Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOSLD)
Glossary for HoNOSLD score sheet
ASHOK ROY, FRCPsych
Brooklands, Marston Green, Birmingham, UK
HELEN MATTHEWS, MRCPsych
St David's, Carmarthen, UK
PAUL CLIFFORD, DClinPsy
British Psychological Society, UK
VANESSA FOWLER, MSc
Galahad Substance Misuse Solutions Ltd, Oxted, Surrey, UK
DAVID M. MARTIN, BA
Brooklands, Marston Green, Birmingham, UK
Correspondence: Dr A. Roy, North Warwickshire NHS Trust, Brooklands, Coleshill Road, Marston
Green, Birmingham B37 7HL, UK
See pp. 6166, this
issue. 
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INTRODUCTION
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Summary rating instructions:
- Complete the front sheet including ICD-10 diagnoses and subjective
rating.
- Rate each in order from item 1 to 18.
- Do not include information rated in an earlier item.
- Rate the person over the previous 4 weeks.
- Rate the most severe problem that has occurred during the period rated.
- All items follow the five-point rating format similar to other HoNOS
instruments:
- 0=no problem during the period rated;
- 1=mild problem;
- 2=moderate problem;
- 3=severe problem;
- 4=very severe problem.
Rate 9 if unknown
1. Behavioural problems (directed at others)
Include behaviour that is directed to other persons. Do not
include behaviour that is directed towards self (Scale 2) or primarily at
property or other behaviours (Scale 3). Rate risk as it is currently
perceived.
- 0= No behavioural problems directed to others during the period rated.
- 1= Irritable, quarrelsome, occasional verbal abuse.
- 2= Frequent verbal abuse, verbal threats, occasional aggressive gestures,
pushing or pestering (harassment).
- 3= Risk, or occurrence of, physical aggression resulting in injury to
others requiring simple first aid, or requiring close monitoring for
prevention.
- 4= Risk, or occurrence of, physical aggression producing injury to others
serious enough to need casualty treatment and requiring constant supervision
or physical intervention for prevention (e.g. restraint, medication or
removal).
2. Behavioural problems directed towards self (self-injury)
Include all forms of self-injurious behaviour. Do not include
behaviour directed towards others (Scale 1), or behaviour primarily directed
at property, or other behaviours (Scale 3).
- 0= No self-injurious behaviour during the period rated.
- 1= Occasional self-injurious behaviour (e.g. face-tapping); occasional
fleeting thoughts of suicide.
- 2= Frequent self-injurious behaviour not resulting in tissue damage (e.g.
redness, soreness, wrist-scratching).
- 3= Risk or occurrence of self-injurious behaviour resulting in reversible
tissue damage and no loss of function (e.g. cuts, bruises, hair loss).
- 4= Risk or occurrence of self-injurious behaviour resulting in irreversible
tissue damage and permanent loss of functions (e.g. limb contractures,
impairment of vision, permanent facial scarring) or attempted suicide.
3. Other mental and behavioural problems
This is a global rating to include behavioural problems not described in
Scales 1 or 2. Do not include behaviour directed towards others (Scale
1), or self-injurious behaviour (Scale 2). Rate the most prominent behaviours
present. Include: A, behaviour destructive to property; B, problems
with personal behaviours, for example, spitting, smearing, eating rubbish,
self-induced vomiting, continuous eating or drinking, hoarding rubbish,
inappropriate sexual behaviour; C, rocking, stereotyped and ritualistic
behaviour; D, anxiety, phobias, obsessive or compulsive behaviour; E,
others.
- 0= No behavioural problem(s) during the period rated.
- 1= Occasional behavioural problem(s) that are out of the ordinary or
socially unacceptable.
- 2= Behaviour(s) sufficiently frequent and severe to produce some disruption
of and impact on own or other people's functioning.
- 3= Behaviour(s) sufficiently frequent and severe to produce significant
disruption and impact on own or other people's functioning, requiring close
monitoring for prevention.
- 4= Constant, severe problem behaviour(s) producing major disruption of and
impact on functioning requiring constant supervision or physical intervention
for prevention.
4. Attention and concentration
Include problems that may arise from underactivity, overactive
behaviour, restlessness, fidgeting or inattention, hyperkinesis or arising
from drugs.
- 0= Can sustain attention and concentration in activities/programmes
independently during the period rated.
- 1= Can sustain attention and concentration in activities/programmes with
occasional prompting and supervision.
- 2= Can sustain attention and concentration in activities/programmes with
regular prompting and supervision.
- 3= Can sustain attention and concentration in activities/programmes briefly
with constant prompting and supervision.
- 4= Cannot participate in activities and programmes even with constant
prompting and supervision.
5. Memory and orientation
Include recent memory loss and worsening of orientation for time,
place and person in addition to previous difficulties.
