Research Article

Construct Validity and Reliability of the

Comprehensive Occupational Therapy
Evaluation Scale (COTES) in People With
Schizophrenia
En-Chi Chiu, Kuan-Yu Lai, Shih-Ku Lin, Shih-Fen Tang, Shu-Chun Lee, Ching-Lin Hsieh

OBJECTIVE. We evaluated the construct validity (i.e., unidimensionality and convergent validity) and Rasch reliability of the
20-item Comprehensive Occupational Therapy Evaluation Scale (COTES) in people with schizophrenia.
METHOD. Retrospective chart review was used to collect COTES data from 505 inpatients with schizophrenia. For construct
validity, we first examined unidimensionality of each of the three COTES subscales using Rasch analysis. After unidimensionality
was supported, we examined convergent validity using Pearson’s r and Rasch reliability of the individual subscales.
RESULTS. After deleting two misfitting items, the remaining items (i.e., the COTES–18) showed unidimensionality. Infit and outfit
mean squares were 0.73–1.25. Moderate correlations were found among the three COTES–18 subscales (r s = .57–.71). The Rasch
reliabilities of the three subscales were .83–.92.
CONCLUSION. The COTES–18 has sufficient construct validity and reliability to assess three specific dimensions of behavior
affecting occupational performance in people with schizophrenia.

S chizophrenia is a chronic mental disorder. As a result of the disorder’s psychiatric symptoms, behaviors such as
untidy appearance, disorganized thoughts, poor social skills, lack of motivation, and short duration of work (Eklund
& Leufstadius, 2007) are present, thereby affecting occupational performance. These impaired behaviors can be
observed in activities of daily living, social functions, and work in the community. Improving behaviors that affect
occupational performance is an important goal for occupational therapy in clinical and research settings. Clinicians and
researchers must be able to measure these behaviors to design plans for interventions.
The Comprehensive Occupational Therapy Evaluation Scale (COTES), designed for people with mental illness, is
one of the most widely used measures to assess behaviors that influence occupational performance in people with
schizophrenia in Taiwan (Chen et al., 2006; Hsiao et al., 2000). It is a revised version of Brayman’s Occupational
Therapy Evaluation Scale (Kau et al., 1981), which was culturally modified for use in Asian countries (e.g., Taiwan). The
COTES was developed on the basis of occupational therapy theories, such as Azima and Azima’s (1959) Dynamic
Theory of Occupational Therapy, Fidler and Fidler’s (1963) Object Relations Theory, and Mosey’s (1971) frames of
reference.
The COTES contains three subscales: General Behavior, Social Behavior, and Work Behavior. The COTES is
an observational measure that can be applied in acute psychiatric settings; it can be administered during a group
activity, which can reduce burden on examiners, and it assesses multidimensional aspects of behaviors that affect
occupational performance, which is useful in developing an occupational profile and determining clients’ strengths
and weaknesses.

Citation: Chiu, E.-C., Lai, K.-Y., Lin, S.-K., Tang, S.-F., Lee, S.-C., & Hsieh, C.-L. (2019). Construct validity and reliability of the Comprehensive
Occupational Therapy Evaluation Scale (COTES) in people with schizophrenia. American Journal of Occupational Therapy, 73, 7306205060.
https://doi.org/10.5014/ajot.2019.026807

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Two important psychometric properties of a measure are construct validity (e.g., unidimensionality, convergent
validity) and reliability. Psychometric properties of a measure are sample dependent. When the measure is applied to
a specific group (e.g., people with schizophrenia), psychometric properties of the measure need to be examined in
that group (Chiu et al., 2014; Chiu, Lee, Lai, et al., 2015). For clinical applications of the COTES in people with
schizophrenia, it is fundamental to examine construct validity and reliability to explain the underlying constructs and
determine the degree of measurement precision.
Rasch analysis has been used for evaluating a measure’s reliability because it offers three advantages: (1) Scores of
the measure can be transformed into interval scores; (2) items fit the assumptions of the Rasch model, demonstrating
unidimensionality; and (3) Rasch reliability can be examined at the unidimensional or multidimensional level. Rasch
reliability using the multidimensional approach takes into consideration the correlations among the subscales, which
can increase the reliability estimates (Hsiao et al., 2015). For the COTES, unidimensionality using Rasch analysis has
been examined in people with mental disorders (Wang et al., 2012) but not specifically in people with schizophrenia.
Convergent validity and Rasch reliability of the COTES have not been examined in people with schizophrenia
exclusively.
Therefore, the purposes of this study were to examine the construct validity (i.e., unidimensionality and convergent
validity) and Rasch reliability of the COTES in people with schizophrenia. We first examined unidimensionality of the
three individual COTES subscales. After unidimensionality was supported, we examined the convergent validity and
Rasch reliability using unidimensional and multidimensional approaches.

