Use of The Vineland Adaptive Behavior Scales in The Assessment of Intellectually Disabled Complainants in Sexual Abuse Cases in The Western Cape

“Use of the Vineland Adaptive Behavior Scales in the
assessment of intellectually disabled complainants in
sexual abuse cases in the Western Cape”
by
Gillian Kathleen Douglas
Dissertation presented for the degree of Doctor of Psychology in the
Faculty of Arts and Social Sciences at Stellenbosch University
Supervisor: Professor Leslie Swartz
Co-supervisor: Dr. Chrisma Pretorius
December 2017
Stellenbosch University https://scholar.sun.ac.za
Acknowledgements
It takes participation, support, guidance and encouragement of many people to complete the
research process. I would like to acknowledge:
• The individuals and their families from whom the data was gathered. This research is
in their service.
• My supervisors, Professor Leslie Swartz and Dr. Chrisma Pretorius for their
thoughtful, empathic and rigorous supervision.
• To my family: Pete, Christy, John, Laurie and Michael.
• Statistical support from Zuhayr Kafaar and editorial support from Jaqueline Gamble.
• To my colleagues in the SAVE team at Cape Mental Health: Sue Manson, Janine
Hundermark, Bev Dickman, Nokuthula Shabalala, Carol Bosch, Zimbini Ogle, and
Jenna-Lee Procter.
• To my work colleagues at the Division of Child and Adolescent Psychiatry,
University of Cape Town, especially to Willem de Jager.
• To the Vera Grover Trust and the Stellenbosch Psychology Department for financial
support.
• To God who loves us all.
i
Abstract
Drawing on a sample of 642 complainants who were people with intellectual disability who
had been sexually abused, the assessment records, psycho-legal reports and clinical
comments of the psychologists involved in their assessment were the data used to assess the
usefulness of the Vineland Adaptive Behavior Scales in a South African context. The sample
group were racially diverse and represented three of the languages commonly used in the area
and participants were predominantly from a low socioeconomic background. A selected
portion of the sample, (n=321) using the Vineland Adaptive Behavior Scales Second edition
(VABS II), was more closely examined. When measured against the range of disability
measured by IQ score and the clinical diagnosis of the psychologist, the VABS II was found
to be a useful and valid instrument for use in people up until the age of 22. Substantial floor
effects for adults over the age of 22 (n=96) were found. Using the rationale of adults,
including those with intellectual disability, reaching asymptote by age 22, recommendation
was made for the younger adult norm tables to be used, where the floor effect was not
pronounced. This was found to be a clinically effective solution. On examination of the
newly published third edition, the same difficulty was found. Clinical item analysis identified
the useful items and the items needing adjustment for reasons categorised as linguistic,
contextual or lacking opportunity in this context. The relevance of valid assessment of
adaptive functioning, in a psycho-legal context, was illustrated by case examples.
ii
Abstract – Afrikaans
Die studie is gebaseer op 'n steekproef van 642 klagtes van persone met intellektuele
gestremdheid, wat seksueel misbruik is. Die data van assesseringsrekords, psigo-regsverslae
en kliniese opmerkings van die sielkundiges wat by hul assessering betrokke was, is gebruik
om die bruikbaarheid van die Vineland Adaptive Behavior Scales in 'n Suid-Afrikaanse
konteks te evalueer. Die steekproefgroep was divers in terme van rasverskeidenheid en
verteenwoordigend van drie van die tale wat algemeen in die gebied gebruik word en
deelnemers was hoofsaaklik van 'n lae sosio-ekonomiese agtergrond. 'n Gekose deel van die
steekproef, (n = 321) wat met behulp van die Vineland Adaptive Behavior Scales Tweede
uitgawe (VABS II) geëvalueer is, is van naderby ondersoek. Toe die VABS II gemeet is teen
die omvang van gestremdheid gemeet deur IK-telling en die kliniese diagnose van die
sielkundige, is die VABS II as 'n nuttige en geldige instrument vir gebruik in mense tot en
met die ouderdom van 22 gevind. Beduidende vloer-effekte vir volwassenes ouer as 22 (n =
96) is gevind. Met die gebruik van die rasionaal dat volwassenes, insluitende diegene met
intellektuele gestremdheid, ŉ asimptoot bereik teen ouderdom 22, is ŉ aanbeveling gemaak
dat die jonger volwasse normtabelle gebruik word waar die vloer-effekte nie merkbaar was
nie. Daar is gevind dat dit 'n klinies-effektiewe oplossing is. Met die ondersoek van die nuut
gepubliseerde derde uitgawe is dieselfde probleem gevind. Deur middel van kliniese
itemanalise is die nuttige items geïdentifiseer en die items wat aanpassing benodig vir redes,
wat beskryf is as taalkundig, kontekstueel of ontbrekend-aan-geleentheid-in-hierdie-konteks,
gekategoriseer. Die toepaslikheid van geldige assessering van aanpassende funksionering, in
'n psigo-regskonteks, is geïllustreer deur gevalle-voorbeelde.
iii
Declaration
By submitting this dissertation electronically, I declare that the entirety of the work contained
therein is my own, original work, that I am the sole author thereof (save to the extent
explicitly otherwise stated), that the reproduction and publication thereof by Stellenbosch
University will not infringe any third party rights and that I have not previously in its entirety
or in part submitted it for obtaining any qualification.
Date: December 2017
Copyright © 2017 Stellenbosch University