- 0= Can reliably find their way around familiar surroundings and relate to
familiar people.
- 1= Mostly familiar with environment/person, but with some difficulty in
finding their way.
- 2= Can relate to environment/person with occasional support and
supervision.
- 3= Can relate to environment/person with regular support and
supervision.
- 4= Not apparently able to recognise or relate to people and
environments.
6. Communication (problems with understanding)
Include all types of responses to verbal, gestural and signed
communication, supported if necessary with environmental cues.
- 0= Able to understand first language (mother tongue) about personal needs
and experience during the period rated.
- 1= Able to understand groups of words/short phrases/signed communication
about most needs.
- 2= Able to understand some signs, gestures and single words about basic
needs and simple commands (food, drink, come, go, sit, etc.).
- 3= Able to acknowledge and recognise attempts at communication with little
specific understanding (pattern of response is not determined by nature of
communication).
- 4= No apparent understanding or response to communication.
7. Communication (problems with expression)
Include all attempts to make needs known and communicate with others
(words, gestures, signs). Rate behaviour under Scales 1, 2 and 3.
- 0= Able to express needs and experience during the period rated.
- 1= Able to express needs to familiar people.
- 2= Able to express basic needs only (food, drink, toilet, etc.).
- 3= Able to express presence of needs, but cannot specify (e.g. cries or
screams when hungry, thirsty or uncomfortable).
- 4= Unable to express need or presence of need.
8. Problems associated with hallucinations and delusions
Include hallucinations and delusions irrespective of diagnosis.
Include all manifestations suggestive of hallucinations and delusions
(responding to abnormal experiences, e.g. invisible voices when alone).
- 0= No evidence of hallucinations or delusions during period rated.
- 1= Occasional odd or eccentric beliefs or behaviours suggestive of
hallucinations or delusions.
- 2= Manifestations of hallucinations or delusions with some distress or
disturbance.
- 3= Manifestations of hallucinations or delusions with significant distress
or disturbance.
- 4= Mental state and behaviour are seriously and adversely affected by
hallucinations or delusions with severe distress or disturbance.
9. Problems associated with mood changes
Include problems associated with low mood states, elated mood
states, mixed moods and mood swings (alternating between unhappiness, weeping
and withdrawal on one hand and excitability and irritability on the
other).
- 0= No evidence of mood change during period rated.
- 1= Mood present but with little impact (e.g. gloom).
- 2= Mood change producing significant impact on self or others (e.g. weeping
spells, decrease in skills, withdrawal and loss of interest).
- 3= Mood change producing major impact on self or others (e.g. severe apathy
and unresponsiveness, severe agitation and restlessness).
- 4= Depression, hypomania or mood swings producing severe impact on self and
others (e.g. severe weight loss from anorexia or overactivity, agitation too
severe to allow time to be engaged in meaningful activity).
10. Problems with sleeping
Do not rate intensity of behaviour disturbance this should be
included in Scale 3. Include daytime drowsiness, duration of sleep,
frequency of waking and diurnal variation of sleep pattern.
- 0= No problem during the period rated.
- 1= Occasional mild sleep disturbance with occasional waking.
- 2= Moderate sleep disturbance with frequent waking, or some daytime
drowsiness.
- 3= Severe sleep disturbance or marked daytime drowsiness (e.g.
restlessness/overactivity/waking early) on some nights.
- 4= Very severe sleep disturbance with disturbed behaviour (e.g.
restlessness/overactivity/waking early most nights).
11. Problems with eating and drinking
Include both increase and decrease in weight. Do not rate pica
which should be rated in Scale 3. This scale does not include problems
experienced by people who cannot feed themselves (e.g. people with severe
physical disability).
- 0= No problem with appetite during the period rated.
- 1= Slight alteration to appetite.
- 2= Severe alteration in appetite with no significant weight change.
- 3= Severe disturbance with some weight change during the period rated.
- 4= Very severe disturbance with significant weight change during the period
rated.
12. Physical problems
Include illnesses from any cause that adversely affects mobility,
self-care, vision and hearing (e.g. dementia, thyroid dysfunction, tremor
affecting dexterity). Do not include relatively stable physical
disability (e.g. cerebral palsy, hemiplegia). Behavioural disorders caused by
physical problems should be rated under Scales 1, 2 and 3 (e.g. constipation
producing aggression).
- 0= No increased incapacity due to physical problems during the period
rated.
- 1= Mildly increased incapacity, for example, viral illness, sprained
wrist.
- 2= Significant incapacity requiring prompting and supervision.
- 3= Severe incapacity requiring some assistance with basic needs.
- 4= Total incapacity requiring assistance for most basic needs such as
eating and drinking, toileting (fully dependent).
