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Functional assessment procedures for individuals with severe cognitive disorders.

The Center for Applied Neuropsychology has had the opportunity to develop a model of performing functional assessment and training staff through a number of demonstration and training projects. The initial project was a 1-year grant funded by the Pittsburgh District of the Pennsylvania Office of Vocational Rehabilitation, which served as a pilot project for functional assessment procedures, report style, and collaboration with referring state vocational rehabilitation (VR) agency counselors. Three additional projects have been funded by the Rehabilitation Services Administration (RSA): a 3-year special project grant in functional assessment and two national training grants. This article discusses the unique rehabilitation needs of persons with cognitive disabilities, describes the process of functional assessment developed through these pilot programs, and presents the implications for rehabilitation practice.

The Challenge of Cognitive Disabilities

Persons with severe cognitive disabilities resulting from traumatic brain injuries (TBI), specific learning disabilities (SLD), attention deficit-hyperactivity disorder (ADHD), and other neurologically based disorders present a difficult challenge to vocational rehabilitation. Due to the multiple disabling conditions (cognitive, physical, behavioral, emotional) that individuals with cognitive disabilities may experience, rehabilitation success rates are low. It has been difficult for state VR agency counselors to make decisions about eligibility, to assist individuals in setting vocational goals, and to construct a realistic rehabilitation plan. Many people have an extensive history of rehabilitation services and assessment, but are no closer to getting a job.

State VR counselors have reported that standard psychological assessments were of limited use in identifying the obstacles to obtaining an employment outcome. These assessments provided information on intellectual capacity and academic achievement but often failed to address the issues of reasonable vocational goals, possible obstacles, and rehabilitation strategies. When these issues were addressed, it was still difficult for the individual to incorporate that information into vocational plans.

Even neuropsychological assessments, which provide information about specific cognitive functions, such as memory or attention, are often difficult to translate to real world issues of employment and independent living. Traditional evaluations leave many needs unmet for persons with a cognitive disability and their referring counselors.

Functional assessments go beyond standard approaches, such as neuropsychological tests, and identify functional obstacles to goal attainment, residual job skills, and the specific conditions under which these skills can be utilized (McCue, 1993). Currently, while several approaches to functional assessment exist (e.g., Functional Assessment Inventory; Crewe & Athelstan, 1984; Rehabilitation Indicators; Diller, Fordyce, Jacobs, et al., 1983), none of these approaches have sufficiently addressed the assessment of cognitive and problem solving demands and abilities. A major shortcoming of most functional assessment instruments has been the restricted range of activities they address (Haffey & Johnston, 1990; Indices, 1979). In order to assess the impact of cognitive disability on functioning and effectively develop a plan to overcome obstacles to an employment outcome with the individual with a cognitive disability, new procedures must be developed and validated. In a report generated from an RSA funded review, final recommendations included the sponsorship of the development of scales or systems to address functional limitations. Further recommendations suggested that innovative work be done in the development of novel approaches to measurement, and ones that can be developed and researched in the everyday environment (Indices, 1979).

Limitations of Standard Psychological or Neuropsychological Assessments

Standard psychological and neuropsychological testing is the most frequently used means for assessing persons with cognitive disabilities. Psychological tests measure abstract concepts such as intellectual capacity or personality, while neuropsychological tests, which were developed to determine the presence or absence of brain damage, assess specific cognitive skills such as verbal memory or divided attention. Both types of tests are frequently utilized for the vocational rehabilitation purposes of diagnosis/eligibility and rehabilitation planning.

Unfortunately, for rehabilitation purposes, most traditional psychological and neuropsychological tests were not developed to predict behavior in the natural environment and, consequently, they fail to provide much of the information that is critical for effective rehabilitation planning. While these tests identify manifestations resulting from cognitive disabilities, they are not optimally effective in detailing how these effects interact with task and environmental demands to impact the individual's functioning in real-life situations (Cicerone & Tupper, 1990). In fact, it is possible that results of psychological assessment procedures alone can be quite misrepresentative of an individual's actual functional level. An individual may function far above or below levels suggested by psychological test results (Naugle & Chelune, 1990).

It is difficult to identify the potential vocational impact of cognitive strengths and weaknesses identified through these more standard assessments, since the demands of the worksite are rarely assessed and integrated into the interpretation of test findings. As a result, planning effective rehabilitation strategies is hampered since the obstacles to be addressed are not clearly delineated.

Advantages of Functional Assessment

Functional assessment can be defined as a process that enables an individual to identify the impact of his/her disability in real world activities, such as employment and independent living. A good functional assessment determines the individual's strengths and limitations and assists in selecting vocational options consistent with the individual's interests and aptitudes. In order to accomplish this, functional assessment must identify the environmental demands that are or will be placed on the individual, given the vocational goal he/she chooses. Functional assessment specifies the obstacles the individual is likely to encounter in pursuing the goal and suggests strategies that match the individual's values and skills for addressing these obstacles.

