Mental Health Outcomes Information Collection Protocol

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Appendix 3: HoNOSCA rating guidelines and glossary

General rating guidelines

• Perform a full clinical assessment of the patient's clinical history and current problems
• Rate items in order from 1 to 15.
• Do not include information already rated in an earlier item.
• Rate the most severe problem that occurred in the period rated.
• The rating period is generally the preceding two weeks for inpatients at admission, for hospital outpatients, and for all clients of community-based services. The exception is at discharge from acute inpatient care, in which case the rating period should generally be the preceding 72 hours.
• Each item is rated on a 5-point scale of severity (0 to 4) as follows:
  0. No problem
  1. Minor problem requiring no formal action
  2. Mild problem. Should be recorded in a care plan or other case record
  3. Problem of moderate severity
  4. Severe to very severe problem
  7. Not known / Unable to rate.
• Specific help for rating each point on each item is provided in the Glossary. 
• As far as possible, the use of rating point 7 should be avoided, because missing data make scores less comparable over time or between settings.

HoNOSCA scores: Clinical significance and recommended actions

Not clinically significant	0	No problem	Problem not present.
	1	Minor problem	Requires no formal action. May or may not be recorded in clinical file.
Clinically significant	2	Mild problem	Warrants recording in clinical file. May or may not be incorporated in care plan.
	3	Moderate problem	Warrants recording in clinical file. Should be incorporated in care plan.
	4	Severe to very severe problem	Most severe category for patients with this problem. Warrants recording in clinical file. Should be incorporated in care plan. Note: Patient can get worse.

HoNOSCA glossary

1. Problems with disruptive, antisocial or aggressive behaviour

Include behaviour associated with any disorder, such as hyperkinetic disorder, depression, autism, drugs or alcohol.

Include physical or verbal aggression (e.g., pushing, hitting, vandalism, teasing), or physical or sexual abuse of other children.

Include antisocial behaviour (e.g., thieving, lying, cheating) or oppositional behaviour (e.g., defiance, opposition to authority or tantrums).

Do not include: Over-activity rated at scale 2; Truancy, rated at scale 13; Self-harm rated at Scale 3.

0.	No problems of this kind during the period rated.
1.	Minor quarrelling, demanding behaviour, undue irritability, lying, etc.
2.	Mild but definitely disruptive or antisocial behaviour, lesser damage to property, or aggression, or defiant behaviour.
3.	Moderately severe aggressive behaviour such as fighting, persistently threatening, very oppositional, more serious destruction of property, or moderately delinquent acts.
4.	Disruptive in almost all activities, or at least one serious physical attack on others or animals, or serious destruction of property.

Additional notes for Scale 1
This item is concerned with a spectrum of behaviours. All three types of behaviour are included, whether or not there is intention, insight or awareness. However, the context must be considered since disagreement, for example, can be expressed more vigorously, but still acceptably, in some social contexts than in others.

Possible causes of the behaviour are not considered in the rating and diagnosis is not taken into account. For example, severity of disruptive behaviour by a child with hyperactivity is rated here, as is aggressive overactivity associated with psychotic disorder or violence associated with conduct disorder.

2. Problems with over-activity, attention or concentration

Include overactive behaviour associated with any disorder such as hyperkinetic disorder, mania, or arising from drugs.

Include problems with restlessness, fidgeting, inattention or concentration due to any cause, including depression.

0.	No problems of this kind during the period rated.
1.	Slight over-activity or minor restlessness, etc.
2.	Mild but definite over-activity or attention problems, but can usually be controlled.
3.	Moderately severe over-activity or attention problems that are sometimes uncontrollable.
4.	Severe over-activity or attention problems that are present in most activities and almost never controllable.

Additional notes for Scale 2
This item is concerned with all attentional problems associated with any cause such as hyperkinetic disorder, mood disorder or arising from drugs. Although children with Attention Deficit Disorder, with Hyperactivity are likely to score highly here, this scale is not intended to refer to a narrow range of diagnoses, restlessness or inattention due to obsessional ruminations for example, should also be rated here.

