Systematic Clinical Outcome and Routine Evaluation (SCORE)

1. Abstract

The Systematic Clinical Outcome and Routine Evaluation (SCORE) is a family assessment and therapeutic outcome measurement system developed to evaluate relational functioning, systemic dynamics, and clinical change across the trajectory of systemic family and couple therapy. Originally operationalized as a comprehensive 40-item scale (SCORE-40) and subsequently refined into condensed versions—most notably the 28-item instrument (SCORE-28) validated in Ireland and the 15-item brief version (SCORE-15) endorsed by the European Family Therapy Association (EFTA) and the Child Outcomes Research Consortium (CORC)—the instrument was engineered to be acceptable to family members, clinically meaningful to therapists, and methodologically sound. The measure evaluates systemic functioning across three core dimensions: Family Strengths (positive relational bonds, adaptive resources, resilience), Family Communication (openness, transparency, clarity of verbal exchanges, freedom from emotional reactivity), and Family Difficulties (pervasive friction, burden, perceived crisis, overt conflict). In addition to standardized Likert-type relational items, the SCORE incorporates qualitative qualitative descriptors, individual problem-definition narratives, and visual analogue scales (VAS) evaluating problem severity, global family management, and perceived therapeutic helpfulness. Psychometric evaluations across clinical and non-clinical national normative populations demonstrate robust internal consistency (Cronbach’s alpha coefficients routinely ranging from α = .78 to α = .93 across subscales and total scores), high test-retest reliability over non-treatment baseline periods, confirmed three-factor and second-order structural validity via confirmatory factor analysis, and significant responsiveness to therapeutic intervention with medium-to-large effect sizes. As an open-access clinical tool accessible across multiple languages and developmental adaptations (including specialized versions for children and adolescents), the SCORE represents an international benchmark in systemic outcome monitoring.

2. Keywords

Systematic Clinical Outcome and Routine Evaluation, SCORE-15, SCORE-28, SCORE-40, family therapy, systemic functioning, outcome measurement, psychometrics, relational assessment, routine outcome monitoring.

3. Authors

The SCORE family of instruments was conceptualized, designed, and psychometrically standardized through a collaborative research consortium led by prominent systemic scholars and clinicians in the United Kingdom and Ireland, in partnership with the Association for Family Therapy and Systemic Practice (AFT) and the European Family Therapy Association (EFTA):

• Peter M. Stratton, PhD, FBPsS: Emeritus Professor of Family Therapy, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, United Kingdom. Dr. Stratton spearheaded the original SCORE development group, coordinating multi-site clinical trials across National Health Service (NHS) trusts and international systemic clinics. (Contact: [email protected]).
• Judith Lask: Institute of Psychiatry, Psychology & Neuroscience, King’s College London, and South London and Maudsley NHS Foundation Trust, United Kingdom.
• Alan Carr, PhD: Professor of Clinical Psychology, School of Psychology, University College Dublin (UCD), Ireland. Dr. Carr directed the national Irish normative standardization, adolescent validation, and factor-analytic studies of the SCORE-28 and SCORE-15.
• Paula Cahill, PhD: School of Psychology, University College Dublin, Ireland.
• Julia Bland, MBBS, MRCPsych: South London and Maudsley NHS Foundation Trust and Guy’s Hospital, London, United Kingdom.
• Elizabeth Janes: Leeds Family Therapy and Research Centre, University of Leeds, United Kingdom.
• Arlene Vetere, PhD: Professor of Family Therapy and Systemic Practice, VID Specialized University, Oslo, Norway, and University of Surrey, United Kingdom.

4. Purpose

The primary purpose of the Systematic Clinical Outcome and Routine Evaluation is to provide a standardized, clinically viable, and psychometrically rigorous instrument capable of monitoring systemic relational processes and tracking therapeutic outcomes within systemic therapy, couple interventions, and multidisciplinary child and adolescent mental health services (CAMHS). Historically, clinical outcome evaluation in mental health settings has been dominated by individual-focused psychiatric instruments, such as the Beck Depression Inventory (BDI-II), the Child Behavior Checklist (CBCL), or the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM). While these measures effectively index individual psychopathology, symptomatic severity, and subjective intrapsychic distress, they are inherently blind to the supra-individual, interpersonal, and transactional processes that define systemic clinical practice.

