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A discussion of inter-rater reliability and content validity of Westphal's decision making inventory (1967), describing developmental processes of adults with developmental delays
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A discussion of inter-rater reliability and content validity of Westphal's decision making inventory (1967), describing developmental processes of adults with developmental delays
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Content
A DISCUSSION OF INTER-RATER RELIABILITY AND CONTENT VALIDITY OF
WESTPHAL’S DECISION MAKING INVENTORY (1967), DESCRIBING
DEVELOPMENTAL PROCESSES OF ADULTS WITH
DEVELOPMENTAL DELAYS
by
Chinna F. Azariah
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(OCCUPATIONAL THERAPY)
December 2006
Copyright 2006 Chinna F. Azariah
ii
TABLE OF CONTENTS
List of Figures iv
Abstract v
CHAPTER I: INTRODUCTION.....................................................................................1
The Problem..............................................................................................2
Statement of the Problem ..........................................................................2
Statement of Purpose.................................................................................2
Assumptions..............................................................................................3
Questions...................................................................................................3
Rationale....................................................................................................4
Importance of the Study ............................................................................4
Definitions of Terms.................................................................................6
Delimitations of the Study.......................................................................10
Limitations of the Study..........................................................................10
CHAPTER II: REVIEW OF THE LITERATURE.........................................................12
Making a Decision ..................................................................................12
Occupational Therapy and the Occupational Behavior Frame of
Reference.................................................................................................15
Psychosocial and Social Variables Which Affect the Adult with
developmental delays Ability to Make Decisions...................................21
a) How Questions are Asked of Persons with Developmental Delays ...21
b) The Effect of Social Reinforcement and/or Rewards and Task
Difficulty on the Adult with Developmental Delays ..............................23
c) Dependency, Personal Identity and Other themes persons with
Developmental Delays Face....................................................................28
d) The Effects of Group Decision Making on the Adult with
Developmental Delays ............................................................................30
Biological Variables Which Affect the Adult with Developmental
Delays Ability to Make Decisions ..........................................................33
a) Central Processing Time in the Adult with Developmental Delays ...33
b) The Effect of IQ and Sex on the Adult with Developmental Delays
Decision Making Process ........................................................................37
Developing the Decision Making Process of Adults with Develop-
Mental Delays using Arts, Crafts, and Other Leisure Occupations
Used as Treatment Media in Occupational Therapy...............................39
iii
Measurement of Adults with Developmental Delays Ability to Make
Decisions .................................................................................................43
a) Validity................................................................................................44
b) Reliability............................................................................................46
Summary and Conclusions......................................................................49
CHAPTER III: METHODOLOGY..................................................................................52
Research Approach: A Descriptive Study...............................................52
Instrumentation........................................................................................53
a) Establishing Content Validity: Instrument Development ...............56
b) Inter-rater Reliability.......................................................................62
A Pilot Study ...........................................................................................63
Methodological Assumptions..................................................................63
Limitations of the study...........................................................................64
Ethical Standards.....................................................................................64
CHAPTER IV: RESULTS: ANALYSIS AND EVALUATION .....................................66
CHAPTER V: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS...........69
Literature Review....................................................................................69
a) Memory Related to Reaction Time .................................................71
b) Motivation.......................................................................................72
c) Mental Age ......................................................................................74
Methodological Results...........................................................................75
Table 1: Categories Comparing Mental Age Matched Adults with
Developmental Delays vs. Control Group ……………………………77
Summary and Conclusions......................................................................78
References ………..………………………………………………………………………79
Appendix A: Letter of Informed Consent..................................................... ................... 84
Appendix B: Questionnaire to Determine the Content Validity of Westphal’s Decision
Making Inventory (1967) ………………………………………………… 87
Appendix C: Decision Making Inventory .........................................................................88
iv
LIST OF FIGURES
Figure 1: Process of Developing Content Validity………………………………………11
Figure 2: Flowchart for Instrument Development……………………………………….57
v
ABSTRACT
This study investigated the decision making process of persons with
developmental delays. Specific assumptions were made after a review of the literature
relating to the decision making process and WDMI Westphal’s Decision Making
Inventory (1967). Several variables effecting an ability to make decisions were revealed
and a conclusion drawn that there are many variables involved in the decision making
process of adults with developmental delays. Westphal’s Decision making Inventory
(1967) was to have been used to observe the decision making process of adults with
developmental delays in a classroom setting using leisure occupations as the medium for
this study. However, because Westphal’s Decision Making Inventory (1967) lacked
acceptable reliability data and had not been tested for validity in the past, instrument
development became necessary. This study used a panel of experts to determine whether
or not Westphal’s Decision Making Inventory (1967) has content validity. The
instrument was found to lack content validity secondary to requiring additional categories
identified by the panel as part of the decision making process. Since Westphal’s
Decision Making Inventory (1967) was found to lack content validity, the study designed
to test for inter-rater reliability was not performed. Finally, suggestions on how to
complete such a study were made as well as suggestions for future research.
1
CHAPTER ONE
INTRODUCTION
Persons with Developmental Delays are sometimes viewed as incompetent and
helpless by teachers, clinician, researchers and others who interact with them. These
professionals often have occasion to ask questions of persons with Developmental
Delays, to test their knowledge, to gather information, or just to converse with them. In
the last decade, legislation emphasis has been placed on persons with Developmental
Delays taking part in decision making which will affect their lives (Nirje, 1972). For
example, adults with Developmental Delays are expected to make some decisions for
themselves, such as where to live, whether or not to continue school, to get married or to
have a family, just to name a few. The ability to make these decisions has become a
mandatory skill in the lives of many persons with Developmental Delays.
In occupational therapy, decision making ability is one of the many skills a patient
is evaluated and treated for through therapist observation of patient task performance or
activity participation. One device for recording such observation is Westphal’s Decision
Making Inventory (1967). Unfortunately, Westphal’s Decision Making Inventory (1967)
used to observe and evaluate decision making behavior is only supported clinically, not
empirically, and therefore it does not have reliability or validity data to support it. Since
adults with Developmental Delays are expected to make some decisions and occupational
therapists evaluate and treat this behavior through clinical measures, this study
investigated the decision making process of persons with Developmental Delays in and
2
attempt to establish validity and reliability data for improvement of one such clinical
observation, specifically Westphal’s Decision Making Inventory (1967).
The Problem
Today in occupational therapy, a clinical measure is being used to evaluate the
ability of a person with a developmental delay to make decisions. This tool is Westphal’s
Decision Making Inventory (1967), which was designed to identify steps in the decision
making process and to provide specific information regarding decision making problems.
However, no attempt has been made to demonstrate the reliability and validity of this
instrument as it is used in occupational therapy. Lack of such documentation cannot be
overlooked because without establishing reliability and validity, there is no way of
knowing whether a clinician is actually measuring decision making or some other
behavior, nor if the measurement represents a stable, reproducible sample of behavior.
Inaccurate measurement may negatively affect training and development of the potential
of the adult with Developmental Delays.
Statement of the Problem
There is a need for an assessment instrument which demonstrates acceptable
validity and reliability data to evaluate the ability of persons with developmental delays
to make decisions.
Statement of Purpose
The purpose of this study is to establish the existence of non-existence of content
validity and inter-rater reliability of Westphal’s Decision Making Inventory (1967) as
3
used in occupational therapy to evaluate adults with Developmental Delays’ ability to
make decisions.
An adjunct purpose was to assess the level of independent decision making ability
of adults with moderate or mild developmental delays enrolled in a human development
course that teaches independent living skills and prevocational skills to high, medium,
and low functioning adults with developmental delays. However, since Westphal’s
Decision Making Inventory (1967) was found not valid, the pilot to test reliability to
assess the level of independent decision making in a selected population of adults with
developmental delays was not tested.
Assumptions
1) The ability to make decisions or problem solve is an indicator of mental health
(Westphal, 1967).
2) Decision making is a learned and conscious act (Westphal, 1967).
3) Decision making variables are identifiable and observable in occupational therapy
arts, crafts, and other leisure occupations (Westphal, 1967).
4) Decision making skills developed in one environment are transferable to other
environments (Westphal, 1967).
Questions
1. What is decision making in adults with developmental delays?
2. Can Westphal’s Decision Making Inventory (1967) be demonstrated to have
content validity.
4
3. Can Westphal’s Decision Making Inventory (1967) be demonstrated to have
inter-rater reliability.
Rationale
The occupational behavior theoretical framework used in occupational therapy
demonstrates an integration of research into clinical program design through the use of
clinical tools (Kielhofner and Takata, 1980). In occupational therapy, many clinical tools
designed by occupational behavior theorists are used to evaluate and treat patients.
However, like most clinical tools, they lack research support demonstrating validity and
reliability. Westphal’s Decision Making Inventory (1967) is one of the tools used in the
clinic without this type of research support. Therefore, this study attempted to establish
content validity and inter-rater reliability to improve Westphal’s Decision Making
Inventory (1967) so that occupational therapists and other professionals can better trust
their findings regarding adults with developmentally delayed decision making processes.
Importance of the study
The occupational behavior frame of reference, using the Model of Human
Occupation (Kielhofner and Burke, 1980a) was chosen to explain the importance of the
decision making process to human function. A more complete presentation of the
concepts and structure supporting this outline is in Chapter Two. Decision making is a
part of the highest of several human subsystems. It is the subsystem which receives
information from all parts of the human system and exerts a controlling influence over
the entire system. Through decision making, individuals can maintain autonomy over
5
their own lives. Such autonomy is necessary for adaptation to environmental challenges.
However, decision making skills are developed in lower subsystems and without those
skills the decision making process cannot occur. To develop skills into habits, decision
making becomes more volitional. If the lower level or simple skills are not practiced
regularly, (i.e. through simple activities of daily living), the higher level decision making
skills (i.e. judgment skills) will be impossible to achieve. For the person with
developmental delays, this means less ability to adapt to environmental demands and
decreased autonomy in making decisions. The measurement and training of deficient
decision making skills may allow more adequate adaptive behavior in adults with
developmental delays. For example, many occupational therapists who work with adults
with developmental delays are in a position to evaluate and train them to become
independent in performance of daily living skills such as self-care (i.e. dressing and
grooming), money management, and pre-vocational skills. In order to apply these skills,
the individual with developmental delays must be able to make decisions and choose
between alternatives in order to function at a higher level of independence.
Since persons with developmental delays are expected to make decisions
regarding activities of daily living in order to live independently, those having difficulty
doing so are forced to live sheltered lives in their communities. In an environment such
as sheltered group homes or board and care facilities, daily decisions are made for them.
This means that adults with developmental delays have little to say about the events that
happen in their daily lives. The result of this type of placement can contribute to a loss of
these individuals’ dignity. In addition to this cost to self concept, one could consider the
yearly state cost of providing supervised room and board for persons with developmental
6
delays as compared to the lesser financial imposition associated with the possibility of
living more independently in their communities. Development of decision making skills
might greatly reduce the personal and economic losses and allow independent function.
Finally, this study’s results could contribute a valid and reliable tool to the field of
occupational therapy as well as to other professions such as social work and psychology
which have occasion to assess conditions developmentally delayed adults best make
decisions for themselves. From this basis, programs could more effectively train
individuals toward independence.
Definition of Terms
The following terms will be defined for use in this study.
Content validity
An estimate of the representativeness of the content of the instrument as a sample of all
possible content. According to Benson and Clark (1982), content validity pertains to
whether the set of items used in an instrument adequately covers the content domain of
interests as well as the set of behaviors implied by the test score. This takes into account
the context in which the items are presented.
7
Decision making
The act or process of formulating and arriving at a conclusion. The decision process is
presented below, with a definition of each component in the decision making process as
presented by Westphal (1967):
1. Setting a goal: A statement of desire to accomplish a task.
2. Recognition of the problem: The obstacle that prevents completion of a
task.
3. Attitude: the readiness to cope with the problem, or the abandonment of
the problem and the goal.
4. Development of the solution:
a. Transforming seeking, which is the act of searching for
information to guide in establishing the solution to the problem.
b. Organization of the information, which is identification of the aids
that exist to accomplish the task, and/or the difficulties that exist in
deterring the accomplishment of the task.
c. Selection of the solution.
5. Results produced: The success or failure of the solution selected.
6. Reworking the problem: Repeating the process if the solution is not
appropriate.
Human Development 912
A class offered at Santa Monica College for adults with mild or moderate retardation who
learn independent living skills and pre-vocational skills in one of three groups.
8
Placement in either the high, medium, or low functioning group is determined on the
basis of each students functional level in independent living and pre-vocational skills.
Independence
A subjective judgment of the extent to which a person is living without the need for
assistance from others (Edgerton, 1967). Independence is defined by Webster (1980) as
the ability to make decisions on your own. According to the American Association on
Mental Deficiency (1977), independence is the ability of individuals to accomplish
successfully those tasks or activities demanded of them by the general community, both
in terms of the critical survival demands for the community and in terms of typical
expectations for specific age groups.
Independent Living Skills
The skill and performance of physical and psychological/emotional self care, work, and
play/leisure occupations to a level of independence appropriate to age, life-space, and
disability. According to the American Occupational Therapy Association (1979), life
space refers to an individual’s cultural background, value orientation, and physical and
social environment.
Inter-rater reliability
The consistency of a measurement or tool accomplished by comparing the score an
individual receives as rated by two or more observers.
9
Mental Retardation (Now referred to as Developmental Delay) is defined as significantly
sub-average general intellectual functioning existing concurrently with deficits in
adaptive behavior, and manifested during the developmental period (American
Association on Mental Deficiency, 1977).
Adaptive behavior refers to the effectiveness with which individuals meet the
standards of personal independence and social responsibility expected of their age and
cultural group.