Functional assessment is designed to enable the individual to understand the effect that cognitive strengths and weaknesses have on everyday functioning and vocational options and helps the individual incorporate this information and consider vocational options that will allow for optimal success. In meeting this goal, functional assessment has several advantages over standard psychological assessment and other forms of interventions. Functional assessments are intensive and allow individuals to work on vocational issues in a matter of weeks as opposed to over an indefinite period of time; and, while many programs focus on group activities, functional assessments are individualized. Participants focus on their own goals and aptitudes and map out an individually tailored plan to follow.

In functional assessment, the goals are to:

* identify any obstacles that may affect the individual's vocational goal,

* recognize functional limitations and their relation, if any, to the obstacles, and

* identify functional assets which may be a key to overcoming the obstacles.

Performance on all assessments should be interpreted in terms of the relevant cognitive and behavioral domains involved, including areas such as attention, memory, receptive and expressive language, information processing, and executive functions (problem solving, planning, initiation, inhibition, judgement, self-monitoring, insight and awareness, self-evaluation, and flexibility).

The Functional Assessment Program

The following is a list of the programmatic components of this pilot program being demonstrated through the RSA sponsored Special Projects Grant entitled Functional Assessment of Cognitive Disabilities. Program components include a pre-assessment staffing, functional interviewing, modified psychometric assessments, questionnaires and rating scales, cognitive and vocational simulations, naturalistic observations in the work environment, and post-assessment staffing and report. These are described below, along with additional features of the pilot project.

Pre-Assessment Staffing

Once a referral has been made and at least preliminary background records have been gathered, a pre-assessment staffing is scheduled. This meeting includes the individual who is considering the assessment, any significant others the individual chooses, the VR counselor, and the service provider. The pre-assessment staffing takes place at the site where the assessment will be completed to familiarize the individual with the setting and in finding it.

The goal of the pre-assessment staffing is to allow the individual to make an informed choice concerning participation in the assessment. To do this, consensus among all parties concerning the purpose of the evaluation and the specific referral questions is established. The individual is at the center of this discussion, is in no way a passive observer, and is asked about his/her understanding of the assessment purpose and procedures. If the individual does not have a clear understanding, the information is provided again in a clear, concise way. All information should be provided in a format that the individual can understand and take for future review. If there is clear consensus among all involved concenting the nature and purpose of the assessment, and the individual is in agreement, a starting date for the assessment can be arranged. The consumer is assured that the assessment depends on his/her investment of time and effort and will only be scheduled with full consent. From this early contact the individual understands that he/she needs to be an active participant in the assessment, and that it is in fact designed for his or her self-discovery.

Functional Interviewing

A functional interview is an extension of the data gathering process that starts with collecting background information. It should serve several purposes:

* To elicit the individual's version of his/her history. Areas of discrepancy with other sources of information need to be explored.

* To determine the individual's view of the problems or obstacles he/she is encountering in daily activities. The nature and cause of the problems, as the individual sees them, should be explored, as well as any strategies and accommodations found effective in dealing with these obstacles.

* To insure that the individual's goals for the assessment are made explicit and can be addressed through the process. The individual should be able to restate the referral question. Often the consumer may have difficulty remembering the information from the pre-assessment staffing. During the functional interview the individual should have another chance to review goals and address any discrepancies.

* To engage the individual as an equal partner in the assessment process and enable him/her to see the assessment as an opportunity for self-discovery.

* To identify the individual's vocational goals, which will be addressed throughout the assessment process.

* To identify any discrepancies between the individual's perception of problems and actual behaviors history or the report of observers.

To help elicit and organize the information from the functional interview, the interviewer should be aware that direct questioning of functional abilities (e.g., Do you have any problems with planning and organization?) may not provide valid results for various reasons. Two tactics may be taken in the interview and, to some extent, both should be used. The first is to ask the question directly For example, if you wanted to know about organizational skills, ask the consumer if he/she has effective organizational abilities. You may have to give examples that pertain to his/her situation, like "Are you able to organize and prioritize the weekly assignments that you have for the four courses you are taking?" While it is important to obtain the perspective of the consumer regarding his/her cognitive abilities and problems, the problems experienced may limit his/her ability to accurately understand and respond to the questions. Because of a cognitive disability involving such areas as comprehension and expression, memory, or self-awareness, the consumer may not be able to accurately appraise and report on his/her abilities in response to direct questioning. This brings us to the second tactic: to question the individual about how he/she carries out certain activities of daily life and infer from this his or her cognitive abilities and limitations. For example, Table 1 lists prompts for generating information from the interview on executive abilities.
Table 1.
Interview Questions for Understanding Executive Abilities

