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Mental Retardation: Determining Eligibility for Social Security Benefits Chapter 4 The Role of Adaptive Behavior Assessment NATURE AND DEFINITION OF ADAPTIVE BEHAVIOR Adaptive behavior has been an integral, although sometimes unstated, part of the long history of mental retardation and its definition. In the 19th century, mental retardation was recognized principally in terms of a number of factors that included awareness and understanding of surroundings, ability to engage in regular economic and social life, dependence on others, the ability to maintain one’s basic health and safety, and individual responsibility (Brockley, 1999). Today, fulfillment of these personal and social responsibilities, as well as the per- This chapter contains material drawn from an unpublished paper commissioned by the committee from Sharon Borthwick-Duffy, Ph.D., University of California, Riverside.
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Mental Retardation: Determining Eligibility for Social Security Benefits formance of many other culturally typical behaviors and roles, constitutes adaptive behavior. By the close of the 19th century, medical practitioners diagnosing mental retardation relied on subjective or unsystematic summaries of such factors as age, general coordination, number of years behind in school, and physiognomy (Scheerenberger, 1983). These practices persisted over that century because of the absence of standardized assessment procedures. And many individuals who would currently be considered to have mild mental retardation were not included in these early definitions. Professionals voiced early caution about diagnosing mental retardation solely through the use of intelligence testing, especially in the absence of fuller information about the adaptation of the individual. In addition, mitigating current circumstances (not speaking English) or past history (absence of schooling) were often ignored in the beginning years of intelligence testing (Kerlin, 1887; Wilbur, 1882). At the turn of the century, intelligence assessment placed primary emphasis on moral behavior (which largely comports with the current construct of social competence) and on the pragmatics of basic academics. (Chapter 3 provides details on the development of intelligence assessment.) Alternative measures to complement intelligence measures began to appear as early as 1916. Edger Doll produced form board speeded performance tests, which were analogues to everyday vocational tasks. During the 1920s, Doll, Kuhlmann, and Porteus sought to develop assessment practices consistent with a definition of mental retardation that emphasized adaptive behavior and social competence. Their work in this area sparked broadened interest in measurement of adaptive behavior among practitioners serving people with mental retardation (Doll, 1927; Kuhlman, 1920; Porteus, 1921; Scheerenberger, 1983). Doll emerged as a leader in the development of a psychometric measure of adaptive behavior, called social maturity at that time. His work emphasized social inadequacy due to low intelligence that was developmentally arrested as a cardinal indication of mental retardation
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Mental Retardation: Determining Eligibility for Social Security Benefits (Doll, 1936a, p. 35). Doll objected to the definition of mental retardation in terms of mental age, which had proven problematic in IQ testing (because it resulted in classification of a significant proportion of the population). In 1936, he introduced the Vineland Social Maturity Scale (VSMS—Doll, 1936b), a 117-item instrument. The VSMS, which measured performance of everyday activities, was the primary measure used to assess adaptive behavior, social competence, or social maturity for several decades. One concern that emerged over time was that it was developed and normed for use with children and youth. It did not cover adults and had a limited range of items tapping community living skills (Scheerenberger, 1983). The assessment of adaptive behavior became a formal part of the diagnostic nomenclature for mental retardation with the publication of the 1959 manual of the American Association of Mental Deficiency (Heber, 1959, distributed in 1961). The 1961 manual (Heber, 1961) discussed adaptive behavior with respect to maturation, learning, and social adjustment. This framework, reiterated in 1983, described adaptive behavior limitations consisting of “significant limitations in an individual’s effectiveness in meeting the standards of maturation, learning, personal independence, or social maturity that are expected for his or her age level and cultural group, as determined by clinical assessment and, usually, standardized scales” (Grossman, 1983, p. 11). The 1983 manual characterized the tasks or activities encompassed by adaptive behavior (and, plausibly social competence) as: In infancy and early childhood: sensorimotor development, communication skills, self-help skills, socialization, and interaction with others; In childhood and early adolescence: application of basic academic skills in daily life activities, application of appropriate reasoning and judgment in mastery of the environment, and social skills—participation in group activities and interpersonal relations; and In adolescence and adult life: vocational and social responsibilities. During the 1960s, a wider variety of adaptive behavior measures was developed and disseminated (e.g., Allen et al., 1970; Balthazar & English, 1969; Leland et al., 1967). Indeed, by the late 1970s, the number of available adaptive behavior measures, largely interview or
