ORIGINAL ARTICLE

The Relationship of Life Satisfaction with
Forecasting in Patients with Spinal Cord
Injuries with Quadriplegia. Part 1—Through Path Analysis—
Hitomi SAKAI, PhD, OTR1, Tamako MIYAMAE, PhD, OTR2
1 Department of Occupational Therapy, YMCA College of Medical and Human Services in

Yonago2 Faculty of Health Science, Hiroshima University School of Medicine

Abstract: This study was conducted with 31 patients with chronic spinal cord injury ata rehabilitation clinic. It clarified the relationship between ‘degrees of satisfaction withlife’ and a ‘forecast future’ and determined factors influencing the degree of life
satisfaction from physical, social and psychological perspectives using data on their
psychological conditions and their forecasts of their lives one, three and five years after
the interview. Results indicate that those who determined their own clinic departure time
had significantly stronger satisfaction with their lives than those who did not. Moreover,those who forecast their own life for the subsequent three years as either positive or
negative show a significantly strong tendency toward life satisfaction. In addition, there
is no correlation and causal connection between physical/social factors and the degree oflife satisfaction. Path analysis shows that the factors directly contributing to strong
positive correlation with the degree of life satisfaction were (1) correlation of forecast andhopes for life three years later and (2) self-acknowledgement. The result regarding
agreement between forecast and hopes supports “client-centered practice” as an ethos foroccupational therapy; that ethos is playing a significant role in quality of life for thepatient subjects.
Key words: life satisfaction, forecasting, spinal cord injury patients, QOL(Asian J Occup Ther 3: 1–13, 2004)

Introduction
Received: December 1, 2002, Accepted: February 15, 2004
Corresponding to: Hitomi Sakai (OTR); Department ofOccupational Therapy, YMCA College of Medical and
Human Services in Yonago, 3–3–2 Kinkai-cho, Yonago,
Tottori, 683-0825, Japan
phone: 81-859-35-3181 fax: 81-859-35-3182
e-mail: h-sakai@hiroshima-ymca.or.jp

Life expectancy for patients with spinal cord
injuries has continued to lengthen, and, due to
medical progress and management technologies, isapproaching normal life expectancy (Whiteneck,1992). Concomitant with this trend, there are
increasing reports of drug abuse, depression, and2

THE RELATIONSHIP OF LIFE SATISFACTION WITH FORECASTING IN SCI

suicide of chronic spinal cord injury patients in the
United States (Geisler, 1983; Macleod, 1988;
DeVivo, 1991). It is estimated that negative,
perhaps pessimistic, forecasts affect the degree oflife satisfaction (Spencer, 1997; Moriya, 1994) inaddition to other psychological, physical andsocial factors (Pentland, 1998; Yerxa, 1990;
Kawamoto, 1998). Moriya, after studying those
who attempted suicide, concluded that thosepatients who cannot find meaning in their present
life because of negative prospects tend to commit
suicide. However, no research has addressed therelationship between patients’ satisfaction withpresent life and their future prospects.
This study examines chronic spinal cord
injury patients to clarify the relationship between
their present degree of satisfaction with life andth ei r fut ure fo rec a s t s ; i t a l s o d e t e r m in e sinterrelations between physical, social andpsychological factors, which influencesatisfaction.

Literature Review and Term Definitions
on ‘Forecasting’
Literature review
We searched related literature by computerand manually from available related and citedbooks. We used the words: perspective, future,
hope, and uncertainty for computer search terms
for a news and magazine article search database, asociology literature information database, and
MEDLINE (1991–2000).
We can now find research that examines
future perspectives in the field of clinicalpsychology from the late 1950s to the early 1970s.
Wallace (1958) defined future time perspective(FTP) as an opposing concept of past time
perspective (PTP); FTP refers to chronologicaladjustment and the order of events that may
happen to each individual, thus including
foresights and coherences.
These studies were developed from the
Logotherapy School. One of the therapies
established by Frankl. Logotherapy (Frankl,
1966) has been utilized to encourage patients toovercome aimlessness and promote the process offinding meaning in life (Kastenbaum, 1961;

Heimberg, 1963; Black, 1973). The number of
new studies addressing such forecasting has
decreased gradually, year by year.
However, during the 1970s, when the Human
Rights Movement engendered ethics of medicine,
behavioral science research was born to explore
the meaning of life when living with illness and theinfluence of patients’ perceptions of life-meaningon their own health. It had been thought
impossible to measure the state of recognition ofself-consciousness objectively by identificationand transformation, but in the second half of the
1980s, some reports were based on the notion thatthey could explore a new stream of cognitive
behavioral study from patients’ experiences. We
obtained some studies that examined relationships
with FTP in these frameworks (Yarcheski, 1988).
Herein, FTP refers to uncertainty of selfrecognition—uncertainty occurring when one
needs to make a decision, i.e., one either cannot
find the meaning of the event or cannot accurately
forecast the future; therefore, FTP focuses on the
span of what one has forecast while also
addressing the importance of the forecast in
proportion to the span.
More recently, it has been acknowledged that
consciousness of the future plays a significant rolein one’s present state of mind (Spencer, 1997;
Johnson, 1997). This argument is supported bythose in the health care field and also by
philosophers, theorists and social scientists, yet the
study of FTP has just started to grow; few theses inthis area have been published.

Definitions of terms
1) Future Time Perspective
FTP, as defined in past studies, refers to“chronological prediction and order of events that
may happen to each individual” and thus applies toindividuals when they may have events already set
up such as retirement and death. It deals withlong-term predictions; it is therefore difficult totake them into consideration for the study of theirrelationship with the present state of mind.
In order to find the relationship of FTP withthe present state of mind, as we do in this study, we
conclude that we should address the immediate
future and the forecasting of the “environment:

Asian J Occup Ther 3: 1–13, 2004

Sakai H et al.

3

Table 1. Characters of the samples (N=31)
Mean error rate
32.84
58.29
24.42
84.35

Standard deviation
9.78
30.19
15.56
19.07

Well
28
7

Bad
3
24

Financial status

Compensation of
Absence from Work
7

Pension12

No Pension
12

Cause of infection

Accident
14

Work
8

Recreation
5

Other
4

Range
C4-III A, II B

Max level
II B1: 8

Complete paralysis
30

Incomplete paralysis
1

Age (year)
Months of infection
Months residence at the clinic
ADL (FIM)
Acceptance by family
Employment relations

Functional level (Zancolli)

people, place and society” surrounding theindividuals; also, the forecast should include bothhope and prediction.
2) Degree of Life Satisfaction
Life Satisfaction is defined as an evaluationof how much one is satisfied with one’s present
condition according to certain criteria such as
one’s hopes and goals. This has been used as anindex of subjective feeling of happiness in thefields of sociology and psychology.
In this paper, the LSI (Life Satisfaction
Index), developed by Neugarten et al. (1961) isused to evaluate correlations between scores fromquestions inquiring about ‘present life satisfaction’and ‘total scores of LSI’; they have a positive
correlation (r=.956, P<.000), so the LSI total isregarded as a legitimate proxy for present life
satisfaction and is used here.

Methods
Samples
Samples used in this study include 31 chronic
external spinal cord injury patients (28 men and 3
women) with low probabilities of recovering
physical functions in the future and who are

Min-Max
18–54
20–145
2–56
53–115

hospitalized at an I Rehab Clinic. Their ages
ranged from 18 to 58 yrs. (mean 32.84 ± 9.78
yrs.). All were informed about the purpose andcontent of this study and agreed to participate in it.
The author went to the clinic as an examiner for
five days from August 10–14, 1998. Sample
characteristics are shown in Table 1.

Research methods
We used interview and questionnaire survey
methods for this research. Details are as follows.
(1) Semi-structured interview on FTP.
The author made the following
questionnaires of FTP based on the concept of
future hopes developed by Spencer (1997); eachquestion was asked individually.
1) Hopes for the Future
Questions addressed what, where and withwhom one would be doing activities in one, threeand five years subsequent to the interview. For thethird year, we hypothesized that the patient would
be discharged from the clinic (given the three-year
limit to which one can remain in the rehabilitation
clinic). Situations where one was able to conceiveof and talk about future hopes were labeled as
possible to express one’s future hope; situations

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THE RELATIONSHIP OF LIFE SATISFACTION WITH FORECASTING IN SCI

where patients were unable to imagine or eventhink of their own future were labeled as
impossible to express one’s future hope.
2) Prediction of the Future
These questions addressed patients’ ability to
predict what, where, and with whom one would bedoing activities one, three and five years hence; forthe third year, we hypothesized that patients would
already be discharged from the clinic (given thethree-year limit for stays in the rehab clinic). If
one is able to conceive of the future, the case islabeled as possible to predict the future; if one
cannot conceive or even want to think of the
future, the case is labeled as impossible to predict
the future.
3) Forecasting the Time of Discharge from theClinicThese questions concern whether the time fordischarge from the clinic is determined andwhether the decision-maker is the patient or
another person.
(2) Questionnaire Survey Regarding the State of
Mind including Life Satisfaction Index: The
following four types of questions were createdbased on the framework of Psychological
Construct by Christiansen & Baum (1991) in aself-marked form.
(i) Degree of Life Satisfaction
Life Satisfaction Index (LSI) by Neugarten(Morimoto, 1991: translation into Japanese). It
consists of 20 questions such as “Are you satisfied
with the life that you have had thus far?” Answers
were chosen from Yes: Point 1, Neither or I don’t
think so: Point 0. The score range is 0–20.
(ii) Degree of Depression
The Self-rating Depression Scale (SDS) by
Zung (1965) is used here. It consists of 20
statements such as “I cannot sleep well at night.”
One then chooses from four answers: No, P 1;
Sometimes, P 2; Often, P 3; and Always, P 4.
The score range is 20–80. The raw score—score total raised to the 1.25th power is called theZung Index; if the index is 50 and more, one isconsidered to have symptoms of depression.
(iii) Self-esteem
The self-esteem scale developed by
Rosenberg (1965) is used here. It consists of 10questions such as “I wish I could be proud of

myself a little more.” One can choose either: I
think so very often, P 5; I often think so, P 4;
Neither, P 3; I don’t think so very much, P 2; or, I
don’t think so at all, P 1. The score range is 10–
50. Self-esteem is indicating by responding with“I like—.” or “I don't like—.” “It is good/bad.”
toward a concept of oneself such as “I am—.”Thus, it indicates values to which one would
consider him/herself attached.
(iv) Internal/External Locus of Control(LOC)
LOC by Kamahara (1982) is a revision ofRotter’s Internal/External Scale. It consists of 18
questions including, “Do you think you makedecisions concerning your own life on your own?”
One chooses from four answers: I think so, P 4; I
think so a little, P 3; I don’t think so very much, P
2; and I don’t think so at all, P 1. The score range
is 18–72. Higher scores indicate stronger feelingsof an external LOC. Therefore, one would believethat the cause of a problem pertains to oneself; one
would then try hard to achieve goals to improve
matters. On the other hand, the lower the LOC, theweaker the external locus of control; one would
feel dependent on fate or luck for their life indealing with a problem.
(3) An individual semi-structured interview on
occupations, the COPM (Canadian Occupational
Performance Measure) developed by Law et al.
(1994), was used to determine problems andinterests in occupational performance. We asked
respondents to list activities that they ‘want to’,‘need to’, and ‘are expected to’ do; then weprioritized them and took the top five of these.
(4) Semi-structured Interview on Life Meaning
Through interviews, we asked for detailed
content and reasons for individuals’ perceived
meaning of life. We excluded items for which
they felt joy, but didn’t attach life-meaning to.

Analysis of results
After having calculated descriptive statistic
values, we analyzed relationships of data.
Spearman’s correlation was used for quantitative
variables (age, FIM, time to leave the clinic, thenumber of occupational needs, the number of lifemeanings, life satisfaction index, degree ofdepression, self-esteem level, and LOC). Mann-Table 2. Hopes and predictions of the time to leave the clinic and the future for 1, 3 and 5 years later

Asian J Occup Ther 3: 1–13, 2004
Sakai H et al.
5

Table 3. The number of occupational needs, their priorities and their fields

6
THE RELATIONSHIP OF LIFE SATISFACTION WITH FORECASTING IN SCI

Asian J Occup Ther 3: 1–13, 2004

Sakai H et al.

7

Table 4. Presence and absence of meanings of life and the contents
No. Value
1

2

2
3
4
5
6

0
0
1
1
2

7

3

8
9
10
11

0
1
1
2

12
13

1
2

14

1

15
16
17

1
1
2

18
19

0
4

20

Areas of meaningsof life
LeisureLeisureContents of meanings of life

Reasons2

Self-care
LeisureLeisureProduction/Role
Self-care

Twin basketball
Driving
Maybe nothing
I don’t feel it.
Computer games
Nothing
Relationship with friends
Relationship with other residents
SCL Flight Project
Demonstration Project of JOIBAN
Writing music lyrics
Nothing special
Training
Trip planned by myself
Existence of mother
Conveying my own life
Improving physical condition
Existence of friends
Existence of a person that I love
Efforts to meet a goal to improve physicalcondition
Living with parents in my hometown
Getting jobs
Meet new people
Socializing with people
Nothing
ADL independence
Reading
W/C Mapping
Stock investment
Preparation for the future

21
22

1
2

LeisureSelfcare
LeisureExistence of friends
Independent life
Existence of friends

23

1

Production/Role
Self-care

Plant to be independent
Independent use of restroom

24
25
26
27

1
1
0
2

Production/Role
Leisure

28
29

0
0

Growth of children
Existence of friends
Searching
Jobs
Broadening possible activities
No
No

30

0

Nothing I can think of as meaning of life

31

1

LeisureLeisureLeisureLeisureLeisureLeisureSelf-care
LeisureProduction/Role
LeisureSelf-care
LeisureLeisureSelf-care
Production/Role
Production/Role
LeisureLeisureProduction/Role
Self-careSelf-care

Training

Whitney’s non-parametric examination andGoodman-Kruskal’s Gamma were used to
examine qualitative variables (presence/absence ofan employment relationship, presence/absence of as e l f - de t e r m i n e d t i m e t o l e a v e t h e c l i n i c ,predictions of life in one, three and five years,
along with the degree of correlation of predictions

Fun. I am originally sports person. I like it.
To expand the area where I can move. I can go to wherever I like.
I can no longer do my former hobby.
I can be excited with it forgetting myself.
There are fun things but I can’t call them the meaning of life.
For recreation, supporting relationship
Motivation to be positive.
I can give others joy and hope.
I can give others joy and hope.
It’s my only way to let others know of me.
I am going for my goal.
Originally, I liked to make a trip.
I cannot die before my mother, so I am making efforts.
I want to tell others that there are fun things about being alive.
I want to change from 80% nursing care to 80% independence.
They can make me feel that I can make efforts.
They can make me feel that I can make efforts.
I need to be cautious about my mental condition.
To apologize to them for doing things I wanted to do.
I want to get paid for what I do.
Fun. There are various kinds of people.
I can learn a lot from them.
I don’t want to have assistance from my daughter.
I can collect information for my job eventually.
It’s useful.
I can feel that I am working myself.
I can have positive forecasting now that I can do 1/4 of the things
I want to do.
Support. They can make me forget that I am disabled.
It’s important to live without getting support from others.
We can solve problems together. I can talk with them about
anything.
It’s important to create a life of my own.
First I thought I could not be independent. But, once I achieve it,
I can feel satisfaction.
I want to keep a close watch on their growth.
Fun. I can have consultation with them.
It’s necessary to live.
Do things for myself on my own.
Movies are fun. Computers and delicious food are also fun.
Never thought of that before. I can have fun chat with my friends,
though.
Before infection, I was an instructor for a swimming school.
It was my meaning of life.
I can get at the moment, I feel I can increase the things I become
able to do.

and hopes, contents of occupational needs, andcontents of life-meanings); their level ofsignificance was less than 5%. Also, in order tocreate a path model with the LSI as a dependent
variable, factors considered to influence LSI wereused for factor analysis. Such factors included thefollowing 25 parts of data: age; purpose for stay at

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THE RELATIONSHIP OF LIFE SATISFACTION WITH FORECASTING IN SCI

Table 5. Order of Positive and Negative Views for Forecasting the Future
OrderWith whom

Where

Negative

Unable to predict
Not specific
Parents
Alone
Partner
SpouseUnable to predict
Nursing care facility
Present clinic
Home
Work rehabilitation
Vocational aid center
Living alone
Living abroad

Positivethe clinic; financial security; presence/absence ofan employment relationship; functionality of the
spinal cord (Zancolli, 1968), ADL (Hamilton,
1987; Chino, 1991); forecasting (prediction andpresence/absence of a self-determined time toleave the clinic, prediction of life one and three
years hence, degree of correspondence between
hope and prediction three years later);occupational needs (content and number);meanings of life (content and number); state ofmind (LSI, depression rate, self-esteem rate, and
LOC). The principle-factor method, regression
analysis, and Waldo Statistic Value were used forpath analysis. Statistical processing was
performed with SPSS (2001). Statistical Package
for the Social Sciences (Version 10.0), and AMOS
(2001) (Version 4.0) [Computer software].
Chicago: Author. The level of significance wasless than 5%.

Results
Results for the ‘degree of life satisfaction andpsychological aspects’ for all subjects were LSI
Mean 7.06 (SD ± 4.39, range 0–15) and Zung
Index Mean 55.65 (SD ± 8.44, range 38.75–72.5);
2 2 p a t i e n t s u b j e c t s s h o w e d s ym p t om s o f
depression (71%) and 9 did not (29%). Regarding
self-esteem, the Mean score was 31.61 (SD ± 4.22,
range 23–44) and the LOC was Mean 48.35 (SD ±19.07, range 33–64). Results of the ‘evaluation of
future forecasting’ are shown in Table 2; Table 3
shows ‘occupational needs’ and Table 4 shows‘meaning of life’.

Doing what
Unable to predict
Nursing care life
ADL training
LeisureLooking for home
Occupational training
Participation in the society
Job
University entrance exam / Studying abroad

Ordinality of positivity and negativity of
future forecasting
Table 5 shows a hypothetical tabledemonstrating that predictions are more negative
than hopes after extracting all data: ‘we can predictand hope but they don’t match’ and ‘we can hope
but cannot predict’. There are two cases out of 279
for which predictions are higher than hopes. After
reviewing the interviews, we found that they were
doing things that they don’t want to do underconditions that they have to do, answering ‘I haveto work though I don’t want to’ or ‘Though I don’tknow what to do, I cannot help having nursing
care’. We checked frequency of occurrence foreach section with Goodman-Kruskal’s Gammacomparison; all predictions and hopes showed
positive correlation (p<.05).

Relationships with future forecasting, degreeof life satisfaction, and each aspect here we
discuss influential factors
Factors influencing the degree of life
satisfaction (Table 6): With the Life Satisfaction
Index, positive correlation was found with selfesteem and LOC; negative correlation was foundwith the depression rating. To a significant
degree, it was found that those with higher LSI and
LOC and lower depression index tend to decide
the time to leave the clinic on their own.
Moreover, those with higher LSI and a lower
depression index can significantly forecast life
even three years later. Positive correlation was
also found between meaning of life and selfesteem index/LOC. Thus, those who have

Asian J Occup Ther 3: 1–13, 2004

Sakai H et al.

9

Table 6. Factors with correlations
Correlations, verification valueLife satisfaction index vs.
Psychological aspect
LOC
0.586**
Self-esteem
0.426*
Depression control
0.600**
Presence / Absence of depression symptom
39.500**Future forecasting
Presence / Absence of self-decision making
40.000**on the time to leave the clinic
Presence / Absence of forecasting for the next 3 years
36.5000*
Number of meaning of life vs.
0.715**
0.529**

LOC
Self-esteem
Depression control
Self-esteem

Statistical method

Spearman rank correlation (rs)Spearman rank correlation (rs)Spearman rank correlation (rs)Mann-Whitney verification (U)Mann-Whitney verification (U)Mann-Whitney verification (U)Spearman rank correlation (rs)Spearman rank correlation (rs)Presence / Absence of meaning of life including leisure fields vs.
1.000**
Mann-Whitney verification (U)7.500*
Mann-Whitney verification (U)** Significance 1%. * Significance 5%

productive tasks and leisure tasks tend to display ahigher self-esteem rate and a lower depression rate
than those who are limited to self-care as their
meaning of life.

Causal relationship of LSI as a dependent
variable with all factors (25) and creation of apath model
We created a path model with the following
path analysis.
1) Factor Analysis and Labeling of Factors
In order to determine potential variables forthe 25 factors on: general characteristics (year of
injury, functioning level, self-esteem level, FIM,
financial state, family acceptance), state of mind
(LSI, Depression Index, Self-esteem Index,
Internal/Ext ernal LO C), m ean ing of l ife,
occupations of interest, and forecasting, we carriedout exploratory factor analysis. Using theprinciple factor method as an extraction method,
six factors (contribution rate 73.1%) wereextracted. We labeled each factor as follows:
factor 1, self-image in the near future; factor 2,

present self-consciousness; factor 3, gap between
hope and prediction in forecasting; factor 4,
decision-maker of the clinic discharge time; factor
5, physical ability; and factor 6, employment.
2) Reliability Analysis of Each Factor, Narrowing
Down of the Section within a Factor and its
Correlations
Next, we carried out reliability analysis for
sections given to each factor (observed variables).
After breaking down the factors to maximize
reliability of each factor, we analyzed respective
correlations be tween six factors and life
satisfaction index (Table 7).
3) Regression Analysis (Stepwise Method) for
Creation of the Path Model
Next, we created a path model for LSI basedon regression analysis results (Fig. 1). In all
factors, the C.R. variance was over 1.96. All path
was the level of significance, less than 5%.The
residual variance matrix was –2.286 to 2.816; nolarge residual was found with fine data matching(χ2=33.433, df=21, p=.042; RMSEA=0.140; CF
I=.977).

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THE RELATIONSHIP OF LIFE SATISFACTION WITH FORECASTING IN SCI

Table 7. Correlations between Credibility Factor / Life Satisfaction and Each Factor
LSI

Factor 1

Factor 2

Factor 3

Credibility factor (α)
0.87380.64650.8225Spearman rank correlation (rs)Life Satisfaction Index (LSI)
1
Factor 1: Self-conception in the near future
0.416*
1
Factor 2: Present self-recognition
0.575** 0.354
1Factor 3: Agreement between future
0.492** 0.550** 0.008
1
hope and prediction
Factor 4: Decision about time to leave
0.588** 0.683** 0.503** 0.297
the clinic
Factor 5: Physical ability–0.1060.137
0.231–0.259
Factor 6: Employment relationship
0.067
0.259
0.266
–0.101

Factor 4

Factor 5 Factor 6

0.86030.25010.6745

1
0.269

1

1
0.049
0.361

**Significance 1%. *Significance 5%.

Fig. 1. A path model for LSI based on regression analysis results

Considerations
The relationship between LOC for the futureand life satisfaction
Those who had decided the ‘time to leave
clinic’ for themselves had a significantly higher
degree of life satisfaction than those who had not.
In addition, with regard to the relationshipbetween life satisfaction and matched/mismatchedgroups of predictions and hopes, the group withsamples with matching of forecasting on ‘what,
where, and with whom one would be doing
activities in three years’ showed a significantly
higher degree of life satisfaction (p<.01). Because
we hypothesized that patients would leave theclinic after three years, we concluded that being
able to forecast life after leaving the clinic was thefactor that increased the degree of life satisfaction.

Asian J Occup Ther 3: 1–13, 2004

Moreover, whether or not patients themselves canforecast their lives in the near future and predict a
hopeful future are keys to change in the life
satisfaction index. This is the same conclusionthat Saka et al. (1998) suggested: “being able tocontrol one’s own life increases life satisfaction.”
From results shown above, ‘three years’ was
the time that influenced present life satisfaction
most. The average number of months of residence
at the clinic for these patients was 24.4; therefore,‘three years’ for most of these patients isinterpreted as about two years after leaving theclinic. At this stage, patients face the reality of
having to consider their future direction ofprogress; therefore, influence on life satisfaction
becomes very high.
Though Post et al. (1998) published a multidimensional path model, it is significant in thispaper that we take the ‘future forecasting’ aspect
into consideration for the path model; this aspect is
a new development in this area of study. The mostinfluential factor in forecasting was the ‘degree ofmatching of hope and prediction’. This is aninteresting result for Occupational Therapy: it
clearly shows that an inherited philosophy fromthe birth of OT—“client-centered practice”(Meyer, 1922/1977)—plays a significant role in
QOL for the patients. This concept should beborne in mind not only for those in OT, but also for
all individuals in medicine, welfare and health caresince the Human Rights Movement has revealed
the significance of ‘medical care ethics’; thepossibility of its application must be high.

Elements that shape the “degree of life
satisfaction”
Factors influencing the degree of life
satisfaction include the ‘factor of gap between
future prediction and hope in three years’ on what,
where and with whom (24.0%), and ‘present selfrecognition factor’ such as “self-esteem,” “LOC”
and “meaning of life” (26.0%). It could beinterpreted that the ‘factor of gap between future
prediction and hope’ either directly influences life
satisfaction or does so indirectly through‘determinant factor of when to leave the clinic’.
Also, the ‘degree of depression’ is influenced only
negatively by life satisfaction. With regard to the

Sakai H et al.

11

relationship with the depression rating, multiple
reports have been presented on acceptance processof disabilities, depression when having injuries,
chronic pain, personality, long-term medication
with narcotics or tranquilizers, and ADL
independence status (Guttmann, 1945; Thom,
1946; Fink, 1967; Elliott, 1991, 1996; Honda,
1992; Nagumo, 1994, 1999; Lo, 1993). Still,
factors other than life satisfaction were found inthese reports. This study did not show the
relationship with physical aspects and social
aspects such as employment and acceptance byfamily members. Though the ‘physical ability’factor influences the ‘employment-relationship’factor and the ‘employment-relationship’ factor
influences the ‘present self-consciousness’ factor
in turn, they have only indirect influences on the
degree of life satisfaction. As a result, this study
found no relationship between physical aspects
and life satisfaction, as with the report by Post etal. (1998). This may be due to the fact that thepatient subjects are in the chronic stage where
there is little chance of recovering full physicalcapability; therefore, they pay more attention to
how to live life. Though Yerxa (1990) and
Kawamoto et al. (1998) reported that presence orabsence of employment and ADL independence
level influences the degree of life satisfaction, thisstudy showed no relation between social aspects
and life satisfaction. One explanation is that all
subjects in this study were hospitalized andunemployed. In addition, it is difficult to explain
the relationship only by presence and absence ofan employment relationship: ‘type of
employment’ and ‘meaning of jobs for eachindividual’ must have some influence on the
degree of life satisfaction in past research.
Results of this study support past researchthat argues for the importance of patients’
forecasting. The fact that the ability to forecast has
more influence than present physical and social
conditions introduces a new perspective into thepractice of rehabilitation.
As the number of subjects was only 31 thistime, there is some restriction on the reading of theoutcome of the multivariate analysis. Further
research must address the authenticity of‘forecasting’ that subjects have; studies should

12

THE RELATIONSHIP OF LIFE SATISFACTION WITH FORECASTING IN SCI

also provide chronological follow-up research andsuggest supportive measures to increase the degreeof life satisfaction.
Acknowledgement: I would like to extend my
gratitude to the patients in the Ito National
handicapped with a high degree of disability
Center and its Occupational Therapist, Mr. Koji
Iwai, for their cooperation in collecting data.

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ORIGINAL ARTICLE

Transition Related Dilemmas of Persons
with Developmental Disabilities
Ma. Concepcion C. CABATAN, MHPEd, OTRP, OTR1
1 Department of Occupational Therapy, College of Allied Medical Professions,

University of the Philippines Manila

Abstract: This study describes school to post-school transition problems, factors,
activities and professionals involved in transition. Parents (n=86) of children with
developmental disabilities, aged 14 and older, answered a questionnaire addressing study
objectives. Parents reported work, psychological, coping and environmental problems
related to transition. Factors perceived to facilitate smooth transition include coordination
among service providers, early planning, presence of support systems and training in andexposure to post-school environments/activities. Lack of adolescent and adult programs,
absence of planning and lack of knowledge about transition were perceived to hindersmooth transition. Activities listed for transitioning include planning, contact withagencies, professionals and potential employers, and work training. Teachers, doctors andoccupational therapists were reported to be involved in the process. Results suggest apractice area addressing adolescent and adult needs. Further studies are needed to explore
the efficacy of transition programs for this population.
Key words: school to work transition, developmental disabilities, transition planning andactivities(Asian J Occup Ther 3: 15–26, 2004)

Introduction
Developmental disability (DD) represents achronic, mild or severe group of disabilities
resulting from mental or physical impairment or a
combination of both. It also results in a substantial
Received: September 1, 2003, Accepted: February 25, 2004
Corresponding to: Ma. Concepcion C. Cabatan;
Department of Occupational Therapy, College of Allied
Medical Professions, University of the Philippines Manila,
P. Faura St. Ermita, Manila, Philippines
phone: 632-524-5113/632-716-0124 fax: 632-526-2271
e-mail:Cabatan@edsamail.com.phmccab@mail.upm.edu.phfunctional limitation in three or more key areas ofliving (McDonnell, Wilcox & Hardman, 1991;
Siporin, 1999). These areas include self-care,
receptive and expressive language, learning,mobility, self-direction, capacity for independent
learning, and economic sufficiency. Anotherworking definition of DD conceptualized by
Shapiro (as cited in Reyes, 1990) characterizes it
as any disorder that critically affects a person’squality of life. This spectrum of disabilities
include diagnoses such as mental retardation,
autism, cerebral palsy, deaf-blind, learning
disabilities, attention deficit disorder, andcommunication disorders (Clark & Kolstoe, 1995;

16

TRANSITION RELATED DILEMMAS

McDonnell et al., 1991; Shapiro as cited in Reyes,
1990).
As major areas of living are affected, persons
with DD require ongoing support from theirfamilies, health, education, and social services
throughout their lifespan (Siporin 1999;
McDonnell et al., 1991). Required services range
from early intervention, special education, andvocational services that are modified as they growolder and their needs change. In the Philippines,
most of the services are focused on earlyintervention and special education programs.
Johnson (1995) asserted that there is a dearth ofpost-school programs for adolescents and adults
with disabilities.
When it is time for persons with DD to leave
the school environment, their families are inquandary as to what they will do. Some families
expect them to be ready for work training, work
per se or to function optimally in the community
following completion of a school program.
Options in the Philippines for this age group arelimited and inadequate. When it is time forfamilies to search for post-school placements, they
discover that their children are inadequately
prepared in terms of work skills and environment.
Because of insufficient training, employment isdifficult to find. Others resort to placing themback to school programs for further training or tosimply keep them occupied. Many were also
reported to stay home. As such, idleness andsometimes regression to infantile behaviors werealso reportedly observed.
These experiences have heightenedawareness among parents and professionals to
address the need to prepare adolescents/adults
with developmental disabilities for post-school
environments. This preparation period is referred
to as transition in this paper. This study
documented transition related dilemmas andexamined the factors that affect transition to a
post-school environment. The investigator also
identified activities and professionals involved intransition. It hoped to contribute to a knowledge
base of the status of transition and adult programsfor persons with developmental disabilities, andthe extent of need for additional support services
required in a developing country such as thePhilippines. This project aimed to provide
impetus to create and develop transition programs
by adult service providers and educational
institutions. With transition programs in place for
persons with disabilities, post-school adjustment
and placement problems can be anticipated andminimized. This study can also be used to justify
the design of individualized transition plans foradolescents with special needs.
Using a survey questionnaire, this study
attempted to answer the following questions:
1. What problems are commonly observed
among those with transition and withouttransition?
2. What factors facilitate/hinder smoothtransition to post school environments?
3. What activities are used to transition
persons with developmental disabilities
from school to post-school environments?
4. Who are the professionals involved in thetransition process?
The words “problem” and “dilemma” areused interchangeably throughout the paper. They
refer to obstacles experienced and observed whena person with DD is prepared for post-school
environments. Problem categories wereoperationally defined as:
1. Psychological—emotional responses to avariety of situations such as confusion,
depression, withdrawal, and anxiety.
2. Coping—difficulties in adjusting orm od if yi ng beh a vio r in r e s po ns e t oenvironmental demands such asaccommodating change, learning newroutines, and interacting with new persons.
3. Behavioral—engagementin
nonproductive or maladaptive responses suchas helplessness, increase in selfstimulatory activities, and preference forinactivity.
4. Work-related—difficulties related tocarrying our tasks or responsibilities inschool or non-school environments such as
irregular attendance, learning work skills,
managing money, and frequent tardiness.
5. Environmental—constraints or limitations
found within context of family,community, and society such as lack ofAsian J Occup Ther 3: 15–26, 2004

support, lack of job options, lack of leisureopportunities, and no income to live
independently.

Literature Review
Transition Events
Social scientists have theorized that in aperson’s lifespan, transitions are inevitable. Going
to school, getting a job, moving to new place, andgetting married are typical examples of transition
events. Because it is a change that brings about“temporary disequilibrium” in a person’s life,
stress is experienced (Blair, 2000, p. 232).One of
Levinson’s stages of adulthood focused on thetransitional period from adolescence to early
adulthood (Rice, 1995). This period ischaracterized by stable and transition episodes.
According to Levinson, it is during stable periods
that adults develop values, belief systems, and life
priorities. It is during times of transition that these
may be modified in response to events. These
episodes are closely related to Havighurst’s
developmental tasks of young adults, which
include finding a job, spouse, and living awayfrom parents (Rice, 1995; Schulz & Ewen, 1993).
For the average person, transitions may be easily
negotiated. A modification in routine, habit, andactivity patterns is a typical response.
For persons with DD, one change is theirtransition from school to post-school
environments that usually occurs between the agesof 14 to 22. A post-school environment may be awork place, new residence, an adult education
program or living in the community. This is aperiod of preparation to enter these adultenvironments (Chandler, O’Brien, & Weinstein,
1996; Clark & Kolstoe, 1995; Horne & Morris,
1998; McDonnell et al., 1991). They need to learn
new response sets to deal with role change, newroutines, responsibilities, occupations, skills, andhabits. (Hanley-Maxwell, Whitney-Thomas, &Pogoloff, 1995; Jacobs, Mazonson, Pepicelli,
Clague, & Leekoff, 1985).
A study by Hanley-Maxwell, WhitneyThomas et al. (1995) described the visions ofparents of children with disabilities. They
portrayed their children working, living

Cabatan CC

17

independently, and having a network of friends
outside of the family unit. Schuster, Graham and
Moloney (2000) conducted a survey on post-highschool expectations of students with disabilities
and their parents. Students had higher
expectations for themselves than their parents.
They expected to work after high school congruent
with their perception that it is a means to earnmoney, meet people, and feel responsible.
Another study by Whitney-Thomas and HanleyMaxwell (1996) revealed that parents experience a“greater discomfort and pessimism” of the futureof their children with disabilities (p. 75). The time
to confront a permanent departure from a school
environment elicits tension and ambivalence(Blair, 2000) that affect family members.
The adjustment from school to a post school
environment can be a difficult process.
It is well documented that a large number of
persons with DD are unemployed orunderemployed, have no or little access to leisureand community activities, are unable to make life
decisions, and have very little independence(Clark & Kolstoe, 1995; McDonnell et al., 1991).
Many are not given opportunities to select theirpreferred placements. For those who work,
Siporin (1999) reported that there was very little, ifany, social interaction occurring between workers
with DD and those without. She postulated that
deficient preparation for a work environment wasa reason for the lack of social interaction.
Similarly, McInerney and McInerney (1994)
found that adolescents with disabilities are
deficient in social skills and work behaviors. A
lack of essential skills for daily life in thecommunity makes adolescents and adults withdisabilities susceptible to maladjustment.
Hanley-Maxwell, Whitney-Thomas et al.
(1995) asserted that the needs of this population
require reliable and accessible services, wider
range of residential options, support networks, anddiverse experiences for successful transition.

Transition programs
In the United States, federal regulations suchas the Individuals with Disabilities Education Act(IDEA) and the School-to-Work Opportunities
Act (STWOA) provided for transition services to18

TRANSITION RELATED DILEMMAS

promote movement from school to post-school
environments. Services included the following:
post-secondary education, vocational training,
integrated employment, adult services,
independent living, and community participation(Clark & Kolstoe, 1995; Horne & Morris, 1998).
In the Philippines, Republic Act 7277, also known
as Magna Carta for Disabled Persons, does nothave an explicit provision for transition services orprograms.
Literature provided a variety of programs that
address transition. Davidson and Fitzgerald(2001) described a client-centered transitionplanning scheme aimed to facilitate a student’s
successful movement and integration from school
to community environments. O’Reilly (2000)
described a Transition Individual-Education
Program of the Rochester Regional Transition
Coordination Site. Getzel and Kregel (1996)
proposed an employment connection program.
McInerney and McInerney (1994) introduced aproactive occupational therapy program that
addressed transition needs. Occupation-based
programs (Ethridge, Dimmer, Harrison, & Davis,
1989; Giese, 2000; Kluver, Clark, & Hoffman,1998) conducted in the community provided
persons with DD opportunities to practice skills innatural settings. Schlien and Ray (1997) proposed
the inclusion of therapeutic recreation services for
a comprehensive transition program.
Occupational therapists are significant
players in transition programs especially in the
training of community living skills. Davidson and
Fitzgerald (2001), Giese (2000), and Kluver et al.
(1998) affirmed that our background on
occupational performance provided occupational
therapists the requisite to create community based
instruction in instrumental activities of daily living(IADL), work task adaptations, communication,
self-advocacy, consumer and legal issues, healthmanagement, housing options, personal assistancemanagement, recreation, and transportation.
In the four programs described above and inother literature (Schuster, Graham, & Moloney,2000), coordination and collaboration among
parents, students with disabilities, teachers, adultservice providers, and employers are emphasized.
Hanley-Maxwell, Pogoloff, and Whitney-Thomas(1998) emphasized the role of families duringtransition periods. Families of young adults withdisabilities played multiple roles, and theseinteracted and overlapped with each other. Only
one literature was found that cited the participationof pediatricians in the transition process (Johnson,
1995).
Early and effective transition services
increase the likelihood that a person with DD willcomplete school equipped with enough skills tomove on to post secondary education andmeaningful work (Gloekler, 1998). Chandler et al.
(1996), Kluver et al. (1998), and McInerney and
McInerney (1996) cited case study evidences of
persons with DD who were able to findemployment and were successfully living in thecommunity. The cases described skills practice innatural environments, job related activities,
assessment of work related capacities, andexposure to various jobs. Much of the report oftransition outcomes described in literature usedcase study designs. Longitudinal studies exploring
effects of programs from transition planning are
scarce, if not nil.

MethodParticipants
The target population for this study included
parents of adolescents and adults with
developmental disabilities. For inclusion in the
study, the only criterion considered was for aparent or guardian to have a son or daughter, aged
14 and older, diagnosed with any one of thefollowing: Autism/Autism Spectrum Disorder(ASD), Down syndrome and Cerebral palsy,
Attention Deficit Disorder, and Mental
retardation.
A list of their parent-members with children
within the specified age group was obtained fromthe Autism Society of the Philippines, Down
Syndrome Association, and the Philippine
Cerebral Palsy, Inc. Assistance from two (2)pediatricians and one (1) occupational therapist
was also sought in the distribution ofquestionnaires to patients/clients who fit thecriterion. Anticipating difficulty in accessing thetarget population, sampling was not done. The

Asian J Occup Ther 3: 15–26, 2004

study intended to include all parents/guardians
who fit the inclusion criterion.

Instrument
A mail questionnaire was designed
containing questions that addressed the researchquestions. Content was gathered from literature(Chandler et al., 1996; Getzel & Kregel, 1996;
Hanley-Maxwell, Whitney-Thomas et al., 1995;
Johnson, 1995; McInerney & McInerney, 1994;
O’Reilly, 2000) and from interviews of 13 parents
seen at the Clinic for Therapy Services, a campus
based clinic. A developmental pediatrician, an
occupational therapist, and survey design expert
reviewed the questionnaire. The University of thePhilippines Manila-Filipino Language Centertranslated the questionnaire to the Filipino
language.
Both the English and Filipino versions of thequestionnaire were pilot tested to 5 parents ofchildren with special needs aged 14 and older.
Revisions were done based on feedback of theparents and experts. Categories/items in thequestionnaire were also coded to facilitate
encoding and data analysis.
Each question contained choices for the
respondents to select what was applicable to them(Fig. 1). The first part asked for demographic
characteristics of respondents and their adolescent/adult child with DD. Part II was for those
respondents whose children were still enrolled in aschool program. They responded to questions
addressing current measures undertaken to prepare
the person with DD from school to a post-school
environment. Parents who reported having started
transition were directed to proceed to questions inPart III that were relevant to them (questions fourto eight). Part III was for those whose children
were already in post-school environments.
Questions pertained to the person’s current
activity level, residential status, transition
activities undertaken, problems encountered(questions four and five), factors that facilitated orhindered the process (questions six and seven),and professionals (question eight) involved intransitioning.

Cabatan CC

19

Which of the following problems did your son/daughter have during or after the transition period?
(cross out all that apply)* Confusion* Depression* Withdrawal from friends and family* Anxiety* Difficulty accommodating change* Difficulty learning new routine* Helplessness* Increase in self-stimulatory behaviors* Preference for inactivity* Inadequate skills learned in school* Lack of recreational/leisure options* Difficulty making decisions* Aggressive behavior* No or lack of paid job options* Frequent tardiness in present program* Others, please specify___________
Fig. 1. Sample question

Data collection and analysis
A survey research method was employed forthis study. Mailed questionnaires were coded withnumbers for confidentiality to enable theinvestigator to track returns. Follow-up was
conducted via telephone calls. Only those who
had listed telephone numbers were contacted.
Questionnaires were accompanied by a cover
letter stating the purpose of the study, criteria forinclusion, and a statement of how their names wereobtained. Postage paid business reply envelopes
were included. A total of 344 questionnaires weresent out. Three hundred thirteen (313) were
mailed. Thirty-one were distributed personally.
Of those mailed, 19 were returned to sender withnotations that addressees had moved with noforwarding addresses. Ninety-nine (99) werereturned, yielding a response rate of 30%.
Response rate was calculated by dividing thenumber of surveys returned and completed (n=99)
by the population (n=325). Of the 99 returned
questionnaires, thirteen (13) were found to beunusable. If questionnaires come with missing
pages, or if the children did not fit inclusion

20

TRANSITION RELATED DILEMMAS

criterion, they were deemed unusable. The
remaining 86 were used for data analysis.
Data analysis was done using descriptive
statistics. Frequency counts and percentages andcross-tabulation were performed using theStatistical Package for the Social Sciences (SPSS)
program.

Results
Although 86 questionnaires were used, somequestions were not applicable to all and not all
respondents completed questions applicable tothem; therefore, the number of responses varied
for some questions. There were also questions that
asked respondents to cross out all options that
apply. In such cases, the sum may be more thanthe N for some of the results presented below.

Demographics
Table 1 shows a demographic profile of theparticipants who were either parents or guardiansof persons diagnosed with a developmental
disability.
The mean age of the participants was 46
years. Clearly, over half of the group were middleaged adults (76%) and female. Young adultparticipants (14%) were sibling-guardians of
persons with DD. There were slightly more
respondents from Manila than from the provinces.
A majority (83%) received higher education. The
group’s (n=71) socio-economic profile reflected a
middleclass to an upper middleclass background.
Mean age of adolescent/adult children with adevelopmental disability was 18 years. Their age
range was 14–41 years old. Over half (67%) of thechildren were adolescents while the rest wereyoung adults. Sixty-four (64) or 74 percent weremales. A majority (48 or 56%) was diagnosed
with Autism. Others were diagnosed with Down
syndrome (20 or 23%), Cerebral palsy (12 or14%), Attention deficit disorder (3 or 1%) andMental retardation (3 or 1%).
Fifty-three (62%) of the children were still
attending a school program. Thirty-three (38%)
were out of a school environment.Of those inschool, more than half (57%) were enrolled in
special education programs. Programs attended

Table 1. Profile of parents/guardians
Profile Characteristics

Frequency

Percentage (%)

2
10
45
18
8

2
12
54
22
10

18
67

21
79

45
40

53
47

5
9
46
22

6
11
56
27

9
19
31
12

13
27
44
17

Age (n=83)
20–30
31–40
41–50
51–60
61–70
Sex (n=85)
MaleFemaleResidence (n=85)
ManilaProvince
Highest educ level (n=82)
ElementaryHigh school
College
Graduate school
Annual family income (n=71)
39,999 & under
40,000–99, 999
100,000–499,999
500,000–overwere described as academic, vocational or both.
Among those in school (n=53), over half(62%) were perceived to extend their stay in aschool environment up to adulthood. Of thisgroup, less than half (22 or 42%) were reported to
be transitioning to a post-school environment. The
rest (31 or 58%) had not begun transition. Reasonsfor non-initiation of transition cited by a majority(77%) included no awareness of need fortransition, no knowledge of available services andprofessionals to consult with.
Among those who had left school
environments (n=33), 30 (91%) were home-based.
One was working fulltime, another was enrolled in
an adult education program, and one used to workin a computer shop but lost his job. Of this group,
25 (76%) reported no measures were adopted toAsian J Occup Ther 3: 15–26, 2004

Cabatan CC

21

Table 2. Problems observed by parents/guardians
Problems
Psychological
CopingBehavioral
Work
Environmental
a=30; b=56.

With Transitionna (%)

No transitionnb (%)

Total
n (%)

22 (73)17 (57)15 (50)23 (77)9 (30)

14 (25)21 (38)19 (34)14 (25)24 (43)36 (42)38 (44)34 (40)37 (43)33 (38)Percentages add up to more than 100 due to multiple responses.

Table 3. Perceived factors affecting transition (n=86)
Facilitating Factorsn%Coordination among service providers
Early planning
Presence of support systems
Prior training/exposure to different
environments/activities

76
53
42

88
62
49

38

44

79
74
42
24
21
13

92
86
49
28
24
15

Barriers
Lack of services/programs
No planning
No knowledge of transition
Lack of support
Lack of coordination
Others (financial, stigma)

prepare their children for a post-school
environment. Only 8 (24%) reported conducting
activities related to transition.
Altogether, 30 (35%) underwent transition
related activities and 56 (65%) did not undergo
any transition.

Problems observed
Problems reported observed during and after
transition were classified into 5: psychological,
coping, behavioral, work related andenvironmental (Table 2). Parents reported a mixof problems.
Table 2 shows that respondents of those withand without transition reported almost equally thesame types of problems. A majority of the
respondents, whose adolescent children underwent
transition, observed more work, psychological,

and coping related problems. In contrast, moreenvironmental problems were observed among
those without transition.

Factors affecting transition
Factors perceived to facilitate a smoothtransition from school to a post-school
environment included the following: earlyplanning, coordination among service providers,presence of support systems (family and friends),
and prior training in different environments/
activities (Table 3). In contrast, parents perceived
the absence, or lack of such factors, to hindersmooth transition, that is, the absence or lack ofplanning, coordination among professionals,
adolescent and adult programs, knowledge oftransition, and support. Financial problems andstigma were also mentioned as barriers.

22

TRANSITION RELATED DILEMMAS

Table 4. Transition activities (n=30)
Transition Activities

In schoolnb (%)

Not in Schoolnc (%)

Planning with Professionals
Training in daily living skills
CounselingContact with GOs/NGOsa for job training
Contact with potential employer
Engagement in adult leisure activities

19 (86)
12 (55)
11 (50)10 (45)6 (27)
1 (5)

2 (25)
7 (88)
4 (50)
00
2 (25)

agovernment organizations/non-government organizations. bn=22. cn=8.

Transition activities
Respondents described measures undertaken.
Varied and multiple activities were employed asshown in Table 4. Those in school utilized a morevaried and broader range of activities than thosealready out of school. Transition planning with
relevant professionals was reported by a majority.
Instruction in daily living skills was reported by allof those in an out of the school environment.
Parents in this group did not contact government,
non-government agencies, and potential
employers during the transition period. Only twoparents reported planning as part of transitioning.

Professionals involved
Of those whose children transitioned (n=30),
they identified educators (46%) to be thepredominant figures in transition. Thirty-sevenpercent reported the involvement of doctors.
Occupational therapists and psychologists werementioned by only 23% of the group. Thirteen
percent involved family and friends. Potential
employers (3%) were hardly sought out in thetransition process.

Discussion
This study elucidated that transition related
dilemmas occur among persons with DD in thePhilippines. It is a growing area of concern amongfamilies of this population. The profile of persons
with DD in this study supported what is stated inliterature that they are mostly unemployed. In thePhilippine context, attention was drawn to one
problem, which was the absence or lack of services

and programs for adolescents/adults with DD.
Some degree of transition activities was slowly
emerging although most were parental initiatives.
It was a multiple strategy process andcollaboration among service providers. There wasan interaction of factors that affected the outcomeof such a process. There was an apparent need toeducate families and professionals on theimportance of transition preparedness anddevelopment of relevant programs for thispopulation.

Transition related problems
The finding that occurrence of problems
related to psychological, coping, work, andbehavior areas of functioning was consistent withliterature (Getzel & Kregel, 1996; McInerney &McInerney, 1994; Siporin, 1999). Work related
problems such as poor attendance, difficultyacquiring new work skills, and mobility between
the home and community environments suggested
a lack of exposure to new environments andin a d e q u a t e p r e p a r a t io n f o r a p o s t -s c ho o lenvironment. This finding also matched with thereport of Herge and Campbell (1999).
The presence of problems also showed thattransition is not an easy phase for persons with DD(Chandler et al., 1996; Clark & Kolstoe, 1995;
Horne & Morris, 1998; Johnson, 1995; McDonnell
et al., 1991). Problems observed did not seem toemerge in isolation. The range of problems
supported the idea that difficulties in one area werelikely to affect others. Work related and coping
problems were observed together with depression,and anxiety. Inability to effectively adjust in post-

Asian J Occup Ther 3: 15–26, 2004

school environments suggested difficulty intransferring skills to daily living situations. This
gave rise to depression, anxiety, and withdrawal
from family and friends. According to Moloney,
Whitney-Thomas, and Dreilinger (2000), these
problems may be attributed to a lack of selfdefinition defined as having a sense of purpose,awareness of strengths and weaknesses, and ability
to convey these to others. They suggested training
to include interest exploration and decisionmaking to facilitate acquisition of self-definition.
Environmental problems least reported bythose with transition, as compared to those
without, implied that even if these problems
existed, transition planning and activities
minimized its negative effects. This was similarly
reported by Chandler et al. (1996); Horne andMorris (1997); Hanley-Maxwell, WhitneyThomas et al. (1995).
The problems also suggested the lack ofattention to the needs of adolescents and adults
with DD (Getzel & Kregel, 1996; Johnson, 1995).
Johnson (1995) opined that the level of “transitionreadiness” affected outcome of transition
programs (p.269). Considering that persons with
DD achieve varying degrees of independence,timing of transition is crucial to success.
Readiness to be transitioned to a post-school
environment includes a critical decision that has tobe made by parents and professionals involved.
Measurement of outcomes related to transition
varies according to set goals, levels of functioning,and cultural context. While many of the parents inthis study expressed the need for transitioning fortheir adolescent and adult children, Filipino
cultural values and beliefs influenced the final
decisions in allowing their children to be more
independent.
The report of these problems and thestaggering number of those without transitionindicated parents’ uneasiness and concern for theirchildren’s future, which was similarly observed byWhitney-Thomas and Hanley-Maxwell (1996).
Their uneasiness was made worse by the lack ofknowledge and relevant services. Parents
appeared to be communicating a quiet but
desperate call for help to address employment andcommunity adjustment requirements of their

Cabatan CC

23growing children.

Factors affecting transition
Parent perceptions of factors affecting
transition showed a pattern of interaction among
multiple factors. A relatively successful transition
outcome could be predicted if most, if not all of the
facilitating factors, were present (see Table 4).
These factors corresponded to the essential
elements of a transition program cited by Getzel
and Kregel (1996); Hanley-Maxwell, WhitneyThomas et al. (1995); McInerney and McInerney(1994), and O’Reilly (2000). Johnson emphasizedthat transition for persons with developmental
disabilities requires a deliberate planning process.
Because transitioning occurs within acontext, its success largely depends on close
collaboration among families, service providers,
professionals, agencies, and potential employers.
Chandler et al. (1996) described the process as a“shared responsibility” (p.55).
Access to support services and work training
programs is important during transition.
Experience in and exposure to work environments
during this period was reported to be beneficial.
The case of an adult child in this study, reported toadjust successfully, was akin to the cases cited by
Chandler et al. (1996), Kluver et al. (1998), andMcInerney and McInerney (1994).
In contrast, the absence of those factors
perceived to facilitate smooth transition turned out
to be barriers. The environmental related
problems cited in a previous section included afactor in transition outcomes. The scarcity or
absence of options such as work, leisure, and laws
had impact on the success of transition among
these persons. It seemed that inadequate
implementation of the Magna Carta, pervading
attitudes of Filipinos, economic, and politicalclimates continue to serve as barriers tocommunity integration of persons withdisabilities. This is not to undermine the efforts inthis positive direction. To a certain extent, thePhilippine government—through the Magna Cartaand its agencies such as the Department of Laborand Employment, National Council for the
Welfare of Disabled Persons, and various nongovernment organizations—has projects that have

24

TRANSITION RELATED DILEMMAS

had successful outcomes for persons with physicaldisabilities. However, it is still wanting for
persons with DD. Major issues such as highunemployment, lack of educational and vocational
opportunities, inaccessible workplaces, limited
financial, and technical support continued toconfront advocates of this movement (“Philippine
disability scenario,” 1995–1999). Perhaps, thePhilippines have yet to learn from the experiences
and models initiated in developed countries suchas the United States, Canada, and Japan.

Activities and involvement of professionals
The scope of transition-related activities
reportedly undertaken by parents and children
included personal initiatives. Parents were theprime movers in the transition process. The
initiative of parents to begin and be involved in theprocess played a significant role. Literature
concurred with this finding (Hanley-Maxwell,
Whitney-Thomas, & Pogoloff, 1995; WhitneyThomas & Hanley-Maxwell, 1996; Schuster,
Graham, & Moloney, 2000). Hanley Maxwell,
Pogoloff, and Whitney-Thomas (1998) establishedthe historic and emerging roles, and relationships
of families during transition for young adults withdisabilities. The network of family and friends,
although not tapped by many, may be a valuable
source of support and assistance in the transition
process.
There was no clear and systematic protocol in
activities undertaken by parents. A lack of clear
guidelines, availability of, and access to transition
programs was pervading. Results also suggested
that there was a lack of vocational counselors,
trainers, and job coaches in the Philippines.
Transition is not only an issue of going through theprocess but also knowing how to go about it. Thisfinding suggested that parents and service
providers were unaware of the importance oftransition. It has gained ground, however, indeveloped countries as reported by otherprofessionals (Clark & Kolstoe, 1995; Horne &Morris, 1998; Johnson, 1995; McDonnell et al.,
1991; Schlien & Ray, 1997) and in OT literature(Ethridge et al., 1989; Getzel & Kregel, 1996;
Jacobs et al., 1985; McInerney & McInerney,
1994; O’Reilly, 2000).

Findings of this study strongly validated thattransition from school to post-school
environments for young adults with DD is aturbulent time not only for them but for families aswell. A shift from “child-centered” to “adultoriented” activities that characterized this period
was not an easy feat (Johnson, 1995 p. 268).
Theoretical frames have long asserted that allindividuals go through life span transitions (Blair,
2000). The average person is able to traverse
transition periods by accepting and managing
change using internal and external resources.
However, persons with developmental disabilities
face additional barriers to overcome transitions.
Hence, they need additional resources and support
to enable them to adjust to adult life demands andbe integrated successfully into their communities.

Study limitations
Given that this study utilized a descriptive
survey research, it is inevitable that it carries manyof the inherent weaknesses of such a design. The
length of the instrument, the interpretation of
items, and use of mail in the collection of data may
have affected response rate and interpretation of
responses. Non-responses and low return rate may
have affected validity and the potential for thefindings of this study to be generalized to therelevant population. Also, the study did not utilize
statistical tests to determine significant differences
between groups.

Conclusions
The dilemmas and status of transition-related
activities reported in this study supported the viewthat the growing population of Filipino
adolescents and adults with DD are underserved.
Programs and services such as work training, job
placement, transportation, group residences wereclearly deficient, if not absent. Another significant
concern is the lack of knowledge on theimportance of transition.
It is imperative for occupational therapy,
educat io n practi tio ners, an d ot her healt hprofessionals in the Philippines to work together in
exploring and developing programs foradolescents and adults with developmental

Asian J Occup Ther 3: 15–26, 2004

disabilities. For Filipino occupational therapy
practitioners, efforts must be exerted to shift froma modality-specific to an occupation-based
practice. The lack of advocacy work toward
community inclusion among government, private
entities and employers remain a continuing
concern. Longitudinal studies are needed to
explore the nature and efficacy of transition
programs in helping these persons respond
appropriately to adult life demands.
Understanding the process of transition in thecontext of Filipino and Asian culture is anotherresearch direction.
Acknowledgements: I thank the parents andguardians who participated in the pilot test andactual conduct of this study; the officers and staffof the Autism Society of the Philippines, Down
Syndrome Association of the Philippines, and thePhilippine Cerebral Palsy, Inc.; Clinic for Therapy
Services; Learning Partners, Inc; Dean Susan B.
Villegas, Prof. Maridel Borja; Drs. Alexis Reyes
and Ria de Guzman, Ms. Josephine Nepomuceno,
Mr. Rolland Lyle Duque, Ms. Hazel Pascua, Mr.
Butch Regala, Ms. Yolanda Capaque, Ms.
Rizalina Cruz, Ms. Fe Cagata, Ms. Mariel Apejas,
Mr. Benjamin Malihan for their support andassistance.
This study was supported by the Charlotte A.
Floro Professorial Chair.
A portion of this study was presented inposter format at the 13th World Congress of
Occupational Therapists in Stockholm, Sweden in
June 23–28, 2002.

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