Functional Assessment of Independent Living Skills

Psychiatric Rehabilitation Skills
ISSN: 1097-3435 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/uzpr20
Functional Assessment of Independent Living

Skills
Anthony A. Menditto , Charles J. Wallace , Robert P. Liberman , Jillon Vander

Wal , Nicole Tuomi Jones & Paul Stuve
To cite this article: Anthony A. Menditto , Charles J. Wallace , Robert P. Liberman , Jillon Vander
Wal , Nicole Tuomi Jones & Paul Stuve (1999) Functional Assessment of Independent Living
Skills, Psychiatric Rehabilitation Skills, 3:2, 200-219, DOI: 10.1080/10973439908408384
To link to this article: http://dx.doi.org/10.1080/10973439908408384
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PSYCHIATRIC REHABILITATION SKILLS 1999 Vol. 3, No. 2, 200-219
Functional Assessment of Independent Living Skills
Anthony A. Menditto
Fulton State Hospital
Charles J. Wallace, Robert P. Liberman

UCLA School of Medicine
Downloaded by [Nanyang Technological University] at 04:46 08 June 2016
Jillon Vander Wal, Nicole Tuomi Jones, Paul Stuve

Fulton State Hospital
Functional assessment of persons with psychiatric disabilities requires

reliable and valid instruments that can be used by clinicians for planning
psychosocial rehabilitation services. Two such instruments, the Independent
Living Skills Inventory and the Independent Living Skills Survey are
operationalized and behaviorally specific tools that can be administered as
questionnaires or interviews. Both instruments have well-documented
reliability and validity and are ‘user-friendly.’
Functional assessment has assumed importance as psychiatric

rehabilitation has led clinicians beyond an exclusive focus on symptoms
and the effectiveness of psychotropic medications for people with
serious mental illness. While the new antipsychotic drugs, mood
stabilizers, and antidepressants have opened up a new era for symptom
control in psychotic and affective disorders (Marder, Wirshing, & Ames,
1997),assessment of individuals’psychosocial functioning is essential
if (1) medications are to be titrated to the optimal benefit-risk ratio for
functional behaviors; (2) psychosocial deficits and strengths are to be
identified in developing a rehabilitation plan after symptoms are
stabilized (American Psychiatric Association, 1996); (3) objective
program evaluation is to inform administrators, managed care organi-
zations, and policy makers regarding allocation of scarce resources
Requests for reprints should be directed to Anthony Menditto, Ph.D,

Fulton State Hospital, 600East
5th St., Fulton, MO 65251
Copyright 1999 Psychiatric Rehabilitation Skills
All rights Rcservcd.
Functional Assessment of Independent Living Skills 201
for mental health; (4)reliable evaluations are to be made of

individuals’disability status for purposes of Social Security and Veterans
Administration pensions (Zarate et al., 1998); (5) a person’s readiness
for rehabilitation is to be determined, so that the most efficient use of
rehabilitation technology can be achieved; and (6) research on crafting
new psychosocial treatments and rehabilitation technology is to be
advanced (Kopelowicz, Wallace, & Zarate, 1997).
Despite major advances in psychopharmacology and

neuroscience, the selection and dosing of psychotropic medications
remains an empirical process that must be guided by changes in
psychosocial or behavioral functioning as well as in symptoms (Lukoff,
Nuechterlein, & Ventura, 1992); in fact, whether or not an individual
is showing improved concentration, alertness, ability to solve problems
and the ability to process information may be a more sensitive indicator
of psychotropic drug efficacy than changes in delusions and
hallucinations (Green et al., 1997). Similarly, undesirable side effects
of drugs-which can assist the prescribing psychiatrist in clinical
decision-making-such as tremor, sedation, slurred speech, akinesia,
and akathisia may be evident sooner to the observer of the individual’s
participation in psychosocial activities than to the psychiatrist who
sees the person in brief, medication review sessions.
Conducting psychiatric rehabilitation begins with a
comprehensive and detailed assessment of the individual’s current
functioning. The assessment is focused is on the degree to which the
individual’s abilities and performance match the demands of his or
her home, work, school, family, and social situations. By comparing
the functional skills and resources possessed by the individual to those
required to maintain community tenure, one gleans information about
functional areas of strengths and deficits so treatment can be targeted
at deficit areas. As treatment progresses, the assessment is repeated,
and changes in functioning measure the treatment’s efficacy. Based
on these changes, the treatment and rehabilitation plan is modified by
altering the mix of services andor the functional areas established as
goals. Since functional assessment is a continuing guide for allocating
202 Anthony Menditto, Charles J. Wallace, Robert Libeman, Jillin Vander Wal,
Nicole Tuomi and Paul Stuve
often scarce and time-limited treatment resources, it must be

