Age-Related Changes in Functional Skills and Daily Life Task Management Among Autistic Youth

IMPORTANCE

Autistic youth who graduate with a high school diploma may experience challenges in acquiring functional skills for everyday independence. Few studies have focused on how their functional and self-management skills change during the transition to adulthood.

OBJECTIVE

To examine cross-sectional differences and longitudinal changes in the functional and self-management skills of transition-age autistic youth.

DESIGN

Exploratory longitudinal study (18-mo follow-up).

SETTING

Community.

PARTICIPANTS

Autistic high school students who graduated with a high school diploma and their parents (N = 50).

OUTCOMES AND MEASURES

Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (ASD).

RESULTS

Older youth (ages 18-20 yr) had significantly lower normative Social/Cognitive and Responsibility domain scores (i.e., self-management) than youth ages 14-17 yr. Approximately 2 yr later, youth in both age groups significantly improved in scaled scores on the Daily Activities and Responsibility domains.

CONCLUSIONS AND RELEVANCE

Autistic youth's functional and self-management skills fell below those of nonautistic peers; however, these skills do change over time and are therefore appropriate targets for intervention. Plain-Language Summary: The findings of this study highlight the importance of focusing on the functional and self-management skills of autistic youth as part of their transition to adulthood. Occupational therapists can play a valuable role in helping autistic youth to achieve independence as adults by assessing their functional needs and strengths and by providing client-centered interventions.

Conceptualizing Adult Dysphagia in the United States Within the International Classification of Functioning, Disability and Health (ICF)

Despite the well-documented safety concerns and effect on quality of life, there does not yet exist a wide-reaching framework that links the etiologies of swallowing disorders to the potential short- and long-term outcomes in the context of International Classification of Functioning, Disability and Health (ICF). This paper introduces an expert-reviewed conceptual framework to highlight common etiologies of dysphagia as well as integrate immediate outcomes of dysphagia with long-term outcomes of dysphagia in terms of medical problems, health-related quality of life, functional effect, and psychosocial features. It also outlines the potential cyclical nature of long-term dysphagia outcomes perpetuating the original dysphagia. This framework serves to inform clinicians of important dysphagic outcomes and to bring awareness to long-term outcomes that should be monitored by health care professionals, caregivers, or people with dysphagia.

Describing Outcomes in Autistic Young Adults One Year After High School Graduation

PURPOSE

Research documents poor outcomes for autistic adults in the domains of employment, independent living, and social relationships. Measurement and sample limitations in prior studies may have amplified past estimates of poor outcomes. The goal of the current study was to improve upon past approaches and to create and describe a measurement approach to capture adult outcomes that reflected the context of young adulthood and the perspectives of autistic individuals, pairing objective outcome indicators with subjective satisfaction indicators.

METHODS

Thirty-six autistic young adults (mean age 19.8 years) and a parent completed self-report surveys. Using these data, we defined an objective and subjective (i.e., satisfaction) outcome indicator in each of three domains: productivity (employment or post-secondary education), social well-being (frequency of contact with friends), and living situation (autonomy).

RESULTS

Three-quarters of young adults experienced at least 5 out of 6 positive outcomes. Over 90% were engaged in school, work, or a structured transition program, and an equal percentage were satisfied with their productivity activity. Over three-quarters of adults had a good amount of contact with friends and were satisfied with their social life. Most young adults had a moderate level of autonomy in their daily lives, and all were satisfied with their living situation.

CONCLUSION

Tailoring outcome measurement approaches specifically for autistic young adults provided a more optimistic portrayal of outcomes than previously noted in the literature. The approach used better reflects a neurodiversity approach and may be useful for evaluating the effectiveness of transition services or interventions.

Parenting With and Beyond Cancer: A Photo-Elicitation Study

The purpose of this study was to understand the occupational performance of parents with cancer and to understand if photo-elicitation would provide new insights into these experiences. In a semi-structured photo-elicitation interview, 36 participants living with and beyond cancer who had children under 18 years old shared and discussed photographs related to their parenting experiences. Transcribed interviews were analyzed using thematic analysis. Two main themes were identified. Parents shared how they (a) managed daily responsibilities and (b) maintained connection with their family. Across all types, stages and phases of the cancer continuum parents shared experiences related to maintaining child and family responsibilities and maintaining connection with their children. Photo-elicitation was an efficient and effective method to gather rich data from parents living with cancer. The results emphasize the clinical utility of using photo-elicitation to understand the occupational performance of parents throughout the cancer continuum of care.

How have Participation Outcomes of Autistic Young Adults been Measured? A Scoping Review

Autistic young adults experience challenges participating in the workforce, post-secondary schooling, and living in the community. We examined how participation outcomes have been measured in autistic young adults. Articles (n = 113) were identified through database searches and citation tracking. Guided by current models in the literature, data were extracted for each measure of participation. Results include a description of the studies in the review, the extent to which participation across life situations has been addressed, and a critical analysis of the measures used to describe participation. While there is some breadth in the investigation of participation across diverse life situations, there is limited depth in what the measures capture and many measures used lack psychometric support.

Adolescents' Perspectives on Learning to Manage the Responsibilities of Adulthood

IMPORTANCE

Throughout childhood, youth learn the skills they need to carry out their daily life tasks. Despite the importance of being able to manage these tasks to succeed in adulthood, limited research has examined the process through which youth learn to do so.

OBJECTIVE

To investigate adolescents' perspectives of parental approaches that help them learn to manage daily responsibilities.

DESIGN

Qualitative pilot study.

SETTING

Community.

PARTICIPANTS

Eight adolescents with and without disabilities.

