Awareness Questionnaire

1. Abstract

The Awareness Questionnaire (AQ) is a premier psychometric instrument engineered to evaluate neurocognitive awareness of deficits, clinically recognized as anosognosia or impaired self-awareness (ISA), following traumatic brain injury (TBI) and other acquired neurological conditions such as cerebrovascular accident (CVA). Developed primarily by Mark Sherer and colleagues in 1998, the AQ employs a triadic rating design comprising three parallel forms: Patient Self-Rating, Significant Other (family caregiver) Rating, and Clinician (treating multidisciplinary professional) Rating. The instrument contains 17 standardized items that evaluate functional abilities post-injury compared to premorbid functioning across three primary neurobehavioral domains: motor/sensory functions, cognitive processes, and behavioral/affective functioning. Responses are recorded on a 5-point Likert scale ranging from 1 (much worse) to 5 (much better), with 3 denoting stability (about the same). Total scores on each form range from 17 to 85. Discrepancy scores are calculated by subtracting the clinician or significant other total score from the patient self-rating score; positive discrepancy values reflect overestimation of functional competence, operationally defining impaired self-awareness. Extensive psychometric evaluations demonstrate high internal consistency (Cronbach’s alpha spanning .88 to .95 across forms), robust test-retest reliability (.84 to .94), and clear factor structures confirming distinct motor, cognitive, and affective dimensions. The AQ displays strong convergent validity with objective neuropsychological benchmarks and behavioral competency indicators, establishing itself as a gold-standard assessment across neurorehabilitation, outcome prediction, and clinical research paradigms.

2. Keywords

Awareness Questionnaire, anosognosia, impaired self-awareness, traumatic brain injury, neurorehabilitation, discrepancy scores, cognitive deficit unawareness, executive functioning, metacognition, caregiver report

3. Authors

The Awareness Questionnaire was conceived, developed, and standardized by Mark Sherer, Ph.D., ABPP-CN, along with distinguished colleagues in the field of clinical neuropsychology and brain injury rehabilitation:

• Mark Sherer, Ph.D., ABPP-CN: Senior Scientist, Associate Vice President for Research, and Director of Research at the TIRR Memorial Hermann Rehabilitation and Research System; Clinical Professor of Physical Medicine and Rehabilitation at Baylor College of Medicine, Houston, Texas, USA. Dr. Sherer is an internationally recognized authority on cognitive rehabilitation, traumatic brain injury outcomes, and the assessment of post-acute anosognosia.
• Karin Boake, Ph.D.: Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.
• Margaret A. Struchen, Ph.D.: Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.
• Carl A. Levunz, Ph.D., ABPP-CN: Neuropsychologist and rehabilitation researcher contributing to early measurement metrics of post-TBI metacognition.
• Dutch Adaptation: Developed and validated by Gerdie J. Geurtsen, Ph.D. (2005), Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Netherlands, extending psychometric evaluation to European clinical cohorts.

4. Purpose

The primary clinical and scientific purpose of the Awareness Questionnaire is to provide an objective, reliable, and standardized operationalization of self-awareness deficits in individuals recovering from acquired neurological insult, most notably traumatic brain injury. Historically, clinical judgment of anosognosia relied on informal, semi-structured interviews or clinician intuition, which introduced substantial subjectivity, poor inter-rater concordance, and limited reproducibility across post-acute milestones. The AQ overcomes these systemic limitations through a multi-informant discrepancy paradigm.

Following moderate-to-severe neurotrauma or ischemic cerebrovascular accidents, patients often demonstrate a pronounced dissociation between their subjective appraisal of functional capacity and their actual day-to-day neurobehavioral performance. This lack of awareness is not mere psychological denial; rather, it reflects a foundational neurobiological disturbance in executive monitoring networks, predominantly implicating prefrontal, frontostriatal, and right parietal systems. The AQ explicitly operationalizes this phenomenon by contrasting the patient’s internal perception against the external perceptions of trained clinical staff and long-term collateral observers (spouses, parents, or designated caregivers).