Sub-average intellectual functioning refers to having an IQ of more than two
standard deviations below the mean on an individually administered IQ test. (Grossman
1977).
Mentally retarded adults (Now referred to as Developmentally delayed adults) are
individuals participating in this study who are classified in the mild (IQ 69 to 55) to
moderate (IQ 54 to 40) range of developmental delay and who are between the ages of 18
to 55. (Grossman, 1977)
Occupation is defined by Kielhofner (1983) as “a behavior which is motivated by
an intrinsic, conscious urge to be effective in the environment in order to enact a
variety of individually interpreted roles that are shaped by cultural tradition and
learned through the process of socialization”. (p. 136).
Pre-vocational skills refers to skill and performance in employment preparation activities
such as: job acquisition skills and performance, organizational and team participatory
skills and performance, work process skills and performance, and work product quality
(American Occupational Therapy Association, 1979).
10
Delimitations of the Study
Delimitations are designed to define the scope and/or boundaries of a population
or a situation to which the results of a study will apply (Fox, 1969). In this study,
attempts were made to find an instrument designed to measure decision making skills. In
searching through references such as the Mental Measurement Yearbook (1972) and
Measurement and Evaluation in Education and Psychology (1973), no tools evaluating
decision making skills were found. For this reason, Westphal’s Decision Making
Inventory (1967) was chosen for this study to evaluate decision making skills in adults
with developmental delays. Unfortunately, Westphal’s Decision Making Inventory
(1967) is not standardized and therefore requires instrument development before this
study can be carried out.
Limitations of the Study
Limitations imply that the findings of the study cannot be generalized beyond the
specific chosen population (Fox, 1969). In this study, the population was limited to
adults with either mild or moderate developmental delays between the ages of 18 and 55.
According to Fox (1969), assumptions are considered with limitations since they
represent any uncontrolled aspects which the researcher considers critical for the research
to make sense. In this study, Westphal’s Decision Making Inventory (1967) was assessed
as an instrument and was found to lack validity data and acceptable reliability data which
could contribute to standardizing Westphal’s Decision Making Inventory (1967) as a
research tool.
This study is limited to exploring the content validity of Westphal’s Decision
Making Inventory (1967) before carrying out a study to establish inter-rater reliability
which could provide documentation of possible differences in the way that persons with
mild versus moderate developmental delays make decisions. The author of this thesis
decided to establish content validity for Westphal’s Decision Making Inventory (1967) as
a first step to begin instrument development toward standardization of such a tool. Please
refer to Figure I below which demonstrates the process of developing content validity for
a tool requiring instrument development.
Hire and Train Item
Writers
Write Pool Items
Develop New
Or Revise
Items
Develop Table of
Specifications
Content
Validation
Phase II Construction
Qualitative
Evaluation
by Judges
Figure I
Benson and Clark, 1982
11
12
CHAPTER TWO
REVIEW OF THE LITERATURE
Making a Decision
According to Westphal (1967), a person makes a decision by receiving a certain
amount of information input. When there are several possible outcomes, or when
uncertainty affects the search for information, a conflict is induced which results in
arousal of the individual or a “need to know” (Westphal, 1967). At this point, a person
will seek information in order to reduce the arousal level to cope with the situation. If no
information is available for problem solving, a person may become frustrated and
abandon the decision making pursuit. On other occasions, a person may set up false
assumptions which delay finding out accurate results.
Corman (1957) found that when a person is provided with guidance, successful
solutions are discovered more frequently than when direction information is given. This
is because the individual fails to recognize the relationship of the structural elements of
the problem and does not transfer specific information to the problem.
Westphal’s Decision Making Inventory (1967) was designed to show that
decision making processes are observable. No attempt was made during Westphal’s
(1967) instrument development stage to establish validity. However, Westphal’s (1967)
study compared a group of psychiatric patients with a control group in an arts and crafts
setting using Westphal’s Decision Making Inventory (1967) to test the internal
consistency of Westphal’s Decision Making Inventory (1967) to see if it was possible to
observe the decision making process. Westphal’s Decision Making Inventory (1967) was
13
found to have between .41 and .97 “reliability” for the control and experimental group
which offered limited confidence in internal consistency because of the wide range in
Pearson “r” values. Finally, evidence to support the validity of Westphal’s Decision
Making Inventory (1967) was lacking.
Decision making has been identified as a problem solving process. This process
has variables that can either promote or hinder the successful follow-through to make a
decision (Westphal, 1967). In Chapter One, the decision making process was defined as
the act or process of formulating a problem and arriving at a conclusion. This process
has six components which are: 1) setting a goal, 2) recognition of the problem, 3)
attitude, 4) development of the solution, 5) results produced, and 6) reworking the
problem (Westphal, 1967) These components were defined to explain the decision
making process. The purpose of this chapter is to provide a general discussion of the
decision making process, to explore the occupational behavior frame of reference and
relate it to the decision making process of adults with developmental delays, and to
examine content validity as a means to develop Westphal’s Decision Making Inventory
(1967) as a research tool.
In recent years, persons with developmental delays have been released from state
hospitals into the community in growing numbers (Kielhofner and Takata, 1980). These
people are now expected to make decisions affecting their lives, indicating a need for
them to problem solve and make decisions independently (Nirje, 1972). However,
persons with developmental delays constitute an often neglected population of
chronically disabled persons who cannot meet societal demands and are therefore in need
of occupational therapy services to aid them in developing their decision making skills.
14
In light of this agreement, a review of the literature concerning persons with
developmental delays decision making process became necessary to identify factors that
hinder the ability to make decisions.
A review of the literature examines several variables identified as part of the
decision making process. These variables are discussed as theories that speculate on why
adults with developmental delays have difficulty making decisions or choices (Brewer
and Nettlebeck, 1979). While all the writers reviewed take a different approach as to
why adults with developmental delays have difficulty making decisions, they all agree
with and start from the premise that adults with developmental delays have difficulty
making decisions.
The literature review begins with an explanation of occupational therapy and the
occupational behavior frame of reference. This section is followed by a discussion of
variables that affect the decision making ability of persons with developmental delays
from a psycho-social and sociological point of view such as: a) how questions are asked
of persons with developmental delays, b) the effect of social reinforcement and/or
rewards and task difficulty on persons with developmental delays, c) dependency,
personal identity and other themes persons with developmental delays face, and d) the
effects of group decision making on the adult with developmental delays. The third
section of the literature review discusses biologically based factors affecting decision
making such as: a) central processing time in the adult with developmental delays, and b)
the effect of IQ and sex of the adult with developmental delays decision making process.
After the above variables are examined, Section Four of the literature review
discusses developing the decision making process of adults with developmental delays
15
using arts, crafts, and other leisure occupations used as treatment media in occupational
therapy. The final section addresses the measurement of adults with developmental
delays ability to make decisions, with a discussion of different types of validity and
reliability including an explanation of why content validity was chosen to represent
validity in this study as well as inter-rater reliability. Chapter Two is concluded with a
summary and conclusions section of the literature review.
Occupational Therapy and the Occupational Behavior Frame of Reference
The purpose of this section is to explore concepts basic to occupational therapy
and occupational behavior as a frame of reference. Occupational therapy is based on the
premise that humans are actively involved in their environment and can influence their
health through this active engagement (Reilly, 1962). According to Reilly (1966, 1974),
health and life satisfaction are derived from the attainment of a basic level of functioning
and a balance in self-maintenance and productive as well as leisure time.
The term “occupation” as used in occupational therapy refers to purposeful
activity which engages the mind, body, time and energy and is culturally meaningful
(Reed and Saunderson, 1980). Hence occupations are daily tasks which are performed by
individuals and approved by society at large. The daily tasks performed provide a
structure to the use of time and are not random. They are organized, purposeful, active
interactions between the individual and the environment.
Another underlying concept in occupational therapy is that of adaptation.
Adaptation is a complex process involving personal and environmental factors by which
a stable relationship between the individual and the environment is maintained (Burke,
1977). Adaptation requires a flexibility which allows a person to learn or enhance skills
16
to meet environmental demands. To acquire skills, or the ability to manipulate the
environment, a person uses the occupations of self-maintenance, productivity and leisure
time (Black, 1976). When these occupations are performed, a person can acquire the
skills necessary to maintain a flexible but stable relationship between the self and the
environment (Reilly, 1966).
Traditionally, occupational therapy has concerned itself with assisting in the
adaptation of the chronically disabled individual (i.e. persons with developmental delays)
by seeking optimal performance of daily tasks within the limitations of the disability.
Also, occupational therapists are well aware of the fact that having a chronic disability
can restrict a person physically, mentally, and socially (Heard, 1977).
One model that addresses these concepts from occupational therapy practice is the
Model of Human Occupation (Kielhofner & Burke, 1980a). This is a conceptual
framework developed from the larger structural frame of occupational behavior, and will
be discussed in order to elaborate on the occupational behavior frame of reference.
The Model of Human Occupation is an open system which is defined as an
organized complex of subsystems that are in dynamic interaction. This model presents a
person as the open system and presents the interaction of the system with the
environment as human occupation (Kielhofner & Burke, 1980a). As a person interacts
with the environment, a process of input, output, throughput and feedback is taking place.
An explanation follows.
Input is the information that comes into the system from the environment.
Without this information the system cannot function. Output consists of the mental,
17
physical, and social aspects of occupation. To produce its output, the system uses its
stock of available information to organize action and predict its consequences.
The concept of feedback refers to information about the consequences of action.
Through feedback, the system is informed about the results of its own output (Kielhofner
& Burke, 1980a).
The human system adapts to the environment through the use of input and
feedback. When this incoming information is organized into the system, the system is
changed, and can produce new output. The output produces new feedback and further
modifies the system. The internal organization process in this flow of information is
throughput. Throughput is the interaction of input and feedback with the internal
structures and functions of the system. It links the other processes of input, output, and
feedback and completes a cycle (Kielhofner & Burke, 1980a).
In the Model of Human Occupation, the above internal parts of an open system
are arranged hierarchically into three subsystems. The highest level governing the other
two subsystems is the volition subsystem. Its structural components are: personal
causation or an individual’s beliefs about the effectiveness of action, valued goals or
those ends to which an individual is willing to commit sustained action; and interests or
the disposition to engage in actions for their own sake and because of the pleasing results
they can achieve. These three component parts of the volition subsystem influence the
lower two subsystems propensity for action (Kielhofner & Burke, 1980a).
The second subsystem is the habituation subsystem. It is structurally made up of
habits and internalized roles. Habits are organized routines of behavior which
incorporate skills into patterns of action that can function automatically without the
18
conscious attention of the actor. Internalized roles refer to the expectations from the
environment for productivity that have been incorporated into the internal makeup of the
system within the habituation subsystem. These internalized roles help individual meet
the demands from the environment for consistent performance (Kielhofner & Burke,
1980a).
The lowest subsystem is the performance subsystem. Its structure consists of
skills—social, cognitive, and/or physical actions—organized to an end. Once the system
is in action, this subsystem serves as a guide to control the quality of action and provides
the system with skill (Kielhofner & Burke, 1980a).
The performance subsystem is critical to the overall adaptation of the system.
Habits and roles can only build routines of behavior from pre-existing skills that are
available to be organized into patterns. The volition subsystem can only enact those
behaviors that the performance subsystem can produce. Hence, the extent to which
individuals have skills in the performance subsystem determines the higher level
subsystem’s output. In turn, the performance subsystem is organized by the higher level
subsystems. By enacting output, the volition subsystem determines which skills will be
learned through exploration and mastery practice (Kielhofner, Burke, & Igi, 1980).
Additionally, the habituation subsystem organizes skills into everyday life
routines and role performance. Skills not used often become obsolete and skills used
frequently become habits. In order for the system to perform, all of the above subsystems
must be providing output (Kielhofner, Burke, & Igi, 1980).
According to Kielhofner (1975), the life affecting decision making process falls
within the highest level subsystem—later defined as the volition subsystem. This
19
subsystem receives information from all parts of the system and the system’s
environment and exerts a controlling influence on the entire system (Kielhofner & Burke,
1980b). Through decision making, an individual maintains autonomy which is necessary
for adaptation (Kielhofner & Burke, 1980a).
Hence, a decision making process would involve, at the lowest level, a choice
between alternatives. The choice guides the output of an activity whereby skilled action
is learned. Then, through repetition of these simple decision making skills, become
organized into habits. Depending upon how well skills are developed into habits and
then internalized roles, the decision making process becomes part of the volition
subsystem. This formulation was in part derived from Kielhofner (1975) and in part the
author’s own synthesis. Therefore, this is an inference about how the Model of Human
Occupation operates regarding the decision making process.
If one considers the difficulty a person with developmental delays has in making
decisions, it becomes apparent that the person is having trouble with a skill that should
have been developed in the performance subsystem. If one does not develop such skills
in this lowest subsystem which serves to guide the quality of an individual’s action, the
overall adaptation of the system is disrupted (Kielhofner & Burke, 1980a). This means
that habits and roles are not developed adequately because they can only build routines of
behavior from preexisting skills developed in the performance subsystem. Additionally,
the volition subsystem only acts behaviors that the performance subsystem can produce
(Kielhofner & Burke, 1980a).
Because of the hierarchical and cyclical nature of the human system, and the
flexibility required for adaptation of an individual in the environment, an inefficient
20
system is the result of poor skill development at the lowest level of the system. This
further results in a lack of development of habits and internalized roles and an inability
for the volitional subsystem’s components to function (Kielhofner & Burke, 1980b). For
instance, a faulty decision making process such as that found in many developmental
delayed adults, means that these individuals are not gaining the skills necessary to make
autonomous decisions at the performance subsystem level of the hierarchy. These faulty
skills are what will later determine independent decision making ability at the volitional
level where individuals freely express beliefs, valued goals and interests about decisions,
in this case, affecting their lives (Kielhofner & Burke, 1980b).
