National Norms for the Vanderbilt ADHD Diagnostic Parent Rating Scale in Children.

OBJECTIVE: To provide national norms and percentiles for both research and clinical scoring modalities of the Vanderbilt Attention Deficit/Hyperactivity Disorder (ADHD) Diagnostic Parent Rating Scale (VADPRS) for a representative sample of children ages 5-12 in the United States. METHOD: The five clinical subscales of the VADPRS were completed by 1,570 caregivers of children ages 5-12 in the United States, with children representative of the national population on key demographic variables including race, sex, ethnicity, family income, and family educational level. Descriptive statistics and measures of internal consistency of both dimensional and symptom count scoring were provided for each of the five clinical subscales of the inventory, as well as percentiles and group comparisons for select dimensional scoring subscales based on age and child sex. RESULTS: Measures of internal consistency for each subscale using both scoring modalities of the VADPRS ranged from high to acceptable. There were statistically significant differences among the different subscales for both age (ADHD hyperactivity, anxiety/depression) and sex [both presentations of ADHD, oppositional defiant disorder (ODD)] for the total sample. These differences, however, were modest in magnitude and unlikely to be clinically meaningful. CONCLUSIONS: This study enhances the research and clinical utility of the VADPRS by providing national norms and percentiles for each of its subscales. Differences between age and sex across the sample were statistically significant for two of the subscales (Hyperactivity and Anxiety/Depression) with additional subscales significant for sex alone (Inattentive and ODD), but these differences were not substantial enough to indicate a need for separate cut-offs for screening purposes.

Assessing Aspects of Social Relationships in Youth Across Middle Childhood and Adolescence: The NIH Toolbox Pediatric Social Relationship Scales.

OBJECTIVE: Social relationships are a critical context for children's socioemotional development and their quality is closely linked with concurrent and future physical and emotional wellbeing. However, brief self-report measures of social relationship quality that translate across middle childhood, adolescence, and adulthood are lacking, limiting the ability to assess the impact of social relationships on health outcomes over time. To address this gap, this article describes the development and testing of the National Institutes of Health (NIH) Toolbox Pediatric Social Relationship Scales, which were developed in parallel with the previously-reported Adult Social Relationship Scales. METHODS: Item sets were selected from the NIH Toolbox adult self-report item banks in the domains of social support, companionship, and social distress, and adapted for use in preadolescent (ages 8-11 years) and adolescent (ages 12-18 years) cohorts. Items were tested across a U.S. community sample of 1,038 youth ages 8-18 years. Classical test and item response theory approaches were used to identify items for inclusion in brief unidimensional scales. Concurrent validity was assessed by comparing resultant scales to established pediatric social relationship instruments. RESULTS: Internal reliability and concurrent validity were established for five unique scales, with 5-7 items each: Emotional Support, Friendship, Loneliness, Perceived Rejection, and Perceived Hostility. CONCLUSIONS: These brief scales represent developmentally appropriate and valid instruments for assessing the quality of youth social relationships across childhood and adolescence. In conjunction with previously published adult scales, they provide an opportunity for prospective assessment of social relationships across the developmental spectrum.

Psychometric Properties of the Emotion Dysregulation Inventory in a Nationally Representative Sample of Youth.

Objective: The Emotion Dysregulation Inventory (EDI) is an informant questionnaire developed based on the Patient-Reported Outcomes Measurement Information System (PROMIS®) Scientific Standards and refined through factor analyses and item response theory (IRT) analyses. Although it was developed to improve measurement of emotion dysregulation in youth with autism spectrum disorder, emotion dysregulation has transdiagnostic significance. Therefore, the aim of this study was to evaluate the EDI's psychometric properties and to establish IRT-based scores for a general population of youth.Methods: Data were collected from a sample of 1000 caregivers of 6- to 17-year-old youth matched to the US census on age, gender, race/ethnicity, years of education, and region. Confirmatory factor analyses and IRT analyses using the two-parameter graded response model were performed to evaluate the EDI's structure and psychometric properties.Results: Analyses supported the original two-factor structure of the EDI, reflecting factors for Reactivity and Dysphoria. Simulations of computerized adaptive testing supported use of the same items for a Reactivity short form as those that emerged as most informative in the original autism psychometric analyses. IRT co-calibration with commonly used measures of emotion regulation and irritability in child clinical or community samples indicated the EDI scales provide more information across a wider range of emotion dysregulation. Validity was supported by moderate correlations with measures of related constructs and expected known-group differences.Conclusions: The EDI is an efficient and precise measure of emotion dysregulation for use in general community and clinical samples as well as samples of youth with ASD.

