Comparison of ADL Motor and ADL Process Skill Profiles Among Groups With Bipolar Disorder Depressed Episode, Bipolar Disorder Manic Episode, and Schizophrenia

COMPARISON OF ADL MOTOR AND ADL PROCESS SKILL PROFILES AMONG
GROUPS WITH BIPOLAR DISORDER DEPRESSED EPISODE, BIPOLAR

DISORDER MANIC EPISODE, AND SCHIZOPHRENIA
by
Karla Moore
Submitted in partial fulfilment of the requirements

for the degree of Master of Science
at
Dalhousie University
Halifax, Nova Scotia
March 2009
© Copyright by Karla Moore, 2009

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Appendices
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TABLE OF CONTENTS
LIST OF TABLES vi
ABSTRACT vii
LIST OF ABBREVIATIONS USED viii
ACKNOWLEGEMENTS ix
CHAPTER I: INTRODUCTION 1
Prologue 1
Introduction 2
CHAPTER II: LITERATURE REVIEW 10
Overview of the Literature Review 10
ADL Performance Limitations Among Persons with Schizophrenia or 10
Bipolar Disorder
Performance Analysis 15
Assessment of Motor and Process Skills 18
Administration 20
Interpretation 23
Intervention Planning 24
Rasch Measurement Model 26
ADL Motor and ADL Process Skill Hierarchies 32
ADL Motor and ADL Process Skill Profiles 34

Purpose of the Study 38
IV
CHAPTER III: STUDY DESIGN AND RESEARCH METHODS 40
Research Design 40
Participants 41
Data Analysis 43
CHAPTER IV: RESULTS 46
Comparison of Diagnostic Groups 46
ADL Motor and ADL Process Ability Measures 47
Differential Item Function and Differential Test Function 48
CHAPTER V: DISCUSSION 51
Clinical Implications 55
Limitations of the Study 59
Future Research 63
CHAPTER VI: CONCLUSION 65
REFERENCES 66
v
LIST OF TABLES
Table 1 AMPS ADL Motor and ADL Process Skill Items and Difficulty
Calibrations 7
Table 2 Mean Age and ADL Ability by Diagnosis , 46
Table 3 Number of Participants in each Diagnostic Group by Functional Level

and Gender 47
Table 4 ADL Motor Skill Item Calibration Values (logits) for each Diagnostic
Group 49
Table 5 ADL Process skill Item Calibration Values (logits) for each Diagnostic
Group 50
VI
ABSTRACT
Background: Knowledge of ADL ability and skill profiles for some diagnostic
groups has lead to recommendations regarding interventions. Similar research has been
recommended for persons with mental illness. Purpose: Determine if there are significant
differences in ADL ability and skill profiles between groups with bipolar disorder
depressed or manic episode, and schizophrenia. Methods: Mean ADL ability and skill
item calibrations of each group were compared. Findings: No clinically significant
differences were found in mean ADL ability among the groups. Attends was more
difficult for the group with bipolar disorder manic episode as compared to the group with
bipolar disorder depressed episode. This difference in skill challenge did not disrupt the
measurement model. Implications: The AMPS is a valid evaluation for the three
diagnostic groups. Interventions are recommended to address limitations in Attends.
There is little evidence to support valid predictions of skill strengths and weaknesses
based on psychiatric diagnosis.
vii
LIST OF ABBREVIATIONS USED
ADL Activities of daily living

