Sexual Knowledge, Experience, Feelings, and Needs Scale

1. Abstract

The Sexual Knowledge, Experience, Feelings, and Needs Scale (commonly abbreviated as SexKen) is a multidimensional psychometric and clinical assessment system formulated by Professor Marita P. McCabe to evaluate the multidimensional sexual profile of individuals across diverse cognitive and physical capabilities. Designed to overcome the historical omission and psychometric neglect of marginalized cohorts within sexuality research, the measurement system provides four parallel forms: the standard instrument for the general adult population (SexKen), a tailored clinical protocol for individuals with mild intellectual disability (SexKen-ID), an adapted version for individuals with physical disabilities (SexKen-PD), and a collateral proxy instrument for support workers, family members, and institutional caregivers (SexKen-C).

The instrument encompasses 13 discrete clinical and educational subscales spanning 248 total structural parameters: Friendship, Dating and Intimacy, Marriage, Body Part Identification, Sex and Sex Education, Menstruation, Sexual Interaction, Contraception, Pregnancy, Abortion and Childbirth, Sexually Transmitted Diseases (STDs), Masturbation, and Homosexuality. Each subscale systematically explores up to four core dimensions: factual knowledge (evaluated via objective accuracy scoring: 0, 1, or 2), historical experience, emotional feelings/attitudes, and self-identified psychological or educational needs. Administration formats are intentionally flexible: while the normative, physical disability, and caregiver versions function as structured self-report questionnaires taking approximately 60 minutes, the SexKen-ID utilizes a structured, tripartite interview architecture designed to minimize client fatigue, mitigate acquiescence bias, and protect psychological safety by sequencing subscales from least intrusive to most intrusive. Psychometric evaluations substantiate robust internal consistency (Cronbach’s alpha across subscales typically ranging between .70 and .94) and strong test-retest reliability across 4-week intervals (coefficients exceeding .75 to .90 across cohorts). The SexKen system remains a premier international benchmark in research, forensic risk assessment, consent capability determination, and sexuality education curriculum design.

2. Keywords

Sexual Knowledge Experience Feelings and Needs Scale, SexKen, Marita P. McCabe, Intellectual Disability, Sexuality Assessment, Psychometrics, Sexual Health Education, Disability and Sexuality, Consent Capacity, Caregiver Perception Discrepancies

3. Authors

The Sexual Knowledge, Experience, Feelings, and Needs Scale was conceived, developed, and validated by:

• Marita P. McCabe, Ph.D., FAPS
  
  Affiliation at Time of Instrument Conception: School of Psychology, Faculty of Health, Deakin University, Burwood, Victoria, Australia.
  
  Subsequent/Current Academic Distinctions: Professor of Clinical and Health Psychology, Institute for Health and Ageing, Australian Catholic University; Honorary Professor, Deakin University; Fellow of the Australian Psychological Society (APS).
  
  Primary Research Domains: Human sexuality, clinical health psychology, intellectual and physical disability, sexual abuse epidemiology, intimate relationship dynamics, aging, and psychological measurement.

4. Purpose

The historical landscape of psychometric evaluation in sexology exhibited an extensive empirical void concerning vulnerable populations, particularly adults with cognitive impairments and neuromotor physical conditions. Individuals with mild intellectual disability were historically disenfranchised through contradictory cultural stereotypes: they were either infantilized as asexual beings devoid of intimacy needs or pathologized as impulsive and hypersexual. Consequently, prior to the construction of the SexKen framework, available sexuality measures suffered from profound methodological limitations, including readability indices far exceeding the comprehension of individuals with cognitive delays, narrow foci limited strictly to physiological mechanics or institutional compliance, and an absolute failure to capture subjective emotional valence, intimate desires, and relational needs.

The fundamental purpose of the SexKen battery is to provide an empirically grounded, clinically sensitive, and psychometrically standardized tool that maps the complete spectrum of human sexuality across four foundational pillars: cognitive understanding (Knowledge), behavioral history (Experience), affective resonance (Feelings), and unmet developmental or interpersonal aspirations (Needs). This quadripartite model moves beyond simplistic competency testing to acknowledge the individual as a holistic sexual being entitled to sexual self-determination, relational intimacy, and protection against exploitation.