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Mental Retardation: Determining Eligibility for Social Security Benefits observational in format, had burgeoned, including checklists pertaining to vocational behaviors (Walls & Werner, 1977). Measures developed in the 1960s have typically been updated in subsequent editions with enhanced psychometric characteristics and scoring (e.g., Sparrow & Cicchetti, 1985). Over the past 25 years there has also been further refinement of the parameters and structure of tests of adaptive behavior and social competence. This refinement was based on large samples of research participants and data from service registries (McGrew & Bruininks, 1990; Siperstein & Leffert, 1997; Widaman et al., 1987, 1993). Novel frameworks for conceptualization of adaptive behavior have been proposed (American Association on Mental Retardation, 1992), and conventional frameworks have been endorsed for application in differential diagnosis and classification practices (Jacobson & Mulick, 1996). Finally, the difficulties and complexities of differentiating mild mental retardation from its absence or from other disabling conditions (e.g., Gresham et al., 1995; MacMillan, Gresham, et al., 1996; MacMillan, Siperstein, & Gresham, 1996) have remained an enduring concern in both professional practice and policy formulation. Differing Conceptualizations In Chapter 1 we summarized the history of definitions of mental retardation and discussed their relevance to the Social Security Administration’s definition. At first glance, current definitions seem to be quite similar; however, there are subtle differences in the conceptualization of adaptive behavior that may affect the outcomes of diagnostic decisions for individuals with mental retardation, particularly those in the mild range. In the recent Manual of Diagnosis and Professional Practice in Mental Retardation (Jacobson & Mulick, 1996), Division 33 of the American Psychological Association put forth a definition of mental retardation that emphasizes significant limitations in intellectual functioning and adaptive behavior. The definition also views adaptive behavior as
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Mental Retardation: Determining Eligibility for Social Security Benefits a multidimensional construct, in that the definition is expanded to include “two or more” factor scores below two or more standard deviations. In describing mild mental retardation, there is minimal reference to adaptive behavior problems, except for the inclusion of “low academic skill attainment.” It is important to note that the Division 33 definition places equal importance on the constructs intellectual functioning and adaptive behavior. The definition speaks to the presence of significant limitations in intellectual functioning and significant limitations in adaptive behavior, which exist concurrently. The term “concurrently” suggests an interdependent relationship in which both constructs are equally important. In this definition, the order of the constructs can be switched without affecting the validity of the definition. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association (1994), definition of mental retardation also has a cutoff of two standard deviations below the mean for intelligence, making an IQ cutoff of 70 to 75 acceptable for a diagnosis of mental retardation. In contrast, there is no mention of a standardized score or cutoff point for operationalizing any “significant limitations in adaptive behavior,” even though it is suggested that one or more instruments be used to assess different domains from “one or more reliable independent sources” (p. 40). The implicit rationale for not providing any statistical criteria for adaptive behavior testing is based on the existing limitations in instruments that measure adaptive behavior, specifically in terms of the comprehensiveness of measuring all domains and the reliability of measuring individual domains. Furthermore, issues are raised about the degree to which existing instruments are able to take into account the cultural context in assessing an individual’s adaptive behavior. One of the key themes throughout the DSM-IV definition is the cultural aspect of adaptive behavior. For example, adaptive behavior is defined in terms of effectively coping with common life demands and the ability to meet the standards of personal independence for a particular age group with a specific sociocultural background.
