Identifying coronary-prone behavior in adolescents using the Bortner Self-rating Scale

J Chren

Dis Vol. 40, No. 8, pp. 785-793, 1987 Prjnted in Great Britain. All rights reserved

Copyright 0

OOZI-9681/87 $3.00 + 0.00 1987 Pergamon Journals Ltd

IDENTIFYING CORONARY-PRONE BEHAVIOR ADOLESCENTS USING THE BORTNER SELF-RATING SCALE BRADLEY

IN

0. BOEKELOO,’ JOYCE A. MAMON’~* and CRAIG K. EWART’

‘Department of Behavioral Sciences and Health Education and 2Health Services Research and Development Center, The Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205, U.S.A. (Received

in revised form

10 September

1986)

Abstract-Brief measures to identify coronary-prone (Type-A) behavior in young persons are greatly needed for longitudinal epidemiologic study of cardiovascular diseases. We examined the suitability of a modified 14-item Bortner Self-rating Scale (ABS) for use in an adolescent population. Responses of 549 racially mixed, low to middle income urban high school students were analyzed to see if ABS measurement properties matched those of the parent version. Construct validity was explored by correlating ABS scores with measures of anger expression, social support, life satisfaction, academic achievement and blood pressure. Results disclosed that the distribution and factor structure of adolescent ABS responses closely resembled findings obtained with adults. Scale validity was supported by significant associations of ABS scores with degree of overt anger expression, lack of social support, and dissatisfaction with school and life in general. Academic achievement and blood pressure were found not to correlate with adolescent ABS scores. Possible race and sex differences are considered. Cardiovascular Coronary-prone behavior Type-A behavior pattern Personality assessment health Anger Social support

INTRODUCTION

Epidemiologic study of the Type A behavior pattern (TABP) early in life may demonstrate new ways of preventing, delaying, or moderating disease [l]. There are, however, few standard assessment measures suitable for the measurement of TABP in adolescents. In adults, the standard measure of TABP is the Structured Interview (SI) [2]. Due to the SI’s high labor intensity and cost, alternative paper and pencil questionnaires have been developed for use in large population studies. Of the various selfreport TABP measures for which there is some This work was supported in part by a research grant to the third author from the National Heart, Lung, and Blood Institute, Bethesda, Maryland (NHLBI ROI-H 129431). Address reprint requests to: Craig K. Ewart, Ph.D:, The Johns Hopkins Medicai Institutions, 624 North Broadway, Baltimore, MD 21205, U.S.A.

risk

Adolescent

validation, the one which seems most appropriate for screening in large populations is the Bortner Scale [3]. The Bortner Scale is shorter and easier to score than other TABP self-report measures and has been found to be as reliable and valid [3-81. The Bortner Scale correctly identifies SI Type A classifications 75% of the time [4] and has been shown to predict incidence of MI and sudden death [9]. As with all Type A measures to date, evidence on the relationship of Bortner Scale measurements and coronary artery disease is inconclusive [lO-131. This paper describes a preliminary effort to validate a modified version of the Bortner Scale for use with low to middle income urban high school students. There have been several previous attempts to adapt the Bortner Scale for use with adolescents [1417]. A seven item modification of the scale for adolescents showed a concordance rate with an adolescent version

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of the SI of around 55% [14]. A 24 item modification of the Bortner Scale was used in a study of fifth- and sixth-grade students and was found to have a stable factor structure and be positively associated with behaviors considered representative of the Type A behavior pattern [ 151. A shorter 17 item version of this scale showed a stable factor structure and small associations between specific factors of the Type A scale and risk factors in children and adolescents [16]. Finally, another group of investigators created an adolescent version of the 1Citem adult scale by rephrasing certain items [17]. Research using this version showed that Type A male adolescents had significantly greater increases in systolic blood pressure in response to a mentally challenging task than did Type B males [18]. We made further modifications in this 1Citem scale and included it in an assessment battery that also contained measures of anger expression, social support, and academic performance. Student responses on the modified “Adolescent Bortner Scale” (ABS) were then examined to determine if: (1) the ABS had measurement properties similar to those of the adult version (i.e. similar distributions and factor structure); and (2) the ABS scores were significantly correlated with other variables that are hypothesized to be related to TABP for adolescents. Specifically, we hypothesized that in comparison to students with low ABS scores, individuals with high scores would report significantly more overt anger expression [19-211, greater dissatisfaction with life [22,23], less perceived social support, and achieve a higher grade point average [20,24-261. Although findings concerning the relationship of TABP to social support have been inconsistent, we predicted that adolescents who are competitive and report frequent overt anger would feel less satisfied with the support they received from family and peers. METHODS