Further, the occupational behavior framework focuses on the balanced activities
of work, rest play and sleep and views a person as a biological, psychological and social
being (Reilly, 1966, 1974). In regard to developmental delayed adults, the3 concept of
work or occupational role must be considered because it allows the occupational therapist
to view the problems of the developmental delayed adult as a role dysfunction, not just a
diagnostic category (Reilly, 1962). It is part of the work of occupational therapy to
select, as part of its content, an interdisciplinary knowledge that interfaces with the
concept of role or work (Reilly, 1966, 1974).
In order for a person to be functioning adequately in their occupational role as a
preschooler, student, worker, homemaker, or retiree, that person must exist as an open
system. In this system, such as the Model of Human Occupation describes, the
component parts are acting together to provide the system or the person with enough
input, throughput, output, and feedback to lead a balanced existence of work, rest, leisure,
and sleep.
21
In summary, the Model of Human Occupation was described as part of a larger
framework known as the occupational behavior. This model demonstrated the
importance of underlying component parts of a system necessary to develop skills into
habits and habits into automatic actions. This is related to the problems some
developmental delayed adults may experience with making decisions on their own.
Psychosocial and Social Variables Which Affect the
Developmentally Delayed Adult’s ability to Make Decisions
How Questions are Asked of Persons with Developmental Delays
Reviewing the literature on this variable revealed that persons with developmental
delays are highly susceptible to one particular form of systematic response bias—
acquiescence or saying “yes” in response to yes/no questions (Rosen, Floor, & Zisfein,
1974). This means developmentally delayed persons may be especially likely to give
biased answers that are influenced by question structure and wording. If these people are
answering questions and making decisions without really giving them thought, can their
answers or decisions really be considered valid? In an attempt to solve this dilemma,
Sigelman, Budd, Spanhel and Schoenrock (1981) examined different formats of
questions, namely yes/no and either/or questions. Yes/no answers were compared to
either/or questions on the same topics in interviews with four samples of developmentally
delayed children and adults. The samples consisted of 52 institutionalized children ages
11-17 years with a mean IQ of 42.08; 58 institutionalized adults with a mean age of 23.3
years and a mean age of 14.03 and a mean IQ of 47.53; and finally, 29 institutionalized
children and adults who, in their interviews a year previously had answered at least one
22
question but fell in the bottom half of their samples in terms of the questions they had
been able to answer (Sigelman, Budd, Spanhel & Schoenrock, 1981).
These four samples were included to assess the generalizability of findings across
diverse segments of the mentally retarded population. In all four samples, two four-
question sets of questions were asked to compare yes/no and either/or questions. One set
had questions like, “Are you usually happy? Are you usually sad? Or, sad or happy?” The
second set, designed to vary format and wording asked” “Are you usually by yourself?
With other people? By yourself or with other people? With other people or by yourself?”
In all interview schedules, alternative questions were randomly ordered and separated by
several unrelated questions.
The authors found that either/or questions yielded answers that were more
consistent from wording to wording. They were also less invalidated by systematic
response bias (automatically saying “yes”) and somewhat more in agreement with
answers given by outside informants such as attendants and parents (Sigelman, Budd,
Spanhel & Schoenrock, 1981). Another study also discovered the importance of a
questions verbal format (Sigelman, Schoenrock, Spanhel, Hromas, Wicker, Budd &
Martin, 1980).
In summary, the results of the study discussed showed that by modifying a
questions format to an either/or design, a developmentally delayed persons understanding
of that question can be enhanced to give a more valid, unbiased answer. Can a person
assume that asking a question in a different, clearer manner will help developmentally
delayed adults decide for themselves? To date, there is no empirical support for this
notion. However, the author of this thesis believes that this is an area that needs to be
23
further investigated. Lastly, the Model of Human Occupation was discussed and related
to the variable in this subsection. Input was identified as the factor in the cycle that can
lead to response bias since questions can be phrased in such a way that the
developmentally delayed adult says “yes” in response to yes/no questions. This response
may not truly be a decision made on the part of the developmentally delayed adult since
the input was leading. Response bias may avoid decision making due to some other
problems.
The Effect of Social Reinforcement and/or Rewards and Task Difficulty on
the Adult with Developmental Delays
This subsection was included in the literature review to take into consideration
intrinsic motivation as one factor that affects the developmentally delayed person’s
ability to make decisions. In addition, social reinforcement was considered as a
motivator for task completion.
Over the last few decades there have been an increasing emphasis on theoretical
formulations that focused on intrinsic motivation (e.g., Deci, 1975; Hunt, 1965). Of these
authors, White’s (1959) model of effectance or competence motivation was used
extensively by other theorists to explain the inherent pleasure, the feeling of efficacy or
satisfaction which individuals derive from cognitive challenge and mastery. These
studies on effectance motivation eventually led to several additional parameters of the
relationship between pleasure and cognitive challenge being investigated including the
use of developmentally delayed subjects as a comparison group to normals (Harter,
1975a; Harter, 1975b; Zigler, 1971).
24
Harter (1975a) found that developmentally delayed children displayed less
effectance motivation than normal children. They examined four components of
effectance motivation: curiosity, variation-seeking, mastery for the sake of competence,
and preference for challenging tasks in normal and mentally age matched
developmentally delayed children. Zigler (1971) believes this is due to the fact that many
developmentally delayed persons have life histories characterized by social deprivation
and failure experience on cognitive tasks in particular. He believes that the
developmentally delayed person’s high need for social reinforcement, lower expectancy
of success and inadequate problem solving style take precedence over affect and
motivation (Zigler, 1971).
Studies such as Zigler’s (1971) and Harter’s (1975a; 1975b) led to an experiment
by Harter in 1977 that examined variables related to intrinsic motivation, social
reinforcement, and task difficulty level on the pleasure derived by normal and
developmentally delayed children from cognitive challenge and mastery.
In Harter’s study (1977), 32 normal first grade children (mental age of 7.7) were
compared with 32 mental age matched developmentally delayed persons. Half of the
subjects in each group were socially reinforced for their successes on puzzles
representing four difficulty levels. The other half performed in an experimenter-absent
condition. The results showed that non-developmentally delayed subjects spontaneously
smiled more than the developmentally delayed subjects in the experimenter-absent
condition. Also, the normal children displayed greater pleasure on the difficult puzzles
than on the easy puzzles, whereas the reverse was true for the developmentally delayed
persons (Harter, 1977).
25
Hence, this study showed that developmentally delayed persons do not experience
the same positive relationship between pleasure derived from mastery of puzzles as do
those without a developmental delay. In fact, Harter (1977) believed that the position of
effectance motivation shifted downward in the motive hierarchy of developmentally
delayed persons as other motives such as fear of failure and need for approval became for
salient.
If one considers the above hypothesis, it seems reasonable to believe that a
developmentally delayed person’s motivation for making independent decisions would be
low. If a person is afraid of failing and feels a need for approval why would that person
attempt to make decisions independently? It seems likely that being a dependent,
helpless person would make a developmentally delayed person feel more secure than
being a more independent one. This idea is discussed in the next subsection on fear of
loss and dependency.
A final point is made about social reinforcement by several researchers who
looked at a way to improve work performance of lower functioning clients in a sheltered
workshop. These investigators believed that giving general work prompts on a fixed
interval schedule, such as “okay guys, let’s get to work”, corrective feedback, i.e. helping
developmentally delayed persons to correct mistakes, providing weekly pay and other
prompts can help to improve work performance of developmentally delayed adults in
sheltered workshops (Martin, Fallotta-Cornick, Johnstone, & Boyos, 1980). Examples
include decreasing distractions, providing initial instructions for a task, and a
reinforcement system for productivity (extra money for more production).
26
These factors did indeed improve work performance up to 150% above baseline
production. However, the author of this thesis would like to point out that in order to
motivate an increase in productivity, the above investigators believed it was necessary to
prompt just about every action that was made in the workshop by the developmentally
delayed persons.
Although helping these people to lead more productive worker roles, the
reinforcements provided also promote dependent behavior, not autonomous behavior, due
to the fact that each step of their daily routine at work was reinforced in one way or
another. This does not in any way mimic actual reinforcements a person would receive in
other environments.
How do the variables discussed above relate to the occupational behavior frame of
reference and relate to occupational therapy? As previously mentioned, the Model of
Human Occupation is hierarchically arranged into three subsystems. These are: the
volition subsystem, the habituation subsystem, and the performance subsystem. The
highest level governing the subsystems is the volition subsystem. It is here that personal
causation, valued goals and interests are developed (Kielhofner & Burke, 1980a).
This author infers that intrinsic motivation is a volitional action requiring the
highest level of decision making and is therefore a part of the volition subsystem.
Although some do not consider motivation to be an action, intrinsic motivation provides
the genesis of the components of the volitional subsystem, in this author's opinion. On
the other hand, social reinforcement is part of the performance subsystem since it is here
that social, cognitive and physical action skills are developed (Kielhofner and Burke,
1980b). Social reinforcement influences how a person’s social skills develop. For
27
example, it was found that the more social reinforcement provided, the more productive
developmentally delayed adults working at a sheltered workshop became (Martin,
Pallotta-Cornick, Johnstone, & Boyos, 1980). Although it promoted the developmentally
delayed persons worker role, it also lead to an increase in dependent behavior which
decreases the skill to make decisions independently.
According to Kielhofner and Burke (1980b), the skills a person acquires in the
performance subsystem are critical to the overall adaptation of an individual. The
performance subsystem serves as a guide to control the quality of action and provides the
human system with skills. Since this is the case, the developmentally delayed person is
not learning the skills necessary to make decisions independently at the volition
subsystem level because dependent behavior is being reinforced to make the
developmentally delayed person perform a task.
Lastly, easier tasks along with more social reinforcement lead to the
developmentally delayed person feeling more secure because easier tasks provide less
fear of failure and more approval from significant others than difficult tasks (Harter,
1977). Unfortunately, this behavior is incorporated into the performance subsystem and
becomes a skill which eventually becomes a part of the habituation system where habits
and internalized roles are developed. These dependent behaviors do not allow the
developmentally delayed adult to make decisions independently and again the
developmentally delayed adult is left without the skills necessary to make decisions.
An occupational therapy program should be addressed at the lowest level
subsystem, the performance subsystem, since it is here that skills are developed and guide
how the rest of the system will operate. Occupational therapy can work with the
28
developmentally delayed person to develop skills into appropriate actions by promoting
the type of behavior that will lead to more functional skills. Westphal’s Decision Making
Inventory (1967) could be used to observe the decision making process as outlined in
Chapter One. The results of the observation could be used to develop a treatment plan by
occupational therapists to increase decision making skills, using tasks or leisure
occupations, in the identified deficit areas. Hence, skills in the performance subsystem
can be properly developed into useful habits and internalized roles in order to make
decisions independently in the volition subsystem.
Can occupational therapy provide the type of social reinforcement that will
increase independence and at the same time decrease fear of loss of dependency? The
author of this thesis believes this is possible for certain reasons. Some environments
provide too much social reinforcement which leads to dependent behavior.
An occupational therapy program could provide an environment to develop
positive aspects of each variable increasing a person with a developmental delay to make
decisions more independently.
Dependency, Personal Identity and Other Themes Persons with Developmental Delays
Face
Many people still believe that developmentally delayed persons and other
handicapped individuals are incapable of leading even partially independent lives
(Empey, 1977). The rationalization for denying these individuals their rights seems to
follow a familiar pattern such as “He’s not capable of self-determination…If he had real
freedom of choice he’d make a mess of his life…He’s like a child” (Empey, 1977,
p.593). Empey believes that this rationalization is due to a deep-rooted fear many people
29
have of becoming disabled themselves or it is because of a misguided feeling of guilt or
responsibility. Whether these are actually unconscious fears of persons with
developmental delays or not, the fact remains that society at large believes that
developmentally delayed persons are incapable of performing most activities of daily
living on their own. These beliefs often can and do interfere with people's everyday
lives. (Empey, 1977). Many of these people had never been given adequate information
about developmental delays and whether marriage, having children, and other major
issues were feasible (Empey, 1977). Empey (1977) also discussed the fact that these
individuals appeared to be afraid to ask about important issues and were also afraid to
hope for a better situation.
The above issues were raised in a group work situation. Empey was a senior
social worker at the time and reported them in a paper published in Social Casework in
1977. She found that the most beneficial part of the group work for the patients was the
therapists’ honest assumption that these people were no different from others. For most
of these individuals, is was the first time anyone had simply expected them to function as
people with growth potential, and live up to that expectation. Also, the social worker felt
that many developmentally delayed persons would welcome the opportunity to express
themselves in a nonstructured group setting (Empey, 1977). As previously mentioned
though, the fear element must be removed from whatever environment these people will
be in to promote independence due to their tendency to depend on staff members and
each other to avoid feelings of loss (Empey, 1977; Zigler, 1971).
This section has described two psychosocial variables that promote dependent
behavior in the developmentally delayed adult. The developmentally delayed adult has a
30
tendency to display dependent behavior because the very idea of independence represents
something unobtainable and threatening (Empey, 1977). In addition, the
developmentally delayed person’s identity is not clearly defined due to factors such as
mental limitations, fear of asking about important issues such as marriage, and moving to
and from different homes. The opportunity to develop a personal identity is lost in the
shuffle along with any chance of making decisions for themselves since the idea in itself
is threatening. In the previous subsection, occupational therapy was discussed as a way
to develop the skills necessary to live a more autonomous lifestyle by developing the
decision making process. The occupational therapy program using leisure occupations
and other tasks could decrease the fear of loss of dependency and encourage the
development of the developmentally delayed adults’ personal identity. Hopefully,
functional skills will be developed to increase the decision making in the
developmentally delayed adult at the volition subsystem level.
