applied recreation research

Journal of

APPLIED RECREATION RESEARCH Associate Editors Sheila J. Backman, Clemson University : Research interests: Consumer behaviour; loyalty; service quality; complaining behaviour; tourism. Frederic Dimanche, University of New Orleans. Research interests: Marketing and consumer behaviour; tourism; cross-cultural research. Alan W. Ewert, University of Northern British Columbia. Research interests: Resource recreation; adventure recreation; motivations in recreation and leisure; natural resource management; resource-based tourism. Maureen A. Harrington, Griffith University. Research interests: Gender; family; work; enforced leisure (retirement, unemployment, homelessness); recreation program development. Peggy Hutchison, Brock University. Research interests: Community development; social action; leisure and disabilities; aging. Kelly J. MacKay, University of Manitoba. Research interests: Tourism; destination image; consumer behaviour; marketing. Donald J. McLean, University of Waterloo. Research interests: Philosophy of leisure; applied ethics for recreation and tourism; epistemology of leisure research. George S. Nogradi, Brock University. Research interests: Recreation management (motivation, performance, job design, organizational behaviour); professional development; certification; community development. Lisalin Ostiguy, Concordia University. Research interests: Therapeutic recreation, youth at-risk, leisure and older adults. R.J. Payne, Lakehead University. Research interests: Parks and protected areas; visitor management; social dimensions of natural resources; recreation and tourism planning. Donald G. Reid, University of Guelph. Research interests: Work and leisure; leisure and the unemployed; recreation and tourism planning; community development; leisure policy; municipal recreation administration. Laurel J. Reid, Brock University. Research interests: Tourism; marketing; communications; distribution systems; social impacts; promotion. Brenda J. Robertson, Acadia University. Research interests: At-risk youth; leisure behaviour; leisure education; trends. Dave W. Robinson, University of Northern British Columbia. Research interests: Outdoor recreation, adventure/risk recreation; ecotourism; social valuation.

Importance of Short-term Benefits of Day-Program Participation for Persons with Dementia Marita Kloseck Department of Recreation and Leisure Studies University of Waterloo Heather A. Davidson Ministry of Health Victoria, British Columbia Gary D. Ellis Department of Parks, Recreation, and Tourism University of Utah

Abstract. Socially and mentally stimulating recreation programs provided by day-care services are thought to have beneficial effects for people with dementia, improving their mental health and possibly slowing the loss of functional abilities. Results of a study conducted in the Alzheimer Community Support Service day program, London, Ontario, Canada, demonstrate that day-program participation may be associated with short-term improvement in social functioning and decreases in confusion. These results suggest that participation in recreation and social activities may optimize day-today functioning even in the presence of a progressive dementia. Keywords. day programs, dementia, therapeutic recreation Resume. Les programmes recreatifs de jour offrant des benefices sociaux et mentaux sont consideres comme ayant des effects salutaires sur des personnes atteint de demence, par une amelioration leur sante mentale, et possiblement par un ralentissement de la perte de capacites foncionnelles. Les resultats d'une etude conduite dans. u.n centre de soins communautaire pour malades d' Alzheimer, demontrent que la part1c1pation aces programmes quotidiens peut etre associee avec une amelioration a courtJournal of Applied Recreation Research, 20(1): 3-15 © 1995 Ontario Research Council on Leisure

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Journal of Applied Recreation Research, Vol. 20 (1995)

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terme en fonctionnement social et peut optimiser un fonctionnement quotidien meme en la presence de demence progressive. Mots clefs. programmes de jour, demence, recreation therapeutique