RESULTS

Semistructured interviews with adolescents were analyzed using recursive, conventional content analysis. Interviews asked about how adolescents viewed the process of developing the skills needed to manage daily responsibilities independently. Parent approaches identified by the adolescents fit into three overarching themes: Parents teach them how to carry out and manage responsibilities, monitor them as they become more responsible for tasks, and provide varied levels of independence. The approaches described by the adolescents explain an implicit and transactional process of shifting responsibility for daily life tasks from parents to youth.

CONCLUSIONS AND RELEVANCE

Further investigation of the transfer of responsibility for daily life tasks is necessary to build our understanding of this complex process and support successful transition to adulthood. What This Article Adds: Adolescents described several approaches parents used to help them to learn to manage tasks, which may provide direction for occupational therapy clinicians working with youth who are transitioning to adulthood.

Assisting hand use and self-care bimanual performance of children with unilateral spastic cerebral palsy

AIM

To examine the relationship between assisting hand use in bimanual activities and children's self-care activities and task performance.

METHOD

We retrospectively analysed daily functioning (Pediatric Evaluation of Disability Inventory [PEDI]) and bimanual performance (Assisting Hand Assessment [AHA]) data from the assessment of 112 children (mean age: 8 years 10 months [SD 2 years 1 month], range 3 years 7 months-17 years 4 months; 66 males, 46 females) with unilateral spastic cerebral palsy (CP). We used Rasch analysis to examine the relationship between individual item scores from the AHA and the self-care items (functional skills, caregiver assistance) from the PEDI.

RESULTS

Most self-care functional skills and caregiver-assisted tasks were located on the middle of the unidimensional continuum. These items showed similar levels of difficulty as the items from the AHA related to the effective coordination of two hands, appropriate pace, and use of the assisting hand to stabilize and release objects, as well as variations in arm movements.

INTERPRETATION

The distribution of the PEDI self-care and AHA items along the unidimensional continuum illustrates the relationship between assisting hand use and self-care bimanual performance. Interpretation of the items' locations on the hierarchical unidimensional continuum may be helpful to therapists' clinical reasoning and suggest intervention goals to improve the hand function and daily functioning of children with unilateral spastic CP. Such an application needs further investigation.

Is Mobility Sufficient to Understand Community Participation of Adolescents and Young Adults With Cerebral Palsy? The Mediating and Moderating Roles of Contextual Factors

OBJECTIVE

To explore whether self-determination and family socioeconomic status (SES) mediate and/or moderate the relationship between mobility and community participation of adolescents and young adults with cerebral palsy (CP).

DESIGN

Survey.

SETTING

Online platform.

PARTICIPANTS

Of 55 eligible adolescents/young adults with CP, 50 agreed to participate and 2 were excluded. The final convenience sample included 48 individuals (N=48), aged 15-32 years, levels I-IV of the Gross Motor Function Classification System and I-II of the Communication Function Classification System.

MAIN OUTCOME MEASURES

The Temple University Community Participation Measure documented the amount, breadth, and insufficiency/sufficiency ratios of participation across 26 community settings. The ARC Self-determination Scale and the Mobility Scale of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) measured individuals' self-determination (ie, autonomy, psychological empowerment, self-realization) and mobility skills, respectively. The Brazilian Economic Classification Criteria-2021 assessed family SES.

RESULTS

Analyses of mediating/moderating effects revealed that the influence of individuals' mobility skills on their breadth of community participation was mediated by autonomy. Family SES moderated the indirect effect of mobility on community participation breadth through autonomy. When the model was adjusted for participants' age, individuals with higher SES reported greater breadth in community participation than those from moderate and lower SES for all mobility levels. However, the magnitude of the differences among individuals of different SES levels diminished as mobility increased.

CONCLUSIONS

The mobility skills of youths with CP influence their community participation through autonomy. To foster greater engagement of these individuals in the community, rehabilitation professionals should focus not only on improvement of mobility skills but also on the promotion of self-determined behaviors, especially autonomy.

Self-management of daily life tasks in diploma-track youth with disabilities

PURPOSE

Youth with disabilities who graduate with a regular high school diploma often continue to have difficulties in their daily functioning that ultimately impact adulthood outcomes. To better understand these functional difficulties and determine how best to address them, it is important to distinguish deficits in discrete skills from difficulty organizing skills to self-manage complex tasks associated with adult roles. The purpose of this study was to explore the extent to which challenges in social, executive function and behavior management factors relate to these two aspects of daily functioning.

METHODS

This is a secondary analysis of the National Longitudinal Transition Study 2 funded by the United States Department of Education. The direct and indirect associations between youth underlying factors and self-management of daily life tasks (SMDLT) versus discrete functional skills were modelled using structural equation modelling.

RESULTS

A model incorporating social skills, communication, and behavior regulation explained 55% of the variance in SMDLT. In contrast, the model predicting discrete functional skills had fewer significant associations and described less variance (37%) in the outcome.

CONCLUSIONS

Findings suggest that using measures of SMDLT and designing targeted interventions for SMDLT might help improve participation in independent living and productivity for diploma-track youth with disabilities.Implications for rehabilitationSuccessful transition from high school to adult roles requires the ability to self-manage the daily life tasks required for those roles, such as employment, post-secondary education, and independent living.The ability to self-manage daily tasks is distinct from mastery of discrete functional skills and should be assessed with measures that uniquely examine this domain.Social and communication skills, executive functioning, and behavioral regulation, are important contributors to the ability to self-manage life tasks for diploma-track youth with disabilities and should be incorporated into multifaceted interventions.Interventions to improve self-management of tasks should include teaching strategies and practice coordinating underlying skills in flexible ways that meet the varying demands of tasks and diverse environments.

