = 72; children/adolescents treated at three outpatient child and adolescent mental health services (CAMHS) in northern Norway; score on HoNOSCA)

  • Mean score at intake = 12.35 (5.29, n = 128)
  • Mean score at assessment = 11.11 (4.41, n = 118)
  • Mean score at follow-up = 7.91 (4.34, n = 97)

 

Outpatient/Day Patient Psychiatric Treatment: (Wyl et al., 2017, n = 1,533; mean age = 12.06 (3.70) years, age range = 4.01-17.98; German translation (HoNOSCA-D))

  • Mean total score = 12.41 (5.76)

Test/Retest Reliability

Eating disorders (Anorexia Nervosa): (Gowers et. al 2022, n = 24; Inpatient treatment test-retest reliability determined within 1 week of admission)

  • Acceptable test-retest reliability for total score (ICC = 0.806)

 

Inpatient Psychiatric Treatment: (Boon et al., 2019; sample of n = 397 patients; HoNOSCA completed twice within ten days during treatment)

  •  Acceptable test-retest reliability for total score: (ICC = 0.812)

 

Inpatient Psychiatric Treatment: (Harnett et. al, 2005, n = 51; calculated from initial HoNOSCA score and subsequent score provided 2-4 weeks later)

  • Acceptable test-retest reliability for total score (ICC = 0.80)

 

Outpatient/Day Patient Psychiatric Treatment: (Garralda et al., 2000; n = 53, cases for which clinicians had considered there had been no global clinical change over the 6-month period—test-retest reliability of initial (mean age (SD) = 11.58 (4.45)) years and 6-month follow-up (10.77 (3.74) HoNOSCA scores.

  • Questionable test-retest reliability between initial and 6-month follow-up scores (r = 0.69)

Interrater/Intrarater Reliability

Inpatient Psychiatric Treatment: (Hunt and Wheatley, 2009; n = 24, female = 16, age range = 13-18 years, mean age for males = 15 years, 8 months, mean age for females = 17 years, 0 months; all participants in secure unit presented with disturbed and challenging behavior and met criteria for detention; Pearson correlation for the total HoNOSCA scores between clinical psychologist and assistant psychologist used to analyze interrater reliability)

  • Excellent interrater reliability for total score (ICC = 0.92)

 

Inpatient Psychiatric Treatment: (Harnett et. al, 2005; interrater reliability between two trained psychologists)

  • Excellent interrater reliability (ICC = 0.96)

 

Outpatient/Day Patient Psychiatric Treatment: (Garralda et al., 2000; n = 15; Case Vignettes rated by three trained raters)

  • Excellent interrater relatiability for psychiatric symptoms (ICC = 0.82)
  • Adequate interrater reliability for physical and social imairment (ICC = 0.42-0.61)
  • Poor interrater reliability for knowledge about difficulties (ICC = 0.27)
  • Poor interrater reliability for knowledge about services (ICC = 0.03)

 

Varied symptoms and problems: (Hanssen-Bauer et al., 2007; n = 169 clinician-raters, each rating 20 one page clinical vignettes of patients with mean age = 10.6 (4.26) years, age range = 4-17, male = 10; mean HoNOSCA total score = 18.34)

  • Excellent interrater reliability (ICC = 0.81)

 

Varied symptoms and problems: (Hanssen-Bauer et al., 2007; n = 3 clinician-raters, each rating 20 one page clinical vignettes of patients with mean age = 10.6 (4.26) years, age range = 4-17, male = 10; mean HoNOSCA total score = 20.05 and sample of 30 consecutively referred patients at intake with mean age = 8.84 (2.24) years, age range = 4.1-12.5, male = 19 ; mean HoNOSCA total score = 18.67)

  • Excellent interrater reliability for 20 clinical vignettes (ICC = 0.88)
  • Adequate interrater reliability for 30 patients at intake (ICC = 0.74)

Internal Consistency

Inpatient Psychiatric Treatment: (Harnett et. al, 2005)

  • Poor internal consistency (Cronbach’s alpha = 0.45)

 

Outpatient/Day Patient Psychiatric Treatment: (Wyl et al., 2017)

