Abstract
The Alexithymia Questionnaire for Children (ASC), frequently referred to in international literature as the Children’s Alexithymia Measure or the Children’s Alexithymia Questionnaire (AQC), is a standardized, self-report psychometric instrument designed to evaluate the multifaceted construct of alexithymia in youth aged 8 to 14 years. Developed by developmental psychologists Carolien Rieffe, Paul Oosterveld, and Mark Meerum Terwogt (2006), the instrument adapts the foundational conceptual architecture of the adult 20-Item Toronto Alexithymia Scale (TAS-20) to ensure linguistic accessibility, developmental appropriateness, and cognitive readability for pediatric and early adolescent cohorts. The ASC comprises 20 items evaluated across three interrelated latent dimensions: Difficulty Identifying Feelings (DIF; 7 items), Difficulty Describing Feelings (DDF; 5 items), and Externally-Oriented Thinking (EOT; 8 items). Respondents rate statements on a simplified 3-point Likert scale (0 = “Not true”, 1 = “Sometimes true”, 2 = “Often true”). Psychometric evaluations in normative and clinical pediatric samples demonstrate adequate to robust internal consistency across the total score (Cronbach’s α = .72–.84) and the DIF and DDF subscales (α = .70–.79), with typical structural attenuations noted in the developmentally complex EOT dimension (α = .55–.64). Confirmatory factor analyses consistently substantiate the theoretical three-factor structure, mirroring adult psychopathology paradigms while reflecting childhood emotional development. The instrument demonstrates strong convergent validity with measures of childhood depression, generalized anxiety, somatization, and functional somatic complaints, alongside discriminant validity against general non-verbal intelligence. The ASC serves as an indispensable tool across developmental psychopathology, pediatric behavioral medicine, clinical psychology, and affective neuroscience.
Keywords
Alexithymia Questionnaire for Children, ASC, pediatric alexithymia, emotion identification, emotion description, externally-oriented thinking, pediatric psychometrics, psychosomatic symptoms, childhood affect regulation, developmental psychopathology
Authors
The Alexithymia Questionnaire for Children was conceptualized, developed, and empirically validated by a collaborative team of developmental psychologists and psychometricians based in the Netherlands:
- Carolien Rieffe, Ph.D. – Professor of Developmental Psychology, Focus on Emotions Research Center, Department of Developmental and Educational Psychology, Leiden University, Leiden, The Netherlands; also affiliated with the University of Twente and University College London. (Email: [email protected] / Focus on Emotions).
- Paul Oosterveld, Ph.D. – Psychometrician and Methodologist, Department of Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands.
- Mark Meerum Terwogt, Ph.D. – Emeritus Professor of Developmental Psychology, Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands.
Purpose
The primary clinical and empirical objective of the Alexithymia Questionnaire for Children is to furnish a developmentally sensitive, reliable, and valid screening and diagnostic research instrument capable of capturing deficits in emotional processing among children and young adolescents. The construct of alexithymia, coined originally in adult clinical populations by Peter Sifneos and John Nemiah, refers to a cognitive-affective disturbance characterized by impaired symbolic representation of emotions, a limited capacity to identify subjective emotional states, an inability to verbalize emotional feelings to others, and a cognitive processing style focused almost entirely on external operational facts rather than inner psychological experiences.
Prior to the development of the ASC in 2006, empirical research investigating childhood alexithymia was severely constrained by the lack of an age-appropriate self-report tool. Researchers routinely attempted either to administer adult scales such as the TAS-20 directly to young cohorts—which introduced severe linguistic, semantic, and conceptual confounds—or to rely exclusively on parent- and teacher-report proxy instruments. However, proxy reports are intrinsically limited because alexithymia is an intrapsychic, experiential state involving internal sensations, subjective feeling tones, and private cognitive styles that external observers frequently misinterpret or fail to detect.
The ASC bridges this diagnostic gap by translating complex introspective concepts into clear, concrete everyday language suitable for primary school children and young adolescents. In clinical environments, the tool facilitates early identification of youths who are prone to somatization, functional neurological disorders, and chronic functional abdominal or cephalalgic pain, where distress is expressed through somatic conduits rather than emotional channels. In psychiatric and psychological research, the ASC enables the examination of affect dysregulation pathways across neurodevelopmental conditions such as Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), pediatric depression, post-traumatic stress, and eating disorders.
