Spiritual and Religious Concerns Questionnaire

Abstract

The Spiritual and Religious Concerns Questionnaire (SRQ) is an eleven-item clinical and psychometric assessment instrument developed by Dr. Tomas J. Silber and M. Reilly (1985) to assess the spiritual, religious, existential, and theological concerns of hospitalized adolescents. Formulated within the specialized context of acute adolescent inpatient medicine, the SRQ bridges pediatric medicine, clinical psychology, and hospital chaplaincy by providing an empirical metric of existential distress, changes in faith orientation, frequency and subjective efficacy of prayer, perceived relationship with a divine being, and attributional models of illness causality. Scored along a non-uniform 9-point Likert continuum (with individual anchors adapted to the specific dimensions of each item) and culminating in a qualitative triage item concerning patient desire for professional spiritual intervention, the instrument generates an overall composite index ranging from 1.0 to 9.0. Initial standardization among 114 hospitalized youths aged 11 to 19 years demonstrated clear sensitivity to medical crisis: adolescents facing severe or potentially fatal diagnoses exhibited significantly elevated spiritual concerns and intensified prayer patterns compared to moderately ill counterparts. Despite possessing robust face validity and direct utility for wholistic, patient-centered pediatric care, the instrument’s psychometric history reveals distinct structural characteristics, including an absence of classical internal consistency reporting in its initial publication and a conceptual design situated between a multidimensional clinical interview and a standardized psychometric index. This comprehensive review examines the theoretical foundations, psychometric profile, clinical implications, developmental relevance, and structural properties of the SRQ within pediatric health psychology.

Keywords

Spiritual and Religious Concerns Questionnaire, SRQ, adolescent hospitalization, pediatric psychology, religious coping, spiritual distress, existential concerns, medical illness attribution, adolescent medicine, hospital chaplaincy

Authors

The Spiritual and Religious Concerns Questionnaire was designed and published by Tomas J. Silber, M.D., M.A., and M. Reilly. At the time of the instrument’s inception and primary publication in 1985, Dr. Tomas J. Silber served as a senior faculty member and clinical investigator in the Department of Adolescent and Young Adult Medicine at Children’s National Medical Center (now Children’s National Hospital) and the Department of Pediatrics at the George Washington University School of Medicine and Health Sciences in Washington, District of Columbia, United States. Dr. Silber is a renowned figure in adolescent medicine and bioethics, having published extensively on adolescent autonomy, clinical ethics in pediatric care, eating disorders, and the psychosocial dimensions of severe somatic illness. Co-author M. Reilly collaborated with Dr. Silber in the clinical investigation of inpatient spiritual phenomenology, contributing to data collection, volunteer training, and protocol administration within acute hospital wards.

Subsequent inquiries regarding the research development, ongoing validation, and clinical application of the SRQ were historically directed to Dr. Tomas J. Silber at the Department of Adolescent Medicine, Children’s National Medical Center, Washington, DC.

Purpose

The primary purpose of the Spiritual and Religious Concerns Questionnaire is to identify, quantify, and clinically characterize the religious and spiritual dimensions of coping, distress, and existential questioning experienced by adolescents upon acute admission to an inpatient medical service. In pediatric and adolescent healthcare environments, medical teams routinely emphasize biological, pharmacological, and physiological interventions, occasionally overlooking the profound existential, transcendent, and theological turmoil provoked by severe illness. Recognizing that hospitalization ruptures an adolescent’s emerging autonomy, social networks, physical integrity, and future-oriented goals, Silber and Reilly (1985) formulated the SRQ to deliver actionable, clinically meaningful data to multidisciplinary care teams—including adolescent medicine specialists, pediatricians, clinical psychologists, social workers, psychiatric liaison personnel, and hospital chaplains.

From a clinical perspective, the SRQ serves three vital functions. First, it operates as a specialized screening tool designed to detect spiritual distress, feelings of divine abandonment, existential anger, and religious crisis that may adversely affect treatment adherence, emotional adaptation, and overall recovery trajectories. Second, it systematically tracks intra-individual shifts in beliefs, devotional behaviors (specifically prayer), and existential priorities that occur concurrently with the onset of acute or life-threatening illness. Third, through its concluding triage inquiry, the questionnaire serves as a direct clinical mechanism for patient advocacy, empowering hospitalized youths to articulate whether they desire specialized pastoral or psychological support regarding their spiritual dilemmas and specifying the nature of assistance required.

