6

Selected Instruments for Assessment of Mental Functional Abilities Relevant to Work Requirements

This chapter reviews instruments available for measuring mental abilities relevant to work requirements. The framework described in Chapter 2 (see Figure 2-3) provides a way to organize specific types of instruments for assessing mental function and helping determine an individual’s ability to perform specific work tasks. For example, computer-assisted testing can be used to assess mental abilities and provide information on an individual’s ability to complete work tasks. However, it is important to ensure that the assessment considers task sequencing and coordination, and the ability to do sustained work on a regular and continuing basis. The chapter also addresses functional assessment in people who have mental impairments.

The U.S. Social Security Administration’s (SSA’s) adult Listing of Impairments for mental disorders includes neurocognitive disorders such as dementia; schizophrenia spectrum and other psychotic disorders; depressive, bipolar, and related disorders; intellectual disorders; anxiety and obsessive-compulsive disorders; somatic symptom and related disorders; personality and impulse-control disorders; autism spectrum disorder; neurodevelopmental disorders; eating disorders; and trauma- and stressor-related disorders.¹ Community functioning and mental illness are closely associated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) definition of mental illness, in which “clinically significant distress or disability” is a key diagnostic criterion for all mental disorders. The definition of what are probably considered the most severe of the major mental illnesses, schizophrenia spectrum disorders, incorporates impairment and

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¹ This text has been revised since prepublication release.

its persistence in psychosocial functioning as part of establishing the diagnosis. In addition to the diagnosis requiring functional limitations, diagnostic symptoms—most notably disorganized speech or behavior and negative symptoms, such as diminished concentration, persistence, and pace; motivation; and goal-directed behavior—also have implications for functioning. And while the majority of individuals with a mental illness diagnosis do not experience significant functional impairment, most psychiatric symptoms, if severe and sufficiently persistent, can cause functional and occupational impairment. The symptoms of depression, for example—such as slowed thought and reduced physical movement that must be observable by others; diminished ability to think, concentrate, or make decisions; and fatigue or loss of energy—have obvious implications for functioning at work and socially and for independent self-care.

An additional important facet of the relationship between mental illness and functioning is that some major mental illnesses are episodic in nature, with the severity of symptoms and functional impairments varying over time, and with periods of greater severity ranging from weeks to months. This variability is particularly important in considering whether an individual can perform substantial gainful activity. For most people with schizophrenia spectrum disorders, for example, acute periods may require temporary hospitalization to prevent harm to self or others, but importantly, even in periods of greater symptom stability, the degree of psychosocial impairment can be significant. Many people do not return to premorbid levels of psychosocial functioning either ever or until many years later in the course of the illness. Mood disorders, such as major depression, are also episodic; in contrast to schizophrenia, however, a return to unimpaired functioning between episodes is possible, including for some people who function at high levels and make significant work contributions, while others display interepisode residual functional impairment. The key point is that it is important to assess the persistence of impairment due to mental disorders associated with episodic or persistent symptoms.

MENTAL FUNCTIONAL ABILITIES RELEVANT TO WORK REQUIREMENTS

Annex Table 6-1 links mental functional domains identified by the committee (defined in Annex Table 6-2) to specific work demands. The committee identified the following mental functional domains: general cognitive/intellectual ability, language and communication, learning and memory, attention and vigilance, processing speed, executive functioning,

adaptability, and work-related personal interactions.² These domains are adapted from the Report of the Mental Cognitive Subcommittee of the Occupational Information Development Advisory Panel (OIDAP, 2009), Psychological Testing in the Service of Disability Determination (IOM, 2015), and Informing Social Security’s Process for Financial Capability Determination (NASEM, 2016) and from the Paragraph B criteria in SSA’s adult Listing of Impairments for mental disorders (SSA, n.d.-a). Annex Table 6-1 links these eight mental functional domains to mental abilities listed in three SSA forms used to collect functional information when making a disability determination: the Psychiatric Review Technique Form (PRTF), the Function Report, and the Mental Residual Functional Capacity Assessment (MRFC). The functional domains identified by the committee are also linked to SSA’s Paragraph B criteria, to mental abilities in the Occupational Requirements Survey (ORS), and to work activities relevant to mental processes in Occupational Information Network (O*NET).

The functional domain of language and communication, for example, refers to “receptive and expressive language abilities” and “how well a person can understand spoken or written language, communicate his or her thoughts, and follow directions” (OIDAP, 2009, pp. C21 and C23).

In the PRTF, the language and communication domain links to language and interacting with others; the PRTF lists language under neurocognitive disorders.³ In the function report, this domain links to getting along with others, understanding, and completing tasks (SSA, 2015); the Function Report allows for self- and third-party reports. Links to this domain in the MRFC form include both social interaction and understanding and memory (SSA, n.d.-b). If the medical evidence provided shows that an individual has the ability to ask simple questions or request assistance, the claimant may not demonstrate a limitation under the category of social interaction (SSA, n.d.-b). For understanding and memory, the MRFC defines the ability to understand and remember through assessing short and simple instructions (SSA, n.d.-b). The ORS’s cognitive demand element most relevant to language and communication is work-related personal interactions, defined as “the requirement of the job to cooperate with others, handle conflict, and respond to social cues, requests, and criticism” (DOL, 2017, p. 64). O*NET’s cognitive abilities are “abilities that influence the acquisition and application of knowledge in

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² The domains of adaptability and work-related personal interactions are included in the cognitive demand elements in the July 2017 version of the Occupation Requirements Survey (ORS) Collection Manual. The cognitive elements were updated in an August 2018 version of the ORS Collection Manual, which became available following the committee’s work on this chapter. Annex Table 6-1 includes relevant cognitive elements from the 2018 ORS Collection Manual as well as those from the 2017 manual.

³ Form SSA-2506-BK (01-2017) UF, obtained via personal communication with Joanna Firmin, U.S. Social Security Administration, February 23, 2018.

problem solving” (O*NET, 2018a). Oral comprehension, oral expression, written comprehension, and written expression link to the language and communication domain. The relevant O*NET work activity that links to this domain is processing information, described as compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data (O*NET, 2018b). Thus, Annex Table 6-1 shows that a limitation in the functional domain of language and communication can limit specific job demands related to interacting with others, processing information, and completing tasks.

