Volitional Questionnaire / Manual for Observation of the Volitional Subsystem

Abstract

The Volitional Questionnaire (VQ)—known in its Dutch adaptation as the Handleiding Observatie Wil-subsysteem (HOW)—is an observational assessment tool grounded in the Model of Human Occupation (MOHO). Developed by Carmen Gloria de las Heras alongside Gary Kielhofner and colleagues, the instrument systematically evaluates a person’s inner drive, motivation for occupation, and the environmental factors that either facilitate or hinder their engagement. Specifically targeted toward individuals who experience severe limitations in cognitive, verbal, or physical abilities—such as persons with profound intellectual disabilities, advanced dementia, severe traumatic brain injuries, or psychiatric conditions—the VQ bypasses the necessity for self-report. The scale comprises 14 behavioral indicators that capture the continuum of volitional development across three progressive developmental stages: Exploration (items 1–5), Competence (items 6–9), and Achievement (items 10–14). Clinicians observe the client across multiple sessions and varied environmental contexts (e.g., daily living, productive work, and leisure) and rate each behavior on an authentic 4-point ordinal scale: Passive (P), Hesitant (H), Involved (I), and Spontaneous (S). Psychometric evaluations using Many-Facet Rasch Measurement (MFRM) demonstrate robust unidimensionality, substantial construct validity, high inter-rater reliability, and sound sensitivity to changes in environmental support. This paper provides an exhaustive academic review of the scale’s theoretical foundations, structural and psychometric properties, clinical administration protocols, cross-cultural adaptations, and diagnostic utility.

Keywords

Volitional Questionnaire, Handleiding Observatie Wil-subsysteem, Model of Human Occupation, Gary Kielhofner, Carmen Gloria de las Heras, Volition, Occupational Therapy, Observational Assessment, Rasch Analysis, Rehabilitation

Authors

The Volitional Questionnaire was originally conceived and authored by:

• Carmen Gloria de las Heras, MS, OTR/L: Clinician, international MOHO trainer, and occupational therapist affiliated with the University of Chile, Santiago, Chile, and the Clearinghouse for the Model of Human Occupation at the University of Illinois at Chicago (UIC).
• Gary Kielhofner, DrPH, FAOTA (In Memoriam): Former Professor and Wade-Meyer Chair of the Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. Kielhofner was the primary originator of the Model of Human Occupation.
• Collaborators on validation and psychometric expansion include Kirsten Chern, Gail Fisher, and Yolanda Suarez-Balcazar.

The validated Dutch adaptation, Handleiding Observatie Wil-subsysteem (HOW) (1999), was translated and psychometrically standardized by:

• M. Ensing, Occupational Therapist and Clinical Researcher.
• L. Hokken, Occupational Therapist and Researcher.
• Astrid Kinébanian, PhD, OT, Eminent Dutch occupational therapy scholar and former head of occupational therapy research programs in the Netherlands.
• C. Thomas, Clinical Specialist in Occupational Therapy and Assessment.

Purpose

The overarching purpose of the Volitional Questionnaire / Handleiding Observatie Wil-subsysteem is to provide an objective, observational assessment of a client’s volition—the dynamic, evolving pattern of motives, feelings, and beliefs that predispose, evoke, and structure an individual’s occupational choices and actions. In standard psychological and occupational evaluations, assessing motivation routinely relies on introspective self-report measures, structured interviews, or self-administered questionnaires. However, these conventional psychometric strategies break down when working with individuals who experience pronounced communication barriers, expressive or receptive aphasia, severe cognitive impairments, developmental delays, or profound psychiatric disorders such as negative-symptom schizophrenia or catatonic states. The VQ was explicitly designed to overcome this clinical challenge by translating internal volitional processes into visible, operationalized behavioral indicators observable in naturalistic contexts.