Prior family assessment batteries—such as the McMaster Family Assessment Device (FAD), the Family Adaptability and Cohesion Evaluation Scales (FACES), and the Systemic Therapy Inventory of Change (STIC)—often presented significant logistical barriers to routine clinical deployment. Many existing scales were either too lengthy for busy outpatient services, copyrighted and cost-prohibitive, conceptually restricted to a single theoretical school (such as structural or circumplex models), or lacked developmentally sensitive parallel versions suitable for younger children. The SCORE was deliberately designed to resolve these clinical-research tensions by meeting five foundational criteria:

• Practice-Based Feasibility: Brief administration time (under 10 minutes for SCORE-28; under 5 minutes for SCORE-15), allowing the measure to be administered routinely at every therapy session, at mid-treatment, or at pre/post-intervention without disrupting therapeutic rapport.
• Multiperspective Relational Assessment: Designed for parallel completion by multiple family members aged 8 to 11 (Child Version), 12 to 17 (Adolescent Version), and adults (Adult Version), facilitating direct clinical comparisons between parental, sibling, and intergenerational perceptions of the family system.
• Ecological and Systemic Content Validity: Items reflect relational interactions, communication clarity, emotional climate, mutual support, problem-solving flexibility, and family burden, rather than individual symptomatic deficits.
• Clinical Utility as an In-Session Therapeutic Intervention: Beyond providing quantitative metric scores for epidemiological or administrative audits, the SCORE acts as a therapeutic dialogue generator. Clinicians utilize divergent scoring profiles between family members to foster meta-communication, externalize recurring conflict patterns, and illuminate hidden relational resources.
• Sensitivity to Therapeutic Change: High responsiveness to systemic therapeutic progress, providing clear psychometric benchmarks for reliable change indices (RCI) and clinically significant movement from distressed to non-distressed normative functional ranges.

5. Psychological Construct

The SCORE evaluates systemic family functioning as an integrated, multi-level construct characterized by transactional feedback loops, shared emotional climates, organizational structure, and coping resilience. Through iterative psychometric distillation—originating from an initial pool of over 80 candidate items down to the 40-, 28-, and 15-item instruments—the underlying construct has consistently resolved into three distinct yet interdependent first-order dimensions, anchored by a higher-order latent factor of Total Family Functioning.

5.1 Family Strengths

The Family Strengths dimension conceptualizes the family system’s collective resilience, positive affective bonds, mutual trust, and adaptive coping resources. Grounded in salutogenic and strengths-based systemic theory, this construct moves beyond the mere absence of pathology to capture proactive, nurturing relational processes. Key behavioral and affective facets within this dimension include:

• Mutual Regard and Care: The overt demonstration of affection, emotional warmth, and reciprocal cherishing among members (e.g., “People do things that show that they care about each other in my family”; “Being in this family is important to us”).
• Interpersonal Trust and Reliability: The implicit psychological safety that allows members to rely on one another during times of emotional or logistical stress (e.g., “We trust each other”; “When one of us is upset he or she get looked after in the family”).
• Collective Efficacy and Solution-Focused Adaptability: The family’s shared belief in its agency to navigate life stressors and formulate creative alternatives to relational stalemates (e.g., “We are good at finding new ways to deal with things that are difficult”; “If something is going wrong in our family we know we can change it”).
• Shared Cohesion and Joy: The capacity of the unit to enjoy shared leisure, play, and positive memory consolidation (e.g., “Our family shares enjoyable times together”).

5.2 Family Difficulties

The Family Difficulties dimension assesses the pervasive sense of systemic strain, emotional distress, chaotic crisis orientation, and systemic demoralization. This construct captures the extent to which the family environment is experienced as exhausting, overburdened, or chronically overwhelmed by ongoing external or internal stressors. Structural components include:

• Pervasive Systemic Demoralization: A sustained negative emotional climate characterized by subjective distress, misery, and hopelessness (e.g., “It feels miserable in our family”; “Life in our family is very difficult”).
• Chronic Crisis Patterning: An allostatic systemic overload where the family experiences life as an unending sequence of disruptions, preventing homeostatic stabilization (e.g., “We seem to go from one crisis to another in my family”).
• Fatalism and Impaired Daily Coping: The perception that everyday operational routines cannot be managed successfully and that adverse outcomes are inevitable (e.g., “We find it hard to deal with everyday problems”; “Things always seem to go wrong for my family”).
• Interpersonal Intrusiveness and Boundary Diffusion: Enmeshment and invasive behaviors that undermine member autonomy (e.g., “People in my family interfere too much in each other’s lives”).

