Preparing for Adulthood: A Systematic Review of Life Skill Programs for Youth with Physical Disabilities

Journal of Adolescent Health 41 (2007) 323–332

Review article

Preparing for Adulthood: A Systematic Review of Life Skill Programs for Youth with Physical Disabilities Shauna Kingsnorth, Ph.D.a,*, Helen Healy, O.T.(C).a, and Colin Macarthur, M.B.Ch.B., Ph.D.b a

Life Skills & Wellness Institute, Bloorview Kids Rehab, Toronto, Ontario, Canada b Bloorview Research Institute, Bloorview Kids Rehab, Toronto, Ontario, Canada Manuscript received January 15, 2007; manuscript accepted June 14, 2007

Abstract

Purpose: With advances in health care, an increasing number of youth with physical disabilities are surviving into adulthood. For youth to reach their full potential, a number of critical life skills must be learned. Specific learning opportunities are important as youth with physical disabilities may be limited in the life experiences necessary to acquire these skills. The aim of this study was to determine the effectiveness of life skill programs emphasizing independent functioning in preparation for adulthood among youth with physical disabilities. Methods: A comprehensive search of electronic databases from 1985 to 2006 was undertaken to identify empirical studies examining the effectiveness of life skill programs for youth and young adults with acquired and congenital physical disabilities. Eligible studies were those with a comparison group and that targeted life skills (as defined by the World Health Organization). Results: Six studies met the inclusion criteria. All used a multi-component group intervention containing a real-world or role-playing experiential component. Five of the six studies demonstrated short-term improvements in targeted life skills. Conclusions are limited because of heterogeneity of interventions, skill focus, disabilities, and outcome measures with respect to the effectiveness of individual components of the programs. Conclusion: With more youth with physical disabilities surviving into adulthood, there is a need to ensure that they have the skills to successfully manage life demands. There are relatively few rigorously designed, published studies that have evaluated the effectiveness of life skill programs. Large-sample, randomized, controlled studies are needed. © 2007 Society for Adolescent Medicine. All rights reserved.

Keywords:

Review; Disabled persons; Adolescent; Adult; Activities of daily living; Life skills

Advances in health care have been associated with a longer life expectancy for many children with disabilities [1]. As a result, there is an increasing need to effectively prepare these children for independence and for the demands of adulthood. For youth to reach their full potential, a number of critical life skills must be learned [1–3]. Life skills include the ability to set realistic goals, solve problems, make de*Address correspondence to: Shauna Kingsnorth, Ph.D., Bloorview Kids Rehab, 150 Kilgour Road, Toronto, ON, Canada M4G 1R8. E-mail address: [email protected]

cisions and evaluate their outcomes, and develop appropriate personal and interpersonal skills [2]. This set of skills is critical for dealing with the everyday challenges of life such as: organizing personal affairs; managing health care; pursuing vocational, leisure, and educational activities; and engaging in positive social interactions [4 – 6]. From a developmental perspective, as children mature and exert independence, opportunities to learn and master life skills are encouraged. By adulthood, these skills are consolidated [7]. Institutional, environmental, and social barriers, however, limit the opportunities and life experiences necessary for children with physical disabilities to

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become independent [2,8,9]. As a result, they often lag behind their able-bodied peers in the life skills required to successfully manage the adult world [2,10,11]. For example, Stevens et al [10] found that youth with physical disabilities were less future-oriented in their educational and vocational plans compared with a national sample. Likewise, Magill-Evans et al [11] also found that young adults with cerebral palsy had lower expectations about future independence, such as employment and post-secondary education, independent living, and personal relationships than their peers. Given these barriers, specific learning opportunities need to be provided to allow youth with physical disabilities to develop and practice life skills [2,12,13]. Although increased responsibility and explicit expectations are two of the most effective ways of encouraging and developing competence [1], little is known about practices that effectively promote independence in youth with physical disabilities. A review of life skill programs for youth with learning and developmental disabilities has been conducted [3], but to date there has been no systematic review of such programs for youth with physical disabilities. The purpose of this review is to summarize the current empirical evidence from the published literature regarding the effectiveness of programs that target life skill development and encourage independence among youth with physical disabilities. Methods A systematic review was undertaken to provide an unbiased and comprehensive summary of the best available evidence regarding life skill development among youth with physical disabilities. By using explicit and reproducible methods, a systematic review allows for more accurate and reliable conclusions; increased generalizability; and increased power and precision in estimating effect size when compared with a traditional literature review [14]. Inclusion criteria Studies were included in the review if they met the following five criteria: (1) study comprised empirical research examining the effectiveness of programs promoting the development of life skills; (2) study included a comparison group; (3) study reported on at least one quantifiable outcome measure; (4) study population comprised youth and young adults between 12–21 years of age, with a primary diagnosis of a physical disability, (including both acquired and congenital disabilities affecting functional ability); and (5) study was published between 1985 and 2006. Definitions for life skills and physical disabilities were those provided by the World Health Organization (WHO). Life skills are “the abilities for adaptive and positive behavior that enable individuals to deal effectively with the de-

