The cultural adaptability of intermediate measures of functional outcome in schizophrenia

Assessment of cognitive impairment in psychosis spectrum disorders through self-reported and interview-based measures

Self-reported and interview-based measures can be considered coprimary measures of cognitive performance. We aimed to ascertain to what extent cognitive impairment in psychotic disorders, as assessed with a neuropsychological battery, is associated with subjective cognitive complaints compared to difficulties in daily activities caused by cognitive impairment. We assessed 114 patients who had a psychotic disorder with a set of neuropsychological tests and two additional measures: the Cognitive Assessment Interview-Spanish version (CAI-Sp) and the Frankfurt Complaint Questionnaire (FCQ). Patients also underwent a clinical assessment. The CAI-Sp correlated significantly with all the clinical dimensions, while the FCQ correlated only with positive and depressive symptoms. The CAI-Sp correlated significantly with all cognitive domains, except for verbal memory and social cognition. The FCQ was associated with attention, processing speed and working memory. The combination of manic and depressive symptoms and attention, processing speed, working memory and explained 38-46% of the variance in the patients' CAI-Sp. Education and negative symptoms, in combination with attention, processing speed, and executive functions, explained 54-59% of the CAI-Sp rater's variance. Only negative symptoms explained the variance in the CAI-Sp informant scores (37-42%). Depressive symptoms with attention and working memory explained 15% of the FCQ variance. The ability to detect cognitive impairment with the CAI-Sp and the FCQ opens the possibility to consider these instruments to approximate cognitive impairment in clinical settings due to their ease of application and because they are less time-consuming for clinicians.

Exploring the effectiveness of family-based interventions for psychosis in low- and middle-income countries: a systematic review

PURPOSE

Of the 80% people with psychosis living in low- and middle-income countries (LMICs), up to 90% are left to the care of families. The World Health Organization has recommended the inclusion of families in community-based rehabilitation and while there is evidence of its implementation in LMICs, this has not been reviewed yet. This study aims to describe the key features and implementation strategies of family-based interventions in LMICs, and appraise their effectiveness.

METHODS

Included are people with psychosis in LMICs who receive any form of family-based intervention, compared to their usual or absence of treatment, with patient outcome measures. We searched (August 2021) through Embase, MEDLINE, Global Health, PsycInfo, Social Policy and Practice, and Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as from grey literature and hand-searched records. Risk of bias was assessed through the Integrated Quality Criteria for Review of Multiple Study Designs (ICROMS) and Consolidated Health Economic Evaluation Reporting Standards (CHEERS), then analyzed narratively.

RESULTS

27 studies were included from the 5254 records. Psychotherapeutic features, systems approach and task-sharing were key intervention elements. Delivery strategies included preliminary research, sustained family engagement, and cultural adaptation. There were positive health impacts across four outcome domains.

CONCLUSION

All studies recommended family-based interventions, with limitations in heterogeneity and 70% of them rated high risk of bias.

OTHER

Review was registered in PROSPERO (CRD42021256856). The authors did not receive funding for this research.

Meta-analysis of cognitive function in Chinese first-episode schizophrenia: MATRICS Consensus Cognitive Battery (MCCB) profile of impairment

Background

Compromised neurocognition is a core feature of schizophrenia. With increasing studies researching cognitive function of Chinese patients with first-episode schizophrenia (FES) using MATRICS Consensus Cognitive Battery (MCCB), it is not clear about the level and pattern of cognitive impairment among this population.

Aim

To provide a meta-analysis systematically analysing studies of neurocognitive function using MCCB in Chinese patients with FES.

Methods

An independent literature search of both Chinese and English databases up to 13 March 2019 was conducted by two reviewers. Standardised mean difference (SMD) was calculated using the random effects model to evaluate the effect size.