* Do you grocery shop for yourself? If so, describe how you go about this.
* Have you ever planned a party? If so, describe what you did. If not,
 what do you think would be important things to do in planning
 a party?
* (If in school) Tell me how you organize your materials, assignments,
 and projects for school.
* How did you find this place? What did you do to learn how to get here,
 and then to actually get here?
* Tell me what you feel your strengths and weakness are and why you
 feel they are either a strength or weakness?
* What is the process you go through in opening, responding to, and filing
 (storing) your mail.
* Where are the following things:
 - the owner's card for your vehicle
 - your birth certificate
 - your social security card
 - a roll of scotch tape or a stapler in your house
 - the instruction manual for your VCR
* What do you do to remember or store important telephone numbers
 that you might need on a day-to-day basis?
* Describe the last significant (important, pressing) problem that
 you solved.


Questionnaires, Rating Scales and Behavioral Observation

Rating scales can be given to the consumer and a variety of independent raters' (with the individual's permission). Rating scales help respondents consider a broad scope of issues and help them organize and report their observations in a consistent fashion. When a rating scale has parallel forms for the individual and an independent rater, discrepancies become apparent and can be explored.

For a questionnaire or rating scale to be useful, it should be specific to obstacles encountered by persons with cognitive disabilities. Several such questionnaires that have been used effectively are available, such as the Patient's Assessment of Own Functioning Inventory (Heaton & Pendleton, 1981) and the Patient Competency Rating Scale (Fordyce, 1983), which may be used to identify the impact of cognitive disability from the perspective of the consumer and an independent rater; these scales, completed by the consumer, also have parallel forms, which are rated by a family member on the same dimensions. The use of relatives' forms allows for validation of self-report and may also help identify possible inaccuracies of self-appraisal. Additional scales may be designed to expand upon and quantify performance observations.

Standardized Testing

Standardized testing provides invaluable information about the consumer's areas of cognitive strengths and limitations. This information can be used to better interpret the individual's performance in the simulations and real-life tasks used in the assessment, increase the consumer's accurate self-appraisal and self-advocacy, and develop recommendations for accommodations to insure that these incorporate the individual's areas of strength.

A neuropsychological assessment is recommended for individuals who have not had recent comprehensive testing. The combination of standardized assessment and tasks that are more directly related to everyday activities (simulations, situational assessments) offers more complete information for rehabilitation planning. For a review of neuropsychological procedures, see Lezak (1983) or Wedding, Horton and Webster (1986).

To draw accurate conclusions from the functional assessment requires careful review of standardized test data and hypothesis testing during the subsequent, nonstandard assessments. From the testing, the evaluator hypothesizes about which cognitive or behavioral domains present functional obstacles. for the individual. Once a potential cognitive limitation has been identified, the evaluator in functional assessment needs to vary the task demands to "control" for that cognitive problem and determine the possible contribution of other cognitive skills. For example, if the evaluator believes that the individual's receptive language is an obstacle, they will watch for a pattern of performance in a number of assessment settings. The evaluator needs to control for the potential receptive language problem by assuring that the individual understands what is asked of him or her. Then the evaluator needs to determine if, for example, attention or memory might be also be affecting the individual's performance.

Simulations

Simulations and role playing of real-life activities are used to determine how an individual utilizes cognitive skills to resolve real-life problems. These activities require the individual to deal with multiple priorities, unforeseen circumstances, and interpersonal interactions. Table 2 presents a brief description of some of the simulations developed for use in the pilot project.
Table 2.
Sample of Cognitive-Vocational Simulations

 CLERICAL SIMULATION: On this task the individual performs a
clerical task which involves organizing a large pile of cards containing
catalog
information. Cards of various colors are organized in different ways.
For example, white cards are sorted alphabetically by name, while blue
cards are sorted in alphanumeric order by invoice code. During the first
hour, the individual receives three phone calls and is asked to take a
message.
The individual is required to keep track of the time and, after 1
hour, take a brief break to deliver the messages to a designated staff
member.
The individual is also asked to count the number of cards indexed and
report it to the staff member as well. The clerical simulation is designed
to
measure concentration, divided attention, learning complex rules,
organization
of materials, comprehension of instructions, and problem solving.
 ACADEMIC SIMULATION: This task is used with individuals whose
goals are to attend college or a vocational training program. The individual
watches a videotaped lecture, takes notes on the lecture itself, and
completes
a brief quiz about the information at the end of the hour. Individuals
are also asked to read a chapter in a beginning college-level book, outline
the chapter, write a one-page summary of the main ideas presented,
and take a brief quiz on the material. This simulation measures ability to
discriminate essential information, learning of new academic material,
written expressive language (essay), concept formation and integration,
organization and planning, and study skills.
 ROUTE FINDING/JOB SEARCH SIMULATION: (STATE OFFICE
BUILDING): The individual is required to locate the state office building
and the office to apply for state jobs. Maps, verbal, or written directions
are offered, but are not supplied unless the individual requests them.
Individuals are asked to bring back information on two jobs that are of
interest
and reasonably matched to their skills for which they might wish
to apply. The individual is also asked to pick up an application form
and bring it to the interview fully completed. This simulation measures
route finding, planning, anticipation, self-evaluation, social interactional
skills, goal formulation, use of resources, and ability to complete an
open-ended task.
 AMERICAN ADAPTATION OF THE MULTIPLE ERRANDS TEST
(AMET): The AMET (Aitken, Chase, Mccue, and Ratcliff, 1993; Shallice and
Burgess, 1991) requires the individual to shop for a standard set of six
items
as quickly and cheaply as possible in a relatively small, contained shopping
area, while obeying several rules. He or she must also mail to the evaluator
a postcard containing information which can reasonably be obtained during
the shopping trip; the consumer must then rendezvous with the evaluator
at a specified place and time. The individual is not told how to acquire
the information, and some task requirements are only implied. The AMET
measures planning or multiple tasks, ability to keep within rules,
organization
of time and money, trial and error learning, novel problem solving and
generation of alternatives, (prospective) memory for appointments, and
self-evaluation and self-correction.