DIF Differential item function
DTF Differential test function
IADL Instrumental activity of daily living
PADL Personal activities of daily living
viu
ACKNOWLEGEMENTS
I have learned that a Master's thesis is not solely the work of one graduate student, but is
shaped and supported by many others. I would like to acknowledge a number of people in
particular for their contributions and support. First, thank you to my mentors Brenda
Merritt (thesis supervisor) and Susan Doble (committee member) for their wisdom and
guidance during the process. A special thank you to Brenda Merritt for her patience,
teachings, and numerous edits and to Susan Doble for her emotional support. Thank you
to Crystal Grass for being my external reviewer and bringing new insights into my thesis.
Next I must thank Ann Fisher for allowing me access to the AMPS Project International
database, Brett Berg for the data collection, and my OT and social worker friends in the
Mental Health Division for their support. Last, but certainly not least, thank you to my
husband, Scott (my personal IT Help desk), and my young daughter, Sarah, for their
support and understanding of the time that I needed to be away from our family.
IX
CHAPTER I: INTRODUCTION
Prologue
One day I was completing an Assessment of Motor and Process Skills (AMPS)
with a client with schizophrenia and I observed that his pace of performance was slow.
Since I had often observed that Paces was an activity of daily living (ADL) process skill
weakness for clients with schizophrenia, I wondered if Paces is an ADL process skill that
is typically for difficult for people with schizophrenia. I explored this query in the
literature and I discovered that unique ADL motor and ADL process skill profiles
(patterns of ADL motor and ADL process skills strengths and weaknesses for a specific
group) have been explored for persons with stroke, intellectual disability, and
Alzheimer's disease (Bernspang & Fisher, 1995a; Cooke, Fisher, Mayberry, & Oakley,
2000; Kottorp, Bernspang, & Fisher, 2003a; Oakley, Duran, Fisher, & Merritt, 2003;
Rexroth, Fisher, Merritt, & Gliner, 2005). Researchers explored unique group ADL
motor and ADL process skill profiles by comparing a diagnostic group to a well group
and/or comparing a diagnostic group to another diagnostic group and subsequently used
their knowledge of the existence or lack of existence of unique ADL motor and ADL
process skill profiles to make recommendations of intervention strategies to improve
persons' quality of ADL performance (Bernspang & Fisher, 1995a; Cooke et al., 2000;
Kottorp et al., 2003a; Oakley et al, 2003; Rexroth et al., 2005). Additionally, I noted that
Girard, Fisher, Short, and Duran (1999) recommended comparing skill profiles among
psychiatric groups, but to date, such research has yet to be completed.
1
As I set out to define my research question, I learned that there were not enough
well people in the AMPS Project International database to enable a comparison of a
diagnostic group to a well group (A Fisher, personal communication, February 20, 2008).
In light of this information, I considered the request of occupational therapists who have
asked the AMPS International Project if there are differences in ADL motor and ADL
process skill profiles between persons with schizophrenia and bipolar disorder manic
episode. Therefore, I decided to compare ADL motor and ADL process skill profiles
among various psychiatric groups to find out if there are specific ADL motor and ADL
process skills that are significantly difficult or easy for a group, knowledge of which may
lead to recommendations regarding intervention strategies to improve the quality of
persons' ADL performance.
Introduction
Bipolar disorder and schizophrenia are two of the ten leading causes of disability
worldwide (World Health Organization [WHO], 2002). Disability is evidenced by
decreased skilled performance in (a) instrumental ADL (IADL) tasks (e.g., cooking,
home maintenance) and/or personal ADL (PADL) tasks (e.g., grooming, dressing), (b)
work tasks, (c) leisure activities, and/or (d) social activities (Calabrese et al., 2003;
Honkonen, 1995; Simon, Bauer, Ludman, Operskalski, & Uniitzer, 2007; Thornicroft et
al., 2004). In many cases, adults with schizophrenia demonstrate limitations in their
quality of performance (Fossey, Harvey, Plant, & Pantelis, 2006; Girard et al., 1999;
Hamera & Kolenbrander, 2000; Honkonen, 1995). More specifically, they may
demonstrate difficulty performing the ADL process skills Searches/Locates, Sequences,
2
and Continues (Rempfer, Hamera, Brown, & Cromwell, 2003; Semkovska, Bedard,
Godbout, Limoge, & Stip, 2004). Initial steps have also been taken to document the ADL
performance limitations of persons with bipolar disorder with depressed or manic episode
(Dion, Tohen, Anthony, & Waternaux, 1998; Levine, Chenpgappa, Brar, Gershon, &
Kupfer, 2001; Pope, Dudley, & Scott, 2007; Simon et al., 2007), although the focus has
not been at the level of specific actions of ADL performance. Thus, while there is
evidence that some persons with bipolar disorder depressed or manic episode, or
schizophrenia demonstrate limitations in their quality of ADL performance, little is
known about the specific actions of ADL performance that they perform well, those
actions that they have difficulty performing, and whether there are diagnostic-specific
patterns of skill strengths and weaknesses among the three groups.
One way to assess persons' overall ADL ability and their quality of ADL
performance is to use the AMPS (Fisher, 2006a). The AMPS is a standardized
performance analysis. A performance analysis refers to an evaluation of persons'
occupational performance by direct observation of their performance of culturally
relevant, familiar, and appropriately challenging tasks within natural environments
(Fisher, 2006a). Quality of ADL performance refers to the "effort, efficiency, safety, and
independence of goal-directed actions that the person enacts" when performing ADL
tasks (Fisher, 2006a, p.4). These goal-directed actions are referred to as ADL motor and
ADL process skills (Fisher, 2006a). ADL motor skills are "observable, goal-directed
actions that a person enacts during the performance of ADL tasks in order to move
oneself or the task object" (Fisher, 2006a, p. 4). For example, when making a pot of
coffee, a person reaches for, grips and lifts the coffee pot. ADL process skills are
3'
"observable actions of performance the person enacts to logically sequence the actions of
the ADL task performance over time, select and use appropriate tools and materials, and
adapt his or her performance when problems are encountered" (Fisher, 2006a, p. 4). For
example, when making a pot of coffee, a person chooses the coffee pot and gathers the
coffee pot to the workspace.
Within the AMPS, 16 ADL motor skills and 20 ADL process skills, the smallest
units of occupational performance that can be observed, are rated (Fisher, 2006a). All of
the ADL motor and ADL process skills are universal goal-directed actions that are
enacted in every PADL and I ADL task performance. In other words, when performing
any PADL or I ADL task, a person will perform each of the 16 ADL motor and 20 ADL
process skills to complete the task.
There is ample evidence that performance analyses, such as the AMPS, are more
valid means of predicting ADL ability than predictions based on underlying
capacities/body functions (Bouwens et al., 2007; Doble, Fisk, Lewis, & Rockwood, 1997;
Evans et al., 2003; Harvey et al, 1998; Kizony & Katz, 2002; Mathiowetz, 1993; Mori &
Sugimura, 2007; Rice, Leonard, & Carter, 1998; Robinson & Fisher, 1996; Nygard,
Amberla, Bernspang, Almkvist, & Winblad, 1998; Velligan et al., 1997, 2000). For
example, even though cognitive impairments are considered a core feature of
schizophrenia (Bowie & Harvey, 2005; Fioravanti, Carlone, Vitale, Cinti, & Clare, 2005;
Sharma & Amtonova, 2003), and possibly bipolar disorder (Green, 2006), cognitive body
function only accounts for small to moderate variation in occupational performance for
persons with schizophrenia (i.e., from between 16% to 62%) (Evans et al., 2003; Harvey
et al., 1998; Velligan et al, 1997, 2000). Other factors, such as chronic
4
institutionalization and side-effects of typical antipsychotic medications, also exert an
influence on occupational performance (Harvey et al., 1998). Due to the small to
moderate associations that body functions have with everyday abilities, it has been
argued that direct observation of ADL performance is the most valid and accurate means
of determining a person's ability to perform desired/necessary daily life tasks (Bouwens
et al., 2007; Robinson & Fisher, 1996; Doble et al, 1997; Kizony & Katz, 2002; Mori &
Sugimura, 2007; Nygard et al., 1998). While occupational therapists may also administer ,
tests of body function assessments, it has been suggested that they only be used when
there is a need to further explain the cause of functional limitations (Fisher, 2006a).
There is also evidence that performance analyses, such as the AMPS, are more
valid means of predicting ADL ability than predictions based on self or proxy reports
(Doble et al., 1997; Doble, Fisk, MacPherson, & Rockwood, 1999; Law, 1993; Zanetti,
Geroldi, Frisoni, & Trabucchi, 1999). Underestimations and overestimations of persons'
occupational performance can reflect (a) clients' lack of insight and/or cognitive
impairment, (b) the lack of knowledge that family members have with regard to clients'
functioning, and (c) caregiver burden (Dickerson, 1997; Doble et al., 1997, 1999; Law,
Baum, & Dunn, 2005; Zanetti et al., 1999). Again, researchers recommend that
occupational performance be assessed using direct observation of performance, rather
than relying solely on self reports and/or proxy reports (Doble et al., 1997, 1999; Law,
1993; Zanetti e t a l , 1999).
An additional advantage of using the AMPS to conduct performance analyses is
that the AMPS generates equal-interval, linear measures of the quality of a person's ADL
performance. The AMPS was developed and standardized using modern test theory,
5
Rasch measurement model, which converts raw scores into linear measures of ability
(Fisher, 2006a). The specific Rasch model used within the AMPS is the many-faceted
Rasch model, which takes into account differences in item difficulty, task challenge, and
rater severity when generating equal-interval linear measures of ADL motor and ADL
process ability measures (Fisher, 2006a). Linear measures of performance are necessary
to make valid comparisons of persons' ability over time and among different people
(Fisher, 2006a).
Based on research using Rasch analysis, we know that the 16 ADL motor and 20
ADL process skills vary in difficulty, such that some skills are easier to perform than
other skills (Fisher, 2006a). The AMPS ADL motor and ADL process skills have been
hierarchically ordered from easier to perform to harder to perform (Table 1) (Fisher,
2006a). One premise behind the Rasch measurement model is that the hierarchical
ordering of the skill items must remain stable regardless of the characteristics of the
persons being tested (Fisher, 2006a). A stable hierarchy of the skill items means that the
skill items remain in the same relative hierarchical order, regardless of the group being
evaluated. Research has shown that the ADL motor and ADL process skill item
hierarchies are stable for persons with stroke (Bernspang & Fisher, 1995b; Rexroth et al.,
2005), persons with intellectual disabilities (Kottorp et al, 2003a), men and women
(Duran & Fisher, 1996; Merritt & Fisher, 2003), and various cultural groups (Fisher, Liu,
Velozo, & Pan, 1992; Goldman & Fisher, 1997; Magalhaes, Fisher, Bernspang, &
Lincare, 1996; Stauffer, Fisher, & Duran, 2000). There is, however, no research to date to
determine if the ADL motor and ADL process skill items hierarchies are stable for
6
persons with bipolar disorder depressed episode, bipolar disorder manic episode, and
schizophrenia.
Table 1
AMPS ADL Motor and ADL Process Skill Items and Difficulty Calibrations
ADL Motor Skills ADL Process Skills
Difficulty Difficulty
Items Calibrations Items Calibrations
(in logits) (in logits)
Lifts 0.6 Uses 1.2
Easier
Endures 0.5 Attends 0.4
Moves 0.5 Chooses 0.4
Reaches 0.3 Searches/Locates 0.4
Transports 0.2 Sequences 0.3
Coordinates 0.2 Handles 0.3
Aligns 0.1 Gathers 0.2
Manipulates 0.0 Inquires 0.1
Grips -0.1 Terminates 0.1
Bends -0.1 Heeds 0.1
Flows -0.1 Continues 0.0
Stabilizes -0.2 Navigates 0.0
Calibrates -0.4 Organizes 0.0
Walks -0.4 Initiates -0.2
Paces -0.4 Restores -0.3
Positions -0.6 Adjusts -0.3
Paces -0.4
Notices/Responds -0.4
Benefits -0.7
Harder
Accommodates -1.0
7
The stability of the ADL motor and ADL process skill item hierarchies are
determined by examining ADL motor and ADL process skill item calibrations for
differential item function (DIF). Differential item function refers to test items (e.g., ADL
motor and ADL process skills) that are significantly more difficult or easier for a specific
group, such that the hierarchical ordering of items is not the same for the two groups
(Tennant & Pallant, 2007). The absence of DIF provides one piece of evidence that the
assessment tool can be used without bias (e.g., gender bias, cultural bias). However, if
DIF does exist, one must examine the data to identify the presence or absence of
differential test function (DTF). If DTF is present, the test may be biased, and caution
must be used when generating and interpreting the estimated linear measures for the
particular group for whom the test is biased. If, however, the presence of DIF does not
disrupt the estimation of the linear measures, then the evaluation tool is considered valid
and can be used without the threat of bias (Wright & Stone, 1979).
In addition to determining if the ADL motor and ADL process skill item
hierarchies are stable and if the tool is valid for use with specific groups, examining
groups for the presence of DIF can provide valuable information that can be used to
guide clinical practice. For example, identification of differences in ADL skill item
profiles for different diagnostic groups has been used to recommend intervention
strategies that build on persons' ADL performance strengths while overcoming their
performance weaknesses (Bernspang & Fisher, 1995a; Cooke et al, 2000; Kottorp et al.,
2003a; Oakley et al., 2003; Rexroth et al., 2005).
8
To date, research has not been completed to examine ADL motor and ADL
process skill profiles of people with various psychiatric diagnoses, even though such
research has been recommended (Girard et al., 1999). Therefore, this study was designed
to examine the ADL skill profiles of those with bipolar disorder depressed episode,
bipolar disorder manic episode, and schizophrenia in order to gain knowledge about their
ADL performance and to use this knowledge to make recommendations regarding
interventions to improve quality of their ADL performance. More specifically, the
purpose of this research project was to compare ADL motor and ADL process skill
profiles of these three psychiatric diagnostic groups to determine if there were clinically
significant differences in the ADL motor and ADL process skill profiles between persons
with bipolar disorder depressed episode, bipolar disorder manic episode, or
schizophrenia. It was hypothesized that:
a. the bipolar disorder depressed and manic episode groups would not differ
clinically significantly in mean ADL motor and ADL process ability
measures;
b. the group with schizophrenia would demonstrate clinically significant lower
mean ADL motor and mean ADL process ability measures than the bipolar-
depressed episode and manic groups; and
c. clinically significant differences would be found in some ADL motor and
ADL process skill item calibrations among the three diagnostic groups.
9
CHAPTER II: LITERATURE REVIEW
Overview of the Literature Review
Within this literature review, the ADL performance limitations among people
with bipolar disorder depressed episode, bipolar disorder manic episode, or schizophrenia
will be discussed and the gaps of knowledge related to this area in the literature will be
highlighted. Next, it will be explained that performance analyses have been
recommended by many researchers as a better way of predicting occupational
performance than self or proxy reports or tests of body function. Following this
discussion of performance analyses, the AMPS will be described in detail, as well as
Rasch measurement, which was used to develop the AMPS. It will be explained that
based on research using Rasch analysis, it is known that the ADL motor and ADL
process skills within the AMPS vary in difficulty, and thus have been hierarchically
ordered. According to Rasch measurement, the hierarchical ordering of the skill items
must remain stable, regardless of the characteristics of the persons being tested, for the
evaluation to be valid (Fisher, 2006a). Lastly, the research that has explored the stability
of the ADL motor and ADL process skill item hierarchies between different diagnostic
groups and the resulting recommendations that emerged with regard to intervention
strategies will be highlighted.
ADL Performance Limitations among Persons with Schizophrenia or Bipolar Disorder
It has been widely documented that some adults with schizophrenia have
limitations performing ADL tasks that are needed for independent community living
10
(Fossey et al., 2006; Girard et al, 1999; Hamera & Kolenbrander, 2000; Honkonen,
1995). For example, Girard et al. (1999) found that the mean ADL motor and ADL
process ability measures for a group with schizophrenia (n = 43), including some
participants with typical secondary diagnosis (i.e., anxiety or depression), were below the
cut-off measures of 2.0 logits on the ADL motor and 1.0 logit on the ADL process ability
scales. Such findings indicate that, in general, the group demonstrated limitations in the
quality of their ADL performance. Quality of ADL performance refers to persons'
performance "measured in terms of effort, efficiency, safety, and independence of goal-
directed actions that the person enacts" when performing ADL tasks (Fisher, 2006a). In
fact, on the basis of the sample's ADL process ability measures, 72% of the participants
in the study likely needed support to live in the community (i.e., their ADL process
ability measures were lower than the ADL process cutoff measure of 1.0 logit) (Girard et
al., 1999).
Likewise, Fossey et al. (2006) found that the ADL motor and/or ADL process
ability measures of 58% of their participants with schizophrenia (n = 43) were below the
cutoff measures of 2.0 and 1.0 logit respectively, indicating limitations in their quality of
ADL performance (i.e., decreased efficiency, decreased safety, and/or decreased
independence when performing ADL tasks). Additionally, most (86%) of the
participants' ADL process ability measures were below or within the risk zone (i.e., 1.0
to 1.3 logits), indicating that they may need assistance to live in the community (Fossey
et al., 2006). When 107 persons with schizophrenia were evaluated three years following
discharge from a psychiatric hospital, their self-report and proxy reports revealed that
approximately 20% of the participants experienced problems with PADL and
11
approximately 35% experienced problems with IADL tasks (i.e., managing money,
shopping, preparing meals, household chores, and using public transportation)
(Honkonen, 1995). Clearly, not only do persons with schizophrenia exhibit decreased
quality of ADL performance, such limitations adversely affected their ability to live
independently in the community.
An assortment of methods have been utilized to develop a greater understanding
of why persons with schizophrenia experience difficulties performing ADL tasks (e.g.,
Hamera & Kolenbrander, 2000; Rempfer et al., 2003; Semkovska et al., 2004). For
example, two studies were specifically designed to identify difficulties experienced when
grocery shopping. Hamera and Kolenbrander (2000) interviewed 50 persons with
schizophrenia or schizoaffective disorder about their grocery shopping habits. Ninety
percent reported barriers to grocery shopping; both men and women reported finding
items was a main barrier to grocery shopping, but women also reported that deciding
which brand, flavor, and size to buy was a major barrier. Rempfer and colleagues (2003)
used the Test of Grocery Shopping Skills (TGSS) (Hamera & Brown, 2000) to
investigate the shopping skills of persons with schizophrenia or schizoaffective disorder
(n = 73) who had some previous experience with grocery shopping. The TGSS is a
performance-based evaluation completed in a real grocery store. They found that
compared to a well group, those with schizophrenia or schizoaffective disorder were
significantly more inefficient when searching and locating grocery items (i.e., made more
trips down unnecessary aisles, and did not select the correct item of the correct size at the
lowest price).
12
Within the context of a shopping and cooking task, Semkovska et al. (2004)
compared the ADL performance of a group with schizophrenia (n = 27) with a control
group (n = 27). The ADL assessment required participants to: (a) choose a three course
menu from among a choice of 12 recipes that would cost no more than the amount of
money they were given, and that they could prepare within one hour, (b) shop at a local
grocery store for eight missing food items, and (c) prepare the meal in the kitchenette in
the hospital. Participants were familiar with the ADL tasks prior to participating in the
study and were shown where to find the cooking tools in the kitchenette. Participants
were scored on their ADL performance based on predetermined optimal sequences of
actions. In comparison to the control group, the group with schizophrenia demonstrated
more omissions when choosing a menu (e.g., not exploring available ingredients before
writing the shopping list); more sequencing errors (e.g., arrived at the cash register and
then returned to get a missing item) and more repetition errors (e.g., explored the same
grocery aisle more than once) when grocery shopping; and more planning, sequencing
(e.g., not cooking first, the food that takes the longest time to cook), repetition (adding
twice the amount of oil into the brownie mix), and omission errors (e.g., not putting an
egg into brownie mix) when preparing the meal. Additionally, the researchers observed
that the participants with schizophrenia were inefficient when preparing the meal ~ they
started to prepare another dish before the previous dish was completely prepared.
Together, these three studies provide evidence that some persons with
schizophrenia demonstrate limitations in their quality of ADL performance. Although not
identified as such, the skill items that the participants in these studies (Hamera &
Kolenbrander, 2000; Rempfer et al., 2003; Semkovska et al., 2004) appeared to
13
experience the most difficulty performing included searching/locating task objects,
sequencing steps of the task, and continuing actions without interruption.
There is also evidence that persons with bipolar disorder manic or depressed
episode may experience limitations performing ADL tasks (Dion et al, 1998; Levine et
al, 2001; Pope et al, 2007; Simon et al, 2007). For example, Dion et al. (1998) followed
44 persons with bipolar disorder manic or mixed episode or atypical bipolar disorder. Six
months after hospitalization, 34% of participants were unable to live independently in the
community even though 78% to 97%) of participants were considered to be asymptomatic
or experiencing only mild symptoms when evaluated using the Brief Psychiatric Rating
Scale (Overall & Gorham, 1962), the Mania Rating Scale (Young, Biggs, Zeigler, &
Meyer, 1978), and the Hamilton Depression Scale (Hamilton, 1960). Similarly, Levine et
al. (2001) found that 62% of 158 participants with bipolar 1 disorder (i.e., those
experiencing one or more manic or mixed episodes) (American Psychiatric Association
[APA], 1994) reported that they were unable to live independently. More specifically,
they reported needing constant support and assistance to perform ADL tasks such as
preparing meals, doing household chores, and paying bills for extended periods of time
(Levine etal., 2001).
In the research of Pope et al. (2007), 68 persons with bipolar I disorder and nine
participants with bipolar II disorder (i.e., they experienced one or more major depressive
episodes and at least one hypomanic episode) (APA, 1994) completed the self-report
Social Adjustment Scale (SAS) (Weissman & Bothwell, 1976). The group mean on the
S AS indicated that the participants experienced a moderate functional impairment in the
area of housework. In another study, Simon et al. (2007) explored symptoms and
14
disability with 441 participants with bipolar disorder, which included 154 (35%)
participants with depressed episode and 68 (15%) participants with manic or hypomanic
episode. Participants with bipolar disorder who were experiencing a depressive episode
reported that their illness was the reason why they were completely unable to manage
household responsibilities for an average of 20 days out of the last three months.
Similarly, participants with bipolar disorder who were experiencing a manic or
hypomanic episode reported that their illness was the reason why they were completely
unable to manage household responsibilities due to their illness for an average of 17 days
out of the last three months (Simon et al., 2007). While these studies (Dion et al., 1998;
Fossey et al., 2006; Girard et al, 1999; Hamera & Kolenbrander, 2000; Honkonen, 1995;
Levine et al., 2001; Pope et al., 2007; Simon et al., 2007) highlight that some persons
with bipolar disorder depressed episode, bipolar disorder manic episode, and
schizophrenia demonstrate limitations in their quality of ADL performance, little is
known about their specific actions of ADL performance that they perform well and those
actions that they have difficulty performing.
Performance Analysis
Many researchers recommend that the most effective way to evaluate persons'
occupational performance, including ADL performance, is to observe their performance