Study population

Subjects were a subgroup of a larger sample of 9th and 10th grade students who participated in a school-based adolescent blood pressure evaluation and intervention study conducted by one of the authors (CE). The sample described here represents one of two large Baltimore public high schools participating in that project. Data collection at the second school is currently being conducted. The source population con-

sists of 799 students between the ages of 14 and 17 whose parents granted permission for them to participate in the study. A sample of 549 students completed the health risk questionnaire and three blood pressure measurements (response rate = 69%). Examination of respondents vs non-respondents on age, race and sex indicated no statistically significant differences. Subjects came from low to middle income (blue collar) neighborhoods and averaged 15.4 (SD = 0.82) years of age. Sixty-five percent of the students were white and 52% were male. Most subjects in the sample (80%) were in grade 10 and the remainder were in grade 9. This imbalance resulted from a newly initiated policy of adding 9th grade classrooms to 3-year high schools due to declining enrollments in city middle schools. Average scores on a standard state-wide test of reading ability revealed that as a group, subjects performed just below the 9th grade level. The high school in which this study took place had a different racial distribution than most other Baltimore High Schools; most city schools are around 80% non-white. Compared to another all black school we are studying, however, there are no differences between schools on achievement tests, absences from school, age, sex or SES. Measures Type-A behavior pattern. Pilot investigation suggested several important modifications of the Bortner Scale [ 171 to render it suitable to an adolescent population. First, the scale was reviewed to insure that its wording would be understandable to high school students. Second, pilot testing showed that a “true”, “false” response format instructing students to circle the preferred response caused fewest misunderstandings. We thus approximated this format with a row of eight equally spaced “X’s” and asked subjects to circle the “X” which reflected his or her position between two adjectives (Appendix). To further ease administration, potentially unfamiliar words were placed on the English Departments’ vocabulary list for the week preceding ABS questionnaire administration. The ABS and other instruments were administered during English classes. Each ABS item was scored on a scale from 1 to 8, with 1 representing the “X” closest to the Type-B self-description and 8 corresponding to the “X” closest to the Type-A descriptor. The I4 item scores were then summed and multiplied by 3 to yield the ABS total score. Multiplication

Identifying Coronary-prone

by 3 was necessary to approximate the scoring procedure of Bortner [3], who scored each item by measuring to the nearest sixteenth inch, marks made by subjects on a 15inch continuous line. The 1Citem modified ABS is shown in the Appendix. Direction of A/B scoring shown for each item is that used by Bortner [3]. Anger expression

The Spielberger Anger Expression Scale [29] was used to measure expressed hostility and is composed of 20 ordinal level items. This scale captures two basic dimensions: Anger-In which reflects unexpressed anger held within oneself and Anger-Out which reflects outward signs of anger directed at other persons or objects. Llj”e satisfaction

Two dimensions of happiness were measured: life in general and more specifically, school life. Two single item questions (“How do you feel about your life in general?” and “How do you feel about school?‘) were used. The items were in the form of a five point Likert Scale ranging from very unhappy to very happy. Social support