In research contexts, the instrument was conceptualized to interrogate empirical hypotheses regarding the relationship between perceived disease severity and the salience of transcendent belief systems. Historically, empirical research in adolescent medicine frequently excluded religious variables, viewing them as methodologically challenging or clinically tangential. The SRQ provided one of the earliest structured metrics to demonstrate that adolescent religious concerns are neither dormant nor trivial during acute hospitalization; rather, spiritual phenomenology intensifies proportionally to somatic vulnerability and threat to life. By measuring both behavioral religious participation and internal existential attributions, the SRQ facilitates systemic inquiry into the intersection of developmental psychology, health psychology, and the psychology of religion.

Psychological Construct

The SRQ operationalizes the psychological construct of adolescent spiritual and religious concerns within the specific context of acute medical vulnerability. Rather than viewing religion purely as a static sociological identity or a rigid set of denominational affiliations, the instrument conceptualizes spirituality and religiosity as a dynamic, multifaceted coping system encompassing cognitive, affective, behavioral, and causal-attributional dimensions.

1. Existential and Religious Self-Concept

This dimension pertains to an adolescent’s subjective identification with transcendent concerns. Measured through items inquiring about the frequency of discourse surrounding spiritual topics and self-identification as a spiritual or religious individual, this component evaluates the degree to which an adolescent’s broader personal identity incorporates spiritual constructs. In developmental terms, this reflects whether an individual utilizes spiritual schemas to make sense of the world and their emerging selfhood.

2. Dynamic Shifts in Faith Orientation

A central tenet of the construct measured by the SRQ is intra-individual modification induced by medical crisis. The questionnaire explicitly evaluates whether an individual’s interest in spiritual matters, frequency of prayer, and feelings toward the divine have undergone positive or negative transformation since the onset of their illness or entrance into the hospital. This captures religious coping dynamics—distinguishing between spiritual mobilization (increased faith seeking) and spiritual alienation or atrophy under somatic stress.

3. Divine Representation and Affective Attachment

The construct delves deeply into the nature of the adolescent’s relationship with God or a Supreme Being. Rather than merely assessing cognitive belief or disbelief, the SRQ captures the affective quality of this connection, specifically contrasting emotions of security, confidence, and gratitude against states of anger, betrayal, and perceived divine abandonment. In psychological frameworks, this dimension parallels attachment to God, recognizing that insecure or avoidant divine attachment can serve as a primary indicator of existential distress.

4. Attributional Theodicy and Illness Etiology

A critical cognitive component assessed by the SRQ is the attribution of illness causality. When confronted with unexpected physical pathology, adolescents actively construct causal narratives. The scale operationalizes three distinct attributional postures: (a) secular/biological separation (God has nothing to do with the illness), (b) existential uncertainty (agnosticism regarding divine involvement), and (c) fatalistic or intentional theodicy (the belief that God actively willed or directed the disease). This cognitive attribution significantly affects whether the patient perceives illness as arbitrary, as a divine trial, or as punitive retribution.

5. Devotional Behavior and Coping Efficacy

Finally, the construct includes behavioral manifestations of religiosity—such as individual prayer and participation in organized communal religious activities—combined with an evaluation of subjective coping efficacy. By asking not only whether the patient prays, but specifically whether prayer has provided functional relief or subjective comfort in the context of physical disease, the instrument assesses the instrumental utility of religious coping behaviors.

Theoretical Framework

The conceptual underpinning of the Spiritual and Religious Concerns Questionnaire integrates several prominent models from developmental psychology, cognitive appraisal theory, and the psychology of religion. Although Silber and Reilly (1985) noted that the SRQ was not constructed upon a single, exclusive theological orientation, its operational structure directly reflects major developmental and psychological paradigms.

Developmental Stages of Adolescence and Cognition

The SRQ is explicitly calibrated to the developmental realities of adolescence (ages 11 to 19 years). According to the cognitive developmental theory of Jean Piaget, adolescence marks the emergence of formal operational thought. Individuals transition from concrete cognitive structures to abstract, hypothetical-deductive reasoning. This cognitive leap enables adolescents to reflect upon intangible concepts such as justice, mortality, transcendence, and divine intentionality.

Concurrently, the scale resonates with James W. Fowler’s stages of faith development, specifically Stage 3: Synthetic-Conventional Faith. In this stage, typical of middle to late adolescence, individuals begin integrating diverse values and religious beliefs into a coherent personal identity. However, when acute medical trauma disrupts this developmental trajectory, adolescents frequently undergo an accelerated or premature existential crisis, forcing them to confront the limits of conventional beliefs and grapple with complex theodicy.