Situational Assessment

Situational assessments are completed by observing how the individual functions over a period of time in a real-life environment. These short-term, real-life experiences can be arranged through temporary employment, often through the use of a temporary personnel agency. Volunteer work or short-term employment arranged through family or friends can also be considered.

Situational assessments can be designed to match the demands of academic or vocational training environments if the individual's vocational goals include training. Arrangements can be made for individuals to sit in on classes on a timelimited basis. They can attend professional seminars or continuing education courses to assess their response to training at this level.

While it may not be necessary to place the individual in the environment of the ultimate vocation, it is important for the individual to be placed in a situational assessment that is related to the vocational goal. The individual may have an easier time understanding how his or her performance in this setting will be related to performance in meeting the vocational goal. Even if the placement for situational assessment is unrelated or only marginary related to the vocational goal, valuable information can be obtained. Cognitive endurance, ability to adjust to new demands, interactions with coworkers and supervisors, and problems with transportation or break times can all be observed during any situational assessment. In the instance where the placement is in an unrelated area, it may require additional counseling and debriefing to help the individual understand the relationship between his/her performance in the situational assessment and performance in the goal area. Situational assessment may also provide an opportunity for the individual to try out a job that more closely matches his/her ability than the job identified as the vocational goal, and is therefore an excellent resource for vocational exploration.

Observation in the Natural Environment

One's ability to perform in the natural environment may be markedly different than performance in other settings would predict, and should be assessed through direct observations, which can be completed at the individual's job site, in the classroom, or in the home, depending on the person's level of functioning.

Performance on tasks in the real world or on simulations of these tasks can be difficult to quantify or even to describe, especially when dealing with covert cognitive skills. Table 3 contains a list of suggested questions that provide a framework for cognitive behavioral observations, both in the natural and in the testing/evaluation environments.
Table 3.
Suggested Questions to be Addressed by Functional Assessment

1. Did the individual attend to directions?
 * Did the individual attend after cuing?
 * Did the individual attend initially, then fade?
2. Were the directions understood?
 * Could the individual explain the task back clearly?
 * Was the individual able to demonstrate the task?
3. If the directions were not understood initially, what if anything,
made the directions more clear?
 * Repetition?
 * Simplifying the language?
 * Breaking directions down into smaller pieces?
 * Providing direction in writing?
 * Using pictures, graphics, or diagrams?
 * Demonstrating the directions?
4. Was the task begun independently or was a cue needed to initiate?
5. Was the task begun prematurely or impulsively before directions
 were completed and understood?
6. After beginning, how long was the individual able to stay on task
 before requiring redirection?
7. Why was redirection necessary?
 * Distraction by another activity?
 * Self-distraction?
 * Loss of interest or motivation?
 * Confusion about how to proceed?
 * Forgetting the instructions?
8. Was the individual able to generalize the instructions to a new situation?
9. Was the individual able to seek additional information that was needed?
10. Was the individual able to problem solve when confronted with
 uncertainty?
11. Was the individual able to persist with the task until completion?
12. Was the task completed in a timely fashion?
13. Was the task completed accurately?
14. Did the individual spontaneously use any accommodations or
 strategies to help him/herself?
15. Was the individual able to detect his/her own errors?
16. Was the individual able to self-correct errors?
17. Could the individual correct errors with feedback?
18. Was the individual's overall rating of own performance accurate?
19. Was the individual able to identify what contributed to difficulties,
 if any?
20. Could the individual identify any strategies or approaches that
 would help?
21. How was the task completed on repetition?