Development and Validation of the Parenting Skill Use Diary (PSUD) in a Nationally Representative Sample.

Objective: We describe the development and psychometric properties of an instrument designed to assess the use of effective parenting skills reported with a daily diary. The Parenting Skill Use Diary (PSUD) was developed iteratively relying on a "common elements" approach to quantify the use of evidence-based parenting techniques for responding to child misbehaviors and positive behaviors.Method: The PSUD was administered online daily for seven days to parents/guardians of children aged 5-12. The nationally representative sample (N = 1,570) was selected to match the US population of such parents/guardians on key demographic variables.Results: The instrument demonstrated the ability to capture significant between person variability in the appropriate use of parent management skills. A weekly summary score discriminated between parents/guardians whose children screened positive versus negative for Conduct Disorder (AUC = .72) and Oppositional Defiant Disorder (AUC = .70).Conclusions: The results supported the reliability of validity of the diary as a research tool for examining mean differences.

PROMIS® Adult Health Profiles: Efficient Short-Form Measures of Seven Health Domains.

BACKGROUND: There is a need for valid self-report measures of core health-related quality of life (HRQoL) domains. OBJECTIVE: To derive brief, reliable and valid health profile measures from the Patient Reported Outcomes Measurement Information System® (PROMIS®) item banks. METHODS: Literature review, investigator consensus process, item response theory (IRT) analysis, and expert review of scaling results from multiple PROMIS data sets. We developed 3 profile measures ranging in length from 29 to 57 questions. These profiles assess important HRQoL domains with highly informative subsets of items from respective item banks and yield reliable information across mild-to-severe levels of HRQoL experiences. Each instrument assesses the domains of pain interference, fatigue, depression, anxiety, sleep disturbance, physical function, and social function using 4-, 6-, and 8-item short forms for each domain, and an average pain intensity domain score, using a 0-10 numeric rating scale. RESULTS: With few exceptions, all domain short forms within the profile measures were highly reliable across at least 3 standard deviation (30 T-score) units and were strongly correlated with the full bank scores. Construct validity with ratings of general health and quality of life was demonstrated. Information to inform statistical power for clinical and general population samples is also provided. CONCLUSIONS: Although these profile measures have been used widely, with summary scoring routines published, description of their development, reliability, and initial validity has not been published until this article. Further evaluation of these measures and clinical applications are encouraged.

Evaluation of options for presenting health-states from PROMIS® item banks for valuation exercises.

PURPOSE: Health status descriptive systems based on item response theory (IRT), such as the Patient-Reported Outcomes Measurement Information System (PROMIS®), have item banks to measure domains of health. We developed a method to present such banks for health-state valuation. METHODS: We evaluated four different presentation approaches: a single item (1S), 2 items presented separately (2S), 2 items presented together (2T), or 5 items presented together (5T). We evaluated these four approaches in three PROMIS item banks (depression, physical function, and sleep disturbance). Adult community members valued health-state descriptions using the visual analog scale and standard gamble methods. We compared the approaches by the range of item bank theta scores captured, participants' assessments of difficulty (1 = very easy to 7 = very hard), and exit interviews. RESULTS: Participants (n = 118) ranged in age from 18 to 71; 63% were female and 54% were white. The 1S approach captured the smallest range of theta scores. A monotonic relationship between theta score and mean standard gamble estimate was found with all approaches except 2S. Across all 3 item banks, mean difficulty assessments were 2.35 (1S), 2.69 (2T), 2.78 (5T), and 2.80 (2S). In exit interviews, participants generally found all four approaches similarly meaningful and realistic. CONCLUSIONS: Creating health descriptions by presenting 2 items maximized the range of theta while minimizing difficulty and maintaining a monotonic relationship with utility estimates. We recommend this approach for valuation of IRT-based descriptive systems such as PROMIS.

