Children’s Health Locus of Control Scale

1. Abstract

The Children’s Health Locus of Control Scale (CHLOCS) is a pioneering psychometric instrument developed by health psychologists Guy S. Parcel and Philip R. Meyer in 1978. Engineered specifically to assess developmental expectations of personal agency, external authority, and stochastic factors over health outcomes, the CHLOCS operationalizes Julian B. Rotter’s social learning framework within pediatric medicine and school health education. The instrument consists of 20 self-report statements calibrated for children aged 7 through 12 years (grades 3 through 6), utilizing an accessible dichotomous response format (YES/NO) preceded by structured practice items to accommodate concrete operational cognitive processing. Psychometrically, the instrument captures three cardinal dimensions: Internal Health Locus of Control (the child’s belief that their personal actions dictate health and disease outcomes), Powerful Others Locus of Control (the conviction that parents, physicians, nurses, and teachers serve as the primary determinants of health), and Chance/Luck Locus of Control (the fatalistic attribution of illness and injury to random occurrences or misfortune).

Original validation studies demonstrated adequate internal consistency for a pediatric screening tool, yielding a Kuder-Richardson 20 (KR-20) reliability coefficient of .72 to .75 and test-retest reliability estimates across a six-week interval ranging from .64 to .71. Construct validity was corroborated through exploratory factor analysis, concurrent associations with general locus of control measures (such as the Nowicki-Strickland Locus of Control Scale), and predictive associations with child health self-advocacy, adherence to therapeutic regimens in pediatric chronic illnesses (e.g., asthma, type 1 diabetes mellitus), and engagement in preventive hygiene. By translating generalized expectancy constructs into age-appropriate pediatric health behaviors, the CHLOCS remains a foundational instrument in pediatric behavioral medicine, developmental psychometrics, and school-based health promotion research.

2. Keywords

Children’s Health Locus of Control Scale, CHLOCS, pediatric health psychology, locus of control, health behavior, Guy S. Parcel, social learning theory, pediatric adherence, chronic illness management, psychometrics, health belief model, health education

3. Authors

The Children’s Health Locus of Control Scale was created and validated by:

• Guy S. Parcel, Ph.D.: Emeritus Professor of Behavioral Sciences and Health Promotion at the University of Texas Health Science Center at Houston (UTHealth School of Public Health). Dr. Parcel is an internationally recognized scholar in child and adolescent health behavior, health education curriculum design, and the application of social-cognitive models to chronic disease self-management. Correspondence: [email protected].
• Philip R. Meyer, Ph.D.: Research psychologist and psychometrician who collaborated with Dr. Parcel at the University of Texas Medical Branch at Galveston, contributing expertise in pediatric measurement, cognitive developmental testing, and test scaling.

4. Purpose

The Children’s Health Locus of Control Scale was developed to address an essential empirical gap in pediatric medicine and developmental psychology: the absence of a reliable, developmentally calibrated measurement tool designed to quantify how children perceive the etiology and control of their physical well-being. Prior to the scale’s introduction in 1978, research into health-related attributional styles was largely restricted to adult populations through instruments such as the Health Locus of Control (HLC) Scale and the Multidimensional Health Locus of Control (MHLC) scales developed by Barbara Strudler Wallston, Kenneth A. Wallston, and colleagues. While generalized pediatric locus of control measures existed—most notably the Nowicki-Strickland Internal-External Scale for Children—generalized scales often failed to predict domain-specific health behaviors, preventive compliance, and coping responses to acute and chronic somatic illness.

Theoretical Rationale and Developmental Considerations

During middle childhood (roughly ages 7 to 12), children transition through what Jean Piaget characterized as the concrete operational stage of cognitive development. In this developmental window, a child’s understanding of causality evolves from undifferentiated magical thinking and external moral determinism toward an objective appreciation of internal biological mechanisms and behavioral consequence. Parcel and Meyer recognized that a child’s health behaviors—such as brushing teeth, complying with medication protocols, wearing protective gear, and eating balanced meals—are profoundly modulated by whether the child perceives an intrinsic causal link between personal actions and physiological outcomes.

If a child maintains a purely fatalistic or external orientation, believing that illnesses are arbitrary misfortunes or exclusively governed by adult authority figures, the motivation to practice self-care diminishes. Conversely, fostering an age-appropriate internal locus of control empowers the child to actively participate in preventive measures and disease management. The CHLOCS was designed to capture these attributional variations, serving as both a diagnostic baseline and an evaluative metric for behavioral interventions.