Post-Assessment Staffing

Following the assessment, a meeting which includes the individual, significant others or advocates (as requested by the individual), the referring counselor, and the assessment staff should be held. In this meeting, a summary of findings should be presented as a review of information that has already been discussed with the person and the counselor over the course of evaluation. The response to the initial referral questions posed in the pre-assessment staffing should be explicitly discussed. A brief written summary or table of key findings and recommendations should be distributed to make the information more accessible and available for the individual's review over time.

Acknowledging that one of the major obstacles to successful vocational integration of persons with cognitive disabilities is difficulty in accurate self-appraisal, the most important outcome of the functional assessment process is agreement among the individual, the rehabilitation counselor, and the evaluator concerning key issues, such as: the answer to the referral question; cognitive strengths; cognitive limitations; functional obstacles; vocational options; vocational impact; and recommended strategies and accommodations for addressing obstacles to goal attainment.

To achieve consensus, direct efforts must be made towards this end. Individuals can be involved in the process by using daily feedback sessions for their input. This time can be used to acquire information about performance and skills and to relate it to vocational goals. A "product monitoring" approach, in which the outcome of their work can be addressed, as opposed to judging performance, may be less threatening and allow for greater growth.

Questions that can help the individual focus on productive change and information gathering include: Were you satisfied with the outcome of that task?"

"Are there things that would help you if you did it again?"

"Is that kind of task related to the work you want to do?"

"Is there any way to get around it?"

"Are there any other options to consider?"

It is important that the VR counselor is included during the functional assessment process and that information or recommendations do not come as a surprise during a post-assessment staff meeting. Frequent brief phone calls to keep the counselor informed of findings and possible recommendations allow the counselor's input to be incorporated throughout the assessment. Regular communication between the referring VR counselor and the consumer during the process is also advocated.

During the post-assessment staffing, formal agreement is established concerning changes in vocational goals and recommendations for accommodations or interventions. If new questions are raised, or if new directions are identified, the final report produced after the meeting can incorporate these issues.

Consumers should be asked to summarize their understanding of assessment findings and recommendations; should clarification be needed, it can then be provided. Sufficient time should be allotted to respond to questions from all participants.

Functional Assessment as an Intervention

Even the most functionally oriented psychological or neuropsychological assessment may fail to help the consumer develop insight into the impact of disability in everyday life. This occurs for several reasons:

* The person being assessed may get little feedback about performance during the assessment session.

* The individual may have difficulty relating the assessment tasks to real-life tasks.

* When the report is delivered to the rehabilitation counselor, it may be difficult for both the counselor and the consumer to understand.

* Finally, because of the nature of cognitive disabilities, the consumer may have difficulty understanding new information and applying it to everyday or work activities. This is possibly due to the problems with language, information processing, memory, and self-evaluation that are common to many persons with cognitive disabilities.

The functional assessment process allows the consumer to participate in a wide range of experiences and to obtain immediate information about strengths and weaknesses, information that is useful as it relates to employment and other aspects of his/her life. With the right kind of feedback, individuals with specific weaknesses, such as in language, memory, information processing, or self-evaluation, learn the extent of these difficulties and understand how these weakness may manifest in a real-life situation.

Following the completion of each structured activity or simulation, a staff member interviews the consumer to identify self-perceptions of performance. The consumer is asked to be specific about areas of competence and weakness and is assisted in keeping a written or audiotaped record of assessment tasks, results, and insights. The staff person discusses the rationale for the activity and offers insight on areas of apparent strength and/or weakness. Possible strategies for accommodation or improving performance are also discussed.

Care is taken to match language and information processing demands to the consumer's ability. Sometimes, a videotape of the activity is reviewed with the individual. Emphasis is placed on the individual's strengths, as opposed to deficits. Information learned in each simulation is added to information learned earlier, thus reinforcing specific areas of strength and weakness with new data. Eventually, consumers are able to better appreciate their strengths and weaknesses and, therefore, are better prepared to apply what they have learned about themselves towards their employment decisions.

Every effort is made to help the individual focus on the obstacles identified, not on deficits. This strategy-creates an expectation of equal participation rather than one of passive assessment and diagnosis and reduces the natural tendency that everyone has to become defensive when being tested. The functional assessment process fosters self-discovery, adaptive change in the individual, and a readiness to implement effective vocational rehabilitation plans. It also helps the individual to see the environmental factors which can affect his/her vocational outcome and shows how to develop strategies to deal with these issues.

Pilot Project Results: Participant Outcomes

Functional assessment and outcome data are available for a total of 21 people who participated in the pilot functional assessment. Of this group, there were 10 men and 11 women, with average educational level of 12.3. Two persons were African-American; all others were Caucasian. Upon referral, seven participants were employed in some capacity and three were volunteering. The others were unemployed or in transition and considering various options. All those who were employed at the onset of the program reported dissatisfaction with their current jobs due to underemployment, problems performing adequately on the job, or chronic, short-term employment. At the end of the project, 12 participants were working, 3 were volunteering, and 3 had entered formal vocational training programs. Of more interest however, are the relative shifts made by individuals over the course of the project: six persons moved from unemployment to competitive employment, two moved from unemployment to a volunteer position, and one moved from unemployment into a suitable training program. Additionally, another individual left a dead end job for a training program consistent with her interests and aptitude. In total, of the 21 people assessed, 10 achieved clear-cut vocational gains as measured by rating of vocational activity pre-assessment versus post-assessment.