Selection of key health domains from PROMIS® for a generic preference-based scoring system.

PURPOSE: We sought to select a parsimonious subset of domains from the patient-reported outcomes measurement information system (PROMIS®) that could be used for preference-based valuation. Domain selection criteria included face validity, comprehensiveness, and structural independence. METHODS: First, 9 health outcomes measurement experts selected domains appropriate for a general health measure using a modified Delphi procedure. Second, 50 adult community members assessed structural independence of domain pairs. For each pair, the participant was asked if it were possible to have simultaneously good functioning in domain 1 but poor functioning in domain 2, and vice versa. The community members also rated the relative importance of the domains. Finally, the experts selected domains, guided by community members' judgments of structural independence and importance. RESULTS: After 3 rounds of surveys, the experts agreed on 10 potential domains. The percent of pairs deemed structurally independent by community members ranged from 50 to 95 (mean = 78). Physical Function, Pain Interference, and Depression were retained because of their inclusion in existing preference-based measures and their importance to community members. Four other domains were added because they were important to community members and judged to be independent by at least 67% of respondents: Cognitive Function-Abilities; Fatigue; Ability to Participate in Social Roles and Activities; and Sleep Disturbance. CONCLUSION: With input from measurement experts and community members, we selected 7 PROMIS domains that can be used to create a preference-based score.

Standardization of health outcomes assessment for depression and anxiety: recommendations from the ICHOM Depression and Anxiety Working Group.

PURPOSE: National initiatives, such as the UK Improving Access to Psychological Therapies program (IAPT), demonstrate the feasibility of conducting empirical mental health assessments on a large scale, and similar initiatives exist in other countries. However, there is a lack of international consensus on which outcome domains are most salient to monitor treatment progress and how they should be measured. The aim of this project was to propose (1) an essential set of outcome domains relevant across countries and cultures, (2) a set of easily accessible patient-reported instruments, and (3) a psychometric approach to make scores from different instruments comparable. METHODS: Twenty-four experts, including ten health outcomes researchers, ten clinical experts from all continents, two patient advocates, and two ICHOM coordinators worked for seven months in a consensus building exercise to develop recommendations based on existing evidence using a structured consensus-driven modified Delphi technique. RESULTS: The group proposes to combine an assessment of potential outcome predictors at baseline (47 items: demographics, functional, clinical status, etc.), with repeated assessments of disease-specific symptoms during the treatment process (19 items: symptoms, side effects, etc.), and a comprehensive annual assessment of broader treatment outcomes (45 items: remission, absenteeism, etc.). Further, it is suggested reporting disease-specific symptoms for depression and anxiety on a standardized metric to increase comparability with other legacy instruments. All recommended instruments are provided online ( www.ichom.org ). CONCLUSION: An international standard of health outcomes assessment has the potential to improve clinical decision making, enhance health care for the benefit of patients, and facilitate scientific knowledge.

An Item Bank for Abuse of Prescription Pain Medication from the Patient-Reported Outcomes Measurement Information System (PROMIS®).