Results

56 studies (FES=3167, healthy controls (HC)=3017) were included and analysed. No study was rated as 'high quality' according to Strengthening the Reporting of Observational Studies in Epidemiology. Compared with HCs, Chinese patients with FES showed impairment with large effect size in overall cognition (SMD=-1.60, 95% CI -1.82 to -1.38, I ²=67%) and all seven cognitive domains, with the SMD ranging from -0.87 to -1.41. In nine MCCB subtests, patients with FES showed significant difference in Symbol Coding (SMD=-1.90), Trail Making Test (TMT) (SMD=-1.36), Continuous Performance Test-Identical Pairs (SMD=-1.33), Hopkins Verbal Learning Test (SMD=-1.24), Brief Visuospatial Memory Test (SMD=-1.18), Mazes (SMD=-1.16), Category Fluency (SMD=-1.01), Spatial Span (SMD=-0.69) and Mayer-Salovey-Caruso Emotional Intelligence Test (SMD=-0.38).

Conclusions

Our meta-analysis demonstrates that Chinese patients with FES show neurocognitive deficits across all seven MCCB cognitive domains and all nine subtests, particularly in two neurocognitive domains: speed of processing and attention/vigilance, with the least impairment shown in social cognition. Symbol Coding and TMT may be the most sensitive tests to detect cognitive deficit in Chinese patients with FES.

Systematic Review of Measurement Property Evidence for 8 Financial Management Instruments in Populations With Acquired Cognitive Impairment

OBJECTIVES

To critically appraise the measurement property evidence (ie, psychometric) for 8 observation-based financial management assessment instruments.

DATA SOURCES

Seven databases were searched in May 2015.

STUDY SELECTION

Two reviewers used an independent decision-agreement process to select studies of measurement property evidence relevant to populations with adulthood acquired cognitive impairment, appraise the quality of the evidence, and extract data. Twenty-one articles were selected.

DATA EXTRACTION

This review used the COnsensus-based Standards for the selection of health Measurement Instruments review guidelines and 4-point tool to appraise evidence. After appraising the methodologic quality, the adequacy of results and volume of evidence per instrument were synthesized. Measurement property evidence with high risk of bias was excluded from the synthesis.

DATA SYNTHESIS

The volume of measurement property evidence per instrument is low; most instruments had 1 to 3 included studies. Many included studies had poor methodologic quality per measurement property evidence area examined. Six of the 8 instruments reviewed had supporting construct validity/hypothesis-testing evidence of fair methodologic quality. There is a dearth of acceptable quality content validity, reliability, and responsiveness evidence for all 8 instruments.

CONCLUSIONS

Rehabilitation practitioners assess financial management functions in adults with acquired cognitive impairments. However, there is limited published evidence to support using any of the reviewed instruments. Practitioners should exercise caution when interpreting the results of these instruments. This review highlights the importance of appraising the quality of measurement property evidence before examining the adequacy of the results and synthesizing the evidence.

Issues and developments related to assessing function in serious mental illness

Serious mental illness (SMI) results in functional disability that imposes a significant burden on individuals, caregivers, and society. Development of novel treatments is under way in an effort to improve the illness domains of cognitive impairment and negative symptoms and subsequently to improve functional outcomes. The assessment of functional outcomes in SMI faces a number of challenges, including the proliferation of assessment instruments and the differential prioritization of functional goals among stakeholder groups. Functional assessments relying on self- and informant report present a number of limitations. Identifying alternative strategies to assess functioning that are reliable, valid, and sensitive to change is necessary for use in clinical trials. Measures of functional capacity have been proposed for clinical trials investigating compounds to treat cognitive impairment in schizophrenia. Alternative approaches employing effort-based decision making or daily activity recording using instruments such as the Daily Activity Report may be more appropriate for studies focused on improving negative symptoms.