directly rather make predictions on the basis of self-reports and/or proxy reports (Doble
et al., 1997, 1999; Law, 1993; Zanetti et al., 1999) or underlying capacities/body
functions (Bouwens et al, 2007; Doble et al, 1997; Fisher, 2006a; Kizony & Katz, 2002;
Mathiowetz, 1993; Mori & Sugimura, 2007; Rice et al. 1998; Robinson & Fisher, 1996;
15
Nygard et al., 1998). Self reports or proxy reports can underestimate or overestimate
occupational performance for several possible reasons (Doble et al., 1999; Dickerson,
1997; Law et al, 2005; Levine et al, 2001; Zanetti et al, 1999). For example,
participants may overestimate their abilities due to lack of insight and/or cognitive
impairments (Dickerson, 1997; Doble et al., 1997). Proxies (e.g., care-giver, family
member) may overestimate or underestimate persons' abilities if they have had few
opportunities to observe persons perform everyday occupations (Dickerson, 1997; Doble
et al., 1999). Additionally, proxies who are experiencing caregiver burden may
underestimate persons' abilities (Zanetti et al., 1999).
There is ample evidence that making predictions of persons' performance on the
basis of body function can be inaccurate. Only small to moderate correlations exist
between tests of body function and occupational performance (Bouwens et al., 2007;
Doble et al., 1997; Evans et al, 2003; Harvey et al., 1998; Kizony & Katz, 2002; Mori &
Sugimura, 2007; Rice et al., 1998; Robinson & Fisher, 1996; Nygard et al., 1998;
Velligan et al., 1997,2000). Even though cognitive impairments are considered a core
feature of schizophrenia (Bowie & Harvey, 2005; Fioravanti et al., 2005; Sharma &
Amtonova, 2003) and maybe bipolar disorder (Green, 2006), predictions of occupational
performance on the basis of persons' cognitive body functions can be unreliable (Greive
& Gnanaskearan, 2008). In fact, cognitive body function accounts for only a small to
moderate variation in occupational performance for persons with schizophrenia (i.e., 16%
to 62%) (Evans et al., 2003; Harvey et al., 1998; Velligan et al., 1997, 2000). While
moderate correlations indicate that the variables are related, larger positive correlations
would be expected if the ADL motor and ADL process ability measures were directly
16
related to physical or cognitive body functions (Fisher, 2006a). Factors other than
cognitive function can also influence persons' occupational performance (e.g., chronic
institutionalization and side-effects of typical antipsychotic medications) (Harvey et al.,
1998).
Additionally, in a study of persons with brain injury, Linden, Boschian, Eker,
Schalen, and Nordstrom (2005) found that while participants' cognitive body functions
improved post discharge, participants' ADL process abilities actually declined. If a direct
relationship existed between ADL process ability and cognitive body functions, we
would have expected a simultaneous improvement or reduction in persons' ADL process
ability and cognitive body functions. Based studies of the relation between cognitive
body function and ADL performance, the sole use of tests of body functions to predict
occupational performance is not supported by the literature. Instead, researchers
recommend assessing ADL performance using direct observation and if necessary,
assessing cognitive body function separately (Bouwens et al., 2007; Robinson & Fisher,
1996; Doble et al., 1997; Kizony & Katz, 2002; Mori & Sugimura, 2007; Nygard et al.,
1998).
The relations between physical body function and occupational performance has
also been examined, although to a lesser degree than the relation between cognitive body
function and occupational performance (Rice et al., 1997; Robinson & Fisher, 1996). For
example, Robinson and Fisher (1996) found only moderate correlations (r = 0.62)
between ADL motor ability and tests of physical body functions for persons with
dementia (n = 48) or mild memory impairment (n = 3). Despite commonly held
17
assumptions that a person needs to demonstrate 20 lbs. of grip strength for his or her hand
to be considered functional, Rice et al. (1997) found only weak correlations
(r = -0.179) between grip and pinch strength and the forces needed to open eight typical
household containers by well college students (n = 49). Additionally, Rice et al. (1997)
found that although men demonstrated greater grip and pinch strength than women, there
was no significant gender difference in the forces needed to open the containers.
Although functional hand use involves more than opening containers, the study revealed
that grip and pinch dynamometry did not have a strong relation with the functional task
of opening containers. Thus, the researchers recommended using functional occupations
(e.g., opening containers relevant to the client) to evaluate client's occupational
performance.
Together, the findings of these diverse studies highlight the need to observe
persons' performances to make accurate predications of their occupational performance.
The AMPS is one such performance-based ADL assessment. To date, however, the
AMPS has not been formally validated for persons with bipolar disorder depressed
episode, bipolar disorder manic episode, or schizophrenia. Before discussing further the
need to validate the AMPS, we need to take some time to more fully describe the AMPS.
Assessment of Motor and Process Skills
The AMPS is a standardized performance-based assessment of the quality of
persons' performance of PADL and IADL (Fisher, 2006a). The AMPS is used to evaluate
the quality of persons' ADL performance in terms of the effort, efficiency, safety and
independence demonstrated during the performance of the 16 ADL motor and 20 ADL
18
process skills within the context of relevant ADL tasks (Fisher, 2006a). ADL motor skills
are defined as "the observable, goal-directed actions that a person enacts during the
performance of ADL tasks in order to move oneself or the task object" (Fisher, 2006a, p.
4). For example, when sweeping the floor or putting on socks, persons reach for, grip and
lift the broom or socks (Fisher, 2006a). ADL process skills are defined as "the observable
actions of performance the person enacts to logically sequence the actions of the ADL
task performance over time, select and use appropriate tools and materials, and adapt his
or her performance when problems are encountered" (Fisher, 2006a, p. 4). For example,
when sweeping the floor or putting on socks, persons chooses the broom or socks,
gathers the broom or socks to the workspace and uses the broom or socks for their
intended purposes (Fisher, 2006a). ADL motor and ADL process skills are the smallest
units of performance, which when stung together over time, formulate the overall
performance of an ADL task and are enacted in nearly every all ADL task performances
(Fisher, 2006a). Although related (r = 0.50), ADL motor and ADL process abilities are
separate but related constructs (Fisher, 2006a).
When administering the AMPS, an occupational therapist does not asses the
person's body functions. Thus, the ADL motor ability scale does not generate a measure
of physical body function (e.g., strength, range of motion, movement, and postural
control) (Dickerson & Fisher, 1997; Fisher, 2006a) but a measure of the quality of the
person's motor actions of performance as they unfold over time. Likewise, the ADL
process ability scale does not generate a measure of cognitive body function (e.g.,
memory, problem solving, abstract reasoning) (Dickerson & Fisher, 1997; Fisher, 2006a)
but a measure of the quality of the person's process actions of performance as they unfold
19
over time. Even if a person demonstrated diminished postural control on tests of physical
body functions and diminished memory ability on tests of cognitive body functions, the
person's ADL ability (occupational performance) may not be adversely affected.
The AMPS is not a measure of persons' global level of ADL ability (Fisher,
2006a). Global ADL assessments such as the Functional Independence Measure (FIM)
(McNally, 1996) and the Barthel Index (Mahoney & Barthel, 1965) are used to determine
if a person is independent in ADL performance and if not, how much assistance is needed
(Fisher, 2006a). Although small to moderate correlations between persons' ADL motor
and ADL process ability measures and global measures of ADL ability have been found
(Bouwens et al, 2007; Doble, Fisk, Fisher, Ritvo, & Murray, 1994; Liu et al., 2007;
McNulty & Fisher, 1999; Robinson & Fisher, 1996), the AMPS generates valuable
information related to why persons have limitations in ADL performance (Fisher, 2006a)
— information that is essential for developing effective intervention strategies to improve
clients' ADL performance (Fisher, 2006a).
Administration
An AMPS evaluation consists of several steps, beginning with the AMPS
interview (Fisher, 2006a). During the AMPS interview, a client identifies those tasks that
are relevant to his/her daily life. Using this information, the occupational therapist
narrows the list of potential task options to approximately five ADL tasks that are
culturally relevant and familiar, and will present sufficient challenge to the client. From
this shortened list, the client chooses two or three ADL tasks to perform for the AMPS
observation and decides the order in which the tasks will be performed. Prior to initiating
20
each task observation, steps are taken to ensure that the client is completely familiarized
with the environment.
After observing the client perform the chosen ADL tasks, his/her task
performance is scored according to the standardized procedures in the AMPS User's
Manual (Fisher, 2006b). The client's performance on each ADL motor and ADL process
skill is rated on a 4-point ordinal scale. A score of "4" means the client's observed
performance on that ADL skill was competent, a score of "3" means the client's observed
performance was questionable, a score of "2" means the client's performance was
ineffective, and lastly a score of " 1 " means the client's performance was markedly
deficient. Scores for each ADL motor and ADL process skill item for each task
performed are then entered into the occupational therapist's owned pass-code protected
application of the AMPS software (Three Star Press, 2005).
The AMPS software uses a specialized multi-faceted Rasch analysis program
(Linacre, 1993) to convert raw ordinal ADL motor and ADL process scores into linear
ADL motor and ADL process ability measures. The ADL motor and ADL process ability
measures generated take into account: (a) the challenge of each tasks performed, (b) the
severity of the rater, (c) the difficulty of the ADL motor and ADL process skill items, and
(d) the raw score on each ADL motor and ADL process skill item (Fisher, 2006a).
The AMPS has been shown to be a valid evaluation tool of ADL performance
with various diagnostic groups (Bernspang & Fisher, 1995a; Cooke et al., 2000; Doble et
al., 1994, 1997; Girard et al., 1999; Hartman, Fisher, & Duran, 1999; Kottorp, Bernspang
& Fisher, 2003b; Oakley et al., 2003; Pan & Fisher, 1994; Rexroth et al., 2005; Robinson
& Fisher, 1999). There is also evidence that valid measures are generated when it is
21
administered to various cultural groups (Bernspang & Fisher, 1995b; Dickerson & Fisher,
1995; Fisher et al., 1992; Goldman & Fisher, 1997; Goto, Fisher, & Mulberry, 1996;
Magalhaes et al., 1996; Stauffer et al., 2000), in different settings (i.e., home and clinic
environments) (Darragh, Sample, & Fisher, 1998; McNulty & Fisher, 2001; Nygard,
Bernspang, Fisher, & Winblad, 1994; Park, Fisher, & Velozo, 1994), for men and women
(Duran & Fisher, 1996; Merritt & Fisher, 2003), and people of various ages (Dickerson &
Fisher, 1993, 1997; Hayase et al., 2004). The AMPS has also been shown to be a
sensitive outcome measure of ADL performance (Fisher, Atler, & Potts, 2007; Graff,
Vernooij-Dassen, Hoefnagels, Dekker, & de Witte, 2003; Kinnman, Anderson,
Wetterquist, Kinnman, & Anderson, 2000; Kottorp, Hallgren, Bernspang, & Fisher,
2003c; Oakley, Khin, Parks, Bauer, & Sunderland, 2002; Oakley & Sunderland, 1997;
Tham, Ginsburg, Fisher, & Tegner, 2001; Waehrens & Fisher, 2007).
The AMPS has acceptable test-retest reliability (r = 0.88, p < 0.001 for ADL
motor ability and r = 0.86, p < 0.001 for ADL process ability) (Doble, Fisk, Lewis, &
Rockwood, 1999). A special component of test-retest reliability is alternative form
reliability, where alternate forms means different pairs of AMPS tasks are performed
(Fisher, 2006a). Kirkley and Fisher (1999) found that the AMPS has high alternative
form reliability when sets of two tasks are observed (r = 0.91 for ADL motor ability and
r = 0.85 for ADL process ability). Moreover, only 7% and 8% of participants' ADL
motor and ADL process ability measures respectively differed significantly after the
researchers accounted for clinical reasons for differences in ADL performance.
Additionally, the AMPS has demonstrated high inter-rater and intra-rater reliability with
95% of raters demonstrating acceptable goodness-of-fit to the Rasch measurement model.
22
The overall rate of misfit of ADL motor and ADL process skill items has remained at the
expected value (1% at t > 3 or < -3) (Fisher, 2006a). Lastly, the calibration values of
AMPS raters remain stable over time, providing further evidence of the high intra-
reliability of the AMPS (Bernspang, 1999).
Interpretation
After completing a performance analysis using the AMPS, the next step is to
define the actions of performance that the client performed effectively and ineffectively
by reviewing the scores to determine which ADL motor and ADL process skills support
and hinder occupational performance (Fisher, 2006a). Additionally, the occupational
therapist examines the ADL motor and ADL process ability measures, which provide an
objective measure of the impact of ADL motor and ADL process skill weakness on the
person's task performance (Fisher, 2006a). ADL motor ability measures below the 2.0
logit cut-off on the motor ability scale, indicate the person is experiencing increased
effort completing ADL tasks (Fisher, 2006a). ADL process ability measures below the
1.0 logit cut-off on the process ability scale indicate that the person is inefficient
performing ADL tasks (Fisher, 2006a). ADL motor and/or ADL process ability measures
below the respective cut-off ability measures may also indicate that the client
demonstrated unsafe performance and/or was in need of assistance during the task
performance (Fisher, 2006a). The ADL process ability can also be used as evidence of
the need for assistance to live in the community. Research has revealed that 93% of
people who score below the cut-off on the ADL process ability scale need assistance to
live in the community (Fisher, 2006a).
23
Intervention planning
Once the occupational therapist has clarified the quality of the client's ADL
performance and uses his/her clinical reasoning to interpret why the client experienced
occupational challenges, the therapist uses this information to develop an intervention
plan to improve the client's occupational performance. Intervention planning is based on
the occupational therapist's clinical judgment and is not part of the standardized
procedures of the AMPS. The occupational therapist may begin intervention planning by
targeting those ADL motor and/or ADL process skills that he/she judged most hinder
occupational performance and/or by targeting those ADL motor and/or ADL process
skills that are defined as easy on the ADL motor and ADL process skill item hierarchies
that were rated as being difficult for the client (scores of " 1 " or "2" were assigned)
(Duran & Fisher, 2006). For example, endures is generally an easy ADL motor skill for
most people and can affect other skills. If a person experiences effort enduring though the
task performance (i.e., the client demonstrates obvious signs of physical fatigue during
the task performance), this may affect his/her ability to maintain an effective pace of
performance, initiate and continue actions of the task, and accommodate for his/her
limited endurance (Duran & Fisher, 2006). Therefore, interventions to improve endures
can result in improvement in other ADL motor and/or ADL process skills.
Fisher (2006a) identified occupational therapy intervention strategies as
therapeutic occupations including adaptive occupation, acquistional occupation,
restorative occupation, and occupation-based education programs. Adaptive occupation
refers to using adaptive methods of doing, using adaptive equipment, and/or making
modifications to the environment (Fisher, 2006a). Teaching a client who has functional
24
use of only one arm to stabilize a can against his body to open the can with one hand is an
example of teaching an adaptive method of opening a can which is typically done using
two hands. Acquistional occupation refers to occupations that are used to enable clients to
learn new occupational skills or further develop existing occupational skills (Fisher,
2006a). An example of the use of acquistional occupation is providing opportunities for a
client to practice preparing meals in his new apartment. Restorative occupation refers to
occupations that are used to enable clients to develop body functions (Fisher, 2006a).
Restorative occupation includes engaging a client in cooking occupations to specifically
improve his balance and activity tolerance. Occupation-based education programs refer to
educational programs for groups, with the group discussion focused on occupational
performance issues (Fisher, 2006a). For example, a return-to-work group in which group
participants discuss and problem solve issues related to returning to work is an example
of the use of an occupation-based education program.
ADL ability measures can also be used to determine the best intervention strategy
for a client (Duran & Fisher, 2006). For example, a client with relatively high ADL
process ability measures (above 0.0 logits) is likely able to benefit from many different
types of therapeutic occupations (e.g., adaptive occupation, acquisitional occupation,
restorative occupation, and occupation-based educational programs) (Fisher, 2006a).
Clients with relatively high ADL process ability measures are more likely to have the
potential to learn new ways of doing, and thus the list of potential interventions strategies
remains fairly open (Fisher, 2006a). On the other hand, very low ADL process ability
measures (below 0.0 logits) or generalized motor skill difficulties (e.g., scores of 1 or 2
across ADL motor skills), suggest that the client is unlikely to be able to benefit from
25
acquisitional occupations/or adaptive occupations which have high learning demands
(Fisher, 2006a). As a result, the client is most likely to be able to benefit from adaptive
occupation strategies that are focused on environmental adaptations and/or caregiver
training.
Rasch Measurement Model
Since the AMPS was developed and evaluated using a Rasch measurement model
(Fisher, 2006a), it is important to discuss this measurement model more fully to gain a
better understanding of the unique features of the AMPS. Some functional assessments,
grounded within traditional statistical methods, have been criticized for their use of
ordinal data and their lack of knowledge of the relative challenge of test items and tasks
(Merbitz, Morris, & Grip, 1989; Wright & Linacre, 1989). More specifically, when
ordinal scores are assigned to qualitative aspects of function, the differences between
adjacent numbers cannot be assumed to be equal (Fisher, 2006a; Merbitz et al., 1989; W.
Fisher, 1993; Vallee, 2006). As a result, summing ordinal data does not generate valid
quantitative measures (A. Fisher, 1993, 2006a; W. Fisher, 1993; Merbitz et al., 1989;
Vallee, 2006).
To illustrate the problems with summing ordinal data, and to make the distinction
between total scores and equal-interval, linear measures, another occupational therapy
assessment will be examined. The Kitchen Task Assessment (KTA) (Baum & Edwards,
1993) is a standardized measurement tool of the level of cognitive support needed to
complete a specific cooking task - cooked pudding. Six cognitive aspects of task
performance are rated using a 4-point rating scale in which a score of "0" is assigned if
26
the person is independent, a score of " 1 " is assigned if verbal cueing is needed, a score of
"2" is assigned if physical assistance is needed, and a score of "3" if the person is totally
incapable. Individual item scores of the KTA are summed to produce a total score (Baum
& Edwards, 1993) even though the quantitative difference between a score of "0" and " 1 "
and a score of " 1 " and "2" are may not be the same. As a result, the same total score may
be achieved even though the actual scores for individual items may be different. No
recognition is given to the fact that the items most likely vary in terms of their difficulty;
that is, some items may be easier and others may be harder. With this in mind, it becomes
clear that a score of 2 on a relatively easy item cannot be equated to a score of 2 on a
relatively harder item (Fisher, 2006a). Thus the same scores on different test items may
or may not be reflective of the same level of performance (Fisher, 2006a).
As noted above, all clients evaluated using the KTA are observed completing the
same cooking task. This at least ensures that an additional facet, that is task difficulty,
will not further complicate the ability to make comparisons between clients or in the
same client over time. However, it also means that the total scores generated do not
account for the influence that the meaning (or lack of meaning) of the KTA cooking task
may have on persons' task performance. In contrast, when persons are tested using the
AMPS, they are observed performing tasks that are relevant and meaningful to them,
with the level of difficulty of the task considered in the generation of ADL ability
measures (Fisher, 2006a).
Additionally, raters assigning scores vary in their scoring, with some raters being
more lenient and other raters being more severe in their scoring, regardless of the
standardization of the administration and scoring of assessments (Lunz, Wright, &
27
Linacre, 1990). Lunz et al. (1990) recommends using the Rasch measurement model to
account for rater severity when generating ability measures, while Bernspang (1999)
found that the calibration values of raters tend to remain stable over time.
Rasch measurement, an objective measurement and modern test theory,
overcomes many of the problems found within traditional methods of assessment (Fisher,
2006a; Wright & Linacre, 1989) and is therefore becoming a more common approach in
health care measurement (A. Fisher, 1993; Velozo, Kielhofner, & Lai, 1998). A powerful
advantage of Rasch measurement is that it enables us to convert ordinal skill item scores
(e.g., ADL motor and ADL process skill item scores) into linear interval data by taking
into account the difficulty of the items being evaluated. Measures are expressed in
logistically transformed probability measures or logits. A logit is an "equal-interval unit
of measurement based on the logarithm of odds ... of obtaining a given skill item score
when a person of a given ability is observed performing a specific task" (Fisher, 2006a, p.
34). As "logits are equal-interval units, they are additive" (Andrich as cited in Fisher,
2006a, p. 34; Wright & Masters as cited in Fisher, 2006a, p.34).
The specific Rasch model used within the AMPS is the many-faceted Rasch
model (Fisher, 2006a). This specific model enables us to not only account for differences
in item difficulty, but also account for differences in task challenge, and rater severity
when generating equal-interval linear measures and thus provides a test-free, rater-free,
and sample-free measure (Fisher, 2006a). More specifically, the many-faceted Rasch
model asserts that (a) all persons are more likely to obtain higher scores on easy skill
items and tasks than on difficult skill items and tasks, (b) lenient raters are more likely to
give higher scores on all skill items and tasks to all persons than severe raters, and (c)
28
persons with higher ability are more likely to score higher on all skill items and tasks than
are persons with lower ability (Fisher, 2006a).
When skill item difficulty, task challenge, rater severity, and person ADL ability
measures respond as expected to the Rasch assertions, they demonstrate high goodness-
of-fit to the many-faceted Rasch measurement model and provide evidence of the
reliability and validity of the AMPS (A. Fisher, 1993, 2006a). Goodness-of-fit to the
many-faceted Rasch measurement model is determined by examining goodness-of-fit
statistics (e.g., mean square values and standardized fit statistics) (f) that are generated by
the FACETS program (A. Fisher, 1993, 2006a). Items, raters, tasks, and/or persons with
infit mean square values > 0.6 or outfit mean square values < 1.4 and standardized fit
statistics (t) > -2 or < 2 indicate high goodness-of-fit to the many-faceted Rasch model
(A. Fisher, 1993). When 95% of items, raters, tasks, and/or persons demonstrate high
goodness-of-fit statistics, the items, raters, tasks and/or persons respond as expected
given the Rasch assertions, and provide evidence of acceptable reliability and validity of
the AMPS (Fisher, 2006a; Kottorp et al., 2003b). A second method for analyzing the
goodness-of-fit of items, raters, tasks, and/or persons respond is to examine the overall
percentage of misfit ratings (Fisher, 2006a). When the overall percentage of misfit ratings
is less than 1% at t > 3 or < -3 (Fisher, 2006a), items, raters, tasks, and/or persons
demonstrate high goodness-of-fit to the many-faceted Rasch model.
To understand the many-faceted Rasch model of the AMPS more fully, each
assertion will be discussed in detail along with the evidence from the literature that
supports the assertion. One assertion of many-faceted Rasch model is that all persons are
more likely to obtain higher scores on easy skill items than on difficult skill items (Fisher,
29
2006a). Research has shown that all of the ADL motor and ADL process skills
demonstrate high goodness-of-fit to the Rasch measurement model (infit and outfit mean
square values > 0.6 and < 1.4 with / < 2 or > -2), validating this first assertion (Fisher,