Five questions, with both dichotomous and categorical responses, were used to measure perceived social support: (1) In general, do you feel there is someone you can turn to in times of need? (2) Do you have any problems you can’t discuss with any friend or relative? (3) In general, how satisfied are you with the support you get from your friends? (4) In general, how satisfied are you with the support that you get from your family? and (5) In general, how satisfied are you with the number of people whom you could call up if you wanted to do something (like talk on the phone, visit each other’s home, go to a movie, etc.)? Grade point average

After the end of the semester in which this study took place, the semester grade point averages (GPA) of the study participants were recorded from student records in the high school administrative offices. On a scale from 0 to 100, the GPA’s ranged from 50 to 92 with a mean of 70.56 (SD = 8.21). Health habits

Included in the health risk questionnaire were measures of self-reported sleep patterns, physical activity, cigarette smoking, and drug and

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alcohol use. Findings concerning these variables are of a more preliminary nature and will not be reported until our findings can be verified in the complete study population. Blood pressure

The average of three blood pressure measurements was obtained on each study participant using a mercury sphygmomanometer and standardized procedures that included checks for accuracy. All pressures were taken at rest in the sitting position from the right arm. Data analysis

The three major questions addressed in this study and the approach to the statistical analysis were: (a) Are the measurement properties of the ABS (mean and dispersion) similar to those of the Bortner scale used with adults? Two-tailed t-tests were used to compare the ABS score distributions with Bortner Type A Scale score distributions reported in three previous studies involving adult [3,6] and adolescent [18] subjects. (b) Does the ABS measure a unidimensional construct or a constellation of independent behaviors as is usually assumed in Type-A research? Principle components factor analysis with varimax rotation and related statistics were used to examine the Bortner Type A Scale factor structure. The factor analysis program used for this phase of the study was PROC FACTOR of the Statistical Analysis System (SAS) [30]. (c) Do Type-A adolescents differ from TypeB adolescents in hypothesized ways? The construct validity of the ABS was explored by comparing subjects in the top ABS quintile (Type-A) to those in the bottom quintile (TypeB) on anger expression, social support, life satisfaction, grade point average and blood pressure. Discriminating power between the top and bottom quintiles was examined via chisquare for ordinal measures and t-tests for interval level measures using the SAS program PROC FREQ and PROC T TEST [30] to determine whether the directionality and size of the differences were as expected. RESULTS

Characteristics of the Type A distribution

ABS scores ranged from 84 to 279 with a mean of 185.3 and a standard deviation of 29.8.

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Table 1. Comparison of Bortner Type A scores obtained in this adolescent population to scores found in other study populations Ponulation This study Total sample Males only White males only Black males only White females only Black females only Coates ef al. [ 181 21 black males and 21 white males aged 14 to 17 years (Mean = 15.6 years) Bortner [3] Adult males Johnston and Shaper [6] Adult males

N

Mean score

SD

549 275 186 89 167 88

185.33 187.76 190.53 181.96 184.19 180.10

29.77 28.69 28.07 29.27 27.17 36.51

42

165.34

34.32

61

196.5

138

180.67

33.09

The distribution of scores had a mode of 189 and median of 186. Skewness was -0.08 and a kurtosis was 0.44. The Kolmogorov D statistic indicated the distribution did not differ significantly from nomality (p < 0.05). Examination of score means (Table 1) revealed that white males had significantly higher scores than black males (p < 0.05), a relationship consistent with previous findings [15]. White males also had significantly higher scores than white females (p < 0.05) and black females (p < 0.01). Present ABS means were compared with those reported in a previous study that used a very similar adolescent version of the scale [18], as well as Bortner means obtained in two studies of adult males [3,6]. The mean obtained in the previous adolescent study using a convenience sample of 2 1 black and 2 1 white males [ 181was lower than the present mean for males by 22 points (p < O.OOl), while the variance was slightly higher. The present mean for adolescent males was lower than the mean of 196.5 which Bortner reported for adult men, although failure to report the sample variance precluded comparison across the two studies. A second study of 138 adult British men [6] yielded a mean Bortner score of 180.7 (SD = 33.09), which was lower (p < 0.01) than that found in our adolescent male sample. Factor structure

