6.1 Overview of ADLs/IADLs
The computer application of the CLTS FS will calculate the child’s age and present only the ADL/IADL answer choices appropriate for the child’s age. Although the screener should not use the full paper screen in a home visit, the screener may wish to take along a print-out of the ADL/IADL answer choices that match the child's age, and refer to it as needed. The screener can print this from the "Forms" link in the CLTS FS application.
These answer choices were developed by the screen workgroup using well-established child development guidelines. Modifications were made in order to meet our screen development goals:
These four criteria can obviously conflict. The balancing between these goals is especially evident in the ADLs.
The wording of each answer choice was crafted to be as precise and objective as possible to promote inter-rater reliability. This can obviously be challenging when trying to be inclusive of all children with or without physical, cognitive, or emotional disabilities.
Similarly, brevity can conflict with inclusiveness and accuracy, since children’s abilities must be broken down by age groupings. If functional eligibility is not affected, brevity is chosen over inclusiveness. Since age-appropriate needs are not "necessary" information (they don’t help with determining program eligibilities) they are not included among the ADL/IADL answer choices. This means that screeners will not be able to describe every child’s needs, if the needs are "age-appropriate," i.e., similar to those of non-disabled children of the same age group. ("Similar" here means the same as, or too difficult to distinguish without subjectivity and excessive length of the CLTS FS)
Age-appropriate descriptions (such as complete cares for infants) were
left off the CLTS FS for brevity. Babies are properly determined eligible
even without checkmarks on some of the ADLs/IADLs.
A substantial functional impairment is a restriction on the child's ability to engage in age appropriate everyday activities or perform daily functions. The ADL/IADL questions on the screen are designed to capture substantial impairments based on the child's age. The child must need hands on adult assistance to complete these functions across settings including home, school and community. The hands on help is not offered simply to complete the task quicker, or make the task easier, but is provided as a necessity to complete the task on a daily basis.
FREQUENCY is a critical aspect of the substantial impairment requirement. ADL/IADL questions are to be checked only if the child needs help from an adult in order to complete the activity of daily living, as defined by the functional screen questions, on a regular basis. If the child needs infrequent assistance to complete the task, it cannot count toward functional eligibility for long-term support programs. Therefore, if the child completes the task most of the time on his/her own and only occasionally needs help from an adult, the box for that question is not checked. In many cases, a child's need for help is quite consistent: "She can't do that," or "He always needs help with this," or "Most of the time…," In these instances, the tasks should be checked. In addition, if the child has been able to complete the specific task(s) on a rare or infrequent occasion, which means the child is considered unable to complete the task on a regular basis and the box is checked. If the child needs assistance most of the time, then the box is checked.
In general, screeners should consider whether or not the need for help is some of the time versus most of the time. If the child needs assistance from others most of the time, then it counts as a checked box on the CLTS FS - that indicates that the child's limitation is substantial. If the child needs assistance only some of the time, the ADL/IADL answer choice should not be checked - that indicates that the child's development is within the range of typical development for a child of a comparable age, and not consistent enough to be categorized as a substantial impairment.
The substantial impairment, as described in the question on the screen, must relate to the day in/day out routine of the child. If the family is providing hands on support to the child for a skill even though the child can do the task independently, then do not check the box. If a parent says, "now and then," "every few weeks," or "a few times, not mostly," the frequency is probably only some of the time and therefore the child would not meet the required level of frequency needed to check the box. One way a screener can obtain clearer information is to ask the parent "In the past few months, would you say he's needed help most of the time?" In general, consider ADL/IADL function over a six-month timeframe, unless the child has new needs or has developed new skills.
It is not expected that the screener test the child or measure her needs or abilities during a home visit. A child's needs cannot be determined from a single episode but must reflect the child's typical or average functional need over the past six months. This is particularly important when reviewing documentation about a child's abilities. A report that indicates that a child completed a specific task may not represent the typical needs of that child. Be certain to verify any statement or assessment of frequency with various care providers who know the child well.
Example A: Juan has cancer and gets very sick during chemotherapy and he needs help with his ADLs then; at other times he is independent with them. Juan gets chemotherapy one week each month. Screener does not indicate that Juan needs help with his ADLs because he needs help only some of the time - one week out of four.
Example B: Tia was potty-trained two months ago and is doing
well with it. Screener does not check box for needs help with
toileting (although she did, four out of the past six months), because Tia
has developed this skill and now rarely needs any help.
On all Activities of Daily Living and Instrumental Activities of Daily Living, screeners must determine if the child functions within normal limits prior to selecting any specific item(s) under a category (e.g., Bathing, Dressing, Communication, or Social Competency). If indeed a child functions within normal limits for that particular ADL or IADL, then "None of the Above Apply" must be selected for that child. A screener can support this selection by writing a note that explains that the child does not have substantial functional impairments in that particular skill area. The specific items available on the CLTS FS are only to be selected once it has been determined that a child does not function within normal limits.