Psychological Construct
The ASC operationalizes childhood alexithymia as a three-dimensional construct grounded in contemporary developmental affective cognitive models:
1. Difficulty Identifying Feelings (DIF)
The Difficulty Identifying Feelings subscale consists of 7 items (e.g., Item 1: “I am often confused about the way I am feeling inside”; Item 6: “When I am upset, I don’t know if I am sad, scared or angry”). DIF reflects a core deficit in interoceptive and affective differentiation. Children scoring high on this dimension struggle to distinguish between discrete negative emotional states (such as separating fear from rage or sadness) and often cannot differentiate the physiological correlates of emotional arousal (e.g., tachycardia, muscle tension, visceral autonomic arousal) from the somatic manifestations of physical illness (Item 3: “I feel things in my body that even doctors don’t understand”; Item 7: “I am often puzzled by things that I feel in my body”). Consequently, these children frequently experience profound visceral distress that remains unstructured, confusing, and unclassified, rendering systematic cognitive emotion regulation nearly impossible.
2. Difficulty Describing Feelings (DDF)
Comprising 5 items (e.g., Item 2: “I find it difficult to say how I feel inside”; Item 9: “Sometimes I can’t find the words to say how I feel inside”; Item 17: “It is difficult for me to say how I really feel inside, even to my best friend”), the DDF dimension captures communicative and verbal expressive deficits. While DIF represents an intrapsychic interpretive challenge, DDF pertains directly to interpersonal expressive functioning. Children scoring high on DDF lack the affective lexicon and mentalizing vocabulary required to communicate internal affective experiences to significant others (peers, parents, teachers, clinicians). This deficit severely hampers help-seeking behaviors and interpersonal empathy, leaving the child socially isolated during episodes of emotional stress.
3. Externally-Oriented Thinking (EOT)
The Externally-Oriented Thinking subscale contains 8 items (e.g., Item 8: “I’d rather wait and see what happens, instead of thinking about why things happen”; Item 15: “I prefer talking to people about everyday things, rather than about how they feel”; Item 16: “I prefer watching funny television programmes, rather than films that tell a story about other people’s problems”). EOT assesses a cognitive orientation characterized by concrete, pragmatic, operational thinking focused almost exclusively on outward environmental events, mechanical processes, and superficial social exchanges, rather than imaginative, introspective, or fantasy-based inner psychological states. Unlike DIF and DDF, which capture subjective distress regarding emotional confusion, EOT reflects a cognitive style or preference that avoids deep mentalization and emotional introspection.
Theoretical Framework
The theoretical foundations of the ASC are anchored in psychosomatic medicine, cognitive-developmental theories of emotional awareness, and contemporary neurodevelopmental emotion regulation paradigms.
The earliest clinical observations of alexithymia emerged from psychoanalytic and psychosomatic inquiries conducted by Nemiah, Freyberger, and Sifneos in the 1970s. They observed that individuals with classic psychosomatic disorders exhibited an impoverished fantasy life (pensée opératoire) and an incapacity to assign words to their feelings. Graeme J. Taylor, Michael Bagby, and James D. Parker formalized this construct into a continuous personality trait reflecting a deficit in the cognitive processing and regulation of emotion within a biobehavioral framework.
To conceptualize the construct developmentally, Rieffe and colleagues integrated the Levels of Emotional Awareness Model formulated by Richard D. Lane and Gary E. Schwartz (1987). Lane and Schwartz proposed a five-tiered structural-developmental hierarchy of emotional awareness resembling Piagetian cognitive stages: (1) visceral sensations, (2) action tendencies, (3) single discrete emotions, (4) blends of emotions, and (5) differentiated blends of emotions in self and others. Under this developmental framework, childhood alexithymia can be viewed as an arrest or delay in emotional awareness progression: children exhibiting elevated alexithymia remain fixated at primary sensorimotor or visceral levels of emotional experience. Because they cannot advance to symbolic and blended cognitive representations of emotion, affective arousal is experienced as unexplained bodily dysregulation, leading directly to functional somatization, visceral panic, or externalized behavioral dysregulation.
Validity
Psychometric evaluations across multiple large-scale developmental investigations have established robust construct, convergent, discriminant, and cross-cultural validity for the ASC.