2006a).
Another assertion of the many-faceted Rasch model is that all persons are more
likely to score higher on easier tasks than on more difficult tasks (Fisher, 2006a). If this
assertion is upheld, then the assessment is a test-free assessment, meaning a person's
ability measure is not dependent on the tasks he/she performs during the evaluation, as
long as the tasks performed offer sufficient challenge (Fisher, 2006a). ! The current
version of the AMPS includes 83 PADL and I ADL tasks that vary in challenge (Fisher,
2006a). All 83 AMPS tasks have demonstrated high goodness-of-fit to the Rasch
measurement model (infit and outfit mean square values were > 0.6 and < 1.4 with t < 2
or > -2). Thus, valid ability measures for clients can be generated regardless of which
tasks they perform as long as clients perform tasks that offer sufficient challenge (Fisher,
2006a). This means that clients can be observed performing tasks that are relevant to their
daily lives, unlike many ADL assessments where clients must perform standard tasks
which may or may not be relevant to their daily lives (Fisher, 2006a).
Likewise, another assertion of the many-faceted Rasch model is that lenient raters
are more likely to give higher scores to all persons than severe raters (Fisher, 2006a). In
other words, if two raters score the same client, even when one rater is more strict or
lenient than the other rater, similar ADL motor and ADL process ability measures will be
generated (within an expected range of variation) since the multi-faceted Rasch computer
1
Twenty two new AMPS tasks were added to the list of available AMPS tasks on February 20, 2009, thus
increasing the number of AMPS tasks to 105.
30
program adjusts the ability measure based on each raters' severity. Thus, the AMPS is
also considered to be a rater-free assessment. In fact, research has shown that 95% of
raters demonstrated high goodness-of-fit statistics to the measurement model (infit &
outfit mean square values < 1.4 with t < 2). The overall rate of misfit of skill items ratings
has remained at expected values (1% at t > 3 or < 3). Together, these findings provide
evidence that the AMPS meets this assertion and the AMPS is a rater-free assessment and
has high inter- and intrarater reliability (Fisher, 2006a).
Lastly, if it is true that within the AMPS, all persons with greater ability are more
likely to score higher on all skill items and tasks than persons with lower ability, then the
AMPS can be considered a sample-free assessment. A sample-free assessment means that
the assessment can be used to measure a single construct independent of the personal
characteristics of the person being assessed (A. Fisher, 1993, 2006a). In other words, all
persons, regardless of gender, diagnosis, and/or cultural background, will be assigned
higher scores on easy skill items and tasks than on difficult skill items and tasks.
Likewise, individuals of higher ability will be assigned higher scores than those of lower
ability, regardless of personal characteristics such as gender, diagnosis, and/or cultural
background. Evidence of the sample-free nature of the AMPS has been provided by
researchers who have found that skill item difficulty, task challenge and/or person
response patterns demonstrate high goodness-of-fit the many-faceted Rasch model
regardless of gender (Duran & Fisher, 1996; Merritt & Fisher, 2003), diagnosis
(Bernspang & Fisher, 1995b; Kottorp et al., 2003a, 2003b; Rexroth et al., 2005), and
cultural background (Bernspang & Fisher, 1995b; Dickerson & Fisher, 1995; Fisher et
31
al., 1992; Goldman & Fisher, 1997; Goto et al., 1996; Magalhaes et al., 1996; Stauffer et
al., 2000).
ADL Motor andADL Process Skill Item Hierarchies
Based on research using Rasch analysis, we know that the ADL motor and ADL
process skills within the AMPS vary in difficulty such that some skills are easier to
perform than other skills (Fisher, 2006a). Thus the ADL motor and ADL process skills
have been hierarchically ordered from easier to harder to perform (Table 1) (Fisher,
2006a). As mentioned earlier, one premise of Rasch measurement is that the hierarchical
ordering of the skill items must remain stable regardless of the characteristics of the
persons being tested (Fisher, 2006a). In other words, the skill items remain in the same
relative hierarchical order regardless if the group includes males or females, persons of
various cultural backgrounds, or persons with different illness. Research has shown that
the ADL motor and ADL process skill item hierarchies have been upheld for persons
with intellectual disabilities (Kottorp et al, 2003a, 2003b), men and women (Duran &
Fisher, 1996; Merritt & Fisher, 2003), and various cultural groups (Bernspang & Fisher,
1995b; Fisher et al., 1992; Goldman & Fisher, 1997; Magalhaes et al., 1996; Stauffer et
al., 2000).
The stability of the ADL motor and ADL process skill items hierarchies is
determined by examining ADL motor and ADL process skill item calibrations for
differential item function (DIF). Differential item function refers to test items (e.g., ADL
motor and ADL process skills) that are significantly more difficult or easier for a specific
group (Tennant & Pallant, 2007). Differential item function is present if item difficulty
32
calibrations differ by more than 0.5 logits and demonstrate a significant /-value atp < 0.5
(Tennant & Pallant, 2007; Wright & Panchapakesan, 1969). A many-faceted Rasch
computer program, such FACETS (Linacre, 1987-2002), can be used to calculate relative
ADL motor and ADL process skill item difficulty calibrations.
The absence of DIF provides one piece of evidence that the assessment tool can
be used without bias (e.g., gender bias, cultural bias). If DIF does exist, one must
examine the data to determine the presence or absence of differential test function (DTF).
If DTF is present, then the test may demonstrate bias, and caution must be used when
determining and interpreting the estimated linear measures. If, however, the presence of
DIF does not disrupt the estimation of the linear measures, then the evaluation tool is
considered valid and can be used without the threat of bias (Wright & Stone, 1979).
Research has not yet been completed to show that the ADL motor and ADL
process skill items hierarchies are stable (i.e., there lacks DIF) for persons with bipolar
disorder depressed episode, bipolar disorder manic episode, or schizophrenia. There is
ample documented evidence that some persons with schizophrenia demonstrate
limitations in their quality of ADL performance (Fossey et al., 2006; Girard et al, 1999;
Hamera & Kolenbrander, 2000; Honkonen, 1995). There is documented evidence that
some people with schizophrenia may demonstrated significant difficulty with skills that
are similar to the ADL process skills of Searches/Locates, Sequences, and Continues
(Hamera & Kolenbrander, 2000; Rempfer et al., 2003; Semkovska et al., 2004).
Searches/Locates and Sequences are relatively easy skill items and Continues is a
relatively average skill item on the on the ADL Process Skills Item Heiarchy (Table 1).
33
This suggests that the ADL process skill item hierarchy may be different for persons with
schizophrenia.
ADL Motor and ADL Process Skill Profiles
In addition to examining DIF to determine if the skill item hierarchies are stable
and if the evaluation is valid for the group being studied, the presence of DIF can reveal
clinically useful information such as which skills are significantly harder (or easier) for a
specific group (Fisher, 2006a). Knowledge of the skills that are significantly harder (or
easier) for a specific group can be used to make recommendations of interventions
strategies to improve the quality of ADL performance for the group for which the DIF
exists. For example, minor differences in ADL motor and/or ADL process skill item
calibrations have been identified between some diagnostic groups, including persons with
stroke (Bernspang & Fisher, 1995a), Alzheimer's disease (Cooke et al., 2000; Oakley et
al., 2003), and intellectual disabilities (Kottorp et al., 2003a). This knowledge has been
used to recommend intervention strategies to improve persons' quality of ADL
performance. It is important to note that these minor disruptions in ADL motor and ADL
process skill item calibrations do not affect the overall estimation of persons' ADL motor
and ADL process measures, and thus the validity of the ADL ability measures generated
when using the AMPS remains sound (Fisher, 2006a).
More specifically, Bernspang and Fisher (1995a) found that persons with right
hemispheric stroke (n = 71) demonstrated greater difficulty maintaining an even pace of
performance, transporting objects, and coordinating two body parts to stabilize objects,
whereas persons with left hemispheric stroke in = 76) experienced more difficulty
34
calibrating the force and extent of movement. Therefore, Bernspang and Fisher (1995a)
recommended that it may be more effective to teach persons who have had a right
hemispheric stroke energy conversation and adaptive methods to transport and stabilize
objects, whereas it maybe more effective to teach those with left hemisphere stroke to
compensate for difficulties experienced when calibrating movements. It is important,
however, to note that their research was limited by a small sample size (Bernspang &
Fisher, 1995a).
Using a much larger sample (n = 3,878), Rexroth and colleagues (2005) found no
significant differences in ADL motor and ADL process skill profiles between people with
left or right hemispheric stroke, and subsequently concluded that people with left or right
stroke have similar ability to perform goal-directed ADL actions. Rexroth et al. (2005)
recommended that occupational therapists use occupation-based interventions that are
targeted toward each individual's ADL skill strengths and weaknesses, rather than
targeting interventions based on assumptions of impairments associated with right versus
left stroke.
Cooke et al. (2000) found that compared to a well group (n = 287), a group with
Alzheimer's disease (n = 341) demonstrated the ADL process skills of chooses, heeds,
inquires, continues, notices/responds and benefits as the most diminished and the ADL
process skills of uses, handles and organizes as the least diminished or intact. The
researchers concluded that the most diminished ADL process skills were related to
"knowing what", whereas the least diminished or intact ADL process skills were related
to "knowing how." Cooke et al. (2000) recommended adapting the environment to
accommodate ADL process skills that are experienced as more difficult and building on
35
those ADL process skills that are the least diminished or intact to improve the quality of
ADL performance for persons with Alzheimer's disease. For example, chooses refers to
the actions of effectively choosing items that are needed for ADL task performance
(Fisher, 2006b). Cooke et al. (2000) recommended accommodating difficulties with
chooses by placing objects that are needed for the task performance on the counter, as a
cue to perform an ADL task. For example, a box of cereal, bowl and spoon could be
placed on the counter as a visual prompt for the person to prepare a bowl of cereal for
breakfast.
Following the research of Cooke et al. (2000), Oakley and colleagues (2003)
explored the ADL motor skills profile for a groups with Alzheimer's disease needing
minimal assistance and moderate to maximum assistance. Oakley et al. (2003) found that
the ADL motor skills of paces and flows, were significantly more difficult for the group
needing minimal assistance {n = 189) when compared to a well group {n = 378). The
ADL motor skills items of paces, flows, walks, transports and coordinates were the most
severely affected for the group needing moderate to maximal assistance (n = 378) when
compared to a well group (n = 378) (Oakley et al., 2003). Oakley et al. (2003)
recommended environmental modifications and caregiver support to compensate for
ADL motor skill difficulties, as they reasoned that cognitive impairments decreased the
potential to learn to compensate for ADL motor skill difficulties. Oakley et al. (2003)
suggested educating caregivers that individuals with Alzheimer's disease may need extra
time to perform ADL to accommodate their slow pace of performance. The researchers
also recommended that individuals with Alzheimer's disease may need supportive shoes,
clipped toenails, caregivers assistance, and environmental modifications (such as
36
removing scatter rugs to reduce hazards for falling) to accommodate for their difficulty
with walking. Interventions to improve walking may also improve the ability to transport
objects during task performance (i.e., walking and carrying) (Oakley et al., 2003).
Additionally, Kottorp and colleagues (2003 a) compared ADL motor and ADL
process skill profiles for groups with mild (n = 178) and moderate intellectual disability
(n = 170). Significant differences were found in group relative skill item calibrations for
the ADL motor skill Endures and the ADL process skill Uses, with both skill items being
relatively easier for the group with moderate intellectual disability (Kottorp et al., 2003a).
Thus, Kottorp et al. (2003a) concluded that the ADL motor and ADL process skill item
hierarchies were stable for the two diagnostic groups, as only one ADL motor and one
ADL process skill demonstrated DIF. When the researchers examined actual skill item
calibrations, they found that there were four ADL motor skills and four ADL process
skills that the group with moderate intellectual disability were able to perform as equally
well as the group with mild intellectual disability. Kottorp et al. (2003a) recommended
that interventions for people with mild or moderate intellectual disability target skills
located in the lower half of the ADL motor and ADL process skill hierarchies (i.e., those
that can be viewed as relative limitations in ADL performance) and/or skills that, while
expected to be relatively easy, are, in fact, experienced as difficult by clients.
Given that occupational therapists also work with clients with mental illness,
research designed to examine the ADL motor and ADL process skills profiles of people
with mental illness such as bipolar disorder depressed episode, bipolar disorder manic
episode, and schizophrenia are needed. The knowledge gained would, in turn, enable
occupational therapists to develop intervention strategies that are specifically targeted to
37
address their skill weakness while maximizing their skill strengths to improve the overall
quality of their ADL performance.
Purpose of the Study
The purpose of this research project was to compare the ADL motor and ADL
process skill profiles of persons among three diagnostically different groups, that is,
groups with bipolar disorder depressed episode, bipolar disorder manic episode, and
schizophrenia to determine if there were clinically significant differences in the ADL
motor and ADL process skill profiles among the groups. It was hypothesized that
a. the bipolar disorder depressed and manic groups would not differ clinically
significantly in mean ADL motor and ADL process ability measures;
b. the group with schizophrenia would demonstrate clinically significant lower
mean ADL motor and ADL process ability measures than the bipolar-
depressed episode and manic groups, as Girard et al. (1999) found that mean
ADL motor and ADL process ability measures differed significantly between
two groups with different mental illness (i.e., schizophrenia and depression)
and there is much more documentation that people with schizophrenia
demonstrate limitations in their ADL performance (Fossey et al., 2006; Girard
et al., 1999; Hamera & Kolenbrander, 2000; Honkonen, 1995) as compared to
people with bipolar disorder depressed and manic episode (Dion et al., 1998;
Levine et al, 2001; Pope et al., 2007; Simon et al., 2007); and
c. clinically significant differences would be found in some ADL motor and
ADL process skill item calibrations among the three diagnostic groups. No
38
specific hypotheses were made as to what which skill items were expected to
be significantly easier or more difficult for one or more of the diagnostic
groups, as the research identifying specific skill limitations that affected ADL
performance for persons with schizophrenia included only three studies with
small sample sizes, the skills were not explicitly defined as ADL process
skills, and only two IADL tasks were explored (i.e., grocery shopping and
preparation of a three course meal) (Hamera & Kolenbrander, 2000; Rempfer
et al., 2003; Semkovska et al., 2004).
39
CHAPTER III: STUDY DESIGN AND RESEARCH METHODS
Research Design
The research design was a three group descriptive comparison study, in which the
ADL motor and ADL process skill profiles of three different diagnostic groups (i.e.,
bipolar disorder depressed episode, bipolar disorder manic episode, and schizophrenia)
were compared. More specifically, the mean ADL motor and ADL process ability
measures and ADL motor and ADL process skill item difficulty calibration values of
each group were examined and compared.
Data used for all analyses were obtained from the AMPS International Project
database. After participating in a five day AMPS training course, occupational therapists
complete AMPS evaluations on 10 clients to complete the rater calibration process. Each
client's sex, diagnoses, date of evaluation, the AMPS tasks completed, raw scores for 16
ADL motor and 20 ADL process skills, global functional level, and quality of
performance ratings for each AMPS task performed are entered into the occupational
therapist's individually owned pass-code protected application of the AMPS software
(Computer Adaptive Technologies & Fisher, 1994-1999). The calibration data is then
exported from their personal AMPS software and sent to the AMPS Project International
for analysis. Personal applications of the AMPS software do not, and cannot export
personal and identifying client information; the data is made anonymous by removing all
identifying information (i.e., the client's name and identification number) before the data
is exported. Upon receiving the exported anonymized files, the AMPS Project
International imports the data into the AMPS Project International database; data from
40
this database were used for this research project. Ethics approval was granted for this
research project (Project # 2008-1739) by the Health Services Human Research Ethic
Board of Dalhousie University on May 30th, 2008.
Participants
Potential participants included all persons 16 years of age or older whose AMPS
data was included within the AMPS Project International database as of July 3, 2008, and
whose medical diagnosis was identified as either bipolar disorder depressed episode, '
bipolar disorder manic episode, or schizophrenia. Individuals excluded from the study
included persons with (a) secondary diagnoses, (b) ADL motor and/or ADL process
ability measures that were associated with rater scoring error as indicated by ADL motor
ability measures greater 4.0 logits and/or ADL process ability measures being greater
than 3.0 logits (Kirkley & Fisher, 1999), and (c) scored by more than 10 raters (Kirkley
& Fisher, 1999). The resultant potential sample consisted of 158 persons with bipolar
disorder depressed episode, 253 persons with bipolar disorder manic episode, and 7119
persons with schizophrenia.
Matching the three diagnostic groups for gender was not deemed necessary as
research has shown that ADL motor and ADL process skill hierarchies are stable for men
and women (Merritt & Fisher, 2003). To eliminate the potential confounding variable of
age on ADL ability (Dickerson & Fisher, 1993; Hayase et al., 2004), the diagnostic
groups were matched by age. More specially, a data file with all potential participants
was created and then stripped of all client demographic information except age,
diagnosis, and subject number. From this file, participants from each diagnostic group
41
were split into five year age increments (e.g., 16 to 20 years, 21 to 25 years old, 26 to 30
years old, and so on with the last five year age span of 86 to 90 years). Since the number
of persons within the bipolar-depressed group was smaller, individuals from the bipolar-
manic group and the group with schizophrenia were randomly selected from within each
of the five year age groupings and matched to those within the corresponding five year
age groupings in the bipolar-depressed group. At this point, each diagnostic group
contained 158 persons.
While 100 people per group is the minimum for a group performance skill profile
analysis, 200 people per group is ideal for generating group specific item calibration
values (A. Fisher, personal communication, July 4, 2008). The bipolar-depressed group
was limited to a total of 158 as that was the maximum number of people with this
diagnosis available from the AMPS database. However, the other two diagnostic groups
had ample data to generate sample sizes of 200 persons. Thus, an additional 42
participants were randomly selected from the bipolar-manic episode group and 42
additional persons were randomly selected from the group with schizophrenia. The
additional 84 participants were not matched by age due to the lack criteria for additional
age matching (i.e., the were no guidelines regarding if one, two, or more participants
should be matched to each five year age group). The final sample included 158 persons
with bipolar disorder depressed episode, 200 persons with bipolar disorder manic
episode, and 200 persons with schizophrenia with an age range of 17 to 87 years.
42
Data Analysis
A one-way analysis of variance (ANOVA), followed by Tukey HSD post-hoc
tests, using the Statistical Package for Social Sciences (SPSS) software (version 14.0),
was calculated to ensure that the diagnostic groups did not differ significantly by age.
The three diagnostic groups were described in terms of gender and functional level.
Two one-way ANOVAs and Tukey HSD post-hoc tests were calculated (one for
ADL motor ability and one for ADL process ability) to determine if the mean ADL motor
and ADL process ability measures differed statistically between the diagnostic groups.
Next, effect size was examined as sample size can influence statistical significance (i.e.,
small samples may show no statistical significant difference between group means when
there is a clinical significant difference and large samples can show statistical significant
differences between group means when no clinical significant difference exists)
(Kranzler, 2007). Effect size is not influenced by sample size and informs us about the
strength of the relationship between the variables, indicating if there are clinically
significant differences between the variables (Kranzler, 2007). There are several different
types of effect sizes, one common measure of association in ANOVAs is eta squared.
Eta squared is the proportion of total variability attributable to a factor (Cohen, 1988).
Within this study, eta squared was calculated for each analysis using SPSS software and
interpreted based on Cohen's measure of association, where 0.01, 0.06, and 0.14 indicate
a small, medium, or large effect respectively (Cohen, 1988). Cohen states that such
guidelines can be equated to those used when interpreting Cohen's d, where 0.2, 0.5 and
0.8 indicate small, medium and large effects, respectively. Lastly, clinically significant
differences in mean group ADL ability measures were identified by examining the data to
43
determine if the mean ability measures differed by 0.3 logits or more (Duran & Fisher,
1996).
A many-faceted Rasch computer program, FACETS (Linacre, 1987-2002), was
used to calculate relative ADL motor and ADL process skill item difficulty calibrations
for each of the three diagnostic groups. Within these analyses, the task challenge, rater
severity calibrations, and ADL ability measure facets were anchored while the skill item
difficulty calibrations facet was allowed to float. This allowed for the generation of
diagnostic group specific skill item difficulty calibrations. Relative skill item calibrations
were generated with the skill item difficulty calibration values for each FACETS analysis
centered at zero. To determine if DIF existed between the three diagnostic groups, the
bias/interaction output tables from FACETS were examined. Differential item function is
present if relative item difficulty calibrations differ by more than 0.5 logits and
demonstrate a significant /-value dXp < 0.5 (Tennant & Pallant, 2007; Wright &
Panchapakesan, 1969).
When DIF was found, the existence of a DTF was explored to determine if the
DIF affected the final estimation of ADL motor and/or ADL process ability for the
relevant diagnostic groups. To test for DTF, each participant's ability measure was
calculated twice, first with the ADL motor and/or ADL process skill item calibrations
based on the entire sample of the three diagnostic groups and second with the diagnostic
specific skill item calibration (Merritt & Fisher, 2003). Each participant's set of ability
measures was then compared and a standardized difference z value is calculated for each
person. When the standardized difference is greater than 2.0 or less than -2.0, the
difference in ability is considered to be significant and a DTF exits (Merritt & Fisher,
44
2003). The difference is considered to a clinically significant difference when the
difference between a person's two estimated ability measures is 0.3 logits or greater
(Duran& Fisher, 1996).
45
CHAPTER IV: RESULTS
Comparison of Diagnostic Groups
The mean age for the bipolar-depressed group was 52 years, while the mean age
for the other two diagnostic groups was 50 years (Table 2). A one-way ANOVA revealed
that the three diagnostic groups did not differ significantly by age (F {2, 555} = 1.36, p >
0.05). The three diagnostic groups included males and females and included participants
who demonstrated a range of functional levels (Table 3).
Table 2
Mean Age and ADL Ability by Diagnosis
Diagnosis
Bipolar Disorder- Bipolar Disorder- Schizophrenia
Depressed. Manic (n = 200)
(«=158) (n = 200)
Age (years)
M 52.3 50.0 50.0
SD 15.8 14.7 15.2
ADL Motor Ability (logits)