Beyond diagnostics, the AQ serves several vital clinical and empirical functions:

• Rehabilitation Goal Setting and Engagement: Patients exhibiting elevated discrepancy scores frequently display diminished therapeutic motivation, fail to adhere to compensatory cognitive strategies (e.g., memory logs, structured planning software), and resist therapeutic constraints (e.g., driving bans, financial oversight). Identifying unawareness profiles enables the clinical team to tailor psychoeducational and feedback-based protocols specifically aimed at rebuilding metacognitive monitoring.
• Risk Stratification and Safety Planning: Overestimation in physical or cognitive domains directly correlates with accidental injury, catastrophic falls, unsafe vehicle operation, and vulnerability to financial exploitation. The AQ assists interdisciplinary teams in establishing necessary environmental scaffolds and legal protective orders.
• Longitudinal Outcome Tracking: Administered repeatedly over the course of acute hospitalization, post-acute residential care, and community reintegration, the AQ tracks the gradual resolution or entrenchment of unawareness, yielding prognostic value for long-term independent living, vocational reintegration, and emotional stability.
• Caregiver Burden Identification: Marked discrepancies between family ratings and patient ratings highlight areas of domestic friction, allowing rehabilitation psychologists to intervene early with family counseling, education, and respite planning to reduce chronic caregiver distress.

5. Psychological Construct

The core psychological construct captured by the AQ is impaired self-awareness (ISA), conceptualized as a multi-layered neurocognitive failure to perceive, process, and integrate changes in functioning caused by brain pathology. Self-awareness after brain injury is inherently multidimensional, spanning distinct yet interconnected functional domains.

The Tripartite Domain Structure

The AQ assesses self-awareness across three foundational behavioral axes:

• Motor and Sensory Functioning (Items 9, 10, 11, 12): This sub-construct captures the patient’s recognition of basic sensorimotor capacity, including visual acuity, auditory perception, upper-extremity motor execution, and lower-extremity ambulation. Clinical research demonstrates that patients generally re-establish awareness of overt sensorimotor impairments more rapidly than cognitive or behavioral deficits, because physical limitations offer direct, immediate sensory feedback (e.g., stumbling during ambulation, dropping an object).
• Cognitive Functioning (Items 4, 5, 6, 7, 8, 15, 16): This domain addresses executive control, retrospective and prospective episodic memory, sustained and divided attention, information processing velocity, and expressive/receptive linguistic clarity. Metacognitive failure within this domain manifests as an inability to anticipate memory breakdowns or recognize attentional lapses, leading the individual to claim complete readiness for complex vocational responsibilities or academic performance despite objective neuropsychological deficits.
• Behavioral and Affective Functioning (Items 1, 2, 3, 13, 14, 17): This domain evaluates interpersonal regulation, anger modulation, behavioral initiation, adaptability to environmental stressors, and high-order functional milestones (e.g., independent living, vehicle operation, personal financial administration). Deficits here frequently emerge from orbitofrontal and anterior cingulate disruption, leaving the patient unable to perceive their own disinhibition, apathy, emotional lability, or poor social judgment, which are consistently identified by significant others as the most distressing long-term outcomes.

The Discrepancy Metric Construct

Impaired awareness is mathematically and conceptually represented through calculated variance between observers:

$$\text{Discrepancy}_{\text{Clinician}} = \text{Total Score}_{\text{Patient}} – \text{Total Score}_{\text{Clinician}}$$
$$\text{Discrepancy}_{\text{Significant Other}} = \text{Total Score}_{\text{Patient}} – \text{Total Score}_{\text{Significant Other}}$$

A score near zero indicates congruent appraisals, reflecting preserved awareness. Substantial positive values (+10 to +30 or greater) signify severe anosognosia or overestimation of abilities, whereas negative discrepancy scores occasionally denote post-traumatic depression, catastrophic reactions, or heightened anxiety wherein the patient under-evaluates their functional capacity relative to objective reality.

6. Theoretical Framework

The Awareness Questionnaire is structurally rooted in comprehensive neuropsychological and cognitive models of metacognition, most prominently the Hierarchical Model of Self-Awareness formulated by George P. Prigatano and expanded by Barco, Crosson, and colleagues (1991), alongside the Dynamic Comprehensive Model of Awareness developed by Joan Toglia and Joyce Kirk (2000).