OBJECTIVE: There is a need to monitor patients receiving prescription opioids to detect possible signs of abuse. To address this need, we developed and calibrated an item bank for severity of abuse of prescription pain medication as part of the Patient-Reported Outcomes Measurement Information System (PROMIS ® ). METHODS: Comprehensive literature searches yielded an initial bank of 5,310 items relevant to substance use and abuse, including abuse of prescription pain medication, from over 80 unique instruments. After qualitative item analysis (i.e., focus groups, cognitive interviewing, expert review, and item revision), 25 items for abuse of prescribed pain medication were included in field testing. Items were written in a first-person, past-tense format, with a three-month time frame and five response options reflecting frequency or severity. The calibration sample included 448 respondents, 367 from the general population (ascertained through an internet panel) and 81 from community treatment programs participating in the National Drug Abuse Treatment Clinical Trials Network. RESULTS: A final bank of 22 items was calibrated using the two-parameter graded response model from item response theory. A seven-item static short form was also developed. The test information curve showed that the PROMIS ® item bank for abuse of prescription pain medication provided substantial information in a broad range of severity. CONCLUSION: The initial psychometric characteristics of the item bank support its use as a computerized adaptive test or short form, with either version providing a brief, precise, and efficient measure relevant to both clinical and community samples.

Interpersonal problems across levels of the psychopathology hierarchy.

We examined the relationship between psychopathology and interpersonal problems in a sample of 825 clinical and community participants. Sixteen psychiatric diagnoses and five transdiagnostic dimensions were examined in relation to self-reported interpersonal problems. The structural summary method was used with the Inventory of Interpersonal Problems Circumplex Scales to examine interpersonal problem profiles for each diagnosis and dimension. We built a structural model of mental disorders including factors corresponding to detachment (avoidant personality, social phobia, major depression), internalizing (dependent personality, borderline personality, panic disorder, posttraumatic stress, major depression), disinhibition (antisocial personality, drug dependence, alcohol dependence, borderline personality), dominance (histrionic personality, narcissistic personality, paranoid personality), and compulsivity (obsessive-compulsive personality). All dimensions showed good interpersonal prototypicality (e.g., detachment was defined by a socially avoidant/nonassertive interpersonal profile) except for internalizing, which was diffusely associated with elevated interpersonal distress. The findings for individual disorders were largely consistent with the dimension that each disorder loaded on, with the exception of the internalizing and dominance disorders, which were interpersonally heterogeneous. These results replicate previous findings and provide novel insights into social dysfunction in psychopathology by wedding the power of hierarchical (i.e., dimensional) modeling and interpersonal circumplex assessment.

Individuals with knee impairments identify items in need of clarification in the Patient Reported Outcomes Measurement Information System (PROMIS®) pain interference and physical function item banks - a qualitative study.

BACKGROUND: The content and wording of the Patient Reported Outcome Measurement Information System (PROMIS) Physical Function and Pain Interference item banks have not been qualitatively assessed by individuals with knee joint impairments. The purpose of this investigation was to identify items in the PROMIS Physical Function and Pain Interference Item Banks that are irrelevant, unclear, or otherwise difficult to respond to for individuals with impairment of the knee and to suggest modifications based on cognitive interviews. METHODS: Twenty-nine individuals with knee joint impairments qualitatively assessed items in the Pain Interference and Physical Function Item Banks in a mixed-methods cognitive interview. Field notes were analyzed to identify themes and frequency counts were calculated to identify items not relevant to individuals with knee joint impairments. RESULTS: Issues with clarity were identified in 23 items in the Physical Function Item Bank, resulting in the creation of 43 new or modified items, typically changing words within the item to be clearer. Interpretation issues included whether or not the knee joint played a significant role in overall health and age/gender differences in items. One quarter of the original items (31 of 124) in the Physical Function Item Bank were identified as irrelevant to the knee joint. All 41 items in the Pain Interference Item Bank were identified as clear, although individuals without significant pain substituted other symptoms which interfered with their life. CONCLUSIONS: The Physical Function Item Bank would benefit from additional items that are relevant to individuals with knee joint impairments and, by extension, to other lower extremity impairments. Several issues in clarity were identified that are likely to be present in other patient cohorts as well.

Evaluating PROMIS® instruments and methods for patient-centered outcomes research: Patient and provider voices in a substance use treatment setting.