M 2.04 2.03 1.97
SD 0.68 0.73 0.71
ADL Process Ability (logits)

M 1.01 0.82 0.81
SD 0.50 0.54 0.60
46
Table 3
Number of Participants in each Diagnostic Group by Functional Level and Gender
Diagnosis
Bipolar Disorder Bipolar Disorder Schizophrenia

Depressed Manic (n = 200)
(n=158) (n = 200)
Functional Level
Independent 43 (27%) 35 (18%) 25 (12.5%)
Minimal 81 (51%) 100 (50%) 82 (41%)
Moderate/Maximal 34 (22%) 65 (32%) 93 (46.5%)
Gender
Male 51 (32%) 84 (42%) 116(58%)
Female 107 (68%) 116(58%) 84 (42%)
ADL Motor and ADL Process Ability Measures
The results revealed that the mean ADL motor and ADL process ability measures
for the three diagnostic groups were at or just below the cut-offs of 2.0 and 1.0 logits
respectively on the ADL motor and ADL process ability scales, with standard deviations
between 0.50 to 0.73 logits. The mean ADL motor ability measures for the three
diagnostic groups were not statistically significantly different (F {2, 555} = 0.59, p >
0.05). Additionally, the mean ADL motor ability measures were not clinically different
between the three diagnostic groups as the effect size (eta squared) was 0.002 and the
greatest logit difference as 0.06 between the means.
In contrast, there were statistically significant differences in the mean ADL
process ability measures of the three diagnostic groups (F {2, 555} = 6.62, p < 0.01). Post
hoc tests revealed that there were statistically significant differences in mean ADL
process ability measures between the bipolar-depressed group and the bipolar-manic
group and between the bipolar-depressed group and the group with schizophrenia. While
47
there were statistically significant differences between these groups, the largest effect size
(Eta squared) was small at 0.02 and the greatest logit difference was 0.19. Therefore,
there was no clinically significant difference in the mean ADL process ability measures
between the three groups.
Differential Item Function and Differential Test Function
The only ADL motor or ADL process skill item that demonstrated DIF was the
ADL process skill item of Attends between the bipolar-depressed group and the bipolar-
manic group (i.e., skill item calibration value difference of 0.54 logit with t = 6.01 at/? =
0.0) (Tables 4 & 5). Attends was a harder skill item for the bipolar-manic group, such
that they experienced significantly more difficulty attending to their task performances
than those within the bipolar-depressed group.
Since DIF was found between the bipolar-depressed group and the bipolar-manic
group, a DTF analysis was conducted to verify that the DIF did not disrupt the final
estimation of the ADL ability measures for these two diagnostic groups. When
participants' ADL process ability measures that were based on diagnostic specific skill
item calibrations were compared to those based on skill item calibrations for the entire
sample, the largest standardized difference z value for ADL process ability measures was
0.43 for the bipolar-depressed group and 0.5 for the bipolar-manic group. The largest
logit difference between the two ADL process ability measures was 0.11 logit. Given that
the standardized differences were less than 2.0 but more than -2.0, there was no evidence
of DTF. Moreover, since the logit difference was less than 0.3 logit, the difference
between persons' two estimated ability measures were not clinically significant.
48
Together, these findings suggest that DTF was not found between the bipolar-depressed
group and the bipolar-manic group based on the DIF of Attends. Therefore, the DIF of
Attends did not affect the final estimation of ADL process ability measures and the ADL
motor and ADL process skill hierarchies are stable among the three diagnostic groups.
Table 4
ADL Motor Skill Item Calibration Values (logits) for each Diagnostic Group
Diagnosis
ADL Motor Skill Bipolar Disorder - Bipolar Disorder- Schizophrenia
(«= 158) (n = 200)
Lifts 0.40 0.55 0.62
Endures 0.10 0.45 0.48
Moves 0.66 0.50 0.57
Reaches 0.13 0.36 0.28
Transports 0.83 0.70 0.58
Coordinates -0.19 -0.24 -0.18
Aligns 0.57 0.32 0.25
Manipulates -0.18 0.21 -0.22
Grips -0.07 -0.07 -0.06
Bends -0.07 0.02 -0.06
Flows -0.06 -0.02 -0.18
Stabilizes -0.01 0.02 0.21
Calibrates -0.74 -1.08 -1.04
Walks 0.34 0.50 • 0.29
Paces -0.82 -1.09 -0.71
Positions -0.83 -0.68 -0.83
49
Table 5
ADL Process Skill Item Calibration Values (logits) for each Diagnostic Group
Diagnosis
Bipolar Disorder - Bipolar Disorder- Schizophrenia
ADL Process Skill
(w=158) in = 200)
Uses 0.96 1.08 1.16
Attends 0.65* 0.11* 0.34
Chooses 0.50 0.63 0.67
Searches/Locates 0.46 0.45 0.64
Sequences 0.40 0.42 0.44
Handles 0.15 0.20 0.19
Gathers 0.24 0.36 0.19
Inquires 0.19 0.13 0.15
Terminates 0.11 0.08 -0.14
Heeds 0.44 0.30 0.15
Continues -0.17 -0.25 -0.02
Navigates 0.26 0.35 0.44
Organizes -0.02 -0.07 -0.10
Initiates -0.29 -0.23 -0.44
Restores -0.25 -0.25 -0.32
Adjusts 0.01 -0.16 -0.15
Paces -0.25 -0.26 -0.06
Notices/Responds -0.71 -0.63 -0.65
Benefits -1.02 -0.88 -1.10
Accommodates -1.40 -1.33 -1.39
* indicates significant difference between skill item calibrations (i.e., difference was
greater than 0.50 logits, p = 0.0000)
50
CHAPTER V: DISCUSSION
ADL Motor and ADL Process Ability Measures
One major finding of the study was that there were no clinically significant
differences in mean ADL motor and ADL process ability measures among the three
diagnostic groups. Therefore, the hypothesis of this study that the bipolar-depressed
group and the bipolar-manic group would demonstrate similar mean ADL motor and
ADL process ability measures was found to be true. However, the hypothesis that the
group with schizophrenia would demonstrate clinically significant lower mean ADL
motor and ADL process ability measures than the bipolar-depressed group and bipolar-
manic group was found not to be true. Instead, the results indicate that the bipolar-
depressed group, the bipolar-manic group, and the group with schizophrenia
demonstrated similar mean ADL motor and ADL process ability measures. The mean
ADL motor and ADL process ability measures, which were at or just below the cut-offs
on the ADL motor and ADL process ability scales, indicate that, in general, persons
within all three diagnostic groups demonstrated increased effort and decreased efficiency
performing ADL tasks, with many of the people within the groups needing assistance to
live in the community.
The finding that the mean ADL motor and ADL process ability measures for the
group with schizophrenia were at or just below the cut-offs is not surprising given the
findings of Girard et al. (1999) and Fossey et al. (2006). Girard et al. (1999) found that
the mean ADL motor and ADL process ability measures for a group with schizophrenia
in = 43), including some participants with typical secondary diagnosis (i.e., anxiety or
depression), were below the AMPS cut-off measures on the ADL motor and ADL
51
process ability scales. Likewise, Fossey et al. (2006) found that 58% of participants with
schizophrenia (n = 43) had ADL motor and/or ADL process ability measures that were
below the ADL motor and ADL process ability measure cutoffs.
This is the first study in which the ADL abilities of persons with bipolar disorder
depressed or manic episode were examined. It was surprising the groups with bipolar
disorder demonstrated similar mean ADL motor and ADL process ability measures as the
group with schizophrenia, as the groups included people with different mental illnesses,
different phases of illness, different symptoms (APA, 1994), and possibly different
severity of cognitive impairments and/or different physical impairments (Chafetz, White,
Collins-Bride, Nickens, & Cooper, 2006; Krabbendam, Arts, van Os, & Aleman, 2005).
Additionally, the finding of similar mean ADL ability measures between the diagnostic
groups was unexpected as Girard et al. (1999) found that mean ADL motor and ADL
process ability measures differed significantly between two groups with different mental
illness (i.e., schizophrenia and depression), although the findings were limited by the
small sample size. Lastly, it was unexpected that the three diagnostic groups would
demonstrate similar mean ADL ability measures as there is much more documentation in
the literature that people with schizophrenia demonstrate limitations in their ADL
performance (Fossey et al., 2006; Girard et al., 1999; Hamera & Kolenbrander, 2000;
Honkonen, 1995) as compared to people with bipolar disorder depressed or manic
episode (Dion et al., 1998; Levine et al., 2001; Pope et al., 2007; Simon et al., 2007).
It is possible that the mean ADL motor and ADL process ability measures of the
two bipolar disorder groups reflect sample bias. The proportion of persons in the AMPS
Project International database diagnosed with schizophrenia (n = 7119) was significantly
52
larger than the proportion diagnosed with bipolar disorder depressed episode or bipolar
disorder manic episode (n = 158 and n = 253 respectively). There are several possible
explanations for the disproportionate amount of data for these diagnostic groups. First,
although AMPS data on persons with schizophrenia and bipolar disorder have been
included since the inception of the database about 20 years ago, it has only been within
the past nine years that occupational therapists have been required to specify the phase of
persons' bipolar illness (i.e., manic episode versus depressed episode) when submitting
AMPS data (B. Merritt, personal communication, January 13, 2009). Second,
occupational therapists who submit calibration data to the AMPS Project International
may be more likely to evaluate clients with bipolar disorder who have obvious
difficulties, and thus, the mean ADL motor and ADL process ability measures of those
with bipolar disorder (depressed and manic) may be under-estimated. Third, occupational
therapists may not receive referrals for persons with bipolar disorder as often as for
persons with schizophrenia. Therefore, participants in the AMPS Project International
database with bipolar disorder depressed or manic episode may be even less
representative of all persons with bipolar disorder depressed and manic episode, than
participants with schizophrenia are representative of all persons with schizophrenia.
Thus, the results need to be interpreted with caution.
Some participants had ADL motor and/or ADL process ability measures above
the cut-off on the ADL motor ability scale and/or above the risk zone on the ADL process
ability scale, and thus demonstrated good quality of ADL performance (i.e. independent,
safe, and efficient ADL performance without increased effort). These findings support
the findings of Girard et al. (1998) and Fossey et al. (2006), that although persons with
53
schizophrenia, on average, experience ADL motor and ADL process skills limitations
that diminish their quality of ADL performance, some persons with schizophrenia
demonstrate good quality of ADL performance. It is unknown from this study, which
factors contribute to high quality of ADL performance measures for people with bipolar
disorder or schizophrenia. When using data from the AMPS Project International
database, there is no way to account for factors such as differences in medications, age of
onset of the illness, and supportive and stable housing that provides a person
opportunities for repeated practice of ADL tasks and/or implementation of strategies to
compensate for limitations in ADL performance. More research is needed to identify the
factors that contribute to high quality of ADL performance.
ADL Motor and ADL Process Skill Profiles
The only skill item that demonstrated DIF was the ADL process skill item,
Attends. The bipolar-manic group experienced significantly more difficulty attending or
maintaining focus when performing ADL tasks than the bipolar-depressed group. This is
not surprising given that one of the key diagnostic criteria for a manic episode is that the
person experiences significant distractibility (i.e., attention is too easily drawn to
unimportant or irrelevant external stimuli) (APA, 1994).
However, while Attends demonstrated DIF, this disruption in the relative skill
item hierarchy did not affect the final estimation of ADL process ability measures (i.e.,
there was no indication of DTF). Therefore, the ADL motor and ADL process skill
hierarchies were determined to be stable for the three diagnostic groups. In other words,
with the exception of Attends, the ADL motor and ADL process skills that were
54
relatively easier and more difficult for one of the diagnostic groups were relatively easier
and more difficult for the other two diagnostic groups. The stability of the ADL motor
and ADL process skill hierarchies confirms one of the assertions of Rasch measurement
model; that is, all persons are more likely to obtain higher scores on easy skill items than
on difficult skill items, regardless of diagnosis. This finding provides further evidence to
support the claim that the AMPS generates valid estimates of ADL motor and ADL
process ability for people with bipolar disorder depressed episode, bipolar disorder manic
episode, or schizophrenia. It also serves as another piece of evidence that the AMPS is a
sample-free measure of ADL ability.
As noted earlier, research suggested that persons with schizophrenia demonstrate
weaknesses with the ADL process skills of Searches/Locates, Sequences and Continues
that limits their ADL performance (Hamera & Kolenbrander, 2000; Rempfer et al., 2003;
Semkovska et al., 2004). The findings of this study, however, revealed that the group
with schizophrenia performed the skills Searches/Locates, Sequencing, and Continues
with the same relative ease/difficulty as the bipolar-depressed and bipolar-manic groups.
It is unknown from this study, if the bipolar-depressed and bipolar-manic groups and the
group with schizophrenia experience the skills Searches/Locates, Sequencing, and
Continues with greater difficulty than well persons.
Clinical Implications
ADL motor and ADL process ability measures
The findings of this study revealed that the three diagnostic groups demonstrated
similar ADL motor and ADL process abilities. However, as mentioned earlier,
55
participants in the AMPS Project International database with schizophrenia may not be
representative of all persons with schizophrenia and participants with bipolar disorder
depressed or manic episode may be even less representative of all persons with bipolar
disorder depressed or manic episode. Participants are likely typical of persons with
bipolar disorder depressed or manic episode or schizophrenia who are referred to an
occupational therapist and complete an AMPS evaluation. If it is true that persons with
bipolar disorder depressed or manic episode or schizophrenia demonstrate similar ADL
motor and ADL process abilities, then these findings challenge the often held assumption
that people with schizophrenia demonstrate greater disability in ADL performance than
people with bipolar disorder depressed or manic episode. Therefore, health professionals
(including occupational therapists) and psychiatrists may be overestimating the quality of
ADL performance of persons with bipolar disorder depressed or manic episode, such that
such persons are not referred to an occupational therapist or once referred to an
occupational therapist, their quality of ADL performance is not assessed. Such persons
may miss the opportunity to benefit from occupational therapy interventions designed to
improve their quality of ADL performance to enhance their ability to live more
successfully in the community. Thus, health professionals and psychiatrists are
encouraged to consider referring persons with bipolar disorder depressed or manic
episode to an occupational therapist for assessment of ADL performance, and (if
necessary) occupational therapy interventions to improve quality of ADL performance.
Additionally, occupational therapists are encouraged to explore with clients with bipolar
disorder depressed or manic episode if they have limitations in their quality of ADL
56
performance and if further ADL assessment and interventions are warranted to improve
their quality of ADL performance are necessary.
Additionally, it is important to note that some persons within this study, across all
three diagnostic categories, demonstrated good quality of ADL performance and may not
need interventions to improve their quality of ADL performance. They may, however,
benefit from occupational therapy interventions that are geared toward improving other
performance areas such as social interaction, computer related skills, and/or work skills.
Lastly, the finding that all three groups' mean ADL motor ability measures were
below the cut-off of 2.0 logits, indicate that, in general, persons within the three
diagnostic groups demonstrated increased effort performing familiar ADL tasks. This
supports the finding of Girard et al. (1998) and Fossey et al. (2006) that some persons
with schizophrenia demonstrated ADL motor limitations that diminished their quality of
ADL performance. Limitations in ADL motor ability may be the result of cognitive
impairments and/or physical impairments due to movement disorders, decreased physical
fitness, side effects from medications, obesity and/or medical disorders such as cardiac
disease and chronic obstructive pulmonary disease (Barrows, 2006; Chugg & Craik,
2002; Fossey et al., 2006). ADL motor skill limitations maybe overlooked in mental
health settings when planning interventions to improve the quality of persons' ADL
performance. These findings highlight the need for occupational therapists to consider
that clients with bipolar disorder depressed or manic episode or schizophrenia may
demonstrate ADL motor skill limitations and well as ADL process skill limitations.
Therefore, such clients may benefit from occupational therapy interventions that target
57
ADL motor as well as ADL process skill limitations to improve their quality of ADL
performance and improve their ability to live successfully in the community.
ADL motor and ADL process skill profiles
The ADL motor and ADL process skill profiles were generally the same for the
three diagnostic groups. The results of this specific study did not identify diagnostically
unique ADL motor and ADL process skill profiles that might be used to differentiate
individuals with bipolar disorder depressed or manic episode or schizophrenia. However,
the sample may have been biased due to the large number of persons with schizophrenia
in the AMPS Project International database compared to the number of persons with
bipolar disorder depressed or manic episode in the database. Therefore the results need to
be interpreted with caution.
The DIF of Attends indicates that as a group, participants with bipolar disorder
manic episode experienced significantly more difficulty attending to their task
performances than participants with bipolar disorder depressive episode. One method
used when planning occupational therapy intervention strategies is to target interventions
toward those ADL motor and/or ADL process skills that diagnostic groups experience as
significantly difficult (Bernspang & Fisher, 1995a; Cooke et al., 2000; Kottorp et al.,
2003a; Oakley et al., 2003). Additionally, a person's ADL process ability measure can be
used to identify intervention strategies that may help to improve their quality of ADL task
performance (Fisher, 2006a). More specifically, if a person's ADL process ability
measure is above 0.0 logits, he/she is more likely to be able to learn new strategies to
overcome performance problems (Fisher, 2006a). Thus, strategies to help a client with
58
bipolar disorder manic episode who experiences significant difficulty with Attends and
has an ADL process ability measure above 0.00 logits, may include coaching the person
to create a quiet and uncluttered environment by turning off the radio, putting his/her pet
in another room, and tidying up the kitchen before starting to prepare lunch. During
interventions sessions, the occupational therapist might provide the client with
opportunities to practice these new strategies while performing occupations that he/she
would normally need or want to do.
In contrast, if a person's ability measure is below 0.0 logits on the ADL process
ability scale, the client is more likely to benefit from environmental modifications and/or
having the support of others who have been trained to support their task performance
(Fisher, 2006a). In this instance, the occupational therapist might collaborate with the
client's caregiver or support person and educate him/her about the importance of
removing potential distracters from the environment to improve the client's quality of
ADL performance.
Limitations of the Study
The results of this study need to be interpreted with caution due to the limitations
of the study. As noted earlier, all participants were referred to occupational therapy and
completed an AMPS evaluation. Thus, participants are likely typical of those persons
who have bipolar disorder depressed or manic episode, or schizophrenia who are referred
to occupational therapy, who were identified by their occupational therapists as
experiencing limitations in ADL performance, and completed an AMPS evaluation.
However, the participants may not be typical of all people who have bipolar disorder
59
depressed or manic episode, or schizophrenia. Some people with bipolar disorder
depressed or manic episode, or schizophrenia may not have limitations in occupational
performance, and subsequently have not been referred to an occupational therapist. Such
persons, therefore, would not likely have data in the AMPS Project International
database, and thus, their data were not included in this study. However, it is important to
note that participants in this study were likely reflective of the array of clients with
bipolar disorder depressed or manic episode or schizophrenia who are typically seen by
occupational therapists and typically evaluated with the AMPS, including those who were
assessed upon referral and those who have been receiving occupational therapy services
for varying lengths of time.
An additional possible source of sample bias relates to the bipolar disorder
groups. The proportion of persons in the AMPS Project International database diagnosed
with schizophrenia (n = 7119) was significantly larger than the proportion diagnosed with
bipolar disorder depressed episode or bipolar disorder manic episode (n = 158 and n =
253 respectively). As mentioned earlier, although the AMPS Project International
database was started approximately 20 years, approximately nine years ago, those
submitting AMPS data were required to specify the phase of bipolar illness (i.e., manic
episode versus depressed episode) (B. Merritt, personal communication, January 13,
2009). This may explain why the database contained data on many more persons with
schizophrenia than persons with bipolar disorder depressed or manic episode.
Additionally, it is also possible that occupational therapists may not receive referrals for
persons with bipolar disorder as often as they do for persons with schizophrenia. Lastly,
occupational therapists who submit calibration data to the AMPS Project International
60
may be more likely to evaluate clients with bipolar disorder who have obvious
difficulties. Therefore, participants in the AMPS Project International database with
bipolar disorder depressed or manic episode may be even less representative of all
persons with bipolar disorder depressed and manic episode, than participants with
schizophrenia are representative of all persons with schizophrenia. Thus, the results need
to be interpreted with caution, meaning due to sample bias, there may actually be
clinically significant differences in mean ADL ability measures and skill profiles between
the bipolar depressed and manic groups and the group with schizophrenia.
A second imitation of this study is the questionable accuracy of the diagnoses.
Occupational therapists are excepted to record for each client in the AMPS International
Project database the clients' diagnosis at the time of the AMPS evaluation. Within the
context of this study, the diagnosis could not be confirmed. It is important to
acknowledge that given the complexity of making a psychiatric diagnosis, specific
individuals' psychiatric diagnosis can change over time. Additionally, the AMPS
International Project database contains data from clients from various countries (Fisher,
2006a); the criteria used when diagnosing mental illnesses may not be the same in all
countries. Lastly, some occupational therapists may enter the diagnosis of bipolar
disorder depressed or manic episode based on the last type of episode that the person
experienced rather than the episode that the client experienced at the time of the AMPS
evaluation (A. Moore, personal communication, July 29, 2008).
The third and last limitation is that it is unknown if the diagnostic groups differed
significantly on all variables that could affect ADL ability measures and ADL motor
and/or ADL process skills. For example, the AMPS Project International database does
61
not include information about whether they are taking medications, and if so, what type
and quantity of medication has been prescribed. People who have bipolar disorder or
schizophrenia are prescribed different medications (Canadian Psychiatric Association,
2005; Yatham et al., 2006) which may affect occupational performance differently
(Dickerson, Sommerville, Origoni, Ringel, & Parente, 2001). Thus, is it unknown if the
groups differed significantly based on taking medications versus not taking medications
and/or taking different medications and if there was a difference, if such differences
affected ADL ability measures and ADL motor and ADL process skill calibration values.
Additionally, ADL process ability measures may be more accurate when AMPS
observations are made when clients complete tasks in a familiar environment (usually the
home) rather than unfamiliar environments (usually the clinic or hospital), due to the
potential effect of the environment on ADL ability (Darragh et al., 1998; McNulty &
Fisher, 2001; Nygard et al, 1994; Park et al., 1994). However, the AMPS International
database does not include information regarding the type of environment of the AMPS
observation (e.g., familiar or unfamiliar). Therefore, it is unknown if the diagnostic
groups differed significantly on type of environment of the AMPS observation and if
there was a difference, if the difference affected ADL ability measures and ADL motor
and ADL process skill calibration values. It is recommended that consideration be given
to include if an AMPS observation was completed in a familiar or unfamiliar
environment in future upgrades of the AMPS software.
62
Future Research
It is recommended that a similar study be completed with a more representative
sample to avoid the sample bias present in this study. In other words, while participants
from the AMPS Project International database may be representative of participants
typically assessed using the AMPS, they may not necessarily be representative of all
persons with bipolar disorder depressed or manic episode, or schizophrenia. Thus, a
follow up study could be conducted where participants are recruited and assessed using
the AMPS regardless, if they were referred to an occupational therapist or not. To
encompass a more diverse and representative sample, participants could be recruited from
health professionals (i.e., psychiatrists, psychologists, social workers, nurses,
psychiatrists, and occupational therapists), in-patient and out-patient mental health
programs, and/or community family physicians. The results gained from a study with a
more representative sample could be interpreted with greater confidence than the results
from this study as the participants would likely be more typical of all persons with
bipolar disorder depressed or manic episode or schizophrenia.
Additionally, similar studies could be completed to determine if ADL motor and
ADL process skill profiles differ among persons with other mental illness such as major
depressive disorder, anxiety disorder, and personality disorder. Knowledge of the
comparisons of ADL motor and ADL process skill profiles among groups with various
mental illnesses would not only provide additional evidence of the validity of the AMPS,
but perhaps lead to clinical recommendations regarding occupational therapy intervention
strategies and/or the need for occupational therapy services.
63
Lastly, it is recommended that future research be completed comparing groups
with specific mental illness to a well group to determine which ADL motor and/or ADL
process skills are more or less maintained by people with a specific mental illness. Again
as above, participants could be recruited from the AMPS Project International database or
from other health professionals. A well group would need to be recruited from outside of
the AMPS Project International database as there are not enough well people in the
database (i.e., more than 200 persons) for such a study (B. Merritt, personal
communication, February 7, 2008). Such evidence could also lead to recommendations
regarding occupational therapy intervention strategies (Cooke et al., 2000; Oakley et al.,
2003 a), as well as serve to educate clients and caregivers about general functional
expectations and signs when a person's mental health may be compromised. Lastly, it is
recommended that future research explore the efficacy of intervention strategies based on
clients' ADL motor and ADL process skill profiles to improve the quality of ADL
performance for people with mental illness, expanding upon the research of Fossey &
Urlic(2001).
64
CHAPTER VI: CONCLUSION
This study represents the first study in which the mean ADL motor and ADL
process ability measures, and the ADL motor and ADL process skill profiles among
groups with bipolar disorder depressed episode, bipolar disorder manic episode, and
schizophrenia were examined. More specifically, it was the first study in which the ADL
motor and ADL process ability measures of persons with bipolar disorder were
examined. The results revealed that the three diagnostic groups demonstrated similar
ADL ability, although the bipolar-manic group demonstrated significantly more difficulty
attending to task performance than the bipolar-depressed group. The findings also
revealed that the ADL motor and ADL process skill hierarchies were stable among the
three diagnostic groups, and this, in turn provides evidence of the validity of the AMPS
for people with bipolar disorder depressed episode, bipolar disorder manic episode, or
schizophrenia. The findings reinforced the idea that when occupational therapists develop
intervention strategies when working with persons with mental illness, they should assess
and address each person's strengths and weaknesses of occupational performance (e.g.,
ADL motor and ADL process skills) to improve the quality of the person's ADL
performance.
65
REFERENCES
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental

Disorders. Fourth Edition, Text Revisions. Washington, DC. American
Psychiatric Association.
Barrows, C. (2006). Home adaptations: Creating safe environments for individuals with
psychiatric disabilities. OT Practice, 12-16.
Baum, C , & Edwards, D.F. (1993). Cognitive performance in senile dementia of the
Alzheimer's type: The Kitchen Task Assessment. American Journal of
Occupational Therapy, 47(5), 431-436.
Bernspang, B. (1999). Rater calibration stability for the Assessment of Motor and Process
Skills. [Electronic version]. Scandinavian Journal of Occupational Therapy, 6
(3), 101-109.
Bernspang, B., & Fisher, A.G. (1995a). Differences between persons with right or left
cerebral vascular accident on the Assessment of Motor and Process Skills.
[Electronic version]. Archives of Physical Medicine and Rehabilitation, 76(12),
1144-1151.
Bernspang, B., & Fisher, A.G. (1995b). Validation of the Assessment of Motor and
Process Skills for use in Sweden. [Electronic version]. Scandinavian Journal of
Bouwens, S.F.M., van Heugten, CM., Aalten, P., Wolfs, C.A.G., Barrends, E.M., van
Menxel, D.A.J., et al. (2007). Relationship between measures of dementia
severity and observations of daily life functioning as measured with the
Assessment of Motor and Process Skills (AMPS). Dementia and Geriatric
Cognitive Disorders, 25, 81-87. DOI: 10.1159/000111694
Bowie, C.R., & Harvey, P.D. (2005). Cognition in schizophrenia: Impairments,