  • Poor internal consistency for total score (Cronbach’s alpha = 0.63) 

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Eating disorders (Anorexia Nervosa): (Gowers et al., 2002)

  • Excellent concurrent validity between the HoNOSCA-SR and the Strengths and Difficulties Questionnaire (r = 0.66, p < 0.001, n = 39)

 

Inpatient Psychiatric Treatment: (Hunt and Wheatley, 2009)

  • Adequate concurrent validity between HoNOSCA and Breif Psychiatric Rating Scale (r = 0.57, p < 0.01)
  • Adequate concurrent validity between HoNOSCA and Beck Depression Inventory (r = 0.42, p < 0.05)
  • Adequate concurrent validity between HoNOSCA and Children’s Global Assessment Scale/Global Assessment Scale (r = -0.35, p < 0.05)

 

Inpatient Psychiatric Treatment: (Harnett et. al, 2005)

  • Adequate concurrent validity between HoNOSCA score at admission and mean number of critical incidents patients were involved in each per month (r = 0.34, p < 0.05)

 

Eating disorders (Anorexia Nervosa): (Gowers et al., 2002; self-report (HoNOSCA-SR) version)

  • Excellent concurrent validity of the HoNOSCA-SR with the Eating Disorder Inventory–2  (r = 0.629, p < 0.001, n = 53)
  • Adequate concurrent validity of the HoNOSCA-SR with the Morgan-Russell severity schedule total score (r = -0.32, p = 0.018, n = 54)

 

Outpatient/Day Patient Psychiatric Treatment: (Yates et al., 1999; n = 248; male = 166; HoNOSCA clinical score equals sum of the 13 clinical features only)

  • Adequate concurrent validity between HoNOSCA clinical score and the Strengths and Difficulties Questionnaire (r = 0.397, p < 0.01)

Construct Validity

Convergent Validity

Eating disorders (Anorexia Nervosa): (Gowers et al., 2002; in-patient group, n = 18; self-report (HoNOSCA-SR) version)

  • Poor convergent validity between clinician rated HoNOSCA and HoNOSA-SR at presentation (r = 0.27)
  • Adequate convergent validity between clinician rated HoNOSCA and HoNOSA-SR at discharge (r = 0.58)

 

Inpatient Psychiatric Treatment: (Harnett et. al, 2005)

  • Adequate convergent validity between total HoNOSCA and Paddington Complexity Scale (PCS) (r = 0.46)
  • Poor to Excellent convergent validity between items of HoNOSCA at intake and mean PCS scores at intake: 
    • Excellent for overactivity/aggression (r = 0.66)
    • Poor for scholastic/language problems (r = 0.26)
    • Poor for psychotic symptoms: (r = 0.25)
    • Adequate for peer relationships: (r = 0.33)
    • Adequate for self-care and relationship problems: (r = 0.33)

 

Eating disorders (Anorexia Nervosa): (Gowers et al., 2002; out-patient group, n = 17; self-report (HoNOSCA-SR) version)

  • Adequate convergent validity between clinician rated HoNOSCA and HoNOSA-SR at presentation (r = 0.58)
  • Excellent convergent validity between clinician rated HoNOSCA and HoNOSA-SR at discharge (r = 0.72)

 

Varied symptoms and problems: (Hanssen-Bauer et al., 2007; n = 3 clinician raters, each rating 20 one page clinical vignettes of patients with mean age = 10.6 (4.26) years, age range = 4-17, male = 10; mean HoNOSCA total score = 20.05)

  • Convergent Validity between mean scores of HoNOSCA and Children’s Global Assessment scale (CGAS)(Hanssen-Bauer et. al, 2007, n = 30)
    • Excellent convergent validity between the mean of all raters for the HoNOSCA total score and Children’s Global Assessment scale (CGAS) (r = 0.84)
    • Excellent convergent validity between mean of all raters for the  HoNOSCA total score and Global Assessment of Psychosocial Disability (GAPD) (r = 0.82)

 

Outpatient/Day Patient Psychiatric Treatment: (Garralda et. al 2000; n = 203, age range = 3 – 17 years; mean change between assessment and 6-month follow-up)