The TABP is comprised of behaviors which are frequently unrelated to each other and are not viewed as risk factors in themselves. Instead, risk is presumed only when these behaviors

appear as a constellation of responses in a given individual. Brief intruments to identify this constellation are designed to contain only the minimum number of items needed to tap each separate TABP component. Hence the items of the adult Bortner scale are not strongly intercorrelated and factor analytic studies in adults have failed to establish a stable factor structure [6,31]. We therefore sought to determine if similar item independence would occur with our modified ABS. This was accomplished by examining: (1) Inter-item correlations; (2) item-total correlations; and (3) the ABS factor structure. An inter-item correlation matrix was calculated using the 14 items of the Bortner Type A Scale. These correlations were small, ranging from 0.001 to 0.26 (ignoring positive or negative signs). The following items had correlations above 0.2. “Always rushing” was correlated with “Hating to wait in lines” (r = 0.26), “Hating to wait in lines” was correlated with “Trying to do more than one thing at a time” (r = 0.21) and “Interrupting and anticipating others” was correlated with “Needing recognition of others” (r = 0.22). To evaluate the importance of each item to the scale, item-to-total correlations were calculated. Corrected item-to-total correlations were all small ranging from 0.01 to 0.22 (ignoring positive or negative signs). Uncorrected item-tototal correlations ranged from -0.05 to 0.43. These correlations indicated that maximum alpha coefficient of 0.30 could have been obtained by deleting the item 1; “I am never late for an appointment.” The alpha coefficient for all 14 items was 0.23. Therefore, it appeared that even after excluding certain items, the scale would have a low coefficient of reliability. Four of the corrected 14 item-to-total correlations were negative; items 1 (r = -0.22), 2 (r = -0.08), 12 (r = -O.Ol), and 13 (r = -0.08). Two of these items, 12 and 13, have sometimes been reverse scored in previous studies [6, 16, 181. A reason given for reverse scoring item 13 has been that studies show Type A is associated with many (not few) interests outside work [6]. We found that reverse scoring of these items only modestly increased coefficient alpha to 0.32. Therefore, lacking a strong theoretical basis for reverse scoring and in an attempt to remain consistent with past research, we decided not to change scoring form Bortner’s original conceptualization [3]. The inter-item correlation matrix was then factor analyzed using a principle components

Identifying Coronary-prone Table 2. Comparisons

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of the Bortner Type A factor structure between race-sex groups of an adolescent population* Item loadings

Item 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Never late Competitive Interrupts Always rushing Hate to wait Go a11out Do many things at once Straight forward Need recognition Eat/walk quickly Hard driving Hide feelings Few interests Unsatisfied with school grades

Males

Females

Total sample N = 549

White N= 186

Black N =89

0.280

0.455

0.460

White N=167

0.543 -0.365

0.411 0.441

Black N = 88

0.506

0.340 0.392 0.508 0.277 0.388 0.360

0.262 -0.499 0.63 1

0.392 0.541

*Due to sample size of race-sex groups, data are presented as tentative. Note: Represented are factor loadings greater than 0.25 in rotated factors with eigenvalues greater than one. (Mineigen set at zero for rotation.)

factor analysis to see if clusters of items would correlate as separate factors. The first factor had an eigenvalue of 1.08; the other six factors with eigenvalues above zero had an eigenvalue less than one. These factors were further analyzed using a varimax rotation with an orthogonal transformation matrix. The rotated factor pattern indicated that dimensions of the scale did not emerge as strong separate factors. The first and strongest factor, however, loaded heavily with items relating to impatience. We further analyzed the items loading above 0.25 on Factor 1 (shown under Total Sample column in Table 2) to determine whether these items might comprise a useful subscale. The inter-item correlations of the five items were small (less than 0.2) and produced a five-item scale with a Cronbach alpha of 0.29. Thus the “impatience subscale” had psychometric properties quite similar to those of the full 1Citem scale. We also explored the possible influence of demographics on ABS factor structure by factor analyzing ABS responses separately for each race-sex subgroup of our study sample. Due to small sample sizes of race-sex subgroups, these analyses are presented as exploratory. The eigenvalues for factors in each race-sex subgroup were small and of similar magnitude to those in the total population. Table 2 shows items with Factor 1 loadings greater than 0.25 in the total population and race-sex subgroups.