5.3 Family Communication

The Family Communication dimension captures the quality, safety, transparency, and behavioral reactivity evident in verbal and nonverbal transactions among family members. Rather than indexing mere communicative frequency, it gauges functional openness versus communicative toxicity, scapegoating, and defensive avoidance. Sub-dimensions include:

• Expressive Safety and Active Listening: The degree to which members feel validated, heard, and emotionally permitted to express authentic perspectives without fear of retaliation (e.g., “Each of us gets listened to in our family”; “In our family we talk to each other about the things that matter to us”; “In our family it is OK to show how you feel”).
• Pervasive Blaming and Scapegoating: Destructive attributional styles where systemic friction is localized into a single member or projected outward (e.g., “One person tends to get blamed for everything in my family”; “In my family we blame others when things go wrong”).
• Communicative Avoidance and Hostile Withholding: The deployment of stonewalling, deliberate silence, or emotional cutoff during conflict (e.g., “When people in my family get angry they ignore each other on purpose”; “People often don’t tell each other the truth in my family”).
• Affective Dysregulation and Overt Hostility: Uncontained expressive volatility that disrupts relational safety (e.g., “People in the family are nasty to each other”; “People slam doors, throw things, or make a lot of noise if they are upset”).

6. Theoretical Framework

The conceptual architecture of the Systematic Clinical Outcome and Routine Evaluation is rooted in classical and contemporary systems theory, cybernetics, and social constructionist therapeutic paradigms. Rather than pathologizing individuals through a linear psychiatric lens (cause → effect; biological deficit → symptom), the SCORE operationalizes family functioning through recursive relational models.

6.1 General Systems Theory and Cybernetics

Rooted in Ludwig von Bertalanffy’s General Systems Theory and the cybernetic principles articulated by Gregory Bateson and the Mental Research Institute (MRI) in Palo Alto, the family is conceptualized as an open, self-regulating, goal-directed system bound by circular causality. From this perspective, symptomatic distress in an individual (“the identified patient”) is an emergent property of systemic relational patterns, recursive feedback loops, and rigid homeostatic mechanisms. The SCORE’s subscales directly capture these cybernetic properties: feedback mechanisms are operationalized through communicative openness or avoidance, while homeostatic flexibility is evaluated through items measuring the family’s capacity to modify rules and discover new solutions under environmental stress.

6.2 Structural and Strategic Family Therapy Paradigms

The structural model formulated by Salvador Minuchin posits that healthy family functioning relies upon clear, flexible boundaries, adaptive hierarchical organization, and appropriate subsystems (spousal, parental, sibling). When boundaries become overly rigid (leading to emotional disengagement) or excessively diffuse (producing enmeshment and over-involvement), systemic dysfunction ensues. The SCORE operationalizes these structural dynamics through items addressing boundary interference (“People in my family interfere too much in each other’s lives”), hierarchical coherence (“Respecting elders is important in our family”; “We get into a muddle about who should do what”), and triangulation/scapegoating (“One person tends to get blamed for everything in my family”).

6.3 Social Constructionism and Narrative Therapy

Acknowledging that families construct subjective meaning through language, shared narratives, and relational discourse, the SCORE integrates social constructionist and collaborative therapeutic principles. Systemic practitioners operating from Milan systemic, solution-focused, or narrative therapy orientations emphasize that a family’s shared reality is co-constructed. Accordingly, the SCORE intentionally includes open qualitative prompts (“What words would best describe your family?”; “What do you think is the biggest problem/challenge for the family at the moment?”) alongside visual analogue scaling of subjective challenge. By doing so, the instrument honors the subjective perspective of each family member, acknowledging that there is no singular objective reality in a family system, but rather multiple intersecting perceptual worlds.

7. Validity

Extensive psychometric investigations across the United Kingdom, Ireland, and continental Europe have established strong evidence for the construct, convergent, discriminant, and criterion-related validity of the SCORE instruments.

7.1 Construct and Factorial Validity

The conceptual triadic architecture of the SCORE has been verified across both non-clinical community samples and clinical cohorts. In the landmark validation study of the SCORE-28 by Cahill et al. (2010), involving a non-clinical sample of 415 Irish adults and adolescents alongside an outpatient clinical cohort, principal components analysis with varimax and oblimin rotations confirmed that the items loaded distinctly onto three robust factors: Family Strengths, Family Difficulties, and Family Communication, jointly accounting for 45.4% of the total variance. Subsequent confirmatory factor analyses of the SCORE-15 across diverse international settings (e.g., Stratton et al., 2010; Fay et al., 2013; Hamilton et al., 2015) consistently demonstrated satisfactory to excellent goodness-of-fit indices (RMSEA ≤ .06, CFI ≥ .92, TLI ≥ .91), substantiating a hierarchical structure where the three distinct subscales load onto an overarching latent dimension of global systemic functioning.

