Description of an intensive residential aphasia treatment program: rationale, clinical processes, and outcomes

More than one way to improve a CAT: Outcomes and reflections on two iterations of the Queen Square Intensive Comprehensive Aphasia Programme

Background

The field of human expert performance teaches us that high quality, high-dose guided practice is required to make large gains in cognitively driven acts. The same also seems to be true for people with acquired brain injury, yet therapy services for people with aphasia (PWA) have traditionally not been designed with this in mind. Intensive Comprehensive Aphasia Programmes (ICAPs) are one way to address the chronic under-dosing of therapy that most PWA experience.

Aims

There are several ways to deliver an ICAP; here we describe two iterations of our Queen Square ICAP. There was a 20-month COVID-induced pause between the Year 1 (Y1) and Year 2 (Y2) ICAP groups. We analyse ICAP-induced changes in both groups of PWA on a series of key outcome measures that span the International Classification of Functioning, Disability and Health, covering language impairment and function as well as mood and social participation.

Methods & Procedures

Forty-six PWA took part in Y1 and 44 in Y2. The PWA were all in the chronic stage post stroke and varied in aphasia severity from mild to severe, with the Y2 group being more impaired than Y1. Quantitative data was collected before and after the ICAP. The Y2 therapy team provided independent reflections on their experiences of delivering an ICAP.

Outcomes & Results

ICAP-related changes in outcome measures (impairment, function and goal attainment) were generally comparable for the Y1 and Y2 groups, with both groups' speech production abilities improving the most. Both groups made clinically and statistically significant gains on the main quality of life measure. Participation in the ICAP made a big difference to PWAs' self-confidence ratings. Their mood ratings also improved significantly, although they were not, on average, in the depressed range at baseline (directly pre-ICAP). All improvements achieved in both groups were maintained at the 3-month follow-up, highlighting the lasting effects that ICAPs can provide.

Conclusions

Evidence continues to accrue that ICAPs are an efficient way of increasing the dose of expert coaching required for people with chronic aphasia to make clinically meaningful improvements in their communicative abilities and quality of life. The main challenge remaining is convincing health-care providers to invest in them.

A systematic review of Intensive Comprehensive Aphasia Programmes - who takes part, what is measured, what are the outcomes?

PURPOSE

This study synthesizes participant and outcome data from peer-reviewed Intensive Comprehensive Aphasia Programme (ICAP) studies.

METHODS

A systematic review was conducted following PRISMA guidelines. Study eligibility criteria were specified in relation to population, intervention, comparison, outcome, and design considerations. Data were extracted according to six research questions. Narrative synthesis was used.

RESULTS

Twenty-one studies were included covering 13 ICAPs (N = 485, aged 18-86 years, between 11 and 335 months post-stroke). Twenty-seven participant selection criteria were identified. Fifty-six outcome measures spanning the WHO-ICF were used, with the majority assessing the body function domain. Only eight studies employed an experimental design with data appropriate for analysis and synthesis. Risk of bias was noted across this sub-group. Participants improved in word-finding, communication, activity/participation, and communication-related quality of life, and maintained their gains; however, except for word finding, evidence of effect came from isolated studies. Factors influencing outcomes were rarely considered. Some drop-outs, missed sessions, and fatigue were noted. Some studies reported IPD alongside group analyses.

CONCLUSIONS

ICAP selection criteria need justification and should contribute to the understanding of candidacy for this treatment model. Rationalisation of ICAP treatment content and outcome measurement is required, spanning all WHO-ICF domains. Employment of the core outcome set for aphasia would enable data synthesis and facilitate comparisons between the ICAP and other therapy models.

Multi-level outcomes for young adults with acquired brain injury through a remote intensive cognitive rehabilitation approach: a pilot intervention study

OBJECTIVE

To investigate the effects of the Intensive Cognitive and Communication Rehabilitation (ICCR) program for young adults with acquired brain injury (ABI) using a quasi-experimental pilot intervention study design while transitioning to remote implementation.

