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Development and validation of Vellore Assessment of Social Performance

among clients with chronic mental illness

Article in Indian Journal of Psychiatry · March 2020

DOI: 10.4103/psychiatry.IndianJPsychiatry_510_19

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Volume 62, Number 2
Indian Journal of Psychiatry • Volume 62 • Issue 2 • March-April 2020 • Pages ***-***
EDITORIAL
Substance use in India – Policy implications
Om Prakash Singh 111
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Gender differences: The new challenge for the next years
Florence Thibaut, Venu Gopal Jhanwar 112
REVIEW ARTICLE
Suicide among doctors: A narrative review
Antonio Ventriglio, Cameron Watson, Dinesh Bhugra 114
ORIGINAL ARTICLES
Development and validation of Vellore Assessment of Social
Performance among clients with chronic mental illness
S. Thamaraiselvi, A. Priyadarshini, Namrata Arisalya,
Reema Samuel, K. S. Jacob 121
Neurocognitive and clinical correlates of insight in schizophrenia
Dhanya Raveendranathan, Jessie Joseph, Tanya Machado,
Ashok Mysore 131
Impact of brief psychosocial intervention on key relatives of
patients with schizophrenia: A randomized controlled trial
Rajneesh Kumar, Anil Nischal, Pronob Kumar Dalal,
Sannidhya Varma, Manu Agarwal, Adarsh Tripathi,
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An exploratory study of cannabis use pattern and treatment
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The pattern of alcohol use and its relationship with
consequences among problem alcohol users: A community-
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Snehil Gupta, Rakesh Lal, Atul Ambekar, Ashwani Kumar Mishra,
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Portrayal of alcohol in Bollywood movies: A mixed methods
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Ravindra Rao, Udit Panda, Swati Kedia Gupta, Atul Ambekar,
Snehil Gupta, Alok Agrawal 159
Depression and diabetes: An experience from Kashmir
Arshad Hussain, Zaid Ahmad Wani, Hamidullah Shah,
Abdul Hamid Zargar, Mushtaq Ahmad Margoob, Waseem Qureshi 167
Age, preoperative higher serum cortisol levels, and lower serum
acetylcholine levels predict delirium after percutaneous
coronary intervention in acute coronary syndrome patients
accompanied with renal dysfunction
Jing Ru Ma, Meng Meng Fan, Zhan Sheng Wang 172
Subjective cognitive complaints and its relation to objective
cognitive performance, clinical profile, clinical insight, and social
functioning in patients of schizophrenia: A cross-sectional study
Sachin Pradeep Baliga, Ravindra M Kamath, Jahnavi S Kedare 178
Association between insight and internalized stigma and other
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study
Luke Sy-Cherng Woon, Siew Im Khoo, Azlin Baharudin,
Marhani Midin 186
March-April 2020
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The incidence of prolonged post-electroconvulsive therapy
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Reducing stress among medical students: A qualitative
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Siddharth Sarkar, Vikas Menon, Santosh Kumar 198
VIEWPOINT
Rehabilitation of long-stay patients in state mental hospitals:
Role for social welfare sector
Thanapal Sivakumar, Jagadisha Thirthalli, Bangalore N. Gangadhar 202
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Vikram Singh Rawat, Vijay Krishnan, Vikas Menon,
Suhas Chandran, Naresh Nebhinani 207
CASE REPORTS
Assessment of tripartite headache in a case of depression with
partial empty sella syndrome
Roshan F. Sutar 209
Stereotypical linear purpura of the upper limbs: A report of
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the literature
Sharmila Sarkar, Sudip Kumar Ghosh, Abheek Sil 212
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Primary hypoparathyroidism: Rare neuropsychiatric presentation
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Pooja Patnaik Kuppili, Mukesh Kumar Swami 217
Art therapy based on painting therapy on the improvement of
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Zeinab Jalambadani 218
A case of delusional parasitosis presented as shared psychotic
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Derya Canlı 219
A case of two culture-bound syndromes (Koro and Dhat
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Recurrent ventricular tachycardia during the electroconvulsive
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Swathy Sheela Sudevan, G. Aparna, Harish M. Tharayil 224
 ORIGINAL ARTICLE

Development and validation of Vellore Assessment of Social Performance

among clients with chronic mental illness
S. Thamaraiselvi, A. Priyadarshini, Namrata Arisalya, Reema Samuel, K. S. Jacob
Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

