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

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.

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)

Characteristic	Mean (SD) frequency (%)
Age	34.22 (10.67)
Illness duration	7.66 (5.77)
Sex
Male	69 (69)
Female	31 (31)
Diagnosis
Schizophrenia	75 (75)
BPAD	25 (25)
Marital status
Married	41 (41)
Unmarried	59 (59)
Socioeconomic status
Low	20 (20)
Middle	58 (58)
High	22 (22)
Education
Secondary	24 (24)
Higher secondary	19 (19)
Undergraduate	44 (44)
Postgraduate	13 (13)
Employment status
Employed	42 (42)
Unemployed	20 (20)
Student	16 (16)
Never employed	14 (14)
Homemaker	8 (8)
Occupation (n=42)
Elementary occupation	14 (33.3)
Skilled/sales workers	9 (21.4)
Plant and machine	6 (14.3)
Craft and trade workers	6 (14.3)
Technicians	5 (11.9)
Clerks	1 (2.4)
Professionals	1 (2.4)

SD – Standard deviation; BPAD – Bipolar affective disorder

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

Characteristic	Mean (SD)	PCC (P)
CEBLS total score	152.05 (34.67)	0.611 (0.001)
BPRS total score	36.62 (11.23)	−0.175 (0.321)
GHQ 12 total score	6.86 (2.79)	−0.260 (0.105)

CEBLS – Comprehensive evaluation of basic living skills; GHQ – General health questionnaire; BPRS – Brief psychiatric rating scale; PCC – Pearson’s correlation coefficient; SD – Standard deviation

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

Domain	Inter–rater reliability ICC (95% CI)	Test–retest reliability ICC (95% CI)
VILS – Bathing	0.815 (0.676–0.897)	0.641 (0.509–0.743)
VILS – Toilet hygiene	0.894 (0.809–0.943)	0.815 (0.737–0.872)
VILS – Oral hygiene	0.848 (0.731–0.917)	0.603 (0.462–0.714)
VILS – Dressing	0.846 (0.727–0.915)	0.560 (0.409–0.681)
VILS – Eating	0.663 (0.446–0.807)	0.487 (0.322–0.623)
VILS – Grooming	0.630 (0.399–0.785)	0.542 (0.388–0.667)
VILS – Financial management	0.922 (0.857–0.958)	0.923 (0.888–0.948)
VILS – Food management	0.924 (0.861–0.959)	0.916 (0.877–0.942)
VILS – Health management and maintenance	0.946 (0.900–0.971)	0.911 (0.871–0.939)
VILS – Community mobility	0.973 (0.949–0.986)	0.908 (0.866–0.937)
VILS – Household management	0.888 (0.798–0.939)	0.875 (0.820–0.914)
VILS – Academic/vocational skills	0.919 (0.851–0.956)	0.959 (0.939–0.972)
VILS – Total	0.938 (0.887–0.967)	0.907 (0.865–0.937)

VILS – Vellore Inventory of Life Skills; ICC – Intraclass correlation coefficient; CI – Confidence interval

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)

Characteristic	Mean (SD) frequency (%)
VILS total score	99.86 (17.13)
VILS – Bathing
Intermediate	32 (32)
Advanced	68 (68)
VILS – Toilet hygiene
Intermediate	14 (14)
Advanced	86 (86)
VILS – Oral hygiene
Intermediate	4 (4)
Advanced	96 (96)
VILS – Dressing
Intermediate	12 (12)
Advanced	88 (88)
VILS – Eating
Intermediate	4 (4)
Advanced	96 (96)
VILS – Grooming
Basic	1 (1)
Intermediate	18 (18)
Advanced	81 (81)
VILS – Financial management
Basic	25 (25)
Intermediate	69 (69)
Advanced	6 (6)
VILS – Food management
Basic	25 (25)
Intermediate	60 (60)
Advanced	15 (15)
VILS – Health management and maintenance
Basic	6 (6)
Intermediate	83 (83)
Advanced	11 (11)
VILS – Community mobility
Basic	11 (11)
Intermediate	65 (65)
Advanced	24 (24)
VILS – Household management
Basic	51 (51)
Intermediate	41 (41)
Advanced	8 (8)
VILS – Academic/vocational skills
Basic	41 (41)
Intermediate	56 (56)
Advanced	3 (3)