Figure 1. Example of series of keywords and descriptors used to search the CINAHL database.

mands and challenges of everyday life” ([4], p. 1). A core set of life skills would include: problem-solving, decisionmaking, goal-setting, critical thinking, communication skills, assertiveness, self-awareness, and skills for coping with stress [15]. Life skills differ from instrumental daily living skills. Daily living skills are the activities required to function independently in the community and include skills such as financial management, meal preparation, or navigation in the community [16]. An approach emphasizing life skill development can however be used to acquire daily living skills [17]. A list of physical disabilities related to impairments in body structure and function as outlined by The International Classification of Functioning, Disability, and Health (ICF) was generated for this project [18]. Selection strategy Identification of relevant databases and search terms was developed in collaboration with a research librarian. The search filter used a series of descriptors and keywords relating to acquired and congenital physical disabilities, life skills, and empirical research designs. In addition to the core set of life skills identified by the WHO, the following phrase was adapted from the work of Robertson et al ([19], p. 3): “[(life or social or self-care or living or community) and (skill or program)]” with the addition of the terms “independent” and “survival.” An example of the search strategy used is provided in Figure 1. The following electronic health science and education databases were searched: HealthSTAR/Ovid Healthstar, 1966 to September 2006; MEDLINE (Medical Literature Analysis & Retrieval System Online), 1966 to October Week 3 2006; EMBASE, 1980 to Week 36 2006; CINAHL (Cumulative Index of Nursing & Allied Health Literature), 1982 to October Week 1 2006; PsycInfo, 1985 to October, week 2, 2006; and ERIC (Education Resources Information Center). There were no language restrictions. The search was restricted to the time period 1985 to 2006, inclusive.

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tailed examination. Figure 2 details the inclusion/exclusion process. Of the 21 studies reviewed, six met the inclusion criteria: Healy and Rigby [12], Johnson and Johnson [20], KappSimon et al [21], Kessell et al [22], Kim [23], and Powers et al [24]. Characteristics and findings of each study are outlined in Tables 1 and 2. Program features Reviewing Table 1, all of the studies were conducted in North America (one in Canada, five in the U.S.). Three studies involved participants with a range of physical disabilities, whereas three focused on participants with craniofacial disfigurements or visual impairments. Interventions

Figure 2. Inclusion and exclusion flowchart for life skills studies.

Systematic review Titles and abstracts were screened independently by two members of the research team to identify potentially relevant studies. Full-text versions of all studies identified were retrieved and reviewed independently by these members against the inclusion criteria. Discrepancies were resolved through discussion. All three members of the research team reviewed the final set of included studies. Data on authorship, year of publication, country, sample, setting, program objective, intervention, study design, data collection period, data source, outcome measures, and key findings were extracted for inclusion in the tables by one member and checked for accuracy by a second member of the team. Conclusions regarding program effectiveness were made by consensus based on the extracted data. Results The search strategy identified 5642 documents. Screening of titles and abstracts eliminated 5621 documents. Studies were excluded if there was no emphasis on life skill development, or the sample did not fit with the age group or type of disability for this project (e.g., developmental or learning disability). Studies were also excluded if there was no program evaluation found or if the focus was on the validation of tools related to measuring life skills. A total of 21 full-text unique documents were obtained for a de-