3. Non-accidental self-injury

Include self-harm such as hitting self and self cutting, suicide attempts, overdoses, hanging, drowning, etc.

Do not include scratching, picking as a direct result of physical illness rated at Scale 6.

Do not include accidental self-injury due, e.g., to severe learning or physical disability, rated at scale 6.

Do not include illness or injury as a direct consequence of drug or alcohol use, rated at scale 6.

0.	No problems of this kind during the period rated.
1.	Occasional thoughts about death, or of self-harm not leading to injury.  No self-harm or suicidal thoughts.
2.	Non-hazardous self-harm, such as wrist scratching, whether or not associated with suicidal thoughts.
3.	Moderately severe suicidal intent (including preparatory acts, e.g., collecting tablets) or moderate non-hazardous self-harm (e.g., small overdose).
4.	Serious suicidal attempt (e.g., serious overdose), or serious deliberate self-injury.

Additional notes for Scale 3
This item deals with ideas or acts of self-harm in terms of their severity or impact.  As in the clinical situation, the issue of intent during the period, though sometimes difficult to assess is part of the current risk assessment.  Thus, harm caused by an impulsive overdose could be rated at severity point 3 rather than 4 if the clinician judged that the child had not intended more than a moderate demonstration. Conversely, an adolescent who acquired a gun with clear intent to commit suicide, but was prevented in time, would be rated at point 4 (although rated 0 at Item 6).  However, in the absence of strong evidence to the contrary, clinicians will usually assume that the results of self-harm were all intended. Non hazardous self-harm without suicidal intent should also be included here with the exception of scratching or picking as a direct result of a physical illness.

4. Problems with alcohol, substance or solvent misuse

Include problems with alcohol, substance or solvent misuse taking into account current age and societal norms.

Do not include aggressive or disruptive behaviour due to alcohol or drug use, rated at Scale 1.

Do not include physical illness or disability due to alcohol or drug use, rated at Scale 6.

0.	No problems of this kind during the period rated.
1.	Minor alcohol or drug use, within age norms.
2.	Mildly excessive alcohol or drug use.
3.	Moderately severe drug or alcohol problems significantly out of keeping with age norms.
4.	Severe drug or alcohol problems leading to dependency or incapacity.

Additional notes for Scale 4
Consider characteristics such as craving or tolerance for alcohol or drugs, priority over other activities given to their acquisition and use, impaired capacity to control the quantity taken, frequency of intoxication and risk- taking. Dependence on alcohol and drugs is rare in children and adolescents thus this item addresses substance misuse out with the norms for a child's age. Aggressive and disruptive behaviour due to alcohol or drug use should not be included here as they are rated at Item 1, whilst physical illness or disability due to alcohol or drug use would be rated at Item 6.

5. Problems with scholastic or language skills

Include problems in reading, spelling, arithmetic, speech or language associated with any disorder or problem, such as specific developmental learning problems, or physical disability such as hearing problems.

Include reduced scholastic performance associated with emotional or behavioural problems.

Children with generalised learning disability should not be included unless their functioning is below the expected level.

Do not include temporary problems resulting purely from inadequate education.

 

0.	No problems of this kind during the period rated.
1.	Minor impairment within the normal range of variation.
2.	Minor but definite impairment of clinical significance.
3.	Moderately severe problems, below the level expected on the basis of mental age, past performance, or physical disability.
4.	Severe impairment, much below the level expected on the basis of mental age, past performance, or physical disability.

 

Additional notes for Scale 5
This item is concerned with problems with reading, spelling, arithmetic, speech or language associated with any disorder or problem such as a specific developmental learning problem or physical disability such as a hearing problem. Emphasis is on under-performance with respect to expectation thus, children with generalised learning disability should not be included unless their functioning is less than optimal. It is often helpful to take into account past performance in deciding the appropriate rating, for example, a child achieving at average level could be rated as having a problem if his prior performance was in the superior range.