Metacognition Mediates the Effect of Social Communication and Internalizing Behaviors on Self-management of Daily Life Tasks for Diploma-Track Autistic Youth

Social communication and executive functioning challenges as well as co-occurring anxiety/depression may make acquiring the skills needed to manage daily life tasks difficult for diploma-track autistic youth, thus limiting their participation in adult roles. This study describes the associations between executive function, social communication skills, and internalizing behaviors on task management in academically capable autistic adolescents (n = 46) using multiple regression with mediator analysis. The three predictors and youth age explained a moderate amount of variance in task management. Metacognition mediated the effect of social communication skills and internalizing behaviors on task management. Relations between underlying factors that influence self-management of daily life tasks are complex, supporting the need for multifaceted assessment and intervention approaches for academically capable autistic youth.

Variables Associated With Shift of Responsibility for Daily Tasks From Parents to Children With and Without Disabilities

Importance: No study has directly investigated which variables are associated with the shift of responsibility for managing daily tasks from parent to child in the transition to adulthood.

Objective: To examine characteristics associated with responsibility for managing daily life tasks in youth with and without disabilities.

Design: A secondary data analysis of parent-report data on typically developing (TD) youth and youth with disabilities.

Setting: An online panel that has regularly participated in online surveys.

Participants: A nationally representative sample of 2,205 TD U.S. children and youth, ages 0 to 20 yr, 11 mo (about 100 children per age year) and a sample of 617 children and youth with disabilities, ages 0 to 20 yr, 11 mo.

Outcomes and Measures: The dependent variable was the Responsibility domain scaled score (from the Pediatric Evaluation of Disability Inventory–Computer Adaptive Test), which reflects the extent to which responsibility for daily tasks has shifted from parent to youth.

Results: Youth with higher levels of responsibility were older in age, reported to be more focused, and youngest in birth order (TD, R² = .79; disability, R² = .35). Youth with developmental delay, intellectual disability, autism spectrum disorder, or orthopedic or movement impairments had assumed less responsibility.

Conclusions and Relevance: Other personal characteristics in addition to disability may have important influences on parents’ decision making as they prepare their children to manage daily life tasks.

What This Article Adds: Clinicians who work with adolescents in the process of transition to adulthood need to consider the potential influence of the personal characteristics, such as birth order and child temperament, on preparation for adulthood.

Determinants of Time to Care for Children and Adolescents With Disabilities

Time use studies uncover the organization of daily routine of families of children with disabilities. The objective of this study is to identify determinants of time spent caring for children/adolescents with cerebral palsy (CP), autism spectrum disorder (ASD), and typical development (TD). Participants were caregivers of children/adolescents with/without disability. Structural equation modeling tested a proposed model of time spent in child care. The variables in the model were as follows: questionnaire (families' socioeconomic status [SES]), children's functioning (The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test [PEDI-CAT]); hours of care (daily diaries), number of adaptations used, and help with child care (parents' report). Distinct variable combinations explained 78% of the variation in the time to care (TD model), followed by 42% (ASD) and 29% (CP). Adaptations indirectly affected time to care through its effect on functioning (CP); family's SES affected functioning through its effect on adaptation use (ASD). In conclusion, knowledge of factors affecting caregivers' time spent on children's care help occupational therapists implement family-centered strategies.

Children's Participation in Household Tasks: Caregiver Importance and Satisfaction

Attribution of importance and satisfaction with performance are key dimensions contributing to engagement in occupations. This study explored caregiver satisfaction with and importance attributed to the participation of their children and adolescents in household tasks. Participants included 109 caregivers of children and adolescents of both sexes, aged 6 to 14 years, from various socioeconomic levels. They were interviewed with two questions of the Children Helping Out: Responsibilities, Expectations and Supports (CHORES), with ratings of importance and satisfaction on Likert-type scales, and asked to explain their ratings. We examined the association between the two dimensions. Results showed no correlation between caregivers' ratings of satisfaction and importance (r_s = .04; p = .699). The majority of caregivers evaluated their children's participation in domestic care as very important, explaining in terms of the need for children's autonomy in adulthood. Caregivers' satisfaction was attributed to children's attitudes. The expressed ideal of children's future autonomy by caregivers is not converted to current engagement in household task.

Differential item functioning in the Patient Reported Outcomes Measurement Information System Pediatric Short Forms in a sample of children and adolescents with cerebral palsy

AIM

The present study examined the Patient Reported Outcomes Measurement Information System (PROMIS) Mobility, Fatigue, and Pain Interference Short Forms (SFs) in children and adolescents with cerebral palsy (CP) for the presence of differential item functioning (DIF) relative to the original calibration sample.

METHOD

Using the Graded Response Model we compared item parameter estimates generated from a sample of 303 children and adolescents with CP (175 males, 128 females; mean age 15y 5mo) to parameter estimates from the PROMIS calibration sample, which served as the reference group. DIF was assessed in a two-step process using the item response theory-likelihood ratio-differential item functioning detection procedure.

RESULTS

Significant DIF was identified for four of eight items in the PROMIS Mobility SF, for two of eight items in the Pain Interference Scale, and for one item out of 10 on the Fatigue Scale. Impact of DIF on total score estimation was notable for Mobility and Pain Interference, but not for Fatigue.

INTERPRETATION

Results suggest differences in the responses of adolescents with CP to some items on the PROMIS Mobility and Pain Interference SFs. Cognitive interviews about the PROMIS items with adolescents with varying degrees of mobility limitations would provide better understanding of how they are interpreting and selecting responses to the PROMIS items and thus help guide selection of the most appropriate way to address this issue.

Measurement properties of a modified measure of participation for persons with spinal cord injury

OBJECTIVE

The primary aim of this study was to examine and refine a modified measure of participation for adults with spinal cord injury (SCI) based on a conceptual model of participation.

