Communication Activities of Daily LivingSecond Edition CADL2

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Communication Activities of Daily Living-Second
Edition (CADL-2)

• November 10, 2004
• Lynn Brenman
• Michele Esses
• Christine Moawad

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What is the Communicative Abilities in Daily
Living (CADL)?

• First test created to assess communicative
  abilities of individuals with aphasia in a
  natural environment.
• Developed by Audrey Holland at the University of
  Pittsburgh with a grant from the National
  Institutes of Health.
• First published in 1980.
• Focused research on the communication strategies
  and pragmatic skills of aphasic patients in their
  natural environments.

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CADL versus CADL-2

• CADL title was changed to Communication
  Activities of Daily Living-2nd Edition (CADL-2)
  to reflect World Health Organization current
  terminology.
• CADL-2 has the same theoretical basis as CADL,
  but is more contemporary and time efficient.

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Administration

• It is recommended that the CADL-2 be administered
  by a licensed, certified speech-language
  pathologist who has experience in the field of
  neurogenic communication disorders.
• CADL-2 has 50 test items.
• Requires 30 minutes to administer.
• Available in Japanese and Italian.

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Intended Population

• CADL-2 was intended for adults with aphasia.
• Evidence for success in individuals with
• Mental Retardation
• Experience in using Hearing Aids
• Alzheimers Disease
• Traumatic Brain Injury
• Post-Stroke Right-Hemisphere Damage

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What does CADL-2 measure?

• Allows the clinician to observe communication
  acts in simulated natural environments.
• Uses a 3-point scoring system based on the idea
  that transmission of a message exists on a
  continuum from correct to incorrect.
• Assesses and scores Getting the message across
  as a communication act.

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Seven Test Categories

• Reading, Writing, or Using Numbers
• Contextual reading tasks, estimations, and
  calculations based on numerical ability (e.g.,
  reading signs or directions, making monetary
  change, or setting dates.)
• Shown an appointment card with the time of the
  patients appointment and a picture of a clock,
  the patient is told, Heres the clock. Its now
  five minutes after ten. How long until your
  appointment?

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Seven Test Categories

• Social Interactions- Pragmatic interchanges,
  which require use of speech, gesture, or writing
  to convey information and intent. (e.g.,
  correcting, making inferences, asking for
  repetitions, and overlearned speech acts such as
  greeting and leaving).
• The examiner greets the patient by saying,
  Hello, Mr./Ms. ______. Examiner waits for
  nonverbal or verbal response.

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Test Categories Contd

• Divergent Communication
• Generation of logical alternatives from
  information provided/readiness to alter direction
  of response. (e.g., choosing from a menu or
  identifying newspaper headline from a photo).
• Given a choice of four times presented on
  pictures of clock faces, the patient is asked,
  Whats the best time here for eating lunch?
• Contextual Information
• Response to direct content presented in a
  context. (e.g., what do you wear on a rainy
  day?, interpreting signs and environmental
  hazards).
• Shown a picture of a rainy street, the patient
  is asked, What should you wear on a day like
  this?

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Test Categories Contd

• Nonverbal Communication
• Nonverbal communication and symbols,
  movement-related communicative behaviors (e.g.,
  map skills and association between facial
  expression, body language, and emotion.)
• Patient is asked, Would you hand me that pencil,
  please?
• Sequential Relationships
• Ability to perform sequential acts and to
  understand cause-effect relationships (e.g.,
  finding an item in a store by looking at aisle
  signs, understanding the relationship between
  speed on speedometer and speed limit sign, and
  judging what the driver should do.)
• Shown a building directory, the patient is told,
  Here is a building directory. What floor is Dr.
  Clarks office on?

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Test Categories Contd

• Humor/Metaphor/Absurdity
• Involves high-level linguistic cognitive
  operations (e.g., find the funny picture from a
  choice of three, figurative language Hit the
  roof., identifying absurd recommendations by a
  physician).
• Patient is asked, If Dr. Clark told you to smoke
  three packs of cigarettes and drink a bottle of
  gin a day, what would you say?

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Test Items Materials

• Realistic - commonly found in patients natural
  environments.
• Color photographs. No b w photos or line
  drawings.
• Everyday life scenarios.
• Naturalistic color in drawings.
• Real items, i.e. telephone and money.
• Universal environmental signs (e.g., railroad
  crossing, poison).
• Common reference materials (e.g., maps, Yellow
  Pages).
• Relevant to most individuals regardless of age,
  gender, socioeconomic status, or cultural or
  ethnic background.

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Administration Preparation

• Complete Examiners Record Booklet History
  section.
• Collect information including diagnosis, level
  of care, education, language background, primary
  communication modality, vision, hearing, and
  premorbid reading/writing skills.
• Gather required materials Examiner Record
  Booklet, Picture Book, Patient Response Booklet,
  pencil, working telephone, four one-dollar bills
  and four quarters .

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Test Administration

• Create a positive, relaxed, friendly, and
  accepting atmosphere.
• Encourage patients to communicate using any means
  that they have.
• Present items at normal rate of speech.
• No penalty for repetition of a question.
• Assess verbal and non-verbal communicative
  behaviors.
• Record content and modality of responses.

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Scoring the CADL-2

• Three-point scoring system. Getting the message
  across is being scored.
• 0 Wrong response (e.g., silence, stereotypic
  response, echoing test item, jargon use).
• 1 Adequate response (e.g., partially correct
  response or correct response after repetition of
  the question).
• 2 Unequivocally correct response.

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Results

• Results reported in three ways
• Raw Score (0-100 points)
• Percentile - Percentage of scores in a normative
  sample that occur below a given raw score.
• Stanine - Expresses score as distance from mean
  using standard deviation. Results are divided
  into 9 levels of functional communication (high
  to low).

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Score Results
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Caveats to Interpreting Results

• CADL-2 does not claim to address full scope of
  conversation.
• Not intended for use in long-term care settings.
• Results taken alone do not diagnose anything.

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Standardization

• Sample included 175 adults with neurogenic
  communication disorders (primarily left or right
  hemisphere stroke or TBI).
• Sample approximated 1997 U.S. Bureau of Census
  statistics for race, ethnicity, gender,
  residence, and geographic region.

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Standardization Contd

• Sample did not consider socio-economic
  characteristics.
• Northeast over-represented by 20.
• South under-represented by 16.

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Test Reliability

• Degree to which test score differences can be
  tied to characteristics being examined versus
  chance.
• Content Sampling (homogeneity) .93
  Chronbach coefficient alpha
• Time Sampling (test-retest consistency) .85
  coefficient
• Interscorer Difference
  .99 coefficient

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Test Validity

• Does test measure what it claims to measure?
• Content
• Examined by 10 certified licensed SLPs
• Item validity coefficient .2
  (.2 - .3 is considered
  acceptable)
• Criteria (r.66, plt.01 Pearson correlation)
• Construct Validity
• Group differentiation (t-ratio 19.5)
• Item Validity (median .47, .2 is acceptable)
• Correlation to Other Assessment Measures
  (Spearman r-.05, plt.01, n127)

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Peer Review

• Worrall, McCooey et al. (2002) cite CADL-2 as an
  example of an assessment specifically designed
  for community-based Americans with aphasia.
• Ross and Wertz (2004) state that CADL-2 is
  accurate in confirming mild aphasia. Results
  suggest it may be administered and interpreted
  reliably.

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Theory/Rationale

• First test designed to measure the communicative
  abilities of individuals with aphasia
  particularly through natural contexts. Prior to
  CADL in 1980 there was no research in this area.
• Developed from a sociolinguistic theory and a
  holistic framework of functional communication,
  which focuses on assessment in a natural,
  contextualized manner.

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Theory/Rationale Contd

• Sociolinguistics is the study of the relationship
  between language and society.
• According to Holmes (1992), the following are
  components of social communication
• The participants who is speaking and to whom are
  they speaking?
• The setting or social context where are they
  speaking?
• The topic what is being talked about?
• The function why are the speaking/listening
• This framework provides better understanding of
  everyday communication of people with aphasia.

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Theory/Rationale Contd

• CADL was created based on the following
  questions
• How do normal speakers demonstrate comprehension
  of communicative acts?
• What functional communication activities do most
  normal speakers engage in?
• What do normal readers read?
• What do normal writers write?
• How do normal speakers use numbers for
  communicative purposes?
• How do people communicate that they cannot or do
  not wish to communicate?
• What are some elementary adaptive strategies for
  clarifying miscommunications?
• CADL and CADL-2 have the same underlying
  principles.

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Theory/Rationale Contd

• The CADL-2 tries to capture the multidimensional
  nature of everyday communication by
• recreating microcosmic interactions of basic
  activities that individuals carry out in daily
  life, that the clinician can directly and
  practically observe.
• objectification of observations using valid and
  reliable methods.
• using a 3 point scoring system (correct,
  adequate, incorrect), emphasizing that getting a
  message across occurs on a continuum from right
  to wrong.
• These contribute to the better understanding of
  communication in adults with language and
  cognitive disorders.

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Theory/Rationale Contd

• Information gathered by recreating the
  environment allows for enhanced
• Assessment and predictability of how the patient
  will communicate in the natural setting.
• selection of therapy targets in intervention
  including communication strategies and pragmatic
  skills.
• Decision making.

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Issues Raised

• Functional communication issues include
• Should functional communication measures contain
  everyday examples or lists of items that are
  important to the individual client/SLP?
• Are the CADL-2 activities applicable to everyone
  and all situations?
• Does everyday communication vary between
  individuals, disorders, cultures and
  environments?
• Do the test items represent the real everyday
  communication of real clients?

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Opinion

• Recreates naturalistic environment and functional
  challenges.
• Assesses in multiple modalities (verbal,
  non-verbal, written and oral)
• Statistically sound.
• Not suited for long-term care settings.
• Doesnt capture subtle speaker and listener
  adjustments.

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Opinion Contd

• While the CADL-2 is not suited for use in
  long-term care settings, does not capture subtle
  speaker-listener adjustments, and is not a
  medical diagnostic tool, it is a valuable
  instrument for making decisions regarding
  treatment and rehabilitation.

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References

• Holland, A. L. (1980). Communication activities
  of daily living. Baltimore, MD University Park
  Press.
• Holmes, J. (1992). An introduction to
  sociolinguistics. London Longman.
• Ross, K. B. and Wertz, R. T. (2004). Accuracy of
  formal tests for diagnosing mild aphasia An
  application of evidence-based medicine,
  Aphasiology, 18 (4), 337-355.
• Worrall, L., McCooey, R. et al. (2002). The
  validity of functional assessments of
  communication and the Activity/Participation
  components of the ICIDH-2 do they reflect what
  really happens in real-life?, Journal of
  Communication Disorders, 35, 107-137.