  • Adequate convergent validity between change in HoNOSCA and change in clinical rated CGAS scores (r = 0.51)
  • Adequate convergent validity between change in HoNOSCA and change in Behaviour Checklist (BCL) scores (r = 0.40)
  • Adequate convergent validity between change in HoNOSCA and change in Strength and Difficulties Questionnaire (SDQ) (r = 0.32)
  • Poor convergent validity between change in HoNOSCA and change in maternal psychopathology as measured by the General Health Questionnaire (GHQ) (r = 0.16)
  • Poor convergent validity between change in HoNOSCA score and number of treatment sessions attended (r = 0.18)
  • Adequate convergent validity between initial HoNOSCA score and number of treatment sessions attended at clinics (r =0.31)

 

Outpatient/Day Patient Psychiatric Treatment: (Wyl et al., 2017)

  • Adequate convergent validity between HoNOSCA-D total score and total difficulties score on the Strengths and Difficulties Questionnaire (SDQ) Parent Report (r = 0.32)
    • Adequate convergent validity between HoNOSCA-D item peer relationships and SDQ peer relationship problems (r = 0.49)
    • Adequate convergent validity between HoNOSCA-D item disruptive, antisocial, or aggressive behavior and SDQ conduct problems (r = 0.45), hyperactivity (r = 0.32), and total difficulties score (r = 0.32)
    • Adequate convergent validity between HoNOSCA-D item overactivity, attention, or concentration and SDQ hyperactivity (r = 0.42)
    • Adequate convergent validity between HoNOSCA-D item emotional and related symptoms and SDQ emotional problems (r = 0.31)

Face Validity

“HoNOSCA also produced results with apparent face validity. Thus, the mean score for in-patients was 15.51 (7.19) compared with a mean score for out-patients of 11.18 (5.30), a statistically significant difference (t = -8.03, d.f. = 1141, p < 0.001, two-tailed). Difference between means = 4.33 (95% CI = 3.28-5.40).” Gowers et al. (1999) concluded that the HoNOSCA “…has satisfactory face validity.”

Responsiveness

Inpatient Psychiatric Treatment: (Boon et al., 2019)

  • All groups underwent significant change between admission and discharge.

Changes between admission and discharge groups based on severity at admission

Patient Group

n (%)

t (p-value)

Effect size*

 

Recovered

 

2,042 (16.3)

 

94.31 (p < 0.001)

 

2.68

 

Improved

 

2,715 (21.6)

 

119.04 (p < 0.001)

 

1.67

No reliable change

 

6,845 (54.6)

 

94.32 (p < 0.001)

 

0.22

 

Deteriorated

 

945 (7.5)

 

-62.07 (p < 0.001)

 

1.27

*Cohen’s d

 

Inpatient Psychiatric Treatment: (Harnett et. al, 2005; changes in HoNOSCA score assessed at 3- and 6-months following intake; positive change scores indicate improved functioning; one-tail tests)

  • Significant, positive difference between intake and 3-month follow-up (n = 45, 47% female)
    • Mean change score = 1.51, t(44) = 2.23, p < 0.05
  • Positive difference in scores between intake and 6-month follow-up approached significance (n = 25, 60% female)
    • Mean change score = 1.92, t(24) = 1.67, p = 0.06

 

Outpatient/Day Patient Psychiatric Treatment: (Garralda et. al 2000; n = 203, age range = 3-17 years; mean change between assessment and 6-month follow-up)

  • Significant positive change in HoNOSCA score of 3.61 (4.7), p <0.001 at 6-month follow-up.
  • Significant positive correlation between initial case severity and change in HoNOSCA score over treatment time (r = 0.468, p < 0.001, n = 215).
  • Significant positive correlation between change in HoNOSCA scores and complexity of diagnosis as measured by Paddington complexity scale for patients diagnosed with mood disorders (r = .039, n = 26) and conduct disorders (r = 0.33, n = 57)

 

Outpatient Psychiatric Treatment for Adolsecents: (Mathiassen et al., 2012, n = 132)

