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Visual Analog Scales (VAS) & This Much!:

Introduction & Bibliography

Helping professionals to help children

(v1.1) 2009, 2012 David V Glasgow

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Introduction
For many children and some adults, "How Much?" can be a very difficult
question to answer, and is also one which often elicits responses that are very
difficult to quantify. Fortunately, for most purposes this is not a major
problem, and feelings & preferences can be discussed or negotiated informally,
even light heartedly.
However, in some situations relative strength of feelings, or changes in
subjective experiences over time can be of enormous importance. For
example, when helping a sick child communicate the severity of pain he or she
is experiencing, professionals are playing a crucial role in both ensuring
adequate analgesia, but also in monitoring recovery. Whether the pain today
is less or more than it was yesterday, is of critical importance.
Many other facets of childrens lives and experience, such as fears and other
emotions about relationships, school, loss, may also be very important to
assess with some accuracy.
Similarly, adults with an intellectual disability, autistic spectrum disorder or
other mental health problems may also struggle to communicate their
preferences, feelings or wishes - and as a consequence may suffer poorly
informed decisions made on their behalf.
Psychologists, counsellors and other therapists working with adults and
children often need to measure symptoms prior to, during and following
intervention, in order to evaluate the effectiveness of an intervention. Where
standardised psychometric measures exist relating to particular symptoms, it
may be possible to use them. However, these are often quite complex and
intimidating, making it very difficult to obtain valid and reliable measures.
This Much!, is an iPad1 app designed to help assessment of children and also
adults with a disability or mental health problems. The aim is to support self
report in such a way as to promote assessment and therapy, as well as
empirical research. It is designed to help answer questions about
circumstances and people which elicit a range of feelings. This Much! can be
used to generate data which can be subjected to quantitative analysis.
However,, it can also be used to interactively explore experiences and even
negotiate therapeutic goals with a child or adult with a disability, using graphic
visual representations. (You can access a brief overview video here)
Although highly flexible and customisable, at the heart of This Much! is a
simple Visual Analogue Scale (VAS).

This Much! Also runs on Mac and Windows computers.

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Visual Analogue Scales

A VAS is a very simple and effective means of measuring attitudes, feelings,
wishes and beliefs. At its simplest, a VAS consists of a line upon which a
person is invited to draw a mark indicating the extent or degree they associate
with a property or condition.
For example, a line might be drawn and labelled 'anxiety in public places'. One
end might be marked zero, or "no anxiety" and the other 100, or "maximum
anxiety".
Similarly, a scale might be labelled regarding severity of pain. In the following
example, the mark might either be interpreted as representing a ratio of actual
to possible pain severity. Alternatively, it might be placed within a series of
repeated assessments in order to give a measure of improvement or
deterioration in condition.

Of course, the questions asked and labels adopted may be more or less
complex and sophisticated, and may relate to different events and
circumstances. Some scales are presented vertically, rather than horizontally
(although there is little compelling evidence this makes much difference).
Others are subdivided into segments (often 5 or 7), and 'calibrated' or
'anchored' with textual descriptors or images. Overall, the visual analogue
scale is an incredibly simple and flexible technique, which has been used in a
great deal of empirical research, as well as more clinically oriented
assessment.
The point at which the mark is made is interpreted as indicating the severity of
anxiety experienced. In the paper and pencil version of the assessment a ruler
is used to measure the number of millimetres from the origin of the scale.
Computerised versions sometimes impose a different range of numbers on the
scale, and sometimes report an arbitrary property such as the number of pixels
from the origin.
It is important to remember that although the numbers generated by a VAS
might appear to offer very fine distinctions and ratio data, the actual precision
of the scale is certain to be considerably less, and whether the data generated
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should be treated as ordinal, interval or ratio is an important consideration2.