ABSTRACT

Background: Social skills deficits are hallmark symptoms of chronic mental illness. The absence of a culturally sensitive
instrument to measure social skills in the Indian population demands the need to develop and standardize such instruments.
Aim: The aim of this study was to develop and validate a context‑specific, culturally relevant, and performance‑based
assessment scale for social performance.
Materials and Methods: An expert committee of mental health professionals reviewed existing literature, identified
standardized scales, examined items for cultural relevance, and identified possible issues for measurement. The items were
categorized into 5 domains with a 7‑point scale. The instrument was initially piloted on 10 participants, then among 101
consecutive clients with chronic mental illness between 18 and 60 years of age who provided written informed consent. They
were assessed by two therapists to evaluate inter‑rater reliability and test–retest reliability. They were also assessed on the
Social Interaction and Communication Skills Checklist (SICSC) to evaluate convergent validity and on the 12‑item General
Health Questionnaire (GHQ‑12) to assess divergent validity. Standard statistical tests were used to study its characteristics.
Results: The scale had good inter‑rater reliability (0.941; 95% confidence interval [CI]: 0.914, 0.960) and
test–retest reliability (0.928; 95% CI: 0.810, 0.965). The correlation between total score of Vellore Assessment of Social
Performance (VASP) and SICSC (Pearson’s correlation coefficient = 0.696; P = 0.001) suggested moderate convergent
validity. The correlation between total score of VASP and GHQ‑12 (Pearson’s correlation coefficient = −0.046; P = 0.648)
implied good divergent validity.
Conclusion: VASP seems to be a promising scale to assess social performance in people with mental illness.

Key words: Assessment, India, mental illness, occupational therapy, social skills

INTRODUCTION development, course, and outcome of the illness.[1] As

Social dysfunction is a hallmark characteristic of chronic
mental illness that has important implications for the
Address for correspondence: Ms. Reema Samuel,
Occupational Therapy Unit, Department of Psychiatry, Christian
Medical College, Vellore, Tamil Nadu, India.
E‑mail: reemasamuel@cmcvellore.ac.in
services for individuals with mental illness have shifted
from the hospital to the community; there has been a
shift in the philosophy of service delivery from symptom
control to optimum participation in life activities. These
activities may include obtaining education, maintaining
employment, and living independently, all of which
require appropriate social skills. Social skills and social

Submitted: 16-Oct-2019, Revised: 25-Nov-2019, This is an open access journal, and articles are distributed under the terms of
Accepted: 08-Feb-2020, Published: 17-Mar-2020 the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
Access this article online as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Quick Response Code
Website: For reprints contact: reprints@medknow.com
www.indianjpsychiatry.org

How to cite this article: Thamaraiselvi S, Priyadarshini A,

DOI:
Arisalya N, Samuel R, Jacob KS. Development and validation
of Vellore Assessment of Social Performance among clients
10.4103/psychiatry.IndianJPsychiatry_510_19
with chronic mental illness. Indian J Psychiatry 2020;62:121-30.

