An Overview o Research on the Model of Human Occupation

Gary Kielhofner

Abstract
The Model of Human Occupation published in the American Journal of Occupational Therapy was proposed as a framework for clinical application and research. This paper briefly overviews the model and tenets derived from it for empirical testing. A number of studies based on the model are presented and evaluated. These studies generally provide support for the theoretical tenets of the model. Further, they illustrate that the model can be used as a framework for research and for developing clinically appropriate assessment procedures. While the studies are generally preliminary and have a number of weaknesses, they collectively constitute a research tradition which will allow the conduct of more sophisticated research in the future.

The purpose of this paper is to report research on the model of human occupation (Kielhofner, 1980 a, b; Kielhofner and Burke, 1980; Kielhofner, Burke and Igi, 1980). It will begin with an overview of the model's theoretical tenets, major variables and their relationships. Then an overview of studies will be presented. Finally, the paper will present an assessment of what the studies have demonstrated about the model, the limitations and value of the studies, and implications of the studies for further research.

The model of human occupation: Theoretical framework

Human beings are conceptualized as open systems according to the model (Kielhofner and Burke, 1980). An open system is a composition of interrelated structure and functions organized into a coherent whole that interacts with an environment and that is capable of maintaining and changing itself. The open system representing human beings and their occupational behavior is composed of three subsystems, volition, habituation and performance. The volition subsystem is the highest level governing subsystem. This subsystem is postulated to contain three sets of personal images that influence decisions for action, values, personal causation and interests. Values are defined as images of what is good, right and important. Personal causation is a collection of beliefs and expectations which persons hold about their effectiveness in the environment. Interests are dispositions to find occupations pleasurable. Together an individual's values, personal causation and interests influence how he or she will choose to enact the system's urge to explore and master. Because the volition subsystem chooses and initiates behavior, it is postulated to be a critical determinant of the system's output or occupational behavior. The habituation subsystem is responsible for the regulation or maintenance of patterns of everyday beGary Kielhofner, Dr. P.H., 0.T.R. Medical College of Virginia, Virginia Commonwealth University, MCV Station Box 8, Richmond, VA 23298. APRIL/AVRIL 1984

havior. This subsystem contains two components, habits and roles. Habits are routine and typical ways in which one person performs. Internalized roles are images that one holds concerning one's positions in society and the obligations they bring with them. Together habits and roles trigger and maintain automated patterns of everyday behavior. They provide consistency and efficiency of performance and thereby constitute an important process in adaptation. The lowest level performance subsystem is responsible for producing skilled action. It is composed of skills and their constituents (Kielhofner & Burke, Manuscript in Preparation). The three types of skills are perceptual-motor, process and communication/interaction skills and their constitutents are symbolic, kinesiological, and neurological. The performance subsystem represents that territory most familiar to the occupational therapist. Skills and their constituents are the basic factors in functional performance and thus are important components of adaptive behavior. The three subsystems function in an integrated mutually dependent relationship. The lower systems constrain the higher systems. For example, the volition subsystem cannot choose to enact a behavior for which the performance subsystem has no capacity or for which habituation has no routines. Higher subsystems can organize or disorganize lower subsystems. For example, when a performance subsystem problem such as spinal cord injury interferes with role performance, the volition subsystem can undergo changes in values and interests and eventually enact a new occupational role compatible with remaining capacity in the performance subsystem. Further, an individual who has a poorly formed sense of personal causation may fail to make appropriate choices for action and skills in the performance subsystem can remain undeveloped or atrophy. Healthy organization of a system is thus represented in a harmony or resonance of features of the three subsystems. According to the definition of an open system, it is not only a collection of internal components, but it also involves interaction with an environment. Interaction with the environment is accomplished through four 59

interrelated processes. Intake is the importation of information from the environment. Throughput is the process whereby information is integrated into the appropriate subsystems and that results in changes in the system. Output is action directed at exploring and mastering the environment or, in other words, occupational behavior. The cycle is completed by feedback, the return of information to the system concerning the process and outcomes of its output. Each of the phases of the cycle are interrelated. The system can only ouput occupational behavior based on information that has entered the system and that has been integrated into the organization of the system in the throughput phase. The feedback a system receives is a function of its output and the relationship of that output to the environment. The system's interface with the environment is referred to as the person/environment fit which is the match or conaruence between individuals and their settings (Barris, 1982). The ongoing cycle of output, feedback, intake and throughput results in a cycle of change in the system. When the cycle is adaptive it results in occupational behavior which satisfies the individual's urge to explore and master and which satisfies environmental expectations. When either or both of these elements are not satisfied an individual is in a maladaptive cycle. From the model there have been derived basic postulates which state relationships between variables. These have. in turn, been investigated through research. Four major postulates are as follows: 1) A disturbance of any part of the system reverberates throughout the system. Lower levels can constrain higher levels whereas higher levels can lead to disorganization of lower levels 2) The output of the system (i.e., occupational behavior) and the status of the system's internal organization are interrelated 3) Feedback to the system is influenced by the overall system dynamic including the relationship of volition or choice with output 4) The output (i.e., occupational behavior) of the system is influenced by the environment of the system and its match to system's characteristics. From these basic postulates a variety of hypotheses have been derived. In addition to studies which are specifically designed to test propositions from the model and clinical research which has attempted to operationalize model concepts into assessment instruments or procedures, there has been descriptive research which elaborates the model. In the following section several studies will be presented in their chronological order. Mailloux (1980) conducted the first empirical investigation using the model as its theoretical basis. Based on the assertion that lower level disturbances could constrain higher levels of the system, she hypothesized that children with visual-motor integration problems (i.e., a disturbance to the performance subsystem) would exhibit a lower sense of personal causation than normals and that the degree of visual-motor problems would negatively correlate with personal causation. A second