6. Physical illness or disability problems

Include physical illness or disability problems that limit or prevent movement, impair sight or hearing, or otherwise interfere with personal functioning.

Include movement disorder, side effects from medication, physical effects from drug or alcohol use, or physical complications of psychological disorders such as severe weight loss.

Include self-injury due to severe learning disability or as of consequence of self-injury such as head banging.

Do not include somatic complaints with no organic basis, rated at scale 8.

0.	No incapacity as a result of physical health problems during the period rated.
1.	Slight incapacity as a result of a health problem during the period (e.g., cold, non-serious fall, etc).
2.	Physical health problem that imposes mild but definite functional restriction.
3.	Moderate degree of restriction on activity due to physical health problems.
4.	Complete or severe incapacity due to physical health problems.

Additional notes for Scale 6
Consider the impact of physical disability or disease on the child in the recent past. Problems likely to clear up fairly rapidly, without longer term consequences (e.g. a cold or bruising from a fall), are rated at point 0 or 1. A child in remission from a possibly long-term illness is rated on the worst state in the period, not on the prospective level. The rating at points 2-4 is made in terms of degree of restriction on activities, irrespective of the type of physical problem. Include impairments of the senses, unwanted side effects of medication, limitations on movement from whatever cause, injuries associated with the effects of drugs or alcohol, etc. The physical results of accidents or self-injury in the context of severe cognitive problems should also be rated here. Include also physical complications of psychological disorders such as severe weight loss in anorexia nervosa

7. Problems associated with hallucinations, delusions or abnormal perceptions

Include hallucinations, delusions or abnormal perceptions irrespective of diagnosis.

Include odd and bizarre behaviour associated with hallucinations and delusions.

Include problems with other abnormal perceptions such as illusions or pseudo-hallucinations, or overvalued ideas such as distorted body image, suspicious or paranoid thoughts.

Do not include disruptive or aggressive behaviour associated with hallucinations or delusions, rated at Scale 1.

Do not include overactive behaviour associated with hallucinations or delusions, rated at Scale 2.

0.	No evidence of abnormal thoughts or perceptions during the period rated.
1.	Somewhat odd or eccentric beliefs not in keeping with cultural norms.
2.	Abnormal thoughts or perceptions are present (e.g., paranoid ideas, illusions or body image disturbance), but there is little distress or manifestation in bizarre behaviour, i.e., clinically present but mild.
3.	Moderate preoccupation with abnormal thoughts or perceptions or delusions; hallucinations, causing much distress, or manifested in obviously bizarre behaviour.
4.	Mental state and behaviour is seriously and adversely affected by delusions or hallucinations or abnormal perceptions, with severe impact on the person or others.

Additional notes for Scale 7
This item addresses all hallucinations, delusions or abnormal perceptions irrespective of diagnosis, as well as odd and bizarre behaviours associated with psychotic symptoms.  Problems with other abnormal perceptions should also be included here such as illusions or pseudo-hallucinations or over-valued ideas such as suspicious or paranoid thoughts or abnormalities of body image in eating disorders.  Disruptive or aggressive behaviour associated with hallucinations or delusions should not be rated here (see Item 1).  Overactive behaviour, for example in hypomania should also be rated elsewhere (Item 2).

8. Problems with non-organic somatic symptoms

Include problems with gastrointestinal symptoms such as non-organic vomiting or cardiovascular symptoms or neurological symptoms or non-organic enuresis and encopresis or sleep problems or chronic fatigue.

Do not include movement disorders such as tics, rated at Scale 6.

Do not include physical illnesses that complicate non-organic somatic symptoms, rated at Scale 6.