All of the programs involved a multi-component group intervention focusing on a variety of approaches to encourage skill building. Four of the programs took place in a classroom setting, with participants meeting on a weekly basis [20,21,23] with one including a community component [24]. The remaining two programs involved intense short-term residential programs in urban or a combination of urban and wilderness settings [12,22]. Details are presented in Table 1. More specifically, Johnson and Johnson [20] examined the impact of a classroom-based group counseling program designed to enhance self-concept. Based on a social learning framework, core components included discussions and roleplaying in the areas of self-perception, assertive behavior, personal relationships, and responsibility, as well as occupational and independent living skills. Social, educational, and occupational roles were also highlighted. The second classroom-based intervention reviewed was Meeting the Challenge: A Social Skills Training for Adolescents with Special Needs [21,25]. This program was designed to encourage more positive social interactions among youth and their peers. Role-playing was a core component. Other elements of the program included modeling, didactic teaching, coaching and behavioral practice of specific social skills (e.g., self-awareness, social initiation, problemsolving, and conflict resolution, among others) [21]. Also focusing on social skills was ATCAVI–The Assertiveness Training Curriculum for Adolescents with Visual Impairments. Program components included problemsolving, self-management, modeling, discussion, didactic instruction, homework, role-play, feedback, and positive reinforcement. Sessions emphasized different types of assertive behavior (e.g., nonverbal), assertive themes (e.g., interpersonal embarrassment), and alternative cognitive strategies (e.g., self-management techniques) to resolve interpersonal issues [23]. The final classroom-based intervention reviewed was TAKE CHARGE [24,26]—a program aimed at increasing

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Table 1 Study characteristics Country

Intervention group

Comparison group

Setting

Program objective

Intervention

Healy, 1999 [12]

Canada

N ⫽ 10 Adolescents (17–21 years) with physical disabilities (mean age ⫽ 19 years)

Single group, pre and post comparison

Student residence & community

Development of independent living skills

Johnson, 1991 [20]

U.S.

n⫽7 Adolescents (12–18 years) with congenital visual impairments from local school (mean age not provided)

Classroom

Enhancement of self-concept

Kapp-Simon, 2005 [21]

U.S.

n ⫽ 13 Adolescents (12–14 years) with craniofacial disfigurements (mean age not provided)

n⫽7 Youth who did not participate in program Matched for age, IQ, race, and sex n⫽7 Wait list participants

The Independence Program is a 20-day intensive residence program involving goal setting, preplanning sessions, problem solving, experiential learning, and review of experiences. A 4-week/12-session counseling program involving discussions and role-playing in the areas of assertive behavior, self-perception, personal relationships, and, occupational and independent living skills.

Outpatient clinic

Examination of impact of social skills training on rate of positive social interactions

Kessell, 1985 [22]

U.S.

n ⫽ 15 1981 sample; Adolescents with physical disabilities or chronic illness (mean age ⫽ 15 years)

Single group, pre and post comparison

Wilderness (camping) & Urban (community)

Attainment of developmental skills including mastery, social skills, positive body-image, and independence

Kim, 2003 [23]

U.S.

n ⫽ 13 Adolescents (12–19 years) with visual impairments who scored below 90th percentile the Social Skills Rating System (mean age ⫽ 16 years)

n ⫽ 13 No details provided Matched for gender and visual acuity

Classroom

Examination of impact of assertiveness training on social and assertiveness skills

Powers, 2001 [24]

U.S.

n ⫽10 Adolescents (12–18 years) with cognitive/physical disabilities, ongoing health concerns, or both (mean age ⫽ 14 years)

n ⫽ 10 Wait list participants (mean age ⫽ 15 years) Matched for cognitive disability

Classroom & Community

Promotion of selfdetermination skills

A 12-week/12-session program, Meeting the Challenge: A Social Skills Training for Adolescents with Special Needs [25] involves skill acquisition through behavioral practice, role-playing, modeling, and coaching. Adventure Etc. is a 2-week program consisting of a 9-day wilderness and 5-day urban phase that stresses skill development and attainment through individual goal-setting, experiential learning, and meeting the collective group needs. A self-developed 12-week/12-session program based on the Assertiveness Training Curriculum for Adolescents with Visual Impairments (ATCAVI) including problemsolving, self-management, modeling, discussion, didactic instruction, homework, role-play, feedback, and positive reinforcement. A 5-month program, TAKE CHARGE [26] involves individualized coaching of selfdetermination skills (i.e., achievement strategies including problem-solving, goal setting), peer-based mentorship, monthly workshops, real-world experiential learning, and support to and from parents.

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Author and year [Ref.]