Crosson and Barco’s Pyramid Model

This classical framework conceptualizes self-awareness as a three-tiered hierarchical pyramid:

• Intellectual Awareness: The lowest foundational tier, representing the static cognitive ability to understand that a particular function is diminished or absent (e.g., acknowledging intellectually, “I have sustained a head injury and my memory is slower”). The AQ directly interrogates this dimension by asking patients to compare present functional states to premorbid status across concrete daily living situations.
• Emergent Awareness: The intermediate tier, defined as the online capacity to recognize a cognitive or functional problem in real time, while it is actively transpiring (e.g., realizing in mid-sentence that words have been forgotten).
• Anticipatory Awareness: The highest, most sophisticated tier of metacognition, entailing the proactive projection of difficulty before an activity commences, prompting the deliberate implementation of compensatory strategies (e.g., writing a checklist prior to executing a complex financial transaction).

The AQ primarily diagnoses deficits originating at the level of intellectual awareness, which inevitably compromise both emergent and anticipatory processing.

Toglia and Kirk’s Dynamic Model

Toglia and Kirk posited that awareness is not a static trait but an ongoing, dynamic transaction involving the individual’s metacognitive knowledge base, online task demands, environmental context, and the psychological defense mechanisms mobilized in response to trauma. Under this view, discrepancy patterns captured by the AQ illustrate an operational breakdown between the patient’s internal “knowledge of capabilities” and external environmental feedback. The AQ’s simultaneous deployment of significant other and clinician ratings accounts for environmental variance: clinicians judge patients against objective functional milestones, while significant others reflect the complex dynamics of everyday domestic and relational demands.

7. Validity

The Awareness Questionnaire has been subjected to rigorous psychometric scrutiny across multiple national cohorts, demonstrating exceptional construct, convergent, predictive, and discriminant validity.

Construct and Convergent Validity

Construct validity is substantiated through marked, statistically significant correlations with alternative validated measures of self-awareness, such as the Self-Awareness of Deficits Interview (SADI), the Patient Competency Rating Scale (PCRS), and the Brain Injury Screening Questionnaire. Sherer et al. (1998, 2003) demonstrated that AQ patient-clinician discrepancy scores correlate significantly with objective cognitive testing, including scores on the Wechsler Adult Intelligence Scale (WAIS), the Trail Making Test (Part B), and the Wisconsin Card Sorting Test (WCST), confirming that deficits in awareness mirror underlying prefrontal executive dysfunction.

In a seminal validation study by Sherer et al. (2003) involving 108 individuals with moderate-to-severe TBI, AQ clinician ratings demonstrated a strong inverse correlation with acute injury severity metrics, including the Glasgow Coma Scale (GCS) and duration of post-traumatic amnesia (PTA). Greater injury severity reliably predicted wider discrepancy scores, confirming the neurogenic origin of the measured unawareness.

Predictive and Ecological Validity

The predictive validity of the AQ is exceptionally robust regarding real-world functional milestones:

• Productive Activity and Employment: Research by Sherer et al. (2002) identified the AQ patient-clinician discrepancy score as one of the most powerful independent predictors of successful return to competitive employment at one-year post-injury, outperforming raw neuropsychological test scores alone. Patients who systematically overestimate their competence display higher rates of job termination, interpersonal conflict with colleagues, and vocational disengagement.
• Functional Independence Measure (FIM): Significant other and clinician AQ forms correlate strongly with motor and cognitive FIM discharge scores ($r = .45$ to $.68, p < .001$), demonstrating that AQ evaluations closely reflect observable activities of daily living (ADLs).

Discriminant Validity

The AQ cleanly differentiates between neurological populations and non-injured control subjects. Non-neurological control dyads (healthy individuals and their family members) typically produce discrepancy scores hovering between $-2$ and $+2$, reflecting near-perfect consensus. Furthermore, studies comparing individuals with focal prefrontal lesions to individuals with peripheral orthopedic injuries confirm that severe overestimation discrepancy profiles are virtually absent in orthopedic cohorts, proving that the AQ does not simply measure general distress or the disruption of hospitalization.