METHOD

Twelve young adults with chronic ABI (treatment n = 7; control n = 5) participated in ICCR (i.e., lectures, seminars, individual cognitive rehabilitation (CR), technology training) for six hours/day, four days/week, for one or two 12-week semesters. Outcomes included classroom metrics, individual therapy performance, including Goal Attainment Scaling (GAS), standardized cognitive-linguistic assessments, and participation and health-related quality of life (QOL) measures.

RESULTS

In the first semester (in-person and remote), treatment participants significantly improved in classroom exams; individual therapy (i.e., memory, writing, GAS); executive function and participation measures, but not QOL. In the second semester (remote), treatment participants significantly improved in classroom exams; essay writing; individual therapy (i.e., writing and GAS); and memory assessment, but not in participation or QOL. Treatment participants enrolled in consecutive semesters significantly improved in classroom exams, individual therapy (i.e., memory), participation and QOL, but not on standardized cognitive assessments. Controls demonstrated no significant group-level gains.

CONCLUSION

These preliminary results highlight the benefit of intensive, integrated, and contextualized CR for this population and show promise for its remote delivery.

Behavioral interventions for poststroke aphasia

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

Outcomes of an interprofessional intensive comprehensive aphasia program's first five years

BACKGROUND AND OBJECTIVES

This ICAP program is a collaboration between an institute of health professions and a rehabilitation hospital. It was a 6-week intensive treatment program for people with post-stroke aphasia designed to maximize recovery and return to activities. This retrospective study investigated outcomes of this program offered annually from 2015 to 2019.

METHODS

This is an analysis of existing data collected for other purposes. While conducting a therapeutic program for people with aphasia, data were not collected for the purpose of conducting research. The treatment components addressed the activity participation goals of 35 participants. Programming consisted of individual and group speech-language and occupational therapy, adaptive sports, swimming, music therapy, and a wellness mindfulness group.. Participants received a comprehensive evaluation and a treatment plan addressing their individual participation goals, delivered primarily by SLP and OT graduate students under faculty supervision. Pre- and post-treatment outcomes were measured within four WHO ICF domains: impairment, participation, environment, person. Each cohort consisted of seven or eight community-dwelling participants seen four days/week.

RESULTS

Significant post-treatment changes were observed on measures within the impairment domain and on self-perception measures of participation, functional communication, and communication confidence. Subsequent analyses found a subset of 15 responders (WAB Aphasia Quotient change of ≥5) drove most significant effects seen on performance-based impairment measures, but that patient-reported self-perception measures showed significant changes in both responders and non-responders.

CONCLUSIONS

Results support research indicating that short-term intensive, interprofessional comprehensive aphasia programs (ICAPs) are effective treatment options for people with moderate-to-severe aphasia.

Is There a Research-Practice Dosage Gap in Aphasia Rehabilitation?

Purpose Aphasia intervention research aims to improve communication and quality of life outcomes for people with aphasia. However, few studies have evaluated the translation and implementation of evidence-based aphasia interventions to clinical practice. Treatment dosage may be difficult to translate to clinical settings, and a mismatch between dosage in research and clinical practice threatens to attenuate intervention effectiveness. The purpose of this study is to quantify a potential research-practice dosage gap in outpatient aphasia rehabilitation. Method This study utilized a two-part approach. First, we estimated clinical treatment dosage in an episode of care (i.e., treatment provided from outpatient assessment to discharge) via utilization in a regional provider in the United States. Second, we undertook a scoping review of aphasia interventions published from 2009 to 2019 to estimate the typical dosage used in the current aphasia literature. Results Outpatient clinical episodes of care included a median of 10 treatment sessions and a mean of 14.8 sessions (interquartile range: 5-20 sessions). Sessions occurred 1-2 times a week over 4-14 weeks. The median total hours of treatment was 7.5 hr (interquartile range: 3.75-15 hr). In contrast, published interventions administered a greater treatment dosage, consisting of a median of 20 hr of treatment (interquartile range: 12-30 hr) over the course of 15 sessions (interquartile range: 10-24 sessions) approximately 3 times per week. Conclusions Results demonstrate a meaningful research-practice dosage gap, particularly in total treatment hours and weekly treatment intensity. This gap highlights the potential for attenuation of effectiveness from research to outpatient settings. Future translational research should consider clinical dosage constraints and take steps to facilitate intervention implementation, particularly with regard to dosage. Conversely, health care advocacy and continued development of alternative delivery methods are necessary for the successful implementation of treatments with dosage that is incompatible with current clinical contexts. Pragmatic, implementation-focused trials are recommended to evaluate and optimize treatment effectiveness in outpatient clinical settings. Supplemental Material https://doi.org/10.23641/asha.15161568.

