Page Last Updated: December 3, 2025

APA Level 1 / Level 2🔗

Table Name:
pex_bm_apa
Full Name:
DSM-5 Self-Rated Level 1 and Level 2 Cross-Cutting Symptom Measure—Adult (APA Level 1 / Level 2)
Construct:
Mental Health
Data Warning â–¸

Consideration of Mental Health Symptoms Experienced During Pregnancy
The co-occurrence of psychiatric symptoms and substance use during pregnancy is well-documented (Massey et al., 2011, Massey et al., 2012). Phenotypic risk in birthing parents may affect offspring neurodevelopment through both prenatal and postnatal mechanisms, beyond direct exposure alone (Estabrook et al., 2016, Massey et al., 2016, Massey et al., 2018). These factors may confound associations between exposures and neuroimaging or neurodevelopmental outcomes, but they also represent malleable targets for prevention and early intervention. When possible, incorporating parental mental health symptoms as covariates offers a robust strategy to account for these confounding influences.

The data for one or more of these instruments has known issues - see details.

Administration & Quality Control🔗

Child Specific No
Respondent Pregnant Participant, Birth Parent, or Primary Caregiver
Administration Self-administered in-person or remote
Visits V01, V02, V03
Completion Time 5 min
Quality Control
  • Checks for missing data based on counts for items completed by each participant
  • Verification of scoring accuracy
  • Summary statistics to examine item-level frequencies and total scores
  • Review of response distributions for potential outliers

Instrument Details🔗

The HBCD mental health screening instrument is a highly sensitive screening tool for use in community samples. It has two levels, adapted from DSM-5 Self-Rated Level 1 and Level 2 Cross-Cutting Symptom Measures:

Level 1 includes 1 - 2 questions for each of 11 mental health domains Depression, Anger, Mania, Anxiety, Somatic Symptoms, Suicidal Ideation, Psychosis, Sleep Disturbance, Memory, Repetitive Behaviors, Dissociation. When symptoms were reported for Level 1, participants were subsequently administered corresponding Level 2 measures, which asked about additional symptoms associated with the following 8 mental health domains: Anxiety, Anger, Depression, Mania, Personality, Repetitive Behavior, Sleep, and Somatic symptoms.

HBCD Modification Details â–¸

Level 1 Modifications
HBCD excluded Personality Functioning and Substance Use present in the original measure (SU is captured by a separate set of instruments for HBCD - see measures listed here).

Gating Modifications
Gating was adapted for the HBCD study population so that participants proceeded automatically to the Level 2 measure for Personality Inventory without completing level 1. In addition, all participants answered the Level 1 questions for Depression and Somatic Symptoms, but proceeded to Level 2* questions irrespective of answers. Future publications should be sure to acknowledge the removal of Level 1 and 2 Substance Use and the gating mechanisms for Personality Inventory, Depression, and Somatic Symptoms.

*For HBCD, Level 2 symptom measures for Depression and Sleep Disturbance were replaced with the PROMIS Short Forms v1.0 Depression 8a questionnaire and Sleep Disturbance 8a. Level 2 additionally includes the Personality Inventory for DSM-5 Brief, which assesses 5 personality trait domains Negative Affect, Detachment, Antagonism, Disinhibition, Psychoticism.

Clinical Alerts
This measure was modified to alert HBCD study staff if responses to the Level 1 APA self-harm question ('Thoughts of actually hurting yourself?') or Level 2 APA Depression questionnaire (items from 'I felt worthless' to 'I felt that nothing could cheer me up') exceed thresholds of 0 and 32, respectively.

Response Option Changes
For HBCD, the response option ‘Decline to answer’ was added to all questions. The response option ‘Don’t know’ was also included at the beginning of data collection, but was subsequently removed. Questions answered with ‘Decline to answer’ or ‘Don’t know’ are marked as missing.

Scoring Procedures â–¸

Level 1 items and scoring overview, including HBCD adaptations:

* All items scored as 0=none, 1=slight, 2=mild, 3=moderate, 4=severe
  Level 1 Items* Gate to level 2 Level 2 measure
Depression depr_001, depr_002 administered, but all to level 2 (no gating) PROMIS Adult Short Form
v1.0 – Depression 8a
Anger apa_1_anger_001 apa_1_anger_001 ge 2 LEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form)
Mania apa_1_mania_001, apa_1_mania_002 apa_1_mania_001 or apa_1_mania_002 ge 2 LEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale)
Anxiety apa_1_anx_001 apa_1_anx_001 ge 2 LEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form)
Somatic apa_1_somat_001, apa_1_somat_002 administered, but all to level 2 (no gating) LEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic
Symptom Severity [PHQ-15])
Self-harm apa_1_suic_001 no level 2 no level 2
Psychosis apa_1_psych_001, apa_1_psych_002 no level 2 no level 2
Sleep apa_1_sleep_001 apa_1_sleep_001 ge 2 Adult v1.0 - Sleep Disturbance 8a
Memory apa_1_memo_001 no level 2 no level 2
Repetitive apa_1_repet_001, apa_1_repet_002 apa_1_repet_001 or apa_1_repet_002 ge 2 LEVEL 2—Repetitive Thoughts and Behaviors—Adult (adapted from the Florida
Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
Dissociation apa_1_disso_001 no level 2 no level 2
Personality not administered not administered- all to personality inventory Personality inventory for DSM-5 Brief
Substance use not administered not administered not administered