© 2020 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow 121

Thamaraiselvi, et al.: Development and validation of Vellore Assessment of Social Performance among clients with chronic mental illness
competence are believed to be protective factors in
the vulnerability–stress model of schizophrenia, the
strengthening of which compensates for the deleterious
effects of psychopathology.[2] Assessment and intervention
for social dysfunction is essential to empower people
with mental illness for leading productive lives as part of
mainstream society.
The constructs “social competence,” “social skills,” and
“social functioning” are often used interchangeably.[3]
Some theorists view social functioning from a hierarchical
perspective with social skills and social competence
representing different levels of social performance.[4] Thus,
social skills are the constituent verbal, nonverbal, and
paralinguistic behaviors, which when used appropriately
in a three‑step process as given below results in social
competence.[5]
1. Social perception or receiving skills consist of the
ability to interpret other’s nonverbal and verbal
behaviors and evaluate the appropriateness of these
behaviors as compared to social norms, considering the
environmental factors affecting the interaction
2. Social cognition or processing skills are made up of the
ability to analyze the current interaction, compare it
with previous experiences, and thus ultimately decide
on the necessary course of action
3. Behavioral response or expressive skills are the
observable verbal and nonverbal behaviors that are
seen at the end of the interaction.
The behavioral model of social skills in schizophrenia
postulates that effective social functioning requires not
only the skills but also the cognitive and motivational
ability to perform the appropriate response.[6] Thus,
separation of what a person can do and what he actually
does, described as the competence/performance divide,
is imperative in chronic mental illness.[7] As confounding
factors such as cognitive deficits, negative symptoms,
and low insight can prevent people with chronic mental
illness from effective social performance, the ability or
capacity of a person to perform socially cannot be inferred
from behavioral performance alone.[3] Furthermore, the
presence of capacity does not automatically translate into
real‑world functioning, as external factors such as reduced
social opportunities can impede an exhibition of these
skills. Therefore, it is imperative that the measurement
of social functioning considers these issues for reliable
assessment.
Assessment instruments for social functioning mostly
take three forms – self‑ or proxy‑rated checklists,
direct observation of performance using role‑plays, and
naturalistic observation of real‑world functioning.[8]
Information from self‑report checklists can be less reliable
due to poor insight and the presence of cognitive, negative,
or depressive symptoms in chronic mental illness.[9] The
122
assessment of real‑world functioning can be impractical
and inaccurate as they are dependent on numerous
environmental factors and may not reveal actual capacity.
Performance‑based measures, most using role‑plays, have
been found to be more feasible, accurate, and predictive of
real‑world outcomes as compared to the other methods of
assessment.[7]
Rationale
The Vellore Assessment of Social Performance (VASP) was
formulated specifically for inpatient rehabilitation setups
providing social skills training for people with chronic
mental illness, to aid in baseline assessment and evaluation
of improvement over the training period. It addresses
the following issues related to the assessment of social
functioning which have been detailed earlier.
1. Constructs and terms for social skills, social
competence, and social functioning are used
interchangeably in literature and in most assessments:
The VASP differentiates between “social skills”
and “social competence” as operationally defined
earlier so that therapists can discriminate whether
social dysfunction is related to capacity or
performance‑related deficits. This, in turn, will help to
tailor social skills training to individual requirements,
for persons with adequate social skills, but inadequate
social functioning; additional factors such as cognitive
or motivational deficits will have to be focused on
during training
2. Dearth of performance‑based measures standardized
for the Indian population: The Maryland Assessment
of Social Competence (MASC)[6] and its shorter
adaptation, the Social Skills Performance
Assessment (SSPA),[10] are widely used role‑play
tests for social competence. However, the role‑play
situations for these assessments include asking the
boss for a promotion, asking for a second chance
at a job training program, and requesting attention
from a landlord regarding a problem, which might
not be familiar for the Indian milieu. The VASP is
scored during routine life interactions, ranging from
unfamiliar life situations (going shopping), familiar
life situations (talking to other patients in the ward),
and test situations (role‑plays during training
sessions). This enables the therapist to determine the
situation‑specific exhibition of skills and thereafter to
ensure generalization of skills from therapy setting to
patient‑specific contexts.
MATERIALS AND METHODS
Study setting
The study was conducted in the department of psychiatry
of a 122‑bed tertiary referral center treating adults and
children with mental and behavioral disorders. Psychiatrists,
occupational therapists, psychiatric nurses, clinical
Indian Journal of Psychiatry Volume 62, Issue 2, March-April 2020
Thamaraiselvi, et al.: Development and validation of Vellore Assessment of Social Performance among clients with chronic mental illness
psychologists, and psychiatric social workers form the
treatment team and employ a multidisciplinary approach
in the care of patients with mental illness. The inpatient
facility is equipped with a comprehensive occupational
therapy program with focus on improving various domains
of social and occupational functioning. This instrument
was developed specifically to assess changes in social
functioning of patients undergoing the six‑session social
skills training program at the unit.
Review of issues
The study design and scale construction was conceptualized
by RS and KSJ, who formed an expert committee consisting
of occupational therapists, clinical psychologists, nurses,
and psychiatrists. The committee reviewed current
literature, identified issues in the field, and provided
input on items and scoring. It was decided to formulate
a performance‑based assessment based on an already
established construct.
Construction of assessment scale
Review of instruments
A search of literature identified the following instruments
assessing social skills: (1) the Social Functioning
Questionnaire,[11] (2) the Assessment of Communication and
Interaction Skills,[12] (3) the Social Functioning Scale,[13] (4) the
Social Dysfunction Rating Scale,[14] (5) the Social Interaction
and Communication Skills Checklist (SICSC),[15] (6) MASC,[6]
and (7) SSPA.[10] The contents, items, scoring, and
interpretation of these scales were reviewed.
Item collection
Each scale and their items were examined for relevance,
adaptability, and clarity by a multidisciplinary panel of
mental health professionals.
Item categorization
The construct of verbal and nonverbal social skills
as constituents of social competence: a process
consisting of social perception, social cognition, and
behavioral response was utilized to categorize the
items into various domains.[5] This is the construct
currently used in the training module for the social
skills training sessions. Hence, items were categorized
into five domains: (i) nonverbal social skills, (ii) verbal
social skills, (iii) receptive social competence skills,
(iv) processing social competence skills, and (v) expressive
social competence skills [Appendix 1].
Scoring
The protocol for the social skills training sessions
conducted in the unit includes therapist‑guided,
graded role‑plays done by patients within the closed
group (e.g., attending an interview – test situation), in the
therapy hall/ward (e.g., talking to other patients – familiar
life situation), or outside the ward (e.g., supervised
Indian Journal of Psychiatry Volume 62, Issue 2, March-April 2020
visits to shops – unfamiliar life situation). Thus, it was
decided to incorporate these situations into the scoring.
A seven‑point incremental scoring system was formulated
for the assessment with 0 for being not able to perform
the skill, 1 and 2 for being able to perform in test
situations, 3 and 4 for being able to perform in familiar life
situations, and 5 and 6 for being able to perform the skill
in unfamiliar life situations. Anchor points for scoring each
item were also elaborated and added [Appendix 1].
Validation of the scale
Face validity, utility, and feasibility for use were assessed
by piloting the scale among 10 patients, after which
modifications were made in discussion with the expert
panel. The sample size was also decided a priori as 100, based
on calculation from pilot study data.
Study sample
One hundred and fifteen consecutive inpatients with
diagnosis of schizophrenia or bipolar affective disorder
attending the occupational therapy program at the
department of psychiatry aged between 18 and 60 years of
age, who gave written informed consent, were recruited for
the study. Fourteen assessments could not be completed;
hence, the final sample size was 101. Clients with a clinical
diagnosis of moderate to profound intellectual disability,
those with organic mental disorders, those with acute
psychotic presentations, and those with <1‑year duration
of illness were excluded from the study.
Assessment tools used
The following instruments were employed:
• SICSC:[15] This is a 20‑item checklist with a scoring
from 1 to 5, 1 implying inability to perform even with
assistance and 5 implying independent performance.
A total score of <29 implies below par social interaction
skills, and a score of above 90 implies exceptional
social interaction skills. For the purpose of this study,
this scale was chosen to evaluate convergent validity as
it had items representing areas of both social skills and
competence
• General Health Questionnaire (GHQ):[16] This is a
measure of current mental health and has been
extensively used in different settings and different
cultures. The questionnaire was originally developed
as a 60‑item instrument, but at present, a range of
shortened versions of the questionnaire including the
GHQ‑30, the GHQ‑28, the GHQ‑20, and the GHQ‑12 is
available. For the purpose of this study, the GHQ‑12 was
used to evaluate divergent validity
• Brief Psychiatric Rating Scale (BPRS):[17] The BPRS is
a widely used instrument for assessing symptoms
of individuals who have psychiatric disorders. The
BPRS consists of 18 items with scores ranging from
1 (not present) to 7 (extremely severe) and 0 for not
assessed. The BPRS scores, which are rated by the
123
Thamaraiselvi, et al.: Development and validation of Vellore Assessment of Social Performance among clients with chronic mental illness