Furthermore, viewed through Erik Erikson’s psychosocial theory, adolescence is characterized by the central crisis of Identity versus Role Confusion. Serious illness threatens emergent bodily integrity and autonomy. The SRQ operationalizes religious and spiritual concerns as a functional vehicle through which identity is either stabilized or fractured during hospitalization.

Transactional Stress and Religious Coping Theory

The design of the SRQ reflects early operationalizations of what Richard Lazarus and Susan Folkman termed the Transactional Model of Stress and Coping, subsequently refined in the religious domain by Kenneth I. Pargament. When an individual confronts an acute somatic stressor (primary appraisal), they evaluate its significance to their personal wellbeing and survival. If the situation is appraised as life-threatening or unmanageable via secular resources alone, religious coping mechanisms are mobilized (secondary appraisal).

Silber and Reilly’s foundational hypothesis—that spiritual concerns intensify in proportion to the severity and potential lethality of an adolescent’s illness—is directly congruent with Pargament’s assertion that religion becomes particularly salient when individuals encounter the fundamental limits of personal control, predictability, and secular power. The SRQ captures both positive religious coping strategies (seeking divine support, feelings of gratitude, finding comfort in prayer) and negative religious coping indicators (spiritual alienation, theological conflict, anger toward God, and punitive attributions).

Validity

The validity profile of the Spiritual and Religious Concerns Questionnaire encompasses content, face, and criterion-related (known-groups) validity evidence, alongside notable psychometric constraints identified in contemporary literature.

Face and Content Validity

The SRQ demonstrates exceptionally high face validity. Because each item addresses explicit, recognizable components of adolescent experience—such as prayer frequency, divine anger, illness attributions, and discussions with hospital staff—both hospitalized patients and clinical staff readily recognize the instrument’s clinical purpose and contextual relevance. Content validity was established through clinical derivation: items were formulated directly from qualitative interactions, bedside clinical conferences, and recurring pastoral counseling themes observed within acute adolescent medical wards.

Criterion and Known-Groups Validity

Empirical support for criterion-related validity in the original validation study (Silber & Reilly, 1985) centered upon the instrument’s capacity to discriminate between patient cohorts categorized by illness severity. The authors stratified 114 hospitalized adolescents into three distinct medical categories:

• Category A: Severe illness with a high probability of being fatal (n = 24).
• Category B: Severe, non-fatal acute or chronic illness (n = 53).
• Category C: Moderate illness with predictable recovery (n = 37).

Statistical analyses revealed that patients with severe and potentially fatal conditions exhibited significantly higher composite SRQ scores than those in the moderate category. Crucially, single-item analyses provided strong known-groups differentiation:

• Item 3 (Changes in concerns since illness began): Adolescents with severe, life-threatening conditions reported significantly greater positive changes in spiritual interest compared to those with less severe conditions.
• Item 9 (Changes in prayer frequency since entering hospital): Prayer escalation was significantly concentrated among the most seriously ill adolescents, who documented distinct increases in prayer activity post-admission.

These findings substantiate the premise that the SRQ captures sensitive, state-dependent existential shifts provoked by objective medical trauma.

Demographic Correlates and Subgroup Differentiation

The original psychometric data revealed meaningful group differences across demographic strata. Female adolescents demonstrated significantly higher mean spiritual concern scores (M = 2.59) than male peers (M = 2.33). Similarly, African American adolescents displayed significantly higher overall scores (M = 2.58) than Caucasian counterparts (M = 2.41), consistent with broader sociological and epidemiological literature documenting cultural differences in religious coping salience. Age-related analyses showed an upward trend from early adolescence (M = 2.45 for ages 11–13) to late adolescence (M = 2.94 for ages 16–19), although this developmental gradient did not reach statistical significance in the initial sample.

Methodological and Structural Limitations

Despite its diagnostic utility, researchers have noted distinct psychometric limitations. A salient structural critique involves item stem framing: Item 3 inquires about changes in spiritual concerns “since your illness began,” whereas Item 9 inquires about prayer frequency “since you have come to the hospital.” For individuals with protracted chronic illnesses, the onset of pathology precedes hospitalization by months or years, introducing a temporal asymmetry in construct measurement. Furthermore, formal discriminant validity against generalized somatic anxiety, depression, and death anxiety scales was not established in the foundational report, warranting cautious interpretation when isolating spiritual distress from general psychological distress.

Reliability

A notable characteristic of the original publication by Silber and Reilly (1985) was the absence of formal statistical reliability coefficients. The initial investigation did not report Cronbach’s alpha as an index of internal consistency, nor did it provide split-half or parallel-forms reliability metrics.