VILS – Vellore Inventory of Life Skills; SD – Standard deviation

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

Items

	Basic activities of daily living	Basic	Intermediate	Advanced
1	Bathing
2	Toilet hygiene
3	Oral hygiene
4	Dressing
5	Eating
6	Grooming
	Instrumental activities of daily living
7	Financial management
8	Food management
9	Health management
10	Community mobility
11	Household management
12	Academic/vocational skills

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

1. Can cooperate when being bathed

2. Can assist in pouring water, applying soap

3. Can identify materials used like soap, towel, mug

4. Can perform one step actions (e.g., pour water) with physical or verbal prompts.

Intermediate

5. Can collect items required for bathing by self

6. Can perform multiple steps (take mug, pour water, apply soap) with supervision

7. Can understand safety precautions required (e.g., guard against falls)

8. Can ensure adequate hygiene during bathing.

Advanced

9. Can do all steps without supervision

10. Can problem solve adequately, e.g., what to do if water runs out

11. 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

1. Can indicate need for toileting

2. Can be continent

3. Can identify appropriate place for toileting

4. Can exhibit regular bladder and bowel patterns

5. Can assist in undressing/dressing related to toileting.

Intermediate

6. Can do toileting with verbal/physical prompts

7. Can wash self adequately with verbal/physical prompts

8. Can undress/dress self independently

9. Can understand safety precautions required (e.g., guard against falls).

Advanced

10. Can do all steps of toileting including washing self without supervision

11. Can problem solve adequately, e.g., what to do if water runs out

12. 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

1. Can cooperate with brushing, rinsing mouth

2. Can identify materials like own brush, paste

3. Can perform one step actions (e.g., brush front teeth) with physical or verbal prompts.

Intermediate

4. Can collect items required for brushing by self

5. Can perform multiple steps (apply paste, rinse mouth) with supervision

6. Can ensure adequate hygiene during brushing with verbal/physical prompts.

Advanced

7. Can perform all steps hygienically without supervision

8. Can make decisions adequately, e.g., amount of tooth paste to be used

9. 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

1. Can cooperate/assist in dressing or undressing

2. Can identify own clothes and place where they are stored

3. Can perform simple steps with supervision, e.g., putting hands into sleeves.

Intermediate

4. Can perform multiple steps, e.g., pull t.shirt over head, and put hands into sleeves, with physical/verbal prompts

5. Can choose clothes appropriate to situation and weather

6. Can ensure need for privacy while dressing or undressing.

Advanced

7. Can perform all steps in dressing/undressing independently

8. Can use fasteners, zippers, girdles without assistance

9. 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

1. Can indicate hunger and thirst

2. Can identify foods consumed regularly

3. Can take food to mouth, chew and swallow with supervision.

Intermediate

4. Can take food to mouth, chew and swallow without supervision

5. Can consume food and water without spilling or choking

6. Can follow regular meal times and snack times.

Advanced

7. Can serve and consume a meal independently

8. Can exhibit adequate table manners

9. Can discriminate food that is too hot/cold

10. 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

1. Can identify own comb, razor, etc.

2. Can perform simple tasks e.g., combing, washing face after shaving, applying bindi, etc., with supervision

3. Can identify the need for grooming, e.g., when hair is untidy.

Intermediate

4. Can perform multiple steps, e.g., shaving beard, washing face, with verbal/physical prompts

5. Can retrieve own items, identify need for replacement

6. Can perform steps with adequate hygiene appropriateness to context.

Advanced

7. Can choose items needed for grooming independently

8. Can replace items when necessary

9. 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

1. Can understand values of coins and currency

2. Can make a complete cash transaction

3. Can shop according to a given list of items

4. Can understand the concept of MRP

5. Can identify one way to save money on purchases

6. Can use a calculator to quantify purchases

7. Can understand difference between essentials and nonessentials.

Intermediate

8. Can use an ATM machine for cash withdrawal

9. Can use a Debit/Credit card for transactions

10. Can open a savings or fixed deposit account

11. Can write checks/make withdrawals and make deposits