Day programs for people with Alzheimer's disease are a relatively new development in the spectrum of community support services. Seniors' day-care services were originally developed to provide social and recreational activities to physically frail elderly who no longer required the active rehabilitative services of a day hospital. People with Alzheimer's disease or other dementias were generally excluded from attending these programs because of perceptions that mentally impaired elderly would not benefit from the activities provided and would be disruptive to other participants (Cherry & Rafkin, 1988; McGovern & Barry, 1991). This exclusion has led to the development of specially designed programs for people with dementia. As with day programs for the physically frail, the objectives of Alzheimer's day programs are: (a) to prevent premature or inappropriate institutional placement of people with dementia; (b) to provide respite for family caregivers; and (c) to provide participants with meaningful activities and socialization experiences so as to maintain functional abilities and enhance psychological well-being (Gallagher, 1985). Little systematic research has been conducted on the effectiveness of Alzheimer's day programs in meeting these objectives. Most reports are anecdotal and desc~pt~ve in nature, focusing on a specific program or agency. These descnptive accounts suggest that activities and environments _People with .dementia must be structured to compensate the c~gmtive and functional deficits inherent in dementia. However, with a highly structured and predictable environment and with structured physical, ~o~ial, ~d intellectual activities, cognitively impaired ~lderly ca~ p~1t1c1pat~ m a variety of activities and engage in meanmgful social mteraction (Conroy, Fincham, & Agard-Evans 1988· Hasselkus, 1991; Weiss & Kronberg, 1986). ' ' De~onstration. of the benefits of day-program participation for people with dementia has been more difficult to establish While current ?eronto~o~ical literature suggests the possibility that ~xercise and ph~s1cal activ1~ may redu~e undesirable mood states such as anger, ~atigu~, depression, and anxiety, relatively few studies have objectively mvestigated how helpful exercise or physical activity may be in en-

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Kloseck, Davidson, and Ellis I Day Programs for Persons with Dementia

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hancing levels of function in the presence of underlying organic disorders such as dementia (Shephard & Leith, 1990). One exception to this is a study conducted by Friedman and Tappen (1991) which suggests that a planned walking program can improve communication performance in individuals with moderate to severe dementia. However, the effect of planned walking on behaviour and mood states was not examined. In another study, patients attending a dementia day program associated with Cornell University showed a slight improvement in cognitive and physical functioning during the first three months of attendance, followed by a steady decline in functional abilities (Panella, Lilliston, Brush, & McDowell, 1984). No objective examination of the effects of specific types of activities on behaviour and mood was conducted and no objective measures of caregiver burden were administered. Nevertheless, families expressed satisfaction with the program and believed they benefited from the respite time provided. An unpublished study of a day program in Ottawa, Ontario (Evalusearch Research Consultants, 1985) showed that patient functioning deteriorated over a six-month period, but measures of caregiver burden showed no change. The researchers concluded that this was evidence of the success of the program, since they assumed that without the respite provided by the day program caregiver burden would have increased as patient function deteriorated. The validity of this assumption cannot be evaluated without the use of a control group. A study conducted by Newman and Ward (1993) confirmed that older adults with dementia demonstrated consistent positive behaviours in the presence of children during structured music therapy sessions. However, demonstration of behavioural changes occurring as a result of participation in other activities requires further investigation. It is evident that there are many gaps in current knowledge about the effectiveness of day programs for people with Alzheimer's disease. Benefits to both patient and family caregivers have been hypothesized, but have not been empirically demonstrated. The purpose of the present study was to address this gap by examining the effect of dayprogram participation on day-to-day changes in patient behaviour. Short-term effects of participation were emphasized for several reasons. Although little is known about day-to-day variability in the functioning of people with dementia, reports from family members suggest these patients do show "ups and downs" in functioning, having "good

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days" and "bad days." While dementia, by definition, involves a process of intellectual and functional deterioration over time, on a day-today basis, patients may demonstrate a range of functioning. By taking full advantage of remaining abilities and optimizing daily performance, it may be possible to assist patients in regaining some control, enhance self-esteem, assist family caregivers in maintaining their relative at home for a prolonged period, and ultimately aid patients and families in coping with the inevitable functional decline.

Method Program The Alzheimer Community Support Service (ACSS) Day Program (Parkwood Hospital, London, Ontario, Canada) is designed for Alzheimer and related dementia patients who reside in their own home. Patients attend the program twice weekly for four hours. The day is organized to provide patients opportunity to participate in structured activities designed to meet the abilities and interests of the group. Consistent with dementia literature, these activities fall into three categories (intellectual activities; social activities; physical activities) and are routinely provided at specific times throughout the day (Kalicki, 1987; Zgola, 1987). T?e ACSS ~ay program begins at 10:00 a.m. and ends at 2:00 p.m. A. typ1~al day mcludes the following group programs: (1) arrival/ one~tation; (2) intellectual activities consisting of reminiscing and discus.s10n groups; (3) social activities based on the general interest of the patients; (4) non-strenuous armchair exercises. Exercises include a warm-up, gentle stretching, flexibility, general mobility, and rhythmic moveme~t of a~l ?ody P";11~ followed by a cool-down; (5) lunch; and (6) physical activity cons1stmg of gross motor activities such as walking, bowling, or shuffleboard. This daily routine of activities is consistently provided eac~ of the pr?gram days. The ACSS Day Program is run by a Therapeutic Recreation Specialist with the assistance of volunt~ers to help provide more individual attention to each patient. All ~atients are ~s~essed by the Therapeutic Recreation Specialist at the t~m~ of admtss1on to determine physical, cognitive, and leisure func~10rung, ~s w~ll as the leisure interests of each patient. This assessment t mformation ts then used to design activities matched to th · t 'li · f · · e m eres s and ab1 ties o patients mvolved in the ACSS day program.