psychometrically sound, and its results must be easily and
unambiguously interpreted by a wide range of practitioners.
In addition to its role in planning individualized treatment,
functional assessment can be used to evaluate the effects of a program
of services on role functioning, and determine individuals’ eligibility
for disability benefits. For program evaluation, the results of the
assessment can be aggregated across a program’s participants, with

the summary statistics describing the program’s case mix and its
participants’ typical level of functioning. Changes in these summary
statistics across repeated administrations would then measure the
efficacy of its services for improving functioning, and point to program-
wide revisions for accommodating new needs of a changing case mix.
Administered across programs, governmental and managed
care organizations could use functional assessment instruments to
compare improvements of persons in various programs and select those
that produce a desired balance between costs and improvement (Smith,
Manderscheid, Flynn & Steinwachs, 1997). Paying for services based
on achieving outcomes, such as improved functioning, has been
advocated by a number of stakeholders, including the providers
themselves (e.g., Meyer, 1997; Smith et al., 1997). These stakeholders
have argued that the typical criterion for purchasing services-lowest
cost-is short-sightedand often self-defeating. Such services maintain
but rarely prevent, improve, or otherwise treat functional areas that
are not easily quantified but are of major interest to participants and
other stakeholders.
Functional assessment can also provide a standardized means
of collecting, recording, and summarizing the information needed to
determine individuals’ eligibility for disability benefits. Eligibility is
defined, in part, by the Social Security Administration (SSA) as
inadequate performance of basic instrumental roles. Performance is
typically assessed by an interviewer who makes a subjective decision
whether or not the applicant meets eligibility criteria. Pincus, Kennedy,
Simmens, and Goldman (1991) found that almost 25% of 732
applicants were classified inconsistentlywhen well trained psychiatrists

used both the SSA’s criteria and their own clinical judgment to
determine eligibility. An objective measure of functioning might
increase the consistency and efficiency of the process, identifying
applicants whose scores clearly indicate eligibility and disability and
referring those with questionable scores for further and more focused
evaluation (Zarate et al., 1998).
Additional needs for psychometrically sound and ‘user-

friendly’ instruments for functional assessment are linked to
determining ‘rehabilitation readiness’ and developing improved
methods of psychosocial rehabilitation. Certain forms and intensities
of rehabilitation must be keyed to the stage or phase of a person’s
illness, and only sensitive and specific methods of assessing social
and independent living skills will enable a practitioner or treatment
team to determine an individual’s readiness for particular types of
intervention. For example, the likelihood of successful discharge from
hospital and adherence to community-based treatment can be predicted
by the appropriateness of a person’s social and instrumental role
behavior (Kopelowicz et al, 1998; Paul & Lentz, 1977). The design
and crafting of new rehabilitation modalities also requires a sound
needs assessment in the various domains of patients’ psychosocial
functioning (Liberman & Corrigan, 1993; Wallace et al., in press).
The two instruments for functional assessment, described and
evaluated in this report, have been designed to meet the criteria set by
recent reviewers of this field and consensus conferences comprising
stakeholders of mental health services (IAPSRS, 1997; Liberman et
al., 1998; Smith et al., 1997): These instruments enable clinicians to
(1) assess role functioning in the lifestyles relevant to the majority of
individuals with disabling forms of mental disorders in both residential
and ambulatory settings; (2) include information from multiple sources;
(3) focus on abilities and competencies, rather than on deficits and
symptoms; (4) include a broad range of skills relevant for community
functioning; (5) use a simple and objective scale focused on current
functioning; and (6) rely on their being psychometrically sound.
204 Anthony Menditto, Charles J. Wallace, Robert Liberman, Jillin Vander Wal,
Independent Living Skills Inventory