Method
Participants
This retrospective study of 505 Taiwanese inpatients with schizophrenia took place in an inpatient psychiatric
center in northern Taiwan. Data were collected from participants’ occupational therapy charts. The COTES was
administered to participants from April 2005 to August 2014. Because participants did not work while living in
the psychiatric center, the COTES Work Behavior subscale was assessed when they performed tasks during
occupational therapy.
The inclusion criterion for data selection was a diagnosis of schizophrenia based on the Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). Patients who had a history of
severe brain injury or who had a diagnosis of mental retardation or substance abuse were excluded. This study was
approved by the psychiatric center’s institutional review board (TCHIRB-1010811).
The age range of participants was 20–76 yr, and about half (49.7%) were male. The mean length of time they
received mental health services was 17.1 yr. The mean scores on the COTES were 23.4, 14.3, and 20.8 for the General
Behavior, Social Behavior, and Work Behavior subscales, respectively. Table 1 lists further details of participant
demographic characteristics.

Procedure
Secondary data from the COTES were collected by 29 occupational therapists during their weekly duties. These
therapists were licensed and trained to administer the COTES (e.g., familiar with test items and scoring). In this
study, research assistants (not the aforementioned occupational therapists) reviewed the occupational therapy
charts and selected the eligible participants. One research assistant recorded participants’ COTES
and demographic data, and another research assistant proofread the records to ensure the accuracy of
the data recorded. The initial COTES assessment for each eligible participant was used for data analysis in this
study.

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Table 1. Patient Characteristics (N = 505) Instrument

Characteristic n (%) or M (SD) The 20-item COTES rates patients’ performance in work, lei-
Gender sure, and daily activities. The General Behavior subscale has
Male 251 (49.7) seven items: attendance, appearance, activity level, emotional
Female 254 (50.3)
disturbance, nonproductive behavior, physiological needs, and
Age, yr 41.8 (12.1)
Onset age, yr 24.9 (9.3) impairment of speech. The Social Behavior subscale has five
No. of admissions 5.8 (5.1) items: sociability, impression of others, acceptance of opinions,
Duration of mental health services, yr 17.1 (11.0) role in groups, and self-assertion. The Work Behavior subscale
Duration of untreated psychosis, yr 2.0 (4.9)
has eight items: motivation, duration, responsibility, frustration
Duration of drug treatment, yr 15.6 (11.4)
Length of time from diagnosis to assessment, yr 12.3 (10.6) tolerance, self-expectation, comprehension, technique, and
Education fine motor.
Elementary school 28 (5.6) The COTES uses a 5-point rating scale (1–5) for each item
Junior high school 84 (16.6)
except for five items (i.e., appearance, nonproductive behavior,
Senior high school 275 (54.4)
College and above 118 (23.4) motivation, comprehension, and technique). These five items
a
Type of antipsychotic allow raters to rate patients’ performance using intervals of 0.5
First generation 151 (29.9) between the integers. The score ranges of the General Behavior,
Second generation 418 (82.8)
Social Behavior, and Work Behavior subscales are 7–35, 5–25,
COTES subscale scores
General Behavior 23.4 (3.9) and 8–40, respectively. A higher score indicates better per-
b
General Behavior (6 items) 19.2 (3.5) formance (Kau et al., 1981).
Social Behavior 14.3 (2.9)
Work Behavior 20.8 (5.0)
Work Behavior (7 items)c 17.7 (4.3)
Data Analysis
Construct Validity.
Note. COTES = Comprehensive Occupational Therapy Evaluation
Scale; M = mean; SD = standard deviation. Unidimensional Rasch analysis was conducted using
a
12.7% of patients were taking two types of antipsychotics. Winsteps (Beaverton, OR) to examine the unidimensionality
b
Attendance item deleted from subscale. cMotivation item deleted
from subscale. of each COTES subscale. We transformed the five items
with intervals of 0.5 into a 9-point rating scale (1–9). Rasch
analysis with the partial credit model was performed because the COTES items have different rating scales
(i.e., 5-point and 9-point rating scales). We used infit and outfit statistics to determine whether item responses
fit the expectations. Items with an infit or outfit mean square (MnSq) less than 0.6 or greater than 1.4 indicated
a misfit (Chiu, Lee, Kuo, et al., 2015). The misfit items of a subscale were deleted, and then Rasch analysis
was reconducted to ensure the unidimensionality of the subscale. Moreover, we conducted principal-
components analysis (PCA) on the standardized residuals to confirm unidimensionality. The eigenvalue of
the residual variance in the first contrast was calculated. The criterion of unidimensionality was eigenvalue <3.0
(Smith, 2002).
For convergent validity, we examined the correlations among the three subscales using Pearson’s r. Correlations
among subscales were defined as strong, r ≥.75, or moderate, .40 ≤ r < .75 (Hsueh et al., 2012). Moderate to strong
correlations among the three subscales should be observed because the subscales were developed to assess
different aspects of behaviors that affect occupational performance.

