Assessment of Awareness of Disability(AAD)

The Assessment of Awareness of Disability (AAD) is an innovative approach in evaluating awareness of disability, developed by Kerstin Tham and Anders Kottorp, Karolinska Institutet, Stockholm, Sweden. The AAD is an assessment based on a semi-structured interview, which is used in conjunction with the Assessment of Motor and Process Skills (AMPS) (Fisher, 2005a; Fisher, 2005b). Since the AMPS is a performance evaluation that allows the client to perform culturally and personally relevant and meaningful tasks, the AAD also takes into consideration these aspects in evaluation of awareness of limitation of performance.

The AAD was developed to be used by occupational therapists with a client-centered and top-down approach in intervention planning. The AAD can, in conjunction with the AMPS, be used to identify areas in occupational performance the client is more or less aware of, and give important information for selecting, planning and implementing different intervention strategies. The AAD may also be used for measuring improvements in awareness of disability over time.

The Assessment of Awareness of Disability has demonstrated expected test-retest reliability (Tham, Ginsburg et al. 2001; Kottorp, Hallgren et al. 2003; Hallgren and Kottorp 2005), internal scale validity and acceptable person response validity (Tham, Bernspang et al. 1999). The AAD measures have also demonstrated sensitivity to change due to intervention (Tham, Ginsburg et al. 2001; Kottorp, Hallgren et al. 2003; Hallgren and Kottorp 2005) . Finally, occupational therapists who have taken the AAD course and finalized calibration demonstrate consistency and stability in their ratings, supporting rater reliability (Kottorp and Tham 2005). Several research studies examining the validity and reliability of AAD are also in progress, with client with dementia, mental retardation, stroke, traumatic brain injury, and mental disorders. The AAD is currently implemented clinically with clients with neurological, psychiatric, developmental, and orthopedic disorders.

Background and Literature

Individuals with varying functional limitations often experience difficulties in performing activities of daily living (ADL). These limitations can also pose difficulties when trying to participate in society and community life (Kielhofner 2002). Rehabilitation services often aim to improve ADL performance and increase opportunities to participate in the community.

Current trends in rehabilitation highlight a top-down approach to intervention planning (Granlund and Bjorck-Akesson 2000; Fisher 2005a). In order to achieve optimal functioning in everyday activities, a top-down approach, in which rehabilitation services focus primarily on everyday situations/tasks that the client experiences as limiting, is more effective than focusing on evaluating and treating underlying personal/environmental characteristics (bottom-up approach). In addition, a client-centered approach is proposed, suggesting the importance of: (a) developing a collaborative relationship with the client and his/her caregivers, (b) focusing goals and interventions relating to everyday situations/tasks of most importance for the client/caregivers, and (c) engaging the client/caregivers in all parts of the rehabilitation process (Rogers 1951; Rogers 1957).

Most everyday tasks are incorporated in a person’s habits and routines (Kielhofner 2002), and generally do not challenge a person’s awareness of him or herself while interacting within an environment (Flavell 1985). Moreover, persons who lack an awareness of their limitations in everyday functioning may be less motivated to change their performance (McGlynn and Schachter 1989; Tham, Borell et al. 2000). In order to promote active participation in intervention planning, awareness of one’s own limitations has been thought crucial for motivatation (Crosson, Barco et al. 1989; McGlynn and Schachter 1989; Prigatano and Schachter 1991; Lindqvist and Skipworth 2000).

A limited awareness of disability is a well-known clinical problem among persons with various disabilities, resulting in consequences on rehabilitation outcomes (Hartman-Maeir, Soroker et al. 2002; Katz, Fleming et al. 2002); for instance, a lack of awareness of disabilities is a phenomenon present among persons with stroke and dementia who often over-estimate their capacities (Mullen, Howard et al. 1996; Hartman-Maeir, Soroker et al. 2002; Hartman-Maeir, Soroker et al. 2003). Persons with mental retardation often present with difficulties in perceiving and processing feedback from the environment, which might have an impact on the person’s awareness of performance limitations (Cumming, Jones et al. 1992; Tannous, Lehmann-Monck et al. 1999). Clients with a spectrum of mental disorders have a tendency to underestimate difficulties in their everyday life, which often limits rehabilitation outcomes as well as community re-integration, consequently causing risk for relapse (Drost 1997; Lindqvist and Skipworth 2000; Hodgins 2002; Lindstedt, Soderlund et al. 2004). The severity of a limited awareness is also considered to have an impact on the choice of different interventions strategies (Duchek and Abreu 1997).

In order to optimize the outcome potential of interventions offered to support these clients to maintain, develop or restore abilities to function in everyday life, it is important to systematically evaluate the awareness of disability among these clients, and take this information into consideration when planning and implementing interventions. An evaluation tool addressing the client’s awareness of his/her disabilities in conjunction with his or her actual ability is therefore an important consideration, given client-centeredness and a top-down approach. Moreover, there is a clinical need for formalized and validated evaluations focusing on assessing the client’s awareness of actual limitations in everyday life (Crosson, Barco et al. 1989; Prigatano and Schachter 1991).