All rights reserved
iv
Table of Contents
Acknowledgements i
Abstract – English ii
Abstract – Afrikaans iii
Declaration iv
Table of Contents v
List of Tables and Figures xx
Chapter One: Introduction 1
1.1. The Stories 1
1.2. The Research 2
1.3. The Stories and the Research 2
1.4. The Context 3
1.5. The Problem 4
1.6. Relevance of the Research 4
1.7. The Aims of the Research 6
1.8. Previous Research 7
1.9. Research Design 7
1.10. Layout of the Dissertation 8
1.10.1. Chapter One: Introduction 8
1.10.2. Chapter Two: Constructs and Measurement 8
1.10.3. Chapter Three: Context 8
1.10.4. Chapter Four: Methodology 9
1.10.5. Chapter Five: Descriptive Results 10
1.10.6. Chapter Six: Results of Statistical and Clinical Item Analysis 10
1.10.7. Chapter Seven: Discussion 11
v
1.10.8. Chapter Eight: Conclusion 12
1.11. Concluding Comments 12
Chapter Two: Literature Review: Constructs and Measurement 13
2.1. Introduction 13
2.2. Intellectual Disability 13
2.2.1. Definition 13
2.2.1.1. Disability 14
2.2.1.2. Intellectual Disability 15
2.2.1.3. Level of Severity in Intellectual Disability 18
2.2.2. Naming and Language 20
2.2.3. Prevalence 22
2.3. Assessment of Intellectual Disability 22
2.3.1. Construct of Intelligence 23
2.3.1.1. Evolutionary Models 23
2.3.1.2. Psychometric Models 24
2.3.1.3. Genetic Inheritance 25
2.3.1.4. Neurobiology of Intelligence 26
2.3.1.5. Intelligence vs. Cognition 26
2.3.2. Diagnostic Criteria 26
2.3.3. Purpose of Assessment 27
2.3.3.1. Using IQ Assessment to Differentiate Cause of Intellectual
Disability 28
2.3.4. Assessment Tools 29
2.3.4.1. Cross Cultural Assessment 29
2.3.4.2. Sensitivity of Tools and Floor Effects 31
vi
2.3.4.3. Use of Mental Age to Estimate Cognitive Level 32
2.3.5. Observation and Clinical Judgement in the Assessment Process 33
2.3.5.1. Clinical Reasoning 33
2.3.5.2. Clinical versus Statistical Prediction 35
2.4. Adaptive Functioning/Behaviour 36
2.4.1. Definition 36
2.4.2. Historical Development of the Construct of Adaptive Functioning 37
2.4.3. Assessment of Adaptive Functioning 38
2.4.3.1. Adaptive Behaviour Assessment Tools 39
2.4.4. Assessment of Adaptive Functioning Through the Life Span 41
2.4.5. Assessment of Adaptive Functioning with Different Aetiological Causes of
Intellectual Disability 42
2.4.5.1. Genetic Syndromes 42
2.4.5.2. Autism Spectrum Disorder (ASD) 43
2.4.5.3. Foetal Alcohol Spectrum Disorders (FASD) 44
2.5. Vineland Adaptive Behavior Scales 45
2.5.1. History of the Development of the Vineland Adaptive Behavior Scales 45
2.5.1.1. Vineland Social Maturity Scale (Doll, 1965) 46
2.5.1.2. Vineland Adaptive Behavior Scales (Sparrow, Balla, &
Cicchetti, 1984) 46
2.5.1.3. Vineland Adaptive Behavior Scales – Second Edition
(Sparrow, Cicchetti, & Balla, 2005) 47
2.5.1.4. Vineland Adaptive Behavior Scales – Third Edition (Sparrow,
Cicchetti, & Saulnier, 2016) 48
2.5.2. Use of the VABS in Other Cultures and Languages 49
vii
2.5.3. Validity and Reliability 52
2.5.4. Identified Areas of Further Research 54
2.5.5. Critique of the VABS and the Measurement of Adaptive Functioning 55
2.6. Intellectual Disability in a Psycho-Legal Context 56
2.6.1. The Question of Competency 56
2.6.2. Questioning 57
2.6.3. Truth Telling and Taking the Oath 58
2.6.4. The Court Process 58
2.6.5. The Use of the Concept of Mental Age 59
Chapter Three: Literature Review: Context 61
3.2. The South African Context 61
3.2.1. Historical Context 61
3.2.2. Long Term Effects of Political Systems: Apartheid Policy 64
3.2.2.1. Educational Opportunity 65
3.2.2.2. Relationship Between Age and Educational Opportunity 65
3.2.2.3. Family Systems 65
3.2.3. Long Term Effects of Economic Systems 66
3.3. Intellectual Disability in the South African Context 67
3.3.1. The Prevalence and Understanding of Intellectual Disability in Africa 67
3.3.2. The Prevalence of Intellectual Disability in South Africa 70
3.3.3. The Prevalence of Intellectual Disability in the Western Cape 71
3.3.4. Financial Support for People with Intellectual Disability 71
3.3.5. The Protection of Disability Rights Within South Africa 72
viii
3.3.5.1. The United Nations Convention on the Rights of Persons with
Disabilities 73
3.3.5.2. The South African Constitution 74
3.3.5.3. Guidelines of the Legal Protection in Relation to Differing Levels of
3.3.5.4. The Criminal Law (Sexual Offences and Related Matters)
Amendment Act 32 of 2007 76
3.3.5.5. The Criminal Law (Sentencing) Amendment Act of 2007 77
3.3.5.6. The Criminal Procedure Act 51 of 1977 77
3.3.5.7. The Domestic Violence Act 116 of 1998 78
3.3.5.8. The Mental Health Care Act 17 of 2002 78
3.4. Psychological Assessment of Intellectual Disability in the South African Context 79
3.4.1. Historical Background 79
3.4.2. The Present Situation 80
3.4.3. Assessment Tools Used in SA Context 81
3.5. Sexual Violence 86
3.5.1. Overview 87
3.5.2. Sexual Abuse in South Africa 87
3.5.3. Sexual Abuse in Intellectual Disability 88
3.5.4. Impact of Sexual Abuse on Persons with Intellectual Disability 88
3.5.5. Access to the Justice System 89
3.6. Cape Mental Health 90
3.6.1. SAVE Programme 90
3.6.2. Prior Research 91
3.6.2.1. Court and Process Outcomes 91
ix
3.6.2.2. Psychiatric and Psychological Consequences 92
Chapter Four: Methodology 95
4.2. Context of the Research 96
4.3. Aim of the Research and Research Questions 97
4.4. Methodology of the Literature Review 100
4.5. Research Design 100
4.5.1. Measurement Instruments 101
4.5.1.1. Vineland Adaptive Behavior Scale (1984) 101
4.5.1.2. Vineland Adaptive Behavior Scales – Second Edition (2005) 102
4.5.1.3. Vineland Adaptive Behavior Scales – Third Edition (2016) 105
4.5.1.4. Individual Scale for General Scholastic Aptitude – 1996 (ISGSA) 108
4.5.2. Skill and Experience of the Clinical Psychologists 111
4.5.3. Gold Standard 111
4.5.4. Language of Assessments 112
4.6. The Sample 113
4.6.1. Description of the Participants 113
4.6.2. Exclusion Criteria 113
4.7. Procedures Used by the CMH SAVE Programme to Assess the Clients 118
4.7.1. Assessment Process 118
4.7.1.1. Initial Referral Process 118
4.7.1.2. Social Work Intervention 119
4.7.1.3. Psychological Assessment 120
4.7.1.4. Process of the Assessment 120
x
4.7.1.5. The Interview 122
4.7.1.5.1. Use of Different Norming Tables for Adults 123
4.8. Data Collection for this Study 127
4.8.1. Development of the Interview Schedule to Enable the Collection of Data 128
4.8.2. Database Development 129
4.8.3. Data Protection 129
4.8.4. Data Entry 129
4.8.5. Detailed Item Entry for the VABS II 130
4.8.6. Classification of Intellectual Disability in Datum Entry 130
4.8.7. Data Collection from the Clinical Psychologists Involved in the Project 131
4.8.8. Added Item Information 133
4.8.9. Further Specific Data Collection from the Psycho-Legal Reports 133
4.9. Data Analysis 134
4.9.1. Descriptive Analysis 134
4.9.2. Statistical and Clinical Item Analysis for Each Research Question 135
4.10. Ethical Considerations 137
4.10.1. Client Privacy 137
4.10.2. Conflict of Interest 138
4.10.3. Permission to Use Client Records 138
4.10.4. Permission to Reproduce Test Protocols and Email Correspondence 138
4.10.5. Access and Storage of Information 138
4.10.6. Ethics Approval 139
Chapter Five: Descriptive Results 140
xi
5.2. The Combined Results from 2005-2013 (n=642) 140
5.2.1. Year by Year Breakdown of Sample Numbers 141
5.2.2. Gender of Sample 142
5.2.3. Age Distribution of Sample 143
5.2.4. Language Groupings of Sample 143
5.2.5. Race Groups of Sample 144
5.2.6. Urban and Rural Geographic Distribution 146
5.2.7. Formal and Informal Housing 147
5.2.8. Housing and Race 148
5.2.9. Reported Causes of Intellectual Disability 148
5.2.10. Relationship of the Informant to the Complainant 150
5.2.11. IQ Range of Full Sample 150
5.2.12. Reported Adaptive Functioning of Full Sample 151
5.2.13. Comparison of IQ Ranges with Reported Ranges of Adaptive Functioning 152
5.2.14. VABS and VABS II Ranges of Adaptive Functioning 153
5.2.15. Comparison of Adaptive Functioning Ranges of the VABS and the
VABS II 154
5.2.16. Comparison of VABS Range with Reported Adaptive Functioning Range 155
5.2.17. Comparison of VABS II Range with Reported Adaptive Functioning
Range 156
5.3. Descriptive Detail of the VABS II Sample (n=321) 157
5.3.1. Nature of the Charge 158
5.3.2. Motivation Regarding Testifying 159
5.3.3. Ability to Testify 159
5.3.4. Relationship Between Motivation and Ability to Testify 160
xii
5.3.5. Relationship Between Family Support and Ability to Testify 161
5.3.6. Use of an Intermediary Recommended for Those Able to Testify 161
5.3.7. Relationship of IQ to Ability to Testify 162
5.3.8. Relationship of Reported Adaptive Functioning to Ability to Testify 163
5.3.9. Relationship of VABS II Range and Ability to Testify 164
5.3.10. Comparison of IQ, VABS II Ranges and Reported Adaptive Functioning
Ranges in Relation to Ability to Testify 164
5.3.11. Range of VABS II Scores 165
5.3.12. Reported Adaptive Functioning Ranges 166
5.3.13. Range of IQ 167
5.3.14. Comparison of IQ, VABS II Score Ranges and Reported AF Ranges 168
5.3.15. Age Categories and VABS II Ranges 169
Chapter Six: Results of the Statistical and Clinical Item Analysis 170
6.2. Question One: Discrimination of Different Ranges of Intellectual Disability 170
6.2.1. Association between Standard Score IQ and Standard Score of
Adaptive Functioning 170
6.2.1.1. VABS 170
6.2.1.2. VABS II 171
6.2.2. Reported Diagnosis of Disability Compared with VABS and VABS II
Measurements 171
6.3. Question Two: Association of Variables to VABS and VABS II Measurements 172
6.3.1. VABS 172
6.3.2. VABS II 173
xiii
6.4. Question Three: Evaluation of Floor Effects, Sensitivity and Specificity of
the VABS II for Adults Over 22 Years Old with Intellectual Disability 174
6.4.1. Full Sample: VABS II Scores onto Psychologists’ Evaluation of IQ 174
6.4.2. Participants Over 22 Years: VABS II Scores onto Psychologists’
Evaluation of IQ 174
6.4.3. Participants Under 22 Years: VABS II Scores onto Psychologists’
Evaluation of IQ 175
6.4.4. Full Sample: VABS II Scores onto Psychologists’ Evaluation of
Adaptive Functioning 176
6.4.5. Participants Over 22 Years: VABS II Scores onto Psychologists’
Evaluation of Adaptive Functioning 176
6.4.6. Participants Under 22 Years: VABS II Scores onto Psychologists’
Evaluation of Adaptive Functioning 176
6.4.7. Full Sample: VABS II Scores onto ISGSA Scores of IQ 177
6.4.8. Participants Over 22 Years: VABS II Scores onto ISGSA Scores of IQ 177
6.4.9. Participants Under 22 Years: VABS II Scores onto ISGSA Scores of IQ 178
6.4.10. Cross Tabulation of ISGSA Standard Scores and the Psychologists’
Assessment of IQ 178
6.4.11. Cross Tabulation of VABS II Standard Scores and the
Psychologists’ Assessment of IQ 181
6.4.12. Cross Tabulation of VABS II Standard Score and the Psychologists’
Assessment of Adaptive Functioning 183
6.5. Results of the Clinical Item Analysis 186
6.5.1. Communication: Receptive 188
6.5.1.1. Results of Psychologists’ Discussion 188
xiv
6.5.1.2. Summary of Clinical Item Analysis of the Receptive Communication
Subdomain 190
6.5.2. Communication: Expressive 191
6.5.2.2. Summary of Clinical Item Analysis of the Expressive Communication
Subdomain 198
6.5.3. Communication: Written 198
6.5.3.2. Summary of Clinical Item Analysis of the Written Communication
Subdomain 201
6.5.4. Daily Living Skills: Personal 202
6.5.4.2. Summary of Clinical Item Analysis of Personal Daily Living Skills
Subdomain 206
6.5.5. Daily Living Skills: Domestic 207
6.5.5.2. Summary of Clinical Item Analysis of Domestic Daily Living Skills
Subdomain 210
6.5.6. Daily Living Skills: Community 211
6.5.6.2. Summary of Clinical Item Analysis of Community Daily Living
Skills Subdomain 216
6.5.7. Socialisation: Interpersonal Relationships 217
xv
6.5.7.2. Summary of Clinical Item Analysis of the Socialisation Interpersonal
Relationships Subdomain 222
6.5.8. Socialisation: Play and Leisure 223
6.5.8.2. Summary of Clinical Item Analysis of the Socialisation Play and
Leisure Subdomain 226
6.5.9. Socialisation: Coping Skills 227
6.5.9.2. Summary of Clinical Item Analysis of the Socialisation Coping Skills
Subdomain 230
6.5.10. Changes in Administration of the VABS II 231
Chapter Seven: Discussion 232
7.2. Research Question 1 232
7.5.1. Receptive Communication 242
7.5.2. Expressive Communication 242
7.5.3. Written Communication 243
7.5.4. Personal Daily Living Skills 244
7.5.5. Domestic Daily Living Skills 244
7.5.6. Community Daily Living Skills 244
7.5.7. Socialisation Interpersonal Relationships 245
xvi
7.5.8. Socialisation Play and Leisure Time 245
7.5.9. Socialisation Coping Skills 246
7.7.1. Discussion of Overall Results 253
7.7.2. Contextual/Cultural Issues 253
7.7.3. Linguistic/Language Issues 254
7.7.4. No Opportunity Issues 254
7.7.5. Many “Don’t know” or “No opportunity” Responses 256
7.7.6. What Changes Does the VABS 3 Offer? 256
7.8. The Construct of Adaptive Functioning in Relation to a Normal Distribution
Pattern 257
7.9. To What Extent do the Newly Published VABS 3 Norm Tables Address This
Issue? 264
7.10. Administration Changes and Use of Norm Tables 269
7.10.1. Administration 270
7.10.2. Use of Norm Tables 271
7.11. Ability to Testify 272
7.12. Exclusions 273
Chapter Eight: Conclusion 275
8.2. Summary of Findings 276
8.2.1. The Validity of the Vineland Adaptive Behavior Scales in the context of this
study 276
xvii
8.2.2. Limitations of the Validity of the Vineland Adaptive Behavior Scales in the
context of this study 277
8.2.3. Significant Association Between Variables and the Vineland Adaptive
Behavior Scales 277
8.2.4. The VABS 3 277
8.2.5. The Role of Clinical Judgement 278
8.2.6. Use in the Psycho-Legal Context 278
8.2.7. Addressing Difficult Items in the VABS II 278
8.2.8. The Asymptotic Nature of Adaptive Functioning 279
8.3. Summary of the Limitations of the Research 279
8.3.1. Clinical Prediction Versus Statistical Prediction 279
8.3.2. Use of Alternative Tests 280
8.3.3. Limitations of Context 281
8.3.4. Limitations of Locally Normed Tests 281
8.3.5. A Skewed Sample 281
8.3.6. Limitations of Generalisability 281
8.3.7. Limitation of Focus 281
8.3.8. Use of Composite Versus Domain Scores 282
8.4. Areas of Further Research 282
8.4.1. Validity of the VABS in Adult Populations 282
8.4.2. Research of Intellectual Disability in Immigrant and Refugee Groups 282
8.4.3. Hidden and Unreported Sexual Abuse 282
8.4.4. Prevalence Studies 282
8.4.5. Prevention of Intellectual Disability 283
8.4.6. Unexplored Data 283
xviii
8.4.7. Research Priorities 284
8.5. The Stories Continued 284
References 288
Appendices 312
A: Vineland Social Maturity Scale 312
B: Vineland Adaptive Behavior Scales Interview Edition Survey Form 316
C: Vineland Adaptive Behavior Scales, Second Edition Survey Interview Form 328
D: Vineland Adaptive Behavior Scales, Third Edition Comprehensive Interview
Form 356
E: Discussion of Exclusion Criteria 388
F: Interview Guide for Psycho-Legal Assessment 393
G: Assessment Tools 404
H: Initial Referral Form 415
I: Screen Shots of Database 417
J: Written Instruction to Psychologists Regarding Identifying Useful and Difficult
Items 422
K: Letter of Support and Permission from Cape Mental Health 423
L: Permission Regarding Copyright of Pearson Material and Email Conversation with
Author, Dr. C. Saulnier 424
M: Stellenbosch Health Research Ethics Committee Approval Notice 431
N: Urban and Rural Police Referrals in the Western Cape 432
O: Affidavit Proforma Regarding Use of Psycho-Legal Report 435
P: Details of ROC Analyses 437
xix
List of Tables and Figures
Tables
Table 2.1. Summary of Severity Levels for Intellectual Disability 18
Table 2.2. Clinical Sample of Persons with Intellectual Disability, Used in Validating
the Norms of the VABS II (USA Norms) 54
Table 3.1. Summary of Poverty Related Indicators for South Africa and the Western
Cape 66
Table 3.2. Guidelines of the Legal Protection in Relation to Differing Levels of
Table 3.3. Commonly Used Assessment Tools in the South African Context 82
Table 4.1. Research Aims and Questions 98
Table 4.2. Sample Size and Age Groupings of Clinical Sample of VABS 3 106
Table 4.3. Sample for Norming of the ISGSA 109
Table 4.4. Experience and Language Skills of Psychologists Involved in the SAVE
Programme 111
Table 4.5. Reasons for Exclusion 114
Table 4.6. Stratified Random Sample of Psycho-Legal Reports undergoing Clinical
Item Analysis 133
Table 4.7. Age Group Distribution of Sample from Psycho-Legal Reports 134
Table 4.8. Statistical and Qualitative Methods Used in Data Analysis 135
Table 5.1. Research Sample Percentages of Race and Language Compared with
General Urban Cape Town and Rural Western Cape Percentages 145
Table 5.2. Comparison of Percentage Reported Cause of Intellectual Disability 149
Table 5.3. Comparison of IQ, Reported AF and VABS II Score in Relation to Ability
to Testify 164
xx
Table 6.1. Cross Tabulation of ISGSA Scores and Psychologists’ Assessment of IQ 179
Table 6.2. Cross Tabulation of the VABS II Overall Standard Score with the
Psychologists’ Assessment of IQ 181
Table 6.3. Comparison of the VABS II Overall Composite Range with the Psychologists’
Assessment of Range of AF 184
Table 6.4. Cross Tabulation of the VABS II Overall Composite Score with the
Psychologists’ Assessment of AF 184
Table 6.5. Clinical Item Analysis of the Receptive Communication Subdomain of the
VABS II 189
Table 6.6. Clinical Item Analysis of the Expressive Communication Subdomain of the
VABS II 193
Table 6.7. Clinical Item Analysis of the Written Communication Subdomain of the
VABS II 199
Table 6.8. Clinical Item Analysis of the Personal Daily Living Skills Subdomain of the
VABS II 203
Table 6.9. Clinical Item Analysis of the Domestic Daily Living Skills Subdomain of the
VABS II 208
Table 6.10. Clinical Item Analysis of the Community Daily Living Skills Subdomain of
the VABS II 212
Table 6.11. Clinical Item Analysis of the Interpersonal Relationship Socialisation
Subdomain of the VABS II 218
Table 6.12. Clinical Item Analysis of the Play and Leisure Socialisation Subdomain of the
VABS II 224
Table 6.13. Clinical Item Analysis of the Coping Skills Socialisation Subdomain of the
VABS II 228
xxi
Table 7.1. VABS 3 Mean Standard Scores for Mild, Moderate and Severe Intellectual
Disability in Two Age Groups 239
Table 7.2. Summary of Useful Information Categories from the VABS II in Psycho-
Legal Report 247
Table 7.3. Summary of Changes Between the VABS II and VABS 3 248
Table 7.4. Summary of Difficulties Identified and Response in VABS 3 250
Table 7.5. Example of the Floor Effect for Adults in the VABS II: Range of Disability at
18 Years 2 Months 260
Table 7.6. Example of the Floor Effect for Adults in the VABS II: Range of Disability at
22 Years 3 Months 261
Table 7.7. VABS 3 Norms for a Female of 18 Years 2 Months 264
Table 7.11. Breakdown of Reasons for Exclusion Regarding Comorbid Psychiatric
Diagnosis at Time of Assessment 273
Table 7.12. Breakdown of Reasons for Exclusion Regarding Datum Previously Entered
for Another Case 274
Table E.1. Reasons for Exclusion of Data Using the VABS and VABS II 391
Table P.1. Summary Information of ROC Curve of VABS II Scores onto the IQ
Evaluation of Full Sample 437
Evaluation of Participants 22 Years and Older 441
Evaluation of Participants Younger than 22 Years 443
xxii
Table P.4. Summary Information of ROC Curve of VABS II Scores onto the
Psychologists’ Evaluation of AF of Full Sample 446
Table P.5. Summary Information of ROC Curve of VABS II Scores onto the
Psychologists’ Evaluation of AF of Participants Younger than 22 Years 449
Table P.6. Summary Information of ROC Curve of VABS II Scores onto ISGSA Scores
of IQ of the Full Sample 452
Table P.7. Summary Information of the ROC Curve of VABS II Scores onto ISGSA
Scores of IQ of the Participants 22 Years and Older 456
Table P.8. Summary Information of ROC Curve of the VABS II Scores onto ISGSA
Scores of IQ of the Participants Under 22 Years 459
Figures
Figure 5.1. Year by Year Breakdown of Sample Numbers 141
Figure 5.2. Gender of Sample 142
Figure 5.3. Age Distribution of Sample 143
Figure 5.4. Language Groupings of Sample 143
Figure 5.5. Race Groups of the Sample 144
Figure 5.6. Urban and Rural Distribution 146
Figure 5.7. Formal and Informal Housing 147
Figure 5.8. Housing and Race 148
Figure 5.9. Reported Causes of Intellectual Disability 148
Figure 5.10. Relationship of Informant to the Complainant 150
Figure 5.11. IQ Range of Full Sample 150
Figure 5.12. Reported Adaptive Functioning of Full Sample 151
Figure 5.13. Comparison of IQ Ranges with Reported Adaptive Functioning Ranges 152
Figure 5.14. VABS and VABS II Ranges of Adaptive Functioning 153
xxiii
Figure 5.15. Ranges of AF Using the VABS and VABS II 154
Figure 5.16. Comparison of VABS Range with Reported Adaptive Functioning Range 155
Figure 5.17. Comparison of VABS II Range with Reported Adaptive Functioning
Range 156
Figure 5.18. Nature of the Charge 158
Figure 5.19. Motivation Regarding Testifying 159
Figure 5.20. Ability to Testify 159
Figure 5.21. Relationship Between Motivation and Ability to Testify 160
Figure 5.22. Relationship Between Family Support and Ability to Testify 161
Figure 5.23. Use of Intermediary for Those Able to Testify 161
Figure 5.24. Relationship of IQ to Ability to Testify 162
Figure 5.25. Reported Adaptive Functioning and Ability to Testify 163
Figure 5.26. VABS II Range and Ability to Testify 164
Figure 5.27. VABS II Ranges 165
Figure 5.28. Reported Adaptive Functioning Ranges 166
Figure 5.29. Range of IQ 167
Figure 5.30. Comparison of IQ, VABS II and Reported AF Ranges 168
Figure 5.31. VABS II Age Categories: VABS II Ranges 169
Figure 7.1. Access to Education 236
Figure 7.2. Mean Adaptive Behaviour Scores from Three School Age Groups with
Different IQ Ranges 240
Figure 7.3. Mean Adaptive Behaviour Scores for Three Adult Groups with Different IQ
Ranges 241
Figure 7.4. Norm Tables VABS II Age 18:0-21:11 262
Figure 7.5. Norm Tables VABS II Age 22:0-49:11 263
xxiv
Figure I.1. Opening Database Screen with Client Details 417
Figure I.2. Assessment Database Screen (VABS I) 418
Figure I.3. Detailed Database Assessment Screen (VABS II) 419
Figure I.4. Assault History Database Screen 420
Figure I.5. Detailed Legal Information Database Screen 421
Figure N.1. Rural Referral Patterns of the Western Cape (by area) 432
Figure N.2. Urban Referral Patterns of the Cape Town Metropole (by police station) 433
Figure P.1. Graphical Representation of ROC Curve of VABS II Scores onto the IQ
Evaluation of Full Sample 437
Evaluation of Participants 22 Years and Older 440
Evaluation of Participants Younger than 22 Years 443
Figure P.4. Graphical Representation of ROC Curve VABS II Scores onto Psychologists’
Evaluation of AF of Full Sample 446
Figure P.5. Graphical Representation of ROC Curve of VABS II Scores onto the
Psychologists’ Evaluation of AF of Participants Younger than 22 Years 449
Figure P.6. Graphical Representation of the ROC Curve of VABS II Scores onto ISGSA
Scores of IQ of the Full Sample 452
Scores of IQ of the Participants 22 Years and Older 455
Scores of IQ of the Participants Under 22 Years 458
xxv
Chapter One: Introduction
1.1. The stories
Sarai1 is a 16-year-old adolescent who lives with an aunt on a small wine farm in a
rural area outside of Cape Town. Her mother was a seasonal worker living and working on
the same farm. Part of her wage was paid in wine and she has a significant drinking problem.
During her pregnancy with Sarai, which was unplanned, she drank heavily, especially on the
weekends after pay day. Sarai’s father denied paternity and had moved into the nearby town
to look for work. Sarai knows who he is but has little contact and no support from him. Her
aunt took over her care when Sarai was found repeatedly neglected and hungry. Her mother
left the farm and the family have lost contact with her. Sarai attended the small farm school
for a year or two but was sent home with the message from the teacher that she was not able
to learn and her progress was too slow. Sarai spends her days helping with household chores.
Sarai was found to be pregnant and she disclosed that one of the other farm workers had
repeatedly raped her and threatened to kill her if she told anyone. She had been too afraid to
tell her aunt.
Themba is a 10-year-old boy. He was born in the rural Eastern Cape. The village
where his mother lived had no local clinic and she received no antenatal care. He was born at
home after a long and difficult labour. His mother came to Cape Town with the hope of
finding work. She works long hours at a fast food outlet and lives in a shack with no
sanitation or running water. She has to leave for work very early to allow for the hour and a
half commuting time and arrives back after dark. Themba attends a local school but he has
always struggled, having to repeat grades. He has been on the waiting list to be assessed by
1
Names used are pseudonyms and the stories are composite in nature, drawn from many
client narratives.
1
the school psychological services for three years. On the way home from school he was way
laid and gang raped by four teenage boys. His mother found him on her return from work,
bleeding and crying.
Madelaine is a 35-year-old woman. She lives in a residential facility for people with
intellectual disability. Her mother was 42 when she conceived Madelaine and discovered that
Madelaine had Down syndrome during her pregnancy. She was offered a termination of
pregnancy but decided against it. Madelaine attended a school for learners with special
educational needs but was given no sex education. Madelaine has lived in the residential
facility since her early twenties. It recently came to light that one of the care workers at the
facility had been offering various residents chocolates as payment for sex. Madelaine was
one of the residents. She was distraught as he had told her that he loved her and she felt hurt
and betrayed.
1.2. The research
The research that follows includes a sample of 642 people with intellectual disability
who had laid charges of rape or sexual assault in the Cape Town metropole in South Africa
and surrounding rural towns and farms between 2005 and 2013. The police or the courts had
referred them to a mental health, community based organisation, Cape Mental Health. The
Sexual Abuse Victim Empowerment (SAVE) programme has been run since 1990 by this
organisation, to assist people with intellectual disability who had been sexually abused, and
their families, who were wanting to access the justice system.
1.3. The stories and the research
The biographical cameos that begin this thesis are described to embed this research in
the lived reality of the clients who are the participants. It is an attempt to acknowledge their
lives and to acknowledge that I, the author, am not classified by my community as
intellectually disabled and I have not experienced sexual trauma. I have only had the
2
opportunity to spend a few hours with each person and their caregiver, listening to the story
of their lives and being witness to their pain. The stories are composite, constructed from the
experience of the clinical psychologists who listen and observe and share with each other as
they work towards trying to understand each person’s reality, which will be documented in a
psycho-legal report and then be presented to the court under examination in a bid to advocate
for their right to tell their story and receive redress.
What follows is an academic document, filled with figures and definitions,
classifications and terminology. It is important to acknowledge at the start that the purpose of
this research is about working towards providing them access to justice, it is holding them in
mind, in humility at their courage, in the face of odds that can barely be imagined. Goodley
(2017) writes: “As soon as we start thinking through the meaning, experience, treatment and
enactment of the impaired body or mind we peel away the socio-cultural layers that enwrap
the phenomena… Impairment evokes deep psychological feelings about minds and bodies…
the notion that some bodies/minds are flawed and others not… minds/bodies can only be
understood as intersecting with other identities” (p. 36).
1.4. The context
A number of clinical psychologists are employed to work for the organisation, Cape
Mental Health, (CMH), a day a week in order to provide a psychological assessment and
submit a psycho-legal report for clients referred by the police and courts. There are three
main questions asked and answered in the report:
What is the nature and severity of the intellectual disability?
Is the client able to testify and be a competent witness in court?
Is the client able to consent to sexual intercourse?
3
1.5. The problem
In the course of the assessments and over time, it became increasingly clear that the
clinical evaluation and conclusions, following the assessment by the clinical psychologist, in
some instances, differed from the findings of the adaptive behaviour2 assessment tool, the
Vineland Adaptive Behavior Scales, the first edition of 1984 (Sparrow, Balla, & Cicchetti,
1984) (VABS) and the second edition published in 2005 (Sparrow, Cicchetti, & Balla, 2005)
(VABS II), particularly for the adult clients. Further, towards the end of the research process,
the third edition of the Vineland Adaptive Scales was published (Sparrow, Cicchetti, &
Saulnier, 2016) (VABS 3). Assessment of adaptive functioning is recognised as a key
element alongside the evaluation of cognitive functioning in the diagnosis of intellectual
disability and in estimating its severity in order to align the level of support needed.
Ethically, as clinical psychologists, we have a responsibility to provide as accurate an
estimation in answer to these three questions as we can. We have a responsibility to our
clients and their families and the court. We enter court and take an oath to tell the truth.
When our tools and our clinical judgment differ, we are called to give account. It became
increasingly clear that the problem needed further examination.
1.6. Relevance of the research
Sexual violence and abuse is a worldwide problem (Dartnell & Jewkes, 2013). People
with intellectual disability are particularly vulnerable to sexual abuse (Murphy, 2016). Due to
their decreased ability to estimate risk and gullibility, they are socially vulnerable
(Greenspan, 2010). There is a tension between protecting people with intellectual disability
from exploitation whilst also providing sex education and promoting sexual autonomy
2
Behaviour is the preferred spelling unless in relation to the Vineland Adaptive Behavior
Scales, another test name or a direct quote.
4
(Kramers-Olen, 2016). In providing access to legal redress, there is an opportunity for the
person to say no, that this was not what they wanted, it was not consensual. Access to legal
process is based on the ability to give evidence or to testify. Perceptions and understanding of
intellectual disability by the police and court are critical to the possibility of taking the matter
to court. Education, advocacy and providing appropriate support can open opportunities for
people with intellectual disability. Qualitative and quantitative description of the nature and
degree of intellectual disability can assist the court to provide access to the legal and justice
system.
Mercier, Saxena, Lecomte, Cumbrera, and Harnois (2008) state that “The low and
middle income countries are particularly at a disadvantage (in regard to data on persons with
ID), with a high proportion of countries without any documentation of ID, or any
management systems, epidemiological data or national research capacities” (p. 87). They
make particular reference to judicial protection, availability and access to services,
government benefits and financing.
Further, research activity in the field of intellectual disability in middle and low
income countries is difficult, given constrained resources and high clinical demand and
despite an increased prevalence of intellectual disability compared with high income
countries. Much of what we know about intellectual disability is from research in high
income countries and extrapolated (Adnams, 2010; Tomlinson et al., 2014). This research
hopes to add to the voice from middle and low income countries in terms of describing the
challenges of a high incidence of intellectual disability and sexual abuse and constrained
psychological resources. In a context of limited professional personnel and high clinical load,
the effectiveness and efficiency of the psychological tools and measurement instruments we
use is of importance. It is also an opportunity to describe the importance of reflective
psychological practice.
5
1.7. Aims of the research
The research aims to address a clinical problem and seeks to answer questions of
clinical utility for the Vineland Adaptive Behavior Scales. The aims are as follows:
1. To evaluate the published norms of the VABS and VABS II in terms of their use
in this particular South African context and their usefulness in discriminating
different ranges of intellectual disability, using the intelligence quotient (IQ)
derived from the Individual Scale for General Scholastic Aptitude (ISGSA), the
documented diagnosis of the evaluating clinical psychologist and the standard
score of composite adaptive functioning of the VABS and VABS II.
2. To explore the relationship between language, gender, age, socioeconomic status,
geographic distribution, access to education and trauma with the standard score of
composite adaptive functioning of the VABS and VABS II.
3. To critically evaluate the floor effect evidenced in the norm tables for adults and
examine the sensitivity and specificity of the VABS II for a sample of
intellectually disabled adults and compare with the norm tables for adults of the
Vinelands-3 (VABS 3) published in 2016.
4. To determine what information is used in the psycho-legal report, which was
captured through the use of the VABS II.
5. To examine and compare the VABS II (2005) with the new edition VABS 3
(2016), using the change in item additions and modifications through the two
editions.
6. To examine and identify those items which may need contextual and or linguistic
adaptation for this group of clients and to assess to what extent these have been
addressed or adapted in the latest edition, the VABS 3.
6
1.8. Previous research
Although the VABS has been investigated as a tool for use in many different contexts
and used in a wide number of research endeavours, some of which are detailed in the
literature review, there was no literature found detailing its use in this particular context. It
has been reported on in a forensic setting, usually pertaining to perpetrators or offenders
(Hayes, 2005; Tassé et al., 2012). There is research pertaining to the person with intellectual
disability within the justice system (Mason & Murphy, 2002; McAfee & Gural, 1988;
Søndenaa, Rasmussen, & Nøttestad, 2008), and specifically to those who have been sexually
abused and their relationship with the justice system (Beckene, Forrester-Jones, & Murphy,
2017; Bornman, White, Johnson, & Bryen, 2016; Bottoms, Nysse-Carris, Harris, & Tyda,
2003; Kennedy, 2003; Pillay, 2012). There is research interest in issues of competency as a
witness and the ability to consent, internationally, and in the South African context
(Dickman, 2013; Kennedy, 2003; Pillay, 2012; Valenti-Hein & Schwartz, 1993; Van
Niekerk, 2014).
Much of the research regarding the use of the VABS pertains to children, but there is
a growing interest in the ongoing trajectory of adaptive functioning amongst adults with
intellectual disability (Fusar-Poli et al., 2017; La Malfa, Lassi, Bertelli, Albertini, & Dosen,
2009; Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009; Widaman, Borthwick-Duffy, &
Little, 1991). Research within the specific context of the SAVE programme has focused on
the court process and outcomes (Cape Mental Health, 2008; Dickman & Roux, 2005), and the
relationship between sexual abuse, intellectual disability and trauma (Jasson, 2009;
Kwendakwema, 2009; Linden, 2010; Mackenzie, 2010).
1.9. Research design
In order to answer the research questions and meet the aims of the research, a mixed
design, including quantitative and qualitative data, was chosen. With the clear understanding
7
of the non-confidential nature of the psycho-legal report, as it is in the public domain as a
court document, by the client and their family, permission was given by the organisation
(CMH) together with ethical permission from the Faculty of Health Sciences Ethics
Committee (S17/01/003, refer to Appendix M). Data were gathered retrospectively from
cases seen at CMH in the SAVE programme between 2005 and 2013. Data from the psycho-
legal reports, case files and protocols were entered into a database. Identifying information
was removed to further protect privacy. The psychologists involved in the assessments
independently scored items of the VABS II and took part in a discussion to identify useful
and difficult items in the tool. This information was transferred onto a spreadsheet and
transcribed and analysed. The psycho-legal reports were examined for reference to particular
items of the VABS II. This was documented by an experienced psychologist. Descriptive,
statistical and clinical item analysis followed of the data collected.
1.10. Layout of the dissertation
1.10.1. Chapter One: Introduction
The current chapter introduces the dissertation.
1.10.2. Chapter Two: Constructs and Measurement
The chapter that follows describes the relevant literature in terms of definitions and
constructed understandings of disability, intelligence, intellectual disability and adaptive
behaviour. It describes the assessment of intellectual disability, adaptive behaviour with a
focus on the history, development and use of the VABS tools and the further editions of the
VABS. The chapter ends with a section describing pertinent issues when thinking about
intellectual disability within a psycho-legal context.
1.10.3. Chapter Three: Context
The third chapter continues the literature review but changes focus to a contextual
understanding of the research. It begins with a brief historical review of South Africa,
8
looking at the long term effects of political and economic systems. The prevalence of
intellectual disability, protection of human rights and applicable legal protection and laws
pertaining to people with intellectual disability in South Africa follows. Psychological
assessment of intellectual disability in the South African context is described. The problem
and prevalence of sexual abuse in South Africa is described with particular focus on people
with intellectual disability and their access to justice. The chapter ends with a description of
the organisation and the SAVE programme and previous research which has focused on
outcomes of the legal process, trauma, behavioural difficulties and dual diagnosis of
psychiatric illness.
1.10.4. Chapter Four: Methodology
Chapter Four describes the methodology in detail. The aims of the research,
mentioned previously, are linked to specific research questions. The methodology of the
literature review is described. The description of the research design includes details of the
measurement instruments, the VABS (1984), the VABS II (2005), the VABS 3 (2016) and
the ISGSA, used for measurement of IQ. The qualifications of the psychologists involved in
the assessment are described and the argument for using their written evaluation, as
documented in the psycho-legal report, as a gold standard within the research is given. The
sample is described as well as the process and criteria for exclusion. Procedure includes the
assessment process from initial referral, on-going social work intervention and the
psychological assessment. The psychological assessment is detailed as it provides
corroborative evidence for the assessment of adaptive functioning.
The data collection is described and includes the development of an interview
schedule, development of a database, data entry and classification, item classification of the
VABS II and its use within a sample of the reports and a group discussion with the
9
psychologists. Description of the descriptive, statistical and clinical item analysis is given and
the chapter ends with a more detailed description of the ethical considerations.
1.10.5. Chapter Five: Descriptive Results
A chapter of descriptive results is included. This provides a rich contextual
framework for the understanding of the nature of the sample group and the commonalities
which run through the lives of Sarai, Themba and Madelaine. The increasing numbers of
referrals over the time period of the research, their age, language, race, rural or urban
geographic location and type of housing is graphically depicted. The reported or understood
cause of intellectual disability by the caregiver is reported. Graphical representation of ranges
of measured adaptive functioning by the VABS and VABS II, measured IQ and comparisons
between these and the conclusions of the psychologist are presented. The data collected for
those assessed by the VABS II was more detailed as this was the current test in use. For this
portion of the sample the nature of the charge, the motivation and ability to testify, together
with level of family support regarding the legal process is described. Comparison of range of
IQ, range of adaptive functioning and ability to testify is made. The chapter ends with a
closer look at the range of IQ scores, range of VABS II scores, the conclusion of the
assessing psychologist and the VABS II ranges in relation to age. This leads into the
statistical analysis which follows in the next chapter.
1.10.6. Chapter Six: Results of Statistical and Clinical Item Analysis3
The statistical and clinical item analysis results chapter answers the research questions
directly and takes a more detailed examination of correlation, relationships of statistical
significance and variance between the ISGSA and the VABS and VABS II. This is further
3
The term “item analysis” refers to a specific statistical method. As each item of the VABS
II has been analysed for clinical utility the term chosen is clinical item analysis.
10
analysed against the conclusion of the assessment as recorded in the psycho-legal report.
Association of variables to the VABS and VABS II is examined. These include language,
gender, geographic distribution and access to education. Trauma was excluded as it was a
common feature for the whole sample, as was socioeconomic groupings as most of our
clients fall into a low socioeconomic group. The floor effects for adults over 22 years was
examined for sensitivity and specificity and compared with the full sample and those under
22 years of age using a receiver operating characteristic curve analysis. Clinical item analysis
provided results for the items within the VABS II that are identified as useful in the
assessment process against those that are actually used and referred to in the psycho-legal
report. This process also identified those items that were difficult and the classification of the
difficulty into categories of context /culture, language and linguistics or that of no
opportunity. The identified items in the VABS II were assessed against the new edition of the
VABS 3 in terms of modification, deletion or retention and sequence or subdomain changes.
Transcription and analysis of the discussion by the psychologists added a qualitative element
to the results.
1.10.7. Chapter Seven: Discussion
This led into the discussion chapter where the results are compared with the research
literature on the validity of the VABS and VABS II, both within the test manuals and in
further research. Comparisons are made with findings from the literature. Items that are
useful in describing everyday functioning to the court are identified and summarised and
compared with what is used commonly in the reports. Summary data of changes and
modifications is presented and discussed. Discussion is included regarding the constraints
within developing countries, with regard to the evolution of new tests, the cost and ongoing
difficulties in validating new tests for use in different cultural and language contexts. The
areas of difficulty are discussed and the implications for this context. The question is raised
11
as to whether adaptive functioning follows a normal distribution curve with adults reaching
asymptote and how this applies to adults with disability and if this affects the norming
statistics used. The floor effect of norms for the VABS II is discussed and an example used
with the VABS 3 to examine if the issue is addressed in the new test. Email discussion with
one of the authors of the VABS 3 is included and discussed. The chapter ends with a
discussion of changes in administration, the adapted use of the norm tables, the ability to
testify and information uncovered through the process of exclusion.
1.10.8. Chapter Eight: Conclusion
The final chapter concludes with a summary of the major findings, a summary of the
limitations of the research, areas which need ongoing and further research and
recommendations for practice within the South African context. A continuation of the stories
of Sarai, Themba and Madelaine and the period of involvement of the psychologist in their
lives ends the chapter.
1.11. Concluding comments
Adaptive functioning and its measurement is about defining and measuring the
ordinary and expected. This varies. Given that the court is structured according to what is
ordinary and expected for most people, when there are differences, these need
accommodation. In what way does the court need to adjust and adapt for this person to give
them access to justice as is their fundamental human right?
The following research is motivated by the duty to practice ethically, in choosing the
best fit in terms of instrument, using and interpreting the findings whilst considering the real
contextual constraints (Floyd et al., 2015).
12
Chapter Two: Constructs and Measurement
2.1. Introduction
In order to better understand the contextual reality of the three personal narratives
which began this dissertation, and stories like them, it is important to understand the historic
and present understanding, which inform the thinking of the society in which they live, the
mental health professionals who attempt to assist them and the legal professionals with whom
they will interact as they seek redress and justice. This chapter will outline and describe
relevant literature with regard to the constructs of intellectual disability, the assessment of
intellectual disability and adaptive functioning (as sometimes referred to as adaptive
behaviour) and related ideas. The measure used in the assessment of the three individuals, the
Vineland Adaptive Behavior Scales (VABS) will be described, including the history of its
development, use in other languages and cultures, and the strengths and limitations. The
chapter will conclude with some pertinent ideas regarding intellectual disability within a
psycho-legal context.
The following chapter will detail the social and historical context of South Africa and
its intersection with psychological assessment, intellectual disability, sexual abuse, the law
and human rights and the organisation, Cape Mental Health (CMH), to which they have been
referred.
2.2. Intellectual disability
In order to begin to understand intellectual disability, it is important to take a step
back and first engage with the concept of disability, then to narrow the focus to intellectual
disability and further to the description of different levels of disability.
2.2.1. Definition.
The World Report on Disability (2011) (cited in Iriarte, McConkey, & Gilligan 2016),
provides data illustrating that the global phenomenon of disability affects more than a billion
13
people, about 80% of whom live in the developing world and are amongst the poorest in
those communities. The Convention on the Rights of Persons with Disabilities (CRPD),
adopted by the United Nations General Assembly in 2006, provides a yardstick in the 50
articles it contains, as to the human rights, the “basic standards that enable people to have
dignified lives and be valued for their inherent worth as human beings” (Iriarte et al., 2016, p.
2)
2.2.1.1. Disability.
In the CRPD (“United Nations Convention on the Rights of Persons with
Disabilities”, 2006) the following is stated, that people with disabilities are those
[w]ho have long-term physical, mental, intellectual or sensory impairments which in
interaction with various barriers may hinder their full and effective participation in
society on an equal basis with others. (p. 4)
Disability is a complex and contested concept involving legal, medical, scholarly and
community definitions. In 2011, the World Health Organization (WHO) and the World Bank
used the bio-psycho-social model of the International Classification of Functioning,
Disability and Health (ICF) which
understands functioning and disability as a dynamic interaction between health
conditions and contextual factors, both personal and environmental. Disability is the
umbrella term for impairments, activity limitations and participation restrictions,
referring to the negative aspects of the interaction between an individual (with a
health condition) and that individual’s contextual factors (environmental and personal
factors). (World Health Organization (WHO), 2001, p. 6)
Wehmeyer et al. (2008) describe five dimensions to human functioning which
contribute to the person’s experience of being “disabled”:
14
1. Context: inclusive of the physical, social and attitudinal environment in which the
person lives. Examples are educational opportunities, familial relationships and
resources. Personal characteristics include gender, age, race, personality and lived
experience. These form a unique web of interdependent context.
2. Health: the level of physical, mental and social well-being.
3. Intellect: mental capability.
4. Adaptive behaviour: skills in social, conceptual and practical domains which are
utilised in everyday life.
5. Participation: functioning in society at home, at work, and in the wider
community in leisure, spiritual and cultural activities.
Schalock (2011) describes that the construct of disability is understood as limited
individual functioning in a social context and which represents significant disadvantage to the
person. It is understood to originate from a medical/health condition which results in
impairments in body functions and structures, which limits activity and restricts participation
in that person’s particular context and environment (Luckasson et al., 2002).
There is an increasing understanding of the significant effect societal attitudes, the
social construction of illness, expected social roles and societal structures in the form of
policies, laws and funding have on the person’s experience. The concept of disability has
evolved to include both organic and social factors which functionally impair tasks and roles
expected of a person in their context (Schalock, 2011).
2.2.1.2. Intellectual disability.
Intellectual disability (ID) or Intellectual Developmental Disorder (IDD, the ICD-11
equivalent term) is defined in the Diagnostic and Statistical Manual of Mental Disorders Fifth
Edition of the American Psychiatric Association as “a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning deficits in
15
conceptual, social and practical domains” (APA, 2013, p. 33). Intellectual disability intersects
with all five dimensions of functioning described by Wehmeyer et al. (2008).
The American Association on Intellectual and Developmental Disabilities (AAIDD)
define intellectual disability as significant limitations in intellectual functioning and adaptive
behaviours which affect the degree of autonomy and independence with which the person can
function in their social world. It is evidenced before the age of 18. It is statistically
understood to include those persons with a measured intelligence quotient (IQ) two standard
deviations below the mean (IQ 70 or lower) (Schalock et al., 2010). Due to limited autonomy
and independence, people living with intellectual disability are understood to be at higher risk
to human rights abuse, including sexual abuse.
Harris (2006) describes four approaches to defining intellectual disability that can be
used:
1. The statistical model: which considers the psychometric test scores.
2. The pathological model: Emphasis is on adaptive functioning and specific causes
of intellectual disability.
3. The social systems model: if so labelled by the social system, commonly the
school.
4. The developmental model which assesses fluid intelligence and problem solving,
more commonly used in intervention than definition.
He further includes three elements to a model of intelligence: conceptual intelligence,
social intelligence and practical intelligence.
Greenspan, Switzky, and Woods (2011) argue for a different approach, asking the
question: “what is unintelligent behaviour?” (p. 246). They suggest that an understanding,
particularly in adults with intellectual disability, that people with intellectual disability
behave in ways which put them at risk as their impairments limit their ability to recognise
16
and avoid both physical (injury, illness) and social dangers (rejection, manipulation,
victimisation). The greater the degree of intellectual disability, the greater the unawareness of
risk and the need for support and protection. They use this model to explain the social
vulnerability evidenced in the courts where they are either manipulated into confessing to
crimes they have not committed or to participation in crime which they had little incentive to
commit. They further argue that people with intellectual disability are “whole people” who
cannot be fully understood in terms of their IQ scores, that academic IQ needs to be
integrated with social and practical aspects of intelligence, using the term “adaptive
intelligence”. As an example, they use the intellectual disability phenotype of Foetal Alcohol
Spectrum Disorder (FASD) who often exhibit poor social and practical judgement skills in
everyday life and have been found, on neuropsychological assessment, to have deficits in
executive functioning. This is a helpful insight in terms of understanding vulnerability to
sexual abuse for people with intellectual disability.
Greenspan and Woods (2014) argue for use of the ICD-11 category name of
Intellectual Developmental Disorder (emphasis added) (IDD) rather than Intellectual
Disability (ID), as the name returns the emphasis to brain development and neurological
impairment (be that due to genetic, birth injury, FASD or other biological causes). They
argue for “…redefining intellectual disability/IDD as a biologically based disorder marked by
limitations in everyday reasoning and judgement, rather than as a purely functional disability
marked by seemingly arbitrary ceilings on psychometric measures that generally fail to
capture the taxonomic essence of the category” (p. 13). The DSM-5 states: “IQ test scores are
approximations of conceptual functioning but may be insufficient to assess reasoning in real
life situations and mastery of practical tasks…thus clinical judgement is needed in
interpreting the results of IQ tests” (APA, 2013, p. 37).
17
Schalock and Luckasson (2013) differentiate between an operational definition of
intellectual disability based on the three criteria of: “limitations in intellectual functioning,
behavioural limitations in adapting to environmental demands, and early age of onset” (p.
87). They describe a constitutive definition of intellectual disability, that “the construct of ID
belongs within the general construct of disability…the process of disablement and its
amelioration…the extensive impact that societal attitudes, roles, and policies have on ways
that individuals experience health disorders…the distinction between biological and social
causes of disability has blurred…a social-ecological conception of ID emphasises the
interaction between the person and the environment” (p. 88-89).
Thus intellectual disability is not a static trait, but can be variably defined and the
influence of environment, appropriate social support, inclusion and recognition is formative.
Appropriate support can strengthen functioning. Intellectual disability is a political issue
which argues for appropriate policies and advocacy (Schalock, 2011).
2.2.1.3. Levels of severity in intellectual disability.
A significant shift in the last few years in specifying severity is that “…levels of
severity are defined on the basis of adaptive functioning and not IQ scores, because it is
adaptive functioning that determines the level of support required. Moreover IQ measures are
less valid in the lower end of the IQ range” (APA, 2013, p. 33). Table 2.1. provides a
descriptive summary of conceptual, social and practical functioning at various levels of
disability and the accompanying level of support needed.
Table 2.1.
Summary of Severity Levels for Intellectual Disability
Severity level Conceptual domain Social domain Practical domain
Mild • Preschool: there may • Immature social • May be independent in
be no obvious delays relations. terms of age appropriate personal
18
(Needing intermittent • School age and • Difficulty reading care and helping with domestic
support) Adults: Difficulties in social cues. tasks
reading, writing, arithmetic, • Difficulty with • Needs assistance with
time and money skills emotional regulation and more complex daily living tasks
• Adults: Limited in appropriate behaviour. needing support in areas such as
abstract thinking, executive • Limited money management, health care,
functioning, short term understanding of social risk legal decisions.
memory. and immature social • Do better in jobs that do
• Concrete approach to judgement. not emphasise conceptual skills.
problems and solutions. May need support in employment.
Moderate • Marked lag in the • Marked • May be independent in
(Needing limited but development of conceptual differences to peers in terms of personal care but needs
consistent support) skills. social engagement. ongoing teaching and reminders.
• Slower learning and • Spoken language • Household tasks can be
limitations of extent. is the primary means of achieved but need ongoing
• Need ongoing communication but less support.
support or others to take full complex than that of peers. • Protected employment.
responsibility • Limited social • Recreation, health care,
judgement, reading of money and time management
social cues and decision need significant support.
making ability.
• Capacity for
friendships with peers
limited by social and
communication difficulties.
• Ties to wider
family and friendships need
support
19
Severe • Little to no • Speech is limited • Requires supervision for
(Needing extensive understanding of written to simple sentences or all activities of daily living.
support) language, numbers and phrases. • Skill acquisition is
quantity, time or money. • Focus on the here ongoing.
• Need extensive and now and the everyday.
support for problem solving • Relationships with
family and familiar others
give pleasure.
Profound (Needing • Often have co- • Limited • Dependent on others for
pervasive support) occurring motor and sensory understanding of speech or all aspect of daily care, may be
impairments. symbolic gestures. able to participate to limited
• Conceptual process • May understand extent.
limited to physical world simple instructions or • Music, walks, water
rather than symbolic gestures. activities, simple games all with
processes. • Self-expression support can be forms of
• May develop some through nonverbal, non- recreation.
self-care, recreational and symbolic communication.
goal directed skills with • Relationships with
support well-known family, care
givers and familiar others
through gestural and
emotional cues
Note. Adapted from the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (2013) and
Luckasson et al. (2002)
2.2.2. Naming and language.
Brown (2007) describes the literal, definitional and social meaning of terms. Although
the term intellectual disability is widely used internationally, other terms such as mental
20
retardation, developmental disability, learning disability, mental handicap and developmental
handicap are used in different countries and contexts. He describes the unique meaning of
each term as being a combination of literal meaning, i.e., lack of ability or restriction, with
definitional meaning, for the purpose of providing services, as in the table above, as well as a
social meaning which reflects attitudes and values and changing social meaning, i.e., the
change from the term mental retardation to intellectual disability, or previous South African
legislation which used terms such as idiot and imbecile.
In 1959, Heber gave the following definition: “Mental retardation refers to sub
average general intellectual functioning which originates during the developmental period
and is associated with impairment in one or more of the following: (1) Maturation, (2)
Learning, and (3) Social adjustment” (Heber, 1959, p. 3). The journal that published his
writing was the American Journal of Mental Deficiency (emphasis added). This definition
marks a move in terminology and marks the inclusion of concepts of adaptive functioning to
the understanding of intellectual disability at this time.
Sinason (2010) adds a useful perspective as she explores the psycholinguistics of
euphemism which accompany the descriptive terms used for people with intellectual
disability. She gives examples of terms used over time such as imbecile, idiot, retarded,
backward, slow, mentally deficient, subnormal, learning difficulty, learning disability, and
intellectual disability. She describes euphemisms as words “brought in to replace the verbal
bedlinen when a particular word feels too raw” (Sinason, 2010, p. 34). She describes the
intellectually disabled person from a psychoanalytic perspective as the “dustbin for the
primitive fears of others” (Sinason, 2010, p. 41) and that the changing use of terms are an
attempt to deal with painful differences.
21
2.2.3. Prevalence.
Emerson, Fujiura, and Hatton (2007) refer to the fact that most of research into
prevalence and knowledge regarding developmental disability is from that undertaken in high
income countries and which represent only a small percentage of the world’s population. It is
characteristic of most health related research. They state that there is no reliable data on the
global distribution of developmental disability, but given the exposure of low and middle
income countries to many of the key environmental risk factors such as transplacental
infections, prenatal exposure to toxins such as alcohol, prenatal undernutrition, birth
difficulties, childhood infections, head injury and undernutrition it could be argued that
developmental disabilities should be markedly more prevalent.
Maulik, Mascarenhas, Mathers, Dua, and Saxena (2011) conducted a meta-analysis of
population based studies examining them for prevalence data. They report a global
prevalence of 1% with studies in middle and low income countries and with children and
adolescents reporting a higher prevalence rate. They found that psychological assessment
failed to assess functional and adaptive ability and tended to overestimate prevalence. Harris
(2006) reported global prevalence rates of between 1-3%. King, Toth, Hodapp, and Dykens
(2009) report that of these, 85% have mild intellectual disability, 10% have moderate
intellectual disability, 4% have severe intellectual disability and 2% have profound
intellectual disability.
2.3. Assessment of intellectual disability
It is important to take a step back, having looked at the broadly accepted definitions
of intellectual disability by the professional community, and acknowledging that these are
socially constructed ways of classifying people, which have significant implications for their
lives, and to be able to critically examine the purpose and usefulness of assessment and
classification itself.
22
2.3.1. Construct of intelligence.
Having examined the construct of disability, it is important to look at what
intelligence is seen to be. This section is summarised from a useful chapter by Carr, Linehan,
O’Reilly, Walsh, and McEvoy (2016, p. 81-204).4
2.3.1.1. Evolutionary models.
Based on Darwin’s ideas, human cognitive abilities have been developing over time
in order to adapt to the environment. Donald (1991, cited in Carr et al., 2016, p. 168)
developed a model which involves three transitions. The first is to mimetic culture which is a
form of cognitively mediated representation which is pre-linguistic, “the ability to produce
conscious, self-initiated, representational acts which are intentional but not linguistic”. He
envisions it including body posture, facial expression, gesture, vocal tone and hand signals. It
is understood collectively and is intentional and representational. This led to group
representational acts which in turn became cultural, including dance and ritual and which
Donald hypothesises led to tool making and the use of fire, coordinated hunting in specific
seasons, adaptation and a more complex social structure.
The second is that of mythic culture which involved symbolic representation and
expression leading to language which in turn led to causative explanation about how the
world worked along with prediction and control.
The third transition he describes is that to theoretic culture, a visuo-graphic system,
i.e., written language. This also mediates an external memory system not dependent on a
4
The authors in the section are referenced as cited in Carr, Linehan, O’Reilly, Walsh, &
McEvoy, J. (2016). I closely follow their very useful summary which they present in The
Handbook of Intellectual Disability and Clinical Psychology Practice (2016). For the most
part in this dissertation, by contrast I use primary sources.
23
biological internal system. With this emerged the development of theoretical rather than
mythical thinking, based on arguments, systematic classification, induction, deduction,
verification and formal methods of measurement and evidence. Mithen (1996 cited in Carr et
al., 2016) describes the evolutionary development of technological intelligence, natural
history intelligence, social intelligence, linguistic intelligence and a fluid, flexible meta-
representational ability.
2.3.1.2. Psychometric models.
Charles Spearman (1927 cited in Carr et al., 2016) can be considered a founding
thinker in terms of psychometric models of intelligence. He observed that there seemed to be
a general factor “g” which influenced a person’s performance of mental tasks in combination
with other lower order factors which he referred to as “s” and proposed a psychological
construct of general intelligence which differs from person to person which, together with a
neurologically based mental energy, is employed in intellectual tasks.
Thurstone (1938 cited in Carr et al., 2016) favoured the separation of abilities into a
number of primary mental abilities. This was further developed by Cattell (1943 cited in Carr
et al., 2016) and Horn (1986 cited in Carr et al., 2016) positing that “g” is comprised of two
distinct types of intelligence: fluid ability (Gf), which draws on biological neurological
resources, and crystallised ability (Gc), drawing on knowledge accumulated and built within
the persons unique and particular cultural context.
Drawing on findings from psychometric evidence, developmental psychology,
neuropsychology, behavioural-genetics, scholastic and occupational achievement, studies of
aging and neurological functioning, Horn and Blankstone (2005 cited in Carr et al., 2016)
describe nine separate mental abilities within the Cattell-Horn model which they cluster into
three categories. They consider this a work in progress.
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1. Vulnerable abilities: Fluid intelligence (Gf)
Short term memory (Gsm)
Processing speed (Gs)
Correct decision speed (CDS)
2. Expertise abilities: Crystallised intelligence (Gc)
Quantitative thinking
Fluency of retrieval from long-term memory (Glr)
3. Sensory Perceptual Abilities: Visual thinking (Gv)
Auditory Thinking (Ga)
Carroll (1993 cited in Carr et al., 2016) reviewed 467 data sets published between
1927 and 1987 in order to develop an evidence based model of intelligence. He proposed
three stratum of intelligence. The first strata comprised of 66 specific aspects of cognitive
functioning, the second strata consisted of eight factors into which these specific aspects
accumulated (Fluid Intelligence, Crystallised Intelligence, General Memory and Learning,
Broad Visual Perception, Broad Auditory Perception, Broad Retrieval Ability, Broad
Cognitive Speediness and Processing Speed). The final strata was the general intelligence
factor “g”, an accumulation of the eight factors.
A consensus view has developed known as the Cattell-Horn-Carroll model (CHC)
with a divergence as to whether “g” represents something real or is a theoretical distillate.
The question remains if these are an accurate reflection of the cognitive processes of the brain
or simply commonalities of the intelligence tests used, or reflect the statistical methods
utilised to organise data in a particular manner.
2.3.1.3. Genetic inheritance.
Plomin et al. (2013 cited in Carr et al., 2016) look at the genetic heritability of
intelligence and its interaction with the environment. Studies thus far have failed to identify
25
specific points of an active gene that contribute to intelligence, but the direction of future
research is Genome-wide Complex Trait analysis involving many thousands of single-
nucleotide polymorphisms (Plomin & Deary, 2015 cited in Carr et al., 2016).
2.3.1.4. Neurobiology of intelligence.
The other area of research interest is the neurobiology of intelligence. Input is through
the visual and auditory pathways fed through the parietal cortex to the frontal cortex with the
whole process reliant on white matter to transmit information from sensory area to processing
area to response selection and output (Jung & Haier, 2007 cited in Carr et al., 2016).
2.3.1.5. Intelligence vs. cognition.
Luckasson and Schalock (2013) differentiate between intelligence and cognition.
They define intelligence as “a general mental capability that includes reasoning, planning,
solving problems, thinking abstractly, comprehending complex ideas, learning quickly and
learning from experience” (p. 96). They further describe intellectual functioning as an
application of this intellectual capability to human functioning and living. Cognition, they
argue, is not a synonym for intelligence. It involves acquiring, interpreting and appraising
knowledge. Cognitive functioning is often a term used in relation to brain injury.
The concept of intelligence continues to be debated, with a growing understanding of
the complexity and variety of processes involved.
2.3.2. Diagnostic criteria.
Internationally, at the turn of the 20th century, with the development of intelligence
tests, as described before, the focus was on measurement of cognitive functioning. Toward
the middle of the century, as evidenced by Heber’s (1959) definition, in the case of
individuals with intellectual disability, there was a growing recognition that assessment of
intellectual disability needed to include an assessment of adaptive functioning. It is now
widely recognised that the assessment of adaptive functioning can provide valuable
26
diagnostic information with regard to social functioning and independent living skills, and
allow for appropriate support and realistic expectations of the person’s abilities and
limitations (Beail, 2003).
The recognised practice, in diagnosis of intellectual disability, requires both the
assessment of cognitive ability and adaptive functioning. The Diagnostic and Statistical
Manual Fifth Edition (APA, 2013) definition of intellectual disability includes deficits in
intellectual functions and adaptive functioning as a diagnostic requirement. Furthermore,
level of severity of intellectual disability is defined on the basis of adaptive functioning as
this determines the level of support needed. This reflects a shift in thinking, emphasising the
importance of assessment of adaptive functioning to the process of diagnosis.
2.3.3. Purpose of assessment.
If intellectual disability is no longer viewed as an invariant trait, but is understood
within a socio-ecological model where the interaction between the environment and the
person is relevant, as are supports, which can enhance functioning, (Schalock, 2011) then
assessment can provide useful information to plan and implement appropriate support in all
of the five domains identified by Wehmeyer et al. (2008). If a multifactorial approach to
aetiology includes biomedical, social, behavioural and educational factors (Schalock, 2011),
then assessment can inform epidemiological knowledge and prevalence and in turn provide
information and motivation for policy and services.
The person with intellectual disability has uniquely configured strengths and
weaknesses and it is important to seek to understand these as best we can, in order to provide
tailored support. We are only just beginning to appreciate the nuanced differences which
apply to both the able and the disabled.
27
2.3.3.1. Using IQ assessment to differentiate cause of intellectual disability.
Several studies have looked at using IQ assessment tools to characterise the cognitive
profiles of particular populations of intellectual disability. Studies using adaptive behaviour
assessment will be dealt with further on in the chapter.
Hessl et al. (2009) used the Wechsler Intelligence Scale for Children (WISC-III) with
a sample of 217 children between the ages of six and 17 with Fragile X syndrome. They
found that meaningful variation in intellectual ability was obscured by floor effects. They
used a z-score transformation using their raw data and the raw norms data from the
Psychological Corporation to achieve a normal distribution of scores. They postulate that this
is probably true for other populations of children with neurodevelopmental disorders.
Couzens, Cuskelly, and Jobling (2004) used the Stanford Binet Fourth Edition for a
longitudinal study of individuals with Down syndrome. The test has been scrutinised with
respect to reliability and validity and has excellent credentials when used with certain general
populations. Issues of reliability and validity are just as important for people with intellectual
disability. Certain causes of intellectual disability may be related to observable patterns of
cognitive strengths and weaknesses. They refer to work being done on establishing
behavioural phenotypes on the basis of assessments of cognitive functioning.
They further question the assumption that a person’s cognitive ability, relative to their
same age peers, is stable over time. Carr (1988) found a decline in IQ in a study of people
with Down’s syndrome. Children with Fragile X syndrome show a decline in IQ scores
(Fisch, 1997; Hodapp et al., 1990) as do those with Lesch-Nyhan syndrome (W. Matthews,
Solan, Barabas, & Robey, 1999), and in intellectual disability of unknown aetiology (Keogh,
Bernheimer, & Guthrie, 1997).
28
The longitudinal data in Couzens et al.'s study (2004) showed considerable instability
in IQ over time for the same individual and large differences in abilities between individuals.
They argue against one approach for all.
2.3.4. Assessment tools.
It is beyond the scope of this review to examine the variety of assessment tools
available. A more detailed appraisal of tools used to assess IQ and to assess adaptive
functioning in the South African context, follows in the next chapter. The tools used in this
research are detailed in the methodology chapter. This section will highlight several pertinent
issues with regard to assessment tools.
2.3.4.1. Cross cultural assessment.
The International Test Commission (2016) brought out the second edition of their
guidelines for translating and adapting tests, indicating the growing awareness of the
complexity of using tools normed and constructed in a particular cultural and economic
setting and based on a particular language. There are 18 guidelines which cover the
preconditions to adaptation, test development, confirmation, administration, scoring and
interpretation and documentation. The first edition of guidelines (2010) began from a
comparative perspective. However, the second edition reflects a wider application.
The most important example is the use of a new or existing instrument in a multicultural
group, such as clients in counselling who come from different ethnic groups, educational
assessment in ethnically diverse groups with a different mastery of the testing
language…items of an existing test should be adapted to increase comprehensibility for non-
native speakers (e.g., by simplifying the language) (2016, p. 5).
Further they state that
…test adaptation refers to all the activities including the decision on whether or not a
test in a second language and culture could measure the same construct in the first
29
language, to selecting translators, to choosing a design for evaluating the work of test
translators…to choosing any necessary accommodations, to modifying the test
format, to conducting the translation and to checking the equivalence of the test in the
second language and culture and conducting other necessary validity studies (2016, p.
7).
A comprehensive document follows this introduction, which to a psychologist
working in South Africa with 11 official languages and a variety of cultures and educational
exposure is overwhelming. In an ideal world, perhaps, but in countries with limited resources,
both in terms of professional and research capacity and who have more urgent research
priorities, it is questionable how pragmatic or possible these recommendations are.
Sattler and Saigh (1990) look at assessment practices across five nations including the
United States, Canada, China, Israel and Lebanon. Four of these were working on developing
their own indigenous products as well as cross validating individually administered tests that
were developed in the United States. There is an argument that test bias is such that all tests
are culturally unfair to segments of any population. All of the nations surveyed recognise that
children who are performing poorly at school should be identified, evaluated and given
support. The procedures in each differ according to the political, social and philosophical
views of the people and the governing bodies. A recommendation is made for further
research on how children with special needs are assessed and identified in various parts of the
world.
Hambleton (2005) discusses several errors and emphasises that the assessment and
interpretation of test results should not be narrowly viewed as just the translation or test
adaptation but considered for all parts of the assessment process. He gives an example of the
need for construct equivalence. If in one country the test reflects a sophisticated mathematics
curriculum, it is of limited value to compare mathematics achievement with another country
30
which has a very different mathematics teaching system. This can also be true within one
country where children are exposed to a vastly different quality of education. South Africa is
a good example. Does the method of test administration communicate clearly what is
needed? Is the item format familiar to this group? Not all cultures have the same
understanding of “speeded” tests or poor reading skills. This becomes a problem where speed
of performance is an important component of the test. Some behaviours are common in
western culture but not in others, so that statements such as “I like to start conversations at
parties” (p.10) have little meaning if parties are unknown, women do not go to parties, or
approaching others is thought inappropriate behaviour. When interpreting scores, curricula,
exposure to educational opportunity, standard of living, socio political factors and cultural
norms and practices impact test performance.
2.3.4.2. Sensitivity of tools and floor effects.
Floor effects, with a standard score of 40 often being the lowest that the test norms
provide, in standard IQ tests, pose difficulties when assessing people with moderate or severe
intellectual disability. Normative samples rarely include the number of participants with ID
that are needed to provide sensitive measurement for people falling in the very low ability
range (Hessl et al., 2009). They make the point that, although people with intellectual
disability represent a small proportion of the population, they should be assessed in as
sensitive and accurate a way as those who are higher functioning.
Dacey, Nelson, and Stoeckel (1999) found that both the Wechsler and Stanford Binet
scales are limited in the assessment of young adults with moderate intellectual disability due
to floor effects. Wilson (1992) found floor effects with the Stanford Binet Fourth Edition
with children under five and children with severe disabilities. Couzens et al. (2004) found
that 35% of the assessments were at “floor level” of her sample of 195 persons with Down
syndrome.
31
Dixon (2007) refers to the report of Luckasson et al. (2002) for the American
Association of Mental Retardation (AAMR), which specifically requires the use of
assessment scales standardised on people without and with disability. This is not reflected in
the norming of IQ tests where people scoring under 40 are not represented. The reliance on
tools assessing adaptive behaviour becomes more important and, likewise, they represent an
accurate level of functioning of the person in this lower ranges of intellectual functioning
(Widaman et al., 1991). Thus the possible floor effects in adaptive behaviour tools are
pertinent.
2.3.4.3. Use of mental age to estimate cognitive level.
The concept of mental age is often used in developmental assessment tools, such as
the Griffiths Mental Development Scales, when estimating a level of development in
comparison to same age peers. Some tests give estimates of mental age and this can be used
when divided by chronological age as a percentage score to estimate cognitive level. As
Grover (2000) wrote:
We must, however be very careful in speaking of Mental Age as it can rather readily
be misunderstood… If we say Mary a sixteen year old girl, has a mental age of 6
years, this does not mean that in every way we should regard her, treat her and expect
her to behave in exactly the same way as we would a 6 year old girl…she is an
adolescent with the physical attributes of a 16 year old… Mary has had 10 more years
in which to acquire and practise self-help and other practical skills and to learn
suitable ways of behaving…she does have limited mental tools at her disposal for
solving problems. (p. 15)
32
2.3.5. Observation and clinical judgement in the assessment process.
A fundamental principle adopted in this research process is explained by Lezak,
Howieson, and Loring (2004) in terms of psychological assessment measures and the results
obtained being a means of refining our clinical observations. Awareness of the limitations of
measurement is important. Foxcroft and Roodt (2009) highlight the approximate nature of
measurement results. There will always be errors of measurement which can be due to
situation, background, administration and interpretation. Assessment is the synthesis and
integration of a wide array of data, together with experience and prior knowledge to reach a
professional opinion.
This opinion is shared by Borthwick-Duffy (2009), Floyd et al. (2015), Luckasson et
al. (2002), Sparrow et al. (2005), Sparrow et al. (2016), Tassé et al. (2012), and Widaman et
al. (1991). Clinical judgement is crucial to the assessment of people with intellectual
disability.
2.3.5.1. Clinical reasoning.
Mattingly and Fleming (1994) provide a more detailed description of the process of
making clinical judgements in relation to a study of the practice of occupational therapists.
They termed it clinical reasoning. Their theory provides insights and is applicable to the
observational and accumulative process needed during psychological assessment.
They differentiate between theoretical reasoning and clinical reasoning. The former
involves using theoretical understanding to formulate probability according to generalised
principles. They argue that whilst a grounding in theory is necessary for good practice, it
does not necessarily guarantee it, that “Theory is not enough” (1994, p. 11). Drawing on the
Aristotelian concept of practical knowledge, they posit the concept of clinical reasoning. This
requires knowing and choosing to act appropriately “to the right person, in the right amount,
at the right time, for the right end and in the right way”. The complexities of a particular
33
situation are always subtler than that of the general, being able to reason “the good” in a
given situation. This draws on experience, flexibility and is often tacit, knowing by doing.
They further identify four components of clinical reasoning : procedural reasoning,
interactive reasoning, conditional reasoning and narrative reasoning. These four processes are
evident in the context of the assessment process examined in this research.
1. Procedural reasoning: applied to psychometric assessment would be the choice
and use of the test within a framework of correct administration but being able to
adapt the procedure to the demands of the situation. Integration of knowledge of
the assessment tool with the contingencies of the person and situation, i.e., length
of assessment fitting level of attention, when to take a break, being able to adhere
to the administration framework with appropriate flexibility and adaptability.
2. Interactive reasoning is the skill drawn on to understand the client within the
interaction, their experience of their disability, and the nature of the relationship
with the caregiver. Psychologists have particular and specific training in this skill
and have many theoretical constructs to understand this process.
3. Conditional reasoning is thinking beyond the specific client to incorporate broader
social, physical and political context in which the person lives.
4. Narrative reasoning is the psychologist’s own story telling. This happened in the
context of a shared office space where client stories could be shared and made
sense of amongst colleagues and in the writing of the report and the findings into a
psycho-legal narrative.
The process of using these different forms of reasoning is fluid and simultaneous,
with certain aspects being foregrounded or temporarily backgrounded.
34
2.3.5.2. Clinical versus statistical prediction.
Meehl (1954) suggested to clinical psychologists that current clinical practice should
be critically examined. He questioned where our reliance should be in predicting how a
person is going to behave, in clinical or statistical methods of prediction. He asked what
makes a good clinician and argues that we should be suspicious of ourselves. Can our brains
analyse and integrate information adequately? What of the errors of observing, recording,
retaining and recalling? He draws a distinction between clinical intuition and mathematical or
statistical procedures. He argues that psychological quantification in terms of class character
of concepts does not negate the unique expression of that dimension by that person. He
argues that the validating use of statistics is unavoidable and necessary (Grove, 2005).
Although, in this dissertation, I am critical of some of the statistical values expressed
in the adult norm tables of the VABS II, as they are at odds with my own and my colleagues’
clinical judgement, it is important to recognise the value of statistical methods of prediction.
The subjectivity of our own clinical judgement should be acknowledged and recognised. The
narrative reasoning, as explained by Mattingly and Fleming (1994), proposes that using the
experience and judgement of other experienced colleagues is an important component of
good clinical judgement. Sound psychometric tests can inform and should continue to inform
our practice. I would argue for an integrative process that uses both clinical judgement and
the best possible fit in terms of tests. We need to retain a critical stance towards statistical
method and information when it does not make clinical sense, and particularly in a context
where test norms have not been validated in the language and cultural framework of the
client. We have to recognise the need but also the limitation of clinical judgement and not
unquestioningly accept statistics at face value. The need for interpretation of test results and
the valuing of clinical judgment is integral to good clinical practice.
35
2.4. Adaptive functioning/behaviour
(The terms are used interchangeably in the literature and within this research. The
preferred term is adaptive functioning.) As adaptive functioning and its assessment have
become integral to the diagnosis and care planning in intellectual disability, it is of value to
examine the construct.
2.4.1. Definition.
Adaptive functioning was conceptually described by Grossman (1983) as the capacity
to meet the social and developmental demands of one’s environment. Expectations of social
competency are developmental in nature and age appropriate skills or behaviour will vary in
different cultural contexts.
Tassé, Schalock, Balboni, Spreat, and Navas (2016) defined adaptive behaviour as
“the collection of conceptual, social and practical skills that have been learned and are
performed by people in their everyday lives” (p. 80). Tassé et al. (2012) further described the
construct of adaptive behaviour as fulfilling four essential functions in the field of intellectual
disability:
1. The definition of intellectual disability is operationally measured in terms of
significant limitations in adaptive functioning and intellectual functioning with
onset prior to 18 years of age.
2. Significant limitations in adaptive functioning are further measured in terms of
conceptual, social and practical adaptive skills.
3. The construct of adaptive functioning provides a framework for charting adaptive
skills development and thus directing educational and rehabilitation goals.
4. It is inclusive of understanding human functioning in a multidimensional way.
36
Sparrow et al. (2016) define adaptive functioning “as the performance of daily
activities required for personal and social sufficiency”. They expand this with four principles
(p. 10).
1. The age related nature of adaptive functioning, i.e., developmental.
2. That it is evaluated in social context, given the social nature of competence in
reference to the expectations and standards of others.
3. That it is modifiable with intervention, change and trauma.
4. It is defined by typical performance not by ability.
2.4.2. Historical development of the construct of adaptive functioning.
Before the development and use of intelligence tests at the turn of the 20th century,
what is known as intellectual disability now was described in terms of social competency,
adaptability to the environment, coping with the demands of everyday life, the power of
fending for one’s life (Greenspan and Granfield, 1992; Nihira, 1999), terms which are
associated with the present construct of adaptive behaviour. Heber (1959) introduced the
concepts of maturation, learning and social adjustment into the understanding of intellectual
disability as the construct of adaptive behaviour. Adaptive behaviour was included in the
definition and diagnosis of intellectual disability by the American Association on Intellectual
and Developmental Disabilities (AAIDD), then known as the American Association on
Mental Deficiencies. This created the need to measure the construct. The only test at this time
was the Vineland Social Maturity Scale published by Doll in 1936.
The inclusion of adaptive behaviour as a diagnostic criterion led to a proliferation of
measurement tools from the 1960’s. Nihira and colleagues published the Adaptive Behavior
Checklist in 1968 which was revised twice and eventually became the AAMD Adaptive
Behavior Scale (Nihira, 1999). During the 1980’s many instruments were developed,
37
alongside research on the factor structure and definition. A three factor model emerged
including:
1. Practical skills: inclusive of activities of daily living and personal care,
occupational skills, money management, health and safety, use of transport, use
of the telephone, and organisation of behaviour.
2. Conceptual skills: including the use and understanding of language, reading,
writing, money, time and numerical concepts.
3. Social skills: including the following of rules and laws, interpersonal skills,
gullibility and naiveté (appropriate social wariness), social responsibility, self-
esteem, social problem solving, and avoidance of victimisation (Tassé et al.,
2012).
Schalock et al. (2010) is of the view that the conceptualisation and measurement of
adaptive functioning is still emerging.
2.4.3. Assessment of adaptive functioning.
Assessment measures the limitations of adaptive functioning. There is a difference
between measuring developmental level and measuring adaptive functioning with a degree of
overlap. Developmental assessment is often dependent on observable behaviours or
demonstration of skills in a once off assessment. Thus the intrusion of anxiety, fatigue and
distraction can influence the ability to perform. When assessment of adaptive functioning is
reported by a caregiver, with a broader knowledge of the person, there is room for emerging
skills to be credited or for experiences which have been outside of the person’s frame of
reference, i.e., they have had no opportunity to develop the skill, to be acknowledged.
Tassé (2009) makes the point that an adaptive behaviour assessment “is not a measure
of capacity or knowing but…a measure of what the individual typically does and what is the
degree of independence in performing these skills” (p. 117). He further adds that assessment
38
is in relation to the person’s age group and culture. He recommends the use of a standardised
adaptive behaviour scale which is normed on a general population and that corroborating
information should support the findings of the information from the standardised assessment.
If possible, this should include qualitative interviews with informants from different contexts,
a review of family history, school records, medical records, past employment history, if
applicable, and any previous psychological, psychiatric or psychosocial evaluations. Clinical
judgement is needed in synthesising the results of the standardised assessment, identifying
who to interview and assessing their reliability, and identifying and reviewing records to
form an opinion based on thorough analysis of the data. This is then added to information
regarding the individual’s intellectual functioning, to make the clinical diagnosis of
2.4.3.1. Adaptive behaviour assessment tools.
Dixon (2007) provides a review of the adaptive behaviour scales used in research
reported between 1996 to 2005 in four journals specialising in research on persons with
intellectual disability. Two hundred and seventy-one studies were identified as including the
use of an adaptive behaviour scale. Of these, the Vineland Adaptive Behavior Scales was
used in 177 of the studies. It was used as a general measure of adaptive functioning or to
determine a classification in terms of level of intellectual disability. He also notes that
researchers are increasingly using adaptive scales to evaluate differences within groups of
individuals.
Hill (2011) identifies the Vineland Adaptive Behavior Scales as one of four widely
used adaptive behaviour assessment tools in the USA. He provides a comparative analysis of
the Scales of Independent Behavior – Revised (SIB-R), the American Association of Mental
Retardation Adaptive Behavior Scales (ABS) and the Inventory for Client and Agency
Planning (ICAP) and the Vineland Adaptive Behavior Scales (VABS).
39
Tassé et al. (2012) identify four psychometrically sound and comprehensive adaptive
behaviour scales.
1. Adaptive Behavior Scale – School. Second Edition (ABS-S:2). This is a revision
of the AAMD Adaptive Behavior Scale mentioned previously. Age range 3-21
years. Developed by Lambert, Nihira and Leland in 1993.
2. Adaptive Behavior Assessment System – Second Edition (ABAS-II). This is a
revision of the ABAS first published in 2000. Age range birth to 89 years.
Developed by Harrison and Oakland in 2003.
3. Scales of Independent Behavior – Revised (SIB-R). This is also a revision of an
earlier version published in 1984. Age range from 3 months to 80+ years.
Developed by Bruininks, Woodcock, Weatherman and Hill in 1996.
4. Vineland Adaptive Behavior Scales – Second edition (Vineland-II). The Vineland
Social Maturity Scale was published by Doll in 1936, revised by Sparrow, Balla
and Cicchetti in 1984. Age range 0-90 years. Developed by Sparrow, Cicchetti
and Balla in 2005.
Further to this the Vineland Adaptive Behavior Scales – Third Edition (Vineland-3)
was published in 2016. The age range remains 0-90 years and it was developed by Sparrow,
Cicchetti and Saulnier.
Tassé et al. (2016) have also published regarding the initial validity and reliability
findings for the Diagnostic Adaptive Behavior Scale (DABS), which at the time of writing
was not yet publicly available. The age range is 4-21 using 75 items by semi-structured
interview across the three domains of conceptual, practical and social skills. Item response
theory models were used in the development. It is significantly shorter than the 381 items of
the newly published Vineland-3. It remains to be evaluated.
40
2.4.4. Assessment of adaptive functioning through the life span.
Widaman et al. (1991) published an extensive review of studies looking at the growth
and life-span development of adaptive behaviours and the contextual factors that influence
this process in people with intellectual development. They differentiated between cross-
sectional, longitudinal design and semi longitudinal design studies. Significant differences
were found for those living in institutional placements and those living in community
placements. Different trends were found for each of the dimensions of adaptive behaviour.
Widaman et al. (1991) then studied a sample of 36 000 people divided into 18 birth cohorts,
further divided into each of the four levels of intellectual disability. The 72 cohort sizes
ranged in size from 123 to 1221 persons with an average size of 506.
In terms of motor development, all levels reached their asymptote at about the same
age (7-10 years). There were some declines associated with aging with profoundly
intellectually disabled people showing earlier and larger declines.
In terms of independent living skills, people with mild to moderate intellectual
disability showed increases in competence through to about 16 years of age. Approximate
stability was shown for all levels between 16 and 45 years, with declines in moderate to
profound intellectual disability after 50 years and mild intellectual disability after 63 years.
In terms of cognitive competence, those with mild intellectual disability reach
asymptote at about 20 years with no changes until the mid-60’s. Those with moderate
intellectual disability reach asymptote at about 18 and show declines from about 50 years.
Those with severe and profound intellectual disability reach asymptote by 7-10 years and
show little change during the rest of the life span.
In terms of social competence, those with mild intellectual disability continue to show
increases until early 20’s, with small but steady decreases from about 30 years. Those with
moderate intellectual disability show gains until about 10 years, with about 15 years of
41
stability, and then decline begins in about the mid 20’s. Those with severe and profound
intellectual disability showed gains until about 8 years with a period of stability for about 10
years when a decline was evident. There was a faster rate of decline for people with profound
They make the point that different dimensions of adaptive behaviour showed different
life span trends. This detail is lost and misrepresented if only a composite score is used. This
correlates to some of the arguments against a “g” factor in thinking about intelligence as
referred to previously.
They further acknowledge that coexisting medical, psychiatric or sensory
impairments, as well as contextual residential, social and economic factors, would moderate
this process.
2.4.5. Assessment of adaptive functioning with different aetiological causes of
There has been much research activity related to using adaptive functioning to profile
particular groupings of people with intellectual disability. It is beyond the scope of this
research to detail this but some of the references are included as they illustrate the importance
of the differential and nuanced functioning of people with intellectual disability and argue
against a one size fits all approach. HIV/AIDS and HIV-Associated Neurocognitive Disorder
(HAND) related issues, although extremely prevalent in the South African context, have not
been included as HIV status was not known or recorded amongst this sample.
2.4.5.1. Genetic syndromes.
Di Nuovo and Buono (2011) compared the adaptive profiles of five of the most
common genetic syndromes: Down syndrome, Williams syndrome, Angelman syndrome,
Prader-Willi syndrome and Fragile-X syndrome. They describe the differing profiles looking
at strengths, and weaknesses, differing rates of development of the different skills and rates
42
of decline. An important finding was that cognitive capacity is not linked to all the adaptive
abilities, particularly Socialisation.
2.4.5.2. Autism Spectrum Disorder (ASD).
The volume of ongoing literature in this field is considerable. Studies which came to
attention relating to the VABS included those by: Volkmar, Carter, Sparrow, and Cicchetti
(1993) looking at measuring social development in ASD using the VABS; Carter et al. (1998)
developed supplementary norms for the VABS for individuals with autism; Fenton et al.
(2003) examined the VABS profiles in Italy of children with autism and moderate to severe
developmental delay; Matson et al. (2009) examined the adaptive behaviour differences,
using the VABS, in adults with ASD, ASD and intellectual disability and ASD, intellectual
disability and Axis I psychopathology. Their results confirmed that the more handicapping
the condition, the greater the adaptive behaviour deficits. Thus they argued that identifying
the cause of adaptive behaviour deficits will result in targeted and effective treatment.
McDonald et al. (2015) used the VABS II to look at the adaptive skills of high
functioning children with ASD. Their adaptive functioning skills fell significantly below their
cognitive level. Mouga, Almeida, Café, Duque, and Oliveira (2015) compared the standard
domain and composite scores of the VABS of school aged children with ASD, matched for
IQ, with those with other neurodevelopmental disorders. The impairment in socialisation
skills remained a distinctive factor. The study was conducted in Portugal.
Fusar-Poli et al. (2017) published a pilot study looking at the long term outcomes of
adults with autism and intellectual disability. Their general finding was that after 10 years the
22 adults included in the study remained stable in terms of their adaptive abilities. Their
findings were not generalisable to the general autistic population as their sample were
inpatients with autism and comorbid intellectual disability.
43
2.4.5.3. Foetal Alcohol Spectrum Disorders (FASD).
There is a high prevalence of FASD in South Africa and in the Western Cape where
this study took place, and alcohol use in pregnancy has been associated with intellectual
disability in the child. (Refer to section 3.3.3 for detail)
Crocker, Vaurio, Riley, and Mattson (2009) compared the adaptive behaviour of
children with heavy prenatal alcohol exposure or attention-deficit/hyperactivity disorder
(ADHD) and a control group matched for age, gender, socioeconomic status and race. Both
showed deficits in adaptive behaviour in all three domains, but the heavy prenatal exposure
group showed greater deficits in the daily living skills domain and arrested development with
a lack of improvement with age in socialisation and communication domain scores. The
ADHD group had developmental delay in terms of adaptive ability but their scores continued
to improve with age although not to the level of the control group.
Whaley, O’Connor, and Gunderson (2001) compared the adaptive functioning of
children prenatally exposed to alcohol with a non-exposed clinical sample. The sample was
matched for gender, age, IQ and outpatient or inpatient status. Both groups showed deficits in
adaptive functioning as measured by the VABS, however deficits in socialisation skills of
prenatally exposed children became more significant with age.
Manning and Hoyme (2007) describe a practical clinical approach to the diagnosis of
FASD, given the public health concern related to this preventable disorder so as to be able to
implement appropriate management.
Kodituwakku (2009, 2010) looked at the neurocognitive profile of children with
FASD. Executive functioning, working memory and a generalised deficit in processing and
integrating information were found. In the second study, this framework was used for the
development of interventions using behavioural methods and cognitive-enhancing
medication.
44
Åse et al. (2012) compared the adaptive behaviour in children and adolescents with
FASD using the VABS with a group of IQ matched children with specific learning
difficulties (SLD) as well as typically developing controls. The FASD group performed at a
lower level than the SLD group on all domains and social skills declined with age.
Davis, Gagnier, Moore, and Todorow (2013) provide a review of four decades of
research into the effects of prenatal alcohol exposure, acknowledging that the threshold for
the teratogenicity of alcohol is unknown and that these effects vary and are also influenced by
environmental context. These effects include diminished intellectual functioning, attentional
impairments, impaired executive functioning, deficits in language use, difficulties with
quantitative reasoning, social cognition, learning and memory.
I shall now turn to a discussion of the main assessment tool used in this study
2.5. Vineland Adaptive Behavior Scales
A detailed overview is given, as this is the assessment tool, the use of which, is being
interrogated in this context and was used in the assessment of Sarai, Themba and Madelaine.
2.5.1. History of the development of the Vineland Adaptive Behavior Scales.
Historically, the Vineland Social Maturity Scale was developed by Edgar A. Doll
(Doll, 1935, 1965) to evaluate adaptive functioning in individuals with intellectual disability.
He recognised that the assessment of disability was incomplete if based only on an estimate
of IQ and that the focus of assessment should be on the individual’s ability in day to day
functioning. Doll also emphasised the developmental nature of adaptive behaviour both in
terms of personal independence and social responsibility and that adaptive behaviour is
inclusive of a number of dimensions or domains. His ideas have been influential in the
definition and understanding of intellectual disability (Sparrow et al., 1984).
45
A revision followed in 1984, the Vineland Adaptive Behavior Scales (VABS) was
developed by S. S. Sparrow, D. A. Balla and D. V. Cicchetti. Three versions were devised: a
survey form, an expanded form and a classroom edition. (Sparrow et al, 1984)
The second edition of the Vineland Adaptive Behavior Scales (VABS II) was
published in 2005 (Sparrow et al., 2005). In this version, the structure of the VABS was
retained, but with a substantial revision of the content, which included new items and
modifications aimed at improving assessment throughout the age ranges.
The Vineland-3, the third edition, was published in 2016 (Sparrow et al., 2016).
2.5.1.1. Vineland Social Maturity Scale (Doll, 1965).
The scale was made up of 117 items and divided up into year age periods until 12
years, then grouped into 12-15 years, 15-18 years, 18-20 years, 20-25 years and over 25
years. Each item was allocated 1 of 8 categories: self-help: general, self-help: dressing, self-
help: eating, communication, self-direction, socialisation, locomotion and occupation. Some
of the items which are reflective of the era and language include: “masticates food”, “gives
up baby carriage”. The understanding and nature of safety has dramatically changed. The
item “Goes about neighbourhood unattended” was indicated to have a mean learnt age of 4
years and 7 months. Some items evidence a vague but optimistic view of people and
possibilities, items such as “contributes to social welfare” and “inspires confidence” or
“creates own opportunities”. (Refer to Appendix A for a copy of the protocol.)
2.5.1.2. Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984).
Building on the start made by Doll, but incorporating changes in society, advances in
test construction and psychometric methodology, the Vineland Adaptive Behavior Scales
(VABS) was published in 1984. It is an assessment tool administered through a semi-
structured interview with a parent or caregiver, in order to determine the level of adaptive
functioning of an individual. Adaptive behaviour is defined within the test manual as “the
46
performance of the daily activities required for personal and social sufficiency” (Sparrow et
al., 1984, p. 6).
It consists of 297 items, with 67 items in the domain of communication, 92 items in
the domain of daily living skills and 66 in the domain of socialisation. There are 36 items in
the motor subdomain and a further 36 items in the maladaptive behaviour domain. The norms
are based on a nationally representative sample of 3 000 persons, drawn from all over the
USA, with about 100 disabled and non-disabled individuals in each of 30 age ranges from
birth to 18 years 11 months. Supplementary norms included a samples of intellectually
disabled adults over 18 years and 11 months, 1 050 participants lived in residential facilities
and 100 participants lived in non-residential facilities. Supplementary norms were also
developed for emotionally disturbed, visually and hearing impaired children. Three types of
reliability estimates were used: internal consistency reliability, test-retest reliability and inter-
rater reliability. Construct validity, content validity and criterion-related validity were also
measured. The first edition (VABS, 1984) is still widely used in the South African context
and was used in the initial data collection period of this study. Further detail is provided in
the methodology chapter. (section 4.5.1.1) (Refer to Appendix B for a copy of the protocol.)
2.5.1.3. Vineland Adaptive Behavior Scales – Second Edition (Sparrow, Cicchetti,
& Balla, 2005).
In the second edition (VABS II), published in 2005, norm samples included 20 age
groups from birth to 90 years. Random sampling from a pool of 25 000 selected 3 695 cases,
which matched the demographic variables within each age group. Eleven clinical groups
were defined and data collected to validate the test in identifying adaptive behaviour deficits
in: “attention-deficit/hyperactivity disorder, autism–nonverbal, autism–verbal, emotional or
behavioural disturbance, deafness/hard of hearing, specific learning disability, mental
retardation–mild (child and adult samples), mental retardation–moderate (child and adult
47
samples) mental retardation–severe/profound (adult sample)” (Sparrow et al., 2005, p. 138).
Reliability and validity of the tool was examined during development.
The scales cover three domains which are further subdivided into nine subdomains:
1. COMMUNICATION: This includes receptive (20 items), expressive (54 items) and
written (25 items) subdomains.
2. DAILY LIVING SKILLS: This includes personal (41 items), domestic (24 items) and
community (44 items) subdomains.
3. SOCIALISATION: This includes interpersonal relationships (38 items), play and leisure
time (31 items) and coping skills (30 items) subdomains.
Two further optional domains include motor skills, for children up to seven years of
age, and a maladaptive behaviour index. These will not be included in the reported research.
There are five possible scoring options in response to the questions: No (0);
Sometimes (1); Usually (2); Don’t know if the respondent has no knowledge of the
performance of the given behaviour (DK); or No Opportunity (N/O). Each sub domain is
scored with a basal and ceiling of four consecutive items at a 2 level for the basal and a 0
level for the ceiling.
Scores are summed and using age normed tables, adaptive functioning standard scores
are given in each domain and an overall adaptive behaviour composite standard score is
calculated. It takes approximately 60-90 minutes to administer. This research is based on the
survey form. Further detail is provided in the methodology chapter. (section 4.5.1.2.) (Refer
to Appendix C for a copy of the protocol.)
2.5.1.4. Vineland Adaptive Behavior Scales, Third Edition (Sparrow, Cicchetti, &
Saulnier, 2016).
In the third edition (VABS 3), published in 2016, three administration forms: the
Interview form, the Parent/Caregiver form and the Teacher form are available online and on
48
paper. Each form has a comprehensive and domain level version. The domains and
subdomains remain structurally the same although the item content has been changed. This is
reviewed in the Discussion chapter. (section 7.7.6.) The Methodology chapter provides a
detailed overview of the norming and reliability and validity during development. (section
4.5.1.3.) (A copy of the protocol is included in Appendix D.)
2.5.2. Use of the VABS in other cultures and languages.
The Vineland Adaptive Behavior Scales are widely used internationally and have
been adapted to various cultures and languages. Reference has already been made to the
widespread use in the study of ASD and FASD. Several studies have been further included to
describe the variety of use.
Kaler and Freeman (1994) used the VABS in analysing the cognitive and social
development of a group of Romanian orphans. The VABS formed part of a test battery which
included the Bayley Scales of infant development and the early social communication scales
(ESCS), a test to measure visual self-recognition, a social referencing measure, a play
measure and observation of behaviour. The VABS was administered through a translator to
the caregiver assigned to each child. The VABS scores revealed a depressed pattern with
significant delays, and correlated highly with the Bayley scores and the ESCS, social
referencing scores and level of play. The results highlighted the deficits in cognitive and
social functioning of the sample of Romanian orphans and their relative strength in peer
interaction; however, the children’s environment allowed restricted access to materials used
in the standardised tests, thus the ecological validity of the measures is open to question. The
non-orphanage sample performed at the expected chronological age level, so the measures
would appear culturally fair. However, there was no correction for the orphanage children’s
poverty of exposure and experience.
49
de Lemos (1989) conducted and reported a study examining the need for standard
score adjustments of the VABS for Australian children. A check norming study was
conducted of children between the ages of 5-9 years, as assessments for placement are
normally conducted during this stage. A sample of 120 children at each of the five year levels
with a total sample of 600 children in New South Wales, was used. It was found that the
mean scores and derived standard scores were consistently below those of the US
standardisation sample. The Otis-Lennon School Ability Test was also administered which
gave information on more scholastic measures of general ability. The finding of the study
was that some adjustment of standard scores is necessary to reflect the differences in average
performance between children in this age group in the USA and Australia.
de Bildt, Sytema, Kraijer, Sparrow, and Minderaa (2005) describe the use of the
VABS as a measurement tool when researching the relationship between adaptive
functioning, behaviour problems and level of education in the Netherlands. They found that
autistic and behaviour problems lower the level of education attained and expected, based on
IQ estimates.
Hayes (2005) conducted a study in Australia, using the VABS and the Kaufman Brief
Intelligence Test (K-BIT) to diagnose intellectual disability amongst a forensic sample. There
is an over representation of people with intellectual disability amongst the offender
population, with prevalence of 20% being found in prisons in New South Wales in Australia.
There is a need for early and accurate identification so that appropriate interventions and
supports can be implemented during the legal process. The correlation coefficient between
the VABS and the K-BIT was .78. The correlation was less robust for young male offenders
and further studies need to look at psychiatric and psychosocial characteristics and their
effect on adaptive functioning.
50
Goldberg, Dill, Shin, and Nguyen (2009) describe a study in Vietnam to translate and
adapt the VABS for preschool children between the ages of 3-6 years, with the aim of
developing a reliable and valid tool to screen for children who would need early intervention
and services in a context of severely limited resources. Goldberg et al. (2009) further refer to
a number of studies of adaptation of the VABS in a non-western context. Anjun, Khadi, and
Phadnis (1990 cited in Goldberg, 2009) used an adaptation of the Vineland Social Maturity
Scale to study social maturity in rural and urban Indian infants. In 1991, Tombokan-
Runtukahu and Nitko (cited in Goldberg, 2009) described an Indonesian adaptation of the
VABS which involved translation, back translation, expert review of items and content
analysis with modification and elimination of certain items. This was then further researched,
matching children by age, gender, socioeconomic status and intellectual ability. They found
that the basic properties of the Indonesian VABS matched those of the original VABS,
arguing that the transfer of the concept of adaptive behaviour to a non-western context is
possible.
However, Goldberg et al. (2009) also refer to a study by Zhang, Wheeler, and Richey
in 2006, which highlights the difficulties of using a western concept of adaptive behaviour in
different cultural contexts. They found that some items were not accurate indicators of
adaptive functioning within the Chinese context. Examples given were: if children were
offered a choice they would possibly not give a preference, in deference to their parents or an
inability to feed themselves with a fork, as chopsticks are commonly used.
La Malfa et al. (2009) used the VABS in a correlation study between the Scheme of
Appraisal of Emotional Development (SAED) and Vineland Adaptive Behavior Scales
(VABS) in Italy. Thirty three adults, living in residential centres, without behavioural or
psychiatric disorders of clinical significance, were assessed with both instruments and
analysis looked at correlations. The SAED was found to be psychometrically reliable with a
51
strong correlation between emotional development and adaptive functioning. The tool
provides a means of gathering important information about the emotional needs of the
person.
Gleason and Coster (2012) used the VABS II at an international level to examine
congruence with the functioning and content framework of the International Classification of
Functioning, Disability and Health (ICF) version for children and youth (ICF-CY). The ICF
uses a framework of a bio-psycho-social model of disability. It identifies three dimensions of
function: body function/body structure, activity, and participation. Function also reflects the
influence of personal factors such as motivation and gender, and environmental factors such
as physical structures and attitudes which make up the context. Each of the 383 items of the
VABS II was coded and assigned codes from the ICF-CY. There were implicit concepts
imbedded in VABS II items, i.e., “turns around when his or her name is called” implies
hearing. The results called attention to the effect motor, sensory and communication abilities
may affect scores across multiple domains because the method of performance may not be
possible for children with disabilities.
This review identifies the VABS as an internationally used and recognised assessment
and research tool. However, used in a cross cultural setting and with participants with
multiple disabilities and limited access to resources, adaptation and consideration of the
criteria of the tool is often needed.
2.5.3. Validity and reliability.
Much of the research mentioned previously has used the VABS or the VABS II as a
standard against which another psychometric tool has been measured. This speaks to its wide
acceptance as a generally valid and reliable tool. Reliability and validity studies during
development are included in the methodology chapter. (section 4.5.1.1. and section 4.5.1.2.)
Some of the further research studies are mentioned.
52
Carter et al. (1998) developed supplementary norms of the VABS for individuals with
autism. They argue that these norms enable comparison of an individual with autism’s level
of adaptive functioning with a peer group of similarly affected individuals as well as
measuring the individual against national normative data. This is helpful to set attainable
treatment goals and inform early diagnosis and intervention.
de Bildt, Kraijer, Sytema, and Minderaa (2005) examined the psychometric
properties of the VABS (1984) in a population of children and adults between the ages of 4-
18 years who had intellectual disability. Their sample was a group of 826. Whilst the original
manual provides corroboration for typically developing children, the authors were critical of
the sample for persons with intellectual disability used in the development of supplementary
norms as being ill defined and described. They argue for the need, for diagnostic and
treatment purposes, of an accurate profile of adaptive functioning. They examined convergent
and discriminant validity and found strong evidence for the construct validity of the VABS.
However, they also pointed to the need for supplementary norms for children and adults with
Dixon's review (2007) points to the wide acceptance of the VABS as a reliable
research tool. An example of the use of the VABS as a gold standard against which other tests
are measured and evaluated, is the study by Villa et al. (2010) to evaluate the Psycho-
Educational Profile Revised (PEP-R), which is used to assess and formulate treatment
programmes for children with autism and related developmental difficulties. This was in an
Italian context and the researchers used an Italian version of the VABS developed by Balboni,
Pedrabissi, Molteni, and Villa in 2001. In 2016, Balboni, Tasso, Muratori, and Cubelli
examined the second edition of the Vineland Scales for item content category analysis with a
group of preschoolers with Autism Spectrum Disorder.
53
Recently, Floyd et al. (2015) conducted a systematic review and psychometric
evaluation of adaptive behaviour scales in order to make recommendations for practice. Their
results found that the VABS II scales were supported by the most recent norming data and the
largest body of validity evidence as well as thorough bias identification studies. Limitations
included low internal consistency estimates for domains and skills for the Survey form and
low test-retest reliability estimates and frequent floor violations at the skills area level.
2.5.4. Identified areas of further research.
The point is made by Hessl et al. (2009), in an earlier section of this chapter, that,
although people with intellectual disability represent a small proportion of the population,
they should be assessed in as sensitive and accurate a way as those who are higher
functioning.
The need for further research of the psychometric properties of the VABS and VABS
II has been identified as including: floor and ceiling effects, item sampling and age
appropriateness, indirect assessments and informant validity and reliability, and cultural,
linguistic and gender considerations of items (Beail, 2003; Dixon, 2007).
In the VABS II, the clinical sample of people with intellectual disability was
relatively small given the wide age distribution (refer to Table 2.2.). This may account for the
floor effects observed in the conversion to standard scores, especially in the adult age groups.
Table 2.2.
Clinical Sample of Persons with Intellectual Disability, Used in Validating the Norms of the
VABS II (USA Norms)
Range of disability Children (n) Children - ages Adults (n) Adults - ages
Mild Intellectual 45 6-18 34 19-69
disability
54
Range of disability Children (n) Children - ages Adults (n) Adults - ages
Moderate 31 6-17 33 18-50
intellectual
disability
Severe to profound 36 6-18 20 26-86
intellectual
disability
(Sparrow et al., 2005, p. 138)
Through clinical use, the impression is that this client population seem subject to floor
effects, particularly adults, when standard scores are calculated. There is a need to examine
the tool and the identify possible variables which may influence the quantitative score. The
validity and reliability of the scales need to be assessed, given the contextual differences of
this clinical population, to the United States sample, on which the test was normed.
2.5.5. Critique of the VABS and the measurement of adaptive functioning.
Despite the VABS being an internationally recognised tool, there are some difficulties
which have been described in the preceding sections. Further to this, Gleason and Coster
(2012) highlighted that the absence of a way to record performance with assistance and/or
support, limits the use of the VABS in describing children with coexisting disabilities and
who are perhaps not credited as they ought.
Greenspan et al. (2011) argue against the indirect indices which psychological tests
give and, because they provide a number, are assumed to be more scientific and more highly
valued that direct real world functioning. They question why 2 standard deviations below the
means should equate to intellectual disability and if we are not giving in to statistical
elegance. They also question content limitations in the measures used with particular
reference to risk awareness and the lack thereof and gullibility.
55
Jenkins (1999) argues that the North American eye has been trained to see through
particular categories and have particular models of normality. He asks if “the local eye may
have had a very different schooling” (p. 224).
A review of the newly published VABS 3 (2016) is included in this study, although
the clinical item data collected includes only the VABS and VABS II which were available
during the period of data collection.
2.6. Intellectual disability in a psycho-legal context
Having examined intellectual disability and its assessment, it is important to consider
the particular psycho-legal context of this research. This is a complex issue and is a subject
for many papers, thinking, and research. This review will only attempt to highlight some of
the pertinent issues. The following chapter will outline the legal protection offered to people
with intellectual disability in the South African context.
2.6.1. The question of competency.
Valenti-Hein and Schwartz (1993) identify the following issues:
1. The distinction between competency and credibility. The former is the witness’s
ability to demonstrate capacity and the latter is the belief by the judge or
magistrate that the witness is providing accurate testimony. Using credibility as a
standard allows greater participation.
2. Competency is not unitary and varies with context and issue. An assessment of
competency needs to be based on the requirements expected of the witness.
3. Intellectual disability likewise is not unitary and is multi-dimensional,
encompassing differing levels of ability. They argue for the documentation of
strengths and weaknesses related to adaptive skills, intellectual functioning,
psychological and emotional concerns, physical and health concerns and the
environment.
56
4. Intellectual disability versus mental illness. Competency for people with
intellectual disability turns on concerns regarding judgement, decision making,
understanding and performance of certain tasks. Terms such as “unsound mind”
conflate emotional and cognitive fluctuations often experienced in mental illness,
with intellectual disability.
Jenkins, (1998) posed an importance question regarding competency. He defines
competence as “the capacity or potential for adequate functioning-in-context as a socialised
human. It is generally taken for granted and axiomatic… Axiomatic suggest that the
competence of most individuals is not in doubt until it is in doubt…competence can be
presumed…there are those to whom the presumption of competence is not extended or from
whom it has been withdrawn…they must strive to be competent…to be seen to be
competent…this presumption is a powerful constraint upon people who are categorised as
‘having learning difficulties’” (p. 1-2).
2.6.2. Questioning.
Cederborg, Danielsson, La Rooy, and Lamb (2009) stress the importance of using
open ended questions followed by more specific questions as this elicits a richer and more
accurate account and does not constrain or shape the witness response. Given limited
memory capacity and thus a possible mistrust of their own capacity, having learnt to rely on
others when they cannot remember or do not understand, may increase suggestibility.
Focused and repeated questions will increase the tendency to acquiesce or give contradictory
answers, thus making them unreliable witnesses. People with intellectual disability are
vulnerable to acquiesce when asked leading questions or when they are unsure of the answer
or do not understand the question (Dickman, 2013; Finlay & Lyons, 2002; Tassé, 2009).
Research by Gentle, Milne, Powell, and Sharman (2013) highlighted the importance of how
questions are asked and how the interview is structured as they found a significant difference
57
in the use of the cognitive interview as opposed to a structured interview in the narrative
accounts of children with intellectual disability.
2.6.3. Truth telling and taking the oath.
The importance of telling the truth needs to be raised at the beginning of any
interview to avoid the person thinking you do not believe him/her. It is useful to add that
everyone has to promise to tell the truth who speaks to the court. It is also helpful to be
explicit about saying you “don’t know” or “can’t remember” and that this is acceptable and
preferable to trying to give a right answer. Benedet and Grant (2013) found interesting
evidence that an admonition to tell the truth is effective.
Pillay (2012) raises a pertinent issue in that people who are not disabled are presumed
to be competent to testify, whereas the intellectually disabled person has to have their
competency assessed before being admitted and that this is discriminatory. It is beyond the
scope of this research to detail the complexities of the issue, but it is an important part of
court preparation to explain the oath taking to the client. It is also helpful to inform the court
official that any questioning to determine competency should be at a conceptual level that the
client will understand and should be simple and easily understood.
2.6.4. The court process.
Education of police and court officials is an ongoing process in providing access to
justice. McAfee and Gural (1988) cite lack of knowledge, the issue of culpability,
competency and the rights of the incompetent defendant [or complainant] as issues needing
attention.
The assessment of adaptive functioning is of particular significance in this psycho-
legal context, as it highlights both the competencies and vulnerabilities which are pertinent
and in preparing the court for the intellectually disabled witness or defendant. The level of
disability indicates the level of support needed in order for the person with intellectual
58
disability to understand and participate in the court process. (Dickman, in preparation; Tassé,
2009)
Court preparation is an important support needed by the person with intellectual
disability and their family, as is recommendations for the use of an intermediary (Dickman,
2013).
2.6.5. The use of the concept of mental age.
The concept of mental age (MA) has already been discussed with reference to Grover
(2000). It re-emerges in the legal context as an accessible way in which to describe the
cognitive level of the complainant. Greenspan (2011) describes the issue well when he says
that “While MA is problematic as a basis for defining ID because of its derivation solely
from intelligence measures, it has the advantage of communicating to judges and juries
…what people are capable of doing, something that statistical deviation units cannot do for
the average layperson” (p. 253). Dickman (in preparation) describes how one age rarely
covers all aspects of the person’s functioning to include cognitive functioning, social skills
and everyday self-help tasks and is generally an oversimplification. The danger is also that it
may lead to incorrect comparisons by the justice personnel and encourages the view that
people with intellectual disability are perpetual children and may well further limit their
participation. A contextual issue is that, in South African law, the Criminal Procedures Act
51 of 1977 (Republic of South Africa, 1977) makes provision in section 170A for access to
an intermediary for complainants under the biological or mental age of 18. Any reference to
mental age in court needs careful explanation with reservation and with an awareness of the
implications, particularly when arguing for the use of an intermediary for adult complainants
with intellectual disability.
59
This chapter has sought to introduce the concepts and debate around the constructed
understanding of disability, intelligence, intellectual disability, adaptive functioning and the
assessment of intellectual disability. It concluded with an application of these ideas to the
psycho-legal context. Although the world of theory, debate and academic discourse is far
removed from the lived reality of Sarai, Themba and Madelaine, it impacts their lives in very
real ways from levels of subsidy and grants, educational opportunity and governmental
policy, to a fair and accurate assessment of their own limitations, to the understanding the
police and legal team will have of their ability to give evidence. The following chapter will
detail contextual issues pertaining to the South African context in which they have grown up
and live. It will examine intellectual disability and its assessment in this context, sexual
abuse, the laws and legal system and the community organisation to which they have been
referred for assistance.
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Chapter Three: Literature Review: Context
3.1. Introduction
Having looked at intellectual disability in terms of concepts, assessment thereof and
the psycho-legal context at a broad level, this chapter focuses on the specific context of South
Africa, giving a brief historical context, an examination of intellectual disability in the South
African context, and the psychological assessment of intellectual disability in this context.
There is a section with a focus on sexual abuse and its impact, and particularly in relation to
people with intellectual disability in South Africa, followed by an overview of the
community mental health non-profit organisation, Cape Mental Health within which the
research was based, and to which Sarai, Themba and Madelaine would have been referred on
reporting the abuse to the police.
3.2. The South African context
An appreciation for the historic, political and economic background is necessary to
understand the context in which Sarai, Themba and Madelaine live. They live in a world
where race, past and present political systems and economic inequality continue to define
opportunity, access to services and support.
3.2.1. Historical context.
South Africa’s history is dominated by ethnic interaction and racial conflict. It is
beyond the scope of this literature review to give but a brief overview of a very complex past.
However, in order to understand present realities, there needs to be some frame of reference.
Various groupings lived in what we now know as South Africa, before the Dutch
Europeans arrived in 1652. They were joined by people, enslaved by the Dutch, from the
East. The Afrikaans language developed from a Dutch base to which were added Malay,
Khoisan, Portuguese, French and other African language influences. In 1834, the slaves were
emancipated. Afrikaans was the common language of both slaves and settlers. Religious
61
persecution brought French Huguenots and Dutch and German Protestants to South Africa.
Tensions increased over land and resources. After the British colonised South Africa in the
early 1800’s, increasing number of English speaking settlers were brought in, particularly
from 1820, to provide a buffer between the expanding colonial base in the Cape and the
resistant local groups. Several wars were fought. White Afrikaners, resisting British
dominance and authority, moved northwards, encountering increasing resistance from local
people. Tensions heightened with resistance to colonisation.
In the 1860’s, labourers from India, also a British colony, were indentured with the
promise of the right to settle after five years to provide labour for the tea, coffee and sugar
plantations. There was also an influx of merchants from India into the Natal region. The main
race groupings of South Africa were forming, namely White people of European origin,
Indian, Coloured, which referred to people of Malay, Khoisan and mixed race groups, and
Black indigenous groups of nine different language groupings5. The discovery of gold,
diamonds and rich sources of minerals added economic impetus to the colonial agenda.