Table 2 Study design and findings Design

Total N

Data collection

Data sources

Outcome measures

Results

Healy, 1999 [12]

Single group

10

Baseline

Self-report

Canadian Occupational Performance Measure (COPM)* [27] Composite Performance Scores

10/10 clinically relevant change between Pretest and Posttest1. 7/10 clinically relevant change between Pretest and Posttest2.

COPM Composite Satisfaction Scores [27]

10/10 clinically relevant change between Pretest and Posttest1 10/10 clinically relevant change between Pretest and Posttest2

Pretest-

20 days

Posttest1Posttest2

4 months

Johnson, 1991 [20]

Observational cohort

14

Baseline 4 weeks

Self-report

Kapp-Simon, 2005 [21]

Observational cohort

20

Baseline 12 weeks

Blinded observational coding of social interactions

(*an individualized tool used to evaluate functional components of targeted goals; scale of 1 to 10 used; clinically relevant change is change of ⬎⫽2 points; composite score ⫽ mean of individual goals/participant) Tennessee Self-Concept Scale (TSCS) [33] Attitudes Towards Blindness Scale (AB Scale) [34] North Carolina Internal/External Scale: short version (assesses perception of degree of control experienced by participants within their environment) [35] Coding [29]

Subject-initiated Total communication score (sum of target initiation, response, & conversation events) Frequency of initiations Frequency of responses Frequency of conversation events Peer-initiated Total communication score Frequency of initiations Frequency of responses Frequency of conversation events

Time

Intervention mean (SD)

Comparison mean (SD)

p

Pre Post

0.69 (.34) 1.32 (.69)

0.77 (.52) 0.83 (.64)

.017

Pre Post Pre Post Pre Post

0.32 (.20) 0.60 (.34) 0.30 (.14) 0.52 (.29) 0.08 (.06) 0.21 (.12)

0.38 (.24) 0.41 (.37) 0.34 (.23) 0.34 (.22) 0.07 (.08) 0.07 (.08)

.057 .076 .023

Pre 0.53 (.30) 0.63 (.42) .035 Post 1.05 (.67) 0.63 (.51) Pre 0.22 (.18) 0.25 (.24) ns Post 0.34 (.28) 0.27 (.19) Pre 0.26 (.14) 0.31 (.20) .015 Post 0.52 (.30) 0.26 (.27) Pre 0.05 (.06) 0.06 (.06) ns Post 0.19 (.32) 0.10 (.11) 5/7 participants in Intervention group demonstrated a significant drop in frequency at posttest (p ⬍ .05)

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Frequency of nondirected communication events (e.g., question, statement, or question not directed to a specific peer)

Higher self-concept scores for intervention group at posttest (p ⬍ .0001); means not provided More favorable attitudes towards disability for intervention group at posttest (p ⬍ .0001); means not provided Improved locus of control for intervention group at posttest (p ⬍ .0015); means not provided

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Author & year [Ref.]

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Table 2 Continued Author & year [Ref.]

Kessell, 1985 [22]

Design

Single group

Total N

11 4 lost to follow-up

Data collection

Baseline 2 weeks 6 months

Data sources

Youth self-report

Offer self-image questionnaire for adolescents [36] Nowicki-Strickland Personal Reaction Survey (NSPR) [37] used to provide a measure of internal locus of control Moos Family Environment Conflict Sub-Scale [38]; a measure of family conflict Moos Family Environment Activities SubScale [38]; a measure of family recreational activities

Results Time

Intervention mean (SD)

Pre Post Pre Post

27.36 (6.36) 25.36 (11.15) 9.36 (3.96) 7.81 (3.63)

⬍.055

Pre Post

49.00 (6.97) 46.27 (8.72)

⬍.048

Means not provided

Time

Kim, 2003 [23]

Randomized controlled trial

23 3 lost to follow-up

Baseline 12 weeks

Student, parent, & teacher reports

Student self-report

Blind observational coding

Social Skills Rating System (SSR) [30]; used Social Skill Scale consisting of Cooperation, Assertion, Self-control, Responsibility, and Empathy; frequency of behaviors rated on a 3-point scale

Modified Rathus Assertiveness Schedule (MRAS) [31] measures assertiveness skills in different situations; self-rate on a 6-point scale Modified Self-criticism and Hopelessness scales of the Cognitive Distortion Scale (CDS) [32]; Self-criticism and Helplessness scales only; self-rate frequency of thought on a 5-point scale Role-Play Test (RPT) [23] consisted of 1 practice scene and 8 test scenes; familiarity of interactant and type of assertiveness were manipulated