hypothesis generated from the model was that the student role performance (i.e. output) would be correlated with both self-esteem and visual-motor integration problems. This hypothesis tested the model's assertion that the output of the system was a function of the status of the subsystems. Mailloux studied 40 children from 10 to 12 years old (28 males and 12 females) who attended a learning disability classroom in the public school. She administered the self esteem inventory developed by Coopersmith (1975) as an index of personal causation. the Gubbay (1974) Standardized Test designed to measure praxis and the Developmental Test of Visual Motor Integration developed by Beery and Buktenica (1967). In addition, teachers filled out the Devereaux elementary School Behavior Rating Scale (Mailloux, 1980) as an assessment of student role performance. The mean scores for the learning disabled population were significantly lower (t = 2.8, P .005) than the mean of the normative group for the instrumnt. The correlation between the degree of visual-motor impairment and self esteem were nonsignificant as was the correlation between praxis and self esteem (See Table 1). There were mild nonsignificant correlations between student role performance and self esteem. In summary, Mailloux's study provides some support for the assertion that lower level subsystem dysfunction can constrain higher level components such as personal causation. The lack of correlation between the degree of impairment and this N, oiition variable may indicate that the association is not a linear one. That is, the major irnpact of this disability on self esteem may be the label and the placement in a special setting as opposed to the degree of impairment. There was no clear support for the association between the self-esteem variable and output of student role performance, the data trends only suggest such an association may exist. Further study, with the possible use of more sensitive measures and a larger sample size is needed to clarify this relationship. Table 1 Correlation Coefficients of Self Esteem Scores with Visual Motor Integration, Praxis and Positive and Negative Student Role Performance Scores in Learning Disabled Children (N = 40) Visual Motor Integration MALES FEMALES* Praxis Positive Student Role Performance Negative Student Role Performance

.0509 .0231 .0314 .2247 .1546

NS

NS NS
NS NS

* Presented separately since there was a statistically significant difference between males and females on this variable. Note: Reprinted with permission from "The relationship between self esteem and visual motor integration, praxis and student role performance in children with learning disabilities" by Z. Mailloux, Master's thesis, University of Southern California, 1980. CJOT VOL. 51 NO. 2

Mailloux indicates as limitations of her study that her instrumentation may not have been sensitive enough, that the study may have been affected by less than optimal testing conditions and by differences in teachers who rated their pupils on the student role assessment. Small sample size and a possible lack of representativeness of these students (who were from a single school district) were also limitations. Thus, the study offers preliminary suggestive findings and paves the way for further study with learning disabled children. Mailloux sees the clinical implication of the study to be that therapy should acknowledge self esteem problems of learning disabled children. Gregory (1983) designed a study to investigate the role of activity in the life satisfaction of the elderly. Within the framework of the model, Gregory hypothesized that the meaningfulness of activities in which an elderly person engaged (i.e., their enjoyability, autonomy, and competency) would correlate with life satisfaction. By examining enjoyability, Gregory was investigating the relationship between the volition dimension, interest, and occupational behavior. By examining autonomy and competency he focused on the relationship between personal causation and occupational behavior. Thus, Gregory's variable of meaningfulness of activities represented the degree of harmony between output and the volition subsystem. In order to gather data on activities, Gregory transformed Nystrom's (1974) Activity Index, which is an interview process, into a paper and pencil tool which asked elderly individuals to report on their engagement in 23 activities typical of elderly individuals The respondent indicated for each of the activities whether they weren't interested and didn't do it; whether they didn't do it but would like to; whether they did it at least once a week; or whether they did it at least 3 times a week. Gregory also developed a second part of this tool which he called the Meaningfulness of Activity Index. In this section of the instrument respondents reported how much they enjoyed the activity; whether they did it of necessity or choice; and how well they did it. Test-retest reliability on a sample of 10 subjects was .70 for the activity index portion and .87 for the meaningfulness portion. Data were gathered on life satisfaction by administering a section of the Attitudes Index developed by Cavin, Burgess, Goldhamer and Havighurst (1979). The study included 79 subjects from rest homes, senior centers, retirement communities, and social and church groups. The mean age for the sample was 75.5 years with a range of 65-90. The resulting correlations (See Table 2) supported the postulate that output is related to life satisfaction. The amount of activity was most strongly correlated with life satisfaction. Correlations with enjoyability of activity and autonomy of activity were comparable, but the correlation between competency of activity and life satisfaction was somewhat lower. Neither age nor length of retirement was significantly correlated with life satisfaction. The findings generally support the importance of occupation for life satisfaction, but the meaningfulness of activity (volitional) dimensions did not demAPRIL/AVRIL 1984

Table 2 Nonpartial Correlation of Variables with Life Satisfaction

Correlation with Life Variable
Saiisfaction

Amount of Activity Enjoyability of Activity Occupational Behavior Autonomy of Activity Competency of Activity Meaningfulness of Activity Age Length of Retirement
*P < .05. **P < .01.