Tensions between the colonial power, Britain, and Afrikaans speaking White South Africans’
5
In contemporary South Africa, the racial labels promulgated first under colonialism and
then under apartheid are no longer officially used to categorise people but they continue to be
used to monitor progress in education and employment equity, for example. In the Western
Cape, where this study was conducted, most of the population are designated “coloured”
according to this usage, with smaller numbers of people designated “White” or “African”,
and very few people designated “Indian”. In line with contemporary South African usage, I
use these terms in this dissertation, not because I believe that racial categories are
scientifically valid, but because the categories continue to hold substantial meaning in a still-
divided and very unequal society.
62
resulted in two wars, known as the Boer Wars. Labour was needed for mining and industry.
Some schools and health services were started through missionary endeavours.
The British began to institute racially based laws and controls. As early as 1929, Fick
began using psychological assessment measures standardised on White children. Initially he
attributed differences in performance to environmental and educational factors, but, by 1939,
had altered his view, giving his opinion that there were innate differences between race
groups. This was challenged and critiqued by Biesheuvel in 1943 in his book African
Intelligence. From 1948, with the National Party coming to power, formal, legalised, racial
segregation became entrenched, known as Apartheid. In 1949, Biesheuvel, at the National
Institute for Personnel Research (NIPR), developed the General Adaptability Battery (GAB)
to identify occupational suitability for Black people who had little or no formal education,
arguing that Black people were not familiar with content of items or the type of test material
used, introducing the concept of “adaptability testing”. Alongside this the Institute for
Psychological and Edumetric Research (IPER) developed educational and clinical tools. In
the late 1980’s they were amalgamated into the Human Sciences Research Council (HSRC)
which specialised in developing local tools. Psychological assessment practices were used to
provide rationale to deny people access to education and economic resources (Nzimande,
1995 cited in Laher & Cockcroft, 2013; Claasen, 1997 cited in Laher & Cockcroft, 2013).
With the release of Nelson Mandela in 1990 and the first democratic elections in 1994, the
new constitution was ratified and promoted a system of mutual respect, protection of human
rights, democracy and freedom of expression.
The HSRC was restructured and psychological testing and assessment was
repositioned. Both the local and international tests were sold to private organisations who
took over test development, adaptation and distribution.
63
Psychological testing remains a contested area, with critics questioning the value in
our diverse population. Proponents have argued for a focus on valid and reliable tests in a
multicultural, multilingual society, which takes exposure to educational opportunity into
account (Foxcroft & Roodt, 2009; Laher & Cockcroft, 2013).
3.2.2. Long term effects of political systems: Apartheid policy.
Posel (2001) writes of the constitutional commitment to non-racialism and eradication
of discrimination, but in the everyday lives of its citizens, many still make choices and
judgements of others based on race. Racial categorisation remains, not only because of the
lasting effects of apartheid-type thinking, but also within an ethical and political argument.
Redress of past disadvantage is linked to racial classification. The transformation agenda has
given new life to racial classification. The geographical boundaries drawn by apartheid
policies still, in effect, separate one group from another, with many still impoverished, living
in distant townships, far from amenities and living in under-resourced communities. This
directly impacts on the lives of those living with intellectual disability, such as Sarai and
Themba.
For the most part, the resources available to the resourced and mostly White members
of the community rival those in any developed nation, such as Madelaine. Juxtaposed are the
under-resourced, stretched state services which can barely cope with the backlog of
assessment and support needed. The burden of disease (as discussed later in this section)
weighs most heavily on the poor and mostly Black members of the South African
community. For many, little has changed since the change to democracy in 1994. As Swartz
(2016) states: “We dare not forget the enduring effects of racism. We dare not focus on
poverty without focusing on racism as its root cause. We dare not attempt to build a ‘normal
society’ without addressing the outrage and pain of entrenched racial inequality” (p. 68).
64
3.2.2.1. Educational opportunity.
Under Apartheid, the differences in educational facilities, made available for different
race groups, was legislated, differently funded, with specific and discriminatory curricula and
resulted in inequity, which is taking decades to redress. Post 1994, 19 differing departments
of education, in a fragmented and inequitable system, had to be restructured, a common
curriculum developed and infrastructure developed (Swartz, 2016). The needs of children
with specific or global learning difficulties are proposed to be addressed within an
inclusionary system where multidisciplinary district based support teams provide support to
schools (Foxcroft & Roodt, 2009). This model is in varying stages of implementation, with
these teams having been established in the Western Cape. The necessary support services are
in high demand and are considerably overstretched, resulting in long delays for appropriate
placement, as evidenced in Themba’s story.
3.2.2.2. Relationship between age and educational opportunity.
Given this history, there are many people with intellectual disability who have never
been formally assessed and have little to no access to education or support, as evidenced in
Sarai’s life. There are no figures available. Given the demand and long waiting lists for
schools and assessment and placement in the Western Cape, which is arguably the most
resourced area in Africa, the need is enormous.
3.2.2.3. Family systems.
Family systems were also ruptured, through migrant labour policies, restriction of
movement into urban areas, the Group Areas Act which moved people from accessible and
stable communities into distinct and distant urban and rural areas, further impoverishing and
distorting existing social structures. The effects of these policies and actions have caused
deep and lasting damage. Given that in poorer communities, the intellectually disabled are
predominantly cared for by family members (McConkey, 2016), and the recognition given to
65
the primacy of the family as the foundational grouping in society by the CRPD (UN, 2006),
this rupture further adds to the disablement, as illustrated in the lives of Sarai and Themba.
3.2.3. Long term effects of economic systems.
The Twenty year review : South Africa, 1994-2014 states that:
…within the first two decades of democracy, the government built roughly 2.8
million houses and delivered 876 774 serviced sites (water, electricity, sanitation) for
those who had been forced to live in the previous Bantustans. This provided roughly
12.5 million people with access to housing and a fixed asset. In 1994, just over 50%
of South Africans had access to basic sanitation; this improved to 83% by 2012.
Access to water improved from 60% of households in 1994, to 95% by 2012.
Electricity supply has improved from 50% to 86%. (The Presidency of the Republic
of South Africa, 2014, p. 86.)
This speaks, not only of improvements, but also of the level of poverty that needs to
be addressed. The general household survey was conducted in 2014 and reported in 2015.
The South African Child Gauge gives the following economic and poverty related figures for
South Africa and the Western Cape (Delany, Jehoma, & Lake, 2016):
Table 3.1.
Summary of Poverty Related Indicators for South Africa and the Western Cape
2014 South Africa Western Cape
Total adults 35 179 000 4 254 000
Total Children under 18 18 508 000 1 876 000
Children living in income poor 11 666 000 (63%) 736 000 (39.2%)
households (<R923/person per
month)
Children receiving Child support 11 972 900 966 345
grant (available on a means –
66
2014 South Africa Western Cape
tested basis to children under 18
years)
Children receiving care 131 040 12 626
dependency grant (physical and
mental disability and chronic
illness)
Under 5 mortality rate 39 per 1 000 live births
Infant mortality rate 28 per 1 000 live births
Neonatal mortality rate 11 per 1 000 live births
School attendance (7-17 years) 97.8% (10 715 000) 97.5% (1 073 000)
Children 16-17 years who passed 66.5% 77.4%
Grade 9 only 60% in poorest quintile
ECD attendance in 5-6 year olds 91.5% (1 872 000) 81.8% (182 000)
Living in traditional housing 11.6% 0%
Living in informal housing 10.6% 15.6%
Living in formal housing 77.7% 84.4%
Access to on site clean water 68.6% 93.5%
Access to basic sanitation 74.4% 91.9%
Adapted from South African Child Gauge, The Children’s Institute, University of Cape Town, 2016 (p. 111-
116 & 119-134)
3.3. Intellectual disability in the South African context
In order to provide a wider context, reference should be made to earlier prevalence
figures in the previous chapter, regarding global prevalence. (section 2.2.3) This section will
look at the African context and then at the South African and local context of the Western
Cape.
3.3.1. The prevalence and understanding of intellectual disability in Africa.
Intellectual disability accounts for the largest disability grouping in Africa (Mckenzie,
McConkey, & Adnams, 2013), but there is a dearth of information regarding its prevalence.
67
Poverty, illness and war impact heavily on the vulnerable who need support. The effect on
the intellectually disabled can be extrapolated. Africa is made up of many different cultures
and groupings who have their own, differing understandings and attitudes and to make broad
generalisations is demeaning and simplistic. Studies from a variety of people groups are
described, which can only provide a flavour of some of the differences in meaning,
understanding and practice which need to be respected and sometimes challenged in relation
to intellectual disability.
Whyte (1998) describes work amongst the Nyote people in Uganda. She highlights
the positioning of personhood within kinship relationships according to the biological father.
This identity belongs to all, regardless of ability. She describes the skills that are valued and
relates them to a concept of social competence. The first is advisability, the “willingness to
accept guidance” (p. 155) and is enacted within social relationship. The second is
intentionality. This involves planning, deciding and acting, “seeing what has to be done and
doing it without having to be told” (p. 156). The third is civility. Again this is enacted within
social relationship, involving attentiveness, respect and courtesy. The fourth is conversation.
This involves both listening and speaking and the flow of conversation. It involves telling
news, sharing stories, humour, understanding subtlety and rhetoric. The fifth is that of
cleverness, where humour, creativity and problem solving is valued. An overriding principle
is that of social responsibility as an important dimension to intelligence.
Tan, Reich, Hart, Thuma, and Grigorenko (2014) describe a study using a translation
of the VABS II into Chitonga and adapted to a setting in rural Zambia. The study found no
association between adaptive behaviour and the chosen cognitive ability indicators but a
strong relationship with reading measures. This differs from studies in developed nations
where there is a modest correlation. They posited that Western based cognitive measures are
aligned with school achievement rather than what is valued as intelligent behaviour within
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the community. School attendance, teacher absenteeism, distance to travel to school, large
classes, negative life circumstances, to mention a few variables, were identified as impacting
school learning.
Mckenzie et al. (2013) cite research carried out by the Africa Child Policy Forum
(2011) which estimates that fewer than 10% of disabled children attend school, of whom
those with intellectual disability and multiple disabilities are most likely to not attend school.
In Senegal, up to 86.5% of children with intellectual disability were found to not be attending
school. The Human Rights Watch report of 2015 highlighted the ongoing discrimination and
gap between policy and practice in providing inclusive education for children with
disabilities in South Africa (Human Rights Watch, 2015). Difficulties included access,
physical and attitudinal barriers, extra costs, vulnerability to abuse, low quality of education
and a lack of preparation for life after school.
Mckenzie et al. (2013) further cite various studies from a variety of African countries
in which the cause of intellectual disability is believed to be of supernatural origin caused by
“divine retribution or witchcraft” (p. 1751) and that this can have detrimental consequences
for the person with intellectual disability. They also describe religious discourses amongst
those of Christian or Muslim faith in which the person is viewed as a “gift from God” (p.
1751) which assumes an innocence on the part of the person with intellectual disability and a
challenge to the faith and strength of the family. This can have both positive and negative
effects.
In Egypt and Nigeria, Scior (2011) found that acceptance of disability was related to
severity of intellectual disability, with a greater acceptance when the person could make a
contribution to the household but less acceptance when dependent and a drain on family
resources.
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Pillay (2003), in a study comparing a rural and urban sample of children in South
Africa, found that the “rural children had significantly higher levels of social maturity than
the urban group relative to their IQ” (p. 178). He concludes that children living in rural
communities, where there is an almost complete lack of formal support structures, are given
tasks by their family and community and participate in domestic life from a very young age
thus giving them life skills to better deal with everyday living.
Services and support are variable through Africa, and as in other middle and low
income countries, there is a reliance on nongovernmental, community and faith organisations
to provide services, but for the most part people with intellectual disability are reliant on
family and kinship relationships.
3.3.2. The prevalence of intellectual disability in South Africa.
Grover (2000) described the following figures as a guide, a prevalence of 3-4% and
those with an IQ below 50, of 0.4%. In terms of prevalence according to severity, she based
her figures from those reported in 1967 by Van Wyk, that 83% of these are in the mild range,
13% in the moderate and upper severe range and 4% in the severe lower and profound range.
Christianson et al. (2002) conducted a study amongst rural children. From a screening
sample of 6 692, 722 were given a paediatric evaluation and 238 children were diagnosed
with intellectual disability, giving a prevalence of 35.6 per 1 000. The prevalence of mild
intellectual disability was 29.1 per 1 000 and severe intellectual disability 0.64 per 1 000.
Kromberg et al. (2008) screened 6 692 children between 2-9 years old in a household
survey in a rural area. Of these, 722 screened positive and were examined and were assessed
neuro-developmentally by a paediatrician. Intellectual disability was found in 3.6% of
children with the prevalence of mild intellectual disability being 2.9% and that of moderate
and severe disability being 0.64%. These are very similar findings to the study by
Christianson et al. (2002).
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Adnams (2010), in a review of available literature, quotes the National Disability
survey figure of 1.1% in 1999, a national census figure in 2001 of 0.5%, noting however that
the census did not include any people living in institutional care. She cites a further national
survey of severe disability at a figure of 0.27%. She found little evidence of description of
geographical distribution or across population or age groups. She found a high incidence of
preventable causes of intellectual disability.
3.3.3. The prevalence of intellectual disability in the Western Cape.
There are no specific figures for this area, however Adnams (2010) reported
prevalence rates of FAS, being the most severe form along the spectrum of FASD, citing
research by May et al. (2007 cited in Adnams, 2010) and Urban et al. (2008 cited in Adnams,
2010) of prevalence rates between 6.7% and 8.9% with FAS or partial FAS in children in
Grade 1. She accords these as being the highest in the western world. She identifies this as a
major public health problem in South Africa. This disorder is highlighted, as it is
symptomatic of the political and economic determinants which significantly determine
incidence of intellectual disability in the region of the Western Cape. Soudien and Baxen
(2006) cite figures from the Department of Education in 2001 of 82 special schools in the
Western Cape, for 9 213 learners (inclusive of a variety of disabilities). The Western Cape
has 5.47% of the disabled population but 21.58% of South Africa’s special schools. There is
marked disparity of services for people with disabilities in different regions of South Africa.
The Western Cape is relatively well resourced when compared with other parts of the
country.
3.3.4. Financial support for people with intellectual disability.
Three social grants are accessible to provide financial support for people with
intellectual disability and their families in South Africa and would be available for Sarai,
Themba and Madelaine:
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1. The Child Support Grant (CSG) currently at R360 per month given to 11 972 900
children nationally which provides income support for caregivers of children
below 18 years living in poverty. It is available to South African citizens,
permanent residents and refugees with a means test of R3 600 per month for a
single caregiver.
2. The Care Dependency Grant provides income support for caregivers of children
under 18 years with a physical or mental disability who require and receive
permanent care or support services. It requires a medical assessment. It is
currently at R1 510 per month. It is available to South African citizens, permanent
residents and refugees with a means test of R15 100 per month if a single
caregiver. This is given to 131 040 children.
3. The Disability Grant provides income support for people with a physical or
mental disability between 18 and 59 years of age after which they qualify for an
old age pension. It requires a medical assessment. It is currently at R1 510 per
month. It is available to South African citizens, permanent residents and refugees.
The South African Child Gauge (Delany et al., 2016) reports that access to the general
CSG is still low with one in five eligible children (1.8 million children) not receiving grants.
However, they estimate that between 2003 and 2014 there has been a drop from 60% food
poverty to 30%. They attribute this to social grants.
3.3.5. The protection of disability rights within South Africa.
At an international level, various resolutions regarding the rights of people with
disabilities coalesced in the United Nations Convention on the Rights of Persons with
Disabilities (UN, 2006) (CRPD) and through the World Report on Disability (WHO and The
World Bank, 2011) as referred to in the previous chapter. International agreements are not
72
legally binding on the signatory country and following, whether this is then encoded into
national law. These agreements do provide a framework for policy (Emerson et al., 2007).
3.3.5.1. The United Nations Convention on the Rights of Persons with Disabilities.
South Africa is a signatory to the United Nations Convention on the Rights of Persons
with Disabilities (CRPD). The following articles are of particular importance with regard to
the subject of this research.
Article 1 states that “Persons with disabilities include those who have long-term
physical, mental, intellectual or sensory impairments which in interaction with various
barriers may hinder their full and effective participation in society on an equal basis with
others.”
It recognises the full range of rights that should be enjoyed by persons with disability
and the greater risk of exploitation, neglect and abuse for this group.
Article 12 enshrines the right to equal recognition before the law; “persons with
disabilities enjoy legal capacity on an equal basis with others in all aspects of life but may
need extra support to exercise this capacity” (section 2). The state is required to take
responsibility for providing this support and it is further required that the person’s rights, will
and preference are respected, the assistance will be free of conflicts of interest and undue
influence and that the measures put in place are proportional and appropriate to the person’s
circumstances.
Article 13 enshrines the right to effective access to justice on an equal basis to others,
including the provision of appropriate accommodations at all stages to support direct
involvement in proceedings, including the investigative stages and the provision of
appropriate training for those involved in the administration of justice.
Article 16 enshrines the right to freedom from exploitation, violence and abuse and
requires that signatory states prevent such abuse and put measures in place to recognise and
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report such abuse when it takes place, that they obtain appropriate assistance for recovery and
that legislation and policies are put in place to investigate and where appropriate prosecute
such cases. (United Nations Convention on the Rights of Persons with Disabilities, 2006)
3.3.5.2. The South African Constitution.
As a country, we generally have sound policy in place but the gap between the ideals
in policy and the implementation on the ground, is large. As a basis, we have a constitution
which is widely regarded and respected as protective of human rights. This forms the basis
and benchmark against which South African laws are formulated and tested. It contains a Bill
of Rights requiring the State to protect and promote the right to dignity, equality and freedom
from violence for all its people (emphasis added). The Constitutional Court provides an
opportunity for legal challenge if human rights are infringed. These are the laws which
should provide protection and recourse for Sarai, Themba and Madelaine
3.3.5.3 Guidelines of the legal protection in relation to differing levels of
Various laws provide protection which are pertinent to people with intellectual
disability. Table 3.2. describes the laws which pertain to various levels of severity of
Table 3.2.
Guidelines of the Legal Protection in Relation to Differing Levels of Intellectual Disability
Level of intellectual disability Relevant South African Legal implications
Legislation
Mild intellectual disability Promotion of Equality and Generally cope well in supportive
Prevention of Unfair structure.
Discrimination Act 4 of 2000 Usually can be sworn in and
(Republic of South Africa, 2000). testify reliably.
Should be seen as vulnerable.
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Legislation
Court preparation necessary and
possibly a simplified oath.
Use of an intermediary.
Care under cross examination.
Moderate intellectual disability Mental Health Act 17 of 2002 – Needing more support but may be
capable of “partial self- able to give reliable testimony.
maintenance under close Use of an intermediary.
supervision together with limited Careful assessment of
self-protection skills in a differentiation of truth and
controlled environment”. (Chapter falsehood using familiar concepts
1, section 1, xxxvi) and concrete examples.
A simplified oath.
Account is simple, usually not
able to give dates or times.
Use of anatomically correct dolls
may assist.
Avoid misleading during cross
examination, be aware of
acquiescence and suggestibility
Severe intellectual disability Mental Health Act 17 of 2002 – Need extensive support in order to
capable of “partial self- testify.
maintenance under close Some possible difficulty
supervision together with limited understanding the difference
self-protection skills in a between truth and falsehood as
controlled environment through they don’t readily understand the
limited self-care and requiring concept, therefore can exclude
constant aid and supervision”. even if they can provide a
(Chapter 1, section 1, xxxvi) consistent account.
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Legislation
Profound intellectual disability Mental Health Act 17 of 2002 – Not be able to consent or act as a
have “severely restricted sensory witness.
and motor functioning” and Court will have to depend on
require “nursing care”. (Chapter 1, witnesses or forensic evidence
section 1, xxxvi)
Adapted from Dickman (2013) and used with permission.
The laws which relate to sexual abuse and are pertinent to this research are listed
below with a brief description of pertinent sections.
3.3.5.4. The Criminal Law (Sexual Offences and Related Matters) Amendment Act
32 of 2007.
This stipulates that at the time of the alleged offence:
• if the complainant was unconscious or under the influence of substances they
could not freely agree to sexual intercourse.
• They could not consent if at the time of the alleged offence they were
mentally disabled. This is further qualified as including any person “affected
by any mental disability or disability of the mind to the extent that he or she,
at the time of the alleged offence was:
a) unable to appreciate the nature and reasonably foreseeable
consequences of a sexual act
b) able to appreciate the nature and reasonably foreseeable
consequences of such an act, but unable to act in accordance
with that appreciation
c) unable to resist the commission of any such act, or
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d) unable to communicate his or her unwillingness to participate
in such an act”.
(Republic of South Africa, 2007a)
3.3.5.5. The Criminal Law (Sentencing) Amendment Act of 2007.
This legislates for discretionary minimum sentences for certain offences. The
minimum sentence is life imprisonment for rape of a complainant who meets the definition of
mental disability in the Sexual Offences Act at the judge’s discretion (Republic of South
Africa, 2007b).
3.3.5.6. The Criminal Procedures Act 51 of 1977.
There are a number of protective measures in this act (Republic of South Africa,
1977) which are helpful when an intellectually disabled person is called to court. Application
can be made for the trial to be heard in camera (not open to the public) and for the identity of
the complainant to be protected.
Section 170A states: “Whenever criminal proceedings are pending before any court
and it appears to such a court that it would expose any witness under the biological or mental
age of eighteen years to undue mental stress or suffering if he or she testifies at such
proceedings, the court may…appoint a competent person as an intermediary in order to
enable such a witness to give his or her evidence…” (paragraph 1)
Paragraph 2 (b) makes provision for the intermediary to “convey the general purport”
of the question.
Paragraph 3 (a) makes provision for the court to direct the witness to give evidence in
a place which is informally arranged in order to set the witness at ease and (b) for this to be
situated away from any person whose presence may upset the witness. Evidence is given
through a closed circuit television.
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It can also be argued that the complainant needs an intermediary to enable or facilitate
her rights to appropriate accommodation to support direct involvement in proceedings
(Article 13).
Further, section 164 (1) makes provision for a witness or complainant to be
admonished to tell the truth if he or she is “found not to understand the nature and import of
the oath or affirmation”. The presiding officer then makes a decision about competence
having heard the evidence.
Section 194 still has outdated wording: “No person appearing or proved to be afflicted
with mental illness or to be labouring under any imbecility of mind due to intoxication or
drugs or the like, and who is thereby deprived of the proper use of his reason, shall be
competent to give evidence while so afflicted or disabled”. There have been calls to update
the language in this section.
3.3.5.7. The Domestic Violence Act 116 of 1998.
The act (Republic of South Africa, 1998) sets out procedure for an application for a
protection order against a perpetrator with the aim of preventing future abuse. The definition
of “domestic relationship” is wide and covers a complainant in a residential facility to apply
for a protection order against another resident or member of staff.
3.3.5.8. The Mental Health Care Act 17 of 2002.
This act (Republic of South Africa, 2002) includes a definition of severe and
profound intellectual disability which can serve as a useful criterion-based definition. Chapter
1, Section 1 xxxvi states, “Severe and profound intellectual disability means a range of
intellectual functioning extending from partial self-maintenance under close supervision
together with limited self-protection skills in a controlled environment through limited self-
care and requiring constant aid and supervision, to severely restricted sensory and motor
functioning and requiring nursing care”.
78
Adnams (2010) makes the point that despite progress in terms of policy and
legislation and the good practices of numerous governmental and non-governmental
departments and organisations, marked inequities in access and human rights are still a reality
for many people with intellectual disability.
3.4. Psychological assessment of intellectual disability in the South African context
Global disparities are reflected in our South African society. For those with resources
to pay for private psychological assessment, there are psychologists available in most urban
areas. Madelaine would have received services from this sector. However, within the state
educational and health sector there are few psychologists employed, and even in the
relatively better resourced urban areas such as Cape Town, children identified at school as
having learning difficulties can wait years for an assessment, as is the case for Themba. Sarai
would have had no access to psychological services growing up. In the last few years
community service psychologists are providing services to rural areas but remain
overstretched and rural areas remain underserved. Psychological assessment
recommendations are often based on the assumption that resources for support and education
are available. However, people are “placed” according to cut off scores due to enormous
pressure for the few available places at school and facilities providing care. For many there
are long waiting periods or there are no facilities or support.
Often there is an over reliance on IQ scores, obtained through using abbreviated tests,
through pressure of clinical need, and assessment of adaptive functioning is not standard
procedure.
3.4.1. Historical background.
Testing and assessment cannot be separated from the social, political and economic
realities which impact the individual being assessed and the community of which they are a
part. Historically, within the South African context, as discussed previously, psychological
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assessment developed in a society where resources and opportunities were dependent on
racial classification and in a context which was deeply divided and unequal. Early
instruments were standardised on Whites only and used for placement and assessment of
special educational needs. Differing performance of different race groups was used to argue
for “Bantu education”, without regard for differing quality in schooling, lack of familiarity
with tasks, cultural bias or previous educational exposure (Foxcroft & Roodt, 2013). Foxcroft
and Roodt (2013) further point out that between 1969 and 1984 the Human Sciences
Research Council (HSRC), during the apartheid era, used western models to develop similar
tools for individual language and race groups.
3.4.2. The present situation.
With socio-political change during the late 1980’s and early 1990’s, researchers
began to critically examine bias and fairness of the tools being used. Since 1994, with the
election of a democratic government, psychological tests and assessment processes have been
viewed with some scepticism and mistrust. In 1996 a Psychometrics Committee was formed
by the Professional Board for Psychology in order to regulate fair and ethical test use in
South Africa. Foxcroft and Roodt (2013) argue that this process has forced psychologists to
critically examine why and what test measures are used, and to address the challenge of using
them ethically in a diverse society. It has further challenged researchers to provide empirical
evidence as to the usefulness of the assessment measure.
At the South African Neuropsychological Association conference, Thomas (2010)
highlighted some factors, particular to test use, that need to be considered in the South
African context. We live in a multilingual society with 11 official languages. Age does not
necessarily predict level of education, because of differing access to educational
opportunities. There is gross economic disparity and disparity in quality of education. There
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are varying levels of acculturation to western cultural norms. He proposed that there were a
number of approaches which could be taken with regard to test development and research:
• Create, standardise and norm South African specific tests;
• Modify existing tests to satisfy local concerns and develop norms for modified
tests; or
• Develop normative data sets for unmodified existing tests.
There are complex ideological issues surrounding the history of intelligence testing in
South Africa. Any research in the area of assessment within the South African context must
take cognisance of these issues (Davidson & Dickman, 1990).
3.4.3. Assessment tools used in SA context.
The importance of choice of appropriate test is amplified as the complexity of
language, socioeconomic differences, quality of educational opportunity, familiarity with test
taking procedures and anxiety in terms of the person’s own sense of their ability.
Two distinct categories of norms are delineated in the psychometric assessment
studies:
1. Population-based norms (standardisation data) which are derived from large
samples representative of the general population and allow for location of ability
relative to the general population.
2. Within-group norms which closely approximate the subgroup to which the
individual belongs. Examples of this are the norms for a variety of clinical
neuropsychological tools where an age group or level of education are delineated.
This allows for comparisons with the subgroup that best approximates the
person’s particular demographic profile for diagnostic purposes (Shuttleworth-
Edwards, Gaylard, & Radloff, 2013). Shuttleworth-Edwards et al. (2013) argue
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that such normative indicators are less prone to false diagnostic conclusions when
using standardisation data which is not demographically applicable.
Table 3.3. describes assessment measures used in the assessment of intellectual
disability in the South African context. Some have local norms but given the variety of
language, educational opportunity and quality, and cultural diversity, most measures have to
be used with caution and corroborated with history. The importance of clinical judgement in
using a variety of sources of information is fundamental to ethical practice in our context.
Table 3.3
Commonly Used Assessment Tools Used in the South African Context
Use Assessment Tool Notes
Screening measures The Goodenough-Harris Drawing Useful quick estimate of ability in
Test or Draw-a-Person younger children
Global development The Griffiths Mental Development South African involvement in
Scales - Extended and Revised development and norms
(GMDS-ER) Birth to 6 years
Griffiths III (newly published -
2016)
The McCarthy Scales of Mental US norms
Abilities 2-8 years
English
Developed in 1972, not revised
General Intelligence Quotient Wechsler Preschool and Primary UK Norms
measures Scale of Intelligence (WPPSI) 4-7 years
English
Junior South African Intelligence Developed in South Africa
Scales (JSAIS) 3-7:11 years
Norms for English and Afrikaans
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Wechsler Intelligence Scale for UK Norms
Children – Revised (WISC-R) 7-16 years
English
Useful for mild intellectual
disability. Using the older version
and norms avoids the Flynn effect
of the later tests and gives a varied
picture of verbal and non-verbal
ability
Wechsler Intelligence Scale for UK Norms
Children - Fourth Edition (WISC 7-16 Years
IV) English
South African within-group norms
for 13-year-olds, stratified for race
and quality of education
Senior South African Intelligence South African Norms
Scales – Revised (SSAIS-R) 7-16 years
English and Afrikaans
Proportional norms for low SES
South African Wechsler Adult Developed in South Africa
Intelligence Scale (SAWAIS) derived from the WAIS
South African norms
Over 16 years
Outdated, published 1969
Wechsler Adult Intelligence Scales South African norms
– Third Edition (WAIS-III) SA Over 16 years
Adapted
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Adapted for English and
Afrikaans
Limited applicability
Wechsler Adult Intelligence Scales UK Norms
– Third Edition (WAIS-III) Over 16 years
South African within-group norms
for 12 years and 15 years of
completed education, stratified for
race and quality of education
The Individual Scale for General Developed in South Africa
Scholastic Aptitude (ISGSA) Norms for 4-16 years
English and Afrikaans
Proportional norms for low SES
Individual Scale for Xhosa, Developed in South Africa
Northern Sotho, Southern Sotho, Norms for 9-19:11 years
Tswana, Zulu speaking Learners Limited clinical usefulness and
(in each language) outdated
Non-verbal tests of intelligence The Ravens Progressive Matrices Local norms have been published
by JvR Psychometrics
Useful for people from
disadvantaged circumstances
Does not require fine motor
coordination as no constructional
arrangement of materials required
Does rely on visual acuity and
processing
Coloured Progressive Matrices Age 6-12 1/2 years
Urban and rural samples
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Standard Progressive Matrices Adults
Advanced Progressive Matrices
The Grover – Counter Scale of Developed in South Africa
Cognitive Development (GCS) Norms for 3-7 years
Intended use is for children who
have expressive and/or receptive
language difficulties
Non-verbal tests from the See above
Wechsler subscales
Neuropsychological assessment Kaufman Assessment Battery for SA Norms
Children, Second Edition (KABC- 3-18 years
II) Designed to minimise verbal
instruction
Uses two models of intelligence,
the CHC or Luria model which
excludes verbal ability
Helpful in identifying a more
detailed profile of cognitive
strengths and weaknesses in the
person with mild disability
NEPSY – Second Edition (NEPSY- Ongoing research to develop SA
II) norms
3-16 years
Helpful in identifying a more
detailed profile of cognitive
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strengths and weaknesses in the
person with mild disability
Adaptive Functioning Vineland Adaptive Behavior US norms
Scales II (2005) 0-90 years
Vineland Adaptive Behavior US Norms
Scales -3 (2016) 0-90 years
Comorbid Psychiatric evaluation Mini Psychiatric Assessment Symptoms may be differently
tools Schedule (Mini PAS ADD) expressed in a person with
intellectual disability
Semi-structured interview with an
informant who is familiar with the
person.
The Diagnostic Criteria for Developed by the Royal College
Psychiatric Disorders for adults of Psychiatrists for use with adults
with Learning Disorders (DC-LD) with mild intellectual disability
Autism Diagnostic Observation A detailed observation schedule
Schedule-Second Edition (ADOS- for the diagnosis across ages,
II) developmental level and language
skill
Adapted from commercial information on tools and information from: Dickman, 2013; Foxcroft & Roodt, 2013;
Mindmusik Media @ mindmuzik.com; Shuttleworth-Edwards et al., 2004; Van Eerden & De Beer, 2013; Van
Zyl & Taylor, 2011.
3.5. Sexual violence
Sexual violence and rape occur in all societies and in all classes of society. The World
Report on Violence and Health define it as follows:
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Any sexual act, attempts to obtain a sexual act, or acts to traffic for sexual purposes,
directed against a person using coercion, harassment or advances made by any person
regardless of their relationship to the victim, in any setting, including but not limited
to home and work. (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002 p. 149)
3.5.1. Overview.
Dartnell and Jewkes (2013) make the following salient points. There is no such thing
as a rape free society, frequency varies from one in twenty to one in two woman have been
raped by an intimate or non-intimate person. The prevalence of rape perpetration is estimated
that between one in twenty and one in three men have perpetrated rape. Men and boys are
also victims and in many settings, prevalence is quite high. (South African studies vary
between 33.4% to 9.6%) Perpetrators include men and women. In child sexual abuse, girls
are more at risk than boys but it is common and affects both boys and girls. The perpetrator is
usually known. Schools are often a site of sexual violence.
3.5.2. Sexual abuse in South Africa.
Prevalence rates of sexual assault in South Africa are high. A conservative estimate of
rape, based on surveys conducted in 1997, reports 134 incidents per 100 000 women in that
year. Of these, 68 per 100 000 had reported the rape incident to the police (Hirschowitz,
Worku, & Orkin, 2000). Jewkes and Abrahams (2002) refer to figures of 240 incidents of
attempted rape and rape per 1 000 000 women but that this represents only “the tip of the
iceberg of sexual coercion” (p. 1231). Hirschowitz et al. (2000) also report that only 47.6% of
rape cases reported to the police were referred to court after investigation. Of those referred
to court, 45.6% were withdrawn and 4.5% settled out of court. Of the 22 121 reported cases
that went to court only a fifth (19.8%) resulted in a conviction of the accused. The reported
rates of sexual violence in South Africa are the highest amongst all of the members of
Interpol. Dartnell and Jewkes (2013) report that 28%-37% of men in South Africa have
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perpetrated rape. Sufficient to say that sexual violence is a very serious and common public
health and societal issue in South Africa. It is not the focus of this research but it is the crime
that makes it necessary. Sarai, Themba and Madelaine had all been victims of the crime.
3.5.3. Sexual abuse in intellectual disability.
There is a growing body of literature describing the extent of sexual abuse of people
with intellectual disability (Dickman, Roux, Manson, Douglas, & Shabalala, 2006). There has
also been an increasing concern about the difficulties of obtaining redress and access to
justice for people with intellectual disability who have had sexual crime committed against
them. The police and justice system do not keep specific records of complainants with
intellectual disability. Sources within the South African Police Service and Department of
Justice estimate that only one or two cases were considered for prosecution annually prior to
1990 in Cape Town (Dickman et al., 2006). One of the key difficulties associated with
obtaining prosecutions for sexual abuse of people with intellectual disability is the
assessment of intellectual disability itself.
3.5.4. Impact of sexual abuse on persons with intellectual disability.
Review of the literature indicates that there is empirical evidence and it is well
documented that adverse or traumatic life events impact the mental health of both those in the
general population and those with intellectual disability (Abrahams & Gevers, 2017;
Hastings, Hatton, Taylor, & Maddison, 2004; Kitzmann, Gaylord, Holt, & Kenny, 2003).
People with intellectual disabilities often do not have the age appropriate verbal
expressive skills, thus distress may be communicated through behavioural changes. Their
response to trauma may be mediated by their developmental level. The effects of trauma
differ in expression in those people with mild disability compared with those with severe
disability (Doyle & Mitchell, 2003; Wigham, Hatton, & Taylor, 2011).
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Wigham et al. (2011) reviewed 15 recent articles on the effects of traumatising life
events on people with intellectual disabilities.
Possible and reported effects include:
• Behavioural problems such as “acting out”, sexualised behaviour, verbal abuse,
self-harm, withdrawal, lethargy, stereotypical behaviour, hyperactivity, overly
compliant, inappropriate speech or unusual statements.
• Emotional problems such as anxiety and fear, depression, Post-Traumatic Stress
Disorder (PTSD), irritability, psychiatric symptoms and diagnoses.
• Physical health changes.
• Changes in skills needed for independent functioning such as decreased self-care
and grooming, decreased personal self-sufficiency and community self-
sufficiency, decreases in social functioning and social engagement.
3.5.5. Access to the justice system.
Pillay and Sargent (2000), in discussing the psycho-legal issues of rape survivors with
intellectual disability, make the point that it is essential that the judiciary is aware of the need
for simple language and questioning in order for people with intellectual disability to be
competent and credible witnesses. An assessment of their day-to-day functioning provides a
qualitative description of the particular vulnerabilities of the person assessed, particularly in
relation to sexual abuse and a quantitative measure of their level of functioning. This
information is helpful in preparing the court for the person coming into the witness box, thus
facilitating access to justice for the person with intellectual disability.
Further, an accurate assessment of the person’s level of disability is significant within
the South African legal system as the legislation differentiates between levels of disability in
terms of ability to give consent and the severity of the sentence, if the accused is found guilty.
The Criminal Law Amendment Act 105 of 1997, Section 51, specifies minimum sentences
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and the Criminal Law (Sexual Offences and related matters) Amendment Act 32 of 2007,
Section 57 (2), defines the relationship between mental disability and the ability to consent to
the sexual act. This amplifies the importance of having assessment tools which are valid and
reliable for this group of clients.
3.6. Cape Mental Health
Cape Mental Health is a registered non-profit organisation based in Cape Town,
South Africa. It is part of the South African Federation for Mental Health. Consumers are
people with intellectual disability, psychiatric disability and emotional adjustment problems.
As an organisation, it is committed to challenging discriminatory practices.
3.6.1. SAVE programme.
In the early 1990s Cape Mental Health Society (CMHS) as it was then, was
approached by the South African Police Services and the Department of Justice to provide a
psycho-legal assessment for complainants with intellectual disability in sexual assault cases.
The Sexual Abuse Victim Empowerment (SAVE) programme was established and its
services are increasingly used.
Services include an initial screening interview, followed by a psycho-legal
assessment. The purpose of the assessment is threefold:
1. to determine the level of intellectual disability;
2. to assess the client’s competence as a witness; and
3. to assess the client’s ability to consent to sexual intercourse.
The findings are written up in a formal report, which is submitted to the police officer
investigating the case. If the case proceeds to court, the psychologist concerned is called upon
to give expert evidence regarding the contents of the report, prior to the person with
intellectual disability coming into the court, thus facilitating this process and assisting the
court in understanding this person’s abilities and limitations. Emotional and practical support,
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together with court preparation are provided for the complainant and their family, by the
social work services of the organisation. (Further detail is provided in the methodology
chapter, section 4.7.1)
3.6.2. Prior research.
Research of the SAVE programme has focused on two areas: programme
effectiveness in relation to court and process outcomes and psychiatric and psychological
consequences to the person with intellectual disability experiencing sexual trauma.
3.6.2.1. Court and process outcomes.
Research was published on the effectiveness of the programme in 2005 (Dickman &
Roux, 2005). Between 1990 and 2000, 94 complainants were assessed. Of these, 92.6% were
female and 7.4% were male. The age range was between six years and 40 years and 40.4%
were under the age of 18. Of the cases in which the matter was finalised (72%), the accused
was found guilty in 28% of the cases, was acquitted in 25% and the matter was withdrawn in
47%. It is important to recognise that, given the high rates of sexual violence nationally and
the lack of reporting to the police, this group represents a small part of a much larger-scale
problem.
A further report (Cape Mental Health, 2008) described the client group between 2000
and 2006. The number of complainants had grown to 354 complainants referred during this
period, however their sample included 303 assessments of people with intellectual disability.
Of these, 92.3% were female, a similar finding to Dickman and Roux (2005). In this sample
43% were under the age of 16. Of the total sample, 69% were found to be able to testify with
support (n=210). Of this number 45.7% were in the range of mild intellectual disability,
42.4% in the range of moderate intellectual disability and 11.9% in the range of severe
intellectual disability. Other studies also have a proportionate over-representation of more
severe levels of disability (Brown, Stein, & Turk, 2010; Mansell, Sobsey, & Calder, 1992).
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Of the cases in which the matter was finalised (79.9%, an increase of 7.9% from the previous
study), 28.1% of the accused were found guilty (28% in previous study), 18.2% were
acquitted (25% in previous study) and 53.7% were withdrawn (47% in previous study).
3.6.2.2. Psychiatric and psychological consequences.
In 2009, two unpublished studies were conducted. The first (Jasson, 2009) conducted
an explorative study regarding the prevalence of PTSD in this group, comparing self-reported
symptoms with caregiver reported symptoms. The sample included 27 participants with a
history of rape or sexual assault and a control group of 27 with no reported sexual trauma.
Tentative evidence of a greater association of rape or sexual assault and PTSD diagnosis was
found with eight people (29.6%) of the 27 meeting DSM-IV-TR criteria, compared to one
person (3.7%) in the control group. There were also significantly more symptoms of PTSD
reported in the participants with a history of sexual trauma, although not meeting the full
criteria for diagnosis. There was no overall significant difference in reporting symptoms
between the caregiver and the self-report. However, the symptoms of re-experiencing and
arousal were significantly different when given by self-report. This endorses the importance
of listening to the person with intellectual disability’s own account when assessing the
emotional impact of sexual trauma.
The second (Kwendakwema, 2009) compared behavioural challenges in people with
intellectual disability who had a history of sexual trauma and those with no history of sexual
trauma. Caregivers of 54 people living with intellectual disability were interviewed using the
Aberrant Behaviour Checklist – Community. In 27 cases there was a history of sexual trauma
and 27 cases formed the control group with no reported history. The key finding was that
those with a history of sexual trauma exhibited a greater number and severity of challenging
behaviours, especially on the irritability, lethargy and hyperactivity subscales. Challenging
behaviours may well be an expression of trauma in people with intellectual disability.
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In 2010, two further exploratory and unpublished studies were conducted with this
group. The first (Linden, 2010) used the PASS-ADD checklist to interview a sample of
caregivers of people with intellectual disability with (n=27) and without (n=27) a known
history of sexual trauma. The total sample had a fairly high prevalence of psychiatric
symptoms. The group who had experienced sexual trauma had significantly higher scores in
the affective/ neurotic subscale and organic conditions subscales with a higher scores but not
statistically significant on the psychotic subscale.
The second (Mackenzie, 2010) used a retrospective archival study of 295 psycho-
legal reports from 2005-2009 with a focus on reported symptoms of trauma. Symptoms of
PTSD and depression were the most common psychopathology reported with behaviour
problems such as aggression, oppositional and sexualised behaviour less frequently reported
than in the literature. Symptoms of increased arousal were more prevalent than symptoms of
re-experiencing and avoidance in the PTSD criteria cluster. The difficulty with eliciting
information from people with severe intellectual disability was highlighted with differing
number of symptoms reported between different intellectual disability levels. There was also
mention made of “loss of skills” amongst 13 of the participants in relation to adaptive
functioning but this was less than reported in the literature. It must be noted that the focus of
the psycho-legal report is not on trauma; this is often submitted, if requested, in a separate
report with regard to the severity of sentencing. It is usually only documented in the initial
report if psychological or psychiatric symptoms will compromise the ability to give evidence
and testify or to consent.
The focus of this research is the usefulness and validity of the psychometric tools
used in the assessment process, and in particular the assessment of adaptive functioning
using the Vineland Adaptive Behavior Scales in order to work toward ethical and sound
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practice for the clients served. There are many other areas needing further research and
investigation in relation to this process, some of which will have been highlighted through the
process of the literature review. The two chapters have examined the concepts, measurement
process and the contextual issues within which the research process is embedded. It has given
a conceptual and environmental context to the assessment of Themba, Sarai and Madelaine
The next chapter will examine the methodology used during the research.
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Chapter Four: Methodology
4.1. Introduction
Having introduced the motivation and reason for the research and discussed the
psychological concepts and related current thinking and given a broader contextual overview
in the previous chapters, this chapter describes the methodology of the research process.
• In section 4.2. I review of the context for the research process.
• The aims of the research and the research questions are described in detail in
section 4.3.
• I describe the methodology of the literature review in section 4.4.
• I present the research design and the measurement instruments used in section
4.5. together with details of the qualifications of the professionals involved in the
measurement and data capture process, and I explain my decision to use the
psychologists’ reported assessments as a ‘gold standard’ measure in the research.
Issues relating to the translation processes are addressed.
• Section 4.6 describes the research sample, inclusive of clients seen between 2005
and 2013, as well as those excluded from this group and the exclusion criteria
used.
• In Section 4.7. I describe the assessment procedures used, including the
assessment process, description of the systemisation of information in the form of
a detailed interview schedule, and the further development of the existing
database.
• Section 4.8 includes data collection and data entry, and data checking is detailed.
• I describe the methodology of the descriptive and statistical analysis in section
4.9.
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• I conclude the chapter with ethical considerations and permissions given in
section 4.10.
4.2. Context of the research
The research context is within a non-governmental mental health organisation, Cape
Mental Health (CMH), based in Cape Town, South Africa. The organisation provides
services to people with mental illness and intellectual disability. A detailed description of the
organisation and the Sexual Abuse Victim Empowerment (SAVE) programme has been
given in the previous chapter and of the broader contextual issues related to sexual abuse of
people with intellectual disability in the South African context. (Refer to sections 3.5.3. and
3.6.1.)
Initial work, in this specialised area of psycho-legal assessment, was begun in 1990 in
response to social workers within Cape Mental Health (CMH) reporting incidents of sexual
assault and rape involving their clients with intellectual disability. Although in some cases
these had been reported to the police, they did not proceed to court. On investigation it was
evident that the courts were ill equipped to manage cases where the complainant was
intellectually disabled and thus the cases were not necessarily brought to court. The courts
often assumed that the person with intellectual disability could not be a reliable witness and
access to justice was denied to this vulnerable group. Dr. Beverley Dickman was the clinical
psychologist employed by the organisation at the time. In collaboration with Amanda Roux,
the social work manager at CMH, and with the prosecutors at Wynberg Sexual Offences
Court, one of the regional courts in the Cape Town metropole, they developed an assessment
process, a protocol for a psychological report and expert witness services to the courts in the
Cape Town Metropole. This was refined over time as the project grew and developed with
experience of the psychologists who joined the team. Their initial work was published in the
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British Journal of Learning Disabilities (Dickman & Roux, 2005) and is detailed in the
literature review.
4.3. Aim of the research and research questions
The motivation for the research study developed from the clinical observations of the
psychologists involved in this psycho-legal assessment process of intellectually disabled
people.
The VABS and latterly the VABS II were used as part of an assessment process to
evaluate the range of intellectual disability of these clients. An accurate assessment is
necessary within the South African legal system, amongst other reasons, as the greater the
disability, the more severe the sentence. Further, psychologists working at CMH reported that
the qualitative information gained through the administration of the scales provides useful
description of the adaptive functioning of the person assessed. They find this information
helpful in preparing the court for the person coming into the witness box, thus facilitating
access to justice for the person with intellectual disability.
Through clinical use, the psychologists (of whom I am one) gained the impression
that, in some areas of the scales, our client population tended to underscore. We identified a
need to explore the use of the tool, as part of our overall concerns about possible problems
with validity within this particular context of use. The results would be used in this
programme but also contribute to appropriate use of the VABS in the South African context
and identify further areas of needed research. The motivation was to be able to use the tool
appropriately, bearing in mind the needs and situation of this client group.
The study is exploratory in nature and, although there is a need for South African
norms for psychological assessment tools, this is not a norming study or a validity study due
to the very particular nature of the client group and also due to the lack of other well-
validated instruments assessing adaptive behaviour.
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The overall aim of the research was, in this context, to critically evaluate the Vineland
Adaptive Behavior Scales – both the VABS (1984) and VABS II (2005) and the newly
published VABS 3 (2016) for a group of persons living with intellectual disability in the
Western Cape using the following research questions as a framework of inquiry. When the
research was first conceptualised the VABS 3 had not yet been published. With the
publication in 2016, it has been included in the research enquiry and the research questions
were adjusted to use the information from the manual and test items. The research aims and
resultant questions are tabulated in Table 4.1. below.
Table 4.1.
Research Aims and Questions
Research Aim Research question
1. To evaluate the published norms of the VABS and 1. Do the published US norms of the VABS and
VABS II in terms of their use in this particular South VABS II discriminate accurately between different
African context and their usefulness in levels of intellectual disability within this particular
discriminating different level of intellectual South African context?
disability, using the Intelligence Quotient (IQ) 1.1. What association is there between the
derived from the Individual Scale of General measured Intelligence Quotient (IQ) score
Scholastic Aptitude (ISGSA), the documented using the Individual Scale of General
diagnosis of the evaluating clinical psychologist and Scholastic Aptitude (ISGSA) and the
the standard score of composite adaptive functioning standard score measurements of adaptive
of the VABS and VABS II. functioning of the VABS and VABS II?
1.2. How does the reported diagnosis and
assessment of the evaluating clinical
psychologist compare with the level of
standard score measured by the VABS and
VABS II?
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Research Aim Research question
2. To explore the relationship between language, 2. Is there a significant association between variables
gender, age, socioeconomic status, geographic of language, gender, age, socioeconomic status,
distribution, access to education and trauma with the geographic distribution, access to education and
standard score of composite adaptive functioning of trauma with measurements obtained in the VABS
the VABS and VABS II. and VABS II?
3. To critically evaluate the floor effect evidenced in 3.1. Is the VABS II able to discriminate between
the norms tables for adults and examine the levels of intellectual disability for the adults of the
sensitivity and specificity of the VABS II for a sample?
sample of intellectually disabled adults and compare 3.2. Do the norm tables for adults, in the newly
with the norm tables for adults of the newly published VABS 3, give evidence of addressing the
published VABS 3. floor effect?
4. To determine what information is used in the 4. What qualitative information is used and reported
psycho-legal report, which was captured through the in the psycho-legal report from the items in the
use of the VABS II. VABS II?
5. To examine and compare the VABS II (2005) 5. How does the VABS II compare with the VABS 3,
with the new edition VABS 3, published in 2016, using changes in sequence, deleted items, added
using the change in item additions and modifications items and modified items between the two versions?
through the two editions.
6. To examine and identify those items in the VABS 6. Which items in the VABS II need contextual or
II which may need contextual and or linguistic linguistic adaptation for this group of clients and to
adaptation for this group of clients and to assess to what extent has this issue been addressed in the
what extent these have been addressed or adapted in VABS 3?
the latest edition, the VABS 3.
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4.4. Methodology of the literature review
The literature review was an ongoing process throughout the time of the research. It
began with submission of the research proposal and has continued. Key words have included
adaptive behaviour, adaptive functioning, Vineland Adaptive Behavior Scales (with the three
versions used in the research), intellectual disability, mental retardation, intellectual
developmental disorder, assessment, sexual trauma, sexual abuse, South Africa, Africa,
ability to give evidence and ability to testify. These were used individually or in combination
to refine the search. Certain information was searched for particularly, i.e., South African
statistics regarding disability.
The following databases were used: Google Scholar, Pub Med, Psych Info via
EBSCO, Africa Wide, Scopus, and Web of Science. Publications which were not readily
available on line were accessed with the assistance of the university librarians.
Recommendations for areas of reading were made during supervision.
Extra literature was accessed through recommendations from others involved in the
field and university research databases for unpublished theses. Literature which other authors
have cited was a useful source of information. Authors and researchers writing in the field
were also followed for recent publications. Searches were repeated in the last months before
completion and hand-in.
4.5. Research design
A mixed method approach was used as the data included both quantitative and
qualitative information. The study was retrospective in part, as the initial data on the VABS
and the clients from this period had already been documented before the research was
formally approved. Data were collected from the client folder, the protocols of the two
measuring instruments used and the psycho-legal report. The further development of an
existing interview schedule was part of the research process, as was the further development
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of a database for purposes of the study. Thus for the latter period of data collection, with use
of the VABS II, the additional documented information on the extended interview schedule
was also included as a source of data. The primary source of information, therefore, was
through record review.
Group discussions involving the five psychologists were part of the development of
the interview schedule and in the later discussion regarding items that appeared useful or
difficult. This is discussed more fully later in the chapter in section 4.8.1. and 4.8.7. The
items of the survey interview form of the VABS II were compared with the items of the
comprehensive interview form of the VABS 3 through clinical item analysis. Changes were
documented and categorised. Results were documented in excel spreadsheets for further
analysis. Further detail is provided in the results chapter.
4.5.1. Measurement instruments.
4.5.1.1. Vineland Adaptive Behavior Scales (1984).
The Vineland Adaptive Behavior Scales (VABS) is an assessment tool used in the
initial period of the data collection. It is administered through a semi-structured interview
with a parent or caregiver, in order to determine the level of adaptive functioning of an
individual. Adaptive behaviour is defined within the test manual as “the performance of the
daily activities required for personal and social sufficiency” (Sparrow et al., 1984, p. 6).
The norms are based on a nationally representative sample of 3 000 persons, drawn
from all over the USA, with about 100 disabled and non-disabled individuals in each of 30
age ranges from birth to 18 years 11 months. Supplementary norms included a sample of
intellectually disabled adults over 18 years; 1 050 participants lived in residential facilities
and 100 participants lived in non-residential facilities. Supplementary norms were also
developed for what the authors termed emotionally disturbed, visually and hearing impaired
children. Three types of reliability estimates were used. Using split-half reliability
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coefficients, internal consistency reliability was measured. The median of 15 age groups for
Communication was .89, for Daily living Skills was .90, Socialisation was .86 and the
Adaptive behaviour composite .86. This was repeated for the supplementary norm groups and
the results were all in the .90’s. Test-retest reliability coefficients for the domains and the
composite score were all in the .80’s and .90’s. Inter-rater reliability coefficients were lower
with .62 for Socialisation, .72 for Daily living skills, .75 for Communication, and .74 for the
composite score. Construct validity included developmental progression of scores, factor
analysis of the domains and subdomains and profiling of scores for the seven supplementary
norm groups. Content validity included the development process with careful review of other
adaptive behaviour scales and literature regarding childhood development. From an initial
pool of 3 000 items in developmental clusters, field testing, national try-out and
standardisation determined the items included in the tool.
Criterion-related validity was measured against the Vineland Social Maturity Scale
(Doll, 1935, 1965). A modest correlation of .55 was understood to be due to the extensive
revision of the test. The correlation with the Adaptive Behavior Inventory for Children
(ABIC) (Mercer & Lewis, 1978 cited in Sparrow et al., 1984) was .58 with composite score
of the VABS and the average scale score of the ABIC. The correlation with the American
Association for Mental Disability Adaptive Behavior Scale (Nihira et al. 1974 cited in
Sparrow et al., 1984) ranged between .40 to .70. Correlation with intelligence tests is detailed
in the discussion chapter (section 7.2.). Detail is given in the VABS manual (Sparrow, Balla,
& Cicchetti, 1984, p. 19-54). This first edition (VABS, 1984) is still used in the South
African context (personal communication with clinical users).
4.5.1.2. Vineland Adaptive Behavior Scales - Second Edition (2005).
In the second edition (VABS II), norm samples included 20 age groups from birth to
90 years. Stratified random sampling from a pool of 25 000 selected 3 695 cases, which
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matched the demographic variables within each age group. The sample was balanced by
gender, representative by race, community size, geographic region and socioeconomic status
(derived from the mother’s educational level) from the 2001 population statistics in the USA
(Sparrow et al., 2005, p. 97). Eleven clinical groups were defined and data collected to
validate the test in identifying adaptive behaviour deficits in: “attention-deficit/hyperactivity
disorder, autism–nonverbal, autism–verbal, emotional or behavioural disturbance,
deafness/hard of hearing, specific learning disability, mental retardation–mild (child and
adult samples), mental retardation–moderate (child and adult samples) mental retardation–
severe/profound (adult sample)” (Sparrow et al., 2005, p. 138). Test score reliability, that
scores can be depended on and reproduced, were examined by means of internal-consistency
reliability which was in the good to excellent range (upper .80 to low .90’s). Lower reliability
for adults was as a result of the ceiling in the subdomains as most people in the norm sample
obtain the maximum subdomain raw score with average values in the .70’s. Test-retest
reliability ranged from .76 to above .90 in the good to excellent range of clinical significance.
Inter-interviewer reliability range was lower at the low to mid .70’s and inter-rater reliability
ranged in the low .80’s.
Validity of the tool was assessed by examination of test content, with linkage to
theoretical constructs, examination of the progression of raw scores for 20 age groups from
birth to 90 years for each subdomain and using item response theory to confirm that an item
belonged in their allocated subdomain and domain and agreed with the developmental
sequence with is expected theoretically. The examination of response process included
measurement of bias at item and scale levels using differences of ethnicity, socioeconomic
status and gender. Correlation between subdomains, domains and composite scores were used
to assess test structure and confirmatory factor analysis was used to indicate the fit between
the theoretical model and the actual data. Specific clinical groups were used to demonstrate
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the relationship between test scores and group membership or performance and the
relationship between the VABS II scores and those of other measures. This is elaborated
more fully in the literature review chapter (section 2.5.1.3.) and the discussion chapter
(section 7.2.). Detail is given in the VABS II manual (Sparrow et al., 2005, p. 109-165).
The scale covers three domains which are further subdivided into three subdomains.
The total number of items is 307. The number of items in each subdomain is given in
brackets:
1. COMMUNICATION: This includes receptive (20), expressive (54) and written
subdomains. (25)
2. DAILY LIVING SKILLS: This includes personal (41), domestic (24) and community (44)
subdomains.
3. SOCIALISATION: This includes interpersonal relationships (38), play and leisure time
(31) and coping skills (30) subdomains.
Two further optional domains include motor skills, for children up to seven years of
age, and a maladaptive behaviour index. These are not included in this research study. There
are five possible scoring options in response to the questions: No (0); Sometimes (1); Usually
(2); Don’t know, if the respondent has no knowledge of the performance of the given
behaviour (DK); or No Opportunity (N/O). Each sub domain is scored with four consecutive
items at a 2 level for the basal and four consecutive items at a 0 level for the ceiling.
Scores are summed and using age normed tables, adaptive functioning standard scores
are given in each domain and an overall adaptive behaviour composite standard score is
calculated. It takes approximately 60-90 minutes to administer. This research was based on
the survey form. A copy of the form is included in Appendix C for reference (Sparrow et al.,
2005).
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4.5.1.3. Vineland Adaptive Behavior Scales - Third Edition (2016).
The definition of adaptive behaviour in this edition remains as referenced to Sparrow
et al. in 1984. There are four principles which the authors of the VABS 3 refer to as inherent
to the concept of adaptive behaviour.
1. It is age related.
2. Social context is necessary for evaluation and competence is in reference to the
expectations and standards of others.
3. It is modifiable with intervention, change in environment, trauma.
4. It is defined by typical performance not ability.
The norm sample included 2 560 people ranging from birth to 80+ and was matched
against the United States community census data of 2014 for sex, education level, race and
geographic region. Further, the statistics on special education services were used as a source
of prevalence of various disabilities such as intellectual disability, developmental delay,
autism, emotional disturbance, specific learning disability and speech and language
impairment informing inclusion in clinical groups which were evaluated with the interview
form. Table 4.2. documents the sample size and age groupings of the different clinical
groups.
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Table 4.2.
Sample Size and Age Groupings of Clinical Sample of VABS 3
Special study groups Sample size Age range
Developmental delay 64 2-9 years
Intellectual Disability: Age 3-18, 53 4-18 years
IQ 50-70 (Mild disability)
Intellectual Disability: Age 3-18 , 38 3-18 years
IQ 35-49 (Moderate disability)
Intellectual Disability: Age 3-18 , 19 6-17 years
IQ < 35 (Severe disability)
Intellectual Disability: Age 19+ , 29 19-70 years
IQ 50-70 (Mild disability)
IQ 35-49 (Moderate disability)
IQ < 35 (Severe disability)
Autism: Age 3-8 years, IQ £ 70 40 3-8 years
Autism: Age 3-8 years, IQ > 70 36 3-8 years
Autism: Age 9-20 years, IQ £ 70 52 9-19 years
Autism: Age 9-20 years, IQ > 70 46 9-18 years
Hearing impaired 78 5-18 years
Visually impaired 32 7-18 years
(Sparrow et al., 2016, p. 156)
The structure of the third edition, comprehensive interview form, retains the three
domain and nine subdomain format. The three scoring options remain of No (0), Sometimes
(1) or Usually (3) remain. The “Don’t know” and “No opportunity” options have been
replaced by an estimated check box (i.e., best guess). The percentage of estimated items for
each subdomain is calculated. According to the manual guidelines, if the estimated
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percentage is less than 15% the validity of the subdomain is probably not compromised, if
between 15% and 25%, interpret the scores with caution and if over 25%, the summative
score is invalid. If two or more sections have over 25% estimated scores, then the informant
is considered unreliable. Basal and ceiling rules remain unchanged. The number of items has
increased so timing of administration is not known. The manual suggests between 20-40
minutes (Sparrow et al., 2016). This tool has not been used within the research context but is
included for means of comparison and to evaluate to what extent concerns about the VABS II
have been addressed in this new edition. (A copy of the form is included in Appendix D for
reference.)
Test score reliability, that scores can be depended on and reproduced, were examined
by means of internal-consistency reliability which was in the excellent range (upper to low
.90’s). In terms of standard errors of measurement, coefficients were generally high except
for the earliest age groups (under a year). Test-retest reliability ranged from .77 to above .90
in the good to excellent range of clinical significance. Inter-interviewer reliability were in the
good to excellent range. Inter-rater reliability is not reported in the manual for the Interview
form.
Validity of the VABS 3 is based on test content and structure, performance of special
study groups and relations to other measures. A wide variety of users and experts, involved in
teaching, research and practice are reported to have been involved in the revision of item
content to ensure relevance and current understanding of adaptive functioning. An analysis of
developmental trend over age range using mean subdomain raw scores of the normative
sample. For all subdomains the means scores rise rapidly in the early years and then rise more
slowly to plateau which declines again at age 70 and older. The special study groups included
developmental delay, intellectual disability, autism spectrum disorder, hearing impairment
and visual impairment (refer to Table 4.2.). The interview form was also correlated with its
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counterpart in the VABS II version. The sample only included ages 0-20 years. Correlations
ranged from moderate to high (.60-.87) with the exception of the communication domain in
the 12-20 years age group which had a correlation of .40. The manual did not address this
difference. The trend was higher overall same scale score on the VABS II than the VABS 3.
They indicate that further research is needed to examine if adaptive functioning has indeed
improved since the early 2000’s when the VABS II was normed (Sparrow et al., 2016).
4.5.1.4. Individual Scale for General Scholastic Aptitude - 1996 (ISGSA).
The ISGSA is a scholastic aptitude test developed in South Africa. It is an adaptation
of the Individual Scale of the National Bureau for Educational and Social Research (also
known as the Old South African Individual Scale). It is based on Binet’s model of
intelligence, understood as being the sum total of the thought processes used in mental
adaptation, with different facets closely interwoven (Terman 1919, cited in Robinson, 1994).
Thus the test structure has a wide variety of 80 heterogeneous items divided into twenty
blocks of four items each. A basal is established when all items in two consecutive blocks are
passed. The ceiling is reached when all items in two consecutive blocks are failed. All items
between the two are administered. Some items are administered in series. Items can be
classified and described according to type. Many of the items are composite consisting of a
number of sub items. Items below the basal are credited. Series items are scored as correct or
wrong, even if beyond the basal or ceiling. The raw score is converted to a normalised
standard score with a mean of 100 and a standard deviation of 15. A test age can also be
determined for the raw score (refer to the literature review for discussion of this concept,
section 2.3.5.3.). The test has been developed in two of the three predominant languages used
in the Western Cape, English and Afrikaans.
Given that the test development was begun in 1990 before South Africa became a
democracy, samples were drawn from 100 primary schools and 50 high schools from three
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provinces of South Africa in the education department of the House of Assembly (for White
students). A further sample pupils from 100 primary schools and 50 high schools was drawn
from four provinces of South Africa in the education department of the House of
Representatives (for Coloured students). They used a systematic sampling method per age
group and included pupils in special or adjustment classes and auxiliary or remedial classes.
The manual states that “three hundred pupils of each year group had to be tested, 200 at each
school for sample 1, but only 100 at each school of sample 2 since the education department
whose schools were drawn for sample 2 did not have enough school psychologists”
(Robinson, 1994, p. 25). A socioeconomic deprivation questionnaire was used to identify
pupils from disadvantaged circumstances. Norms were developed for the disadvantaged
group (referred to as proportional norms - 95% of the research sample) and the non-
environmentally disadvantaged group (5% of the research sample). Only 6.6% of the English
speakers were environmentally deprived. A summary of the norming sample is provided in
Table 4.3. Ratios were not proportionate to population ratios and weighting during data
processing had to be done.
Table 4.3.
Sample for Norming of the ISGSA
Age 5-16 years Gender Language Geographic
Proportional sample Boys n=1543 English n=877 Urban n=1862
(n=3099) Girls n=1556 Afrikaans n=2222 Rural n=1237
Non-environmentally Boys n=1139 English n=819 Urban n=1515
disadvantaged group Girls n=1153 Afrikaans n=1473 Rural n=777
(n=2292)
(Robinson, 1994, p. 37-38)
Reliability of the instrument was measured in terms of internal consistency, with
reliability coefficients ranging between .81 and .91 for the proportional group and .77 and .88
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for the non-environmentally disadvantaged group. Test-retest reliability was measured using
to groups of 7, 9 and 11 year olds, with an average coefficient range of .84. Validity was
examined by use of evaluating content validity, by a committee of researchers and practising
psychologists. The items were accepted as relevant but the lack of performance items in the
scale led the group to the term general scholastic aptitude rather than general intelligence.
Construct validity was evaluated by means of factor analysis and the ranking order of the
items. The correlation between age in months and the total score was .83. The items were
logically grouped into seven groups and seven composite variables were evaluated against
the total score. Coefficients ranged from .62 to .89 with relatively high percentages of
variance of 55% to 64% explained. Correlations with other intelligence tests included other
South African normed and developed tests, the Junior South African Individual Scale
(JSAIS) with correlations of .52 to .68 and the Senior South African Individual Scale –
Revised, with correlations of .62 to .75. In terms of criterion-related validity, teacher ratings,
the use of one minute reading and arithmetic tests, scores of pupils with a history of learning
disability and those learners in adaptation classes, school marks and scholastic achievement
tests were used to examine concurrent validity.
The authors emphasise that the measure should be used as part of an assessment
process and that scores should not be interpreted in isolation and the test only gives a global
index. For a more comprehensive and detailed assessment of cognitive profile, a cognitive
scale which provides a differential profile should be used (Robinson, 1994).
A significant limitation is that the test was not developed in isiXhosa or normed on
isiXhosa speakers, the third predominant language spoken in the Western Cape. There is an
isiXhosa intelligence scale, the Individual Scale for Xhosa-Speaking Learners, which was
developed by Landman (1989), but has been found to be out-dated, clinically unhelpful and
inaccurate (personal communication with clinical users). In this study, the ISGSA was
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administered to isiXhosa speakers either by the psychologist, herself, translating or with the
assistance of a translator. The results are used with caution as language, exposure to
education and the quality of the education are all unmeasured variables.
4.5.2. Skill and experience of the clinical psychologists.
During the period under review in this research (2005-2013), five clinical
psychologists were employed by the organisation on Wednesday each week to provide
services to SAVE. I was one of these five. All the psychologists involved were registered
clinical psychologists, had extensive experience in assessing and working with people with
intellectual disability, and had all worked for the project for a number of years. All had
extensive experience of the role of expert witness in this field and had a working knowledge
of court requirements and the needs of the traumatised clients. Table 4.4 summarises their
experience.
Table 4.4.
Experience and Language Skills of Psychologists Involved in the SAVE Programme
Psychologist Years of registration as Years of experience in Languages spoken
a clinical psychologist Psycho-legal
assessment in SAVE
programme
Psychologist 1 8 8 English and Afrikaans
Psychologist 4 18 13 English and IsiXhosa
4.5.3. Gold standard.
An important component of the methodology is the use of the psychologists’ reported
concluding assessment of adaptive functioning in the psycho-legal report as a form of gold
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standard against which other measures are evaluated. Harrison and Boney (2002), in their
chapter regarding best practices in the assessment of adaptive behaviour, make the following
points:
• Norm referenced adaptive behaviour scales are useful but have limitations (refer
to literature review, section 2.3.5.2.).
• Given these limitations, they should form a part of a whole assessment inclusive
of informal interviews, observations, other socio metric techniques, collateral
from different settings, family, school, work and community environments.
• They suggest that this data should be integrated with a balanced consideration of
intellectual assessment results and that everyday competence and conceptual
intelligence should be included in diagnostic and intervention planning.
They argue strongly against relying on a single source of information in the form of
norm-referenced rating scales. In the psycho-legal assessment of these clients, in their
concluding assessment of adaptive behaviour, the psychologists have used a norm referenced
rating scale in the form of the VABS or VABS II, but have also taken a thorough history,
evaluated the client’s ability to give evidence, their ability to consent to sexual intercourse,
heard the client give a narrative account of their experience and spent 4-6 hours in
consultation with the client and their caregiver. All of this informs their assessment. The
details of each of these contributions to the concluding assessment will be discussed further
in this chapter in section 4.7.
4.5.4. Language of assessments.
Whenever possible, a psychologist who could speak the home language of the client
conducted the assessment. In 86% of the cases, this was achieved, and in the remaining 14%
an interpreter was used. This only applied to the group of isiXhosa speakers. The interpreters
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were either isiXhosa speaking social workers or one of the administrative staff who had had
training as an interpreter.
The International Test Commission (2016), with reference to the use of tests in a
cross cultural context, provide the following guidelines with regard to scale scores and
interpretation: “Consider a number of possible interpretations of results…rule out differential
motivation…context effects…may simply be part of a less effective education system” (p.
27). Given the complexities and varying levels of quality of education in post-apartheid
South Africa, the lack of reliable, appropriately normed tools, the translation of responses
further added to the challenge of the assessment of intellectual disability in this context.
These were some of the clinical realities, which reflect contemporary realities of clinical
psychology practice in South Africa.
4.6. The sample
4.6.1. Description of the participants.
The population included complainants referred to CMHS between the beginning of
2005 until the end of 2013 for assessment by the SAVE programme. Charges had been laid
on behalf of these complainants with regard to sexual abuse, and an alleged perpetrator had
been identified. There were 790 cases seen during this period.
4.6.2. Exclusion criteria.
Initial exclusion criteria were related to incomplete records or inability to complete
the assessment. The database had an exclusion tab so that excluded clients would not appear
on the Excel spreadsheet which extracted the relevant data. These criteria included:
• The interview of the VABS was by self-report rather than with a caregiver/family
member.
• Copies of the court report, the ISGSA or VABS original test sheet were missing
from the file.
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• Profound intellectual disability prevented completion of the ISGSA.
• Assessment was incomplete due to withdrawal of the case or refusal by the client
to participate in the ISGSA.
Further, an Excel spreadsheet list was drawn up of all cases seen in each year 2005-
2013 from the physical file and referral records. This detail included name, gender, age, date
of birth, language, name of the assessing psychologist, date of assessment, number of
incidents/cases, whether the VABS or VABS II was used in the assessment and relevant
notes. Notes were made from the file records of possible exclusion criteria. A list of
exclusion criteria was compiled and taken to supervision for discussion and agreement.
Table 4.5. lists the 19 exclusion criteria and the numbers of cases in each year which were
excluded and the overall percentage of cases excluded in each year. A detailed discussion of
the reasons for the exclusion criteria is detailed in Appendix E.
Table 4.5.
Reasons for Exclusion
2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
1. No VABS protocol 1 2 1 4
on record
2. No physical file for 1 1 1 1 4
the client could be
found in the records
3. No psychological 1 2 3
report in the file or
electronic copy
available
4. The legal case was 1 1 1 3
withdrawn, alleged
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2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
perpetrator not
identified
5. The client or family 1 2 2 7 3 1 1 2 19
did not want to take
the matter further
6. The legal case was 1 1
finalised before
completion of the
assessment
7. Self-report, 4 1 2 4 3 5 1 1 3 24
unaccompanied or
unreliable informant
for VABS assessment
8. Head injury 1 3 1 2 1 8
accounted for
diminished intellectual
and adaptive ability
9. Other neurological 1 1 2
condition accounted
for decreased
cognitive functioning
10. Epileptic episode 1 1
at time of assessment
11. Active comorbid 2 2 2 2 4 2 4 0 0 18
psychiatric diagnosis
at time of assessment
12. Primary physical 1 1
disability is not ID
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2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
13. Date of birth 1 1 1 3
unknown
14. Profoundly/ 2 1 2 2 1 1 1 2 1 13
verbally disabled,
unable to participate in
assessment
15. Low 2 3 2 2 2 11
average/average
cognitive functioning
16. Client assessed by 1 1 1 3
other health services
17. Data previously 4 2 1 4 5 16
entered for another
case
18. Co-existing 1 2 3
physical disability
necessitated the use of
alternative tools
19. Grover, Griffiths, 1 1 2 1 1 3 2 5
SAWAIS, SSAIS-R,
WISC used for IQ
assessment
TOTAL excluded 19 18 16 20 16 16 14 14 15 148
% of cases assessed 31.2% 22.5% 22.5% 26% 18.6% 17.3% 14.7% 12.4% 14.6% 18.7%
and excluded
Total included 42 62 55 57 70 88 81 99 88 642
Total cases assessed 61 80 71 77 86 104 95 113 103 790
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The total number of cases assessed during 2005-2010 using the Vineland Adaptive
Behavior Scales (1985) was 419. There were 98 cases excluded from the sample used in the
analysis (23.4%). The total number of cases assessed during 2009-2013 using the Vineland
Adaptive Behavior Scales II (2005) was 371. There were 50 cases excluded from the sample
used in the analysis (13.5%). The total number of cases assessed during the period 2005-2013
was 790 and 148 were excluded (18.7%).
The database had an exclusion tab which was used at the time of data entry when a
case was due to be excluded and, although the case remained in the database, it was excluded
from the data to be analysed. As a cross check, each year’s list was examined for exclusions.
Those cases which were questionable or not enough information was known were tagged and
highlighted in green. Reference was made back to case files to clarify and decisions made as
to whether these cases met the exclusion criteria and should be included or excluded.
The excluded cases were highlighted in red within the data lists and reasons
documented and numbered and grouped with relevant exclusion criteria. These cases were
cross checked as having been deleted in the data sheets for VABS and VABS II and the
detailed data sheets of VABS II in preparation for analysis.
Duplicate entries were also identified and deleted. This occurred in cases where there
had been more than one incidence of abuse between 2005 and 2013 so that the same
assessment datum was not used more than once. There were several cases where the VABS
had been used in an earlier year and the VABS II used in a later assessment. These were
highlighted in blue for easy identification and comparison. These were included in the
sample.
Following exclusion, the sample size was 642. Of these, 321 had been assessed using
the VABS and 321 with the VABS II. Female complainants made up 87% of the sample with
13% male complainants. Ages varied between four years and 64 years with a mean age of 22
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years. The clients referred are generally from socioeconomically disadvantaged
circumstances. The assessing clinical psychologist evaluated this on the basis of a
description of housing and living conditions, access to specialised services, level of income,
level of maternal/caregiver education, and dependency on welfare grants. This is not a
representative sample of people with intellectual disability in South Africa, but is particular
to this psycho-legal assessment context which offers services to indigent people. Detailed
description of sample characteristics are given in the following chapter. (section 5.2.)
4.7. Procedures used by the CMH SAVE programme to assess the clients
4.7.1. Assessment process.
This is reported in some detail as it serves to explicate and argue for the importance of
using a variety of sources of information to inform the overall assessment of disability by the
psychologist and inform the conclusions drawn. This is used as a baseline or gold standard in
the research analysis.
4.7.1.1. Initial referral process.
Prosecutor and police training over a number of years and on a sustained basis, has
enabled police officers and prosecutors to identify complainants with intellectual disability,
where the charge was sexual assault, rape or rape with assault and to refer them to the SAVE
programme.
Generally, the investigating officer or the prosecutor would make telephonic contact
with the programme manager of SAVE. Telephonic screening would determine if this was an
appropriate referral or if other services were needed. Client contact details were recorded on a
standardised form including details such as name, age, date of birth of the complainant,
caregiver contact details and the relationship with the complainant, physical residential
address, the police case number, the nature of the charge and the name of the alleged
perpetrator. Psychological assessment appointments were allocated and the police and
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caregiver notified of the date, time and physical locality of the CMH offices. Initial datum
was entered into the database.
4.7.1.2. Social work intervention.
All cases were registered as active cases in the broader organisation of CMH. The
family and client were seen for an intake interview to gather information and offer necessary
social work services. This process also functioned as a further screening process so that
trauma debriefing, the identification of posttraumatic stress disorder or other comorbid
psychiatric disorders as well as ensuring the present safety of the client could be evaluated.
Appropriate counselling or referral could be offered. The need and application for social
service grants such as the disability grant or special care grant could also be set in motion.
The case was then assigned to a social worker case manager. Their role was to facilitate the
on-going care of the client and their family, and to provide counselling and support up until
the time of the assessment and during the court process. They were trained in court
preparation and support for the client during the court process. Any concerns raised during
the psychological assessment process were also reported to the case manager.
Allocation to social workers was done on a geographic basis within the greater Cape
Town Metropole. With the growth of the programme and with exposure to training, referrals
began coming in from the wider region of the Western Cape Province. Contact had to be
made with social services operating in these districts and towns to provide this support.
Clients from areas beyond the Cape Town metropole were still evaluated by the intake social
worker but the case management had to be devolved to understaffed and often overloaded
social service agencies in the particular area. This is an on-going area of development for the
programme.
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4.7.1.3. Psychological assessment.
This took place over two sessions, each 2-4 hours in length, depending on the needs
of the clients. These were whenever possible and usually within a week of each other to
provide continuity in the assessment process. For those clients who were from outside of the
Cape Town Metropole, arrangements were made for them to stay overnight at a local bed and
breakfast facility, if needed. The full assessment was completed within the day and the clients
and caregiver were provided with lunch. Donors provided a care pack which the clients took
home. The police were often involved in providing transport and facilitating the process.
4.7.1.4. Process of the assessment.
If possible, the case manager or intake social worker would introduce the client and
the accompanying person to the psychologist. Otherwise the psychologist would meet the
client and their family member in the waiting area and introduce herself. The interview would
take place in a private interview room. Most often, the clients had been collected early in the
day, or travelled some distance to get to the CMH offices for their 9am appointment. Offering
tea or coffee and biscuits at the start promoted an atmosphere of care and normalised the
interaction around a social ritual. In many instances the clients and their caregiver came from
impoverished circumstances and they had not yet eaten that day.
Often the client and their family member had anxieties about the assessment process
and what it would involve. It was important for the psychologist to spend some time
establishing rapport with the client and explaining the process. The client often did not know
why they had been brought here, and their understanding of what they were doing here was
explored. A simple explanation of the assessment process was given. Consent was re-
evaluated and the public nature of the report was explained, i.e., that confidentiality was
limited. Permission was explicitly given to the clients and the caregivers to ask questions at
any stage.
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The first part of the interview was conducted with the caregiver present and the
Vineland Adaptive Behavior Scales were administered with the client present. This allowed
for some items to be assessed directly if the caregiver had no knowledge of the skill. Once
the client had become more comfortable and the caregiver had given the necessary collateral
and background history, the caregiver was asked to leave and the complainant was asked to
give an account of the alleged incident. The ability to consent and their knowledge of sexual
matters was explored, as was their ability to give evidence in court and be a competent
witness.
The second part of the interview took place the following week or after a lunch break
for the clients from outside of the city metropole. The IQ test was administered. In the second
instance, possible fatigue was weighed against the advantage of having established rapport
and diminished anxiety. This was generally found to be more helpful to the assessment
process. This is an example of use of the clinical reasoning process in terms of timing. A
retelling of their account of the alleged incident was used to evaluate consistency and their
ability to give evidence. This also provided an opportunity for questions regarding missing
information or clarification of information. When the caregiver re-joined the complainant, the
subsequent process was explained with regards to the compilation of the report, submission
to the police, the court process and initial court preparation of the complainant. The court
process is lengthy with long delays and this was explained as well as what would be expected
of the complainant in court. There was an opportunity for questions and fears to be expressed.
Due to the low conviction rate it was also necessary to explain the meaning of a “not guilty”
verdict and that it would not invalidate their experience. Their motivation to go through with
the court process was also re-evaluated given this information.
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4.7.1.5. The interview.
An interview guide was developed to standardise the process and provide a
comprehensive assessment framework. It was devised to promote best practice and is
inclusive of many more details than is the focus of this research, but provided useful
information for on-going evaluation of the programme and a collection of data for possible
further formal research. The interview guide provided the basis for the information included
in the database. The development of this guide is discussed more fully in the section detailing
of the development of the database. (section 4.8.1.) Detail of the interview guide is included
in Appendix F and included the following categories:
• Identifying information.
• Referral.
• Personal history.
• Family history.
In particular, the socioeconomic status (SES) of the family was evaluated as described
previously. This was then categorised as below the poverty level, low SES, middle SES or
high SES. The overwhelming majority of our clients come from impoverished circumstances
and fell into the category of low SES or below the poverty level.
Various social grants are available through the government Department of Social
Development. Access to grants was documented. A care dependency grant or a disability
grant are the two most common categories of grants available to support families with a
member who is intellectually disabled. There is also a child care grant and foster care grant
available through the state. Documenting this also served to flag the need for action on the
part of the social worker case manager. Details are given in the literature review (section
3.3.4.).
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• Assault history.
This was an important aspect of the assessment process, although some aspects were
not reported on directly as the information was sub judice (under judicial
consideration and public discussion is prohibited). However, it formed an important
component of the evaluation regarding competency to give evidence.
• Appearance and behaviour at assessment
• Adaptive functioning assessment.
The Vineland Adaptive Behavior Scales were administered. In the period between
2005 and 2011 the VABS (1984) was used. The VABS II (2005) was introduced and phased
in from 2009 until 2011 when it was used exclusively to assess adaptive functioning.
4.7.1.5.1. Use of different norming tables for adults.
If a different set of norms was used by the psychologist to calculate scores for the
VABS II (i.e., the 18-21.11 norms for adults due to the floor effects in the older age
categories), this was noted and the norms for the appropriate age category were entered into
the database to allow for statistical analysis of the published norms. Refer to the discussion
chapter for more detail on this issue (section 7.10.).
• IQ assessment.
The ISGSA was used as part of the assessment of all those included in this study. This
is a test normed on a South African population of English and Afrikaans speakers (refer to
the previous measurement instrument section for details). There are norms from four years of
age to 16 years. Our clients’ cognitive development generally fell within this range. For those
who were higher functioning or had other physical disabilities such as sight or hearing or
motor difficulties, alternative tests were used which were more appropriate. (Refer to the
exclusion section of this chapter for detail (4.6.2.)and Appendix E.)
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• Understanding of sexual matters.
The ability to consent to sexual intercourse was evaluated against the legal definitions
given in the South African Criminal Law (Sexual Offences and Related Matters) Amendment
Act 32 of 2007. The Act defines mental disability being inclusive of any disability or disorder
of the mind at the time of the alleged offence in that he or she was:
a. unable to appreciate the nature and reasonably foreseeable consequences of a
sexual act;
b. able to appreciate the nature and reasonably foreseeable consequences of such an
act, but unable to act in accordance with that appreciation;
c. unable to resist the commission of any such act; or
d. unable to communicate his or her unwillingness to participate in any such act.
(Section 57 (2))
This is in line with Williams' (2008) understanding of the elements of consent as
including:
• information;
• capacity (ability to understand the information, apply it to oneself and make
decisions);
• voluntariness (freedom to decide).
The following areas were explored with the client:
• their understanding of the physical mechanics of sexual intercourse;
• their interest and knowledge of sexual matters;
• previous sexual history both consensual and non-consensual;
• their understanding of conception;
• contraception;
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• sexually transmitted disease, with particular reference to HIV/AIDS in order to
explore their understanding of the consequences of sexual intercourse and the
need for protective action.
Through this process, their sexual vocabulary was assessed, including commonly used
terms in their community, as was the sources of their sex education being through school,
home, the media or through other means. The ability to refuse was evaluated and an overall
assessment made and recorded using this information. Use was made of anatomically correct
dolls and pictures demonstrating consensual and non-consensual touching and sexual
foreplay and sexual intercourse (Johns, 2005). (Refer to Appendix G.) There is ongoing
discussion in the literature regarding the relationship between level of intellectual disability,
sexual rights and the ability to consent to sexual intercourse (Benedet & Grant, 2013;
Dickman, 2017; Murphy & O’Callaghan, 2004). Reflection and examination of best practice
of this part of the assessment is outside the scope of this research but is very pertinent to the
work of the project and is a point of ongoing discussion and debate.
• Competence as a witness.
The clients’ understanding and knowledge of court proceedings was evaluated. The
ability to differentiate truth and falsehood was explored at both a concrete and abstract level.
The tool used was developed by Lyon and Saywitz (2000). Their concept of perjury and their
understanding of what it means to promise were important components of their readiness for
the court process, their ability to be a reliable witness and exploratory in terms of, if with
further court preparation, they would be a competent witness.
Their ability to give a narrative, sequential, consistent account of the alleged incident
was evaluated over two tellings. The anatomically correct dolls were also available, if
needed, to assist. Some clients could not verbalise their experience but could demonstrate
with the dolls. Their ability to answer simple clarifying questions was also evaluated.
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Their motivation to testify was explored and categorised as motivated, wanting justice
but ambivalent, no understanding of the injustice, that the sexual activity was not a crime, or
they were afraid of the consequences of testifying. In the great majority of cases the use of an
intermediary was recommended (96%). This was often an opportunity to do initial court
preparation and to give a careful explanation of court process. An overall assessment was
recorded, often with the proviso of further adequate court preparation and given the
understanding of the court of the limitations of the witness and giving the complainant
appropriate support (refer to the results chapter for the number of clients found to be
competent witnesses and the support requested (section 5.3.3-6)). The competence of people
with intellectual disability to give evidence and participate in court processes is also an area
of ongoing debate and discussion and is important in realising access to justice for this
vulnerable group (Bala, Lee, Lindsay, & Talwar, 2010; Benedet & Grant, 2013; Meintjies,
2015; Gentle et al., 2013; Pillay, 2012; Van Niekerk, 2014).
• Psycho-legal report and legal process.
Findings were written up in a psycho-legal report and submitted to the investigating
officer or the prosecutor depending on the pathway of the referral. The outcome of the
assessment was fed back to the client, their caregiver and the referrer. If the client was found
unable to give evidence, this was carefully explained. This process, together with the usually
long wait for a court date, was explained to the client and their caregiver at the closure of the
interview. Wherever possible, the client was referred back to the appropriate social work
services, either within the organisation, or services in the geographic area for those clients
residing outside of the Cape Town metropole for ongoing support and court preparation.
Whenever possible, the social worker would accompany the client and their family to court
on the date of court appearance. The assessing psychologist would often be called as an
expert witness to present their report and findings to court and answer questions from the
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legal team. This was often an opportunity to advocate for and educate regarding the needs
and rights of people with intellectual disability and correct misconceptions. Wherever
possible, this was prior to the client being called to give evidence in order to prepare the court
for the needs of the client. The aim was to prepare the court for the client and the client for
court.
Ongoing areas of difficulty in terms of the legal process are: the length of wait
between reporting the alleged assault and appearance in court, the families and clients not
being informed of the outcome of the trial, and ongoing education of the police and officers
within the legal system regarding the particular needs of people with intellectual disability.
4.8. Data collection for this study
Retrospective information was gleaned from a basic interview schedule, the test
protocols, the notes and psycho-legal report of the assessing psychologist on file for this
period of 2005 to 2010 when the VABS (1985) was used. With the conceptualisation of the
research and the development of a more detailed interview schedule, data were collected with
the VABS II (2005) from 2010 until the end of 2013.
The hard copy of the client file and psychologist report was examined and relevant
quantitative and qualitative data extracted and entered into a data set. Quantitative item
scores for each subdomain were entered, together with the relevant total scores and derived
scores. The concluding evaluation of the clinical psychologist in terms of level of disability,
as reported on the court report, was recorded. Qualitative information regarding age, gender,
race, socioeconomic status, access to education, geographic distribution, language, evidence
and degree of trauma was included. The use of racial categories is controversial as to further
entrenching divisions. Given the South African context and history, race continues to be
linked to economic, social and resource inequity. The categories used of African, Coloured,
White and Indian/Asian concur with those used in the present census data for South Africa
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(Statistics South Africa, 2017). It is acknowledged that race is a social construct, but
continues to play a determining role (refer to literature review, section 3.2.2).
4.8.1. Development of the interview schedule to enable the collection of data.
Although an existing interview schedule was already in regular use within the
programme, this needed revision in order to systemise and classify the information collected.
This process happened in parallel to the extension and development of a database. Here too,
there was an existing database used by the organisation. The aim was to classify the
information into categories which were realistic in terms of the amount of detail which could
be given by the clients and their caregivers. An example of this was documenting the cause of
intellectual disability. In many cases the caregiver or parent did not know the cause or could
give only a broad reason, so the classification of cause had to be limited to birth trauma,
childhood illness, FASD (which broadly included exposure to alcohol prenatally), epilepsy,
trauma and an other category. The information gathered needed to be comprehensive in terms
of this focused research, however the intention was to provide a basis for the collection of
data for further research.
A series of collaborative meetings were held with the psychologists involved in the
project and the social worker manager. Ideas for the development of the interview schedule
were discussed regarding feasibility and what information was necessary for assessment
purposes and also pertinent in terms of this, further or existing research, i.e., follow up in
terms of the legal process and outcome and the expression of distress and trauma in people
living with intellectual disability. This was a reiterative process, with the preparation of an
adapted schedule, which was discussed, reformulated and revised a number of times. The
schedule was informally used in the assessment process and then reviewed. The categories
included in the interview schedule have been previously described.
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The final interview schedule which was in use for the collection of data for the
VABS II from 2010 is included in Appendix F.
4.8.2. Database development.
Information already captured by the existing database was identified. Changes were
made to the initial referral form (Appendix H) as the process of information collection was
examined and to prevent unnecessary duplication. These initial data were entered by the
social work manager into the database. Discussions with the database developer were held in
parallel to the development of the interview schedule. The database was further developed to
include the more detailed information and designed for ease of entry with drop down
categories. Internal checks for correlation of data were inserted to flag discrepancies, i.e.,
date of birth, age at assessment and date of assessment or scoring not adding up to entered
totals in relation to the quantitative data. (Refer to Appendix I for screen shots of the
database.) This, too, was a reiterative process with data being entered, the identification of
problems and redesign until a working model was found. The database was designed in a
layered manner so that the SAVE programme client information could be entered and
extracted with increasing and varied comprehensiveness.
4.8.3. Data protection.
The information was password protected so that only the SAVE manager and the
researcher and assistants had access to inputting data to protect both confidentiality and data
being incorrectly entered or altered inadvertently. The data were backed up on the server of
the organisation and independently by the researcher.
4.8.4. Data entry.
Datum entry was initially done using the referral form by the social work manager.
This set up the client on the system. Once the assessment was complete and the report
submitted to the police and legal system, the client file was used to enter the relevant data
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into the database. Data were entered directly from the interview schedule, the tests protocols
and the hard copy of the psycho-legal report. This was initially done by two undergraduate
students in their capacity as research assistants. Data checking included both built-in checks
and manual checks. If there was a query about a score or comment this was noted and
communicated to the researcher who then checked and made the necessary corrections. At
times the research assistants did not have the necessary clinical experience to be able to judge
the correct response. The process required translating qualitative data into discrete categories.
Missing data were also identified, checked against file records and inserted by the researcher.
The information from the database was transferred onto excel spreadsheets and further
checking for missing information was done using the sort and filter functions of Excel.
4.8.5. Detailed item entry for the VABS II.
A detailed item entry format was designed for those clients who had been assessed
using the VABS II to include the response to each individual item. In this way, summative
scores on the database could also be checked against manual scoring. Discrepancies were
checked and corrected. Although some errors were identified, they were minor and although
numerical scoring was corrected to reflect the recalculated score, these were checked in terms
of documented range of intellectual disability and none of the scoring changes resulted in a
different result once translated into ranges of disability. The corrected scores were entered
into the database.
4.8.6. Classification of intellectual disability in datum entry.
Ranges of disability were in line with the ICD-10 classification system and that used
by the developers of the VABS II (p. 139 of the manual). A person with intellectual disability
had an adaptive composite standard score and IQ standard score below 70 (approximately
two standard deviations below the mean).
• Mild intellectual disability was classified as standard scores between 50 and 70.
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• Moderate intellectual disability was classified as standard scores between 35 and
49.
• Severe intellectual disability was classified as standard scores between 20 and 34.
• Profound intellectual disability is classified as standard scores below 20.
However, the developers of the VABS II combined the categories of severe and
profound disability. In terms of the purposes of this project these two categories were
delineated, as people with profound disability were not ever found to be able to give evidence
in court, whereas a few clients with severe disability, with appropriate support, could give
evidence. It could also be argued that the support and service needs of people with severe
disability are qualitatively and quantitatively different from those people with profound
disability. In a resource constrained society such as South Africa, placement in appropriate
services is often difficult due to limited places. It is of importance to place people in
appropriate services which are geared to their level of need. Many of our clients had never
formally been assessed before or necessarily been able to access resources. The assessment
also provided a baseline and sometimes a motivation for appropriate placement or change of
placement.
4.8.7. Data collection from the clinical psychologists involved in the project.
In order to answer the latter research questions (4 and 6), data were collected from the
clinical psychologists involved in the project. The aim was to identify the items within the
VABS II which were useful, in terms of qualitative description of the persons everyday
functioning, particularly in the context of the legal process and the information that the court
needed, to inform decisions about the use of an intermediary, the ability to be a reliable
witness and to prepare the court for the particular needs of the client and thus provide access
to justice. Further, the purpose was to examine and identify those items in the VABS II which
the psychologists found difficult to score which might need contextual or linguistic
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adaptation for this group of clients. The participants were the psychologists who had
participated in the assessment of the sample and who would have been called to court as
expert witnesses with regard to the client assessed.
A meeting was held with five of the psychologists involved in the programme. Each
psychologist was handed a blank VABS II form and a written instruction. (Refer to Appendix
J.) They were asked to highlight those items which provide useful information for the written
psycho-legal report or in giving evidence in court. They were then asked to highlight the
items they found difficult to administer. Further to this, they were asked to identify the nature
of the difficulty and label the difficult items with lettering:
L – if the difficulty was due to translation into another language or related to a language
issue.
N/O – if the client had had no opportunity but the test did not give that as an option for that
item
C – the item was culturally inappropriate.
O – other and to state a reason.
This was completed individually and was followed by a group discussion which was
recorded. Two of the psychologists were not able to be at the joint meeting and recorded their
scoring separately.
The highlighted items of the seven psychologists were entered into a spreadsheet and
useful and difficult items identified and classified. These are reported in the results in section
6.5.. The group discussion was transcribed and notes taken of concurrence and disagreement
and the findings are described in the results. Formal thematic or content analysis was not
done. The transcription was examined for elaboration on the items already identified by the
participating psychologists.
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4.8.8. Added item information.
Clinical item analysis of scores of the full sample (n=321) highlighting “Don’t know”
or “No opportunity” responses were recorded on an Excel spreadsheet as these were
hypothesised as tagging items which are difficult to score in this group of people.
In each subdomain of the VABS II and the VABS 3 items were examined, compared
and labelled as repeated, modified, deleted, moved into a different developmental sequence
or moved to a different domain.
4.8.9. Further specific data collection from the psycho-legal reports.
A stratified random sample of the psycho-legal reports was used to identify which
items of the VABS II were used by the psychologists in their reports. Twenty percent (n=65)
of the total sample of VABS II reports (n=321) were stratified in terms of the five different
psychologists (n=13) doing assessments during the period of data collection. Further the
sample was stratified in terms of developmental stage of client, given that the adaptive
functioning of an adult is different to that of an adolescent or child. The analysis examined if
different items would be more or less significant for different age groups. This included
analysis of difference in terms of developmental sequence with children under 13 years
(n=15), adolescents between 13 and 18 years (n=23) and adults over 18 years (n=27) (refer to
Tables 4.6 and 4.7. for detail regarding the sample).
Table 4.6.
Stratified Random Sample of Psycho-Legal Reports Undergoing Clinical Item Analysis
Age groups Total sample VABS II Stratified Random % of total sample
Sample
Children <13 years 44 15 34%
Adolescents 13-18 131 22 17%
Adults >18 146 28 19%
Total 321 65 20%
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Table 4.7.
Age Group Distribution of Sample from Psycho-Legal Reports
Clinician Children <13 Adolescents 13-18 Adults >18
Psychologist 1 3 3 7
Total 15 23 27
A clinical psychologist, who now works on the SAVE project, but was not involved
in the period when the data were collected, collated the data. She had the necessary
psychological knowledge and experience of using the VABS II in this setting and could
interpret what was written in the psycho-legal report which pertained to use of the VABS II.
This was entered onto a spreadsheet of all the items of the VABS II. This was analysed and
compared to the highlighted items and the discussion which followed. The results are
reported in section 6.5.. Discussion of the results is in section 7.5. and 7.7..
4.9. Data analysis
4.9.1. Descriptive analysis.
Using pivot tables on the excel spread sheets, quantitative data, which described the
sample, was extracted and reported upon. The entire sample 2005-2013 was initially analysed
and described (inclusive of use of the VABS and VABS II) and then a more focused
description of the sample where the VABS II was used followed, using the information from
the developed interview schedule and entered on the database.
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4.9.2. Statistical and clinical item analysis for each research question.
Data were transferred onto the IBM SPSS programme for detailed analysis. A
colleague from the university psychology department assisted with the statistical analysis.
Table 4.8. documents the quantitative statistical and qualitative methods used to answer to
detailed research questions.
Table 4.8.
Statistical and Qualitative Methods Used in Data Analysis
Research Question: Method used:
Do the published US norms of the Vineland Regression analysis was run using the ISGSA score
Adaptive Behavior Scales (VABS and VABS as the dependent variable and the VABS or VABS
II) discriminate accurately between different II score as the independent variable. A subgroup
levels of intellectual disability within this analysis was run on the different language groups.
particular South African context? In order to
answer this:
What association is there between the measured
Intelligence Quotient (IQ) score using the
Individual Scale of General Scholastic Aptitude
(ISGSA) and the standard score measurements
of adaptive functioning using the Vineland
Adaptive Behavior Scales (VABS and VABS
II)?
Do the published US norms of the Vineland A Chi-square analysis of the psychologist’s
Adaptive Behavior Scales (VABS and VABS diagnosis and its association with the level of
II) discriminate accurately between different disability measured by the VABS and VABS II.
levels of intellectual disability within this
particular South African context? In order to
answer this:
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How does the reported diagnosis and
assessment of the evaluating clinical
psychologist compare with the level of standard
score measured by the Vineland Adaptive
Behavior Scales (VABS and VABS II)?
Is there a significant association between A logistic regression analysis was conducted, using
variables of language, gender, age, the VABS or VABS II score as the dependent
socioeconomic status, geographic distribution, variable. As this only allows for binary variables,
access to education and trauma with the mild and borderline categories were combined
measurements obtained in the Vineland as were the moderate and severe categories.
Adaptive Behavior Scales? (VABS and VABS Language, gender, access to education and
II) geographic location in terms of rural or urban were
used as the independent variables. Trauma and SES
were not used as they were fairly consistent through
the sample.
Is the VABS II able to discriminate between A receiver operating characteristic curve (ROC)
levels of intellectual disability for the adults in analysis was conducted using the moderate and
the sample? severe levels of disability amongst the VABS II
Do the norm tables for adults, in the newly sample. The following analyses were run:
published VABS 3, give evidence of addressing • VABS II score onto the psychologist
the floor effect? rating of IQ.
• VABS II score onto the psychologist
rating of AF.
• VABS II score onto the ISGSA rating of
IQ.
Each analysis was run for the full sample and then
divided into those below 22 years and those over 22
years in age.
136
What useful qualitative information is used and Independent clinical item analysis by the seven
reported in the psycho-legal report from the psychologists who have been involved in the
items in the Vineland Adaptive Behavior programme, followed by a group discussion which
Scales? (VABS II) was transcribed and analysed for further
information.
How does the VABS II compare with the VABS Clinical item analysis, using the two comparative
3, using changes in sequence, deleted items, forms, identifying those items which remained the
added items and modified items between the same, those modified, those deleted and new items
two versions? added. Developmental sequence changes were also
noted.
Which items in the VABS II need contextual or Independent clinical item analysis by the seven
linguistic adaptation for this group of clients and psychologists who have been involved in the
to what extent has this been addressed in the programme, followed by a group discussion which
VABS 3? was transcribed and analysed for further
information. Using the results, the VABS 3 items
were further examined to assess adaptation.
4.10. Ethical considerations.
4.10.1. Client privacy.
The results of the assessments included in the data are anonymous. No names are
identified in the results or in any publication of the results. Clients are identified by client
number in the analysis. Clients and their families were aware that the assessments are used to
prepare the court for the client giving evidence and that, as such, are read into the court
record and are in the public domain. This was further explained by the psychologist at the
beginning of each assessment. It is of importance that each family and client understood that
the process was not confidential in nature. Informed consent was given at the time of the
137
assessment knowing that information gathered in the assessment would be in the public
domain.
4.10.2. Conflict of interest.
The researcher has no commercial interest in the ongoing use of the Vineland
Adaptive Behavior Scales.
4.10.3. Permission to use client records.
A request for permission for use of the data from the records of Cape Mental Health,
together with the aim and purpose of the research, has been given in written form. A written
response was received giving full support to the research. (Appendix K) Ongoing feedback
will be given to the agency and the results of the research will be made available to them in
written form.
4.10.4. Permission to reproduce test protocols and email correspondence.
Permission to reproduce VABS II survey interview form and Vineland-3
comprehensive interview form, from the publisher, Pearson, along with email correspondence
referred to in the discussion, given by one of the authors of the VABS 3, Dr Saulnier, is
included in the appendices. (Appendix L)
4.10.5. Access and storage of information.
Data at CMH was stored and backed up on the organisation server. Access was
limited to the researcher, the project manager and for limited periods to the research
assistants involved in data capture. This was accessed by an identifying code and a password.
Data on the computers used for the research process was user name and password protected,
The statistician was given access to the appropriate spread sheets, as were the research
supervisors. Clients were identified by a unique client number to ensure anonymity.
138
4.10.6. Ethics approval.
Ethics approval for the research study was applied for and given by the Health
Sciences Faculty at Stellenbosch University. Ethics approval Number: S17/01/003 (Appendix
M.)
This chapter has detailed a review of the context of the research, described the aims
and research questions and the methodology of the literature review. The research design and
the measurement instruments have been presented. Data base development together with the
systemization of information gleaned during the assessment process has been detailed. Details
of the research sample and reasons for exclusion have been given. The process of data
collection and capture has been described. Descriptive, statistical and clinical item analysis
procedures are presented and the chapter concluded with details regarding ethical
considerations. The following chapter will detail the results of the descriptive analysis.
139
Chapter Five: Descriptive Results
5.1. Introduction
The descriptive results form an important part of the research enquiry and process and
have been included as a separate chapter as a prelude to the results pertaining to the formal
research questions. It is discrepancies in the descriptive results which gave rise to the need
for more detailed statistical analysis and which substantiate the formal research questions.
These are addressed in the next chapter.
The results are presented, using the complete sample, inclusive of the data collected
for the clients assessed using the VABS and the VABS II. Comparison of the two groups is
included where pertinent. The more detailed data of the group assessed using the VABS II is
then presented. Many questions arose from the descriptive results and are noted. These are
not necessarily pertinent to the research questions but point to areas of needed research.
5.2. The combined results from 2005-2013 (N=642)
These include:
• Year by year breakdown of numbers of clients in the sample and the transition
between use of the VABS and the VABS II.
• Gender.
• Age distribution.
• Language.
• Race.
• Urban and Rural geographic distribution.
• Formal and informal housing.
• Housing and race.
• Reported cause of ID.
• Reported causes of ID in rural and urban sample.
140
• The relationship of the informant to the client.
• IQ ranges.
• Reported adaptive functioning by the psychologist in the concluding section of the
psycho-legal report, combined and differentiated.
• Comparison of IQ with level of adaptive functioning.
• Adaptive functioning ranges as measured by the VABS and VABS II, combined
and differentiated.
• Comparison of adaptive functioning as measured by the VABS and the reported
conclusion of the psychologist.
• Comparison of adaptive functioning as measured by the VABS II and the reported
conclusion of the psychologist.
5.2.1. Year by year breakdown of sample numbers.
Figure 5.1. Year by Year Breakdown of Sample