The Effects of Group Decision Making on the Adult with Developmental Delays
The previous subsections addressed some psychosocial variables that influence
the developmentally delayed adults’ ability to make decisions. The last variable to be
discussed in this section addresses a social aspect of the developmentally delayed adults’
inability to make effective decisions, namely group decision making. Can group decision
making aid developmentally delayed adults to find solutions to problems and increase
their ability to make decisions more independently?
Earlier in this chapter, it was mentioned that developmentally delayed adults are
now expected to make their own decisions as part of their normalization process (Nirje,
1972). Studies have shown that decisions made by groups of developmentally delayed
31
residents in group homes can be beneficial in teaching them interpersonal skills, self-
assertion, greater social maturity and aid them in their ability to problem solve (Heller,
1978; Nirje, 1972).
Other authors have found that in research with non-developmentally delayed
persons as well as developmentally delayed persons, group decision making has been
shown to be effective as a learning device and as a means of attaining commitment and
improving performance (Tuckman & Lorge, 1962). However, in order to have an
effective group decision in developmentally delayed persons, the nature and difficulty of
the task, and the group decision making process must be taken into account (Heller,
1978). Heller (1978) discussed the fact that although making group decisions in the
group home can be a beneficial learning experience for the residents, the effects are only
temporary. More research needs to be carried out to examine effects of group decision
making in general. Also, no indication was made that developmentally delayed persons
could make autonomous decisions. This was true of several other studies as well
(Bjannes & Butter, 1974; Lewis & Rosenblum, 1975; Wills, 1973).
These findings are encouraging in one sense because they show that
developmentally delayed persons can make decisions as a group. On the other hand, the
data does not indicate that developmentally delayed adults can make decisions on their
own after making decisions within a group. In other words, the ability to make decisions
in a group does not have a transfer effect to independent decision making.
Relating group decision making to the occupational behavior frame of reference
using the Model of Human Occupation (Kielhofner & Burke, 1980a) requires first a look
at input, which gives information to the system about the environment. Social influence,
32
through group members is a large part of the information given to the system. Any
“decisions” made at the throughput level are influenced by the other members of the
group. Feedback is giving information about the response made by the developmentally
delayed adult. So, how can making a decision as a group help the developmentally
delayed adult make decisions more independently? Perhaps in the performance
subsystem, a skill can be developed by making group decisions in order to practice that
task. As the skill becomes a habit, the adult with developmental delays could learn
splinter skills or sub-skills to gradually make decisions more independently. If this
occurs, after starting with just the ability to make decisions as a group, there may be a
chance of developing parts of the volition subsystem such as personal causation, valued
goals and interests.
An occupational therapy program to work with developmentally delayed adults to
begin the task of practicing decision making as a group could be the first step in
increasing independence in decision making. Once this is accomplished, the task of
developing splinter skills (or subskills) could be the next step in enhancing the decision
making process of developmentally delayed adults.
Although the above is entirely speculative, this type of occupational therapy
program exists as a possibility for further research in this area. In summary, group
decision making was examined to explore the idea that developmentally delayed adults
can learn to make decisions more independently after making decisions as a group. This
variable revealed that making decisions as a group member does not mean that
developmentally delayed persons can effectively make decisions on their own. The
Model of Human Occupation was used to identify how group decision making ties into
33
this model and how it can influence a systems output. The author of this thesis then
speculated on possibilities that could be explored in terms of the subsystems of the Model
of Human Occupation and developing an occupational therapy program with groups of
developmentally delayed persons practicing decision making to develop it into a skill.
Biological Variables Which Affect the Developmentally Delayed Adult’s ability to Make
Decisions
Central Processing Time in the Adult with Developmental Delays
Over the last several decades, there has been considerable research activity
directed toward the identification of the particular mechanisms contributing to the
generally slower performance of developmentally delayed persons on various perceptual-
motor tasks (Brewer, 1978; Brewer & Nettlebeck, 1979a; Wade, Newell & Wallace,
1978). These authors and many others believe that certain responses, such as making
decisions, are made more slowly by developmentally delayed persons when compared
with non-developmentally delayed persons because the reaction time or ability of the
person with developmental delays to make response is slower (Brewer & Nettlebeck,
1979b). However, there are other explanations why developmentally delayed person’s
reaction time is slower. Therefore, this subsection presents a number of studies that
attempt to explain this phenomenon.
In 1960, Berkson (1960a, 1960b) conducted several studies in an effort to
establish which particular mechanisms contributing to the speed of reaction time (RT)
were responsible for the slower performance of developmentally delayed persons. In this
series of studies, Berkson examined intelligence and stimulus complexity in a choice
reaction time paradigm, but found no relationship between these two variables.
34
However, the data suggested that the difference in reaction times between
developmentally delayed and non-developmentally delayed persons might be related to
response complexity. In other words, the developmentally delayed subjects gave simpler
answers and required more time to respond. So Berkson (1960c) tested this notion in a
follow up study and found significant results causing him to conclude that a person’s IQ
is more instrumental than differentiating incoming stimuli in terms of slower reaction
time in persons with developmental delays.
This idea was supported by Wade, Newell and Wallace (1978) who conducted a
study to examine decision time and movement time as a function of response complexity
in developmentally delayed persons. These authors document empirical support for the
fact that developmentally delayed persons have slower reaction time and that the lower
the person’s IQ, the slower the reaction time. However, they offered various possible
explanations for why this is the case.
These authors believe that the low-level reaction time could be due to organic effects:
“Because reaction-time is a measurement of the time or the translation of
stimulus information into the initiation of some appropriate response to
environmental demand…Therefore, the central processing capabilities of
retarded persons is limited”. (Wade, Newell & Wallace, 1978, p.135).
These experimenters, after examining motor responses (movement precision and
movement amplitude) and decision times (reaction time) of developmentally delayed and
non-developmentally delayed subjects, found information processing differences between
the two samples (Wade, Newell & Wallace, 1978). This suggests that persons with
developmental delays may not be capable of making decisions independently due to
35
difficulty processing information. The answer to the question of whether or not
developmentally delayed persons can overcome this problem remains to be seen.
In another study, an investigator examined motor components in the choice
reaction time of mildly developmentally delayed adults (Brewer, 1978). This investigator
found that there was a disproportionate increase in reaction time for the developmentally
delayed subjects when the stimuli were separated and the corresponding response
required more inspections. Brewer (1978) concluded from these results that slower
reaction times among developmentally delayed persons are, at least in part, the result of
longer time taken to accumulate information necessary for the dissemination of the
stimulus and the appropriate response (Brewer, 1978). In other words, the investigator
found that an increase in motor complexity led to a decrease in processing/reaction time
in developmentally delayed adults. However, no explanation was offered as to why this
occurred.
In 1979, Brewer and Nettlebeck (1979a) tried to identify factors through article
review that underly slower responses of developmentally delayed persons. These
researchers reviewed Berkson’s (1960a, 1960b, 1960c) work and found that he concluded
that reaction time is slower in developmentally delayed persons due to motor components
responsible for initiating and executing movement rather than factors governing speed of
stimulus identification or response planning. However, they found evidence that
supported a different view (Nettlebeck & Brewer, 1976; Groden, 1969). These articles
argued that tasks used to examine response mechanisms appeared to involve components
of stimulus dissemination and stimulus response translation, which means that central
processing precedes actions. These authors also found that the slower reaction time or
36
decision time could be due to differences in the encoding or selection process during the
initial stages of the reaction time process (Brewer & Nettlebeck, 1979a).
The studies presented in this subsection presented different theories of why
reaction time is slower in persons with developmental delays. They attempted to identify
those mechanisms underlying differences in information processing abilities between
developmentally delayed and non-developmentally delayed persons. However, they
found that because of variations in theoretical emphasis, the experimental methodologies
used by the different researchers were markedly dissimilar. They concluded that research
findings differed due to methodological differences and from different levels of response
complexity involved in the various experimental tasks. A final conclusion they made,
after trying to clarify the factors underlying slower response time in developmentally
delayed persons, was that this issue is not resolved by any means (Brewer & Nettlebeck,
1979a).
Other studies on this topic that were not included in the literature review had
either a) similar designs and conclusions to the above studies, and/or b) were studies
conducted by the same authors using slightly different designs (Baumeister & Kellas,
1968; Brewer, 1978; Brewer & Nettlebeck, 1977; Klapp, 1975; Nettlebeck & Brewer,
1976; Welford, 1971).
In summary, this subsection described one of the simplest forms of decision
making namely, reaction time. A person’s ability to react or respond is related to the
throughput portion of the Model of Human Occupation (Kielhofner & Burke, 1980a).
This is where a decision is made after taking in information from input and feedback
portions of the model. How quickly a person adapts to his or her environment is a
37
product of how well information from input and feedback are interpreted. If a person is
unable to interpret incoming information and the results of an action made, decision
making time is prolonged since the person may not know what to do with the incoming
information. This could be the case with many developmentally delayed adults. How
can developmentally delayed persons develop adequate skills in the performance
subsystem if they are unable to use the information they have to make decisions? The
answer to this question is beyond the scope of this thesis. However, more research on
this topic may one day reveal which factors cause slower decision making in
developmentally delayed adults.
The Effect of IQ and Sex on the Adult with Developmental Delays Decision Making
Process
This section identified two other biological factors that affect the developmentally
delayed adults’ ability to make decisions. In a study on choice-sequence preferences,
Gerjuoy and Winters (1968) found that the response-sequence of normals and
developmentally delayed persons, i.e., perseveration, alternation, or more complex
response patterns, changes as a function of a person’s mental age. These authors also
found that there is an hierarchical pattern of development. First a person perseverates,
then alternation develops and finally the adoption of complex strategy occurs (Gerjuoy &
Winters, 1968). This means that in order to perform more complex tasks, a certain
mental age or IQ is necessary. Among complex tasks is the ability to make decision or
choose independently (Winters, Gerjuoy, & Pullen, 1969).
In a study on choice behavior, Winters, Gerjuoy and Pullen (1969) examined
three groups of normal people and three groups of developmentally delayed persons.
38
There were 20 subjects in each group with mental ages of approximately 3, 5-6, and 8
years (chronological age was not given). Each subject was given a simple binary choice
task on the Wisconsin General Task apparatus under two counterbalanced reinforcement
schedules (reinforced every time or not reinforced). The results showed that subjects
with the lowest mental age perseverated the most, the group with the intermediate mental
age tended to alternate the most and the subjects with the highest mental age adopted
more complex response patterns independent of the reinforcement schedule (Winters,
Gerjuoy & Pullen, 1969). These results further support the notion that in order to
adequately make decisions, a certain mental age is required. A person’s IQ is not the
only influential factor in task performance of course, but it is a very important one to
consider. There is no single underlying factor that has yet explained why
developmentally delayed individuals have difficulty making decisions.
The next variable discussed is a developmentally delayed person’s sex, as an
influential factor on the decision making process. In a study comparing no-choice,
initial-choice and idiosyncratic choice reward strategies in developmentally delayed
persons, Alexander (1974) examined task performance, IQ and sex with subjects matched
on mental age and sex. The results showed that no differences existed in task
performance from the three reward strategies. However, the person’s sex and IQ were
related to performance on the experimental task. Female subjects required fewer trials to
perform on discrimination and perseverance tasks and had a lower proportion of errors on
the discrimination task than male subjects (Alexander, 1974). Although this hypothesis
has limited empirical support, it suggested that females with developmental delays might
have less difficulty making independent decisions than developmentally delayed males.
39
In summary, the biological factors discussed in this section indicated that a certain
mental age is required to make decisions adequately and that although no research
support has been established, developmentally delayed females might be able to make
decisions more effectively than developmentally delayed males. Since these factors are
innate, they provide a baseline from which to start in terms of initiating an occupational
therapy program to begin to develop decision making skills in the performance
subsystem.
Developing the Decision Making Process of Adults with Developmental Delays Using
Arts, Crafts and Other Leisure Occupations Used as Treatment Media in Occupational
Therapy
Certain elements are necessary for an individual to successfully make decisions.
These elements are part of the problem solving process in which factors such as
motivation and choice have been considered integral parts of the problem solving process
(Westphal, 1967). Each of these factors is discussed below.
Motivation has been considered part of the problem solving and decision making
process by several authors (McClelland, 1967; Weiner, 1972; Weiner, 1974; Worchel &
Cooper, 1979). Adler (1959) assumed that an individual, in order to make effective
adjustments and achieve goals, must have strong social interests. He called this concept a
person’s “style of life” which means that each person has a unique way of implementing
goals. This is made meaningful by an interpretation of their own interests, traits and
values (Adler, 1959). Since each person has a different way of achieving goals, each
person also has a different level of motivation (Weiner, 1974).
40
In order to achieve a goal such as arriving at a decision, one must acknowledge
that a problem exists and that there is a need to solve the problem (Weiner, 1974). This is
a difficult process for many developmentally delayed persons (Zetlin & Bilsky, 1980).
To test this theory, Zetlin (1981) studied problem solving in preoperational youngsters
comparing 54 trainable developmentally delayed persons with chronological ages
between 7.9 and 16 years, with normals, ages 3.6 to 7.3 years. A task was given to each
child twice during a single session to examine problem solving performance of the
samples. The results showed that in both groups, some students needed prompting by the
examiner to answer questions. However, the developmentally delayed students needed
more prompting and generated answers more frequently through trial and error than
normal students who were able to generate solutions without trial and error behavior or
prompting (Zetlin, 1981).