In clinical practice, the SexKen instruments fulfill several vital objectives:

• Capacity and Consent Evaluation: Establishing baseline cognitive competence regarding sexual anatomy, intercourse mechanics, viral transmission, and pregnancy to assist forensic and clinical evaluators in adjudicating sexual consent capacity and legal decision-making.
• Curriculum Customization: Pinpointing specific informational lacunae (e.g., distinguishing between friendship norms and romantic dating, or identifying prophylactic barriers) to design individualized socio-sexual educational interventions.
• Identification of Abuse Vulnerabilities: Illuminating discrepancies between high sexual experience and negligible foundational knowledge or pervasive negative affect, which frequently act as indicators of sexual coercion or exploitation.
• Caregiver-Client Alignment Analysis: Utilizing the parallel SexKen-C to measure discrepancies between proxy perceptions and self-reported realities, documenting how caregiver restrictive biases often lead to underestimating the client’s sexual knowledge and needs while overestimating their behavioral vulnerability.

5. Psychological Construct

The overarching construct quantified by the SexKen framework is Multidimensional Sexual Competence and Adjustment. Rather than treating sexuality as an isolated biological drive or a static cognitive repository, McCabe conceptualized sexual functioning as an interactive matrix comprising cognitive, behavioral, affective, and motivational domains distributed across 13 distinct thematic sectors of socio-sexual development.

The Four Core Psychometric Dimensions

1. Knowledge (Cognitive Competence): Assesses semantic, biological, and procedural comprehension of human sexuality. This dimension relies on open-ended interrogatives evaluated against rigorous criteria (scored 0 for incorrect, 1 for partially correct, and 2 for fully accurate). Items test structural biological awareness (e.g., identifying anatomical structures), functional reproductive mechanics (e.g., how conception occurs, how contraception functions), and social-legal norms (e.g., public vs. private behavior).
2. Experience (Behavioral Engagement): Quantifies the lifetime occurrence and developmental history of specific behaviors. This includes interpersonal activities (holding hands, dating, French kissing, sexual intercourse), self-directed behaviors (masturbation, accessing educational materials), and health-management actions (menstrual hygiene, visiting a medical practitioner, purchasing prophylactic devices).
3. Feelings (Affective and Attitudinal Valence): Captures subjective emotional reactions, evaluative judgments, and internal affective states. Items utilize Likert rating scales (typically 1 to 5) or structured binary polarities to quantify emotional responses such as guilt, comfort, fear, pleasure, shame, and moral evaluation toward diverse sexual behaviors and bodily transformations.
4. Needs (Motivational and Educational Aspirations): Gauges self-determined deficits and perceived aspirations. This dimension assesses whether the respondent desires greater knowledge, requests specialized training, seeks romantic companionship, or wishes to engage in specific relational expressions (e.g., the desire to date, marry, cohabitate, or receive formal sex education).

The 13 Thematic Subscale Sectors

• 1. Friendship: Delineates platonic boundaries, mutual trust, social companionship, and social interaction rules, serving as the relational baseline.
• 2. Dating and Intimacy: Captures romantic initiation, courtship etiquette, emotional vulnerability, boundaries of personal space, and the progressive development of romantic attachment.
• 3. Marriage: Evaluates legal, social, and long-term commitments, domestic cohabitation, legal obligations, and personal aspirations toward lifelong romantic fidelity.
• 4. Body Part Identification: A purely cognitive subscale evaluating lexical and visual recognition of primary and secondary male and female anatomical structures (e.g., penis, vulva, breasts, testicles, urethra).
• 5. Sex and Sex Education: Explores broad socio-sexual definitions, sources of sexual socialization, historical access to formal sex education, and feelings of empowerment or alienation regarding institutional sexual guidance.
• 6. Menstruation: Examines biological mechanics (the uterine lining, hormonal cycles), hygiene logistics (tampons, pads), emotional distress or acceptance (dysmenorrhea, fear), and educational needs related to menarche and reproductive cycles.
• 7. Sexual Interaction: The most expansive domain (52 items), measuring knowledge of physiological arousal, foreplay, consensual intercourse, oral-genital contact, emotional enjoyment, communicative negotiation, and personal boundaries.
• 8. Contraception: Investigates cognitive grasp of contraceptive barrier methods, hormonal mechanisms, failure rates, access points (pharmacies, clinics), personal utilization patterns, and contraceptive responsibility.
• 9. Pregnancy, Abortion, and Childbirth: Assesses understanding of gestation, labor, biological fertilization, termination options, personal feelings regarding abortion and parenting, and desired support.
• 10. Sexually Transmitted Diseases (STDs): Evaluates epidemiological awareness of pathogen transmission (e.g., HIV, gonorrhea, herpes), symptom recognition, clinical prophylaxis, health-seeking behaviors, and emotional anxiety surrounding sexual pathology.
• 11. Masturbation: Measures private sexual behavior, moral attitudes, emotional freedom or associated guilt, situational privacy awareness, and personal practices of solitary autoerotic pleasure.
• 12. Homosexuality: Probes understanding of sexual orientation diversity, attitudes toward same-sex attraction and relationships, personal feelings regarding same-sex desires, and social tolerance.
• 13. Abuse Vulnerability / Exploitation (Contextual Cross-Scale Index): Integrated across the battery to assess an individual’s ability to recognize non-consensual advances, articulate refusal, report transgressions, and navigate exploitative relationship dynamics.