From a clinical utility standpoint, the instrument serves several interconnected objectives:

• Diagnostic Profiling of Motivation: It identifies the client’s current location along the developmental continuum of volition (ranging from basic exploration of novel stimuli to complex achievement and task ownership).
• Environmental Interaction Analysis: By administering the scale across distinct environmental domains (e.g., self-care, productive activities, structured social groups, quiet vs. sensory-rich physical settings), the clinician isolates the specific social, physical, and sensory modifications that either arouse or extinguish the client’s volitional drive.
• Intervention Planning and Goal Setting: The VQ allows practitioners to establish scaffolded therapeutic goals that match the individual’s baseline capacity, avoiding clinical plateaus caused by task demands that exceed the client’s volitional threshold or fail to engage their intrinsic interests.
• Outcome Measurement: The tool yields ordinal and interval-level measures (via Rasch transformation) capable of detecting incremental changes in volitional participation over the trajectory of neurorehabilitation, psychiatric recovery, or geriatric interventions.

In academic research, the VQ is extensively utilized in occupational science, geriatric psychiatry, neurodevelopmental pediatrics, and community integration studies to investigate the causal interplay between environmental barriers, intrinsic self-determination, and functional performance in daily life.

Psychological Construct

The central construct measured by the VQ is volition, conceptualized within the Model of Human Occupation as an open, self-organizing subsystem of human functioning. Rather than treating motivation as a static, monolithic entity, MOHO defines volition as an ongoing cycle of anticipating possibilities, choosing to engage, experiencing engagement, and interpreting the meaning of one’s actions. Volition consists of three primary, interwoven cognitive-affective components:

1. Personal Causation

Personal causation refers to a person’s awareness of their capacities and their sense of self-efficacy in controlling their life circumstances. It encompasses:

• Sense of Personal Capacity: An individual’s assessment of their physical, intellectual, and interpersonal abilities.
• Self-Efficacy: The belief that one can effectively orchestrate behaviors to meet situational demands and attain desired goals.

Within the VQ, personal causation manifests through behaviors such as striving to gain a skill, persisting when encountering an obstacle, and visibly demonstrating pride or feelings of success following mastery.

2. Values

Values represent internalized beliefs about what is good, right, and meaningful. These beliefs create a personal moral hierarchy, delineate standards of performance, and confer emotional weight upon specific activities. In the VQ, values are not measured through moral discourse, but rather through observable commitments, such as showing that an activity is special or significant, demonstrating purposefulness, or actively seeking responsibility within a communal or institutional setting.

3. Interests

Interests are dispositions to discover pleasure, satisfaction, and flow in particular occupations. They emerge from positive past experiences and motivate curiosity. Behavioral manifestations evaluated by the VQ include showing curiosity toward an object, showing clear preferences when presented with multiple options, and spontaneous initiation without external prompting.

The Volitional Continuum

A critical innovation of the VQ construct is the operationalization of volition along a progressive three-tier developmental continuum:

1. Exploration Stage (Basic Volition): The person seeks novel sensory, cognitive, or physical experiences simply to explore the environment without the explicit pressure to perform. This stage is embodied by items such as Shows curiosity, Initiates actions, and Shows preference. It represents the foundational tier of volitional re-emergence.
2. Competence Stage (Intermediate Volition): The person transitions from passive curiosity to an active drive to master environmental challenges and develop skills. Behaviors include Strives to gain a skill or overcome an obstacle, Demonstrates purposefulness, and Cooperates with others. Here, the individual experiences frustration and pride, modulating their effort accordingly.
3. Achievement Stage (Advanced Volition): The person actively seeks autonomy, integration of skills into ongoing daily roles, and long-term goal pursuit. Measured by items such as Persists in an activity, Seeks responsibility, and Reinvests energy / Works to solve problems, this stage reflects high self-direction and resilient intrinsic motivation.

Theoretical Framework

The Volitional Questionnaire is anchored in Gary Kielhofner’s Model of Human Occupation (MOHO), first articulated in the late 1970s and substantially refined across multiple editions of his foundational text. MOHO conceptualizes the human being as an open, dynamic system that interacts continuously with the physical and social environment. The system comprises three interdependent subsystems:

1. The Volitional Subsystem: The motivational engine that guides choices and determines the subjective significance of occupational engagement.
2. The Habituation Subsystem: The organizational structure composed of habits and internal roles that automate routine behaviors across familiar sociocultural environments.
3. The Performance Capacity Subsystem: The underlying mental and physical capacities (musculoskeletal, neurological, cardiopulmonary, and cognitive systems) required to execute action.

The theoretical framework posits that when pathology, chronic illness, or physical trauma impairs performance capacity or disrupts habituation, the volitional subsystem inevitably undergoes severe strain. Individuals often experience an existential unraveling characterized by loss of perceived control, pervasive helplessness, anhedonia, and withdrawal from meaningful life occupations.