12. Can make list of items needed for a week

13. Can understand the concept of insurance policies and saving plans.

Advanced

14. Can draw up a monthly budget plan

15. Can compare between various commodities on price, quality, etc.

16. Can balance a check book and address discrepancies

17. Can understand tax and procedure for filing tax forms

18. 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

1. Can observe hygiene while washing and storing food

2. Can choose and order food in a restaurant

3. Can understand foods that contribute to a balanced diet

4. Can serve oneself

5. Can exhibit adequate table manners.

Intermediate

6. Can make a simple meal for one

7. Can use cooking utensils and appliances safely

8. Can prepare a grocery shopping list for a meal

9. Can identify spoilt food

10. Can clean up adequately after a meal

11. Can use a refrigerator.

Advanced

12. Can follow the instructions from a recipe

13. Can adjust recipes according to need

14. Can prepare and serve a meal for a few people

15. Can plan a daily menu of three meals

16. 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

1. Can identify own medication

2. Can understand that alcohol, tobacco and drugs are harmful to health

3. Can identify symptoms of common cold, fever, diarrhoea, etc.

4. Can understand need for good diet, exercise and eating habits.

Intermediate

5. Can manage common cold, fever, diarrhoea, etc., with medicines

6. Can manage a minor cut or burn by self

7. Can take medication without supervision

8. Can understand how pregnancy occurs

9. Can understand the role of different health care workers

10. Can dispose of medicines in a safe manner

11. Can use a First Aid Kit.

Advanced

12. Can take own temperature using a thermometer

13. Can nurse self through cold or fever

14. Can buy OTC medicines for pain, diarrhoea, fever, cold or allergy

15. Can take an appointment for a doctor

16. Can read a prescription label correctly and follow the instructions

17. 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

1. Can ride a bicycle safely

2. Can use seat belts/helmets on personal vehicles

3. Can use public transport like auto/bus/train with supervision

4. Can identify nearest public bus/train station

5. Can identify amount required for bus/train fare.

Intermediate

6. Can provide directions to home and nearby places

7. Can use public transport to familiar places without supervision

8. Can arrange for private transport to nearby places

9. Can fill fuel for private vehicle

10. Can understand need for driving license/vehicle ownership forms.

Advanced

11. Can read a map and get location

12. Can use public transport with transfers or to unfamiliar places

13. Can do basic bike/car maintenance

14. Can organise car/bike insurance

15. 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

1. Can change bed linen and make a bed

2. Can dispose of garbage

3. Can use cup boards for storage

4. Can sweep and dust floors and furniture

5. Can operate taps and electrical appliances

6. Can understand difference between rented and own accommodation.

Intermediate

7. Can wash and clean various rooms using appropriate cleaning products

8. Can clean refrigerator and stove

9. Can do routine house cleaning to maintain home and surroundings clean

10. Can arrange to get rid of household pests

11. Can understand rights and responsibilities with respect to neighbours.

Advanced

12. Can unclog sinks and toilets

13. Can change a fused bulb or reset circuit breaker

14. Can do minor household repairs

15. Can contact necessary personnel for major repairs

16. 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

1. Can set realistic goals for academic plans

2. Can understand the types of jobs available for respective qualification

3. Can exhibit adequate work habits

4. Can identify own responsibilities for studying/working.

Intermediate

5. Can enrol self in an academic course

6. Can understand the kind of jobs available after completion of the course

7. Can understand the financial resources necessary for completing a course

8. Can fill out a job application form

9. Can search for jobs through advertisements in various media

10. Can attend a mock interview

11. Can exhibit appropriate behaviour with colleagues and supervisors

12. Can understand concept of leaves, performance appraisal, salary, etc.

Advanced

13. Can apply and attend a job interview

14. Can apply to employment agencies and choose between jobs

15. Can prepare own resume

16. Can understand legal rights and grievance redressal mechanisms related to job.

*Definition of ADLs and IADLs based on

1. World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001

2. 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.