Importance of Milestones and Consideration of Subthreshold Performance to Assessment

In a largely healthy population, achievement of functional milestones such as fulltime work, living independently, and having friends, family, and social network are expected. Individuals who have achieved these milestones and are seeking cognitive or functional enhancement may be trying to increase their level of functioning. In these individuals, the real-world outcome would be school grades, promotions, and other indicators of greater functional success. In impaired populations, however, these milestones often present major challenges. Further, their lack of experience with successfully or optimally meeting functional demands may prohibit individuals from being able to accurately evaluate their own functioning.

For instance, in a recent study of ours, people with severe mental illness who had never had a job in their lives rated themselves as more socially, vocationally, and residentially capable than other individuals who were employed full time (Harvey et al., 2012). As many populations seeking cognitive or functional enhancement may have a lack of functional success to date and even lack experience with efforts to attain functional success, modification of the typical assessment strategy may be required. As a result, previous achievement needs to be an ongoing index to which to compare both current functioning and improvements from the initiation of the intervention. There may be a large difference between regaining some elements of previous functioning that were impaired or lost owing to illness or injury or normative age-related changes in cognition, and aspects of functioning, though a normative part of healthy experience, that were never fully learned due to early-onset neuropsychiatric or other illness conditions. Thus, it is important to be aware of an individual’s baseline threshold when establishing treatment goals or assessing change related to an intervention program.

For example, if one is currently unemployed and has not held a job for an extended time period, there are a variety of functional acts that are preparatory to employment that are positive from the perspective of vocational outcomes. For instance, preparing a resume, applying for jobs, and going on job interviews are positively valenced vocational activities. Similarly, obtaining independent residential functioning has a number of similar subthreshold steps. However, they do not equate to having a full-time job or living as the head of a household. For a variety of populations where there are long-term aspects of disability and the assessment of job performance or residential independence is not possible, we are limited to collecting information about the preparation and background activities aimed at real-world functioning. However, these subthreshold milestones can be positively affected by skills training and cognitive enhancement interventions and are relevant measures related to eventual real-world successes.

Subthreshold milestones are particularly amenable to performance-based assessments. There are a variety of performance-based assessments that measure the specific skills associated with residential and vocational achievement that are the building blocks of obtaining and sustaining employment or obtaining and sustaining independent living, but are not the same as working full time or living independently.

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