Intensive Comprehensive Aphasia Programmes: a systematic scoping review and analysis using the TIDieR checklist for reporting interventions

PURPOSE

Aphasia is an acquired language disorder that typically occurs as a result of a stroke. People with aphasia experience communication difficulties and risk secondary impacts, for example, affecting social and work life and mental health. Intensive Comprehensive Aphasia Programmes (ICAPs) aims to address the multiple consequences of aphasia using intensive intervention and a wide range of therapy approaches. Although basic parameters of ICAP intervention have been defined, a fuller characterisation is needed. This systematic scoping review aimed to determine what constitutes an ICAP.

METHODS

Peer-reviewed and Grey databases were searched for articles on ICAPs using Joanna Brigg's Institute methodology. Data was extracted following the Template for Intervention Description and Replication (TIDieR) checklist for reporting interventions and synthesised using a narrative synthesis.

RESULTS AND CONCLUSIONS

17 ICAPs were reported in 20 peer-reviewed literature sources (9 ICAPs supplemented by Grey literature sources). There were high degrees of variation in dose, professionals involved, and no qualitative data from participants. Of note, ICAP intervention was highly tailored to individual participants on the same ICAP, and intervention content varied between ICAPs. ICAPs appear to be rationalised as intensive impairment-based programmes with other components added for comprehensiveness. Stronger rationale and a logic model are required to justify the core components of ICAPs. The input of stakeholders into designing future ICAP interventions is recommended.IMPLICATIONS FOR REHABILITATIONThe ICAP model is in its infancy when it comes to mainstream clinical application as only the intensity component of the ICAP has clear theoretical underpinning as reported in the peer-reviewed literature.There have been clinical uptakes of the ICAP model which is likely to continue and is valid in the context of an under-researched area of aphasia therapy and on a background of a less than perfect relationship between evidence base and practice.Aspects of the ICAP model are valid for clinicians to implement, for example, intensive evidence-based aphasia therapy in combination with therapy which addresses some of the broader implications of aphasia, for example, social isolation.Clinicians can use the ICAP model to review their existing service provision and explore whether their service provides aphasia therapy that addresses the multiple aspects of aphasia (i.e., ensuring the focus is not only on impairment-based therapy).

Developments in the application of Intensive Comprehensive Aphasia Programs: an international survey of practice

PURPOSE

Intensive Comprehensive Aphasia Programs (ICAPs) were first described in 2013 with an international survey documenting 12 unique programs. ICAPs involve high dose intervention delivered in both group and individual settings, targeting communication across impairment, functioning, participation, and contextual domains. In this study, we aimed to investigate international growth in ICAPs.

MATERIALS AND METHODS

We developed a 43-item questionnaire expanding on the original 2013 version to investigate program modifications, activities, protocolised therapies, software and apps, and family involvement. The survey was disseminated to aphasia clinicians and researchers internationally (November 2019-February 2020).

RESULTS

Thirty-nine unique respondents completed the survey from nine countries. Twenty-one met the criteria for an ICAP or modified ICAP (mICAP): 14 ICAPs; 7 mICAPs, and 13 of these were new programs. ICAPs differed from mICAPs with greater emphasis on group sessions, use of technology, total communication, advocacy, and art activities. A large range of protocolised therapies were used across programs. An increased focus on mood and psychosocial well-being was observed compared to the 2013 survey.

CONCLUSIONS

The number and comprehensiveness of ICAPs has grown since 2013 with development of modified versions. Future research should focus on comparative efficacy of ICAPs/mICAPs and other forms of aphasia interventions and factors underpinning growth and sustainability.Implications for RehabilitationClinicians who coordinate or are considering commencing an ICAP in future can use these results to consider the design of their program.Coordinators should carefully consider the components of their ICAPs and advise consumers whether they meet the definition of an ICAP or a mICAP.With the increasing number of ICAPs across the globe, clinicians commencing an ICAP may wish to contact existing ICAPs within their country for advice.Program sustainability may be challenging and these results provide an indication of some of the key challenges coordinators may face.