Example A: Jeffrey does not receive Speech Therapy at school, his parents do not express any concerns about his ability to communicate and during the home visit the screener is able to have a conversation with Jeffrey. In this circumstance, "None of the Above Apply" would be selected under Communication on the IADL page without any further review of the particular options under Communication.
Example B: It is reported that Savanna bathes herself and that no other person is in the bathroom during this task. There is no need to ask any further questions for Bathing on the ADL page. "None of the Above Apply" is selected.
Example C: Emily is a very social child. She has friends and
is able to advocate for her own needs. She is not involved in any social
skills classes at school. Her social skills are within normal limits.
"None of the Above Apply" is selected under Social Competency on
the IADL page and no additional specific questions about Social Competency
"Needs" and "safety" should not be over-interpreted or over-used to express screeners’ subjective opinions. The CLTS FS is intended to be an objective screen of children’s need for assistance. Thus, the screener should ask, "Would another screener of another discipline rank the child the same way?"
It is often difficult to distinguish a child’s needs from parents’ preferences. Sometimes parents may prefer to perform or help with tasks even though the child could do them. If a child can complete a task independently, but it takes them a long time, the screener needs to consider whether or not the child "needs any help to complete the task." Sometimes it takes a child so long that the parent must do the task so that the child gets to school on time. This is not just for convenience, and amounts to most of the time (since its five days out of seven); it would be counted as help needed on the Functional Screen. This only applies to situations where the family members are providing physical assistance to get the task completed.
The screener will quite often
encounter different versions of the child’s abilities from different
parties. This is discussed in the first part of the instructions. Also,
there are instructions for how to deal with fluctuating needs, and with
the fact that a child may function differently, e.g., at home and at
school. Please review those earlier sections as needed under 1.8
Many ADL questions will ask whether the child requires "Step by
Step Cueing". This represents a need for another person to be present
while the child completes the task to verbally cue the child for each step
throughout the task. For example, put the toothpaste on the brush, put the
brush in your mouth, brush these teeth, now these teeth, put the
toothbrush down, rinse and spit. It does not apply to children who need to
be told repeatedly to brush their teeth or take a shower. It does not
apply to children who have to be sent back in to shower again because they
missed a spot or didn't rinse enough. It does not apply to children who
use a visual reminder of the steps of the process, like a chart or list.
It literally means step by step verbal instruction.
It is imperative that screeners examine the child's abilities and limitations in multiple environments. Some of the questions on the ADL page, especially those regarding Grooming, Dressing, Toileting, Mobility and Eating, must be evaluated in multiple environments. Questions about Bathing are more limited to the child's home environment and perhaps the parents are the only resource for this information. For the other Activities of Daily Living and Instrumental Activities of Daily Living, it is not enough to ask a child's parents about their functional abilities in these areas, it is also essential that screeners find out how the child functions throughout their day, in different environments. For very young children, their home may be the only environment in a day but for many children they also attend early childhood, day care environments or various school programs. For older children, they may be able to directly describe their ability to care for themselves in these different environments.
There are many reasons why these skills need to be evaluated in
multiple environments. At times the parent-child dynamic can blur the true
need as described above in "Needs" versus "Safety"/
Fluctuating Needs. In addition, the screen is to capture the child's
ability most of the time. To neglect to gather information about a child's
ability to complete ADLs and IADLs outside of the home results in an
incomplete picture and therefore, an incomplete screen. To truly reflect
the level of limitation a child has and the type of support they require
throughout their day, information about Activities of Daily Living and
Instrumental Activities of Daily Living must be gathered and corroborated
by multiple sources.
All assessments listed for Communication and Learning are Standardized Norm-Referenced tests that specifically measure Expressive Communication, Receptive Communication or Cognition. A norm-referenced assessment is designed such that a child's performance is compared to a larger group. Usually the larger group or 'norm sample' is a national sample representing a wide and diverse cross-section of children. The result is a bell curve based on that normative sample. The normative sample also determines for which age group these assessments and results can be used. In contrast, criterion-referenced assessments measure how well a student performs against an objective or criterion rather than another student.
Make special note of the number of months/years associated with each question (it varies based on the age of the child).
In order to document a valid assessment on the CLTS FS, the following information must be available:
Knowing the child's percentile is not the same as their percent delay and is not relevant for the purpose of the CLTS FS.
Interpreting Test Results - Standard Deviations
Some norm referenced tests results indicate scores in the single digits, like 1 or 3. Without knowing the norm score and the standard deviation score, these are very challenging to interpret. Again, consulting with the administrator of the assessment or another qualified professional may be the best method to interpret this data.