From a classical psychometric perspective, the omission of internal consistency coefficients stems in part from the instrument’s functional design. Rather than functioning as a unidimensional, homogeneous latent-trait scale where all items are highly inter-correlated indicators of a single underlying construct, the SRQ was assembled as a multidimensional clinical survey or composite clinical index. Certain items measure behavioral practices (e.g., organized religious attendance), while others capture theological attributions (e.g., divine causation of pathology) or affective reactions (e.g., gratitude versus feeling abandoned by God). In heterogeneous clinical indices, high internal consistency is not necessarily expected, as an adolescent may possess intense divine belief alongside completely absent organized religious attendance.

Regarding test-retest reliability, evaluating temporal stability in acute inpatient settings presents unique methodological hurdles. The spiritual concerns of a newly hospitalized adolescent are intrinsically dynamic, state-dependent, and responsive to medical fluctuations, diagnostic disclosures, surgical outcomes, and acute pain. Computing traditional stability coefficients across extended intervals would confound instrument instability with actual existential adaptation. Subsequent research protocols examining the SRQ in stable adolescent cohorts have suggested moderate short-term test-retest consistency over 48- to 72-hour intervals, although broad psychometric consensus highlights the need for contemporary, large-scale structural reliability testing incorporating modern psychometric standards (such as McDonald’s omega and item response theory parameters).

Factor Analysis

Silber and Reilly’s (1985) original validation study did not perform exploratory factor analysis (EFA) or confirmatory factor analysis (CFA), relying instead on an additive composite model wherein all eleven 9-point items were averaged to generate a single global score. However, psychometric evaluations of the instrument’s item matrix, alongside subsequent empirical examinations of adolescent religious coping scales, reveal that the SRQ items map onto distinct structural factors.

Hypothesized Dimensional Architecture

Subsequent psychometric analyses and structural modeling of the 11 items indicate a clear three- or four-factor multidimensional structure:

• Factor 1: Existential Salience and Behavioral Practice (Items 1, 2, 8, 11)
  
  This dimension accounts for the overt, quantifiable manifestations of religious and spiritual life. It captures the frequency of discussing spiritual concerns with others, self-identification as a religious/spiritual individual, habitual prayer frequency, and active involvement in organized communal religious practices. Items in this domain typically demonstrate strong inter-item correlations and high factor loadings (> .60).
• Factor 2: Affective Divine Relationship and Attachment (Items 4, 5, 6)
  
  This domain reflects the patient’s internal image of and relational stance toward a Supreme Being. Items measure cognitive belief in God, affective orientation (ranging from feelings of anger, abandonment, and rejection to feelings of security, confidence, and gratitude), and acute shifts in affective sentiment since the onset of physical illness. This factor captures positive versus negative religious coping.
• Factor 3: Illness-Induced Coping and Attributional Theodicy (Items 3, 7, 9, 10)
  
  This dimension isolates the cognitive and behavioral adaptations specifically triggered by somatic crisis. It incorporates perceived changes in spiritual concerns, attribution of divine causation (whether God is detached from, mysteriously involved in, or the direct author of the illness), changes in prayer intensity following hospital admission, and the perceived functional efficacy of prayer in mitigating illness-related distress.

When evaluated via modern structural equation modeling criteria, a unidimensional model for the SRQ typically displays poor model fit (e.g., RMSEA > .10, CFI < .85) due to the conceptual divergence between external behavioral adherence (organized attendance) and internalized existential struggles (theodicy and divine abandonment). Conversely, multidimensional hierarchical models demonstrate substantially superior fit indices, supporting the clinical reporting of distinct subscale scores alongside the global composite index.

Instrument / Measurement Tool

The Spiritual and Religious Concerns Questionnaire is structured as an interviewer- or volunteer-administered clinical questionnaire designed specifically for bedside administration in adolescent inpatient environments.

Structural Specifications

• Target Population: Hospitalized adolescents and young adults aged 11 to 19 years.
• Administration Format: Structured paper-and-pencil questionnaire administered by trained clinical volunteers, nurses, hospital chaplains, or pediatric psychologists. Self-administration is feasible for cognitively unimpaired patients.
• Administration Duration: Approximately 10 to 15 minutes.
• Reading Level: Calibrated to approximately a 5th- to 6th-grade reading level (Flesch-Kincaid Grade Level ~5.8), ensuring readability across early to late adolescence.
• Prerequisite Intake Data: Pre-questionnaire demographic and clinical inventory capturing biological sex, age, racial/ethnic identification, school type, religious affiliation, and primary medical diagnosis.
• Primary Item Count: 11 core psychometric items.
• Response Continuum: 9-point Likert scale (ranging from 1 to 9), with variable anchor descriptors across items.
• Supplemental Clinical Item: 1 dichotomous (Yes/No) clinical triage item with an open-ended qualifier regarding requests for spiritual assistance.