The Independent Living Skills Inventory (ILSI), developed at
the University of Nebraska, is a multi-faceted, functional assessment
instrument measuring the extent to which individuals are able to
competently perform a broad range of skills important for successful
community living. Each item is rated by staff according to the extent
to which an individual is able to perform a skill, as well as the extent
of assistance or guidance required. Psychometric information on the

nine original subscales of the ILSI revealed strong internal consistency,
with coefficient alphas ranging from .91 to .98 (mean = .96). Inter-
rater reliability coefficients (Pearson r) ranged from .59 to .89 (mean
= .73) across subscales in an inpatient hospital setting, and .54 to .94
(mean = .75) for a day treatment setting (Sanchez, 1987). Construct
validity was demonstrated by comparing ILSI subscale scores with
subscale scores on the Nurses’ Observational Scale for Inpatient
Evaluation (NOSIE-30; Honigfeld, Gillis, & Klett, 1966). Significant
positive associations were found between the following NOSIE-30
and ILSI subscales: NOSIE-30 Social Competence Subscale with ISLI
Personal Management, Hygiene & Grooming, Clothing, Interpersonal
Skills, Home Maintenance, and Resource Utilization; NOSIE-30
Personal Neatness with ILSI Hygiene & Grooming, Clothing, Money
Management, and Cooking; and NOSIE-30 Manifest Psychosis with
ILSI Interpersonal Skills. A significant negative association was
reported between the NOSIE-30 Manifest Psychosis subscale and the
ILSI Resource Utilization subscale.
Several modifications have been made to the instrument
subsequent to the original analyses and prior to its current form. Two
additional subscales have been added: the General Occupational Skills
subscale and the Medication Management subscale. Other slight
modifications were made by rewording three items to remove
ambiguity, turning a two-part item into two separate items, and adding
three items to existing subscales.
The resulting instrument contains 89 items spread across 1 1
different subscales (See Table 1 for a list of sample items from each
subscale). Each subscale reflects a different domain of community

functioning such as Personal Management, Hygiene and Grooming,
Clothing, Basic Skills, Interpersonal Skills, Home Maintenance,Money
Management, Cooking, Resource Utilization, General Occupational
Skills, and Medication Management. Summary scores are obtained
for each subscale as well as for the instrument as a whole. Competence
for each item is rated on a 4-point scale (No Competence, Limited
Competence, Dependent Competence, and Independent Competence)

according to the individual’s ability to perform the skill over the past
30 days. Definitions and examples for each of these anchors are
included with the instrument, and staff are encouraged to refer to these
as often as necessary when completing the subscale.
Table 1. Examples of items from the 11scales or domains of the

Independent Living Skills Inventory.
Domains Sample Items
Personal Management Maintains a simple daily schedule in a structured
environment (appearing for group activities and meals,
keeping appointments, getting proper amount of sleep)
Hygiene and Grooming Keeps body clean, including hands and face (washes
before meals, showers or bathes regularly, uses
deodorant)
Clothing Dresses appropriately for weather and situation
Basic Skills Knows own address and phone number
Interpersonal Skills Responds to approach of others (responds to greetings,
answers simple questions)
Home Maintenance Maintains basic hygienic conditions of living areas (keeps
kitchen and bathroom adequately clean)
Money Management Can figure out how much money shehe has available (in
cash, bank accounts, from income)
Cooking Prepares food from recipes or package instructions
Resource Utilization Locates addresses (uses maps or directory)
General Occupational Skills Interacts appropriately with coworkers
Medication Management Knows the names, dosage, purpose, and basic side effects
of each mescribed medication
Inter-raterreliability, internal consistency, and construct validity

of the revised version of the ILSI were examined. To examine validity,
data from the ILSI were compared with data collected on two other
well-established measures-the Brief Psychiatric Rating Scale (BPRS),
which measures the presence and severity of psychiatric sympto-
matology, and the Time-Sample Behavioral Checklist (TSBC, Paul,
1987), which is a direct observational measure indicating the ongoing
frequency with which individualsengage in a wide range of appropriate

and inappropriate behavior. The BPRS and TSBC provided measures
of two constructs which would be expected to be related-psychiatric
symptomatology and ongoing level of functioning. It was hypothesized
that individuals who exhibited high rates of psychiatric symptoms and
inappropriate behaviors, as indicated by high scores on the BPRS and
the inappropriate behavior scales of the TSBC, would be rated as having
lower levels of competency on functional living skills as indicated by
lower ILSI scores. Conversely, individuals who were rated as having
higher levels of skills on the ILSI should have exhibited more
appropriate behavior as assessed by the TSBC.
Participants in the validation study of the ILSI consisted of 5 1
individuals on six inpatient wards of a large Midwestern state hospital.
Twenty participants were from maximum-security forensic wards, 12
were from a minimum-security forensic ward, and 19 were from general
adult psychiatric wards. Only 10 participants were female, as the
forensic wards serve exclusively male populations. Of the participants,
18 were African-American and the remainder were Caucasian. Most
participants (43) had never been married, one was currently married,
and 7 were divorced or widowed. Primary diagnoses consisted of
schizophrenia (32), schizoaffective disorder ( 1 8), and psychotic
disorder not otherwise specified (1). The average age of the participants
was 41.67 (SD = 8.39). Average length of continuous hospitalization
was 7.71 years (SD = 6.70 years).
Time-Sample Behavioral Checklist (TSBC; Paul, 1987)