0.	No problems of this kind during the period rated.
1.	Slight problems only, such as occasional enuresis, minor sleep problems, headaches or stomach aches without organic basis.
2.	Mild but definite problem with non-organic somatic symptoms.
3.	Moderately severe, symptoms produce a moderate degree of restriction in some activities.
4.	Very severe problems or symptoms persist into most activities.  The child or adolescent is seriously or adversely affected.

Additional notes for Scale 8
This should include difficulties with gastro-intestinal symptoms such as non-organic vomiting or cardio-vascular symptoms or neurological symptoms without demonstrable organic cause.  Non-organic enuresis or encopresis should also be included here.  Include also sleep symptoms and those related to chronic fatigue.  Movement disorders such as tics or those related to the side-effects of medication should not be included and should be rated under Item 6.

9. Problems with emotional and related symptoms

Rate only the most severe clinical problem not considered previously.

Include depression, anxiety, worries, fears, phobias.  obsessions or compulsions, arising from any clinical condition including eating disorders.

Do not include aggressive, destructive or over-activity behaviours attributed to fears or phobias, rated at Scale 1.

Do not include physical complications of psychological disorders, such as severe weight loss, rated at Scale 6.

0.	No evidence of depression, anxiety, fears or phobias during the period rated.
1.	Mildly anxious, gloomy, or transient mood changes.
2.	A mild but definite emotional symptom is clinically present, but is not preoccupying.
3.	Moderately severe emotional symptoms, which are preoccupying, intrude into some activities, and are uncontrollable at least sometimes.
4.	Severe emotional symptoms which intrude into all activities and are nearly always uncontrollable.

Additional notes for Scale 9
Only the most severe clinical problem not considered previously should be rated here.  This might include depression, anxiety, worries, fears, phobias, obsessions or compulsions arising from any clinical condition including eating disorders.  Aggressive destructive or overactive behaviours attributed to fears or phobias should be rated at Item 1.  Physical complications of psychological disorders such as severe weight loss should be rated at Item 6.  If a child has two or more symptoms in this category, choose only the most severe.  Items 10 to 13 (ratings of social functioning and of autonomy) unlike Items 1 to 9 which are concerned with the most severe example of difficulty occurring in the time period, address the mean level of functioning during the rating period.  For example, in considering peer relationships (Item 10) the general level of friendships should be considered rather than giving undue weight to a child who has fallen out with one friend.

10. Problems with peer relationships

Include problems with school mates and social network.  Problems associated with active or passive withdrawal from social relationships or problems with over intrusiveness or problems with the ability to form satisfying peer relationships.

Include social rejection as a result of aggressive behaviour or bullying.

Do not include aggressive behaviour, bullying, rated at Scale 1.

Do not include problems with family or siblings rated at Scale 12.

0.	No significant problems during the period rated.
1.	Either transient or slight problems, occasional social withdrawal.
2.	Mild but definite problems in making or sustaining peer relationships.  Problems causing distress due to social withdrawal, over-intrusiveness, rejection or being bullied.
3.	Moderate problems due to active or passive withdrawal from social relationships, over-intrusiveness, or to relationships that provide little or no comfort or support, e.g., as a result of being severely bullied.
4.	Severe social isolation with hardly any friends due to inability to communicate socially or withdrawal from social relationships.

Additional notes for Scale 10
This should include problems with school friends and the social network.  This item is concerned with absence of friendships or social contacts with peers, as well as problems with over-intrusiveness and inappropriate play.  Aggressive behaviour and bullying by the child however, should not be rated here but under Item 1.  Difficulties within the family or with siblings are rated under Item 12. Difficulties making or sustaining friendships should be included as well as passive withdrawal from social relationships.

11. Problems with self-care and independence

Rate the overall level of functioning, e.g., problems with basic activities of self-care such as feeding, washing, dressing, toilet, and also complex skills such as managing money, travelling independently, shopping etc.; taking into account the norm for the child's chronological age.