No consistent patterns were observed between the factor structure of the total population and race-sex subgroups. Taking into consideration the low inter-item and item-total correlations, the small magnitudes of the eigenvalues found in the factor analysis, and apparent instability of the first factor across race-sex groups, the hypothesis that separate ABS items tend to assess different behavioral dimensions was supported. These results suggested that the modified ABS was quite similar to its adult (parent) version [6].

One way of testing construct validity is to determine whether the instrument in question is related to other concepts in hypothesized ways [32]. If the ABS measures coronary-prone behavior, ABS scores should correlate significantly with other measures of TABP components. To evaluate this, we examined the relationship between ABS scores and relevant TABP variables noted in the literature but as yet untested in an adolescent population. The hypotheses were that Type-A adolescents relative to Type B’s would express anger openly (argue, fight, strike objects) rather than hold it in (sulk, pout, withdraw) [19-211, be less happy with school and life in general [22,23], perceive less social support from both family and friends, and have higher grade point averages [20,24-261. These hypotheses were examined in

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Table 3. Comparison of extreme Type A and Type B quintiles by race-sex category Race-sex category White Black White Black

males females females males

Total

N

Type A

Type B

186 88 167 89

51 (27%) 20 (23%) 27 (16%) 14 (16%)

26 (14%) 25 (28%) 34 (20%) 22 (25%)

530

112 (21%)

107 (20%)

two ways. First, extreme ABS groups were created by selecting subjects whose ABS scores were in the top quintile of the distribution (Type-A) and those with ABS scores in the bottom quintile (Type-B). This procedure was adopted because it should be maximally sensitive to A/B differences. Second, because comparing extreme groups omits a large segment of the population and may misrepresent relationships, the data were subsequently analyzed using the entire distribution of ABS scores. The average Type-A score in the top quintile was 225 (SD = 15.5) and the average Type-B score in bottom quintile was 144 (SD = 16.6). These means were significantly different (t = 38.4 df= 225, p < 0.0001). The race-sex groups most highly represented among the extreme Type-A’s were white males and black

females (Table 3). The race-sex groups most highly represented among the extreme Type-B’s were black females and black males. Only 14% of white males were labeled extreme Type-B. Comparisons of these extreme groups revealed that they differed significantly in the directions hypothesized above (Tables 4 and 5) except that Type-A’s in this population were not more likely to have higher grade point averages and blood pressures. The most significant relationships were of TABP with outward expression of anger, unhappiness with life in general and perception of low social support from family and friends. Findings using the entire ABS distribution were similar to those using the extreme quintiles except that self-perceived social support in times of need and social support from friends did not differ across Type-A scores. Also, among all the variables measured, Bortner Type-A scores correlated most strongly with anger expressed outward (r = 0.33, p -c 0.001). Several additional findings should be noted regarding the construct validity of the Bortner Type-A Scale. Although sample sizes were too small to allow more than preliminary testing, some race-sex A and B differences were observed. In particular, black Type-A (extreme

Table 4. Differences between “Type A” and ‘Type B” adolescents on categorical dependent variables Al (N=llS)

A2 (N=99)

Unhappy With school With life in general

23% 16%

29% 17%

Do not perceive support From family From friends In times of need In discussing all problems Too few friends

23% 17% 7% 38% 15%

21% 11%

Dependent variable

2z 6%

X (N=116)

Ordinal categoriest

82 (N=l07)

Bl (N=lll)

29% 10%

13% 11%

17% 10%

0.02 0.01

0.01 0.04

9% 10% 9% 38% 10%

13% 22% 3% 34% 10%

12% 5% 5% 23% 6%

0.007 0.03 0.02 0.02 0.03

0.04 NS NS 0.03 NS

Al vsBl*

*Chi-square p-values using only extreme Type A and Type B groups. tChi-square p-values using entire population grouped with five categories.