Finally, SSA uses the Listing of Impairments at step 3 of its process for determining whether a claimant qualifies for benefits (see Chapter 2). The claimant’s mental disorder must satisfy requirements listed in both paragraphs A and B (or C for listings with a paragraph C).⁴ Paragraph A includes the medical criteria that must be present in a claimant’s medical evidence. Paragraph B provides information on the functional criteria assessed to determine how a mental disorder limits functioning. Four criteria represent the areas of mental functioning a person uses in a work setting: understand, remember, or apply information; interact with others; concentrate, persist, or maintain pace; and adapt or manage oneself. The language and communication functional domain links to the criteria understand, remember, or apply information, which refer to the “abilities to learn, recall, and use information to perform work activities” (SSA, n.d.-a). Examples include understanding and learning terms, instructions, and procedures; following one- or two-step oral instructions to carry out a task; describing work activity to someone else; asking and answering questions and providing explanations; recognizing a mistake and correcting it; identifying and solving problems; sequencing multistep activities; and using reason and judgment to make work-related decisions. SSA does not require documentation of all of these examples.

With respect to the other functional criteria in the Listing of Impairments, interact with others refers to the “abilities to relate to and work with supervisors, co-workers, and the public” (SSA, n.d.-a). Examples listed include cooperating with others; asking for help when needed; handling conflicts with others; stating own point of view; initiating or sustaining conversation; understanding and responding to social cues (physical, verbal, emotional); responding to requests, suggestions, criticism, correction, and challenges; and keeping social interactions free of excessive irritability, sensitivity, argumentativeness, or suspiciousness. Again, SSA does not require documentation of all of these examples.

Concentrate, persist, or maintain pace refers to the “abilities to focus attention on work activities and stay on task at a sustained rate” (SSA, n.d.-a). Examples include initiating and performing a task that you understand and know how to do, working at an appropriate and consistent pace,

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⁴ This text has been revised since prepublication release.

completing tasks in a timely manner, ignoring or avoiding distractions while working, changing activities or work settings without being disruptive, working close to or with others without interrupting or distracting them, sustaining an ordinary routine and regular attendance at work, and working a full day without needing more than the allotted number or length of rest periods during the day. As with other Paragraph B criteria, SSA does not require documentation of all of these examples.

Adapt or manage oneself refers to the “abilities to regulate emotions, control behavior, and maintain well-being in a work setting” (SSA, n.d.-a). Examples listed include responding to demands, adapting to changes, managing psychologically based symptoms, distinguishing between acceptable and unacceptable work performance, setting realistic goals, making plans for oneself independently of others, maintaining personal hygiene and attire appropriate to a work setting, and being aware of normal hazards and taking appropriate precautions. Again, SSA does not require documentation for all of these examples.

INSTRUMENTS USED TO ASSESS MENTAL FUNCTIONAL ABILITIES RELEVANT TO WORK REQUIREMENTS

The committee applied the following criteria in deciding which instruments to describe in this chapter: (1) sufficient representation in the scientific literature and/or widespread use; (2) evidence of sound psychometric properties, including (when applicable) construct validity, internal consistency, sensitivity to change, test-retest reliability, intra-/interrater agreement (including subject/proxy and telephone/in-person administration); (3) normative data; (4) applicability across a range of conditions and functional levels; (5) availability in the public domain; (6) ease of administration; (7) brevity; (8) availability in multiple languages; (9) validation in subpopulations; (10) multiple administration formats (telephone interview versus in-person administration; self- versus proxy respondent); and (11) availability of alternative forms to minimize the risk of practice effects for performance measures. Some of the instruments discussed do not fulfill all of these criteria, but they are included because they illustrate the range of potential assessment instruments. Discussion of the instruments turns first to general assessment tools (see Annex Table 6-3), then to neuropsychological testing used to assess the mental functional domains described above (see Annex Table 6-4), and finally to measures of disorder severity and work-related functional impairment (see Annex Table 6-5). Annex Tables 6-3, 6-4, and 6-5 provide information on selected functional assessment tools for mental abilities, including qualifications to administer, how to administer, time to administer, psychometric properties, proprietary considerations, and the populations to which they apply.

General Assessment Tools

The instruments described below are used to assess mental function across multiple domains.

Work Disability Functional Assessment Battery (WD-FAB) Mental Health Measures

To support its disability determination process, SSA funded a contract to the National Institutes of Health (NIH) to develop the WD-FAB, a claimant-reported measure of mental health. Marfeo and colleagues (2018) developed four mental health measures assessing cognition and communication (68 items), self-regulation (34 items), resilience and sociability (29 items), and mood and emotions (34 items). To develop these measures, the authors collected data from a random, stratified sample of 1,695 SSA claimants and a general-population sample of 2,025 working-age adults (Marfeo et al., 2018). To expand the WD-FAB scales, 169 new items were developed, and responses were analyzed using factor analysis and item response theory (IRT) analysis to construct unidimensional scales (Marfeo et al., 2018). In addition, computer adaptive testing (CAT) simulations were conducted to examine the instrument’s psychometric properties. Results of confirmatory factor analysis revealed acceptable fit statistics across all mental health subdomains in both samples and for all scales (root mean square error of approximation ≤ 0.08, comparative fit index and Tucker-Lewis index ≥ 0.9) (Marfeo et al., 2018). Correlations between the CAT simulations and the full item bank exceeded 0.95. Differential item functioning related to age, sex, and race was minimal in both samples. The authors concluded that all four scales displayed acceptable psychometric properties. Further, results of a recent study of the psychometric properties of the WD-FAB demonstrated reliability and construct validity in a large group of working-age adults (N = 335), as well as in adults unable to work because of permanent physical (N = 375) or mental (N = 296) disability (Meterko et al., 2018). The WD-FAB is unique in its use of IRT and CAT.

