Mental Retardation Determining Eligibility for Social Security Benefits (2002) / Chapter Skim
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4. The Role of Adaptive Behavior Assessment
4. The Role of Adaptive Behavior Assessment
Pages 141-207
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From page 141... ...
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, 19991.
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From page 142... ...
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.
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351. 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)
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From page 144... ...
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.
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From page 145... ...
, 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.
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From page 146... ...
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)
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From page 147... ...
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.
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From page 148... ...
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.
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From page 149... ...
No one instrument produced a factor structure that included all of the domains" that were identified by the American Association on Mental Retardation (19921. Breadth of Domains.
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From page 150... ...
Social Skills Dimension of Social Competence. Most adaptive behavior scales contain factors addressing interpersonal relationships or social skills, but they do not auaress overall social competence.
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. 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.
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proposed ideas for assessing vulnerability in a comprehensive assessment of adaptive behavior or social competence. As there is no research yet on credulity in people with mental retardation, these proposals for assessment are unlikely to be found in practice in the next several years.
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153 Z [L o ~ ~ o o in tr [L o C' .
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also has argued for many years that the presence of maladaptive behavior, or mental illness, is irrelevant for the purpose of diagnosing of mental retardation. If it is assumed that maladaptive behavior ratings should not contribute to diagnostic decisions about adaptive functioning, then problems in their measurement need not affect this process.
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From page 155... ...
Assessment Methods There are a number of ways to assess the level, quality, and pattern of adaptive functioning, each with its own strengths and weaknesses. These include clinical assessment by interview methods (unstructured, structured, semistructured, direct observation)
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From page 156... ...
Checklists completed by teachers, parents, or other caregivers are often used to rate individuals' behavior for a broad variety of suspected conditions (e.g., mental retardation, autism, other pervasive developmental disorders, attention deficit disorder)
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Administration of adaptive behavior scales generally foliows one of two possible formats. One is an interview with a professionally trained interviewer and a respondent who knows the individual being assessed well.
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From page 158... ...
Newer adaptive behavior scales evidence more robust psychometric properties than older scales. In this section, we discuss a variety of psychometric features of adaptive behavior scales that have implications for decision making about mental retardation.
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From page 159... ...
Thus, to the extent that a young adult with mild mental retardation has selected skills that are well developed relative to others, it may not be accurate to describe those skills in developmental terms. Instead, it may be possible to establish only that their skills are superior to those achieved by other young adults with
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From page 160... ...
In unpublished data on some 27,000 people with mild mental retardation, between 75 and 100 percent of participants obtained perfect scores (100 percent) on three of five indices of one scale ]
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. item Density Adaptive behavior scales are structured to be comprehensive without being cumbersome (Adams, 20001.
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Full details on standardization and reliabilities are provided in the manuals associated with the major adaptive behavior scales (Adams, 2000; Bruininks et al., 1996; Harrison & Oakland, 2000b; Lambert et al., 1993b; Sparrow et al., 1984b; see also Harrington, 19851. Additional discussion is provided in Chapter 3.
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From page 163... ...
Adequacy of Normative Samples Another psychometric concern is whether the norming samples are adequate. Although normed on smaller samples than comprehensive intelligence tests use, current adaptive behavior measures typically have adequate norming samples in relation to both representation of people with and without mental retardation and representation of age groups in the population in relation to the age span of the measure.
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From page 164... ...
This has generalized to adaptive behavior measures. As the importance of adaptive behavior measures in classification of mental retardation has increased, this concern has been heightened as disproportionate numbers of minority children have been identified as having mental retardation, primarily because of low-income status and the overrepresentation of individuals with mental retardation among low-income people (Boyle et al., 19961.
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From page 165... ...
To some extent, inclusion of participants representative of the general population, including racial and ethnic minorities, in norming samples should mitigate against biases in scoring of adaptive behavior scales. To the extent that low income or very low income is more common among certain ethnic minority groups, however, differences in developmental trajectories for children may reflect differences in childrearing practices and stimulation that are associated with economic and social class and related levels of parental education (Hart, 2000; Hart & Risley, 1992; Walker et al., 1994~.
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From page 166... ...
1061. Among the very large number of adaptive behavior scales on the market, very few have adequate norms and reliability to diagnose mental retardation in people with IQs in the questionable range (e.g., 60-801.
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From page 167... ...