primary treating psychiatrist and presented during Reliability

weekly case conferences, were documented Table 2 documents the inter‑rater and test–retest
• VASP: The final version of the scale has 20 items reliabilities. All five domains as well as the total scores
under 5 domains, with a scoring ranging from 0 to
6 [Appendix 1]. Table 1: Characteristics of the study population (n=101)
Characteristics Mean (SD) PCC (P) n (%)
Procedure Age (years) 30.00 (8.24)
The details of the study were explained to all participants, Education
and written informed consent was obtained. The Undergraduate 51 (50.2)
VASP was scored by two investigators (TS and PA) Postgraduate 20 (19.8)
independently and simultaneously for evaluating Higher secondary 15 (14.9)
Up to high school 15 (14.9)
inter‑rater reliability. A third investigator (NA) scored Duration of illness (years) 6.74 (4.94)
the participants on the SICSC and GHQ‑12 for evaluating Sex
convergent and divergent validity. The VASP was scored Male 55 (54.5)
again by one investigator (TS) after 2 days to evaluate Female 46 (45.5)
test–retest reliability. The scores of the participants on Diagnosis
Paranoid schizophrenia 90 (90.1)
the BPRS, which is routinely done weekly, were also Bipolar affective disorder 10 (9.9)
documented. Marital status
Unmarried 61 (60.4)
Data analysis Married 40 (39.6)
Summary statistics, mean and standard deviation Employment
Unemployed 78 (77.2)
frequencies and percentages, were used for reporting Employed 23 (22.8)
demographic and clinical characteristics. The correlation Socioeconomic status
between VASP, SICSC, GHQ, and BPRS was evaluated Low 14 (13.9)
using the Pearson’s correlation coefficient. Differences Middle 79 (78.2)
were considered significant at P < 0.05. Inter‑rater and Upper 8 (7.9)
VASP total score (120) 76.63 (26.05)
test–retest reliabilities were evaluated using the intraclass VASP - nonverbal social skills 15.80 (5.04)
correlation coefficient with a 95% confidence interval. All (24)
the statistical analysis was performed using SPSS 18.0 (SPSS VASP - verbal social skills (30) 19.18 (6.70)
Inc., Chicago, Ill., USA). VASP - receptive social 13.48 (3.95)
competence skills (18)
VASP - processing social 10.49 (4.67)
RESULTS competence skills (18)
VASP - expressive social 18.20 (7.85)
One hundred and one participants were recruited for the competence skills (30)
study. The sociodemographic and clinical characteristics SICSC total score (100) 67.70 (16.91)
of the sample are shown in Table 1. The majority of GHQ total score (36) 13.83 (8.04)
Correlation - VASP/SICSC 0.696* (0.001)
the participants were male, young adults, single, with Correlation - VASP/GHQ 0.046 (0.648)
undergraduate education, middle socioeconomic status, Correlation - VASP/BPRS −0.221 (0.026)
and currently unemployed. *Correlation is significant at the 0.01 level (two‑tailed). SICSC – Social Interaction
and Communication Skills Checklist; VASP – Vellore Assessment of Social
Performance; GHQ – General Health Questionnaire; BPRS – Brief Psychiatric
Validity Rating Scale; SD – Standard deviation; PCC – Pearson Correlation Coefficient
Convergent validity
The SICSC was used to measure convergent validity. The
Table 2: Reliability data for all domains of Vellore
correlation between the total scores on the two scales
Assessment of Social Performance
was moderate (Pearson’s correlation coefficient = 0.696;
Domain ICC (95% CI)
P = 0.001), suggesting that these scales seem to assess
Test-retest reliability Inter‑rater reliability
similar constructs. The individual domains of the VASP
could not be correlated as the SICSC is not further divided Nonverbal social skills 0.841 (0.732-0.901) 0.846 (0.781-0.894)
Verbal social skills 0.885 (0.802-0.930) 0.894 (0.847-0.927)
into domains. Receptive social 0.884 (0.787‑0.932) 0.936 (0.907-0.957)
competence skills
Divergent validity Processing social 0.876 (0.771-0.928) 0.946 (0.921-0.963)
The VASP scores were correlated with the GHQ‑12, which competence skills
is a measure of overall mental health. The correlation Expressive social 0.831 (0.746-0.887) 0.894 (0.846-0.927)
competence skills
between the total score of VASP and the total score of VASP total score 0.928 (0.810-0.965) 0.941 (0.914-0.960)
GHQ was low (Pearson’s correlation coefficient = 0.046; VASP – Vellore Assessment of Social Performance; CI – Confidence interval;
P = 0.648), suggesting divergent validity. ICC – Intraclass Correlation Coefficient