Reliability.
After the unidimensionality of the three subscales was confirmed, we calculated Rasch reliability using unidimensional
and multidimensional Rasch analyses. The multidimensional analysis was performed using ConQuest software
(Australian Council for Educational Research, Camberwell, Victoria, Australia). The standard of reliability was ≥.70 for
group comparisons and ≥.90 for individual comparisons (Chiu et al., 2014). Theoretically, multidimensional Rasch

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analysis can improve the precision of estimating participants’ abilities by considering the correlations between sub-
scales (Hsiao et al., 2015).
The reliabilities of the three subscales in the multidimensional approach should be greater than those in the
unidimensional approach. We used the Spearman–Brown prophecy formula to calculate the increment in the number of
items (i.e., subscale length) for unidimensional reliability to reach multidimensional reliability (Hsiao et al., 2015). In
addition, we estimated the percentage of reliability improvement using the following formula: (the difference between
unidimensional and multidimensional reliabilities/multidimensional reliability) × 100.

Results
Construct Validity
Two misfitting items were demonstrated in Rasch analysis. In the General Behavior subscale, the infit and outfit
MnSqs of the attendance item were 1.64 and 2.08, respectively. In the Work Behavior subscale, the infit and
outfit MnSqs of the motivation item were 1.64 and 1.73, respectively. We removed these two items and reconducted
the Rasch analysis. The remaining items of the General Behavior and Work Behavior subscales fit the expectations
of the Rasch model (the ranges of the infit and outfit MnSqs were 0.84–1.20 and 0.73–1.25, respectively; Table 2).
The Social Behavior subscale items met the criteria of infit and outfit MnSqs (0.81–1.18). In addition, the residuals in
PCA of the subscales in the now 18-item COTES (COTES–18) showed that the eigenvalues of the first contrast were
1.6, 1.6, and 2.7 in the General Behavior, Social Behavior, and Work Behavior subscales, respectively. For con-
vergent validity, our results showed moderate correlations among the three COTES–18 subscales: r = .71 between
General Behavior and Social Behavior, r = .57 between General Behavior and Work Behavior, and r = .59 between
Social Behavior and Work Behavior.