The remaining participants, for which there was "no change" in vocational status, represent an even more interesting outcome in functional assessment. For many of these individuals, change came in the form of acceptance of current circumstances as a rewarding and reasonable activity (e.g., choosing to remain employed in a grocery store and pursue on-the-job managerial training), or manipulation of system variables (family or employer expectations, for example) so that inappropriate goals of vocational change were lifted.

In order to capture these changes across the project, clinical ratings were assigned on a four point scale, representing:

1) a significant shift toward more realistic goals or acceptance of current position;

2) some change in behavior or a significant increase in verbalization toward more realistic goals;

3) minimal change; or

4) decreased willingness or ability to consider realistic vocational options.

Of those participants whose overall vocational status remained the same (e.g., employed vs. unemployed), eight made some positive change toward accepting their current circumstances. Only two were felt to have remained relatively unchanged, meaning that their ongoing status may not represent their optimal choice.

Using the same rating system to evaluate change over the course of involvement for the group as a whole, 12 participants were felt to have made fairly dramatic shifts in orientation or awareness of problem impact, and 6 were judged to have made some change in awareness. Only three were evaluated as having made minimal or no change. None of the participants appeared to have become more reluctant to consider vocational options or in any other way had a negative therapeutic outcome as a result of participation. In summary, results of this pilot project were felt to have direct impact on vocational choice and outcomes.

Case Illustration

Steve, a 20-year-old white male with a history of early life brain trauma, is referred by the local office of the state VR agency for functional assessment. He has been working in a retail store, providing stock assistance in a supported work setting but expresses interest in completing college and obtaining a well paying managerial job in an office setting. His stated interests include photography, hospital work, and emergency medical technician (EMT) training.

His functional assessment included review of recent, comprehensive neuropsychological evaluation; interviews with high school teachers and recent tutors used as he attempted EMT training; multiple situational assessments and informational interviews with providers on applied training programs; and a jobsite evaluation. Additionally, family members were interviewed and old records were reviewed.

Previous to his current job, Steve had spent 3 years in a vocational technical training program for EMT's, with minimal progress toward completing any minimal criteria. He had attempted to enroll in a local community college, but was discouraged from applying after being unable to complete the tests for the remedial, pre-college coursework. In addition to these problems, Steve also experienced multiple problems in interpersonal relationships, particularly inappropriate and disinhibited verbalizations toward others, abrupt and tangential personal questions, and a great deal of difficulty remaining focused on topics and activities at hand. His family additionally reported great concern over his poor social judgement and his being very influenced by peers. Finally, Steve appeared to have little appreciation of the ways in which these factors related to his unhappiness with his vocational status and he was unable to identify any personal goals or life plan to move him toward a better alternative. His general intellectual functions measured in the borderline range, while academics were approximately at the fourth grade level.

Throughout the assessment, every opportunity was taken to assist Steve in comparing his strengths and interests with vocational options and requirements for successful education and for long-term employment in various fields. Over the course of the assessment, Steve made a decision to pursue training as a nursing assistant in the special needs program of a local community college.

A vocational impact table was prepared for several job options; the table relevant to his chosen career field is shown on the next page. Note that the table begins (left column) with a brief abstract of the job tasks, taken from the Dictionary of Occupational Titles. The table then identifies probable functional limitations, as indicated by functional assessment. The third column integrates information from the first two columns and lists the vocational impact of functional limitations for the particular job being considered. Under "rehabilitation strategies," specific recommendations are presented that respond to the vocational impact concerns.

The vocational impact table guided discussions with Steve regarding identified areas of weakness, how those might affect a job in the identified field, and some suggestions to accommodate those issues. These efforts were successful in assisting Steve in understanding how his career aspirations were not a good match with his abilities, which resulted in the decision to pursue specialized training in which he had both an interest and a good chance of finding success. This example supports a primary outcome of good functional assessment, which is to align consumer goals with vocational options so that the individual succeeds in the chosen job and also feels good about making the choice. Had a more traditional approach been taken, Steve may have been told that his goals were "unrealistic," he would have been asked to choose among several fields he perceived as "low-level," and he would have entered training or a job with low motivation to succeed, poor self-esteem, and anger at the few options open to him.