Numbers
120
Numbers of Clients
100
80
60 7 53
74 99 88
40
62 55 57 63
20 42 35
0 7
2005 2006 2007 2008 2009 2010 2011 2012 2013
VABS VABS II
Figure 5.1. illustrates the year by year breakdown of cases seen and version of VABS
used. It also illustrates the increasing numbers of referrals with the growth of the SAVE
programme with the parallel targeted training of police and prosecutors in identifying those
complainants who should be referred to our services. Although the VABS II was published in
141
2005 it was only by 2010 that it was accessible and increasingly used. The total number of
cases seen over this period was 790. The exclusions amounted to 148 cases (18.7%). Reasons
for exclusion and numbers each year are detailed in Appendix E.
5.2.2. Gender of sample.
Figure 5.2. Gender of Sample

600 558
500
Number of clients
400
282 276
300
200
84
100 39 45
0
VABS VABS II Total
Male Female
Figure 5.2. illustrates that in the VABS sample, 87.9% were female and 12.1% were
male and in the VABS II sample 86% were female and 14% were male. The ratios are very
similar over the two time periods of the study.
142
5.2.3. Age distribution of sample.
Figure 5.3. Age Distribution of Sample

70
60
50
Number of clients
40
30
20
10
0
0 10 20 30 40 50 60 70
Age in years
Figure 5.3. illustrates the age distribution of the sample. This is similar to the
prevalence of sexual abuse in the general population (Jewkes, Fulu, Roselli, & Garcia
Moreno, 2013). Very few children are referred to SAVE as they are mostly served by child
abuse services and non-governmental organisations within the Cape Town metro and
surrounding areas.
5.2.4. Language groupings of sample.
Figure 5.4. Language Groupings of Sample

450 399
400
350
Number of Clients
300
250 211
188 192
200
150 107
85
100 44
50 26 18 7 7
0
VABS I VABS II Both Groups
Afrikaans isiXhosa English Other
143
Figure 5.4. illustrates the breakdown of home language groups of the sample. These
are the three predominant languages in the Western Cape. The “Other” category refers to
South African languages spoken in other parts of the country or other African languages. It is
striking that we are not getting many referrals of other African nations. The question arises as
to whether this is due to xenophobia, access to the justice system for immigrants, whether
people with intellectual disability are left behind and are not part of the immigrant or refugee
group.
The percentage of isiXhosa speakers has reduced from 33.3% of the VABS sample
group to 26.5% in the second period of the VABS II sample. Cape Mental Health have had a
focused rural outreach, where Afrikaans is more commonly spoken, in the latter part of the
data collection period and isiXhosa speakers are possibly more clustered in urban settings
(refer to 5.2.6. on increasing numbers of rural referrals).
5.2.5. Race groups of sample.
Figure 5.5. Race Groups of the Sample

100% 14 11 25
90%
80%
Percentage of clients
70%
193 208 401
60%
50%
40%
30%
20% 114 102 216
10%
0%
VABS VABS II Total
Black Coloured White
144
Figure 5.5. illustrates the race groups of the sample. Race and language remain social
and economic categories and are included as they remain significant in the South African
context.
Table 5.1.
Research Sample Percentages of Race and Language Compared with General Urban Cape
Town and Rural Western Cape Percentages
Language and Rural Western Urban Cape VABS VABS II Total % of
Race Cape. Town Sample
(Drakenstein Metropole
municipality)
English 4.9% 27.8% 8.1% 5.6% 6.9%
Afrikaans 72.5% 34.9% 58.6% 65.7% 62.1%
isiXhosa 16.2% 29.2% 33.3% 26.5% 29.9%
Other 1% 2.8% 0% 2.2% 1.1%
Black 22.7% 38.6% 35.5% 31.8% 33.6%
White 13.5% 15.75% 4.4% 3.4% 3.9%
Coloured 62.5% 42.4% 60.1% 64.8% 62.4%
Indian/Asian 0.4% 1.45% 0% 0% 0%
Source: Statistics South Africa : Census 2011 figures published at statssa.gov.za
Using the figures given in Table 5.1., there are a proportionate number of isiXhosa
speakers with intellectual disability being referred. The percentage of Black people living in
the Western Cape is estimated to be 30.7%. This is similar to the sample percentage of
33.6%. The percentage of Coloured people in the sample is higher at 62.4% than the reported
population percentage in the province of 52.5%. There is a notable difference in English
speakers, with less referrals, than is representative in the area. In terms of race, there are
disproportionately less White people with intellectual disability being referred. This warrants
145
further investigation and is possibly related to a greater proportion of White, English speakers
being placed in institutional care and more protected environments or having access to better
health services. Of this sample, 12% lived in residential facilities and 88% were community
based. Are these cases being reported to the police? Does higher socioeconomic status
provide protection from sexual abuse for people with ID, and lower the risk of sexual
violence? Is it hidden and not reported? This would be of interest for further research.
5.2.6. Urban and rural geographic distribution.
Figure 5.6. Urban and Rural Distribution

450 418
400
350
Number of Clients
300
228
250
190
200 154
150 96
100 58 70
35 35
50
0
VABS VABS II Total
Rural farm Rural town Urban
Figure 5.6. illustrates the geographic distribution of the sample. Urban refers to clients
living the Cape Town Metropole, rural town refers to towns in the Western Cape but outside
the Metropole and rural farm refers to clients living on farms in the Western Cape. These
would be referred via their nearest police station and local town (refer to Appendix N for
details). The number of rural farm referrals remained steady throughout the two periods of
data collection, however there was an increase of 11.8% (from 18.1% to 29.9%) of referrals
from rural towns. These figures merit detailed analysis in terms of access to services,
assisting in prevalence data but are beyond the scope of this study.
146
5.2.7. Formal and informal housing.
Figure 5.7. Formal and Informal Housing

476
500
450
400
Number of Clients
350
300 245
231
250
200 166
150 90 76
100
50
0
VABS VABS II Total
Formal Housing Informal Housing
Figure 5.7. illustrates the number of people living in formal and informal housing.
This is an indicator of socioeconomic level. Informal housing typically consists of a
corrugated iron one roomed structure with limited and variable access to electricity, water
and sanitation. In relation to national and provincial percentages of population living in
informal housing, Statistics SA report from the 2011 census that nationally 13.6% of people
are living in informal housing, Cape Town reports 78.4% in formal housing and the
Drakenstein municipality (using these figures as a typical rural area for the Western Cape)
reports 85.1% formal housing. In the research sample 25.8% are living in informal housing
and only 74.1% in formal housing. There is a decrease in the latter period of data collection.
This is a marker for the low socioeconomic status of this sample. Living in informal housing
would be Themba’s situation.
147
5.2.8. Housing and race.
5.8. Housing and Race

400 377
350
Number of Clients
300
250
200
142
150
100 74
50 24 25
0
Black Coloured White
Formal Housing Informal Housing
Figure 5.8. gives an indication of the disparity in our society and a reflection of the
historically more recent influx of Black Africans into the urban areas. None of the White
subset of the sample where living in informal housing, 5.9% of the Coloured subset were in
informal housing and 65.7% of the Black subset were in informal housing.
5.2.9. Reported causes of intellectual disability.
Figure 5.9. Reported Causes of Intellectual

Disability
300
Number of Clients
250
200
150
244
100
50 106 122
66 61 40
0 1 2
Figure 5.9. reflects the reasons given by the caregiver as to the cause of intellectual
disability. Foetal Alcohol Syndrome Disorder (FASD) was used, when there was a history of
alcohol use in pregnancy. No formal diagnosis of Foetal Alcohol Syndrome was possible
148
within the time constraints of the assessment. Many of the caregivers were unaware of, or did
not know the reason for, the disability (38%). Many of these causes are preventable and the
incidence of FASD is not unexpected (19%), given the history of paying workers in alcohol
in the Western Cape. (Refer to prevalence figures in the literature review sections 2.5.4.3. and
3.3.3..)
Table 5.2.
Comparison of Percentage Reported Cause of Intellectual Disability
Total sample (N=642) Urban (n=418) Rural (town and farm)
(n=224)
Birth 16.5% 18.9% 12.1%
Childhood illness 10.3% 10.8% 9.4%
Drug exposure 0.15% 0.2% 0%
Epilepsy 9.5% 10% 8.5%
FASD 19% 12.4% 31.3%
Prenatal 0.3% 0.2% 0.5%
Trauma 6.2% 6% 6.7%
Unknown 38% 41.4% 31.7%
Table 5.2. breaks down the differences between the urban and rural sample. Two
figures stand out. The 31.3% prevalence of FASD in the rural sample and the 41.4% of
unknown cause by the caregiver amongst the urban sample, although the numbers of
caregiver who do not know the cause of the disability is high across the sample. This is
possibly due to inadequate health education and knowledge.
149
5.2.10. Relationship of the informant to the complainant.
Figure 5.10. Relationship of Informant to the

Complainant
500
381
Number of clients
400
300
200 143
100 58 52
7 1
0
Parent Family Caregiver Sibling Other Social
member worker
Figure 5.10. illustrates that 59.3% of the informants when using the Vineland Survey
interview form were parents, 36.3% were family members, 9% were caregivers (usually from
residential institutions), 8.1% were siblings of the complainant. In a few cases, a community
member such as a neighbour was the informant. This was often in cases where the
complainant was living with a non-family member.
5.2.11. IQ range of full sample.
5.11. IQ Range of Full Sample

300
258
246
250
Number of clients
200
150 125
100
50
12
1
0
Low Average Borderline Mild ID Moderate ID Severe ID
150
Figure 5.11. illustrates the ranges of IQ as measured by the ISGSA, of the full sample.
The outlier, with a low average IQ, was functioning in the range of mild intellectual disability
in terms of her adaptive functioning so was included in the sample. In relation to prevalence
data there would seem to be a disproportionate number of people with moderate intellectual
disability in terms of IQ. This may be related to the referral sources finding it easier to
identify people with moderate intellectual disability and that mild intellectual disability is
more difficult for the layperson to identify.
5.2.12. Reported Adaptive Functioning of full sample.
Figure 5.12. Reported Adaptive Functioning of

Full sample
300
249
250
213
Number of clients
200 167
150
100
50
11 2
0
Borderline Mild ID Moderate ID Severe ID Profound ID
Figure 5.12. illustrates the different ranges of full sample of client’s level of adaptive
functioning as documented by the psychologist in the psycho-legal report.
151
5.2.13. Comparison of IQ ranges with reported ranges of adaptive functioning
(AF).
Figure 5.13. Comparison of IQ Ranges with Reported Adaptive

Functioning Ranges
300
258
246
250
200
183
NUmber of clients
Low Average
150 Borderline
122 125
Mild ID
Moderate ID
95
100 Severe ID
69 68
55
50
22
12
8 7
3 13 13 11 1
0
Borderline Mild Moderate Severe Profound Total IQ
disability AF disability AF disability AF disability AF ranges
Range of AF
Figure 5.13. makes a comparison of ranges of disability as displayed in the previous
two figures between measured IQ and reported adaptive functioning.
Of the 249 scores in the mild disability range of AF, 73.5% of IQ scores fall in the
same range, 29.5% in the moderate range, 2.8% in the severe range, 1.2% in the borderline
range and 0.4% in the low average range.
152
Of the 213 scores in the moderate disability range of AF, 57.3% of IQ scores fall in
the same range, 32.4% have a measured IQ in the mild range and 10.3% in the severe range.
Of the 167 scores in the severe disability range of AF, 56.9% of IQ scores fall in the
same range, 40.7% have a measured IQ in the moderate range and 1.8% in the mild range and
0.6% in the borderline range.
The psychologists’ concluding evaluation is used for AF and the trend broadly
follows the expected bell curve, with variation in IQ levels. This is further investigated and
reported in the following results chapter (section 6.2., p. 170).
However, when the VABS and VABS II score ranges are used, a different trend
emerges.
5.2.14. VABS and VABS II ranges of adaptive functioning.
Figure 5.14. VABS and VABS II Ranges of Adaptive

Functioning
250
213 204
200 171
NUmber of Clients
150
100
46
50
8
0
Borderline Mild disability Moderate Severe Profound
disability disability disability
As Figure 5.14. illustrates, using the VABS and VABS II scores to calculate ranges of
disability, there are more people scoring in the range of severe disability than moderate
disability. This is contrary to prevalence trends (refer to literature review section 3.3.2.), the
IQ score trend (Figure 5.11.) and the evaluation of the assessing psychologist (Figure 5.12.)
and indicated the need for more detailed analysis.
153
5.2.15. Comparison of adaptive functioning ranges of the VABS and the VABS
II.
Figure 5.15. Ranges of AF Using the VABS and

VABS II
200 182
Number of Clients
150 121 123
100 81
50 46
50 31
8
0
Borderline Mild disability Moderate Severe Profound
VABS VABS II
Figure 5.15. highlights difficulties with the VABS. Very few clients scored in the
mild disability range. Those scoring in the moderate disability and severe disability range are
almost equal and there is a significant number of people scoring in the profound range. Given
that one of the purposes of our assessment, is to evaluate ability to give evidence and testify
in court, those people with profound disability would have been screened out of this process
by the police or in the initial social work interview, due to their significant communication
difficulties.
Difficulty reflected in VABS II results are primarily that there are more clients
scoring in the range of severe disability than moderate disability. The VABS and VABS II
scores were then plotted against the concluding assessment of the psychologist as recorded in
the psycho-legal report.
154
5.2.16. Comparison of VABS range with reported adaptive functioning range.
Figure 5.16. Comparison of VABS Range with Reported

Adaptive Functioning Range
140
121 123
120
100 94
Number of clients
80 73
Mild disability
60 50 Moderate disability
46 44
Severe disability
40 31
27 24 Profound disability
20
4 3 2
0
VABS Total Borderline Mild Moderate Severe Profound
disability disability disability disability
Reported adaptive functioning range
In Figure 5.16., the discrepancy between the range measured by the VABS and the
reported range of the assessing psychologist is evident.
Of the 31 clients scoring in the range of mild disability according to the VABS, the
psychologist evaluated that four were functioning in the borderline range and agreed with the
VABS that 27 were functioning in the mild disability range.
Of the 121 clients scoring in the range of moderate disability according to the VABS,
the psychologist evaluated that 24 were functioning in the mild disability range, agreed that
94 were functioning in the moderate disability range and that three were in the severe
disability range.
Of the 123 clients scoring in the range of severe disability according to the VABS, the
psychologist evaluated that 50 were functioning in the moderate disability range and agreed
that 73 were functioning in the severe range.
155
Of the 46 clients scoring in the range of profound disability according to the VABS,
the psychologist evaluated that 44 were functioning in the severe disability range and only
two were functioning in the profound disability range.
In 36.8% of the total number of cases, the VABS scores tended to underestimate
adaptive ability in the moderate, severe and profound range of scores. (Refer to methodology
section 4.5.3. regarding the psychologists’ evaluation as gold standard.)
5.2.17. Comparison of VABS II range with reported adaptive functioning range.
Figure 5.17. Comparison of VABS II Range with Reported

Adaptive Functioning Range
200
182
180 172
160
140
Number of clients
120
Borderline
100
81
Mild disability
80
60 50 Moderate disability
44
38
40 Severe disability
23
20 8 6 1 10 14 8
2 1 2
0
VABS II Borderline Mild Moderate Severe
Reported adaptive functioning range
In Figure 5.17. the discrepancy between the range measured by the VABS II and the
range reported by the assessing psychologist is explored.
Of the eight clients scoring in the range of borderline adaptive functioning according
to the VABS II, the psychologist evaluated that two were functioning in the mild disability
range and agreed with the VABS II that six were functioning in the borderline range.
Of the 182 clients scoring in the range of mild disability according to the VABS II,
the psychologist evaluated that one was functioning in the borderline range and agreed with
156
the VABS that 172 were functioning in the mild disability range and that eight were
functioning in the range of moderate disability.
Of the 50 clients scoring in the range of moderate disability according to the VABS
II, the psychologist evaluated that 10 were functioning in the mild disability range, agreed
that 38 were functioning in the moderate disability range and that two were in the severe
disability range.
Of the 81 clients scoring in the range of severe disability according to the VABS II,
the psychologist evaluated that 14 were functioning in the mild disability range, 23 in the
moderate disability range and agreed that 44 were functioning in the severe range.
No clients scored in the range of profound disability according to the VABS II or the
conclusion of the psychologist. This may reflect greater attention to capacity in the screening
process prior to being assessed.
The VABS II scores more closely approximate the psychologists’ evaluation except in
the severe disability range where a portion of the VABS II scores (45.7%) tended to
underestimate adaptive ability. (This is further explored towards the end of the next section in
5.3.14 (p. 168) and 5.3.15 (p. 169)and in detail in the statistical analysis in section 6.2.2. (p.
171).)
5.3. Descriptive detail of the VABS II sample (n=321)
Due to the revised interview schedule in the latter part of the data collection, more
detailed data were entered into the database and are presented in summary here, thus the data
collected for those clients assessed by the VABS II were more detailed.
The following results are included:
• Nature of the charge.
• Motivation regarding testifying.
• Ability to testify.
157
• Relationship between motivation and ability to testify.
• Relationship between family support and ability to testify.
• Use of intermediary recommended for those able to testify.
• Relationship between IQ range and ability to testify.
• Relationship between reported AF and ability to testify.
• Relationship between VABS II range and ability to testify.
• Comparison of IQ, reported AF and VABS II ranges in relation to ability to
testify.
• Range of VABS II scores.
• Range of reported AF.
• Range of measured IQ.
• Comparison of IQ, reported AF and VABS II ranges.
• Relationship of norms age ranges to VABS II ranges.
5.3.1. Nature of the charge.
Figure 5.18. Nature of the Charge

300 278
250
NUmber of clients
200
150
100
40
50
3
0
Rape Sexual assault Rape with assault
Figure 5.18. gives a picture of the nature of the complainant’s charge, with the vast
majority being rape (86.6%), a small cohort of sexual assault (12.5%) and a few cases of rape
with assault (0.9%).

158
5.3.2. Motivation regarding testifying.
Figure 5.19. Motivation Regarding Testifying

160 148
140
Number of clients
120
100 78
80 59
60
40 26
20 2 8
0
Classification of motivation
The information in Figure 5.19. was collected from the interview schedule and the
psycho-legal reports. The “Not Known” figure reflects when this was not recorded. The last
column includes those wanting justice but were ambivalent. This represented 46.1% of the
sample’s motivation.
5.3.3. Ability to testify.
Figure 5.20. Ability to Testify
33%
67%
Not able to testify Able to Testify
159
Figure 5.20. represents an important finding. This differs from previously published
research in the South African setting and challenges the assumption even by mental health
professionals regarding ability to testify (refer to literature review section 2.6.).6
5.3.4. Relationship between motivation and ability to testify.
Figure 5.21. Relationship Between Motivation and Ability to

Testify
Wanting justice but ambivalent 22 126

Motivated 8 70
Motivation
Not Known 46 13
Consequences of testifying 21 5
No understanding of injustice 8
Not a crime 11
0 20 40 60 80 100 120 140 160

Numbers of clients
Not able to testify Able to Testify
Figure 5.21. describes the connection between motivation and the ability to testify. In
a small number of cases, the clients were motivated but were found to be unable to testify
(2.5%). (Refer to the methodology section 4.1.7.5., as to the criteria used to evaluate the
ability to testify.) Ambivalence is common even in those able to testify (39.3%). Where
motivation was not recorded or unknown, 78% were found to be unable to testify.
6
It would be important research to match the psychologist’s evaluation and that of the
prosecutor and judge and speaks to the ongoing effort of both to engage with the legal system
in providing the necessary support to ensure access to justice. This is not a focus of this
research but will be discussed further under section 5.3.9. (p. 164) in relation to adaptive
functioning.
160
The consequences of testifying were substantial for 6.5% of the population and
detracted from their ability to testify.
5.3.5. Relationship between family support and ability to testify.
Figure 5.22. Relationship Between Family

Support and Ability to Testify
200 151
Number of clients
150
100 65
50 20 34 11 17 10 13
0
Full support Ambivalent No support Not known
Level of family support
Not able to testify Able to testify
Figure 5.22. demonstrates the importance of family support for the person who is able
to testify. In many cases the family have been instrumental in accessing police and reporting
the alleged incident and providing ongoing emotional and instrumental support. It is also
important to note that there are some cases that, despite there being ambivalent family
support or no support, the client was still found able to testify.
5.3.6. Use of an intermediary recommended for those able to testify.
Figure 5.23. Use of Intermediary for Those Able

to Testify
4%
96%
Not use intermediary Use intermediary
161
Figure 5.23. illustrates that of the 215 people found able to testify, in 209 cases, the
psycho-legal report recommended the use of an intermediary. In only nine cases, the
complainant was able to give evidence in open court.
This support allows the complainant the space to give an account with a person who
has taken time to establish rapport with them and who can ask the questions posed by the
court in a nonthreatening manner and simplified form. The intermediary acts to filter the
often times aggressive manner and anxiety provoking nature of the court process, thus
reducing undue mental stress for the complainant.
5.3.7. Relationship of IQ to ability to testify.
Figure 5.24. Relationship of IQ to Ability to Testify

160
140
Number of clients
120
100
112
80 72
60
40 25
1 6
20 33 38 33
0 1
Level of IQ
Figure 5.24. illustrates the importance of evaluating each client and that whilst a level
of IQ is important in terms of overall assessment and preparation of the court for the
limitation and support needed by the client, the one client who scored in the low average
range was found not able to testify and 7.8% of the sample who were able to testify had been
assessed as having severe disability in terms of IQ. It would be of interest to follow up how
many of the clients assessed by the psychologist as able to testify, were able to do so in situ
and to document how the court process was managed.
162
5.3.8. Relationship of reported adaptive functioning to ability to testify.
Figure 5.25. Reported Adaptive Functioning and Ability

to Testify
160 149
140
120
Number of clients
100
80
60 49
39
40 30 27
20
20 7
0
Borderline Mild disability Moderate Severe disability
disability
Range of adaptive functioning
Figure 5.25. uses the reported conclusion of the assessing clinical psychologist in
terms of adaptive functioning and compares this with those identified as able to testify. The
ability to testify in a court of law could be thought of as a measure of adaptive functioning in
a specific social institution. Of the 67% of the sample found able to testify, 46% of these
were assessed as being mildly disabled in terms of adaptive functioning, 12.2% were
moderately disabled and 6.2% were severely disabled.
163
5.3.9. Relationship of VABS II range to ability to testify.
Figure 5.26. VABS II Range and Ability to Testify

150 131
Number of Clients
100
51 50
50 24 26 31
8
0
Borderline Mild disability Moderate Severe
disability disability
Range of adaptive functiong measured by VABS II
Figure 5.26. uses the range of the VABS II evaluation and examines the relationship
with the ability to testify. From this, the numbers of people identified as severely disabled
seem disproportionately high.
5.3.10. Comparison of IQ, VABS II ranges and reported adaptive functioning
in relation to ability to testify.
Using the number of people assessed as able to testify, Table 5.3. compares the
percentages of each range of disability as assessed by IQ, the reported assessment of AF and
the VABS II range.
Table 5.3.
Comparison of IQ, Reported AF and VABS II Score in Relation to Ability to Testify
Able to testify: (n=215) Range of IQ Range of reported AF Range of VABS II score
Borderline 2.8% 3.3% 3.7%
Mild disability 52.1% 69.3% 60.9%
Moderate disability 33.5% 18.1% 12.1%
Severe disability 11.6% 9.3% 23.3%
Total 100% 100% 100%
164
The bold figures in the ranges of moderate and severe disability highlight the
discrepancy between the VABS II score ranges and the reported assessment and IQ ranges.
The range of VABS II scores were examined.
5.3.11. Range of VABS II scores.
Figure 5.27. VABS II Ranges

2%
25%
57%
16%
Borderline Mild disability Moderate disability Severe disability
Figure 5.15. gives the numbers of clients described in each range. Figure 5.27.
presents this as percentage. The percentage of clients assessed in the severe range would
seem disproportionate to those in the moderate range. Comparison with the percentages of
disability ranges of the concluding adaptive functioning given in the psycho-legal report was
made.
165
5.3.12. Reported adaptive functioning ranges.
Figure 5.28. Reported Adaptive Functioning

Ranges
2%
15%
21%
62%
Figure 5.28. illustrates percentages as recorded by the reported psychologist
evaluation of adaptive functioning, which follow the expected distribution. These were
compared with the percentage ranges of the VABS II. The percentages in the borderline
range were the same at 2%. The percentages in the mild disability ranges were similar with
the VABS II at 57% and the concluding AF at 62% (5% difference). The differences in the
moderate range were not too dissimilar with the VABS II at 15% and the reported AF at 21%
(6% difference) although the trend is that reported AF percentage of clients falling into that
range is higher than that of the VABS II. This would suggest that the VABS II tends to
undervalue these clients abilities.
The largest difference is in the severe range with the VABS II at 25% and the
reported AF at 15%. Not only is there a 10% difference of clients falling into that range but it
also does not follow a normal distribution.
Further comparison with the percentages of IQ distribution was made.
166
5.3.13. Range of IQ.
Figure 5.29. Range of IQ

1% 2%
18%
45%
34%
Figure 5.29. illustrates similar percentages in the borderline range of functioning to
the previous two graphs. In the range of mild disability, 45% had a measured IQ, compared to
57% of the VABS II and 62% of the reported AF. This points to the IQ underestimating the
level of disability of these clients. The historically poor provision of education for the
predominant race groups in this sample and further limited exposure to education, being
disabled, would be a contributing factors.
In the range of moderate disability, 34% had a measured IQ, compared to 16% of the
VABS II and 21% of the reported AF.
In the range of severe disability, 18% had a measured IQ, compared to 25% of the
VABS II and 15% of the reported AF. Figure 3.29. illustrates this comparison.
167
5.3.14. Comparison of IQ, VABS II score ranges and reported AF ranges.
Figure 5.30. Comparison of IQ, VABS II and Reported AF

Ranges
250
198
200 182
NUmber of clients
145
150
110 IQ
100 81 VABS II
69
58 Concluding AF
50 47
50
1 7 8 7
0
Range of Disability
Figure 5.30. illustrates very clearly the tendency of the IQ score to underestimate
ability and that the adaptive functioning assessment is crucial to giving a more accurate
description of the range of disability. It also illustrates the recurring theme of the VABS II
underestimating the ability of people in the severe range. In order to understand this
discrepancy further, the VABS II scores were examined against the domain age groups given
in the manual.
168
5.3.15. Age categories to VABS II ranges.
Figure 5.31. VABS II Age Categories : VABS II Ranges

80
72
70
60
Number of clients
50
38
40
30 29
30
21 20 19
20 15
13
11
8 9
10 6 5
4 4 3
1 1 1 1 2 1 1 2 2 1 1
0
VABS II Domain Age Categories
Figure 5.31. illustrates very clearly that for those clients over 22 years in age there
was a sharp and unexplained increase of those falling in the range of severe disability when
scored according to the VABS II norms. This is examined in greater detail in the statistical
analysis chapter (section 6.4., p. 174) and the discussion chapter (section 7.4., p. 236).
There is much interesting contextual data presented in this chapter. It is included to
give a richer picture of the group to which Sarai, Themba and Madelaine belong, but the
focus returns to the research questions. The next chapter looks in more detail at the statistical
and clinical item analysis pertaining to the questions posed.
169
Chapter Six: Results of the Statistical and Clinical Item Analysis
6.1. Introduction
The results are reported in order of the research questions posed. Discussion of the
results follows in the next chapter. Pages of relevant discussion are indicated in the text and
hyperlinked for ease of reference in the electronic version.
6.2. Question One: Discrimination of different ranges of intellectual disability
The first research question asked if the norms of the Vineland Adaptive Behavior
Scales (1984) (referred to as the VABS) and the Vineland Adaptive Scales, Second Edition
(2005) (referred to as the VABS II), developed in the United States, discriminated accurately
between different ranges of intellectual disability within this particular South African context.
This was examined at two levels.
6.2.1. Association between standard score IQ and standard score of adaptive
functioning (AF).
The first of these questions asked what association there was between the measured
intelligence quotient (IQ) score using the Individual Scale of General Scholastic Aptitude
(referred to as the ISGSA) and the standard score measurements of AF using the VABS and
VABS II
6.2.1.1. VABS.
The results of the initial correlation analysis indicated a statistically significant
relationship between the ISGSA and the VABS, with a Pearson product-moment correlation
coefficient of .685 (p < .001). Further analysis using regression analysis, with the ISGSA
standard score as the dependent variable and the VABS composite standard score as the
independent variable, resulted in a statistically significant prediction (p < .001) with the
VABS accounting for 46.8% of the variance in the ISGSA score. (n=321)
170
6.2.1.2. VABS II.
Using the same data analytic methods but substituting the relevant ISGSA scores and
VABS II scores, it was found that the ISGSA and the VABS II were significantly associated
with each other, with a Pearson product-moment correlation coefficient of .619 (p < .001).
The regression analysis similarly indicated that the VABS II significantly predicted the
ISGSA (p < .001) with the VABS II accounting for 38.3% of the variance in the ISGSA score
(n=321).
A sub group analysis was run on the Afrikaans home language speakers and both the
correlation (.633) and prediction remained significant (p < .001) with a marginally higher
(40%) percentage variance in the ISGSA accounted for by the VABS II (n=211).
A sub group analysis was run on the isiXhosa speakers and both the correlation (.578)
and prediction remained significant (p < .001) but the VABS II accounted for a lower
percentage of the variance in ISGSA scores (33.4%) (n=85).
The results will be discussed further in the following chapter (section 7.2., p. 232.).
6.2.2. Reported diagnosis of disability compared with VABS and VABS II
measurements.
The second part asked how the reported diagnosis and assessment of the evaluating
clinical psychologist as reported in the conclusion of the psycho-legal report compared with
the range of disability measured by the VABS and VABS II.
A Chi-square analysis of the psychologists’ diagnosis and its association with the
level of disability as measured by the VABS (n=321) and the VABS II (n=321) was run.
A statistically significant association (p < .001) was found between the psychologists’
diagnosis and the level of disability measured by both the group assessed with the VABS and
group assessed with the VABS II.
The results will be discussed further in the following chapter (section 7.2., p.232.).
171
6.3. Question Two: Association of variables to VABS and VABS II measurements
The next research question asked if there was a significant association between
variables of language, gender, geographic distribution, and access to education with
measurements obtained using the VABS and VABS II. Socioeconomic status was not used as
a variable as the sample was predominantly from a low socioeconomic bracket, neither was
exposure to trauma used as a variable, as all participants had been exposed to sexual trauma.
Those whose response to the sexual trauma resulted in a psychiatric diagnosis, were excluded
from the sample.
6.3.1. VABS.
Language correlated with VABS significantly (p <.05). Correlation coefficient is
weak (-.115) but significant (p=.039). Gender correlated with VABS = non-significant
(p>.05). Geographic distribution correlated with VABS = non-significant (p>.05).
The more appropriate analysis for these relationships would be chi-square given the
binary nature of gender and geographic distribution. Chi-square analysis shows that the
relationship between:
Gender and VABS categories was non-significant (p>.05). Geographic distribution
and VABS categories was non-significant (p>.05).
A logistic regression analysis was conducted with the VABS sample measurement as
the dependent variable. The moderate and severe levels of ID were combined into one
category as were the mild and borderline categories of ID as the analysis only allows for
binary dependent variables. Independent variables were language, gender, and urban or rural
geographic distribution. Information regarding access to education was not reliable for the
VABS sample so was excluded from the analysis. The only significant predictor of the newly
formed categories was language (p <.01) where English speakers were 3.09 times more likely
(95% CI: 8.77 - 1.08) to be in the moderate/severe category than Afrikaans speakers and 6.77
172
times more likely (95% CI: 6.77 - 22.73) to be in the moderate/severe category than isiXhosa
speakers.
6.3.2. VABS II.
Language correlated with VABS II = non-significant (p >.05). Gender correlated with
VABS II = non-significant (p >.05). Geographic distribution correlated with VABS II = non-
significant (p >.05). Access to education correlated with VABS II = significant (p <.001).
The more appropriate analysis for these relationships would be chi-square given the
binary nature of gender, geographic distribution and access to education. Chi-square analysis
shows that the relationship between:
• Gender and VABS II is non-significant (p>.05).
• Geographic distribution and VABS II is non-significant (p>.05).
• Access to education and VABS II is significant (chi-square=13.27, p<.01).
The same method was used but to the independent variables of language, gender, and
urban or rural geographic distribution was added access to education. The VABS II sample
measurements were grouped as before as the dependent variable. The only significant
predictor was whether participants had access to education or not (p <.01). Those participants
who did not have access to education were 2.93 times (95% CI: 1.39 - 6.20) more likely to be
in the moderate/severe category than those who did have access to education.
The results will be discussed further in the following chapter (section 7.3., p. 235.).
6.4. Question Three: Evaluation of floor effects, sensitivity and specificity of the VABS
II for adults over 22 years old with intellectual disability
The third research question asked if the VABS II was able to discriminate between
levels of intellectual disability for the adults in the sample and asked for the critical
evaluation of the floor effects, evidenced in the norm tables for adults and examine the
sensitivity and specificity of the VABS II for a sample of intellectually disabled adults.
173
A receiver operating characteristic curve analysis (ROC) was conducted comparing
moderate and severe ID in the sample of 321 participants assessed using the VABS II ranging
in age from four to 55 years. Hanley and McNeil (1982) describe the Area Under the Curve
(AUC) as indicative of a scale’s ability to discriminate between participants with and without
a particular diagnosis. AUC’s of .50 to .70 are indicative of low accuracy, .70 to .90 indicate
utility and an AUC greater than .90 indicates high accuracy (Fischer, Bachman, & Jaesche,
2003; Swets, 1998). (For graphical representation and detailed tables of the results of the
analysis, refer to Appendix P.)
6.4.1. Full sample: VABS II scores onto psychologists’ evaluation of IQ.
Using the psychologists’ evaluation of Intelligence Quotient (IQ) as the gold standard
and the psychologists’ rating of severe IQ as caseness the following was found:
• The AUC was .758 which is indicative of utility.
• At the upper end of the severe IQ range, at the cut off score of 34 on the VABS II,
the true positive probability (sensitivity) is .654 while the true negative probability
(specificity) is .310. The VABS II can predict severe IQ 65.4% of the time.
• The VABS II predicts IQ correctly 100% of the time when the standardised score
on the VABS II reaches 56, where the true positive probability (sensitivity) is 1.0
and the true negative probability (specificity) is .265.
6.4.2. Participants over 22 years: VABS II scores onto psychologists’ evaluation
of IQ.
Using the same analysis for those participants over 22 years (n=96) using the
psychologists’ evaluation of IQ as the gold standard and the psychologists’ rating of severe
IQ as caseness the following was found:
• The AUC was .691 which is barely indicative of utility.
174
• At the upper end of the severe IQ range at the cut off score of 34 on the VABS II,
the true positive probability (sensitivity) is 1.0 while the true negative probability
(specificity) is .171.
• The VABS II predicts severe IQ correctly 100% of the time when the standardised
score on the VABS II reaches 33, where the true positive probability (sensitivity)
is 1.0 and the true negative probability (specificity) is .195.
• Due to the AUC of .691 this could be by chance.
6.4.3. Participants younger than 22 years: VABS II scores onto psychologists’
evaluation of IQ.
Using the same analysis for those participants younger than 22 years (n=225) using
the psychologists’ evaluation of IQ as the gold standard and the psychologists’ rating of
severe IQ as caseness the following was found:
• The AUC was .854 which is indicative of the high end of utility.
• The lowest score is such that the first coordinate on the ROC is 27. There are
limited cases within this age group with only 21 cases of Severe IQ, 72 of
Moderate IQ and 132 of Mild IQ.
the true positive probability (sensitivity) is .143 while the true negative probability
(specificity) is .986. The VABS II can predict severe IQ 14.3% of the time.
The VABS II predicts IQ correctly 100% of the time when the standardised score on
the VABS II reaches 56, where the true positive probability (sensitivity) is 1.0 and the true
negative probability (specificity) is .417.
175
6.4.4. Full sample: VABS II scores onto psychologists’ evaluation of adaptive
functioning (AF).
Using the psychologists’ evaluation of Adaptive Functioning (AF) as the gold standard
and the psychologists’ rating of severe AF as caseness the following was found:
• At the upper end of the severe ID range at the cut off score of 34 on the VABS II,
the true positive probability (sensitivity) increases to .936 while the true negative
probability (specificity) decreases to .667. The VABS II can predict severe AF
93.6% of the time.
• The VABS II predicts AF correctly 100% of the time when the standardised score
and the true negative probability (specificity) is 0.
6.4.5. Participants over 22 years: VABS II scores onto psychologists’ evaluation
of adaptive functioning.
Using the same analysis for those participants over 22 years (n=96) using the
psychologists’ evaluation of AF as the gold standard and the psychologists’ rating of severe
AF as caseness the following was found:
• The AUC was .659 which is barely indicative of low accuracy.
• It is of no use to further interrogate the data.
6.4.6. Participants younger than 22 years: VABS II onto psychologists’
evaluation of adaptive functioning.
the psychologists’ evaluation of AF as the gold standard and the psychologists’ rating of
severe AF as caseness the following was found:
176
• At the upper end of the severe ID range at the cut off score of 34 on the VABS II,
probability (specificity) stays the same at .1.0. The VABS II can predict severe
AF 57.1% of the time.
• The VABS II predicts AF correctly 100% of the time when the standardised score
and the true negative probability (specificity) is 0.
6.4.7. Full sample: VABS II scores onto ISGSA scores of IQ.
A ROC analysis was used to compare moderate IQ scores (ISGSA scores of 35-49)
and severe IQ scores (ISGSA scores of 20-34) from within the sample, using the ISGSA
ratings of IQ as the gold standard and the ISGSA rating of severe IQ as caseness the
following was found:
• The AUC was .719 which is barely indicative of utility.
probability (specificity) decreases to .679. The VABS II can only predict severe
IQ 58.6% of the time.
• The VABS II only predicts IQ correctly 100% of the time when the standardised
score on the VABS II reaches 64, where the true positive probability (sensitivity)
is 1.0 and the true negative probability (specificity) is .009.
6.4.8. Participants over 22 years: VABS II scores onto ISGSA score of IQ.
Using the same analysis for those participants over 22 years (n=96) using the ISGSA
ratings of IQ as the gold standard and the ISGSA rating of severe IQ as caseness the
following was found:
• The AUC was .655 which is indicative of low accuracy.
177
• It is of no use to further interrogate the data.
6.4.9. Participants under 22 years: VABS II scores onto ISGSA scores of IQ.
the ISGSA ratings of IQ as the gold standard and the ISGSA rating of severe IQ as caseness
the following was found:
• The AUC was .810 which is indicative of utility.
there is a true positive probability (sensitivity) of .115 and a true negative
probability (specificity) of .986. The VABS II can only predict severe ID 11.5%
of the time.
• The VABS II predicts IQ correctly 100% of the time when the standardised score
and the true negative probability (specificity) is .014.
6.4.10. Cross tabulation of ISGSA standard scores and the psychologists’
assessment of IQ.
Table 6.1, gives an indication of the number of cases where the psychologists’
evaluation of IQ range differed from the numerical score as categorised by the ICD-10 but
was within the confidence interval of +/- 5 (green) in all but one case (cerise).
ICD-10 categories were used but with the allowance of standard deviation differences
described by the DSM-5:
• Severe ID range: Standard score of 20-34 +/- 5
• Moderate ID range: Standard score of 35-49 +/- 5
• Mild ID range: Standard score of 50-69 +/-5
• Borderline range: Standard score of 70-80 +/-5
178
Table 6.1.
Cross Tabulation of ISGSA Standard Score and Psychologists’ Assessment of IQ
ISGSA Standard score Psychologists’ assessment of IQ Total
Borderline Mild Moderate Severe
ID ID ID
26 0 0 0 2 2
27 0 0 1 2 3
28 0 0 0 7 7
29 0 0 0 15 15
30 0 0 0 10 10
31 0 0 0 2 2
32 0 0 1 4 5
33 0 0 0 4 4
34 0 1 4 5 10
35 0 0 5 1 6
36 0 0 5 0 5
37 0 0 4 0 4
38 0 0 11 0 11
39 0 0 9 0 9
40 0 0 12 0 12
41 0 0 10 0 10
42 0 0 6 0 6
43 0 1 12 0 13
44 0 0 8 0 8
45 0 0 1 0 1
46 0 2 9 0 11
47 0 0 2 0 2
48 0 1 6 0 7
49 0 0 4 0 4
179
ID ID ID
50 0 11 3 0 14
51 0 16 0 0 16
52 0 11 0 0 11
53 0 15 0 0 15
54 0 19 0 0 19
55 0 5 0 0 5
56 0 9 0 0 9
57 0 9 0 0 9
58 0 6 0 0 6
59 0 7 0 0 7
60 0 8 0 0 8
61 0 2 0 0 2
62 0 3 0 0 3
63 0 2 0 0 2
64 0 6 0 0 6
65 0 4 0 0 4
66 0 2 0 0 2
67 0 4 0 0 4
68 0 3 0 0 3
69 0 1 0 0 1
71 2 0 0 0 2
72 1 0 0 0 1
75 1 0 0 0 1
76 1 0 0 0 1
77 1 0 0 0 1
81 1 0 0 0 1
180
ID ID ID
83 1 0 0 0 1
Total 8 148 113 52 321
6.4.11. Cross tabulation of VABS II standard score and the psychologists’
assessment of IQ.
Table 6.2. gives a tabulated comparison of the VABS II score (AF) to the
psychologists’ assessment of IQ Level. The highlighted areas indicate where these are within
the confidence interval of +/- 5 points (green) and which scores are beyond that boundary
(cerise) according to the criteria described above. A modest correlation is expected. (Refer to
the earlier described correlation.) In 103 (32%) of assessments the IQ range varied from the
VABS II score range by more than the confidence interval of +/- 5.
Table 6.2.
Cross Tabulation of the VABS II Overall Standard Score with the Psychologists’
Assessment of IQ
VABS II Overall Standard Score Psychologists’ assessment of IQ Total
ID ID ID
20 0 0 13 17 30
21 0 1 3 5 9
22 0 1 2 2 5
23 0 0 1 2 3
24 0 0 2 1 3
25 0 2 3 1 6
26 0 1 3 0 4
181
28 0 0 1 0 1
29 0 3 1 1 5
30 0 1 2 0 3
31 0 0 1 1 2
32 0 0 2 2 4
33 0 1 0 0 1
34 0 2 1 2 5
35 0 2 4 1 7
36 0 0 1 3 4
38 0 1 0 0 1
40 0 1 2 1 4
41 0 1 2 1 4
42 0 2 0 0 2
44 0 1 1 1 3
45 0 0 1 1 2
46 0 0 4 4 8
47 0 0 2 1 3
48 0 3 1 0 4
49 0 2 5 1 8
50 0 2 3 0 5
51 0 1 2 0 3
52 0 2 7 0 9
53 0 3 3 1 7
54 0 4 6 2 12
55 0 2 1 0 3
56 0 4 3 1 8
57 1 8 6 0 15
58 1 11 11 0 23
59 0 7 3 0 10
182
60 0 13 1 0 14
61 1 16 7 0 24
62 0 12 1 0 13
63 1 9 0 0 10
64 0 10 0 0 10
65 0 4 0 0 4
66 0 5 1 0 6
67 0 3 0 0 3
68 0 2 0 0 2
69 0 1 0 0 1
70 1 1 0 0 2
71 2 0 0 0 2
73 0 1 0 0 1
74 1 0 0 0 1
75 0 1 0 0 1
77 0 1 0 0 1
Total 8 148 113 52 321
6.4.12. Cross tabulation of VABS II standard score and the psychologists’
assessment of adaptive functioning.
Table 6.3. compares the numbers of clients in each range as assessed by the VABS II
and the psychologists’ assessment of AF. Of note is the difference in number of people
assessed as falling in the range of severe AF by the psychologists (47) and the VABS II
scores (81) highlighted in cerise.
183
Table 6.3.
Comparison of the VABS II Overall Composite Range with the Psychologists’ Assessment of
Range of AF
Psychologists’ Assessment of Adaptive Functioning Total
VABS II Range Borderline 6 2 0 0 8
Mild 1 172 8 1 182
Moderate 0 10 38 2 50
Severe 0 14 23 44 81
Total 7 198 69 47 321
Table 6.4. gives a tabulated comparison of the VABS II standard score to the
psychologists’ assessment of AF range. The highlighted areas indicate where these are within
the confidence interval of +/- 5 points (green) and which scores are beyond that boundary
(cerise) according to the criteria described previously. A strong correlation is expected.
(Refer to the earlier described correlation.) In 45 (14%) assessments, the AF range, as
reported by the psychologist, varied from the VABS II score range by more than the
confidence interval of +/- 5.
Table 6.4.
Cross Tabulation of the VABS II Overall Composite Score with the Psychologists’
Assessment of AF
VABS II Overall 20 0 0 8 22 30
Standardised Score 21 0 0 4 5 9
22 0 0 2 3 5
23 0 0 0 3 3
184
24 0 0 1 2 3
25 0 3 2 1 6
26 0 0 3 1 4
28 0 0 0 1 1
29 0 3 1 1 5
30 0 3 0 0 3
31 0 0 1 1 2
32 0 1 1 2 4
33 0 1 0 0 1
34 0 3 0 2 5
35 0 2 5 0 7
36 0 1 2 1 4
38 0 1 0 0 1
40 0 1 2 1 4
41 0 1 3 0 4
42 0 2 0 0 2
44 0 1 2 0 3
45 0 0 2 0 2
46 0 0 8 0 8
47 0 0 3 0 3
48 0 0 4 0 4
49 0 1 7 0 8
50 0 3 2 0 5
51 0 2 1 0 3
52 0 6 3 0 9
53 0 7 0 0 7
54 0 12 0 0 12
185
55 0 3 0 0 3
56 1 6 1 0 8
57 0 14 1 0 15
58 0 23 0 0 23
59 0 10 0 0 10
60 0 14 0 0 14
61 0 23 0 1 24
62 0 13 0 0 13
63 0 10 0 0 10
64 0 10 0 0 10
65 0 4 0 0 4
66 0 6 0 0 6
67 0 3 0 0 3
68 0 2 0 0 2
69 0 1 0 0 1
70 1 1 0 0 2
71 2 0 0 0 2
73 1 0 0 0 1
74 1 0 0 0 1
75 1 0 0 0 1
77 0 1 0 0 1
Total 7 198 69 47 321
6.5. Results of the Clinical Item Analysis
This section provides results for the following research questions:
186
Question Four: to identify what useful qualitative information is used and reported in
the psycho-legal reports from the items in the VABS II.
Question Five: to examine and compare the VABS II published in 2005 with the
third edition Vineland-3, (VABS 3) published in 2016, using the change in item additions and
modification in the new edition.
Question Six: to examine and identify those items in the VABS II which may need
contextual and linguistic adaptation for this group of clients and to assess to what extent these
have been addressed or adapted in the 2016 edition of the VABS 3.
The following results are synthesised from a number of sources of data:
• The data from the clinical item analysis of the VABS II survey interview form
where seven psychologists, who have been involved in the SAVE programme,
identified useful items and difficult items and further classified the difficulty as
cultural, no opportunity or linguistic.
• The transcription of the discussion which followed by five psychologists involved
in the clinical assessments, regarding the useful and difficult items in the VABS
II.
• The data from a sample of psycho-legal reports, (n=65) whereby information from
items in the VABS II, used within the body of the report, was analysed and
classified. This included analysis of difference in terms of developmental
sequence with children under 12 years (n=15), adolescents between 13 and 18
years (n=23) and adults over 18 years (n=27).
• Clinical item analysis of scores of the full sample (n=321) highlighting “Don’t
know” or “No opportunity” responses as these were hypothesised as tagging items
which are difficult to score in this group of people.
• Comparison of the items of the VABS II and the VABS 3.
187
The results provide the framework for the later discussion (sections 7.5., 7.6. and 7.7.,
p.242-256.). The results will be presented by domain and subdomain, following the order of
the survey interview form. Each subdomain is referenced to the page in the appendix for
reference to the content of the item and hyperlinked in the electronic version.
6.5.1. Communication: Receptive. (Appendix C, p. 330)
6.5.1.1. Results of psychologists’ discussion.
• Assessment using the items pertaining to following instruction was particularly
helpful in reference to helping the court understand the client’s limitations in
terms of questioning in court and the need to keep questions simple and singular.
• Evaluation of attention and concentration was also highlighted as important for
the court process.
• A general point is made about the VABS II eliciting “things…that maybe one
wouldn’t necessarily talk about in a general history taking, that it…brings to
light…that are useful in terms of having a picture of this person that you are
representing in court”. (P5)
• Difficulties were mentioned in relation to understanding of idiomatic speech (Item
18) and that it is helpful to have colloquial examples, especially in different
languages and that using colloquial examples can help the respondent understand
what you are asking.
188
Table 6.5.
Clinical Item Analysis of the Receptive Communication Subdomain of the VABS II
VABS II Comparison No of % of % of % used in % No of Marked Difficulty
Receptive with VABS psychologists that that adolescent used psychologists use of addressed
communication 3 items marking item item report in marking D/K or in VABS
items with items as used in used in (n=23) adult items as N/O 3
content useful (n=7) psycho- child report difficult response
category (Survey legal report (n=27) (n=7) (n=321)
Interview report (n=15) (Survey
Form) (n=65) interview
Form)
1 Deleted
Understanding
2 Listening & Repeated
attending
3 Repeated
Understanding
4 Adapted
Understanding
5 Adapted 1/5
Understanding
6 Listening & Deleted 3% 13% N/O 1/7 Yes
attending
7 Repeated 1.5% 6.6%
Understanding
8 Adapted
Understanding
9 Listening & Adapted 5/7 18.5% 13% 8,7% 25.9%
attending
10 Following Repeated 5/7 21.5% 20% 13% 25.9%
instructions
11 Deleted 3/7 3% 6.6% 4.3%
Understanding
12 Following Adapted 4/7 27.7% 20% 17.4% 33.3%
instruction
189
Receptive with VABS psychologists that that adolescent used psychologists use of addressed
category (Survey legal report (n=27) (n=7) (n=321)
Interview report (n=15) (Survey
Form) (n=65) interview
Form)
13 Following Repeated 4/7 20% 20% 26.1% 22.2% 1 D/K
instructions
14 Listening & Repeated 3/7 15.4% 13% 26.1% 7.4% N/O 1/7 Retained
attending
15 Listening & Adapted 16.9% 20% 26.1% 7.4% N/O 1/7 7 D/K Adjusted
attending
16 Following Repeated 5/7 21.5% 20% 21.7% 22.2% 1 D/K
instructions
17 Listening & Deleted 3/7 21.5% 20% 21.7% 22.2% 2 D/K
attending
18 Deleted 1.5% 4.3% L 15 D/K Yes
Understanding 2/7 (4.7%)
19 Listening & Adapted 4.6% 8.7% 3.7% 6 D/K
attending
20 Listening & Adapted 3% 8.7% 6 D/K
attending
NOTES: Repeated Items Items Items N/O – No
items scoring scoring scoring Opportunity
include over over over 20% L–
those with 20% 20% noted in Linguistic
minor noted noted text C – Cultural
wording in text in text
changes
6.5.1.2. Summary of clinical item analysis of the receptive communication
subdomain.
• Differentiation of scores starts from Item 6.
190
• Two of the items (6 and 18) identified as difficult by the psychologists have been
deleted from the VABS 3.
• Difficulty with two items (14 and 15) was related to never having been read
stories therefore no opportunity offered. The VABS 3 retains the first item related
to attention to a story for 15 minutes but adapts Item 15 to paying attention to a
television show for 30 minutes.
• Five items are reported on extensively (>20%) in the psycho-legal report (10, 12,
13, 16 and 17). Six items are used extensively in child reports (including Item 15),
five items for adolescents (13-17) and six items in adult reports (including Item
9).
• Five items were described as useful by the majority of the psychologists (9, 10,
12, 13 and 16).
• The results correlate with the discussion regarding the percentage reporting of
items and marked as useful related to listening and attending (Items 9, 14, 15 and
17) and following instructions (Items 10, 12, 13 and 16). Description in the report
relates to what a person both can and cannot do, thus defining a limited capacity.
• The spread of percentage reporting is understood to reflect differing levels of
ability in terms of individual clients and developmental sequencing through
childhood into adulthood.
6.5.2. Communication: Expressive. (Appendix C, p. 331)
• For a person with a limited vocabulary, Items 20 and 26, which ask if the person
can say 50 or 100 recognisable words respectively, help to quantify this. It further
informs further test choice in terms of the assessment with regards to the use of a
non-verbal IQ test.
191
• The usefulness of Item 38 was emphasised as to whether the person speaks clearly
without sound substitutions. This is an important observation to note in relation to
testifying in court. (Note: This item has been deleted in the VABS 3.)
• Items 24, 39, 42 and 43 relate to the person’s ability to give a narrative account of
their experience and giving directions. This is useful for assessment regarding the
ability to testify in court.
• Exploring goal setting was identified as useful (Item 52 and 54) “…it’s very
helpful to say that although this person might have a Standard 6 [primary school]
education, they’re sitting at home doing nothing, they don’t have any sense of
how they might want to work if they didn’t work”. (P1)
• The use of prepositions, tenses, plurals, possessives and pronouns was identified
as very “English orientated” and “…not terribly friendly for cross cultural
language stuff”. (P1) (Items 27, 32, 33, 34, 36, 37, 44, 50). They question that, in
different languages, these skills might develop in a different linguistic and
developmental sequence.
• They identify the remembering of telephone numbers as asked in Item 45 as
changing with the common use of cell phones and referencing numbers by name
rather than having to enter a number sequence. (This item has been deleted in the
VABS 3.)
• Item 51, which requires knowing your full home address, was identified as both
important and difficult. The difficulty is that of no opportunity (N/O) as many of
the clients live on rural farms and have not been taught a formal address. They
also discussed what would qualify contextually for people living on a rural farm,
i.e., knowing the name of the farm and the local area as being “good enough” (P3)
to score the item. There was also discussion regarding whether the intention was
192
knowing your postal address or “if you got lost, you could tell someone where you
lived”. (P5) There was some discussion as to whether that met criteria as the
VABS II manual states “the individual must state the address as it would be
written on an envelope” (Sparrow et al., 2005, p. 305). The zip or postal code is
optional. (Refer to section 7.7.4. for further discussion.)
Table 6.6.
Clinical Item Analysis of the Expressive Communication Subdomain of the VABS II
VABS II Comparison No of % of % of % used in % used No of Marked Difficulty
Expressive with VABS 3 psychologists that item that adolescent in adult psychologists use of addressed
communicati items marking items used in item report report marking items D/K or in VABS
on items with as useful psycho- used in (n=23) (n=27) as difficult N/O 3
content (n=7) legal child (n=7)(Survey response
category (Survey report report interview (n=321)
Interview (n=65) (n=15) Form)
Form)
1 Pre-speech Repeated
expression
2 Pre-speech Moved to
expression Interpersonal
relationships
subdomain
expression
4 Pre-speech Adapted
expression
expression
expression
7 Pre-speech Condensed
expression and adapted*
8 Beginning Repeated
to talk
193
Form)
11 Beginning Repeated 1/7
to talk
to talk
to talk
14 Interactive Repeated 1/7
speech
15 Beginning Deleted 3/7 1.5% 6.6%
to talk
to talk
17 Interactive Repeated 1/7
speech
to talk
19 Interactive Deleted 1/7 2 D/K
speech
to talk
21 Speech Repeated 6/7
skills
22 Interactive Deleted 2/7
speech
194
Form)
23 Beginning Repeated 1/7 1.5% 3.7%
to talk
24 Beginning Adapted 6/7 4.6% 4.3% 7.4%
to talk
25 Interactive Adapted 6/7 30.8% 46.7% 21.7% 29.6%
speech
26 Beginning Deleted 3/7
to talk
27 Speech Repeated 1/7 3% 6.6% 4.3% 2 D/K
skills
28 Speech Repeated 1/7 3% 6.6% 4.3% 1/7 L Retained
skills
29 Interactive Repeated 5/7 9.2% 20% 4.3% 7.4% 1 D/K
speech
30 Speech Deleted 5/7 9.2% 6.6% 4.3% 14.8% 1 D/K
skills
31 Interactive Expanded 3% 6.6% 4.3% 2/7 L 1 D/K Adjusted
speech
32 Speech Deleted 10.8% 20% 8.7% 7.4% 6/7 L 10 D/K Yes
skills (3.1%)
33 Speech Repeated 4.6% 13.3% 4.3% 4/7 L 13 D/K Retained
skills (4%)
34 Speech Repeated 7.7% 20% 4.3% 3.7% 3/7 L 11 D/K Retained
skills (3.4%)
35 Interactive Repeated 6.2% 6.6% 4.3% 7.9% 2/7 L Retained
speech
36 Speech Repeated 1/7 13.8% 20% 8.7% 14.8% 5/7 L 7 D/K Retained
skills
195
Form)
37 Speech Condensed 1/7 9.2% 13.3% 4.3% 11% 3/7 L 22 D/K Adjusted
skills and adapted# (6.7%)
38 Speech Deleted 6/7 18.5% 26.7% 21.7% 11% 1/7 L 1 D/K Yes
skills
39 Expressing Repeated 6/7 16.9% 26.7% 13% 14.8% 6 D/K
complex
ideas
40 Interactive Repeated 4/7 47.7% 40% 60.9% 40.7% 1/7 C Retained
speech
41 Speech Moved to 1/7 10.8% 13.3% 17.4% 3.7% 13 D/K Retained
skills interpersonal (4%)
relationships
subdomain
42 Expressing Adapted 6/7 35.4% 33.3% 30.4% 40.7% 1 D/K
complex
ideas
43 Expressing Adapted 2/7 4.6% 6.6% 8.7% 5 D/K
complex
ideas
44 Speech Condensed 1/7 9.2% 6.6% 4.3% 14.8% 3/7 L 28 D/K Adjusted
skills and adapted# (8.7%)
45 Interactive Deleted 3/7 12.3% 6.6% 17.4% 11% 3/7 N/O 5 D/K Yes
speech
46 Interactive Moved to 2/7 12.3% 8.7% 22.2% 5 D/K
speech interpersonal
relationships
subdomain
47 Interactive Moved to 5/7 15.4% 13.3% 8.7% 22.2% 4 D/K
speech interpersonal
196
Form)
relationships
subdomain
48 Expressing Deleted 2/7 3% 4.3% 3.7% 1/7 C 7 D/K Yes
complex
ideas
49 Speech Deleted 4/7 13.8% 6.6% 8.7% 22.2% 3 D/K
skills
50 Speech Deleted 1.5% 6.6% 6/7 L 16 D/K Yes
skills (5%)
51 Interactive Repeated 3/7 32.3% 13.3% 43% 33.3% 4/7 N/O Retained
speech
52 Expressing Moved to 2/7 2 D/K
complex community
ideas subdomain
53 Expressing Adapted 2/7 1 D/K
complex
ideas
54 Expressing Moved to 1/7 1/7 C 1 D/K Retained
complex community
ideas subdomain
items include scoring scoring scoring Opportunity
minor over over over 20% L – Linguistic
wording 20% 20% noted in C – Cultural
changes noted in noted text
text in text
197
6.5.2.2. Summary of clinical item analysis of the expressive communication
subdomain.
• Five of the items (32, 38, 45, 48 and 50) identified as difficult by the
psychologists have been deleted from the VABS 3.
• Nine of the items (28, 33, 34, 35, 36, 40, 41, 51, 54) identified as difficult by the
psychologists have been retained in the VABS 3. Item 51 is reported extensively
in adolescents and adults (>33%). It related to being able to say their complete
address. The psychologists’ discussion identified the difficulty and the importance
of this as an expressive life skill.
• Three of the items (31, 37 and 44) identified as difficult by the psychologists have
been adjusted in the VABS 3.
• Items reported on extensively in the psycho-legal report included numbers 25
(>30%), 40 (>40%), 42 (> 30%) and 51 (>30%), the latter particularly in adults
and adolescents.
• Six items (29, 32, 34, 36, 38 and 39) were used in more than 20% of the reports
for children.
• One item (38) was used in more than 20% of the reports for adolescents.
• Items 46, 47 and 49 were used in more than 20% of the reports for adults.
• There were eleven items with which the psychologists identified linguistic
difficulties.
6.5.3. Communication: Written. (Appendix C, p. 334)
• The usefulness of this subdomain was quantifying the person’s level of reading
and writing skill “a kind of level to peg it at”. (P2)
198
• One psychologist identified the need to check and show people a page with
numbers and letters to score Item 1 to see if they could distinguish them, as many
times the caregiver would underestimate this skill. (P3)
• A general difficulty with this domain was that “exposure to education
opportunity” (P5) was very influential and discriminated in this group as many,
particularly in the rural areas had had little or no exposure to education.
• Item 19, requiring writing “complete mailing and return addresses on letters or
packages” (VABS II Survey Interview Form Communication Written, 2005, p. 9)
was identified as “people just don’t do that kind of thing”. (P2)
Table 6.7.
Clinical Item Analysis of the Written Communication Subdomain of the VABS II
Written with VABS psychologists that that adolescent used psychologists use of addressed
category (Survey legal report (n=27) (n=7)(Survey (n=321)
Interview report (n=15) interview
Form) (n=65) Form)
1 Beginning to Repeated 5/7 27.7% 20% 17.4% 40.7%
Read
2 Beginning to Repeated 5/7 24.6% 26.6% 13% 33%
Read
3 Beginning to Repeated 5/7 30.8% 33.3% 17.4% 40.7% 1 D/K
Read
4 Writing skills Adapted 5/7 26% 26.6% 13% 37%
5 Writing skills Repeated 4/7 26% 26.6% 13% 37%
6 Beginning to Repeated 5/7 43% 40% 39.1% 48.1% 4 D/K
Read
7 Writing skills Repeated 4/7 38.5% 33.3% 30.4% 48.1% 2 D/K
8 Writing skills Repeated 7/7 52.3% 60% 56.5% 44.4%
199
Form) (n=65) Form)
9 Beginning to Repeated 5/7 43% 46.7% 39.1% 44.4% 1 D/K
Read
10 Writing Repeated 5/7 32.3% 40% 26% 33% 2 D/K
skills
11 Beginning Adapted 5/7 23% 13.3% 21.7% 29.6% 1/7N/O 2 D/K Adjusted
to Read
12 Writing Adapted 4/7 15.4% 6.7% 17.4% 18.5%
skills
13 Writing Repeated 5/7 7.7% 13% 7.4% 2 D/K
skills
14 Reading Adapted 6/7 27.7% 13.3% 43.5% 22.2% 2 D/K
skills
15 Reading Adapted 1/7 3% 4.3% 3.7% 2/7 N/O 4 D/K Adjusted
skills
16 Writing Repeated 1/7 4.6% 13% 1/7N/O 3 D/K Retained
skills
17 Reading Adapted 5/7 13.8% 6.7% 13% 18.5%
skills
18 Writing Adapted 1/7 1/7N/O 1 D/K Adjusted
skills
19 Writing Deleted 1/7 3/7N/O 1 D/K Yes
skills
20 Reading Adapted 2/7 1 D/K
skills
21 Writing Repeated 1/7N/O Retained
skills
22 Writing Adapted 1/7N/O Adjusted
skills
200
Form) (n=65) Form)
23 Reading Adapted 1/7
skills
24 Reading Deleted 1/7N/O Yes
skills
25 Writing Adapted 1/7N/O Adjusted
skills
minor 20% 20% noted in Linguistic
wording noted noted text C – Cultural
changes in text in text
6.5.3.2. Summary of the clinical item analysis of the written communication
domain.
deleted from the VABS 3. Neither item was used or referenced in the psycho-legal
report.
retained in the VABS 3. In both cases only one of the seven psychologists
described a difficulty of no opportunity. This may relate to a contextual issue of
exposure to educational opportunity.
201
• Five of the items (11, 15, 18, 22 and 25) identified as difficult by the
psychologists have been adjusted in the VABS 3.
• Items 1-11 and 14 are extensively used in the psycho-legal reports. All pertain to
early reading and writing skills. In children there is a greater referencing to early
items as expected developmentally using Items 1-10, in adolescents Items 6-11
and 14 are used in more than 20% of the reports. However, in adults the earlier
items are used with Items 1-11 and 14 being used in more than 20% of the reports.
This may also reflect a lack of opportunity in terms of access to education as
discussed by the psychologists for this age group.
• Items 1-14 and 17 were rated as useful by the majority of the seven psychologists.
This subdomain is reported extensively in the psycho-legal reports with Item 8,
requiring the person to write their own first and last name from memory, being
referred to in 52.3% of the reports.
6.5.4. Daily Living Skills: Personal. (Appendix C, p. 335)
• There was agreement that all the items that give “levels of how they can look after
themselves” in terms of eating, dressing, toileting “…they are all helpful”. (P2)
• Item 23 was discussed in relation to cultural valuing of eating correctly with a
knife, fork and spoon, but that in some homes spoons are used with little use of
knife or fork to eat. One psychologist described exploring the use in terms of
utility: “…can they butter their own bread and cut their meat”. (P5)
• Item 30, regarding being able to turn taps on and adjusting temperature by adding
hot or cold water, was discussed with regard to access to water. The point was
made that “…adding it [hot water] from a tap is much safer than carrying a kettle
202
to a basin of water”. (P5) This is at a six-year-old level “and you would never ask
a six-year-old to do that”. (P2)
• Item 34 requires washing and drying of hair with a towel or hair dryer. Again
different types of hair require different levels of skills “…for some people it’s
much more difficult to brush [or wash] your hair because your hair is much
tighter…so you need an adult to do it for longer” and that “sometimes people have
shaved heads, so they don’t need to wash hair”. (P5)
• Item 36 to 40 regarding health care were described as difficult to assess if the
person had been “…really healthy their whole lives and haven’t needed to take
medication and there hasn’t been an opportunity”. (P2)
Table 6.8.
Clinical Item Analysis of the Personal Daily Living Skills Subdomain of the VABS II
Personal with VABS psychologists that item that adolescent in psychologists use of addressed
Daily 3 items marking used in item report adult marking D/K or in VABS
Living items as psycho- used in (n=23) report items as N/O 3
Skills items useful (n=7) legal child (n=27) difficult response
with (Survey report report (n=7)(Survey (n=321)
content Interview (n=65) (n=15) interview
category Form) Form)
1 Eating Retained
and
Drinking
2 Eating Retained
and
Drinking
3 Eating Retained
and
Drinking
203
4 Eating Retained 1/7
and
Drinking
5 Toileting Retained 1.5% 6.7%
6 Eating Retained 1/7
and
Drinking
7 Eating Deleted
and
Drinking
8 Dressing Retained 1/7 1.5% 6.7% 1/7 C Retained
9 Dressing Retained 1/7 3% 6.7% 4.3% 1/7 C Retained
10 Eating Retained 2/7 3% 8.6% 3/7 C Retained
and
Drinking
11 Eating Retained 1/7 1.5% 4.3%
and
Drinking
12 Eating Retained 3/7 6.2% 13% 3.7%
and
Drinking
13 Toileting Adapted 2/7 6.2% 6.7% 13% 1/7 C Adjusted
14 Dressing Retained 2/7 6.2% 6.7% 8.6% 3.7%
15 Toileting Deleted 2/7 6.2% 6.7% 8.6% 3.7% 1/7 C Yes
16 Toileting Retained 1/7 6.2% 6.7% 13%
17 Toileting Adapted 4/7 38.5% 46.7% 30.4% 40.7%
18 Dressing Deleted 3/7 35.4% 33.3% 26% 44.4%
19 Health Adapted 3/7 15.4% 13.3% 26% 7.4% 1/7 C Adjusted
Care
204
20 Toileting Adapted 4/7 47.7% 46.7% 47.8% 48.1% 1 D/K
21 Dressing Adapted 3/7 50.8% 53.3% 52.2% 48.1% 1 D/K
22 Dressing Retained 2/7 43% 33.3% 52.2% 40.7% 3 D/K
23 Eating Deleted 1/7 36.9% 53.3% 30.4% 33% 6/7 C 4 D/K Yes
and
Drinking
24 Bathing Adapted 4/7 55.4% 60% 56.5% 51.9% 1/7 C 1 D/K Adjusted
25 Retained 5/7 49.2% 40% 47.8% 55.6% 1/7 C 1 D/K Retained
Grooming
26 Dressing Retained 4/7 66.2% 66.6% 65.2% 66.6% 1/7 C 1 D/K Retained
27 Health Retained 1/7 18.5% 13.3% 21.7% 18.5%
Care
28 Dressing Retained 5/7 72.3% 73.3% 69.6% 74.1% 1/7 C Retained
30 Bathing Retained 4/7 24.6% 26.6% 30.4% 18.5% 2/7 C 6 D/K Retained
32 Bathing Adapted 6/7 90.7% 93.3% 82.6% 96.3% 1/7 C Retained
33 Toileting Adapted 3/7 12.3% 21.7% 11.1% 1/7 C 21D/K Adjusted
(6.5%)
34 Adapted 5/7 67.7% 66.6% 60.8% 74.1% 4/7 C 1 D/K Adjusted
Grooming
35 Health Deleted 2/7 9.2% 13% 11.1% 4 D/K
Care
36 Health Adapted 1/7 13.8% 17.4% 18.5% 1/7 N/O 3 D/K Adjusted
Care
37 Health Adapted 10.8% 13% 14.8% 4/7 N/O 3 D/K Adjusted
Care
38 Health Deleted 2/7 10.8% 13% 14.8% 1 D/K Yes
Care 8 N/O
205
39 Health Deleted 1/7 9.2% 8.6% 14.8% 1/7 N/O 9 N/O Yes
Care
40 Health Retained 1/7 3% 4.3% 3.7% 2/7 N/O Retained
Care
41 Health Adapted 1/7 1.5% 4.3% 2/7 N/O Adjusted
Care
minor 20% 20% noted in Linguistic
wording noted in noted text C – Cultural
changes text in text
6.5.4.2. Summary of the clinical item analysis of the personal daily living skills
subdomain.
• Differentiation of scores starts from item 8.
• Four of the items (15, 23, 38 and 39) identified as difficult by the psychologists
have been deleted from the VABS 3. Item 23, regarding eating utensil use was
raised by six of the seven psychologists as culturally inappropriate.
• Nine of the items (8, 9, 10, 25, 26, 28, 29, 30 and 40) identified as difficult by the
psychologists have been retained in the VABS 3. Of these, four (25, 26, 28, 29)
are reported on extensively in the reports and were reported by one psychologist
as a culturally related difficulty. Item 30 was discussed by the psychologists and
206
relates to access to running water and socioeconomic conditions in terms of using
taps (faucets) to adjust hot and cold water.
• Eight of the items (13, 19, 24, 33, 34, 36, 37 and 41) identified as difficult by the
psychologists have been adjusted in the VABS 3.
• Fifteen of the items are extensively used in all the psycho-legal reports. Fifteen
items are referred to in the child reports, 18 are used extensively in adolescent
reports and 14 in adult reports. In all, 81.5% of reports referred to the ability to be
able to choose clothing appropriate to the weather (Item 31) and 90.7% referred to
the level of independence in terms of washing themselves (Item 32).
• Eleven items (17, 20, 24, 25, 26, 28, 29, 30, 31, 32, and 34) were rated as useful
by the majority of the seven psychologists. This subdomain is reported
extensively in the psycho-legal reports and is discussed by the psychologists as
very useful.
6.5.5. Daily Living Skills: Domestic. (Appendix C, p. 337)
• Many items are helpful as the skills are “easy to relate to…paint a picture of
functioning…very helpful”. (P5)
• Reference to the “table” was often inappropriate, needing to first ascertain where
people eat their meals and if they have a table and then to adapt the questioning
around that. (P1)
• Household products are sometimes limited in very poor households with families
using a bar of soap for all cleaning, so the Item 16 asking about household
products being used correctly can need a no opportunity option.
207
Table 6.9.
Clinical Item Analysis of the Domestic Daily Living Skills Subdomain of the VABS II
Domestic with VABS psychologists that that adolescent in psychologists use of addressed
Daily Living 3 items marking item item report adult marking D/K or in VABS
Skills items items as used in used in (n=23) report items as N/O 3
with content useful (n=7) psycho- child (n=27) difficult response
category (Survey legal report (n=7)(Survey (n=321)
Form) (n=65) Form)
1 Safety at Retained 4/7 4.6% 13.3% 4.3% 1 D/K
Home
2 Kitchen Adapted 5/7 20% 26.7% 33.3% 14.8% 1/7 N/O Adjusted
chores 1/7 C
3 Kitchen Deleted 3/7 16.9% 26.7% 17.4% 11.1%
chores
4 Combined 3/7 7.8% 8.7% 11.1%
Housekeeping and
adapted*
5 Combined 3/7 9.2% 13.3% 14,8% 2 D/K
Housekeeping and
adapted*
6 Safety at Retained 4/7 3.1% 6.7% 3.7% 2 D/K
Home
7 Kitchen Adapted 4/7 18.5% 20% 33.3% 14.8% 3/7 N/O Adjusted
chores 1/7 C
8 Kitchen Deleted 6/7 56.9% 33.3% 65.2% 59.3%
chores
9 Kitchen Combined 6/7 15.4% 6.7% 13% 22.2% 1/7 N/O 1 D/K Adjusted
chores and
adapted#
10 Kitchen Combined 5/7 4.6% 6.7% 7.4% 1/7 N/O 1 D/K Adjusted
chores and 61 N/O
adapted#
11 Retained 4/7 30.8% 13.3% 30.4% 40.7% 1D/K
Housekeeping
208
Form) (n=65) Form)
12 Deleted 3/7 10.8% 8.7% 18.5% 2/7 N/O 9 D/K Yes
Housekeeping
13 Kitchen Retained 7/7 73.8% 60% 82.6% 74.1% 1 D/K
chores
14 Retained 7/7 73.8% 60% 78.3% 77.8%
Housekeeping
15 Kitchen Adapted 3/7 27.7% 6.7% 34.8% 33.3% 2/7 N/O 3 D/K Adjusted
chores 1/7 C
16 Retained 2/7 43.1% 20% 52.2% 48.1% 1/7 N/O 6 D/K
Housekeeping
17 Kitchen Deleted 6/7 55.4% 26.7% 60.9% 66.7%
chores
18 Deleted 4/7 30.8% 13.3% 30.4% 40.7%
Housekeeping
19 Kitchen Adapted 3/7 7.7% 8.7% 11.1% 3 D/K
chores
20 Kitchen Retained 5/7 46.2% 33.3% 47.8% 51.9% 1/7 N/O 1 D/K
chores
21 Kitchen Deleted 3/7 27.7% 13.3% 34.8% 29.6% 1/7 N/O Yes
chores
22 Adapted 5/7 33.8% 13.3% 39.1% 40.7%
Housekeeping
23 Adapted 2/7 4.6% 4.3% 7.4% 1 D/K Adjusted
Housekeeping
24 Kitchen Adapted 4/7 10.8% 17.4% 11.1%
chores
include over over over 20%
209
Form) (n=65) Form)
minor 20% 20% noted in L–
wording noted in noted text Linguistic
changes text in text C – Cultural
6.5.5.2. Summary of the clinical item analysis of the domestic daily living skills
subdomain.
• One of the items (12) identified as difficult by the psychologists, asking about the
use of tools, has been deleted from the VABS 3. Three items about the increasing
involvement in the preparation of food (8, 17 and 12) have been deleted. All of
these were used extensively in the psycho-legal reports. In the VABS 3 the items
refer to making a snack, preparing and eating leftovers and then preparing a full
meal as items of increasing difficulty.
• Five of the items (2, 7, 9, 10 and 15) identified as difficult by the psychologists
have been adjusted in the VABS 3. Two items (16 and 20) have been retained but
are used extensively in the reports.
• Twelve of the items are extensively used (>20%) in all the psycho-legal reports
(2, 8, 11, 13, 14, 15, 16, 17, 18, 20, 21 and 22). Nine items are used extensively in
the child reports (2, 3, 7, 8, 13, 14, 16, 17 and 20), 13 items are used in adolescent
reports (2, 7, 8, 11, 13, 14, 15, 16, 17, 18, 20, 21 and 22) and 12 items in adult
reports (8, 9, 11, 13, 14, 15, 16, 17, 18, 20, 21 and 22). More than 50% of the
210
information gleaned is referred to in the psycho-legal report. In all, 73.8% of the
reports referred to the ability to wash dishes and the cleaning of floors.
• Fourteen items (1, 2, 6, 7, 8, 9, 10, 11, 13, 14, 17, 18, 20, and 22) were rated as
useful by the majority of the seven psychologists. This subdomain is reported
extensively in the psycho-legal reports and is discussed by the psychologists as
very useful.
6.5.6. Daily Living Skills: Community. (Appendix C, p. 338)
• Many items were useful but particularly those relating to knowledge of time and
date. This assists describing the person’s limits, in this regard, in relation to the
courts expectations around questioning.
• There was reference to “anything to do with safety” in the category of rules, rights
and safety. This was also acknowledged to be covered in the Coping Skills
subdomain. (P2)
• Item five, which asks about appropriate behaviour whilst riding in a car, was
problematic for those who only use public transport, therefore have no
opportunity.
• The changing use of landline telephones to cell phones made some of the
telephone skills redundant or different.
• Demonstrating the right to personal privacy (Item 15) was highlighted as a
culturally determined issue and also relates to space in the home if people are
living in informal settlements with the whole family in one room, thus relates to a
socioeconomic issue.
• There was discussion about using the South African coins and bank notes when
asking about money skills.
211
• No opportunity was also highlighted regarding exposure to traffic lights and a
calendar in very rural areas (Items 20 and 21).
• There was discussion about the lack of community safety delaying many of the
skills in terms of independent travel. “Safety stuff impacts a lot… I know that,
that person would be doing that [travelling], and they are not [doing that] here, for
reasons other than their competence”. (P3)
• There was also discussion around curfew (Item 28). Does it require being able to
tell the time, or if they are given a more general signal such as supper time or
before dark, is that partial competence? The VABS II manual (Sparrow, 2005, p.
314) requires telling the time and returning within half an hour of the agreed time
to score fully.
Table 6.10.
Clinical Item Analysis of the Community Daily Living Skills Subdomain of the VABS II
Community with VABS psychologists that that adolescent in adult psychologists use of addressed
Daily Living 3 items marking item item report report marking D/K or in VABS
Skills items items as used in used in (n=23) (n=27) items as N/O 3
with content useful (n=7) psycho- child difficult response
Form) (n=65) Form)
1 Telephone Deleted 2/7 1.5% 3.7%
skills
2 Telephone Adapted 2/7 2 D/K
skills
3 Television Adapted 4/7 5 N/O
and radio and
combined*
4 Money Retained 3/7 13.8% 26.7% 13% 7.4% 3 D/K
skills
212
Form) (n=65) Form)
5 Rules, Retained 1/7 5/7 N/O 16 D/K Retained
rights and (5% of
safety sample)
6 Money Retained 4/7 32.3% 26.7% 43.5% 25.9%
skills
7 Rules, Deleted 3.1% 8.7% 1/7 N/O Yes
rights and
safety
8 Time and Retained 3/7 46.2% 53.3% 56.5% 33.3%
Dates
9 Rules, Deleted 1/7 4.6% 6.7% 7.4% 2 D/K
rights and
safety
10 Computer Adapted 1/7 4 D/K Adjusted
Skills and 100 N/O
combined* (31.2%
of
sample)
11 Telephone Deleted 3/7 26.2% 33.3% 17.4% 29.6% 1/7 C 4 D/K Yes
skills
12 Money Retained 5/7 80% 73.3% 82.6% 81.5% 1/7 C 6 D/K Retained
skills
13 Rules, Retained 4/7 9.2% 13.3% 8.7% 7.4% 4 D/K
rights and
safety
14 Time and Retained 7/7 64.6% 53.3% 73.9% 63% 1 D/K
Dates
213
Form) (n=65) Form)
15 Rules, Retained 3/7 3.1% 13.3% 3/7 N/O 30 D/K Retained
rights and 2/7 C (9.3% of
safety sample)
16 Rules, Retained 5/7 4.6% 13% 4 D/K
rights and
safety
17 Time and Retained 7/7 86.2% 86.7% 87% 85.2%
Dates
18 Money Retained 5/7 78.5% 66.7% 82.6% 81.5% 1/7 C 2 D/K Retained
skills
19 Money Retained 3/7 78.5% 66.7% 82.6% 81.5% 1/7 C 1 D/K Retained
skills
20 Rules, Retained 2/7 4.6% 6.7% 8.7% 4/7 N/O 27 D/K Retained
rights and (8.4% of
safety sample)
21 Time and Retained 3/7 56.9% 53.3% 52.2% 63% 3/7 N/O 3D/K Retained
Dates
22 Money Retained 3/7 6.2% 4.3% 11.1% 3 D/K
skills
23 Time and Deleted 5/7 72.3% 73.3% 73.9% 70.4% 2 D/K
Dates
24 Adapted 5/7 46.2% 53.3% 39.1% 48.1% 1/7 N/O 1 D/K Adjusted
Telephone
skills
25 Restaurant Adapted 1/7 1/7 N/O 2 D/K Adjusted
skills 50 N/O
(15,6%
of
sample)
214
Form) (n=65) Form)
26 Money Expanded 4/7 13.8% 6.7% 8.7% 22.2% 2/7 N/O 3 D/K Adjusted
skills
27 Time and Deleted 4/7 21.5% 20% 8.7% 33.3% 1 D/K
Dates
28 Rules, Moved to a 1/7 1.5% 3.7% 1/7 L 1 D/K Retained
rights and different 1/7 C
safety subdomain
29 Television Adapted 2/7 1 D/K
and radio 1 N/O
30 Money Retained 5/7 72.3% 66.7% 69.6% 77.8%
skills
31 Computer Adapted 2/7 2 D/K 28 Adjusted
Skills N/O
(8.7% of
sample)
32 Money Retained 5/7 1 D/K
skills
33 Job Skills Deleted 1/7 1.5% 4.3% 1/7 N/O 4 D/K Yes
34 Going Adapted 3/7 7.7% 13% 7.4% 2/7 C Adjusted
places
independently
35 Rules, Adapted 2/7 1/7 C 2 D/K Adjusted
rights and
safety
36 Job Skills Retained 1/7 1/7 N/O 1 D/K Retained
37 Money Retained 1/7 N/O Retained
skills
215
Form) (n=65) Form)
38 Going Adapted 4/7 1.5% 4.3%
places
independently
39 Job Skills Adapted 2/7 1.5% 4.3% 1/7 N/O Adjusted
40 Job Skills Moved to a 1/7 N/O 2 N/O Retained
different
subdomain
41 Money Adapted 3/7
skills
42 Job Skills Deleted 1/7 N/O Yes
43 Money Adapted 1/7 N/O Adjusted
skills
44 Money Adapted 1/7 N/O Adjusted
skills
include over over over 20% L – Linguistic
minor 20% 20% noted in C–
wording noted noted text Cultural/Cont
changes in text in text extual
6.5.6.2. Summary of clinical item analysis of the community daily living skills
subdomain.
• Four of the items (7, 11, 33 and 42) identified as difficult by the psychologists
have been deleted from the VABS 3. Safe behaviour in a car is retained (Item 5),
216
although many clients do not use cars, but rely on public transport such as mini
buses, buses, trains as discussed by the psychologists.
• Nine of the items (24, 25, 26, 31, 34, 35, 39, 43, and 44) identified as difficult by
the psychologists have been adjusted in the VABS 3. Four difficult items have
been retained and are used extensively in the reports (12 - 80%, 18 - 78.5%, 19 -
78.5% and 21 - 56.9%). Seven of the items identified as difficult by the
psychologists are not used much in the reports (5, 15, 20, 28, 36, 37, and 40).
• Thirteen of the items are extensively used (>20%) in all the psycho-legal reports
(6, 8, 11, 12, 14, 17, 18, 19, 21, 23, 24, 27 and 30). Fourteen items are used
extensively in the child (also Item 4) and adult reports (also Item 26) and 11 items
in adolescent reports (not Item 11 or 27). Items relating to time and money skills
were reported frequently (60-80%).
• Fifteen items (3, 6, 12, 13, 14, 16, 17, 18, 23, 24, 26, 27, 30, 32, and 38) were
rated as useful by the majority of the seven psychologists. This subdomain is
reported extensively in the psycho-legal reports and is discussed by the
psychologists as very useful. Item 23 detailing telling the time by the half hour is
deleted in the VABS 3 but was used in 72.3% of the reports.
6.5.7. Socialisation: Interpersonal Relationships. (Appendix C, p. 340)
• Indiscriminate friendliness was discussed and that it is covered in the coping skills
subdomain. Its relevance in this context was stressed “…I think the point is
terribly important”. (P1)
• The items are useful in describing social interaction skills
217
• The importance of what they do and what they do not do in reference to Item 37
relating to dating behaviour was discussed and the cultural norms which differ
relating to dating behaviour.
• The difficulty regarding language in Item 18, of a person repeating phrases heard
spoken before, by a parent or adult, was discussed. The suggestion was to ask for
examples of things the person might say from the caregiver and they often come
up with their own examples rather than having to find language and culturally
appropriate examples as the interviewer.
• Discussion included the cultural and subjective nature of personal space as asked
in Item 26, regarding keeping a comfortable distance between self and others in
social situations. “…it’s…about a subjective sense of coming in too close.” (P1)
Table 6.11.
Clinical Item Analysis of the Interpersonal Relationship Socialisation Subdomain of the
VABS II
Socialization with VABS 3 psychologists that that adolescent in adult psychologists use of addressed
Interpersonal items marking item item report report marking D/K or in VABS
Relationship items as used in used in (n=23) (n=27) items as N/O 3
Skills items useful (n=7) psycho child difficult response
with content (Survey -legal report (n=7)(Survey (n=321)
category Interview report (n=15) interview
Form) (n=65) Form)
1 Responding Retained
to others
2 Responding Deleted
to others
3 Expressing Adapted
and
recognizing
emotions
218
Form) (n=65) Form)
4 Expressing Retained
and
recognizing
emotions
5 Social Adapted
communicati
on
6 Responding Retained 1 D/K
to others
7 Responding Adapted 2/7
to others
8 Expressing Retained 3/7
and
recognizing
emotions
9 Imitating Retained 1 D/K
10 Adapted
Responding
to others
11 Retained 1/7 4.6% 6.7% 4.3% 3.7%
Responding
to others
12 Imitating Adapted and 1 D/K
moved to
receptive and
expressive
communicatio
219
Form) (n=65) Form)
13 Expressing Adapted 2/7 1.5% 3.7%
and
recognizing
emotions
14 Expressing Adapted 3/7 1.5% 3.7% 1 D/K
and
recognizing
emotions
15 Friendship Retained 5/7 35.4% 33.3% 52.2% 26.1%
16 Imitating Retained 2/7 1.5% 3.7% 4 D/K
17 Social Retained 4/7 6.2% 13% 3.7%
communicati
on
18 Imitating Deleted 1/7 3/7 L 21 D/K Yes
(6.5% of
sample)
19 Expressing Retained 6/7 12.3% 13.3% 13% 11.1% 1/7 C 2 D/K Retained
and
recognizing
emotions
20 Friendship Retained 5/7 47.7% 53.3% 52.2% 40.7%
21 Imitating Retained 1/7 6 D/K
22 Expressing Adapted and 3/7 10.8% 13.3% 17.4% 3.7% 3 D/K
and combined*
recognizing
emotions
220
Form) (n=65) Form)
23 Adapted and 2/7 13.8% 6.7% 17.4% 14.8% 5 D/K
Thoughtfulne combined*
ss
24 Expressing Retained 2/7 3.1% 4.3% 3.7% 6 D/K
and
recognizing
emotions
25 Expressing Deleted 6/7 6.2% 20% 3.7% 2 D/K
and
recognizing
emotions
26 Social Retained 4/7 9.2% 13.3% 4.3% 11.1% 2/7 C 6 D/K Retained
communicati
on
27 Social Retained 3/7 4.6% 6.7% 4.3% 3.7% 4 D/K
communicati
on
28 Social Retained 4/7 7.7% 6.7% 8.7% 7.4% 1/7 C Retained
communicati
on
29 Friendship Deleted 6/7 16.9% 20% 8.7% 26.1% 1/7 N/O 1 D/K Yes
30 Social Deleted 5/7 9.2% 6.7% 8.7% 11.1% 2 D/K
communicati
on
31 Friendship Deleted 1/7 1/7 N/O 17 D/K Yes
32 Social Adapted 2/7 1.5% 6.7% 17 D/K
communicati
on
221
Form) (n=65) Form)
33 Social Deleted 3/7 4.6% 6.7% 4.3% 3.7% 2 D/K
communicati
on
34 Social Deleted 1/7 N/O 1 D/K Yes
communicati
on
35 Social Adapted 4/7 4.6% 8.7% 3.5% 2 D/K
communicati
on
36 Social Retained 1/7 1 D/K
communicati
on
37 Dating Deleted 2/7 4.6% 13% 2/7 C Yes
38 Dating Deleted 1/7 6.2% 13% 3.7% 2/7 C Yes
wording 20% 20% noted in C–
changes noted noted text Cultural/Cont
in text in text extual
6.5.7.2. Summary of the clinical item analysis of the interpersonal relationship
socialisation subdomain.
• Six of the items (18, 29, 31, 34, 37 and 38) identified as difficult by the
psychologists have been deleted from the VABS 3.
222
• Three of the items (19, 26 and 28) identified as difficult by the psychologists have
been retained in the VABS 3.
• Two of the items are extensively used (>20%) in all the psycho-legal reports (Item
15 and 20). Both relate to friendship. A further two items are used over 20% of
times in the child reports (Items 25 and 29).
• Ten items (15, 17, 19, 20, 25, 26, 28, 29, 30, and 35) were rated as useful by the
majority of the seven psychologists. Only two of these were used extensively in
the report and three have been deleted from the VABS 3.
6.5.8. Socialisation: Play and Leisure. (Appendix C, p. 342)
• Asking about self-protection by moving away from those who “destroy things or
cause injury” was identified as helpful (Item 12). (P1)
• Assessing being able to read non-verbal social cues was useful (Item 23).
• The playing of card or board games requires access and for many clients in poorer
communities, those games are not available. There was some discussion around
cell phone games which are more accessible but that these lacked the component
of social interaction (Items 20 and 26).
• Some of the items regarding going places with friends with and without
supervision were difficult to assess in a very rural community as there were
limited opportunities due to poverty compounded by the limitations of intellectual
disability (Items 21, 27, 29 and 31).
• There was also discussion around poverty of environment influencing opportunity
to play and share (Items 9, 11 and 13).
223
Table 6.12.
Clinical Item analysis of the Play and Leisure Socialisation Subdomain of the VABS II
VABS II Comparison No of % of % of % used in % No of Marked use of Difficulty
Socialization with VABS psychologists that that adolescent used psychologists D/K or N/O addressed
Play and 3 items marking item item report in marking items response in VABS
Leisure items items as used in used in (n=23) adult as difficult (n=321) 3
with content useful (n=7) psycho- child report (n=7)(Survey
category (Survey legal report (n=27) interview
Interview report (n=15) Form)
Form) (n=65)
1 Playing Retained
2 Playing Adapted
3 Playing Retained 1/7
4 Playing Retained 1/7 1.5% 4.3%
5 Playing Adapted
6 Playing Adapted 1/7
and
combined*
7 Playing Adapted 1/7
and
combined*
8 Playing Adapted 1/7 1 D/K
and
combined*
9 Sharing Retained 2/7 1.5% 6.7% 2/7 N/O 1 D/K Retained
and
cooperating
10 Playing Retained 2/7
11 Playing Retained 1/7 1/7 N/O 3 D/K Retained
12 Playing Adapted 6/7 4.6% 6.7% 4.3% 3.7% 5 D/K
13 Playing Retained 1/7 3.1% 6.7% 3.7% 1/7 N/O 7 D/K Retained
14 Playing Retained 4/7 13.8% 6.7% 13% 18.5% 1 D/K
224
Form) (n=65)
15 Sharing Retained 3/7 13.8% 20% 4.3% 18.5% 1 D/K
and
cooperating
16 Playing Adapted 5/7 4.6% 13.3% 3.7% 3 D/K
games
17 Sharing Retained 4/7 13.9% 20% 13% 11.1% 3 D/K
and
cooperating
18 Playing Adapted 5/7 9.2% 13.3% 8.7% 7.4% 1/7 N/O 16 D/K (5% Adjusted
games and of sample)
combined#
19 Sharing Retained 4/7 12.3% 20% 13% 7.4% 6 D/K
and
cooperating
20 Playing Retained 4/7 6.2% 13.3% 4.3% 3.7% 3/7 N/O 6 D/K Retained
games
21 Going Adapted 3/7 10.9% 6.7% 4.3% 18.5% 3/7 N/O Adjusted
places with and
friends combined*#
22 Sharing Retained 4/7 7.7% 6.7% 13% 3.7% 11 D/K
and
cooperating
23 Retained 5/7 13.9% 13.3% 13% 14.8% 37 D/K Retained
Recognizing (11.5% of
social cues sample)
24 Playing Adapted 3/7 7.7% 6.7% 8.7% 7.4% 8 D/K
games
25 Playing Adapted 3/7 13.9% 13.3% 26% 3.7% 10 D/K
games
225
Form) (n=65)
26 Playing Adapted 1/7 3.1% 4.3% 3.7% 5/7 N/O 3 D/K Adjusted
games
27 Going Adapted 4/7 3.1% 4.3% 3.7% 3/7 N/O 1 D/K Adjusted
places with and
friends combined*#
28 Playing Adapted 1/7 1.5% 4.3% 3 D/K
games and
combined#
29 Going Retained 1/7 1.5% 4.3% 3/7 N/O Retained
places with
friends
30 Going Retained 1.5% 3.7% 2/7 N/O Retained
places with
friends
31 Going Retained 3.1% 4.3% 3.7% 3/7 N/O Retained
places with
friends
include over over over 20% L – Linguistic
minor 20% 20% noted in C–
wording noted noted text Cultural/Cont
changes in text in text extual
6.5.8.2. Summary of the clinical item analysis of the play and leisure socialisation
subdomain.
226
• Four items were adjusted which were identified as difficult by the psychologists
(18, 21, 26 and 27).
• Eight items which were identified as difficult by the psychologists have been
retained (9, 11, 13, 20, 23, 29, 30 and 31).
• This subdomain is not widely reported in the psycho-legal reports with no item
being used in more than 20% of the reports. In the child reports, sharing and
cooperating was used in 20% (Items 15, 17 and 19) of the reports.
• Nine items were identified as useful by the majority of the psychologists (12, 14,
16, 17, 18, 19, 22, 23 and 27). As in the discussion, recognising social cues was
one of the more commonly used items in the report (Item 23 - 13.9%) but also had
a large number of D/K responses scored (11.5% of the whole sample) thus
indicating difficulty in eliciting caregiver’s responses.
6.5.9. Socialisation: Coping skills. (Appendix C, p. 343)
• Many of the items closely relate to the assessment regarding the ability to give
consent: “Stop or stays away from relationships or situations that are hurtful or
dangerous” (Item 25), “Acts appropriately when introduced to strangers” (Item
11), “Controls anger or hurt feelings when he or she does not get his or her own
way” (Item 23 and 17), the items relating to social caution (Item 22, 25 and 29).
• There was only a no opportunity difficulty for one psychologist in relation to
changing voice level depending on situation (Item 12), otherwise no difficulties in
this subdomain. (P1)
227
Table 6.13.
Clinical Item Analysis of the Coping Skills Socialisation Subdomain of the VABS II
Socialization with VABS 3 psychologist that that adolescen in adult psychologists use of addressed
Coping Skills items s marking item item t report report marking D/K or in VABS 3
items with items as used in used in (n=23) (n=27) items as N/O
content useful (n=7) psycho child difficult response
category (Survey -legal report (n=7)(Survey (n=321)
Form) (n=65) Form)
1 Transitions Retained 4/7
2 Manners Adapted 5/7 6.2% 13.3% 7.4%
3 Transitions Adapted 5/7 1.5% 3.7% 2 D/K
4 Manners Deleted 2/7 2 D/K
5 Manners Adapted 4/7 7.7% 13.3% 11.1% 1 D/K
6 Manners Deleted 5/7 1.5% 6.7%
7 Manners Moved to 2/7 2 D/K
Personal
Daily Living
Skills
subdomain
8 Transitions Expanded 6/7 13.8% 6.7% 8.7% 22.2% 5 D/K
9 Apologizing Adapted 3/7 15.4% 20% 13% 14.8% 5 D/K
10 Controlling Deleted 1/7 1.5% 6.7% 2 D/K
impulses
11 Manners Retained 5/7 12.3% 13.3% 13% 11.1%
12 Manners Deleted 1/7 1.5% 3.7% 1/7 N/O 23 D/K Yes
(7.2% of
sample)
13 Apologizing Adapted 3/7 7.7% 13.3% 13% 3 D/K
14 Manners Deleted 1/7 2 D/K
228
Form) (n=65) Form)
15 Manners Moved to 3/7 7.7% 13.3% 4.3% 7.4%
Socialization
Interpersonal
Relationships
16 Controlling Retained 4/7 7,7 6,7% 8,7% 7,4% 3 D/K
impulses
17 Controlling Retained 5/7 15.4% 6.7% 17.4% 18.5% 1 D/K
impulses
18 Keeping Deleted 4/7 13.8% 13% 22.2% 28 D/K Yes
secrets (8.7% of
sample)
19 Apologizing Deleted 2/7 3.1% 8.7% 5 D/K
20 Controlling Deleted 2/7 4.6% 6.7% 4.3% 3.7% 3 D/K
impulses
21 Retained 1/7 5 D/K
Responsibility
22 Appropriate Moved to 5/7 20% 13.3% 21.7% 22.2% 2 D/K
social caution Community
Daily Living
Skills
23 Controlling Retained 3/7 12.3% 6.7% 21.7% 7.4% 1 D/K
impulses
24 Adapted 1/7 1.5% 4.3% 4 D/K
Responsibility
25 Appropriate Adapted and 4/7 18.5% 6.7% 21.7% 22.2% 2 D/K
social caution expanded
26 Controlling Retained 3/7 6.2% 13% 3.7% 2 D/K
impulses
229
Form) (n=65) Form)
27 Keeping Deleted 4/7 6.2% 8.7% 7.4%
secrets
28 Controlling Retained 4/7 1.5% 4.3%
impulses
29 Appropriate Adapted 3/7 9.2% 8.7% 14.8%
social caution
30 Adapted 1/7 N/O Adjusted
Responsibility
wording 20% 20% noted in C–
changes noted noted in text Cultural/Con-
in text text textual
6.5.9.2. Summary of the clinical item analysis of the coping socialisation skills
subdomain.
• One item identified as difficult by one psychologist and a marked use of “Don’t
know” response was deleted. Another with a marked “Don’t Know” response was
deleted but was also used in 22.2% of the adult reports regarding the keeping of
secrets and one item identified as difficult was adapted.
• One item is extensively used (>20%) in all the psycho-legal reports (Item 22)
regarding choosing to avoid dangerous or risky activities. One item is used
230
extensively in the child reports (Item 9), three items in the adolescent reports (22,
23 and 25) and four items in the adult reports (8, 18, 22 and 25).
• Fourteen items (46% of total items) were identified as useful by the majority of
the psychologists (1, 2, 3, 5, 6, 8, 11, 16, 17, 18, 22, 25, 27 and 28).
• This subdomain is not reported on extensively overtly but from the discussion is
information used in the assessment of the ability to consent which forms a primary
purpose of the report.
6.5.10. Changes in administration of the VABS II.
This arose out of the psychologists’ discussion. It will be discussed in the following
chapter (section 7.10., p. 269.).
This chapter has presented the statistical results and clinical item analysis and
reported these according to the research questions posed. The discussion chapter which
follows will consider the implications and examine the results in the context of use of the
VABS.
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Chapter Seven: Discussion
7.1. Introduction
There are many issues and further questions which arose out of this research process.
Some of these have been highlighted in previous chapters. This chapter will begin with
attention to the research questions posed and then follow this with some discussion with
regard to further highlighted issues and questions identified in the descriptive analysis and
through the course of the research.
7.2. Research question 1
The first aim was to evaluate the published norms of the VABS and VABS II in terms
of their use in this particular South African context and their usefulness in discriminating
different levels of intellectual disability. The question is one of discriminant validity or what
Kaufman and Kaufman (1993) refer to as clinical validity, testing the extent to which
cognitive assessment instruments provide diagnostic information by use of cross-validation
samples, thus being able to apply the test to groups other than those on which it was
originally normed and standardised (Cicchetti, 1994).
This was done through examining the association between the measured IQ score
using the ISGSA and the standard score measurements of the VABS and the VABS II. The
Pearson product-moment correlation coefficient was .685. Using regression analysis, the
VABS accounted for 46.8% and the VABS II for 38.3% of the variance in ISGSA scores.
The prediction was significant for both tests (p<.001). Given the understanding that IQ and
adaptive functioning are two different, but related concepts, a modest correlation between the
standard scores is expected. Both are necessary for an understanding of the nature of the
limitations of the person with intellectual disability and for diagnosis.
In development, the VABS was measured against tests which assess IQ, for example
the Kaufman Assessment Battery for Children (K-ABC, 1983). The highest correlation was
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.52 between the communication domain and the K-ABC Achievement Scale which was
explained by the content of the communication domain containing items most closely related
to cognitive ability.
Using the Peabody Picture Vocabulary Test – Revised (1981), the highest correlation
was .37 with the communication domain of the VABS due to the common language
component of both measures. The supplementary norm groups were assessed against a
variety of measures. The adults with ID over 18 years, in non-residential facilities, had a
correlation of .46 in terms of the adaptive behaviour composite and the mean IQ using the
Wechsler Adult Intelligence Scale (WAIS) or the Wechsler Adult Intelligence Scale –
Revised (WAIS-R) full scale score (Sparrow & Cicchetti, 1985; Sparrow et al., 1984).
During the development of the VABS II, in children aged 6-16 years, correlation with
the Wechsler Intelligence Scale for Children – Third Edition (WISC-III) was reported as low
with near zero correlation with the VABS II composite score and the full scale IQ score.
Correlation between the communication domain and the WISC-III scales ranged from .30 -
.36 thus a modest relationship with IQ scores. In adults aged 17-68 years, the correlation
between the VABS II composite score and the full scale IQ score, using the WAIS–III, was
.20 and between the communication domain and full scale IQ was .30 (Sparrow et al., 2005).
In this study there was a stronger correlation than that found in the validity studies
referred to in the VABS and VABS II manuals. The correlation for the Afrikaans group, .633
with a variance of 40% and the Xhosa group, .578 with a variance of 33.4% was also
moderate. This may be related to the finding that the ISGSA tended to underscore in the mild
and moderate ranges of IQ for this population. (section 5.3.13.)
The second part of answering this question related to comparing the reported
diagnosis and assessment of the evaluating clinical psychologist as reported in the psycho-
legal report with the level of disability measured by the VABS and VABS II using a Chi-
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square analysis. The practice of using the “best clinician diagnosis” as a gold standard or
criterion to which standardised and normed tests can be compared, has been used (Cicchetti,
1994).
Both the VABS and VABS II were found to have a statistically significant association
(p<.001) with the psychologists diagnosis. Given the findings of the descriptive analysis,
regarding the adults over 22, this was analysed further and the discussion regarding these
findings follows further in this chapter. (section 7.4.)
In the development of the VABS, use was made regarding the validity of the tool, by
comparing the VABS scores with those of other adaptive behaviour assessment tools. The
original Vineland Social Maturity Scale (Doll, 1935, 1965) was used. A moderate correlation
of .55 was found between the VABS composite score and the original Vineland social
quotient. Higher correlations were not expected as there were major differences in content
and standardisation. Using the Adaptive Behavior Inventory for Children developed by
Mercer and Lewis (ABIC, 1978), a correlation of .58 was found between the VABS
composite score and the ABIC average Scaled Score. Raw scores of the domains of the
VABS were compared with the raw scores of the subdomains of the American Association
for Mental Deficiency Adaptive Behavior Scale developed by Nihira et al. in 1974.
Correlations varied between .40 and .70, in most instances in the moderate to moderately
high range (Sparrow et al., 1984).
During the development of the VABS II, correlations with the VABS were generally
found to be high, in the upper .80’s and .90’s. Correlations of composite scores with the
Adaptive Behavior Assessment System, Second edition developed by Harrison and Oakland
(ABAS-II; 2003) were .70 in the birth to 5 group, .78 in the 5-20 years age group and .69 in
the 17-74 years age group. Using the Behavior Assessment System for Children, Second
edition (BASC-2) developed by Reynolds and Kamphaus in 2004, and using the preschool,
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child and adolescent forms, correlations between the VABS II composite and the adaptive
skills composite of the BASC-2 ranged from .46 to .50 (Sparrow et al., 2005).
Broadly speaking the findings point to a modest but statistically significant correlation
between the VABS and the VABS II and the ISGSA standard scores, with the proviso that
the adult portion of the sample needed closer analysis.
Logistic regression analysis using the VABS or VABS II score as the dependent
variable and language, gender, age, geographic distribution and access to education as
independent variables, the following significant predictors were found.
In the analysis of the VABS scores, the only significant predictor was language
(p<.01), with English speakers being 3.09 times more likely to be in the moderate/severe
category than Afrikaans speakers and 6.77 times more likely to be in the moderate/severe
category than isiXhosa speakers. This is understood within the South African context, as
language being a proxy for race and socioeconomic status. The client group is constrained by
the referrals received from the police and the courts. It is of interest that during the period in
the study when the VABS was used, a greater proportion of English speakers were more
severely disabled than Afrikaans and isiXhosa clients. This may be an incidental finding or
point to a different pattern of reporting abuse, amongst this group of the community. This
would require further study. (Refer to descriptive results section 5.2.4..)
In the analysis of the VABS II scores, the only significant predictor was whether
clients had access to education (p<.01). Those who did not were 2.93 times more likely to be
in the moderate to severe category. Figure 7.1. provides graphical representation of the
numbers in the sample who had no access to education, those who were placed in special care
centres for severely and profoundly disabled people, those who had access to schools for
people with ID, usually with an IQ below 50, those who were in adaptation classes which
235
operate within a mainstream school and those who had been to mainstream schools. In the
latter case, many had just dropped out of the schooling system when they could not cope with
the academic demands and had never had further access to specialised or supportive
education. Sixty of the sample participants had moved from one form of schooling to another
and are represented in two categories, i.e., had moved from mainstream schooling into a
specialised class or school.
Figure 7.1.
Access to education
This would need further investigation as to whether functioning in the moderate-
severe ID group gave less chance of being placed in schooling or if the lack of schooling
itself, further disadvantaged the person in terms of opportunity, thus increasing the level of
disability.
In order to answer the question of whether the VABS II was able to discriminate
between levels of intellectual disability for the adults in the sample, and given that the
difficulty was at the lowest end of the adaptive functioning spectrum, ROC analyses were
conducted using those identified as moderate and severe ID. The full sample was analysed,
236
then the sample was divided between those aged under 22 years and those over 22 years,
according to the norms table groupings of the VABS II. The results were examined for
caseness. Sensitivity and specificity were examined.
For the full sample using the psychologists rating of severe IQ as caseness, the VABS
II was estimated to predict IQ, as estimated by the psychologist, as having utility and
sensitivity was only reached at the defined mild to moderate border of a standard score of 56.
Due to the conceptual differences between AF and IQ, this is as expected. However there was
a difference between the under 22 years group which had a finding of high utility (however
with a small sample) and the over 22 years group which was barely indicative of utility.
For the full sample, using the Psychologists rating of severe AF as caseness the
VABS II was estimated to predict the AF as evaluated by the psychologist at the high end of
caseness but sensitivity and specificity was only reached at a standard score of 62. With the
group under 22 years it was of high utility, with sensitivity and specificity being reached at a
standard score of 62; however, in the group of clients over 22 years, the AUC was barely
indicative of low accuracy. The VABS II is found lacking in terms of discriminating between
severe and moderate adaptive functioning in the over 22 years client group.
For the full sample, using the ISGSA score in the ranges of moderate IQ and severe
IQ from within the sample and the ISGSA rating of severe ID as caseness, the VABS II was
found to barely be of utility. For those in the sample under 22 years, it was of utility but of
low accuracy for those over 22 years.
The second part of the question asked if the VABS 3 norm tables give evidence of
having addressed this floor effect.
In the development of the VABS 3, three IQ segmented samples of people with ID,
IQ’s of 70-50 (Mild disability), 49-35 (Moderate disability) and below 35 (Severe disability)
were divided into two age groups, 3-18 years and over 19 years. The authors report that the
237
mean scores are lower for the adult than school-age subjects and refer to this being consistent
with the VABS II findings. They conclude that “adults with low IQ display even greater
adaptive deficits than do school-age individuals with comparable IQs” (Sparrow et al., 2016,
p. 157). They further argue that there are “consistently greater standard differences for the
three lowest-scoring samples. This indicates that the Comprehensive version has greater
clinical sensitivity among extremely low functioning individuals” (Sparrow et al., 2016, p.
166). This does not concur with the following analysis. Table 7.1. gives the mean figures of
the VABS 3 domains and composite scores in the various IQ groups. There are very large
differences, particularly in IQ below 49 between the IQ score and the scores of the VABS 3.
In the severe group over 19 years (column 6) the scores are all at the interface between severe
and profound disability. Given what has been presented previously, it would seem that the
same difficulty remains with the floor effect for those with severe and moderate ID. The
manual states that there is strong evidence “for the sensitivity of the Interview form in
identifying individuals with ID… Additional research is needed to determine if
communication is indeed a relative adaptive weakness among individuals with ID” (Sparrow
et al., 2016, p. 166). Whilst it does have sensitivity for identifying intellectual disability, the
norm tables would point to a lack of sensitivity at the lower end of mild disability and below.
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Table 7.1.
VABS 3 Mean Standard Scores for Mild, Moderate and Severe Intellectual Disability in Two
Age Groups
Column 1 Column 2 Column 3 Column 4 Column 5 Column 6
Comprehensive IQ 70-50 IQ 49-35 IQ <35 IQ 70-50 IQ 49-35 IQ <35
Interview form 3-18 years 3-18 years 3-18 years 19+ years 19+ years 19+ years
domain and
composite score
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Communication 58.4 (15.9) 41.9 (18.4) 24.3 (12.6) 47.2 (23.9) 22.5 (7.4) 20.0(0.0)
Daily Living 68.0 (19.8) 52.4 (22.0) 31.5 (19.9) 54.4 (27.8) 27.7 (14.2) 21.1 (5.3)
Skills
Socialization 71.3 (15.8) 61.9 (20.6) 33.8 (17.7) 50.0 (21.7) 36.1 (21.9) 21.3 (6.3)
AB Composite 65.8 (13.2) 53.1 (17.3) 30.1 (15.7) 51.6 (20.7) 29.3 (13.4) 20.9 (4.3)
From Vineland Adaptive Behavior Scales – Third Edition manual (p. 187) by S. S. Sparrow, D. V. Cicchetti and
C. A. Saulnier, 2016, Bloomington MN: Pearson. Copyright (2016) by NCS Pearson. Adapted with permission.
Figure 7.2. and Figure 7.3. from the manual illustrates the difference graphically.
Here the floor effect is very evident as is the different sensitivity amongst the school age
groups and the adults. The communication subdomain also consistently scores the lowest of
all the subdomains across age groups. Note the flattened graph indicating the floor effect in
the group of adults with adaptive functioning in the range of severe disability.
239
Figure 7.2.
Mean Adaptive Behaviour Scores from Three School Aged Groups with Different IQ Ranges
C. A. Saulnier, 2016, Bloomington MN: Pearson. Copyright (2016) by NCS Pearson. Copied with permission.
240
Figure 7.3.
Mean Adaptive Behaviour Scores for Three Adult Groups with Different IQ Ranges
C. A. Saulnier, 2016, Bloomington MN: Pearson. Copyright (2016) by NCS Pearson. Copied with permission.
241
This question asked what useful qualitative information is used and reported in the
psycho-legal report from the items in the VABS II. The results were drawn from items
identified and discussed by the clinical psychologists’ experience in the assessment, and a
quantitative analysis of the psycho-legal reports as to the information from specific items
referred to in the text of the report. A “functional assessment is required which takes account
of the specific skills required in a legal context” (Dickman et al., 2006, p. 123). The results
will be discussed by subdomain.
7.5.1. Receptive communication.
This is particularly important in helping the court understand the receptive limitations
in relation to questioning and in keeping the questions the court asks of the client simple and
singular (Dickman et al., 2006; Pillay, 2012; Van Niekerk, 2014). Items regarding following
instructions (10, 12, 13, 16) and listening and attending (9, 14, 15 and 17) were used
extensively according to developmental level. Van Niekerk (2014) makes a valid point that
questions that are inappropriate can cause barriers to participation in the court process.
7.5.2. Expressive communication.
Limitations of extent of vocabulary (Item 20 and 26) was referred to as important
both in terms of court process and in terms of choice of verbal or non-verbal test in terms of
IQ assessment. Being able to speak clearly (Item 38) was also important in relation to court
proceedings or if support in the use of an intermediary would assist the court in
understanding the complainant. The items relating to giving a narrative account (Items 24,
39, 42 and 43) were highlighted. Goal setting (Items 52 and 54), although positioned at an
almost adult level, were identified as helpful in relation to what people could not do, thus
understanding their lack of goal directed behaviour.
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Additional items included knowing their age (Item 25), knowing their name and
surname (Item 29) for the child group, knowing or not knowing their month and year of birth
across all ages (Item 40 in 47.7% of the reports), knowing or not knowing their address (Item
51) in the adult (33.3%) and adolescent (43%) reports. These are often details which will be
asked in court as biographical details. There was more detail given in the child reports on
expressive communication with six items being referred to in more than 20% of the reports
(Items 29, 32, 34, 36 and 39). In keeping with developmental expectations, there was more
reference to their ability in terms of conversational speech (Items 46, 47 and 49) for the
adults and again this relates to the understanding of the court in relation to their giving
evidence.
Differentiation only began from Item 14 which points to all clients referred having
some measure of expressive speech. The spread of different items being reported at different
ages was evidence of the need to tailor the report to the differing social expectations of a
child, an adolescent and an adult.
7.5.3. Written communication.
There was difficulty with caregivers knowing this information at times, particularly if
illiterate themselves so the recommendation was to be flexible to reference from the client
and deviate from the recommended administration and use simple charts to evaluate skills.
Exposure to education was identified as influential and discriminatory. Almost all reports had
some reference to level of reading or writing skill with children reported on using items 1-10,
and adolescents and adults using items 6-11 and 14. The ability to write their own name and
surname was referred to in 52.3% of the reports.
7.5.4. Personal Daily Living Skills.
This subdomain was reported extensively, was widely reported and received wide
agreement that describing “how they look after themselves” is very easy for the court to
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relate to developmentally and if within expectations for a particular age group or not. Cultural
differences impacted, especially on eating habits and norms and socioeconomic realities in
terms of access to hot and cold running water. The ability to choose clothing appropriate to
the weather was reported in 81.5% of the reports (Item 31) and the ability to wash themselves
was reported in 90.7% of the reports (Item 32). Important skills which were highlighted were
toileting (Items 17 and 20), dressing (Items 18, 21, 22, 16, 28 and 29), eating and drinking
(Item 23), bathing (Items 24, 30 (in adolescents and adults), and 32) and grooming (Items 25
and 34).
7.5.5. Domestic Daily Living Skills.
This was also an area that was easy for others to relate to as to what is
developmentally expected and described a picture of level of functioning. It was reported on
extensively and found to be very useful. In all, 73.8% of reports referred to the ability to
wash dishes or clean floors. Kitchen chores in general were commonly used (Items 2 (child
and adolescent), 3 (adolescent), 7 (adult and adolescent), 8 (all), 9 (adult), 13 (all), 15
(adolescent and adult), 17 (all), 20 (all) and 21 (adolescent and adult)).
Housekeeping skills were commonly reported (Items 11 (adolescent and adult), 14
(all), 16 (all) and 22 (adolescent and adult)).
7.5.6. Community Daily Living Skills.
Two sets of skills were widely reported: knowledge of time and date, and money
skills. Although it was discussed that items to do with safety were important and that there
was an overlap in terms of the socialisation subdomain of coping skills, the safety items were
not widely used in this domain in the reports. Discussion included the effect of levels of
community safety on the acquisition of safety skills, i.e., in relation to travel and curfews.
Greenspan and Woods (2014) describe this as a key feature in relation to intellectual
disability (refer to literature review section 2.2.1.2). In terms of money skills, the identifying
244
different coins and notes, (Item 12-80% of reports and Item 19 – 78.5% of reports), and being
able to calculate change (Item 30 – 72.3% of reports) was important.
7.5.7. Socialisation Interpersonal Relationships.
The discussion amongst the psychologists identified friendship behaviour and
particularly indiscriminate friendliness as important and general social interaction skills and
dating behaviour, both in terms of what they do and do not do. There was discussion
regarding what the various cultural norms are and how they differ even within the South
African context. The majority of psychologists rated 10 items as useful, however, only two
were used extensively in the reports (Item 15 and 20). Both related to friendship behaviour.
The items rated as useful but not used included those related to making small talk (Item 17
and 28), emotional expression (Items 19 and 25), observing and respecting personal space
(Item 26), meeting with friends regularly (Item 29), choosing not to say rude, embarrassing or
mean things in public (Item 30) or recognising indirect hints or cues in conversation (Item
35). Further investigation is needed. Possible hypotheses may be that these items are difficult
to write about/quantify in the context of the report, or that the caregivers do not give a good
account of these items therefore making it difficult to report.
7.5.8. Socialisation Play and Leisure Time.
The discussion amongst the psychologists highlighted the ability to protect oneself
(Item 12) and reading of non-verbal cues (Item 23) as important and that impoverished
environments limited the opportunity to engage in play and leisure activities (Items 9, 11 and
13). For children the items related to sharing and turn taking were more frequently reported
(Items 15, 17 and 19). Although recognising non-verbal social cues was seen as important
there was a high rate of “Don’t know” responses to the item (11.5%) indicating difficulty in
eliciting caregivers’ responses. Items which were rated as useful by the psychologists, but not
used in the reports, included moving away to protect self (Item 12), seeking others out to play
245
(Item 14), playing informal games (Item 16), following the simple rules of games (Item 18),
asking permission before using something which belongs to another person (Item 22) and
going places with friends in the evening with adult supervision (Item 27). This last item was
also identified as a “No opportunity” item. This area of socialisation is indicated as important
but not recorded in the reports and warrants further investigation.
7.5.9. Socialisation Coping Skills.
In the psychologists’ discussion, there was recognition of the usefulness of many of
the items in the evaluation of being able to consent (Items 11, 17, 22, 23, 25, 29). Moreover
14 items (46% of total items) were identified as useful by the majority of the psychologists
(1, 2, 3, 5, 6, 8, 11, 16, 17, 18, 22, 25, 27 and 28). However, the only items where more than
20% of the reports referred to the item included the response to change in adults (Item 8),
apologising in children (Item 9), appropriate social caution in adolescents and adults (Items
22 and 25), controlling anger and hurt feelings in adolescents (Item 23) and keeping
confidences or secrets in adults (Item 18). Once again, for this area of socialisation skills,
there was relatively sparse information in the report.
The domain of socialisation is under reported in the actual reports whilst
acknowledged as very useful by the psychologists. Table 7.2. summarises the useful
categories of information gleaned from use of the VABS II in describing the adaptive
functioning of these clients in relation to their ability to testify, their ability to consent to
sexual intercourse and to give the court an idea of their particular strengths and weaknesses
and what support is needed.
246
Table 7.2.
Summary of Useful Information Categories from the VABS II in Psycho-Legal Report
Communication Daily Living Skills Socialization skills
Following instructions Toileting Friendship behaviour
Listening and attending Dressing Emotional expression
Extent of vocabulary Eating and Drinking Recognizing social cues and non-
verbal communication
Clear speech Bathing Sharing
Giving a narrative account of Grooming Apologizing
experience
Biographical details Kitchen chores Manners and social norms
Level of reading and writing skill Housekeeping Controlling impulses
Telling the time Appropriate social caution
Money skills Negotiating change and transition
Community safety Acting appropriately with
strangers
The VABS II provides much useful qualitative information for the court. It assists in
describing a level of functioning to which the court can relate and in motivating for support
through the court process. The magistrate or judge will often ask for a description of how to
recognise a particular level of intellectual disability and how that is distinguishable from
other levels, i.e., mild and moderate intellectual disability. The VABS II provides a general
but also individualised account of this difference.
The question asked what changes in terms of sequencing of items, deleted items,
added items and modified items had been made between the two versions: the VABS II and
the VABS 3. Table 7.3. summarises the changes.
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Table 7.3.
Summary of Changes Between the VABS II and VABS 3
VABS 3 Deletions Sequencing Subdomain Repeated Additional Modification No of No of
from changes changes items items in of existing items items
VABS II VABS 3 items VABS VABS
II 3
Receptive 5 2 7 20 12 20 39
Communication
Expressive 10 19 6 28 12 9 54 49
Communication
Written 2 6 13 13 12 25 38
Communication
Personal Daily 5 9 1 23 19 13 41 55
Living Skills
Domestic Daily 5 7 8 15 7 24 30
Living Skills
Community 10 14 3 21 18 19 44 58
Daily Living
Skills
Socialization 10 9 5 17 14 12 38 43
Interpersonal
Relationships
Socialization 1 6 16 10 10 31 36
Play and
Leisure
Socialization 9 5 3 10 13 10 30 33
Coping Skills
Totals 57 77 18 143 134 104 307 381
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The figures in Table 7.3. indicate that the VABS 3 is an extensive revision of the
VABS II. It is longer, with 74 more items (an increase of 19.4%). Of the original VABS II
items, 18.5% are deleted. In all, 33.9% of the items of the VABS II were modified, expanded
or condensed. Changes to the developmental sequencing of items included 25% of the items.
Items from the VABS II which were moved to different subdomains included 5.9%. In all,
46.6% of the items were repeated, including some minor wording changes. Less than 50% of
the previous version has been reused in the VABS 3.
It remains to be seen how clinically useful this version is. Being longer, it will take
longer to administer. Many of the new items include interaction and use with changing
technology. Some of that change has happened in this South African context, i.e., use of cell
phones, but due to the socioeconomic status of most of the families of our clients, there is
often limited opportunity with regards to other technologies. There is also a greater degree of
sophistication in the responses and understanding of social processes needed by the
respondent. It will be of interest to see if this new version will be of greater help in eliciting
useful information in this psycho-legal context.
With the new version also comes the challenge of trying to validate it for use in this
context. In a context of limited professional and academic resources and competing demands
for clinical time, with many clients needing to be seen and long waiting lists, it is difficult to
ethically devote more time to researching each new version of various psychometric tools.
This is a real challenge for the valid use of psychometric instruments in developing countries.
Further, there is a real cost constraint for the tests and forms to be purchased as new
editions are published in cost constrained public sector psychology services and non-
governmental organisations and as exchange rates makes the tests very expensive.
The degree to which difficulties with particular items have been addressed is
discussed in the next section.
249
The last question asked to what extent the items identified by the psychologists as
needing adaptation in the VABS II: linguistic or language, cultural or contextual, and having
no opportunity, had been addressed in the VABS 3. Some of the discussion has been included
in the results chapter as it was dealt with in the discussion of the psychologists involved in
the programme. Table 7.4. summarises the findings.
Table 7.4.
Summary of Difficult Items Identified and the Response in VABS 3
(Note: some items had more than one category of difficulty)
Play and Leisure

Communication
Communication
Communication
Domestic Daily
Personal Daily
Coping Skills
Relationships
Interpersonal
Socialization
Socialization
Socialization
Living Skills
Living Skills
Daily Living
Community
Expressive
Receptive
Difficulty
Written
Contextual/ 40- 8- 2- 11- Skills19-
Cultural Retained Retained Adjusted Deleted Retained
issues 48- 9- 7- 12- 26-
Deleted Retained Adjusted Retained Retained
54- 10- 15- 15- 28-
Retained Retained Adjusted Retained Retained
13- 18- 37-
Adjusted Retained Deleted
15- 19- 38-
Deleted Retained Deleted
19- 28-
Adjusted Retained
23- 34-
Deleted Adjusted
24- 35-
Adjusted Adjusted
25-
Retained
26-
Retained
28-
Retained
250
Play and Leisure

Communication
Communication
Communication
Domestic Daily
Personal Daily
Coping Skills
Relationships
Interpersonal
Socialization
Socialization
Socialization
Living Skills
Living Skills
Daily Living
Community
Expressive
Receptive
Difficulty
Written
Skills
29-
Retained
30-
Retained
33-
Adjusted
34-
Adjusted
Linguistic/ 18- 28- 28- 18-
Language Deleted Retained Retained Deleted
Issues 31-
Adjusted
32-
Deleted
33-
Retained
34-
Retained
35-
Retained
36-
Retained
37-
Adjusted
38-
Deleted
44-
Adjusted
50-
Deleted
No 6- Deleted 45- 11- 36- 2- 5- 29- 9- 12-
opportunity 14- Deleted Ajusted Adjusted Adjusted Retained Deleted Retained Deleted
Retained 51- 15- 37- 7- 7- Deleted 31- 11- 30-
15- Retained Adjusted Adjusted Adjusted 15- Deleted Retained Adjusted
Adjusted Retained
251
Play and Leisure

Communication
Communication
Communication
Domestic Daily
Personal Daily
Coping Skills
Relationships
Interpersonal
Socialization
Socialization
Socialization
Living Skills
Living Skills
Daily Living
Community
Expressive
Receptive
Difficulty
Written
Skills
16- 39- 9- 20- 34- 13-
Retained Deleted Adjusted Retained Deleted Retained
18- 40- 10- 21- 18-
Adjusted Retained Adjusted Retained Adjusted
19- 41- 12- 24- 20-
Deleted Adjusted Deleted Adjusted Retained
21- 15- 25- 21-
Retained Adjusted Adjusted Adjusted
22- 16- 33- 26-
Adjusted Retained Deleted Adjusted
24- 20- 36- 27-
Deleted Retained Retained Adjusted
25- 21- 37- 29-
Adjusted Deleted Retained Retained
39- 30-
Adjusted Retained
40- 31-
Retained Retained
42-
Deleted
43-
Adjusted
44-
Adjusted
Many “don’t 32- 33- 10- 10- 18- 18- 12-
know” or Deleted Adjusted Adjusted Adjusted Deleted Adjusted Deleted
“No 33- 38- 15- 23- 18-
opportunity” Retained Deleted Retained Retained Deleted
responses 34- 20-
Retained Retained
41- 25-
Retained Adjusted
44- 31-
Adjusted Adjusted
50-
Deleted
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Play and Leisure

Communication
Communication
Communication
Domestic Daily
Personal Daily
Coping Skills
Relationships
Interpersonal
Socialization
Socialization
Socialization
Living Skills
Living Skills
Daily Living
Community
Expressive
Receptive
Difficulty
Written
Skills
Total items 4/20 17/54 9/25 21/41 9/24 24/44 9/38 12/31 3/30
(20%) (31.5%) (36%) (51.2%) (37.5%) (54.5%) (23.7%) (38.7%) (10%)
Total 2 5 2 4 2 4 6 0 2
deleted
Total 1 3 5 8 5 9 0 4 1
adjusted
Total 1 9 2 9 2 11 3 8 0
retained
7.7.1. Discussion of overall results.
Total number of items on the VABS II is 307. One hundred and eight (35.2%) items
had varying levels of difficulty in various areas for the psychologists using them in this
context. Twenty-seven (25%) had been deleted in the VABS 3 so this is assuming that the
difficulty was common with other users, in other contexts. Thirty-six (33.3%) had been
adjusted in various ways and it remains to be seen if this addresses the difficulty. Forty-five
(41.6%) were unchanged and retained in the VABS 3.
7.7.2. Contextual/Cultural issues.
There were 34 items which had identified cultural issues, six of which are deleted
from the VABS 3, 10 of which have been adjusted and the remaining 18 are unchanged. Of
these, eight related to personal daily living skills and five related to community daily living
skills. Considering the relationship between daily living skills and cultural practices, this
makes sense.
Most of the items raised were of concern to one or two within the group of
psychologists, however Item 10, in personal daily living skills (Feeds self with fork; may
spill), was of concern to three of the seven psychologists. This is retained in the VABS 3 as
Item 10. For some of our clients, it is not common practice to use a fork, using a spoon to eat,
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or their fingers, is much more common. Some children would not have had the opportunity to
learn this skill at this developmental stage.
Item 15 in community daily living skills (Demonstrates understanding of right to
personal privacy for self and others (for example, while using restroom or changing clothes,
etc.)) was of concern to five of the seven psychologists. There was also a high rate of “Don’t
Know” responses to this item. It was classified as a cultural (2/7 psychologists) and no
opportunity (3/7 psychologists) issue. This relates to crowed living conditions (refer to the
number of clients living in informal settlements in the descriptive results) but also to
differences in cultural norms regarding privacy.
7.7.3. Linguistic/Language issues.
There were 14 items which had identified language issues, five of which are deleted
in the VABS 3, three have been adjusted and six have been retained. Of those retained, one
was in the community daily living skills domain and the remainder in the expressive
communication subdomain.
There were three items which were of concern to three or more of the psychologists.
Item 33 (Uses possessives in phrases or sentences (for example, “That’s her book”; “This is
Carlos’s ball”; etc.)), Item 34 (Uses pronouns in phrases or sentences; must use correct
gender and form of the pronoun but sentences need not be grammatical correct (for example
“He done it”; “They went”; etc.)) and Item 36 (Uses regular past tense verbs (for example,
walked, baked, etc.); may use irregular past tense verbs ungrammatically (for example, “I
runned away”; etc.)). They all relate to the differences in language and linguistic equivalence
in other languages, especially when the language structure is very different, such as the use
of gender pronouns in isiXhosa.
7.7.4. No opportunity issues.
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There were 59 items which had identified no opportunity issues, which is the largest
grouping and were present in every subdomain. This possibly relates to poor socioeconomic
circumstances of our client group. Of these, 14 items had been deleted from the VABS 3, 24
items had been adjusted and 21 items had been retained. Of the 21 items retained, seven
items were of concern to three or more of the psychologists.
Item 51 in the expressive subdomain (Says complete home address (that is, street or
rural route, apartment, number, city, and state) with or without zip code, when asked) was
discussed by the psychologists as both important and difficult, for many of our rural clients
had never been taught their full home address, or regularly received post, but had, for
example, been taught how to describe the way home from the local town. It is therefore
difficult to meet the criteria as given, but functionally they do know and can describe where
they live.
In the community daily living skills domain, Item 5 was a concern to five of the seven
psychologists (Is aware of and demonstrates appropriate behaviour while riding in car (for
example, keeps seat belt on, refrains from distracting driver etc.)). Many of our clients use
public transport in the form of mini bus taxis or in rural areas on the back of a small truck.
There is no opportunity to demonstrate the skill asked for in this item. Item 20 was also a
concern for four of the seven psychologists in this subdomain (Obeys traffic lights and Walk
and Don’t walk signs). This also relates to rural location with little to no exposure to traffic
signage. Item 21 was a concern for three of the seven psychologists (Points to current or
other date on calendar when asked). Once again in very impoverished, often rural
circumstances, some of our clients have not had exposure to calendars.
In the Play and Leisure Socialisation subdomain the following items were of concern.
Item 20 (Plays a simple card or board game based only on chance (for example, Go Fish,
Crazy Eights, SorryÔ, etc.)) was identified by three of the four psychologists as a no
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opportunity issue for some of our clients, as was Item 29 (Goes places with friends during the
day without adult supervision (for example to a shopping mall, park, community centre, etc.))
and Item 31 (Goes places with friends in evening without adult supervision (for example to a
concert, lecture, sporting event, movie, etc.)). These all relate to limited opportunity for some
of our rural clients.
7.7.5. Many “Don’t know” or “No opportunity” responses.
Although there were 59 items which were identified as “no opportunity”, there were
19 items which had a high number of “don’t know” or “no opportunity” responses from the
analysis of item responses. These are included in the discussion as they indicate a less than
optimal response to the question posed by the item. Of these, six items had been deleted from
the VABS 3, seven items had been adjusted and six items were retained. Of these three have
been discussed in the Language and Linguistic section above (Items 33, 34 and 41 in the
expressive communication subdomain), two were discussed in the cultural and contextual
issues (Items 15 and 20 in the community daily living skills subdomain) and the outstanding
item was from the play and leisure subdomain (Item 23: Refrains from entering group when
nonverbal cues indicate that he or she is not welcome). There were a number of respondents
who could not answer this question (11.5% of the sample). Given the low rate of using
socialisation items in the psychologists reports, it may be that these more subtle and nuanced
social interactions are more difficult to ascertain than the overt observations of the
communication and daily living skills domains.
7.7.6. What changes does the VABS 3 offer?
The VABS 3 is more detailed, with a 19.4% increase in number of items and possibly
asking increasingly nuanced questions and relating to the greater and wider use of
technology. It remains to be seen if this helps or hinders our client population.
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Many of the items identified as problematic have been deleted. Those that have been
adapted need further and later evaluation once the tool has been used for a period of time and
with a number of clients. Of those that have been retained, most of them were not
problematic for many of the psychologists. The semi-structured interview method provides
leeway to ask the question in many ways and probe the response.
For the remainder, the VABS 3 has changed the scoring, giving an option of
estimating if the client could do this, given the opportunity from a person who is very
familiar with the client’s behaviour rather than using the “Don’t Know” or “No opportunity”
options. The margins given are that within each subdomain if the percent estimation is less
than 15% “the validity of the section is probably not compromised”, if it is between 15-25%
then “interpret the scores for that section with caution” and if over 25% “do not interpret the
scores for that section” (Sparrow et al., 2016, p. 47). It remains to be seen how effective this
is in clinical practice with our population and the extent to which, with this client group, the
estimate option would have to be used.
7.8. The construct of adaptive functioning in relation to a normal distribution pattern
The construct of adaptive behaviour/functioning differs from intelligence. Intelligence
varies from those who are severely cognitively impaired, to those who join the majority, in
what is termed average, to those who have significantly greater cognitive abilities than most
people. This is described along a normal distribution curve. This is what we used to allocate
terms such as mild intellectual disability, average IQ and gifted.
A separate and parallel concept is that of adaptive functioning. This is the
development over time, of skills and the performance of daily activities to function and
maintain ourselves with increasing complexity and maturity according to the expectations of
the social context and environment in which we live. The expectations of a child of four years
old differ from those of an adolescent of 13 years old, from those of a young adult, and again
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from those of an elderly person. It is impacted by various limitations, be they cognitive,
sensory impairments, mental or physical illness. However, a common assumption is that by
the time a person reaches adulthood, unless there is an ongoing limitation such as chronic
illness, disability or cognitive impairment, they function at a fairly sustained level throughout
adulthood with possible fluctuations when needing more support and as the person
approaches old age.
Widaman et al. (1991) describe the reaching of asymptote by various levels of
disability and in various domains, as described in the literature review. (section 2.4.4.) Tassé
et al. (2012) refer to this in their discussion regarding the construct of adaptive behaviour.
“Adaptive behavior reflects skills demonstrated by the overwhelming majority of the general
public. These skills can be arranged into a series of largely developmental tasks that are
generally accomplished by the time most individuals enter adulthood” (p. 298). They further
ask if adaptive behaviour scores follow a normal distribution in the general population.
Norm tables for adults force raw scores which are not normally distributed into a normally
distributed standard score. They argue that this overestimates the importance of small raw
score differences.
Using a tool such as the VABS, which itemises the performance of these skills, scores
them and then measures performance against same age peers, there will be children and
adolescents who are able to do things ahead of most of their peers, however, by the time
adulthood is reached, a ceiling is reached. Most adults are functioning at the expected level.
To use examples from the VABS: most adults can listen to an informational talk for at least
30 minutes, can describe a realistic long term goal, can make regular medical and health
related appointments, can plan and prepare a meal, have a full time job and can budget and
manage money, can plan a social activity and have committed relationships, can work
collegially with others in the workplace.
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Translating this into standard score norms on the VABS II, the highest standard score
an adult over 22 years can score on the VABS II is 107 (average range) in terms of
communication, 112 (just above average range) in terms of daily living skills and 111
(slightly above average) in terms of socialisation (Sparrow et al., 1984, p. 243). This
demonstrates the ceiling reached. However, on the same norms table, there is a significant
floor effect for adults between the ages of 22 and 49:11, with domain standard scores in the
severe disability range for a wide range of scores. (Refer to Figure 7.4. and 7.5. for an
example.)
Is the use of normal distribution and the associated statistics applicable to adaptive
functioning? In adults, it would seem to give rise to significant ceiling and floor effects.
This is demonstrated in our sample of adults, where the floor effect results in significant
underscoring for this adult group, with an overly high proportion scoring in the severe range
of disability and in contrast to the clinical judgment of the assessing psychologist. This is not
only applicable to our sample, as it is an integral problem evidenced in the norm tables for
adults in the VABS II manual.
With reference to the two norm tables photographed in the text, the following
scenario is described using the norm table to illustrate this difficulty (Figure 7.4. and Figure
7.5.). Tables 7.5. and 7.6. illustrate a case example of the use of the VABS II norm tables for
an 18 year and 2 months old person who scores in the mild intellectual disability range across
all domains and in terms of their adaptive behaviour composite score. If she was reassessed
three years later, at 22 years and 3 months and scored in a similar raw score range, so
functioning more or less similarly to when last assessed, but using the 22:0 - 49:11 norm
table, her VABS II composite score, is in the overall range of severe intellectual disability
with only her Daily Living Skills domain score in the Moderate range (refer to Table 7.6.).
This is out of keeping with her IQ score which was consistently 54 and 55 (Mild intellectual
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disability) on reassessment, accepting a moderate correlation, but more importantly with the
psychologist’s clinical impressions in terms of her adaptive functioning.
The adaptive functioning of a person with mild intellectual disability is significantly
different to that of a person with severe intellectual disability. The problem is that the adult
norm tables have a serious floor effect when used in adults at the lower end of mild
intellectual disability and below, thus tending to underestimate their adaptive abilities.
Table 7.5.
Example of the Floor Effect for Adults in the VABS II: Range of Disability at 18 Years 2
Months
18yrs 2 months VABS II 18:0-21.11 Norms Survey interview form
Sum of V-Scale
Domain Standard score Range of Intellectual Disability
Score
Communication 59
21 Mild ID
Daily Living
18 54 Mild ID
Skills
Socialization 16 51 Mild ID
Sum of standard
scores
AB Composite 54 Mild ID
164
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Table 7.6.
Example of Floor Effects for Adults in the VABS II: Range of Disability at 22 Years 3 Months
22yrs 3 months VABS II 22:0-49:11 Norms Survey interview form
Domain Sum of v-scale Standard Score

Range of Intellectual Disability
scores
Communication 20 21 Severe ID
Daily Living
17 44 Moderate ID
skills
Socialization 30
17 Severe ID
Sum of standard
scores
AB Composite 28 Severe ID
95
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Figure 7.4.
Norm Tables VABS II Age 18:0-21:11
From Vineland Adaptive Behavior Scales – Second Edition manual (p. 242) by S. S. Sparrow, D. V. Cicchetti
and D. A. Balla, 2005, Bloomington MN: Pearson. Copyright (2005) by NCS Pearson. Copied with permission.
262
Figure 7.5.
Norm Tables VABS II Age 22:0-49:11
From Vineland Adaptive Behavior Scales – Second Edition manual (p. 243) by S. S. Sparrow, D. V. Cicchetti
and D. A. Balla, 2005, Bloomington MN: Pearson. Copyright (2005) by NCS Pearson. Copied with permission.
263
7.9. To what extent do the newly published VABS 3 norm tables address this issue?
The VABS 3 has not yet been used clinically in this context but it was of interest to
see if the new test, published in the latter part of 2016, had a similar problem. Using the
comprehensive form norms published on line by Pearson (2016), the nearest equivalent
standard scores were used of a hypothetical 18 year and 2 month old client to work
backwards to a sum of V-Scale Scores, given that the test has different items and would score
differently. The overall standard score were calculated and the ranges of intellectual
disability using the 17:0 - 18:11 VABS 3 norms. This correlated well to the findings of the
VABS II, her IQ score (Std. Score of 54) and clinical impressions. The results are tabulated
in Table 7.7.
Table 7.7.
VABS 3 Norms for a Female of 18 Years 2 Months
Comprehensive
18 years 2 months VABS 3 17:0-18:11 Norms
interview form
Range of Intellectual
Domain Sum of V-Scale Score Standard score
Disability
Communication 60
25 Mild ID
Daily Living Skills 24 55 Mild ID
Socialization 51
18 Mild ID
Sum of standard
scores
166
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Using the same scores, it was extrapolated how she would score at a hypothetical 19
years and 4 months using the 19:0 - 21:11 VABS 3 norms (refer to Table 7.8.). This also was
as expected.
Table 7.8.
19 years 4 months 19:0-20:11 Norms Comprehensive interview

VABS 3
form
Domain Standard score Range of Intellectual

Sum of V-Scale Score
Disability
Communication 25 60 Mild ID
Daily Living Skills 24 55 Mild ID
Socialization 51
18 Mild ID
Sum of standard scores
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However, at 22 years and 3 months using the 21:0-49:11 norms (refer to Table 7.9.).
the standard score had dropped, with an AB Composite score in the moderate ID range,
moderate range in the domain of Communication and severe ID in the domain of
Socialisation.
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Table 7. 9.
22 years 3 months 21:0 - 49:11 Norms

VABS 3 Comprehensive interview form
Domain Sum of V-Scale Standard score

Range of Intellectual Disability
Score
Communication 25 48 Moderate ID
Daily Living skills 24 51 Mild ID
Socialization 18 20 Severe ID
Sum of standard
scores
AB Composite 41 Moderate ID
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Given a hypothetical age of 51 years and 6 months I used the 50:0 - 69:11 VABS 3
norms (refer to Table 7.10.). At this age the standard scores equated with those scored in the
21:0 - 49:11 norms.
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Table 7.10.
Comprehensive
51 years 6 months VABS 3 50:0 - 69:11 Norms
interview form
Range of Intellectual
Domain Sum of V-Scale Score Standard score
Disability
Communication 48
25 Moderate ID
Daily Living skills 24 51 Mild ID
Socialization 20
18 Severe ID
Sum of standard
scores
AB Composite 41 Moderate ID
119
The difference is not as marked across domains in the VABS 3 but still poses a
difficulty in using the VABS 3 to evaluate adaptive functioning in this group of adults falling
at the lower end of mild intellectual disability.
In trying to understand this discrepancy, I contacted the author of the newly published
VABS 3, Dr. Celine Saulnier. She, in turn, asked the director of psychometrics at the
publisher, Pearson. I received the following communication: (C. Saulnier, personal
communication, January 25, 2017, quoted with permission)
Please see the response below from our Director of Psychometrics, who supervises all
norms development. I would add that any time standard scores are compared in this
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way for two cases just on either side of an age divide, this kind of finding is
possible…and somewhat inevitable unless norms were provided for extremely narrow
age groups, which is impractical. Hope this helps.
The standard scores reflect the relative standing in light of the reference group (e.g.,
age peers). For the current scenario, although the sum of v-scaled score are the same
for the two cases, because the reference groups are different for the two ages, the
derived standard scores tend to differ. This is especially true for the socialization
domain. Because the related adaptive function is much lower for ages (14-20) than
for ages (21-69), the same sum of v-Scaled score means quite different when
compared to different standards (e.g., the ages 14-20 reference group or ages 21-69
reference group).
Although standard scores 51 and 20 appears quite different, they are both very low
scores & their percentile rank is both below 0.001. If considering the confidence
interval, 51(±6) and 20(±3) will put both cases in severe range.
Also, it is important to note that, given the nature of this test, scores based on
different reference groups may not be compared directly. If the comparison is
extremely necessary, I suggest the customer to use the same norms to derive the
domain standard scores.
The problem is that, in terms of adaptive functioning, what a person with mild
disability can do is very different to a person with moderate or severe disability and we do the
person an injustice to lump them all together. The very purpose of the assessment is to be
able to differentiate levels of disability. Although standard scores of 51 and 20 are both
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within the 0.001 percentile, there is the wide range of difference of adaptive functioning.
The person with a standard score of 46 and 23, pushing the confidence limits to their
nearest point, has very different adaptive functioning. Why is it that this difficulty does not
evidence itself at younger ages?
Is it a matter of small sample numbers of adults? Or is it possibly a difficulty with
imposing statistical analyses which give a normal distribution onto measured skills which do
not follow a normal distribution pattern as described above, that follow an asymptote pattern
of development. Is the box the wrong shape?
Other published adaptive functioning assessment research regarding adults with
intellectual disability was sought. There is a growing interest in assessment of adults with ID,
particularly where there is a comorbidity of autism or psychiatric illness and in looking at
specific patterns in adaptive functioning with distinct syndromes (Di Nuovo & Buono, 2011;
Fisher, Lense, & Dykens, 2016; Hayes, 2005; Matson et al., 2009; Matthews et al., 2015).
Matson et al. (2009) used raw scores of the VABS (1984) rather than standard scores
“to avoid possible floor effects due to participants impairment level” (p. 1319). Carter et al.
(1998) identified the VABS (1984) standard scores as unreliable in patients with comorbid
intellectual disability and autism. In a study looking at the long term outcome of adults with
autism and intellectual disability, Fusar-Poli et al. (2017) chose to use raw sores and
compared them to changes in standard scores because of floor effects. There is evidence in
other settings of a similar issue.
7.10. Administration changes and use of norm tables
Two of the adaptation changes made with use within this context have been in
administration and the use of norm tables.
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7.10.1. Administration.
This was discussed by the psychologists and did not pertain directly to the research
questions but is included as useful information. The VABS II manual recommends that
“only you and the respondent should be in the room during the interview; the individual
being assessed should not be present” (Sparrow et al., 2005, p. 13).
Given that many of our clients and some of their caregivers come from impoverished
rural areas, many of the respondents are illiterate or barely literate, having had little to no
formal schooling themselves. Further, given the limited time of the assessment, it is very
helpful to both establish rapport and to get the best clinical estimate of the person’s
intellectual and adaptive functioning. There is also no one with whom the client feels
comfortable, with whom she can sit, whilst interviewing the caregiver who has accompanied
them. Given that this is already an emotionally stressful, given the context of sexual abuse
and unknown situation, we have found it best that the client remains in the room with the
caregiver during the interview and participates in the discussion. Ethically, this allows for a
greater degree of inclusion in the process and allows the psychologist to verify information.
The change is aimed at getting the most reliable information. For example, the first
item in the written subdomain is: Identifies one or more alphabet letters as letters and
distinguishes them from numbers. A small chart with numerals to 10 and the letters of the
alphabet is used to evaluate this item. The second item asks: Recognises own name in printed
form. The psychologist may write their name and ask it directly from the client. Including the
client in the process enables the psychologist to listen to those who know the client but also
to listen to the client themselves, to hear their voice.
The other shift in administration was of needing to ask quite specifically about items.
A response to asking what “Anna” helps with around the house may elicit an answer such as
“Niks” [Nothing]. It would take more detailed and explicit questioning and probing to
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explore that response. This has resulted in a more structured administration than suggested in
the manual, at times more item by item, particularly when working in a different language to
make sure that the responses were understood correctly.
7.10.2. Use of norm tables.
Clinically, it has been found that the norms tables for adults from 18-21:11 (Sparrow
et al., 2005, p. 242) provide a differentiated spread of raw score conversions to standard score
conversions in all three domains and in the further conversion to a composite score and that
the scoring is a much closer estimate to our clinical judgement in older adults. These tables
are used to inform clinical judgement for older adults as advised by Pearson and as informed
by the following study.
Widaman et al. (1991), in their study of life span development of adaptive behaviours,
found that adults across the ranges of intellectual disability reach asymptote in terms of
independent living skills by approximately 16 years of age with approximate stability until 45
years. Cognitive competence asymptote is reached by 18-20 years in mild to moderate
intellectual disability with no changes in mean levels until the mid-60’s, with severe and
profound intellectual disability reaching asymptote at 7-10 years with little to no change
thereafter. In terms of social competence mild intellectual disability show improvements until
the early 20’s and show a small but steady decline after 30. Moderate intellectual disability
show improvements in social competence until 10 years and then have an approximately 15
year period of stability before declines are small but steady thereafter. People with severe and
profound disability show gains in social competence until about eight years of age, remain
stable for about 10 years when declines then begin. Those with profound disability show a
faster rate of decline than those with severe disability. After 20, people at all levels of
intellectual disability show steady and parallel increase in social maladaptation levels through
the remainder of the life span (see literature review section 2.4.4.).
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This change in norm table use is documented in the psycho-legal report. The thinking
behind it is linked to the reaching of asymptote of adaptive skills in adults as described
previously. Developmentally, there is little change in adaptive skills during adulthood unless
injury, trauma or illness result in limitations. We have applied the same to our thinking with
people with intellectual disability. Even given the cultural differences and the trauma of the
sexual abuse, the clinical findings for adult clients are often at odds with the standard scores
of the VABS II if the age appropriate norms are used. The norms for adults with intellectual
disability are inaccurate as described in the earlier chapters and in this discussion, with
significant floor effects. Use of the 18-21:11 tables is more useful in providing information
which agrees with clinical impressions. This is particularly important in a psycho-legal
context. Large differences in test results and clinical diagnosis lead to questions regarding the
validity of the diagnosis. The evaluation of adaptive functioning is informed by multiple
sources: a comprehensive assessment and history, including using the VABS II with the
client in the room, an assessment of their ability to testify, an assessment of their ability to
consent to sexual intercourse. It is also acknowledged that clinical judgement is imperfect
and limited and that in seeking best practice, there is an ongoing need to re-evaluate and keep
informed.
7.11. Ability to testify
The results of this study are very different to results published in some research in this
field in South Africa. Calitz et al. (2014) stated that in a study in Bloemfontein between 2003
and 2009 of 137 complainants, only one was able to testify in a court of law. During the
period of 2000 to 2006, a study conducted by CMH regarding the effectiveness of the SAVE
programme found that in 303 cases of abuse, 69% were found to be competent to testify in
court with adequate court preparation and in many cases with the support of an intermediary.
Those found competent (11.9%) were functioning in the range of severe intellectual
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disability, 42.4% at the level of moderate disability and 45.7% at the level of mild disability
(Cape Mental Health, 2008). The results of this study support that with 67% found able to
testify, with 6.2% functioning in the range of severe intellectual disability, 12.2% in the range
of moderate disability and 46% in the range of mild disability.
7.12. Exclusions
The process of exclusion uncovered the following information. There were no cases
excluded for the reason of active comorbid psychiatric diagnosis at time of assessment in the
latter years under review, 2012 and 2013 (refer to Table 7.11.). This points to a more rigorous
initial screening process, undertaken by the social worker by which persons referred with an
active comorbid psychiatric diagnosis would be identified and referred for treatment. These
people would continue with the psycho-legal assessment once they were psychiatrically
stable.
Table 7.11.
Breakdown of Reasons for Exclusion Regarding Comorbid Psychiatric Diagnosis at Time of
Assessment
Reasons for exclusion 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
11. Active comorbid psychiatric 2 4 1 3 2 2 4 0 0 18
diagnosis at time of assessment
11a. Degree of PTSD and 2 2 1 2 0 0 1 0 0 8
trauma
11b. Dissociation with regards 0 1 0 0 1 1 2 0 0 5
to sexual trauma
11c. Distractibility 0 1 0 0 0 0 0 0 0 1
11d. Heavily medicated 0 0 0 1 0 0 0 0 0 1
11e. Severe psychiatric 0 0 0 0 0 1 0 0 0 1
disability accounts for low
adaptive functioning not ID
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11f. Psychotic symptoms at 0 0 0 0 1 0 1 0 0 2
time of assessment
The other, rather disturbing, trend identified in the exclusions analysis was the
increasing number of cases seen for a further, second assessment. This points to a significant
failure in providing the necessary protection for persons already identified by social services,
the police and the legal system as especially vulnerable (refer to Table 7.12.).
Table 7.12.
Breakdown of Reasons for Exclusion Regarding Datum Previously Entered for Another Case
Reasons for exclusion 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
17. Datum previously entered 4 2 1 4 5 16
for another case
This chapter has discussed the various research questions raised, summarised the
findings of the research process and reviewed these in the light of other published research.
Further discussion has included the construct of adaptive functioning and its relation to a
normal distribution pattern, changes in administration of the VABS II, use of alternative
norms tables and the validation thereof, challenged different findings in terms of ability to
testify by people with intellectual disability published in South Africa and highlighted some
of the issues raised through the process of exclusion. The final chapter will summarise the
major findings of the research, identify areas of further research, further summarise the
limitations of this research, as already discussed in various parts of the dissertation, and
return to the stories of Sarai, Themba and Madelaine and link the motivation for this research
and the examination of the assessment process to their lives.
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Chapter Eight: Conclusion
8.1. Introduction
The sexual violence perpetrated on people with intellectual disability happens at
alarming rates all over the world, an abuse of power and trust. South Africa is no exception.
In 2015/16, a total of 51 895 sexual offences were recorded by police records in South Africa
and are regarded as underreported (South African Police Service, 2016). Those with
intellectual disability are not recorded separately.
Less able than the community around them, they may feel powerless or unable to
reject the sexual demands of another or to say no to this when they are expected to be
compliant in multiple ways in many contexts (Benedet & Grant, 2014).
The participants in this study represent a few, who have chosen to, or whose families
have chosen to, say no, and have filed a police report. This process is often complicated by
feelings of ambivalence, powerlessness, pressure and pain. The SAVE programme attempts
to assist them in overcoming the systemic barriers which prevent access to the judicial system
and to ask for an opportunity to be heard, for their right to say no, to be respected and
acknowledged and for those who have taken advantage of their vulnerability to be examined.
Formalised assessment, to describe their unique and general abilities and context to the court,
is necessary and can and should be protective of further trauma, with due regard to the
support needed.
Adaptive functioning is the intersection of the personal with the social environment
and its demands, the very nature of adaptation is embedded in context. Assessment of
adaptive functioning is needed, to be able to facilitate this person, to intersect with the social
context of court and its demands.
Ranges of intellectual disability give the bare bones descriptively. It is useful to
provide a description of personal context and distinctive abilities and difficulties in a nuanced
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and individual picture. In this research, the statistical analysis has examined the normative
data and appraised the categorical groupings and conclusions. The descriptive analysis has
sought to provide the broad contextual information and the clinical item analysis to examine
the useful and difficult in describing the particular for this person.
Mittler (2016) quotes the purpose of the UN Convention on the Rights of Persons
with Disabilities:
The purpose of the present Convention is to promote, protect and ensure the full and
equal enjoyment of all human rights and fundamental freedoms by all persons with
disabilities, and to promote respect for their inherent dignity.
(UN CRPD Article 1: Purpose, 2006)
He further quotes the chair of the drafting committee, MacKay as stating that
“Central to this convention is the paradigm shift in the treatment of persons with disabilities
from being objects of the law to being subjects of the law with the same rights as everyone
else” (Mittler, 2016, p. 33). This paradigm shift has been central to the process and purpose
of this research.
8.2. Summary of findings
8.2.1. The validity of the Vineland Adaptive Behavior Scales in the context of this
study.
The VABS appears to be a reliable and valid assessment tool for people with
intellectual disability in this context for those up to 22 years of age in all ranges of disability.
It shows a moderate but statistically significant correlation with IQ scores as measured by the
ISGSA as expected.
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8.2.2. Limitations of the validity of the Vineland Adaptive Behavior Scales in the
context of this study.
Over 22 years of age and into adulthood, there seems to be a pronounced floor effect
evident in the norms tables. This is particularly evidenced for people scoring in the lower end
of the mild disability range and below. Using the psychologists’ assessment of adaptive
functioning as caseness, the VABS was of high utility for the group under 22 but with
sensitivity and specificity being reached at a standard score of 62, however, for the group of
participants over 22 it was barely indicative of utility. Thus, it does not discriminate
accurately between different levels of intellectual disability for this group. In 36.8% of cases,
the VABS II underscores the range found in the concluding assessment of adaptive
functioning by the psychologist. When examined more closely, the VABS II scores closely
approximate the concluding range of adaptive functioning, except in the severe range, where
45.7% tended to underscore.
8.2.3. Significant association between variables and the Vineland Adaptive
Behavior Scales in the context of this study.
There was a significant association between English language in the VABS and
access to education in the VABS II with measurements of adaptive functioning. In both of
these instances further research was indicated to explore and understand the relationship
further. This is discussed later in the chapter.
8.2.4. The VABS 3.
Initial examination of the newly published VABS 3 norms for adults (2016), indicates
some improvement but a continued floor effect, across all domains for those in the severe
range, in the communication and daily living skills domains for those in the moderate range
and in communication domain for those in the mild disability range. This warrants closer
examination.
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8.2.5. The role of clinical judgment.
Norms for adults should be used with caution and careful corroboration in the taking
of the history, the measurement of IQ, collateral information from reliable informants and
using descriptions such as that given in the DSM-5 of level of expected functioning and
support needed, to come to a diagnosis. The importance of clinical judgment and its
limitations were discussed. The findings referred to in sections 5.2.16. and 5.2.17.
corroborate this.
8.2.6. Use in the psycho-legal context.
There was much useful qualitative information gained from the use of the VABS II
and used in the psycho-legal report. Direct reference was made to information gleaned from
the Communication and Daily Living Skills domains. The Socialisation domain was
underreported and although valued in terms of assessment of capacity to give evidence and
ability to consent, items from this domain were not reported with the frequency and diversity
as in the other two domains. This needs further investigation
8.2.7. Addressing difficult items in the VABS II.
There has been extensive revision of the VABS II, in the new edition of the VABS 3.
Many of the items, identified as difficult for contextual/cultural, linguistic/language or lack of
opportunity reasons, for this group of clients, have been deleted (18.5%) or adapted (33.9%).
Developmental sequencing of the items has been changed (25%) and some items moved to
different subdomains (5.9%). Overall less than 50% has been retained. It is, however, longer,
with a 19.4% increase in number of items and its evaluation for use in this particular context
remains to be done. Its use for adults in discriminating different ranges of intellectual
disability needs a cautious approach. The VABS 3 also introduces a slightly different scoring
system for items which are given an estimated score. It remains to be seen how useful this is,
278
in addressing items for which our clients have no opportunity or their caregivers can only
estimate their skill.
8.2.8. The asymptotic nature of adaptive functioning.
The asymptotic nature of adaptive functioning was described and the use of a normal
distribution curve was questioned with regard to adaptive functioning being a different
construct to the measurement of IQ. This is echoed by Tassé et al. (2012): “The threat of
nonnormality seems less likely to have a significant impact among children, where one might
expect some normal variability with respect to age of skill acquisition…the need to rely on
assessment methods other than normative scoring to assess adaptive behavior” (p. 299).
8.3. Summary of the limitations of this research
8.3.1. Clinical prediction versus statistical prediction.
Meehl (1954) argues against clinical prediction and for statistical prediction. One of
the limitations of this research is the lack of instruments which have been validated for use
within our South African context, given the varied cultural, language, socioeconomic and
educational background of the people who live here. We make use of an IQ test which has
not been normed on isiXhosa speakers and use translators to assist in administration. In an
ideal world it could be argued, this should change, as the International Test Commission
(2016) recommend. In reality, as clinicians we have little time to do the needed research,
given the clinical load. Whilst recognising the value of accurate statistical prediction, this
research has also highlighted the limitations, even within a well-researched and tried and
tested tool. We need to remain critical of our own practice but also of the inconsistencies
between our own observations and judgment and that of the tests we use. Our clinical
judgment and the tools we use are limited and need to be recognised as such.
279
8.3.2. Use of alternative tests.
The psychologists do use other tests, as referred to in the literature review (section
3.4.3), which were excluded from this sample for analysis purposes but it would be
interesting to explore the use of some alternate tools for which there are applicable South
African norms or which have been used in other countries. Cost, availability and appropriate
norms are limitations to practice and to this research. The Ravens Matrices and the K-ABC II
are examples where some South African norms have been developed, and the Leiter-R has
been used cross culturally in other recent studies (Fusar-Poli et al., 2016). It would be useful
to explore their use in this context.
Another tool which has been recently developed in terms of adaptive functioning, is
the development under the auspices of the American Association of Intellectual and
Developmental Disability (AAIDD) of the Diagnostic Adaptive Behavior Scales (DABS – at
time of writing not available through the suppliers in this country). Several studies have been
published regarding validity and reliability(Tassé et al., 2016), sensitivity and specificity
(Balboni et al., 2014) and content factor structure (Arias, Ángel Verdugo, Navas, & E.
Gómez, 2013). It has 25 items under Conceptual Skills, 25 items under Social Skills and 25
items under Practical skills. The aim was a tool that was as short as possible without losing
precision. Item selection was by means of Item Response Theory within the three subscales
so that those items would be selected that provided the most accurate information towards a
cut off point for determining significant limitations in adaptive functioning. The norms were
constructed on a sample of Americans from 4-21years. DABS sensitivity coefficients range
from 81% to 98% and specificity from 89% to 91% indicating very good levels of diagnostic
efficacy. Convergent validity coefficients, with the VABS II, ranged from 0.70 to 0.84, test-
retest reliability coefficients ranged from 0.78 to 0.95 and inter-rater coefficients ranges from
280
0.61 to 0.87. The authors emphasise interpreting the DABS scores with reference to clinical
judgment and to possible measurement error.
8.3.3. Limitations of context.
Time and resources limit the nature and depth of the assessment, with long waiting
lists of clients to be seen. Assessment of trauma is often superficial and can only be referred
to other sources of support either within the organisation or with other community or state
services.
8.3.4. Limitations of locally normed tests.
These are often outdated and with limited reliability and validity research. A further
limitation was the reliability and validity of IQ test translation, as mentioned previously.
8.3.5. A skewed sample.
The research accessed a skewed sample, with referral sources in the police services
finding it easier to identify people in the moderate or low mild range of intellectual disability
and below but finding it more difficult to necessarily identify people functioning at the higher
range of mild disability.
8.3.6. Limitation of generalisability.
The very select nature of sample group of people all having had some form of sexual
trauma, limits the ability to generalise findings but also adds a voice to those of others noting
a difficulty with floor effects.
8.3.7. Limitation of focus.
The focus of the research imposes limitations. Many issues which arose out of this
clinical context have not been addressed in the research. The issue of consent to sexual
intercourse and sexuality amongst people with intellectual disability; the area of having to
prove competency as a witness, as highlighted by Pillay (2012), is in and of itself
discriminatory, as that proviso is not extended to every witness.
281
8.3.8. Use of composite versus domain scores.
Widaman et al. (1991) recommend the description of adaptive functioning to be
inclusive and differentiated of the domains of conceptual skills, practical skills and social
skills as their trajectories and pattern within the lifespan vary. By using a composite range,
important detail is lost. In this research composite scores were used. A more detailed look at
the pattern and differences in the domain scores, a limitation in this study, would be of
interest for further research.
8.4. Areas of further research
8.4.1. Validity of the VABS in adult populations.
The use of adaptive functioning tools specifically with regard to their validity in adult
populations of people with intellectual disability as described previously.
8.4.2. Research of intellectual disability in immigrant and refugee groups.
What happens to people with intellectual disability in immigrant and refugee
situations? Mckenzie et al. (2013) ask what the impact of displacement due to conflict or
forced migration is on families with disabled family members.
8.4.3. Hidden and unreported sexual abuse.
There is a disproportionately small number of White English speaking people with
intellectual disability being referred according to urban Cape Town statistics. Where do they
go? What is the relationship to rates of sexual abuse? Is sexual abuse hidden or underreported
in this community?
8.4.4. Prevalence studies.
There is a need for prevalence studies both of intellectual disability and of rates of
sexual abuse. Combrinck, Meer, and Bosch (2013) stress the need and importance of research
in order to understand sexual violence, disability and access to justice.
282
8.4.5. Prevention of intellectual disability.
There is a need for education within communities regarding the preventable causes of
intellectual disability. There has been a significant health education drive regarding the
dangers of alcohol use in pregnancy in South Africa. However, it was striking how many
caregivers did not know the cause of the intellectual disability of their family member,
pointing to the powerlessness of not only the person with intellectual disability but also their
caregiver. Do they feel free to ask? Do they understand what they are told? How do they
make sense of the disability (Aldersey, Rutherford Turnbull, & Turnbull, 2014)?
8.4.6. Unexplored data.
The data set collected is rich with unexplored data which were beyond the scope of
this research.
• Issues of consent, how it was evaluated, sex education, tools used to evaluate it,
vitiated consent, the ability to refuse, and the understanding of sexually related
matters, all warrant further investigation.
• Competence as a witness is another area which has rich research interest. The
concepts of truth and falsehood and how these are understood by the clients, the
court and how that intersects with disability, the issue of oath taking and the legal
debate around requirements for people with intellectual disability being more
rigorous and difficult and thus discriminatory in itself, than the standards by
which other people are assessed (Pillay, 2012).
• The court process and outcomes, including the use of dolls and pictures and
assistive aids in court is an area of interest and importance (Bornman et al., 2016),
the importance and difference that use of an intermediary can make.
• The effectiveness of the social work intervention both for the urban clients and in
the rural areas.
283
• Replicability of the services and adaptations to other contexts in South Africa.
• The importance and need for sex education as a preventive measure (Johns &
Adnams, 2016).
8.4.7. Research priorities.
The consideration of research priorities in our context, given the limited resources for
research, must be a part of research planning. The importance of targeted research to work
toward “evidence of what works consistent with international human rights standards”
(Tomlinson et al., 2014, p. 1121) must be considered.
8.5. The stories continued
Sarai was assessed and found to be functioning at the lower end of the mild range of
intellectual disability, in terms of her adaptive functioning, and her IQ was a little higher, in
the middle of the mild range. She was able to give a sequential and simple account of the
alleged incidents. She had been unaware of the consequences of sexual intercourse possibly
resulting in pregnancy, although she now understood this. She was very ambivalent about
testifying due to threats from the family of the accused who live on the same farm. He had
also threatened to kill her if she told anyone and that fear remained. Due to the pregnancy,
there was undisputable evidence from the DNA regarding the paternity of the baby. The case
went to court and the defence argued that it was consensual. Being 16 years old and because
of the report of her anxiety by the psychologist, the recommendation for the use of an
intermediary was allowed by the magistrate and Sarai could be clear that it was not
consensual. The accused was sentenced to a seven-year prison term. She had the baby, who
to this point seems to be developing normally and her aunt is helping her with his care. She
was referred to the local social services agency in the area for ongoing support as it was
difficult for her aunt to be absent from work and it was expensive to travel to our offices.
284
There was a great sense of heaviness when Sarai was re-referred to our services
following another attempted sexual assault. This time, however, she was aware that she did
not have to submit and could resist and could tell her aunt what had happened. Sarai was now
22. On reassessment, her IQ remained in the same range as before. If anything, she was
functioning better and was actively involved in the care of her son. The trial and the resultant
decision, no longer being subjected to ongoing abuse, despite this attempt by another person,
had improved her self-agency. She had managed to push the alleged perpetrator away and
had run home. She had wanted to press charges. However, when adaptive functioning was
assessed, using the VABS II, she scored in the severe disability range of adaptive
functioning. This made no sense.
Themba was assessed and found to be functioning in the upper moderate range of
intellectual disability both in terms of IQ and adaptive functioning. He found it very difficult
to talk about the alleged incident to a strange psychologist who did not speak his language,
even though he developed a good relationship with the CMH social worker who served his
geographic area and who was the case manager and acted as a translator for the assessment
process. It was decided that the court process would traumatise him further and that he was
not able to give evidence. His mother had acted with foresight and taken him to the nearest
health centre on finding him at home. The doctor had taken samples on examination and
there was convincing medical evidence of the rape. Of the four teenage boys who were
arrested, two were found to have been sexually abused themselves, one was living in a home
with ongoing domestic violence and the fourth was found to be mildly intellectually disabled
himself. He had been the one who had had to hold Themba down during the assault. He was
the one who admitted involvement.
As the boys involved were between the ages of 10 and 14 years, the court referred
them to a diversionary programme (Omar, 2012). Themba’s formal assessment and his
285
deteriorated adaptive functioning, due to the trauma, was communicated to the support team
in the department of education with motivational letters for appropriate school placement.
The trauma he had suffered placed him in a higher need category and he was placed in a
school nearer to his mother’s workplace. A letter of motivation was also written to his
mother’s employer, with her consent, motivating for her work to be limited to day shifts to
allow her to provide adequate care and supervision for Themba. The social worker with
whom he had formed a good relationship facilitated these interventions, provided court
preparation for Themba and his mother and support through the court process. An application
has been made for housing which remains to be allocated as there are very long waiting lists,
despite the letter of motivation by the social worker.
Madelaine was assessed and found to be functioning in the range of mild intellectual
disability in terms of her IQ score, but the VABS II composite score placed her in the range
of severe disability. Given her participation in the protective workshop at the residential
facility and her level of communication during the assessment, along with a report from the
care worker at the residential facility, the psychologist assessed her to be in the range of mild
intellectual disability. This was documented in the report. Recommendation was made for the
use of an intermediary but, given her age, this is at the discretion of the magistrate. It was not
allowed. During the trial, the defence lawyer picked up on the discrepancy of the VABS II
assessment and the conclusion of the psychologist. The prosecutor was inexperienced and did
not facilitate the psychologist being able to explain her reasoning to the court whilst in the
witness stand giving expert testimony. Madelaine had to give evidence in open court. She
found this very difficult given her conflicted feelings about the perpetrator. Further, the
complicated questioning of the defence lawyer led her to contradict herself and she was not
given adequate protection from this line of aggressive questioning by the prosecutor. The
accused was acquitted.
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Madelaine’s family decided to move her to an alternative care facility which was
much more proactive in terms of sex education and she has settled there.
Psychological assessment within this context has far reaching consequences. It was
cases such as the ones described above, that motivated this research. If we are to make access
to justice a reality for people with intellectual disability, then we have to keep working at
ensuring that the tools we use are sensitive and specific, and that we continue to update our
skills to provide thoughtful and reflective practice.
287
References
Abrahams, N., & Gevers, A. (2017). A rapid appraisal of the status of mental health support
in post-rape care services in the Western Cape. South African Journal of Psychiatry,
23(0), 8. Retrieved from http://doi.org/10.4102/sajpsychiatry.v23i0.959
Adnams, C. M. (2010). Perspectives of intellectual disability in South Africa: epidemiology,
policy, services for children and adults. Current Opinion in Psychiatry, 23(5), 436–
440. Retrieved from http://doi.org/10.1097/YCO.0b013e32833cfc2d
Aldersey, H. M., Rutherford Turnbull, I., & Turnbull, A. P. (2014). Intellectual and
developmental disabilities in Kinshasa, democratic republic of the Congo: Causality
and implications for resilience and support. Intellectual and Developmental
Disabilities, 52(3), 220–233. Retrieved from http://doi.org/10.1352/1934-9556-
52.3.220
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, Va: American Psychiatric Association.
Arias, B., Ángel Verdugo, M., Navas, P., & E. Gómez, L. (2013). Factor structure of the
construct of adaptive behavior in children with and without intellectual disability.
International Journal of Clinical and Health Psychology, 13(2), 155–166. Retrieved
from http://doi.org/10.1016/S1697-2600(13)70019-X
Åse, F., Ilona, A.-R., Mirjam, K., Pekka, S., Eugene, H. H., Sarah, M. N., & Marit, K. (2012).
Adaptive behaviour in children and adolescents with foetal alcohol spectrum
disorders: a comparison with specific learning disability and typical development.
European Child & Adolescent Psychiatry, 21(4), 221–231. Retrieved from
http://doi.org/10.1007/s00787-012-0256-y
Bala, N., Lee, K., Lindsay, R. C. L., & Talwar, V. (2010). The competency of children to
288
testify: Psychological research informing Canadian law reform. The International
Journal of Childrens Rights. Retrieved from
http://doi.org/10.1163/157181809X458544
Balboni, G., Pedrabissi, L., Molteni, M., & Villa, S. (2001). Discriminant validity of the
Vineland Scales: Score profiles of individuals with mental retardation and a specific
disorder. American Journal on Mental Retardation, 106(2), 162. Retrieved from
http://doi.org/10.1352/0895-8017(2001)106<0162:DVOTVS>2.0.CO;2
Balboni, G., Tassé, M. J., Schalock, R. L., Borthwick-Duffy, S. A., Spreat, S., Thissen, D., …
Navas, P. (2014). The Diagnostic Adaptive Behavior Scale: Evaluating its diagnostic
sensitivity and specificity. Research in Developmental Disabilities, 35(11), 2884–
2893. Retrieved from http://doi.org/10.1016/j.ridd.2014.07.032
Balboni, G., Tasso, A., Muratori, F., & Cubelli, R. (2016). The Vineland-II in preschool
children with Autism Spectrum Disorders: An item content category analysis. Journal
of Autism and Developmental Disorders, 46(1), 42–52. Retrieved from
http://doi.org/10.1007/s10803-015-2533-3
Beail, N. (2003). Utility of the Vineland Adaptive Behavior Scales in diagnosis and research
with adults who have mental retardation. Mental Retardation, 41(4), 286–289.
Retrieved from http://doi.org/10.1352/0047-6765(2003)41<286:UOTVAB>2.0.CO;2
Beckene, T., Forrester-Jones, R., & Murphy, G. H. (2017). Experiences of going to court:
Witnesses with intellectual disabilities and their carers speak up. Journal of Applied
Research in Intellectual Disabilities, (00), 1–12. Retrieved from
http://doi.org/10.1111/jar.12334
Benedet, J., & Grant, I. (2013). More than an empty gesture: Enabling women with mental
disabilities to testify on a promise to tell the truth. Canadian Journal of Women and
the Law, 25(1), 31–55. Retrieved from http://doi.org/10.3138/cjwl.25.1.031
289
Benedet, J., & Grant, I. (2014). Sexual assault and the meaning of power and authority for
women with mental disabilities. Feminist Legal Studies, 22(2), 131–154. Retrieved
from http://doi.org/10.1007/s10691-014-9263-3
Bornman, J., White, R., Johnson, E., & Bryen, D. N. (2016). Identifying barriers in the South
African criminal justice system: implications for individuals with severe
communication disability. Acta Criminological: Southern African Journal of
Criminology, 29(1), 1–17. Retrieved from
http://doi.org/http://reference.sabinet.co.za/document/EJC198539
Borthwick-Duffy, S. A. (2009). Adaptive behavior. In J. W. Jacobson, J. A. Mulick, & J.
Rojahn (Eds.), Handbook of intellectual and developmental disabilites (pp. 279–293).
New York, NY: Springer.
Bottoms, B. L., Nysse-Carris, K. L., Harris, T., & Tyda, K. (2003). Jurors’ perceptions of
adolescent sexual assault victims who have intellectual disabilities. Law and Human
Behavior, 27(2), 205–227. Retrieved from http://doi.org/10.1023/A:1022551314668
Brown, H., Stein, J., & Turk, V. (2010). The sexual abuse of adults with learning disabilities:
Report of a second two-year incidence survey. Mental Handicap Research, 8(1), 3–
24. Retrieved from http://doi.org/10.1111/j.1468-3148.1995.tb00139.x
Brown, I. (2007). What is meant by Intellectual and Developmental Disabilities. In I. Brown
& M. Percy (Eds.), A comprehensive guide to intellectual and developmental
disabilities (pp. 3–15). Baltimore: Paul H Brookes.
Calitz, F. J. W., De Ridder, L., Gericke, N., Pretorius, A., Smit, J., & Joubert, G. (2014).
Profile of rape victims referred by the court to the Free State Psychiatric Complex,
2003 to 2009. South African Journal of Psychiatry, 20(1), 2. Retrieved from
http://doi.org/10.7196/sajp.459
Cape Mental Health. (2008). An exploratory study of the experiences of victims of sexual
290
abuse who have an intellectual disability in accessing the justice system and other
support services. Cape Town: Cape Mental Health Society.
Carr, A., Linehan, C., O’Reilly, G., Walsh, P. N., & McEvoy, J. (2016). The handbook of
intellectual disability and clinical psychology practice. Routledge. Retrieved from
http://public.eblib.com/choice/publicfullrecord.aspx?p=4505930
Carr, J. (1988). Six weeks to twenty-one years old: A longitudinal study of children with
Down syndrome and their families. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 29, 407–431.
Carter, A. S., Volkmar, F. R., Sparrow, S. S., Wang, J.-J., Lord, C., Dawson, G., … Schopler,
E. (1998). The Vineland Adaptive Behavior Scales: Supplementary norms for
individuals with autism. Journal of Autism and Developmental Disorders, 28(4), 287–
302. Retrieved from http://doi.org/10.1023/A:1026056518470
Cederborg, A.-C., Danielsson, H., La Rooy, D., & Lamb, M. E. (2009). Repetition of
contaminating question types when children and youths with intellectual disabilities
are interviewed. Journal of Intellectual Disability Research, 53(5), 440–449.
Retrieved from http://doi.org/10.1111/j.1365-2788.2009.01160.x
Christianson, A. L., Zwane, M. E., Manga, P., Rosen, E., Venter, A., & Downs, D. (2002).
Children with intellectual disability in rural South Africa: prevalence and associated
disability. Journal of Intellectual Disability Research : JIDR, 46(2), 179–186.
Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and
standardized assessment instruments in psychology. Psychological Assessment, 6(4),
284–290. Retrieved from http://doi.org/10.1037/1040-3590.6.4.284
Combrinck, H., Meer, T., & Bosch, C. (2013). Gender-based violence against women with
psychological and intellectual disabilities in South Africa: Promoting access to
justice. Retrieved from
291
http://www.ghjru.uct.ac.za/sites/default/files/image_tool/images/242/GBV_against_w
omen_with_disabilities_in_SA.pdf
Couzens, D., Cuskelly, M., & Jobling, A. (2004). The Stanford Binet fourth edition and its
use with individuals with Down Syndrome: cautions for clinicians. International
Journal of Disability, Development and Education, 51(1), 39–56. Retrieved from
http://doi.org/10.1080/1034912042000182193
Crocker, N., Vaurio, L., Riley, E. P., & Mattson, S. N. (2009). Comparison of adaptive
behavior in children with heavy prenatal alcohol exposure or attention-
deficit/hyperactivity disorder. Alcoholism: Clinical and Experimental Research,
33(11), 2015–2023. Retrieved from http://doi.org/10.1111/j.1530-0277.2009.01040.x
Dacey, C. ., Nelson, W., & Stoeckel, J. (1999). Reliability, criterion-related validity and
qualitative comments of the Fourth Edition of the Stanford-Binet Intelligence Scale
with a young adult population with intellectual disability. Journal of Intellectual
Disability Research, 43, 179–184.
Dartnell, E., & Jewkes, R. (2013). Sexual violence against women: The scope of the problem.
Best Practice & Research: Clinical Obstetrics & Gynaecology, 27(1), 3–13.
Davidson, J., & Dickman, B. (1990). Issues in the assessment of people regarded as mentally
handicapped. In S. Lea & D. Foster (Eds.), Perspectives on mental handicap in South
Africa (pp. 136–157). Durban: Butterworths.
Davis, K. M., Gagnier, K. R., Moore, T. E., & Todorow, M. (2013). Cognitive aspects of
fetal alcohol spectrum disorder. Wiley Interdisciplinary Reviews: Cognitive Science,
4(1), 81–92. Retrieved from http://doi.org/10.1002/wcs.1202
de Bildt, A., Kraijer, D., Sytema, S., & Minderaa, R. (2005). The psychometric properties of
the Vineland Adaptive Behavior Scales in children and adolescents with mental
retardation. Journal of Autism and Developmental Disorders, 35(1), 53–62. Retrieved
292
from http://doi.org/10.1007/s10803-004-1033-7
de Bildt, A., Sytema, S., Kraijer, D., Sparrow, S., & Minderaa, R. (2005). Adaptive
functioning and behaviour problems in relation to level of education in children and
adolescents with intellectual disability. Journal of Intellectual Disability Research,
49(9), 672–681. Retrieved from http://doi.org/10.1111/j.1365-2788.2005.00711.x
Delany, A, Jehoma, S., & Lake, L. (2016). South African child gauge. Cape Town:
University of Cape Town.
de Lemos, M. (1989). The Vinelands Adaptive Behavior Scales: Standard score adjustments
for Australian children. Psychological Test Bulletin, 2(1), 3–15.
Dickman, B. (2013). Access to justice for people with intellectual disabilites. Cape Town.
Dickman, B. (in preparation). Assessment of Competence.
Dickman, B. (2017). Psycho-legal assessment with complainants who have intellectual or
psycho-social disabilities.
Dickman, B. J., & Roux, A. J. (2005). Complainants with learning disabilities in sexual abuse
cases: A 10-year review of a psych-legal project in Cape Town, South Africa. British
Journal of Learning Disabilities, 33, 138–144.
Dickman, B., Roux, A., Manson, S., Douglas, G., & Shabalala, N. (2006). “How could she
possibly manage in court?” An intervention programme assisting complainants with
intellectual disabilities in sexual assault cases in the Western Cape. In B. Watermeyer,
L. Swartz, T. Lorenzo, M. Schneider, & M. Priestly (Eds.), Disability and social
change (pp. 116–133). Cape Town: HSRC Press.
Dixon, D. R. (2007). Adaptive Behavior Scales. International Review of Research in Mental
Retardation, 34, 99–140. Retrieved from http://doi.org/10.1016/S0074-
7750(07)34003-2
Di Nuovo, S., & Buono, S. (2011). Behavioral phenotypes of genetic syndromes with
293
intellectual disability: Comparison of adaptive profiles. Psychiatry Research, 189(3),
440–445. Retrieved from http://doi.org/10.1016/j.psychres.2011.03.015
Doll, E. A. (1935). A genetic scale of social maturity. American Journal of Orthopsychiatry,
5, 180–188.
Doll, E. A. (1965). Vineland Social Maturity Scale. Circle Pines MN: American Guidance
Service Inc.
Doyle, C., & Mitchell. (2003). Post-traumatic stress disorder and people with learning
disabilites: a literature based discussion. Journal of Learning Disabilities, 7(1), 23.
Emerson, E., Fujiura, G. T., & Hatton, C. (2007). International perspectives. In S. L. Odom,
R. H. Horner, M. E. Snell, & J. Blatcher (Eds.), Handbook of developmental
disabilities (pp. 593–613). New York: Guilford Press.
Fenton, G., D’ardia, C., Valente, D., Del Vecchio, I., Fabrizi, A., & Bernabei, P. (2003).
Vineland Adaptive Behavior profiles in children with autism and moderate to severe
developmental delay. Autism, 7(3), 269–287. Retrieved from
http://doi.org/10.1177/1362361303007003004
Finlay, W. M. L., & Lyons, E. (2002). Acquiescence in interviews with people who have
mental retardation. Mental Retardation, 40(1), 14–29. Retrieved from
http://doi.org/10.1352/0047-6765(2002)040<0014:AIIWPW>2.0.CO;2
Fisch, G. S. (1997). Longitudinal assessment of cognitive-behavioral deficits produced by the
fragile-X mutation. In International Review of Research in Mental Retardation, 21,
221–247. Retrieved from http://doi.org/10.1016/S0074-7750(08)60281-5
Fischer, J., Bachman, L. & Jaesche, R. (2003). A readers’ guide to the interpretation of
dignostic test properties: clinical example of sepsis. Intensive Care Medicine, 29,
1043–1051.
Fisher, M. H., Lense, M. D., & Dykens, E. M. (2016). Longitudinal trajectories of intellectual
294
and adaptive functioning in adolescents and adults with Williams syndrome. Journal
of Intellectual Disability Research, 60(10), 920–932. Retrieved from
http://doi.org/10.1111/jir.12303
Floyd, R. G., Shands, E. I., Alfonso, V. C., Phillips, J. F., Autry, B. K., Mosteller, J. A., …
Irby, S. (2015). A systematic review and psychometric evaluation of adaptive
behavior scales and recommendations for practice. Journal of Applied School
Psychology, 31(1), 83–113. Retrieved from
http://doi.org/10.1080/15377903.2014.979384
Foxcroft, C., & Roodt, G. (2009). Introduction to psychological assessment in the South
African context (3rd ed.). Cape Town: Oxford University Press.
Foxcroft, C., & Roodt, G. (2013). Introduction to Psychological Assessment in the South
African context (4th ed.). Cape Town: Oxford University Press.
Fusar-Poli, L., Brondino, N., Orsi, P., Provenzani, U., De Micheli, A., Ucelli di Nemi, S., …
Politi, P. (2017). Long-term outcome of a cohort of adults with autism and intellectual
disability: A pilot prospective study. Research in Developmental Disabilities, 60,
223–231. Retrieved from http://doi.org/10.1016/j.ridd.2016.10.014
Gentle, M., Milne, R., Powell, M. B., & Sharman, S. J. (2013). Does the cognitive interview
promote the coherence of narrative accounts in children with and without an
intellectual disability? International Journal of Disability, Development and
Education, 60(1), 30–43. Retrieved from
http://doi.org/10.1080/1034912X.2013.757138
Gleason, K., & Coster, W. (2012). An ICF-CY-based content analysis of the Vineland
Adaptive Behavior Scales-II. Journal of Intellectual and Developmental Disability,
37(4), 285–293. Retrieved from http://doi.org/10.3109/13668250.2012.720675
295
Goldberg, M. R., Dill, C. A., Shin, J. Y., & Nguyen, V. N. (2009). Reliability and validity of
the Vietnamese Vineland Adaptive Behavior Scales with preschool-age children.
Research in Developmental Disabilities, 30(3), 592–602. Retrieved from
http://doi.org/10.1016/j.ridd.2008.09.001
Goodley, D. (2017). Disability studies: an interdisciplinary introduction (2nd ed.). Los
Angeles: Sage.
Greenspan, S. (2010). Functional concepts in mental retardation: Finding the natural essence
of an artificial category. Exceptionality, 14(4), 205–224. Retrieved from
http://doi.org/10.1207/s15327035ex1404
Greenspan, S., & Granfield, J. (1992). Reconsidering the construct of mental retardation:
Implications for a model of social competence. American Journal on Mental
Retardation, 96, 442–453.
Greenspan, S., Switzky, H. N., & Woods, G. W. (2011). Intelligence involves risk-awareness
and intellectual disability involves risk-unawareness: Implications of a theory of
common sense. Journal of Intellectual and Developmental Disability, 36(4), 246–257.
Retrieved from http://doi.org/10.3109/13668250.2011.626759
Greenspan, S., & Woods, G. W. (2014). Intellectual disability as a disorder of reasoning and
judgement. Current Opinion in Psychiatry, 27(2), 110–116. Retrieved from
http://doi.org/10.1097/YCO.0000000000000037
Grossman, H. (1983). Classification of mental retardation. Washington DC: American
Association on Mental Deficiency.
Grove, W. M. (2005). Clinical versus statistical prediction: The contribution of Paul E.
Meehl. Journal of Clinical Psychology, 61(10), 1233–1243. Retrieved from
http://doi.org/10.1002/jclp.20179
Grover, V. M. (2000). An introduction to mental handicap. Cape Town.
296
Hambleton, R. (2005). Issues, designs, and technical guidelines for adapting tests into
multiple languages and cultures. In R. Hambleton, P. Merenda, & C. Spielberger
(Eds.), Adapting educational and psychological tests for cross-cultural assessment
(pp. 3–38). New Jersey: Lawrence Erlbaum Associates.
Hanley, J. A., & McNeil, B. J. (1982). The meaning and use of the area under a receiver
operating characteristic (ROC) curve. Radiology, 143, 29–36.
Harris, J. C. (2006). Epidemiology: Who is affected? In J. C. Harris (Ed.), Intellectual
disability: Understanding its development, causes, classification, evaluation and
treatment (pp. 79–95). New York: Oxford.
Harrison, P. L., & Boney, T. L. (2002). Best practices in the assessment of adaptive
behaviour. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology IV
(pp. 1167–1179). Retrieved from https://faculty.unlv.edu/sloe/Courses/EPY 715/Best
Practices in Adaptive Beh Assessment.pdf
Hastings, P. R., Hatton, C., Taylor, L. J., & Maddison, C. (2004). Life events and psychiatric
symptoms in adults with intellectual disabilities. Journal of Intellectual Disability
Research, 48(1), 42–46. Retrieved from
http://web.a.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?vid=1&sid=
6494f81c-c05a-4724-a526-4881560f90ab@sessionmgr4006
Hayes, S. C. (2005). Diagnosing intellectual disability in a forensic sample: Gender and age
effects on the relationship between cognitive and adaptive functioning. Journal of
Intellectual and Developmental Disability, 30(2), 97–103. Retrieved from
http://doi.org/10.1080/13668250500124968
Heber, R. (1959). A manual on the terminology and classification in mental retardation.
American Journal of Mental Deficiency, 64(2), 1–111.
Hessl, D., Nguyen, D. V., Green, C., Chavez, A., Tassone, F., Hagerman, R. J., … Hall, S.
297
(2009). A solution to limitations of cognitive testing in children with intellectual
disabilities: the case of fragile X syndrome. Journal of Neurodevelopmental
Disorders, 1(1), 33–45. Retrieved from http://doi.org/10.1007/s11689-008-9001-8
Hill, B. (2011). Adaptive and maladative behavior scales. Retrieved from http://www.come-
over.to/FAS/VinelandCompare.htm
Hirschowitz, R., Worku, S., & Orkin, M. (2000). Rape in South Africa. Pretoria.
Hodapp, R. M., Dykens, E. M., Hagerman, R., Schreiner, R., Lachiewicz, A. M., & Leckman,
J. F. (1990). Developmental implications of changing trajectories of IQ in males with
fragile X syndrome. Journal of the American Academy of Child & Adolescent
Psychiatry, 29(2), 214–219. Retrieved from http://doi.org/10.1097/00004583-
199003000-00009
Human Rights Watch. (2015).“Complicit in exclusion” South Africa’s failure to guarantee
an inclusive education for children with disabilities. Retrieved from
https://www.hrw.org/sites/default/files/report_pdf/southafrica0815_4up.pdf
International Test Commission. (2010). International Test Commission guidelines for
translating and adapting tests. Retrieved from http://www.intestcom.org
International Test Commission. (2016). The ITC guidelines for translating and adapting tests
(2nd ed.). Retrieved from www.INTestCom.org
Iriarte, E. G., McConkey, R., & Gilligan, R. (Eds.). (2016). Disability and human rights:
Global perspectives. London: Macmillan Education.
Jasson, A. E. (2009). The prevalence of posttraumatic stress disorder in a sample of people
living with intellectual disability that have been raped or sexually assaulted.
(Unpublished Master's thesis). Cape Town: University of Cape Town.
Jenkins, R. (1998). Culture, classification and (in)competence. In R. Jenkins (Ed.), Questions
of competence (pp. 1–24). Cambridge: Cambridge University Press.
298
Jenkins, R. (1999). Towards a social model of (in)competence. In R. Jenkins (Ed.), Questions
of competence (pp. 222–229). Cambridge, GBR: Cambridge University Press.
Retrieved from http://public.eblib.com/choice/publicfullrecord.aspx?p=4640390
Jewkes, R., & Abrahams, N. (2002). The epidemiology of rape and sexual coercion in South
Africa: an overview. Social Science & Medicine, 55(7), 1231–1244. Retrieved from
http://doi.org/10.1016/S0277-9536(01)00242-8
Jewkes, R., Fulu, E., Roselli, T., & Garcia-Moreno, C. (2013). Prevalence of and factors
associated with non-partner rape perpetration: findings from the UN multi-country
cross-sectional study on men and violence in Asia and the Pacific. The Lancet Global
Health, 1(4), e208–e218. Retrieved from http://doi.org/10.1016/S2214-
109X(13)70069-X
Johns, R. (2005). Step by step: A life skills, sexuality and HIV/AIDS education programme
for young adults with intellectual disability. A facilitator’s manual. Cape Town:
Western Cape Forum for Intellectual Disability.
Johns, R., & Adnams, C. (2016). My right to know: Developing sexuality education
resources for learners with intellectual disabilities in the Western Cape, South Africa.
The African Disability Rights Year Book 2016, 100–123.
Kaler, S. R., & Freeman, B. J. (1994). Analysis of environmental deprivation: Cognitive and
social development in Romanian orphans. Journal of Child Psychology and
Psychiatry, 35(4), 769–781. Retrieved from http://doi.org/10.1111/j.1469-
7610.1994.tb01220.x
Kaufman, A. S., & Kaufman, N. L. (1993). Kaufman Adolescent and Adult Intelligence Test
(KAIT) manual. Circle Pines, MN: American Guidance Service.
Kennedy, C. H. (2003). Legal and psychological implications in the assessment of sexual
consent in the cognitively impaired population. Assessment, 10(4), 352–358.
299
Retrieved from http://doi.org/10.1177/1073191103258592
Keogh, B., Bernheimer, L., & Guthrie, D. (1997). Stability and change over time in cognitive
level of children with delays. American Journal of Mental Retardation, 101, 365–373.
King, B. H., Toth, K. E., Hodapp, R. M., & Dykens, E. M. (2009). Intellectual disability. In
B. J. Sadock, V. A. Sadock, & P. Ruiz (Eds.), Comprehensive textbook of psychiatry
(9th ed., pp. 3444–3474). Philadelphia: Lippincott Williams & Wilkins.
Kitzmann, K. M., Gaylord, N. K., Holt, A. R., & Kenny, E. D. (2003). Child witnesses to
domestic violence: A meta-analytic review. Journal of Consulting and Clinical
Psychology, 71(2), 339–352. Retrieved from http://doi.org/10.1037/0022-
006X.71.2.339
Kodituwakku, P. W. (2009). Neurocognitive profile in children with fetal alcohol spectrum
disorders. Developmental Disabilities Research Reviews, 15(3), 218–224. Retrieved
from http://doi.org/10.1002/ddrr.73
Kodituwakku, P. W. (2010). A neurodevelopmental framework for the development of
interventions for children with fetal alcohol spectrum disorders. Alcohol, 44(7-8),
717–728. Retrieved from http://doi.org/10.1016/j.alcohol.2009.10.009
Kramers-Olen, A. (2016). Sexuality, intellectual disability, and human rights legislation.
South African Journal of Psychology, 46(4), 504–516. Retrieved from
http://doi.org/10.1177/0081246316678154
Kromberg, J., Zwane, E., Manga, P., Venter, A., Rosen, E., & Christianson, A. (2008).
Intellectual disability in the context of a South African population. Journal of Policy
and Practice in Intellectual Disabilities, 5(2), 89–95. Retrieved from
http://doi.org/10.1111/j.1741-1130.2008.00153.x
Krug, E., Dahlberg, L., Mercy, J., Zwi, A., & Lozano, R. (2002). World report on violence
and health. Retrieved from
300
http://www.who.int/violence_injury_prevention/violence/world_report/en/introductio
n.pdf
Kwendakwema, M. (2009). Behavioural challenges in people with intellectual disability : a
comparison between those with a history of sexual assault and those without.
(Unpublished Master's thesis). Cape Town: University of Cape Town.
Laher, S., & Cockcroft, K. (Eds.). (2013). Psychological assessment in South Africa.
Johannesburg: Wits University Press.
La Malfa, G., Lassi, S., Bertelli, M., Albertini, G., & Dosen, A. (2009). Emotional
development and adaptive abilities in adults with intellectual disability. A correlation
study between the Scheme of Appraisal of Emotional Development (SAED) and
Vineland Adaptive Behavior Scales (VABS). Research in Developmental Disabilities,
30(6), 1406–1412. Retrieved from http://doi.org/10.1016/j.ridd.2009.06.008
Landman, J. (1989). The development and standardization of an individual intelligence scale
for Xhosa-speaking pupils. Potchefstroom: Potchefstroom University for Christian
Higher Education.
Lezak, M., Howieson, D., & Loring, D. (2004). Neuropsychological assessment (4th ed.).
New York: Oxford University Press.
Linden, A. (2010). An exploratory study of psychiatric symptoms in intellectually disabled
people with and without a known history of sexual abuse. (Unpublished Master's
thesis). Cape Town: University of Cape Town.
Luckasson, R. A., Borthwick-Duffy, S. A., Buntinx, W. H. E., Coulter, D. L., Craig, E. M.,
Reeve, A., … Tassé, M. J. (2002). Mental retardation: Definition, classification, and
systems of supports (10th ed.). Washington, DC.: American Association on Mental
Retardation.
301
Luckasson, R., & Schalock, R. L. (2013). What’s at stake in the lives of people with
intellectual disability? Part II: Recommendations for naming, defining, diagnosing,
classifying, and planning supports. Intellectual and Developmental Disabilities, 51(2),
94–101. Retrieved from http://doi.org/10.1352/1934-9556-51.2.094
Lyon, T. D., & Saywitz, K. J. (2000). Qualifying children to take the oath: Materials for
interviewing professionals. Retrieved from
https://www.judcom.nsw.gov.au/publications/benchbks/sexual_assault/articles/Lyon-
Qualifying_children_to_take_oath.pdf
Mackenzie, T. (2010). Reported responses to sexual trauma in people with intellectual
disability: an analysis of clinical psychologists’ psych-legal reports. (Unpublished
Master's thesis). Cape Town: University of Cape Town.
Manning, M. A., & Eugene Hoyme, H. (2007). Fetal alcohol spectrum disorders: A practical
clinical approach to diagnosis. Neuroscience & Biobehavioral Reviews, 31(2), 230–
238. Retrieved from http://doi.org/10.1016/j.neubiorev.2006.06.016
Mansell, S., Sobsey, D., & Calder, P. (1992). Sexual abuse treatment for persons with
developmental disabilities. Professional Psychology: Research and Practice, 23(5),
404–409. Retrieved from http://doi.org/10.1037/0735-7028.23.5.404
Mason, J., & Murphy, G. (2002). People with an intellectual disability in the criminal justice
system: developing an assessment tool for measuring prevalence. The British Journal
of Clinical Psychology / the British Psychological Society, 41(Pt 3), 315–320.
Retrieved from http://doi.org/10.1348/014466502760379163
Matson, J. L., Rivet, T. T., Fodstad, J. C., Dempsey, T., & Boisjoli, J. A. (2009). Examination
of adaptive behavior differences in adults with autism spectrum disorders and
intellectual disability. Research in Developmental Disabilities, 30(6), 1317–1325.
Retrieved from http://doi.org/10.1016/j.ridd.2009.05.008
302
Matthews, N. L., Smith, C. J., Pollard, E., Ober-Reynolds, S., Kirwan, J., & Malligo, A.
(2015). Adaptive functioning in Autism Spectrum Disorder during the transition to
adulthood. Journal of Autism and Developmental Disorders, 45(8), 2349–2360.
Retrieved from http://doi.org/10.1007/s10803-015-2400-2
Matthews, W., Solan, A., Barabas, G., & Robey, K. (1999). Cognitive functioning in Lesch-
Nyhan syndrome: A 4-year follow-up study. Developmental Medicine & Child
Neurology, 41, 260–262.
Mattingly, C., & Fleming, M. (1994). Clinical reasoning: forms of inquiry in a therapeutic
practice. Philadelphia: F.A. Davis Company.
Maulik, P. K., Mascarenhas, M. N., Mathers, C. D., Dua, T., & Saxena, S. (2011). Prevalence
of intellectual disability: A meta-analysis of population-based studies. Research in
Developmental Disabilities, 32(2), 419–436. Retrieved from
http://doi.org/10.1016/j.ridd.2010.12.018
McAfee, J., & Gural, M. (1988). Individuals with mental retardation and the criminal justice
system: The view from States’ Attorneys General. Mental Retardation, 26(1), 5–12.
McConkey, R. (2016). Supporting family caregivers. In E. G. Iriarte, R. McConkey, & R.
Gilligan (Eds.), Diability and human rights: Global perspectives (pp. 231–244).
London: Palgrave.
McDonald, C. A., Thomeer, M. L., Lopata, C., Fox, J. D., Donnelly, J. P., Tang, V., &
Rodgers, J. D. (2015). VABS-II ratings and predictors of adaptive behavior in
children with HFASD. Journal of Developmental and Physical Disabilities, 27(2),
235–247. Retrieved from http://doi.org/10.1007/s10882-014-9411-3
Mckenzie, J. A., McConkey, R., & Adnams, C. (2013). Intellectual disability in Africa:
implications for research and service development. Disability and Rehabilitation,
35(20), 1750–1755. Retrieved from http://doi.org/10.3109/09638288.2012.751461
303
Meehl, P. E. (1954). Clinical versus statistical prediction: A theoretical analysis and a
review of the evidence. Minneapolis MN: University of Minnesota Press.
Meintjies, R. (2015). South African Professional Society on the Abuse of Children –
SAPSAC. Newsletter, 16(1), 1–3. Retrieved from
http://www.sapsac.co.za/newsletters/SAPSAC_Newsletter_Vol_16.1.pdf
Mercier, C., Saxena, S., Lecomte, J., Cumbrera, M. G., & Harnois, G. (2008). WHO atlas on
global resources for persons with intellectual disabilities 2007: Key findings relevant
for low- and middle-income countries. JPPI Journal of Policy and Practice in
Intellectual Disabilities, 5(2), 81–88.
Mindmusik Media. (n.d.). Mindmusik. Retrieved from Muzik.com
Mittler, P. (2016). The UN Convention on the Rights of Persons with Disabilities:
Implementing a paradigm shift. In E. G. Iriarte, R. McConkey, & R. Gilligan, R.
(Eds.), Disability and human rights: Global perspectives. London: Macmillan
Education.
Mouga, S., Almeida, J., Café, C., Duque, F., & Oliveira, G. (2015). Adaptive profiles in
autism and other neurodevelopmental disorders. Journal of Autism and
Developmental Disorders, 45(4), 1001–1012. Retrieved from
http://doi.org/10.1007/s10803-014-2256-x
Murphy, G. (2016). Intellectual disability, sexual abuse, and sexual offending. In A. Carr, G.
O’Reilly, P. N. Walsh, & J. McEvoy (Eds.), The handbook of intellectual disability
and clinical psychology practice (2nd ed., pp. 831–865). London: Routledge.
Murphy, G. H., & O’Callaghan, A. (2004). Capacity of adults with intellectual disabilities to
consent to sexual relationships. Psychological Medicine, 34(7), 1347–1357. Retrieved
from http://doi.org/10.1017/S0033291704001941
Nihira, K. (1999). Adaptive behavior: A historical overview. In R. Schalock (Ed.), Adaptive
304
behavior and its measurement: Implications for the field of mental retardation (pp. 7–
14). Washington DC: American Association on Mental Retardation.
Omar, S. (2012). Children who sexually abuse other children. Sun Press.
Pillay, A. (2003). Social competence in rural and urban children with mental retardation:
preliminary findings. South African Journal of Psychology, 33(3), 176–182.
Pillay, A. L. (2012). The rape survivor with an intellectual disability vs. the court. South
African Journal of Psychology, 42(3), 312–322. Retrieved from
http://doi.org/10.1177/008124631204200303
Pillay, A. L., & Sargent, C. (2000). Psycho-legal issues affecting rape survivors with mental
retardation. South African Journal of Psychology, 30(3), 9–13. Retrieved from
http://doi.org/10.1177/008124630003000302
Posel, D. (2001). Article What’s in a name? Racial categorisations under apartheid and their
afterlife. Transformation, 47, 59–80.
Republic of South Africa. (1977). The Criminal Procedures Act 51 of 1977. Retrieved from
http://www.justice.gov.za/legislation/acts/1977-051.pdf
Republic of South Africa. (1998). The Domestic Violence Act 116 of 1998. Retrieved from
Republic of South Africa. (2000). Promotion of Equality and Prevention of Unfair
Discrimination Act 4 of 2000. Retrieved from
Republic of South Africa. (2002). Mental Health Care Act 17 of 2002. Retrieved from
http://www.justice.gov.za/legislation/acts/2002-017_mentalhealthcare.pdf
Republic of South Africa. (2007a). The Criminal Law (Sexual Offences and Related Matters)
Amendment Act 32 of 2007. Retrieved from
305
Republic of South Africa. (2007b). The Criminal Law (Sentencing) Amendment Act, 2007.
Retrieved from http://www.justice.gov.za/legislation/acts/2007-038.pdf
Robinson, M. (1994). Individual Scale for General Scholastic Aptitude. Pretoria: Human
Sciences Research Council.
Sattler, J., & Saigh, P. (1990). School-based assessment research in five nations. McGill
Journal of Education, 25(1), 109–112.
Schalock, R. (2011). International perspectives on Intellectual Disability. In K. D. Keith
(Ed.), Cross cultural psychology: contemporary themes and perspectives (pp. 312–
328). New York: Wiley Blackwell.
Schalock, R., Borthwick-Duffy, S., Bradley, V., Buntix, D., Coulter, D., Craig, E. P. M., …
Yeager, M. H. (2010). Intellectual disability: Definition, classification, and systems of
supports (11th ed.). American Association on Intellectual and Developmental
Disabilities.
Schalock, R. L., & Luckasson, R. (2013). What’s at stake in the lives of people with
intellectual disability? Part I: The power of naming, defining, diagnosing, classifying,
and planning supports. Intellectual and Developmental Disabilities, 51(2), 86–93.
http://doi.org/10.1352/1934-9556-51.2.086
Scior, K. (2011). Public awareness, attitudes and beliefs regarding intellectual disability: A
systematic review. Research in Developmental Disabilities, 32(6), 2164–2182.
Retrieved from http://doi.org/10.1016/j.ridd.2011.07.005
Shuttleworth-Edwards, A., Gaylard, E., & Radloff, S. (2013). WAIS-III test performance in
the South African context: extension of a prior cross-cultural normative database. In
S. Laher & K. Cockroft (Eds.), Psychological assessment in South Africa (pp. 17–32).
Johannesburg: Wits University Press.
Shuttleworth-Edwards, A. B., Kemp, R. D., Rust, A. L., Muirhead, J. G. L., Hartman, N. P.,
306
& Radloff, S. E. (2004). Cross-cultural effects on IQ test performance: A review and
preliminary normative indications on WAIS-III test performance. Journal of Clinical
and Experimental Neuropsychology, 26(7), 903–920. Retrieved from
http://doi.org/10.1080/13803390490510824
Sinason, V. (2010). Mental handicap and the human condition (2nd ed.). London: Free
Association Books.
Søndenaa, E., Rasmussen, K., & Nøttestad, J. A. (2008). Forensic issues in intellectual
disability. Current Opinion in Psychiatry, 21(5), 449–453. Retrieved from
http://doi.org/10.1097/YCO.0b013e328305e5e9
Soudien, C., & Baxen, J. (2006). Disability and schooling in South Africa. In B. Watermeyer,
L. Swartz, T. Lorenzo, M. Schneider, & M. Priestly (Eds.), Disability and social
change (pp. 148–163). Cape Town: HSRC Press.
South African Police Service. (2016). Crime situation in South Africa. Retrieved from
https://www.saps.gov.za/services/final-crime-stats-release-02september2016.pdf
Sparrow, S., Balla, D., & Cicchetti, D. (1984). The Vineland Adaptive Behavior Scales:
Interview edition, survey. In Major psychological assessment instruments (Vol. 2, pp.
199–231).
Sparrow, S. S., & Cicchetti, D. V. (1985). Diagnostic uses of the vineland adaptive behavior
scales. Journal of Pediatric Psychology, 10(2), 215–225. Retrieved from
http://doi.org/10.1093/jpepsy/10.2.215
Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior Scales
(2nd ed.). Bloomington, MN: Pearson.
Sparrow, S. S., Cicchetti, D. V, & Saulnier, C. A. (2016). Vineland Adaptive Behavior Scales
- Third Edition Manual (3rd ed.). Bloomington: Pearson.
Statistics South Africa. (2017). The South Africa I know, the home I understand. Retrieved
307
from http://www.statssa.gov.za/
Swartz, S. (2016). Another country: Everyday social restitution. Cape Town: BestRed.
Swets, J. (1998). Measuring the accuracy of diagnostic systems. Science, 240, 1285–1293.
Tan, M., Reich, J., Hart, L., Thuma, P. E., & Grigorenko, E. L. (2014). Examining the
specific effects of context on adaptive behavior and achievement in a rural African
community: six case studies from rural areas of Southern province, Zambia. Journal
of Autism & Developmental Disorders, 44(2), 271–282. Retrieved from
http://doi.org/10.1007/s10803-012-1487-y
Tassé, M. J. (2009). Adaptive behavior assessment and the diagnosis of mental retardation in
capital cases. Applied Neuropsychology: Adult, 16(2), 114–123. Retrieved from
http://doi.org/10.1080/09084280902864451
Tassé, M. J., Schalock, R. L., Balboni, G., Bersani, H., Borthwick-Duffy, S. A., Spreat, S., …
Zhang, D. (2012). The construct of adaptive behavior: Its conceptualization,
measurement, and use in the field of intellectual disability. American Journal on
Intellectual and Developmental Disabilities, 117(4), 291–303. Retrieved from
http://doi.org/10.1352/1944-7558-117.4.291
Tassé, M. J., Schalock, R. L., Balboni, G., Spreat, S., & Navas, P. (2016). Validity and
reliability of the Diagnostic Adaptive Behaviour Scale. Journal of Intellectual
Disability Research, 60(1), 80–88. Retrieved from http://doi.org/10.1111/jir.12239
The Presidency of the Republic of South Africa. (2014). Twenty year review : South Africa,
1994-2014. Retrieved from
http://www.dpme.gov.za/news/Documents/20%20Year%20Review.pdf
Thomas, K. (2010). Test development in the South African cross-cultural arena. Paper
presented at the 12th Biennial South African Clinical Neuropsychological Association
Conference. Johannesburg.
308
Tomlinson, M., Yasamy, M. T., Emerson, E., Officer, A., Richler, D., & Saxena, S. (2014).
Setting global research priorities for developmental disabilities, including intellectual
disabilities and autism. Journal of Intellectual Disability Research, 58(12), 1121–
1130. Retrieved from http://doi.org/10.1111/jir.12106
United Nations. (2006). Convention on the Rights of Persons with Disabilities. Retrieved
from www.un.org/disabilities/conventionfull.shtml
Valenti-Hein, D. C., & Schwartz, L. (1993). Witness competency in people with mental
retardation: Implications for prosecution of sexual abuse. Sexuality and Disability,
11(4), 287–294.
Van Eerden, R., & De Beer, M. (2013). Assessment of cognitive functioning. In C. Foxcroft
& G. Roodt (Eds.), Introduction to psychological assessment in the South African
context (4th ed., pp. 147–169). Cape Town: Oxford University Press.
Van Niekerk, H. A. (2014). Determining the competency of children with developmental
delays to testify in criminal trials. Rhodes University.
Van Zyl, C. J., & Taylor, N. (2011). The Ravens Progressive Matrices: South African norms.
Villa, S., Micheli, E., Villa, L., Pastore, V., Crippa, A., & Molteni, M. (2010). Further
empirical data on the psychoeducational profile-revised (PEP-R): Reliability and
validation with the vineland adaptive behavior scales. Journal of Autism and
Developmental Disorders, 40(3), 334–341. Retrieved from
http://doi.org/10.1007/s10803-009-0877-2
Volkmar, F. R., Carter, A., Sparrow, S. S., & Cicchetti, D. V. (1993). Quantifying social
development in autism. Journal of the American Academy of Child and Adolescent
Psychiatry, 32(3), 627–32. Retrieved from http://doi.org/10.1097/00004583-
199305000-00020
309
Wehmeyer, M. L., Buntinx, W. H. E., Lachapelle, Y., Luckasson, R. A., Schalock, R. L.,
Verdugo, M. A., … Yeager, M. H. (2008). The intellectual disability construct and its
relation to human functioning operational versus constitutive definitions. Intellectual
And Developmental Disabilities, 46(4), 311–318.Retrieved from
http://doi.org/10.1352/2008.46:311–318
Whaley, S. E., O’Connor, M. J., & Gunderson, B. (2001). Comparison of the adaptive
functioning of children prenatally exposed to alcohol to a nonexposed clinical sample.
Alcoholism: Clinical and Experimental Research, 25(7), 1018–1024.
Whyte, S. R. (1998). Slow cookers and madmen: competence of heart and head in rural
Uganda. In R. Jenkins (Ed.), Questions of competence: Culture, classification and
intellectual disability (pp. 153–175). Cambridge University Press.
Widaman, K. F., Borthwick-Duffy, S. A., & Little, T. D. (1991). The structure and
development of adaptive behaviors. International Review of Research in Mental
Retardation, 17, 1–54. Retrieved from http://doi.org/10.1016/S0074-7750(08)60102-0
Wigham,S., Hatton, C., & Taylor, J. (2011). The effects of traumatising life events on people
with intellectual disability: A systematic review. Journal of Mental Health Research
in Intellectual Disabilites, 4(1), 19–39.
Williams, J. R. (2008). The declaration of Helsinki and public health. Bulletin of the WHO,
86(8), 650–652.
Wilson, W. (1992). The Stanford-Binet: Fourth Edition and Form L-M in assessment of
young children with mental retardation. Mental Retardation, 30, 81–84.
World Health Organization (WHO). (2001). International Classification of Functioning,
Disability and Health (ICF). Geneva. Retrieved from http://www.sustainable-
design.ie/arch/ICIDH-2Final.pdf
Zhang, J., Wheeler, J. J., & Richey, D. (2006). Cultural validity in assessment instruments for
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children with autism from a Chinese cultural perspective. International Journal of
Special Education, 21(1), 109–114. Retrieved from
http://digitalcommons.brockport.edu/ehd_facpub/5
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Appendices
Appendix A: Vineland Social Maturity Scale
312
313
314
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Appendix B: Vineland Adaptive Behavior Scales Interview Edition Survey Form
316
317
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319
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321
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323
324
325
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Appendix C: Vineland Adaptive Behavior Scales, Second Edition Survey Interview
327
Form
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
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Appendix D: Vineland Adaptive Behavior Scales, Third Edition Comprehensive
Interview Form
356
357
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359
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362
363
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365
366
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Appendix E: Discussion of Exclusion Criteria
The total number of cases assessed by the SAVE programme during 2005-2010, using
the Vineland Adaptive Behavior Scales (1985), was 419. Cases included on the sample,
numbered 321 (76.6%) and 98 (23.4%) cases were excluded.
The total number of cases assessed during 2009-2013 using the Vineland Adaptive
Behavior Scales II (2005) was 371. Included cases numbered 323 (86.5%) and 50 (13.5%)
cases were excluded from the sample used in the analysis.
Exclusion included both incomplete records and assessments, and those factors which
would substantially affect the reliability of the data analysed. There were 19 categories of
exclusion.
Reasons for exclusion were:
1. There was no VABS protocol on record. Data could not be entered in necessary detail
for analysis. (VABS-4)
2. No physical file for the client could be found in the stored records. Data were not
available. (VABS-3; VABS II-1)
3. There was no psychological report in the file or electronic copy available. The
concluding assessment of the psychologist could not be ascertained. (VABS-3).
4. The legal case was withdrawn because the police had not been able to identify the
alleged perpetrator which resulted in the assessment process and the legal process
being curtailed.(VABS-2; VABS II-1)
5. The psychological assessment process was incomplete due to the client or the family
not wanting to take the matter further with regard to legal proceedings. Non-
attendance at the second scheduled appointment was interpreted in this category as
was the client consenting to sexual intercourse or refusing to participate. Further care
388
and follow up was provided but the psycho-legal process was curtailed (VABS-16;
VABS II-3)
6. The legal case was finalised before the assessment process was complete. (VABS-1)
7. The VABS was completed by means of self-report, or the client was unaccompanied
or the informant was documented as unreliable for the VABS assessment. Some
clients came to the assessment unaccompanied. In some cases higher functioning
individuals were able to give self-report of their own level of functioning. These
instances were documented in the psycho-legal reports and were excluded from the
data set due to a possible lack of objectivity and reliability. Where the psychologist
had documented concerns regarding the reliability of the informant, i.e., the client was
not well known to the informant, these were also excluded. (VABS-16; VABS II-8)
8. Cases were excluded where a head injury accounted for diminished intellectual
and/or adaptive ability. Pre-existing crystallised cognitive functioning was a
confounding variable in these cases. (VABS-7; VABS II-1)
9. Cases were excluded where another neurological condition accounted for decreased
cognitive functioning. These included a previous stroke and history of a brain tumour.
(VABS-2)
10. In one instance an epileptic episode occurred at time of assessment. This possibly
compromised the reliability of the assessment. It was not clear from the record.
(VABS II-1)
11. There was an active comorbid psychiatric diagnosis at time of assessment. (VABS-
11; VABS II-7). These cases were referred for further psychiatric treatment. Priority
was given to mental health rather than the legal process. These fell into the following
categories:
389
11a. Degree of Post-Traumatic Stress Disorder and trauma response. (VABS-2;
VABS II-2)
11b. Dissociation with regards to sexual trauma. (VABS-1)
11c. Distractibility. (VABS-1)
11d. Heavily medicated. (VABS II-1)
11e. Severe psychiatric disability accounted for low adaptive functioning, not
intellectual disability. (VABS II-1)
11f. Psychotic symptoms at time of assessment. (VABS-7; VABS II-3)
12. The primary issue with regards to limited adaptive ability was a physical disability
and not intellectual disability. (VABS-1)
13. The date of birth was unknown. The client could not be accurately compared with
same age group peers in terms of adaptive or cognitive functioning. (VABS-1;VABS
II-2)
14. The client was profoundly/verbally disabled, to the extent that they were unable to
participate in the cognitive assessment. (VABS-8; VABS II-5)
15. Cognitive functioning was in the low average or average range even if adaptive
functioning was in the disabled range. In order to diagnose intellectual disability an
assessment of cognitive functioning and adaptive functioning should be in the
disabled range. (APA, 2013, p. 33) (VABS-9;VABS II-2)
16. The client was previously assessed by other health services and not by the
psychologists within the project. The results were used in the psycho-legal report
however the reliability of this assessment could not be determined. (VABS-1:VABS
II-2)
17. A number of clients were seen where there were more than one police case due to
repeat offences, by different alleged perpetrators. The datum was only entered on the
390
initial case. An exception to this was if the client has previously been assessed using
the VABS I. This was useful comparative data. (VABS-7; VABS II-9)
18. Co-existing physical disability necessitated the use of alternative tools of cognitive
assessment. (VABS-1; VABS II-2)
19. The Grover-Counter Scale of Cognitive Development, the Griffiths Scale of Mental
Development (Griffiths), the South African Wechsler Adult Individual Scale
(SAWAIS), the Senior South African Individual Scale-Revised (SSAIS-R) or the
Wechsler Intelligence Scale for Children – Revised (WISC-R) was used to assess
cognitive functioning in clinical preference to the Individual Scale for General
Scholastic Aptitude (ISGSA) which was the cognitive test that was generally
administered and results used in the analysis. (VABS-5; VABS II-6)
Table E.1.
Reasons for exclusion of data using the VABS and VABS II
Reason VABS VABS II
1 No VABS protocol on record 4 0
2 No physical file for the client could be found in the records. 3 1
3 No psychological report in the file or electronic copy available 3 0
4 The legal case was withdrawn, alleged perpetrator not identified 2 1
5 The client or family did not want to take the matter further 16 3
6 The legal case was finalised before completion of the assessment 1 0
7 Self-report, unaccompanied or unreliable informant for VABS assessment 16 8
8 Head injury accounted for diminished intellectual and adaptive ability 7 1
9 Other neurological condition accounted for decreased cognitive functioning 2 0
10 Epileptic episode at time of assessment 0 1
11 Active comorbid psychiatric diagnosis at time of assessment 11 7
11a Degree of PTSD and trauma 2 2
391
11b Dissociation with regards to sexual trauma 1 0
11c Distractibility 1 0
11d Heavily medicated 0 1
11e Severe psychiatric disability accounted for low adaptive functioning not ID 0 1
11f Psychotic symptoms at time of assessment 7 3
12 Primary physical disability and not ID 1 0
13 Date of birth unknown 1 2
14 Profoundly/verbally disabled, unable to participate in assessment 8 5
15 Low average/average cognitive functioning 9 2
16 Client assessed by other health services 1 2
17 Datum previously entered for another case 7 9
18 Co-existing physical disability necessitated the use of alternative tools 1 2
19 Grover, Griffiths, SAWAIS, SSAIS-R, WISC-R used for IQ assessment 5 6
TOTAL 98 50
% of sample 23.4% 13.5%
392
Appendix F
INTERVIEW GUIDE FOR PSYCHO-LEGAL ASSESSMENT. (Circle correct option)
Identifying Info:
Client name: Psychologist name:
Address:
Tel:
Urban / Rural town / Rural farm
Male / Female D.O.B
Age at assessment:
Date of referral to SAVE: Dates of assessment:
Accompanied by:
Relationship: Mother/ Father / Caregiver / Family member / Other…………
Referred by: Social Worker (CMH):
Police Investigating Officer involved: Tel:
Case No: Police station reported:
Home Language:
393
Has the case been to court? Name of perpetrator:
Next appearance date?
Prosecutor’s name: Tel:
Personal history:
394
Personal History (con.)
395
Cause of ID if known: Birth trauma / Childhood illness / FAS / Epilepsy / Trauma /
Other……………………………….
Level of care: adequate / lack of supervision / neglect / phys abuse / history of sexual
abuse / other………………………
396
Living arrangements: residential care / living in community.
Access to special needs education: main stream / adaptation class / ELSEN school /
Special care / None / Other ………………………
Other medical/ psychiatric history: (Inc. Substance history) ………………………………………………
………………………………………………………………………………………………
Family SES:
Maternal occupation: …………………………………………………………………….
Maternal level of education: ………………………………………………………
Paternal occupation: …………………………………………………………………….
Paternal level of education: …………………………………………………………….
Client employment: workshop / protected employment / open labour with support /
open labour / unemployed/ N/A
Family SES: below poverty level / low SES / middle SES / high SES
Grant: disability / care dependency / other …………………………… / none
Assault History:
397
Date of assault:
Charge: Rape / Sexual / Indecent assault / Rape with Assault / Other…………….
Date reported to the police:
Name/s of perpetrator:
No of perpetrators:
Relationship to perpetrator: stranger / acquaintance/ friend / family member distant / family member
immediate / staff member / other……………….
Reported account:
398
399
Level of functioning of perpetrator: Intellectually disabled/ psychiatric illness /
not known / not applicable / other ………
Did the perpetrator know of the client’s disability? Yes / No
Degree of violence: verbal threat of harm or shame / threat of weapon / weapon used / death threat /
need med. intervention / other……………….
Emotional changes since incident: …………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
Behavioural changes since incident: ……………………………………………….
……………………………………………………………………………………………
……………………………………………………………………………………………
400
No of incidents: Once / Several / Repeated
……………………………………………………………………………………………
…………………………………………………………………………………………….
Previous history of rape/ sexual assault: Yes / No
Supporting evidence: DNA / other witnesses / med exam / other………………………………………………
Referral source: FCS / NPA / NGO / Other……………………………………
Family support: No support / ambivalent / full support
Post-assault counselling received: None / State / NGO / CMH / Private /
Other………………………………
Appearance and Behaviour at assessment:
401
Understanding of sexual matters:
Sexual vocab:
Conception:
Contraception:
STI’s & HIV:
Sex education: school / media / home / other………………………….
Previous consensual sexual relationship Yes / No
Sexual interest: Yes /No
Ability to consent:
Knowledge Yes / No (mechanics and vocabulary)
Consequences Yes / No (STI’s, pregnancy, HIV/AIDS)
Vitiated consent (coerced) Yes / No
Ability to refuse Yes / No
Overall assessment Yes /No
402
Competence as a witness:
Understanding of court proceedings
Differentiate truth and falsehood: Yes – concrete / Yes – abstract / No
Perjury punishable Yes / further prep / No
Narrative account Yes / No
Use of dolls only Yes / No / N.A.
Narrative account with dolls Yes / No / N.A.
Answer clarifying questions Yes / No
Ability to promise Yes / No
Motivation to testify Yes: motivated / Wanting justice but ambivalent
No: No understanding of injustice / not a crime /
consequences of testifying
Use of an intermediary Yes / No
Overall assessment: Yes / No
NOTES:
403
Appendix G: Assessment Tools
The following pictures illustrate the tools used during the assessment of ability to
consent and the ability to give a narrative account of the alleged abuse. The first is of the
anatomically correct dolls used to assist with the narrative of the alleged abuse, if needed.
The dolls are also used to explore the client’s knowledge of sexually related body parts. The
pictures that follow are: the cover of the manual developed by Johns (2005) and published by
the Western Cape Forum for Intellectual Disability, and following, the pictures frequently
used to discuss good and bad touch and the abuse with the adult clients. This also facilitates
sexuality education for the client. The last picture indicates the resources in the sexuality
education picture pack which accompanies the manual (Johns, 2007).
404
405
406
407
408
409
410
411
412
413
414
Appendix H: Initial Referral Form
SAVE REFERRAL – CLIENT INFORMATION
Date of Referral: ___________________________
Name of client:_________________________________
D.O.B: ______________ Age: ________________
Gender: M F Language Preference: Eng. /Afr. / IsiXhosa
Address: _________________________________________________________________
Name of caregiver:__________________________________
Contact tel. Number: ___________________________
Referral agent: CMH, FCS, PROSECUTOR, OTHER AGENCY: ____________
Investigating/Police Officer: ________________________
Tel work:___________________________ Cell number:____________________
Fax number: __________________________ Email: ________________________________
Police station: ___________________Case Number: _______________________________
Name(s) of accused:__________________________________________________________
Dates for assessment:_________________ and ___________________
Charge laid: YES_____NO_____
Statement taken: YES _____NO_____
For Office Use:
Psychologist:
415
Social Worker:
File number: __________
PLEASE FAX TO: 021 44 88475 OR EMAIL: teri@cmh.org.za
416
Appendix I: Screen Shots of Database
Figure I.1. Opening Database Screen with Client Details
Figure I.1 shows the opening screen with identifying details (Name and address have
been hidden to maintain confidentiality) Drop down menus are indicated by arrows to the
right of the information box. This screen provides an option to exclude records from the
specific SAVE research database but be included in the database of the organisation. It also
provides an option to export to the excel spreadsheet from which data were analysed.
Figure I.2. demonstrates the assessment window with details of the assessment
recorded. Raw scores, domain scores and standard scores and ranges of disability could be
checked for accuracy of entry. An option to include VABS or VABS II score depending on
the date of the assessment was also included.
417
Figure I.2. Assessment Database Screen (VABS I)
418
Figure I.3. Detailed Database Assessment Screen (VABS II)
Figure I.3. details the more detailed data collected for the VABS II
assessments. Checking of score totals was built into the programme to ensure
accuracy.
419
Figure I.4. Assault History Database Screen
Figure I.4. details the history of the assault.
420
Figure I.5. Detailed Legal Information Database Screen
Figure I.5. details the information required by the court regarding the ability to give
evidence and consent to sexual intercourse.