Reliability
Table 2. Rasch Estimates of Difficulty and Infit and Outfit Mean
The multidimensional reliability of the three COTES–18
Squares
subscales was .88–.92 (Table 3). The unidimensional re-
Subscale and Item Difficulty Logita Infit MnSq Outfit MnSq
liability of the subscales was .83–.90. Regarding the
General Behavior
Appearance −0.19 1.09 1.07
results using the Spearman–Brown prophecy formula, the
Activity level 0.79 1.20 1.15 three subscales had to be increased by 27.8%–50.2% of
Emotional disturbance 0.83 0.94 0.94 the number of items for the unidimensional approach to
Nonproductive behavior −0.66 0.88 0.84
achieve the same reliability level as the multidimensional
Physiological needs −1.43 0.95 0.94
Impairment of speech 0.66 0.92 0.93
approach. For example, the length of the General Behavior
Social Behavior subscale needed to be increased from six to nine items to
Sociability 1.27 1.13 1.15 achieve the reliability level of the multidimensional ap-
Impression of others 0.20 1.11 1.18
proach. The reliability improvement from unidimensional to
Acceptance of opinions 0.86 0.85 0.81
Role in groups −1.71 0.85 0.92
multidimensional approaches was 2.2%–5.7%.
Self-assertion −0.63 0.99 0.96
Work Behavior
Duration 0.96 1.25 1.24 Discussion
Responsibility −0.70 1.06 1.04 Rasch analysis was used to examine the unidimension-
Frustration tolerance −0.20 0.95 0.90 ality of the three COTES subscales in patients with
Self-expectation −0.42 0.90 0.88
schizophrenia. We deleted two items (one item each from
Comprehension −0.91 1.09 1.11
Technique 0.12 0.91 0.92 the General Behavior and Work Behavior subscales),
Fine motor 1.16 0.75 0.73 thereby supporting the unidimensionality of the three
Note. MnSq = mean square. individual subscales from the results of the infit and
a
Mean value of four or eight adjacent response categories in item difficulty. outfit MnSqs and PCA in residuals. Our findings on

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Table 3. Rasch Reliability and the Effect of the Multidimensional Approach on the Increment in Subscale Length
Subscale Unidimensional Reliability Multidimensional Reliability Increment in Subscale Length, % Reliability Improvement,a %
General Behavior .83 .88 50.2 5.7
Social Behavior .85 .88 29.4 3.4
Work Behavior .90 .92 27.8 2.2
a
Improvement from unidimensional to multidimensional reliability.

unidimensionality were different from those in a previous study (Wang et al., 2012). In the previous study, one item (i.e.,
sociability) was removed in the Social Behavior subscale and the remaining items fit the model’s expectations.
However, in that study, unidimensionality was not supported in the other two subscales.
A possible reason for the different results between our study and the previous study was the difference in the
samples. The sample in the previous study was mixed, including patients with schizophrenia, mood disorder, and other
mental disorders. The sample in our study was exclusively patients with schizophrenia. These inconsistent results
among different populations indicate that our findings on unidimensionality should not be generalized to people with the
other mental disorders.
The COTES–18 showed satisfactory unidimensionality for each subscale, indicating that each subscale measures a
single construct. For clinical meaning of unidimensionality, the items’ scores in each subscale can be summed up to
reflect the subscale-specific function. Clinicians and researchers can use the scores of the three subscales to un-
derstand subscale-specific functions of people with schizophrenia and follow up on progress of behaviors that affect
occupational performance.
Convergent validity is defined as the degree to which the constructs that should be theoretically related correlate in
reality (Chiu et al., 2014). Moderate correlations were found among the three COTES–18 subscales, which supports the
theoretical framework (i.e., these subscales assess behaviors that affect occupational performance). The results of
these correlations are similar to those in the previous COTES study (Kau et al., 1981). According to our findings, the
COTES–18 has adequate convergent validity in people with schizophrenia.
Rasch reliability for the three COTES–18 subscales using the multidimensional approach was higher than that of the
unidimensional approach. Future studies may increase the number of subscale items to increase the unidimensional
reliability (i.e., achieve the same reliability level as the multidimensional approach). In clinical use, higher reliability
means that clinicians and researchers can more precisely assess the abilities of people with schizophrenia. However,
the increments are small (<6.0%). Possible reasons are that moderate correlations were found among the three
subscales and that the number of COTES–18 subscales is small.
For the multidimensional approach, the higher the correlations among the subscales and the greater the number of
subscales, the greater the precision will be (Wang & Chen, 2004). In the unidimensional approach, the Work Behavior
subscale had high reliability (.90), necessary for individual comparisons of test scores (e.g., clinical application). The
reliabilities of the other two subscales (.83–.85) are suitable for group comparisons of test scores. Therefore, the
COTES–18 can be used to precisely assess behaviors that affect occupational performance in people with
schizophrenia.
We deleted two misfitting items (i.e., the attendance item in the General Behavior subscale and the motivation item in
the Work Behavior subscale). The possible reason for the misfitting of the attendance item is the concept of scale
descriptors (frequency vs. capacity; Chien et al., 2005). The attendance item rates frequency of attending activities of
occupational therapy. However, other items of the General Behavior subscale rate the capacity for participating in the
activities. The reason for the misfitting of the motivation item may be a characteristic of our sample (i.e., inpatients in the
acute phase). Inpatients in the acute phase have severe symptoms that are not associated with motivation (Fervaha
et al., 2018; Kim et al., 2016). In this study, the motivation item showed relatively low correlation with the Work Behavior

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subscale compared with other items. In the acute phase, the motivation item may be excluded for people with
schizophrenia. Further studies may reexamine the unidimensionality after revising the scale descriptor of the at-
tendance item and recruiting participants from different phases.