7.2 Convergent Validity

Convergent validity has been established through extensive correlations with established, gold-standard measures of family and individual functioning:

• McMaster Family Assessment Device (FAD): Cahill et al. (2010) and Hamilton et al. (2015) observed strong, statistically significant correlations between the SCORE subscales and the FAD General Functioning scale (ranging from r = .65 to r = .82, p < .001). Specifically, the SCORE Family Difficulties and Communication subscales correlated positively with FAD dysfunctional scoring, while the Family Strengths subscale exhibited robust negative correlations.
• Strengths and Difficulties Questionnaire (SDQ): In pediatric CAMHS settings, child- and parent-reported SCORE scores correlate significantly with parent-reported SDQ Total Difficulties scores (r = .40 to .58, p < .001), indicating that systemic family distress is closely coupled with child behavioral and emotional symptomatology.
• Clinical Outcomes in Routine Evaluation (CORE-OM): In adult populations, higher SCORE family dysfunction scores correlate moderately to strongly with adult psychological distress and symptomatic impairment (r = .52 to .68), demonstrating that family system dysfunction mirrors individual psychological vulnerability.

7.3 Discriminant Validity

The SCORE exhibits exceptional discriminant capacity, reliably differentiating between clinical families seeking systemic psychological treatment and non-clinical community families. In the national Irish normative standardization study conducted by Fay et al. (2013) across a representative general population telephone sample of 1,003 individuals, non-clinical respondents consistently demonstrated significantly higher Family Strengths and substantially lower Family Difficulties and Communication problems than clinical cohorts presenting to outpatient family therapy centers. Multivariate analyses of variance (MANOVA) indicated large between-group multivariate effect sizes (Wilks’ λ = .68 to .74, p < .001, partial η² = .26 to .32), confirming that the instrument sensitively identifies true relational pathology without misclassifying normative family conflict.

7.4 Sensitivity to Change and Predictive Validity

In prospective longitudinal studies evaluating families undergoing systemic family therapy (Hamilton et al., 2015; Stratton et al., 2014), the SCORE demonstrated marked sensitivity to therapeutic change. Statistically significant improvements were observed across all three subscales and the visual analogue problem severity scales between pre-treatment baseline and session-by-session, mid-treatment, and completion time points. Calculated Cohen’s d effect sizes ranged from 0.45 (moderate change by session 4) to 0.85–1.12 at treatment termination, confirming that the tool effectively tracks clinical progress and identifies clinically significant systemic improvements.

8. Reliability

The reliability of the SCORE instruments has been documented across clinical and non-clinical cohorts, linguistic translations, and diverse developmental groups.

8.1 Internal Consistency

Internal consistency estimates (Cronbach’s alpha, α) for the SCORE versions consistently meet and exceed professional standards for both research applications and clinical decision-making (≥ .80):

• SCORE-28: In the initial validation by Cahill et al. (2010), Cronbach’s alpha coefficients were α = .93 for the Total Score, α = .90 for Family Strengths (13 items), α = .88 for Family Difficulties (6 items), and α = .86 for Family Communication (9 items). Similar internal consistency was demonstrated in national normative samples (Fay et al., 2013; α = .84 to .92).
• SCORE-15: Across multi-country European studies (Stratton et al., 2010; Hamilton et al., 2015), the brief 15-item instrument showed alpha values ranging from α = .85 to α = .90 for the Total Score, α = .81 to .86 for Family Strengths (5 items), α = .78 to .84 for Family Difficulties (5 items), and α = .77 to .83 for Family Communication (5 items).
• Child and Adolescent Adaptations: In youth aged 12 to 17, alpha coefficients across subscales range from α = .79 to .89; in younger cohorts aged 8 to 11 completing the child-adapted version, alpha coefficients remain acceptable (α = .74 to .82).

8.2 Test-Retest Reliability and Temporal Stability

Temporal stability evaluated over non-intervention waiting-list intervals (ranging from 2 to 6 weeks) demonstrated robust intraclass correlation coefficients (ICC) and Pearson correlation coefficients. Cahill et al. (2010) reported test-retest coefficients for the SCORE-28 ranging from r = .78 to r = .86 across the three subscales, confirming that in the absence of clinical intervention or major systemic life events, relational appraisals remain temporally stable.