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Mental Retardation: Determining Eligibility for Social Security Benefits The DSM-IV definition identifies four levels of mental retardation based on IQ: mild, moderate, severe, and profound. No mention is made of the degree of severity of adaptive deficits for each of these levels, nor of the number or types of impaired adaptive behavior domains at each level. The DSM-IV definition places a greater emphasis than the Division 33 one on intelligence than on adaptive behavior, defining mental retardation as “significantly sub-average general intellectual functioning accompanied by significant limitations in adaptive functioning” (p. 39). In using the term “accompanied,” the definition suggests that adaptive behavior is a supplementary variable to intelligence, although both criteria must be present. The World Health Organization (1996) also includes a definition of mental retardation in its International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). ICD-10 views the relationship between intellectual functioning and adaptive behavior as causal, with deficits in adaptive behavior resulting from deficits in intellectual functioning. In describing the different severity levels of mental retardation, the ICD-10 guide presents IQ levels not as strict cutoffs but as “guides” to categorizing individuals with mental retardation. There is no mention of any standardized cutoffs for adaptive ability, except for mention of the use of “scales of social maturity and adaptation” in the measurement of adaptive behavior. In the characterization of mild mental retardation, the ICD-10 guide points out that, “some degree of mild mental retardation may not represent a problem.” It goes on to state that the consequences will only be apparent “if there is also a noticeable emotional and social immaturity.” This statement implies that for individuals with mild mental retardation, intellectual deficits are apparent only when represented by problems in adaptive behavior (emotional and social immaturity). Furthermore, “behavioral, emotional, and social difficulties of the mildly mentally retarded . . . are most closely akin to those found in people of normal [range of] intelligence.” It is important to note that the terminology used in the ICD-10 is international English rather than North American English, and that, as a result, word usage in ICD-10 is
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Mental Retardation: Determining Eligibility for Social Security Benefits not entirely consistent with contemporary North American terminology with respect to functional limitations or depiction of social performance. The most cited definition in the field is that of the American Association on Mental Retardation (AAMR). In their most recent classification system (American Association on Mental Retardation, 1992), AAMR defines mental retardation as subaverage intellectual functioning existing concurrently with limitations in adaptive skills. These limitations in adaptive skills are operationally defined as limitations in two or more of ten applicable adaptive skill areas (e.g. self-care, home living, social skills, self-direction, health and safety, etc.). The definition also includes the notion that adaptive skills are affected by the presence of “appropriate supports” and with “appropriate supports over a sustained period, the life functioning of the person with mental retardation will generally improve.” AAMR departs significantly from other organizations by eliminating the grouping of individuals with mental retardation into levels of severity. AAMR no longer differentiates, either qualitatively or quantitatively, differences in intellectual or adaptive functioning of individuals with mild, moderate, severe, and profound mental retardation. Instead, they differentiate individuals with mental retardation based on the supports they need. The result is that the unique aspects and characterization of individuals with mild mental retardation are no longer the basis for differentiating them from more moderately and severely involved individuals. In so doing, AAMR ignores the substantial theoretical and empirical foundation that validates the difference between individuals with mild mental retardation and other individuals with mental retardation (MacMillan et al., in press). Among these four definitions, there is little variation in the intelligence construct for individuals with mental retardation. The differences occur rather in their consideration of the contributing role of adaptive behavior. In some definitions (Division 33 and AAMR), adaptive behavior is construed as distinct from intellectual functioning and of equal importance, while in other definitions it is considered a result of deficits in intellectual functioning. The definitions also
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Mental Retardation: Determining Eligibility for Social Security Benefits vary as to whether they consider adaptive behavior to be made up of a single factor or to have multiple factors or domains. In the definitions that imply a multifactor construct, deficits in adaptive behavior must be specified in a certain number of areas/domains. With regard to identifying decision-making criteria, Division 33 presents the only definition that employs a statistical cutoff based on standard norms. In contrast, the other definitions employ more qualitative terms, which are open to interpretation in describing deficits and limitations in adaptive behavior. Dimensions of Adaptive Behavior Structure Multidimensional or Unidimensional? Answers to this question have been mixed. Meyers et al. (1979) concluded from their review of factor analytic studies that adaptive behavior was definitely multidimensional and that the use of a total score would be inappropriate to indicate a general level of adaptation. Their view has been both supported and disputed in the past two decades, and there are currently firm adherents on each side of this issue. McGrew and Bruininks (1989) and Thompson et al. (1999) have concluded, for example, that the number of factors emerging from factor analyses depends on whether data were analyzed at the item, parcel, or subscale level, with fewer factors found for subscale-level data than item- or parcel-level data. They also found that it was not the selection of the instrument that determined the number of factors. This important finding has direct implications for definitions that require limitations to be observed in a specific number of areas. If there is actually one underlying domain that “causes” behaviors in all different conceptual domains, and there is relatively little unique variance found in each domain, then a total score with a single cutoff point could reliably distinguish those with and without significant limitations. If not, diagnosticians would have to consider a profile of adaptive behavior deficits that takes all domain scores into account. Widaman et al. (1991) and Widaman and