PURPOSE: Our work as a primary research site of the Patient-Reported Outcomes Measurement Information System (PROMIS®), combined with support from the Patient-Centered Outcomes Research Institute, allowed us to evaluate the real-world applicability and acceptability of PROMIS measures in an addiction medicine setting. METHODS: As part of a 3-month prospective observational study, 225 outpatients at a substance abuse treatment clinic completed PROMIS item banks for alcohol use (as well as 15 additional item banks from 8 other PROMIS domains, including emotional distress, sleep, and pain), with assessments at intake, 1-month follow-up, and 3-month follow-up. A subsample of therapists and their patients completed health domain importance ratings and qualitative interviews to elicit feedback regarding the content and format of the patients' assessment results. RESULTS: The importance ratings revealed that depression, anxiety, and lack of emotional support were rated highest of the non-alcohol-related domains among both patients and clinicians. General alcohol use was considered most important by both patients and clinicians. Based on their suggestions, changes were made to item response feedback to facilitate comprehension and communication. CONCLUSIONS: Both therapists and patients agreed that their review of the graphical display of scores, as well as individual item responses, helped them to identify areas of greatest concern and was useful for treatment planning. The results of our pilot work demonstrated the value and practicality of incorporating a comprehensive health assessment within a substance abuse treatment setting.

Using patient-reported outcomes and PROMIS in research and clinical applications: experiences from the PCORI pilot projects.

PURPOSE: The field of patient-centered outcomes research (PCOR) continues to develop. Patient-reported outcomes and, in particular the Patient-Reported Outcomes Measurement Information System (PROMIS) contribute complementary data to clinician-derived outcomes traditionally used in health decision-making. However, there has been little work to understand how PROMIS measures may inform or be integrated into PCOR or clinical applications. METHODS: Lead investigators from four pilot projects funded by the Patient-Centered Outcomes Research Institute (PCORI) collaborated to discuss lessons learned about the use of PROMIS in PCOR studies via virtual and in-person meetings. In addition, a qualitative data collection tool was used to assess the pilot projects' experiences. RESULTS: Lessons learned from the pilot projects centered on practical elements of research design, such as choosing the right outcomes to study, considering the advantages and limitations of the PROMIS short forms and computer adaptive technology versions, planning ahead for a feasible data collection process, maintaining the focus on patients by ensuring that the research is truly patient-centered, and helping patients and providers make the most of PROMIS in care. CONCLUSION: The PCORI pilot projects demonstrated that PROMIS can be successfully used to conduct research that will help patients make decisions about their care. Interest in PCOR continues to grow and the lessons learned from these projects about the use of PROMIS will be helpful to investigators. Given the numerous benefits of PROMIS, implementing this tool in research and care will hopefully lead to significant progress in measuring health outcomes that are meaningful and relevant to all stakeholders.

Measuring nonspecific factors in treatment: item banks that assess the healthcare experience and attitudes from the patient's perspective.

PURPOSE: Nonspecific factors that accompany healthcare treatments, such as patients' attitudes and expectations, are important parts of the experience of care and can influence outcomes. However, no precise, concise, and generalizable instruments to measure these factors exist. We report on the development and calibration of new item banks, titled the Healing Encounters and Attitudes Lists (HEAL), that assess nonspecific factors across a broad range of treatments and conditions. METHODS: The instrument development methodology of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) was used. Patient focus groups and clinician interviews informed our HEAL conceptual model. Literature searches of eight databases yielded over 500 instruments and resulted in an initial item pool of several thousand items. After qualitative item analysis, including cognitive interviewing, 296 items were included in field testing. The calibration sample included 1657 respondents, 1400 obtained through an Internet panel and 257 from conventional and integrative medicine clinics. Following exploratory and confirmatory factor analyses, the HEAL item banks were calibrated using item response theory. RESULTS: The final HEAL item banks were Patient-Provider Connection (57 items), Healthcare Environment (25 items), Treatment Expectancy (27 items), Positive Outlook (27 items), and Spirituality (26 items). Short forms were also developed from each item bank. A six-item short form, Attitudes toward Complementary and Alternative Medicine (CAM), was also created. CONCLUSIONS: HEAL item banks provided substantial information across a broad range of each construct. HEAL item banks showed initial evidence of predictive and concurrent validity, suggesting that they are suitable for measuring nonspecific factors in treatment.