Include poor levels of functioning arising from lack of motivation, mood or any other disorder.

Do not include lack of opportunities for exercising intact abilities and skills, as might occur in an over-restrictive family, rated at Scale 12.

Do not include enuresis and encopresis, rated at Scale 8.

0.	No problems of this kind during the period rated; good ability to function in all areas.
1.	Minor problems, e.g., untidy, disorganised.
2.	Self-care adequate, but major inability to perform one or more complex skills (see above).
3.	Major problems in one or more areas of self-care (eating, washing, dressing) or major inability to perform several complex skills.
4.	Severe disability in all or nearly all areas of self-care or complex skills.

Additional notes for Scale 11
The overall level of functioning should be rated here, taking into account the norm for the child's chronological age. The child's actual performance should be rated not their potential competence.

12. Problems with family life and relationships

Include parent-child and sibling relationship problems.

Include relationships with foster parents, social works or teachers in residential placements.  Relationships in the home with separated parents and siblings should both be included.  Parental personality problems, mental illness, marital difficulties should only be rated here if they have an affect on the child or adolescent.

Include problems such as poor communication, arguments, verbal or physical hostility, criticism and denigration, parental neglect or rejection, over-restriction, sexual or physical abuse.

Include sibling jealousy, physical or coercive sexual abuse by sibling.

Include problems with enmeshment and overprotection.

Include problems with family bereavement leading to reorganisation.

Do not include aggressive behaviour by the child or adolescent, rated at Scale 1.

0.	No problems during the period rated.
1.	Slight or transient problems.
2.	Mild but definite problem, e.g., some episodes of neglect or hostility or enmeshment or overprotection.
3.	Moderate problems, e.g., neglect, abuse, hostility.  problems associated with family or carer breakdown or reorganisation.
4.	Serious problems with the child or adolescent feeling or being victimised, abused or seriously neglected by family or carer.

Additional notes for Scale 12
Usually this item will refer to relationships with parents and siblings in the family home but if the normal home is with foster parents or in residential placements, relationships there should be rated. Where the child is living away from home, relationships within the institution and with separated parents and siblings should both be rated. Parental personality problems, mental illnesses and marital difficulties should only be rated here if they have an effect on the child, though this will usually be the case.  Problems associated with physical, emotional or sexual abuse should be included but this scale is not intended to address abusive or neglectful features alone. Difficulties arising from over-involvement and overprotection should be included, as well as difficulties arising from family re-organisation as a result of relocation or bereavement. Sibling jealousy or physical coercion by a sibling should be included but aggressive behaviour by the child should be rated under Item 1.

13 . Poor school attendance

Include truancy, school refusal, school withdrawal or suspension for any cause.

Include attendance at type of school at time of rating, e.g., hospital school, home tuition, etc.  If school holiday, rate the last two weeks of the previous term.

0.	No problems of this kind during the period rated.
1.	Slight problems, e.g., late for two or more lessons.
2.	Definite but mild problems, e.g., missed several lessons because of truancy or refusal to go to school.
3.	Marked problems, absent several days during the period rated.
4.	Severe problems, absent most or all days.  Include school suspension, exclusion or expulsion for any cause during the period rated.

Additional notes for Item 13
School non-attendance for any reason should be included. This will include truancy, school refusal, school withdrawal or suspension for any cause. Where the child is an inpatient or day patient, attendance at the appropriate educational facility at the time of rating should be recorded. This may include the hospital school or home tuition. During school holidays, the last two weeks of the previous term should be rated. As with other items, future intentions should not be rated, thus a school refusing a child expressing intention to return after the school holidays would score on this item until satisfactory school attendance had been achieved.

The above 13 items in Section A are generally summed to give a total score. The additional 2 items (Section B) may be used for children seen for brief interventions, where the main problem is of diagnostic uncertainty or lack of familiarity with appropriate services.