Clinical and Research Applications

In pediatric clinical settings, the CHLOCS provides behavioral health specialists, pediatricians, and clinical nurse specialists with granular insight into how young patients conceptualize their medical conditions. It is widely utilized in the management of pediatric chronic diseases, including:

• Pediatric Asthma: Assessing whether a child believes they possess personal agency to recognize early bronchospasm triggers and use rescue inhalers, versus passively waiting for parents or school nurses to intervene.
• Type 1 Diabetes Mellitus: Evaluating the developmental trajectory toward self-monitoring of blood glucose, carbohydrate estimation, and insulin administration adherence.
• Pediatric Oncology and Hematology: Understanding how children coping with leukemia or sickle cell disease interpret somatic crises, pain flares, and infection risks.
• Pediatric Dentistry and Preventive Hygiene: Measuring the child’s personal perceived responsibility for caries prevention and oral hygiene routines.

In public health and academic research, the CHLOCS serves as an indispensable outcome measure for health curricula (such as school-based smoking prevention, nutrition interventions, and accident prevention programs). By assessing shifts from external or fatalistic beliefs toward internalized health responsibility, educators can empirically validate the behavioral efficacy of health education programs.

5. Psychological Construct

The core construct evaluated by the CHLOCS is health locus of control in children—defined as a generalized expectancy regarding whether health, illness, physical well-being, and injury are contingent upon one’s own behavioral actions versus external forces beyond personal control. Drawing from Rotter’s multidimensional conceptualization and its specialized medical adaptation, the CHLOCS delineates three functional dimensions:

1. Internal Health Locus of Control (IHLC)

This dimension reflects the child’s belief that personal lifestyle choices, hygiene habits, safety practices, and treatment compliance directly govern their physical health status. Children scoring high on this dimension view health maintenance as an active, self-regulated endeavor. For example:

• “I can do things to keep from getting sick” (Item 2)
• “When I am sick, I can do things to get better” (Item 9)
• “I can make many choices about my health” (Item 16)

High internal scores correlate positively with self-efficacy, health literacy, proactive coping, resilience, and greater engagement in physical activity and nutritional hygiene. However, an excessively high internal orientation in the presence of severe, uncontrollable chronic illness can occasionally engender maladaptive self-blame if the child erroneously believes their somatic symptoms reflect personal moral or behavioral failure.

2. Powerful Others Health Locus of Control (PHLC)

This subscale captures the attribution of health outcomes to authoritative adult figures—primarily parents, doctors, school nurses, and teachers. For a developing child, reliance on powerful others is normative, adaptive, and structurally essential for survival. This dimension is exemplified by statements such as:

• “I can only do what the doctor tells me to do” (Item 4)
• “My mother must tell me how to keep from getting sick” (Item 7)
• “Whenever I feel sick I go to see the school nurse right away” (Item 18)

In early childhood, a high PHLC score reflects secure attachment and medical compliance. However, as children enter late childhood and early adolescence, an over-reliance on powerful others without a concurrent rise in internal locus can inhibit autonomous disease self-management, leading to therapeutic passivity and learned helplessness.

3. Chance / Fatalistic Health Locus of Control (CHLC)

The Chance dimension gauges the extent to which a child attributes health, disease, and injury to random luck, destiny, fate, or unavoidable circumstance. Exemplified by items including:

• “Good health comes from being lucky” (Item 1)
• “Bad luck makes people get sick” (Item 3)
• “If I get hurt it is because accidents just happen” (Item 10)

A dominant chance orientation is typically associated with poor adherence, health fatalism, disregard for preventive safety guidelines (such as helmet or seatbelt use), and an externalized explanatory style. In clinical settings, high chance scores serve as a psychometric marker for risk-taking behavior and medical non-adherence.

6. Theoretical Framework

The theoretical architecture of the Children’s Health Locus of Control Scale rests upon the integration of two major psychological paradigms: Social Learning Theory and Cognitive Developmental Theory.

Rotter’s Social Learning Theory

In 1954 and 1966, Julian B. Rotter articulated that the potential for a specific behavior to occur in a given psychological situation is a function of the expectancy that the behavior will lead to a particular reinforcement, and the value of that reinforcement to the individual:

BP_x,s1,Ra = f(E_x,Ra,s1 & RV_a,s1)

Rotter posited that when individuals encounter novel or ambiguous situations, they rely on generalized expectancies developed through cumulative learning histories. These expectancies form a continuum from internal locus (reinforcement is contingent upon personal behavior) to external locus (reinforcement is controlled by external forces, chance, or powerful others). Parcel and Meyer adapted this paradigm by focusing on health as the specific reinforcement value. In pediatric populations, health value is generally high (avoiding pain, hospital stays, and restricted play), meaning that variability in health actions is largely driven by individual differences in expectancy—specifically, whether the child expects their actions to have any therapeutic or protective utility.