Cognitive impact of lower-grade gliomas and strategies for rehabilitation

Outcomes for patients with lower-grade gliomas (LrGGs) continue to improve with advances in molecular characterization and treatment. However, cognitive sequela from the tumor and its treatment leave a significant impact on health-related quality of life for these patients. Several factors affect each patient's cognition, such as tumor location, treatment, medication, and comorbidities. However, impairments of processing speed, attention, concentration, working memory, and executive function are common across LrGG patients. Cognitive rehabilitation strategies, well established in traumatic brain injury and stroke populations, are based on neural plasticity and functional reorganization. Adapting these strategies for implementation in patients with brain tumors is an active area of research. This article provides an overview of cognitive domains commonly impaired in LrGG patients and evidence for the use of cognitive rehabilitation strategies to address these impairments with the goal of improving health-related quality of life in this patient population.

Convergence of heteromodal lexical retrieval in the lateral prefrontal cortex

Lexical retrieval requires selecting and retrieving the most appropriate word from the lexicon to express a desired concept. Few studies have probed lexical retrieval with tasks other than picture naming, and when non-picture naming lexical retrieval tasks have been applied, both convergent and divergent results emerged. The presence of a single construct for auditory and visual processes of lexical retrieval would influence cognitive rehabilitation strategies for patients with aphasia. In this study, we perform support vector regression lesion-symptom mapping using a brain tumor model to test the hypothesis that brain regions specifically involved in lexical retrieval from visual and auditory stimuli represent overlapping neural systems. We find that principal components analysis of language tasks revealed multicollinearity between picture naming, auditory naming, and a validated measure of word finding, implying the existence of redundant cognitive constructs. Nonparametric, multivariate lesion-symptom mapping across participants was used to model accuracies on each of the four language tasks. Lesions within overlapping clusters of 8,333 voxels and 21,512 voxels in the left lateral prefrontal cortex (PFC) were predictive of impaired picture naming and auditory naming, respectively. These data indicate a convergence of heteromodal lexical retrieval within the PFC.

"It's like a lifeboat": stakeholder perspectives of an intensive comprehensive aphasia program (ICAP)"

Background

Intensive comprehensive aphasia programs (ICAPs) have gained popularity in recent years. Outcomes from ICAPs have demonstrated measurable improvements for most who take part, but how do people with aphasia and their family members experience an ICAP?

Aim

The aim of this paper was to explore, through qualitative interviews, the experiences of persons with aphasia and their family members who took part in an ICAP.

Methods & Procedures

Twelve interviews were conducted with persons with aphasia and family members regarding their experiences with the ICAP that they had just completed. Nine persons with aphasia were interviewed with their family members and three chose to take part in the interview alone. The Framework Analysis method was used to identify themes from the transcribed interviews.

Outcomes & Results

The interviewees discussed four themes related to treatment, psychosocial environments, physical environments, and outcomes. The interviewees remarked on the challenges that were provided by the treatment and how the treatment was different from previous treatment. Comments were made related to the relationships the participants and families developed within the context of the program. The physical environment allowed for relationships to develop. The interviewees discussed the physical and social environment as important additional factors that contribute to the overall therapeutic effect of the ICAP. Positive outcomes were noted in language skills and psychosocial contexts.

Conclusions

Based on interviewees' descriptions of this one ICAP, the concept of a therapeutic milieu was developed to describe how the intersection of the treatment, psychosocial interactions, and physical setting related to outcomes. Interviewees described how the therapeutic milieu of the ICAP was interwoven with the intensive therapy to create a "package" of therapy that led to improved outcomes. Implications for non-ICAP clinical practice is that participants linked more intensive therapy and greater social interactions with better outcomes.