The PROMIS of QALYs.

Measuring health and health-related quality of life (HRQoL) is important for tracking the health of individuals and populations over time. Generic HRQoL measures allow for comparison across health conditions. One form of generic HRQoL measures are profile measures, which provide a description of health across several different domains (such as physical functioning, depression, and pain). Recent advances in health profile measurement include the development of measures based on item response theory. The Patient-Reported Outcomes Measurement Information System (PROMIS®) has been constructed using this theory. Another form of generic HRQoL measures are utility measures, which assess the value of health states. Multi-attribute utility theory provides a framework for valuing disparate domains of health and aggregating them into a single preference-based score. Such a score provides an overall measure of health outcomes as well as a quality of life weight for use in decision analyses and cost-effectiveness analyses. Developing a utility score for PROMIS® would allow simultaneous estimation of both health profile and utility scores using a single measure. The purpose of this paper is to provide a roadmap of the methodological steps necessary to create such a scoring system.

Non-suicidal self-injury and suicidal ideation as predictors of suicide attempts in adolescent girls: a multi-wave prospective study.

Although both suicide ideation (SI) and non-suicidal self-injury (NSSI) are known risk factors for suicidal behavior, few longitudinal studies have examined whether having a history of one or both of these factors prospectively predicts increased risk for suicide attempts. According to the theory of acquired capability for suicide, engagement in NSSI may reduce inhibitions around self-inflicted violence, imparting greater risk for suicide attempts among those with SI than would be observed in those with SI who do not have a history of NSSI. We used prospective data from the Pittsburgh Girls Study, a large community sample, to compare groups of girls reporting no SI or NSSI, SI only, or both NSSI and SI between early to late adolescence on any lifetime or recent suicide attempts in late adolescence and early adulthood. As compared to girls with no SI or NSSI history and those with only an SI history, girls with a history of both NSSI and SI were significantly more likely to subsequently report both lifetime and recent suicide attempts. Results are consistent with the acquired capability theory for suicide and suggest that adolescent girls who have engaged in NSSI and also report SI represent a particularly high-risk group in need of prevention and intervention efforts.

Assessing psychological well-being: self-report instruments for the NIH Toolbox.

OBJECTIVE: Psychological well-being (PWB) has a significant relationship with physical and mental health. As a part of the NIH Toolbox for the Assessment of Neurological and Behavioral Function, we developed self-report item banks and short forms to assess PWB. STUDY DESIGN AND SETTING: Expert feedback and literature review informed the selection of PWB concepts and the development of item pools for positive affect, life satisfaction, and meaning and purpose. Items were tested with a community-dwelling US Internet panel sample of adults aged 18 and above (N = 552). Classical and item response theory (IRT) approaches were used to evaluate unidimensionality, fit of items to the overall measure, and calibrations of those items, including differential item function (DIF). RESULTS: IRT-calibrated item banks were produced for positive affect (34 items), life satisfaction (16 items), and meaning and purpose (18 items). Their psychometric properties were supported based on the results of factor analysis, fit statistics, and DIF evaluation. All banks measured the concepts precisely (reliability ≥0.90) for more than 98% of participants. CONCLUSION: These adult scales and item banks for PWB provide the flexibility, efficiency, and precision necessary to promote future epidemiological, observational, and intervention research on the relationship of PWB with physical and mental health.

Emotion dysregulation as a maintenance factor of borderline personality disorder features.

