New assessment tools for
people with Intellectual
Disabilities:
APC Meeting
Dr Karen Dodd & Dr Zillah Webb
March 2014
Summary
sHALO
•
Surrey and Hampshire Assessment for Living with Others
BADS-ID
•
Behavioural Assessment of DisExecutive Syndrome – Intellectual
Disabilities
MEP
•
Measure of Everyday Planning
HALO to sHALO
Devised by Shackleton- Bailey, Pidcock and Hampshire
social services, 1980 &1982)
10 main sections: self-care, domestic, community living,
skills, communication,personality and social adjustment,
close personal relations, use of leisure, health/physical
disability, group membership and employment.
HALO is a residential assessment with three main aims:
• To help come to decisions about a client's future home
needs.
• To help make decisions about a clients teaching needs
• To help service managers to plan residential resources
Issues with HALO
Dated – 33 years old
Items needed updating
Services / support needs changing
Scoring needed updating
Tracked down Mike Shackleton Bailey and got agreement
from him and Hampshire Social Services to take over its
development.
sHALO example page – domains 1 -3
SOURECE OF INFORMATION
SOURCE OF INFORMATION
DO = Direct Observation RP = Role Play
IP = Interviewed Person II = Interviewed Informant
EA = unable to assess – ability estimated
1.1
1.2
1.3
1.4
1.5(a)
1.5(b)
Eating/feeding
Drinking
Hand washing
Managing in toilet
Continence – day
Continence – night
1. SELF-CARE
LEVEL OF INDEPENDENCE
Fully independent (no Fairly independent
Some
Very little or no
assistance required) (some help and/ or independence independence (full
prompting
(much help and/ or
assistance
needed)
prompting
required)
needed)
A
B
C
D
A
B
C
D
A
B
C
C
A
B
C
D
A
B
C
D
A
B
C
C
A
B
C
D
1.6
Feminine hygiene/
managing periods
1.7
Strip washing/ bathing/
showering
A
B
C
D
1.8
Hair washing and care of
scalp
A
B
C
D
Total A =
Total N =
Total B =
Total DO =
Total D =
Comments
Give details of help required, with what components of the
task and any factors which impact on the person’s abilities,
eg. Are there any motivational issues?
Y/N
Where there is an ‘OR’ option please indicate which is
applicable.
Expected to do a minimum of one of these.
SUBTOTAL
Total C =
Is this an
issue at
night?
Updated Behavioural Anchors
SELF CARE
1.1 Eating / feeding
Description of “full independence”
Eats well, with good control over use of cutlery (including ability to cut
food). Exhibits appropriate manners (ie. no spitting) and eats at an
appropriate pace and without distraction. Eats an appropriate amount and
does not steal other people’s food. Understands and complies with
dietary requirements (eg. gluten free, vegetarian etc.)
Description
None (individual is capable of all the behaviours without any
assistance)
Occasional prompting / verbal reminders or physical
assistance
Regular prompting / verbal reminders or physical help
Level of Independence
Fully independent
Fairly independent
Some independence
Full help required (individual either cannot or will not behave Very little / no independence
in any of the ways described without full assistance)
sHALO – example page domain 4 - 9
4.
COMMUNICATION (COMM)
SOURCE OF INFORMATION
DO = Direct observation RP = Role play
IP = Interviewed person II = Interviewed informant
EA = unable to assess - ability estimated
SOURCE OF
INFORMATION
4.1
Read all the
Is this an issue
Comments
statements under
at night?
Give details of help required, with what components of the task and any factors
each item and
which impact on the person’s abilities, eg. Are there any motivational issues?
choose the most
Y/N
appropriate.