These results indicate a difference in the way problems are solved by people with
developmental delays and people with higher IQ's. This may be due to developmentally
delayed person’s inability to arrive at a new idea through the mental reorganization of
previously learned parts of the problem as quickly as normal people (Zetlin, 1981).
However, the fact remains that given the opportunity, developmentally delayed persons
can problem solve and make decisions if they receive prompts and more time to come up
with solutions (Zetlin, 1981).
The choice process involves a person selecting from alternative solutions and
arriving at a decision (Westphal, 1967). For some individuals, being faced with several
alternatives can result in an inability to make a choice (Westphal, 1967). How can people
with developmental delays overcome this dilemma?
41
In order to make a decision, a certain amount of information input is necessary
(Westphal, 1967). When there is a lack of information for problem solving, individuals
may become frustrated and find themselves unable to problem solve. From another view,
the case may be that the person has failed to recognize that the information is present and
therefore does not use this information to problem solve (Westphal, 1967). In either case,
the result is an inability to problem solve. How can developmentally delayed adults
overcome their inability to make decisions?
A possible solution to the above question lies within the field of occupational
therapy. Occupational therapy uses arts, crafts, and/or other leisure occupations as
treatment media to assess, evaluate, and provide therapy for patients with various
physical and mental disabilities (Hopkins & Smith, 1978). According to Westphal
(1967), “the arts and crafts media have the potential as instruments for developing the
elements of decision making in individuals” (p.14). The reason for this assumption
follows.
Arts, crafts and many other leisure occupations use the same tools and machinery
as each other, yet art can be created as a result of inspiration or the unconscious
(Westphal, 1967). However, a craft and some leisure occupations (i.e. puzzle games),
must be planned out first in order to make a meaningful end product. On the basis of the
above description of an art, craft and/or other leisure occupation, it is necessary to
consider an individual’s creativity—or how a person perceives and defines a given
project no matter what type of leisure occupation is performed.
In order to create an art, craft or leisure occupation, a person must be able to make
several decisions in order to initiate the task. For example, if a person wants to paint a
42
free-hand picture, certain tools and supplies are necessary, such as paints, brushes, and
paper. The person must decide on the kind of brush, the color of paints and the type of
paper to be used. Another example is that of putting together a puzzle. Here, a person
must decide where the corners, edges, and center pieces fit in order to complete the
project. Also, a person may have to figure out how to correct problems that arise,
develop solutions, and choose one solution that can solve the dilemma.
If an individual decides on a leisure occupation such as a craft, the above
obstacles become more complex. In a craft, one must set a goal and decide what product
is suitable. When problems arise, a certain solution must be arrived at in order to
maintain the project as a craft. The person must approach the problem with a certain
attitude to solve problems so the craft is not changed. Since a craft has a series of
hierarchical steps to be followed, the person must proceed in a uniform manner to reach
the end product (Westphal, 1967).
This decision making process is complex and similar to many that individuals
encounter in everyday life. The steps a person must follow in order to complete an art,
craft and/or other leisure occupation may be similar to the steps one must take during the
types of tasks encountered at work, school or other settings (Westphal, 1967). Crafts can
offer a highly flexible, easily controlled medium, through which an individual may
explore, practice and develop a wide range of basic physical, perceptual and cognitive
skills (Hopkins & Smith, 1978).
A comparison of motivation, choice and creative aspects of arts, crafts, and/or
other leisure occupations was attempted to illustrate that these factors, when considered
together, are analogous or at least similar to decisions a person makes in various roles at
43
work, school, or in other activities. The author of this thesis assumed that teaching
developmentally delayed adult’s leisure occupations in an occupational therapy clinic,
carries over to other environments. Hence, these individuals can begin to develop skills
in the performance subsystem and develop them into habits to complete the decision
making process. The exposure and opportunity available to developmentally delayed
persons in an occupational therapy program using leisure occupations to develop decision
making skills may carry over to other environments in which the developmentally
delayed adult is expected to have solutions for issues that directly affect their lives.
Measurement of Ability to Make Decisions in Adults with Developmental Delays
This study was designed to use Westphal’s Decision Making Inventory (1967).
This instrument has been used extensively in clinical practice, but not as a research tool
because no attempts have been made to standardize the instrument or to establish
reliability and validity. Hence, this study will attempt to establish inter-rater reliability
and content validity in an effort to make this instrument useful as a research tool and
improve it as a clinical measure.
Westphal’s Decision Making Inventory (1967) is an observational tool designed
to identify faulty decision making skills which may be causing role dysfunction. The
approach used in this study is the descriptive method, designed to systematically describe
a situation or area of interest factually and accurately (Isaac & Michael, 1982). This
method was chosen because the tool used in this study is an observational one designed
to describe a situation or event in a scientific manner. The descriptive approach is
relevant to this study since the investigator will describe and evaluate on the basis of
44
what was observed from the instrument. According to Isaac and Michael (1982), the
descriptive approach is appropriate for a study such as this one.
Validity. This subsection of the paper was included in the instrumentation section
to provide an explanation of the various types of validity and why the author of this thesis
chose content validity to support Westphal’s Decision Making Inventory (1967). The
question of whether Westphal’s Decision Making Inventory (1967) can be demonstrated
to have content validity will be addressed later in this chapter.
Validity is the extent to which a procedure actually measures what it seeks to
measure. This can be accomplished in various ways. A brief discussion is provided to
describe the different types of validity in order to show each type of validity’s strong and
weak areas.
The types of validity discussed are: face validity, construct validity, concurrent
validity, predictive validity, and content validity.
Face validity is considered the weakest procedure because its claim for validity is
based upon a superficial examination of the nature of the instrument, that is, the face of
the instrument (Fox, 1969). The face validity approach tries to defend the fact that the
instrument is valid in an either-or sense by saying that the instrument looks like it is
measuring what it is supposed to measure. However, face validity can be useful under
specific circumstances. For example, if test-retest reliability is going to be used when the
data being sought are relatively fixed and finite, face validity can be useful.
Construct validity is the ability of the instrument to distinguish between groups
known to behave differently on the variable or construct under study. Therefore, in
construct validity, differences between groups are identified. However, the differences
45
are often deliberately extreme and therefore construct validity provides only gross level
measurements. Hence, if fine level measurements are needed, construct validity would
not provide a fully satisfactory method of estimating validity (Fox, 1969).
Concurrent or congruent validity is said to parallel the approaches used to obtain
reliability. In order to achieve concurrent validity, a researcher must present correlational
data to show that performance of the new instrument correlates with performance on
some already existing and accepted measure of the variable under study. The criterion is
only valid when it is of the same family as the new instrument (i.e., validating a new
attitude survey by correlating scores on it with scores on some existing survey of
attitude).
Predictive validity is the most powerful validity because it has the ability to
predict. Investigators using predictive validity argue that they have used data obtained
from the instrument to make predictions about the respondents future behavior. This
requires researchers to wait until sufficient time has elapsed before knowing whether or
not those predictions came true and evaluated the extent to which the researcher was
correct. Data from predictive validity can be presented as a correlation, like concurrent
validity, or on terms of differences, like construct validity. Even though predictive
validity is the ultimate test of validity, it is time consuming and can become very costly.
Finally, content validity, used in this study, is described by Fox (1969) to be the
strongest technique available to a researcher using data gathering procedures such as
questionnaires or interview guides. Westphal’s Decision Making Inventory (1967) is
considered an interview guide since the responses to be rated are stated in a fixed list
(Fox, 1969). Although content validity depends on an either-or judgment, true content
46
validity argues that the instrument measures what it seeks to measure because there was a
rationale, and ideally an empirical basis to the selection of the actual content. Please see
Appendix A for an example of a flowchart demonstrating instrument development for
content validity.
Reliability. To date, Westphal’s Decision Making Inventory (1967) has neither
reliability nor validity data to support it. The preceding subsection attempted to provide
support in terms of content validity. In Chapter 3, an attempt is made to provide support
for content validity using inter-rater reliability with a panel of three experts to comment
on the current content of Westphal’s Decision Making Inventory (1967). This subsection
was designed to provide an overview of the different kinds of reliability as well as to
explain why inter-rater reliability was chosen to demonstrate reliability in this study.
Fox (1969) stated that reliability is “the basic attribute which every procedure
must possess” (p.352) because it represents the accuracy of the data in terms of their
stability, repeatability or precision. The following discussion includes four types of
reliability which are test-retest reliability, alternate form reliability, split-half or odd-even
reliability, and inter-rater reliability.
Test-retest reliability consists of producing the first of two sets of data by
administering the instrument (the “test”). After a period of time, long enough for
forgetting to take place but not so long that change would be expected, the instrument is
administered again to the same people a second time (the “retest”). Thus, this technique
involves administering the same instrument to the same people on two different
occasions. Then the two sets of data are correlated to estimate the reliability of the
instrument (Fox, 1969).
47
The main problem in test-retest reliability is optimizing the delay between the two
administrations to offset a spuriously high effect due to recall, if too short; or spuriously
low effect due to a change in the make up of the subject, if too long (Isaac & Michael,
1982). Therefore, test-retest reliability has been identified to be the most effective only
when estimating the reliability of data analysis procedures because no change is able to
occur and analysis of the same data at two different points in time should produce
identical results.
Test-retest reliability was not vital to this study because the characteristic measured was
accepted as specific to this time and the test circumstance and not predictive of total
decision making ability. Also, a non-parametric statistic known as Spearman’s rank-
order correlation was used to test for degree of correlation between raters (Fox, 1969).
Alternate form reliability involves the successive administration of two parallel
forms of the same test. In terms of testing theory, Isaac and Michael (1982) believe that
this type of reliability is the most desirable index of reliability because it involves two
different representative samples of items. However, many researchers do not use this
procedure because they find it difficult enough to develop one form of an instrument, let
alone two. Also, when using questionnaires, there is sometimes no sensible way of
asking the same or similar questions twice (Fox, 1969).
Split half or odd-even reliability is a substitute for the “alternate forms” approach
to reliability in that it divides the items of a test independently into two equivalent halves.
One problem with split half reliability is the fact that extreme increases in test length
must be made which can introduce boredom and may decrease reliability (Fox, 1969). In
addition, added items or added periods of observation may not confer the same behavior
48
or ability as the original test (Isaac & Michael, 1982). The major advantage of using split
half reliability is that the correlation made between the halves to estimate reliability is
obtained by only one test and one testing session with the subjects.
This brings us to the last type of reliability to be discussed and the one used in this
study which is inter-rater reliability. Inter-rater reliability consists of two or more
observers scoring subjects on the same test at the same time or in the same session. The
rater’s score are compared by correlation to determine how reliable the instrument is.
The question of whether Westphal’s Decision Making Inventory (1967) can be
demonstrated to have inter-rater reliability remains to be seen.
This study can be considered a small study, similar to a pilot study in which a first
attempt was made to establish content validity on Westphal’s Decision Making Inventory
(1967). The advantages of conducting such a study are as follows. A small study can
allow for a preliminary test of hypotheses that can lead to testing more precise hypothesis
in a larger study later on. For example, after an evaluation of the content of a tool, such
as Westphal’s Decision Making Inventory (1967), has been made, the tool can be revised
or new items can be developed to enhance the content validity. The next step could then
be to prepare the tool for the first pilot testing (Benson and Clark, 1982). Statistical
procedures and possible errors can also be checked for through such a procedure. If the
small study or pilot study turns out to be unproductive, a great deal of time and funds can
be saved. Lastly, through a small study, various measurements can be tested out and then
the most productive one can be selected (Isaac & Michael, 1982). In this study,
Westphal’s Decision Making Inventory (1967) was explored to see if decision making is
observable in an arts and crafts setting. According to Benson and Clark (1982), several
49
studies across different populations and across different times are usually necessary to
ensure that the new instrument is valid for all individuals it will be used on. In addition,
validation is considered a continual process, one in which an end point is rarely achieved,
but is only successfully approximated.
Summary and Conclusions
The review of literature in this chapter presented some variables which affect the
developmentally delayed adults’ ability to make decisions. The literature review began
with an introduction to the decision making process and how essential it is today for a
developmentally delayed person to have the skills necessary to make decisions that effect
their lives. An explanation of occupational therapy and the occupational behavior frame
of reference followed to explain some basic concepts in occupational therapy and the
occupational behavior using the Model of Human Occupation as a guide.
The last sections of the literature review discussed psychosocial, social and
biological variables that affect the developmentally delayed adults’ ability to make
decisions. At the end of each of these subsections, occupational therapy and the
occupational behavior frame of reference were related to the variables in terms where
each variable fit into the model of human occupation and prospective occupational
therapy programs that could develop decision making skills. This format was designed to
provide the reader with a biological-psychological-social view of the developmentally
delayed adult since this is a basic premise in occupational therapy and the occupational
behavior frame of reference. In doing so, some of the problems surrounding an inability
for developmentally delayed adults to make effective decisions were identified through
the variables discussed.
50
Section four reviewed literature on the use of arts, crafts, and other leisure
occupations used as treatment media in occupational therapy. Factors such as motivation,
choice and the difference between arts, crafts, and/or other leisure occupations were
considered important parts in the decision making process since a person must be
interested as well as able to select from alternatives to successfully complete a task. The
occupational behavior was briefly touched upon to keep in mind how it related to these
treatment media used in occupational therapy.
Each subsection raised questions, concerns and/or prospects for future research
endeavors that the author of this thesis believed to be important issues to promote a
further understanding of the decision making process of developmentally delayed adults.
Some sections also mentioned how occupational therapy programs could begin to
develop decision making skills in developmentally delayed adults.