We examined within-individual changes in emotion dysregulation over the course of one year as a maintenance factor of borderline personality disorder (BPD) features. We evaluated the extent to which (1) BPD symptom severity at baseline predicted within-individual changes in emotion dysregulation and (2) within-individual changes in emotion dysregulation predicted four BPD features at 12-month follow-up: affective instability, identity disturbances, negative relationships, and impulsivity. The specificity of emotion dysregulation as a maintaining mechanism of BPD features was examined by controlling for a competing intervening variable, interpersonal conflict. BPD symptoms at baseline predicted overall level and increasing emotion dysregulation. Additionally, increasing emotion dysregulation predicted all four BPD features at 12-month follow-up after controlling for BPD symptoms at baseline. Further, overall level of emotion dysregulation mediated the association between BPD symptom severity at baseline and both affective instability and identity disturbance at 12-month follow-up, consistent with the notion of emotion dysregulation as a maintenance factor. Future research on the malleability of emotion dysregulation in laboratory paradigms and its effects on short-term changes in BPD features is needed to inform interventions.

Negative affect and sleep disturbance may be associated with response to epidural steroid injections for spine-related pain.

OBJECTIVE: To describe whether negative affect and sleep impairment are associated with the clinical effect of epidural steroid injections (ESIs) for low back pain. DESIGN: Observational study; patients were evaluated before ESI and 1 and 3 months after ESI. SETTING: Spine center and related treatment sites. PARTICIPANTS: Participants (N=158) seeking treatment for low back pain with or without radiculopathy. INTERVENTION: ESI for low back pain with or without radiculopathy. MAIN OUTCOME MEASURES: We assessed the dependent (global pain severity for back and leg pain, pain behavior, pain interference) and independent variables (depression, sleep disturbance, and covariates of back pain response) with the Patient-Reported Outcome Measurement Information System (PROMIS) and legacy measures. Outcome was assessed cross-sectionally using multiple regression and longitudinally with path analysis. RESULTS: After 1 month, sleep disturbance was the only predictor for the global ratings of improvement in back pain (R(2)=16.8%) and leg pain (R(2)=11.4%). The proportions of variance explained by sleep disturbance and negative affect for all dependent variables were greater at 3 months than 1 month. Mediation analysis was significant for negative affect for the 3-month outcomes on PROMIS pain behavior (ß=.87, P<.01) and pain interference (ß=.37, P<.01). There was no evidence of mediation by sleep disturbance for any outcome. CONCLUSIONS: Negative affect and sleep disturbance are associated with worse outcomes after ESI. Further research is needed to determine if treatment of negative affect and sleep disturbance prior to or concurrently with ESI will improve outcomes.

Adult Attachment Ratings (AAR): an item response theory analysis.

The Adult Attachment Ratings (AAR) include 3 scales for anxious, ambivalent attachment (excessive dependency, interpersonal ambivalence, and compulsive care-giving), 3 for avoidant attachment (rigid self-control, defensive separation, and emotional detachment), and 1 for secure attachment. The scales include items (ranging from 6-16 in their original form) scored by raters using a 3-point format (0 = absent, 1 = present, and 2 = strongly present) and summed to produce a total score. Item response theory (IRT) analyses were conducted with data from 414 participants recruited from psychiatric outpatient, medical, and community settings to identify the most informative items from each scale. The IRT results allowed us to shorten the scales to 5-item versions that are more precise and easier to rate because of their brevity. In general, the effective range of measurement for the scales was 0 to +2 SDs for each of the attachment constructs; that is, from average to high levels of attachment problems. Evidence for convergent and discriminant validity of the scales was investigated by comparing them with the Experiences of Close Relationships-Revised (ECR-R) scale and the Kobak Attachment Q-sort. The best consensus among self-reports on the ECR-R, informant ratings on the ECR-R, and expert judgments on the Q-sort and the AAR emerged for anxious, ambivalent attachment. Given the good psychometric characteristics of the scale for secure attachment, however, this measure alone might provide a simple alternative to more elaborate procedures for some measurement purposes. Conversion tables are provided for the 7 scales to facilitate transformation from raw scores to IRT-calibrated (theta) scores.