Decisions about which instrument to use depend on the age of the individual to be tested and available norms, available sources of information, the context in which the individual is known, and the training of the rater. Vineland Adaptive Behavior Scales The Vineland Adaptive Behavior Scales (VABS Sparrow et al., 1984a)
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From page 168... ...
It also determines strengths and weaknesses, documents progress, and assesses the effects of intervention programs. Although it is linked to AAMR by name, the ABS does not provide subscale scores in the 10 adaptive skill areas listed in the 1992 AAMR definition of mental retardation.
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From page 169... ...
Because standard scores and percentile ranks do not indicate standing relative to people without developmental disabilities, and because the norming sample is probably not representative of the population of adults with developmental disabilities, the ABS-RC:2 may not fit the psychometric criteria used in determining a diagnosis of mental retardation according to AAMR requirements (American Association on Mental Retardation, 19921. Scales of /ndependent Behavior The Scales of Independent Behavior (SIB-R Bruininks et al., 1984)
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From page 170... ...
. sing scores without considering opportunity and societal expectations for a person with physical limitations could be problematic for a diagnosis of mental retardation.
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From page 171... ...
and is appropriate for children from birth to age 8 (Spector, 19991. It does not have the problems with floor effects in diagnosing developmental delays at the youngest ages that are present in other adaptive behavior scales.
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From page 172... ...
cited many problems with the norm tables but concluded the ABI could contribute some information to the determination of mental retardation. The Independent Living Scales (ILS Loeb, 1996)
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The Adaptive Behavior: Street Survival Skills Questionnaire (SSSQ Linkenhoker & McCarron, 1983) was designed to assess adaptive behavior in youth from age 9 years and adults with mild to moderate mental retardation.
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It is unclear whether individuals with lownormal intelligence or mild mental retardation would be able to respond reliably to hypothetical situations. The Social Skills Rating Scales (SSRS Gresham & Elliott, 1987)
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They also have utility in documenting delays or functional limitations consistent with marked impairment in motor development, activities of daily living, communication, social functioning, or personal functioning. These measures also may be validly used, with repeated or periodic administrations, for assessment of changes in status.
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176 MENTAL RETARDATION TABLE 4-1 Principal Comprehensive Aclaptive Behavior Measures and Their Characteristics Adaptive Age Age Behavior Range: Range: Year Measurea Use Norms Published AAMR Adaptive Behavior 18-79 years 18.0 to 60+ years 1993 Scale-Residential and Community N = 4,103 people with DO AAMR Adaptive 3-18 or Behavior Scale-School 3-21 years 3.0-18.1 1 years 1993 N = 2,074 students with MR; N = 1,254 students w/o MR Adaptive Behavior 5-89 years 5-21 years; 2000 Assessment System N = 1,670 &1,690; general population 1 6-89 years; N = 920 & 990; general population
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completion by a -Community -Domains: r = .88 to .99 paraprofessional, self-sufficiency Interrater: (N = 16) with professional -Personal-social -Factors: r = .97 to .99 supervision responsibility & -Domains: r = .83 to .99 (perhaps Class C, 10 domain scores not specified)
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From page 178... ...
178 TABLE 4-1 Continuecl MENTAL RETARDATION Adaptive Age Age Behavior Range: Range: Year Measurea Use Norms Published Version Comprehensive Test of Birth-60+ years 5-22 years; 2000 -Normal Adaptive Behavior-Revised N = 2,094; Adaptive students with MR Behavior Checklis 10-60+ years; Revised N = 4,456; with MR (NABC-F compost 5-22 years: a subset N = 4,525; CTAB-R students who MR -Also a parenVg form of CTAB-R Scales of Independent 3 months-SO years 3 months-SO years; 1996 -Shortf' Behavior-Revised N = 2,182; -Early general population developr form -Other ret instrum' Vineland Adaptive 1-99 years 0.1 to 18.11 years 1984 -Intervie Behavior ScalesC survey f N = 3,000 -Expand general population form -Classro edition
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From page 179... ...
survey form completion by -Communication Test-retest: (N = 484) -Expanded social worker -Daily living -Composite r= .88 form or educator -Motor -Domains r = .81 to .86 -Classroom -Socialization I nterrater: (N = 1 60)
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From page 180... ...
CThe Vineland Adaptive Behavior Scales are undergoing revision, and a new edition should be available within one to two years. mented by an individual's ability to initiate social contacts with others, communicate clearly with others, interact, and actively participate in group activities.