World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

Validity and reliability have been demonstrated for WHODAS 2.0⁵ through extensive field testing in international, multicenter studies, and it has demonstrated robust factor structure for general disability and specific life domains (WHO, 2010). An IRT-based scoring method is used that

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⁵ Refer to Chapter 4 for a detailed description of WHODAS 2.0.

accounts for item difficulty and employs an algorithm (available from WHO) to determine a summary score that is converted into a metric rating from 0 (no disability) to 100 (full disability). Its advantages include public availability, brevity (20-minute administration), a simple scoring algorithm (items scored as 0 [none], 1 [mild], 2 [moderate], and 3 [extreme], with scores summed across items); multiple administration modalities (interviewer, self-, or proxy report), and telephone administration by an interviewer with basic skills. A 12-item, 5-minute version provides a brief assessment of global functioning that explains 81 percent of the variance of the 36-item version (WHO, 2010).

University of California, San Diego, Performance-Based Skills Assessment (UPSA)

Ratings of functional capacity are of increasing interest in studies of people with mental illness because they are highly correlated with cognition and some aspects of community functioning. In particular, the UPSA has shown some promise in being able to predict real-world functioning in middle-aged and older adults with schizophrenia (Mausbach et al., 2011) and mood disorders (Bowie et al., 2006; Mausbach et al., 2010). Specifically, the UPSA has demonstrated high correlations with measures of personal care skills, interpersonal skills, and community activities (Mausbach et al., 2010). It has high interrater and cross-temporal reliability, as well as demonstrated validity in assessing functional skills in healthy adults and the elderly. Disadvantages are that it is not strongly associated with employment and does not serve as a predictive factor for employment (Mausbach et al., 2011). Furthermore, it is not publicly available; it requires training to administer; and it is not validated in neurological disorders, including stroke and dementia.

Occupational Functioning Scale (OFS)

The OFS is an observer rating scale of work ability in people with mental health disorders. Its validity was established by comparison with other work ability measures (e.g., SAS-Work, Work Ability Index, sickness absence) and other measures not related to work ability, such as the SCL-90-GSI and Inventory of Interpersonal Problems (Hannula et al., 2006). Acceptable interrater reliability was demonstrated (intraclass correlation coefficient [ICC] = 0.91), as was validity, with the strongest relationships found with other measures of work compared with symptoms or interpersonal problems (Hannula et al., 2006).

Global Assessment of Functioning (GAF) Scale

The GAF is a scoring system for the severity of illness. The rating on the scale is derived from a clinician’s judgment of a person’s ability to function in daily life based on a composite of psychological symptoms and social and occupational functioning. It does not take into account impairment in function caused by physical or environmental limitations. Ratings range from 0 to 100, with the lowest score consistent with the worst area. The GAF has limited reliability and predictive validity because the domains assessed do not vary together. Problems with predictive utility arise from the tendency of clinicians to overweigh symptoms. Because the GAF is an unstandardized, unreliable rating of disability, SSA no longer uses it in the assessment of disability claims, and it is considered only to the extent that it is consistent with other evidence. Prior to DSM-5, the GAF was endorsed as an assessment of functioning and reported on the fifth axis of a multiaxial system. DSM-5 no longer maintains a multiaxial system and eliminated the use of the GAF “for several reasons, among which were its lack of conceptual clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice” (APA, 2013, p. 16). These limitations motivated efforts to develop alternative ways of measuring social and occupational functioning separate from psychological symptoms, but inclusive of physical impairment.

Social and Occupational Functioning Assessment Scale (SOFAS)

SOFAS is derived from the GAF (DSM Axis V) (Morosini et al., 2000). It focuses on social and occupational functioning without the influence of psychological symptoms. The influence of general medical conditions is considered in SOFAS ratings if impairment is due to the consequences of physical and/or mental health problems; not considered is the lack of opportunity or environmental limitations. The SOFAS describes functioning during the current period or a specified period of time, such as the highest level of functioning in the past 12 months. Its ratings are based on a scale of 100–0, reflecting a range from excellent to grossly impaired functioning: 100 = superior functioning in a range of activities; 60 = moderate difficulty in social and occupational or school functioning (few friends, conflict with peers and co-workers); 50 = serious impairment in social and occupational or school functioning (no friends, unable to keep job); 40 = major impairment in several areas, such as work or school and family relations (e.g., depressed individual avoids friends, neglects family, and is unable to work); and 0 = unable to rate because of inadequate information. As with the GAF, evidence of reliability and validity is limited by the confounding of ratings that include both social and occupational functioning.

Mental Illness Research, Education and Clinical Center (MIRECC) GAF Social and Occupational Functioning Scales

The MIRECC GAF was developed by the U.S. Veterans Health Administration (VHA) to facilitate clinicians’ GAF ratings, which are required every 90 days for patients receiving mental health services (Niv et al., 2007). The MIRECC version of the GAF provides separate ratings of occupational, social, and psychological functioning. It is similar to the GAF in providing scores ranging from 100 to 0, with the following clinical ranges: 70–100 = “fully functional” (e.g., works consistently, socially effective with minimal symptoms); 50–69 = “borderline functional” (e.g., misses work frequently, interpersonal conflicts, mild to moderate symptoms such as moderate depression); 20–49 = “dysfunctional” (e.g., some sheltered work, difficulty with coherent conversation, impairment in reality testing); and 10–19 = “dangerous” (e.g., unable to self-care or interact with others; dangerous to self or others and grossly impaired communication) (Niv et al., 2007). A large (N = 398) multisite study, Enhancing Quality of Care in Psychosis, conducted at three VHA sites, demonstrated adequate concurrent and predictive validity for the MIRECC GAF’s three subscales, superior to the concurrent and predictive validity of the GAF (Niv et al., 2007). The strongest convergent validity was in occupational scores, which were strongly correlated with employment in the past month and work status.

Specific Level of Functioning Scale (SLOF)

The SLOF, a multidimensional behavioral rating scale developed in the early 1980s (Schneider and Struening, 1983), is designed to measure directly observable functioning and daily living skills. It consists of 43 behavioral items measured on a 5-point Likert scale and six subscales: physical functioning (e.g., vision, hearing), personal care skills (eating, personal hygiene), interpersonal relationships (interacts with others), social acceptability (acts within bounds of social norms), activities of community living (household responsibilities), and work skills (completes assigned tasks), as well as an “other” item addressing areas of functioning not included on the instrument. Scores range from 43 to 215, with lower scores indicating better functioning. The SLOF requires 15–20 minutes to complete.