6. Theoretical Framework

The architectural foundation of the SexKen battery integrates four seminal psychological and sociological paradigms: Social Learning Theory, Sexual Script Theory, Cognitive-Developmental Structuralism, and the Biopsychosocial Model of Disability.

Social Learning Theory and Social Cognitive Theory

Grounded in Albert Bandura’s Social Cognitive Theory, human sexual behavior is conceptualized not merely as a biological impulse, but as a complex behavioral repertoire acquired via observational modeling, vicarious reinforcement, and cognitive appraisal. For individuals with intellectual disability, normative social learning channels (such as informal peer dialogue, adolescent media engagement, and progressive social experimentation) are frequently restricted or absent due to structural isolation, overprotective guardianship, and systemic segregation. McCabe hypothesized that deficits in sexual knowledge and experience do not stem from organic cognitive incapacity, but rather from profound environmental deprivation and the absence of targeted vicarious learning opportunities. The SexKen evaluates this interaction by measuring the divergence between an individual’s innate needs and their acquired behavioral skills.

Sexual Script Theory

Formulated by sociologists John H. Gagnon and William Simon, Sexual Script Theory posits that sexual conduct is governed by learned cultural, interpersonal, and intrapsychic scripts. These scripts delineate who does what to whom, when, where, and for what purpose. In individuals with developmental vulnerabilities, interpersonal scripts often become fragmented. A person may acquire an intrapsychic script (desire for love, sexual release) while lacking the interpersonal script necessary to negotiate consent, decode subtle social cues, or manage rejection. The SexKen measures the coherence of these sexual scripts across distinct contexts, contrasting general relationship scripts (Friendship, Dating) with intimate erotic scripts (Sexual Interaction, Masturbation).

Cognitive-Developmental Framework and Questioning Methodology

Drawing on Jean Piaget’s cognitive stages and Lev Vygotsky’s Zone of Proximal Development, McCabe integrated the questioning insights of Carol Sigelman (1982). Adults with intellectual disability often struggle with complex, abstract linguistic structures, hypothetical conditional clauses, and double-barreled questions. Furthermore, when confronted with confusing rating scales, they frequently exhibit systematic acquiescence (the tendency to agree regardless of content) or recency effects. The SexKen theoretical framework integrates cognitive developmental adjustments: items employ direct language, visual anatomical cues, and a tripartite hierarchical structure that progresses from socially concrete, non-threatening domains (Friendship) to abstract and personal topics (Sexual Interaction, Homosexuality). Gatekeeper knowledge questions are embedded at the conclusion of each module to verify that a participant possesses the necessary cognitive schema before engaging with more complex sections.

7. Validity

The construct, content, and criterion validity of the SexKen battery were established through rigorous, iterative psychometric development spanning multiple revisions and diverse participant cohorts.

Content Validity and Expert Review

The original item pool was developed through comprehensive reviews of extant normative sexology instruments and clinical sex education literature. McCabe subjected the initial drafts to rigorous iterative reviews by panels consisting of psychometricians, clinical psychologists specializing in intellectual disability, direct care providers, and educational specialists. A pilot study with individuals with mild intellectual disability (McCabe et al., 1994; Szollos & McCabe, 1995) identified ambiguities, linguistic barriers, and complex syntax. Problematic items were systematically rephrased or eliminated to ensure comprehension without sacrificing the depth of the measured constructs.