.43** .42** .38** .37** .33** .29* .11 .01

Reprinted with the permission of The American Occupational Therapy Association, Inc.. Copyright 1983, The American Journal of Occupational Therapy, Vol. 37, No. 8, p. 551. Occupational Behavior and Life Satisfaction among Retirees, AJOT, Mark D. Gregory, Table 2 Correlation of Variables with Life Satisfaction.

onstrate stronger correlations with satisfaction as anticipated. However, because the instrument only measured participation in a fixed number of activities that are likely to be engaged in primarily by choice, it may not have been sensitive to the overall influence of volition in the full range of daily activities. In summary, Gregory's study provides support for the model assertion that occupational behavior (output) influences the satisfaction (feedback) of the individual. It also provides some support for the importance of volition harmony with output as evidenced in correlations of interest, competency and autonomy of activity with life satisfaction. The instrument design was an important weakness in this study. Further, Gregory did not control for a number of important demographic factors that impact life satisfaction. Scaffa (1981) studied differences between alcoholics and normals. She hypothesized that alcoholics would show differences in the habituation and volition subsystems based on the rationale that alcoholic behavior patterns (output) would reflect disorganization in the subsystems responsible for decision-making and patterning of behavior. Scaffa compared 25 persons in the early to middle stages of alcoholism with 25 non-alcoholics; all were between the ages of 18 and 30 years. She collected data on habit patterns by having subjects fill out a time log from which the amount of time in work, leisure, self maintenance and alcohol related activities could be determined An adapted version of Matsutsuyu's Interest Checklist (1969) which gave information on past and present interests and on whether the individual was currently pursing interest was administered. 61

Scaffa determined that interests patterns vvere similar for both groups. While there was a statistically significant difference in the number of strong interests in the cultural/educational category of interests, this difference of only one interest does not appear substantive. More importantly, there was no difference in the overall pattern of interests. Scaffa did find a marked and statistically significant difference in the number of activities in which the alcoholic group and the normal group participated (Alcoholic -= 21; Non-alcoholic = 39.3, p < .01).
The clearest differences between the two groups were found in the habituation subsystem (See Table 3). The alcoholic group had over one-and-a-half fewer waking hours each day; they spent over 26 percent of their time in alcohol related activities compared to less than one percent for norrnals. The use of time in self-maintenance and leisure activities were comparable for the two groups, but alcoholics spent only slightly more than half the arnount of time that normals did in work. Table 3 Percentage of Time Spent in Various Activities and Total Hours Awake Daily
Mean (Standard Deviation) Hourly Time Log Activities Nonalcoholic Alcoholic Significance Level

Self-maintenance 21.89 (6.35) 18.48 (6.72) Work 53.29 (16.69) 28.96 (25.00) p < .001 23.85 (15.21) 25.80 (16.50) Leisure Alcohol-related

activites
Total hours awake daily

0.97 (2.41) 26.76 (20.29) p < .001 16.18 (1.31) 14.84 (2.39) p < .05

*Not significant Note: Reprinted with permission from "Temporal Adaptation and Alcoholism" by M. Scaffa. Master's Project, Virginia Commonwealth University, 1981.

In summary, this study provided preliminary evidence that the volition and habituation subsystems of alcoholics may differ from that of normals. There was decreased participation in interests, and a maladaptive habit pattern characterized by deficits in the worker role. It would, thus, be interesting in future studies to examine the perceived roles of alcoholics. The major weaknesses of this study were that the sample was one of convenience; that the time log did not have demonstrated reliability and validity; and that there was some variation in the format for administration of the instruments. Owens (1982) conducted a study of spinal cord injured persons in which she predicted an association between the status of the volition subsystem and the level of productive output. She examined a group of 30 middle class persons who had incurred paraplegia or incomplete quadriplegia (i.e., with upper extremity strength rated as good or above). These subjects ranged from 4 to 39