Phonomotor Versus Semantic Feature Analysis Treatment for Anomia in 58 Persons With Aphasia: A Randomized Controlled Trial

Purpose The ultimate goal of anomia treatment should be to achieve gains in exemplars trained in the therapy session, as well as generalization to untrained exemplars and contexts. The purpose of this study was to test the efficacy of phonomotor treatment, a treatment focusing on enhancement of phonological sequence knowledge, against semantic feature analysis (SFA), a lexical-semantic therapy that focuses on enhancement of semantic knowledge and is well known and commonly used to treat anomia in aphasia. Method In a between-groups randomized controlled trial, 58 persons with aphasia characterized by anomia and phonological dysfunction were randomized to receive 56-60 hr of intensively delivered treatment over 6 weeks with testing pretreatment, posttreatment, and 3 months posttreatment termination. Results There was no significant between-groups difference on the primary outcome measure (untrained nouns phonologically and semantically unrelated to each treatment) at 3 months posttreatment. Significant within-group immediately posttreatment acquisition effects for confrontation naming and response latency were observed for both groups. Treatment-specific generalization effects for confrontation naming were observed for both groups immediately and 3 months posttreatment; a significant decrease in response latency was observed at both time points for the SFA group only. Finally, significant within-group differences on the Comprehensive Aphasia Test-Disability Questionnaire (Swinburn, Porter, & Howard, 2004) were observed both immediately and 3 months posttreatment for the SFA group, and significant within-group differences on the Functional Outcome Questionnaire (Glueckauf et al., 2003) were found for both treatment groups 3 months posttreatment. Discussion Our results are consistent with those of prior studies that have shown that SFA treatment and phonomotor treatment generalize to untrained words that share features (semantic or phonological sequence, respectively) with the training set. However, they show that there is no significant generalization to untrained words that do not share semantic features or phonological sequence features.

The Intensive Cognitive-Communication Rehabilitation Program for Young Adults With Acquired Brain Injury

Purpose This study investigated the effects of an intensive cognitive-communication rehabilitation (ICCR) program for young individuals with chronic acquired brain injury. Method ICCR included classroom lectures; metacognitive instruction, modeling, and application; technology skills training; and individual cognitive-linguistic therapy. Four individuals participated in the intensive program (6 hr with 1-hr lunch break × 4 days × 12 weeks of treatment): 3 participants completed 3 consecutive semesters, and 1 participant completed 1 semester. Two controls did not receive treatment and completed assessments before and after the 12-week treatment interval only. Results All 4 experimental participants demonstrated significant improvements on at least 1 standardized cognitive-linguistic measure, whereas controls did not. Furthermore, time point significantly predicted participants' scores on 2 of the 4 standardized outcome measures, indicating that as duration in ICCR increased, scores also increased. Participants who completed multiple semesters of ICCR also improved in their therapy and personal goals, classroom behavior, life participation, and quality of life. Conclusion After ICCR, participants showed gains in their cognitive-linguistic functioning, classroom participation, and individual therapy. They also demonstrated improvements outside the classroom and in their overall well-being. There is a gap between the large population of young adults with acquired brain injury who wish to return to higher education and a lack of rehabilitation programs supporting reentry into academic environments; ICCR is a first step in reducing that gap.

Study on Language Rehabilitation for Aphasia

OBJECTIVE

The aim is to update our clinical recommendations for evidence-based language rehabilitation of people with aphasia, based on a systematic review of the literature from 1999 to 2015.

DATA SOURCES

Articles referred to in this systematic review of the Medline and PubMed published in English language literatures were from 1998 to 2015. The terms used in the literature searches were aphasia and evidenced-based.

STUDY SELECTION

The task force initially identified citations for 51 published articles. Of the 51 articles, 44 studies were selected after further detailed review. Six articles, which were not written in English, and one study related to laryngectomy rehabilitation interventions, were excluded from the study. This study referred to all the important and English literature in full.

RESULTS

Aphasia is the linguistic disability, which usually results from injuries to the dominant hemisphere of the brain. The rehabilitation of aphasia is until in the process of being debated and researched. Evidence-based medicine (EBM), EBM based on the clinical evidence, promotes the practice of combining the clinicians' first-hand experience and the existing objective and scientific evidence encouraging making decisions based on both empirical evidence and the scientific evidence. Currently, EBM is being gradually implemented in the clinical practice as the aim of the development of modern medicine.