Table 5. Differences between “Type A” and “Type B” adolescents on interval level dependent variables Pearson r with ABS Continuum

Al vs Bl Dependent variable Anger expression Anger-out Anger-in Grade point average Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)

Al Mean (SD)

Bl Mean (SD)

20 (5.1) 17 (4.8) 70 (7.5) 111 (10.5) 65 (11.1)

16 (3.8) 16 (3.8) 72 (8.0) 110 (10.5) 64 (10.5)

t* 7.62 0.90 -1.31 0.27 0.23

*Two-tailed Student’s l-test using only extreme Type A and Type B groups. tPearsons product-moment correlation using entire population.

p-value

rt

p-value

0.0001 NS NS NS NS

0.33 0.08 -0.05 0.02 0.02

0.0001 NS NS NS NS

Identifying Coronary-prone

ABS) differed from black Type-B adolescents regarding perceived social support to a greater degree than did white A/B subjects. In view of the low inter-item correlations and ABS factor structure, we considered the possibility that the 5 “impatience” items comprising Factor 1 might be largely responsible for the association of the ABS with the other psychosocial variables. We therefore divided the ABS into two separate scales: a 5-item impatience scale and a 9-item scale containing the “nonimpatience” items. This disclosed that the 5-item impatience scale was significantly associated with scores on anger expression, social support and life satisfaction but that the 9-item scale was not related to these variables. The direction and magnitude of association between the impatience subscale and other variables were virtually identical to those obtained when the total 1Citem ABS score was used. With the exception of one item (“I hate to wait in lines and can’t stand still while waiting”), impatience items did not show significant individual associations with anger, social support or life satisfaction. It thus appears that the association of the 1Citem ABS with other psychosocial constructs is largely explained by the degree to which adolescent subjects tended to manifest impatience.

DISCUSSION

The weight of evidence to date continues to suggest the etiologic importance of competitive “coronary prone” behavior in cardiovascular disease despite definitional problems and conflicting findings reported by some investigators [l]. Especially intriguing is the possible contribution of TABP to the development of other risk factors in children and adolescents. For example, a recent study shows that future young smokers exhibit more Type-A personality traits, anger, and restless sleep than continued nonsmokers [33]. Considering the lack of prospective epidemiologic data on the development of high risk life styles and cardiovascular disease, a valid and easily administered assessment tool for adolescents could greatly help in standardizing diagnostic and research efforts. This study addresses the suitability of one such instrument, an adolescent version of the Bortner Type-A Behavior Scale. The Bortner Type-A Scale has been shown to have substanCD

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tial agreement with Standardized Interview Classifications of TABP in adult men [4,8]. Furthermore, the scale contains only 14 items and is easily administered and scored. In the 549 low to middle SES 14-17 year olds assessed in this study, the modified Bortner, or ABS, demonstrated measurement properties similar to those of the parent version. The greatest difference was in the sample means reported by various investigators. In addition to demographic influences, variation in scoring procedures used by different investigators may account for this. Although the direction of scaled items used in the present study was the same as that used by Bortner [3], Bortner’s scoring method used finer scale gradations. The version of the Bortner Scale used by Johnston and Shaper [6] was the same as that used by Bortner, but item 13 was reverse scored. A version of the ABS previously used by Coates et al. [18] with an adolescent male population scored the items on a nine-point (range (r8) scale rather than an eight point scale and reverse scored item 12. As in the adult version [6,31], scale items were not strongly intercorrelated but each contributed independent information concerning presence or absence of hypothesized TABP characteristics. We are aware, however, that other adolescent versions of the Bortner Scale have disclosed an identifiable factor structure when administered to children and adolescents [15, 161. The five items loading heavily on Factor 1 in the factor analysis of this study are not the same as those found in these other studies. They reflect impatience and account for much of the covariation between the ABS and several dependent variables in this study. Further work is clearly needed to clarify the factor structure of the ABS. Construct validity of the ABS is supported by the finding that subjects designated extreme Type-A tended to differ from extreme Type-B’s in the directions hypothesized based on observations by Friedman and Rosenman [34]. Comparison of anger expression scores revealed that Type-A subjects reported openly expressing anger more often and more intensely than did Type-B?. As expected, ABS Type-A’s were less satisfied with their lives and perceived family and friends to be less supportive than did ABS Type-B’s. The relationship of ABS Type-A to low perceived social support was somewhat inconsistent and appeared to vary with demographic characteristics. The relationship was