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A registered nurse is available for medical management and care of patients if necessary. Family support groups and some individual counselling are available to family members of the patients and are provided by a social worker, if a need is identified.

Participants Participants in the study were 15 patients attending the Alzheimer Community Support Service (ACSS) and their caregivers. All of the participants were living at home with a primary caregiver. One patient was hospitalized shortly after the study began and one patient did not attend the group during the six weeks of the study. Two other relatives dropped out during the first week, leaving a final sample of 11 patients (6 male, 5 female) with a mean age of 79 ± 4.53 years (SD). All patients were diagnosed, by a geriatrician, as being moderately demented. Behavioural rating forms were completed by the primary caregivers. Caregivers included 6 wives, 3 husbands, and 2 daughters.

Procedure Data were collected over a six-week period. Each caregiver was assigned four mornings per week to make behaviour ratings-two control days and two program days. The rating form, which was to be completed first thing in the morning, instructed caregivers to rate their relative's behaviour for the past 24 hours. Control ratings were completed the morning the patient attended the group and thus represented the day preceding program attendance. Program ratings were completed the morning after the patient attended the day program and included the afternoon and evening after the patient returned from the group as well as the few hours in the morning before the patient left for the group. Although this possibly weakened the treatment effects, it was decided that 24-hour time blocks would be least confusing to the family raters. Morning ratings were used to capture possible effects of day-program participation on sleep and nighttime activity, a benefit frequently mentioned by family caregivers in anecdotal reports. New forms marked with the date and time to be completed were mailed to participants each week along with stamped, addressed envelopes for the return of the completed forms. Written and telephone contact was maintained with caregivers over the course of the study, to ensure compliance with the study procedures.

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Instruments To assess day-to-day changes in patient behaviour and functioning, the Elder Mental Impairment Scale (Poulshock & Deimling, 1984) was used. This scale was developed to measure levels of mental impairment in community residents with dementia and was designed for use by family caregivers. It consists of three factorially validated subscales: sociability (8 items)--evaluates level of co-operativeness, withdrawal, isolation; disruptive behaviour (7 items)-includes acting out, violent beh~viour, swearing, and disrupting meals; cognitive incapacity (8 items)-assesses forgetfulness and confusion. Poulshock and Deimling validated the Elder Impairment subscales with a sample of 614 family caregivers. Two changes were made to the scale for the present study. Four . items of the sc_ale (1 item from the sociability and cognitive incapacity subscale~, 2 items from the disruptive behaviour subscale) were dropped m order to fit the scale to a single page-a limitation that was felt to be critical for subject compliance. One additional item was added to the disruptive behaviour subscale to assess the extent to which ~he caregiver's sleep was disrupted by the patient's behaviour or activity. F?r ea~h of the 20 items of the revised scale (see Appendix A), ~aregivers m the present study were asked to rate how often the behav10ur had occurred in the past 24 hours on a 4-point scale from almost never to almost all the time. As part of the ongoing mo~toring and record keeping, daypr?gram staff ~~de m~nthly behavioural ratings of patient behaviour usmg the Multidimensi~nal Observational Scale for Elderly Subjects ~MOSES!·. The MOSES is a behavioural observational scale for assessmg cogmtlon (disorientation subscale), social behaviour (social with?raw~l ~ubs_c~le), mood (depression/anxiety), and oppositional behav10ur us e wi·th cog· · (imtabihty 1 · · subscale). It has been well validated "or 1 mtlve y impaired elderly and can be easily administered by professionals (Helmes, Csapo, & Short, 1985). Due t~ absenteeism and other factors, the number of completed Elder Scale ratings varied from 16 to 24 wi"th th e average b · Impairment 20 · e~ng . Ratmgs from control days were averaged to provide a single ratmg Ratings from treatment days were a1so averd for each · subject. . age to provide a smgle score for each subject. . As a check on the validity of the care iver ratin . vised scales, ratings made by family caregiv~rs of the ~:t~:~~~ ~:~~~:


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iour at home were compared to the monthly rating made by dayprogram staff of the patient's behaviour while attending the day program. Correlations between staff ratings on the MOSES and the family ratings on the Elder Impairment Scale are shown in Table 1. As can be seen, correlations are generally high and statistically significant. This result demonstrates that family members showed consistency with staff members in their observations of the patient's behaviour and supports the validity of the revised Elder Impairment Scale. Analysis A post-hoc power analysis was conducted to determine the probability of rejecting a false null hypothesis with the n = 11 sample size, at p < .05. These analyses were based on the assumption of an r of .90 between program day and control day data. Despite the fact that such a liberal value r will produce higher estimates of power, estimates of power with the current data were found to be quite low. The power analyses were followed by tests of the homogeneity of variance assumption that underlies the t ratio and the calculation of paired sample t ratios and their associated probabilities. Finally, point biserial correlation coefficients were calculated to measure the strength of the relationship between program participation (program versus control day) and each of the three outcome variables: sociability, disruptive behaviour, and cognitive incapacity.

Results A summary of the results is presented in Table 2. As can be seen from a review of the table, the pattern of each of the sample means was consistent with the expectation of a participation treatment effect. The social behaviour mean score was .8 units higher on participation days (13.8 on participation days versus 13.0 on control days), the disruptive behaviour mean was .4 units lower on treatment days (13.3 on control days versus 12.9 on participation days), and the cognitive incapacity mean was .5 units lower on participation days (11.3 on control days versus 10.8 on participation days). Estimates of strength of the relationships within the sample data were moderate, ranging from .43 for disruptive behaviour to .57 for social behaviour. The F ratios associated with the test of homogeneity of variance assumption all had p values in excess of .3, suggesting that the assumption of homogeneity of variance under the two conditions is tenable.

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Kloseck, Davidson, and Ellis I Day Programs for Persons with Dementia 11

Tests of hypotheses were, however, complicated by the small sample sizes. Power estimates were well below Cohen's (1977) recommended magnitude of .8, with estimates of .42 (social behaviour), .22 (disruptive behaviour), and .25 (cognitive incapacity). Thus, the observed effect sizes provided little opportunity to detect the existence of a treatment effect, given then = 11 sample size and the alpha level of .05. As our power analysis would lead us to expect, p values all exceeded the .05 level.

Discussion Alzheimer's disease and the dementing process gradually erode a person's ability to seek out and maintain meaningful relationships and activities. Yet even in the face of declining abilities, a patient with Alzheimer's disease is capable of a range of functioning, showing ups and downs in mood and behaviour, just as do most adults. The results of the present study suggest that day-program participation by patients with dementia may result in short-term changes in social functioning and mental impairment. This suggests that Therapeutic Recreation Specialists may be able to maximize functional ability, ensuring that patients function at the maximum or upper level of their limited range of functioning. Short-term benefits are often overlooked when dealing with a process characterized by progressive functional deterioration over time. Further investigation is needed to determine the practical significance of the day-to-day behavioural improvements demonstrated in the present study for both patients and caregivers. For example, do the behavioural changes observed in the present sample translate into improved quality of life for the person with dementia? Were the behavioural changes noticeable to family caregivers and what impact did they have on caregiver burden? Also, an alternative method of analyzing these data in future studies would be to examine the individual differences in the behaviour of patients with Alzheimer's disease who participate in day programs by analyzing individual responses rather than aggregating data of participants. Further studies are also necessary to examine effects of specific types of day-program activities, facilitation style of Therapeutic Recreation Specialists, therapeutic techniques or approaches employed, program environment, and numbers of day-program participants. The present study, for example, included the participants of a single day