This literature review also provided justification for the use of leisure occupations
or arts and crafts used in occupational therapy to develop decision making skills in the
developmentally delayed. Occupational behavior, using the Model of Human Occupation,
with its internal and component parts, provided an explanation of how these parts effect
the human system. It was explained that these parts must work together in order to
provide for a functioning balanced being. Because these parts do not work in harmony in
the developmentally delayed adult, problems exist in their ability to make decisions.
In conclusion, the author of this thesis would like to point out that the variables
discussed are just a few that affect developmentally delayed adults’ decision making
process. In Chapter One, a definition of decision making was provided with six
component parts to explain decision making as a process. Chapter Two did not attempt
51
to give other definitions of decision making. Instead, it provided a review of some
factors that affect the decision making process as defined in Chapter One. These factors
revealed that: 1) many variables affect the developmentally delayed adults’ ability to
make effective decisions; and 2) no one factor, to date, can account for why so many
developmentally delayed adults are unable to make decisions independently.
52
CHAPTER THREE
METHODOLOGY
This chapter analyses the research approach used in this study – the descriptive
method. This is followed by a discussion of the specific descriptive approach – the
observation method. The next section discusses instrumentation with subsections on the
establishment of content validity and inter-rater reliability. An explanation of the pilot
study in which research was to have been carried out is then briefly discussed. Finally,
methodological assumptions are made, limitations of the study which was to have been
carried out are discussed and ethical considerations given.
Research Approach: A Descriptive Study
According to Fox (1969) a descriptive study attempts to describe a particular set
of phenomena in and of themselves. The descriptive study literally describes situations
or events. This research approach does not necessarily seek or explain relationships
make predictions or test hypotheses, nor does it imply or try to explain meanings of
phenomena. In addition, the descriptive approach is appropriate for studies, such as this
one, that intend to describe systematically a situation or area of interest factually and
accurately by way of the observation method (Isaac and Michael, 1982),.
One aspect of the descriptive approach is the observation method (Isaac and
Michael, 1982). Observation involves watching subjects or a research situation in a
natural setting. From these observations, conclusions can be drawn as to what happened
during the research observation (Fox, 1969).
53
According to Westphal (1967), observation is an activity that is carried on in daily
life involving “looking at” an action or event and recording what occurs. It becomes a
scientific technique when it is used in research, when it is planned systematically, when
results are recorded systematically, and when it can be subjected to checks on reliability
and validity.
Using the observation technique, observers are the primary instrument for
perceiving, documenting and interpreting the research situation. Hence, it is a must that
observers know the context or setting they observe as well as their own perceptions and
knowledge of themselves. Also, observers should fully understand how to utilize the
observation technique for the instrument they will be scoring (Westphal, 1967).
Instrumentation
Westphal’s Decision Making Inventory (1967) measures decision making
behavior by the observation method. In this study, observers or raters watch subjects in a
classroom setting and rated their ability to make decisions on each of the six categories of
Westphal’s Decision Making Inventory (1967). These six categories, based on the
decision making process are: 1) setting a goal; 2) recognizing problems; 3) attitude; 4)
developing a solution; 5) results produced; and 6) reworking the problem. The first five
categories are set up in a Likert type scale. A scale is a measuring device in which
symbols or numbers are assigned to an individual’s behaviors. In Westphal’s Decision
Making Inventory (1967), the numbers 1 through 4 are used to indicate an individual’s
possession of a corresponding amount of decision making behavior.
According to Westphal (1967), the scale was developed to reflect the decision
making process which occurs through the integration of the achievement process, the
54
problem solving process and the creative process. Westphal (1967) believed that the
integration of these processes occurred because they incorporate whole individuals by
way of their beliefs, views, desires and needs. The achievement, problem solving, and
creative processes are elements in an individual’s style of life and the statement of
decision. Westphal (1967) states that:
“the decisions to be made in the social living portion of an
individuals life are not unlike the decisions to be made in that
portion of life relating to creativity in regard to intensity and
sincerity” (p. 19).
A desire to meet a goal is the motivational force compelling involvement in the decision
making process. Within occupational therapy, for example, the goal can be set at various
levels of difficulty ranging from selecting a project in the broad category of arts, crafts
and other leisure occupations to performing a specific portion or step of a certain art, craft
and/or other leisure occupation. The above overview of the decision making process was
included to illustrate underlying concepts in the decision making process which
Westphal’s Decision Making Inventory (1967) measures.
A Likert scale was used to score Westphal’s Decision Making Inventory (1967)
which contains a set of items, all of which are considered approximately equal in attitude
or value loading (Isaac and Michael, 1982). The raters respond with varying degrees of
intensity on a scale ranging between extremes such as agree-disagree, like-dislike, or
accept-reject. In the case of Westphal’s Decision Making Inventory (1967), the extremes
are based on behavioral responses to various decision making tasks. For example, the
first category is goal setting, which is the desire to accomplish a task (Westphal, 1967).
The Likert scale for this category ranges from: 1) unable to decide; 2) task is chosen for
55
person; 3) task selected from suggestions; to 4) person selects own goal and acts on own
initiative.
The score of the position responses for each of the separate scales are summed, or
summed and averaged to yield an individual’s decision making score. In Westphal’s
Decision Making Inventory (1967), scores made closer to the beginning of each scale (i.e.
closer to number 1 of each scale) indicated less decision making ability than scores closer
to the other end of each scale (i.e. closer to number 4 of each scale) which indicated more
decision making ability. Thus, if the six items were summed, a score of 10 or less would
indicate little to no decision making and a score of approximately 15 or more would
indicate more ability to make decisions.
According to Isaac and Michael (1982), Likert scales seem to be the most useful
in behavioral research studies such as this one. Westphal’s Decision Making Inventory
(1967) was not designed to determine how much more or less distance each point on the
scales were from each other in terms of exact quantitative units. For this reason, it is
considered weaker than other measurements such as interval measurements which
involve a measure sufficiently precise for one unit of the measure to have the same
quantitative meaning at any point in the scale measurement. However although ordinal
measurement tools such as Westphal’s Decision Making Inventory (1967) are weaker
than some other measurement devices, they are the simplest level to develop and for
many educational, psychological and sociological variables, the most realistic level to
which an investigator can aspire (Fox, 1969).
56
Establishing Content Validity: Instrument Development
In order to begin instrument development, a researcher is required to plan,
develop and validate an instrument (Benson and Clark, 1982). In this study, Westphal’s
Decision Making Inventory (1967) was used as an example of a clinical tool used in
occupational therapy sans validation. Since Westphal’s Decision Making Inventory
(1967) attempted the planning and development of an instrument designed to measure a
person’s decision making capabilities, the next step would be to examine the instruments'
content to see if it is valid or not (Benson and Clark, 1982). To do this, Benson and
Clark’s (1982) Flowchart for Instrument Development was used as a general guideline to
establish the content validity of Westphal’s Decision Making Inventory (1967). Please
refer to Figure I below.
Phase I
Planning
Phase II Construction
(1) (2) (3) (4) (5) (6)
Write Pool Items
Qualita-
tive
Evalua-
tion by
Judges
Develop
New
Or Revise
Items
Content
Validation
Interpret
Open- ended
Comments
Review
Literature
on
Construct
or Variable
of
Interest
Write
Objec-
tives
Select
Item
Format
Hire and Train
Item Writers
Give Open-
ended
Questions to
Target Group
Develop Table
of
Specifications
Identify and
Define Domain
of Test
State Purpose of
Test and Target
Groups
Phase III
Quantitative
Evaluation
Prepare
Instrument
for First Pilot
Testing
First Pilot
Administra-
tion
Debrief
Subjects
Run
Items
Analysis
Calcu-
late
Reliabil-
ity
Revise
Instrument
Prepare for
Second Pilot
Testing
Second
Pilot
Adminis-
tration
Run Item
Analysis
Repeat Steps 9-
10 as Necessary
Begin
Valida-
tion
Admin-
ister for
Valida-
tion Date
Continue
Valida-
tion
Phase IV
Validation
(7) (8) (9) (10) (11) (12) (13)
FIGURE II
57
58
This chart was used as a general guide as it was not the original intent of this
study to focus on instrument development of Westphal’s Decision Making Inventory
(1967). Further explanation follows in Chapters 4 and 5.
To establish content validity for Westphal’s Decision Making Inventory (1967),
phase II or the construction phase of instrument development used by Benson and Clark
(1982) was examined. This phase leads up to another step which requires a qualitative
evaluation by judges to establish content validity. Since Westphal’s Decision Making
Inventory (1967) has already been written and the items on the likert scale planned, a
panel of experts was used to examine the already existing categories of Westphal’s
Decision Making Inventory (1967) to review each item.
The panel consisted of three experts: 1) A registered occupational therapist; 2) A
neuropsychologist; 3) A sociologist. Each in some way is involved with clinical practice
in occupational therapy and all of the members of the panel have a background in
research of the decision making process.
The three members of the “content validity committee”, as this author calls it,
worked at Daniel Freeman Memorial Hospital in Inglewood, California at the time the
committee was held in April of 1984. The purpose of this panel was to communicate
their thoughts to the author of this thesis through a questionnaire to find out whether or
not content validation is possible. If Westphal’s Decision Making Inventory (1967) is not
valid, the panel was to provide suggestions on how to revise the tool in order to perform
the first pilot test to calculate inter-rater reliability of Westphal’s Decision Making
Inventory (1967).
59
In order to begin the test of content validation, each panelist was given a copy of
portions of Westphal’s (1967) original unpublished master’s thesis as presented to the
faculty of the Graduate School at USC in the Department of Occupational Therapy (p. 7-
34) and a copy of Westphal’s Decision Making Inventory (1967). Written authorization
from Westphal is attached (please refer to front page). In addition, the panelists were
given a copy of Westphal’s original bibliography and a questionnaire devised by this
researcher entitled: Questionnaire to Determine the Content Validity of Westphal’s
Decision Making Inventory (1967). Please see Appendix B.
Each panelist was given one month to review their materials and complete the
questionnaire. This researcher contacted each panelist on a weekly basis to provide
answers to any questions that may have arisen. The panelists were instructed to bring
their materials to the validity committee meeting and expect to spend at least 3 hours to
discuss the results of the questionnaire. In addition, the panelists were informed that
future meetings might be necessary to finalize content validity of Westphal’s Decision
Making Inventory (1967) . The meeting was audio tape recorded.
Following is an explanation of Westphal's Content Validity describing what each
category was designed to measure.
Content validity is considered an estimate of the representativeness of the content of
an instrument as a sample of all possible content. Content validity argues that the
instrument measures what it seeks to measure because there was a rationale and a basis to
the selection of the actual content. In the case of Westphal’s Decision Making Inventory
(1967), the basis for the selection of the actual content is explained by each observation
category as follows:
60
1. Setting a Goal is a statement of a desire to accomplish a task. Broad general
goals can be selected with several goals within the activity. The motivational
forces behind a desire to perform a task vary for several reasons, such as the
ultimate use of the project, its artistic value, to acquire skill, as a
preoccupation of the mind, to work with others, and other various motives.
When individuals select the goal, this represents an involvement in the project
proceeding towards an achievement sequence (Westphal, 1967).
2. Recognizing Problems represents the obstacle that prevents completion of
the task. This may be due to a lack of skills, a lack of plan for a course of
action, an inability to start or finish a project, not knowing how to obtain
materials, or knowing when to ask for assistance, and other possibilities. In
order to continue the decision making sequence, the individual must be able
to recognize problems (Westphal, 1967).
3. Attitude is the readiness to cope with the problem, or the abandonment of the
problem and the goal. Abandonment may be revealed by disinterest, fear of
failure, or the recognition of difficulty beyond the level of achievement.
Abandonment can mean a total withdrawal or reduction of the goal to a level
at which achievement is possible.
4. Developing a solution (a) Information seeking—to discover what is not
known about the obstacle. This takes the form of asking questions, reading
information sources, reworking instructions or watching a demonstration.
(b) The information must be organized. This means the information is
weighed according to what will apply in accomplishing the task or what will
61
hinder the completion of the steps. (c) A solution is chosen from the best
possible solutions which are formulated in an order according to the
feasibility of carrying them out. (Westphal, 1967).
5. Results produced is the success or failure of the selected solution. The
results depend on the effectiveness of the solution such as removal of the
obstacle or failure to remove the obstacle. If the obstacle is not removed
successfully, an alternative solution becomes necessary (Westphal, 1967).
6. Reworking the problem means that each phase of the decision making
process should be reworked if a more appropriate solution can be developed
(Westphal, 1967).
These six points represent the areas observed by Westphal’s Decision
Making Inventory (1967). Each point provided a basis for its inclusion in the
decision process. The question of whether Westphal’s Decision Making
Inventory (1967) can be demonstrated to have content validity remains to be
seen.
This section concludes with the purpose of the validity committee. The purpose
of this panel was to communicate its thoughts on Westphal’s Decision Making
Inventory (1967) as a check on its content validity. The panel can make suggestions
for additions and/or deletions but this information will not be included on Westphal’s
Decision Making Inventory (1967). The reason being that this would change
Westphal's Decision Making Inventory's (1967) original purpose which was to
present decision making in six components identified by Westphal as part of the
decision making process. It is not the intent of this study to create another tool.
62
Instead, the panel was designed to provide input and feedback which will be included
in Chapter 4 as a discussion on the current content of Westphal’s Decision Making
Inventory (1967).