Intervention mean (SD)

p

⬍.048

ns

Comparison mean (SD)

Student report Pre 102.18 (17.30) 101.83 (12.76) Post 104.67 (17.44) 106.75 (13.21) Parental report Pre (values not provided) Post 94.00 (15.30) 109.60 (19.68) Teacher report Pre 92.36 (13.84) 95.25 (20.34) Post 95.64 (17.24) 97.08 (13.81) Pre 78.82 (13.12) 70.75 (12.62) Post 79.00 (16.08) 64.17 (13.44)

p

.52

— .06 .95 .08

Pre Post

32.27 (17.07) 29.73 (19.52)

33.17 (11.17) 31.25 (5.26)

.83

Pre Post

3.11 (.68) 3.33 (.64)

2.96 (.60) 3.18 (.53)

.85

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Parental report

Outcome measures

⬍.01 1.60 (1.35) 5.70 (2.49) Pre Post

1.50 (1.27) 2.10 (1.29)

ns 2.85 (.45) 3.38 (.42) Pre Post

2.94 (.45) 3.05 (.54)

⬍.01 3.06 (.39) 3.82 (.57) Pre Post

3.61 (.45) 3.66 (.57)

⬍.01 3.32 (.43) 3.14 (.22) 2.89 (.37) 3.24 (.42) Pre Post

Personal Adjustment and Role Skills Scale (PARS III) [39]; 28-item measure of adolescent psycho-social adjustment Family Empowerment Scale [40]; 34-item measure assesses management of daily situations, use of services, and advocacy on behalf of others Disability-Related Self-Efficacy Scale [41]; 8-item scale measures degree to which adolescents believe they can overcome disability-related barriers and achieve specific outcomes Adolescent Accomplishment [24] (frequency of activity accomplishments within the two time periods: 3 months pre- and 3 months post-intervention) Self-report

Time

Outcome measures Data sources

Results

Intervention mean (SD)

Comparison mean (SD)

p

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self-determination among youth. This program involved individualized coaching of self-determination skills (i.e., achievement strategies including problem-solving and goalsetting), monthly workshops, real-world experiential learning (e.g., community activities), and support to and from parents (e.g., telephone and home visits). Peer-based mentorship was a very strong component of this program— mentors played significant roles in the workshops and the experiential learning activities [24]. With respect to the residential programs, The Independence Program (TIP) was an intensive urban residential program involving individualized goal-setting, preplanning sessions, problem-solving, experiential learning, and review of experiences designed to foster the development of independent living skills. Experiential learning was a core component of this program. For example, one of the key learning exercises was “City survival,” in which youth planned and then participated in various self-selected community activities. Participants were given many opportunities to practice and refine their skills, both individually and in a group format [12]. Adventure Etc. used a similar emphasis on experiential learning in promoting the acquisition of age-appropriate developmental skills among its participants. In this live-in program, youth were challenged with both a wilderness and an urban component. Similar to The Independence Program, individualized goal-setting was a core component. At the end of the program, participants were tested with a minimarathon to assess their skill acquisition: participants were dropped off blindfolded in the city and had to navigate (e.g., by bus, canoe, and finally by running/walking/wheeling) their way back to a predetermined location. Of interest, Adventure Etc. was the only program that integrated youth with and without physical disabilities [22].

Baseline 6 weeks Randomized controlled trial Powers, 2001 [24]

20

Design Author & year [Ref.]

Table 2 Continued

Total N

Data collection

Methodological features Study designs included: pre/post intervention and comparison groups; pre/post intervention group only; and pre/ post1/post2 intervention group only designs (Table 2). Two studies randomized assignment of participants to intervention and comparison groups [23,24]. Across studies, sample sizes were small, ranging from 10 –23 participants (Table 1). Collection periods Interventions ranged in time period from 2 weeks to 5 months (Table 1). Two studies included a longer follow-up component. Healy and Rigby [12] evaluated outcomes 4 months after the end of program. Kessell et al [22] conducted interviews 6 months after completion of the program; however, few details were reported. Data collection methods With respect to outcome measures, three studies attempted to quantify change in skill acquisition. Healy and