9. Factor Analysis

The psychometric transition from the exploratory 40-item prototype (SCORE-40) to the streamlined SCORE-28 and SCORE-15 instruments was driven by sequential exploratory factor analyses (EFA) followed by multi-group confirmatory factor analyses (CFA).

9.1 Exploratory Factor Analysis (SCORE-40 to SCORE-28)

Initial developmental trials on the SCORE-40 analyzed responses from clinical and non-clinical respondents using Principal Axis Factoring (PAF) and Principal Component Analysis (PCA) with oblimin (oblique) rotation to account for expected correlations among family dynamic variables. Items exhibiting low primary factor loadings (< .40), severe cross-loadings (> .30 on secondary factors), or poor clinical face validity were systematically excised. This reduced the instrument to 28 core items (Cahill et al., 2010), which unambiguously resolved into a three-factor solution with eigenvalues greater than 1.5:

• Factor 1: Family Strengths (accounting for 26.8% of variance), characterized by heavy positive loadings (.52 to .78) from items reflecting care, mutual listening, resilience, shared activities, and trust (e.g., Item 2 “People do things that show that they care…”; Item 26 “We trust each other”).
• Factor 2: Family Communication (accounting for 10.4% of variance), defined by loadings (.45 to .72) on items evaluating blaming, deception, hostile withdrawal, and emotional unresponsiveness (e.g., Item 6 “One person tends to get blamed…”; Item 10 “When people in my family get angry they ignore each other…”).
• Factor 3: Family Difficulties (accounting for 8.2% of variance), driven by loadings (.48 to .76) on items indexing pervasive hardship, crisis cycling, and fatalism (e.g., Item 9 “We find it hard to deal with everyday problems”; Item 19 “It feels miserable in our family”; Item 28 “We seem to go from one crisis to another…”).

9.2 Confirmatory Factor Analysis and Structural Equivalence (SCORE-15)

To maximize routine clinical uptake, Stratton et al. (2010) and Fay et al. (2013) refined the scale down to 15 items, selecting the top 5 highest loading, clinically rich items for each of the three latent dimensions. Confirmatory factor analysis testing the three-factor model yielded excellent model fit statistics:

• Root Mean Square Error of Approximation (RMSEA): .048 to .056 (90% CI [.041, .063]), indicating close structural fit below the .06 benchmark.
• Comparative Fit Index (CFI): .945 to .962, surpassing the .90 conventional threshold for model adequacy.
• Tucker-Lewis Index (TLI): .938 to .954.
• Standardized Root Mean Square Residual (SRMR): .041.

Alternative single-factor models (forcing all items onto a solitary general functioning factor) demonstrated significantly degraded fit (χ² difference tests p < .001; CFI < .80; RMSEA > .10), validating the multidimensionality of the construct while supporting a second-order model where the three factors coalesce into an overarching systemic functioning index.