METHOD

This study involved secondary analysis of data from a larger study designed to identify a standard measure of participation for use in SCI research. The larger study recruited 634 community-dwelling adults with SCI from seven collaborating SCI Model Systems Centers, of whom 520 subjects (average age 45.1 ± 13.6 years, 76% were male) completed the survey that is the focus of the present analysis. Content review, confirmatory factor analysis (CFA), Rasch analysis, and precision analysis were employed to select the items for the modified participation measure.

RESULTS

Three participation domains were supported: Productivity, Social, and Community, that displayed good model-fit (CFI=0.984, TLI=0.982, RMSEA=0.043) in CFA and good item-fit (infit= 0.6 to 1.4) in Rasch analysis. Differential Item Functioning (DIF) was found in one item, however its magnitude was small. The precision of each scale was better for participants in the middle range of participation and was lower for participants with extremely low or high participation.

CONCLUSION

The study results support the proposed three-dimensional construct of participation by demonstrating good model-fit and item-fit. Ongoing efforts are needed to expand the domain coverage and increase the precision of the instrument.

New version of the Pediatric Evaluation of Disability Inventory (PEDI-CAT): translation, cultural adaptation to Brazil and analyses of psychometric properties

Background

The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), developed with innovative measurement methodologies, evaluates functioning of children and youth, from 0 to 21 years, with different health conditions. It is a revision of an earlier instrument (PEDI) that has been used in national and international clinical practice and research. It was felt to be necessary to make this new version (PEDI-CAT) available in Brazil.

Objectives

Translate and culturally adapt the PEDI-CAT to the Brazilian-Portuguese language and test its psychometric properties.

Method

This methodological study was developed through the following stages: (1) translation, (2) synthesis, (3) back-translation, (4) revision by an expert committee, (5) testing of the pre-final version, and (6) evaluation of the psychometric properties. The 276 translated PEDI-CAT items were divided into three age groups (0-7, 8-14, and 15-21 years).

Results

The PEDI-CAT translation followed all six stages. The adaptations incorporated cultural and socioeconomic class specificities. The PEDI-CAT/Brazil showed good indices of inter-examiner (intraclass correlation coefficient-ICC=0.83-0.89) and test-retest (ICC=0.96-0.97) reliability, good internal consistency (0.99) and small standard error of measurement in all three age groups (0.12-0.17). Factor analyses grouped the items from the three functional skills domains into one factor, and items from the responsibility scale into three factors, supporting the adequacy of these factor solutions to the conceptual structure of the instrument and the developmental model.

Conclusion

The PEDI-CAT/Brazil is a theoretically consistent, culturally appropriate, and reliable instrument. Its availability in Brazil will contribute to the evaluation and measurement of functional outcomes from clinical interventions, longitudinal follow-up, and rehabilitation research.

Development of a first-contact protocol to guide assessment of adult patients in rehabilitation services networks

OBJECTIVE

This paper describes the development of the Protocol for Identification of Problems for Rehabilitation (PLPR), a tool to standardize collection of functional information based on the International Classification of Functioning, Disability and Health (ICF).

DEVELOPMENT OF THE PROTOCOL

The PLPR was developed for use during the initial contact with adult patients within a public network of rehabilitation services. Steps to develop the protocol included: survey of the ICF codes most used by clinical professionals; compilation of data from functional instruments; development and pilot testing of a preliminary version in the service settings; discussion with professionals and development of the final version. The final version includes: user identification; social and health information; brief functional description (BFD); summary of the BFD; and PLPR results. Further testing of the final version will be conducted.

CONCLUSIONS

The protocol standardizes the first contact between the user and the rehabilitation service. Systematic use of the protocol could also help to create a functional database that would allow comparisons between rehabilitation services and countries over time.

Predictive Factors of Household Task Participation in Brazilian Children and Adolescents

Home environment is an important setting for child participation. This study investigated the participation of Brazilian children and adolescents in household self-care (SC) and family-care (FC) tasks. Interviews were conducted with 109 caregivers of children and adolescents ages 6 to 14 years residing in Belo Horizonte (Brazil). Multiple regression models revealed that a greater number of FC tasks were performed by children and adolescents (R2 = .23) from families who did not have a housekeeper and those in which the mothers did not work outside of the home; children and adolescents from this subgroup also received less assistance from the caregivers (R2 = .21) and showed greater independence in task performance (R2 = .20). On average, Brazilian children and adolescents participate in about half of the SC and 25% the FC household tasks. Factors related to family structure and child's age were associated with task performance, caregiver assistance, and child and adolescent independence in household tasks.

Factors Associated with Community Participation among Individuals Who Have Experienced Homelessness

Community participation is an important goal for people who have experienced homelessness. The aim of this study was to use the International Classification of Functioning, Disability and Health (ICF) as a framework to examine factors associated with community participation among people who are homeless or recently housed through housing programs. Participants (n = 120) recruited from six housing placement and search programs completed measures of community participation (including productivity, social and leisure, and community-services-use domains), psychiatric and physical symptoms, functional limitations, and a demographic form. Multiple regression analyses were used to identify predictors of overall community participation and subdomain scores. Results suggested that cognitive and mobility limitations, relationship status, and housing status significantly predicted both overall participation and participation in productivity and social and leisure subdomains. Participants who were housed through housing programs, who had cognitive and mobility limitations, and who were single showed less community participation. The findings suggest that activity limitations and environmental and personal factors may need to be addressed in efforts to enhance community participation in this population.

Evaluating the appropriateness of a new computer-administered measure of adaptive function for children and youth with autism spectrum disorders

The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test is an alternative method for describing the adaptive function of children and youth with disabilities using a computer-administered assessment. This study evaluated the performance of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test with a national sample of children and youth with autism spectrum disorders aged 3-21 years. Parents (n = 365) completed an online survey that included demographics, the Social Communication Questionnaire, and the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test Social/Cognitive, Daily Activities, and Responsibility domains. Item response theory analysis confirmed items in each domain fit a unidimensional model and few items misfit. A large number of items in the Social/Cognitive domain showed differential item functioning, indicating a unique order of item difficulty in this population in this domain. Differences in item difficulty estimates were addressed through a parameter linking (equating) process. Simulations supported the accuracy and precision of the Computer Adaptive Test. Results suggest that the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test, as modified for autism spectrum disorder, is an efficient and sound assessment for this population.