Scales 14 and 15 are concerned with problems for the child, parent or carer relating to lack of information or access to services.  These are not direct measures of the child's mental health but changes here may result in long-term benefits for the child.

14. Problems with knowledge or understanding about the nature of the child or adolescent's difficulties (in the previous two weeks)

Include lack of useful information or understanding available to the child or adolescent, parents or carers.

Include lack of explanation about the diagnosis or the cause of the problem or the prognosis.

0.	No problems during the period rated.  Parents and carers have been adequately informed about the child or adolescent's problems.
1.	Slight problems only.
2.	Mild but definite problems.
3.	Moderately severe problems.  Parents and carers have very little or incorrect knowledge about the problem which is causing difficulties such as confusion or self-blame.
4.	Very severe problems.  Parents have no understanding about the nature of their child or adolescent's problems.

Additional notes for Item 14
This item is concerned with difficulties the child might be experiencing due to a lack of understanding within the family, about the nature of his difficulties. Difficulties may arise because the parents ascribe a wrong diagnosis or attribute problems to the wrong cause.

15. Problems with lack of information about services or management of the child or adolescent's difficulties

Include lack of useful information or understanding available to the child or adolescent, parents or carers or referrers.

Include lack of information about the most appropriate way of providing services to the child or adolescent, such as care arrangements, educational placements, or respite care.

0.	No problems during the period rated.  The need for all necessary services has been recognised.
1.	Slight problems only.
2.	Mild but definite problems.
3.	Moderately severe problems.  Parents and carers have been given very little information about appropriate services, or professionals are not sure where a child should be managed.
4.	Very severe problems.  Parents have no information about appropriate services or professionals do not know where a child should be managed activities.

Additional notes for Item 15
This item is concerned with difficulties arising out of a lack of knowledge of appropriate services or management. Included here would be a child with a learning difficulty whose family were unaware of routes to special educational provision.

Important variations in rating guidelines

	Core rules
Scale	Rate the worst manifestation	Rate over the past two weeks
Scales 1-9	Always	Always
Scales 10-15	Based on usual or typical	Always

HoNOSCA summary scores

Data element	HoNOSCA item number and description	Item score	Summary score
HoNOSCA Behavioural problems summary score		4 items	0 - 16
HoNOSCA item 01	1. Disruptive, antisocial, or aggressive behaviour.	0 - 4
HoNOSCA item 02	2. Problems with overactivity, attention or concentration.	0 - 4
HoNOSCA item 03	3. Non-accidental self-injury.	0 - 4
HoNOSCA item 04	4. Alcohol, substance or solvent misuse.	0 - 4
HoNOSCA Impairment summary score		2 items	0 - 8
HoNOSCA item 05	5. Problems with scholastic or language skills.	0 - 4
HoNOSCA item 06	6. Physical illness or disability problems.	0 - 4
HoNOSCA Symptomatic problems summary score		3 items	0 - 12
HoNOSCA item 07	7. Problems associated with hallucinations, delusions, or abnormal perceptions.	0 - 4
HoNOSCA item 08	8. Problems with non-organic somatic symptoms.	0 - 4
HoNOSCA item 09	9. Problems with emotional and related symptoms.	0 - 4
HoNOSCA Social problems summary score		4 items	0 - 16
HoNOSCA item 10	10. Problems with peer relationships.	0 - 4
HoNOSCA item 11	11. Problems with self-care and independence.	0 - 4
HoNOSCA item 12	12. Problems with family life and relationships.	0 - 4
HoNOSCA item 13	13. Poor school attendance.	0 - 4
HoNOSCA Information summary score		2 items	0 - 8
HoNOSCA item 14	14. Problems with lack of knowledge or understanding about the nature of the child or adolescent's difficulties.	0 - 4
HoNOSCA item 15	15. Problems with lack of information about services or management of the child or adolescent's difficulties.	0 - 4
HoNOSCA Total (13-item) score			0 - 52

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Page last updated: 25 September 2008