10. Instrument / Measurement Tool

• Instrument Type: Standardized, multi-informant, self-report clinical rating scale incorporating closed Likert-type items, qualitative family descriptors, open-ended problem identification fields, and visual analogue scales.
• Available Versions:
  • SCORE-40: 40-item original developmental research version.
  • SCORE-28: 28-item validated clinical outcome version.
  • SCORE-15: 15-item brief clinical version (Adult/Adolescent and Younger Child adaptations).
• Target Population: Adults and adolescents aged 12 and older (Standard Version); children aged 8 to 11 (Child-Adapted Version with simplified vocabulary).
• Administration Format: Paper-and-pencil questionnaire, digital psychometric platform, or clinical outcome portal; self-administered individually by all participating family members.
• Time to Complete: Approximately 3–5 minutes for SCORE-15; 8–10 minutes for SCORE-28.
• Response Scale (Standard Relational Items): 6-point Likert-type scale reflecting relational congruence:
  • 1 = Extremely well
  • 2 = Very well
  • 3 = Well
  • 4 = A bit
  • 5 = Not well
  • 6 = Not at all
• Response Scale (Visual Analogue / Severity Scales): 11-point continuous rating scale anchored from 0 (No problem at all / Very well / Very helpful) to 10 (Really bad / Really awful / Very badly / Unhelpful / Totally spoils our family life).
• Scoring and Computational Rules:
  • Items are balanced between positive systemic competencies and negative difficulties. Standard operational scoring across research studies converts raw scores such that higher numerical averages reflect greater systemic difficulty/dysfunction, or alternatively computes individual subscale means where positive items are appropriately reversed.
  • Scoring Formula for SCORE-28 (Cahill et al., 2010; Fay et al., 2013):
    • Family Strengths (13 items): Calculated as the arithmetic mean of items: (1 + 2 + 3 + 5 + 8 + 12 + 14 + 17 + 18 + 23 + 24 + 26) / 13. Note: When calculating a unified Total Difficulty score, positive strength items are reverse-coded: R = 7 − Raw Score.
    • Family Difficulties (6 items): Calculated as the arithmetic mean of reversed items: (R9 + R11 + R16 + R19 + R22 + R28) / 6.
    • Family Communication (9 items): Calculated as the arithmetic mean of reversed items: (R4 + R6 + R7 + R10 + R15 + R20 + R21 + R25 + R27) / 9.
    • Total SCORE-28 Score: The grand mean of all 28 items (with positive strength items reversed), yielding a single overall index ranging from 1.0 to 6.0, where 1.0 represents optimal family functioning and 6.0 indicates severe systemic dysfunction.
  • Scoring Formula for SCORE-15 (Stratton et al., 2010; Fay et al., 2013):
    • Family Strengths (5 items): Items 1, 3, 6, 10, 15 (corresponding to items 23, 12, 26, 17, 24 of the broader pool). Mean = (1 + 3 + 6 + 10 + 15) / 5.
    • Family Difficulties (5 items): Items 5, 7, 9, 11, 13 (corresponding to items 9, 19, 28, 22, 4). Mean = (5 + 7 + 9 + 11 + 13) / 5.
    • Family Communication (5 items): Items 2, 4, 8, 12, 14 (corresponding to items 7, R4-alt, 10, 25, 21). Mean = (2 + 4 + 8 + 12 + 14) / 5.
    • Total SCORE-15 Score: The grand mean across all 15 items (with positive items reverse-coded), ranging from 1.0 (optimal) to 6.0 (severe dysfunction).
  • Qualitative and Analogue Components: Item 29/42 (open narrative challenge description, problem severity rating, and impact rating) are analyzed qualitatively for therapeutic goal-setting and tracked as continuous longitudinal single-item metrics.

11. Permissions & Fee and Test Year

The Systematic Clinical Outcome and Routine Evaluation was initially published in 2010 through groundbreaking developmental papers by Stratton, Bland, Janes, and Lask (2010) and Cahill, O’Reilly, Carr, Dooley, and Stratton (2010). In deliberate alignment with the ethical commitments of the systemic family therapy community, the authors placed the SCORE instruments in the public domain as an open-access, non-commercial assessment resource.

No licensing fees, commercial royalties, or user registration charges are required for clinical, educational, or academic research use. Health authorities, academic institutions, and clinicians are permitted to reproduce and administer the scale, incorporate it into electronic health record (EHR) systems, or utilize validated translations, provided appropriate academic citation is maintained. The complete instrument batteries, user guides, scoring templates, and international translations are freely hosted and distributed through the Child Outcomes Research Consortium (CORC) and the European Family Therapy Association (EFTA).

12. References

• Cahill, P., O’Reilly, K., Carr, A., Dooley, B., & Stratton, P. (2010). Validation of a 28-item version of the Systemic Clinical Outcome and Routine Evaluation in an Irish context: The SCORE-28. Journal of Family Therapy, 32(3), 210–231. https://doi.org/10.1111/j.1467-6427.2010.00506.x
• Fay, D., Carr, A., O’Reilly, K., Cahill, P., Dooley, B., Guerin, S., & Stratton, P. (2013). Irish norms for the SCORE-15 and 28 from a national telephone survey. Journal of Family Therapy, 35(1), 24–42. https://doi.org/10.1111/1467-6427.12001
• Hamilton, E., Carr, A., Cahill, P., Cassells, C., & Hartnett, D. (2015). Psychometric properties and responsiveness to change of 15- and 28-item versions of the SCORE: A family assessment questionnaire. Family Process, 54(3), 454–463. https://doi.org/10.1111/famp.12117
• Stratton, P., Bland, J., Janes, E., & Lask, J. (2010). Developing a practicable outcome measure for systemic family therapy: The SCORE. Journal of Family Therapy, 32(3), 232–258. https://doi.org/10.1111/j.1467-6427.2010.00507.x
• Stratton, P., Lask, J., Bland, J., Nowakowska, E., & Evans, C. (2014). Detecting the outcomes of systemic family therapy: An examination of the SCORE-15 in routine practice. Journal of Family Therapy, 36(3), 282–303. https://doi.org/10.1111/1467-6427.12022

13. Items of the Scale (Questionnaire)