Facilitated Learning Model to Teach Habits of Evidence-Based Reasoning Across an Integrated Master of Science in Occupational Therapy Curriculum

We describe an integrated master of science in occupational therapy curriculum and a coordinated sequence of evidence-based practice (EBP) courses that incorporate systematic, pragmatic teaching strategies to develop students’ EBP skills and habits of reasoning. The EBP courses focus sequentially on the occupational lives of clients and methods for gaining information about occupational performance and needs; appraising the internal, external, and statistical validity of intervention evidence; and generating evidence from one’s own practice to answer questions about individual or group client outcomes. All EBP courses use facilitated learning processes that encourage graduate students to take responsibility for their own learning, guided by a carefully structured series of assignments. The integrated curriculum scaffolds the translation and application of previously learned knowledge and skills, including EBP knowledge, into different contexts. Student survey data suggest that graduating students view EBP as an integral part of the clinical process and begin to internalize the habits necessary to be evidence-based practitioners.

Conceptualizing the construct of participation in adults with disabilities

Participation is a key indicator of health and well-being and a critical rehabilitation goal for individuals with disabilities. Despite the numerous participation measures that have been developed, there is still an absence of agreement on the definition, domains, and dimensions of this construct. The result is that instruments intending to measure the same construct may actually measure quite different aspects of daily life and therefore yield significantly different findings. A solid conceptual model is needed to provide consistent guidance for measurement selection and development. In this article we identify the relevant content areas of participation and propose a conceptual model for adults that is intended to apply across diagnoses, conditions, and settings. We classified participation into 3 main domains: work and education, household, and community. Subdomains are defined within each. The model was reviewed using a semistructured survey by 8 rehabilitation measurement experts. Their feedback regarding the relevance, clarity, and comprehensiveness of the model led to the creation of an alternative structure in which the 3 main domains were recategorized as productivity, social, and community. The proposed conceptual model provides a clear framework for practitioners and researchers to understand the concept of participation and to guide selection or development of measures.

Household task participation of children and adolescents with cerebral palsy, Down syndrome and typical development

This cross-sectional study compared patterns of household task participation (e.g., performance, assistance and independence) of youth with cerebral palsy (CP), Down syndrome (DS) and typical development (TD). Parents of 75 children and adolescents were interviewed to report on their youths' active engagement in daily self-care and family-care tasks, using the children helping out: responsibilities, expectations and supports (CHORES) questionnaire. Groups were equivalent in age (mean=9.3 years; SD=2.2 years), sex (male=39; female=36), respondent education, presence of maid, and number of siblings at home, but differed on child cognitive function and family socioeconomic status, with the DS and the CP groups scoring lower than the TD group but not different from each other. ANOVA revealed group differences on CHORES performance of self-care tasks (p=0.004), on total participation score (p=0.04) and on assistance scores (p<0.02). Post hoc comparisons showed that TD group scored higher than CP and DS groups on performance and assistance in self-care tasks and total assistance; TD and CP groups were similar on total performance and assistance in family-care tasks. The groups also differed on independence indices; the TD index was greater than the CP and DS, and the CP index was greater than the DS. Parents from the three groups did not differ on ratings of importance regarding their children's household participation (p=0.416). In spite of observed differences, children and adolescents with CP and DS are actively engaged in daily self-care and family-care tasks; their participation at home is not prevented by the presence of their disabilities.

Media use among adolescents with autism spectrum disorder

This study explores how adolescents with autism spectrum disorder (ASD) use media, and the factors associated with their media use. A total of 91 adolescents with ASD and their parents completed mail-based surveys. In all, 78% of the adolescents with ASD watched television (approximately 2 h/day), and 98% used computers (approximately 5 h/day) on any given day. They most frequently watched cartoons, played computer or video games that involved shooting, and visited websites that contained information on video games. Adolescents with ASD who watched television with parents reported more positive parent-child relationships. Adolescents with ASD who visited social networking websites or received emails from friends reported more positive friendships. The findings help us understand media-use habits of adolescents with ASD and suggest areas for future research.

Making the best match: selecting outcome measures for clinical trials and outcome studies

Selecting an appropriate outcome measure is a critical step in designing valid and useful clinical trials and outcome studies. This selection process needs to extend beyond examining basic psychometric properties to consider additional features of instruments that may affect their validity and utility for the study's purpose. This article discusses these additional factors and their potential impact on outcome measurement. Guidelines are proposed to help clinical researchers and consumers of clinical research literature evaluate the match between the study purpose, population, and instrument.

Psychometric Properties of the Practical Skills Test (PST)

The Practical Skills Test (PST) is a new assessment of individuals' knowledge of life skills. We evaluated the PST's reliability, validity, and sensitivity to change among a homeless population. Participants were 123 homeless persons in a longitudinal experimental study who were assessed before and after intervention with the PST, Allen Cognitive Level Screen-2000 (ACLS-2000), and Impact of Event Scale-Revised (IES-R). The PST showed generally good internal consistency, no floor effects, and limited ceiling effects (<20% on each test). Supportive evidence for the PST's convergent validity was seen in its moderate correlations with the ACLS-2000; we found no significant correlation with the IES-R. Paired t tests indicated that the PST is sensitive to changes in life skills after intervention, but effect sizes were small. The results suggest that the PST has generally good reliability and validity. However, ceiling effects suggest an area for further development.