One rule of thumb is to assume that any scale VAS is roughly equivalent to a 7
(or at best 10) point scale, unless there is empirical evidence that it is more or
less sensitive. On the other hand, there is evidence that placing multiple
elements on a single scale offers greater precision3.
One of the drawbacks of paper and pencil VAS is that they can be rather
difficult for less able individuals to understand. For example children, those
with a learning disability or autistic spectrum disorder, may struggle to
perceive the scale as a representation of an internal state, understand what is
required of them, or have the skill or confidence to make the mark on paper
using a pen. Nevertheless, visual analogue scales have been used with adults
with a disability, and also with children. With respect to the latter, they are
commonly used in order to enable children to report the severity of pain
suffered prior to, during and following surgical intervention.
A great advantage of using a VAS app is that each childs ability to understand
and use a scale can be both explored and enhanced by practice. To this end a
number of induction stories have been developed, and can be downloaded
from the This Much! web page.
Unipolar or Bipolar scales?
Some assessments are better served by using unipolar scales, and others to
bipolar scales. However, personal construct psychologists believe that both
children and adults naturally tend to apply bipolar scales to their experiences
and beliefs about the world, themselves and other people.
Deciding which approach to adopt is a matter of choice for the professional
involved in assessment. This is likely to depend on the purpose to which the
results of the assessment might be put, and the particular cognitive
characteristics of the individual being assessed. Unipolar scales are more
simple to understand and use, but give less sophisticated, perhaps less
individually salient information.
Bipolar scales can be quite idiosyncratic in both construction and psychological
application, particularly in the case of social constructs. It is therefore very
easy for a professional to provide a bipolar construct which has face validity,
but which may not correspond to the evaluation used by a particular individual
in their day to day life. For example, one person might typically evaluate
others using the scale Scared<--->Strong, another using the scale Weak<-->Strong, and yet another Weak<--->Logical. This information alone gives an

For example, see Couper (2006) and Vautier (2011).

See Granqvist, (2003)

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important insight into the values and experiences of the person, and also offers
a powerful tool for measuring his or her evaluations of others.
This Much! allows the professional to decide on the best approach given the
circumstances of the assessment. It can even be used to elicit and explore
(both qualitatively and quantitatively) bipolar constructs, and then apply them
to different individuals or situations. Alternatively,This Much! can be used to
quantify responses to a number of unipolar dimensions (such as the pain
example above), the data from which can be aggregated across individuals and
reported in group research.
VAS bibliography
The following bibliography has not been cherry picked to only include papers
praising the virtues of VAS. It includes papers which critically evaluate the
approach. Notwithstanding the limitations of VAS, the overall message that
emerges is that most variants are remarkably simple, flexible and effective
psychometric procedures. If used carefully, they offer a great deal to those
who engage in evidence based practice - particularly in contexts in which
other assessments are unwieldy, inappropriate or simply unavailable.
Although practitioners should feel free to use and (carefully) interpret such
scales in day to day work, it is important to be aware of the limitations of VAS,
some of which have been alluded to above. Those proposing to use VAS and
indeed This Much! in research would do well to read the literature carefully.

Adamchic, I., Langguth, B., Hauptmann, C., & Tass, P. A. (2012). Psychometric evaluation
of Visual Analog Scale for the assessment of chronic tinnitus. American journal of
audiology.
Ahearn, E. P., & Carroll, B. J. (1996). Short-term variability of mood ratings in unipolar and
bipolar depressed patients. Journal of affective disorders, 36(3-4), 107115.
Aitken, R. (1969). Measurement of feelings using visual analogue scales. Proceedings of
the royal society of medicine, 62(10), 989.
Arons, A. M. M., Krabbe, P. F. M., van der Wilt, G. J., Olde Rikkert, M. G. M., & Adang, E.
M. M. (In Press). Visual analogue scales: scale recalibration by patients with dementia
and their proxies. Quality of Life Research.
Azorin, J. M., Kaladjian, A., Besnier, N., Adida, M., Hantouche, E., Lancrenon, S., &
Akiskal, H. (2009). Suicidal behaviour in a French Cohort of major depressive patients:
Characteristics of attempters and nonattempters. Journal of affective disorders, 18.