421
Appendix J: Written Instruction to the Psychologists Regarding Identifying Useful and
Difficult Items
Instructions to Psychologists:
1. Highlight in green the items on the VABS II interview form, which provide useful
information for your report or in giving evidence.
2. Highlight in pink the items which are difficult to administer. Further identify:
a. L : If due to translation into another language/language issue
b. N/O: No opportunity but the test doesn’t give that option
c. C: Culturally inappropriate
d. O: Other (give reason)
422
Appendix K: Letter of Support and Permission from Cape Mental Health
423
Appendix L : Permissions From Pearson Publishers and Dr. Saulnier to Quote Email
Correspondence
From: "Licensing, -" <pas.licensing@pearson.com>
Subject: Re: Permissions Request
Date: 08 July 2017 at 9:45:54 PM SAST
To: Gill Douglas <gilldouglas@mweb.co.za>
Dear Ms. Douglas,
All references to the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3)
will apply equally to the Vineland Adaptive Behavior Scales, Second Edition
(Vineland-II) without exception.
You have the permission you requested to eight edition of both.
Regards,
William H. Schryver
Senior Legal Licensing Specialist
Please respond only to pas.licensing@pearson.com
424
On Sat, Jul 8, 2017 at 1:01 PM, Gill Douglas <gilldouglas@mweb.co.za> wrote:
Dear Mr Schryver
Thanks you for the permission regarding the VABS 3
Please refer to the last portion of the email for the application to also use portions of
the VABS II. I would greatly appreciate a response to my request
Many thanks
Gill Douglas
On 01 May 2017, at 9:06 PM, Licensing, - <pas.licensing@pearson.com> wrote:. Ms
Douglas,
Your request has been reviewed at several levels with the following results.
Pearson has no objection, and you have permission to include selected pages from
the Vineland Adaptive Behavior Scales, Third Edition (Vineland™-3) in your
evaluative study in the appendices for reference for your examiners.
The following content is permitted, provided you also include a Vineland-3 copyright
at the first mention of the included content. The content is Vineland-3 Manual pages
141, 142, 242, and 243 plus Pages 5-19 of the Vineland-3 Survey Interview form.
Inclusion of the above content is fee-waived, and the permission expires on May 31,
2018.
425
Regards,
William H. Schryver
Senior Legal Licensing Specialist
Please respond only to pas.licensing@pearson.com
---------- Forwarded message ----------
From: gilldouglas@mweb.co.za <gilldouglas@mweb.co.za>
Date: Tue, Apr 11, 2017 at 2:40 AM
Subject: Permissions Request
To: pas.licensing@pearson.com, haiwebadmin@pearson.com
The following is feedback submitted via the Contact Us page on:
www.PearsonClinical.com
================================================================
================
Contact Information
426
================================================================
================
Name: Ms. Gillian Kathleen Douglas
Email Address: gilldouglas@mweb.co.za
Telephone: 021 6711222
Fax:
Customer ID:
Position / Title: Senior Clinical Psychologist
Company Name: Stellenbosch University
Address: 8 Rose Street
Newlands
427
City, State, Zip: Cape Town, Western Cape, 7700
Country/Region: South Africa
================================================================
================
Legal Department/Permission Requests
================================================================
================
Title of Publication: Vineland Adaptive Behavior Scales
Edition: 2nd
Author (if available):
Copyright Date: 2005
Brief Description of your request: I have done an evaluative study of the use of
428
the VABS II in a South African context. In order to explicate the detail of my item
analysis it would be helpful to put selected pages of the manual and sections of the
Survey interview form in the appendices for reference for my examiners.
Specific list of materials to reproduce: Pgs 141,142, 242, 243 Manual Pgs 5-19
Survey interview form
Number of subjects/administrations or copies needed per year: 1
Name of party responsible for tracking reproductions and payment of fees:
Inclusive Dates:
Adaptation and/or format changes required?
Is this request for permission to translate? No
Is this request for permission to use materials in a book? No
429
430
Appendix M: Stellenbosch Health Research Ethics Committee Approval Notice
Approval Notice
New Application
08-Feb-2017
Douglas, Gillian GK
Ethics Reference #: S17/01/003

Exploring the use of the Vineland Adaptive Behavior Scales in assessment of intellectually disabled complainants in
Title:
sexual abuse cases in the Western Cape
Dear Ms Gillian Douglas,
The New Application received on 05-Dec-2016, was reviewed by members of Health Research Ethics Committee 2 via Expedited review procedures
on 08-Feb-2017 and was approved.
Please note the following information about your approved research protocol:
Protocol Approval Period: 08-Feb-2017 -07-Feb-2018
Please remember to use your protocol number (S17/01/003) on any documents or correspondence with the HREC concerning your research protocol.
Please note that the HREC has the prerogative and authority to ask further questions, seek additional information, require further modifications, or
monitor the conduct of your research and the consent process.
After Ethical Review:

Please note a template of the progress report is obtainable on www.sun.ac.za/rds and should be submitted to the Committee before the year has expired.
The Committee will then consider the continuation of the project for a further year (if necessary). Annually a number of projects may be selected
randomly for an external audit.
Translation of the consent document to the language applicable to the study participants should be submitted.
Federal Wide Assurance Number: 00001372

Institutional Review Board (IRB) Number: IRB0005239
The Health Research Ethics Committee complies with the SA National Health Act No.61 2003 as it pertains to health research and the United States
Code of Federal Regulations Title 45 Part 46. This committee abides by the ethical norms and principles for research, established by the Declaration of
Helsinki, the South African Medical Research Council Guidelines as well as the Guidelines for Ethical Research: Principles Structures and Processes
2004 (Department of Health).
Provincial and City of Cape Town Approval
Please note that for research at a primary or secondary healthcare facility permission must still be obtained from the relevant authorities (Western Cape
Department of Health and/or City Health) to conduct the research as stated in the protocol. Contact persons are Ms Claudette Abrahams at Western
Cape Department of Health (healthres@pgwc.gov.za Tel: +27 21 483 9907) and Dr Helene Visser at City Health (Helene.Visser@capetown.gov.za Tel:
431
Appendix N: Urban and Rural Police Referrals in the Western Cape
Figure N.1. Rural Referral Patterns of the Western Cape (by area).
Count of CLIENT_ID Column Labels

Rural Areas Rural farm Rural town Total
ASHTON 1 1 2
I 1 1
II 1 1
ATLANTIS 16 16
I 8 8
II 8 8
BOT RIVER 2 2
I 1 1
II 1 1
BOTRIVIER 1 1
II 1 1
BREDASDORP 4 4
I 1 1
II 3 3
CALEDON 1 1 2
I 1 1 2
CERES 1 1
I 1 1
CITRUSDAL 2 2
I 1 1
II 1 1
CLANWILLIAM 1 2 3
II 1 2 3
CLOETESVILLE 1 1
II 1 1
DARLING 2 2
I 2 2
DASSENBERG 1 1
II 1 1
DE DOORNS 3 3 6
I 1 1
II 2 3 5
DELFT 1 1
I 1 1
DURBANVILLE 2 2
I 2 2
EENDEKUIL 3 3
I 1 1
II 2 2
ELIM 1 2 3
II 1 2 3
FIRGROVE 1 1
I 1 1
FRANSCHHOEK 3 5 8
I 2 2 4
II 1 3 4
GANSBAAI 1 1
II 1 1
GENADENDAL 3 3
II 3 3
GEORGE 1 1
II 1 1
GOUDA 1 1
II 1 1
GRAAFWATER 1 1
II 1 1
GRABOUW 1 7 8
I 3 3
II 1 4 5
GREYTON 1 1
II 1 1
GROOT-DRAKENSTEIN 3 3
I 2 2
II 1 1
HAWSTON 2 2
I 1 1
II 1 1
HERMANUS 1 1
II 1 1
HERMON 1 1
I 1 1
KLAPMUTS 1 2 3
I 1 1
II 2 2
KLAWER 1 1
I 1 1
KOUE BOKKEVELD 1 1
II 1 1
LAINGSBURG 1 1
II 1 1
LAMBERTSBAAI 1 1
II 1 1
LUTZVILLE 1 1
II 1 1
MACASSAR 1 1
I 1 1
MALMESBURY 3 6 9
I 1 2 3
II 2 4 6
MASIPHUMELELE 1 1
II 1 1
MCGREGOR 1 1
I 1 1
MONTAGU 1 1
II 1 1
MOORREESBURG 2 2
I 2 2
OUDTSHOORN 2 2
I 2 2
PAARL 5 8 13
I 2 3 5
II 3 5 8
PAARL EAST 3 3
I 1 1
II 2 2
PACALTSDORP 1 1
I 1 1
PHILIPPI 2 1 3
I 2 2
II 1 1
PIKETBERG 2 2
I 2 2
PORTERVILLE 1 1 2
I 1 1
II 1 1
PRINCE ALFRED HAMLET 4 4
I 2 2
II 2 2
RAWSONVILLE 5 5
I 3 3
II 2 2
RIEBEEK KASTEEL 1 1
I 1 1
RIEBEEK WEST 1 1
II 1 1
RIVIERSONDEREND 1 1
I 1 1
ROBERTSON 2 2
II 2 2
SARON 2 2
I 1 1
II 1 1
SIR LOWRY'S PASS 1 1
II 1 1
ST HELENA BAY 2 2
I 1 1
II 1 1
STELLENBOSCH 4 10 14
I 2 3 5
II 2 7 9
SWELLENDAM 2 2
II 2 2
TOUWS RIVER 6 6
I 1 1
II 5 5
TOUWSRIVIER 1 1
II 1 1
TULBAGH 1 1 2
I 1 1
II 1 1
VILLIERSDORP 3 3
I 2 2
II 1 1
VREDENBERG 1 2 3
I 1 1 2
II 1 1
VREDENBURG 1 1
I 1 1
VREDENDAL 3 3
II 3 3
WELLINGTON 4 8 12
I 3 3 6
II 1 5 6
WOLSELEY 1 1
I 1 1
WORCESTER 10 14 24
I 4 4 8
II 6 10 16
Total 70 154 224
432
Figure N.2. Urban Referral Patterns of the Cape Town Metropole (by police station).
Count of CLIENT_ID
Column Labels
Urban Urban Total Total
Urban Areas VABS I VABS II
ATHLONE 4 1 5 5
BELGRAVIA 1 1 1
BELHAR 1 2 3 3
BELLVILLE 1 1 1
BELLVILLE SOUTH 1 1 2 2
BELLVILLE-SUID 1 1 1
BISHOP LAVIS 1 5 6 6
BLACKHEATH 2 2 2
BLUE DOWNS 1 1 1
BONTHEUWEL 4 5 9 9
BROOKLYN 2 1 3 3
BROWNS FARM 1 2 3 3
CAPE TOWN 2 2 2
CROSSROADS 1 1 1
DELFT 10 9 19 19
DELFT SOUTH 1 1 2 2
DIEP RIVER 1 1 1
DUNOON 1 5 6 6
DURBANVILLE 3 1 4 4
EASTRIDGE 1 1 1
EERSTE RIVER 5 1 6 6
ELSIES RIVER 7 3 10 10
FACTRETON 1 3 4 4
FISH HOEK 1 1 1
GOEDVERWAG 1 1 1
GOODWOOD 4 4 4
GRASSY PARK 4 4 4
GUGULETHU 17 5 22 22
HANOVER PARK 7 2 9 9
HEATHFIELD 1 1 1
HEIDEVELD 3 2 5 5
HEYNS PARK 1 1 1
HOUT BAY 1 1 1
KALK BAY 1 1 1
KALKSTEENFONTEIN 1 1 2 2
KEWTOWN 1 1 1
KHAYELITSHA 38 29 67 67
KLEINVLEI 1 1 1
KRAAIFONTEIN 1 3 4 4
KTC 1 1 1
KUILS RIVER 4 2 6 6
LANGA 6 6 6
LAVENDER HILL 2 2 2
LOTUS RIVER 3 3 6 6
LOWER CROSSROADS 2 2 2
MACASSAR 1 2 3 3
MAITLAND 2 2 2
MANDALAY 1 1 1
MANENBERG 6 4 10 10
MASIPHUMELELE 1 1 1
MFULENI 4 9 13 13
MILNERTON 1 2 3 3
MITCHELLS PLAIN 18 20 38 38
MOUNT VIEW 1 1 1
NEW CROSS ROADS 3 1 4 4
NORTH PINE 1 1 1
NYANGA 8 4 12 12
OCEAN VIEW 1 3 4 4
OLD CROSS ROADS 2 2 2
OTTERY 1 1 2 2
PARKWOOD 1 2 3 3
PARKWOOD EST 1 1 2 2
PAROW 2 2 2
PHILIPPI 11 3 14 14
PHILIPPI EAST 1 1 1
PHILLIPI FASE 4 2 2 2
PLUMSTEAD 1 1 2 2
RAVENSMEAD 5 5 10 10
RETREAT 1 1 2 2
RICHWOOD 1 1 1
RUGBY 1 1 1
RUYTERWACHT 1 1 1
SAMORA MACHEL 2 1 3 3
STEENBERG 4 4 4
STRAND 3 7 10 10
STRANDFONTEIN 1 1 1
TABLE VIEW 1 1 2 2
UITSIG 2 2 4 4
VALHALLA PARK 1 2 3 3
WALLACEDENE 2 2 2
WESBANK 1 3 4 4
WESTLAKE 1 1 1
WOODSTOCK 1 1 1
WYNBERG 1 1 2 2
YSTERPLAAT 1 1 1
ZWELETEMBA 1 1 1
Total 228 190 418 418
433
There were 45 rural police stations reporting and referring for the VABS sample and
48 for the VABS II sample. There were 28 police stations which referred clients to both
samples and an overall total of 65 different police stations referred clients to SAVE during
the data collection period. In the urban sample 85 different police stations referred clients to
the programme. Of note was the large number of referrals from the following police stations:
• Khayelitsha – 67 referrals
• Delft – 19 referrals
• Elsies River –10 referrals
• Gugulethu – 22 referrals
• Manenberg – 10 referrals
• Mitchell’s Plain – 38 referrals
• Nyanga – 12 referrals
• Phillipi – 14 referrals
• Ravensmead – 10 referrals
• Strand – 10 referrals
This could be a reflection of perceptive interviewing and relevant referrals, greater
incidence in these areas, particularly good networking relationships with the police or other
reasons. It warrants further investigation. Referrals to the SAVE programme come from a
wide range of police stations both in urban and rural areas of the Western Cape.
434
Appendix O: Affidavit Proforma Regarding Use of Psycho-Legal Report
AFFIDAVIT IN TERMS OF SECTION 212 (4) OF ACT 51 OF 1977 (As
amended)
I, Gillian Kathleen Douglas, hereby make oath and state:
I am a registered Clinical Psychologist practicing in the Regional Division of Cape Town and
in the service of Cape Mental Health in the capacity of a Clinical Psychologist.
On the ……………………………………..at Cape Mental Health, 22 Ivy Street
Observatory, Cape Town I interviewed and assessed …………………….………………..
I recorded my findings and observations in the attached report. The facts in the report were
established by an assessment requiring skills in Human Behavioural Science.
I know and understand the contents of this statement.
I have no objection in taking the prescribed oath
I consider the oath to be binding on my conscience.
Signature: ……………………………………………………
Gillian Kathleen Douglas
CLINICAL PSYCHOLOGIST
435
MA (Clin Psych) UCT.
Date: ……………………………….
I certify that the above statement was taken by me and that the deponent has
acknowledged that she knows and understands the contents of this statement. This
statement was sworn/ affirmed before me and the deponent’s signature was placed
thereon in my presence
at……………………………………………..on……………………………………
at……………………………………………..
Signature COMMISSIONER OF OATHS:……………………………………………..
……………………………………………………………..
FULL NAME AND SURNAME (In Print)
436
Appendix P: Details of the ROC Analyses
P.1. Full sample: VABS II Scores onto Psychologists’ evaluation of IQ.
Evaluation of Full Sample.
Table P.1.
Summary Information of ROC Curve of VABS II Scores onto the IQ Evaluation of Full
Sample.
Case Processing Summary
Valid N
ROC Mod Vs *Severe (listwise)
Positiveb (Severe) 52
Negative (Moderate) 113
Missing 156
Smaller values of the test result variable(s)
indicate stronger evidence for a positive
actual state.
b. The positive actual state is 1.00.
437
Area Under the Curve
Test Result Variable(s): VABS II Overall Standard Score
Asymptotic 95% Confidence
Asymptotic Interval
Area Std. Errora Sig.b Lower Bound Upper Bound
.758 .037 .000 .684 .831
The test result variable(s): VABS II Overall Standard Score has at least one tie
between the positive actual state group and the negative actual state group.
Statistics may be biased.
a. Under the nonparametric assumption
b. Null hypothesis: true area = 0.5
Coordinates of the Curve
Test Result Variable(s): VABS II Overall
Standard Score
Positive if Less
Than or Equal
Toa Sensitivity 1 - Specificity
19.00 .000 .000
20.50 .327 .115
21.50 .423 .142
22.50 .462 .159
23.50 .500 .168
24.50 .519 .186
25.50 .538 .212
27.00 .538 .239
28.50 .538 .248
29.50 .558 .257
30.50 .558 .274
438
31.50 .577 .283
33.00 .615 .301
34.50 .654 .310
35.50 .673 .345
38.00 .731 .354
40.50 .750 .372
42.50 .769 .389
44.50 .788 .398
45.50 .808 .407
46.50 .885 .442
47.50 .904 .460
48.50 .904 .469
49.50 .923 .513
50.50 .923 .540
51.50 .923 .558
52.50 .923 .619
53.50 .942 .646
54.50 .981 .699
55.50 .981 .708
56.50 1.000 .735
57.50 1.000 .788
58.50 1.000 .885
59.50 1.000 .912
60.50 1.000 .920
61.50 1.000 .982
64.00 1.000 .991
67.00 1.000 1.000
439
The test result variable(s): VABS II Overall
Standard Score has at least one tie between the
positive actual state group and the negative
actual state group.
a. The smallest cutoff value is the minimum
observed test value minus 1, and the largest
cutoff value is the maximum observed test value
plus 1. All the other cutoff values are the
averages of two consecutive ordered observed
test values.
P.2. Participants 22 years and older: VABS II scores onto Psychologists’
evaluation of IQ.
Evaluation of Participants 22 Years and Older.
440
Table P.2.
Summary Information of ROC Curve of VABS II Scores onto the IQ Evaluation of
Participants 22 Years and Older.
Valid N
ROC Mod Vs *Severe (listwise)
Positivea 31
Negative 41
Missing 24
Smaller values of the test result
variable(s) indicate stronger evidence for
a positive actual state.
a. The positive actual state is 1.00.
Asymptotic Interval
.691 .062 .006 .569 .812
441
Standard Score
Positive if Less
Than or Equal
19.00 .000 .000
20.50 .516 .293
21.50 .677 .366
22.50 .742 .415
23.50 .806 .439
24.50 .839 .488
25.50 .871 .561
27.00 .871 .634
28.50 .871 .659
29.50 .903 .683
30.50 .903 .732
31.50 .935 .756
33.00 1.000 .805
34.50 1.000 .829
35.50 1.000 .927
38.00 1.000 .951
46.50 1.000 .976
54.00 1.000 1.000
actual state group.
442
test values.
P.3. Participants younger than 22 years: VABS II scores onto Psychologists’
evaluation of IQ.
Evaluation of Participants Younger than 22 Years.
Table P.3.
Summary Information of ROC Curve of VABS II Scores onto the IQ Evaluation of
Participants Younger than 22 Years.
ROC Mod Vs *Severea Valid N (listwise)
443
Missing 132
indicate stronger evidence for a positive actual
state.
Asymptotic 95% Confidence Interval
Area Std. Errora Asymptotic Sig.b Lower Bound Upper Bound
.854 .045 .000 .765 .943
The test result variable(s): VABS II Overall Standard Score has at least one tie between
the positive actual state group and the negative actual state group. Statistics may be biased.
Test Result Variable(s): VABS II Overall Standard
Score
Positive if Less
Than or Equal Toa Sensitivity 1 - Specificity
19.00 .000 .000
27.00 .048 .014
34.50 .143 .014
35.50 .190 .014
38.00 .333 .014
40.50 .381 .028
42.50 .429 .056
44.50 .476 .069
444
45.50 .524 .083
46.50 .714 .139
47.50 .762 .167
48.50 .762 .181
49.50 .810 .250
50.50 .810 .292
51.50 .810 .319
52.50 .810 .417
53.50 .857 .444
54.50 .952 .528
55.50 .952 .542
56.50 1.000 .583
57.50 1.000 .667
58.50 1.000 .819
59.50 1.000 .861
60.50 1.000 .875
61.50 1.000 .972
64.00 1.000 .986
67.00 1.000 1.000
The test result variable(s): VABS II Overall Standard
Score has at least one tie between the positive actual
state group and the negative actual state group.
a. The smallest cutoff value is the minimum observed
test value minus 1, and the largest cutoff value is the
maximum observed test value plus 1. All the other
cutoff values are the averages of two consecutive
ordered observed test values.
445
P.4. Full sample: VABS II scores onto Psychologists’ evaluation of Adaptive
Functioning (AF).
Figure P.4. Graphical Representation of ROC Curve VABS II Scores onto Psychologists’
Evaluation of AF of Full Sample.
Table P.4.
Summary Information of ROC Curve of VABS II Scores onto the Psychologists’ Evaluation of
AF of Full Sample.
Adaptive Functioning Valid N
ModVsSev (listwise)
Missing 205
state.
446
Asymptotic Interval
.826 .039 .000 .749 .903
Standard Score
Positive if Less
Than or Equal
19.00 .000 .000
20.50 .468 .116
21.50 .574 .174
22.50 .638 .203
23.50 .702 .203
24.50 .745 .217
25.50 .766 .246
27.00 .787 .290
28.50 .809 .290
30.00 .830 .304
31.50 .851 .319
447
33.00 .894 .333
34.50 .936 .333
35.50 .936 .406
38.00 .957 .435
40.50 .979 .464
42.50 .979 .507
44.50 .979 .536
45.50 .979 .565
46.50 .979 .681
47.50 .979 .725
48.50 .979 .783
49.50 .979 .884
50.50 .979 .913
51.50 .979 .928
54.00 .979 .971
56.50 .979 .986
59.00 .979 1.000
62.00 1.000 1.000
actual state group.
test values.
448
P.5. Participants younger than 22 years: VABS II scores onto Psychologists’
evaluation of AF.
Figure P.5. Graphical Representation of ROC Curve of VABS II Scores onto the
Psychologists’ Evaluation of AF of Participants Younger than 22 Years.
Table P.5.
Summary Information of ROC Curve of VABS II Scores onto the Psychologists’ Evaluation of
AF of Participants Younger than 22 Years.
Adaptive Functioning Valid N
ModVsSev (listwise)
Missing 177
state.
449
Asymptotic Interval
.838 .130 .005 .582 1.000
The test result variable(s): VABS2 Overall Standardised Score has at least one tie
Test Result Variable(s): VAB II Overall
Standard Score
Positive if Less
Than or Equal
19.00 .000 .000
27.00 .286 .000
34.50 .571 .000
35.50 .571 .024
38.00 .714 .073
40.50 .857 .098
42.50 .857 .171
44.50 .857 .220
45.50 .857 .268
46.50 .857 .463
47.50 .857 .537
450
48.50 .857 .634
49.50 .857 .805
50.50 .857 .854
51.50 .857 .878
54.00 .857 .951
56.50 .857 .976
59.00 .857 1.000
62.00 1.000 1.000
actual state group.
test values.
451
P.6. Full sample: VABS II scores onto ISGSA scores of IQ.
Scores of IQ of the Full Sample.
Table P.6.
Summary Information of ROC Curve of VABS II Scores onto ISGSA Scores of IQ of the Full
Sample.
ISGSA IQ Moderate VS Valid N
Severea (listwise)
Missing 154
state.
452
Asymptotic Interval
.719 .040 .000 .642 .797
Standard Score
Positive if Less
Than or Equal
19.00 .000 .000
20.50 .276 .128
21.50 .379 .147
22.50 .414 .156
23.50 .448 .165
24.50 .466 .183
25.50 .483 .211
27.00 .483 .248
28.50 .483 .257
29.50 .500 .266
30.50 .500 .284
453
31.50 .517 .294
33.00 .552 .312
34.50 .586 .321
35.50 .621 .349
38.00 .672 .358
40.50 .690 .376
42.50 .707 .394
44.50 .724 .404
45.50 .741 .404
46.50 .828 .431
47.50 .845 .450
48.50 .845 .459
49.50 .862 .505
50.50 .879 .523
51.50 .879 .541
52.50 .879 .606
53.50 .914 .624
54.50 .966 .661
55.50 .966 .670
56.50 .983 .697
57.50 .983 .761
58.50 .983 .872
59.50 .983 .908
60.50 .983 .917
61.50 .983 .982
62.50 .983 .991
64.50 1.000 .991
67.00 1.000 1.000
454
actual state group.
test values.
P.7. Participants 22 years and older: VABS II scores onto ISGSA score of IQ.
Scores of IQ of the Participants 22 Years and Older.
455
Table P.7.
Summary Information of the ROC Curve of VABS II Scores onto ISGSA Scores of IQ of the
Participants 22 Years and Older.
Severea (listwise)
Missing 24
state.
Asymptotic Interval
.655 .065 .024 .528 .782
Standard Score
456
Positive if Less
Than or Equal
19.00 .000 .000
20.50 .469 .325
21.50 .656 .375
22.50 .719 .400
23.50 .781 .425
24.50 .813 .475
25.50 .844 .550
27.00 .844 .650
28.50 .844 .675
29.50 .875 .700
30.50 .875 .750
31.50 .906 .775
33.00 .969 .825
34.50 .969 .850
35.50 1.000 .925
38.00 1.000 .950
46.50 1.000 .975
54.00 1.000 1.000
actual state group.
457
test values.
P.8. Participants under 22 years: VABS II scores onto ISGSA scores of IQ.
Scores of IQ of the Participants Under 22 Years.
458
Table P.8.
Summary Information of ROC Curve of the VABS II Scores onto ISGSA Scores of IQ of the
Participants Under 22 Years.
Severea (listwise)
Missing 130
state.
Asymptotic Interval
.810 .051 .000 .710 .911
Standard Score
459
Positive if Less
Than or Equal
19.00 .000 .000
27.00 .038 .014
34.50 .115 .014
35.50 .154 .014
38.00 .269 .014
40.50 .308 .029
42.50 .346 .058
44.50 .385 .072
45.50 .423 .072
46.50 .615 .116
47.50 .654 .145
48.50 .654 .159
49.50 .692 .232
50.50 .731 .261
51.50 .731 .290
52.50 .731 .391
53.50 .808 .406
54.50 .923 .464
55.50 .923 .478
56.50 .962 .522
57.50 .962 .623
58.50 .962 .797
59.50 .962 .855
60.50 .962 .870
61.50 .962 .971
62.50 .962 .986
460
64.50 1.000 .986
67.00 1.000 1.000
actual state group.
test values.
461

Use of The Vineland Adaptive Behavior Scales in The Assessment of Intellectually Disabled Complainants in Sexual Abuse Cases in The Western Cape

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Use of The Vineland Adaptive Behavior Scales in The Assessment of Intellectually Disabled Complainants in Sexual Abuse Cases in The Western Cape

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“Use of the Vineland Adaptive Behavior Scales in the

assessment of intellectually disabled complainants in

sexual abuse cases in the Western Cape”

Gillian Kathleen Douglas

Dissertation presented for the degree of Doctor of Psychology in the

Faculty of Arts and Social Sciences at Stellenbosch University

Supervisor: Professor Leslie Swartz

Co-supervisor: Dr. Chrisma Pretorius

research process. I would like to acknowledge:

thoughtful, empathic and rigorous supervision.

• To my family: Pete, Christy, John, Laurie and Michael.

• To my work colleagues at the Division of Child and Adolescent Psychiatry,

University of Cape Town, especially to Willem de Jager.

• To God who loves us all.

and participants were predominantly from a low socioeconomic background. A selected

pronounced. This was found to be a clinically effective solution. On examination of the

contextual or lacking opportunity in this context. The relevance of valid assessment of

adaptive functioning, in a psycho-legal context, was illustrated by case examples.

konteks te evalueer. Die steekproefgroep was divers in terme van rasverskeidenheid en

intellektuele gestremdheid, ŉ asimptoot bereik teen ouderdom 22, is ŉ aanbeveling gemaak

wat beskryf is as taalkundig, kontekstueel of ontbrekend-aan-geleentheid-in-hierdie-konteks,

gekategoriseer. Die toepaslikheid van geldige assessering van aanpassende funksionering, in

'n psigo-regskonteks, is geïllustreer deur gevalle-voorbeelde.

or in part submitted it for obtaining any qualification.

Date: December 2017

Copyright © 2017 Stellenbosch University

Abstract – Afrikaans iii

List of Tables and Figures xx

Chapter One: Introduction 1

1.1. The Stories 1

1.2. The Research 2

1.3. The Stories and the Research 2

1.4. The Context 3

1.5. The Problem 4

1.6. Relevance of the Research 4

1.7. The Aims of the Research 6

1.8. Previous Research 7

1.9. Research Design 7

1.10. Layout of the Dissertation 8

1.10.1. Chapter One: Introduction 8

1.10.2. Chapter Two: Constructs and Measurement 8

1.10.3. Chapter Three: Context 8

1.10.4. Chapter Four: Methodology 9

1.10.5. Chapter Five: Descriptive Results 10

1.10.6. Chapter Six: Results of Statistical and Clinical Item Analysis 10

1.10.7. Chapter Seven: Discussion 11

1.10.8. Chapter Eight: Conclusion 12

1.11. Concluding Comments 12

Chapter Two: Literature Review: Constructs and Measurement 13

2.2. Intellectual Disability 13

2.2.1.2. Intellectual Disability 15

2.2.1.3. Level of Severity in Intellectual Disability 18

2.2.2. Naming and Language 20

2.3. Assessment of Intellectual Disability 22

2.3.1. Construct of Intelligence 23

2.3.1.1. Evolutionary Models 23

2.3.1.2. Psychometric Models 24

2.3.1.3. Genetic Inheritance 25

2.3.1.4. Neurobiology of Intelligence 26