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Mental Retardation: Determining Eligibility for Social Security Benefits McGrew (1996) concluded that evidence supported a hierarchical model with four distinct domains: (1) motor or physical competence; (2) independent living skills, daily living skills, or practical intelligence; (3) cognitive competence, communication, or conceptual intelligence; and (4) social competence or social intelligence. Widaman and McGrew (1996) further argued that agreement on a common set of terms for domains of adaptive behavior (in contrast to the use of “or” as above) would contribute to a better consensus on the structure of adaptive behavior. The review by Thompson et al. (1999) is the most recent summary of studies using factor analysis; it concludes that adaptive behavior is a multidimensional construct. The three most common dimensions found were in these broad categories: (1) personal independence, (2) responsibility, i.e., meeting expectations of others or getting along with others in social contexts, and (3) cognitive/academic. Physical/developmental and vocational/community dimensions were found less often. Thompson et al. concluded: “No single adaptive-maladaptive behavior assessment instrument completely measures the entire range of adaptive and maladaptive behavior dimensions. . . It is clear that different scales place different levels of emphasis on different adaptive behavior domains. No one instrument produced a factor structure that included all of the domains” that were identified by the American Association on Mental Retardation (1992). Breadth of Domains. The domains assessed by adaptive behavior scales, and thus the individual items included on them, depend in part on the context, target age group, and purpose of the measure. Thus, considerable variation has been found in the content covered by different scales (Holman & Bruininks, 1985; Thompson et al., 1999). Measures used in schools may not need a work domain, for example, if students are too young for employment or the school does not have a work experience program. Conversely, adult scales would not need items on school-related behaviors (Kamphaus, 1987a). In their review, Thompson et al. (1999) suggest that this incongruity reflects the problem noted by Clausen (1972) and Zigler et al. (1984), that adaptive behavior lacks
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Mental Retardation: Determining Eligibility for Social Security Benefits a unifying theoretical foundation. A consequence of this, according to Thompson et al., is the inability to develop precise measures of adaptive behavior that would objectively differentiate individuals by disability. An alternative explanation is that adaptive behavior must be understood in the context of the individual’s relevant daily and social life, which is determined by age, culture, and context (Thompson et al., 1999). Independence of Domains. The 1992 AAMR definition requires that an individual show significant limitations in at least 2 of the 10 adaptive skill areas. A danger of accepting “erroneous domains that are not truly distinct from one another” (Thompson et al., 1999, p. 17) is that it can lead to the inconsistent application of eligibility criteria and unequal treatment across groups of people. Thus, characteristics of the factor structure of a measure of adaptive behavior have important implications for diagnosis. Thompson et al. (1999) reviewed studies that reported factor analyses of adaptive behavior measures. They made two important points before summarizing their findings: (1) highly correlated factors may indicate that they do not represent independent dimensions and (2) different methods of factor analysis can support different factor structures. Domains Missing from Adaptive Behavior Scales Greenspan (1999) noted that a drawback to the factor analytic approach to determining the dimensional structure of adaptive behavior is that this statistical method cannot determine whether some domains do not make conceptual sense (i.e., items should not have been included on tests in the first place) or whether missing content domains should have been included. Social Skills Dimension of Social Competence. Most adaptive behavior scales contain factors addressing interpersonal relationships or social skills, but they do not address overall social competence. For indi-
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Mental Retardation: Determining Eligibility for Social Security Benefits viduals whose diagnosis is most in question because their measured IQs are near the cutoff, this vital area may determine the presence or absence of mental retardation. Gresham and Elliott (1987) and Greenspan (1999) have argued that social competence has received too little attention in the conceptualization and measurement of adaptive behavior (Figure 4-1). Their model divides social competence into two overall dimensions: (1) adaptive behavior, which includes the factors contained on most adaptive behavior scales (independent functioning, self-direction, personal responsibility, vocational activity, functional academic skills, physical development) and (2) social skills, including domains that are likely to be most key to identifying mental retardation at the borderline levels (interpersonal behaviors, self-related behaviors, academic-related skills, assertion, peer acceptance, communication skills). The dimensions of adaptive behavior and social skills in the Gresham and Elliott model are surprisingly similar to the 10 adaptive skill areas in the 1992 AAMR definition of mental retardation. Gullibility/Credulity Component of Social Competence. Greenspan and colleagues (Greenspan, 1999; Greenspan & Driscoll, 1997; Greenspan & Granfield, 1992) have argued that social intelligence, some aspects of which are not contained on any current scales of adaptive behavior or social skills (e.g., credulity, gullibility), should be a key determinant of a diagnosis of mental retardation for adults (Figure 4-2). Greenspan and Driscoll (1997) proposed a “dual nature of competence.” They suggest that intelligence, as measured by IQ, is typically viewed as an independent variable that predicts outcomes, whereas personal competence is the combination of what individuals “bring to various goals and challenges as well as their relative degree of success in meeting those goals and challenges” (p. 130). Greenspan (1999) argues that the victimization of people with mental retardation, observed in social and economic exploitation, is “a more central (and generally more subtle) problem that goes to the heart of why people with mental retardation are considered to need the protections (ranging from in-home services to conservators) associated