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Badia, X., Monserrat, S., Roset, M., & Herdman, M. (1999). Feasibility, validity and test
retest reliability of scaling methods for health states: the visual analogue scale and the
time trade-off. Quality of Life Research. 8(4):303-10
Brumfitt, S., & Sheeran, P. (1999). The development and validation of the Visual Analogue
SelfEsteem Scale (VASES) 1. British Journal of Clinical Psychology. (4):387-400
Camfield, C., Breau, L., & Camfield, P. (2008). Impact of Pediatric Epilepsy on the Family:
A New Scale for Clinical and ResearchUse Epilepsia 42(1):104-12
Cline, M. E., Herman, J., Shaw, E. R., & Morton, R. D. (1992). Standardization of the
Visual Analogue Scale. Nursing Research, 41(6),
Couper, M. P. (2006). Evaluating the Effectiveness of Visual Analog Scales: A Web
Experiment. Social Science Computer Review, 24(2), 227245.
Crawford, B. K., Piault, E. C., Lai, C., & Bennett, R. M. (2011). Assessing fibromyalgiarelated fatigue: content validity and psychometric performance of the Fatigue Visual
Analog Scale in adult patients with fibromyalgia. Clinical and experimental
rheumatology, 29(6 Suppl 69), S3443.
de Boer, A. G. E. M., van Lanschot, J. J. B., Stalmeier, P. F. M., van Sandick, J. W.,
Hulscher, J. B. F., de Haes, J. C. J. M., & Sprangers, M. A. G. (2004). Is a single-item
visual analogue scale as valid, reliable and responsive as multi-item scales in
measuring quality of life? Quality of Life Research, 13(2), 311320.
DeLoach, L. J., Higgins, M. S., Caplan, A. B., & Stiff, J. L. (1998). The visual analog scale
in the immediate postoperative period: intrasubject variability and correlation with a
numeric scale. Anesthesia & Analgesia, 86(1), 102.
Eaton, T. A., Comer, S. D., Revicki, D. A., Trudeau, J. J., van Inwegen, R. G., Stauffer, J.
W., & Katz, N. P. (2012). Determining the clinically important difference in visual analog
scale scores in abuse liability studies evaluating novel opioid formulations. Quality of
Life Research, 21(6), 975981. doi:10.1007/s11136-011-0012-7
Franchignoni, F., Salaffi, F., & Tesio, L. (2012). How should we use the visual analogue
scale (VAS) in rehabilitation outcomes? I:How much of what? The seductive VAS
numbers are not true measures. Journal of rehabilitation medicine : official journal of
the UEMS European Board of Physical and Rehabilitation Medicine, 44(8), 798799.
Gallagher, E., Liebman, M., & Bijur, P. (2001). Prospective validation of clinically important
changes in pain severity measured on a visual analog scale. Annals of emergency
medicine. 38(6):633-8.

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Granqvist, S. (1996). Enhancements to the Visual Analogue Scale, VAS, for listening tests.
Speech Music and Hearing Quarterly Progress and Status Report, 4.
Granqvist, S (2003). The visual sort and rate method for perceptual evaluation in listening
tests., Logopedics, phoniatrics, vocology 28(3), 109116.
Harms-Ringdahl, K. (2012). How should we use the visual analogue scale (VAS) in
rehabilitation outcomes?III: On the validation requirements for assessments using VAS
with ratio properties. Journal of rehabilitation medicine : official journal of the UEMS
European Board of Physical and Rehabilitation Medicine, 44(8), 801802.
Hofmans, J., & Theuns, P. (2010). On the linearity of predefined and self-anchoring Visual
Analogue Scales. British Journal of Mathematical and Statistical Psychology, 61(2),
401413.
Hunt, O., Burden, D., Hepper, P., Stevenson, M., & Johnston, C. (2007). Parent reports of
the psychosocial functioning of children with cleft lip and/or palate. The cleft palatecraniofacial journal, 44(3), 304311.
Jamison, R. N., Gracely, R. H., Raymond, S. A., Levine, J. G., Marino, B., Herrmann, T. J.,
Daly, M., et al. (2002). Comparative study of electronic vs. paper VAS ratings: a
randomized, crossover trial using healthy volunteers. Pain, 99(1-2), 341347.
Joyce, C. R., Zutshi, D. W., Hrubes, V., & Mason, R. M. (1975). Comparison of fixed
interval and visual analogue scales for rating chronic pain. European journal of clinical
pharmacology, 8(6), 415420.
Kawada, T., Suzuki, H., Shimizu, T., & Katsumata, M. (2012). Polygraphic sleep latency
and subjective sleepiness by visual analog scale (VAS): the limitation of VAS. Applied
ergonomics, 43(1), 266author reply 267.
Kersten, P., Kkdeveci, A. A., & Tennant, A. (2012a). How should we use the visual
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Kersten, P., Kkdeveci, A. A., & Tennant, A. (2012b). The use of the Visual Analogue
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journal of the UEMS European Board of Physical and Rehabilitation Medicine, 44(7),
609610.