Implications for Vocational Rehabilitation Practice

So what can the reader take away and implement from this pilot project? With the existing constraints on counselor time and resources, it is easy to become overwhelmed at the idea of revamping the world of rehabilitation. It is equally challenging to change the world of specialty assessments like neuropsychology, particularly when most readers far somewhere outside of that world, as consumers of the reports rather than writers of them. All members of the rehabilitation community, however, can move toward more functional assessment. Some pragmatic suggestions that can be implemented include the following:

* Identify a way of understanding the cognitive strengths and challenges of the individuals with whom you work, such as the model of cognitive domains described in this article. Post a copy of it on your wall. When observing or thinking about a consumer, consider what you know about him/her concern-drug each domain. Then think about what you know about the cognitive demands of their everyday life. How do they match up?

* Don't neglect the importance of understanding the cognitive demands that will be placed on the individual. hi order to understand the impact of a disability, abilities and limitations must be contrasted with task and environmental demands. Use resources such as the Dictionary of Occupational Titles, job descriptions from other sources, discussions with supervisors or training instructors, and job analyses to detail the cognitive task demands that will be placed on the individual (e.g., the degree to which the worker must pay attention and respond to multiple sources of information simultaneously). Use a cognitive domains format, similar to what you might use with a consumer, to organize information about the cognitive demands of a particular job or training program.

* When you make your next referral for specialty psychological or neuropsychological assessment, identify the vocational directions under question by the individual; present referral questions that are directly relevant to the individual's life choices. For example, will his impaired memory be an obstacle on the job? If so, is there any way to get around it? What will be the consumer's needs for accommodation when he/she returns to college, to a 2-year vocational training program, or to a previous job?

Be sure your consumers can understand test results in terms of their areas of strengths and in the context of their everyday lives; and that they understand the impact of their disability. Use vendors and providers to help with this and to insure that you fully understand the functional impact of identified problems or deficits before attempting to devise a rehabilitation plan.

* Ask consumers and their families/friends to talk about everyday activities: Who does the laundry, shopping, planning of dinners, bills, and how do the tasks get done? Look for discrepancies between the consumers' and independent raters' responses; followup to determine reasons for differences.

* Regularly ask consumers to evaluate their own performance on specific job tasks, in job interviews, and in daily living or rehabilitation related activities. Rather than focus exclusively on basic facts--such as, "What did you tell them?" "What did they say?"--elicit the consumers' ideas on how they might do things differently, how others might describe their performance, and what might be effective in improving their performance.

* Change your language when working with consumers and providers. Focus on the demands they anticipate in various jobs or environments and, rather than targeting deficits and impairments, discuss the specific obstacles that consumers face as they approach work and functional independence. Discourage consumers from describing themselves in terms of personal deficits; substitute real-life characteristics instead.

How to Arrange and Manage Functional Assessment Services

A single service provider in the community, working closely with the VR counselor, may be able to manage the assessment process. In the special project described in this article, the assessments were managed by rehabilitation psychologists. The standardized neuropsychological testing and all other aspects of the testing were completed by project staff or coordinated by the staff with other agencies in the community. Project staff was responsible for scheduling meetings with consumers and counselors, collecting all relevant data, and developing the final, comprehensive report. Other options include having the assessments managed by a vocational evaluator or the staff of a rehabilitation facility or other community agency.

Functional assessment providers need an indepth knowledge of the characteristics of various cognitive disabilities, the impact of cognitive disabilities on everyday activities, and the domains of cognitive function and the assessment of these domains. In some cases, no one provider will be able to complete all aspects of the evaluation. For example, the provider may be unable to complete a formal neuropsychological evaluation or may not have the resources to complete an assessment at a jobsite. In this case, one provider--working with other providers in the community--may still be contracted to manage the assessment, possibly through authorizations or contracts from the VR agency. The agency responsible for managing the assessment coordinates all meetings and activities, gathers data from each of the other agencies involved, and generates a final comprehensive report. One staff member should work closely with the consumer throughout each component of the assessment. This assessment manager should help the consumer review outcomes in each segment of the assessment, usually in cooperation with the staff who administered the assessment. Every effort should be made to help the consumer apply this information to his/her everyday life and vocational options and to record this information in an accessible format.

To initiate these services in a community, the VR agency may wish to invite proposals from multiple community agencies. An initial workshop explaining the need and the anticipated scope of the service could be offered prior to the submission of proposals.

In some communities, it may not be practical to have the assessments managed by a service provider. In these instances the VR counselor can serve as the assessment manager. The VR counselor can complete functional interviews with the consumer and significant others, collect all relevant records, and interview family members, teachers, employers, and counselors. The VR counselor can authorize standard psychological assessments and, if indicated, may authorize worksite assessments or assessments aimed at real-life skills through community agencies. If this is not possible, the counselor could make arrangements to observe at the worksite, the training site, or in other situations in the consumer's natural environment.