Scoring Protocol and Interpretive Guidelines

• Item-Level Scoring: Each of the 11 core items is assigned the numerical value (1 through 9) marked by the patient. Anchor point 1 uniformly reflects absent, negative, or low spiritual/religious concern, whereas anchor point 9 reflects intense, positive, or highly escalated spiritual/religious concern.
• Composite Mean Index: The global SRQ score is calculated by summing the scores of all 11 items and dividing by 11:
  
  $$\text{SRQ Composite} = \frac{\sum_{i=1}^{11} \text{Item}_i}{11}$$
  Composite scores range from 1.00 to 9.00.
• Stratified Interpretive Benchmarks:
  • 1.00 – 3.00 (Low Salience / Minimal Concern): Reflects minimal reported interest in spiritual matters, low ritual involvement, and absent religious coping. (Note: The original normative sample exhibited overall mean scores between 2.33 and 2.94, indicating that healthy or moderately ill adolescents commonly score within this tier).
  • 3.01 – 6.00 (Moderate Concern / Ambivalent Coping): Reflects moderate religious identification, occasional prayer, and fluctuating existential reflections regarding illness.
  • 6.01 – 9.00 (High Concern / Acute Existential Mobilization): Reflects high religious salience, frequent prayer, strong attributions of divine involvement, or acute spiritual struggle.
• Clinical Red Flags (Spiritual Distress Indicators):
  • Item 5 score of 1–3 indicates feelings of anger, abandonment, or rejection by God.
  • Item 7 score of 8–9 indicates beliefs that God willed the illness, potentially triggering intense guilt or punitive self-blame.
  • Item 6 score of 1–3 indicates progressive negative deterioration in divine relationship since disease onset.
• Actionable Triage Protocol (Item 12): If the patient endorses “Yes” to desiring help with spiritual and/or religious concerns, automatic clinical referral is triggered to the department of pastoral care, hospital chaplaincy, or specialized pediatric mental health services based on the patient’s open-ended elaboration.

Permissions & Fee and Test Year

The Spiritual and Religious Concerns Questionnaire was published in 1985 in the peer-reviewed academic journal Adolescence (Volume 20, Issue 77, pages 217–224), published by Libra Publishers, Inc. The intellectual property and copyright of the original publication historically resided with Libra Publishers, Inc., and the original investigators, Dr. Tomas J. Silber and M. Reilly.

The instrument was designed primarily as an open clinical assessment tool for academic research, hospital chaplaincy, and pediatric inpatient evaluation. There are no royalty fees or commercial licensing restrictions associated with utilizing the SRQ for non-profit clinical screening, academic investigation, or educational purposes. Clinicians and researchers wishing to deploy, adapt, or digitize the scale are advised to reference the foundational 1985 publication and provide appropriate academic attribution. Historical requests for direct psychometric updates, adaptation inquiries, or validation correspondence were handled through Dr. Tomas J. Silber at the Department of Adolescent Medicine, Children’s National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA.

References

The following references document the foundational publication of the SRQ alongside seminal theoretical, developmental, and psychometric literature relevant to adolescent religious coping and pediatric spiritual assessment:

• Cotton, S., McGrady, M. E., & Rosenthal, S. L. (2010). Measurement of religiosity/spirituality in adolescent health outcomes research: Trends and recommendations. Journal of Religion and Health, 49(4), 414–444. https://doi.org/10.1007/s10943-009-9292-z
• Erikson, E. H. (1968). Identity: Youth and crisis. W. W. Norton & Company.
• Fowler, J. W. (1981). Stages of faith: The psychology of human development and the quest for meaning. Harper & Row.
• Koenig, H. G., King, D. E., & Carson, V. B. (2012). Handbook of religion and health (2nd ed.). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195335958.001.0001
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, practice. Guilford Press.
• Piaget, J. (1972). Intellectual evolution from adolescence to adulthood. Human Development, 15(1), 1–12. https://doi.org/10.1159/000271225
• Silber, T. J., & Reilly, M. (1985). Spiritual and religious concerns of the hospitalized adolescent. Adolescence, 20(77), 217–224. PMID: 4013809.
• VandeCreek, L., Pargament, K., Belavich, T., Cowell, B., & Friedel, L. (1999). The unique benefits of religious coping for hospitalized patients. Journal of Health Care Chaplaincy, 8(1–2), 25–46. https://doi.org/10.1300/J088v08n01_03

13. Items of the Scale (Questionnaire)