The TSBC is a direct observational measure which indicates
the frequency with which individuals engage in a wide range of

appropriate and inappropriate behavior. It is used for ongoing clinical
decision-making and program evaluation research. Data were collected
through direct observations using a stratified hourly time-sampling
schedule. Observationsoccured during all waking hours for all subjects,
yielding a weekly average of about 90-105 such observations per
subject. Using highly standardized definitions,a team of non-interactive
observers coded the presence or absence of 69 specific behavioral codes

for each participant during each observation. The seven categorical
groupings for these codes were as follows: Location (e.g., bedroom,
activity area); Physical Position (e.g., sitting, standing);Awake-Asleep
Status (eyes open or closed); Facial Expression (e.g., smiling,
grimacing); Social Orientation (e.g., alone, with residents); Concurrent
Activities (e.g., watching others, group activity); and Crazy Behavior
(e.g., talking to self, posturing). These codes were aggregated into
nine higher order scores, which included a Total Appropriate Behavior
Index and its subcomponents (Interpersonal Interaction Index,
Instrumental Activity Index, Self-Maintenance Index, and Individual
Entertainment Index) and a Total Inappropriate Behavior Index and
its subcomponents (Bizarre Motor Behavior Index, Bizarre Facials and
Verbals Index, and Hostile-Belligerence Index). Extensive research
on this instrument has established its exceptional inter-rater reliability
(Licht & Paul, 1987), as well as excellent convergent, discriminant,
and predictive validity (Mariotto, Paul, & Licht, 1987; Paul &
Marriotto, 1987).
Procedure
ILSI’s were completed on all 5 1 participants. To examine the
instrument’s reliability, two raters independently completed an ILSI
for 19 of the 51 participants. Staff training included an orientation to
the instrument and verbal instructions on how to assess participants
and record ratings. Detailed written instructions, which included
scoring definitions and examples, accompanied the instrument. Raters
were asked to assess each subject’s living skills according to the
208 Anthony Menditto, Charles J. Wallace, Robert Libeman, Jillin Vander Wal,
individual’s typical functioning over the past 30 days, based on

information obtained from direct contact with the subject, interviewing
the subject, reviewing records, and/or discussing the subject’s ability
with other staff. The only restriction placed on raters who were involved
in reliability checks was that they were not permitted to discuss the
subject’s functioning with the other assigned rater.
Client BPRS ratings were obtained from an interview with
either a psychiatrist, psychologist, or social worker. Each of the raters

received at least three hours of training in the use of the BPRS, which
included watching a video-taped interview with a hospitalized person
and completing ratings on each of the 18 items using the anchored
version of the instrument. These ratings were then reviewed and
discussed with an expert trainer.
The TSBC was used routinely as part of ongoing clinical
operations on several of the hospital’s wards. Since all participants in
this study resided on wards that incorporated the TSBC, these data
were available archivally. TSBC data were collected by experienced
observers, each of whom completed 6-10 weeks of initial training
followed by weekly reliability checks in which they were required to
maintain levels of raw agreement in excess of 95%.
Internal Consistency
The internal consistency of the ILSI was assessed with both
item-total correlations and coefficient alphas (see Table 2). For the
ILSI total score, item-total correlations ranged from r = .53 to 1= .87
(Mean 1 = .75), with a coefficient alpha of = .99. For the individual
subscales, the average item-total correlations ranged from r = .82 to r
= .94 (Mean 1 = .83), with only one correlation below = .70.Alphas
for the subscales ranged from = .86 to = .97 (Mean = .93).
Inter-Rater Reliability
Intraclass correlation coefficients (ICCs) were used as indices
of reliability across raters. Variance components, calculated with the
SAS varicomp procedure, were entered into a program originating from
Table 2. Standard Deviations & Alpha Coefficients of the