Where there is an ‘OR’ option please indicate which is applicable.
language understanding
understands almost all of an everyday conversation; can indicate this by
rephrasing, or signing back, what is said. Good understanding of TV and
radio programmes, evidenced by relating back story, or giving correct
responses to queries about story line, characters, etc.
a)
A
moderate difficulties in understanding everyday conversation. If special
allowance is made (e.g. simple words/short sentences/word repetition) can
rephrase or sign back what is said with few errors. Can carry out most
requests (e.g. “please get me a book” and “please get me a cup”) without
accompanying gestures (eg. pointing).
b)
B
difficulty in understanding everyday conversation. Special allowances must
be made; requests, sentences, words must be simple and additional gestures
used (e.g. “please get me a cup” whilst pointing to cup), otherwise cannot
respond, rephrase, or sign back what is said.
c)
B
great difficulty in understanding others; can only use one or two words at a
time. Relies heavily on exaggerated gestures (e.g. overstated pointing),
otherwise cannot sign back or respond to requests.
d)
C
no apparent understanding of any language. Does not respond to requests.
e)
C
SUBTOTAL
Total A =
Total N =
Total B =
Total DO =
Total C =
Total D =
Support needs
A = 0-2 hours daily or aggregated to weekly - no night
support
B = 3-5 hours daily – no night support
C = 24/7 support
D = 1:1 support
N = Nighttime support
Summary page for each section
Summary Page for Self-Care
Item Count
Use this space for comments, descriptive assessment,
noting strengths etc.
Page no.
A
B
C
D
N
No Direct
Obs
1
2
3
Section
total
Maximum
obtainable
27
27
18
Number of items rated by Direct observation
9
18
27
Graphing
Simple
Put scores into Excel spreadsheet
Spreadsheet gives you graphs and summary page
Demonstration
Case Example and Discussion
These are the graphs for person K
Was undergoing a period of assessment and treatment in
our inpatient service
Look at the graphs in groups – and see what these tell you
about her needs
Discussion
Why are Executive Functions important?
There appears to be a general consensus that executive functions
have a central role in human adaptive behaviour (Ardila & Surloff,
2004), enabling us to function and adapt within environments that are
constantly changing (Miyake & Friedman, 2012).
Lezak (1982): “executive functions form the basis of many cognitive,
emotional, and social skills”
◦ Volition, planning, purposeful action, & effective
performance
Miyake et al
Evidence from research with healthy adults suggests executive
functions are both “separable but also moderately related constructs”
This model, explained recently as the unity/diversity framework of
executive functioning, has been frequently cited as the most
comprehensive model of executive functions that is available at
present
This model posits the importance of three specific, lower-level
executive functions of:
•
Shifting – ability to switch between tasks.
•
Updating – a component of working memory involved in operating on incoming
information.
•
Inhibition – ability to deliberately suppress automatic responses as necessary.
Miyake and colleagues (2000) said that these lower-level functions are
necessary for the successful initiation of higher level functions (such
as executive processes of volition, planning, purposeful action and
effective performance as suggested by Lezak in 1982).
Measuring EF in people with LD
There is little research examining the structure of executive functions
in adults with a learning disability
However, based on the available findings from research conducted
with adults with Downs’s syndrome and fragile X syndrome it appears
that the structure of executive functions closely resembles the tripartite
model.
The majority of research in this area tends to rely on using specific
tests of executive function rather than administering more
comprehensive test batteries.
As a result, there may be some ambiguity as to whether the narrow
range of measures are actually measuring the functions of shifting,
updating and inhibition or some other aspect of neuropsychological
functioning.
BADS-ID
The behavioural assessment of the dysexecutive syndrome in
adults with a learning disability (BADS-ID; Webb, 2008).
The BADS-ID is a modified version of the original behavioural
assessment of the dysexecutive syndrome (BADS; Wilson, Alderman,
Burgess, Emslie & Evans, 2000)
Takes approximately 60 minutes to complete.
Made up of six sub-tests
Sub test
Skill tested
Rule shift cards
Perseveration
Action programme
Problem solving and rule maintenance
Key search
Planning and problem solving
Temporal judgement
Judgement and abstraction
Supermarket map
Planning and rule maintenance
Modified four elements
Time management, planning and rule maintenance
BADS v BADS-ID
BADS
BADS-ID
Rule shift cards
Rule shift cards
Action programme
Action programme
Key search
Key search
Temporal judgement
Temporal judgement
Zoo map
Supermarket map
Modified six elements
Modified four elements
Rule shift cards
Participants were presented with red and black cards. Responses were
determined by rules attached to each colour e.g. when a red card is shown
the participant should say “no”. In the second test, the procedure was the
same but the rule changed. There were six trials for each test and two
practice trials. This subtest was timed.