124 Indian Journal of Psychiatry Volume 62, Issue 2, March-April 2020

Thamaraiselvi, et al.: Development and validation of Vellore Assessment of Social Performance among clients with chronic mental illness
of VASP recorded high inter‑rater and test–retest
reliabilities.
Correlation with psychopathology
The VASP scores, when correlated with the BPRS scores,
were statistically significant (Pearson’s correlation
coefficient = −0.221; P = 0.026). The negative correlation
between the VASP and BPRS implies that those with higher
psychopathology had lower social performance.
DISCUSSION
Since most chronic mental illnesses begin in early adulthood
or late teenage, the development of age‑appropriate
interpersonal skills is hindered. The cognitive deficits,
psychotic symptoms, and negative symptoms of chronic
mental illnesses also further impair social functioning. The
stigma associated with mental illness further perpetuates
social isolation, unemployment, and lack of community
support, thus initiating a vicious cycle of psychopathology
superimposed on deficits which, in turn, contributes to
social dysfunction. Hence, social dysfunction assessment
and intervention remains an integral part of psychosocial
management in chronic mental illness.
Most available assessments examining social functioning are
in the form of pen‑and‑paper questionnaires with majority
relying on self‑report, while some revert to using peers or
family in proxy. While these have certain advantages, they
nevertheless appear to be inferior to direct assessment of
skills with performance‑based measures. There is also a
discrepancy regarding the definition of social functioning
and subsequently a lack of connection between measures
to a theoretical model.
The VASP addresses these two main drawbacks of currently
available social functioning assessments. The differentiation
of domains into verbal and nonverbal social skills and
receptive, processing, and expressive social competence
skills enables better identification of the extent of deficit
in order to tailor intervention strategies. The scoring
system which differentiates between performance in life
situations and performance in a simulated setting allows
for more accurate competence/performance distinction.
Although the scoring system is time‑consuming and cannot
be done in a single setting, the performance‑based nature
of assessment in contexts which are individually relevant
makes up for this shortcoming. Considering the fact that
the purpose of social functioning assessment is to provide
in‑depth information which can, in turn, be used to
generalize social skills through training, the VASP seems to
meet this requirement.
Limitations
The limitations of the VASP include relatively longer
time taken for assessment, around 45 min, and need for
Indian Journal of Psychiatry Volume 62, Issue 2, March-April 2020
observation in life situations, which might not be practical
in all health‑care settings. Since the VASP was specifically
formulated for a setting with an on‑going social skills
training program where participants were already exposed
to supervised practice in life situations, it was feasible to be
scored. It has only limited utility in busy outpatient settings
and as a screening or diagnostic tool for social functioning.
There was only moderate convergent validity of the VASP
with the SICSC; domain wise convergent validity could
not be assessed as the SICSC does not differentiate social
skills into domains. The lack of convergent validity could
be considered acceptable as the VASP was purposely
developed with a different theoretical construct and
scoring system in comparison to available instruments. The
predictive validity of the VASP in terms of being able to
predict employment needs has also not been looked into
and is a recommendation for further studies. Furthermore,
only preliminary analysis of correlation between VASP and
BPRS was done; future studies can consider assessing the
sensitivity of the VASP to the severity of psychopathology.
CONCLUSION
The VASP was developed to aid in detailed baseline as
well as follow‑up assessment of social skills in the patients
who avail of the psychosocial rehabilitation services of an
inpatient mental health setup. Preliminary data suggest
that VASP seems to be valid and reliable for assessing the
social skills of those with chronic mental illness among the
Indian population. The findings need to be replicated and
revalidated across diverse populations in India.
Acknowledgment
This study was approved by the Institutional Review and
Ethics Board (IRB Min. No. 10899).
Financial support and sponsorship
This study was funded by an internal grant from the
Institutional Review and Ethics Board, Christian Medical
College, Vellore (IRB Min. No.10899).
Conflicts of interest
There are no conflicts of interest.
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APPENDIX