Full Scale ILSI and Subscale Scores (N=51)
Scale or Domain of Independent Score Item-Total Alpha
Living Skills Inventory Mean (SD) Correlations Coefficients ICCs
Total Score 138.06 (57.35) .88 .99 .81
Personal Management 9.14 (4.1 1) .94 .93 .83
Hygiene and Grooming 15.84 (6.24) .88 .95 .88

Clothing 1 1.74 (4.16) .82 .91 .77
Basic Skills 14.80 (5.01) .83 .92 .47
Interpersonal Skills 3 1.20 (13.41) .93 .97 .86
Home Maintenance 8.33 (4.81) .86 .95 .49
Money Management 6.25 (3.83) .84 .92 .63
Cooking 10.14 (6.59) .90 .96 .67
Resource Utilization 8.74 (5.21) .90 .94 .72
General Occupational Skills 16.06 (8.66) .86 .97 .7 1
Medication Management 4.96 (2.7) .90 .86 .74
the work of Dunn (1989), which generated a maximum likelihood

estimation based on a simple one-way random effects model. ICCs
for the total score and subscales of the ILSI are provided in Table 2.
The ICC for the ILSI total score was .8 1, while ICCs for the individual
subscales averaged .7 1 (range = .47-38). Only 2 of the subscales had
ICCs lower than .60. The average ICC across individual items was .55
(range = .11-32).
Construct Validity
The construct validity of the ILSI was assessed by measuring
its relationship to other well-established measures of conceptually
related constructs. Correlations between the ILSI and the BPRS are
presented in Table 3. A total of 16 subjects refused to participate in the
BPRS interviews, and therefore analyses involving BPRS data included
only 35 of the original 51 participants. The ILSI total score was
significantly negatively correlated with the total BPRS score as well

as with the BPRS factors of Thinking Disorder and Withdrawal]
Retardation.Each ILSI subscale was significantly negatively correlated
with these two factors as well. There were no significant correlations
between ILSI scores and the BPRS factors of AnxiousDepression or
Hostile-Suspiciousness. Together, these correlations indicated an
inverse relationship between level of functioning and overall level of
psychopathology, particularly with regard to the positive and negative

symptoms of schizophrenia.
Correlations between ILSI total scores, ILSI subscales, and
the TSBC higher-order scores are presented in Table 4.Correlations
were in the predicted direction in all cases, with ILSI scores positively
associated with TSBC indices of appropriate behavior and negatively
associated with indices of inappropriate behavior. Significant positive
Table 3. Correlations between the ILSI and BPRS (N = 35)

BPRS Factors
Independent Living BPRS Thinking Withdrawal Anxious Hostile
Skills Inventory Scales Total Disorder Retardation Depression Suspicious
ILSI Full Scale Score -.43** -.54*** -.51** -.01 .04

Personal Management -.51** -,62**** -.54*** -.lo .01
Hygiene and Grooming -.40* -.52** -.48** -.06 .I1
Clothing -0.27 -.36* -.40* -.lo .I9
Basic Skills -.36* -.49** -.46** .05 .11
Interpersonal Skills -.53** -.56*** -.51** -.08 -.09
Home Maintenance -.28 -.42* -.38* .07 .ll
Money Management -.26 -.39* -.48** .10 .I8
Cooking -.38* -.44** -.46** -.06 .o1
Resource Utilization -.30 -.48** -.48** .09 .15
General Occupational Skills -.41* -.45** -.34* -.02 -.I0
Medication Management -.34 -.55** -.53* .17 .I3
correlations were found between the ILSI total score and the TSBC
indices for Total Appropriate Behavior, Interpersonal Interaction, and
Instrumental Activity. ILSI subscale scores were significantly and
positively correlated with the TSBC Total Appropriate Behavior Index
for all but two subscales (Hygiene & Grooming, Medication
Management), and all 1 1 subscales were significantly and positively
correlated with the TSBC Instrumental Index, which assesses the extent
to which individuals exhibit functional skills such as working, reading,

and writing. Several other significant relationships were found between
ILSI subscale scores and TSBC indices, most notably a significant
positive correlation between the ILSI Interpersonal Skills subscale and
the TSBC Interpersonal Interaction Index, a significant negative
correlation between the ILSI total scores and the TSBC Bizarre Facials
and Verbals Indices, and a significant negative correlation between
the ILSI Medication Management subscale and the TSBC Bizarre
Facials and Verbals Indices. There were no significant relationships
between ILSI scores and the TSBC Bizarre Motor Behavior Index.
Independent Living Skills Survey
Created five years earlier than the ILSI by an independent