Inter-rater Reliability
In this study, having three or more raters observe the subjects in one session with
one test instrument would have a major advantage because of limitations in the
availability of the sample subjects. Briefly, the sample would have consisted of 20
adults with either mild or moderate developmental delays in human development
class learning independent living and pre-vocational skills. Several raters observing
and rating the class’s decision making processes using Westphal’s Decision Making
Inventory (1967) in a single session would have decreased the amount of class time
subjects used to participate in the study compared to what would have been needed
for repeated measures in the study compared to what would have been needed for
repeated measures in test-retest reliability.
Besides being an efficient means of obtaining data, another advantage of inter-
rater reliability is that several raters, aside from the investigator, would have rated
subjects’ scores. This can decrease the likelihood of bias on the part of the researcher
affecting the outcome of the study.
In this study, Inter-rater reliability was not achievable because reliability can only
be calculated after some type of validity (i.e. content validity) has been established.
The instrument has to adequately reflect the process and content dimensions of the
specific objectives of an instrument as determined by expert opinion (Benson and
Clark, 1982). Also, since an acceptable level was not established for Westphal’s
63
Decision Making Inventory (1967), further instrument development must be carried
out to bring the instrument to a point where reliability can be attempted.
A Pilot Study
This study was to have been a pilot study. The main reason for this strategy was
that there is no existing normative data with which to compare the research sample.
The other reason is that Westphal’s Decision Making Inventory (1967) has not been
standardized or used as a research tool. Therefore, no data are available on the
instrument’s validity and only internal consistency explored for reliability with non-
significant results by today’s standards.
A pilot study has several advantages. It can provide a trial run of the data
collection approach. It can test out the data collection method of an instrument to see
if revisions are necessary. It can be used to see if the instrument is at the appropriate
level for the sample, and in this study, this would have been an important advantage
considering the target population would have been adults with developmental delays.
Finally, a pilot study can help to increase the researcher’s experience in working with
the subjects of the research, as well as administering the data collection instrument
and analyzing the research data (Fox, 1969).
Methodological Assumptions
7. Problem solving is a conscious function, a learned activity, and an observable
behavior.
8. Occupational Therapy, using leisure occupations, allows for legitimate decision
making on the part of the client.
9. Panel is capable, qualified group of medical professionals.
64
10. Information provided and methodology are adequate to ascertain validity.
Limitations of the Study
Arts, crafts, and/or other leisure occupations do not always easily identify the
decision making process. For example, a client may already be familiar with a certain
craft and perform the task from memory by rote. Hence, the client may not actually
be making decisions to proceed through the steps of a given task.
Ethical Standards
It is the responsibility of the researcher to treat subjects in the sample as human
beings. This means that each respondent is told the purpose of the research, the
nature of the instrument and the research conditions prior to data collection as
extensively as possible. For instance, in this study, students were to have been
observed knowingly on a leisure occupation of their choice to assess their decision
making ability. If the respondents would have chosen not to be a part of the research
just described, they have the right to refuse to be a part of this study (Fox, 1969).
In conjunction with the above, each student was to have been required to sign an
informed consent in order to participate in this study. If subjects would have chosen
not to sign an informed consent, this would have reflected their decision and right not
to participate in this study.
The researcher is responsible for making sure subjects do not experience
unpleasant effects due to administering the instrument. The respondents are entitled
to have their confidence respected. A last ethical consideration in this study would
have been that the research situation permits the subjects to profit maximally from
participation in this study (Fox, 1969).
65
This chapter explained the methodology used in this study by defining the type of
research approach which would have been used, namely the descriptive and
observation methods. Instrumentation was then described with subsections on content
validity and inter-rater reliability. This was followed by a discussion of why a pilot
study would have been beneficial for this type of research project since the instrument
lacked normative data in terms of content validity and inter-rater reliability. A
discussion of the panel of experts who examined the content validity of Westphal’s
Decision Making Inventory (1967) was described.
Finally, methodological assumptions were made, limitations of the study revealed
and ethical considerations were discussed emphasizing the rights of the subjects in
any study and the importance of each subject signing an informed consent. Also, the
responsibility of researchers to ensure that no unpleasant effects are experienced due
to data collection of the study was discussed.
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CHAPTER FOUR
RESULTS: ANALYSIS AND EVALUATION
This study set out to show the need for a decision making tool, namely
Westphal’s Decision Making Inventory (1967), that could demonstrate validity and
reliability when used to observe the decision making process of adults with
developmental delays in an arts and crafts setting. Returning to the original research
questions posed in Chapter I, an analysis of the results of each research questions will be
discussed.
In response to research question number one which asks: What is decision making
in adults with developmental delays? The answer is not clear because many variables
affect a person with developmental delays’ ability to make decisions. In Chapter Two, a
number of these variables were discussed and an attempt made to demonstrate how each
factor effects the decision making process of adults with developmental delays. The
conclusion drawn was that no one factor can account for a given decision making process
used by adults with developmental delays. To date, all factors affecting this process have
not been identified indicating the need for further research to complete the task of
identifying what decision making involves in the person with developmental delays. A
more complete discussion follows in Chapter Five.
The second research question asked: Can Westphal’s Decision Making Inventory
(1967) be demonstrated to have content validity? This question was addressed through
the use of a panel of experts composed of an occupational therapist, a psychologist, and a
sociologist familiar with the decision making process. Following the procedure described
67
in Chapter Three, the panelists responded to a questionnaire (please refer to Appendix A)
developed by this author. These questions will now be addressed.
The three members of the “content validity committee” found Westphal’s
Decision Making Inventory (1967) not valid when addressing question number one: “Do
the categories of Westphal’s Decision Making Inventory (1967) provide a complete
definition of decision making”? The panelists felt that the decision making categories
were incomplete. For example, memory, motivation, mental age versus IQ, reaction
time, and distractibility were cited as other factors involved in the decision making
process. The author of this thesis realizes that it is improbably that all factors associated
with the decision making process can be identified at this time. However, the factors
listed above appeared in the decision making literature and therefore the most frequently
found factors will be described in a brief literature review in Chapter Five. This literature
review which describes memory related to reaction time, motivation, and mental age also
provides a discussion of how these factors and others addressed in this thesis tie in with
the decision making process.
How did the panelists then answer question number two which asks: “Which
categories of Westphal’s Decision Making Inventory (1967) do not fit a definition of
decision making”? The members of the content validity committee did not dispute the
fact that goal setting, problem recognition, attitude and problem solving action are a part
of decision making. However, they declined to state how they actually fit a definition of
decision making.
The last question the panelists partially chose to answer was question 1A which
asks: “What categories could be added to Westphal’s Decision Making Inventory (1967)
68
to provide a more complete definition of decision making”? After a lengthy discussion,
only three additional factors were agreed upon namely memory, motivation and mental
age.
The panelists declined to answer the remaining questions regarding the content of
Westphal’s Decision Making Inventory (1967) because of a general feeling amongst the
panel that Westphal’s Decision Making Inventory (1967) requires instrument
development before an attempt can again be made to assess content validity or to attempt
a pilot study to begin reliability testing.
Finally, the third research question asks: Can Westphal’s Decision Making
Inventory (1967) demonstrate inter-rater reliability”? The answer is “no”, because
content validity must be upgraded and Westphal’s Decision Making Inventory (1967)
further developed as an instrument before a pilot study can be carried out.
In summary, this chapter provided the available data using a questionnaire
presented to a panel of experts to determine the content validity of Westphal’s Decision
Making Inventory (1967). Note: this panel reviewed pages 7-34 of Westphal's (1967)
Thesis as a reference.
69
CHAPTER FIVE
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Literature Review
This thesis was designed to describe the decision making process of adults with
developmental delays. To accomplish this, Westphal’s Decision Making Inventory
(1967), a frequently used tool in the occupational therapy clinic, was chosen to observe
the decision making ability of a group of adults with mild or moderate developmental
delays enrolled in an independent living skills-human development course at Santa
Monica College. These students were to have been observed during a regularly
scheduled class time using Westphal’s Decision Making Inventory (1967) on various
arts/crafts or other leisure occupations. However, before this study was to have been
carried out, Westphal’s Decision Making Inventory (1967) required instrument
development because it lacked validity and reliability data to support it as a research tool.
In Chapter One, the problem of lacking a standardized tool to assess decision
making was discussed and an introduction to the decision making process was made. In
addition, the need for a valid and reliable tool to assess decision making and why the
decision making process is important to human function was described.
Also included in Chapter One was a list of the definition of terms important to
this study. Chapter One was concluded by an explanation of the limitations and
delimitations pertaining to this study. For example, Westphal’s Decision Making
Inventory (1967) has been found to lack normative data (i.e. content validity and inter-
rater reliability). In this study, content validity and inter-rater reliability were chosen to
begin instrument development toward standardizing Westphal’s Decision Making
70
Inventory (1967) after careful examination of Benson and Clark’s (1982) Flowchart for
Instrument Development. Please refer to Figure 1.
Chapter Two provided a literature review which focused on the decision making
processes that adults with developmental delays may utilize. To relate this discussion to
occupational therapy, the initial discussion pertained to occupational therapy and the
occupational behavior Frame of Reference. The intention was to provide the reader with
basic concepts used in the field of occupational therapy and the occupational behavior
frame of reference. The literature review then focused on four sections related to
psychosocial and social variables affecting an adult with developmental delays’ decision
making process. A different focus was then made on two sections related to biological
variables which affect an adult with developmental delays’ ability to make decisions.
The use of arts, crafts and other leisure occupations was then described to show
how this treatment medium used in occupational therapy can develop the decision
making process in adults with developmental delays. Finally, one of the most important
portions of the literature review explained how adults with developmental delays’
decision making abilities can be measured using Westphal’s Decision Making Inventory
(1967). However, since Westphal’s Decision Making Inventory (1967) required
standardization, the types of validity and reliability available were discussed. A choice
was made using Benson and Clark’s Flowchart for Instrument Development (1982) to
begin instrument development of Westphal’s Decision Making Inventory (1967).
Since content validity, or step 5 in phase II of Benson and Clark’s (1982)
flowchart precedes reliability described in step 7 and 8 of phase III, methodology as
described in Chapter Three focused on developing content validity. This was done
71
through the use of a questionnaire devised by this author to be answered by a panel of
experts from the fields of occupational therapy, neuropsychology, and sociology familiar
with the decision making process.
The results of the questionnaire and meeting with the content validity committee
revealed the need for Westphal’s Decision Making Inventory (1967) to be further
developed as an instrument before a test of reliability could be performed. Why did the
panel of experts chosen to examine the content of Westphal’s Decision Making Inventory
(1967) decide not to fully answer the questionnaire given to them by this author? One
reason was because the panel felt that the decision making categories were incomplete.
They felt that at least three other factors play a part in the decision making process. The
factors identified as most important were: memory related to reaction time, motivation,
and a persons mental age. These factors were found intermittently throughout the
decision making literature and will now be discussed in a brief literature review.
Memory related to reaction time. Upon reviewing the decision making literature
for memory, reaction time was primarily discussed. This literature review produced the
same or similar references as used in Chapter Two of this thesis during the discussion of
central processing time of the adult with developmental delays. In one way or another,
central processing time or reaction time was described as one of the simplest forms of
decision making. The literature basically revealed that if a person is unable to interpret
incoming information and the results of an action made, decision making time is
prolonged. This is due to the fact that the person may not know what to do with the
incoming information (Brewer and Nettlebeck, 1979a and 1979b; Wade, Newell and
72
Wallace, 1978; Berkson, 1960a, 1960b, and 1960c; Brewer, 1978; Nettlebeck and
Brewer, 1976; Groden, 1969; Yuker, 1955).
Motivation. Although Westphal (1967) did not identify motivation as one of the
categories of Westphal’s Decision Making Inventory (1967), she did include a brief
discussion of motivation as it related to the problem solving process. However, the
panelists of the validity committee reviewing Westphal’s Decision Making Inventory
(1967) on the basis of content felt that a category on motivation should be included to
take into account that a persons state of intrinsic and/or extrinsic motivation affects one’s
own ability to make many types of decisions. For instance, Chapter Two devoted a
subsection of the literature review to intrinsic motivation. The subsection was entitled:
The Effect of Social reinforcement and/or Rewards and Task Difficulty on the Adult with
MR. The literature review took into account both intrinsic motivation (e.g., Deci, 1975;
Hunt, 1965; White, 1959) and social reinforcement as a motivator for task completion
(Harter, 1975a, 1975b; Zigler, 1971).
In 1971, Harter conducted a study to test the hypothesis that maximum
gratification will be experienced when a child successfully completes tasks which are
challenging at an optimal level. The eleven year old children in this study were given an
anagram task in which letters had to be rearranged to make a word. The anagrams varied
in their degree of difficulty from extremely easy to relatively challenging. Pleasure was
measured by smiling responses made by the subjects. Harter (1971) found that there was
greater smiling and enjoyment for correct versus incorrect anagrams. This study supports
general findings that children derive pleasure from cognitive mastery on problem solving
tasks. For the purpose of this thesis, the most important finding in Harter’s (1971) study
73
was that the greatest gratification was derived from the solution of the most challenging
problems, and little pleasure from easily solved tasks. The children were more
intrinsically motivated to solve the more challenging tasks.
For persons with developmental delays, effectance motivation is often lower than
for other persons. For example, Zigler (1971) examined four components of effectance
motivation of mental age matched normal children with children with developmental
delays on curiosity, variation seeking, mastery for the sake of competence, and
preference for challenging tasks. For each component, the children with developmental
delays demonstrated less effectance motivation than did the normal children. Zigler
(1971) believes this may be due to the fact that children with developmental delays have
life histories characterized by social deprivation and failure experiences on cognitive
tasks in particular. Zigler (1971) continues on to say that persons with developmental
delays have a higher need for social reinforcement, lower expectancy of success and an
outer-directed style of problem solving which takes precedence over effectance
motivation.
