development and validation of the paediatric care and needs scale (pcans) for assessing support...
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Developmental Neurorehabilitation, July 2008; 11(3): 204–214
Development and validation of the Paediatric Care and Needs Scale
(PCANS) for assessing support needs of children and youth with
acquired brain injury
CHERYL SOO1,2, ROBYN L. TATE1,3, LINDY WILLIAMS4, SKYE WADDINGHAM5, &MARY-CLARE WAUGH4
1Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, University of Sydney, Australia,2Australian Centre for Child Neuropsychology Studies, Murdoch Children’s Research Institute, Royal Children’s
Hospital, Melbourne, Australia, 3Royal Rehabilitation Centre Sydney, Australia, 4Rehabilitation Department,
Children’s Hospital at Westmead, Sydney, Australia, and 5Occupational Therapy Department, Sydney Children’s
Hospital, Australia
(Received 18 April 2008; accepted 10 June 2008)
AbstractAim: The Paediatric Care and Needs Scale (PCANS) is a newly developed scale that assesses support needs followingchildhood acquired brain injury (ABI). It yields three measures of support: overall, extent and intensity. The developmentalprocess of the PCANS is described and concurrent and construct validity examined.Method: In the validation study, 32 parents/caregivers of children with ABI aged 5–18 years completed the PCANS andother validating measures: Vineland Adaptive Behavior Scales (VABS), Functional Independence Measure for Children(Wee-FIM) and King’s Outcome Scale of Childhood Head Injury (KOSCHI). VABS and Wee-FIM sub-scales examiningsimilar and dissimilar domains to the PCANS were used to investigate convergent and divergent validity, respectively.Discriminant validity analysis used sub-groups dichotomized by VABS and KOSCHI data.Results: Statistically significant correlation coefficients of moderate-to-strong magnitude were found between the PCANSsupport intensity score and most of the VABS, Wee-FIM and KOSCHI variables (rs¼�0.46 to rs¼�0.77, p50.01). Someevidence for convergent and divergent validity was also found. Correlation coefficients between similar domains of thePCANS and other scales were moderately high (e.g. VABS socialization vs PCANS psychosocial items, rs¼�0.64,p50.01). Conversely, correlation coefficients between dissimilar domains were low (e.g. Wee-FIM self-care vs PCANSpsychosocial items, rs¼�0.29). In terms of discriminant group differences, PCANS support extent and intensity scoreswere able to distinguish between sub-groups dichotomized by VABS and KOSCHI scores.Conclusions: These findings provide preliminary evidence for the validity of the PCANS for assessing support needs afterpaediatric ABI.
Keywords: Acquired brain injury, support needs, assessment, children, youth
Objetivo: La escala pediatrica de cuidados y necesidades (PCANS) es una escala recientemente desarrollada que evalua lasnecesidades de apoyo posterior a la lesion cerebral adquirida en la infancia (ABI). La escala consta de tres mediciones deapoyo: una medicion general, una medicion del alcance y una medicion de la intensidad. El proceso de desarrollo de laPCANS se describe y se examina la validez de construccion y concurrencia.Metodo: En el estudio de validacion, 32 padres / cuidadores de ninos con ABI, con edades en el rango entre 5–18 anoscompletaron la escala PCANS y otras medidas de validacion tales como la escala de comportamiento adaptativo deVineland (VABS), Medicion de Independencia Funcional para ninos (Wee-FIM) y la escala King de resultado para ninoscon Traumatismo craneoencefalico (KOSCHI). Las subescalas Wee-FIM y VABS que evaluan dominios similares y nosimilares en relacion con la PCANS, fueron utilizadas para investigar la validez convergente y divergente respectivamente.La validez de discriminacion uso subgrupos divididos por los datos de la VAPS y de la KOSCHI.Resultados: Se encontro una correlacion de coeficientes significativamente estadıstica en magnitudes dentro del rango demoderada a fuerte, entre la calificacion de intensidad de apoyo de la escala PCANS y la mayorıa de las variables de lasescalas VABS, Wee-FIM y KOSCHI (rs¼�0.46 a rs¼�0.77, p50.01). Tambien se encontro cierta evidencia para lavalidez convergente y divergente. Los coeficientes de correlacion entre dominios similares de la escala PCANS y otrasescalas, fueron moderadamente altos (Por ejemplo socializacion VABS vs ıtems psicosociales PCANS, rs¼�0.64,p50.01). Por el contrario los coeficientes de correlacion entre dominios desiguales fueron bajos (por ejemplo, Wee-FIMauto-cuidado vs PCANS ıtems psicosociales, R¼�0.29). En cuanto a las diferencias de los grupos de discriminacion, las
Correspondence: Cheryl Soo, PhD, Australian Centre for Child Neuropsychology Studies, Murdoch Children’s Research Institute, Royal Children’s Hospital,Flemington Rd, Parkville, Victoria 3052, Australia. Tel: þ61 3 9090 5253. Fax: þ61 3 9345 5544. E-mail: [email protected]
ISSN 1751–8423 print/ISSN 1751–8431 online/08/030204–11 � 2008 Informa UK Ltd.DOI: 10.1080/17518420802259498
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calificaciones de intensidad alcance y apoyo de la escala PCANS, permitieron hacer una distincion entre los subgruposdivididos por los resultados de las escalas VABS y KOSCH.Conclusiones: Estos hallazgos proporcionan una evidencia preliminar para la validez de la escala PCANS para evaluar lasnecesidades de apoyo despues de un ABI pediatrico.
Introduction
Acquired brain injury (ABI) encompasses a range ofconditions referring to events such as traumaticbrain injury (TBI), stroke, hypoxia, tumours andbrain infections [1]. TBI is the most common causeof acquired brain disability in childhood [2],occurring in an estimated 185–230 per 100 000children under the age of 15 years in the generalpopulation [3]. The more severe degrees of child-hood ABI may result in acute and longer-termdifficulties in areas such as cognition, behaviour andemotion [4–10], which in turn will impact onpost-injury adjustment to everyday activities andpsychosocial functioning [11–14].
