![](media/image1.png){width="6.0in" height="5.996527777777778in"}U.S.
DEPARTMENT OF EDUCATION

Functional Limitations of\
Vocational Rehabilitation (VR) Consumers

Final Report

 

**Functional Limitations of\
Vocational Rehabilitation (VR) Consumers\
Final Report**

Submitted to:

U.S. Department of Education

Office of Special Education and Rehabilitative Services

Rehabilitation Services Administration

Prepared by:

Beth Overman\
Holly Schmidt-Davis

Research Triangle Institute

Research Triangle Park, N.C.

2006

This report was produced under U.S. Department of Education Contract No.
HR 92022001 with the Research Triangle Institute. Harold Kay served as
the contracting officer's representative. The views expressed herein do
not necessarily represent the positions or policies of the Department of
Education. No official endorsement by the U.S. Department of Education
of any product, commodity, service or enterprise mentioned in this
publication is intended or should be inferred.

U.S. Department of Education

Margaret Spellings

*Secretary*

Office of Special Education and Rehabilitative Services

John H. Hager

*Assistant Secretary*

Rehabilitation Services Administration

Edward Anthony

*Acting Commissioner*

January 2006

This report is in the public domain. Authorization to reproduce it in
whole or in part is granted. While permission to reprint this
publication is not necessary, the citation should be: U.S. Department of
Education, Office of Special Education and Rehabilitative Services,
Rehabilitation Services Administration. *Functional Limitations of
Vocational Rehabilitation (VR) Consumers Final Report.* Washington,
D.C., 2006.

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# Contents

[Figures iv](#figures)

[Tables v](#tables)

[Summary of Findings vii](#summary-of-findings)

[Introduction 1](#introduction)

[Study Methods 5](#study-methods)

[Study Findings 9](#study-findings)

[Conclusion 27](#conclusion)

[References 29](#references)

[Appendix A: Theoretical Background and Scale Development
31](#appendix-a-theoretical-background-and-scale-development)

# Figures

1\. Employment outcome [23](#__RefHeading___Toc87859519)

2\. Competitive employment outcome [24](#__RefHeading___Toc87859520)

# Tables

[1. Functional status by service group 9](#__RefHeading___Toc124564942)

[2. Functional status by disability type (NHIS-D)
10](#__RefHeading___Toc124564943)

[3. Functional status by disability type (Longitudinal Study)
11](#__RefHeading___Toc124564944)

[4. Functional status by demographic characteristics
12](#__RefHeading___Toc124564945)

[5. Functional status by education attainment
13](#__RefHeading___Toc124564946)

[6. Functional status of transitional youths (youths with disabilities
between the ages of 18 and 25) by receipt of special education services
13](#__RefHeading___Toc124564947)

[7. Functional status by work status at application to VR
14](#__RefHeading___Toc124564948)

[8. Functional status by receipt of SSI/SSDI
14](#__RefHeading___Toc124564949)

[9. Functional status by significance of disability
15](#__RefHeading___Toc124564950)

[10. Functional status by automatic significance designation
15](#__RefHeading___Toc124564951)

[11. Functional status by vocational goal
16](#__RefHeading___Toc124564952)

[12. Gross motor function by receipt of selected services (individuals
with orthopedic disabilities) 18](#__RefHeading___Toc124564953)

[13. Cognitive function by receipt of selected services (individuals
with orthopedic disabilities) 18](#__RefHeading___Toc124564954)

[14. Personal care function by receipt of selected services (individuals
with orthopedic disabilities) 19](#__RefHeading___Toc124564955)

[15. Gross motor function by receipt of selected services (individuals
with mental retardation) 19](#__RefHeading___Toc124564956)

[16. Cognitive function by receipt of selected services (individuals
with mental retardation) 20](#__RefHeading___Toc124564957)

[17. Personal care function by receipt of selected services (individuals
with mental retardation) 20](#__RefHeading___Toc124564958)

[18. Overall functional status by average cost of services
20](#__RefHeading___Toc124564959)

[19. Functional status by closure status
21](#__RefHeading___Toc124564960)

[20. Regression models of consumer outcomes
22](#__RefHeading___Toc124564961)

[21. Functional status by earnings levels
25](#__RefHeading___Toc124564962)

[22. Functional status by supported employment and disability type
25](#__RefHeading___Toc124564963)

[23. Functional status by sheltered workshop versus competitive
employment 26](#__RefHeading___Toc124564964)

[24. Functional status by retention of employment over time
(competitively employed only) 26](#__RefHeading___Toc124564965)

[A-1. Review of functional status literature
35](#__RefHeading___Toc124564966)

[A-2. Exploratory factor analysis of selected ADL and IADL questions
from NHIS‑D\* 40](#__RefHeading___Toc124564967)

[A-3. Interfactor correlations among NHIS-D functional status scales
41](#__RefHeading___Toc124564968)

[A-4. Reliability coefficients for NHIS-D functional status scales
41](#__RefHeading___Toc124564969)

[A-5. Factor analysis of Longitudinal Study ADL and IADL items
43](#__RefHeading___Toc124564970)

[A-6. Interfactor correlations among Longitudinal Study functional
status scales 43](#__RefHeading___Toc124564971)

[A-7. Reliability coefficients for Longitudinal Study functional status
scales 44](#__RefHeading___Toc124564972)

# Summary of Findings

In response to a request from the Rehabilitation Services Administration
(RSA), the Research Triangle Institute (RTI) conducted a study to
examine the feasibility of developing functional status measures for
planning and implementing services to consumers in the State-Federal
Vocational Rehabilitation (VR) Services Program.

To investigate this issue, RTI used the 1994--95 National Health
Interview Survey-Disability Followback (NHIS-D) and data available from
the ongoing Longitudinal Study of the VR Services Program to develop
composite measures of functional status in three areas: 1) gross motor
function; 2) personal care function; and 3) cognitive function. We then
conducted analyses to address the study's questions regarding the
robustness of these measures in comparison with traditional definitions
of "significance of disability" for describing VR consumers' status and
predicting outcomes of VR services.

In this summary, we have organized our findings by the eight questions
that RSA developed for the study.

1\. What functional limitations do VR consumers have?

-   VR consumers had more functional limitations in all three
    areas---gross motor, cognitive and personal care functioning---than
    did persons with disabilities who did not receive any VR services
    (NHIS-D).

2\. What is the relationship between functional limitations and selected
consumer characteristics?

Type of disability:

Gross motor function

-   Individuals with hearing impairment, learning disabilities or
    disabilities associated with substance abuse had particularly high
    gross motor functioning.

> **Cognitive function**

-   Individuals with disabilities associated with substance abuse had
    the highest cognitive functioning.

-   Individuals with mental retardation had the lowest cognitive
    function.

#### Personal care function

-   Individuals with learning disabilities, hearing impairment or
    disabilities associated with substance abuse had particularly high
    personal care functioning.

Age:

-   Individuals under 26 had significantly fewer gross motor limitations
    than those who were over 55.

-   Individuals over 55 had significantly fewer personal care
    limitations than those who were under 26.

Sex:

-   Males had fewer limitations than females in gross motor functioning.

Education:

-   Consumers with less than a high school diploma ranked significantly
    higher than other consumers on gross motor function and
    significantly lower than other consumers on cognitive function.

-   Consumers with at least a high school diploma had higher cognitive
    function than other consumers.

-   Consumers with more than a high school education ranked lower on
    gross motor function than other consumers.

-   Consumers who did not receive special education services in high
    school had fewer cognitive limitations than those who did receive
    such services.

Employment experience:

-   Individuals who were working at application to VR had fewer
    limitations in gross motor and personal care functioning than did
    applicants who were not employed.

Receipt of public assistance, including SSI/SSDI:

-   Consumers who received financial assistance at application to VR had
    more functional limitations on all three dimensions than other
    consumers with significant or most significant disabilities.

Race and ethnicity:

-   White consumers had significantly fewer limitations in cognitive and
    personal care functioning than consumers of other races.

3\. What are the interrelationships between functional limitations and
the designation of individuals as: a) most significantly disabled; b)
significantly disabled; c) nonsignificantly disabled; and d) Social
Security recipients who "automatically" meet the first of the three
criteria in the definition of "significant disability"? Are persons with
these different designations of disability significance different from
each other in terms of their functional limitations?

-   On all three dimensions (gross motor, cognitive and personal care
    functioning), persons classified as having nonsignificant
    disabilities were significantly higher functioning than those with
    either significant or most significant disabilities.

-   Consumers with significant disabilities averaged higher in cognitive
    functioning than persons with most significant disabilities, but
    these two groups did not differ significantly on the other two
    dimensions of function.

-   Consumers who received financial assistance (e.g., SSI/SSDI, public
    assistance) at application to VR were more limited on all three
    dimensions of function than other consumers with significant or most
    significant disabilities.

4\. What are the relationships between consumers' functional limitations
and each of the following areas?

Vocational goals:

-   Consumers whose vocational goal was structural work had the fewest
    gross motor limitations. Those with vocational goals in the service
    industry also had fewer gross motor limitations than average.

-   Consumers with homemaker as their vocational goal had many more
    gross motor limitations than other consumers.

-   The highest level of cognitive function occurred among consumers
    with professional, managerial or technical vocational goals.
    Individuals with clerical or sales goals; agricultural, fishing or
    forestry goals; structural work goals; or miscellaneous goals also
    had higher than average cognitive function.

-   The lowest level of cognitive function occurred among consumers with
    homemaker goals. Those with machine trades, benchwork or other goals
    also had lower than average cognitive function.

-   Consumers with structural work as their vocational goal had the
    highest personal care function. Those with service as their
    vocational goal also had higher than average personal care function.

-   The lowest levels of functioning occurred among individuals with
    homemaker as their vocational goal.

Services received (e.g., type, duration and cost):

-   Among individuals with orthopedic disabilities, those who received
    assistive technology assessments, devices or services ranked lower
    on all three functional status scales than other individuals. Those
    who received medical services or occupational therapy ranked lower
    on gross motor function.

-   Among individuals with mental retardation, VR consumers who received
    supported employment services had higher levels of gross motor
    function but lower levels of cognitive function. Those who received
    maintenance services had higher levels of personal care function
    than did consumers who did not receive this service.

-   Individuals with low levels of functioning in all three areas were
    likely to have higher average costs of purchased services and to
    have spent more time in VR.

-   The average cost of services for individuals with low functional
    status in all three areas was over twice that of individuals with
    high functional status.

-   The average number of services that individuals with low functional
    status in all three areas received was also significantly higher
    than that of individuals with high functional status.

5\. Are there differences in functional limitations for consumers whose
cases were closed: a) without receiving services; b) despite the fact
that they were nonrehabilitated after receiving services; c) when they
were rehabilitated into noncompetitive employment; or d) when they were
rehabilitated into competitive employment?

-   VR consumers who achieved competitive employment outcomes were the
    highest functioning of all consumers on all three functional status
    scales.

-   Consumers who achieved a noncompetitive employment outcome, those
    who were eligible but did not receive services, and those who
    achieved noncompetitive employment outcomes having particularly low
    cognitive function were ranked lowest in terms of functional status.

6\. Are functional limitations a more consistent predictor of vocational
outcome than: a) severity of disability designation; or b) other
consumer characteristics, including type of disability, age, sex,
education, employment experience, receipt of public assistance, and race
and ethnic group?

-   When we included functional status scales in models of employment
    outcomes, disability significance was not a statistically important
    predictor of either employment outcome or competitive employment
    outcome. Functional status was a significant predictor of both
    outcomes, even after the model accounted for important consumer
    characteristics.

7\. What is the relationship between functional limitations and: a) the
earnings levels of persons closed into competitive employment; b) other
rehabilitants by category (e.g., homemaker, unpaid family worker); and
c) stability of employment over time?

-   Among individuals who achieved competitive employment outcomes,
    those who earned more than \$9.00 per hour had a significantly
    higher cognitive function than those who earned \$5.00 or less per
    hour.

-   Consumers who exited into extended employment did not differ
    significantly from those who exited into competitive employment on
    gross motor and personal care function, but they ranked
    significantly lower on cognitive function.

8\. Do functional limitations change over time, especially with receipt
of VR services?

-   To examine changes over time, we compared consumers' functional
    status at entry to VR and at exit from VR. We found no significant
    differences, even among consumers who exited more than three years
    after they entered VR.

    In conclusion, because the functional status scales are based on
    Activities of Daily Living (ADL) and Instrumental Activities of
    Daily Living (IADL) items, their utility for certain disabilities
    may be limited. For example, these items, while in widespread use on
    national surveys of individuals with disabilities, are not sensitive
    indicators of functional status among persons with mental illnesses
    or visual impairments. Therefore, as this report shows, this
    approach to measurement of functional status more accurately
    predicts outcomes; it may be appropriate to conduct further research
    designed to improve the utility of these measures of functional
    limitations for specific types of disabilities (e.g., vision
    impairments and mental illnesses).

# Introduction

In the more than 30 years since the enactment of the *Rehabilitation Act
of 1973*, Congress has consistently emphasized targeting VR services to
persons whose disabilities are significant[^1]. This pattern culminated
in the requirement of the *Rehabilitation Amendments of 1992*, which
mandated that Designated State Units (DSUs) target services to the
individuals whose disabilities are "most significant," and charged each
of the 83 DSUs responsible for implementing the VR service program with
defining "most significant" within its jurisdiction. Three years after
this statutory change, the distribution of VR consumers in terms of
severity of disability reflected the new requirement, with over
one-quarter of consumers classified as having a "most significant
disability," about half classified as "significantly disabled" and less
than 20 percent determined to be "nonsignificantly disabled" (Hayward
and Tashjian, 1996).

The fact that Congress assigned DSUs the responsibility to establish the
criteria for determining a disability as "most significant" has
implications for how they address one of the critical challenges in the
VR system---the difficulty in assessing precisely what aspects of a
sensory, physical or cognitive impairment result in specific functional
limitations and how those limitations constrain an individual's ability
to obtain and retain employment.

At present, the Rehabilitation Services Administration's (RSA) reporting
system contains approximately 212 disability codes, along with
specialized provisions for many of these codes (e.g., codes covering
mental illness). Based on the medical model of disability, these codes
require rehabilitation counselors to classify the disability according
to the single code that best fits the individual's condition. Once the
counselor determines the type of disability based on medical records or
assessments, he or she must then establish whether the individual has a
significant disability. According to Section 7(21) of the
*Rehabilitation Act of 1973*, as amended, an "individual with a
significant disability" is someone:

-   Who has a severe physical or mental impairment which seriously
    limits one or more functional capacities (such as mobility,
    communication, self-care, self-direction, interpersonal skills, work
    tolerance, or work skills) in terms of an employment outcome;

-   Whose vocational rehabilitation can be expected to require multiple
    VR services over an extended period of time; and

-   Who has one or more physical or mental disabilities ... or
    combination of disabilities determined ... to cause comparable
    substantial limitation.

Most states, in defining most significant disability, have simply
increased the number of functional limitations a person must have to be
considered most significantly disabled. Without accurate information on
the relationships between functional measures and vocational outcomes,
DSUs have had little basis on which to develop more appropriate criteria
for targeting services.

While the state of the art in assessment in functional status (as it
relates to vocational rehabilitation) has matured in the past 10 to 15
years, the perception persists that the VR system may not be fully
accessible to persons most in need of services. Although persons with
significant or most significant disabilities do gain access to the VR
system, constituents, advocates and Congress raise the concern that
counselors may not be very effective in matching persons' functional
abilities and limitations to the appropriate vocational goals, services
and jobs, hence reducing the potential effectiveness of services in
terms of employment and earnings outcomes.

Information available from the Longitudinal Study of the Vocational
Rehabilitation Services Program permits us to examine these issues and
to contribute to a better understanding of the relationships among
disability classification, functional status and other factors that can
be expected to affect an individual's likelihood both to seek, and to
benefit from, VR services. These findings will, in turn, be helpful to
RSA and Congress in deliberations regarding the reauthorization of the
program, and to DSUs in their ongoing efforts to provide high-quality
services leading to positive employment outcomes for persons with
significant or most significant disabilities. Among the issues addressed
in this report are:

-   What functional limitations do VR consumers share?

-   What is the relationship between functional limitations and selected
    consumer characteristics?

-   What are the interrelationships between functional limitations and
    the designation of individuals as: a) most significantly
    disabled; b) significantly disabled; c) nonsignificantly disabled;
    and d) Social Security recipients who "automatically" meet the first
    of the three criteria in the definition of significant disability?
    Are persons with these different designations of disability
    significance different from each other in terms of their functional
    limitations?

-   What are the relationships between consumers' functional limitations
    and vocational goals and services received (including type, duration
    and cost of services)?

-   Are there differences in functional limitations for consumers whose
    cases were closed: a) without receiving services; b)
    nonrehabilitated after receiving services; c) rehabilitated into
    noncompetitive employment; or d) rehabilitated into competitive
    employment?

-   Are functional limitations a more consistent predictor of vocational
    outcome than: a) severity of disability designation; or b) other
    consumer characteristics, including type of disability, age, sex,
    education, employment experience, receipt of public assistance and
    race and ethnic group?

-   What is the relationship between functional limitations and: a) the
    earnings levels of persons closed into competitive employment; b)
    other rehabilitants by category (e.g., homemaker, unpaid family
    worker); and c) stability of employment over time?

-   Do functional limitations change over time, especially with receipt
    of VR services?

# Study Methods

New paradigms of disability are typically distinguished among
impairments, functional limitations and disabilities. Impairments refer
to "anatomical, physical, or mental abnormalities or losses in one
physical system" (Spector and Fleishman, 1998), while functional
limitations, such as difficulty reaching, affect the performance of the
whole person. Disabilities, on the other hand, are limitations in the
performance of roles or tasks in the context of the social, cultural and
physical environments, such as difficulty bathing. Therefore, the
concept of functional disability refers to limitations in basic
activities that are necessary to function in the community. These are
often divided into Activities of Daily Living (ADLs), which include
basic activities such as hygiene and personal care, and Instrumental
Activities of Daily Living (IADLs), which include activities necessary
to live in the community, such as shopping and managing money (Spector
and Fleishman, 1998).

Surveys of elderly persons and of individuals with disabilities
frequently include ADL and IADL items. The Survey of Income and Program
Participation (SIPP), the National Health Interview Survey (NHIS) and
the National Long-Term Care Survey (NLTCS) regularly collect responses
to these items and provide valuable information to program planners,
researchers and practitioners about individuals' functional status.
While the survey items individually are useful for estimates of overall
levels of functioning on specific activities, composite measures of
functional status incorporating these items both facilitate comparisons
among groups and reduce the number of variables needed for statistical
modeling. Furthermore, practitioners who work with individuals with
disabilities may find such measures useful for decisions about how best
to inform consumers of their services and to assist them in minimizing
the effects of functional limitations through assistive technology or
other types of accommodations. In particular, such measures would be
highly relevant to programs that serve individuals with disabilities,
especially those that must identify the nature and significance of
individuals' disabilities to make eligibility decisions, to develop
feasible employment goals, and to plan appropriate services. The VR
Services Program, whose goal is to help individuals with disabilities
achieve appropriate employment outcomes, is one such program.

Section 7(20) of the *Rehabilitation Act* defines an individual with a
disability as "any individual who has a physical or mental impairment
which for such individual constitutes or results in a substantial
impediment to employment; and can benefit in terms of an employment
outcome from vocational rehabilitation services." As stated earlier, an
individual with a significant disability is defined by Section 7(21) of
the *Rehabilitation Act* as an individual with a disability who, among
other things, has a severe physical or mental impairment that seriously
limits one or more functional capacities in terms of an employment
outcome and whose vocational rehabilitation can be expected to require
multiple services over an extended period of time. Finally, an
individual with a most significant disability is defined as "an
individual with a significant disability who meets criteria established
by the State" (Section 7(21) of the *Rehabilitation Act Amendments*).

Traditionally, the VR system has relied on medical documentation and
counselors' assessments of the significance or severity of individuals'
disabilities to determine their eligibility for VR services. Although
counselors use the federally mandated definition to determine if a
disability is significant, each state determines its own criteria for
deciding if a disability is most significant. In determining whether a
disability is most significant, most DSUs have expanded the federal
definition of significant by increasing the number of limitations from
"one or more" to "three or more." These determinations lack the
precision and sensitivity that the system needs to serve consumers as
effectively as possible.

We used two data sources for the analyses in this report: the 1994--95
National Health Interview Survey-Disability Supplement (NHIS-D), and the
Longitudinal Study of the Vocational Rehabilitation Services Program.
Both surveys contain ADL and IADL items. NHIS‑D contains two parts, one
of which was administered along with the core survey to a sample
designed to represent the civilian noninstitutionalized population of
the United States. The second part, the Disability Followback Survey,
was administered later only to those individuals whose responses
indicated that they met the NHIS definition of "disability." The
Longitudinal Study of the VR Services Program is a national impact
evaluation that investigates the effects of VR services on economic and
other outcomes for individuals with disabilities who receive such
services. The Longitudinal Study drew a nationally representative sample
of more than 8,000 respondents, including applicants for VR services
(some of whom were not accepted for services), VR consumers, and former
VR consumers.

Based on statistical techniques and a review of the functional status
literature, we developed three functional status scales using ADL and
IADL items from these surveys. The first scale, gross motor function,
includes items such as "walking for a quarter of a mile" and "walking up
a flight of stairs." The cognitive function scale includes "managing
your money" and "shopping for personal items," and the personal care
scale includes "bathing or showering" and "dressing." Values on each
scale range from one to two, with a high score indicating a higher level
of functioning.

# Study Findings

In this section we organize study findings around the questions that
formed the basis for the study.

## What functional limitations do VR consumers have? {#what-functional-limitations-do-vr-consumers-have .Question}

Using data from NHIS-D, we compared the average functional status scores
of three groups of respondents with disabilities. The first group
reported having received VR services through a VR agency; the second
group received similar services through other means; and the third group
did not report receiving any VR services. As table 1 indicates,
individuals who received services through a VR agency had more
limitations on all three scales than those who did not receive any
services. They also had more cognitive function limitations than those
who received services through other means.

+--------------------------------+-----------+-----------+-----------+
| [                              |           |           |           |
| ]{#__RefHeading___Toc124564942 |           |           |           |
| .anchor}Table 1. Functional    |           |           |           |
| status by service group        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Service group                  | Gross     | C         | Personal  |
|                                | motor\    | ognitive\ | care\     |
|                                | fu        | func      | fu        |
|                                | nction^b^ | tion^a,b^ | nction^b^ |
+--------------------------------+-----------+-----------+-----------+
| Received VR services through   | > 1.61    | > 1.86    | > 1.86    |
| VR agency                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Received VR services through   | > 1.61    | > 1.90    | > 1.87    |
| other means                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Non-service disabled           | > 1.76    | > 1.95    | > 1.94    |
| population^c^                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Source: National Health        |           |           |           |
| Interview Survey ---           |           |           |           |
| Disability Supplement          |           |           |           |
|                                |           |           |           |
| High values indicate fewer     |           |           |           |
| functional limitations.        |           |           |           |
|                                |           |           |           |
| ^a^ Indicates a statistically  |           |           |           |
| significant difference         |           |           |           |
| (p\<.05) between individuals   |           |           |           |
| who received services through  |           |           |           |
| a VR agency and individuals    |           |           |           |
| who received services through  |           |           |           |
| other means.                   |           |           |           |
|                                |           |           |           |
| ^b^ Indicates a statistically  |           |           |           |
| significant difference         |           |           |           |
| (p\<.05) between individuals   |           |           |           |
| who received services through  |           |           |           |
| a VR agency and members of the |           |           |           |
| non-service disabled           |           |           |           |
| population.                    |           |           |           |
|                                |           |           |           |
| ^c^ Did not receive any VR     |           |           |           |
| services.                      |           |           |           |
|                                |           |           |           |
| ## What is t                   |           |           |           |
| he relationship between functi |           |           |           |
| onal limitations and selected  |           |           |           |
| consumer characteristics such  |           |           |           |
| as: a) type of disability; b)  |           |           |           |
| age; c) sex; d) education; e)  |           |           |           |
| employment experience; f) rece |           |           |           |
| ipt of public assistance, incl |           |           |           |
| uding SSI/SSDI; and g) race an |           |           |           |
| d ethnicity? {#what-is-the-rel |           |           |           |
| ationship-between-functional-l |           |           |           |
| imitations-and-selected-consum |           |           |           |
| er-characteristics-such-as-a-t |           |           |           |
| ype-of-disability-b-age-c-sex- |           |           |           |
| d-education-e-employment-exper |           |           |           |
| ience-f-receipt-of-public-assi |           |           |           |
| stance-including-ssissdi-and-g |           |           |           |
| -race-and-ethnicity .Question} |           |           |           |
+--------------------------------+-----------+-----------+-----------+

Using the NHIS-D scales, we compared individuals with different types of
disabilities (table 2). Individuals with vision impairments had
significantly fewer limitations in the areas of gross motor function and
personal care function, while those with hearing impairments had
significantly fewer limitations on all three scales. On average,
individuals with both orthopedic and nonorthopedic physical disabilities
had significantly more limitations on gross motor function and personal
care function. Those with orthopedic disabilities had fewer cognitive
limitations. The number of limitations for individuals with mental
illnesses, learning disabilities or disabilities associated with
substance abuse was lower than average on all three scales. Individuals
with mental retardation had more than the average number of limitations
in cognitive function, and fewer than average gross motor limitations.

+--------------------------------+-----------+-----------+-----------+
| [                              |           |           |           |
| ]{#__RefHeading___Toc124564943 |           |           |           |
| .anchor}Table 2. Functional    |           |           |           |
| status by disability type      |           |           |           |
| (NHIS-D)                       |           |           |           |
+================================+===========+===========+===========+
| Disability type                | Gross     | C         | Personal  |
|                                | motor\    | ognitive\ | care\     |
|                                | function  | function  | function  |
+--------------------------------+-----------+-----------+-----------+
| Vision impairment              | 1.80^b^   | \*        | 1.96^b^   |
+--------------------------------+-----------+-----------+-----------+
| Hearing impairment             | 1.91^b^   | 1.97^b^   | 1.99^b^   |
+--------------------------------+-----------+-----------+-----------+
| Orthopedic, including          | 1.53^a^   | 1.90^b^   | 1.85^a^   |
| amputation                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Nonorthopedic physical         | 1.55^a^   | 1.88      | 1.88^a^   |
+--------------------------------+-----------+-----------+-----------+
| Mental illness                 | 1.80^b^   | 1.92^b^   | 1.96^b^   |
+--------------------------------+-----------+-----------+-----------+
| Mental retardation             | 1.82^b^   | 1.58^a^   | 1.91      |
+--------------------------------+-----------+-----------+-----------+
| Substance abuse                | 1.92^b^   | 1.98^b^   | 1.98^b^   |
+--------------------------------+-----------+-----------+-----------+
| Learning disability            | 1.93^b^   | 1.92^b^   | 2.00^b^   |
+--------------------------------+-----------+-----------+-----------+
| All disabled persons           | 1.62      | 1.89      | 1.89      |
+--------------------------------+-----------+-----------+-----------+
| Source: National Health        |           |           |           |
| Interview Survey ---           |           |           |           |
| Disability Supplement          |           |           |           |
|                                |           |           |           |
| High values indicate fewer     |           |           |           |
| functional limitations.        |           |           |           |
|                                |           |           |           |
| ^a^ Individuals with this type |           |           |           |
| of disability function         |           |           |           |
| significantly (p\<.05) lower   |           |           |           |
| on this dimension than         |           |           |           |
| individuals with all other     |           |           |           |
| disabilities.                  |           |           |           |
|                                |           |           |           |
| ^b^ Individuals with this type |           |           |           |
| of disability function         |           |           |           |
| significantly (p\<.05) higher  |           |           |           |
| on this dimension than         |           |           |           |
| individuals with all other     |           |           |           |
| disabilities.                  |           |           |           |
|                                |           |           |           |
| \* As noted in Appendix A,     |           |           |           |
| individuals with vision        |           |           |           |
| impairments are excluded from  |           |           |           |
| the cognitive function scale.  |           |           |           |
+--------------------------------+-----------+-----------+-----------+

[Similarly, table 3 presents a comparison of functional status across
disability type for participants in the Longitudinal Study. Consumers
with hearing impairments ranked significantly higher than others on all
three dimensions. Individuals with orthopedic and nonorthopedic physical
disabilities ranked higher than other consumers on cognitive function;
however, while those with orthopedic disabilities ranked lower than
other consumers on gross motor function, there was no significant
difference between consumers with nonorthopedic physical disabilities
and other consumers on this dimension. Furthermore, while consumers with
orthopedic disabilities ranked lower than average on personal care
functioning, those with nonorthopedic disabilities ranked higher than
average. Individuals with mental illnesses and disabilities associated
with substance abuse ranked higher on all three functional status
measures than those with other disabilities. Individuals with mental
retardation ranked higher than average on gross motor function and lower
than average on cognitive function. Consumers with learning disabilities
ranked significantly higher than other consumers on both gross motor
function and personal care function.]{.mark}

+--------------------------------+-----------+-----------+---+-----------+
| [                              |           |           |   |           |
| ]{#__RefHeading___Toc124564944 |           |           |   |           |
| .anchor}Table 3. Functional    |           |           |   |           |
| status by disability type      |           |           |   |           |
| (Longitudinal Study)           |           |           |   |           |
+--------------------------------+-----------+-----------+---+-----------+
| Disability type                | Gross     | C         |   | Personal  |
|                                | motor\    | ognitive\ |   | care\     |
|                                | function  | function  |   | function  |
+--------------------------------+-----------+-----------+---+-----------+
| Vision impairment              | 1.74      | N/A\*     | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 6 |           |
+--------------------------------+-----------+-----------+---+-----------+
| Hearing impairment             | 1.93^b^   | 1.92^b^   | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 9 |           |
|                                |           |           | ^ |           |
|                                |           |           | b |           |
|                                |           |           | ^ |           |
+--------------------------------+-----------+-----------+---+-----------+
| Orthopedic, including          | 1.64^a^   | 1.89^b^   | 1 |           |
| amputation                     |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 3 |           |
|                                |           |           | ^ |           |
|                                |           |           | a |           |
|                                |           |           | ^ |           |
+--------------------------------+-----------+-----------+---+-----------+
| Nonorthopedic physical         | 1.80      | 1.92^b^   | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 9 |           |
|                                |           |           | ^ |           |
|                                |           |           | b |           |
|                                |           |           | ^ |           |
+--------------------------------+-----------+-----------+---+-----------+
| Mental illness                 | 1.91^b^   | 1.90^b^   | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 9 |           |
|                                |           |           | ^ |           |
|                                |           |           | b |           |
|                                |           |           | ^ |           |
+--------------------------------+-----------+-----------+---+-----------+
| Mental retardation             | 1.92^b^   | 1.56^a^   | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 8 |           |
+--------------------------------+-----------+-----------+---+-----------+
| Substance abuse                | 1.93^b^   | 1.94^b^   | 2 |           |
|                                |           |           | . |           |
|                                |           |           | 0 |           |
|                                |           |           | 0 |           |
|                                |           |           | ^ |           |
|                                |           |           | b |           |
|                                |           |           | ^ |           |
+--------------------------------+-----------+-----------+---+-----------+
| Learning disability            | 1.96^b^   | 1.85      | 2 |           |
|                                |           |           | . |           |
|                                |           |           | 0 |           |
|                                |           |           | 0 |           |
|                                |           |           | ^ |           |
|                                |           |           | b |           |
|                                |           |           | ^ |           |
+--------------------------------+-----------+-----------+---+-----------+
| Traumatic brain injury         | 1.84      | 1.81      | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 4 |           |
+--------------------------------+-----------+-----------+---+-----------+
| All other conditions           | 1.92^b^   | 1.82      | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 8 |           |
+--------------------------------+-----------+-----------+---+-----------+
| All consumers                  | 1.82      | 1.85      | 1 |           |
|                                |           |           | . |           |
|                                |           |           | 9 |           |
|                                |           |           | 7 |           |
+--------------------------------+-----------+-----------+---+-----------+
| Source: VR Longitudinal Study  |           |           |   |           |
|                                |           |           |   |           |
| High values indicate fewer     |           |           |   |           |
| functional limitations.        |           |           |   |           |
|                                |           |           |   |           |
| ^a^ Individuals with this type |           |           |   |           |
| of disability function         |           |           |   |           |
| significantly (p\<.05) lower   |           |           |   |           |
| on this dimension than         |           |           |   |           |
| individuals with all other     |           |           |   |           |
| disabilities.                  |           |           |   |           |
|                                |           |           |   |           |
| ^b^ Individuals with this type |           |           |   |           |
| of disability function         |           |           |   |           |
| significantly (p\<.05) higher  |           |           |   |           |
| on this dimension than         |           |           |   |           |
| individuals with all other     |           |           |   |           |
| disabilities.                  |           |           |   |           |
|                                |           |           |   |           |
| \* As noted in Appendix A,     |           |           |   |           |
| individuals with vision        |           |           |   |           |
| impairments are excluded from  |           |           |   |           |
| the cognitive function scale.  |           |           |   |           |
+--------------------------------+-----------+-----------+---+-----------+

These two sets of analyses reveal common trends in levels of functioning
across disability type. Individuals with hearing impairments, learning
disabilities and disabilities associated with substance abuse had
particularly high gross motor function in both data sets, while
individuals with orthopedic disabilities had very low gross motor
function in both data sets. However, while individuals with
nonorthopedic disabilities in the Longitudinal Study were closer in rank
to the overall average on gross motor function, individuals with this
same type of disability in NHIS-D ranked much lower on this dimension.
In both data sets, individuals with disabilities associated with
substance abuse had the highest cognitive function, while individuals
with mental retardation had the lowest. Individuals in both data sets
with learning disabilities, hearing impairments and disabilities
associated with substance abuse had particularly high personal care
function, while those with orthopedic disabilities had particularly low
personal care function. Individuals with nonorthopedic disabilities in
the Longitudinal Study had lower than average personal care function,
while those in NHIS-D had higher than average personal care function.
These differences may be due to differences in the questions that make
up the scales or to differences in the populations studied in the two
data sets. (For more information, see Overman and Schmidt-Davis, 2000.)

We also compared the functional status of participants in the
Longitudinal Study by age group, race and ethnicity and gender (table
4). We compared the youngest consumers (under 26) with the oldest (over
55); overall, individuals under 26 had significantly fewer gross motor
limitations than those who were over 55, while individuals over 55 had
significantly fewer personal care limitations that those who were under
26. White consumers had significantly fewer limitations in cognitive
functioning than consumers of any other race. There were no significant
differences between consumers of Hispanic origin and other consumers. On
average, males had fewer limitations on the gross motor functioning
scale than females.

+---------------------+---------------+---------------+---------------+
| []{#__RefHea        |               |               |               |
| ding___Toc124564945 |               |               |               |
| .anchor}Table 4.    |               |               |               |
| Functional status   |               |               |               |
| by demographic      |               |               |               |
| characteristics     |               |               |               |
+---------------------+---------------+---------------+---------------+
| Characteristic      | Gross motor\  | Cognitive\    | Personal      |
|                     | function^a,c^ | function^b^   | care\         |
|                     |               |               | function^a,b^ |
+---------------------+---------------+---------------+---------------+
| ***Age***           |               |               |               |
+---------------------+---------------+---------------+---------------+
| > Less than 26      | 1.93          | 1.82          | 1.98          |
+---------------------+---------------+---------------+---------------+
| > 26 to 35          | 1.85          | 1.86          | 1.97          |
+---------------------+---------------+---------------+---------------+
| > 36 to 45          | 1.79          | 1.87          | 1.97          |
+---------------------+---------------+---------------+---------------+
| > 46 to 55          | 1.75          | 1.87          | 1.96          |
+---------------------+---------------+---------------+---------------+
| > Over 55           | 1.70          | 1.81          | 1.96          |
+---------------------+---------------+---------------+---------------+
| ***Race and         |               |               |               |
| ethnicity***        |               |               |               |
+---------------------+---------------+---------------+---------------+
| > White             | 1.82          | 1.86          | 1.97          |
+---------------------+---------------+---------------+---------------+
| > Other races       | 1.80          | 1.80          | 1.97          |
+---------------------+---------------+---------------+---------------+
| > Of Hispanic       | 1.81          | 1.85          | 1.97          |
| > Origin            |               |               |               |
+---------------------+---------------+---------------+---------------+
| ***Gender***        |               |               |               |
+---------------------+---------------+---------------+---------------+
| > Male              | 1.84          | 1.85          | 1.97          |
+---------------------+---------------+---------------+---------------+
| > Female            | 1.79          | 1.86          | 1.97          |
+---------------------+---------------+---------------+---------------+
| Source: VR          |               |               |               |
| Longitudinal Study  |               |               |               |
|                     |               |               |               |
| High values         |               |               |               |
| indicate fewer      |               |               |               |
| functional          |               |               |               |
| limitations.        |               |               |               |
|                     |               |               |               |
| ^a^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between those under |               |               |               |
| 26 years and those  |               |               |               |
| over 55 years.      |               |               |               |
|                     |               |               |               |
| ^b^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between white       |               |               |               |
| consumers and       |               |               |               |
| consumers of other  |               |               |               |
| races.              |               |               |               |
|                     |               |               |               |
| ^c^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between males and   |               |               |               |
| females.            |               |               |               |
+---------------------+---------------+---------------+---------------+

Table 5 compares functional status across educational level. Consumers
without a high school diploma were significantly higher than other
consumers on gross motor function and significantly lower than other
consumers on cognitive function. Those with high school diplomas or
higher levels of education had higher cognitive function than other
consumers. Individuals with more than a high school education ranked
lower on gross motor function than other consumers.

+---------------------+---------------+---------------+---------------+
| []{#__RefHea        |               |               |               |
| ding___Toc124564946 |               |               |               |
| .anchor}Table 5.    |               |               |               |
| Functional status   |               |               |               |
| by education        |               |               |               |
| attainment          |               |               |               |
+---------------------+---------------+---------------+---------------+
| Education level     | **Gross       | **Cognitive\  | **Personal    |
|                     | motor\        | function**    | care\         |
|                     | function**    |               | function**    |
+---------------------+---------------+---------------+---------------+
| Less than high      | 1.84**^a^**   | 1.81**^a^**   | 1.98          |
| school              |               |               |               |
+---------------------+---------------+---------------+---------------+
| High school         | 1.82          | 1.89**^a^**   | 1.97          |
| diploma/GED         |               |               |               |
+---------------------+---------------+---------------+---------------+
| More than high      | 1.80**^a^**   | 1.89**^a^**   | 1.97          |
| school              |               |               |               |
+---------------------+---------------+---------------+---------------+
| All consumers       | 1.82          | 1.87          | 1.97          |
+---------------------+---------------+---------------+---------------+
| Source: VR          |               |               |               |
| Longitudinal Study  |               |               |               |
|                     |               |               |               |
| High values         |               |               |               |
| indicate fewer      |               |               |               |
| functional          |               |               |               |
| limitations.        |               |               |               |
|                     |               |               |               |
| ^a^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between those at    |               |               |               |
| this educational    |               |               |               |
| level and other     |               |               |               |
| consumers.          |               |               |               |
+---------------------+---------------+---------------+---------------+

In a separate report (Hayward and Schmidt-Davis, 1999), we analyzed the
functional status of VR consumers between the ages of 18 and 25 by
receipt of special education services. As table 6 shows, while they did
not differ significantly in terms of gross motor and personal care
function, individuals who did not receive special education services in
high school had fewer cognitive limitations.

+---------------------+---------------+---------------+---------------+
| []{#__RefHea        |               |               |               |
| ding___Toc124564947 |               |               |               |
| .anchor}Table 6.    |               |               |               |
| Functional status   |               |               |               |
| of transitional     |               |               |               |
| youths (youths with |               |               |               |
| disabilities        |               |               |               |
| between the ages of |               |               |               |
| 18 and 25) by       |               |               |               |
| receipt of special  |               |               |               |
| education services  |               |               |               |
+---------------------+---------------+---------------+---------------+
| **Functional        | Received      |               |               |
| limitation**        | special       |               |               |
|                     | education     |               |               |
|                     | services in   |               |               |
|                     | high school   |               |               |
+---------------------+---------------+---------------+---------------+
|                     | **Yes**       | **No**        | **Total**     |
+---------------------+---------------+---------------+---------------+
| Gross motor         | 1.94          | 1.93          | 1.93          |
| function            |               |               |               |
+---------------------+---------------+---------------+---------------+
| Cognitive           | 1.73          | 1.94          | 1.82          |
| function^a^         |               |               |               |
+---------------------+---------------+---------------+---------------+
| Personal care       | 1.98          | 1.99          | 1.98          |
| function            |               |               |               |
+---------------------+---------------+---------------+---------------+
| Source: VR          |               |               |               |
| Longitudinal Study  |               |               |               |
|                     |               |               |               |
| High values         |               |               |               |
| indicate fewer      |               |               |               |
| functional          |               |               |               |
| limitations.        |               |               |               |
|                     |               |               |               |
| ^a^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between those who   |               |               |               |
| received special    |               |               |               |
| education services  |               |               |               |
| in high school and  |               |               |               |
| those who did not.  |               |               |               |
+---------------------+---------------+---------------+---------------+

As table 7 shows, individuals who were working at application to VR had
fewer limitations on the gross motor scale and on the personal care
scale.

+---------------------+---------------+---------------+---------------+
| []{#__RefHea        |               |               |               |
| ding___Toc124564948 |               |               |               |
| .anchor}Table 7.    |               |               |               |
| Functional status   |               |               |               |
| by work status at   |               |               |               |
| application to VR   |               |               |               |
+---------------------+---------------+---------------+---------------+
| Work status at\     | Gross motor\  | Cognitive\    | Personal      |
| application to VR   | function^a^   | function      | care\         |
|                     |               |               | function^a^   |
+---------------------+---------------+---------------+---------------+
| Working             | 1.88          | 1.89          | 1.98          |
+---------------------+---------------+---------------+---------------+
| Not working         | 1.81          | 1.89          | 1.97          |
+---------------------+---------------+---------------+---------------+
| Source: VR          |               |               |               |
| Longitudinal Study  |               |               |               |
|                     |               |               |               |
| High values         |               |               |               |
| indicate fewer      |               |               |               |
| functional          |               |               |               |
| limitations.        |               |               |               |
|                     |               |               |               |
| ^a^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between those       |               |               |               |
| working at          |               |               |               |
| application to VR   |               |               |               |
| and those not       |               |               |               |
| working at          |               |               |               |
| application to VR.  |               |               |               |
+---------------------+---------------+---------------+---------------+

[As table 8 indicates, individuals who received SSI or SSDI at entry to
VR ranked much lower on all three functional status scales.]{.mark}

+---------------------+---------------+---+---------------+---+---------------+---+
| []{#__RefHea        |               |   |               |   |               |   |
| ding___Toc124564949 |               |   |               |   |               |   |
| .anchor}Table 8.    |               |   |               |   |               |   |
| Functional status   |               |   |               |   |               |   |
| by receipt of       |               |   |               |   |               |   |
| SSI/SSDI            |               |   |               |   |               |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Received            | Gross motor   | C |               | P |               |   |
|                     |               | o |               | e |               |   |
| SSI/SSDI            | function^a^   | g |               | r |               |   |
|                     |               | n |               | s |               |   |
|                     |               | i |               | o |               |   |
|                     |               | t |               | n |               |   |
|                     |               | i |               | a |               |   |
|                     |               | v |               | l |               |   |
|                     |               | e |               | c |               |   |
|                     |               | \ |               | a |               |   |
|                     |               | f |               | r |               |   |
|                     |               | u |               | e |               |   |
|                     |               | n |               | f |               |   |
|                     |               | c |               | u |               |   |
|                     |               | t |               | n |               |   |
|                     |               | i |               | c |               |   |
|                     |               | o |               | t |               |   |
|                     |               | n |               | i |               |   |
|                     |               | ^ |               | o |               |   |
|                     |               | a |               | n |               |   |
|                     |               | ^ |               | ^ |               |   |
|                     |               |   |               | a |               |   |
|                     |               |   |               | ^ |               |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Yes                 | 1.79          |   | 1.78          |   | 1.96          |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| No                  | 1.84          |   | 1.90          |   | 1.98          |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Source: VR          |               |   |               |   |               |   |
| Longitudinal Study  |               |   |               |   |               |   |
|                     |               |   |               |   |               |   |
| High values         |               |   |               |   |               |   |
| indicate fewer      |               |   |               |   |               |   |
| functional          |               |   |               |   |               |   |
| limitations.        |               |   |               |   |               |   |
|                     |               |   |               |   |               |   |
| ^a^ Indicates a     |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| difference (p\<.05) |               |   |               |   |               |   |
| between those who   |               |   |               |   |               |   |
| received SSI/SSDI   |               |   |               |   |               |   |
| and those who did   |               |   |               |   |               |   |
| not.                |               |   |               |   |               |   |
+---------------------+---------------+---+---------------+---+---------------+---+

## What are the interrelationships between functional limitations and the designation of individuals as: a) most significantly disabled; b) significantly disabled; c) nonsignificantly disabled; and d) Social Security recipients who are presumed to be individuals with a significant disability? Are persons with these different designations of disability significance different from each other in terms of their functional limitations? {#what-are-the-interrelationships-between-functional-limitations-and-the-designation-of-individuals-as-a-most-significantly-disabled-b-significantly-disabled-c-nonsignificantly-disabled-and-d-social-security-recipients-who-are-presumed-to-be-individuals-with-a-significant-disability-are-persons-with-these-different-designations-of-disability-significance-different-from-each-other-in-terms-of-their-functional-limitations .Question}

As table 9 indicates, all three functional status scales differentiate
between: 1) consumers with significant disabilities and those with
nonsignificant disabilities; and 2) between consumers with most
significant disabilities and those with nonsignificant disabilities.
Only the cognitive functioning scale distinguishes between those with
significant disabilities and those with most significant disabilities.
On all three dimensions, those with nonsignificant disabilities ranked
significantly higher than those with significant disabilities and those
with most significant disabilities. Consumers with significant
disabilities ranked higher on the cognitive functioning scale than those
with most significant disabilities, but these two groups did not differ
significantly on the other two scales.

+---------------------+---------------+---+---------------+---+---------------+---+
| []{#__RefHea        |               |   |               |   |               |   |
| ding___Toc124564950 |               |   |               |   |               |   |
| .anchor}Table 9.    |               |   |               |   |               |   |
| Functional status   |               |   |               |   |               |   |
| by significance of  |               |   |               |   |               |   |
| disability          |               |   |               |   |               |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Significance        | **Gross       | * |               | * |               |   |
|                     | motor\        | * |               | * |               |   |
| of disability       | f             | C |               | P |               |   |
|                     | unction^ab^** | o |               | e |               |   |
|                     |               | g |               | r |               |   |
|                     |               | n |               | s |               |   |
|                     |               | i |               | o |               |   |
|                     |               | t |               | n |               |   |
|                     |               | i |               | a |               |   |
|                     |               | v |               | l |               |   |
|                     |               | e |               | c |               |   |
|                     |               | \ |               | a |               |   |
|                     |               | f |               | r |               |   |
|                     |               | u |               | e |               |   |
|                     |               | n |               | \ |               |   |
|                     |               | c |               | f |               |   |
|                     |               | t |               | u |               |   |
|                     |               | i |               | n |               |   |
|                     |               | o |               | c |               |   |
|                     |               | n |               | t |               |   |
|                     |               | ^ |               | i |               |   |
|                     |               | a |               | o |               |   |
|                     |               | b |               | n |               |   |
|                     |               | c |               | ^ |               |   |
|                     |               | ^ |               | a |               |   |
|                     |               | * |               | b |               |   |
|                     |               | * |               | ^ |               |   |
|                     |               |   |               | * |               |   |
|                     |               |   |               | * |               |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Not significant     | 1.86          |   | 1.92          |   | 1.99          |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Significant         | 1.81          |   | 1.86          |   | 1.97          |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Most significant    | 1.81          |   | 1.80          |   | 1.96          |   |
+---------------------+---------------+---+---------------+---+---------------+---+
| Source: VR          |               |   |               |   |               |   |
| Longitudinal Study  |               |   |               |   |               |   |
|                     |               |   |               |   |               |   |
| High values         |               |   |               |   |               |   |
| indicate fewer      |               |   |               |   |               |   |
| functional          |               |   |               |   |               |   |
| limitations.        |               |   |               |   |               |   |
|                     |               |   |               |   |               |   |
| ^a^ Indicates a     |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| difference (p\<.05) |               |   |               |   |               |   |
| between those with  |               |   |               |   |               |   |
| nonsignificant      |               |   |               |   |               |   |
| disabilities and    |               |   |               |   |               |   |
| those with most     |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| disabilities.       |               |   |               |   |               |   |
|                     |               |   |               |   |               |   |
| ^b^ Indicates a     |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| difference (p\<.05) |               |   |               |   |               |   |
| between those with  |               |   |               |   |               |   |
| nonsignificant      |               |   |               |   |               |   |
| disabilities and    |               |   |               |   |               |   |
| those with          |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| disabilities.       |               |   |               |   |               |   |
|                     |               |   |               |   |               |   |
| ^c^ Indicates a     |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| difference (p\<.05) |               |   |               |   |               |   |
| between those with  |               |   |               |   |               |   |
| most significant    |               |   |               |   |               |   |
| disabilities and    |               |   |               |   |               |   |
| those with          |               |   |               |   |               |   |
| significant         |               |   |               |   |               |   |
| disabilities.       |               |   |               |   |               |   |
+---------------------+---------------+---+---------------+---+---------------+---+

Table 10 presents a comparison between the functional status of
individuals who received SSI or SSDI at entry to VR and of other
individuals with significant or most significant disabilities. Overall,
consumers who received financial assistance had more functional
limitations on all three dimensions.

+---------------------+---------------+---------------+---------------+
| []{#__RefHea        |               |               |               |
| ding___Toc124564951 |               |               |               |
| .anchor}Table 10.   |               |               |               |
| Functional status   |               |               |               |
| by automatic        |               |               |               |
| significance        |               |               |               |
| designation         |               |               |               |
+---------------------+---------------+---------------+---------------+
| Recipient           | Gross motor   | Cognitive\    | Personal care |
|                     | function^a^   | function^a^   | function^a^   |
+---------------------+---------------+---------------+---------------+
| SSI/SSDI recipient  | 1.79          | 1.78          | 1.96          |
+---------------------+---------------+---------------+---------------+
| Other significantly | 1.83          | 1.89          | 1.97          |
| or most             |               |               |               |
| significantly       |               |               |               |
| disabled            |               |               |               |
+---------------------+---------------+---------------+---------------+
| Source: VR          |               |               |               |
| Longitudinal Study  |               |               |               |
|                     |               |               |               |
| High values         |               |               |               |
| indicate fewer      |               |               |               |
| functional          |               |               |               |
| limitations.        |               |               |               |
|                     |               |               |               |
| ^a^ Indicates a     |               |               |               |
| significant         |               |               |               |
| difference (p\<.05) |               |               |               |
| between SSI/SSDI    |               |               |               |
| recipients and      |               |               |               |
| other individuals   |               |               |               |
| with                |               |               |               |
| significant/most    |               |               |               |
| significant         |               |               |               |
| designations.       |               |               |               |
+---------------------+---------------+---------------+---------------+

##  What are the relationships between consumers' functional limitations and: a) vocational goals; and b) services received (type, duration and cost)? {#what-are-the-relationships-between-consumers-functional-limitations-and-a-vocational-goals-and-b-services-received-type-duration-and-cost .Question}

As table 11 indicates, consumers whose vocational goal is structural
work had the fewest gross motor limitations. Those with vocational goals
in the service industry also had fewer gross motor limitations than
average. Consumers with homemaker as their vocational goal had many more
gross motor limitations than other consumers.

+-----------------------+---+--------------+---+--------------+---+--------------+
| []{#__RefH            |   |              |   |              |   |              |
| eading___Toc124564952 |   |              |   |              |   |              |
| .anchor}Table 11.     |   |              |   |              |   |              |
| Functional status by  |   |              |   |              |   |              |
| vocational goal       |   |              |   |              |   |              |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Vocational            | G |              | C |              | P |              |
|                       | r |              | o |              | e |              |
| goal                  | o |              | g |              | r |              |
|                       | s |              | n |              | s |              |
|                       | s |              | i |              | o |              |
|                       | m |              | t |              | n |              |
|                       | o |              | i |              | a |              |
|                       | t |              | v |              | l |              |
|                       | o |              | e |              | c |              |
|                       | r |              | \ |              | a |              |
|                       |   |              | f |              | r |              |
|                       | f |              | u |              | e |              |
|                       | u |              | n |              | f |              |
|                       | n |              | c |              | u |              |
|                       | c |              | t |              | n |              |
|                       | t |              | i |              | c |              |
|                       | i |              | o |              | t |              |
|                       | o |              | n |              | i |              |
|                       | n |              |   |              | o |              |
|                       |   |              |   |              | n |              |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Professional          |   | 1.83         |   | 1.92**^a^**  |   | 1.97         |
| /managerial/technical |   |              |   |              |   |              |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Clerical/sales        |   | 1.79         |   | 1.88**^a^**  |   | 1.97         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Service               |   | 1.87**^a^**  |   | 1.80         |   | 1.98**^a^**  |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Agricul               |   | 1.87         |   | 1.87**^a^**  |   | 1.98         |
| ture/fishing/forestry |   |              |   |              |   |              |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Processing            |   | 1.76         |   | 1.76         |   | 1.93         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Machine trades        |   | 1.83         |   | 1.85 **^a^** |   | 1.97         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Benchwork             |   | 1.83         |   | 1.71**^a^**  |   | 1.97         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Structural work       |   | 1.91**^a^**  |   | 1.88**^a^**  |   | 1.99**^a^**  |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Homemaker             |   | 1.49**^a^**  |   | 1.29**^a^**  |   | 1.92**^a^**  |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Miscellaneous         |   | 1.85         |   | 1.89**^a^**  |   | 1.97         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Other                 |   | 1.79         |   | 1.85**^a^**  |   | 1.96         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| All consumers         |   | 1.83         |   | 1.86         |   | 1.97         |
+-----------------------+---+--------------+---+--------------+---+--------------+
| Source: VR            |   |              |   |              |   |              |
| Longitudinal Study    |   |              |   |              |   |              |
|                       |   |              |   |              |   |              |
| High values indicate  |   |              |   |              |   |              |
| fewer functional      |   |              |   |              |   |              |
| limitations.          |   |              |   |              |   |              |
|                       |   |              |   |              |   |              |
| ^a^ Indicates a       |   |              |   |              |   |              |
| significant           |   |              |   |              |   |              |
| difference (p\<.05)   |   |              |   |              |   |              |
| between those with    |   |              |   |              |   |              |
| this vocational goal  |   |              |   |              |   |              |
| and those with all    |   |              |   |              |   |              |
| other vocational      |   |              |   |              |   |              |
| goals.                |   |              |   |              |   |              |
+-----------------------+---+--------------+---+--------------+---+--------------+

The highest level of cognitive function occurred among consumers with
professional, managerial or technical vocational goals. Individuals with
clerical or sales goals; agricultural, fishing, or forestry goals;
structural work goals; and miscellaneous goals also had higher than
average cognitive function. The lowest level of cognitive function
occurred among consumers with homemaker goals. Those with machine
trades, benchwork and other goals also had lower than average cognitive
function.

Consumers with structural work as their vocational goal had the highest
personal care function. Those with service as their vocational goal also
had higher than average personal care function. Again, the lowest levels
of functioning occurred among individuals with homemaker as their
vocational goal.

To investigate the relationship between consumers' functional status and
the services they receive, we focused on two groups of consumers: those
with orthopedic disabilities and those with mental retardation. We
selected these two groups because they represent a large subset of the
VR population (28.9 percent of Longitudinal Study participants had
orthopedic disabilities; 8.4 percent had mental retardation) and because
of the differences in their functioning levels. As discussed earlier,
individuals with orthopedic disabilities had higher than average
cognitive function but lower than average gross motor function, while
the reverse was true for individuals with mental retardation. For each
group, we selected services that are relevant to consumers' functional
status and compared individuals who received that service with those who
did not. Next, we examined: 1) the relationship between functional
status measures and the number of months an individual received VR
services; 2) the relationship between these measures; and 3) the cost of
VR services by calculating correlation coefficients for each group.

Among individuals with orthopedic disabilities, those who received
assistive technology assessments, devices or services ranked lower on
all three functional status scales than other individuals (tables 12, 13
and 14). Those who received medical services or occupational therapy
ranked lower on gross motor function.

Among individuals with mental retardation, those who received supported
employment services had higher levels of gross motor function (table
15), but lower levels of cognitive function (table 16). Those who
received maintenance services had higher levels of personal care
function than those who did not (table 17).

While a correlational analysis of all consumers revealed no significant
correlations between: 1) functional status measures individually and
throughout their time in VR; 2) the cost of VR services; or 3) the
number of services, there was a small but significant relationship
between an overall measure of functional status[^2] and their time in
VR, the cost of VR services and the number of services received. In all
three cases, the correlation was negative (-.06 for cost of services;
-.03 for time in VR; and -.05 for number of services), indicating that
individuals with low levels of functioning were likely to have higher
costs and more time in VR. Furthermore, the average cost of services for
individuals with low functional status was over twice that of
individuals with high functional status, and the average number of
services for individuals with low functional status was also
significantly higher than that of individuals with high functional
status (table 18).

+--------------------------------+------------------+------------------+
| [                              |                  |                  |
| ]{#__RefHeading___Toc124564953 |                  |                  |
| .anchor}Table 12. Gross motor  |                  |                  |
| function by receipt of         |                  |                  |
| selected services (individuals |                  |                  |
| with orthopedic disabilities)  |                  |                  |
+--------------------------------+------------------+------------------+
| **Service**                    | **Received       | **Did not        |
|                                | service**        | receive          |
|                                |                  | service**        |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.34             | 1.66             |
| assessment^a^                  |                  |                  |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.47             | 1.68             |
| devices^a^                     |                  |                  |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.37             | 1.65             |
| services^a^                    |                  |                  |
+--------------------------------+------------------+------------------+
| Medical services^a^            | 1.61             | 1.65             |
+--------------------------------+------------------+------------------+
| Physical therapy               | 1.60             | 1.65             |
+--------------------------------+------------------+------------------+
| Occupational therapy^a^        | 1.42             | 1.65             |
+--------------------------------+------------------+------------------+
| In-house vocational evaluation | 1.69             | 1.64             |
+--------------------------------+------------------+------------------+
| Off-site vocational evaluation | 1.66             | 1.64             |
+--------------------------------+------------------+------------------+
| Source: VR Longitudinal Study  |                  |                  |
|                                |                  |                  |
| High values indicate fewer     |                  |                  |
| functional limitations.        |                  |                  |
|                                |                  |                  |
| ^a^ Indicates a significant    |                  |                  |
| difference (p\<.05) between    |                  |                  |
| individuals who received the   |                  |                  |
| service and those who did not. |                  |                  |
+--------------------------------+------------------+------------------+

+--------------------------------+------------------+------------------+
| [                              |                  |                  |
| ]{#__RefHeading___Toc124564954 |                  |                  |
| .anchor}Table 13. Cognitive    |                  |                  |
| function by receipt of         |                  |                  |
| selected services (individuals |                  |                  |
| with orthopedic disabilities)  |                  |                  |
+--------------------------------+------------------+------------------+
| Service                        | Received service | Did not receive  |
|                                |                  | service          |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.71             | 1.90             |
| assessment^a^                  |                  |                  |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.81             | 1.90             |
| devices^a^                     |                  |                  |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.72             | 1.89             |
| services^a^                    |                  |                  |
+--------------------------------+------------------+------------------+
| Medical services               | 1.88             | 1.89             |
+--------------------------------+------------------+------------------+
| Physical therapy               | 1.88             | 1.89             |
+--------------------------------+------------------+------------------+
| Occupational therapy           | 1.79             | 1.89             |
+--------------------------------+------------------+------------------+
| In-house vocational evaluation | 1.90             | 1.89             |
+--------------------------------+------------------+------------------+
| Off-site vocational evaluation | 1.88             | 1.89             |
+--------------------------------+------------------+------------------+
| Source: VR Longitudinal Study  |                  |                  |
|                                |                  |                  |
| High values indicate fewer     |                  |                  |
| functional limitations.        |                  |                  |
|                                |                  |                  |
| ^a^ Indicates a significant    |                  |                  |
| difference (p\<.05) between    |                  |                  |
| individuals who received the   |                  |                  |
| service and those who did not. |                  |                  |
+--------------------------------+------------------+------------------+

+--------------------------------+------------------+------------------+
| [                              |                  |                  |
| ]{#__RefHeading___Toc124564955 |                  |                  |
| .anchor}Table 14. Personal     |                  |                  |
| care function by receipt of    |                  |                  |
| selected services (individuals |                  |                  |
| with orthopedic disabilities)  |                  |                  |
+--------------------------------+------------------+------------------+
| Service                        | Received service | Did not receive  |
|                                |                  | service          |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.73             | 1.94             |
| assessment^a^                  |                  |                  |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.84             | 1.94             |
| devices^a^                     |                  |                  |
+--------------------------------+------------------+------------------+
| Assistive technology           | 1.70             | 1.93             |
| services^a^                    |                  |                  |
+--------------------------------+------------------+------------------+
| Medical services               | 1.93             | 1.93             |
+--------------------------------+------------------+------------------+
| Physical therapy               | 1.92             | 1.93             |
+--------------------------------+------------------+------------------+
| Occupational therapy           | 1.83             | 1.93             |
+--------------------------------+------------------+------------------+
| In-house vocational evaluation | 1.93             | 1.93             |
+--------------------------------+------------------+------------------+
| Off-site vocational evaluation | 1.93             | 1.93             |
+--------------------------------+------------------+------------------+
| Source: VR Longitudinal Study  |                  |                  |
|                                |                  |                  |
| High values indicate fewer     |                  |                  |
| functional limitations.        |                  |                  |
|                                |                  |                  |
| ^a^ Indicates a significant    |                  |                  |
| difference (p\<.05) between    |                  |                  |
| individuals who received the   |                  |                  |
| service and those who did not. |                  |                  |
+--------------------------------+------------------+------------------+

+--------------------------------+------------------+---+------------------+---+
| [                              |                  |   |                  |   |
| ]{#__RefHeading___Toc124564956 |                  |   |                  |   |
| .anchor}Table 15. Gross motor  |                  |   |                  |   |
| function by receipt of         |                  |   |                  |   |
| selected services (individuals |                  |   |                  |   |
| with mental retardation)       |                  |   |                  |   |
+--------------------------------+------------------+---+------------------+---+
| Service                        | Received service |   | Did not receive  |   |
|                                |                  |   | service          |   |
+--------------------------------+------------------+---+------------------+---+
| Work adjustment                | 1.92             | 1 |                  |   |
|                                |                  | . |                  |   |
|                                |                  | 9 |                  |   |
|                                |                  | 2 |                  |   |
+--------------------------------+------------------+---+------------------+---+
| Supported employment ^a^       | 1.95             | 1 |                  |   |
|                                |                  | . |                  |   |
|                                |                  | 9 |                  |   |
|                                |                  | 1 |                  |   |
+--------------------------------+------------------+---+------------------+---+
| Maintenance                    | 1.93             | 1 |                  |   |
|                                |                  | . |                  |   |
|                                |                  | 9 |                  |   |
|                                |                  | 2 |                  |   |
+--------------------------------+------------------+---+------------------+---+
| Transportation                 | 1.92             | 1 |                  |   |
|                                |                  | . |                  |   |
|                                |                  | 9 |                  |   |
|                                |                  | 2 |                  |   |
+--------------------------------+------------------+---+------------------+---+
| In-house vocational evaluation | 1.92             | 1 |                  |   |
|                                |                  | . |                  |   |
|                                |                  | 9 |                  |   |
|                                |                  | 2 |                  |   |
+--------------------------------+------------------+---+------------------+---+
| Off-site vocational evaluation | 1.90             | 1 |                  |   |
| ^a^                            |                  | . |                  |   |
|                                |                  | 9 |                  |   |
|                                |                  | 2 |                  |   |
+--------------------------------+------------------+---+------------------+---+
| Source: VR Longitudinal Study  |                  |   |                  |   |
|                                |                  |   |                  |   |
| High values indicate fewer     |                  |   |                  |   |
| functional limitations.        |                  |   |                  |   |
|                                |                  |   |                  |   |
| ^a^ Indicates a significant    |                  |   |                  |   |
| difference (p\<.05) between    |                  |   |                  |   |
| individuals who received the   |                  |   |                  |   |
| service and those who did not. |                  |   |                  |   |
+--------------------------------+------------------+---+------------------+---+

+--------------------------------+------------------+------------------+
| [                              |                  |                  |
| ]{#__RefHeading___Toc124564957 |                  |                  |
| .anchor}Table 16. Cognitive    |                  |                  |
| function by receipt of         |                  |                  |
| selected services (individuals |                  |                  |
| with mental retardation)       |                  |                  |
+--------------------------------+------------------+------------------+
| Service                        | Received service | Did not receive  |
|                                |                  | service          |
+--------------------------------+------------------+------------------+
| Work adjustment                | 1.51             | 1.58             |
+--------------------------------+------------------+------------------+
| Supported employment ^a^       | 1.48             | 1.59             |
+--------------------------------+------------------+------------------+
| Maintenance                    | 1.59             | 1.56             |
+--------------------------------+------------------+------------------+
| Transportation                 | 1.55             | 1.57             |
+--------------------------------+------------------+------------------+
| In-house vocational evaluation | 1.62             | 1.56             |
| ^a^                            |                  |                  |
+--------------------------------+------------------+------------------+
| Off-site vocational evaluation | 1.51             | 1.59             |
+--------------------------------+------------------+------------------+
| Source: VR Longitudinal Study  |                  |                  |
|                                |                  |                  |
| High values indicate fewer     |                  |                  |
| functional limitations.        |                  |                  |
|                                |                  |                  |
| ^a^ Indicates a significant    |                  |                  |
| difference (p\<.05) between    |                  |                  |
| individuals who received the   |                  |                  |
| service and those who did not. |                  |                  |
+--------------------------------+------------------+------------------+

+--------------------------------+------------------+------------------+
| [                              |                  |                  |
| ]{#__RefHeading___Toc124564958 |                  |                  |
| .anchor}Table 17. Personal     |                  |                  |
| care function by receipt of    |                  |                  |
| selected services (individuals |                  |                  |
| with mental retardation)       |                  |                  |
+--------------------------------+------------------+------------------+
| Service                        | Received service | Did not receive  |
|                                |                  | service          |
+--------------------------------+------------------+------------------+
| Work adjustment                | 1.99             | 1.98             |
+--------------------------------+------------------+------------------+
| Supported employment           | 1.99             | 1.98             |
+--------------------------------+------------------+------------------+
| Maintenance^a^                 | 2.00             | 1.98             |
+--------------------------------+------------------+------------------+
| Transportation                 | 1.98             | 1.98             |
+--------------------------------+------------------+------------------+
| In-house vocational evaluation | 2.00             | 1.98             |
+--------------------------------+------------------+------------------+
| Off-site vocational evaluation | 1.96             | 1.99             |
+--------------------------------+------------------+------------------+
| Source: VR Longitudinal Study  |                  |                  |
|                                |                  |                  |
| High values indicate fewer     |                  |                  |
| functional limitations.        |                  |                  |
|                                |                  |                  |
| ^a^ Indicates a significant    |                  |                  |
| difference (p\<.05) between    |                  |                  |
| individuals who received the   |                  |                  |
| service and those who did not. |                  |                  |
+--------------------------------+------------------+------------------+

  --------------------------------- ----------------------- -----------------------
  []{#__RefHeading___Toc124564959                           
  .anchor}Table 18. Overall                                 
  functional status by average cost                         
  of services                                               

  Overall functional status         Average cost of         Average number of
                                    services                services

  High                              \$4,667                 8.8

  Middle                            \$5,796                 9.0

  Low                               \$11,213                10.1

  Source: VR Longitudinal Study                             
  --------------------------------- ----------------------- -----------------------

## Are there differences in functional limitations for consumers whose cases were closed: a) without receiving services; b) nonrehabilitated after receiving services; c) rehabilitated into noncompetitive employment; and d) rehabilitated into competitive employment? {#are-there-differences-in-functional-limitations-for-consumers-whose-cases-were-closed-a-without-receiving-services-b-nonrehabilitated-after-receiving-services-c-rehabilitated-into-noncompetitive-employment-and-d-rehabilitated-into-competitive-employment .Question}

As table 19 shows, the highest functioning levels on all three
functional status scales were for consumers who achieved competitive
employment outcomes. Individuals who were ineligible for services had
the second highest level on all three scales (although their personal
care function did not differ significantly from consumers who achieved a
competitive employment outcome), followed by those who received services
but failed to achieve an employment outcome. Consumers who achieved a
noncompetitive employment outcome and those who were eligible but did
not receive services were the lowest-scoring groups, with those who
achieved noncompetitive employment outcomes having particularly low
cognitive function.

+--------------------------------+-----------+-----------+-----------+
| [                              |           |           |           |
| ]{#__RefHeading___Toc124564960 |           |           |           |
| .anchor}Table 19. Functional   |           |           |           |
| status by closure status       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
|                                | Gross     | Cognitive | Personal  |
|                                | motor     | function  | care      |
|                                | function  |           | function  |
+--------------------------------+-----------+-----------+-----------+
| Achieved a competitive         | 1.87      | 1.89      | 1.98      |
| employment outcome             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Achieved a noncompetitive      | 1.79^a^   | 1.67^a^   | 1.96^a^   |
| employment outcome             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Received services, but failed  | 1.80^a^   | 1.85^a^   | 1.97^a^   |
| to achieve an employment       |           |           |           |
| outcome                        |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Eligible, but did not receive  | 1.77^a^   | 1.85^a^   | 1.96^a^   |
| services                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Ineligible for services        | 1.80^a^   | 1.86^a^   | 1.97      |
+--------------------------------+-----------+-----------+-----------+
| Source: VR Longitudinal Study  |           |           |           |
|                                |           |           |           |
| High values indicate fewer     |           |           |           |
| functional limitations.        |           |           |           |
|                                |           |           |           |
| ^a^ Indicates a significant    |           |           |           |
| difference (p\<.05) between    |           |           |           |
| those in this category and     |           |           |           |
| those who achieved a           |           |           |           |
| competitive employment         |           |           |           |
| outcome.                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+

## Are functional limitations a more consistent predictor of vocational outcome than: a) severity of disability designation; or b) other consumer characteristics, including type of disability, age, sex, education, employment experience, receipt of public assistance and race and ethnic group? {#are-functional-limitations-a-more-consistent-predictor-of-vocational-outcome-than-a-severity-of-disability-designation-or-b-other-consumer-characteristics-including-type-of-disability-age-sex-education-employment-experience-receipt-of-public-assistance-and-race-and-ethnic-group .Question}

We conducted two regression analyses to investigate the effect of
functional status on employment outcomes. In both analyses, we included
the following variables: disability type, age, sex, years of education,
work status at application, receipt of SSI or SSDI, race (white or
nonwhite), and the three functional status scales. Table 20 shows which
of these factors significantly predict whether consumers achieved an
employment outcome at closure and if they did, whether this outcome was
competitive. Figures 1 and 2 present these results graphically.

Individuals with visual or hearing impairments and those with mental
retardation were more likely than individuals with orthopedic
disabilities to achieve an employment outcome at closure, while
consumers with mental illnesses were less likely than those with
orthopedic disabilities. Working at application of VR services increased
the odds of achieving an employment outcome, while receiving SSI or SSDI
and being nonwhite decreased the odds. Higher levels of gross motor
function were associated with achieving an employment outcome.

Having either a visual impairment, mental illness or mental retardation
decreased the likelihood of achieving a competitive employment outcome.
Older individuals and those who received SSI or SSDI were also less
likely to achieve a competitive employment outcome. Higher levels of
gross motor function and cognitive function were associated with
achieving a competitive employment outcome.

+----------+------------------------------------+-------------+-------+
| []{#__R  |                                    |             |       |
| efHeadin |                                    |             |       |
| g___Toc1 |                                    |             |       |
| 24564961 |                                    |             |       |
| .anch    |                                    |             |       |
| or}Table |                                    |             |       |
| 20.      |                                    |             |       |
| Re       |                                    |             |       |
| gression |                                    |             |       |
| models   |                                    |             |       |
| of       |                                    |             |       |
| consumer |                                    |             |       |
| ou       |                                    |             |       |
| tcomes\* |                                    |             |       |
+----------+------------------------------------+-------------+-------+
| Model    | Influencing\                       | **Uns       | p     |
|          | factor                             | tandardized |       |
|          |                                    | weight**    |       |
+----------+------------------------------------+-------------+-------+
| ***Em    |                                    |             |       |
| ployment |                                    |             |       |
| Outcome  |                                    |             |       |
| (R^2^ =  |                                    |             |       |
| .06)***  |                                    |             |       |
+----------+------------------------------------+-------------+-------+
|          | Vision (versus orthopedic          | 0.80        | .0013 |
|          | physical)                          |             |       |
+----------+------------------------------------+-------------+-------+
|          | Hearing (versus orthopedic         | 0.62        | .0003 |
|          | physical)                          |             |       |
+----------+------------------------------------+-------------+-------+
|          | Mental illness (versus orthopedic  | -0.21       | .0392 |
|          | physical)                          |             |       |
+----------+------------------------------------+-------------+-------+
|          | Mental retardation (versus         | 0.62        | \<    |
|          | orthopedic physical)               |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | Working at application for VR      | 0.79        | \<    |
|          | services                           |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | Receipt of SSI/SSDI                | -0.41       | \<    |
|          |                                    |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | Nonwhite                           | -0.26       | .0029 |
+----------+------------------------------------+-------------+-------+
|          | High gross motor function          | 0.77        | \<    |
|          |                                    |             | .0001 |
+----------+------------------------------------+-------------+-------+
| ***Com   |                                    |             |       |
| petitive |                                    |             |       |
| Em       |                                    |             |       |
| ployment |                                    |             |       |
| Outcome  |                                    |             |       |
| (R^2^ =  |                                    |             |       |
| .17)***  |                                    |             |       |
+----------+------------------------------------+-------------+-------+
|          | Vision (versus orthopedic          | -0.71       | .0229 |
|          | physical)                          |             |       |
+----------+------------------------------------+-------------+-------+
|          | Mental illness (versus orthopedic  | -0.79       | \<    |
|          | physical)                          |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | Mental retardation (versus         | -1.36       | \<    |
|          | orthopedic physical)               |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | Age (older)                        | -0.03       | \<    |
|          |                                    |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | Receipt of SSI/SSDI                | -0.63       | \<    |
|          |                                    |             | .0001 |
+----------+------------------------------------+-------------+-------+
|          | High gross motor function          | 1.00        | .0004 |
+----------+------------------------------------+-------------+-------+
|          | High cognitive function            | 2.08        | \<    |
|          |                                    |             | .0001 |
+----------+------------------------------------+-------------+-------+
| Source:  |                                    |             |       |
| VR       |                                    |             |       |
| Long     |                                    |             |       |
| itudinal |                                    |             |       |
| Study    |                                    |             |       |
|          |                                    |             |       |
| \* We    |                                    |             |       |
| used     |                                    |             |       |
| un       |                                    |             |       |
| weighted |                                    |             |       |
| stepwise |                                    |             |       |
| logistic |                                    |             |       |
| re       |                                    |             |       |
| gression |                                    |             |       |
| te       |                                    |             |       |
| chniques |                                    |             |       |
| to       |                                    |             |       |
| create   |                                    |             |       |
| these    |                                    |             |       |
| two      |                                    |             |       |
| models.  |                                    |             |       |
+----------+------------------------------------+-------------+-------+

After including the functional limitation scales in the analysis, we
found that in these two models, disability significance was not a
statistically important predictor of either employment outcome or
competitive employment outcome. While information about individuals'
functional limitations contributed to our understanding of employment
outcomes, information about the significance of their disabilities was
decidedly less useful in this regard.

In a related analysis, we tested the combined effect of all three
functional status measures on these two outcomes after including all of
the aforementioned factors. The effect of functional status was
significant for both outcomes, indicating that functional status had a
relationship with employment outcomes even after other important
characteristics were considered.

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc87859519 .anchor}Figure 1. Employment outcome
  (R^2^ = .06)

  ![](media/image2.wmf){width="5.9875in" height="2.113888888888889in"}
  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc87859520 .anchor}Figure 2. Competitive employment
  outcome (R^2^ = .17)

  ![](media/image3.wmf){width="6.25in" height="1.5638888888888889in"}
  -----------------------------------------------------------------------

##  {#section .Question}

## What is the relationship between functional limitations and: a) the earnings levels of persons closed into competitive employment; b) other rehabilitants by category (e.g., homemaker, unpaid family worker); and c) stability of employment over time? {#what-is-the-relationship-between-functional-limitations-and-a-the-earnings-levels-of-persons-closed-into-competitive-employment-b-other-rehabilitants-by-category-e.g.-homemaker-unpaid-family-worker-and-c-stability-of-employment-over-time .Question}

Among individuals who achieved a competitive employment outcome, those
who earned more than \$9.00 per hour had significantly higher cognitive
function than those who earned up to \$5.00 per hour. There were no
significant differences on the other two functional status scales (table
21).

Tashjian and Schmidt-Davis (2000) looked at the functional status of
consumers who exited VR into supported employment (SE) and compared them
with other consumers who achieved an employment outcome at exit (table
22). To separate the effect of disability type from the effect of type
of employment at exit, we compared individuals with mental retardation
who achieved a supported employment outcome with other individuals who
achieved a supported employment outcome. We discovered that consumers
with mental retardation had more cognitive limitations than other SE
consumers. Next, we compared consumers with mental retardation who
achieved an employment outcome other than by supported employment with
consumers with other types of disabilities who achieved a nonsupported
employment outcome. The data showed that consumers with mental
retardation in this group had fewer gross motor limitations and more
cognitive limitations than other consumers in this group.

+--------------------------+-------------+-------------+-------------+
| []{#__R                  |             |             |             |
| efHeading___Toc124564962 |             |             |             |
| .anchor}Table 21.        |             |             |             |
| Functional status by     |             |             |             |
| earnings levels          |             |             |             |
+--------------------------+-------------+-------------+-------------+
|                          | Gross       | Cognitive\  | Personal    |
|                          | motor\      | function^a^ | care        |
|                          | function    |             | function    |
+--------------------------+-------------+-------------+-------------+
| Less than or equal to    | 1.88        | 1.83        | 1.98        |
| \$5.00 per hour          |             |             |             |
+--------------------------+-------------+-------------+-------------+
| \$5.01 - \$7.00 per hour | 1.86        | 1.89        | 1.99        |
+--------------------------+-------------+-------------+-------------+
| \$7.01 - \$9.00 per hour | 1.86        | 1.93        | 1.98        |
+--------------------------+-------------+-------------+-------------+
| More than \$9.00 per     | 1.87        | 1.93        | 1.98        |
| hour                     |             |             |             |
+--------------------------+-------------+-------------+-------------+
| Source: VR Longitudinal  |             |             |             |
| Study                    |             |             |             |
|                          |             |             |             |
| High values indicate     |             |             |             |
| fewer functional         |             |             |             |
| limitations.             |             |             |             |
|                          |             |             |             |
| ^a^ Indicates a          |             |             |             |
| significant difference   |             |             |             |
| in means or percentages  |             |             |             |
| between those earning    |             |             |             |
| less than or equal to    |             |             |             |
| \$5.00 per hour and      |             |             |             |
| those earning more than  |             |             |             |
| \$9.00 per hour          |             |             |             |
| (p\<.05).                |             |             |             |
+--------------------------+-------------+-------------+-------------+

+----------+---------+---------+---------+---------+---------+---------+
| []{#__R  |         |         |         |         |         |         |
| efHeadin |         |         |         |         |         |         |
| g___Toc1 |         |         |         |         |         |         |
| 24564963 |         |         |         |         |         |         |
| .anch    |         |         |         |         |         |         |
| or}Table |         |         |         |         |         |         |
| 22.      |         |         |         |         |         |         |
| Fu       |         |         |         |         |         |         |
| nctional |         |         |         |         |         |         |
| status   |         |         |         |         |         |         |
| by       |         |         |         |         |         |         |
| s        |         |         |         |         |         |         |
| upported |         |         |         |         |         |         |
| em       |         |         |         |         |         |         |
| ployment |         |         |         |         |         |         |
| and      |         |         |         |         |         |         |
| di       |         |         |         |         |         |         |
| sability |         |         |         |         |         |         |
| type     |         |         |         |         |         |         |
+==========+=========+=========+=========+=========+=========+=========+
| Function | Su      |         |         | Other   |         |         |
|          | pported |         |         | co      |         |         |
|          | emp     |         |         | nsumers |         |         |
|          | loyment |         |         |         |         |         |
|          | co      |         |         |         |         |         |
|          | nsumers |         |         |         |         |         |
+----------+---------+---------+---------+---------+---------+---------+
|          | SE      | Other   | Total   | Co      | Other   | Total   |
|          | co      | SE      | SE      | nsumers | co      | co      |
|          | nsumers | co      | co      | with    | nsumers | nsumers |
|          | with    | nsumers | nsumers | mental  |         |         |
|          | mental  |         |         | reta    |         |         |
|          | reta    |         |         | rdation |         |         |
|          | rdation |         |         |         |         |         |
+----------+---------+---------+---------+---------+---------+---------+
| Gross    | 1.87    | 1.82    | 1.83    | 1.93    | 1.82    | 1.83    |
| motor    |         |         |         |         |         |         |
| fun      |         |         |         |         |         |         |
| ction^b^ |         |         |         |         |         |         |
+----------+---------+---------+---------+---------+---------+---------+
| C        | 1.59    | 1.83    | 1.82    | 1.54    | 1.85    | 1.82    |
| ognitive |         |         |         |         |         |         |
| funct    |         |         |         |         |         |         |
| ion^a,b^ |         |         |         |         |         |         |
+----------+---------+---------+---------+---------+---------+---------+
| Personal | 1.97    | 1.98    | 1.98    | 1.98    | 1.97    | 1.97    |
| care     |         |         |         |         |         |         |
| function |         |         |         |         |         |         |
+----------+---------+---------+---------+---------+---------+---------+
| Source:  |         |         |         |         |         |         |
| VR       |         |         |         |         |         |         |
| Long     |         |         |         |         |         |         |
| itudinal |         |         |         |         |         |         |
| Study    |         |         |         |         |         |         |
|          |         |         |         |         |         |         |
| High     |         |         |         |         |         |         |
| values   |         |         |         |         |         |         |
| indicate |         |         |         |         |         |         |
| fewer    |         |         |         |         |         |         |
| fu       |         |         |         |         |         |         |
| nctional |         |         |         |         |         |         |
| limi     |         |         |         |         |         |         |
| tations. |         |         |         |         |         |         |
|          |         |         |         |         |         |         |
| ^a^      |         |         |         |         |         |         |
| I        |         |         |         |         |         |         |
| ndicates |         |         |         |         |         |         |
| a        |         |         |         |         |         |         |
| sig      |         |         |         |         |         |         |
| nificant |         |         |         |         |         |         |
| di       |         |         |         |         |         |         |
| fference |         |         |         |         |         |         |
| between  |         |         |         |         |         |         |
| SE       |         |         |         |         |         |         |
| c        |         |         |         |         |         |         |
| onsumers |         |         |         |         |         |         |
| with     |         |         |         |         |         |         |
| mental   |         |         |         |         |         |         |
| ret      |         |         |         |         |         |         |
| ardation |         |         |         |         |         |         |
| and      |         |         |         |         |         |         |
| other SE |         |         |         |         |         |         |
| co       |         |         |         |         |         |         |
| nsumers. |         |         |         |         |         |         |
|          |         |         |         |         |         |         |
| ^b^      |         |         |         |         |         |         |
| I        |         |         |         |         |         |         |
| ndicates |         |         |         |         |         |         |
| a        |         |         |         |         |         |         |
| sig      |         |         |         |         |         |         |
| nificant |         |         |         |         |         |         |
| di       |         |         |         |         |         |         |
| fference |         |         |         |         |         |         |
| between  |         |         |         |         |         |         |
| c        |         |         |         |         |         |         |
| onsumers |         |         |         |         |         |         |
| with     |         |         |         |         |         |         |
| mental   |         |         |         |         |         |         |
| ret      |         |         |         |         |         |         |
| ardation |         |         |         |         |         |         |
| and      |         |         |         |         |         |         |
| other    |         |         |         |         |         |         |
| co       |         |         |         |         |         |         |
| nsumers. |         |         |         |         |         |         |
+----------+---------+---------+---------+---------+---------+---------+

We also compared consumers who achieved an employment outcome by the
type of job they had at exit from VR. Table 23 shows that, while
consumers who exited into sheltered workshops did not differ
significantly from those who exited into competitive employment on gross
motor and personal care function, they ranked significantly lower on
cognitive function.

+--------------------------+--------------------+---------------------+
| []{#__R                  |                    |                     |
| efHeading___Toc124564964 |                    |                     |
| .anchor}Table 23.        |                    |                     |
| Functional status by     |                    |                     |
| sheltered workshop       |                    |                     |
| versus competitive       |                    |                     |
| employment               |                    |                     |
+==========================+====================+=====================+
| Function                 | **Consumers closed | **Consumers closed  |
|                          | into sheltered     | into competitive    |
|                          | workshops**        | employment**        |
+--------------------------+--------------------+---------------------+
| Gross motor function     | 1.81               | 1.86                |
+--------------------------+--------------------+---------------------+
| Cognitive function^a^    | 1.67               | 1.91                |
+--------------------------+--------------------+---------------------+
| Personal care function   | 1.95               | 1.98                |
+--------------------------+--------------------+---------------------+
| Source: VR Longitudinal  |                    |                     |
| Study                    |                    |                     |
|                          |                    |                     |
| High values indicate     |                    |                     |
| fewer functional         |                    |                     |
| limitations.             |                    |                     |
|                          |                    |                     |
| ^a^ Indicates a          |                    |                     |
| significant difference   |                    |                     |
| between consumers closed |                    |                     |
| into sheltered workshops |                    |                     |
| and consumers closed     |                    |                     |
| into competitive         |                    |                     |
| employment.              |                    |                     |
+--------------------------+--------------------+---------------------+

Table 24 presents a comparison of functional status of consumers who
were employed at closure only with those who were employed up to three
years later. This analysis revealed no significant differences on any of
the three scales.

+-----------------------------+------------+------------+------------+
| []{#                        |            |            |            |
| __RefHeading___Toc124564965 |            |            |            |
| .anchor}Table 24.           |            |            |            |
| Functional status by        |            |            |            |
| retention of employment     |            |            |            |
| over time (competitively    |            |            |            |
| employed only)              |            |            |            |
+-----------------------------+------------+------------+------------+
| Length of time employed     | Gross      | Cognitive  | Personal   |
|                             | motor      | function   | care       |
|                             | f          |            | function   |
|                             | unction^a^ |            |            |
+-----------------------------+------------+------------+------------+
| Employed at exit from VR,   | 1.85       | 1.89       | 1.98       |
| not employed in subsequent  |            |            |            |
| years                       |            |            |            |
+-----------------------------+------------+------------+------------+
| Employed at 1-year          | 1.86       | 1.90       | 1.99       |
| follow-up, not employed in  |            |            |            |
| subsequent years            |            |            |            |
+-----------------------------+------------+------------+------------+
| Employed at 2-year          | 1.88       | 1.89       | 1.99       |
| follow-up, not employed in  |            |            |            |
| subsequent years            |            |            |            |
+-----------------------------+------------+------------+------------+
| Employed at 3-year          | 1.89       | 1.89       | 1.98       |
| follow-up, not employed in  |            |            |            |
| subsequent years            |            |            |            |
+-----------------------------+------------+------------+------------+
| Source: VR Longitudinal     |            |            |            |
| Study                       |            |            |            |
|                             |            |            |            |
| High values indicate fewer  |            |            |            |
| functional limitations.     |            |            |            |
|                             |            |            |            |
| ^a^ Indicates a significant |            |            |            |
| difference (p\<.05) between |            |            |            |
| those employed at closure   |            |            |            |
| and up to their one year    |            |            |            |
| follow-up and those who     |            |            |            |
| were employed at the time   |            |            |            |
| of their two- or three-year |            |            |            |
| follow-up.                  |            |            |            |
+-----------------------------+------------+------------+------------+

##  {#section-1 .Question}

## Do functional limitations change over time, especially with receipt of VR services? {#do-functional-limitations-change-over-time-especially-with-receipt-of-vr-services .Question}

To examine changes over time, we compared consumers' functional status
scores at entry to VR and at exit from VR. We found no significant
differences, even among consumers who closed more than three years after
they entered VR.

# Conclusion

Functional status scales provide more comprehensive information about
the nature of consumers' impairments and about how these impairments
constrain their abilities to obtain and retain employment than the
traditional classification of disabilities as nonsignificant,
significant or most significant. These scales offer efficient ways of
capturing differences between groups. As our analyses have shown, VR
consumers differ on these three dimensions across disability,
demographic, vocational characteristics, type of services received and
employment outcomes. Furthermore, functional status scales are much more
powerful predictors of employment outcomes and of competitive employment
outcomes than the significance designation set forth in the
*Rehabilitation Act*. We plan to use these scales in more complex
structural equation and path analysis models that will provide better
information about the effect of initial functional status over time and
the effect of receipt of services on functional status.

In conclusion, because the functional status scales are based on
Activities of Daily Living (ADL) and Instrumental Activities of Daily
Living (IADL) items, their utility for certain disabilities may be
limited. These items, while in widespread use on national surveys of
individuals with disabilities, are not sensitive indicators of
functional status among persons with mental illness or visual
impairments, for example. Therefore, since this approach to the
measurement of functional status has promise, it may be appropriate to
conduct further research designed to improve the utility of these
measures for specific types of disabilities.

# References

Clark, D.O., T.W. Stump, and F.D. Wolinsky. 1997. "A race- and
gender-specific replication of five dimensions of functional limitation
and disability." *Journal of Aging and Health* 9 (1): 28-42.

Fitzgerald, J.F., D.M. Smith, D.K. Martin, J.A. Freedman, and F.D.
Wolinsky. 1993. "Replication of the multidimensionality of activities of
daily living." *Journal of Gerontology* 48 (1): S28-S31.

Hayward, B.J. and H.A. Schmidt-Davis. 1999. *A longitudinal study of the
Vocational Rehabilitation Service Program: Fourth interim report.*
Research Triangle Park, NC: Research Triangle Institute.

Hayward, B.J. and M.D. Tashjian. 1996. *A longitudinal study of the
Vocational Rehabilitation Service Program: Second interim report.*
Research Triangle Park, NC: Research Triangle Institute.

Johnson, R.J. and F.D. Wolinsky. 1993. "The structure of health status
among older adults: Disease, disability, functional limitation, and
perceived health." *Journal of Health and Social Behavior* 34 (2):
105-121.

Overman, B.M. and H.A. Schmidt-Davis. 2000. "Analysis of the National
Health Interview Survey: The vocational rehabilitation perspective."
Research Triangle Park, NC: Research Triangle Institute.

Spector, W.D. and J.A. Fleishman. 1998. "Combining activities of daily
living with instrumental activities of daily living to measure
functional disability." *Journal of Gerontology* 53B (1): S46-S57.

Tashjian, M.D. and H.A. Schmidt-Davis. 2000. *Vocational Rehabilitation
experiences among individuals who achieved a supported employment
outcome*. Research Triangle Park, NC: Research Triangle Institute.

Thomas, V.S., K. Rockwood, and I. McDowell. 1998. "Multidimensionality
in instrumental and basic activities of daily living." *Journal of
Clinical Epidemiology* 51 (4): 315-321.

Wolinsky, F.D. and R.J. Johnson. 1991. "The use of health services by
older adults." *Journal of Gerontology* 46 (6): S345-357.

#   {#section-2 .unnumbered}

# Appendix A:  Theoretical Background and Scale Development

##   {#section-3 .unnumbered}

## Theoretical Background

Gerontology researchers have used factor analysis to explore the number
of underlying dimensions in ADL and IADL items with differing results
(table A-1). Johnson and Wolinsky (1993) identified five factors---Basic
ADL, Household ADL, Advanced ADL, and Lower and Upper Body
Limitations[^3]---that seemed to summarize the functional status of
individuals aged 70 or older. In a study of hospital patients aged 45 or
older, Fitzgerald et al. also identified the Basic, Advanced and
Household ADL dimensions in addition to a fourth dimension,
incontinence. Clark, Stump and Wolinsky (1997) found further evidence
for these first three factors. Using data from the National Long-Term
Care Survey, they identified three factors: Self-care (similar to Basic
ADL), Home-care (similar to Household ADL), and Cognitive function
(similar to Advanced ADL).

However, using the same data source but different analysis techniques,
Spector and Fleishman (1998) concluded that only one dimension underlies
these items. Thomas, Rockwood and McDowell (1998) found three factors
that they labeled basic self-care, intermediate self-care and complex
self-management. These factors do not correspond very closely to the
factors that earlier researchers identified.

Overall, Wolinsky and his colleagues seem to have found a stable set of
three factors within the ADL and IADL items. Differences between their
results and the results of Spector and Fleishman and Thomas and his
colleagues are attributable to: different populations; different
analysis techniques (principal components analysis versus principal axis
factor analysis; tetrachoric correlations versus Pearson correlations);
slightly different sets of items (i.e., Spector and Fleishman used
"going outside of walking distance" while other researchers did not);
and different assumptions about the structure of these items (for
example, Clark et al. attempted to confirm Johnson and Wolinsky's model
rather than to conduct an exploratory analysis).

None of this research, however, has examined the dimensionality of
functional status in the nonelderly population. Thus, it is unclear if
the factor structure underlying older adults' responses to these items
is similar to that of younger individuals. To address this issue, we
used data from the 1994--95 National Health Interview Survey-Disability
Supplement (NHIS-D) and the Longitudinal Study of the Vocational
Rehabilitation Services Program.[^4] Both of these surveys include ADL
and IADL items. NHIS-D contains two parts, one of which was administered
along with the core survey to a sample designed to represent the
civilian noninstitu­tionalized population of the United States. The
second part, the Disability Followback Survey, was administered later
only to those individuals whose responses indicated that they met the
NHIS definition of disability. The National Center for Health Statistics
used a variety of questions from the Core Questionnaire and the
Disability Supplement to select respondents for the Disability
Followback Survey, including questions about limitations in major life
activities, use of assistive devices, selected physical or mental health
conditions, receipt of or application for public assistance,
participation in employment services or other programs, difficulty in
social functioning, and ADL and IADL questions. The ADL and IADL items
used in our analysis appear on the Disability Followback Survey.

The Longitudinal Study of the VR Services Program is a national impact
evaluation that investigates the effects of VR services on economic and
other outcomes for individuals with disabilities who receive such
services. The Longitudinal Study drew a nationally representative sample
of more than 8,000 respondents, including applicants for VR services
(some of whom were not accepted for services), VR consumers, and former
VR consumers. The data used in our analysis come from an interview
conducted with applicants and VR consumers at entry into the study.

[]{#__RefHeading___Toc124564966 .anchor}Table A-1. Review of functional
status literature

+-----------------+-----------------+-----------------+-----------------+
| Source          | Population      | Data source     | Factors         |
+=================+=================+=================+=================+
| Johnson, Robert | 5,151           | 1984            | ***Basic ADL*** |
| J., and         | individuals     | Longitudinal    | (Bathing,       |
| Wolinsky,       | aged 70         | Study on Aging  | dressing,       |
| Fredric D.      | or older        | (a supplement   | getting out of  |
| (1993). "The    |                 | to the 1984     | bed, walking,   |
| Structure of    |                 | Health          | toileting)      |
| Health Status   |                 | Interview       |                 |
| Among Older     |                 | Survey)         | ***Household    |
| Adults:         |                 |                 | ADL*** (Meal    |
| Disease,        |                 |                 | preparation,    |
| Disability,     |                 |                 | shopping, light |
| Functional      |                 |                 | housework,      |
| Limitation, and |                 |                 | heavy           |
| Perceived       |                 |                 | housework)      |
| Health."        |                 |                 |                 |
| *Journal of     |                 |                 | ***Advanced     |
| Health and      |                 |                 | ADL***          |
| Social          |                 |                 | (Managing       |
| Behavior,*      |                 |                 | money, using    |
| 34(2): 105‑121. |                 |                 | the telephone,  |
|                 |                 |                 | eating)         |
|                 |                 |                 |                 |
|                 |                 |                 | ***Lower body   |
|                 |                 |                 | limitations***  |
|                 |                 |                 | (Walking a      |
|                 |                 |                 | quarter of a    |
|                 |                 |                 | mile; walking   |
|                 |                 |                 | up 10 steps     |
|                 |                 |                 | without rest;   |
|                 |                 |                 | standing or     |
|                 |                 |                 | being on your   |
|                 |                 |                 | feet for two    |
|                 |                 |                 | hours;          |
|                 |                 |                 | stooping,       |
|                 |                 |                 | crouching or    |
|                 |                 |                 | kneeling; and   |
|                 |                 |                 | lifting or      |
|                 |                 |                 | carrying 25     |
|                 |                 |                 | pounds)         |
|                 |                 |                 |                 |
|                 |                 |                 | ***Upper body   |
|                 |                 |                 | limitations***  |
|                 |                 |                 | (Sitting for    |
|                 |                 |                 | two hours;      |
|                 |                 |                 | reaching up     |
|                 |                 |                 | over your head; |
|                 |                 |                 | reaching out as |
|                 |                 |                 | if to shake     |
|                 |                 |                 | hands; and      |
|                 |                 |                 | using fingers   |
|                 |                 |                 | to grasp        |
|                 |                 |                 | objects)        |
+-----------------+-----------------+-----------------+-----------------+
| Fitzgerald,     | 668 hospital    | A randomized    | ***Advanced     |
| John F., Smith, | patients aged   | controlled      | ADL*** (Using   |
| David M.,       | 45 years or     | trial of an     | the telephone,  |
| Martin, Douglas | older           | intervention    | managing money, |
| K., Freedman,   |                 | using case      | eating, and     |
| Jay A., and     |                 | managers to     | taking          |
| Wolinsky,       |                 | reduce hospital | medications)    |
| Fredric D.      |                 | utilization at  |                 |
| (1993).         |                 | a Veterans      | ***Basic ADL*** |
| "Replication of |                 | Administration  | (Dressing,      |
| the             |                 | medical center  | transferring,   |
| Mult            |                 | in              | walking, and    |
| idimensionality |                 | Indianapolis,   | bathing)        |
| of Activities   |                 | Ind.            |                 |
| of Daily        |                 |                 | ***Household    |
| Living."        |                 |                 | ADL***          |
| *Journal of     |                 |                 | (Preparing      |
| Gerontology,*   |                 |                 | meals,          |
| 48(1): S28-S31. |                 |                 | shopping,       |
|                 |                 |                 | performing      |
|                 |                 |                 | housework, and  |
|                 |                 |                 | traveling to    |
|                 |                 |                 | places out of   |
|                 |                 |                 | walking         |
|                 |                 |                 | distance)       |
|                 |                 |                 |                 |
|                 |                 |                 | ***             |
|                 |                 |                 | Incontinence*** |
+-----------------+-----------------+-----------------+-----------------+
| Clark, Daniel   | 14,415          | 1989 National   | ***Self-care*** |
| O., Stump,      | com             | Long-Term       | (Getting in/out |
| Timothy W., and | munity-dwelling | Care Survey     | of bed, getting |
| Wolinsky,       | individuals     |                 | around inside,  |
| Fredric D.      | aged 65 or      |                 | bathing,        |
| (1997). "A      | older who       |                 | toileting)      |
| Race‑ and       | identified      |                 |                 |
| Gender‑         | themselves as   |                 | ***Home-care*** |
| Specific        | Black or White  |                 | (Light          |
| Replication of  | (for some       |                 | housework,      |
| Five Dimensions | analyses, the   |                 | laundry,        |
| of Functional   | authors used    |                 | grocery         |
| Limitation and  | data from 4,297 |                 | shopping, meal  |
| Disability."    | of these        |                 | preparation)    |
| *Journal of     | individuals who |                 |                 |
| Aging and       | reported an     |                 | ***Cognitive*** |
| Health,* 9(1):  | ADL- or         |                 | (Managing       |
| 28-42.          | IADL-based      |                 | money, using    |
|                 | disability)     |                 | telephone,      |
|                 |                 |                 | taking          |
|                 |                 |                 | medication)     |
+-----------------+-----------------+-----------------+-----------------+
| Spector,        | 2,977           | 1989 National   | ***One overall  |
| William D. and  | individuals     | Long-Term       | factor***       |
| Fleishman, John | aged 65 or      | Care Survey     | (Going outside  |
| A. (1998).      | older with      |                 | of walking      |
| "Combining      | functional      |                 | distance;       |
| Activities of   | disabilities in |                 | shopping; doing |
| Daily Living    | at least one of |                 | laundry;        |
| With            | 16 ADLs or      |                 | bathing;        |
| Instrumental    | IADLs           |                 | getting around  |
| Activities of   |                 |                 | outside;        |
| Daily Living to |                 |                 | preparing       |
| Measure         |                 |                 | meals; taking   |
| Functional      |                 |                 | medications;    |
| Disability."    |                 |                 | managing money; |
| *Journal of     |                 |                 | getting around  |
| Gerontology,*   |                 |                 | inside; light   |
| 53B (1):        |                 |                 | housework;      |
| S46-S57.        |                 |                 | dressing;       |
|                 |                 |                 | transferring;   |
|                 |                 |                 | toileting;      |
|                 |                 |                 | using the       |
|                 |                 |                 | telephone; help |
|                 |                 |                 | with            |
|                 |                 |                 | incontinence;   |
|                 |                 |                 | feeding)        |
+-----------------+-----------------+-----------------+-----------------+
| Thomas, Vince   | 9,008           | 1991--92        | ***Basic        |
| S., Rockwood,   | nonin           | Canadian Study  | self-care***    |
| Kenneth, and    | stitutionalized | of Health and   | (toileting,     |
| McDowell, Ian   | individuals     | Aging           | dressing,       |
| (1998).         | over 65         |                 | eating,         |
| "Mult           |                 |                 | transferring,   |
| idimensionality |                 |                 | grooming)       |
| in Instrumental |                 |                 |                 |
| and Basic       |                 |                 | ***Intermediate |
| Activities of   |                 |                 | self-care***    |
| Daily Living."  |                 |                 | (bathing,       |
| *Journal of     |                 |                 | walking,        |
| Clinical        |                 |                 | housework, meal |
| Epidemiology,*  |                 |                 | preparation,    |
| 51(4): 315-321. |                 |                 | shopping,       |
|                 |                 |                 | walking         |
|                 |                 |                 | outside)        |
|                 |                 |                 |                 |
|                 |                 |                 | ***Complex      |
|                 |                 |                 | sel             |
|                 |                 |                 | f-management*** |
|                 |                 |                 | (handling       |
|                 |                 |                 | money, phone    |
|                 |                 |                 | use,            |
|                 |                 |                 | s               |
|                 |                 |                 | elf-medicating) |
+-----------------+-----------------+-----------------+-----------------+

##  {#section-4 .unnumbered}

## Scale Development

####### National Health Interview Survey

To discover underlying traits that influence respondents' answers to ADL
and IADL questions, we conducted two sets of exploratory factor
analyses, one with data from NHIS-D and one with data from the
Longitudinal Study. The NHIS-D analysis revealed three underlying
dimensions, as shown in table A-2.[^5] The first dimension corresponds
to gross motor function; the second contains items related to personal
care function; and the third set of items involves cognitive function.
The gross motor dimension corresponds somewhat to Johnson and Wolinsky's
Lower Body Limitation Scale, while the personal care dimension matches
their Basic ADL Scale and the cognitive dimension is similar to the
Advanced ADL Scale. All but three items load heavily on only one factor.
Where items loaded heavily on more than one factor, we grouped them with
the factor on which their loading was highest. Table A-3 presents the
correlations among these factors. As expected, gross motor function and
cognitive function are moderately correlated (.52). Personal care
function is more strongly related to gross motor function and to
cognitive function (.58 and .65 respectively).

To create scales for these items, we assigned a value of one for each
response that indicates a limitation and a value of two for each
response that does not indicate a limitation. Next, we took the mean
score on all items for each respondent. Therefore, a high score means a
higher level of functioning, with a maximum score of two, while a low
score means a lower level of functioning, with a minimum score of one.

To confirm that these three scales have acceptable levels of
reliability, we calculated Cronbach's alpha for each of them. We present
these results in table A-4. Although the reliability coefficient is
highest for the gross motor function (.89), all three are within
acceptable limits.

+--------------------------------+-----------+-----------+-----------+
| [                              |           |           |           |
| ]{#__RefHeading___Toc124564967 |           |           |           |
| .anchor}Table A-2. Exploratory |           |           |           |
| factor analysis of selected    |           |           |           |
| ADL and IADL questions         |           |           |           |
| from NHIS‑D\*                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| **Question**                   | **Gross   | **C       | *         |
|                                | motor     | ognitive\ | *Personal |
|                                | f         | f         | care      |
|                                | unction** | unction** | f         |
|                                |           |           | unction** |
+--------------------------------+-----------+-----------+-----------+
| ***By yourself and without     |           |           |           |
| using aids, do you have any    |           |           |           |
| difficulty:***                 |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Standing or being on your    | .86       | \-        | \-        |
| > feet for about two hours?    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Walking for a quarter of a   | .86       | \-        | \-        |
| > mile (that is about two or   |           |           |           |
| > three blocks)?               |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Walking up 10 steps without  | .85       | \-        | \-        |
| > resting?                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Lifting or carrying          | .83       | \-        | \-        |
| > something as heavy as 25     |           |           |           |
| > pounds (such as two full     |           |           |           |
| > bags of groceries)?          |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Stooping, crouching or       | .81       | \-        | \-        |
| > kneeling?                    |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| ***Because of a health or      |           |           |           |
| physical problem, do you have  |           |           |           |
| any difficulty:***             |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Doing heavy housework, like  | .76       | \-        | \-        |
| > scrubbing floors or washing  |           |           |           |
| > windows?                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Managing your money, such as | \-        | .94       | \-        |
| > keeping track of expenses or |           |           |           |
| > paying bills?                |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Managing your medication?    | \-        | .90       | \-        |
+--------------------------------+-----------+-----------+-----------+
| > Preparing your own meals?    | \-        | .77       | \-        |
+--------------------------------+-----------+-----------+-----------+
| > Shopping for groceries and   | .60       | .74       | \-        |
| > personal items, such as      |           |           |           |
| > toiletries or medicines?     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Getting to places outside of | .59       | .70       | \-        |
| > walking distance?            |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Getting into or out of bed   | \-        | \-        | .72       |
| > or chairs?                   |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Dressing?                    | \-        | \-        | .68       |
+--------------------------------+-----------+-----------+-----------+
| > Using the toilet, including  | \-        | \-        | .65       |
| > getting to the toilet?       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| > Bathing or showering?        | .57       | \-        | .58       |
+--------------------------------+-----------+-----------+-----------+
| Source: National Health        |           |           |           |
| Interview Survey-Disability    |           |           |           |
| Supplement                     |           |           |           |
|                                |           |           |           |
| \* Loadings less than .55 are  |           |           |           |
| omitted from this table.       |           |           |           |
+--------------------------------+-----------+-----------+-----------+

  --------------------------------- ---------------- ---------------- ----------------
  []{#__RefHeading___Toc124564968                                     
  .anchor}Table A-3. Interfactor                                      
  correlations among NHIS-D                                           
  functional status scales                                            

  Scale                             Gross motor\     Cognitive\       Personal care
                                    function         function         function

  Gross motor function              1.00             0.52             0.58

  Cognitive function                0.52             1.00             0.65

  Personal care function            0.58             0.65             1.00

  Source: National Health Interview                                   
  Survey-Disability Supplement                                        
  --------------------------------- ---------------- ---------------- ----------------

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc124564969            
  .anchor}Table A-4. Reliability             
  coefficients for NHIS-D functional         
  status scales                              
  ------------------------------------------ ----------------------------
  Scale                                      Cronbach's alpha

  Gross motor function                       .89

  Personal care function                     .84

  Cognitive function                         .85

  Source: National Health Interview          
  Survey-Disability Supplement               
  -----------------------------------------------------------------------

####### Longitudinal Study of the Vocational Rehabilitation Services Program

The factor analysis in which we used data from the Longitudinal Study
also uncovered three underlying dimensions, as shown in table A-5. The
first dimension corresponds to gross motor function; the second contains
items related to personal care function; and the third set of items
involves cognitive function. While the resulting scales did not include
exactly the same items as the NHIS-D scales, they appear to measure
similar constructs. The Longitudinal Study's gross motor scale includes
four of the same items as the NHIS-D gross motor scale, but does not
include "standing or being on your feet for about two hours" or
"stooping, crouching or kneeling." Likewise, the NHIS-D gross motor
scale does not include "getting around outside the house," which is not
included in the follow-back survey. While "eating" appears on both
instruments, in the NHIS-D survey this item did not load heavily on any
of the three factors, so we did not include it in these scales. However,
in the Longitudinal Study this item loaded on the personal care factor,
so it is included in this scale. Four items in the Longitudinal Study's
cognitive scale, "reading and understanding the newspaper," "writing,"
"driving" and "using public transportation," appear in the Longitudinal
Study questionnaire but not in the NHIS-D survey, while two items,
"preparing your own meals" and "getting to places outside of walking
distance," appear in the NHIS-D survey but not in the Longitudinal Study
instrument. As shown in table A-6, these factors are also correlated
with each other. Cognitive function is only moderately related to gross
motor function and to personal care function (.31 and .36 respectively).
Personal care function is more strongly related to gross motor function
(.58).

+--------------------------------+-----------+-----------+-----------+
| [                              |           |           |           |
| ]{#__RefHeading___Toc124564970 |           |           |           |
| .anchor}Table A-5. Factor      |           |           |           |
| analysis of Longitudinal Study |           |           |           |
| ADL and IADL items\*           |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Item                           | Gross     | Cognitive | Personal  |
|                                | motor     | function  | care      |
|                                | function  |           | function  |
+--------------------------------+-----------+-----------+-----------+
| ####### Are you able to do thi |           |           |           |
| s by yourself? The activity is |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Walking for a quarter of a     | 0.77      | \-        | \-        |
| mile---about three city blocks |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Walking up a flight of stairs  | 0.70      | \-        | \-        |
| without resting                |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Doing heavy housework (such as | 0.62      | \-        | \-        |
| scrubbing floors or washing    |           |           |           |
| windows)                       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Lifting and carrying something | 0.54      | \-        | \-        |
| as heavy as 10 pounds (such as |           |           |           |
| a full bag of groceries)       |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Getting around outside the     | 0.52      | \-        | \-        |
| house                          |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Reading and understanding the  | \-        | 0.69      | \-        |
| newspaper                      |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Writing                        | \-        | 0.58      | \-        |
+--------------------------------+-----------+-----------+-----------+
| Managing your money (such as   | \-        | 0.61      | \-        |
| keeping track of expenses or   |           |           |           |
| paying bills)                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Shopping for personal items    | \-        | 0.58      | \-        |
| (such as toilet items or       |           |           |           |
| medicines)                     |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Driving                        | \-        | 0.57      | \-        |
+--------------------------------+-----------+-----------+-----------+
| Using public transportation    | \-        | 0.50      | \-        |
+--------------------------------+-----------+-----------+-----------+
| Using the toilet, including    | \-        | \-        | 0.73      |
| getting to the toilet          |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Dressing                       | \-        | \-        | 0.65      |
+--------------------------------+-----------+-----------+-----------+
| Bathing or showering           | \-        | \-        | 0.64      |
+--------------------------------+-----------+-----------+-----------+
| Getting into and out of bed    | \-        | \-        | 0.64      |
+--------------------------------+-----------+-----------+-----------+
| Eating                         | \-        | \-        | 0.50      |
+--------------------------------+-----------+-----------+-----------+
| Source: VR Longitudinal Study  |           |           |           |
|                                |           |           |           |
| \* Loadings less than .40 are  |           |           |           |
| omitted from this table.       |           |           |           |
+--------------------------------+-----------+-----------+-----------+

+--------------------------------+-----------+-----------+-----------+
| [                              |           |           |           |
| ]{#__RefHeading___Toc124564971 |           |           |           |
| .anchor}Table A-6. Interfactor |           |           |           |
| correlations among             |           |           |           |
| Longitudinal Study functional  |           |           |           |
| status scales                  |           |           |           |
+--------------------------------+-----------+-----------+-----------+
| Scale                          | Gross     | C         | Personal  |
|                                | motor\    | ognitive\ | care\     |
|                                | function  | function  | function  |
+--------------------------------+-----------+-----------+-----------+
| Gross motor function           | > 1.00    | > 0.31    | > 0.58    |
+--------------------------------+-----------+-----------+-----------+
| Cognitive function             | > 0.31    | > 1.00    | > 0.31    |
+--------------------------------+-----------+-----------+-----------+
| Personal care function         | > 0.58    | > 0.36    | > 1.00    |
+--------------------------------+-----------+-----------+-----------+
| Source: VR Longitudinal Study  |           |           |           |
+--------------------------------+-----------+-----------+-----------+

Based on a review of the items in each scale, we questioned the
appropriateness of the items in the cognitive function scale for
individuals with visual impairments. Consequently, we tested whether the
factor loadings of items on the cognitive scale for individuals with
visual impairments differs from the loadings for other individuals by
using a confirmatory factor analysis for each group of cognitive
function. The loadings for "driving" were significantly different, with
a lower loading (.562) for individuals with visual impairments than for
other individuals (1.183). As this analysis confirms, the
characteristics of vision impairment confound our ability to
discriminate based on cognitive function. Therefore, we omitted
individuals with visual impairments from our analysis of the reliability
of this measure and we do not report cognitive functioning for this
subgroup. The results of the reliability analysis for these scales
appear in table A-7. All three reliability coefficients are within
acceptable limits.

+------------------------------------------+---------------------------+
| []{#__RefHeading___Toc124564972          |                           |
| .anchor}Table A-7. Reliability           |                           |
| coefficients for Longitudinal Study      |                           |
| functional status scales                 |                           |
+==========================================+===========================+
| Scale                                    | Cronbach's alpha          |
+------------------------------------------+---------------------------+
| Gross motor function                     | > .80                     |
+------------------------------------------+---------------------------+
| Personal care function                   | > .81                     |
+------------------------------------------+---------------------------+
| Cognitive function                       | > .82                     |
+------------------------------------------+---------------------------+
| Source: VR Longitudinal Study            |                           |
+------------------------------------------+---------------------------+

To create the scales for the longitudinal study, we assigned a value of
one for each response that indicates a limitation and a value of two for
each response that does not indicate a limitation. Next, we took the
mean score on all items for each respondent. Therefore, a high score
means a higher level of functioning, with a maximum score of two, while
a low score means a lower level of functioning, with a minimum score of
one.

Our mission is to ensure equal access to education and to promote\
educational excellence throughout the nation.\
\
www.ed.gov

[^1]: With the *1998 Amendments to the Rehabilitation Act*, the
    statutory language changed from "severity" to "significance" of
    disability. We use the current term in this report.

[^2]: To create an overall measure of functional status, we standardized
    values on the three functional status scales (to put them on the
    same metric) and then averaged the three values. Because we did not
    assign values on the cognitive function scale for individuals with
    vision impairments (see Appendix A), they are not included in this
    analysis.

[^3]: In this study, Johnson and Wolinsky used items from Nagi's
    disability scale. These items make up the Lower and Upper Body
    Limitations Scales and do not appear in the other models we discuss.

[^4]: Under contract to the Rehabilitation Services Administration, U.S.
    Department of Education, the Research Triangle Institute is
    conducting this congressionally mandated impact evaluation of the
    State-Federal VR Services Program. The study is scheduled for
    completion in 2002.

[^5]: We specified an oblique promax rotation for these analyses. We
    determined the number of factors based on the

    > number of eigenvalues greater than one.