years since their original injury and all demonstrated favorable adjustment to their disability. The productivity or output variable was assessed by having subjects report their daily activities in a log over a 2-day period typical of their lifestyle. The log was adapted from a 24 hour diary developed by Berk and Berk (1979). Data from the log were compiled into fact sheets that were independently rated by three occupational therapists. Each therapist ranked the 30 subjects from most to least productive. Interrater reliability for this procedure was .84 and the average rank from the three ratings was used as the productivity score of each subject. Owens also administered the expectancy questionnaire designed by Kemp and Vash (1971) which determines a subject's future goals. The goals are categorized as functional, vocational, avocational, materialistic and family/interpersonal. Personal causation of the subjects was measured by the Personal Opinion Srvey (Owens, 1982). This instrument provides a series of scores in seven subscales such as achievement through conscientious effort and control over large-scale social and political events. Data on interests were collected by administering the Interest Checklist (Matsutsuyu, 1969) in the likert format developed by Rogers, Weinstein, and Figone 0 978). Owens predicted correlations between the measures of personal causation, interests, and goals and the productivity levels of the subjects. The number of goals expressed overall and the number of goals in each of the subcategories of goals, failed to yield significant correlations with productivity levels (See Table 4). Similarly the number of interests in the "like" and "like very much" categories failed to correlate significantly with productivity. However, the number of interests expressed in association with goals for the future showed a significant correlation with productivity. Only one of the personal opinion subscales, "control over large-scale social and political events" had a significant correlation with productivity. A number of factors may explain the results. First of all, quantifying interests and goals as the total reported, is probably not optimal. Sheer numbers of interests and goals may not be reflective of healthy patterns. The fact that interests associated with goals showed the only significant correlation suggests that the overall meaningfulness of the activities may be important. In response to these study findings, related concepts in the literature, and the observations of therapists, the original concept of valued goals (Kielhofner and Burke, 1980) has been expanded to include time orientation goals, standards, and meaningfulness of activities (Kielhofner and Burke, Manuscript in Preparation). Findings on the personal causation variables are more difficult to interpret. It might be that the more global outlook of control indicated in the variable which did correlate, is the dimension of personal causation that most effects productivity. Other factors that may have affected the overall pattern of correlations are the instrument, the sample size and the overall homogeneity of subjects on the productivity variable. Inclusion of subjects expressing more difficulty in adjusting to their
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Table 4 Correlations of Goals and Interests and Personal Causation with Productivity
R-Value P-Value

Total goals Vocational Goals Avocational Goals Functional Goals Materialistic Goals Family Goals Total Interests (like & like very much Interests in Association with Goals Achievement through Conscientious Effort Personal Confidence in Mastery Capacity of Mankind to Control its Destiny Successful planning and organization Self-control over internal processes Control over large-scale political/social events Control in social interaction

- .004 .30 - .04 - .04 - .29 .13 .24 .55 - .17 .08 - .19 - .16 .03 .43 .13

.98 .11 .83 .84 .12 .49 .21 .005 .37 .65 .31 .39 .88 .02 .48

Note: Table adapted from "A Study of the Occupational Behavior of Physically Disabled Persons: Motivation and Productivity" by J. Owens. Master's Project. Virginia Commonwealth University, 1982. Reprinted with permission.

disability may provide a clearer picture of the relationship of volition to adaptation. Finally, this study only examined one aspect of adaptation, fulfilling the external demands of the environment. Adaptation also involves personal satisfaction. Since the volition subsystem is responsible for choices the individual makes it would be of interest to examine the relationship between volition status and the degree of personal satisfaction in the output or occupational behavior of such subjects. Riopel (1983) studied elderly individuals, examining how the relationship between the output, (i.e., occupational behavior) and volition impacted their life satisfaction. The study was conducted in two phases: 1) instrument development, and 2) empirical examination of the relationship between operationalization of volition in occupational behavior and life satisfaction. In order to study how volition was operationalized in everyday occupational behavior, the investigator developed the Occupational Questionnaire. This instrument is an adaptation of the traditional activity configuration in which persons report the activities of a typical day for each half hour period of waking. Subjects also categorize each activity as either work, leisure, daily living tasks, or rest, and rate each activity according
APRIL/AVRIL 1984

to the degree of value, interest and competence (or personal causation) it represents for them. In this way the instrument seeks to examine not only what a person does, but also its relationship to the three components of the volition subsystem. In the first phase of the study, retest reliability of the measure was examined by administering it two weeks apart to a convenience sample of 20 adults. Percent agreement on daily activities for the two administrations was 68%. The ratings of activities reported on both forms, yielded percent agreements ranging from 77% to 87%. The validity of the report of a typical day can be seen as the degree to which it is a good estimate of an actual day in the respondent's current life. Thus, to examine validity, data gathered with the instrument was compared to the responses on an activity diary (Berk and Berk, 1979) for 18 senior occupational therapy students. Percent agreement between the typical day report on the occupational questionnaire and the diary was 82% for the type of activity done in a given half-hour period. Percent agreement for classification of activities was also quite stable: 97% of those activites classified as work and 90% of those classfied as leisure were similarly designated on both questionnaires. There was also a high percent agreement between activities rated as pleasant and satisfying on the log and those designated as being highly related to the volition dimensions of value (92%), interests (89%), and personal causation (86%). In the second phase of the study the occupational questionnaire was administered to sixty individuals from 65 to 99 years of age who lived in a nursing home or attended a senior center. It was hypothesized that the life satisfaction expressed by these subjects would be correlated with the degree of volitional influence on their activities. Volition scores for each of the three variables was calculated by assigning values to the ratings 1 = lowest, 5-highest) and adding up the scores. Correlations between interest, valued goals and personal causation were found (see table 4). Positive correlations were also found for work, recreation and the overall amount of active time (See table 5). Interestingly, the correlation was slightly negative for the amount of time spent in daily living tasks and rest. This, as well as other correlations, may have been affected by confounding variables such as health status. That is, a person with poorer health may require more time for activities of daily living and rest. In order to control for such effects, partial (Pearson) correlations were calculated for all the activity and volition variables while controlling for 10 demographic variables which were found in the literature to influence life satisfaction. As expected most of the correlations were eliminated by this procedure. However, the value dimension of volition was still significantly correlated (r = .35, p = .03) when other variables were controlled. This suggests that the degree of importance or worth that elderly persons attach to their daily activities has an impact on life satisfaction apart from other important variables such as their health, marital and economic status. However, since the partial correlations were Pearson as opposed to Spear-