Construct and Structural Validity
In the seminal psychometric validation study conducted by Rieffe, Oosterveld, and Meerum Terwogt (2006) involving 744 Dutch schoolchildren aged 9 to 15, confirmatory factor analyses verified that a three-factor model representing DIF, DDF, and EOT exhibited superior construct validity compared to alternative unidimensional or two-factor models. Subsequent replications across international cohorts—including Iranian pediatric samples (Nasiri, Latifian, & Rieffe, 2009; Rieffe et al., 2010), Italian school-aged cohorts, and Spanish translations—consistently replicated this structural stability.
Convergent Validity
Convergent validity has been repeatedly demonstrated through significant, theoretically expected correlations with validated clinical and affective measures:
- Somatization and Somatosensory Amplification: ASC total scores, particularly the DIF subscale, demonstrate strong positive correlations (r = .45 to .58, p < .001) with the Children’s Somatization Inventory (CSI) and pediatric physical complaint inventories. Children with high DIF scores report markedly higher incidences of unexplained abdominal pains, headaches, nausea, and fatigue.
- Internalizing Affective Symptoms: Robust correlations are observed between the ASC and standardized pediatric depression inventories (e.g., Children’s Depression Inventory [CDI], r = .40 to .52) and anxiety measures (e.g., Revised Children’s Manifest Anxiety Scale [RCMAS], r = .38 to .49). Longitudinal analyses confirm that alexithymia acts as a predisposing vulnerability factor for depressive episode onset during early adolescence.
- Emotion Recognition and Competency: Children with elevated ASC scores exhibit significantly slower reaction times and lower accuracy scores on experimental facial emotion recognition batteries and cognitive mentalizing/theory-of-mind tasks.
Discriminant Validity
Discriminant validity is supported by near-zero correlations between the ASC and standard measures of general fluid and non-verbal cognitive intelligence (e.g., Raven’s Standard Progressive Matrices; r values typically between −.04 and .08, non-significant). This confirms that the ASC captures emotional cognitive deficits rather than general intellectual or cognitive delays.
Reliability
The ASC demonstrates acceptable to excellent reliability across standard psychometric parameters:
Internal Consistency
In the initial normative sample of 744 children (Rieffe et al., 2006), the total 20-item scale demonstrated high internal consistency, yielding a Cronbach’s alpha of α = .77. Subscale reliability analyses yielded:
- Difficulty Identifying Feelings (DIF): α = .75 to .79 across samples, indicating strong internal consistency.
- Difficulty Describing Feelings (DDF): α = .70 to .75, denoting robust scale coherence.
- Externally-Oriented Thinking (EOT): α = .55 to .64. While modest, this lower coefficient mirrors findings observed in adult TAS-20 literature and reflects the developmental complexity, item heterogeneity, and cognitive maturity required to self-evaluate abstract externalized thinking in childhood.
Cross-cultural investigations, such as Rieffe et al. (2010) with 418 Iranian children and adolescents, produced comparable internal consistencies (α = .78 for DIF, α = .71 for DDF, and α = .61 for EOT).
Test-Retest Reliability
Stability across time has been substantiated across intervals of 4 to 8 weeks. In developmental retest cohorts, the total ASC score demonstrated intra-class correlation coefficients (ICC) ranging from .72 to .81, confirming that childhood alexithymia exhibits trait-like stability rather than reflecting transient affective states.
Factor Analysis
The factorial validity of the ASC has been extensively modeled using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).
During preliminary instrument construction, principal component analysis with oblique (Oblimin) rotation demonstrated that the 20 items loaded cleanly onto three prominent factors with eigenvalues > 1.5, jointly accounting for over 41% of the total variance. Factor loadings for individual items onto their designated latent constructs consistently exceeded the conventional psychometric threshold of .40:
- DIF Items (e.g., Items 1, 3, 6, 7, 13, 14) demonstrated primary loadings on Factor 1 ranging from .48 to .73, with minimal secondary cross-loadings (< .20).
- DDF Items (e.g., Items 2, 4, 9, 11, 17) loaded strongly onto Factor 2 with standardized loadings between .51 and .76.
- EOT Items (e.g., Items 5, 8, 10, 15, 16, 18, 19, 20) loaded onto Factor 3 with loadings ranging from .34 to .58.
Subsequent CFA testing confirmed acceptable model fit indices under standard structural equation modeling guidelines:
- Comparative Fit Index (CFI): .91 to .94
- Tucker-Lewis Index (TLI): .90 to .93
- Root Mean Square Error of Approximation (RMSEA): .041 to .053 (90% CI [.034, .058]), indicating close approximate model fit
- Standardized Root Mean Square Residual (SRMR): .051
Comparative model testing definitively rejected single-factor models (Δχ² test p < .001, CFI < .80), affirming that pediatric alexithymia cannot be understood as a monolithic trait, but requires distinct evaluation across identifying, verbalizing, and externally focused sub-components.