  • Participants with highest initial HoNOSCA scores showed greater improvement across the intake session, start of treatment, and after six months of treatment
  • Change in HoNOSCA scores at the 3 time points showed significant variance in intercepts (29.12, p < 0.01) but not slopes (2.30, p = 0.06) across participants, and both covaried negatively and significantly. 
  • Small effect size between intake and start of treatment was non-significant (r = 0.12)
  • Moderate effect size between the start of treatment and 6 months post treatment (r = 0.34)

Bibliography

Boon, A. E., B.B. de Boer, S., van Dorp, M., & Nijssen, Y. A.M. (2019). Reliable and clinically significant change based on the Health of the Nation Outcome Scales, Psychiatry Research, 281. https://doi.org/10.1016/j.psychres.2019.112587

Garralda, M. E., Yates, P., & Higginson, I. (2000). Child and adolescent mental health service use.HoNOSCA as an outcome measure. British Journal of Psychiatry, 177(1), 52–58. doi: 10.1192/bjp.177.1.52

Gowers, S. G., Harrington, R. C., Whitton, A., Beevor, A. S., Lelliott, P., & Wing, J. K. (n.d.). HoNOSCA: Health of the Nation Outcome Scales (Child & Adolescent Mental Health): Trainer's Guide. Retrieved from https://www.anq.ch/wp-content/uploads/2017/12/ANQ_PSY_KJP_HoNOSCA_Trainers-Guide_Gowers.pdf

Gowers, S., Levine, W., Bailey-Rogers, S., Shore, A., & Burhouse, E. (2002). Use of a routine, self-report outcome measure (HoNOSCA–SR) in two adolescent mental health services. British Journal of Psychiatry, 180(3), 266–269. doi: 10.1192/bjp.180.3.266

Gowers, S. G., Harrington, R. C., Whitten, A., Elliot, P., Beevor, A., Wing, J. & Jezzard, R. (1999). Brief scale for measuring the outcomes of emotional and behavioral disorders in children. British Journal of Psychiatry, 174, 413-416. https://doi.org/10.1192/bjp.174.5.413 

Hanssen-Bauer, K., Aalen, O. O., Ruud, T., & Heyerdahl, S. (2007). Inter-rater Reliability of Clinician-rated Outcome Measures in Child and Adolescent Mental Health Services. Administration and Policy in Mental Health and Mental Health Services Research, 34. 504-512. https://doi.org/10.1007/s10488-007-0134-y

Harnett, P. H., Loxton, N. J., Sadler, T., Hides, L., & Baldwin, A. (2005). The Health of the Nation Outcome Scales for Children and Adolescents in an Adolescent In-Patient Sample. Australian & New Zealand Journal of Psychiatry, 39(3), 129–135. doi: 10.1080/j.1440-1614.2005.01533.

Hunt, J., & Wheatley, M. (2009). Preliminary Findings on the Health of the Nation Outcome Scales for Children and Adolescents in an Inpatient Secure Adolescent Unit. Child Care in Practice, 15(1), 49–56. doi: 10.1080/13575270802504446

Mathiassen, B., Brondbo, P. H., Waterloo, K., Martinussen, M., Eriksen, M., Hanssen-Bauer, K., & Kvernmo, S. (2012). IQ as a moderator of outcome in severity of children’s mental health status after treatment in outpatient clinics. Child and Adolescent Psychiatry and Mental Health, 6(22). https://doi.org/10.1186/1753-2000-6-22

Pirkis, J. E., Burgess, P. M., Kirk, P. K., Dodson, S., Coombs, T. J., & Williamson, M. K. (2005). A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures. Health and Quality of Life Outcomes, 3(76).

Wyl, A., Toggweiler, S., & Zollinger, R. (2017). HoNOSCA-D As a Measure of the Severity of Diagnosed Mental Disorders in Children and Adolescents-Psychometric Properties of the German Translation. Frontiers in Psychiatry, 8(186). doi: 10.3389/fpsyt.2017.00186

Yates, P., Garralda, M. E., & Higginson, I. (1999). Paddington Complexity Scale and Health of the Nation Outcome Scales for Children and Adolescents. British Journal of Psychiatry, 174(5), 417–423. doi: 10.1192/bjp.174.5.417

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