The SLOF has separate scales for self- and collateral ratings; the collateral rating scale includes a question about how well the reporter knows the person, rated on a scale from 1 to 5. In a study involving 173 outpatients with schizophrenia, the ICC for the combined scales was r = 0.62, and for individual scale items, the ICC range was 0.38–0.80. The same study also measured the ICC of the SLOF in 982 inpatients with schizophrenia; the ICC for the combined scales was r = 0.42, and for individual scale items,

the ICC range was 0.13–0.72 (Schneider and Struening, 1983), indicating better correlations among scale items in outpatients versus inpatients with schizophrenia. In a study of 221 community-dwelling and nursing home patients, the ICC range was 0.74–0.85. The convergent validity of the SLOF was assessed with the UPSA measure of functional capacity and found to be highest in 78 community-dwelling people with schizophrenia for community activities (r = 0.61, p < 0.01), but also significant for interpersonal skills (r = 0.34, p < 0.01) and work skills (r = 0.54, p < 0.01). In addition, the SLOF was significantly correlated with cognitive functioning as measured by tests of problem solving, inhibition, information processing speed, object recognition, attention, and praxis, as follows: interpersonal skills, r = 0.23, p < 0.05; community activities, r = 0.50, p < 0.01; and work skills, r = 0.41, p < 0.01 (Bowie et al., 2006). The SLOF was also found to be significantly correlated with symptom measures, including the Positive and Negative Symptom Scale (r = 0.5, p < 0.0001) (Cramer et al., 2000). Significant interrater reliability was demonstrated in one study in schizophrenia using self-ratings from 67 patients and ratings from their case managers (overall r = 0.28, p < 0.01) (Bowie et al., 2007). Some sensitivity to functional change in the context of treatment was demonstrated in 60 people with schizophrenia in residential treatment and enrolled in an Assertive Community Treatment program. Ratings were obtained at baseline and 1 year later: t = 4.024; df = 29, p = 0.0004 (Chandler et al., 1999). In comparison with the “gold standard” Personal and Social Performance scale, the SLOF was found to be valid and reliable in a large sample of Italian people with serious psychiatric disorders (Mucci et al., 2014). In a study of people with schizophrenia and schizoaffective disorder, significant relationships were found between poorer cognition and overestimation of work function, as well as between higher depression levels and underestimation of interpersonal function (Ermel et al., 2017). Overall, the SLOF had significantly stronger correlations with interpersonal and work function compared with the other areas of function.

Neuropsychological Testing⁶

Neuropsychological testing provides valuable information regarding functional capacity in the domain of cognitive functioning. Relevant to SSA’s considerations, cognitive functioning includes intellectual capacity,

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⁶ Neuropsychology is a subspecialty of psychology with defined training. A clinical neuropsychologist is “a professional psychologist trained in the science of brain-behavior relationships [and] specializes in the application of assessment and intervention principles based on the scientific study of human behavior across the lifespan as it relates to normal and abnormal functioning of the central nervous system” (Bieliauskas, 1998, p. 161).

attention and concentration, processing speed, language and communication, visual-spatial abilities, and memory (IOM, 2015). Most tests of cognitive functioning require the test taker to complete timed tasks in a controlled testing environment. Neuropsychologists interpret results relative to population norms and in terms of the test taker’s pattern of relative strengths and weaknesses across cognitive domains. Neuropsychological testing allows SSA to evaluate the severity of cognitive impairments and claimants’ residual functional capacity.

A wide variety of performance-based neuropsychological tests can be used to assess a claimant’s level of cognitive functioning. Numerous performance and symptom validity measures are in use that can assist professionals in interpreting the validity of psychological test results (IOM, 2015). Described below are several commonly used tests within domains of cognitive functioning that are relevant to the mental listings’ Paragraph B criteria. (See Lezak et al. [2012] and Strauss et al. [2006] for a comprehensive perspective on performance-based cognitive tests.)

General Cognitive/Intellectual Ability

General cognitive/intellectual ability encompasses reasoning, problem solving, and meeting cognitive demands from basic to high levels of complexity. The most widely used test of cognitive/intellectual functioning is the Wechsler Adult Intelligence Scale, fourth edition (WAIS-IV) (Wechsler, 2008).

Montreal Cognitive Assessment (MoCA) The MoCA is a 30-item screener used to detect cognitive impairment. It assesses orientation (time and place), attention (target detection using tapping, digit span forward), working memory (serial subtraction, digit span backward), verbal short-term memory (two acquisition trials of five nouns with a 5-minute delayed-recall trial), executive functioning (shortened, adapted version of Trail Making Test B), and language (phonemic fluency, confrontation naming, and complex sentence repetition) (Nasreddine et al., 2005). In a validation trial, the MoCA has demonstrated high sensitivity and specificity (approximately 0.9) for detection of mild cognitive impairment⁷ (cutoff score of 22; behavioral correlates of mild cognitive impairment include complaints about memory and memory deficits without notable functional impairment) and dementia (cutoff score of 16; behavioral correlates of dementia include notable cognitive and functional impairment) (Nasreddine et al., 2005), as well

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⁷ Mild cognitive impairment is “an intermediate clinical state between normal cognitive aging and dementia, and it precedes and leads to dementia in many cases” (Nasreddine at al., 2005, p. 695).

as acceptable reliability (internal consistency [Cronbach’s alpha = 0.83]). Using these cutoffs, sensitivity and specificity were consistently higher for the MoCA than for the Mini-Mental State Exam (MMSE). The MoCA requires in-person administration because it includes performance-based tasks. Advantages include a 10-minute administration time; public availability; translation to more than 40 languages; a large peer-reviewed literature; and evidence of ability to detect early cognitive changes in a range of neurological disorders, including Parkinson’s disease (Hu et al., 2014). Disadvantages include limited validation and a lack of precise cutoff scores for non-English versions.