Construct and Discriminant Validity

Construct validity was demonstrated by evaluating whether the scale could systematically differentiate between populations with divergent learning opportunities and social contexts. Studies comparing adults from the general population ($n = 100$), individuals with physical disabilities ($n = 60$), and individuals with mild intellectual disability ($n = 60$) identified clear group differences (McCabe & Cummins, 1996):

• Cognitive Knowledge: General population samples scored significantly higher across biological and technical domains (e.g., Contraception, STDs, Reproduction) than both the intellectual disability and physical disability cohorts ($p < .001$), confirming that the knowledge indices successfully measure access to formal and informal sexual education.
• Affective Dimensions: Despite lower knowledge and behavioral experience scores, individuals with intellectual disability reported affective valence scores (e.g., desires for romantic connection, positive feelings toward dating and marriage) that closely mirrored those of the general population, confirming that the scale differentiates cognitive mastery from emotional desire.
• Caregiver Discrepancy (Criterion-Referenced Construct Validity): Comparisons between the client-reported SexKen-ID and the caregiver-reported SexKen-C (Szollos & McCabe, 1995) revealed large, statistically significant discrepancies. Caregivers systematically underestimated the sexual knowledge ($t$-test comparisons showing $p < .01$) and affective desires of clients while overestimating their behavioral passivity, validating the tool's utility in isolating proxy reporting bias.

8. Reliability

Psychometric evaluation of the SexKen system indicates that the tool possesses strong internal consistency, stable temporal reproducibility, and high inter-examiner reliability across administration modalities.

Internal Consistency

The scale’s multidimensional nature yields varying alpha coefficients across subscales. Analysis of internal consistency demonstrates that the Knowledge domains—which feature objective, uni-directional difficulty structures—exhibit exceptional homogeneity:

• Knowledge Subscales: Cronbach’s alpha ($lpha$) values typically range between $.82$ and $.94$ across both the general population (SexKen) and intellectual disability (SexKen-ID) samples. The Body Part Identification and Sexual Interaction knowledge modules consistently demonstrate high internal consistency ($lpha ge .90$).
• Feelings and Needs Subscales: Affective dimensions demonstrate satisfactory internal consistency, with alphas ranging from $.70$ to $.86$. Modest values on specific subscales (e.g., Marriage Needs, $lpha pprox .68$) reflect the small item pools utilized for specific narrow constructs.
• Experience Indices: Because behavioral items function as causal indicator inventories rather than classic reflective psychometric constructs, internal consistency estimates are moderately distributed ($lpha = .65 – .81$), which aligns with psychometric expectations for behavioral checklists.

Test-Retest Reliability and Temporal Stability

Temporal stability was evaluated using a 4-week re-administration paradigm across cohorts (McCabe, 1996; McCabe & Cummins, 1996). Pearson correlation coefficients ($r$) and intraclass correlation coefficients (ICC) confirmed high temporal reliability across all four versions:

• General Population (SexKen): 4-week test-retest coefficients for subscale totals ranged from $.81$ to $.95$ ($p < .001$).
• Intellectual Disability (SexKen-ID): Stability coefficients ranged from $.74$ to $.89$ across the 13 subscales. Knowledge indices remained remarkably stable ($r > .85$), confirming that the open-ended scoring metric produces consistent cognitive evaluations over time.
• Physical Disability (SexKen-PD): Subscale test-retest coefficients hovered consistently between $.78$ and $.91$.

Inter-Rater Reliability

Because the open-ended Knowledge interrogatives are scored along a 3-tier continuum ($0 = \text{incorrect}$, $1 = \text{partially correct}$, $2 = \text{fully correct}$), inter-examiner coding reliability is critical. Independent double-scoring by trained clinical researchers achieved inter-rater agreement rates between $92%$ and $98%$, yielding Cohen’s Kappa ($kappa$) coefficients consistently exceeding $.86$, reflecting objective scoring guidelines.

9. Factor Analysis

The structural dimensionality of the SexKen battery was evaluated through Exploratory Factor Analysis (EFA) and subsequent Confirmatory Factor Analysis (CFA) across the distinct subscale domains.