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Mental Retardation: Determining Eligibility for Social Security Benefits lie the ability to perform situationally appropriate behavior. With regard to the direct assessment of processes, the overarching construct of social cognition has been put forth by developmentalists over the past four decades (e.g., Crick & Dodge, 1994; Dodge, 1986; McFall, 1982; Trower, 1982). Social cognition encompasses such constructs as social problem solving (Spivack & Shure, 1974), decision making (Hickson & Khemka, 1999), and social and emotional learning (Elias et al., 1997). Overall, the construct of social cognition represents the cognitive aspects of social functioning. As social cognition has matured as a research discipline, researchers have developed methodologies for assessing social-cognitive processes and have demonstrated the usefulness of these methodologies for detecting the limitations that individuals with mild mental retardation exhibit in their ability to adapt to changing social situations. Currently, instruments and interviewing procedures for assessing social-cognitive processes can provide examiners with valuable supplemental information about the social functioning of individuals with mental retardation. This information may otherwise be lacking because of inadequacies in existing adaptive behavior measures. In addition, social-cognitive assessment can also be helpful in establishing that an individual’s social problems are indeed a manifestation of an underlying cognitive impairment (in accordance with standard definitions of mental retardation), rather than primarily reflecting other factors, such as environmental constraints or motivational characteristics. Thus, social-cognitive assessment increases the likelihood of making accurate diagnostic and disability determination decisions by increasing the pool of information available to an examiner regarding an individual’s functional limitations, while simultaneously reducing the risk of “false positive” decisions. The potential utility of social-cognitive assessment techniques for the evaluation of individuals with mild mental retardation for eligibility determination purposes is evident in focusing on three major skill areas: social perception, the generation of strategies for resolving social problems, and consequential thinking. These three processes oc-
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Mental Retardation: Determining Eligibility for Social Security Benefits cupy a prominent place in most theoretical models of social cognition (e.g., Crick & Dodge, 1994; Gumpel, 1994; Leffert & Siperstein, in press; McFall, 1982). Social perception refers to an individual’s ability to interpret or “read” relevant social messages from others (Maheady et al., 1984). These messages, known as social cues, consist of verbal and nonverbal stimuli, such as physical actions, words, facial expressions, tone of voice, and body language, which tell about others’ behaviors, feelings, and intentions. Individuals with mental retardation often demonstrate difficulties at the most basic level of recognizing specific types of social cues (e.g., recognizing a person’s emotional state on the basis of his or her facial expression) (Adams & Markham, 1991; Gumpel & Wilson, 1996; Harris, 1977; Hobson et al., 1989). Research with children and adolescents with mental retardation has found that they also have difficulty integrating information from multiple cues in order to interpret a social situation (Brosgole et al., 1986; Doman, 1967; Gomez & Hazeldine, 1996; Leffert & Siperstein, 1996; Leffert et al., 2000; Maheady et al., 1984). The assessment of social perception skills in individuals with mild mental retardation has involved a variety of instruments, with subsequent methodological refinements, which have been developed and employed over four decades with children, adolescents, and adults. For example, the Test of Social Inference (TSI—de Jung et al., 1973) employs the technique of presenting an individual with mild mental retardation with illustrations of common social situations and asking him or her, for each illustration, to tell the examiner what the picture is about. Of the various social perception assessment instruments that have been developed, the TSI is the instrument that has been used most widely to assess social perception skills in this population (de Jung et al., 1973; Matthias & Nettelbeck, 1992). The second social-cognitive process is the generation of strategies for resolving social problems. Through the assessment of strategy generation, researchers have been able to evaluate an individual’s fund of social knowledge (i.e., his or her repertoire of social strategies), as well as the ability to adapt to varied social situations by generating
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Mental Retardation: Determining Eligibility for Social Security Benefits situationally appropriate strategies. Research with individuals with mental retardation has consistently documented limitations in their performance of both of these components of strategy generation. Regarding strategy repertoires, for example, researchers have found that children and adults with mental retardation have a limited repertoire of appropriate social strategies to draw from (Herman & Shantz, 1983; Smith, 1986). Their repertoires often exclude certain types of socially adaptive strategies. For example, they rarely employ the strategy of attempting to work out a mutually acceptable compromise solution in instances when one’s interests conflict with another person’s wishes (Hickson & Khemka, 1999; Hickson et al., 1998; Jenkinson & Nelms, 1994; Smith, 1986). Regarding the ability to adjust one’s social strategies to fit the needs of a particular social situation, children with mild mental retardation often fail to use information from the specific social cues present in the social situation to guide their search for appropriate strategies (Leffert et al., 2000). As a result, they often rely on generic, one-size-fits-all strategies, such as appealing to an authority, rather than adjusting their strategies in accordance with situational demands. At the workplace, for example, overdependence on the strategy of appealing to a supervisor, regardless of the nature of the problem, can be a problem in creating tension with peers or in creating a perception that the person cannot function autonomously in a work setting. Unlike the area of social perception, there is no single instrument for assessing strategy generation in individuals with mental retardation. Rather, there is a standard clinical methodology that consists of presenting the individual with a hypothetical situation in the form of a story and asking “What would you do if this happened to you?” The Social Problem-Solving Test (Castles & Glass, 1986) is an example of an assessment instrument employing this methodology that was specifically designed for use with individuals with mental retardation. The technique of asking open-ended questions that tap the process of generating strategies for solving problems is widely used in standard assessments of intellectual functioning, such as the Wechsler scales.