Short Orientation-Memory-Concentration Test of Cognitive Impairment (OMCT) The OMCT is a 6-item brief version of the 26-item Blessed test, designed to assess the cognitive domains of orientation, attention, and working memory (Katzman et al., 1983). The total score is 28; up to six errors are within normal limits, with scores of 20 and below indicating cognitive impairment. Performance scores discriminate among mild, moderate, and severe cognitive deficits. A discriminant analysis in elderly patients indicated that orientation and easier attention items distinguished those with severe levels of impairment from those with no impairment. The more difficult working memory items differentiated mild from no cognitive impairment, although a subgroup of elderly adults living independently in the community made errors on these items. The sensitivity and specificity of the OMCT are high (about 90 percent) for determining the presence of Alzheimer’s disease. A postmortem study demonstrated a positive correlation between scores on the OMCT and plaque counts obtained from the cerebral cortex of 38 subjects (Katzman et al., 1983). The OMCT was equivalent to the MMSE in identifying the presence of dementia in a study comparing unimpaired patients with those with vascular or degenerative dementia. In patients with Alzheimer’s disease, performance on the OMCT was equivalent to mean values of a simple reaction time, and was correlated with Wechsler global memory quotient and orientation, logical memory, and paired associate items of the scale. Performance scores were reliable a month later, with no evidence of practice effects (Davous et al., 1987). The advantages of the OMCT are similar to those of the MoCA in that it is brief (5–10 minutes administration time), is easy to score, requires no third-party input or special equipment or training, and has high sensitivity and specificity in persons with mild cognitive impairments and dementia. Its disadvantages reflect (1) bias due to education such that OMCT scores are related to years of education and (2) low specificity with elderly black community residents (Fillenbaum et al., 1990). The OMCT is not widely used despite its advantages.

Brief Assessment of Cognition (BAC) The BAC is a neuropsychological battery assessing verbal learning (List Learning), working memory (Digit Sequencing Test), verbal fluency (Category Instances and Controlled Word Association Test), information processing speed (Symbol Coding), motor speed (Token Motor Task), and problem solving (Tower of London) (Keefe et al., 2004). These cognitive domains often are impaired in individuals with schizophrenia and other severe mental illnesses and are correlated highly with community functioning (Keefe et al., 2006). The BAC predicted work outcomes in approximately 900 subjects with schizophrenia, schizoaffective disorders, and mood disorders as part of the Mental Health Treatment Study (McGurk et al., 2018). It was sufficiently sensitive to detect minimal cognitive impairment (low to average range) in a group of Social Security Disability Insurance (SSDI) recipients, with verbal learning being the strongest predictor of work functioning of any cognitive domain or demographic characteristic assessed. The BAC demonstrates evidence of concurrent and predictive validity, test-retest reliability (ICC = 0.79 or greater), and interrater reliability (ICC = 0.89), with established norms for adults with mental illness and normal-functioning adults of all ages (Keefe et al., 2008). Its advantages include standardized administration requiring relatively minimal training, comprehensive cognitive assessment, brief administration time (30 minutes), being well researched with a high uptake in clinical trials and community settings, versions translated into more than eight languages, and significant use in national and international studies. Recently, test developers released a tablet administration version, the BAC App (Atkins et al., 2017). Disadvantages of the BAC are its proprietary nature; limited evidence of cross-cultural validity; and limited use in samples of neurological disorders, including acquired brain injury and dementia.

Cognitive Capacity Screening Examination (CCSE) The CCSE is a motor-free, 30-item mental status screener designed to detect cognitive limitations in individuals not receiving mental health services (Jacobs et al., 1977). A score of less than 20 indicates cognitive impairment. The CCSE assesses orientation, thought content, attention, language ability, general knowledge, short-term memory, abstraction, and judgment (Foreman, 1987; Jacobs et al., 1977). Its reliability, sensitivity, specificity, and convergent validity have been established (Foreman, 1987; Kaufman et al., 1979; Spitzer et al., 1980).

Language and Communication

Language and communication functioning includes receptive and expressive language skills in both spoken and written modalities. The mental listings’ Paragraph B criterion understand, remember, or apply information

(see Annex Table 6-1) requires consideration of language and communication skills as these skills are crucial to effective performance in all jobs. The mental functions associated with language include decoding messages; expressing ideas; and organizing semantic and symbolic meaning, structuring grammar, and producing messages. A variety of tests can be used to assess language abilities, including the Boston Naming Test, Controlled Oral Word Association, and Boston Diagnostic Aphasia Examination (Goodglass and Kaplan, 1983; Kaplan et al., 2001; Spreen and Strauss, 1991).

The NIH Toolbox provides a comprehensive set of performance assessments that allow quick assessment of cognitive, emotional, sensory, and motor functions using a tablet computer (NU, 2018b). The Toolbox includes 100 stand-alone measures and takes 30 minutes to assess cognitive, emotional, sensory, and motor function. It was developed and validated using state-of-the-science methods to enhance its psychometric properties. The Toolbox is normed on a nationally representative sample to enable cross-measure comparisons. It was designed to enable measuring outcomes in longitudinal studies, and is available in English, Spanish, and other languages. The cognition battery assesses the mental processes required to learn, thinking, knowing, remembering, judging, and problem solving (Weintraub et al., 2013). It assesses higher-level functions including language, imagination, perceptions, and the planning and execution of complex behaviors. Highlighted below are tests relevant to SSA’s mental functional domains.

NIH Toolbox: Picture Vocabulary This test measures receptive vocabulary (Gershon et al., 2014), with respondents selecting the picture that most closely matches the meaning of a word displayed on a video screen using a multiple-choice option. Carlozzi and colleagues (2017) established its construct validity in a poststroke sample. The average time for its completion is 4 minutes. It is administered using a tablet computer with proprietary software that requires an annual license.

NIH Toolbox: Oral Reading Recognition This test measures reading decoding skills and crystallized cognitive abilities (Gershon et al., 2014). Respondents read aloud and pronounce letters and words as accurately as possible. The average time for completion is 3 minutes.

