This simulation study sought to compare four different computerized adaptive testing (CAT) content-balancing procedures designed for use in a multidimensional assessment with respect to measurement precision, symptom severity classification, validity of clinical diagnostic recommendations, and sensitivity to atypical responding. The four content-balancing procedures were (a) no content balancing, (b) screener-based, (c) mixed (screener plus content balancing), and (d) full content balancing. In full content balancing and in mixed content balancing following administration of the screener items, item selection was based on (a) whether the target numberof items for the item’s subscale was reached and (b) the item’s information function. Mixed and full content balancing provided the best representation of items from each of the main subscales of the Internal Mental Distress Scale. These procedures also resulted in higher CAT to full-scale correlations for the Trauma and Homicidal/Suicidal Thought subscales and improved detection of atypical responding.Keywords