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Rigby [12] used the Canadian Occupational Performance Measure (COPM) [27]. The COPM is a self-report clinical tool designed to assess change in functional performance and satisfaction [28]. In the work by Kapp-Simon et al [21] and Kim [23], the frequency of targeted social behaviors in a natural setting [29] and assertiveness in a structured roleplaying exercise (Role-Play Test) [23], respectively, were coded by external observers. The latter was used with a combination of parental, teacher, and student self-report measures that included the Social Skills Rating System (SSR) [30]; a modified Rathus Assertiveness Schedule (MRAS) [31]; and modified Self-criticism and Hopelessness scales of the Cognitive Distortion Scale (CDS) [32] to assess program impact. The remaining studies used a combination of self-report psychometric measures addressing self-image, self-efficacy, self-concept, assertiveness, social skills, and empowerment among others [20,22–24]. More specifically, to measure change in self-concept, Johnson and Johnson [20] used the Tennessee Self-Concept Scale (TSCS) [33], the Attitudes Towards Blindness Scale (AB Scale) [34], and the North Carolina Internal/External Scale [35]. In the Adventure Etc. program [22], participants completed the Offer Self-image Questionnaire for Adolescents [36] and the NowickiStrickland Personal Reaction Survey (NSPR) [37] to assess their attainment of the targeted developmental skills. Parents also completed the Moos Family Environment Scale [38]. The success of TAKE CHARGE [24] was evaluated using the Personal Adjustment and Role Skills Scale (PARSIII) [39], the Family Empowerment Scale [40], the Disability-related Self-efficacy Scale [41], and a measure of Adolescent Accomplishment [24]. A brief overview of each measure is provided in Table 2. Several studies also provided qualitative reports among their results. In addition to assessing skill level four months post-program, Healy and Rigby [12] documented all comments made by participants during their follow-up COPM interviews. Observations made during post-program and follow-up interviews with parents of youth who participated in Adventure Etc. were also documented [22]. And finally, three of the studies discussed the clinical impressions of the program leaders and provided specific examples of observed changes in skill among the participating youth [12,20,24].

lowing section will provide a brief overview of the findings of each of the six studies reviewed. Beginning with The Independence Program, all of the participants demonstrated clinically relevant changes in their COPM performance and satisfaction scores at program end. More than half of the participants maintained their occupational performance levels at follow-up [12]. Significant improvements in self-concept among a group of youth with visual impairments were also documented by Johnson and Johnson [20]. Participating youth demonstrated significantly more favorable attitudes towards disability, and an improved locus of control relative to the comparison group. Qualitative reports by program leaders support the quantitative findings. Observations noted include behaviors consistent with increased self-awareness, independence, selfassertiveness, and empathy among the participants. Likewise, Meeting the Challenge was found to have a positive impact on its targeted life skill: social interaction. Relative to the comparison group, participating youth demonstrated a significant increase in the total number of social interactions experienced during the school lunch period. This increase was seen for both self- and peer-initiated interactions [21]. At program-end, significant improvements in body image and personal efficacy were documented for youth involved in Adventure Etc. Qualitative observations by parents post-program and at follow-up further support the finding of increased independence, self-confidence, and social involvement. Although the program was anticipated to increase the recreational activities of participating families, no consistent pattern of change could be found as measured by the Moos Family Environment Scale. A significant decline in family conflict was noted, however [22]. TAKE CHARGE was also found to be beneficial for participating youth. Significant improvements in psychosocial adjustment and empowerment were found. As well, levels of personal accomplishment increased significantly following the intervention. Qualitative reports by parents and coaches support these findings. The program did not change self-efficacy as measured by the Disability-Related Self-Efficacy Scale however [24]. And finally, although it was predicted that participants in ATCAVI would improve their social and assertiveness skills and reduce levels of self-criticism and helplessness, no significant differences were reported [23]. Discussion

Review of effect Because of the heterogeneity of the interventions, disabilities, and skills examined, and the range of research designs and outcome measures used, it was neither feasible nor appropriate to combine the data in a meta-analysis. Detailed findings of each study are presented in Table 2. With the exception of one study, all interventions demonstrated significant changes in targeted life skills. The fol-

The findings of this systematic review of the literature provide some support for the use of multi-component interventions as a means of developing life skills among youth with physical disabilities. With the exception of one study, short-term improvements in life skills were reported regardless of the skill focus, physical disability examined, or outcome measure used [12,20 –24]. More specifically, a self-designed program for visually impaired youth demon-