Learning and Memory

Learning and memory abilities include registering and storing new information and retrieving information. This domain links to the Paragraph B criterion understand, remember, or apply information. Memory functions include short- and long-term memory; immediate, recent, and remote

memory; memory span; and retrieval of memories. Commonly used tests of learning and memory include the Wechsler Memory Scale (Wechsler, 2009), the Wide Range Assessment of Memory and Learning (Sheslow and Adams, 2003), and the California Verbal Learning Test (Delis et al., 2000; Sheslow and Adams, 2003; Wechsler, 2009).

NIH Toolbox: Picture Sequence Memory Test This test measures episodic memory (Dikmen et al., 2014; Loring et al., 2019). Respondents reproduce a sequence of pictures that are displayed on a video screen. Practice sequences and test items are available for respondents 8 years of age and older. Typical time to complete the test is 7 minutes.

NIH Toolbox: List Sorting Working Memory Test This test measures working memory (Tulsky et al., 2013, 2014). Respondents recall and sequence stimuli they hear read aloud and presented on a video screen. Average time for completion is 7 minutes.

NIH Toolbox: Auditory Verbal Test (Rey) This test measures immediate recall (Weintraub et al., 2013). Respondents listen to words presented via audio recording and recall as many as possible. Respondents with visual limitations that preclude reading may complete the Picture Sequence Memory Test. Average time for completion is 3 minutes.

Attention and Vigilance

Attention and vigilance tests measure the ability to maintain attentional focus despite typical distractions. As shown in Annex Table 6-1, attention and vigilance link to the Paragraph B criterion concentrate, persist, or maintain pace. Commonly used tests include the WAIS-IV working memory index, the Paced Auditory Serial Addition Test, and the Continuous Performance Test (Conners and Multi-Health Systems Staff, 2000; Gronwall, 1977; Wechsler, 2009).

NIH Toolbox: Flanker Inhibitory Control and Attention Test This test measures attention and inhibitory control (Akshoomoff et al., 2014; Zelazo et al., 2013). Respondents focus on a visual stimulus displayed on a video screen while inhibiting attention to stimuli flanking it. Average time for completion is 3 minutes.

Processing Speed

Processing speed reflects how long it takes a person to answer questions and process information. This domain links to the Paragraph B criterion

concentrate, persist, or maintain pace. Tests of processing speed include the WAIS-IV processing speed index and the Trail Making Test Part A (Reitan and Wolfson, 1993; Wechsler, 2008).

NIH Toolbox: Pattern Comparison Processing Speed Test This test measures speed of processing (Carlozzi et al., 2015). Respondents discern whether a sequence of two simple pictures presented side by side are the same or different in 85 seconds. Average time for completion is 4 minutes.

NIH Toolbox: Oral Symbol Digit Test This test also measures speed of processing (Denboer et al., 2014). Respondents view symbol–number pairs on a video screen. They are then asked to press a number on a keyboard to indicate the number that is associated with a symbol. A Pattern Comparison Processing Speed Test is available for respondents whose motor skills preclude key pressing.

Executive Functioning

Executive functioning reflects complex cognitive abilities, including planning, prioritizing, organizing, decision making, task switching, responding to feedback, correcting errors, inhibiting behavior, and mental flexibility. Tests that assess aspects of executive functioning include the Trail Making Test Part B, the Wisconsin Card Sorting Test, and the Delis-Kaplan Executive Function System (Delis et al., 2001; Heaton, 1993; Reitan, 1992).

The standard error of IRT-delivered measures provides clues to exaggeration of symptoms or attempts to “fake bad.” A large standard error suggests that test scores may not be valid. The NIH Toolbox application produces standard errors for most measures. Tests built on IRT help identify people who answer difficult items correctly but then fail easier items. Standard errors are likely to be inflated when test takers “fake bad” in an inconsistent manner.

NIH Toolbox: Flanker Inhibitory Control and Attention Test This test measures attention and inhibitory control (Weintraub et al., 2013; Zelazo et al., 2013). Respondents focus on a visual stimulus displayed on a video screen while inhibiting attention to stimuli flanking it. Average time for completion is 3 minutes.

NIH Toolbox: Dimensional Change Card Sort Test This test measures cognitive flexibility and attention (Weintraub et al., 2013; Zelazo et al., 2013). Respondents view pictures that vary in two dimensions, such as shape and color. A word displayed on the video screen cues them as to

which dimension they should use to sort stimuli. Average time for completion is 4 minutes.

Adaptability and Work-Related Personal Interactions

Adaptability “measures characteristics of an occupation that cause a worker to adjust to changes in work routines” (DOL, 2017, p. 61) and links to the Paragraph B criterion adapt or manage oneself. Work-related personal interactions include cooperating with others; handling conflict; and responding to social cues, requests, and criticism (DOL, 2017, p. 64). This domain links to the Paragraph B criterion interact with others.

WD-FAB Behavioral Health: Social Interactions Scale This scale is grounded in a theoretic framework intended to distinguish five domains of behavioral health functioning: behavioral control, temperament and personality, adaptability, basic interactions, and workplace behaviors (Marfeo et al., 2013a,c). Four domains (self-efficacy, mood and emotions, behavioral control, and social interactions) are supported empirically (Marfeo et al., 2013b,c, 2014). The four item banks demonstrate strong reliability, accuracy, and breadth of coverage, as well as large correlations between simulated 5- or 10-item CATs and the full item bank. The six items making up the social interaction factors demonstrate excellent goodness-of-fit indices in unidimensional confirmatory factor analyses (Marfeo et al., 2013b). The correlation between a four-item CAT and all six items was 0.99 in a sample of 1,015 SSDI claimants and a comparative sample of 1,000 adults in the United States (Marfeo et al., 2013b). Administration requires less than 2 minutes.

Personal and Social Performance Scale (PSP) The PSP was derived from the SOFAS to measure social functioning. It assesses four domains: socially useful activities (e.g., work and school), personal and social relationships, self-care, and disturbing and aggressive behavior (Sivec et al., 2017). Its validity and reliability have been demonstrated in outpatients diagnosed with schizophrenia (Kawata and Revicki, 2008).