Comparing the functional performance of children and youths with autism, developmental disabilities, and no disability using the revised pediatric evaluation of disability inventory item banks

OBJECTIVE. We compared the functional performance of children with autism spectrum disorders (ASD), intellectual and developmental disabilities (IDD), and without disabilities using the revised Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) Social/Cognitive, Daily Activities, and Responsibility domains. METHOD. A nationally representative sample of parents of children ages 0-21 without disabilities (n = 2,205), with ASD (n = 108), or with IDD (n = 150) completed an online survey. We obtained predicted PEDI-CAT scaled scores for three reference ages (5, 10, 15) from a modified analysis of covariance model and compared each group's scores using contrasts of the regression parameters. RESULTS. We found no significant differences between the ASD and IDD groups. The group with ASD demonstrated significantly lower performance than the group without disabilities across the three domains at ages 10 and 15. CONCLUSION. Scores on the PEDI-CAT differentiated the group with ASD from the group without disabilities. Children with ASD and IDD did not demonstrate different performance profiles.

A new approach to the measurement of adaptive behavior: development of the PEDI-CAT for children and youth with autism spectrum disorders

The use of current adaptive behavior measures in practice and research is limited by their length and need for a professional interviewer. There is a need for alternative measures that more efficiently assess adaptive behavior in children and youth with autism spectrum disorders (ASDs). The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) is a computer-based assessment of a child's ability to perform activities required for personal self-sufficiency and engagement in the community. This study evaluated the applicability, representativeness, and comprehensiveness of the Daily Activity, Social/Cognitive, and Responsibility domains for children and youth with an ASD. Twenty professionals and 18 parents provided feedback via in-person or virtual focus groups and cognitive interviews. Items were perceived to represent relevant functional activities within each domain. Child factors and assessment characteristics influenced parents' ratings. In response to feedback, 15 items and additional directions were added to ensure the PEDI-CAT is a meaningful measure when used with this population.

Accuracy and precision of the Pediatric Evaluation of Disability Inventory computer-adaptive tests (PEDI-CAT)

AIM

The aims of the study were to: (1) build new item banks for a revised version of the Pediatric Evaluation of Disability Inventory (PEDI) with four content domains: daily activities, mobility, social/cognitive, and responsibility; and (2) use post-hoc simulations based on the combined normative and disability calibration samples to assess the accuracy and precision of the PEDI computer-adaptive tests (PEDI-CAT) compared with the administration of all items.

METHOD

Parents of typically developing children (n = 2205) and parents of children and adolescents with disabilities (n = 703) between the ages of 0 and 21 years, stratified by age and sex, participated by responding to PEDI-CAT surveys through an existing Internet opt-in survey panel in the USA and by computer tablets in clinical sites.

RESULTS

Confirmatory factor analyses supported four unidimensional content domains. Scores using the real data post hoc demonstrated excellent accuracy (intraclass correlation coefficients ≥ 0.95) with the full item banks. Simulations using item parameter estimates demonstrated relatively small bias in the 10-item and 15-item CAT versions; error was generally higher at the scale extremes.

INTERPRETATION

These results suggest the PEDI-CAT can be an accurate and precise assessment of children's daily performance at all functional levels.

Friendship characteristics and activity patterns of adolescents with an autism spectrum disorder

This study compared perceptions of adolescents' friendships between adolescents with an autism spectrum disorder (ASD) and their parents, examined factors associated with friendship qualities, and investigated the adolescents' reports on the activities they did with friends and how activity patterns differed by gender. Ninety-one adolescents with an ASD and their parents completed mail-based surveys during the summer months. Adolescents with an ASD identified more friends than did their parents, but they agreed on the friends' characteristics. About half of the adolescents spent an average of 4 hours per day with friends during the summer months. Male adolescents with an ASD most frequently played video games with friends, whereas females most frequently had conversations with friends. The findings suggest that adolescents with an ASD and their parents identify different peers as the adolescent's friends. The findings also reveal similarities and differences in friendships between adolescents with an ASD and typically developing adolescents.

Linking the activity measure for post acute care and the quality of life outcomes in neurological disorders

OBJECTIVE

To use item response theory (IRT) methods to link physical functioning items in the Activity Measure for Post Acute Care (AM-PAC) and the Quality of Life Outcomes in Neurological Disorders (Neuro-QOL).

DESIGN

Secondary data analysis of the physical functioning items of AM-PAC and Neuro-QOL. We used a nonequivalent group design with 36 core items common to both instruments and a test characteristic curve transformation method for linking AM-PAC and Neuro-QOL scores. Linking was conducted so that both raw and scaled AM-PAC and Neuro-QOL scores (mean ± SD converted-logit scores, 50 ± 10) could be compared.

SETTING

AM-PAC items were administered to rehabilitation patients in post-acute care (PAC) settings. Neuro-QOL items were administered to a community sample of adults through the Internet.

PARTICIPANTS

PAC patients (N=1041) for the AM-PAC sample and community-dwelling adults (N=549) for the Neuro-QOL sample.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mobility (N=25) and activity of daily living (ADL) items (N=11) common to both instruments were included in analysis.

RESULTS

Neuro-QOL items were linked to the AM-PAC scale by using the generalized partial credit model. Mobility and ADL subscale scores from the 2 instruments were calibrated to the AM-PAC metric.

CONCLUSIONS

An IRT-based linking method placed AM-PAC and Neuro-QOL mobility and ADL scores on a common metric. This linking allowed estimation of AM-PAC mobility and ADL subscale scores based on Neuro-QOL mobility and ADL subscale scores and vice versa. The accuracy of these results should be validated in a future sample in which participants respond to both instruments.

Parent perspectives to inform development of measures of children's participation and environment

OBJECTIVE

To obtain parents' perspectives on children's participation and environment to inform the development of new measures.

