Awareness Questionnaire

Abstract

The Awareness Questionnaire (AQ) is a standardized instrument developed within the field of neuropsychology to assess limitations in self-awareness following a Traumatic Brain Injury (TBI). It utilizes a multi-rater approach, collecting data from three distinct perspectives: the patient, a family member or partner, and a knowledgeable clinician. The core methodology involves comparing the individual’s current functional abilities post-injury against their perceived abilities prior to the TBI across three key domains: motor/sensory, cognitive functioning, and behavioral/affective functioning. Discrepancies between the patient’s self-report and the collateral reports from family or clinicians are used to quantify the degree of impaired self-awareness. The AQ is crucial for identifying specific areas of functional concern that require attention during neurorehabilitation.

Keywords

Self-Awareness, Traumatic Brain Injury, TBI, Anosognosia, Neurorehabilitation, Cognitive Functioning, Multi-rater assessment, Questionnaire.

Authors

Sherer M (1998), Geurtsen GJ (2005) [Dutch Version].

Purpose

The primary purpose of the AQ is to provide a quantitative and qualitative assessment of impaired self-awareness, often referred to as anosognosia, in individuals recovering from acquired brain injuries, particularly Traumatic Brain Injury. This assessment is crucial because deficits in self-awareness can significantly impede engagement in rehabilitation and negatively impact overall functional outcomes and safety.

Beyond diagnostic quantification, the AQ serves a practical clinical purpose by identifying specific areas of functional concern—whether motor, cognitive, or behavioral—that are either overlooked by the patient or prioritized by the caregivers. This detailed information allows rehabilitation teams to tailor treatment plans, focusing on psychoeducation and compensatory strategies that acknowledge the patient’s existing level of insight.

Construct

The AQ specifically measures the psychological construct of self-awareness, which is understood in the context of brain injury as the capacity to accurately perceive one’s own strengths and weaknesses, functional limitations, and behavioral changes resulting from the injury. The scale is designed to capture different levels of awareness, often conceptualized hierarchically (e.g., intellectual, emergent, and anticipatory awareness).

The methodology relies on the discrepancy model, where the difference between the patient’s rating (what they perceive their abilities to be post-injury) and the proxy rating (what reliable observers observe) serves as the operational definition of impaired awareness. A large positive discrepancy (where the patient rates abilities significantly higher than observers) indicates poor insight into deficits, a hallmark of reduced self-awareness. The domains assessed include motor/sensory function, cognitive functioning, and behavioral/affective regulation.

Validity

The validity of the Awareness Questionnaire has been extensively studied, primarily focusing on its construct and ecological validity within neurorehabilitation settings. Studies generally support the scale’s ability to differentiate between patients with high versus low levels of awareness, demonstrating strong construct validity in measuring insight deficits post-TBI.

Specifically, the discrepancy scores derived from the AQ have shown significant correlations with objective measures of functional outcome and rehabilitation participation, lending support to its ecological validity. Patients exhibiting greater discrepancy scores (indicating poorer awareness) typically demonstrate poorer performance on real-world tasks and often require more intensive supervision. Furthermore, comparisons against other established measures of insight, such as the Patient Competency Rating Scale, often yield moderate to high correlations, supporting convergent validity.

Reliability

The reliability of the AQ is generally reported as acceptable to good, particularly concerning the internal consistency of the subscales and the inter-rater reliability among collateral reporters. Internal consistency, measured by Cronbach’s alpha, typically falls within the 0.70 to 0.90 range for the overall scale and its primary sub-domains (motor/sensory, cognitive functioning, and behavioral/affective functioning).

Inter-rater reliability is a critical consideration given the instrument’s multi-rater design. Research indicates that the agreement between family members and clinicians is often higher than the agreement between the patient and either proxy, highlighting the consistent external perspective. Test-retest reliability is also generally robust, suggesting that the measured level of awareness remains stable over relevant periods in the chronic phase of recovery from Traumatic Brain Injury.

Factor Analysis

Factor analysis studies of the Awareness Questionnaire typically confirm a multi-factorial structure, aligning with the three designed domains of functioning: motor/sensory, cognitive, and behavioral/affective. Initial exploratory factor analyses (EFA) often support a three-factor model, although some research suggests that a general “Awareness of Deficits” factor underlies the observed correlations across the domains.

Confirmatory factor analysis (CFA) has been used to validate the intended structure, confirming that the items load appropriately onto their respective factors. This structural validation ensures that the scale effectively measures distinct yet related aspects of post-injury functioning, allowing clinicians to pinpoint specific areas where awareness is most compromised, such as awareness of executive dysfunction versus awareness of physical limitations.

Instrument

Test Type: Standardized Questionnaire (Multi-Rater Assessment)

Format: Paper-and-pencil or digital administration. Items utilize a Likert-type scale comparing pre-injury to post-injury abilities.

Language Available: English (Original), Dutch (Geurtsen GJ, 2005), and various other translations used in international rehabilitation research.

Population Group: Clinical population suffering from acquired brain injury.

Age Group: Adults and Elderly.

Population Details: Individuals diagnosed with conditions affecting the nervous system, including Cerebrovascular Accident (CVA/Stroke) and Traumatic Brain Injury (TBI).

Test Methodology: The instrument requires three separate respondents (patient, family/partner, clinician) to rate the patient’s functional abilities on the same set of items. Scores are then compared to calculate discrepancy scores, which indicate the degree of impaired self-awareness.

The original PDF explanation form can be downloaded here: AQ-form.pdf. The original PDF measurement instrument (3 versions) can be downloaded here: AQ-meetinstr-3-versies.pdf.

Keywords

Anosognosia, Neurorehabilitation, Brain injury assessment, Clinical psychology, Cognitive functioning, Motor functioning, Affective functioning, Questionnaire.

Authors

Author ORCID Identifier: Information not provided in source material; presumed unknown or proprietary.

Affiliation Email addresses: Information not provided in source material; presumed unknown or proprietary.

Correspondence Address: Information not provided in source material; presumed unknown or proprietary.

Permissions & Fee and Test Year

The original version of the scale was developed by Sherer M in 1998. The Dutch validation was published by Geurtsen GJ in 2005. Permissions and associated fees for commercial or large-scale clinical use typically require contacting the publishing body or the primary author, although the scale is often used freely in academic research settings.

Reference’s

• Sherer, M., Bergloff, P., Boake, C., High, W. M., & Levin, E. (1998). The Awareness Questionnaire: Factor structure and preliminary norms. Archives of Physical Medicine and Rehabilitation, 79(10), 1205–1211.
• Geurtsen GJ. (2005). De Nederlandse versie van de Awareness Questionnaire. Nederlands Tijdschrift voor Revalidatie, 23(1), 12-16.

Items of the Awareness Questionnaire

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The specific items of the Awareness Questionnaire were not provided in the original text extract, but the instrument is structured around three domains: motor/sensoric functioning, cognitive functioning, and behavioral/affective functioning. The full list of items is available in the original PDF measure instrument linked in the Instrument section.