Study Limitations and Future Research

Three limitations of this study are noted. First, we used secondary data from occupational therapy records. We could
not ensure the fidelity of the ratings and the interrater reliability among the 29 occupational therapists. The quality
of our data and consistency of ratings could cause concerns. Future research may include a prospective study with a
few trained raters who reach interrater reliability (e.g., intraclass correlation coefficient >.80) to cross-validate our
findings.
Second, our data were collected from inpatients with schizophrenia and evaluated using only Rasch analysis,
restricting generalization to other populations (e.g., outpatients and healthy people). Future studies are warranted
to recruit other populations to evaluate unidimensionality using confirmatory factor analysis and to identify
the cutoff score using the receiver operating characteristic curve to discriminate between patients and healthy
people.
Third, we could not collect certain information for some participants, such as whether they had early psychosis or
established schizophrenia and the duration of untreated illness. The results of psychometric validations in participants
with early psychosis could differ from results in those with established schizophrenia.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:
n The COTES–18 includes three subscales that provide a profile of clients’ behaviors that affect their occupational
performance.
n The three subscales showed a unidimensional construct, and subscale scores are suitable to represent subscale-
specific functions in both clinical and research settings.
n Good construct validity and Rasch reliability indicate that the COTES–18 appears to be useful for assessing
behaviors that affect occupational performance, designing intervention programs, and following clients’ progress.

Conclusion
In this study, we deleted two items from the COTES, after which each of the three subscales showed a unidimensional
construct. The COTES–18 had satisfactory convergent validity. Rasch reliability of the three subscales was sufficient in
both unidimensional and multidimensional approaches for group or individual comparisons. Therefore, the COTES–18
appears to be a valid and reliable tool that can be used in occupational therapy practice to interpret the behaviors that
affect engagement in occupation in clients with schizophrenia.
The COTES–18 provides structures for observing diverse patient behaviors that are addressed in treatment for
mental illness. The observations made using the COTES–18 include a wide range of behaviors involving client factors
and performance skills that affect the ability to effectively react to the demands of various occupations. Because the
COTES–18 is a behavior rating scale, it can contribute bottom-up information to the treatment planning process.
Moreover, it can be administered while observing a group of clients in an activity. It can be complementary to measures
of occupational performance used in psychiatric settings such as the Kohlman Evaluation of Living Skills (Gary, 2011),
the Independent Living Scales (Revheim & Medalia, 2004), and the Texas Functional Living Scale (Cullum et al., 2009).
It is therefore worthy of consideration for use in occupational therapy with people with schizophrenia and other mental
health disorders.

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En-Chi Chiu, OTD, PhD, is Associate Professor, Department of Long-Term Care, National Taipei University of Nursing and Health Sciences, Taipei,
Taiwan.
Kuan-Yu Lai, MS, is Occupational Therapist, Department of Occupational Therapy, Taipei City Psychiatric Center, Taipei City Hospital, Taipei,
Taiwan.
Shih-Ku Lin, MD, is Psychiatrist, Department of Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan.
Shih-Fen Tang, MS, is Occupational Therapist, Department of Occupational Therapy, Taoyuan Psychiatric Center, Ministry of Health and Welfare,
Taoyuan, Taiwan.

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Shu-Chun Lee, MS, is Doctoral Candidate, School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, and
Occupational Therapist, Department of Occupational Therapy, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; A1057@
tpech.gov.tw
Ching-Lin Hsieh, PhD, is Professor, School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, and Adjunct
Professor, Department of Occupational Therapy, College of Medical and Health Science, Asia University, Taichung, Taiwan.

Acknowledgments
We are grateful to all participants for their involvement. This study was supported by a research grant from the Taipei City Hospital
(TPCH-103-063), Taipei, Taiwan. Shu-Chun Lee and Ching-Lin Hsieh contributed equally to this study.

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