SAY YES TO RED
Say yes if the card is the same colour
as the last one.
SAY NO TO BLACK
Say no if the card is not the same
colour as the last one.
Action programme
Participants were instructed to remove a
cork from a tube without touching the cork
or the tube. Removal of the cork required
the participant to use other materials
provided. This subtest was timed and
participants were given hints about how to
progress every 2 minutes until completion.
Key Search
Participants were asked to imagine that
someone has lost their keys in a field. They
were asked to use a pen to draw a continuous
line to represent how they would search for the
keys. This subtest was timed, but participants
were told they could take as much time as was
necessary for them to be confident they would
find the keys.
Temporal judgement
Participants were asked to guess how long they thought it would take
to do a number of everyday activities
How long does it take people to put their shoe on?
How long does it take people to have a shower?
How long is a TV show?
Supermarket Map
Supermarket map
Involved plotting or following a route through a map of a supermarket
that did not contravene a set of rules. Their score was based on
successful implementation of their plan. Penalties were imposed for
rule breaks and lack of speed.
Task 1 – can collect the items in any order
Task 2 – have to collect the items in order
Modified four elements
Time to try!!!
Comparison of skills intended to be assessed
Test
CEFA
VF
C&D
SR
WCS
ToL
SB
BADSID
RS
AP
KS
TJ
ZM1
ZM2
4P
Initiation
Set
shifting
Verbal
Set
shifting
Visual
Rule
maintenance
Inhibition
Abstract’
Common
principles
Novel
problem
solving
Planning
Monitor’
Prospective
memory
Working
memory
Organisation of
retrieval &
recall
Estimation
Follow
plan
Psychometric properties
Has been used in 2 D Clin Psych MRP’s with total of 89 people
(50.60% male) with a mean age of 42.91 (SD 12.68)
Mean FSIQ was 61.91, (SD 6.64) range 33-88.
The battery has excellent inter-rater reliability (.91), internal
consistency (.87) and acceptable face, content and concurrent validity
(Sunak, 2009).
Temporal estimation questions do not hold together as a single test
Has been compared to CEFA-EF (Ball et al. 2008).
•
Has lower floor than CEFA but similar ceiling
•
Covers wider range of executive functioning skills than CEFA (but still not
comprehensive)
•
Less reliance on working memory
Factor structure
BADS-ID has 1 or 2 factor structure depending on the
tests combined
Combined BADS-ID & CEFA-EF tests results in a 4 factor
model
•
Each battery has items loading of factors 1 & 2
•
Factor 3 (CEFA-EF only) Factor 4 BADS-ID only
Further statistical analysis to decide on final composition
of the test battery
What next?
Currently writing up for publication
Have submitted application to Pearsons to make it
available
Applying for permission to approach original participants to
obtain test-retest data.
What is everyday planning?
The ability to independently organise self to undertake activities of
daily living, for example:
•
Meeting basic needs for food and drink
•
Completing tasks with multiple elements
•
Getting to appointments on the right day with the right information
•
Getting to work on time
•
Planning for future events
Getting started on tasks
Seeing them through to conclusion
Tackling unexpected problems
Assessment
Tools are available to assess many of the factors that
impact on everyday planning e.g. IQ assessments,
assessments of executive functioning
However these require extrapolation to the actual situation
Other assessments are highly detailed and require
specialist training e.g. AMPS
Some areas are not adequately addressed by existing
assessments e.g. impact of emotional regulation and
impulsivity
The tool
•
•
•
•
Comprises grids to rate:
Initiation
Planning / sequencing
Memory
Attention / concentration
Space to record qualitative information on:
Emotional Regulation
Impulsivity
Prepared grids on common tasks
Basic grid that can be adapted for any activity chosen by the
assessor
Prepared grid:
Task
You’re at
home and you
feel thirsty,
what do you
do?