Appendix 1: Vellore Assessment of Social Performance

Instructions:
To be scored by therapist after direct observation of performance in life situations, role‑play simulation scores to be taken
only when real‑life observation is not possible, which will result in a lower score. Gathering information from caregivers is
to be done only to complement information after direct observation of actual performance.

a. Test situation: dyadic as well as group interaction during role‑play situations in the group
b. Familiar life situation: interaction with family, familiar therapists, or patients in the ward
c. Unfamiliar life situation: interaction with unfamiliar people such as shopkeepers and public outside the ward.

Scoring key:
• 0 – Does not exhibit this skill
• 1 – Exhibits this skill inconsistently with prompts in test situations
• 2 – Exhibits this skill consistently without prompts in test situations
• 3 – Exhibits this skill inconsistently with prompts in familiar life situations
• 4 – Exhibits this skill consistently without prompts in familiar life situations
• 5 – Exhibits this skill inconsistently with prompts in unfamiliar life situations
• 6 – Exhibits this skill consistently without prompts in unfamiliar life situations.

Items
I a Nonverbal social skills 0 1 2 3 4 5 6
1 Eye contact
2 Facial expression
3 Gestures
4 Proximity
Ib Verbal social skills
5 Coherence
6 Volume and tone of speech
7 Initiation of conversation
8 Termination of conversation
9 Asking for needs appropriately
II a Receptive social competence skills
10 Follow directions
11 Understand questions
12 Take turns in conversation/activity
II b Processing social competence skills
13 Understand others’ verbal and nonverbal behavior
14 Understand impact of own behavior on others
15 Understand social norms
II c Expressive social competence skills
16 Answer questions
17 Use social routines – thank you, good, sorry
18 Offer help
19 Modify behavior according to feedback
20 Participate in a social situation

Anchor points:
Ia. Nonverbal social skills
1. Ability to maintain eye contact in social situations (e.g., while greeting therapist)
• 0 – Does not maintain eye contact
• 1 – Maintains eye contact inconsistently with prompts in test situations
• 2 – Maintains eye contact consistently with prompts in test situations
• 3 – Maintains eye contact inconsistently with prompts in familiar real‑life situations
• 4 – Maintains eye contact consistently without prompts in familiar real‑life situations
• 5 – Maintains eye contact inconsistently with prompts in unfamiliar real‑life situations
• 6 – Maintains eye contact consistently without prompts in unfamiliar real‑life situations.
2. Ability to change facial expression according to social situation (e.g., smiling at familiar people)

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• 0 – Has blunt affect

• 1 – Affect changes occasionally with prompts in test situations
• 2 – Affect changes consistently with prompts in test situations
• 3 – Affect changes occasionally with prompts in familiar real‑life situations
• 4 – Affect changes consistently without prompts in familiar real‑life situations
• 5 – Affect changes occasionally with prompts in unfamiliar real‑life situations
• 6 – Affect changes consistently without prompts in unfamiliar real‑life situations.
3. Ability to use gestures to complement verbal content in interaction (e.g., waving hands while saying “bye”)
• 0 – Does not make any gestures
• 1 – Gestures present occasionally with prompts in test situations
• 2 – Gestures present consistently with prompts in test situations
• 3 – Gestures present occasionally with prompts in familiar real‑life situations
• 4 – Gestures present consistently without prompts in familiar real‑life situations
• 5 – Gestures present occasionally with prompts in unfamiliar real‑life situations
• 6 – Gestures present consistently without prompts in unfamiliar real‑life situations.
4. Ability to maintain appropriate proximity with others during interaction (e.g., not coming too close when talking)
• 0 – Does not maintain proximity
• 1 – Maintains proximity inconsistently with prompts in test situations
• 2 – Maintains proximity consistently with prompts in test situations
• 3 – Maintains proximity inconsistently with prompts in familiar real‑life situations
• 4 – Maintains proximity consistently without prompts in familiar real‑life situations
• 5 – Maintains proximity inconsistently with prompts in unfamiliar real‑life situations
• 6 – Maintains proximity consistently without prompts in unfamiliar real‑life situations.