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strated that a group approach is beneficial in promoting self-concept [20]. Kapp-Simon et al demonstrated that focused training increased the frequency of positive social interactions experienced by youth with craniofacial disfigurements [21]. In a similar vein, the TAKE CHARGE model was successful in promoting self-determination among youth with varied physical disabilities [24]. Finally, The Independence Program [12] and Adventure Etc. [22]— two residential programs—aided youth with a range of physical disabilities to achieve their personal goals related to life preparedness in the form of age appropriate developmental tasks. The one exception concerned ATCAVI—a program aimed at improving social skills through assertiveness training among a group of youth with visual impairments. Before dismissing this program, two important points must be noted. First, despite sharing many of the same components as the other programs reviewed, this study differed significantly in the population examined. Unlike the other included studies, the participating youth also had markedly poor social skills—scoring less than the 90th percentile on the Social Skills Rating System [30]. Second, the program was not implemented as outlined. Session times were often cut short due to scheduling issues and homework was rarely completed; as a consequence, opportunities for role-playing were often missed [23]. Though significant improvements in life skills were reported, a critical appraisal of these 6 studies identified a number of limitations. First, the gold standard for evaluation of effectiveness, i.e., the randomized controlled trial design, was only used in two of the studies [23,24]. Although the single group and observational cohort designs allow for an assessment of change across time as a function of participation, the strength of the conclusions regarding program effectiveness are limited without a controlled comparison group. Second, a range of outcome measures were used. Though many were designed for use with youth with physical disabilities, the majority of the outcome measures were not standardized and relied on self-report [12,20,22–24]. Before definitive conclusions can be drawn, the relationship between observed skill competence and self-report psychometric measures of these same skills needs to be examined. A combination of these two types of outcome measures within a single study may provide a more comprehensive picture of the level of competence achieved by participants. Only one study took this approach [23]. Third, the small sample sizes (ranging from 10 –23 participants) coupled with the limited variability of physical disabilities within individual studies limit the extent to which the findings can be generalized to youth with different types of physical disabilities. An important issue that was not explored is the transferability of the life skills acquired. By definition, life skills are adaptable to time and place [15]. Despite several interventions providing multiple real-world opportunities to practice

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the skills being acquired [12,21,22,24], variations in testing situations were not used. Although qualitative reports of increased independence among participating youth were documented [12,20,22], and one study assessed change in ratings by parents and teachers on the Social Skills Rating System [30], this information was not obtained by unblinded observers. Formal evaluation of the effectiveness of life skill interventions should involve multiple testing opportunities with blinded observation of participants. Evidence of increased autonomy in a variety of contexts as a function of program participation would provide strong support for the effectiveness of life skill programs in increasing the life preparedness of youth with physical disabilities. Similarly, the retention of the acquired skills also had little focus. Only two studies included a follow-up component in their evaluation [12,22]. Thus, strong conclusions regarding the long-term effectiveness of the interventions used cannot yet be drawn. A strength of the research was the range of skills examined. Although studies varied by objective (e.g., acquisition of independent living skills, social skills, or self-determination skills), the WHO core life skills were used in the learning process. For example, Meeting the Challenge [25] used exercises in self-awareness, communication skills, problemsolving, and skills for coping with stress to increase the social skills of the youth involved. Furthermore, within the learning process, there were few differences in the strategies and methods used in the multi-component group interventions. All of the programs involved a variety of approaches to encourage skill building. More generally, program approaches included goal-setting, coaching or mentorship, group discussions of experiences, didactic teaching, homework assignments, and experiential learning opportunities through structured role-playing or real-world interactions. Three exceptions were noted, however. The first variation concerned the inclusion of parents in the intervention to provide additional support to the youth [22,24]. For example, parents whose youth participated in TAKE CHARGE were provided with a program guide, home visits and regular telephone calls. They were also invited to the workshops [24]. The second variation concerned the inclusion of an individualized approach. In the TAKE CHARGE program, individualized coaching sessions were provided in addition to the group workshops. Youth worked with mentors to meet their self-identified goals and interests [24]. Similarly, in The Independence Program, working with an occupational therapist, participants set their own goals in identifying occupational performance activities of interest [12]. Finally, two of the studies included a homework component. In both instances, however, this element was met with resistance by the participating youth. Contracts and/or incentives were suggested to encourage future compliance [20,23]. Future studies may wish to explore the impact of these variations on life skill acquisition.

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