research team at UCLA (Wallace, 1986; Vaccaro, Pitts and Wallace,
1992), the Independent Living Skills Survey (ILSS) has been
administered to over 300 persons with severe mental illness in three
clinical research projects and has been adopted for widespread clinical
use. While both self-report and informant’s versions are available for
the ILSS (Psychiatric Rehabilitation Consultants, 1999), only
psychometric data on the informant’s version will be reported here to
be consistent with the way in which the ILSI is rated.
The ILSS consists of 1 18 items that assess performance in 12
areas of community functioning: Personal Hygiene, Appearance and
Care of Clothing, Care of Personal Possessions and Living Space, Food
Preparation, Care of One’s Own Health and Safety, Money
Management, Transportation, Leisure and RecreationalActivities, Job
Table 4. Correlations between the ILSI and TBSC

~ ~~
Independent Living TSBC Total Total Bizarre

Skills Inventory Appropriate Interpersonal Instrumental Inappropriate Bizarre Facial/
Scales Behavior Interaction Activity Behavior Motor Verbal
ILSI Full Scale Score .35* .29* .42** -.27 -.09 -.32*
Personal Management .31* .27 .37** -.27 -.05 -.32*
Hygiene and Grooming .25 .2 1 .28* -.19 -.I0 -.20
Clothing .33* .32* .33* -.25 -.11 -.23

Basic Skills .30* .23 .33* -.24 -.16 -.26
Interpersonal Skills .32* .33* .39** -.I9 -.04 -.27
Home Maintenance .42** .30* .51**** -.31* -.24 -.19
Money Management .35* .22 .33* -.29* -.09 -.35*
Cooking .36* .24 .40** -.31* -.16 -28*
Resource Utilization .34* .24 .47*** -.29* -.I4 -.3 1*
General
Occupational Skills .36* .33* .38** -.25 -.03 -.30*
Medication Management .25 .19 .45*** -.26 -03 -.32*
*P<.O5,**p<.Ol,***p<.Ool ,****p<.OoOl
Seeking, Job Maintenance, Eating, and Social Interactions. The items

describe relatively specific behaviors and skills such as “washes hair
twice a week,” “stores money in a safe place,” “cleans and stores dishes
and utensils after a meal,” and “reads the want ads.” Informants indicate
how frequently an individual has performed each skill within the past
month on the 5-point scale used in the Nurses Observation Scale for
Inpatient Evaluation, a frequently administered measure of inpatients’
functioning; Never, Sometimes, Often, Usually, and Always. To
accommodate the possibility that an informant in the community
facilities for which the ILSS is intended may have only limited contact
with a particular individual, a sixth response option was added, No
Opportunity to Observe.
The ILSS can be conveniently administered in-person, by
phone, or by mail since completion requires only a brief verbal or
written explanation of the response scale and from 20 to 35 minutes of
the informant’s time. The answers are scored from 0 (“Never”) to 4

(“Always”); summed and averaged per functional area, ignoring those
items answered “No Opportunity to Observe.” An area is not scored,
however, if three or fewer items are answered with other than the “No
Opportunity” option.
Participants
The psychometric properties of the ILSS were studied in three

different projects involving persons with serious mental illness, most
of whom were reliably diagnosed as having schizophrenia using
structured diagnostic interviews. One project took place at the West
Los Angeles VA Medical Center where 84 subjects were randomly
assigned to receive six months of skills training or occupational therapy
on an intensive, 4 day per week, 5 hour per day schedule. A second
project, involving 13 1 persons with serious mental illness, took place
at the Santa Barbara Mental Health Center. This project also compared
skills training with occupational therapy; however, a third condition
was added-routine services.The final project, sponsored by the Social
Security Administration, was a study of factors that influenced
psychiatric disability, work capacity and employment outcomes and
included 233 subjects. The ILSS was administered in these projects at
baseline and at varying frequencies and intervals thereafter, up to 42
months. More details on the methods are available in other publications
(Liberman, Kuehnel, & Backet, 1998; Wallace et al., in press; Zarate
et al., 1998).
Internal Consistency & Stability