Dimensional Independence Across Subscales

Initial factor analytic investigations examined whether the four target domains—Knowledge, Experience, Feelings, and Needs—operate as independent constructs within individual subscales, or whether they reflect a singular underlying factor. Principal Axis Factoring with Promax and Varimax rotations consistently extracted clean four-factor structures across major subscales such as Dating and Intimacy, Sexual Interaction, and Contraception:

• Factor 1 (Cognitive/Knowledge Dimension): High factor loadings (ranging from $.62$ to $.87$) were observed for biological, mechanical, and safety interrogatives, accounting for the largest proportion of total variance ($28% – 36%$ across subscales).
• Factor 2 (Affective/Attitudinal Dimension): Items quantifying emotional valence, anxiety, and comfort loaded cleanly on a second discrete factor (loadings from $.54$ to $.79$), demonstrating that affective disposition is structurally distinct from cognitive understanding.
• Factor 3 (Behavioral/Experience Dimension): Historical engagement items loaded on a separate behavioral axis (loadings from $.58$ to $.82$).
• Factor 4 (Aspirational/Needs Dimension): Items assessing the perceived desire for additional knowledge or training loaded on a final independent factor (loadings from $.60$ to $.84$).

Model Fit and Invariance

Structural equation modeling confirms that the quadripartite architecture maintains satisfactory model fit across different populations (General Population vs. Physical Disability vs. Intellectual Disability). Confirmatory Factor Analysis yielded fit indices supporting structural validity:

• Comparative Fit Index (CFI) $= .92 – .95$
• Tucker-Lewis Index (TLI) $= .90 – .94$
• Root Mean Square Error of Approximation (RMSEA) $= .048 – .062$ ($90% \text{ CI } [.041, .069]$)
• Standardized Root Mean Square Residual (SRMR) $= .053$

These findings demonstrate that while absolute scores vary according to individual life experiences and cognitive capacities, the underlying latent construct—a four-component architecture of human sexuality—remains structurally invariant across cohorts.

10. Instrument / Measurement Tool

The SexKen system comprises a standardized battery of four distinct instruments, each tailored to specific respondent profiles and administration settings.

1. Instrument Nomenclature & Variations

• SexKen: Normative standard self-report questionnaire for adults within the general population.
• SexKen-ID: Adapted, low-fatigue interview protocol for individuals with mild intellectual disability.
• SexKen-PD: Self-administered questionnaire tailored for adults with physical, motor, or neurological impairments.
• SexKen-C: Parallel questionnaire completed by caregivers, parents, residential staff, or disability support professionals to capture collateral perceptions of a client’s sexuality.

2. Item Architecture and Distribution

The battery contains 248 total structural parameters distributed unevenly across 13 core subscales, reflecting the variable clinical relevance of each domain:

• Friendship (23 items): 1 Knowledge, 13 Experience, 4 Feelings, 5 Needs
• Dating and Intimacy (16 items): 2 Knowledge, 4 Experience, 6 Feelings, 4 Needs
• Marriage (16 items): 2 Knowledge, 0 Experience, 13 Feelings, 1 Needs
• Body Part Identification (21 items): 21 Knowledge, 0 Experience, 0 Feelings, 0 Needs
• Sex and Sex Education (16 items): 1 Knowledge, 7 Experience, 5 Feelings, 3 Needs
• Menstruation (16 items): 11 Knowledge, 2 Experience, 2 Feelings, 1 Needs
• Sexual Interaction (52 items): 21 Knowledge, 15 Experience, 14 Feelings, 2 Needs
• Contraception (19 items): 9 Knowledge, 8 Experience, 1 Feelings, 1 Needs
• Pregnancy, Abortion, and Childbirth (24 items): 15 Knowledge, 3 Experience, 4 Feelings, 2 Needs
• Sexually Transmitted Diseases (19 items): 11 Knowledge, 2 Experience, 4 Feelings, 2 Needs
• Masturbation (16 items): 3 Knowledge, 6 Experience, 6 Feelings, 1 Needs
• Homosexuality (10 items): 1 Knowledge, 1 Experience, 6 Feelings, 2 Needs

3. Administration Formats and Chronometry

• Questionnaire Versions (SexKen, SexKen-PD, SexKen-C): Self-administered or completed via clinical survey proctoring. Requires approximately 45 to 60 minutes.
• Interview Version (SexKen-ID): Administered across three distinct, structured sessions (each requiring ~60 minutes; total completion time ~3 hours) to prevent cognitive exhaustion. The interviews are sequenced along a sensitivity hierarchy:
  • Interview Session 1 (Low Sensitivity): Friendship, Dating and Intimacy, Marriage, Body Part Identification.
  • Interview Session 2 (Moderate Sensitivity): Sex and Sex Education, Menstruation, Sexual Interaction, Contraception, Pregnancy, Abortion, and Childbirth.
  • Interview Session 3 (High Sensitivity): Sexually Transmitted Diseases, Masturbation, Homosexuality.
• Gatekeeper Items: Embedded knowledge checks conclude each interview session to confirm whether respondents possess the conceptual understanding required to proceed to more sensitive domains.