Measures of Disorder Severity and Work-Related Functional Impairment

Psychiatric disorders are generally defined by the presence of specific symptoms. Clinical care is built around psychiatric diagnosis; therefore, it is important to consider the possible link between diagnosis and work-related functional impairment. This link would be at least partially mediated by the severity of symptoms related to the specific diagnosis. As already noted, for some psychiatric diagnoses, such as schizophrenia, impairment

specifically refers to a significantly reduced capacity to participate in social relationships; care for oneself; or meet basic role obligations such as those of a worker, student, or parent. Impairment sustained for a minimum of 6 months is required for the diagnosis. Although not part of the diagnostic criteria for schizophrenia, the disorder is characterized by a decline in premorbid cognitive functioning, such that cognitive levels of individuals with schizophrenia are typically below those of the general population and of other psychiatric populations, such as individuals with bipolar disorder and major depression, which can also have a very serious course (Rosenheck et al., 2006). The level of psychosocial impairment in schizophrenia is also generally lower than that of individuals with other psychiatric disorders, including those having conditions that result in significant disability, such as bipolar disorder and major depression. Despite the fact that on average, schizophrenia is the most severe of the mental illnesses, the degree of impairment can be highly variable across different areas of functioning, as well as across people with the disorder, some of whom are capable of working part- or full-time. A number of reports suggest that the employment rate among individuals diagnosed with schizophrenia ranges from 10 to 20 percent for those not receiving supported employment services (Rosenheck et al., 2006). It should be noted that better symptom and functional outcomes are often associated with the receipt of evidence-based pharmacological and psychosocial treatments, but for others, it is important to consider the possibility of significant work-related functional impairment.

This section examines whether there are symptom assessments related to some common psychiatric diagnoses that have been found to be associated with work-related functional impairment. One such diagnosis is major depression, measures for which are discussed in Chapter 7. Disorders addressed below are anxiety disorders (see Desk Reference to the Diagnostic Criteria from DSM-V, e.g., agoraphobia [pp. 121–122]; generalized anxiety disorder [GAD] [pp. 122–123]), obsessive-compulsive and related disorders (obsessive-compulsive disorder [OCD] [pp. 129–130]), trauma-related disorders (posttraumatic stress disorder [PTSD] [pp. 143–149]); and autism spectrum disorder [ASD] [APA, 2014]).

Anxiety Disorder

In a review of functional outcomes and anxiety symptoms, McKnight and colleagues (2016) identified 83 articles examining the relationship between common anxiety-related disorders and functional impairment, including occupational impairment. Of these articles, 40 consider PTSD, 17 OCD, 13 social anxiety disorder, 9 GAD, 6 panic disorder, and 7 agoraphobia. The review produced a total of 497 correlations between individual disorders and functional impairment. The authors found that these

anxiety-related disorders were only modestly correlated with functional outcomes (social, occupational, and physical functioning). An important question is whether any specific measures used for these disorders are useful in estimating the extent of occupational impairment. The following discussion focuses on OCD and PTSD measures, as measures of other anxiety-related disorders showed weak correlations with occupational impairment.

Obsessive-Compulsive Disorder

The intrusive thoughts and compulsive behaviors found in OCD can adversely affect work performance and functioning. Mancebo and colleagues (2008) evaluated the relationship between OCD severity and functional outcomes in 238 individuals with OCD from the Brown Longitudinal OCD Study. They found that OCD severity as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was the greatest predictor of occupational disability. Specifically, occupational disability rose 2.26 times for each standard deviation score increase (5.83) on the Y-BOCS (Mancebo et al., 2008). Eisen and colleagues (2006) recruited and interviewed 197 individuals who were part of a larger-scale OCD study to evaluate functional impairment and quality of life among individuals with this disorder. They found that higher scores on the Y-BOCS were related to poorer quality-of-life measures. Specifically, a score of 20 or higher on the Y-BOCS “appeared to be an inflection point” at which impairment became significantly more pronounced. Poor work outcomes were associated with greater severity of compulsions.

Posttraumatic Stress Disorder

PTSD can reduce work functioning through limitations in the ability to sustain attention on tasks, get along with peers, and leave the safety of one’s home. These effects can be worse if the trauma occurred in the workplace. Smith and colleagues (2005) conducted a study evaluating the relationship of symptom severity on the PTSD Checklist (PCL) and Clinician-Administered PTSD Scale (CAPS) with unemployment among 325 adult male Vietnam War veterans with PTSD participating in a randomized controlled trial of two different therapies for this disorder. They found that PCL and CAPS scores were 8 to 13 percent higher for individuals who were unemployed than for employed individuals. A score increase of 10 points on the CAPS was associated with a 5.9 percent increase in the probability of an individual’s not working. The mean score for workers on the CAPS was 76.62 (standard deviation [SD] = 18.78), compared with 84.09 (SD = 17.74) for nonworkers (Smith et al., 2005). On the CAPS subscale for reexperiencing symptoms, workers had a mean score of 20.48 (SD = 7.02),

compared with 23.2 (SD = 6.92) for nonworkers (Smith et al., 2005). On the avoidance scale, the mean score for workers was 31.72 (SD = 9.58) and for nonworkers was 34.27 (SD = 8.81). On the hyperarousal scale, workers had a mean score of 24.42 (SD = 6.07), compared with 26.62 (SD = 5.97) for nonworkers. Similarly, the mean scores on the PCL differed for workers (58.76, SD = 12.73) and nonworkers (64.03, SD = 10.66) (Smith et al., 2005). Taylor and colleagues (2006) found associations between specific PTSD symptoms and work disability (inability to work due to disability from PTSD). Hyperarousal and reexperiencing symptoms as reported via the CAPS were the symptoms most highly correlated with collecting benefits as the result of an inability to work because of PTSD.

Autism Spectrum Disorder

With respect to ASD, its distinguishing diagnostic features include impairments in social communication and social interaction across multiple contexts, coupled with restricted, repetitive patterns of behavior, interests, or activities that result in significant difficulties with current social, occupational, or community functioning (APA, 2013). Several studies have documented worse employment-related outcomes for adults with autism compared with adults with other types of mental or developmental impairments and matched on general measures of health and socioeconomic status. For instance, Roux and colleagues (2013) examined whether young adults had ever worked for pay since high school, whether they were currently employed, and whether their employment status was full-time. They compared youth with autism with four other groups: youth with an intellectual disability, youth with severe mental illness, youth with learning disabilities, and youth with language impairment. Covariates included measures of sex, age, ethnicity, household income, overall health, conversation ability, and a scale of functional skills. The adjusted odds were significant for 10 of the 12 comparisons. Youth with autism had worse outcomes on every measure for every comparison.