Piagetian Cognitive Development and Illness Concepts

The CHLOCS is deeply anchored in developmental epistemology, specifically the developmental stages of children’s concepts of illness identified by researchers such as Roger Bibace and Mary E. Walsh (1980), extending Piaget’s stages:

• Preoperational Stage (Ages 2–6): Phenomenism and contagion. Illness is caused by an external, often magical event that co-occurs spatially or temporally. Causality is external and poorly differentiated.
• Concrete Operational Stage (Ages 7–11): Contamination and internalization. The child recognizes that illness is caused by external agents entering the body or by physical actions. Crucially, the child begins to understand that personal preventative behaviors (e.g., washing hands, wearing warm clothes) can prevent disease.
• Formal Operational Stage (Ages 12+): Physiological and psychophysiological explanations. The adolescent comprehends internal bodily organs, systemic dysfunction, and the impact of psychological stress on somatic health.

Parcel and Meyer strategically calibrated the CHLOCS for the concrete operational period. During this window, children are actively constructing the boundary between self-initiated agency and external constraint. The instrument’s linguistic structure minimizes syntactic complexity, avoiding conditional clauses that might overwhelm concrete operational cognitive processing.

7. Validity

The psychometric validity of the CHLOCS has been rigorously evaluated across multiple experimental, cross-sectional, and clinical investigations over several decades.

Construct and Convergent Validity

Construct validity was initially established by Parcel and Meyer (1978) through administration of the scale alongside the Nowicki-Strickland Internal-External Scale for Children. The correlation between the CHLOCS total internal orientation and the Nowicki-Strickland generalized internal orientation was statistically significant (r = .31 to .42, p < .001). This moderate magnitude supported both convergent validity (confirming that health locus of control is rooted in generalized control expectancies) and discriminant validity (confirming that health-specific locus of control is distinct from generalized locus of control, capturing variance unique to health and illness domains).

Predictive and Criterion-Related Validity

Empirical studies have documented the predictive power of the CHLOCS across diverse behavioral and clinical metrics:

• Asthma Self-Management: Parcel et al. (1980) demonstrated that children participating in an asthma self-management program exhibited significant increases in Internal Health Locus of Control scores, which in turn predicted enhanced self-care behaviors, reduced emergency department visits, and decreased school absenteeism.
• Pediatric Dental Health: Studies evaluating oral hygiene among school-aged children revealed that children with higher scores on internal items (e.g., Item 19: “There are things I can do to have healthy teeth”) had significantly lower plaque indices and higher frequencies of daily brushing and flossing compared to children with dominant chance scores.
• Coping with Acute Somatic Distress: Pediatric research in preoperative and venipuncture settings indicates that children with higher Powerful Others scores exhibit lower anxiety when accompanied by healthcare providers or trusted caregivers, whereas children with high Chance scores display greater behavioral distress and treatment resistance.

Discriminant and Known-Groups Validity

The scale successfully discriminates between healthy normative cohorts and pediatric populations diagnosed with chronic medical conditions. Children with chronic illnesses typically demonstrate higher Powerful Others scores relative to healthy peers, reflecting their realistic and adaptive dependence upon medical regimens and healthcare professionals. Furthermore, longitudinal developmental research confirms that internal scores systematically increase with age, confirming developmental progression across grades 3 through 6.

8. Reliability

The reliability of the Children’s Health Locus of Control Scale has been extensively evaluated across diverse socioeconomic, demographic, and international samples.

Internal Consistency

Because the CHLOCS utilizes a dichotomous response format (YES/NO), internal consistency is primarily evaluated using the Kuder-Richardson Formula 20 (KR-20) rather than conventional Cronbach’s alpha for continuous data. In the original validation sample of 168 children across grades 3 through 5, Parcel and Meyer (1978) reported an overall KR-20 reliability coefficient of .72. Subsequent large-scale normative studies in school districts confirmed internal consistency values ranging from .70 to .76.

Subscale reliability analyses yield slightly lower values, which is typical for brief pediatric scales with dichotomous scoring:

• Internal Subscale (6 items): KR-20 = .65 to .71
• Powerful Others Subscale (9 items): KR-20 = .64 to .70
• Chance Subscale (5 items): KR-20 = .61 to .68

Test-Retest Reliability and Stability

Temporal stability was established by administering the scale to elementary school cohorts across intervals ranging from two to six weeks. Parcel and Meyer observed a test-retest reliability coefficient of r = .69 over a six-week interval. Independent evaluations by subsequent researchers yielded stability coefficients between .64 and .73 over intervals of four to eight weeks, demonstrating that the scale measures relatively enduring attributional dispositions while remaining sensitive to targeted educational interventions.

9. Factor Analysis

The structural dimensionality of the CHLOCS was originally evaluated using exploratory factor analysis (EFA) and later corroborated through confirmatory factor analysis (CFA).