Initiation
Memory
Attention/Concentration
0 Do nothing.
0 Not able to plan / sequence
steps required to make a drink
0 Can’t remember they are
feeling thirsty long enough to
take any action
0 Makes no attempt to get a
drink.
Accepts offer of a drink
1 when given by staff / carer
e.g. at certain times of day
only
Will ask for a drink when
2 feeling thirsty or will move
to get drink if prompted.
Able to assemble some or all of
1 the necessary items but
requires prompting to get
steps in the right order
Able to assemble the necessary
2 items and complete most
steps, but would miss out or
mix up some steps if not
prompted e.g. boiling kettle
Able to assemble items and
3 make a drink successfully given
no problems
e.g. all materials available
Able to assemble items and
4 make drink successfully, even
when faced with a problem
e.g. kettle not working
May move to get a drink but
1 will forget why they have
moved, e.g. forgotten why they
have walked to the kitchen.
Able to remember the first
2 steps needed to make a drink
but not able to complete / may
repeat earlier steps
Will take the first step to get
1 a drink but will become
distracted and not complete.
Able to remember the steps to
3 successfully make a drink
according to plan
Able to make a drink when
3 there are no major
distractions
Able to successfully remember
4 task and hold in mind long
enough to solve a problem
e.g. no milk for tea so what can
I drink instead
Able to make a drink
4 independently despite major
distractions
Is able to fetch a drink
3 made by someone else
Gets up and goes to
4 suitable area e.g. kitchen
and starts making drink
whenever thirsty
Comments
Planning/Sequencing
Able to complete several
2 steps of making a drink
before getting distracted by
something else.
Qualitative Information:
Comments about emotional regulation:
…………………………………………………………………………………………………………………………………………
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Comments about motivation:
…………………………………………………………………………………………………………………………………………
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Any other comments:
…………………………………………………………………………………………………………………………………………
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Presenting the results:
Example grid:
Task
To be
specified
Initiation
Memory
Attention/Concentration
0 Do nothing.
0 Not able to plan / sequence
0 Can’t remember long enough to
take any action
0 Makes no attempt
Co-operates when
1 prompted by others
Able to do task but needs
1 prompting to assemble
materials and sequence steps
Mostly assembles items
2 needed and completes steps.
Needs supervision to ensure
they are all in correct order
Able to plan / sequence when
3 there are no difficulties
Does not remember long
1 enough to complete sequence
need prompting at each step
Able to remember the first
2 steps needed but not able to
complete / may repeat earlier
steps
Able to remember the steps to
3 successfully provided there are
no problems
Able to successfully remember
4 task even when faced with
problems
Will take the first step but
1 become distracted.
Will indicate a need but
2 not initiate action
Initiates action but not
3 problem solving
Initiates action and also
4 initiates problem solving if
encounters difficulties
Comments
Planning/Sequencing
Able to plan / sequence
4 including addressing problems
Able to complete several
2 steps before getting
distracted by something else.
Able to complete all steps
3 when there are no major
distractions
Able to complete all steps
4 independently despite major
distractions
Group work
Use the example grid format and choose a task to try and
complete the descriptors for that task.
Feedback on ease and practicality.
Any Questions?
Contact details
Dr. Karen Dodd
Surrey & Borders Partnership NHS Foundation Trust,
Ramsay House,
West Park,
Epsom,
Surrey KT19 8PB
 DrKaren.dodd@sabp.nhs.uk
 01372 205767
Contact Details
Dr. Karen Dodd
Surrey & Borders Partnership NHS
Foundation Trust,
Ramsay House,
West Park,
Epsom,
Surrey KT19 8PB
Dr. Zillah Webb
Surrey & Borders Partnership NHS
Foundation Trust,
April Cottage
Farmfield
Charlwood
Surrey RH6 0BN
 DrKaren.dodd@sabp.nhs.uk
 zillah.webb@sabp.nhs.uk
 01372 205767
 01293 774919