A variety of supports is often required toaccommodate difficulties in both children andadults who sustain ABI [15–20]. These supportsrange from assistance with self-care activities(e.g. bathing and dressing) and instrumentalactivities of daily living (IADL; e.g. completinghousehold chores and use of transport) to schooland leisure participation and forming andmaintaining interpersonal relationships [21–26].These supports take the form of physical assistance
(i.e. hands-on and set-up assistance) and/or super-
vision (i.e. verbal prompts and reminders) and varywidely in terms of the amount of help required, forexample whether more than one person is needed toprovide the support (two-person support requiredfor physical assistance with personal hygiene activ-ities). Further, for a given activity, the frequencywith which supports are required is variable (e.g.supports required every day vs only intermittentlyduring times of stress).
Overlaying these definitional issues, Patrick andPeach [27] conceptualize support needs according toa number of levels. They suggest that needs are felt orunfelt (perceived want for supports vs needs of whichindividuals are unaware, respectively) as well asexpressed and unexpressed. Expressed or requestedneeds may also be met, unmet or undermet, with thelatter two corresponding, respectively, to needs thatare not met or which are only partially met. Thus,support needs can be viewed from a variety ofperspectives. Appropriately designed assessmenttools for assessing support needs provide a basis fordelivery of appropriate services.
Currently, there is a dearth of instrumentsspecifically designed for assessing support needs ofpeople with ABI [26], especially for children andyoung people [28]. This is the case despite the
growing research reporting family and child relatedsupport needs following paediatric ABI [20,29,30].The lack of appropriate resources means that scalesdeveloped for other clinical (e.g. developmentaldisability) as well as non-clinical populations areused as proxies. This practice can lead to theinaccurate (e.g. under-reporting) assessment ofsupport needs, given that these measures are limitedin the way they capture characteristics specific to theABI population. The newly developed assessmentsystem by Bedell [21] is an exception to this paucityof resources. It incorporates the following threescales: (1) Child and Adolescent Scale ofParticipation (CASP), (2) Child and AdolescentFactors Inventory (CAFI) and (3) Child andAdolescent Scale of Environment (CASE). Thiscomprehensive set of scales, designed to reflectcomponents of the International Classification ofFunctioning, Disability and Health (ICF) [31],measures the child’s current level of participationin a range of activities compared to other children ofthe same age. This assessment system does not,however, directly focus on the level of supportneeded in terms of physical assistance or supervisionacross all areas of everyday functioning.
The Paediatric Care and Needs Scale (PCANS)was developed as a measure of support needs forchildren with ABI. The two aims of this paper are to(i) describe the development of the PCANS (Part 1)and (ii) examine its concurrent and construct validity(Part 2).
Part 1: Development of the PCANS
The PCANS was adapted from the Care andNeeds Scale (CANS) [26] which was developedfor adults with TBI. In brief, the CANS measuresboth the type and level of support need. Type ofsupport uses a 24-item checklist which is organizedinto broad groups that are hierarchically based infive domains: special high level needs(e.g. tracheostomy management), basic ADL,IADL, psychosocial and informational/emotionalneeds. Checklist items are endorsed if there is aneed. The number of different types of supportendorsed thus translates into the extent of supportrequired, ranging between 0–27 (24 items andthree ‘other’ categories). Using information fromthe checklist, the level of support is then classifiedin one of eight categories, which range from24-hour care (Level 7) to complete independence
Development and validation of the Paediatric Care and Needs Scale (PCANS) 205
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(Level 0). The type of need maps to the Activityand Participation component of the ICF [31].Checklist items are rated according to the con-textual factors of the person’s situation, therebyalso corresponding to domains of theEnvironmental Factors component of the ICF.The CANS shows excellent reliability (inter-raterreliability ICC¼ 0.93–0.96 and 1-week temporalstability ICC¼0.98) [32], as well as evidence ofconcurrent and construct validity [26].
The structure of the PCANS was derived directlyfrom the CANS, but changes were required, both tothe checklist of items, as well as the conceptualframework of measuring support need within adevelopmental context. Adapting the PCANS fromthe CANS involved three distinct phases, conductedover a 2-year period.
Item development was conducted with a group ofexperienced clinicians from multi-disciplinary back-grounds in paediatric brain injury rehabilitationrepresenting occupational therapy, psychology andrehabilitation medicine. First, the 24-item checklistfrom the CANS was examined. Three CANSchecklist items were considered not appropriate forthe PCANS: parenting, because this would (withrare exception) not apply, and informational andemotional supports, because it was deemed that allchildren require such supports. The CANS categoryof employment/school was separated into two dis-tinct items for the PCANS and the three ‘other’items were retained, yielding a 25-item checklist (seeAppendix).
In the next step of this first phase, the CANS itemswere expanded to cover the variety of activitiesthat are pertinent from a developmental perspective.A comprehensive list exceeding 150 activitieswas compiled and hierarchically organized,based on the expected age of achievement ofactivities.
For example, in the CANS, a single item coversbathing/dressing—the norm for all adults being anexpectation that the task can be completedindependently. In the PCANS, however, this itemcontains five distinct activities, in which dependence,emerging independence or independence isexpected, depending upon the child’s age.Specifically, the five activities within the bathing/dressing item are: ‘washing self in bath/shower’,‘simple dressing and undressing including fasteners’,‘putting on socks and shoes’, ‘forethought to ensurebath/shower safety’ and ‘dressing to suit theweather’. In other words, for each CANS item anassessment of support needs was evaluated in thecontext of whether the child of a given age would beexpected to have mastered developmentally parti-tioned activities representing that item. Selection ofactivities to be included in the PCANS list was based
on clinical judgement and review of scales currentlyused for assessment of childhood disability includingABI. In compiling the list of developmentallyappropriate activities, focus was placed on (1) post-ABI participation in everyday activities rather thanimpairments and (2) activities with direct relevanceto paediatric ABI sequalae, some of which are notincluded in currently available scales.
The second phase of development involved a pilotstudy trialling the PCANS activities. Parents oftypically developing children (n¼ 19, aged 5–18years) were asked whether their child requiredsupports for each activity. On the basis of this pilotstudy, the administration procedures werestreamlined and activities were revised (e.g. poorlyworded phrases were revised and some activitieswere re-sequenced or deleted).
In the final stage, the list of activities was clusteredaccording to four age ranges, resulting in fourseparate forms: (i) Form A: 5–7 years, (ii) Form B:8–11 years, (iii) Form C: 12–14 years and (iv) FormD: 15–18 years. Within each age band three levels ofskill were identified for each activity: independenceexpected for age, emerging independence andindependence not expected for age. Additionally, anumber of activities were deleted as they were notdirectly related to having support needs. Theseincluded a number of leisure activities which weremore related to the interests of the child rather thansupport needs [33]. These procedures resulted in thefinal version of the PCANS, which comprises 130activities nested within the 25-item checklist, whichin turn can be classified into four domains (SpecialNeeds, ADL, IADL and Psychosocial). All PCANSforms (A–D) have the same number of activities;however, the number of activities where indepen-dence was expected is higher in the forms for olderchildren. That is, for the 15–18 year group,independence was expected for 119/130 activities,whereas independence was expected for 100/130activities in the 12–14 year group. In the 8–11 yearold group, independence was expected for 64/130activities for 10 and 11 year olds and 61/130activities for 8 and 9 year olds. For the youngestgroup, 5–7 year olds, independence was expected for13/130 activities.
Administration of the PCANS is straight-forward.The checklist of activities is administered ‘interview-style’ to a person who has current knowledge of thelevel of functioning of the child or it can be self-completed by a clinician or other respondent basedon their knowledge. Interview format takes�30 minutes. For each activity a rating is made asto whether the child is independent in that activity orneeds support. Where support is required, it isclassified as needing physical assistance (‘hands on’ or‘set up’) and/or supervision (verbal prompts or
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indirect supervision). A 3-point scale is used: nosupports (score 0), some supports (score 1) and a lotof supports (score 2).
Three summary scores are calculated using onlythose activities which the child is expected to beindependent for the particular age group: (i) Overalllevel of support is represented by the single highestrating obtained across all activities (range 0–2),irrespective of the number of activities which requiresuch support. Our reasoning was that if, for example,the most support required by a 7 year-old was score2 (‘a lot’) for the activity ‘washing self in the bath/shower’, then that is the level of overall support,irrespective of lower ratings on other activities.(ii) Extent of support is calculated by summing thenumber of items (range 0–25) in which support isrequired. (iii) Intensity of support is calculated bymultiplying the number of items endorsed (max-imum 25) by the support rating (maximum 2;thence, the score range for Intensity is 0-50).Because of the structure of the rating system,separate scores can be generated for physicalassistance vs supervision, as well as the four broaddomain groupings (Special Needs, ADL, IADL andPsychosocial).
Part 2: Validity of the PCANS
Method
Participants. Thirty-two participants were recruitedfrom the Brain Injury Rehabilitation Programmesof Sydney Children’s Hospital (SCH, n¼ 8) andthe Children’s Hospital at Westmead (CHW,n¼ 24), Sydney, Australia. Participants were care-givers of children who satisfied the followingcriteria: (1) a history of an ABI (e.g. encephalitis,stroke or hypoxia) or TBI where there was headtrauma and loss of or altered consciousnessas defined by Glasgow Coma Score (GCS),post-traumatic amnesia (PTA) or intra-cranialabnormalities on brain scan; (2) aged between5–18 years at time of the interview; and (3) timepost-discharge from hospital greater than 6 months.Exclusion criteria were: (1) caregiver non-fluency inEnglish and (2) child history of psychiatric illness,developmental disability or pre-injury neurologicaldisorder.
Materials. Informants were asked to complete thePCANS (described above), a semi-structured inter-view and the standardized questionnaires describedbelow. Injury details, including date of injury, causeof injury and GCS were taken from hospital medicalrecords.
. Vineland Adaptive Behavior Scales (VABS) [34].The VABS assesses personal and social skills usedfor everyday living. The scale was normed on non-handicapped and handicapped individuals(including children with mental retardation,visual handicap and hearing impairment). Thefollowing sub-scales were used in this study:Communication, Daily Living Skills,Socialization and the Adaptive BehaviorComposite (ABC). Communication coversreceptive, expressive and written areas. DailyLiving Skills includes personal (e.g. eating, dres-sing), domestic (e.g. ability to perform householdtasks) and community (e.g. use of time, moneymanagement and job skills) functioning.Socialization covers items focusing on interperso-nal relationships, leisure activities and copingskills. The ABC is an overall index of functioning.Analyses were based on standardized scores(M¼100, SD¼15), with higher scores represent-ing better functioning. Reliability coefficientsbased on a national standardization samplehave been established: split-half (medianr¼ 0.83–0.94), test-re-test (r¼ 0.81 to �0.88)and inter-rater (r¼0.62–0.78); construct,content and criterion-related validities are alsoreported [34].
. Functional Independence Measure for Children
(Wee-FIM) [35]. The Wee-FIM was designed toassess functional independence in non-disabledand developmentally disabled populations [36].Normative data for children between 6 monthsand 8 years are available [37]. The Wee-FIM has18-items which are rated on a 7-point scale(1 indicating need for total assistance and 7indicating complete independence). The followingscores were used in this study: Self-care (six self-care and two sphincter control items), Mobility(three transfers and two locomotion items),Cognition (two communication and three socialcognition items) and Total (sum of self-care,mobility and cognition domains). Analyses werebased on raw scores, with higher scores represent-ing better functioning. Several studies on theassessment properties of the Wee-FIM have beenpublished using samples of individuals with arange of health conditions [38–40]. For example,test–re-test reliability coefficients ranging fromr¼ 0.89–0.99 and inter-rater reliability coeffi-cients ranging from r¼ 0.80–0.96 have beenreported [39]. Validity has also been establishedwith moderate-to-high correlation coefficientsfound for Wee-FIM against the BattelleDevelopmental Inventory Screening Test andVineland Adaptive Behavior Scales, ranging fromr¼ 0.42–0.92 [41].
Development and validation of the Paediatric Care and Needs Scale (PCANS) 207
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. King’s Outcome Scale for Childhood Head Injury
(KOSCHI) [42]. The KOSCHI is an outcomemeasure adapted from the well-known GlasgowOutcome Scale [43]. It describes the extent ofrecovery following paediatric TBI. The scale hasfive main categories: Good Recovery (GR),Moderate Disability (MD), Severe Disability(SD), Vegetative State and Death. The firstthree categories are each further separated intotwo sub-levels, upper and lower, resulting in an8-point scale. Crouchman et al. [42] indicatedthat, based on regression analyses of indepen-dently assigned functional scores and overallKOSCHI category, ‘it is reasonable to treat theKOSCHI categories . . . as an eight point intervalscale’ (p. 122). Inter-rater reliability coefficients(kappa statistic) across categories of the KOSCHIrange from 0.28–0.88, with the highest agreementfor very severely disabled children [42].
. Child Behavior Checklist (CBCL/6-18) [44]. TheCBCL is a 118-item standardized questionnairefor 6–18 year olds focusing on children’s compe-tencies and behavioural/emotional problems in awide range of health conditions. Parents wereasked to provide information on their child’sactivities, social relations and school performance.The following empirically based indices were usedin this study: Internalizing, Externalizing andTotal problems. Analyses were based on normal-ized T-scores with scores less than 60 consideredto be within the normal range, scores between60–63 in the borderline clinical range and scoresabove 63 indicating clinical range. Reliability ofthe CBCL is good with test–re-test coefficients forthe empirically based indices ranging fromr¼0.82–0.94 and alpha coefficients ranging fromr¼0.78–0.97 [44]. Validity is evidenced byassociation of the CBCL with the ConnersRating Scales and Behavior Assessment Systemfor Children (BASC) scales (r¼ 0.38–0.89 forempirically based indices) [44].
Procedure. Ethical approval to conduct the studywas obtained from the ethics committee of eachparticipating clinical institution. A conveniencesample was recruited to represent four equalsub-groups (n¼ 8), based on child’s age at time ofinterview and corresponding to the PCANS forms:Form A (5–7 years), Form B (8–11 years), Form C(12–14 years) and Form D (15–18 years).
Families were telephoned and invited to partici-pate in the study. All caregivers were told they wouldbe part of study which aimed to develop aquestionnaire to assess the support needs of childrenwho have had a brain injury. Caregivers consented toattend an interview on one occasion at the hospital
or in their home. The interview lasted �2 hoursduring which time participants were asked tocomplete the PCANS, VABS, Wee-FIM andCBCL. The PCANS was administered first followedby the standardized questionnaires. All question-naires were administered in interview format withthe clinical researcher (author, CS) who completedall interviews. After the interview, the clinicalresearcher completed a KOSCHI classificationrating based on information obtained from theinterview. Informants interviewed were the child’sparent (n¼28, 87.5%), grandparent (n¼ 2, 6.3%),guardian (n¼1, 3.1%) and aunt (n¼ 1, 3.1%). Inalmost all cases, one informant provided informationabout their child, with both parents being inter-viewed in two cases. The child was not intervieweddirectly.
Statistical analysis. Non-parametic analyses wereused for all statistical analyses. Correlations wereconducted using Spearman’s rank order correlation.Concurrent validity was examined by correlatingPCANS scores with the VABS, Wee-FIM andKOSCHI. To examine convergent validity,PCANS domain scores were correlated with mea-sures of similar constructs (e.g. VABS socializationvs PCANS psychosocial items). For divergentvalidity, PCANS domain scores were correlatedwith measures of dissimilar constructs (e.g. Wee-FIM self-care vs PCANS psychosocial items).Interpretation of the magnitude of the correlationcoefficients was guided by recommendations byCohen [45]. For discriminant (construct) validity,the VABS and KOSCHI data were dichotomizedand Mann-Whitney U-tests were conducted usingPCANS scores as dependent variables, withBonferroni corrections applied to control for multi-ple comparisons (critical alpha level, p50.01).Dichotomization was achieved by the followingprocedures: a median split was applied to theVABS ABC data yielding two equal groups of 16children with high (VABS ABC575.5) and low(VABS ABC > 75.5) functioning scores. KOSCHIdata were dichotomized, with the higher functioninggroup consisting of GR and MD-upper levelclassifications (n¼ 12) and the lower functioninggroup comprising MD-lower level and SD classifica-tions (n¼20). The rationale for this sub-divisionwas to create two sub-groups with sample sizes thatwere as comparable as possible, other combinationsyielding very unbalanced sub-groups.
Results
Table I shows demographic and injury informationof the sample. Median age at onset was 5.3 years andtime post-onset was 60.4 months. The majority of
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participants in the sample sustained a TBI (84.4%),with the most common cause of TBI being motorvehicle crash (n¼ 18), followed by fall (n¼ 5) andother (n¼4; including three cases of non-accidentalinjury and one case of vacuum extraction birthtrauma with subdural haematoma). Cause of non-TBI cases was stroke (n¼ 1), meningitis (n¼ 1) andother (n¼3). According to GCS where this informa-tion was available, the majority of injuries in thesample were severe. Eighty-eight per cent (n¼28) ofparticipants resided in metropolitan areas of Sydney.
Figure 1 shows the frequency of support needsacross domains of everyday functioning according tothe PCANS forms A–D (age groups). For example,
50% of the 5–7 year old children (Form A) requiredsupports for Special Needs activities, as did 25% ofthe 8–11 year olds (Form B) and 12–14 year olds(Form C), but none of the 15–18 year olds(Form D). Comparison of frequency of supportneeds across domains of everyday functioning ingeneral (age groups collapsed) revealed no signifi-cant differences. Within the special needs domain,more children aged between 5–7 years requiredsupports than youth aged between 15–18 years(�2¼ 5.33, p50.05). No other significant differ-
ences were found across PCANS age forms withinany other domain.
Descriptive data for functional outcome andPCANS variables are shown in Table II. Themajority of the sample was classified in the MDgroup with 41% in the upper and 25% in the lowerlevel MD groups. Total Wee-FIM scores rangedfrom 20–126, with a median score of 113. Medianstandard scores for CBCL internalizing, externaliz-ing and total scales were within normal range(T-scores ranging 55–58). In terms of PCANSscores, the median overall support score was 2(‘a lot of support needed’) and for support extentand support intensity, median scores were 7/25(range 1–18) and 10/50 (range 2–38), respectively.
Concurrent validity. Table III presents results ofSpearman’s rank order correlation coefficients forVABS, Wee-FIM and KOSCHI scores with PCANSmeasures. All correlation coefficients for KOSCHIand VABS measures with PCANS support extentand intensity scores were statistically significant andmoderate-to-strong (rs¼�0.57 to �0.77, p50.01).Similarly, significant correlation coefficients ofmoderate-to-strong magnitude were found between
Figure 1. Frequency data for presence of support needs across PCANS domains of special needs, activities of daily living (ADL),instrumental activities of daily living (IADL) and psychosocial functioning according age forms A–D.
Table I. Demographic and injury characteristics for thesample (n¼ 32).
Median Range n %
Age (years) 11.7 5.5–17.6Age at onset (years) 5.3 0–14.2Time post-onset
(months)60.4 8.7–206.9
SexMales 24 75.0Females 8 25.0
Cause of injuryTBI—total 27 84.4MVC 18 56.3Fall 5 15.6Other 4 12.5Non-TBI 5 15.6
GCSa
3–8 15 62.59–12 4 16.713–15 5 20.8
MVC¼Motor vehicle crash; GCS¼Glasgow coma scale.an¼ 8 missing data.
Development and validation of the Paediatric Care and Needs Scale (PCANS) 209
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Wee-FIM measures and the PCANS support inten-sity score (rs¼�0.46 to �0.69, p50.01), with theone exception being for the Wee-FIM self-caremeasure at rs¼�0.38. Correlation coefficients forWee-FIM measures with PCANS overall supportand support extent were more variable ranging fromrs¼�0.23 to �0.63, with the lowest coefficientsfound for Wee-FIM against PCANS overall supportitems (rs¼�0.23 to �0.32).
Convergent and divergent validity. Correlation coef-ficients for the four domains of the PCANS againstthe VABS and Wee-FIM measures are displayed inTable IV. In terms of convergent validity, statisti-cally significant correlation coefficients which wereof moderate-to-strong magnitude were foundbetween the following: VABS daily living skills andPCANS ADL items (rs¼�0.71, p50.01), VABSdaily living and PCANS IADL items (rs¼�0.43,p50.05), VABS socialization and PCANSpsychosocial items (rs¼�0.64, p50.01) and VABScommunication and PCANS psychosocial items(rs¼�0.48, p50.05). Moderate-to-strong andsignificant correlations were also found betweenWee-FIM self-care and PCANS ADL items(rs¼�0.64, p50.01) and between Wee-FIM mobi-lity and PCANS ADL items (rs¼�0.63, p50.01).
In terms of divergent validity, as expected, low andnon-significant correlation coefficients were foundfor the following: Wee-FIM self-care with thePCANS IADL items (rs¼�0.11) and Wee-FIMself-care with PCANS psychosocial items(rs¼�0.29). Interestingly, a number of significantcorrelation coefficients of moderate-to-strong mag-nitude were found between VABS daily living andsocialization scores and PCANS domains. This is
Table II. Descriptive data for functional outcome (KOSCHI,Wee-FIM and CBCL) and PCANS variables.
n % Median Range
KOSCHI (1–8)Good recovery—upper 0 0Good recovery—lower 7 22Moderate disability—upper 13 41Moderate disability—lower 8 25Severe disability—upper 2 6Severe disability—lower 2 6Vegetative 0 0Death 0 0
Wee-FIMSelf-care—items 1–8 (0–56) 54 8–56Mobility—items 9–13 (0–35) 35 5–35Cognitive—items 14–18
(0–35)29 7–35
Total (0–126) 113 20–126CBCLa
Internalizing (33–100) 56 34–84Externalizing (33–100) 55 33–77Total (24–100) 58 34–86
PCANS overall support (0–2) 2 1–2PCANS support extent (0–25) 7 1–18
Special needs (0–10) 0 0–6ADL (0–4) 1 0–3IADL (0–6) 3 0–6Psychosocial
functioning (0–5)3 0–4
PCANS support intensity(0–50)
10 2–38
Special needs (0–20) 0 0–12ADL (0–8) 1 0–6IADL (0–12) 4 0–12Psychosocial
functioning (0–10)5 0–7
KOSCHI¼King’s Outcome Scale of Childhood Head Injury;Wee-FIM¼Functional Independence Measure for Children;CBCL¼Child Behavior Checklist; PCANS¼Paediatric Careand Needs Scale; ADL¼ activities of daily living;IADL¼ instrumental activities of daily living.an¼ 29, T-scores.
Table III. Spearman’s rank correlation coefficients for PCANS scores with VABS, Wee-FIM and KOSCHI scores.
PCANSoverall support
PCANSsupport extent
PCANSsupport intensity
VABSCommunication �0.39* �0.63** �0.66**Daily living skills �0.35 �0.68** �0.72**Socialization �0.47** �0.66** �0.72**Adaptive behaviour composite (total) �0.47** �0.71** �0.77**
Wee-FIMSelf-care �0.24 �0.31 �0.38*Mobility �0.23 �0.63** �0.69**Cognitive �0.31 �0.39* �0.46**Total �0.32 �0.41* �0.49**
KOSCHI �0.32 �0.57** �0.63**
PCANS¼Paediatric Care and Needs Scale; VABS¼Vineland Adaptive Behavior Scales; Wee-FIM¼FunctionalIndependence Measure for Children; KOSCHI¼King’s Outcome Scale of Childhood Head Injury.*p50.05; **p50.01.
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somewhat unexpected given these VABS domainsare not directly related to a number of these PCANSdomains; for example, VABS socialization andPCANS ADL items (rs¼ 0.59, p50.01).
Discriminant validity. Table V presents data com-paring PCANS scores between the dichotomizedVABS and KOSCHI data. Lower scores on thePCANS represents lower support needs. Results ofMann-Whitney U-tests indicated that compared tochildren with low functioning scores on the VABSABC, those with high functioning scores hadsignificantly lower PCANS extent and intensityscores (p50.01). Similarly, children in the higherfunctioning KOSCHI group had significantly lowerPCANS intensity scores (p50.01) compared to thelower functioning group.
Discussion
This study found evidence for concurrent andconstruct validity of the newly-developed PCANSscale for identifying and assessing support needs in apaediatric ABI population. The capacity of the
PCANS to capture overlapping areas of otherassessment tools used in childhood ABI was shownwith PCANS support intensity scores generallyyielding moderate-to-strong correlation coefficientswith these other scales (rs¼�0.46 to �0.77, withone exception, rs¼0.38, for the Wee-FIM self-caremeasure). Yet the coefficients were not so high toindicate complete overlap between measures,indicating that the PCANS measures somethingdifferent that is not captured by other scales. Furtherevidence for validity was demonstrated by the abilityof the PCANS support extent and intensity scores todistinguish groups categorized by overall andadaptive functioning outcome.
The pattern of findings indicates that evidence forconvergent and divergent validity is equivocal. Thereis data to suggest that the PCANS is associated withmeasures tapping similar domains (e.g. rs¼�0.71for VABS daily living vs PCANS ADL items),whereas not associated with measures of dissimilardomains (e.g. rs¼�0.29 for Wee-FIM self-care vsPCANS psychosocial items). On the other hand,moderate-to-strong correlation coefficients were alsofound for VABS daily living skills and socialization
Table IV. Spearman’s rank correlation coefficients for PCANS intensity of support scores for special needs, ADL, IADL and psychosocialdomains with VABS and Wee-FIM scales (n¼ 32).
PCANS Specialneeds (e.g. tracheostomy
management,bed mobility)
PCANS ADL(personal hygiene,bathing dressing,
simple food preparation)
PCANS IADL(shopping, home,
health, money,everyday devices, transport)
PCANSPsychosocial
(interpersonal relationships,leisure and school)
VABSCommunication �0.31 �0.43* �0.69** �0.48**Daily Living �0.70** �0.71** �0.43* �0.62**Socialization �0.54** �0.59** �0.55** �0.64**
Wee-FIMSelf-care �0.59** �0.64** �0.11 �0.29Mobility �0.59** �0.63** �0.53** �0.50**Cognitive �0.63** �0.54** �0.19 �0.43**
PCANS¼Paediatric Care and Needs Scale; ADL¼Activities of Daily Living; IADL¼ Instrumental activities of daily living;VABS¼Vineland Adaptive Behavior Scales; Wee-FIM¼Functional Independence Measure for Children.*p50.05; **p50.01.
Table V. Median (range) PCANS scores by VABS Adaptive Behavior Composite (ABC) and KOSCHI groupings.
VABS ABC KOSCHIa
Median (range) Median (range)
High functioning(n¼ 16)
Low functioning(n¼ 16) U (z)
Mann-Whitney U (z)
Higher levelfunctioning (n¼20)
Lower levelfunctioning (n¼12)
Mann-Whitney U (z)
PCANS extent 5.5 (1–10) 9.0 (3–18) �3.26** 6.50 (1–12) 10.00 (3–18) �2.43*PCANS intensity 6.0 (2–17) 16.5 (4–38) �3.50** 8.00 (2–19) 19.00 (4–38) �2.79**
VABS¼Vineland Adaptive Behavior Scales; KOSCHI¼King’s Outcome Scale for Childhood Head Injury.aKOSCHI higher level functioning group includes GRþMD (b) categories and lower level functioning group includes MD (a)þSDcategories.*p50.05; **p50.01.
Development and validation of the Paediatric Care and Needs Scale (PCANS) 211
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scores, with a number of PCANS domains thatare not directly measuring the same domain.For example, the correlation coefficient for VABSsocialization with PCANS ADL items wasrs¼�0.59 (p50.01). This suggests the ability toperform socialization activities may be dependent onmastery of basic everyday functional tasks and hencethese activities may be indirectly related.
The convergent and divergent validity findingsmay be influenced by the concept of support needsbeing a relatively general construct, which encom-passes a number of sub-components. The ability tolocate a convergent or divergent validity comparisonmeasure for this construct is challenged by the inter-relatedness (including indirectly) of support needswith a number of other domains. Future researchexamining factors such as personality of the child orcertain demographic variables and their relation tosupport needs will assist in unravelling some of thesecomplexities.
The findings from the present study indicate thatthe PCANS shows good promise as a measure ofsupport needs following paediatric ABI. ThePCANS has a number of advantages over otherscales. First, it was specifically designed to capturecharacteristics unique to the ABI population byincorporating and building upon the domains of theadult CANS which was developed for TBI. Second,the structure of the PCANS is such that it directlyfocuses on whether the child requires support toperform each activity rather than whether the child isable or unable to perform the activity. That is, foreach PCANS item, the parent is explicitly asked:‘Does your child require supports in terms ofphysical assistance and/or supervision for the follow-ing activities?’ It is crucial to separate and capturethese two dimensions of support so that clinicianshave specific information upon which to base theirinterventions. It is especially important to identifythe need for supervision or verbal prompts for agiven activity because it is often this type of supportthat is required in the ABI population [46].Additionally, like the assessment system incorporat-ing the CASP, CAFI and CASE [21], ratings ofsupport needs on the PCANS are made taking intoaccount contextual factors such as personal andenvironmental variables thereby capturing the sumtotal of a child’s impairments, activity limitationsand participation restriction.
There are a number of limitations to the presentstudy. A relatively small sample size was used and,although an attempt was made to sample across the5–18-year age range, the sample sizes within each ofthe four age bands was small. Nonetheless, thecorrelation coefficients were of an acceptable mag-nitude supporting the validity of the PCANS, buteven so it is recognized that further work with the
PCANS should be based on larger samples.Additionally, the three independence classificationsfor each of the 130 activities (expected independencefor age, emerging independence and independencenot expected for age) was based upon knowledge ofthe developmental literature and clinical experiencein paediatric ABI. An important next step is tocollect normative data to verify these classificationsand the authors are currently conducting such astudy.
Findings from this study add to the existingliterature documenting support needs followingpaediatric ABI [29,30]. They confirm previousresearch indicating that care and support needsfollowing childhood ABI are required in the longerterm, beyond the initial acute recovery phase[20,30,47]. Present findings suggest that post-ABIadjustment in everyday living requires supportsacross a wide range of areas, particularly inIADL and psychosocial functioning domains, with75–100% of children across the age groups of thepresent sample requiring supports in at least one ofthese areas. In addition, childhood ABI has beenfound to negatively affect family (parental) stresslevels [48] and quality of life [49,50]. Family factorssuch as cultural background may also interact withthe types and levels of support required. Therelationship between the above factors and supportneeds is an important avenue of investigation forfuture research.
Acknowledgements
This study was funded by the Motor Accidents ofAuthority of NSW. We would like to thank allfamilies who participated in this study and the staffat the Children’s Hospital at Westmead and SydneyChildren’s Hospital for their support of this research.
Declaration of interest: The authors report noconflicts of interest. The authors alone are respon-sible for the content and writing of the paper.
References
1. Limmond J, Leeke R. Practitioner review: cognitive rehabilita-tion for children with acquired brain injury. Journal of ChildPsychology and Psychiatry 2005;46:339–352.
2. Sharples PM. Head injury in children. In: Ward Platt MP,Little RA, editors. Injury in the young. Cambridge: CambridgeUniversity Press; 1998. pp 263–299.
3. Kraus JF, Rock A, Hemyari P. Brain injuries among infants,children, adolescents, and young adults. American Journal ofDiseases of Children 1990;144:684–691.
4. Anderson VA, Morse SA, Catroppa C, Haritou F,Rosenfeld JV. Thirty month outcome from early childhoodhead injury: a prospective analysis of neurobehaviouralrecovery. Brain 2004;127:2608–2620.
212 C. Soo et al.
Dev
Neu
rore
habi
l Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Uni
vers
ity o
f A
uckl
and
on 1
1/02
/14
For
pers
onal
use
onl
y.
5. Bloom DR, Levin HS, Ewing-Cobbs L, Saunders AE, Song J,Fletcher JM, Kowatch RA. Lifetime and novel psychiatricdisorders after pediatric traumatic brain injury. Journal of theAmerican Academy of Child and Adolescent Psychiatry2001;40:572–579.
6. Donders J, Warschausky S. Neurobehavioural outcomes afterearly versus late childhood traumatic brain injury. Journal ofHead Trauma Rehabilitation 2007;22:296–302.
7. Fay GC, Jaffe KM, Polissar ML, Liao S, Rivara JB,Martin KM. Outcome of pediatric traumatic brain injury atthree years: a cohort study. Archives of Physical Medicineand Rehabilitation 1994;75:733–741.
8. Max JE, Levin HS, Landis J, Schachar R, Saunders A,Ewing-Cobbs L, Chapman S, Dennis M. Predictors ofpersonality change due to traumatic brain injury in childrenand adolescents in the first six months after injury. Journal ofthe American Academy of Child and Adolescent Psychiatry2005;44:434–442.
9. Middleton JA. Practitioner review: psychological sequalae ofhead injury in children and adolescents. Journal of ChildPsychology and Psychiatry 2001;42:165–180.
10. Yeates KO, Taylor HG, Barry CT, Drotar D, Wade SL,Stancin T. Neurobehavioral symptoms in childhood closed-head injuries: changes in prevalence and correlates during thefirst year post-injury. Journal of Pediatric Psychology2001;26:79–91.
11. Anderson V, Catroppa C. Advances in post-acute rehabilita-tion after childhood brain injury: a focus on cognitive,behavioral, and social domains. American Journal ofPhysical Medicine and Rehabilitation 2006;85:767–778.
12. Andrews TK, Rose FD, Johnson DA. Social and behaviouraleffects of traumatic brain injury in children. Brain Injury1998;12:133–138.
13. Levin HS, Zhang L, Dennis M, Ewing-Cobbs L, Schachar R,Max J, Landis JA, Roberson G, Scheibel RS, Miller DL,Hunter JV. Psychosocial outcome of TBI in children withunilateral frontal lesions. Journal of the InternationalNeuropsychological Society 2004;10:305–316.
14. Stancin T, Drotar D, Taylor G, Yeates O, Wade SL,Minich NM. Health related quality of life of children andadolescents after traumatic brain injury. Pediatrics2002;109:e34–e41.
15. Corrigan JD. Conducting statewide needs assessments forpersons with traumatic brain injury. Journal of Head TraumaRehabilitation 2001;16:1–19.
16. Heinemann AW, Sokol K, Garvin L, Bode RK. Measuringunmet needs and services among persons with traumaticbrain injury. Archives of Physical Medicine andRehabilitation 2001;83:1052–1059.
17. High WM, Gordon WA, Lehmkuhl LD, Newton CN,Vandergoot D, Thoi L, Courtney L. Productivity and serviceutilization following traumatic brain injury: results of a surveyby the RSA region TBI centers. Journal of Head TraumaRehabilitation 1995;10:64–80.
18. Hodgkinson AE, Veerabangsa A, Drane D, McCluskey A.Service utilization following traumatic brain injury. Journal ofHead Trauma Rehabilitation 2000;15:1208–1226.
19. Murray HM, Maslany GW, Jeffery B. Assessment of familyneeds following acquired brain injury in Saskatchewan. BrainInjury 2006;20:575–585.
20. Slomine BS, McCarthy ML, Ding R, MacKenzie EJ,Jaffe KM, Aitken ME, Durbin D, Christensen JR,Dorsch AM. Paidas CN and the CHAT study group.Health care utilization and needs after pediatric traumaticbrain injury. Pediatrics 2006;17:e663–e674.
21. Bedell GM. Developing a follow-up survey focused onparticipation of children and youth with acquired brain
injuries after discharge from inpatient rehabilitation.NeuroRehabilitation 2004;19:191–205.
22. Brooks BM, Rose FD, Johnson DA, Andrews TK,Gulamali R. Support for children following traumatic braininjury: the view of educational psychologists. Disability andRehabilitation 2003;25:51–56.
23. Glang A, Tyler J, Pearson S, Todis B, Morvant M. Improvingeducational services for students with TBI through statewideconsulting teams. NeuroRehabilitation 2004;19:219–231.
24. Pickelsimer EE, Selassie AW, Sample PL, Heinemann AW,Gu JK, Veldheer LC. Unmet service needs of persons withtraumatic brain injury. Journal of Head TraumaRehabilitation 2007;22:1–13.
25. Rotondi AJ, Sinkule J, Balzer K, Harris J, Moldovan R.A qualitative needs assessment of persons who haveexperienced traumatic brain injury and their primary familycaregivers. Journal of Head Trauma Rehabilitation2007;22:14–25.
26. Tate R. Assessing support needs for people with traumaticbrain injury: the Care and Needs Scale (CANS). Brain Injury2004;18:445–460.
27. Patrick DL, Peach H. Disablement in the community.Oxford: Oxford University Press; 1989.
28. Hiller J, Bakker K. Evaluation of assessment tools todetermine care and needs of children with traumatic braininjuries. Report submitted to the Motor Accidents Authorityof NSW; 2002.
29. Armstrong K, Kerns K. The assessment of parent needsfollowing paediatric traumatic brain injury. DevelopmentalNeurorehabilitation 2002;5:149–160.
30. Hawley CA, Ward AB, Magnay AR, Long J. Children’s braininjury: a postal follow-up of 525 children from one healthregion in the UK. Brain Injury 2001;16:969–985.
31. World Health Organisation (WHO). International classifica-tion of functioning, disability and health. Geneva: WorldHealth Organisation; 2001.
32. Soo CA, Tate RL, Hopman K, Forman M, Secheny T,Aird V, Browne S, Coulson C. Reliability of the Care andNeeds Scale for assessing support needs after traumatic braininjury. Journal of Head Trauma Rehabilitation 2007;22:288–295.
33. Soo CA, Tate RL, Williams L, Waddingham S, Waugh MC.The PCANS: adapting the Care and Needs Scale to apaediatric population with traumatic brain injury. BrainInjury 2005;19:37.
34. Sparrow SS, Balla DA, Cicchetti DV. Vineland AdaptiveBehavior Scales Interview Edition: survey form manual.Circle Pines, Minnesota: American Guidance Service; 1984.
35. Braun SL, Granger CV. A practical approach to functionalassessments in pediatrics. Occupational Therapy Practice1991;2:46–51.
36. Msall ME, DiGaudio K, Duffy LC, LaForest S, Braun S,Granger CV. Normative sample of an instrument for trackingfunctional independence in children. Clinical Pediatrics1994;33:431–438.
37. Granger CV, Msall ME, Braun S, Griswald K, McCabe M,Heyer N, Hamilton BB. Wee-FIM System clinical guide:Version 5.01. Buffalo, NY: University of Buffalo; 1998.
38. Chen CC, Bode RK, Granger CV, Heinemann AW.Psychometric properties and developmental differences inchildren’s ADL item hierarchy: a study of the Wee-FIMinstrument. American Journal of Physical Medicine andRehabilitation 2005;84:671–679.
39. Msall ME, DiGaudio K, Rodgers BT, LaForest S,Catanzaro NL, Campbell J, Wilczenski F, Duffy LC. Thefunctional independence measure for children (Wee-FIM).Clinical Pediatrics 1994;33:421–430.
Development and validation of the Paediatric Care and Needs Scale (PCANS) 213
Dev
Neu
rore
habi
l Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Uni
vers
ity o
f A
uckl
and
on 1
1/02
/14
For
pers
onal
use
onl
y.
40. Sperle PA, Ottenbacher KJ, Braun SL, Lane SJ,Nochajski S. Equivalence reliability of the functionalindependence measure for children (Wee-FIM) adminis-tration methods. American Journal of OccupationalTherapy 1996;51:35–41.
41. Ottenbacher KJ, Msall ME, Lyon N, Duffy LC, Granger CV,Braun S. Measuring developmental and functional status inchildren with disabilities. Developmental Medicine and ChildNeurology 1999;41:186–194.
42. Crouchman M, Rossiter L, Colaco T, Forsyth R. A practicalscale for paediatric head injury. Archives of Disease inChildhood 2001;84:120–124.
43. Jennett B, Bond M. Assessment of outcome after severe braindamage. A practical scale. Lancet 1975;1:480–484.
44. Achehbach TM, Rescorla, LA. Manual for the ASEBASchool-Age Forms & Profiles. Burlington, VT: University ofVermont, Research Center for Children, Youth, & Families;2001.
45. Cohen J. Statistical power analysis for the behaviouralsciences. Hillsdale, NJ: Erlbaum; 1988.
46. Boake C. Supervision rating scale: a measure of functionaloutcome from brain injury. Archives of Physical Medicineand Rehabilitation 1997;77:765–772.
47. Ylvisaker M, Todis B, Glang A, Urbancyk B, Franklin C,DePompei R, Feeney T, Maxwell NM, Pearson S, SiantzTyler JS. Educating students with TBI: Themes andrecommendations. Journal of Head Trauma Rehabilitation2001;16:76–93.
48. Wade SL, Taylor G, Drotar D, Stancin T, Yeates KO.Family burden and adaptation during the initial year aftertraumatic brain injury in children. Pediatrics 1998;102:110–116.
49. McCarthy ML, MacKenzie EJ, Durbin DR, Aitken ME,Jaffe KM, Paidas CN, Slomine B, Dorsch AM,Christensen JR, Ding R. Health-related quality oflife during the first year after traumatic brain injury.Archives of Pediatric and Adolescent Medicine2006;160:252–260.
50. Souza LMDN, Braga LW, Filho N, Dellatolas G. Quality oflife: child and parent perspectives following severe traumaticbrain injury. Developmental Neurorehabiliation 2007;10:35–47.
Appendix: Domains (and items) of the PCANS
Group A: Special needs
(1) tracheostomy management(2) nasogastric/PEG feeding(3) bed mobility for those who lie still(4) prevention of wandering behaviour(5) prevention of harmful behaviour(6) communicating basic needs due to language
impairments(7) continence(8) feeding(9) transfers/indoor mobility
(10) other
Group B: ADL
(11) personal hygiene/toileting(12) bathing/dressing(13) simple food preparation(14) other
Group C: IADL and psychosocial
(15) shopping(16) housework/home living skills(17) health, safety and medication use(18) money management(19) everyday devices(20) transport and outdoor surfaces(21) interpersonal relationships(22) leisure, recreation and play(23) school(24) employment(25) other
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