I b. Verbal social skills

5. Ability to speak coherently during interaction (e.g., use grammatically correct sentences)
• 0 – Speech is not coherent
• 1 – Occasional coherent speech with prompts in test situations
• 2 – Consistent coherent speech with prompts in test situations
• 3 – Occasional coherent speech with prompts in familiar real‑life situations
• 4 – Consistent coherent speech without prompts in familiar real‑life situations
• 5 – Occasional coherent speech with prompts in unfamiliar real‑life situations
• 6 – Consistent coherent speech without prompts in unfamiliar real‑life situations.
6. Ability to modulate volume and tone of speech as appropriate to situation (e.g., speak softer in dyadic interactions,
louder in group situations)
• 0 – Unable to modulate volume and tone of speech
• 1 – Occasionally modulates speech with prompts in test situations
• 2 – Consistently modulates speech with prompts in test situations
• 3 – Occasionally modulates speech with prompts in familiar real‑life situations
• 4 – Consistently modulates speech without prompts in familiar real‑life situations
• 5 – Occasionally modulates speech with prompts in unfamiliar real‑life situations
• 6 – Consistently modulates speech without prompts in unfamiliar real‑life situations.
7. Ability to appropriately initiate conversation with others (e.g., greet therapist during sessions)
• 0 – Does not initiate conversation
• 1 – Occasionally initiates conversation with prompts in test situations
• 2 – Consistently initiates conversation with prompts in test situations
• 3 – Occasionally initiates conversation with prompts in familiar real‑life situations
• 4 – Consistently initiates conversation without prompts in familiar real‑life situations
• 5 – Occasionally initiates conversation with prompts in unfamiliar real‑life situations
• 6 – Consistently initiates conversation without prompts in unfamiliar real‑life situations.
8. Ability to appropriately terminate conversation with others (e.g., say “goodbye,” “thank you,” before leaving session)
• 0‑ Does not know when/how to terminate conversation
• 1‑ Occasionally terminates conversation with prompts in test situations
• 2‑ Appropriately terminates conversation with prompts in test situations
• 3‑ Occasionally terminates conversation with prompts in familiar real‑life situations
• 4‑ Appropriately terminates conversation without prompts in familiar real‑life situations

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• 5‑ Occasionally terminates conversation with prompts in unfamiliar real‑life situations

• 6‑ Appropriately terminates conversation without prompts in unfamiliar real‑life situations.
9. Ability to ask for needs appropriately in social situations (e.g., ask shopkeeper for items required)
• 0 – Does not ask questions or needs when needed
• 1 – Occasionally asks questions/for help with prompts in test situations
• 2 – Appropriately asks questions/for help with prompts in test situations
• 3 – Occasionally asks questions/for help with prompts in familiar real‑life situations
• 4 – Appropriately asks questions/for help without prompts in familiar real‑life situations
• 5 – Occasionally asks questions/for help with prompts in unfamiliar real‑life situations
• 6 – Appropriately asks questions/for help without prompts in unfamiliar real‑life situations.

II a. Receptive social competence skills

10. Ability to follow directions provided by others (e.g., find things in the shop as directed by shopkeeper)
• 0 – Unable to follow verbal directions or supervision
• 1 – Follows single‑step direction or supervision in test situations
• 2 – Follows multiple‑step directions or supervision in test situations
• 3 – Follows single‑step direction or supervision in familiar real‑life situations
• 4 – Follows multiple‑step directions or supervision in familiar real‑life situations
• 5 – Follows single‑step direction or supervision in unfamiliar real‑life situations
• 6 – Follows multiple‑step directions or supervision in unfamiliar real‑life situations.
11. Ability to understand questions asked by others (e.g., queries by therapist for formal testing)
• 0 – Unable to understand questions
• 1 – Understands closed‑ended questions in test situations
• 2 – Understands open‑ended questions in test situations
• 3 – Understands closed‑ended questions in familiar real‑life situations
• 4 – Understands open‑ended questions in familiar real‑life situations
• 5 – Understands closed‑ended questions in unfamiliar real‑life situations
• 6 – Understands open‑ended questions in unfamiliar real‑life situations.
12. Ability to take turns in conversation/activity (e.g., during group discussions in therapy)
• 0 – Does not take turns
• 1 – Takes turns occasionally with prompts in test situations
• 2 – Takes turns consistently with prompts in test situations
• 3 – Takes turns occasionally with prompts in familiar real‑life situations
• 5 – Takes turns consistently without prompts in familiar real‑life situations
• 6 – Takes turns occasionally without prompts in unfamiliar real‑life situations
• 7 – Takes turns consistently without prompts in unfamiliar real‑life situations.