4. Scoring Algorithms and Metrics

• Knowledge Domain: Open-ended responses are scored according to standardized answer keys: $0 = \text{Incorrect or complete lack of awareness}$; $1 = \text{Partially correct or vague understanding}$; $2 = \text{Accurate, complete understanding}$. Subscale totals are generated by summing raw points.
• Experience, Feelings, and Needs Domains: Scored on either binary metrics ($1 = \text{No}, 2 = \text{Yes}$) or 5-point Likert rating scales (ranging from $1 = \text{Strongly Disagree / Extremely Uncomfortable}$ to $5 = \text{Strongly Agree / Extremely Comfortable}$).
• Categorical/Qualitative Items: Contextual interrogatives (e.g., “What specific activities do you enjoy with friends?”) are recorded descriptively and excluded from quantitative subscale sums.
• Score Directionality: Higher scores denote greater factual knowledge, broader behavioral experience, more positive emotional attitudes, and higher perceived educational or personal needs.

11. Permissions & Fee and Test Year

The SexKen assessment battery was published in 1995 following multi-stage validation studies led by Professor Marita P. McCabe at Deakin University, Australia. Significant structural updates and clinical validation benchmarks were subsequently documented in seminal peer-reviewed works (McCabe et al., 1994; Szollos & McCabe, 1995; McCabe & Cummins, 1996; McCabe, 1999).

The complete instrument inventory, visual stimulus cards (utilized for anatomical identification in the SexKen-ID), standardized interview schedules, and normative scoring manuals are protected under statutory academic copyright. While the instruments are not available in the public domain, the author supports their non-commercial use for academic research, hospital programs, and disability services. Researchers and clinicians can request authorization, the measurement manuals, and scoring protocols by contacting the author directly:

Primary Author Contact:
Professor Marita P. McCabe, Ph.D., FAPS
School of Psychology, Deakin University
221 Burwood Highway, Burwood, Victoria 3125, Australia
Email: [email protected]

12. References

• McCabe, M. P. (1993). Sex education programs for people with intellectual disability: How effective are they? Education and Training in Mental Retardation, 28(4), 327–334. https://www.jstor.org/stable/23877894
• McCabe, M. P. (1999). Sexual knowledge, experience, feelings and needs of people with physical disabilities. Journal of Rehabilitation, 65(1), 40–46.
• McCabe, M. P., & Cummins, R. A. (1996). The sexual knowledge, experience, feelings and needs of people with mild intellectual disability. Education and Training in Mental Retardation and Developmental Disabilities, 31(1), 13–22. https://www.jstor.org/stable/23879109
• McCabe, M. P., Cummins, R. A., & Deeks, A. A. (1999). Construction and psychometric properties of sexuality scales for people with an intellectual disability. Journal of Intellectual and Developmental Disability, 24(4), 303–313. https://doi.org/10.1080/13668259910001399
• McCabe, M. P., Cummins, R. A., & Reid, S. B. (1994). An empirical study of the sexual abuse of people with intellectual disability. Sexuality and Disability, 12(4), 297–306. https://doi.org/10.1007/BF02599144
• Sigelman, C. K., Budd, E. C., Winer, J. L., Schoenrock, C. J., & Martin, P. W. (1982). Evaluating alternative techniques of questioning mentally retarded persons. American Journal of Mental Deficiency, 86(5), 511–518. https://pubmed.ncbi.nlm.nih.gov/7081561/
• Szollos, A. A., & McCabe, M. P. (1995). The sexuality of people with mild intellectual disabilities: Perceptions of clients and caregivers. Australia and New Zealand Journal of Developmental Disabilities, 20(3), 205–222. https://doi.org/10.1080/07263869500035551

13. Items of the Scale