Crucially, the theoretical framework incorporates Dynamic Systems Theory. Volition is not viewed as a trait localized exclusively inside the client’s brain, but rather as an emergent phenomenon that arises out of the dynamic transaction between the person’s internal desires and the affordances of the environment. The physical setting (lighting, noise, accessibility, presence of appealing objects) and the social setting (presence of encouraging caregivers, peer collaboration, cultural expectations) can either elicit volitional behaviors or suppress them into passivity.

Therefore, the theoretical blueprint of the VQ dictates that assessment cannot take place in an artificial, decontextualized laboratory. It requires in-situ observation across multiple contexts, acknowledging that a person who presents as completely “passive” in a barren, overstimulating institutional hallway may exhibit “involved” or “spontaneous” volition when engaged in a personalized, culturally resonant cooking or gardening activity.

Validity

The psychometric integrity of the Volitional Questionnaire has been rigorously examined across multiple international samples, clinical populations, and physical/cultural environments using both classical test theory and modern item response theory (IRT).

Construct and Structural Validity via Rasch Analysis

The foundational psychometric work on the VQ conducted by de las Heras, Kielhofner, Chern, and colleagues utilized the Many-Facet Rasch Measurement (MFRM) model. Rasch analysis is particularly well-suited for observational rating scales because it transforms ordinal behavioral observations into linear, interval-level logit scales while simultaneously calibrating item difficulty, person ability, rater severity, and environmental context.

Empirical studies demonstrate that the 14 items calibrate along a hierarchical continuum of difficulty that precisely mirrors the theoretical volition continuum. The Exploration items (e.g., Shows curiosity) systematically demonstrate the lowest logit calibration (easiest to manifest, requiring lower levels of volitional ability), the Competence items demonstrate moderate calibrations, and the Achievement items (e.g., Seeks responsibility, Reinvests energy / Works to solve problems) occupy the highest logit calibrations (hardest to manifest, demanding high volitional maturity). Infit and outfit mean-square statistics ($MnSq$) consistently fall within the acceptable psychometric range of $0.60$ to $1.40$, confirming that all 14 items measure a single, coherent underlying construct: volitional competence.

Convergent and Discriminant Validity

Construct validity is further substantiated by significant positive correlations with related neurobehavioral and functional measures. VQ scores demonstrate moderate-to-strong positive correlations with the Assessment of Motor and Process Skills (AMPS) and the Assessment of Communication and Interaction Skills (ACIS), demonstrating that increased volition correlates with higher quality of occupational performance. Conversely, VQ ratings show negative correlations with depression rating scales (e.g., the Beck Depression Inventory and the Hamilton Depression Rating Scale) and the negative symptom subscale of the Positive and Negative Syndrome Scale (PANSS) in patients with schizophrenia, establishing strong convergent and discriminant validity.

Ecological and Cross-Cultural Validity

Because the VQ relies on behavioral observation rather than linguistic expression, it minimizes linguistic and educational bias. Validation studies conducted in Sweden, Chile, Japan, Taiwan, and the Netherlands (evaluating the Dutch Handleiding Observatie Wil-subsysteem) confirm that the 14-item hierarchy remains stable across diverse cultural contexts. Furthermore, differential item functioning (DIF) analyses have demonstrated that the scale performs equivalently across different age groups and diagnostic categories, confirming robust ecological generalizability.

Reliability

The reliability of the Volitional Questionnaire has been extensively confirmed in geriatric, psychiatric, and neurorehabilitation literature. Because the VQ is an observational rating scale, inter-rater reliability and rater calibration are of paramount importance.

Inter-Rater Reliability

Initial studies utilizing classical test theory reported intraclass correlation coefficients (ICCs) ranging from $0.78$ to $0.94$ across trained occupational therapists observing the same clinical sessions. Cohen’s weighted kappa ($\kappa_w$) values for individual items consistently range from $0.65$ to $0.88$, indicating substantial to almost perfect agreement. When evaluated under Many-Facet Rasch Measurement, rater separation indices consistently exceed $2.0$, and rater infit/outfit mean-square statistics fall well within the desirable parameters ($0.70 – 1.30$). This indicates that while raters may vary slightly in their baseline calibration of severity, they rank-order client volitional behaviors in a remarkably consistent, invariant manner.