Table 5 Spearman Correlations of Life Satisfaction with

Likert Values of the Components of the Volition

Subsystem and Percent of Time Spent in Daily Occupations
Variables Spearman correlation Probability level

Interests Valued goals Belief in skill and efficacy Work Daily living tasks Recreation Rest Active time

0.26 0.40 0.39 0.27 0.11 0.18 0.23 0.36

0.04 0.002 0.002 0.007 0.21 0.05 0.02 0.0001

Note: Adapted from "An Examination of the Occupational Behavior and Life Satisfaction of the Elderly" by N. Riopel, (Master's Project, Virginia Commonwealth University, 1982). Reprinted with Permission.

man correlations, comparisons must be interpreted cautiously. This study provides support for the model assertion that the output of the system or occupational behavior, is related to the type of feedback (i.e., satisfaction) the individual receives. Because the study measured output in terms of harmony with volition it supports the system's principle that the overall organization and harmony of a system is more important than the status of discrete elements. For example, it was not the sheer amount of activity, but the value of activity, which appears to be most associated with life satisfaction. Oakley (1982) designed a study to investigate the practical utility of the model in psychiatric occupational therapy and to investigate theoretical tenets of the model. A battery of instruments was developed to measure the organization of the three subsystems. It was hypothesized that organization of the system, which reflected both the state and interrelationships of the subsystems, would be associated with the adaptive behavior or output of the system. In addition the model assertion that the system's past history of experiences is reflected in present organization was examined by collecting data on the patient's occupational behavior and hospitalization in the past five years and correlating it with present organizational status. An instrument battery was selected after a review of the literature identified areas of potential difficulty and disorganization in psychiatric patients. The volition section of battery consisted of: 1) the Personal Causation variable, locus of control as measured by the Rotter (1966) internal/external scale; 2) the value dimensions of time orientation as measured by Roos' & Albers' (1965) Time Inventory and goals as measured by the Expectancy Questionnaire of Farham-Diggory, (1966);

and 3) interest pattern as reported on the Interest Checklist (Matsutsuyu, 1969). The habituation subsystem data was gathered by the Role Checklist, an instrument developed for this study to identify internalized roles Finally, skills in the performance subsystem were measured by using the shell sort, deposit slip, and house floor plan subtasks of the Bay Area Functional Performance Evaluation (Bloomer & Williams, 1975). The data from all these instruments were converted into a single score which represented the overall organization of the system. This score was obtained by providing the subjects' responses on each instrument to an occupational therapist unaware of the subject's identity, sex, medication status a.nd diagnosis. Based solely on data from the instrument battery and the subject's age and occupation, the therapist blindly rated each subject on the organization disorganization continuum. This continuum ranged from "very organized", defined as the ability to function independently in the community, to "very disorganized", defined as the inability to function independently even with assistance. Additional data collection for the study included: 1) determination of the subject's diagnosis from the charts, 2) a measure of the patient's level of symptomatology using the patient self-report and staff versions of the Modified Brief Psychiatric Rating Scale (Overall and Goharn, 1962), and 3) measurement of the patient's present level of adaptive functioning by having the nursing staff administer the independent functioning, economic activity, and domestic activity subsections of the Adaptive Behavior Scale (American Association on Mental Deficiency, 1975) a measure of past history including the percent of time hospitalized and the percent of time in an occupational role in the past 5 years. Thirty subjects (13 males and 17 females) were included in the study. Fifteen subjects were diagnosed as having a major affective disorder, nine as schizophrenics, four as personality disorders and two as unclassified psychotic disorders. At the time of the study 17 subjects were on psychoactive medication. Data on the organization of the system revealed interesting patterns for this group. Subjects scored more in the direction of external locus of control than the norm for the scale, a finding compatible with other studies that feelings of external control are associated with psychiatric disorder. The subjects were more pastoriented and less future-oriented than the norm and two-thirds of the sample could express no more than two goals. Interest patterns were variable and difficult to interpret in aggregate form. All the subjects had at least one disrupted occupational role and as a whole they performed few roles on a continuous basis. Finally, as a group the subjects performed below the norm on the Bay Area Functional Performance Evaluation subtasks. In sum, this group demonstrated disorganization throughout the three subsystems. The utility of the organization/disorganizational rating was examined by correlating it with the adaptive level of functioning score obtained from the Adaptive Behavior Scale. Correlation between the organizational
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status variable and adaptive level of functioning was .85 (p = .0001) for all patients and remained similarly high for affective disorders (r = .82, p = .0002) and schizophrenia (r = .86, p = .0003), females (r = .85, p = .0003) and males (r = .92, p = .0001), patients on medication (r = .92, p. 0001) and off medication (r =