determinants and functional importance. Psychiatry Clinics of North America, 28,
613-633.
Calabrese, J.R., Hirschfeld, R.M.A., Reed, M., Davies, M.A., Frye, M.A., Keck, et al.
(2003). Impact of bipolar disorder on a U.S. community sample. [Electronic
version]. Journal of Clinical Psychiatry, 64(4), 425-432.
Canadian Psychiatric Association (2005). Clinical Practice Guidelines: Treatment of

chizophrenia. Canadian Journal of Psychiatry, 50(Suppl 1), 7S-48S.
Chafetz, L., White, M.C., Collins-Bride, G., Nickens, J., & Cooper, B.A. (2006).
Predictors of physical functioning among adults with severe mental illness.
[Electronic version]. Psychiatric Services, 57(2), 225-230.
66
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. 2n ed. Hilldale,
NJ: Lawrence Eribaum Associates.
Computer Adaptive Technologies & Fisher, A.G. (1994-1999). AMPS Version 3.

[Computer Software]. Chicago: Computer Adaptive Technologies.
Cooke, K.Z., Fisher, A.G., Mayberry, W., & Oakley, F. (2000). Differences in activities
of daily living process skills of persons with and without Alzheimer's disease.
Occupational Therapy Journal of Research, 20(2), 87-105.
Darragh, A.R., Sample, P.L., & Fisher, A.G. (1998). Environment effect on functional
task performance in adults with acquired brain injuries: Use of the Assessment of
Motor and Process Skills. [Electronic version]. Archives of Physical Medicine and
Rehabilitation, 79(A), 418-423.
Dickerson, A.E., & Fisher, A.G. (1993). Age differences in functional performance.
American Journal of Occupational Therapy, 47, 686 - 692.
Dickerson, A.E., & Fisher, A.G. (1995). Culture-relevant functional performance

assessment of the Hispanic elderly. Occupational Therapy Journal of Research,
15, 50-68.
Dickerson, A.E., & Fisher, A.G. (1997). Effects of familiarity of task and choice on the
functional performance of younger and older adults. [Electronic version].
Psychology and Aging, 12(2), 247 - 254.
Dickerson, F.B. (1997). Assessing clinical outcomes: The community functioning of

persons with serious mental illness. Psychiatric Services, 48(1), 897-902.
Dickerson, F.B., Sommerville, J., Origoni, A.E., Ringel, N.B., & Parente, F. (2001).
Outpatients with schizophrenia and bipolar I disorder: Do they differ in their
cognitive and social functioning? [Electronic version]. Psychiatry Research, 102,
21-27.
Dion, G.L., Tohen, M., Anthony, W.A., & Waternaux, C.S. (1988). Symptoms and
functioning of patients with bipolar disorder six months after hospitalization.
[Electronic version]. Hospital and Community Psychiatry, 39(6), 652-657.
67
Doble, S.E., Fisk, J.D., Fisher, A.G., Ritvo, P.G., & Murray, T.J. (1994). Functional
competence of community-dwelling persons with multiple sclerosis using the
Assessment of Motor and Process Skills. Archives of Physical Medicine and
Rehabilitation, 75, 843-851.
Doble, S.E., Fisk, J.D., Lewis, N., & Rockwood, K. (1999). Test-retest reliability of the
Assessment of Motor and Process Skills in elderly adults. Occupational Therapy
Journal of Research, 19(3), 203-215.
Doble, S.E., Fisk, J.D., MacPherson, K.M., Fisher, A.G., & Rockwood, K. (1997).
Measuring functional competence in older persons with Alzheimer's disease.
[Electronic version]. International Psychogeriatrics, 9(1), 25-38.
Doble, S.E., Fisk, J.D., MacPherson, K.M., & Rockwood, K. (1999). Assessing the ADL
functional of persons with Alzheimer's disease: Comparison of family
informants' ratings and performance-based assessment findings. [Electronic
version]. International Psychogeriatrics, 11(4), 399-409.
Duran, L.J., & Fisher, A.G. (1996). Male and female performance on the Assessment of
Motor and Process Skills. [Electronic version]. Archives of Physical Medicine
and Rehabilitation, 77( 10), 1019-1024.
Evans, J.K., Heaton, R.K., Paulsen, J.S., Palmer, B.W. Patterson, T., & Jeste, D.V.
(2003). The relationship of neuropsychological abilities to specific domains of
functional capacity in older schizophrenia patients. Biological Psychiatry, 53(5),
422-430. Retrieved October 25, 2008 from Psychlnfo database.
Fioravanti, M., Carlone, O., Vitale, B., Cinit, M.E., & Clare, L. (2005). A meta-analysis
of cognitive deficits in adults with a diagnosis of schizophrenia. Neuropsychology
Review, 15(2), 73-95. Retrieved January 20, 2008 from the PsychlNFO database.
Fisher, A.G. (1992). Functional measures, Part 2: Selecting the right test, minimizing the
limitations. American Journal of Occupational Therapy, 46(3), 278-281.
Fisher, A.G. (1993). The assessment of IADL motor skills: An application of the many-
faceted Rasch analysis. American Journal of Occupational Therapy, 47(4), 319-
329.
Fisher, A.G. (2006a). Assessment of Motor and Process Skills Volume 1: Development,
standardization, and administration manual (6rd ed.). Fort Collins, CO: Three Star
Press.
Fisher, A.G. (2006b). Assessment of Motor and Process Skills Volume 2: User
administration manual (6rd ed.). Fort Collins, CO: Three Star Press.
68
Fisher, A.G., Atler, K., & Potts, A. (2007). Effectiveness of occupational therapy with
frail community living older adults. [Electronic version]. Scandinavian Journal of
Fisher, A.G., Liu, Y., Velozo, C.A., & Pan, A.W. (1992). Cross-cultural assessment of
process skills. American Journal of Occupational Therapy, 46, 876-885.
Fisher, W.P. (1993). Applications of Rasch analysis to studies in occupational therapy.

Physical Medicine and Rehabilitation Clinics of North America, 4(3), 551-569.
Fossey, E., Harvey, C , Plant, G., & Pantelis, C. (2006). Occupational performance of
people diagnosed with schizophrenia in supportive housing and outreach
programmes in Australia. [Electronic version]. British Journal of Occupational
^Therapy, 69(9), 409-419.
Fossey, E., & Urlic, K. (2001). Evaluating occupational performance using the
Assessment of Motor and Process Skills (AMPS): A mental health practice
perspective. Mental Health Special Interest Section Quarterly, 24, 1-4.
Girard, C , Fisher, A.G., Short, M.A., & Duran, L. (1999). Occupational performance
differences between psychiatric groups. [Electronic version]. Scandinavian
Journal of Occupational Therapy, 6(3), 119-126.
Goldman, S.L., & Fisher, A.G. (1997). Validation of the cross-cultural universality of the
Assessment of Motor and Process Skills. British Journal of Occupational
Therapy, 60, 77-85.
Goto, S., Fisher, A.G., & Mulberry,W.L. (1996). AMPS applied cross-culturally to the
Japanese. American Journal of Occupational Therapy, 50, 798-806.
Graff, M.J.L., Vernooij-Dassen, M.J.R.J., Hoefnagels, W.H.L., Dekker, J., & de Witte,
L.P. (2003). Occupational therapy at home for older individuals with mild to
moderate cognitive impairments and their primary caregivers: A pilot study.
OTJR: Occupation, Participation and Health, 23(4), 155-163.
Green, M.F. (2006). Cognitive impairment and functional outcome in schizophrenia and
bipolar disorder. [Electronic version]. Journal of Clinical Psychiatry, 67 (suppl
9), 3-8.
Greive, J., & Gnanaskearan, L. (2008). Neuropsychology for occupational therapists:

Cognition in occupational performance. (3rd ed.). Maiden, M.A: Blackwell
Publishing.
Hamera, E., & Brown, C. (2000). Developing a context-based performance measure for
persons with schizophrenia: The Test of Grocery Shopping Skills. American
Journal of Occupational Therapy, 54(1), 20-25.
69
Hamera, E., & Kolenbrander, A. (2000). Grocery shopping habits of persons with
schizophrenia. Mental Health Special Interest Section Quarterly, 23(4), 1-4.
Hamilton, M.A. (1960). A rating scale for depression. [Electronic version]. Journal of
Neurology, Neurosurgery, and Psychiatry, 25(1), 56-62.
Hartman, M.L., Fisher, A.G., & Duran, L. (1999). Assessment of functional ability of
people with Alzheimer's Disease. [Electronic version]. Scandinavian Journal of
Harvey, P.D., Howanitz, E., Parrelia, M., White, L., Davidson, M., Mohs, R.C., et al.
(1998). Symptoms, cognitive functioning and adaptive skills in geriatric patients
with lifelong schizophrenia: A comparison across treatment sites. [Electronic
version]. American Journal of Psychiatry, 755(8), 1080-1086.
Harvey, P.D., Velligan, D.I., & Bellack, A.S. (2007). Performance-based measures of
functional skills: Usefulness in clinical treatment studies. Schizophrenia Bulletin,
33, 1138-1148.
Hayase, D., Mosenteen, D., Thimmaiah, D., Zemke, S., Atler, K., & Fisher, A.G.
(2004). Age-related changes in activities of daily living ability. [Electronic
version]. Australian Occupational Therapy Journal, 51,192-198.
Honkonen, T. (1995). Problems and needs for care of discharged schizophrenia patients.
Psychiatria Fennica, 26,21-32.
Kinnman, J., Anderson, U., Wetterquist, L., Kinnman, Y., & Anderson, U. (2000).
Cooling suit for multiple sclerosis: Functional improvement in daily living?
Scandinavian Journal of Rehabilitation Medicine, 32, 20-24.
Kirkely, K.N., & Fisher, A.G. (1999). Alternate forms reliability of the Assessment of
Motor and Process Skills. Journal of Outcome Measurement, 5(1), 53-70.
Kizony, R., & Katz, N. (2002). Relationships between cognitive abilities and the process
scale and skills of the Assessment of Motor and Process Skills (AMPS) in patients
with stroke. [Electronic version]. OTJR: Occupation, Participation and Health,
22(2), 83-92.
Kottorp, A., Bernspang, B., & Fisher, A.G. (2003a). Activities of daily living in persons
with intellectual disability: Strengths and limitations in specific motor and process
skills. [Electronic version]. Australian Occupational Therapy Journal, 50(4), 195-
204.
70
Kottorp, A., Bernspang, B., & Fisher, A.G. (2003b). Validity of a performance
assessment of activities of daily living for people with developmental disabilities.
[Electronic version]. Journal of Intellectual Disability Research, 47(8), 597-605.
Kottorp, A., Hallgren, M., Bernspang, B., & Fisher, A.G. (2003c). Client-centred
occupational therapy for persons with mental retardation: Implementation of an
intervention programme in activities of daily living tasks. Scandinavian Journal
of Occupational Therapy, 10, 51-60.
Krabbendam, L., Arts, B., van Os, J., & Aleman, A. (2005). Cognitive functioning in
patients with schizophrenia and bipolar disorder: A quantitative review.
[Electronic version]. Schizophrenia Research, 80, 137-149.
Kranzler, J.H. (2007). Statistics for the terrified (4th ed.). New Jersey: Prentice Hall.
Law, M. (1993). Evaluating activities of daily living: Directions for the future. American
Journal of Occupational Therapy, 47, 233-237.
Law, M., Baum, C , & Dunn, W. (2005). Measuring occupational performance:

Supporting best practice in occupational therapy. Thorofare, NJ: Slack Inc.
Levine, J., Chenpgappa, K.N.R., Brar, J.S., Gershon, S., & Kupfer, D.J. (2001). Illness
characteristics and their association with prescription patterns for bipolar 1
disorder. Bipolar Disorders, 3, 41-49. Retrieved September 24, 2008 from
Psychlnfo database.
Linacre, J.M. (1987-2002). Facets for Windows Version No. 3.38.1. Chicago: MESA
Linacre, J.M. (1993). Facets, many-facet Rasch measurement computer program:

Chicago: MESA Press.
Linden, A., Boschian, K., Eker, C , Schalen, W., & Nordstrom, C - H. (2005).
Assessment of Motor and Process Skills reflects brain-injured patients' ability to
resume independent living better than neuropsychological tests. [Electronic
version]. Acta Neurologica Scandinavica, 111(1), 48- 53.
Liu, K.P.Y., Chan, C.C.H., Chu, M.M.L., Ng, T.Y.L., Chu, L.W., Hui, F.S.L., et al.
(2007). Activities of daily living performance in dementia. [Electronic version].
Acta Neurologica Scandinavica, 116(2), 91-95.
Magalhaes, L.C., Fisher, A.G., Bernspang, B., & Lincare, J.M. (1996). Cross-cultural
assessment of functional ability. Occupational Therapy Journal of Research, 16,
45-63.
Mahoney, F.I., & Barthel, D.W. (1965). Functional evaluation: The Barthel Index.
Maryland State Medical Journal, 14, 61-65.
71
Mathiowetz, V. (1993). Role of physical performance component evaluations in
occupational therapy functional assessment. American Journal of Occupational
Therapy, 47(3), 225-230.
McNally, B. (1996). A review of the Functional Independence Measure (F.I.M.): A

functional assessment and outcome measurement tool. Irish Journal of
McNulty, M.C., & Fisher, A.G. (2001) Validity of using the Assessment of Motor and
Process Skills to estimate overall home safety in persons with psychiatric
conditions. [Electronic version]. American Journal of Occupational Therapy,
55(6), 649-655.
Merbitz, C , Morris, J., & Grip, J.C. (1989). Ordinal scales and foundations of
misinference. Archives of Physical Medicine and Rehabilitation. 70, 308-312.
Merritt, B.K., & Fisher, A.G. (2003). Gender differences in the performance of activities
of daily living. [Electronic version]. Archives of Physical Medicine and
Rehabilitation, 84{\2), 1872-1877.
Mori, A., & Sugimura, K. (2007). Characteristics of Assessment of Motor and Process
Skills and Rivermead Behavioral Memory Test in elderly women with dementia
and community-dwelling women. Nagoya Journal of Medical Science, 69, 45-53.
Nygard, L., Bernspang, B., Fisher, A.G., & Winblad, B (1994). Comparing motor and
process ability of persons with suspected dementia in home and clinic settings.
American Journal of Occupational Therapy, 48(%), 689-696.
Nygard, L., Amberla, K., Bernspang, B., Almkvist, O., & Winblad, B. (1998). The
relationship between cognition and daily activities in cases of mild Alzheimer's
disease. [Electronic version]. Scandinavian Journal of Occupational Therapy,
5(4), 160-166.
Oakley, F., Duran, L., Fisher, A., & Merritt, B. (2003). Differences in activities of daily
living motor skills of persons with and without Alzheimer's disease. [Electronic
version]. Australian Occupational Therapy Journal, 50(2), 72-78,
Oakley, F., Khin, N.A., Parks, R., Bauer, L., & Sunderland, T. (2002). Improvement in
activities of daily living in elderly following treatment for post-bereavement
depression. Acta Psychiatr Scandinavian, 105, 231-234.
72
Overall, J.E., & Gorham, D.R. (1962). The Brief Psychiatric Rating Scale. Psychological
Reports, 70,799-812.
Pan, A-W., & Fisher, A.G. (1994). The Assessment of Motor and Process Skills of
persons with psychiatric disorders. American Journal of Occupational Therapy,
4S(9),775-780.
Park., S., Fisher, A.G., & Velozo, C.A. (1994). Using the Assessment of Motor and
Process Skills to compare occupational performance between clinic and home
settings. American Journal of Occupational Therapy, 48(S), 697-709.
Pope, M., Dudley, R., & Scott, J. (2007). Determinants of social functioning in bipolar
disorder. Bipolar Disorders, 9, 38-44.
Rempfer, M.V., Hamera, E.K., Brown, C.E., & Cromwell, R.L. (2003). The relations
between cognition and the independent living skill of shopping in people with
schizophrenia. Psychiatry Research, 111(2), 103-112. Retrieved January 20, 2008
from Psychlnfo database.
Rexroth, P., Fisher, A.G., Merritt, B., & Gliner, J. (2005). Differences in individuals with
unilateral hemispheric stroke. [Electronic version]. Canadian Journal of
Rice, M.S., Leonard, C , & Carter, M. (1997). Grip strengths and required forces in
accessing everyday containers in a normal population. American Journal of
Robinson, S., & Fisher, A.G. (1996). A study to examine the relationship of the
Assessment of Motor and Process Skills (AMPS) to other tests of cognition and
function. British Journal of Occupational Therapy, 59, 260-263.
Semkovska, M., Bedard, M.-A., Godbout, L., Limoge, F., & Stip, E. (2004). Assessment
of executive dysfunction during activities of daily living in schizophrenia.
[Electronic version]. Schizophrenia Research, 69(2-3), 289-300.
Sharma, T., & Antonova, L. (2003). Cognitive function in schizophrenia. Deficits,

functional consequences, and future treatment. Psychiatric Clinics of North
America, 26, 24-40.
Simon, G.E., Bauer, M.S., Ludman, E.J., Operskalski, B.H., & Uniitzer, J. (2007). Mood
symptoms, functional impairment, and disability in people with bipolar disorder:
Specific effects of mania and depression. [Electronic version]. Journal of Clinical
Psychiatry, 68(8), 1237-1245.
73
Stauffer, L.M., Fisher, A.G., & Duran, L. (2000). ADL performance of black Americans
and white Americans on the Assessment of Motor and Process Skills. [Electronic
version]. American Journal of Occupational Therapy, 54(6), 607-613.
Tennant, A., & Pallant, J.F. (2007). DIF matters: A practical approach to test if
differential item functioning makes a difference. Rasch Measurement
Transactions, 20(4), 1082-1084.
Tham, K., Ginsburg, E., Fisher, A.G., & Tegner, R. (2001). Training to improve
awareness of disabilities in clients with unilateral neglect. American Journal of
Thornicroft, G., Tansella, M., Becker, T., Knapp, M., Leese, M., Schene, A., et al.
(2004). The personal impact of schizophrenia in Europe. [Electronic version].
Schizophrenia Research, 69(2-3), 125-132.
Three Star Press (2005). Assessment of Motor and Process Skills computer-scoring
program. Fort Collins, CO: Author
Vallee, C. (2006). Comparing learning of cooking in home and clinic for people with
schizophrenia. (Critically appraised paper - commentary). [Electronic version].
Occupational Therapy Now, 8, 11-13.
Velligan, D.I., Bow-Thomas, C.C., Mahurin, C.C., Roderick, K. Miller, A.L., &
Halgunseith, L.C (2000). Do specific neurocognitive deficits predict specific
domains of community function in schizophrenia? [Electronic version]. Journal of
Nervous and Mental Disease, 755(8), 518-524.
Velligan, D.I., Mahurin, R.K., Diamond, P.L., Hazleton, B.C., Eckert, S.L., & Millier,
A.L. (1997). The functional significance of symptomatology and cognitive
function in schizophrenia. [Electronic version]. Schizophrenia Research, 25, 21-
31.
Velozo, C.A., Kielhofner, G., & Lai, J.-S. (1998). The use of Rasch analysis to produce
scale-free measurement of functional ability. American Journal of Occupational
Therapy, 55(1), 83-90.
Waehrens, E.E., & Fisher, A.G. (2007). Improving quality of ADL performance after
rehabilitation among people with acquired brain injury. [Electronic version].
Scandinavian Journal of Occupational Therapy, 1-8.
Wallace, C.J. (1986). Functional assessment in rehabilitation. Schizophrenia Bulletin,

12(4), 604-130.
Weissman, M., & Bothwell, B. (1976). Assessment of social adjustment by patient self-
report. Archives of General Psychiatry, 33(9), 1111 -115.
74
World Health Organization. (2002). Mental health and work: Impact, issues and good
practices. Geneva: Switzerland: WHO. Retrieved February 16, 2008
fromhttp://www.who.int/mental health/media/en/73.pdf
Wright, B.D., & Linacre, J.M. (1989). Observations are always ordinal: Measurements,
however, must be interval. Archives of Physical Medicine and Rehabilitation, 70,
857-860.
Wright, B.D., & Stone, M.H. (1979). Test test design. Chicago: Mesa Press.
Wright, B.D., & Panchapakesan, N. (1969). A procedure for sample-free item analysis.
Educational and Psychological Measurement, 29, 23-48.
Yatham, L.N., Kennedy, S.H., O'Donovan, C , Parikh, S.V., MacQueen, G., Mclntyre,
R.S., et. al. (2006). Canadian Network for Mood and Anxiety Treatments
(CANMAT) guidelines for the management of patients with bipolar disorder:
update 2007. Bipolar Disorders, 8, 721-739. Retrived September 26, 2008 from
PubMed database.
Young, R.C., Biggs, J.T., Zeigler, V.F., & Meyer, D.A. (1978). A rating scale for mania:
Reliability, validity, and sensitivity. [Electronic version]. British Journal of
Psychiatry, 133,429-435.
Zanetti, O., Geroldi, C , Frisoni, G.B., & Trabucchi, M. (1999). Contrasting results
between caregiver's report and direct assessment of activities of daily living in
patient affected by mild and very mild dementia: The contribution of the
caregiver's personal characteristics. Journal of the American Geriatrics Society,
47(2), 196-202.
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Comparison of ADL Motor and ADL Process Skill Profiles Among Groups With Bipolar Disorder Depressed Episode, Bipolar Disorder Manic Episode, and Schizophrenia

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Comparison of ADL Motor and ADL Process Skill Profiles Among Groups With Bipolar Disorder Depressed Episode, Bipolar Disorder Manic Episode, and Schizophrenia

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COMPARISON OF ADL MOTOR AND ADL PROCESS SKILL PROFILES AMONG

GROUPS WITH BIPOLAR DISORDER DEPRESSED EPISODE, BIPOLAR

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LIST OF ABBREVIATIONS USED viii

CHAPTER II: LITERATURE REVIEW 10

Overview of the Literature Review 10

ADL Performance Limitations Among Persons with Schizophrenia or 10

Assessment of Motor and Process Skills 18

Rasch Measurement Model 26

ADL Motor and ADL Process Skill Hierarchies 32

ADL Motor and ADL Process Skill Profiles 34

CHAPTER IV: RESULTS 46

Comparison of Diagnostic Groups 46

ADL Motor and ADL Process Ability Measures 47

Differential Item Function and Differential Test Function 48

ADL Motor and ADL Process Ability Measures 51

ADL Motor and ADL Process Skill Profiles 54

ADL Motor and ADL Process Ability Measures 55

ADL Motor and ADL Process Skill Profiles 58

Limitations of the Study 59

CHAPTER VI: CONCLUSION 65

Table 2 Mean Age and ADL Ability by Diagnosis , 46

Table 3 Number of Participants in each Diagnostic Group by Functional Level

ADL Activities of daily living

process skill profiles to make recommendations of intervention strategies to improve

psychiatric groups, but to date, such research has yet to be completed.

well people in the AMPS Project International database to enable a comparison of a

lead to recommendations regarding intervention strategies to improve the quality of

persons' ADL performance.

worldwide (World Health Organization [WHO], 2002). Disability is evidenced by

demonstrate difficulty performing the ADL process skills Searches/Locates, Sequences,

schizophrenia demonstrate limitations in their quality of ADL performance, little is

patterns of skill strengths and weaknesses among the three groups.

performance is to use the AMPS (Fisher, 2006a). The AMPS is a standardized

performance analysis. A performance analysis refers to an evaluation of persons'

occupational performance by direct observation of their performance of culturally

relevant, familiar, and appropriately challenging tasks within natural environments

coffee pot to the workspace.

process skills to complete the task.

valid means of predicting ADL ability than predictions based on underlying

example, even though cognitive impairments are considered a core feature of

influence on occupational performance (Harvey et al., 1998). Due to the small to

of determining a person's ability to perform desired/necessary daily life tasks (Bouwens

Geroldi, Frisoni, & Trabucchi, 1999). Underestimations and overestimations of persons'

occupational performance be assessed using direct observation of performance, rather

1993; Zanetti e t a l , 1999).

An additional advantage of using the AMPS to conduct performance analyses is

hierarchically ordered from easier to perform to harder to perform (Table 1) (Fisher,

ADL Motor Skills ADL Process Skills

2003a; Oakley et al., 2003; Rexroth et al., 2005).

ADL performance and to use this knowledge to make recommendations regarding

interventions to improve quality of their ADL performance. More specifically, the

with bipolar disorder depressed episode, bipolar disorder manic episode, or

schizophrenia. It was hypothesized that:

clinically significantly in mean ADL motor and ADL process ability

b. the group with schizophrenia would demonstrate clinically significant lower

depressed episode and manic groups; and