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Mental Retardation: Determining Eligibility for Social Security Benefits The third social-cognitive process, consequential thinking (i.e., reasoning regarding the consequences of carrying out different social strategies), is also a critical process in the adaptive behavior of individuals with mild mental retardation. Recent studies with these individuals have documented limitations in their reasoning about the consequences of strategies that make it difficult for them to select a social strategy that is appropriate for a given social situation. Rather than weighing the likely outcomes of enacting a particular strategy in a given situation, these individuals tend to render global judgments (e.g., whether a strategy is generally a good thing or bad thing to do) when evaluating behavioral options. Consequently, they have difficulty evaluating which potential strategy is best to enact in a particular situation (Hickson et al., 1998; Jenkinson & Nelms, 1994). Methodologies for assessing consequential reasoning have existed for several decades. A widely used technique, which was first employed by Spivack and Shure (1974), is to present the individual with a story describing a social problem, as well as a particular strategy that the protagonist might use to resolve the problem. The person is then asked, “What will happen after” the protagonist carries out this strategy? Another, more open-ended assessment technique is to present a social problem and then to ask the interviewee to relate everything that is going through the protagonist’s mind as he or she tries to decide what to do about resolving the problem (e.g., Hickson et al., 1998; Jenkinson & Nelms, 1994). A third approach is to ask individuals with mild mental retardation to select the best strategy for resolving a social problem from among several alternatives. This is the approach that has been utilized in the Test of Interpersonal Competence for Employment (TICE—Foss et al., 1986). The TICE, which is commercially available, consists of two subtests that assess the individual’s ability to evaluate strategies in relation to the situational demands of two distinct social interaction contexts common in work settings: interaction with coworkers and interaction with supervisors. Auty and colleagues (1987) have found positive correlations between subtest scores on the
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Mental Retardation: Determining Eligibility for Social Security Benefits TICE and supervisor-rated work skills, self-reported job satisfaction, and worker productivity among adults with mild mental retardation. Social-cognitive assessments have already demonstrated their usefulness as a supplement to standard adaptive behavior rating scales. They have provided valuable information that has informed decision making about interventions to improve the social functioning of individuals with mental retardation. Specifically, instruments such as the TSI, the Social Problem-Solving Test (Castles & Glass, 1986), and the TICE have been successfully employed with this population for the purposes of determining where to begin instruction in social skills and documenting the improvements that have resulted from instructional interventions. These assessment instruments, which have been useful in instructional contexts, can also be valuable for the evaluation of an individual’s eligibility for SSA services. The social-cognitive processes and the approaches that are used to measure them can also inform and enrich the interviews that examiners conduct with individuals with mild mental retardation and other informants. Table 4-4 presents examples of questions that can guide examiners in eliciting information regarding the three social-cognitive processes reviewed here. By eliciting information about an individual’s performance of these processes, the examiner can increase the likelihood of detecting impairments in social functioning that often characterize this population. Additional measures of social cognition or social skills and issues relevant to social skills assessment of people with mental retardation have been discussed further (Bell-Dolan & Allan, 1998; Blacher, 1982; Blake & Andrasik, 1986; Jackson et al., 1981; Matson et al., 1983; Meyer et al., 1990; Monti, 1983; Smith & Greenberg, 1979; Van Hasselt et al., 1981). Overall, as a supplement to standardized adaptive behavior assessment scales, social-cognitive assessment has the potential to contribute to the improvement of SSI and DI eligibility determination practices by enriching the pool of relevant information that is available for resolving uncertainty in decisions regarding impairment in the social domain. In this fashion, the assessment of social-cognitive processes can