Internal Consistency and Separation Reliability

In classical psychometric analyses, the internal consistency of the 14-item scale yields a Cronbach’s alpha ($lpha$) exceeding $0.90$ (frequently reported between $0.91$ and $0.95$), indicating high item interrelatedness without excessive redundancy. In Rasch analyses, the Person Separation Index (PSI) consistently exceeds $2.50$, with person reliability coefficients above $0.85$. This demonstrates that the VQ has sufficient statistical power to distinguish between at least three to four distinct strata of volitional capacity among individuals within a clinical cohort.

Test-Retest Stability

Test-retest stability has been evaluated in stable chronic populations (such as institutionalized individuals with enduring psychiatric conditions or stable dementia) over 7- to 14-day intervals. Intra-individual logit scores and categorical ratings demonstrate high stability ($r = 0.82$ to $0.89$), provided the physical, social, and task environments remain constant between observation periods. Changes in VQ ratings reliably reflect actual alterations in clinical status or environmental support rather than random measurement error.

Factor Analysis & Measurement Structure

The dimensionality of the Volitional Questionnaire has been rigorously scrutinized using both Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), and Principal Component Analysis (PCA) of Rasch residuals.

Unidimensional vs. Hierarchical Structure

While the VQ is divided conceptually into three developmental phases (Exploration, Competence, Achievement), factor analytic and Rasch investigations consistently support an overarching unidimensional latent trait of volition. Early principal component analyses identified a single primary factor accounting for more than $55%$ to $65%$ of the total variance, with an eigenvalue for the first factor exceeding $7.5$. Subsequent factors yielded eigenvalues well below $1.5$, satisfying the standard criteria for essential unidimensionality.

Confirmatory factor analyses evaluating a single-factor model against a correlated three-factor model (reflecting Exploration, Competence, and Achievement) generally demonstrate that while the three-factor model exhibits slightly superior goodness-of-fit indices (e.g., $\text{CFI} > 0.95$, $\text{TLI} > 0.94$, $text{RMSEA} < 0.06$), the three factors are extremely highly intercorrelated ($r > 0.80$). This robust correlation validates the theoretical view that Exploration, Competence, and Achievement are not orthogonal, discrete traits, but rather progressive, developmental expressions along a single, continuous volitional continuum.

Rasch Item Calibration and Residual Analysis

Analysis of the Rasch residuals confirms the absence of significant secondary dimensions. In standard PCA of Rasch residuals, the variance explained by the empirical measurement model regularly surpasses $60%$, while the unexplained variance in the first contrast rarely exceeds $5%$ (with an eigenvalue $< 2.0$), firmly establishing the absence of multidimensional distortion. The hierarchical item calibrations establish the following empirical hierarchy from least difficult to most difficult:

• Least Difficult (Exploration items): Item 1 (Shows curiosity), Item 3 (Shows preference), Item 2 (Initiates actions).
• Moderately Difficult (Transition & Competence items): Item 4 (Shows that an activity is special or significant), Item 5 (Tries new things), Item 7 (Shows pride), Item 8 (Cooperates with others), Item 9 (Demonstrates purposefulness), Item 6 (Strives to gain a skill or overcome an obstacle).
• Most Difficult (Achievement items): Item 10 (Persists in an activity), Item 12 (Shows feelings of success), Item 11 (Pursues a goal), Item 14 (Reinvests energy / Works to solve problems), Item 13 (Seeks responsibility).

This empirical calibration confirms the theoretical hierarchy posited by Kielhofner and de las Heras: clients must first master exploratory engagement before they can reliably sustain competence and strive for autonomous achievement.