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Kersten, P., White, P. J., & Tennant, A. (2010). The Visual Analogue WOMAC 3.0 scale internal validity and responsiveness of the VAS version. BMC Musculoskeletal
Disorders, 11(1), 80.
Kontou, E., Thomas, S. A., & Lincoln, N. B. (In press). Psychometric properties of a
revised version of the Visual Analog Mood Scales. Clinical rehabilitation.
Lenert, L. A., & Sturley, A. E. (2001). Acceptability of computerized visual analog scale,
time trade-off and standard gamble rating methods in patients and the public..
American Medical Informatics Association Symposium, 364368.
Lerdal, A., Kottorp, A., Gay, C. L., & Lee, K. A. (In Press). Development of a short version
of the Lee Visual Analogue Fatigue Scale in a sample of women with HIV/AIDS: a
Rasch analysis application. Quality of Life Research.
Lesage, F.-X., Berjot, S., & Deschamps, F. (2012). Clinical stress assessment using a
visual analogue scale. Occupational medicine (Oxford, England).
Lucas, C., Romatet, S., Mekis, C., Allaf, B., & Lantri-Minet, M. (2012). Stability,
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in migraine. Headache, 52(6), 10051018.
Marsh-Richard, D. M., Hatzis, E. S., Mathias, C. W., Venditti, N., & Dougherty, D. M.
(2009). Adaptive Visual Analog Scales (AVAS): A modifiable software program for the
creation, administration, and scoring of visual analog scales. Behavior Research
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Matamalas, A., Ramrez, M., Mojal, S., Garca De Frutos, A., Molina, A., Sal, G., Llad,
A., et al. (2010). The visual analog scale and a five-item verbal rating scale are not
interchangeable for back pain assessment in lumbar spine disorders. Spine, 35(21),
E11159.
Maxwell, C. (1978). Sensitivity and accuracy of the visual analogue scale: a psychophysical classroom experiment. British journal of clinical pharmacology, 6(1), 1524.
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Miller, M. D., & Ferris, D. G. (1993). Measurement of subjective phenomena in primary
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Moullec, G., Maano, C., Morin, A. J. S., Monthuy-Blanc, J., Rosello, L., & Ninot, G. (2011).
A very short visual analog form of the Center for Epidemiologic Studies Depression
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Scale (CES-D) for the idiographic measurement of depression. Journal of affective

disorders, 128(3), 220234.
Parker, B., Sturm, K., MacIntosh, C., & Feinle, C. (2004). Relation between food intake
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Price, D. D., Staud, R., & Robinson, M. E. (2012). How should we use the visual analogue
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Ramachandran, S., Lundy, J. J., & Coons, S. J. (2008). Testing the measurement
equivalence of paper and touch-screen versions of the EQ-5D visual analog scale (EQ
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Reips, U.-D., & Funke, F. (2008). Interval-level measurement with visual analogue scales
in internet-based research: VAS Generator. Behavior Research Methods, 40(3), 699
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Riker, R., Fraser, G., Simmons, L., & Wilkins, M. (2001). Validating the Sedation-Agitation
Scale with the Bispectral Index and Visual Analog Scale in adult ICU patients after
cardiac surgery. Intensive Care Medicine, 27(5), 853858.
Sindhu, B. S., Shechtman, O., & Tuckey, L. (2011). Validity, reliability, and responsiveness
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Stratton, R., Stubbs, R., Hughes, D., & King, N. (1998). Comparison of the traditional
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Toupet, M., Ferrary, E., & Grayeli, A. B. (2011). Visual analog scale to assess vertigo and
dizziness after repositioning manoeuvres for benign paroxysmal positional vertigo.
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Vautier, S. (2011). Measuring Change with Multiple Visual Analogue Scales: Application to
Tense Arousal. European Journal of Psychological Assessment, 27(2), 111120.
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Vickery, C. D. (2006). Assessment and correlates of self-esteem following stroke using a

pictorial measure. Clinical rehabilitation, 20(12), 10751084.
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