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Mental Retardation: Determining Eligibility for Social Security Benefits TABLE 4-4 Question Guide for the Assessment of Social-Cognitive Processes Social perception: encoding of social cues Does the person recognize that a social problem has occurred? Can the person accurately describe the problem? Does the person attend to and recognize the specific social cues (e.g., facial expression, tone of voice, body language, sequence of actions) present in social situations that indicate others’ emotions and intentions? Interpretation of social cues Does the person accurately interpret others’ emotions and intentions on the basis of the available cues? Strategy generation Is the person familiar with and able to think of a variety of strategies that are potentially appropriate for resolving social problems? Does the person modify his or her strategy from one situation to another based on the type of social problem, the other person’s intentions, and related considerations? Strategy evaluation and selection Can the person anticipate the consequences of carrying out different strategies for resolving particular social problems in a given social context? In doing so, does the person consider long-term and more abstract consequences of a carrying out a particular strategy (e.g., impact on maintaining interpersonal relationships or keeping one’s job) as well as the immediate and more tangible consequences (e.g., personal gratification, escaping from an immediate problem)? become part of a more comprehensive approach to individual assessment that includes information from informants about day-to-day behavior, as well as direct assessment of skills of a social-cognitive nature. The information obtained from this type of evaluation can clarify the
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Mental Retardation: Determining Eligibility for Social Security Benefits nature and extent of the limitations those individuals with mild mental retardation experience in adapting their behavior to meet the social demands and expectations of the school, workplace, and recreational and residential settings. Alternative Assessment Instruments There are a small number of well-normed adaptive behavior scales that are especially suitable for use in initial determinations for children and youth with possible mental retardation. There is a much larger number of scales that do not have extensive norms but may nonetheless be suitable as a means of gathering and summarizing information that can be assessed on a clinical basis. In addition to summarizing adaptive behavior status for the purposes of diagnosis and establishing SSI and DI eligibility, some adaptive behavior scales, such as the AAMR Adaptive Behavior Scales (both school and residential or community versions) and the Scales of Independent Behavior permit the recording of maladaptive behavior. A record of maladaptive behavior may permit an individual to be qualified for SSI by virtue of concurrent IQ in the range of –2 to –2.66 SD and presence of another mental (or behavioral) disorder (Jacobson, 1990; Jacobson & Janicki, 1983). Whereas situational and functional assessment are appropriate in intervention design for maladaptive behavior or behavior disorders or problems, norm-referenced or criterion-referenced instruments are appropriate for initial assessment (Reschly, 1992). Possibly the most thoroughly researched and well understood instrument to assess both prosocial and problem behavior among children generally is the Achenbach Child Behavior Checklist (CBC—see Achenbach & Edelbrock, 1978). The CBC differentiates between internalizing (e.g., withdrawal, diminished interests, depressive affect) and externalizing (e.g., aggression against peers or adults, property destruction) behavior problems that may be consistent with a mental disorder (see also Borthwick-Duffy et al., 1997; Fidler et al., 2000; Hodapp et al., 1997). Norms for several versions of the CBC, which are age-graded, are available for both clinical and nonclinical child and youth populations.
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Mental Retardation: Determining Eligibility for Social Security Benefits In addition to the CBC, there are other instruments available to assess overt behavior, affect, or verbal statements consistent with the presence of mental or behavioral disorders among children and youth with mild mental retardation. Generally, these instruments do not have well-established norms but rather have been assessed for their sensitivity with diagnosed cases (e.g., Reiss & Valenti-Hein, 1994), and some scales are more suitable for youth than for children: the Assessment of Dual Diagnosis (Matson & Bamburg, 1998); the Psychopathology Instrument for Mentally Retarded Adults (Balboni et al., 2000; Linaker, 1991; Sturmey & Ley, 1990; Watson et al., 1988); and the Reiss Screen for Maladaptive Behavior (Havercamp & Reiss, 1997; Prout, 1993; Sturmey & Bertman, 1994) For practitioners skilled in clinical interviewing, a field-tested adaptation of a structured clinical interview is available. This scale is the Psychiatric Assessment Schedule for Adults with Developmental Disability or PASS-ADD (Moss et al., 1996, 1998, 2000; Prosser et al., 1998). All of the measures above have demonstrated concordance with psychiatric diagnosis. They can contribute to accurate and appropriate clinical diagnosis of concurrent conditions that may meet listing requirements for SSI and DI as an alternative to assessment of adaptive behavior. Finally, as this chapter is being written, the World Health Organization (WHO) has completed development of ICIDH-2, the International Classification of Functioning, Disability, and Health (World Health Organization, 2000; see also Post et al., 1999), a functionally based nomenclature. This nomenclature has dimensions of impairments of body functions, impairments of body structures, activity limitations and participation restrictions, and environmental factors. For the purposes of assessment focused on ascertainment of mental and physical conditions, the most salient measurement dimensions of ICIDH-2 are body functions (e.g., mental processes), and activity limitations and participation restrictions. In conjunction with the ICIDH-2, WHO has developed the World Health Organization Disability Assessment Schedule II (WHODAS II), which, in its most extensive form, contains 36 items tapping domains of: (1) understanding and communicating, (2) getting around, (3) self-care, (4) getting along with