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found only when extreme Type-A’s were contrasted with extreme Type-B’s and was more evident among blacks than among whites. The previous literature on the relation of Type A to social support is also inconsistent [27,28]. Contrary to expectations, Type-A subjects did not evidence more intense competitive academic striving as judged from student grade point averages. This might indicate that the ABS correlates with the social-emotional (aggression-hostility) TABP components but does not tap competitve drive. An alternative possibility is that course grades are not an object of intense competition in a community where most students aspire to manual or blue collar occupations. Regarding Type-A variations in different populations, our preliminary findings indicate that both the ABS factor structure and derived Type A/B differences may vary by both sex and race. In addition to validating the ABS against interview and observational measures of TABP [S], future investigation should explore the possibility that competitive striving may assume different forms in different adolescent subgroups, and should examine the relationship of ABS scores to other health risk indicators. Research in our second study school is currently examining the relationship between TABP, anger expression, hostility and risk behavior (use of alcohol, tobacco and illicit drugs) to see if interactions of these variables may have implications for eventual development of sustained high blood pressure. Acknowledgements-We

wish to thank Dr C. Hendricks Brown and Dr Thomas A. Pearson for their insightful comments during the preparation of this manuscript and Dorothy Pumphrey for her typing assistance. We gratefully acknowledge the assistance oftheadministrative and teaching staff of the Baltimore City Public Schools. esneciallv Pt&cipals Frank Thomas and Samuel Billips, Reba Bullock of the Office of Science and Health, and Dr Thomas Dorsett of the Baltimore City Health Department.

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793

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APPENDIX Adolescent

Bortner Self-rating

Scale (ABS)

Read the statements on both sides of each line. Circle the X that best describes your behavior. (Circle only ONE “X” on each line.)

1. I am never late for an appointment.

xxxxxxxx

I don’t think that being on time for an appointment is important.

2. I do not like competition. 3. I know what others will say (nod, interrupt.

xxxxxxxx

I like competition.

xxxxxxxx

I am a good listener (I never nod, interrupt, or finish for others.)

I do not rush, even under pressure. 5. I don’t mind waiting in lines in the cafeteria.

xxxxxxxx xxxxxxxx

6. I go “all out” to complete everything

xxxxxxxx

I am always rushing I hate to wait and can’t stand still while waiting.

4, finish for them) before they say it.

I attempt

to do.

7. I try to do tasks one at a time.

xxxxxxxx

8. I “tell-it-like-it-is”

xxxxxxxx

when I speak.

9. I often do a job just to be recognized by others. 10. I eat and walk quickly.

x

xxxxxxx

x xxxxxxx

11. I am easy going. 12. I frequently hide my real feelings.

xxxxxxxx xxxxxxxx

13. I have many interests outside of school. 14. I am satisfied with my grades.

xxxxxxxx xxxxxxxx

Note: The adjective phrase thought to be typical of Type A is italicized.

I am a very relaxed person. I often start new projects before finishing one or more d@Iicult tasks.

I speak slowly and think carefully what I’m going to say. I choose most jobs for my personal enjoyment. I eat and walk more slowly and carefully than others. I am hard driving. I have no dt@culty expressing my feelings under any circumstances. I have a few interests outside school. I am not satisfied with my grades and constantly try to improve them.