.64, p = .02).
The pattern of telationships between symptomatology and adaptive level of functioning was much weaker. For the entire sample, correlations for self-reported symptomatology was .41 (p = .05) and for staff-reported symptomatology was .55 (p = .05). These correlations did not hold up for diagnostic subsamples, except for an association (r = .57, p = .03) of staff rating of symptomatology with adaptive level of functioning of the major affective disorder subsample. The relative utility of the organizational status variable as opposed to diagnosis in indicating adaptive level of functioning was examined through a Gineral Linear models procedure. Organization status had an effect on adaptive level of functioning (significant at the .0001 level) whereas diagnosis had no effect (p = .71). Correlation between the time in an occupational role in the past 5 years and present organizational status was in the expected direction but nonsignificant (r = .30, p = .11). Within the major affective disorder subsamples there as a significant correlation (r = .53, p = .04), but the schizophrenia subsample did not yield a significant correlation (r = .08, p = .85). Correlations with the percent of time hospitalized in the past five years was negative as expected for the overall sample (r = .37, p = .04) although the diagnostic subsamples did not yield significant correlations. In summary the study provided support for the utility of the model of occupation as a framework for understanding function and dysfunction in psychiatric patients. When compared to diagnosis and symptomatology the organization/disorganization variable was more strongly associated with a measure of adaptive functioning. This finding also supports the model assertion that the status of the system's internal organization is an important determinant of output. The findings were supportive but mixed on the relationship between past experience and present organization of the system. Refinement of the measures to include not only the amount of time in an occupation but also the quality of performance, is needed.

A limitation of this study was the non-random sample. However a number of psychiatric diagnosis were represented and the association supporting the model tended to hold up for diagnostic subsamples. The study raises a number of questions for further study (such as the predictive validity of this battery) and invites further investigation to refine the battery and replicate findings in other psychiatric settings. Kavanagh (1982) examined the relative impact of intellectual deficits, volition variables and environment on mentally retarded adults' levels of competency. Data were collected on all three volition variables. Personal causation was measured via the Farham-Diggory (1966) Self Evaluation Scale. Data on interests were collected through the use of the Avocational Picture Interest Inventory (Kavanagh, 1982) which was developed for use in this study by modifying the interest checklist (Matsutsuyu, 1969). Forty activities from the interest checklist were chosen based on judgements of their relevance to the study population. Photographs of each activity were presented to each subject who responded to whether or not they were interested in the activity. Values were operationalized through two measures, the shortened form of the Time Reference Inventory developed by Roos and Albers (1965) which measures temporal orientation, and the Expectancy Questionnaire of Farham-Diggory (1966) which collects data on the future goals of subjects. Data were collected from official records on the degree of intellectual impairment of each subject. The degree of competency in occupational behavior was assessed by three instruments which indicated the level of participation of subjects in three environments, work (i.e., the sheltered workshop) leisure, and home. These instruments were based on procedures of ecological observation originally developed by Barker and Wright (1971). The scales rate degrees of penetration (i.e. the degree of competent participation) in activities in each behavior setting. The lowest level of penetration is onlooker and the highest is leader. Based on the instrumentation of this study it was hypothesized that the level of penetration of persons would be correlated with volition variables and that it would vary from setting to setting. Finally, the impact of the environment and volition was compared to the impact of intellectual impairment on levels of penetration.

Table 6 Correlations of Level of Retardation and Volition with Environment Penetration

Penetration Level of retardation Personal causation Interests Future orientation Valued goals

Work Play Home Total

.12 .24 .10 .24

.09 .29 .16 .10

.34* .37* .52** .16

.32 .18 .12 .23

* P < .10 ** P < .05 Note: From "Person-Environment Interaction: The Model of Human Occupation Applied to Mentally Retarded Adults" by M. Kavanaugh (Master's Project, Virginia Commonwealth University, 1982) Reprinted vvith permission. APR1L/AVRIL 1984