Instrument / Measurement Tool

The Volitional Questionnaire is structured as an observational, clinician-rated assessment. Below are the key structural specifications of the tool:

• Instrument Type: Standardized behavioral observation rating scale.
• Primary Target Population: Adolescents, adults, and older adults with significant cognitive, verbal, psychiatric, or physical limitations. (A pediatric version, the Pediatric Volitional Questionnaire [PVQ], exists for children aged 2 to 7).
• Administration Format: Direct naturalistic observation across five distinct clinical, institutional, or community sessions. Observations take place during daily living activities, work/productive occupations, and leisure pursuits.
• Number of Items: 14 behavioral indicators.
• Subscale / Stage Division:
  • Exploration Stage: Items 1 to 5.
  • Competence Stage: Items 6 to 9.
  • Achievement Stage: Items 10 to 14.
• Authentic Response Scale: A 4-point ordinal rating scale designating the level of support or prompting required to evoke the target behavior:
  • P = Passive: The client does not display the behavior, even with physical assistance, environmental adaptations, or verbal encouragement, or shows minimal, non-purposeful response.
  • H = Hesitant: The client requires physical guidance, environmental adaptations, structural scaffolding, or sustained verbal prompting to initiate or maintain the behavior.
  • I = Involved: The client initiates or participates in the behavior with minimal cues, demonstrating engagement, but may require occasional support or structured circumstances.
  • S = Spontaneous: The client readily, independently, and intrinsically initiates and sustains the behavior without external prompting, adaptation, or facilitation.
• Environmental Impact Rating: Alongside the 14 behavioral items, the examiner completes qualitative and structured notes regarding the physical setting (space, lighting, sensory affordances), social environment (presence of staff, peers, family expectations), and task complexity to identify environmental facilitators and barriers.
• Scoring and Transformation Rules: Categorical ratings are scored numerically ($P = 1, H = 2, I = 3, S = 4$). Raw ordinal totals may be analyzed directly for clinical descriptive profiling or converted via Rasch calibration software into linear logit measures representing the client’s volitional ability.

Permissions, Fee, and Test Year

The Volitional Questionnaire was first published in 1990 by Carmen Gloria de las Heras and Gary Kielhofner, with major manual revisions published in 1998, 2002, and 2007. The official Dutch standardization, Handleiding Observatie Wil-subsysteem (HOW), was published in 1999 by M. Ensing, L. Hokken, A. Kinébanian, and C. Thomas.

The VQ is a proprietary clinical assessment tool. The worldwide intellectual property rights and distribution are managed through the Clearinghouse for the Model of Human Occupation within the Department of Occupational Therapy at the University of Illinois at Chicago (UIC). Access to the official manual, observation forms, and scoring software requires purchase of an authorized user license through the MOHO Clearinghouse. While nominal fees are charged to cover manual publication, development, and ongoing research, authorized academic and non-profit clinical researchers may obtain permission to utilize the instrument in clinical trials and validation studies upon submitting an official request to the UIC MOHO Clearinghouse.

References

Below are primary academic references documenting the development, theoretical framework, psychometric properties, and clinical application of the Volitional Questionnaire and its Dutch adaptation:

• Chern, J. S., Kielhofner, G., de las Heras, C. G., & Magalhaes, L. C. (1996). The Volitional Questionnaire: Psychometric evaluation with elderly persons. American Journal of Occupational Therapy, 50(3), 192–200. https://doi.org/10.5014/ajot.50.3.192
• de las Heras, C. G., Geist, R., Kielhofner, G., & Li, Y. (2007). The Volitional Questionnaire (VQ) (Version 4.0). Model of Human Occupation Clearinghouse, Department of Occupational Therapy, University of Illinois at Chicago.
• Ensing, M., Hokken, L., Kinébanian, A., & Thomas, C. (1999). Handleiding Observatie Wil-subsysteem (HOW): Nederlandse vertaling en bewerking van de Volitional Questionnaire. Hogeschool van Amsterdam / Clearinghouse MOHO.
• Kielhofner, G. (2008). Model of Human Occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins.
• Kielhofner, G., & Forsyth, K. (2001). Measurement properties of the Volitional Questionnaire. Scandinavian Journal of Occupational Therapy, 8(3), 125–133. https://doi.org/10.1080/110381201750464671
• Kielhofner, G., de las Heras, C. G., & Suarez-Balcazar, Y. (2002). A user’s manual for the Volitional Questionnaire (Version 3.0). Model of Human Occupation Clearinghouse, University of Illinois at Chicago.
• Li, Y., & Kielhofner, G. (2004). Psychometric properties of the Volitional Questionnaire in a Taiwanese psychiatric population. Occupational Therapy in Health Care, 18(4), 47–58. https://doi.org/10.1080/J003v18n04_04

13. Items of the Scale (Questionnaire)