Instrument / Measurement Tool
- Instrument Name: Alexithymia Questionnaire for Children (ASC) [also referenced as Children’s Alexithymia Questionnaire (AQC)]
- Authors: Carolien Rieffe, Paul Oosterveld, and Mark Meerum Terwogt
- Year of Publication: 2006
- Target Population: Children and young adolescents aged 8 to 14 years
- Administration Format: Self-report paper-and-pencil questionnaire or digital computerized survey; group or individual administration
- Estimated Completion Time: 5 to 10 minutes
- Total Item Count: 20 items
- Factor Structure / Subscales:
- Difficulty Identifying Feelings (DIF): 7 items (Items 1, 3, 6, 7, 12, 13, 14)
- Difficulty Describing Feelings (DDF): 5 items (Items 2, 4, 9, 11, 17)
- Externally-Oriented Thinking (EOT): 8 items (Items 5, 8, 10, 15, 16, 18, 19, 20)
- Response Format: 3-point ordinal Likert scale:
- 0 = Not true
- 1 = Sometimes true
- 2 = Often true
(Alternative descriptive labels used in initial Dutch/English pilot formulations: “not true”, “a bit true”, “true”)
- Scoring and Directionality:
- Positively keyed items are scored: Not true = 0; Sometimes true = 1; Often true = 2.
- Reverse-Scored Items: Items 4, 10, 18, and 19 represent emotionally competent or introspective statements and MUST be reverse-scored prior to summing (i.e., Not true = 2; Sometimes true = 1; Often true = 0).
- Total Score: Calculated by summing all 20 items following reverse-scoring (range: 0 to 40). Higher total scores reflect greater levels of childhood alexithymia.
- Subscale Scores: Derived by summing designated items for DIF (range: 0 to 14), DDF (range: 0 to 10), and EOT (range: 0 to 16).
Permissions & Fee and Test Year
The Alexithymia Questionnaire for Children (ASC) was developed in 2006. In alignment with open-science developmental research initiatives led by Dr. Carolien Rieffe and the Focus on Emotions research consortium, the ASC is made freely accessible for academic, clinical, and non-commercial research purposes without charging licensing or per-administration fees. The scale is hosted in English, Dutch, and several translated versions via institutional academic repositories. Researchers and clinical practitioners utilizing the instrument are required to maintain authentic item phrasing and provide proper attribution by citing the foundational validation study (Rieffe et al., 2006). Commercial publication, incorporation into proprietary digital diagnostics, or distribution for profit requires formal written authorization from the primary authors.
References
- Bagby, R. M., Parker, J. D., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1
- Lane, R. D., & Schwartz, G. E. (1987). Levels of emotional awareness: A cognitive-developmental theory and its application to psychopathology. American Journal of Psychiatry, 144(2), 133–143. https://doi.org/10.1176/ajp.144.2.133
- Nasiri, H., Latifian, M., & Rieffe, C. (2009). Alexithymia and its relationship with physical complaints and emotional competency in children and adolescents. Iranian Journal of Psychiatry and Clinical Psychology, 15(3), 248–257. http://ijpcp.iums.ac.ir/article-1-807-en.html
- Nemiah, J. C., Freyberger, H., & Sifneos, P. E. (1976). Alexithymia: A view of the psychosomatic process. In O. W. Hill (Ed.), Modern Trends in Psychosomatic Medicine (Vol. 3, pp. 430–439). Butterworths.
- Rieffe, C., Oosterveld, P., & Meerum Terwogt, M. (2006). An alexithymia questionnaire for children: Factorial and concurrent validation results. Personality and Individual Differences, 40(1), 123–133. https://doi.org/10.1016/j.paid.2005.05.013
- Rieffe, C., Oosterveld, P., Meerum Terwogt, M., Novin, S., Nasiri, H., & Latifian, M. (2010). Relationship between alexithymia, mood and internalizing symptoms in children and young adolescents: Evidence from an Iranian sample. Personality and Individual Differences, 48(4), 425–430. https://doi.org/10.1016/j.paid.2009.11.015
- Taylor, G. J., Bagby, R. M., & Parker, J. D. (1997). Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press. https://doi.org/10.1017/CBO9780511526831