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Twenty three subjects with a mean age of 32 were included in the study. The level of retardation ranged from mild to severe; most subjects fell in the moderate range. The degree of intellectual impairment yielded no significant correlations with levels of penetration in any of the environments or with an overall penetration score (See Table 6). Similarly, there were no significant associations between personal causation and penetration. However, both interests and valued goals yielded significant associations and the general patterns of correlations (though not all were significant at the p = .05 level) were in the expected directions. Future orientation yielded a pattern of negative associations, though none were statistically significant. When the variation of penetration across environments was examined via one-way analysis of variance, there was a significant effect (F = 19.76, p .001). Tukey's Test of Honest Significant Difference indicated a significant (p = .05) difference of penetration in all three settings with home being the highest and work the lowest. The pattern of findings generally supports the model of human occupation. While level of retardation was not associated with environmental penetration, both interests and valued goals yielded a pattern of correlations in the expected direction. While this group showed the greatest competence in the home environment, they demonstrated the most autonomy in the play environment. Findings for the personal causation measure and the time orientation measure are difficult to interpret but may be related to the limitations of instrumentation. Both personal causation and temporal orientation are complex and elusive variables especially for this population. The overall pattern of findings supports the argument that volition variables and the environment are important factors in determing the level of competence in the behavior of retarded persons. This study is certainly limited by a number of factors including the fact that several preliminary and untested measures were developed and used. However, it paves the way for other related studies of mentally retarded adults.

which assume randomness, they must be interpreted cautiously. Further, small sample sizes may also account for some nonsignificant and weak associations found in the studies. It will be the pattern of findings over several investigations that is important to look at when weighing the plausibility and generalizability of findings. Another vveakness of the studies is that few well-developed measures exist for many of the model variables, especially those in the habituation and volition subsystems. Thus, studies often have to employ measures with no or little reliability and validity data to support them. Finally, because the research tradition on the model is just beginning, there are not clear pathways of inquiry charted for researchers. Thus, the studies are largely descriptive studies asking first level questions and providing only tentative answers. Each of these weaknesses can, in one way or another, be linked to the fact that inquiry on the model is in its infancy. The major strength of these inquiries is that the model has become a framework for a tradition of research. Researchers can now begin to look to work that has preceded their own as a framework for further inquiry. A number of planned studies and studies in process will refine or develop needed measures for research on the model. Other studies seek to replicate and improve the methods of previous studies. These studies will become the bases for more refined inquiry over time, so that the quality and specificity of research naturally increases. Thus, the most important aspect of all the research examined herein is that it provides a foundation for future directions and efforts. REFERENCES
American Association on Mental Deficiency, Adaptive Behavior Scale Manual, 1975. Barker, R. and Wright, H. Midwest and its Children. Hamden, Conn.: Archon Books, 1971 (Reprint of 1955 edition). Barris, R. Environmental Interactions: An extension of The Model of Occupation. American Journal of Occupational Therapy, 1982, 36, 637-644. Beery, K. and Buktenica, N. The Development Test of Visual Motor Integration, Chicago: Follett Publishing Company, 1967. Berk, R. A. and Berk, S. F. Labor and Leisure at Home: Content and Organization of the Household. Beverly Hills, California: Sage Publications, 1979. Bloomer, J. & Williams, S. Bay Area Functional Performance Evaluation. San Francisco: (Research Edition), 1979. Cavin, R., Burgess, E., Goldhamer, H., and Havighurst, R. Personal .44justment in Old ,4ge. New York: Arno Press, 1979. Coopersmith, S., "A Method for Determining Self Esteem". Journal of Abnormal and Social Psychology, 1975, 59, 187-194. Farham-Diggory, S. Self, Future, and Time: A Developmental Study of the Concepts of Psychotic, Brain-Damaged, and Normal Children. Monographs of the Society for Research in Child Development, 1966. 31, (1, Serial No. 103). Gregory. M. Occupational Behavior and Life Satisfaction Among Retirees. American Journal of Occupational Therapy. 1983. 37, 548-553. Gubbay, S. S. "A Standardized Test Battery for the Assessment of Clumsy Children". Australian Association of Neurologists Proceedings, 1974, //, 19-25. Kavanagh, M. Person-Environment Interaction: The Model of Human Occupation .4 pplied to Mentally Retarded Adults. Masters' Project, Virginia Commonwealth University, 1982. Kemp, B. J. and Vash. C. L. Productivity after Injury in a Sample of Spinal Cord Injured Persons: A Pilot Study. Journal of Chronic Disease, 1971, 24, 259-275. CJOT VOL. 51 NO. 2

Summary and Conclusions

This paper overviewed studies based on the model of human occupation presenting their research focus and findings. Several points can be derived from these studies: 1) the model is a workable conceptual framework for research with applications in many areas of occupational therapy, 2) the patterns of findings provide preliminary, tentative support for the theoretical tenets of the model, 3) empirical investigation can profitably be used to correct, expand and elaborate this model, and 4) findings point to the potential utility Of the model as a clinical tool. The studies represented in this paper all have weaknesses that should be acknowledged and considered in evaluating the findings. One major weakness is that the studies had to rely on small convenience samples. Because the analyses often employed inferential statistics