CONCLUSIONS

At present, the research for the aphasia rehabilitation mainly focuses on the cognitive language rehabilitation and the intensive treatment and the precise treatment, etc. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for linguistic disability after traumatic brain injury and stroke, which can be used to develop linguistic rehabilitation guidelines for patients with aphasia.

Does Naming Therapy Make Ordering in a Restaurant Easier? Dynamics of Co-Occurring Change in Cognitive-Linguistic and Functional Communication Skills in Aphasia

PURPOSE

This study was conducted to investigate the static and dynamic relationships between impairment-level cognitive-linguistic abilities and activity-level functional communication skills in persons with aphasia (PWA).

METHOD

In Experiment 1, a battery of standardized assessments was administered to a group of PWA (N = 72) to examine associations between cognitive-linguistic ability and functional communication at a single time point. In Experiment 2, impairment-based treatment was administered to a subset of PWA from Experiment 1 (n = 39) in order to examine associations between change in cognitive-linguistic ability and change in function and associations at a single time point.

RESULTS

In both experiments, numerous significant associations were found between scores on tests of cognitive-linguistic ability and a test of functional communication at a single time point. In Experiment 2, significant treatment-induced gains were seen on both types of measures in participants with more severe aphasia, yet cognitive-linguistic change scores were not significantly correlated with functional communication change scores.

CONCLUSIONS

At a single time point, cognitive-linguistic and functional communication abilities are associated in PWA. However, although changes on standardized assessments reflecting improvements in both types of skills can occur following an impairment-based therapy, these changes may not be significantly associated with each other.

Structure, Processes, and Retrospective Outcomes From an Intensive Comprehensive Aphasia Program

PURPOSE

This study describes the structure, processes, and outcomes of an intensive comprehensive aphasia program (ICAP). The aim was to identify treatment gains and determine if outcomes were significantly different between participants grouped according to severity and type of aphasia, and time postonset.

METHOD

Data from 74 first-time ICAP participants were analyzed. Pre- and posttreatment scores on the Western Aphasia Battery-Revised and other impairment and participation measures were compared using paired t tests. Analyses of variance were used to compare outcomes related to aphasia severity (severe, moderate, and mild aphasia), aphasia type (fluent, nonfluent), and chronicity (0-6 months postonset, 7-12 months postonset, and 12+ months postonset).

RESULTS

Participants made significant changes on all impairment and participation measures. Large effect sizes were noted for one participation and three impairment measures. Medium effect sizes were noted for one impairment and three participation measures. There was no significant difference among groups on any factor.

CONCLUSION

ICAPs can have a significant effect on the language impairment and participation of people with aphasia, but further research is required to determine if the effect is comparable to other types of service delivery.

The Aphasia Communication Outcome Measure (ACOM): Dimensionality, Item Bank Calibration, and Initial Validation

PURPOSE

The purpose of this study is to investigate the structure and measurement properties of the Aphasia Communication Outcome Measure (ACOM), a patient-reported outcome measure of communicative functioning for persons with aphasia.

METHOD

Three hundred twenty-nine participants with aphasia responded to 177 items asking about communicative functioning. The data were analyzed using a categorical item factor analysis approach. Validity of ACOM scores on the basis of their convergence with performance-based, clinician-reported, and surrogate-reported assessments of communication was also assessed.

RESULTS

Fifty-nine items that obtained adequate fit to a modified bifactor measurement model and functioned similarly across several demographic and clinical subgroupings were identified. The factor model estimates were transformed to item response theory graded response model parameters, and the resulting score estimates showed good precision and moderately strong convergence with other measures of communicative ability and functioning. A free software application for administration and scoring of the ACOM item bank is available from the first author.

CONCLUSIONS

The ACOM provides reliable measurement of patient-reported communicative functioning in aphasia. The results supported the validity of ACOM scores insofar as (a) factor analyses provided support for a coherent measurement model, (b) items functioned similarly across demographic and clinical subgroups, and (c) scores showed good convergence with measures of related constructs.