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Mental Retardation: Determining Eligibility for Social Security Benefits others, (5) household and work activities, and (6) participation in society. The utility of the WHODAS II remains to be established as a means to consolidate adaptive or maladaptive behavior information of value in informing the SSI and DI eligibility determination process. CONCLUSIONS AND RECOMMENDATIONS Review of the extensive literature on adaptive behavior and its assessment suggests that adaptive behavior is best viewed as a multidimensional construct. That is, current science suggests that there are various domains of behavior that form the construct of adaptive behavior. Factor analyses of existing measures finds consistent domains of functioning. These domains vary by age, consistent with the development of adaptive behavior. The committee therefore, makes two major recommendations to SSA: Recommendation: Standardized adaptive behavior instruments should be used to determine limitations in adaptive functioning. In general, the cutoff scores for adaptive behavior should be one standard deviation below the mean in two adaptive behavior areas or one and one-half standard deviations below the mean in one adaptive behavior area. Adaptive behavior measures should be used whenever possible, but only when there is an instrument that matches the client’s characteristics and when an appropriate third-party respondent is available. A client can be determined to have a significant limitation in adaptive functioning even with scores that do not meet the above criteria IF there is compelling evidence of adaptive behavior deficits that significantly impair performance of expected behaviors. Recommendation: Revisions should be made in the adaptive behavior areas or domains emphasized in SSA regulations to con-
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Mental Retardation: Determining Eligibility for Social Security Benefits form to factor analysis results. The following areas by age should be adopted by SSA: Infancy/early childhood (approximate ages birth to 4): motor/ mobility, social, communication, daily living skills (self-help). Childhood (approximate ages 5 to 17): motor/mobility, social, communication/functional academic skills, daily living skills. Adolescence/adulthood (approximate ages 18 and older): motor/mobility, social, communication/practical cognitive skills, daily living skills, work skills/work-related behaviors. Current science also suggests that several measures of adaptive behavior tap into these domains. These measures have excellent psychometric properties, with reliabilities of about .90. Also, current measures also evidence strong validity, as described in the chapter. The committee has identified several measures that would be useful in disability determination for mental retardation. Unlike intelligence tests, which measure maximum performance, adaptive behavior assessment focuses on what the individual typically does. Assessments work best when they document: (a) quantitative level of performance, (b) fluency of performance (e.g., qualitative criterion performance), (c) the extent to which the individual has failed to acquire skills or failed to perform skills already learned, and (d) the inability of the individual to perform skills through lack of opportunity. The committee’s review of the scientific and practice literature also reveals that adaptive behavior is a broadly focused construct. The focus is on the ability of the individual to function independently, with minimal external supports, by adjusting his or her behavior in a self-guided fashion to meet varied situational demands and expectations. Our review of the practice literature reveals that adaptive behavior scales are in wide use by some groups of clinicians. In our judgment, good clinical practice requires that data from standardized adaptive behavior scales be combined with other clinical or behaviorally oriented information in determining the presence or the absence of adaptive behavior deficits. These other bits of data could include a review
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Mental Retardation: Determining Eligibility for Social Security Benefits of developmental and social history, direct observation of the individual’s behavior, verbal reports from interviews, and the use of the other structured and semistructured interviews. Best-practice guidelines require that clinicians using adaptive behavior measures employ those that are culturally compatible and have suitably contemporary and age-related norms. Finally, the committee has identified a number of research areas, focusing on which would improve the measurement of adaptive behavior for mental retardation diagnosis. These areas include social-cognitive and social skill assessment—with a specific focus on social cognitive processes of social perception, strategy generation, and consequential thinking—and vocational and work-related skills assessment with prognostic value. In addition, there is a strong need to fund studies examining the nature and distribution of adaptive behavior deficits among individuals with mental retardation in general and those with mild mental retardation more specifically.
Representative terms from entire chapter: