Development and validation of Vellore Inventory of Life Skills among people with severe mental illness

Meghana C Chandran; Febin Saji; Reema Samuel; KS Jacob

doi:10.4103/psychiatry.IndianJPsychiatry_872_20

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Abstract

Introduction

Materials and Me...

Results

Discussion

Conclusion

Appendix

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ORIGINAL ARTICLE

Year : 2021 | Volume : 63 | Issue : 1 | Page : 15-27

Development and validation of Vellore Inventory of Life Skills among people with severe mental illness

Meghana C Chandran¹, Febin Saji², Reema Samuel¹, KS Jacob¹
¹ Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
² Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Tamil Nadu, India

Click here for correspondence address and email

Date of Submission	16-Jul-2020
Date of Decision	27-Aug-2020
Date of Acceptance	23-Oct-2020
Date of Web Publication	15-Feb-2021

Abstract

Background and Aim: Rehabilitation for people with severe mental illness is incomplete without life skills assessment and intervention. The aim of the study was develop a culturally specific performance-based measure assessing life skills of patients with severe mental illness.
Materials and Methods: The items for the Vellore Inventory of Life Skills (VILS) were drawn after consultation with a reference group and from existing standardized scales. The items were categorized into two sections with six components each, which was further hierarchically arranged into activities at either basic, intermediate, or advanced level. One hundred consecutive clients between 18 and 60 years of age who provided written informed consent were assessed on the Comprehensive Evaluation of Basic Living Skills (CEBLS) and the VILS to evaluate convergent validity and inter-rater reliability. The General Health Questionnaire (GHQ-12) was used to evaluate divergent validity. The assessments were repeated after a week to evaluate test–retest reliability.
Results: The scale had good inter-rater reliability 0.938 (95% confidence interval [CI] 0.887–0.967) and test–retest reliability 0.907 (95% CI 0.865–0.937). The correlation between total score of VILS and CEBLS (Pearson's correlation coefficient [PCC] = 0.611; P = 0.001) suggested moderate convergent validity. The correlation between total score of VILS and GHQ-12 (PCC = −0.260; P = 0.105) implied good divergent validity.
Conclusion: Preliminary data suggest that the VILS is clinically useful for the Indian population.

Keywords: Activities of daily living, assessment, India, life skills, occupational therapy, severe mental illness

How to cite this article:
Chandran MC, Saji F, Samuel R, Jacob K S. Development and validation of Vellore Inventory of Life Skills among people with severe mental illness. Indian J Psychiatry 2021;63:15-27

How to cite this URL:
Chandran MC, Saji F, Samuel R, Jacob K S. Development and validation of Vellore Inventory of Life Skills among people with severe mental illness. Indian J Psychiatry [serial online] 2021 [cited 2021 Jul 28];63:15-27. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/1/15/309496

Introduction

Life skills, otherwise called as activities of daily living (ADLs), have been defined by the World Health Organization as abilities for adaptive positive behavior that enable us to deal effectively with the demands and the challenges of everyday life.^[1] Life skills include basic ADL (BADLs), routine everyday activities like bathing, dressing, feeding, personal hygiene, grooming, and toilet hygiene. They also include instrumental ADL (IADLs), which are the more complex ADLs necessary for living in the community, including competence in skills such as shopping, cooking, and managing finances. They are essential for developing psychosocial, emotional, cognitive, behavioral, and resilience skills to negotiate everyday challenges and productive involvement in the community.^[1] Impairments in adaptive life skills are a major source of disability in patients with chronic mental illnesses.^[2] Interventions targeting optimal independent functioning have been found to be essential for re-integration of persons with mental illness.^[3] Failure to focus on independent living skills is also thought to increase family burden and economic disadvantage.^[4]

While assessing everyday performance, it is important to differentiate between what a person is able to do (functional capacity) and what he actually does (real-world performance), called as the competence/performance distinction.^[5],[6] Among the assessment methods available for measuring functional capacity, performance-based measures are more predictive of real-world outcomes than self-report instruments and direct observation of behavior.^[7] The University of California San Diego Performance-Based Skills Assessment (UPSA) is a widely used scale, assessing performance in five domains of independent community living skills-household chores, communication, finance, transportation, and planning recreational activities.^[8] However, since the tasks in a performance-based measure vary according to the cultural context, and since everyday self-care activities are also essential for independent living, there is a need to tailor these assessments to meet local standards. For example, the use of spoons, forks, and knife by other populations cannot be compared with rural Indian population as hands are preferred for eating. The materials, procedures, and cuisines related to meal preparation vary significantly even within India. The use of electrical appliances in home management tasks like iron box, food processor, washing machine, and dishwasher is not as prevalent in rural populations as compared to manual hand techniques.

Despite evidence supporting the importance of assessment and training in life skills for people with mental illness, research in this area has been minimal in India and is a need of the hour.^[9] A recent meta-analysis also documents the lack of good evidence for the effectiveness of life skill programs and emphasizes the need for more robust studies.^[10] The Vellore Inventory of Life Skills (VILS) was thus developed to address the dearth of a culturally relevant performance-based measure to assess the life skills of persons with severe mental illness in low- and middle-income countries (LMIC).

Materials and Methods

Study setting

The study was conducted in the department of psychiatry of a 122-bedded tertiary referral center with an average daily footfall of around 500 outpatients. The treatment team consisting of psychiatrists, occupational therapists, psychiatric nurses, clinical psychologists, and psychiatric social workers employs a multidisciplinary approach in treating adults and children with mental and behavioral disorders. The center runs an inpatient occupational therapy program with a focus on improving various domains of life skills and occupational functioning. This inventory was developed specifically to aid in the assessment and thereafter goal setting for improving the life skills of inpatients undergoing the training program at the unit.

The study design and inventory construction was conceptualized by RS and KSJ, who aided by an expert committee of occupational therapists, reviewed current literature and provided input on items and scoring. It was found that there were no performance-based measures for daily living skills adapted for developing countries like India. Furthermore, most scales assessed either BADLs or IADLs, although developmentally, basic self-help skills act as precursors to advanced living skills, and both need to be essentially focused on in life skills training. Hence, focusing on a performance-based measure which assesses both BADLs and IADLs was thought to be more resource optimizing and reliable.

Construction of the inventory

Review of instruments

The contents, items, scoring, and interpretation of the following scales were reviewed during the search of literature: (1) Kohlman Evaluation of Living Skills,^[11] (2) Life Skills Profile,^[12] (3) Milwaukee Evaluation of Daily Living Skills,^[13] (4) Lawton IADL Scale,^[14] (5) Independent Living Skills Survey,^[15] and (6) Comprehensive Evaluation of Basic Living Skills (CEBLS).^[16]

Item collection and categorization

Each scale and their items were examined and the inventory was categorized into two domains, namely BADL and IADL, each with six components. Since the skills are multidimensional, the items were not distributed across a uniform scale but rather as an inventory of minimum skill levels achieved. Hence, each component was broken down into steps using task analysis and was hierarchically arranged into skills at either Basic, Intermediate, or Advanced level, keeping the self-help developmental milestones from childhood till adolescence as a reference. Thus, the final version of the VILS has six BADL components of (i) bathing, (ii) toilet hygiene, (iii) oral hygiene, (iv) dressing, (v) eating, (vi) grooming, and six IADL components of (i) financial management, (ii) food management, (iii) health management, (iv) community mobility (v) household management, and (vi) academic/vocational skills [Appendix 1].

Scoring

The scoring was prepared progressively from basic to advanced level, giving one score for each step that the person is able to perform at each level. For example, the component of bathing has four items each at the basic and intermediate level and three items at advanced level, adding up to a total possible score of 11. A person scoring from 1 to 4 will be considered to be at the basic level, 5 to 8 at the intermediate level, and 9 to 11 at the advanced level in bathing. Likewise, it would be possible to designate the current level of functioning of a person in each of the 12 components of the VILS. Subsequently, the goal of intervention would be to train the skills directly above the current functional level.

Study sample

The sample size calculation based on the guidelines for estimating sample size for intraclass correlation coefficient (ICC), for two observations, with a prespecified alpha value of 0.05, power of 0.9, and ICC value of 0.3 was 91.^[17] Out of one hundred and ten consecutive inpatients recruited, ten assessments could not be completed due to unplanned discharge or emergence of psychotic symptoms; hence, data were collected till a sample size of 100 was reached. Patients with a diagnosis of schizophrenia or bipolar affective disorder attending the inpatient occupational therapy program at the department of psychiatry aged between 18 and 60 years of age and who gave written informed consent were included for the study. Clients with a clinical diagnosis of moderate to profound intellectual disability, those with organic mental disorders, and those with acute psychotic presentations were excluded from the study.

Assessment tools used

CEBLS:^[16] This is a measure with seven domains of basic living skills, (i) meal planning (ii) telephone (iii) bus (iv) shopping (v) meal preparation (vi) serving and eating and (vii) meal cleanup. Each component is marked on a scale of 1–4 where 1 is “can't perform,” 2 is “requires much assistance,” 3 is “requires some assistance,” and 4 is “performs independently and correctly.” It has a maximum possible score of 232 across 58 items. This scale was chosen to evaluate convergent validity as the scale had domains similar to the IADL domains of VILS and was also the only one to include few BADL components also
The General Health Questionnaire (GHQ):^[18] This is a measure of current mental health originally developed as a 60-item instrument; for the current study, the 12-item GHQ-12 was used. The GHQ-0011 scoring method was used, which yields a maximum possible score of 12. The GHQ-12 was used to evaluate divergent validity as the construct of psychological well-being is sufficiently dissimilar to that of independent living skills
Brief Psychiatric Rating Scale (BPRS):^[19] The BPRS assesses psychiatric symptoms and consists of 18 items with scores ranging from 1 (not present) to 7 (extremely severe) and 0 for not assessed, with a maximum possible score of 126. The BPRS scores, which are routinely rated by the primary treating psychiatrist, were documented
VILS: The final version of the inventory has 12 domains, six each under BADLs and IADLs.

Procedure

The details of the study were explained to all participants, and written informed consent was obtained. The VILS was scored by two investigators (MCC and FS) independently and simultaneously for evaluating inter-rater reliability. The BADL items were scored during direct observation of performance in the patient's residential area. For the items of bathing and toilet hygiene, to respect patient privacy, investigators only observed preparations made for the activity and information was supplemented from caregiver report. The IADL items of food management, health management, and household management were also scored with direct observation in the patient's residential area. The items of community mobility and financial management were scored while taking the patient out to nearby shops/bank/ATM kiosk, accompanied by the caregiver. The component of academic/vocational skills was simulated in the therapy setting. The assessments were timed to coincide with the usual time patients routinely performed the ADLs and thus were not completed at a stretch. Overall, each assessment took around an hour to complete. A third investigator (RS) scored the participants on the CEBLS and GHQ-12 for evaluating convergent and divergent validity. The VILS was scored again by one investigator (MCC) after a week to evaluate test–retest reliability.

Data analysis

Summary statistics, mean and standard deviation, frequencies, and percentages were used for reporting demographic and clinical characteristics. The correlation of VILS with the CEBLS, BPRS, GHQ-12, and continuous sociodemographic variables was evaluated using the Pearson's correlation coefficient (PCC). Differences were considered significant at P < 0.05. The association between categorical sociodemographic variables and the VILS was measured using one-way ANOVA test. The initial assessment score of VILS administered by MCC was used for the correlation and association tests. Inter-rater and test–retest reliabilities were evaluated using the ICC with a 95% confidence interval (CI). All the statistical analyses were performed using SPSS 18.0 (SPSS Inc., Chicago, Ill., USA).

Results

One hundred participants were recruited for the study. The majority of the participants were male, young adults, single, with undergraduate education, middle socioeconomic status, and currently employed. The sociodemographic characteristics of the sample are shown in [Table 1].

Table 1: Demographic characteristics of the study population (n=100)

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Validity

The CEBLS was used to measure convergent validity. The correlation between the total scores on the two scales was moderate (PCC = 0.611; P = 0.001), suggesting that these scales seem to assess similar constructs. The GHQ-12 scores, which is a measure of overall mental health, when correlated with the VILS, provided low correlation (PCC = −0.260; P = 0.105), suggesting divergent validity. The details of the correlations are shown in [Table 2].

Table 2: Correlation of Vellore Inventory of Life Skills with other scales

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Reliability

The test–retest and inter-rater reliability scores of all domains of the VILS have been documented in [Table 3]. Most individual domains of VILS as well as the total score recorded good inter-rater reliability; the domains of 'eating' and 'grooming' had moderate levels of reliability. Most individual domains of VILS as well as the total score also recorded good test-retest reliability; the domains of “bathing,” “oral hygiene,” “dressing,” “eating,” and “grooming” had moderate levels of reliability.

Table 3: Reliability data for all domains of Vellore Inventory of Life Skills

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Extent of life skills deficit

In terms of BADLs, most of the study population was at the advanced level, with only one person at the basic level. However, in the domain of IADLs, most of the population was at the intermediate level, with more than half of them being at a basic level in the domain of “household management.” The details regarding the extent of life skills deficit can be found in [Table 4].

Table 4: Description of Vellore Inventory of Life Skills score among the study population (n=100)

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Correlation between psychopathology and life skills

The correlation between the total score of VILS and BPRS was not statistically significant (PCC = −0.175; P = 0.321). Domain wise correlation of the VILS with the BPRS scores also failed to yield statistically significant results. The details regarding the BPRS scores are shown in [Table 2].

Comparison between sociodemographic factors and domains of life skills

The group means differences for “educational status” was statistically significant for BADL domains of “bathing” (F = 4.882; P = 0.003), “toilet hygiene” (F = 4.742; P = 0.004), “dressing” (F = 2.995; P = 0.036), “eating” (F = 2.848; P = 0.042) and for almost all IADL domains of “financial management” (F = 10.252; P = 0.001), “food management” (F = 7.006; P = 0.001), “health management” (F = 6.669; P = 0.001), “household management” (F = 4.665; P = 0.004), and “academic/vocational skills” (F = 7.213; P = 0.001). The group mean differences for “community mobility” neared significance (F = 2.646; P = 0.053) and the total VILS score was also statistically significant (F = 9.354; P = 0.001) between the groups. There were statistically significant differences between group means for diagnosis and the IADL domains of “financial management” (F = 4.273; P = 0.041), “community mobility” (F = 9.914; P = 0.002), and “health management” (F = 4.047; P = 0.047). There were also statistically significant differences between group means of employment status and the domains of “eating” (F = 4.046; P = 0.005), “financial management” (F = 3.836; P = 0.006), “community mobility” (F = 3.121; P = 0.019), “academic/vocational skills” (F = 2.661; P = 0.037) as well as the total VILS score (F = 2.715; P = 0.034). In comparing group means of various types of occupation among the employed participants, there were statistically significant differences in the IADL domains of “financial management” (F = 2.924; P = 0.020), “health management” (F = 2.455; P = 0.044), “'academic/vocational skills” (F = 2.743; P = 0.027), and the total VILS score (F = 2.821; P = 0.024). With respect to group mean differences in socioeconomic status, the IADL domains of “health management” (F = 3.381; P = 0.038), “community mobility” (F = 4.037; P = 0.021), and “academic/vocational skills” (F = 6.208; P = 0.003) were statistically significant. The IADL domains of “food management” (F = 5.876; P = 0.017) and “household management” (F = 8.200; P = 0.005) had statistically significant differences in group means when compared with gender.

When correlated with duration of illness, there were statistically significant results in the IADL domains of “financial management” (PCC = −0.206; P = 0.040) and “community mobility” (PCC = −0.200; P = 0.046) but not in the total score of VILS. Other than the BADL domain of “eating” (PCC = −0.239; P = 0.017), there was no statistically significant correlation between the various domains of VILS and age of participants. There was no statistically significant difference between group means when the VILS domains were compared with the marital status of the participants.

Discussion

The VILS had only moderate correlation with the CEBLS scores; this could be because the CEBLS assesses only seven domains, one in BADL and six in IADL, as opposed to six BADL and IADL domains each of the VILS. Since the VILS was specifically formulated to comprise of domains not included in other assessments, this can be considered acceptable. The test–retest reliability of most of the BADL domains was lower than that of the IADL domains. The reason for the lower levels of reliability scores could be that the assessments were spaced a week apart; however, training on BADLs is initiated immediately after admission to the setting. The change in scores could be attributed to improvement in skills as a result of intervention. The BADL performance among the population was better than the IADL performance, which can be representative of the increased complexity of IADLs as compared to the BADL skills. The lack of correlation between the VILS and BPRS scores can imply that life skills dysfunction can be present irrespective of the severity of illness; this finding is similar to a previous study done at the same center.^[3]

Many IADL domains also seem to have significant group differences when compared with sociodemographic variables of educational status, employment status, type of occupation, socioeconomic status, and gender. Longitudinal follow-up studies and interventional studies are warranted to understand the directionality of these associations.

The VILS addresses two pertinent issues related to the assessment of life skills in LMIC. The direct, performance-based nature of assessment yields more reliable results than self- or proxy-rated checklists. The combining of BADLs and IADLs in one assessment ensures ease of goal setting and seamless progression in life skills training. Although the assessment is time consuming and can only be done in a residential/home setting; considering that the purpose of any functional training is the generalization of skills to real-life performance, assessing skills in such settings is justified. Since most of the assessment utilizes direct observation in the residential area, the person-specific context of skill performance is retained, thus making it feasible to be used across varying social and cultural backgrounds.

Limitations

The VILS is not feasible to be used in outpatient settings and its exhaustive nature precludes completion of the entire assessment at one stretch. It is also necessary to have key informants present during the assessment to complement the information given, which can be cumbersome in some healthcare settings. Since the VILS was developed with the aim of measuring progress in life skills as a result of intervention, longitudinal studies of repeated assessments will also have to be conducted. Recommendations for future would include evaluating the predictive validity of the VILS for employment/independent living and validation in the adolescent age group when life skills are developing.

Conclusion

The VILS was developed to aid in baseline assessment and subsequent documentation of progress in facilities providing life skills training for persons with severe mental illness. Preliminary data suggest that VILS seems to meet this requirement. The findings would need to be reinforced with longitudinal data to evaluate change over time.

Financial support and sponsorship

This study was approved and funded by the Institutional Review and Ethics Board, Christian Medical College, Vellore (IRB Min. No. 11585). The funding source had no further involvement in the conduct of the research or preparation of the article.

Conflicts of interest

There are no conflicts of interest.

Appendix

Appendix 1: Vellore Inventory of Life Skills

Instructions

To be scored by therapist after direct observation of performance in life situations. Simulation can be done only when the above is not possible.

Scoring

Scoring should be progressively done from basic to advanced level. A score of 1 can be given for each item that the person is able to do adequately at each level. Thus, maximum score possible for basic level of bathing is 4. If a person has scored maximum at the basic level, therapist can set the items at the intermediate level as goals of therapy, and so on.

Items

Basic Activities of Daily Living

1. Bathing (Washing and drying one's whole body/body parts; obtaining and using water and appropriate cleaning/drying materials or methods; includes soaping, rinsing, and drying body parts adequately)

Items required: Bucket, soap, towel, mug

Basic

Can cooperate when being bathed
Can assist in pouring water, applying soap
Can identify materials used like soap, towel, mug
Can perform one step actions (e.g., pour water) with physical or verbal prompts.

Can collect items required for bathing by self
Can perform multiple steps (take mug, pour water, apply soap) with supervision
Can understand safety precautions required (e.g., guard against falls)
Can ensure adequate hygiene during bathing.

Can do all steps without supervision
Can problem solve adequately, e.g., what to do if water runs out
Can make competent decisions on time, duration and frequency of bathing.

2. Toilet hygiene (Planning and carrying out the elimination of human waste (menstruation, urination and defecation), and cleaning oneself afterwards; includes managing clothing, cleaning body, and caring for menstrual and continence needs)

Items required: Bucket, mug, towel, soap

Basic

Can indicate need for toileting
Can be continent
Can identify appropriate place for toileting
Can exhibit regular bladder and bowel patterns
Can assist in undressing/dressing related to toileting.

Can do toileting with verbal/physical prompts
Can wash self adequately with verbal/physical prompts
Can undress/dress self independently
Can understand safety precautions required (e.g., guard against falls).

Can do all steps of toileting including washing self without supervision
Can problem solve adequately, e.g., what to do if water runs out
Can ensure privacy and safety while toileting.

3. Oral hygiene (Taking care of dental hygiene; includes cleaning mouth and brushing teeth)

Items required: Tooth brush, tooth paste, towel

Basic

Can cooperate with brushing, rinsing mouth
Can identify materials like own brush, paste
Can perform one step actions (e.g., brush front teeth) with physical or verbal prompts.

Can collect items required for brushing by self
Can perform multiple steps (apply paste, rinse mouth) with supervision
Can ensure adequate hygiene during brushing with verbal/physical prompts.

Can perform all steps hygienically without supervision
Can make decisions adequately, e.g., amount of tooth paste to be used
Can make competent decisions on time, duration and frequency of brushing.

4. Dressing (carrying out the coordinated actions and tasks of putting on and taking off clothes and footwear in sequence; in keeping with weather, occasion, time of day and social conditions; includes selecting clothing and accessories appropriately, obtaining clothing from storage area, dressing and undressing in a sequential fashion, fastening and adjusting clothing and shoes)

Items required: Clothes such as t-shirt, pants with zippers and shirts, churidar, sandals or shoes

Basic

Can cooperate/assist in dressing or undressing
Can identify own clothes and place where they are stored
Can perform simple steps with supervision, e.g., putting hands into sleeves.

Can perform multiple steps, e.g., pull t-shirt over head, and put hands into sleeves, with physical/verbal prompts
Can choose clothes appropriate to situation and weather
Can ensure need for privacy while dressing or undressing.

Can perform all steps in dressing/undressing independently
Can use fasteners, zippers, girdles without assistance
Can make competent decisions on need for changing clothes.

5. Eating (Carrying out the coordinated tasks and actions of eating food that has been served, bringing it to the mouth and consuming it in culturally acceptable ways; includes cutting or breaking food into pieces, opening bottles and cans, using eating implements and having meals)

Items required: Plate, glass, spoon, regular food

Basic

Can indicate hunger and thirst
Can identify foods consumed regularly
Can take food to mouth, chew and swallow with supervision.

Can take food to mouth, chew and swallow without supervision
Can consume food and water without spilling or choking
Can follow regular meal times and snack times.

Can serve and consume a meal independently
Can exhibit adequate table manners
Can discriminate food that is too hot/cold
Can identify spoilt food.

6. Grooming (planning and carrying out the coordinated tasks of removing body hair, combing, caring for nails (hands and feet), caring for skin, ears, eyes, and nose, putting on make-up)

Items required: Comb, powder, soap, razor, deodorant

Basic

Can identify own comb, razor, etc.
Can perform simple tasks e.g., combing, washing face after shaving, applying bindi, etc., with supervision
Can identify the need for grooming, e.g., when hair is untidy.

Can perform multiple steps, e.g., shaving beard, washing face, with verbal/physical prompts
Can retrieve own items, identify need for replacement
Can perform steps with adequate hygiene appropriateness to context.

Can choose items needed for grooming independently
Can replace items when necessary
Can perform activity in different ways, e. g. change hair style, make up, shape of beard, etc., as necessary.

Instrumental Activities of Daily Living

1. Financial management (Using fiscal resources, including alternate methods of financial transaction, in exchange for money, goods and services required for daily living; planning and using finances with long-term and short-term goals)

Items required: Coins, currency, packed grocery items, calculator, ATM card, bank forms, paper, pen, check book

Basic

Can understand values of coins and currency
Can make a complete cash transaction
Can shop according to a given list of items
Can understand the concept of MRP
Can identify one way to save money on purchases
Can use a calculator to quantify purchases
Can understand difference between essentials and nonessentials.

Can use an ATM machine for cash withdrawal
Can use a Debit/Credit card for transactions
Can open a savings or fixed deposit account
Can write checks/make withdrawals and make deposits
Can make list of items needed for a week
Can understand the concept of insurance policies and saving plans.

Can draw up a monthly budget plan
Can compare between various commodities on price, quality, etc.
Can balance a check book and address discrepancies
Can understand tax and procedure for filing tax forms
Can understand buying on EMI, loans, and related interest rates.

2. Food management (planning, organizing, cooking and serving nutritious meals for oneself and others; includes making a menu, selecting edible food and drink, getting together ingredients for preparing meals, cooking with heat and preparing cold foods and drinks, and serving the food and cleaning up food and utensils after meals)

Items required: Paper, pen, grocery list, regular food items, utensils

Basic

Can observe hygiene while washing and storing food
Can choose and order food in a restaurant
Can understand foods that contribute to a balanced diet
Can serve oneself
Can exhibit adequate table manners.

Can make a simple meal for one
Can use cooking utensils and appliances safely
Can prepare a grocery shopping list for a meal
Can identify spoilt food
Can clean up adequately after a meal
Can use a refrigerator.

Can follow the instructions from a recipe
Can adjust recipes according to need
Can prepare and serve a meal for a few people
Can plan a daily menu of three meals
Can do weekly grocery shopping.

3. Health management and maintenance (caring for oneself by being aware of the need and doing what is required to look after one's health, both to respond to risks to health and to prevent ill-health; includes seeking professional assistance; following medical and other health advice; and avoiding risks to health)

Items required: Basic medicines, First aid kit

Basic

Can identify own medication
Can understand that alcohol, tobacco and drugs are harmful to health
Can identify symptoms of common cold, fever, diarrhoea, etc.
Can understand need for good diet, exercise and eating habits.

Can manage common cold, fever, diarrhoea, etc., with medicines
Can manage a minor cut or burn by self
Can take medication without supervision
Can understand how pregnancy occurs
Can understand the role of different health care workers
Can dispose of medicines in a safe manner
Can use a First Aid Kit.

Can take own temperature using a thermometer
Can nurse self through cold or fever
Can buy OTC medicines for pain, diarrhoea, fever, cold or allergy
Can take an appointment for a doctor
Can read a prescription label correctly and follow the instructions
Can understand methods of birth control and how to obtain birth control devices.

4. Community mobility (Planning and moving around in the community; using public or private transportation to move around as a passenger, such as being driven in a car or on a bus, rickshaw, taxi, train or aircraft)

Items required: Direction symbols, Map and Location on GPS app in phone

Basic

Can ride a bicycle safely
Can use seat belts/helmets on personal vehicles
Can use public transport like auto/bus/train with supervision
Can identify nearest public bus/train station
Can identify amount required for bus/train fare.

Can provide directions to home and nearby places
Can use public transport to familiar places without supervision
Can arrange for private transport to nearby places
Can fill fuel for private vehicle
Can understand need for driving license/vehicle ownership forms.

Can read a map and get location
Can use public transport with transfers or to unfamiliar places
Can do basic bike/car maintenance
Can organise car/bike insurance
Can understand RTO regulations.

5. Household management (managing and maintaining personal and household possessions and environment; includes cleaning the house by sweeping, mopping, washing counters, walls and other surfaces; collecting, washing, drying, folding and ironing clothes; using household appliances, storing food and disposing of garbage)

Items required: Bed linen, broom, mop, utensils

Basic

Can change bed linen and make a bed
Can dispose of garbage
Can use cup boards for storage
Can sweep and dust floors and furniture
Can operate taps and electrical appliances
Can understand difference between rented and own accommodation.

Can wash and clean various rooms using appropriate cleaning products
Can clean refrigerator and stove
Can do routine house cleaning to maintain home and surroundings clean
Can arrange to get rid of household pests
Can understand rights and responsibilities with respect to neighbours.

Can unclog sinks and toilets
Can change a fused bulb or reset circuit breaker
Can do minor household repairs
Can contact necessary personnel for major repairs
Can measure furniture for upholstery.

6. Academic/Vocational skills (carrying out the tasks and actions required to engage in education, work and employment; seeking, finding and choosing employment, being hired and accepting employment, maintaining and advancing through a job, trade, occupation or profession, and leaving a job in an appropriate manner)

Items required: Model academic course/job application form, Model questions for mock interview

Basic

Can set realistic goals for academic plans
Can understand the types of jobs available for respective qualification
Can exhibit adequate work habits
Can identify own responsibilities for studying/working.

Can enrol self in an academic course
Can understand the kind of jobs available after completion of the course
Can understand the financial resources necessary for completing a course
Can fill out a job application form
Can search for jobs through advertisements in various media
Can attend a mock interview
Can exhibit appropriate behaviour with colleagues and supervisors
Can understand concept of leaves, performance appraisal, salary, etc.

Can apply and attend a job interview
Can apply to employment agencies and choose between jobs
Can prepare own resume
Can understand legal rights and grievance redressal mechanisms related to job.

*Definition of ADLs and IADLs based on

World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001
Occupational Therapy Practice Framework. Domain and Process 3^rd ed.. Am J Occup Ther 2014; 68:S1-48.

*Items required are given only as examples; therapists are encouraged to modify items as per patient specific needs.

References

1.	World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001.
2.	Bowie CR, Reichenberg A, Patterson TL, Heaton RK, Harvey PD. Determinants of real-world functional performance in schizophrenia subjects: Correlations with cognition, functional capacity, and symptoms. Am J Psychiatry 2006;163:418-25.
3.	Samuel R, Thomas E, Jacob KS. Instrumental activities of daily living dysfunction among people with schizophrenia. Indian J Psychol Med 2018;40:134-8. [PUBMED] [Full text]
4.	Saha S, Chauhan A, Buch B, Makwana S, Vikar S, Kotwani P, et al. Psychosocial rehabilitation of people living with mental illness: Lessons learned from community-based psychiatric rehabilitation centres in Gujarat. J Family Med Prim Care 2020;9:892-7. [Full text]
5.	Harvey PD, Velligan DI, Bellack AS. Performance-based measures of functional skills: Usefulness in clinical treatment studies. Schizophr Bull 2007;33:1138-48.
6.	Mantovani LM, Teixeira AL, Salgado JV. Functional capacity: A new framework for the assessment of everyday functioning in schizophrenia. Rev Bras Psiquiatr 2015;37:249-55.
7.	McIntosh BJ, Zhang XY, Kosten T, Tan SP, Xiu MH, Rakofsky J, et al. Performance-based assessment of functional skills in severe mental illness: Results of a large-scale study in China. J Psychiatr Res 2011;45:1089-94.
8.	Patterson TL, Goldman S, McKibbin CL, Hughs T, Jeste DV. UCSD performance-based skills assessment: Development of a new measure of everyday functioning for severely mentally Ill adults. Schizophr Bull 2001;27:235-45.
9.	Chandrashekar H, Prashanth NR, Kasthuri P, Madhusudhan S. Psychiatric rehabilitation. Indian J Psychiatry 2010;52:S278-80. [PUBMED] [Full text]
10.	Tungpunkom P, Maayan N, Soares-Weiser K. Life skills programmes for chronic mental illnesses. Cochrane Database Syst Rev 2012;1:CD000381.
11.	Burnett J, Dyer CB, Naik AD. Convergent validation of the Kohlman evaluation of living skills as a screening tool of older adults' ability to live safely and independently in the community. Arch Phys Med Rehabil 2009;90:1948-52.
12.	Rosen A, Trauer T, Hadzi-Pavlovic D, Parker G. Development of a brief form of the life skills profile: The LSP-20. Aust N Z J Psychiatry 2001;35:677-83.
13.	Askew AY. The milwaukee evaluation of daily living skills: Evaluation in long-term psychiatric care. Am J Occup Ther 1990;44:474.
14.	Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-86.
15.	Wallace CJ, Liberman RP, Tauber R, Wallace J. The independent living skills survey: A Comprehensive measure of the community functioning of severely and persistently mentally ill individuals. Schizophr Bull 2000;26:631-58.
16.	Casanova JS, Ferber J. Comprehensive evaluation of basic living skills. Am J Occup Ther 1976;30:101-5.
17.	Bujanga MA, Baharum N. A simplified guide to determination of sample size requirements for estimating the value of intraclass correlation coefficient: A review. Arch Orofac Sci 2017;12:1-11.
18.	Goldberg D, Williams P. A User's Guide to the General Health Questionnaire. Slough, United Kingdom: NFER–Nelson; 1988.
19.	Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep 1962;10:799-812.

Correspondence Address:
Reema Samuel
Occupational Therapy Education and Services, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/psychiatry.IndianJPsychiatry_872_20

Tables

[Table 1], [Table 2], [Table 3], [Table 4]