II b. Processing social competence skills

13. Ability to understand others’ verbal and nonverbal behavior (e.g., when others are interested in on‑going conversation,
they will maintain eye contact)
• 0 – Does not understand others’ behavior
• 1 – Occasionally understands others’ behavior with prompts in test situations
• 2 – Consistently understands others’ behavior with prompts in test situations
• 3 – Occasionally understands others’ behavior with prompts in familiar real‑life situations
• 4 – Consistently understands others’ behavior without prompts in familiar real‑life situations
• 5 – Occasionally understands others’ behavior without prompts in unfamiliar real‑life situations
• 6 – Consistently understands others’ behavior without prompts in unfamiliar real‑life situations.
14. Ability to understand impact of own behavior on others (e.g., others respond more positively when they are treated
with respect)
• 0 – Does not understand impact of own behavior on others
• 1 – Occasionally understands impact of own behavior with prompts in test situations
• 2 – Consistently understands impact of own behavior with prompts in test situations
• 3 – Occasionally understands impact of own behavior with prompts in familiar real‑life situations
• 4 – Consistently understands impact of own behavior without prompts in familiar real‑life situations
• 5 – Occasionally understands impact of own behavior without prompts in unfamiliar real‑life situations
• 6 – Consistently understands impact of own behavior without prompts in unfamiliar real‑life situations.

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15. Ability to understand social norms (e.g., it is not polite to interrupt when two people are talking)
• 0 – Does not understand social norms
• 1 – Occasionally understands social norms with prompts in test situations
• 2 – Consistently understands social norms with prompts in test situations
• 3 – Occasionally understands social norms with prompts in familiar real‑life situations
• 4 – Consistently understands social norms without prompts in familiar real‑life situations
• 5 – Occasionally understands social norms without prompts in unfamiliar real‑life situations
• 6 – Consistently understands social norms without prompts in unfamiliar real‑life situations.

II c. Expressive social competence skills

16. Ability to answer questions adequately in social situations (e.g., answer appropriately to being asked ‘how are you’)
• 0 – Does not answer questions
• 1 – Answers questions occasionally with prompts in test situations
• 2 – Answers questions appropriately with prompts in test situations
• 3 – Answers questions occasionally with prompts in familiar real‑life situations
• 4 – Answers questions appropriately without prompts in familiar real‑life situations
• 5 – Answers questions occasionally without prompts in unfamiliar real‑life situations
• 6 – Answers questions appropriately without prompts in unfamiliar real‑life situations.
17. Ability to use social routines such as “thank you,” “sorry,” “excuse me”
• 0 – Does not use social routines
• 1 – Uses social routines occasionally with prompts in test situations
• 2 – Uses social routines appropriately with prompts in test situations
• 3 – Uses social routines occasionally with prompts in familiar real‑life situations
• 4 – Uses social routines appropriately without prompts in familiar real‑life situations
• 5 – Uses social routines occasionally without prompts in unfamiliar real‑life situations
• 6 – Uses social routines appropriately without prompts in unfamiliar real‑life situations.
18. Ability to offer help to others in need (e.g., offer help to other patients while doing group activities)
• 0 – Does not offer help
• 1 – Offers help occasionally with prompts in test situations
• 2 – Offers help appropriately with prompts in test situations
• 3 – Offers help occasionally with prompts in familiar real‑life situations
• 4 – Offers help appropriately without prompts in familiar real‑life situations
• 5 – Offers help occasionally without prompts in unfamiliar real‑life situations
• 6 – Offers help appropriately without prompts in unfamiliar real‑life situations.
19. Ability to modify own behavior according to feedback provided by others (e.g., changes behavior according to corrective
feedback from therapist in role‑plays)
• 0 – Does not modify behavior
• 1 – Modifies behavior occasionally with prompts in test situations
• 2 – Modifies behavior appropriately with prompts in test situations
• 3 – Modifies behavior occasionally with prompts in familiar real‑life situations
• 4 – Modifies behavior appropriately without prompts in familiar real‑life situations
• 5 – Modifies behavior occasionally without prompts in unfamiliar real‑life situations
• 6 – Modifies behavior appropriately without prompts in unfamiliar real‑life situations.
20. Ability to participate in a social situation (e.g., joins informal chat groups in the ward)
• 0 – Does not participate in social situations
• 1 – Participates occasionally with prompts in therapeutic situations
• 2 – Participates adequately with prompts in therapeutic situations
• 3 – Participates occasionally with prompts in familiar real‑life situations
• 4 – Participates adequately without prompts in familiar real‑life situations
• 5 – Participates occasionally without prompts in unfamiliar real‑life situations
• 6 – Participates adequately without prompts in unfamiliar real‑life situations.

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