Finally, an evaluation of awareness of disability should preferably be based on a systematic comparison between observable limitations in performance and self-described limitations (Gist and Mitchell 1992; Katz and Hartman-Maeir 1997). This program is therefore building upon results from research projects regarding development of an evaluation of actual ability to perform ADL tasks: the Assessment of motor and Process Skills (AMPS). The AMPS has been extensively evaluated in research for validity and utility for the groups defined in this study. See the AMPS manual for further references (Fisher 2005a).

- Anders Kottorp, Ph.D., Reg. OT.

Karoliska Institutet (Sweden) - Assessment of Awareness of Disability Research Project

 

Related References

Crosson, B., P. P. Barco, et al. (1989). "Awareness and compensation in postacute head injury rehabilitation." Journal of Head Trauma Rehabilitation: 45-64.

Cumming, J., A. Jones, et al. (1992). "It is possible: A process for teaching community living skills." Australian Occupational Therapy Journal 39: 35-38.

Drost, M. (1997). Personality disorders: the challenge for residential treatment. Challenges in forensic psychiatry. H. van Marle. London, Jessica Kingsley: 53-62.

Duchek, J. M. and B. C. Abreu (1997). Meeting the challenges of cognitive disabilities. Occupational therapy: enabling function and well-being. C. H. Christiansen and C. M. Baum. Thorofare, NJ, Slack Inc.: 289-312.

Fisher, A. G. (2005a). Assessment of Motor and Process Skills: Development, standardization and administration manual. Fort Collins, CO, Three Star Press.

Fisher, A. G. (2005b). Assessment of Motor and Process Skills: User's manual. Fort Collins, CO, Three Star Press.

Flavell, J. H. (1985). Cognitive development. Englewood Cliffs, NJ, Prentice-Hall.

Gist, M. and T. Mitchell (1992). "Self-efficacy: A theoretical analysis of its determinants and malleability." Academy of Management Review 17: 183-211.

Granlund, M. and E. Bjorck-Akesson (2000). "Integrating inservice training in family centered practices in context: Implications for implementing change activities." Infant and Young Children 12: 46-60.

Hartman-Maeir, A., N. Soroker, et al. (2003). "Awareness of disabilities in stroke rehabilitation - a clinical trial." Disability and Rehabilitation 25: 35-44.

Hartman-Maeir, A., N. Soroker, et al. (2002). "Awareness of deficits in stroke rehabilitation." Journal of Rehabilitation Medicine 34: 158-164.

Hodgins, S. (2002). "Research priorities in forensic mental health." International Journal of Forensic Mental Health 1: 7-23.

Hallgren, M. and A. Kottorp (2005). "Effects of occupational therapy program in activities of daily living and awareness of disability in persons with intellectual disabilities." Australian Occupational Therapy Journal 52: 350-359.

Katz, N., J. Fleming, et al. (2002). "Unawareness and/or denial of disability: Implications for occupational therapy." Canadian Journal of Occupational Therapy 69: 281-292.

Katz, N. and A. Hartman-Maeir (1997). "Occupational performance and metacognition." Canadian Journal of Occupational Therapy 64: 53-62.

Kielhofner, G., Ed. (2002). A model of human occupation: Theory and application. Baltimore, Lippincott Williams & Wilkins.

Kottorp, A., M. Hallgren, et al. (2003). "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.

Kottorp, A. and K. Tham (2005). Assessment of Awareness of Disability (AAD). Manual for administration, scoring, and interpretation. Stockholm, Sweden, Karolinska Institutet, NEUROTEC Department, Division of Occupational Therapy.

Lindqvist, P. and J. Skipworth (2000). "Evidence-based rehabilitation in forensic psychiatry." British Journal of Psychiatry 176: 320-323.

Lindstedt, H., A. Soderlund, et al. (2004). "Mentally disordered offenders' abilities in occupational performance and social participation." Scandinavian Journal of Occupational Therapy 11: 118-127.

McGlynn, S. M. and D. L. Schachter (1989). "Unawareness of deficits in neuropsychological syndromes." Journal of Clinical Experimental Neuropsychology: 143-205.

Mullen, R., R. Howard, et al. (1996). "Insight in Alzheimer's disease." International Journal of Geriatric Psychiatry 11: 645-651.

Prigatano, G. P. and D. L. Schachter, Eds. (1991). Awareness of deficits after brain injury. New York, Oxford University Press.

Rogers, C. R. (1951). Client-centred therapy. Its current practice, implications, and theory. Boston, Houghton Mifflin.

Rogers, C. R. (1957). "The necessary and sufficient conditions of therapeutic personality change." Journal of Consulting Psychology 21: 95-103.

Tannous, C., V. Lehmann-Monck, et al. (1999). "Beyond good practice: issues in working with people with intellectual disability and high support needs." Australian Occupational Therapy Journal 46: 24-35.

Tham, K., B. Bernsprang, et al. (1999). "Development of Assessment of Awareness of Disability." Scandinavian Journal of Occupational Therapy 4: 184-190.

Tham, K., L. Borell, et al. (2000). "The discovery of disability: a phenomenological study of unilateral neglect." American Journal of Occupational Therapy 54: 398-406.

Tham, K., E. Ginsburg, et al. (2001). "Training to improve awareness of disabilities in clients with unilateral neglect." American Journal of Occupational Therapy 55: 46-54.