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program run by Therapeutic Recreation Specialists with a relatively high staff:patient ratio. It would be interesting to determine whether similar outcomes would be achieved, for example, with a different staff mix and lower staff:patient ratios. Knowledge gained through such studies would allow more precise identification of the unique requisites necessary for maximum day-program effectiveness. Finally, discussion of the sample size challenge in therapeutic recreation research is warranted. One of the enormous challenges associated with the limited research funding for therapeutic recreation research is accessing sample sizes that are sufficiently large to provide acceptable levels of statistical power (Cohen, 1977). This is particularly true in circumstances like this study, in which the research involves well-defined populations such as individuals with Alzheimer's disease. Although hypothesis tests can appropriately be conducted using ~he familiar sampling distributions of t and F if underlying assumpt10ns are met (e.g., Huck, Cormier, & Bounds, 1974; Kirk, 1982; Roscoe, 1975; Stevens, 1990) small to moderate effect sizes combined with.the small sample sizes, tend to create insufficient statis~ical power to reject n~ll hy.potheses. This situation gives rise to the "Type 2 error" problem, m which researchers fail to reject a null hypothesis that is actually false. In the context of the current study and studies similar to it ~ailure to. reject false null hypotheses can lead to the impression that a~ ~ntervent~on has no effect on patients' functioning when, in fact, that i~terventlon can substantially improve crucial dimensions of patients' hves. Be.caus~ Type 2 error may lead efficacy researchers to conclude that a given mtervention has no effect on dimensions of patients• lives t~~t form of error would seem to be of at least equal concern to the tra~ ditlonally protected "Type 1 error." In the context of treatment efficac~, a Typ~ 1 error would be committed if a researcher concluded that an mterventlon was effective when it actually was not R h · therapeutic recreation thereby face a variety of compl~ eseart.c ers md d'l th · f x ques 10ns an i. emmas ~t arise . ro.m research funding and resource constraints. In wisely spendmg their limited research dollars should the 'fi th study of interventions carefully designed to' meet the y s:cn f ce 1 defined, relatively homogeneous groups (e g Al h . n~e s ? we. d t t · ., z eimer s patients) m or er o est m~re generally applicable (but perhaps less potent) ap~roaches that ~ill enable them to increase sample sizes? Should they ignore evaluation of treatment efficacy £or spec1'fi c groups because

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constraints associated with tradition in hypothesis testing will surely lead to a failure to reject a null? Should they put aside their interest in psychological constructs, commit to the study of observable behaviours, and approach their inquiry through single case designs (e.g., Kazdin, 1982; Malkin & Howe, 1993)? Should more liberal alpha levels be accepted (e.g., Stevens, 1990)? Should interest shift from hypothesis testing to interpretation of effect sizes in sample data? In the current study, the decision was made to focus on a well-defined group (Alzheimer's patients) and, as a result of the limited sample size, to extend interpretation of results beyond traditional hypothesis tests to patterns of sample means and to effect sizes. The patterns of means and the moderate effect sizes suggest that the program was exerting a meaningful effect, yet the hypothesis test results did not allow rejection of the null hypothesis. The acceptability of this approach and other questions related to this issue demand attention of, and discussions by, therapeutic recreation efficacy researchers.

Acknowledgments The authors would like to acknowledge the support of the Alzheimer Community Support Service, Parkwood Hospital, London, Ontario, Canada. References Cherry, D.L., & Rafkin, M.J. (1988). Adapting day care to the needs of adults with dementia. Gerontologist, 28, 116-120. Cohen, J. (1977). Statistical power analysis for the behavioral sciences. New York: Academic Press. Conroy, M.C., Fincham, F., & Agard-Evans, C. (1988). Can they do anything? Ten single-subject studies of the engagement level of hospitalized demented patients. British Journal of Occupational Therapy, 51 (4), 129-132. Evalusearch Research Consultants. (1985). Day Away/Home Assistance Programs Evaluation. Report prepared for the Ministry of Community and Social Services, Ottawa, ON. Friedman, R., & Tappen, R.M. (1991 ). The effect of planned walking on communication in Alzheimer's disease. Journal of the American Geriatrics Society, 39, 650-654. Gallagher, D.E. (1985). Intervention strategies to assist the caregivers of frail elders: Current research status and future research directions. Annual Review of Gerontology and Geriatrics, 5, 249-282.