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From page 181... ...
The overall correspondence of several adaptive behavior measures to the content within the functional areas that are considered in ascertaining marked limitations is shown in Table 4-2. Each of the four adaptive behavior measures included in the table collects or assesses information regarding developmental status or performance in the areas of motor development, activities of daily living, communication, social functioning, and personal functioning.
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From page 184... ...
Table 4-3, adapted from Harrison and Oakland (2000b) , shows the percentage of adaptive behavior domain scores for a sample of children with mild mental retardation (N = 66)
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From page 185... ...
One-half of children with mild mental retardation (column 2) had a summary score falling in the marked limitation range (< 2 SDs)
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2. About three-quarters of children with mild mental retardation had two or more domain scores falling in the marked limitation range, compared with slightly less than one-third of the children without mental retardation (last row)
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These findings are generally consistent with other findings regarding service utilization, showing, for example, that people with mental retardation, regardless of age, are less likely than others in need to receive psychological services in the community mental health systems, including assessment services.
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From page 188... ...
Presumably, these findings reflect the importance of the schools as a setting in which the presence of mild mental retardation is frequently first identified and the use of adaptive behavior scales as a component of this practice. Nonetheless, available research on the clinical use of adaptive behavior scales for diagnosis and treatmentrelated purposes by either school psychologists or community clinical psychologists appears to be relatively sparse and does not focus on groups of people with mental retardation, as such (i.e., Clinger et al., 1988; McNamara et al., 1994; Pearson & Lachar, 1994; Roberts et al., 1993; Voelker et al., 1990; Wolber et al., 1997~.
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From page 189... ...
Clinical Considerations in the Selection and Use of Adaptive Behavior Scales In the committee's view, adaptive behavior is an essential component of the mental retardation diagnostic construct, and all agencies contemplating mental retardation diagnoses should give consideration to adaptive behavior. This consensus rests on the accumulated wisdom in the field of mental retardation, including the fact that adaptability in meeting the demands of everyday living was fundamental to conceptions of mental retardation long before effective tests of intellectual functioning were developed.
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From page 190... ...
For most people, the use of currently available adaptive behavior instruments along with other information on adaptive functioning will improve decisions about mental retardation classification. The decision on which standardized instrument to use must be informed by knowledge of the following characteristics of clients, respondents, and instruments.
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From page 191... ...
For example, the ABAS is organized into 9 or, depending on age, 10 adaptive skills areas, clearly reflecting the 1992 AAMR manual on classification (American Association on Mental Retardation, 1992) , which also iacntifieu 10 adaptive skills areas.
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From page 192... ...
Inventories or checklists that attempt to assess vocational interests, emotional status, and personality traits nearly always are typical performance measures. The adaptive behavior construct has both typical performance and maximum performance elements, a characteristic that complicates measurement operations.
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In addition to the usual considerations attendant on any measure of individuals, special considerations always exist with typical performance measures (Cronbach, 19901. Some Differences Among Typical Performance Measures Adaptive behavior measures differ regarding the use of typical or maximum performance methods.
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Many of the parents of children suspected of meeting criteria for mild mental retardation may themselves experience cognitive difficulties and are relatively nonverbal (Ramey et al., 1996) , making semi- or unstructured interviews much more difficult to conduct in a standardized manner.
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The social domain is particularly important to assess for individuals with mild mental retardation because prominent limitations that these individuals experience are often in the domain of interpersonal relationships, rather than in skill domains that are not predominantly social in nature (e.g., activities of daily living, motor skills)
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From page 196... ...
il Clearly, examiners need to be concerned about whether available nstruments and practices for assessing adaptive behavior adequately document critical difficulties in social functioning that prevent individuals with mild mental retardation from fulfilling key roles and expectations in society. At present, a variety of assessment instruments have been employed in research and clinical settings that attempt to capture these individuals' social limitations.
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From page 197... ...
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 socialcognitive processes can provide examiners with valuable supplemental information about the social functioning of individuals with mental retardation.
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From page 198... ...
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~.
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From page 199... ...
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; Tenkinson & Nelms, 1994; Smith, 19861. 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., 20001.
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From page 200... ...
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; Tenkinson & Nelms, 19941. 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.
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From page 201... ...
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.
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From page 202... ...
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?
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From page 203... ...
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)
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From page 204... ...
, 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.
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From page 205... ...
· 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.
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From page 206... ...
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.
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From page 207... ...
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.
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