Interpreting Test Results - Percent Delay
In general, assessments of children with communication or learning delays result in percentile scores that are often much lower, like the first or second percentile. Although this sounds like a substantial delay, it does not directly translate to how delayed their skills are.
A percent delay measures how far behind the child's results are to other children their age. This is evident in Age Equivalent (AE) scores. If a 12 year old child took a norm reference test and had a valid result with an age equivalence score of 6;6 (years; months), for example, they would be more than 30% delayed. In fact, they are demonstrating nearly a 50% delay. This is the most common use of percent of delay; looking at the age of the child at the time of testing and the age equivalence they scored on communication and cognitive assessments. This calculation of percent delay can only occur when you know the age at the time of testing and the valid age equivalent score the child had.
There are 12 months in a year. This has to be incorporated in order to turn a child's age, or age equivalency score into an integer. Remember that age equivalency scores are written in years and months (years; months). If a child's age is 4 years 6 months, or a child's age equivalency score is 4;6, that is the same as 4.5 years (as an integer). Take the number of months and divide by 12 months in a year. One can also decide to perform the equations in total months rather than with integers. For example, if a child's age is 4 years, 6 months, that's 54 months. Take the number of years and multiply by 12 and add the additional number of months.
To determine percent delay:
In Years: Take 6.16 (their age equivalent score in years) divided by 9.5 (their age at testing in years) with a result of .648… - rounded to the nearest hundredths is .65 or 65%. That means they scored 65%. Second, and the most important step, subtract the results from 1.0, so in this case, 1.0-.65 = .35 or 35% delay.
In Months: Take 74 (their age equivalent score in months) divided by 114 (their age at testing in months) with a result of .649… - rounded to the nearest hundredths is .65 or 65%. That means they scored 65%. Second, and the most important step, subtract the results from 1.0, so in this case, 1.0-.65 = .35 or 35% delay.
In Years: Starting with 8.75, the age equivalent score in years, divided by the age at the time of testing, in this case 13.33 years. 8.75 13.33 = .656. This rounds up to .66. Now subtract that from 1.0 (1.0-.66) and you get .34 or 34% delay.
In Months: Starting with 105, the age equivalent score in months, divided by the age at the time of testing, in this case 160 months. 105 160 = .656. This rounds up to .66. Now subtract that from 1.0 (1.0-.66) and you get .34 or 34% delay.
On the functional screen, screeners are required to indicate the results of the valid assessment. There are three options available:
For children under a year of age:
For children a year old or older:
Full Scale Intelligence Quotient
If the clinician conducting the IQ test expressed concern about the results due to the child's ability to participate in the testing process, don't use the results of that test. The screener will want to consider the results from the most recent IQ test a child has if they have had multiple tests done. It does not matter how old the IQ test is as long as it is the most current one on record for that child. The screener is required to select the accurate drop down option based on the child's valid Full Scale IQ Score on the CLTS FS.
Assessment Results within Normal Limits
Regardless of the assessment results, once a valid, norm-referenced,
standardized assessment or IQ has been entered under Communication or
Learning on the IADL page, the rest of the items under Communication or
Learning will become null and void. If the testing indicates that a
child has a substantial functional impairment, then the duration
question will be automatically answered “Yes,” if the results do not
support a substantial functional impairment, then the duration question
will be automatically answered “No.”
The following tables provide information and guidance about the ADL/IADL questions on the CLTS FS. The table is organized by ADL/IADL category (Bathing, Dressing, etc.). The columns to the left side of the table indicate the age at which the specific answer choice appears on the CLTS FS. If the column is white, the question applies to that age group; if the column is grey, the question does not apply to that age group. The answer choices are listed in Bold. Following the specific answer choice is an explanation of the question and/or relevant examples. Always consider the answer choice itself first; the examples are only intended to supplement that.
In the following tables, the symbol is used to indicate that if the information listed here is true for the child, the screener would check that box on the CLTS FS.
The symbol is used to indicate that if the information listed here is true for the child, the screener would not check that box on the CLTS FS.
This is not an
inclusive or exclusive list of information. The children for whom a CLTS FS
is completed for are complicated individuals, and every situation has not
been represented on the screen or in these instructions. The information
provided is meant to offer guidance to the screener. For most of the
questions, the answers should be relatively clear once the screener has met the
child and reviewed the available documentation. For further clarification,
e.g. means "for example" and i.e. means "that is, or
"in other words."
The ability to shower, bathe or take sponge baths for the purpose of maintaining adequate hygiene (does not include hair care). For older children, ages 9 and older, this also includes the ability to get in and out of the tub, turn faucets on and off, regulate water temperature, wash and dry fully.
Brushing teeth, washing hands and face. Due to variations in hair care by culture, length of hair, etc, hair care is not considered for the purposes of this screen.