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Journal of Applied Recreation Research, Vol. 20 ( 1995)


Hasselkus, B. (1991). The meaning of activity: Day care for persons with Alzheimer's disease. The American Journal of Occupational Therapy, 46(3), 199-206. Helmes, E., Csapo, K.G., & Short, I.A. (1985). History, development, and validation of a new rating scale for the institutionalized elderly: The Multidimensional Observation Scale for Elderly Subjects (MOSES). University of Western Ontario Bulletin 8501. Huck, S.W., Cormier, W.H., & Bounds, W.G. (1974). Reading statistics and research. New York: Harper & Row. Kalicki, A.C. (1987). Confronting Alzheimer's disease. Washington, DC: National Health Publishing and American Association of Homes for the Aging. Kazdin, A.E. (1982). Single-case research designs: Methods for clinical and applied settings. New York: Oxford University Press. Kirk, R.E. (1982). Experimental design: Procedures for the behaviour sciences (2nd ed.). Belmont, CA: Brooks/Cole. Malkin, M., & Howe, C.Z. (Eds.). (1993). Research in therapeutic recreation: Concepts and methods. State College: Venture. McGovern, C.M., & Barry, P.P. (1991). Day programs for clients with dementia. The American Journal of Alzheimer's Care and Related Disorders and Research, 6(6), 37-42. Newman, S., & Ward, C. (1993). An observational study of intergenerational activities and behaviour change in dementing elders at adult day care centres. International Journal of Aging and Human Development, 36(4), 321-333. Panella, J.J., Lilliston, B.A., Brush, D., & McDowell, P.H. (1984). Day care for dementia patients: An analysis of a four-year program. Journal of the American Geriatric Society, 32(12), 883-886. Paulshock, S.W., & Deimling, G.T. (1984). Families caring for elders in residence: Issues in the measurement of burden. Journal of Gerontology, 39, 230-239. Roscoe, J.T. (1975). Fundamental research statistics for the behavioral sciences. Toronto: Holt Rinehart Winston. Shephard, R.J., & Leith, L.M. (1990). Physical activity and cognitive changes with aging. In M.L. Howe, M.J. Stones, & CJ. Brainerd (Eds.), Cognitive and behavioral performance factors in atypical aging (pp. 153179). New York: Springer-Verlag. Stevens, J. (1990). Intermediate statistics: A modern approach. Hillsdale, NJ: Lawrence Erlbaum Associates. Weiss, .c.~ .. & Kronberg, J. (1986). Upgrading TR service to severely d1sonented elderly. Therapeutic Recreation Journal, 20, 32-42. Zgola, J.M. (~987). D~ing ~hin~s: A guide to programming activities for persons with Alzheimer s disease and related disorders. Baltimore MD: Johns Hopkins University Press. '

Appendix A The Modified Elder Mental Impairment Scale (Poulshock & Seimling, 1984) Used to Assess Day-to-Day Changes in Patient Behaviour In the past 24 hours, was your relative ... Interesting to 1 Not at all _2 Somewhat talk to _3 Moderately so _ 4 Very much so Enjoyable to 1 Not at all be with _2 Somewhat _3 Moderately so _ 4 Very much so 1 Not at all Interested in things - 2 Somewhat _3 Moderately so _ 4 Very much so Co-operative 1 Not at all _2 Somewhat _3 Moderately so _ 4 Very much so Confused 1 Almost never 2 - Sometimes - 3 Often _ 4 Almost always I Almost never Withdrawn or non-responsive - 2 Sometimes - 3 Often _ 4 Almost always Friendly or I Almost never sociable 2 Sometimes _3 Often _ 4 Almost always How often did he/she ... Interfere with I Almost never _2 Sometimes your activities - 3 Often _ 4 Almost always I Almost never Disrupt your sleep - 2 Sometimes - 3 Often _ 4 Almost always I Almost never Appreciate your help - 2 Sometimes - 3 Often _ 4 Almost always

In the past 24 hours, how often did your relative ... 1 Almost never Do harmful things _2 Sometimes to self or others (e.g., strike out) - 3 Often _ 4 Almost always I Almost never Repeat him/herself - 2 Sometimes - 3 Often _ 4 Almost always I Almost never Talk or mumble to _2 Sometimes him/herself - 3 Often _ 4 Almost always I Almost never Have unrealistic fears - 2 Sometimes 3 Often _ 4 Almost always I Almost never Wander inside the 2 Sometimes house - 3 Often _ 4 Almost always I Almost never Hear or see things _2 Sometimes that weren't there - 3 Often _ 4 Almost always I Almost never Disrupt means _2 Sometimes and make them 3 Often unpleasant _ 4 Almost always Complain and be critical

Yell or swear at people

Physically strike out at people

I Almost never 2 - Sometimes 3 Often _ 4 Almost always 1 Almost never _2 Sometimes 3 Often _ 4 Almost always I Almost never _2 Sometimes _3 Often _ 4 Almost always

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