Exploratory Factor Structure (Parcel & Meyer, 1978)

In the seminal psychometric investigation, Parcel and Meyer conducted a principal components factor analysis with varimax orthogonal rotation on the 20 items. Although the authors initially evaluated both unidimensional and multidimensional models, the factor analysis revealed three dominant factors accounting for approximately 41.3% of the total variance, mirroring the tripartite division of the Multidimensional Health Locus of Control (MHLC) scale developed by Wallston et al.:

Confirmatory Factor Analysis (CFA) and Structural Invariance

Modern psychometric re-examinations employing structural equation modeling have tested the three-factor oblique model against alternative single-factor and two-factor (Internal vs. External) representations. CFA analyses on diverse pediatric samples generally support the three-factor model, exhibiting acceptable goodness-of-fit indices (Root Mean Square Error of Approximation [RMSEA] ≤ .055; Comparative Fit Index [CFI] ≥ .91; Tucker-Lewis Index [TLI] ≥ .90). These structural analyses confirm that children as young as eight years old reliably differentiate between the influence of powerful adult caregivers and uncontrollable random chance.

10. Instrument / Measurement Tool

• Test Type: Pediatric psychological self-report inventory / attributional rating scale.
• Target Population: School-age children in grades 3 through 6 (chronological ages 7 to 12 years). Can be administered orally to younger children or children with reading delays.
• Administration Format: Individual or group pencil-and-paper questionnaire; also adaptable to digital/tablet formats.
• Administration Time: Approximately 10 to 15 minutes (including instructional warm-up and practice items).
• Total Item Count: 20 substantive items (plus 3 standardized practice items).
• Response Scale: Forced-choice dichotomous format: YES or NO.
• Practice / Instructional Component: Prior to completing the scale, respondents complete three standardized practice questions (“Children can get sick”, “Children never get sick”, and “When I am not sick, I am healthy”) designed to verify comprehension of the dichotomous response format and eliminate response bias.
• Scoring Models:
  • Original Unidimensional Scoring: 1 point awarded for each response reflecting internal locus of control (Internal items answered YES = 1; External items answered NO = 1). Total possible score ranges from 0 to 20, with higher composite scores indicating higher overall internality.
  • Multidimensional Tripartite Scoring: Yields three distinct subscale scores:
    • Internal Health Locus of Control (IHLC): Sum of items 2, 9, 11, 16, 19, 20 answered YES (Score range: 0–6).
    • Powerful Others Health Locus of Control (PHLC): Sum of items 4, 7, 8, 12, 13, 14, 15, 17, 18 answered YES (Score range: 0–9).
    • Chance Health Locus of Control (CHLC): Sum of items 1, 3, 5, 6, 10 answered YES (Score range: 0–5).
• Standardized Scoring Rule: Omitted items or items where both YES and NO are circled are coded as missing. If more than 2 items are missing, the administration is deemed invalid.

11. Permissions & Fee and Test Year

The Children’s Health Locus of Control Scale was developed in 1977 and officially published in the scientific literature in 1978 by Guy S. Parcel and Philip R. Meyer. The instrument is protected under copyright (© Guy S. Parcel, Ph.D., 1977). In keeping with academic research traditions, the authors placed the instrument in the public domain for clinical, educational, and non-commercial scientific research purposes.

No licensing fee is required for academic or non-profit investigative use. Investigators and clinicians wishing to employ the scale in published research, large-scale health system interventions, or commercial adaptations are requested to cite the original validation literature and may contact the corresponding author, Dr. Guy S. Parcel, at UTHealth Houston (email: [email protected]).

12. References

• Bibace, R., & Walsh, M. E. (1980). Development of children’s concepts of illness. Pediatrics, 66(6), 912–917. https://doi.org/10.1542/peds.66.6.912
• Nowicki, S., & Strickland, B. R. (1973). A locus of control scale for children. Journal of Consulting and Clinical Psychology, 40(1), 148–154. https://doi.org/10.1037/h0033978
• Parcel, G. S., & Meyer, P. R. (1978). Development of an instrument to measure children’s health locus of control. Health Education Monographs, 6(1), 149–159. https://doi.org/10.1177/109019817800600108
• Parcel, G. S., Nader, P. R., & Tiernan, K. (1980). A health education curriculum for elementary school children with asthma. Journal of School Health, 50(7), 379–381. https://doi.org/10.1111/j.1746-1561.1980.tb02116.x
• Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), 1–28. https://doi.org/10.1037/h0092976
• Tinsley, B. J. (2003). How Children Learn to Be Healthy. Cambridge University Press. https://doi.org/10.1017/CBO9780511543951
• Wallston, B. S., Wallston, K. A., Kaplan, G. D., & Maides, S. A. (1976). Development and validation of the Health Locus of Control (HLC) Scale. Journal of Consulting and Clinical Psychology, 44(4), 580–585. https://doi.org/10.1037/0022-006X.44.4.580
• Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6(2), 160–170. https://doi.org/10.1177/109019817800600109

13. Items of the Scale