The challenge for the counselor is to integrate information identifying the consumer's functional strengths and weaknesses and determining the vocational impact. The counselor must also help the consumer to understand and integrate the information. Some of these tasks may be difficult for counselors, especially if they have not had extensive experience working with individuals with cognitive disabilities. Other tasks are a very natural extension of the counselor's routine activities and training. With support and technical assistance that may be available from specialists working with persons with cognitive disabilities, VR counselors can become effective in conducting all facets of this assessment procedure.

Training Opportunities

The Center for Applied Neuropsychology has obtained two RSA-sponsored training grants in the area of functional assessment. Functional Assessment and the Vocational Rehabilitation Process, a series of three video satellite teleconferences focussing on understanding the impact of cognitive disability and enhancing the functional utility of standardized psychological and neuropsychological assessments were broadcast nationally in November and December 1993. Facing the Challenge: Functional Assessment of Individuals with Cognitive Disabilities, a two-part interactive video satellite teleconference, was aired on August 31 and September 14,1994. This series featured step-by-step approaches to cognitive skills-based functional assessment, including manageable ways of incorporating functional assessment into everyday rehabilitation practice. For more information on either of these training opportunities, contact the Center for Applied Neuropsychology, 100 First Avenue, Suite 900, Pittsburgh, PA 15222 or call (412) 391-4583.

Note

1. An independent rater can be anyone--family, friends, employers, teachers, counselors, etc.)--who provides information on the consumer for the purpose of improving services and providing the necessary supports to acquire and maintain employment.

Functional assessments go beyond standard approaches, such as neuropsychological tests.

Bibliography

1. Aitken, S., Chase, S., McCue, M., Ratcliff, G. (1993). An American adaptation of the Multiple Errands test: Assessment of executive abilities in everyday life (Abstract). Archives of Clinical Neuropsychology, 8(3), 212.

2. Cicerone, K.D., & Tupper, D.E. (1990). Neuropsychological Rehabilitation: Treatment of Errors in Everyday Functioning. In D.E. Tupper and K.D. Cicerone (Eds., The Neuropsychology of Everyday Life: Issues in Development and Rehabilitation. Boston: Kluwer Academic Publications.

3. Crewe, N.M., & Athelstan, G.T. (1984). Functional Assessment Inventory Manual. Menomonie, WI: University of Wisconsin-Stout.

4. Diller, L., Fordyce, W, Jacobs, D., Brown, M., Gordon, W., Simmens, S., Orazem, J., & Barrett, L. (1983). Final Report: Rehabilitation indicators project (R&D Project No. G008003039). Washington, DC: National Institute of Handicapped Research.

5. Fordyce, D.J. (1983). Psychometric assessment of denial of illness in brain injured patients. Paper presented at the 91st Annual Convention of the American Psychological Association, Anaheim, CA.

5. Haffey, W.J., & Johnston, M.V. (1990). A Functional Assessment System for Real-World Rehabilitation Outcomes. In D.E. Tupper & K.D. Cicerone (Eds. , The Neuropsychology of Everyday Life: Issues in Development and Rehabilitation. Boston: Kluwer Academic Publications.

6. Heaton, R.K., & Pendleton, M.G. (1981). Use of neuropsychological tests to predict adult patients' everyday functioning. Journal of Consulting and Clinical Psychology, 49(6), 807-821.

7. Indices, Inc. (1979). Functional Limitations: A State of the Art Review (RSA Grant No. 13 P 59220/3 01). Falls Church, VA: Author.

8. Lezak. M.D. (1983). Neuropsychological Assessment (Second Edition). New York: Oxford University Press.

9. McCue, M. (1993). Clinical diagnostic and functional assessment of adults with learning disabilities. In P.J. Gerber and H.B. Reiff (Eds. , Learning disabilities in adulthood: Persisting problems and evolving issues. Andover Medical Publishers.

10. Naugle, R., & Chelune, G. (1990). Integrating neuropsychological and "real-life" data: A neuropsychological model for assessing everyday functioning. In D.E. Tupper & K.D. Cicerone (Eds.), The neuropsychology of everyday life: Assessment and basic competencies (pp. 57-73). Norwell, Massachusetts: Kluwer Academic Press.

11. Shallice, T., & Burgess, RW (1991). Deficits in strategy application following frontal lobe damage in man. Brain, 114,727-741.

12. Wedding, D, Horton, A.M., & Webster, J. (1986). The Neuropsychology handbook. New York: Springer Publishing.

Dr. McCue is a neuropsychologist and Executive Director, Mr. Pramuka is Project Coordinator of Functional Assessment, and Ms. Chase is a speech/language pathologist and Training Coordinator at the Center for Applied Neuropsychology, Pittsburgh, PA. Ms. Fabry is a psychologist and Inhome Wraparound Unit Manager at Northern/Southwest Communities MH/MR, also in Pittsburgh.
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Author:Fabry, Pamela
Publication:American Rehabilitation
Date:Sep 22, 1994
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