13. Seizures
Include all types of fits (partial, focal, generalised, mixed, etc.)
to rate the short-term effect on the individual's daily life. Rate the effects
of the fits. Do not include behavioural problems caused by, or
associated with, fits (use Scales 1, 2 and 3).
- 0= No increased incapacity due to physical problems during the period
rated.
- 1= Occasional seizures with minimal immediate impact on daily activities
(e.g. resumes after seizures).
- 2= Seizures of sufficient frequency or severity to produce a significant
immediate impact on daily activities (e.g. resumes activity after a few
hours).
- 3= Seizures of sufficient frequency or severity producing a severe
immediate impact on daily activities requiring simple first aid for injuries
etc. (e.g. resumes activities next day).
- 4= Frequent poorly controlled seizures (may be accompanied by episodes of
status epilepticus) requiring urgent clinical attention.
14. Activities of daily living at home
Include such skills as cooking, cleaning and other household tasks.
Do not rate problems with daily living outside the home (Scale 15). Do not
rate problems with selfcare (Scale 16). Rate what is seen regardless of cause,
for example, disability, motivation etc. Rate performance not potential. Rate
the current level achieved with the existing support.
- 0= Performs or contributes towards activities of daily living at home.
- 1= Some limitations in performing or contributing towards household
tasks.
- 2= Significant limitations in performing or contributing towards household
tasks (e.g. failure to wash or tidy up, difficulty in preparing meals).
- 3= Major limitations in performing or contributing towards household tasks
(e.g. home neglected, dirty, untidy; no domestic routine).
- 4= Gross neglect or danger resulting from no apparent contribution to daily
living activities.
15. Activities of daily living outside the home
Include skills such as budgeting, shopping, mobility and the use of
transport, etc. Do not include problems with activities of daily living
at home (Scale 14). Do not rate problems with self-care (Scale 16). Rate the
current level with the existing support.
- 0= Regular use of facilities and public amenities (e.g. shopping).
- 1= Some limitation in activity (e.g. difficulty with the use of public
amenities or transport).
- 2= Significant limitations of activity relating to any one of: shopping,
use of transport, public amenities.
- 3= Major restrictions in activity relating to more than any one of:
shopping, use of transport, public amenities.
- 4= Severe restrictions in the use of shops, transport, facilities, etc.
16. Level of self-care
Rate the overall level of functioning in activities of self-care such as
eating, washing, dressing and toileting. Rate the current level achieved with
the existing support. Rate appearance not motivation.
- 0= Appearance and personal hygiene maintained.
- 1= Some deficits in personal appearance, personal hygiene or attention to
health (e.g. poor grooming).
- 2= Significant deficits in personal appearance, personal hygiene or
attention to health causing a problem with social acceptability, but not
sufficient to pose a health risk (e.g. body odour, unkempt hair or nails).
- 3= Major deficits in personal appearance, personal hygiene or attention to
health posing a health risk (e.g. skin rashes, gum infection, not fully
dressed).
- 4= Gross self-neglect with severe difficulties relating to appearance,
hygiene and diet posing a major health risk (e.g. pressure sores).
17. Problems with relationships
Include effects of problems with relationships with family, friends
and carers (in residential and day/leisure settings). Measure what is
occurring regardless of cause, for example, somebody who is known to have good
relationships may still display problems.
- 0= Positive and frequent contact with family or friend or carers.
- 1= Generally positive relationships, but some strain or limitations in
contact.
- 2= Some positive relationships, but current disruptions of contact or
worsening of relationships.
- 3= Difficulties in relationships with risk of breakdown or infrequent
contact.
- 4= Significant relationships broken down with no current contact.
18. Occupation and activities
Rate the overall level of problems with quality of daytime environment.
Take account of frequency and appropriateness of, and engagement with, daytime
activities. Consider factors such as lack of qualified staff, equipment and
appropriateness with regard to age and clinical condition. Do not rate
problems with self-care (Scale 16).
- 0= Fully engaged with acceptable range of activities.
- 1= Uses reasonable range of activities, but some limitation of access or
appropriateness.
- 2= Uses limited range of activities, limited availability or
appropriateness.
- 3= Attends daytime activity irregularly.
- 4= No engagement with daytime activity.
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APPENDIX
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Received for publication March 29, 2000.
Revision received September 19, 2000.
Accepted for publication September 19, 2000.
Related articles in BJP:
- Highlights of this issue
- ELIZABETH WALSH
BJP 2002 180: 0.
[Full Text]
- Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOSLD)
- ASHOK ROY, HELEN MATTHEWS, PAUL CLIFFORD, VANESSA FOWLER, and DAVID M. MARTIN
BJP 2002 180: 61-66.
[Abstract]
[Full Text]