8. Reliability

The psychometric integrity of the Awareness Questionnaire is reinforced by robust reliability metrics spanning multiple cultures, language adaptations, and clinical cohorts.

Internal Consistency

Extensive studies have systematically examined the internal consistency of the AQ across its three independent forms using Cronbach’s alpha ($lpha$):

• Clinician Form: $\alpha$ consistently ranges from .88 to .95, reflecting exceptional item homogeneity and precise target-construct alignment across physical, cognitive, and affective domains.
• Significant Other Form: $\alpha$ routinely spans .86 to .92, indicating that family observers perceive a cohesive constellation of altered functional behaviors.
• Patient Form: $\alpha$ typically yields slightly lower, yet robust values ranging from .78 to .88. This expected variance reflects the fragmented, heterogeneous nature of post-traumatic metacognition in patients experiencing varying degrees of unawareness.

Test-Retest and Inter-Rater Reliability

Temporal stability evaluations conducted across stable post-acute intervals (2- to 4-week retest paradigms) reveal high stability coefficients:

• Significant Other ratings demonstrate test-retest correlations between $r = .84$ and $.92$.
• Clinician ratings, when evaluated across stable interdisciplinary staff members, yield intra-class correlation coefficients (ICC) between .83 and .94.
• Patient self-ratings maintain test-retest coefficients between $r = .72$ and $.81$, demonstrating that while unawareness is a dynamic trait subject to neurorehabilitation gains, short-term measurement remains structurally stable.

9. Factor Analysis

Psychometric evaluations employing both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across diverse international cohorts have verified the multidimensional construct of the Awareness Questionnaire.

Factor Architecture

Early psychometric work by Sherer et al. (1998) established an underlying three-factor solution explaining between 54% and 62% of the total variance across clinician and caregiver forms:

• Factor 1: Cognitive Functioning: Encompassing attention, processing speed, memory, communication, and complex academic/occupational performance (Items 4, 5, 6, 7, 8, 15, 16). Item loadings within this factor consistently exceed .60, with Item 7 (remembering recent events) and Item 16 (focus and attention) regularly demonstrating loadings above .75.
• Factor 2: Behavioral and Affective Functioning: Encompassing anger control, interpersonal relationships, emotional adaptation to unexpected changes, and advanced independent executive management (Items 1, 2, 3, 13, 14, 17). Loadings within this factor typically range from .52 to .78.
• Factor 3: Motor and Sensory Functioning: Encompassing basic physical ambulation, upper extremity dexterity, vision, and hearing (Items 9, 10, 11, 12). Items 11 and 12 display high factor purity, with primary loadings frequently exceeding .80 and minimal cross-loadings onto the cognitive or behavioral axes.

Confirmatory Structural Equation Modeling

Subsequent psychometric investigations, including structural validation studies performed on European and North American cohorts (such as the Dutch validation by Geurtsen et al., 2005), confirm that a correlated three-factor model demonstrates superior fit compared to a unidimensional model:

• Comparative Fit Index (CFI): $ge .93$
• Tucker-Lewis Index (TLI): $ge .91$
• Root Mean Square Error of Approximation (RMSEA): $le .062$ (90% CI: .048–.075)
• Standardized Root Mean Square Residual (SRMR): $le .054$

These findings substantiate the use of both aggregate discrepancy scores and targeted domain-specific subscale analyses in clinical neuropsychological practice.

10. Instrument / Measurement Tool

The operational specifications of the Awareness Questionnaire are organized as follows:

• Instrument Type: Standardized multi-informant rating scale / neurobehavioral questionnaire.
• Parallel Versions: Three distinct forms with identical item phrasing adjusted for grammatical perspective:
  • Patient Self-Rating Form (completed independently or via interview).
  • Significant Other Rating Form (completed by spouse, parent, child, or close friend).
  • Clinician Rating Form (completed by treating neuropsychologist, speech-language pathologist, occupational therapist, or physician).
• Total Item Count: 17 items per form.
• Response Format: 5-point Likert scale:
  • 1 = Much worse
  • 2 = Worse
  • 3 = About the same
  • 4 = Better
  • 5 = Much better
• Comparative Baseline: Current post-injury ability is explicitly rated in direct comparison to the individual’s premorbid (pre-injury) ability level.
• Scoring Metrics:
  • Total Score Range: 17 to 85 points per completed form.
  • Neutral Baseline: A score of 51 (17 items × 3) signifies an overall perception that current functioning is identical to premorbid functioning.
  • Patient-Clinician Discrepancy Score: Patient Total Score minus Clinician Total Score.
  • Patient-Significant Other Discrepancy Score: Patient Total Score minus Significant Other Total Score.
• Clinical Interpretation of Discrepancies:
  • Substantial Positive Discrepancy (> +5 to +10 or higher): Indicates clinically significant overestimation of abilities, diagnosing impaired self-awareness (anosognosia).
  • Congruent Scores (between -5 and +5): Reflects intact, realistic self-awareness.
  • Substantial Negative Discrepancy (< -5 to -10 or lower): Indicates underestimation of competence, often correlating with post-traumatic mood disorders, situational depression, or excessive catastrophic performance anxiety.

11. Permissions & Fee and Test Year

The Awareness Questionnaire was formally published and standardized in 1998 by Dr. Mark Sherer and colleagues. As part of clinical research initiatives within physical medicine, traumatic brain injury model systems, and neuropsychology, the AQ is widely classified in the public domain for clinical, non-commercial, and academic research purposes.

No formal licensing fee is required for non-commercial academic research, institutional rehabilitation tracking, or doctoral training initiatives. However, clinicians and investigators are expected to preserve the intellectual property attribution by citing original validation works (Sherer et al., 1998, 2003; Geurtsen et al., 2005) and to avoid unauthorized commercial distribution or incorporation into closed, commercial software suites without obtaining direct written authorization from the primary authors or copyright administrators.

12. References

• Barco, P. P., Crosson, B., Bolesta, M. M., Werts, D., & Stout, R. (1991). Approved cognitive rehabilitation: Awareness training in brain injury rehabilitation. The Clinical Neuropsychologist, 5(3), 281–290. https://doi.org/10.1080/13854049108403303
• Crosson, B., Barco, P. P., Velozo, C. A., Bolesta, M. M., Werts, D., & Brophy, J. J. (1989). Awareness and compensation in postacute head injury rehabilitation. The Journal of Head Trauma Rehabilitation, 4(3), 46–54. https://doi.org/10.1097/00001199-198909000-00008
• Geurtsen, G. J., van Heugten, C. M., Martina, J. D., & Geurts, A. C. (2005). Comprehensive rehabilitation programmes in the chronic phase after severe brain injury for patients with impaired self-awareness: The Dutch version of the Awareness Questionnaire. Journal of Rehabilitation Medicine, 37(4), 209–215. https://doi.org/10.1080/16501970510027663
• Prigatano, G. P. (1999). Principles of Neuropsychological Rehabilitation. Oxford University Press. https://doi.org/10.1093/med/9780195081480.001.0001
• Sherer, M., Bergloff, P., Boake, C., High, W. M., & Levin, E. (1998). The Awareness Questionnaire: Factor structure and internal consistency. Archives of Physical Medicine and Rehabilitation, 79(9), 1052–1058. https://doi.org/10.1016/S0003-9993(98)90170-8
• Sherer, M., Boake, C., & Levin, E. (2002). Predictors of return to work after severe traumatic brain injury: A quantitative review. Journal of Head Trauma Rehabilitation, 17(3), 207–221. https://doi.org/10.1097/00001199-200206000-00004
• Sherer, M., Hart, T., & Nick, T. G. (2003). Measurement of impaired self-awareness after traumatic brain injury: A comparison of the Patient Competency Rating Scale and the Awareness Questionnaire. Brain Injury, 17(1), 25–37. https://doi.org/10.1080/0269905021000010122
• Toglia, J., & Kirk, U. (2000). Understanding awareness deficits following brain injury. NeuroRehabilitation, 15(1), 57–70. https://doi.org/10.3233/NRE-2000-15107

13. Items of the Scale