What does this mean for a person with developmental delays? According to
Harter (1974) and Zigler (1971), children with developmentally delayed have a different
motive hierarchy than non-developmentally delayed children. This could explain why
persons with developmental delays have greater difficulty making decisions. Since
motivation for task completion is lowered by obstacles such as a lower expectancy for
success, or a greater need for social reinforcement, motivation to make decisions or
problem solve is negatively effected. In conclusion, a variable such as motivation should
74
not be overlooked as an important part of the decision making process if one takes into
consideration the above data.
Mental Age. The final factor to be discussed is mental age. The members of the
content validity committee believe that assessing a person on the basis of their IQ is not
as significant as mental age for an information processing task such as decision making.
In fact, Morelan (1980) found that when a group of developmentally delayed and non-
developmentally delayed children were tested in information processing performance
tasks to examine the relationship between IQ, mental age, and task complexity, an
interaction between mental age and task complexity showed significant results. This
means that mental age, not IQ, plays an important part in information processing such as
decision making.
Can a person with developmental delays learn to make decisions in an
occupational therapy setting? Evidence indicates that given a certain mental age, a person
with developmental delays can learn to make decisions which can enhance his or her
lifestyle. In a study performed at Brigham Young University as a dissertation project,
Harris (1975) found that when 66 institutionalized persons with developmental delays,
whose mean mental age was six, were placed in three chronological age groups,
subjected to different types of training in moral judgment, the persons with
developmentally delayed over 30 years of age were able to make better moral judgments
after training. The study also found that older subjects made better moral judgments
before training than the two younger groups. However, after additional training, the two
younger groups’ ability to make moral decisions improved to a level comparable to that
of the older subjects.
75
In summary, this brief literature review was included in Chapter Five to reveal
two important variables involved in the decision making process, namely memory and
motivation. The third variable pertaining to the decision making process of adults with
developmental delays was included to bring forward the importance of examining mental
age instead of IQ as an index when evaluating persons with developmental delays on
decision making processes. This is an important consideration for this study since it was
designed to assess adults with either mild or moderate developmental delays on their
decision making processes using Westphal’s Decision Making Inventory (1967).
Methodological Results
At this time, the methodological results of Chapter Four will be addressed to
reveal positive and negative findings for this study. To begin this discussion, we return
to the first research question: “What is decision making in adults with developmental
delays”? The answer found in this study is that many variables play a part in the decision
making process of people with developmental delays. Factors such as memory,
motivation and mental age appeared in the literature review in relation to the decision
making process used by adults with developmental delays. These factors were also
identified by the panel of experts examining the content of Westphal’s Decision Making
Inventory (1967) as important categories that could be added to Westphal’s Decision
Making Inventory (1967) to further develop it as a research tool to increase its credibility
before testing for reliability. The author of this thesis also found memory related to
reaction time, and motivation to be variables associated with the decision making process
used by adults with developmental delays.
76
What about mental age? This factor was brought forward by the members of the
content validity committee because the panelists believed that mental age, and not IQ is
the factor associated with information processing when making decisions. The panel also
felt that in this study, IQs could not be compared because the sample which was to have
been used is a subpopulation with no control data with which to compare scores. In
addition to this, the IQs of the students were not available as was originally thought. It
would have been more practical to compare mental age matched groups of adults with
developmental delays to a control group to observe and assess the decision making
process similar to Harris’s (1975) study especially since mental age is a prevalent factor
in the decision making literature. The panel felt that instead of comparing adults with
mild versus moderate developmental delays, a mentally age matched group could have
been compared to a control group on decision making capabilities on this basis of mental
age as well as all the other factors identified as part of the decision making process.
However, this type of study would require instrument development, further research and
planning to develop Westphal’s Decision Making Inventory (1967) as a research tool.
Such measures are beyond the scope of this thesis, but present realistic and feasible
possibilities for students looking for a practical project that has a foundation laid for
instrument development.
At this point, one might ask why Westphal (1967) did not include some of the
factors identified in this thesis as part of the decision making process. There are two
possibilities. One is the fact that 20 years ago when Westphal (1967) was gathering data
for her literature review, many of the studies that identified variables such as mental age
versus IQ, memory and reaction time, and others had not yet been researched. Also,
77
Westphal’s Decision Making Inventory (1967) was designed to observe decision making
processes in an arts and crafts setting on a psychiatric population versus a control group.
A most important question at this time is whether the categories identified in this
study on the decision making process could produce significant results if a comparison
was made of mentally age matched adults with developmental delays to a control group.
A proposed method would be to use a grid design which would produce a matrix of data
such as in Table I below:
Chronological Age > 18
MA 5 MA 6 MA 7 Control Group
Memory/RT
Motivation
(intrinsic)
Motivation
(extrinsic)
Problem Rec.
P.S. Action
Goal Setting
TABLE I
The above table could provide a neat, well documented and researched group of
data. Whether these factors would be enough to identify a decision making process
cannot be answered until such research is carried out. This particular idea is beyond the
scope of this thesis. However, small future studies could examine a few of the above
78
factors at a time (i.e. memory and motivation comparing mentally age matched adults vs.
a control group) and then put the data together to produce a large matrix. An example of
such a grid is Susan Knox’s “Play Scale” as shown revised in Benson and Clark’s
(19820) article on instrument development.
Summary and Conclusions
In summary, it is time for tools such as Westphal’s Decision Making Inventory
(1967) to be revised and developed into research tools. If the original purpose of this
thesis had not been to compare adults with either mild or moderate developmental delays
using Westphal’s Decision Making Inventory (1967), the focus would have been to solely
develop Westphal’s Decision Making Inventory (1967) as a research tool. Westphal’s
Decision Making Inventory (1967) has a great deal of potential for revision. The
revisions would involve adding categories such as memory, reaction time, mental age and
motivation to broaden the scope of the instrument so as to prepare it for reliability testing
in other studies.
In conclusion, this author believes that the next step for a research project such as
this is to use a guideline for instrument development such as Benson and Clark’s (1982)
Flowchart for Instrument Development. Since these future steps are beyond the scope of
this thesis, perhaps new students entering the field of occupational therapy at the master’s
level would consider continuing a colleague’s research to enhance and enrich the field of
occupational therapists credibility in the allied health profession.
79
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Zigler, E. The retarded child as a whole person. In H.E. Adams & W.K. Boardman
(Eds.), Advances in experimental clinical psychology. New York: Pergamon Press,
1971.
84
APPENDIX A
Letter of Informed Consent
Project Title: A Comparison of Mild and Moderately Retarded Adults’ Decision Making
Processes
Investigator’s Name: Chinna F. Azariah
Investigator’s Phone Number: (213) 932-8212
Subject’s Name: Date:
Purpose:
The purpose of this study is to find out if mentally retarded adults can make
decisions independently or on their own. This information will help occupational
therapists in choosing activities to use in treatment that may improve decision making
ability in mentally retarded clients.
Procedure:
The procedure for this study involves using 10 mildly retarded adults and 10
moderately retarded adults enrolled in a Santa Monica College human development class.
These students will be observed by the investigator as well as four other raters who will
rate their decision making skills using Westphal’s Decision Making Inventory (1967).
You will be observed by the investigator and the raters while you work on a task
that you have selected from several choices during your regularly scheduled Human
Development 912 class at Santa Monica College.
Experimental procedure:
Since the setting is your regularly scheduled Human Development 912 class, the
only experimental procedure is that you are being observed for approximately 30-45
minutes during one class time.
Risks:
I understand that there are no risks to me as a result of my participation in this
study. The meeting will be made at my convenience while I am at school during regular
class time hours. The information from this study will be used to improve independent
85
decision making skills in mentally retarded adults. In addition, the information will be
used to determine the reliability and validity of Westphal’s Decision Making Inventory
(1967).
Benefits to the subject:
You will receive no direct benefits from this study.
Confidentiality:
The results of this research may be published for the information of other
physicians and scientists, however, your identity will remain anonymous. Your
laboratory tests, photographs, videotapes, and x-rays, if any, may be published.
However, your name will not be given without your consent, unless required by law.
Research Review, Voluntary Participation and Offer to Answer Questions:
A committee of medical and non-medical people periodically reviews and
approves this research for scientific and ethical merit. You will be told of any new
information which may affect your willingness to continue in this research. Your refusal
to participate in the project will in no way involve penalty or loss of benefits to which
you are otherwise entitled. Your participation is strictly voluntary. You may withdraw
from the research project at any time without jeopardizing your medical care at this
hospital. If you have any questions now or later please ask us. You will be given a copy
of this form to keep. If at any time you feel any infringement of your rights, you may
contact the Hospital Medical Director for answers to any questions about the research and
your rights.
Alternative Procedures and Their Relative Risks And Benefits:
There are no alternative procedures which will give the same information.
Emergency Medical Treatment in the Event of Physical Injury and Financial
Responsibility:
Emergency medical care will be available at UCLA’s hospital emergency room
by a physician. If you need medical treatment as a result of physical injury rising from
your participation in this study, the financial responsibility for such care will be yours.
Subject’s Consent:
I acknowledge that I have fully reviewed and understand the contents of this
consent form. I have been given a copy of the consent and Experimental Subject’s Bill of
Rights.
86
Subject’s Signature Date
Signature of Authorized Other Date
(if necessary)
Signature of Witness Date
Statement of Investigator
I certify that I have reviewed the contents of this form with the person signing
above, who, in my opinion, understood the explanation. I have explained the known side
effects and benefits of the research.
87
APPENDIX B
QUESTIONNAIRE TO DETERMINE THE CONTENT VALIDITY
OF WESTPHAL’S DECISION MAKING INVENTORY (1967)
By Chinna F. Azariah, 1984
4. Do the categories of Westphal’s Decision Making Inventory (1967) provide a
complete definition of decision making?
YES NO
1a. If not, what categories could be added to provide a more complete definition
of decision making?*
5. Which categories of Westphal’s Decision Making Inventory (1967) do not fit
a definition of decision making?
6. Goal Setting?
7. Problem Recognition?
8. Attitude?
9. Problem Solving Action?
10. What can be inferred about what is being measured by Westphal’s Decision
Making Inventory (1967)?
11. What can be inferred about other behaviors?
12. Please summarize your thoughts on Westphal’s Decision Making Inventory
(1967) in terms of its claim to measure what it says it measures?
* NOTE: It is not the purpose of Azariah’s (1984) thesis to add or delete categories
from Westphal’s Decision Making Inventory (1967). The information
provided by your input onto this questionnaire will be used as a check on
the content validity of Westphal’s Decision Making Inventory (1967).
88
APPENDIX C
DECISION MAKING INVENTORY
INSTRUCTIONS: Circle the statement number which best describes the subject
working on a craft project, such as leather, clay, painting, or other
craft.
GOAL SETTING: The desire to accomplish a task.
(1) (2) (3) (4)
Unable to decide. Task is chosen for
him.
Task selected from
suggestions.
Selects own goal
and acts on own
initiative.
PROBLEM RECOGNITION: The obstacle that prevents completion of the task.
(1) (2) (3) (4)
Does not recognize
obstacle exists.
Recognizes obstacle
exists but cannot
identify it.
Identifies obstacle
but uncertain of his
definition.
Clearly identifies
obstacle.
ATTITUDE: Readiness to cope with the problem.
(1) (2) (3) (4)
Task abandoned; no
longer wants goal.
Wants goal but
does not work
for it.
Moves toward the goal
with encouragement.
Strong goal
determination, and
works for it with
appropriate action.
PROBLEM SOLVING ACTION:
A. Information Seeking: The act of searching for information leading to a
solution.
(1) (2) (3) (4)
Does nothing to
find information.
Knows neither how
nor where to seek
information.
Seeks information
only with guidance or
encouragement.
Actively seeks
information on his
own.
89
APPENDIX C, Cont’d.
DECISION MAKING INVENTORY (CONTINUED)
B. Organization of Information: Organizing information as to what will help, or
what will hinder finding a solution, or working the solution to remove the
obstacle
(1) (2) (3) (4)
Does not understand
information.
Does not know how
to use information.
Requires assistance
in organizing.
Can organize on
own and into a
logical form.
C. Selection of a solution:
(1) (2) (3) (4)
Solution is not
chosen.
Cannot select
solution from
alternatives.
Requires reassurance
as to solution
chosen.
Selects solution
completely on own.
RESULTS:
(1) (2) (3) (4)
Solution failed;
project abandoned
Failed; does not
want to rework
but wants goal.
Failed; will rework
problem with
encouragement.
Successful (obstacle
removed); failed;
will rework.
Abstract (if available)
Linked assets
University of Southern California Dissertations and Theses
Asset Metadata
Creator
Azariah, Chinna F.
(author)
Core Title
A discussion of inter-rater reliability and content validity of Westphal's decision making inventory (1967), describing developmental processes of adults with developmental delays
School
College of Letters, Arts and Sciences
Degree
Master of Arts
Degree Program
Occupational Therapy
Publication Date
11/30/2006
Defense Date
10/01/2006
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
decison making,OAI-PMH Harvest
Language
English
Advisor
Parham, L. Diane (
committee chair
)
Creator Email
cazariah1@yahoo.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-m201
Unique identifier
UC1455378
Identifier
etd-Azariah-20061129 (filename),usctheses-m40 (legacy collection record id),usctheses-m201 (legacy record id),usctheses-c127-157987 (legacy record id)
Legacy Identifier
etd-Azariah-20061129.pdf
Dmrecord
157987
Document Type
Thesis
Rights
Azariah, Chinna F.
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Repository Name
Libraries, University of Southern California
Repository Location
Los Angeles, California
Repository Email
cisadmin@lib.usc.edu
Tags
decison making