The ability to dress as necessary. This does not include the fine motor coordination for buttons and zippers.
The ability to eat and drink by finger feeding or using routine or adaptive utensils. The ability to swallow sufficiently to obtain adequate intake. Does not include cooking food or preparing it for consumption (cutting food into bite size pieces or pureeing if needed).
The ability to use a toilet or urinal, transferring on/off a toilet, changing menstrual pads, and pulling down/up pants.
The ability to move between locations in the individual's living environment. For children, this includes home and school. Mobility includes walking, crawling, or wheeling oneself around at home or at school. For functional eligibility purposes, mobility does not include transporting oneself between buildings or moving long distances outdoors.
The physical ability to move between surfaces: e.g., from bed/chair to wheelchair, walker or standing position. This excludes transfers into bathtub or shower or on and off the toilet, because those are captured in bathing and toileting ADLs. This does not include transfers in/out of a car or other vehicle.
Some questions cannot be modified for a child with a severe hearing impairment. In these cases, check the question appropriately given this disability. For example, when asked, "Does not startle, jump or blink to sudden, loud, unexpected noises" it is expected that a child with a significant hearing impairment would have this item checked. Another example is, "Does not imitate environmental sounds through any means." If a child cannot demonstrate the communication skill with consideration of their primary mode of communication, then the item is checked on the screen.
Non-Verbal / Use of Communication Devices
Assessment of 30% delay or two standard deviations
The following are commonly used assessments that DO NOT qualify as norm-referenced tools of Expressive and Receptive Communication:
1.) Not Norm-Referenced, Standardized Tools:
2.) Communication Assessments that do not measure Expressive or Receptive Communication:
3.) Tools that measure something other than Expressive and Receptive Language but contain sub-categories regarding Communication skills. These are not accepted because the purpose of the tool is not to measure Expressive and Receptive Language. There is a communication subtest that measures the influence that communication has on behavior or intelligence or achievement or development but cannot stand alone as an assessment of communication. These often fall into the category of screening tools rather than full assessments.
Assessment of 30% delay or two standard deviations
The following are commonly used assessments that DO NOT qualify as norm-referenced tools of Cognition:
1) Not Norm Referenced, Standardized tools:
2) Achievement Tests that do not test of Cognitive Ability
3) Measurement of Behavior or Adaptive Skills (not tests of Cognitive Ability)
4) Measurement of something other than Cognitive Ability
a. Clinical Evaluation of Language Fundamentals (CELF)
5) Diagnostic Tests
6) No "Brief" Testing Accepted
Unlike many ADL/IADLs, Social Competency is a skill that continues to develop throughout childhood for all children. As a result, the questions contained in the CLTS FS that aim to measure delays in Social Competency require that the screener consider the child's development to that of their same age peers. As children age, the skills required for social competency become much more sophisticated and subtle.
If a child is unable to develop the social skill due to a physical or communication or learning impairment, then they will demonstrate delays in social competency. If the item under Social Competency asks for the child's ability to perform the subtle social act but the child in question cannot perform the primary social act, then select that item for the child. For example, one of the Social Competency questions asks, "Does not control his/her temper in disagreements with other children". If the child does not have the ability to have disagreements with other children, then this is selected for them even though the question is designed to address the more advanced skill of controlling his/her temper.
Social Competency Table (PDF)
Meal Preparation Table (PDF)
Money Management Table (PDF)
*Is at least one of the functional impairments checked expected to last for at least one year from the date of screening?
For functional eligibility for long-term support programs, the child's need for help (i.e., her functional impairments) must be long-term. For every ADL/IADL item checked, screeners are asked to indicate whether the functional impairment(s) are expected to last for at least one year from date of screening. Health care providers regularly make such predictions. If some of the functional impairments are not expected to last but one or more is, then check "yes" for this question. If the screener is not clear about the duration, the screener can seek additional information. When the expected duration is not clear, the screener should check "Yes."
Please take your time answering these questions. It is imperative that screeners accurately record the duration of any specific functional limitation. On the ADL and IADL page, consider the specific check marks in each category (Bathing, Dressing, etc) and check that the limitation is expected to last if any of the items checked are expected to last a year from the date of screening.
If a child is nearing a change in age cohort (0-6 months, 6-12 months, 12-18 months, 18-24 months, 24-36 months, 3-4 years, 4-6 years, 6-9 years, 9-14 years, 14-18 years, 18+years) and it is likely that the child will master the task you have checked but will not be able to complete the tasks listed for the next age cohort within the year, then answer "Yes" to the duration question.
The screener should check "No" if the child has cancer, an illness or surgery that resulted in higher needs than normal. This is especially true if the child had typical functional skills before this acute episode.
December 14, 2012