Calculation of the internal consistency reliability was done with
coefficient alpha for each functional area at each of the testing periods.
As shown in Table 5 , the coefficient alphas ranged from good to
excellent. While the items in each functional area are not
unidimensional ‘traits,’ they are realistic groupings of situations that
can be linked to treatment planning. The functional area, Leisure and
Recreational Activities, for example, includes items as diverse as
watching TV, playing a table game, attending church and civic events,
seeing a movie or a play, and participating in a sport. From a clinical
and treatment planning perspective, all of these items belong in the
same grouping since they are activities conducted at times (other than
work) that can function as opportunities to build a social network.
The weighted average stability coefficients across the four lag
one correlations for 10 of the functional areas are presented in Table 5 .
Each average was calculated by transforming its component

correlations to z scores, weighting each component z by its sample
size, averaging them, and then converting the average z to r. Like the
results for internal consistency, the stabilities of the functional areas
for the ILSS ranged from good to excellent.
Inter-rater Reliability
Inter-rater reliability was computed on the ratings made by
subjects themselves on the self-report version of the ILSS and the rating
of the subject by an informant for the same time interval. The weighted
average inter-rater correlation coefficients across the five testings for
the ten functional areas that the two versions of the ILSS have in
common are presented in Table 5. Each average was calculated by
transforming its component correlations to z scores, weighting each
component z by its sample size, averaging them, and then converting
the average z to r.
The results indicate that there was moderate agreement between
respondents and informants. Although it might be argued that the two
sources of information should be in relatively high to almost perfect
agreement,their opportunities to observe participants’behaviors were
considerably different, and these differences were likely magnified by
the specificity of the items. As noted previously, the participants had
more immediate information about the variations in the frequency and
topography of their own behaviors than informants, and were able to
respond to the specific questions about the ILSS with the most recent
information about these changes. In contrast, informants typically had
global impressions of participants that were updated sporadically at
best.
Validity
Informants’ ILSS means on each functional area and overall
for the entire instrument were correlated with BPRS and GAS scores.
Each average was calculated by transforming its component
correlations to z scores, weighting each component z by its sample
size, averaging them, and then converting the average z to r. Eight of
23 correlations were significant at the pcO.01 level. Albeit low (in the
range of 0.12 to 0.3 l), all correlations were in the expected direction;
for example, negative correlations between BPRS symptom ratings
and ILSS scores and positive correlations between GAS functional
ratings and ILSS scores. In terms of sensitivity to treatment, informants
reported that the functioning of the subjects who received skills training
was significantly higher after treatment than the two other groups for
the total ILSS score (pc0.05) and for the scales of Cure of Personal
Possessions, Money Management, Transportation, Job Seeking, and
Job Maintenance (pcO.01).
Discussion
In the aggregate, the results of psychometric analyses of these

two, similar instruments for measuring social and independent living
skills suggest that they possess good reliablity, stability, internal
consistency, construct or concurrent validity, and sensitivity to
treatment. In addition, these assessment tools possess several practical
advantages from a rehabilitation standpoint. They are ‘user-friendly’
in that a mental health worker or team can complete ratings accurately
and conveniently. Individual items have a high degree of ‘face validity’
and are relevant to planning services for fostering community
adaptation. These scales are also based on the adaptive strengths and
assets of individual clients or consumers, a key focal point for
developing goals and interventions in psychiatric rehabilitation. By
referring to the assessments obtained from the ILSI or ILSS,
rehabilitation practitioners can work collaboratively with consumers
to identify areas that need to be targeted for rehabilitation interventions,
216 Anthony Menditto, Charles J. Wallace, Robert Liberman, Jillin Vander Wal.
either through skills training or appropriate environmental supports.

Since these instruments lend themselves to repeated administrations,
they provide clinicians with methods for assessing the effectiveness
of treatment over time, and, cumulatively, for program evaluation
purposes.
Although these two instruments have much clinical utility, more
work is needed to increase the chance that they will be adopted as part
of routine procedures in psychiatric facilities and agencies. For