Few studies have examined the link between the severity of ASD’s distinguishing features and the ability to work, the likelihood of employment, or work performance. Most extant studies of these employment-related outcomes among people on the autism spectrum exclude validated measures of these core autistic features and instead focus on such factors as IQ and verbal ability (which is not synonymous with social communication).

A few recent studies have begun to examine the linkages between distinctly autistic impairments and employment-related outcomes, with mixed results. For example, a nationally representative study of postsecondary outcomes among young adults with autism who had formerly received special education services examined the association between parent-rated

conversation ability and whether youth had ever had any paid employment since high school. Among youth with “no trouble” conversing, 72 percent (95% confidence interval [CI]: 52.3–86.2) had ever held a job, compared with 17 percent (95% CI: 7.1–36.0) of youth who could not converse at all (Shattuck et al., 2012). On the other hand, a 10-year longitudinal study of 161 adults with autism aged 18.4 to 52.1 years at baseline examined the association between severity of autism symptoms (as measured by the Autism Diagnostic Interview-Revised) and changes over time in an ordinal vocational outcomes index. Vocational outcomes were worse for those with an intellectual disability and better for those with higher levels of independence in activities of daily living. However, there was no significant association between autistic impairments and vocational outcomes (Taylor and Mailick, 2014).

The committee found no studies examining how autistic strengths might affect employment-related outcomes, despite influential review articles suggesting this as an area for future inquiry (Scott et al., 2018).

FINDINGS AND CONCLUSIONS

Findings

6-1. It is important to assess the persistence of impairment due to mental disorders, given the possibility of episodic or persistent symptoms.

6-2. When assessing mental functional abilities relevant to work requirements, it is important to assess the following domains: general cognitive/intellectual ability, language and communication, learning and memory, attention and vigilance, processing speed, executive functioning, adaptability, and work-related personal interactions.

6-3. The Work Disability Functional Assessment Battery (WD-FAB) is unique in its use of item response theory and computer adaptive testing.

6-4. The Mental Illness Research, Education, and Clinical Center (MIRECC) Global Assessment of Functioning (GAF) provides separate scores for symptoms, social functioning simulations, and occupational functioning, and has demonstrated the strongest convergent validity in occupational scores, which were strongly correlated with employment in the past month and work status.

6-5. While the Social and Occupational Functioning Assessment Scale (SOFAS) advances measurement by separating the original GAF into one scale for symptoms and another for social and occupational functioning, SOFAS scores confound work and social functioning.

6-6. The Specific Level of Functioning Scale demonstrated significantly strong correlations with interpersonal and work function compared with the other areas of function.

6-7. The Brief Assessment of Cognition demonstrates evidence of predictive validity for work outcomes in persons with schizophrenia, schizoaffective disorders, and mood disorders.

6-8. The Yale-Brown Obsessive Compulsive Scale demonstrates evidence of predictive validity for occupational disability in persons with obsessive-compulsive disorder (OCD).

6-9. The National Institutes of Health Toolbox provides a comprehensive set of performance assessments that allow quick assessment of cognitive, emotional, sensory, and motor functions using a tablet computer.

6-10. Anxiety disorders are only modestly correlated with functional outcomes (social, occupational, and physical functioning).

6-11. The intrusive thoughts and compulsive behaviors found in OCD can adversely affect work performance and functioning.

6-12. Posttraumatic stress disorder can reduce work functioning through limitations in the ability to sustain attention on tasks, get along with peers, and leave the safety of one’s home.

6-13. Symptoms associated with depression, including fatigue, difficulty concentrating, and slowed response speed, can impair work functioning.

6-14. On average, young adults with autism have worse employment outcomes relative to youth with other types of impairments, after adjusting for a range of covariates.

6-15. Results of cognitive testing are likely to be less stable for individuals whose mental disorders are characterized by an intermittent or fluctuating course than for those with stable conditions.

Conclusions

6-1. There are no conclusive studies examining the association between the severity of impairments specific to autism and abilities relevant to work.

6-2. Understanding the relationship between mental illness and functioning is important because some major mental illnesses are episodic in nature, with severity of symptoms and functional impairments varying over time, and with periods of greater severity ranging from weeks to months.

6-3. There is no single measure that captures all important aspects of mental abilities needed for work, although the WD-FAB, as a self-report battery of relevant questions, shows promise. More development

work is needed for the WD-FAB to fulfill its promise for use in disability determination.

6-4. It is important to perform more frequent assessments of disability applicants with mental disorders that are characterized by an intermittent or fluctuating course.

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ANNEX TABLE 6-1
Mental Functional Domains Relevant to Work Requirements

^aThis text has been revised since prepublication release.

^bThe domains of “adaptability” and “work-related personal interactions” are included in the cognitive demand elements in the July 2017 version of the Occupation Requirements Survey (ORS) Collection Manual. The table was updated to include both the 2017 elements and the revised elements from the August 2018 version of the ORS Collection Manual.

ANNEX TABLE 6-2
Definitions of Mental Functional Domains

^aThe domains of “adaptability” and “work-related personal interactions” are included in the cognitive demand elements in the July 2017 version of the Occupation Requirements Survey (ORS) Collection Manual. The cognitive elements were updated in an August 2018 version of the ORS Collection Manual, which became available following the committee’s work on this chapter.

SOURCES: DOL, 2017; OIDAP, 2009.

CHAPTER 6 ANNEX TABLES CONTINUE ON THE NEXT PAGE

ANNEX TABLE 6-3
Selected General Assessments for Mental Function

ANNEX TABLE 6-4
Selected Psychological Assessments

ANNEX TABLE 6-5
Selected Measures of Disorder Severity and Work-Related Functional Impairment

NOTE: α = Cronbach’s alpha.

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