DESIGN

Descriptive design using qualitative methods with focus groups and semistructured interviews.

SETTING

Focus groups and interviews with parents of children with disabilities were held on campus, in the home, and at community agencies; interviews with parents of children without disabilities were conducted in their homes.

PARTICIPANTS

Parents (N=42): parents of children with disabilities (n=25) from the United States (n=14) and Canada (n=11) and parents of children without disabilities (n=17) from the United States. Most children (93%) were aged 5 to 16 years. Children with disabilities had diagnoses characterized by psychosocial, learning, attention, and sensory-processing difficulties.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Not applicable.

RESULTS

Parents described common life activities and environmental factors that were similar to and expanded on categories currently reported in the literature. Differences identified among parents mainly focused on impairments and challenges of children with disabilities and concerns related to activities and programs designed for them. Parents spontaneously talked about participation and environmental factors together. Their descriptions consistently included information about features of the physical and social environment and other factors that influenced their child's participation, such as demands of the activity, parent strategies, and the child's age, preferences, and abilities. Parents' standards and expectations for their child's participation often varied depending on the specific setting, activity, and situation.

CONCLUSIONS

Findings have informed the development of a parent-report measure that explicitly links participation and environmental factors specific to home, school, and community settings. Having 1 measure to assess participation and environment rather than using distinct tools to assess each construct separately should situate the child's participation in real-life contexts.

Effectiveness of Cheek and Jaw Support to Improve Feeding Performance of Preterm Infants

OBJECTIVE. We examined the effects of cheek and jaw support on the feeding ability of inefficient feeders born prematurely.

METHOD. Twenty preterm infants served as their own controls. Each infant received either intervention (feeding with oral support) or control (feeding without oral support) for 2 consecutive feedings per day on 2 consecutive days.

RESULTS. Infants displayed a greater intake rate during the intervention feedings, both during the first 5 min (p = .046) and throughout the entire feeding (p = .023). The percentage of leakage during the first 5-min feeding was smaller in the intervention condition than in the control condition (p = .040). No significant differences were found between the two conditions in the sucking, physiological, and alertness variables.

CONCLUSION. Findings confirm oral support as a safe and effective strategy to improve the feeding performance of preterm infants who are poor feeders.

Expressive behavior in Parkinson's disease as a function of interview context

OBJECTIVE

Parkinson's disease affects the ability to express motivation through face, body, and voice; contextual factors may facilitate or inhibit expressive behavior. The purpose of this study was to determine whether qualities of the interview context are associated with client motivational behavior in Parkinson's disease.

METHOD

Men and women with Parkinson's disease (N = 106) discussed 2 topics (enjoyable activity vs. frustrating activity) during an assessment with a female or male interviewer. From videotaped clips, displays of 4 categories of motivation and 12 verbal and 18 nonverbal, behavioral patterns were rated.

RESULTS

During the discussion of enjoyable activities, participants used more positive words, smiled more, and were more facially expressive. Participants were less talkative about their negative feelings and appeared to be more apathetic with the same-gender interviewer.

CONCLUSION

Occupational therapy practitioners should vary the emotional tone of their questions to improve the validity of motivation assessments.

Play and cognition among young children reared in an institution

The relationship between cognitive functioning and play behaviors of children residing in an orphanage was examined. Twenty-six young children (15 boys) between 10 and 38 months of age participated. More developmentally competent play behaviors were highly related to better performance on cognitive functioning as measured by the Bayley Scales of Infant Development (r = .78, p < or = .01). The participants' play behaviors were less competent compared to previous data for children of the same chronological age living at home on four out of five levels of symbolic play (p < or = .05). However, when compared to data for children living at home with similar cognitive development, the participants demonstrated no significant differences in symbolic play (p > or =.05). The findings suggest that the relationship between thinking and playing is robust, even in an institutional environment. Additionally, practitioners assessing children from institutions who cannot engage in standardized testing may consider observing play behaviors to make an initial estimate of developmental status.

Factors associated with participation of children with and without ADHD in household tasks

Children's preparation for adult roles and independent living occur largely through participation with their families in home routines including household tasks. This preparation may involve learning related to family roles, socialization, and occupational performance. This study was designed to explore the extent to which child, environmental, and task factors are associated with household task participation by school-aged children, 9 to 11 years of age, with and without attention deficit/hyperactivity disorder (ADHD). Forty-four parents of children with and without ADHD completed a series of measures that examined family routine frequency and importance, parenting stress, parenting sense of competence, and a measure of their children's participation in household tasks. Child's age, the presence of an older sibling, and the importance of family routines were significant predictors of the number of household tasks performed by children. Diagnosis of ADHD, the presence of an older sibling, and parental stress were significant predictors of the amount of assistance the children required to do the household tasks.

Household task participation of children with and without attentional problems

Children with attention deficit/hyperactivity disorder (ADHD) often demonstrate problems in their participation in family occupations, such as household tasks, due to their needs for assistance and their behavior. Because participation in household tasks is part of family life and may be one way that families prepare children for adult roles, it is important to have a better understanding of the nature and extent of these difficulties. Forty-four parents of children in grades three through five (22 who had a child with ADHD and 22 whose child had no disabilities) completed the Children Helping Out: Responsibilities, Expectations, and Supports (CHORES) measure to provide quantitative and qualitative information about their child's participation in household tasks. Children with ADHD did not differ significantly from the comparison group in their frequency of participating in household tasks. Children with ADHD, however, required significantly more assistance with the tasks than did the comparison group. The results have implications for family occupations and children's occupational development.