example, formats for summarizing the results across items and domains
or scales, are clearly needed. These summaries can be used to provide
comparisons with various norms; for example, other persons with
serious and persistent mental illness who live in a variety of settings,
consumers who are “successful” vs. “unsuccessful” in their reha-
bilitation, and minimum requirements to live successfully in particular
settings with specified levels of supervision.
Given the demands on practitioners to make billable every
instant of their time, efforts for shortening documentation of functional
assessments and the time to complete it are highly valued. Totalling
item scores, graphing the totals, and consulting comparison Tables
would be highly discouraged for clinicians. Rather, producing relatively
automated summaries and even suggesting treatment plans would
greatly enhance the acceptability of the ILSS and ILSI by clinicians
and clinical program managers.
Fortunately, the ubiquity of the personal computer makes
automation of scoring and summarizing the ILSS and ILSI a feasible
goal, and efforts are currently underway to devise a PC-based “expert”
system that would automate the process for the ILSS, but not violate
JCAHO standards for individuation of care. Such a system could
accommodate various groupings of items to use only those that were
relevant for a particular use, highlight the extreme base rate items whose
answers suggested a change in clinical status, and assist less
experienced clinicians to acquire the knowledge of the experts who
established the system’s rules.
Table 5. Reliability coefficients for the 2 scales or domains of the Independent Living SkiZZs Survey
of Care of Job Job
Reliability Hygiene Appearance Possessions Food Health Money Transport Leisure Seeking Maintenance Eating Social
Alpha 0.915 0.914 0.920 0.918 1.869 0.817 0.905 *
I I I I I
I
0.741 1 0.944 I 1 I
0.821 I 0.829
~~
Stability 0.760 0.934 I 0.827 10.858 I I 0.811 0.907 I 0.854 I 0.702 I 0.595 I 0.340 I
4
0.89010.858 0.661
I
r
-.
<
5'
218 Anthony Menditto, Charles J. Wallace, Robert Liberman, Jillin Vander Wal.
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Psychiatric Rehabilitation Skills

ISSN: 1097-3435 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/uzpr20

Functional Assessment of Independent Living

Anthony A. Menditto , Charles J. Wallace , Robert P. Liberman , Jillon Vander

To link to this article: http://dx.doi.org/10.1080/10973439908408384

Published online: 18 Jan 2011.

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Functional Assessment of Independent Living Skills

Charles J. Wallace, Robert P. Liberman

Jillon Vander Wal, Nicole Tuomi Jones, Paul Stuve

Functional assessment of persons with psychiatric disabilities requires

Functional assessment has assumed importance as psychiatric

Requests for reprints should be directed to Anthony Menditto, Ph.D,

for mental health; (4)reliable evaluations are to be made of

Despite major advances in psychopharmacology and

often scarce and time-limited treatment resources, it must be

assessment can be aggregated across a program’s participants, with

applicants were classified inconsistentlywhen well trained psychiatrists

Additional needs for psychometrically sound and ‘user-

Independent Living Skills Inventory

of assistance or guidance required. Psychometric information on the

subscale). Each subscale reflects a different domain of community

Competence, Dependent Competence, and Independent Competence)

Table 1. Examples of items from the 11scales or domains of the

Inter-raterreliability, internal consistency, and construct validity

frequency with which individualsengage in a wide range of appropriate

Time-Sample Behavioral Checklist (TSBC; Paul, 1987)

the frequency with which individuals engage in a wide range of

observers coded the presence or absence of 69 specific behavioral codes

individual’s typical functioning over the past 30 days, based on

either a psychiatrist, psychologist, or social worker. Each of the raters

Table 2. Standard Deviations & Alpha Coefficients of the

Hygiene and Grooming 15.84 (6.24) .88 .95 .88

the work of Dunn (1989), which generated a maximum likelihood

significantly negatively correlated with the total BPRS score as well

psychopathology, particularly with regard to the positive and negative

Table 3. Correlations between the ILSI and BPRS (N = 35)

ILSI Full Scale Score -.43** -.54*** -.51** -.01 .04

to which individuals exhibit functional skills such as working, reading,

Independent Living Skills Survey

Created five years earlier than the ILSI by an independent

Table 4. Correlations between the ILSI and TBSC

Independent Living TSBC Total Total Bizarre

Clothing .33* .32* .33* -.25 -.11 -.23

Seeking, Job Maintenance, Eating, and Social Interactions. The items

the informant’s time. The answers are scored from 0 (“Never”) to 4

The psychometric properties of the ILSS were studied in three

Internal Consistency & Stability

Each average was calculated by transforming its component

In the aggregate, the results of psychometric analyses of these

either through skills training or appropriate environmental supports.

of routine procedures in psychiatric facilities and agencies. For

American Psychiatric Association (1996). Practice guidelines for schizophrenia.

memory in treatment-resistant schizophrenia? American Journal of

Research-the Time-Sample Behavioral Checklist f o r Assessment in

Cambridge, MA: Harvard University Press.

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ILSI Full Scale Score -.43 -.54* -.51** -.01 .04