Level two items and scoring overview, including HBCD adaptations. Scores were derived following linked documentation and as documented in the ‘Notes’ column.

  Level 2 Items Scoring Notes
Depression apa_2_depr_001-apa_2_depr_008 sum all items; look up t-score All items must be answered in order to produce a valid score using the scoring tables
Anger apa_2_anger_001-apa_2_anger_005 sum all items; look up t-score One missing item, pro-rate ((raw score * 5)/(number answered)). Two or more missing items should not be scored
Mania apa_2_mania_001-apa_2_mania_005 sum all items; score of ge 6 indicates high probability of mania One missing item, pro-rate ((raw score * 5)/(number answered)). Two or more missing items should not be scored
Anxiety apa_2_anx_001-apa_2_anx_007 sum all items; look up t-score Less than 3 missing items, pro-rate ((raw score *7)/(number answered)). Three or more missing items should not be scored
Somatic apa_2_somat_001-apa_2_somat_015 sum all items; interpreted using the Interpretation Table for the PHQ-15 Somatic Symptom Severity scale Less than 4 missing items, pro-rate ((raw score *15)/(number answered)). Four or more missing items should not be scored
Sleep apa_2_sleep_001-apa_2_sleep_008 sum all items; look up t-score All items must be answered in order to produce a valid score using the scoring tables
Repetitive apa_2_repet_001-apa_2_repet_005 sum all items; look up t-score One missing item, pro-rate ((raw score * 5)/(number answered)). Two or more missing items should not be scored
Personality apa_2_pers_001-apa_2_pers_025 sum all items; look up t-score Six missing item, pro-rate ((raw score *25)/(number answered)). Seven or more missing items should not be scored

References🔗

Doss, R. A., & Lowmaster, S. E. (2022). Validation of the DSM-5 Level 1 Cross-Cutting Symptom Measure in a Community Sample. Psychiatry Research, 318, 114935. https://doi.org/10.1016/j.psychres.2022.114935

Estabrook, R., Massey, S. H., Clark, C. A. C., Burns, J. L., Mustanski, B. S., Cook, E. H., O’Brien, T. C., Makowski, B., Espy, K. A., & Wakschlag, L. S. (2016). Separating family-level and direct exposure effects of smoking during pregnancy on offspring externalizing symptoms: Bridging the behavior genetic and behavior teratologic divide. Behavior Genetics, 46(3), 389–402. https://doi.org/10.1007/s10519-015-9762-2

Massey, S. H., Lieberman, D. Z., Reiss, D., Leve, L. D., Shaw, D. S., & Neiderhiser, J. M. (2011). Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy. The American Journal on Addictions. https://doi.org/10.1111/j.1521-0391.2010.00110.x

Massey, S. H., Mroczek, D. K., Burns, J. L., Clark, C. A. C., Espy, K. A., & Wakschlag, L. S. (2018). Positive parenting behaviors in women who spontaneously quit smoking during pregnancy: Clues to putative targets for preventive interventions. Neurotoxicology and Teratology, 67, 18–24.https://doi.org/10.1016/j.ntt.2018.02.003

Massey, S. H., Neiderhiser, J. M., Shaw, D. S., Leve, L. D., Ganiban, J. M., & Reiss, D. (2012). Maternal self concept as a provider and cessation of substance use during pregnancy. Addictive Behaviors, 37(8), 956–961. https://doi.org/10.1016/j.addbeh.2012.04.002

Massey, S. H., Reiss, D., Neiderhiser, J. M., Leve, L. D., Shaw, D. S., & Ganiban, J. M. (2016). Maternal personality traits associated with patterns of prenatal smoking and exposure: Implications for etiologic and prevention research. Neurotoxicology and Teratology, 53, 48–54. https://doi.org/10.1016/j.ntt.2015.11.010

Roche, M. J., Pincus, A. L., & Cole, P. E. (2019). Linking dimensions and dynamics in psychopathology research: An example using DSM-5 instruments. Journal of Research in Personality, 82, 103852. https://doi.org/https://doi.org/10.1016/j.jrp.2019.103852