Embracing Ambiguity: Facing the Challenge of Measurement

Assigning numbers to variations in the behaviors, experiences, or beliefs of individuals and groups is a firmly established tradition in Western culture. In many areas of occupational therapy practice, quantitative measures are required to document need for services and, increasingly, quantitative measures are required to document the value of these services in terms of the outcomes achieved. In order to meet these expectations, occupational therapy frequently has adopted both methods and instruments from other disciplines including psychology, medicine, and education. However, the assumptions and modes of thinking about people that accompany these methods are not always compatible with the values and practice of occupational therapy. This paper explores tensions inherent in the assessment process in a profession that is holistic and humanistic in its orientation. I propose that in order for assessment to serve our goal of supporting health and participation through engagement in occupation we must accept the uncertainty and be vigilant about the biases in thinking that are inherent in our measures.

Voluntary Manual Exploration and Vision in Rod Bisection

Two experiments were carried out to investigate contributions of voluntary manual exploration and vision to rod-bisection performance when the rod was placed in different spatial positions. Analysis showed both voluntary manual exploration and vision contributed to the accuracy of rod-bisection performance in healthy adults (Exp. 1: 12 men, 13 women; Exp. 2: 10 men, 11 women). Advantages of voluntary manual exploration were related to rod position and initial search direction. Results are discussed with regard to ecological approach to action and perception, two cortical systems (ventral and dorsal streams) for perception and control of actions, and the hemispheric activation hypothesis.

Analyzing change in recovery patterns in the year after acute hospitalization

OBJECTIVE

To examine trajectories of recovery and change in patterns of personal care and instrumental functional activity performance to determine whether different assessment interval designs within a 12-month period yield different estimates of improvement and decline after acute hospitalization and inpatient rehabilitation.

DESIGN

Secondary analysis of a 12-month prospective cohort study.

SETTING

Transition to the community.

PARTICIPANTS

Adults (N=419) admitted to acute care and receiving inpatient rehabilitation for a neurologic, lower-extremity musculoskeletal, or medically complex condition.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Improvement, no change, and decline as measured by the personal care and instrumental scale of the Activity Measure for Post-Acute Care.

RESULTS

Assessment at the end of a single 12-month follow-up assessment interval showed that over 60% of the participants improved. In contrast, analysis of 2 fixed-length 6-month assessment intervals revealed an almost 40% decrease in the proportion who improved from 6 to 12 months. Fewer participants continued to improve in the time periods further from the acute hospitalization and the proportion of subjects who declined increased from 21.4% to 31.2% to 38.0% over the 3 consecutive assessment intervals (baseline to 1 mo, 1-6 mo, 6-12 mo). Only 58 (19.7%) participants continued on the same path of recovery from baseline to 12 months (9.8% improved over all 3 consecutive time periods, 3.1% made no change, 6.8% declined).

CONCLUSIONS

Examination of change over shorter compared with longer assessment intervals revealed considerable variability in the trajectories of recovery. Research is needed to determine the appropriate frequency and timing for measuring and monitoring function and recovery after an acute hospitalization.

Assessing self-care and social function using a computer adaptive testing version of the pediatric evaluation of disability inventory

OBJECTIVE

To examine score agreement, validity, precision, and response burden of a prototype computer adaptive testing (CAT) version of the self-care and social function scales of the Pediatric Evaluation of Disability Inventory compared with the full-length version of these scales.

DESIGN

Computer simulation analysis of cross-sectional and longitudinal retrospective data; cross-sectional prospective study.

SETTING

Pediatric rehabilitation hospital, including inpatient acute rehabilitation, day school program, outpatient clinics; community-based day care, preschool, and children's homes.

PARTICIPANTS

Children with disabilities (n=469) and 412 children with no disabilities (analytic sample); 38 children with disabilities and 35 children without disabilities (cross-validation sample).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary scores from prototype CAT applications of each scale using 15-, 10-, and 5-item stopping rules; scores from the full-length self-care and social function scales; time (in seconds) to complete assessments and respondent ratings of burden.

RESULTS

Scores from both computer simulations and field administration of the prototype CATs were highly consistent with scores from full-length administration (r range, .94-.99). Using computer simulation of retrospective data, discriminant validity, and sensitivity to change of the CATs closely approximated that of the full-length scales, especially when the 15- and 10-item stopping rules were applied. In the cross-validation study the time to administer both CATs was 4 minutes, compared with over 16 minutes to complete the full-length scales.

CONCLUSIONS

Self-care and social function score estimates from CAT administration are highly comparable with those obtained from full-length scale administration, with small losses in validity and precision and substantial decreases in administration time.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: II. Participation outcomes

OBJECTIVES

To measure participation outcomes with a computerized adaptive test (CAT) and compare CAT and traditional fixed-length surveys in terms of score agreement, respondent burden, discriminant validity, and responsiveness.

DESIGN

Longitudinal, prospective cohort study of patients interviewed approximately 2 weeks after discharge from inpatient rehabilitation and 3 months later.

SETTING

Follow-up interviews conducted in patient's home setting.

PARTICIPANTS

Adults (N=94) with diagnoses of neurologic, orthopedic, or medically complex conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participation domains of mobility, domestic life, and community, social, & civic life, measured using a CAT version of the Participation Measure for Postacute Care (PM-PAC-CAT) and a 53-item fixed-length survey (PM-PAC-53).

RESULTS

The PM-PAC-CAT showed substantial agreement with PM-PAC-53 scores (intraclass correlation coefficient, model 3,1, .71-.81). On average, the PM-PAC-CAT was completed in 42% of the time and with only 48% of the items as compared with the PM-PAC-53. Both formats discriminated across functional severity groups. The PM-PAC-CAT had modest reductions in sensitivity and responsiveness to patient-reported change over a 3-month interval as compared with the PM-PAC-53.

CONCLUSIONS

Although continued evaluation is warranted, accurate estimates of participation status and responsiveness to change for group-level analyses can be obtained from CAT administrations, with a sizeable reduction in respondent burden.