Kielhofner, G. A Model of Human Occupation, Part II. Ontogenesis from the Perspective of Temporal Adaptation. American Journal of Occupational Therapy. I980a, 34, 657-663. Kielhofner, G. A Model of Human Occupation, Part III. Benign and Vicious Cycles, A merican Journal of Occupational Therapy, 19806, 34, 731-737. Kielhofner, G. and Burke, J. A Model of Human Occupation, Part I. Structure and Content. American Journal of Occupational Therapy, 1980, 34, 572-581. Kielhofner, G. & Burke, J. Human Occupation: Its Components and Determinants. In G. Kielhofner (Ed.) A Model of Human Occupation; Theory and Application. Baltim . ore: Williams & Wilkins, Manuscript in Preparation. K elhofner, G., Burke, J. & Igi, C., A Model of Human Occupation. Part IV. Assessment and Intervention. A merican Journal of Occuparional Therapy, 1980, 34, 777-788. Mailloux, Z. The Relationship Between Self Esteem and Visual Motor
Integration, Praxis, and Student Role Performance in Children with Learning Disabilities. Masters' Thesis. Los Angeles, CA: University

of Southern California, 1980. Matsutsuyu, J. S. The Interest Checklist. American Journal of Occupational Therapy, 1969, 23, 323-328. Nystrom, E. Activity Patterns and Leisure Concepts Among the

Elderly. American Journal of Occupational Therapy. 1974, 28, 337345. Oakley, F., Barris, R., Kielhofner, G. The Model of Human Occupation in Psychiatry'. Masters' Project, Virginia Commonwealth University, 1982. Overall, J., and Gorham, D. The Brief Psychiatric Rating Scale, Psychological Reports, 1962, /0, 770-812. Owens, J. S. A Study of the Occupational Behavior of Physically Disabled Persons: Motivation and Productivity. Masters' Project, Virginia Commonwealth University, 1982. Riopel, N. An Examination of the Occupational Behavior and Life Satisfaction of the Elderly. Masters' Project, Virginia Cornrnonwealth University, 1983. Rogers, J., Weinstein, J., and Figone, J. Interest Checklist: An Empirical Assessment. American Journal of Occupational Theraps 1978, 32, 628-630. Roos, P., and Albers, R. Performance of Retardates and Normals on a Measure of Temporal Orientation. A merican Journal of Mental Deficiency, 1965, 69, 835-838. Rotter, J. Generalized Expectancies for Internal versus External Control of Reinforcement. Psychological Monographs, 1966, 80, (1, Whole No. 609). Scaffa, M. Temporal Adaptation and Alcoholism. Masters' Project, Virginia Commonwealth University, 1981.

Rsum
Le modle de l'Occupation humaine publi dans l'American Journal of Occupational Therapy fut propos comme systme de rfrence pour la recherche et l'application clinique. Cet article revoit brivement le modle et les principes en provenant pour l'exprimentation empirique. Un certain nombre d'tudes, selon le modle, sont prsentes et values. Ces tudes fournissent gnralement un appui aux principes thoriques du modle. En plus, elles illustrent que le modle peut tre utilis comme systme de rfrence pour la recherche et pour dvelopper, dans le milieu clinique, des procdures valuatives appropries. Mme si les tudes sont prliminaires et montrent certaines faiblesses, elles constituent une tradition de recherche qui permettra la conduite de recherches plus sophistiques dans l'avenir.

NOTICE
Canadian Association of Occupational Therapists, CERTIFICATION EXAMINATION As of October 1985, a CAOT Certification Examination will be in place. Individuals required to write the examination will be: Anyone seeking to establish eligibility for membership in CAOT including, but not limited to: (i) All new graduates from Canadian university programs in occupational therapy accredited by CAOT; (ii) All graduates educated outside Canada from programs recognized by the World Federation of Occupational Therapists. Note: Those occupational therapists who are members of CAOT at the date of implementation of the examination and who maintain that membership will not be required to write the examination. Therapists having established their eligibility for membership prior to the date of implementation of the examination will not be required to write the examination, until it comes time to re-establish their eligibility.

AVIS Association Canadienne des Ergothrapeutes EXAMEN DE CERTIFICATION

partir du mois d'octobre 1985 aura lieu un examen de certification de l'ACE. Ceux qui devront passer cet examen sont: Toute personne cherchant . tablir son ligibilit tre membre de l'ACE, y compris (mais sans tre exclusif

a):

(i) tous les nouveaux gradus de programmes universitaires canadiens en ergothrapie accrdits par l'ACE; (ii) tous les gradus ayant reu leur ducation hors du Canada dans des programmes reconnus par la Fdration Mondiale d'Ergothrapie. noter: Il ne sera pas exig aux ergothrapeutes membres de l'ACE au moment de l'entre en vigueur de la date de l'examen et qui maintiennent cette qualit de membre, de passer l'examen. La prsentation de l'examen ne sera pas exige non plus (jusqu'au moment de rtablir leur ligibilit de membre) aux ergothrapeutes ayant dj tabli cette ligibilit pralablement la date d'entre en vigueur de l'examen. 67

APRIL/AVRIL 1984