Developing an international scoring system for a consensus-based social cognition measure: MSCEIT-managing emotions

BACKGROUND

Measures of social cognition are increasingly being applied to psychopathology, including studies of schizophrenia and other psychotic disorders. Tests of social cognition present unique challenges for international adaptations. The Mayer-Salovey-Caruso Emotional Intelligence Test, Managing Emotions Branch (MSCEIT-ME) is a commonly-used social cognition test that involves the evaluation of social scenarios presented in vignettes.

METHOD

This paper presents evaluations of translations of this test in six different languages based on representative samples from the relevant countries. The goal was to identify items from the MSCEIT-ME that show different response patterns across countries using indices of discrepancy and content validity criteria. An international version of the MSCEIT-ME scoring was developed that excludes items that showed undesirable properties across countries.

RESULTS

We then confirmed that this new version had better performance (i.e. less discrepancy across regions) in international samples than the version based on the original norms. Additionally, it provides scores that are comparable to ratings based on local norms.

CONCLUSIONS

This paper shows that it is possible to adapt complex social cognitive tasks so they can provide valid data across different cultural contexts.

The Korean Version of the University of California San Diego Performance-based Skills Assessment: Reliability and Validity

Objective

The study's aim was to develop and standardize a Korean version of the University of California San Diego Performance-based Skills Assessment (K-UPSA), which is used to evaluate the daily living function of patients with schizophrenia.

Methods

Study participants were 78 patients with schizophrenia and 27 demographically matched healthy controls. We evaluated the clinical states and cognitive functions to verify K-UPSA's reliability and validity. For clinical states, the Positive and Negative Syndrome Scale, Clinical Global Impression-Schizophrenia scale, and Social and Occupational Functioning Assessment Scale and Schizophrenia Quality of Life Scale-fourth revision were used. The Schizophrenia Cognition Rating Scale, Short-form of Korean-Wechsler Adult Intelligence Scale, and Wisconsin Card Sorting Test were used to assess cognitive function.

Results

The K-UPSA had statistically significant reliability and validity. The K-UPSA has high internal consistency (Cronbach's alpha, 0.837) and test-retest reliability (intra-class correlation coefficient, 0.381-0.792; p＜0.001). The K-UPSA had significant discriminant validity (p＜0.001). Significant correlations between the K-UPSA's scores and most of the scales and tests listed above demonstrated K-UPSA's concurrent validity (p＜0.001).

Conclusion

The K-UPSA is useful to evaluate the daily living function in Korean patients with schizophrenia.

The Cognitive Assessment Interview: A comparative study in first episode and chronic patients with psychosis

The Cognitive Assessment Interview (CAI) is an interview-based instrument to assess cognition considering the impact of cognitive impairment on daily activities. We aimed to explore the associations of the Spanish version of the CAI (CAI-Sp) with a neuropsychological battery and a measure of psychosocial functioning in psychosis. The sample consisted of fifty-six first episode psychosis (FEP) patients and 66 non-FEP patients, who were assessed with a neuropsychological battery, the CAI-Sp and the Short Disability Schedule (DAS-S). Patients also underwent clinical assessment. Additionally, 37 controls were assessed with the neuropsychological battery and CAI-Sp, for normalization purposes. The results showed that CAI-Sp scores were overall correlated with the neuropsychological battery in non-FEP patients. In FEP patients, we found fewer significant correlations. Most associations were maintained after controlling for clinical symptoms. CAI-Sp rater scores contributed to the variance in the DAS-S scores in both groups, as did negative and disorganized symptoms. The CAI-Sp may be a good instrument to assess cognition in non-FEP patients. In FEP patients, it was less effective in capturing cognitive impairments and their functional consequences, probably because cognitive deficits have yet to become evident, due to the recency of illness onset, and no functional disturbances were observed due to these cognitive impairments.

Using the cognitive assessment interview to screen cognitive impairment in psychosis

Cognitive impairment in psychosis is closely related to functional outcome, so research into psychotic disorders is focusing most effort on treatments for improving cognition. New treatments must show not only an improvement on neuropsychological tests but also in co-primary measures of cognition. The cognitive assessment interview (CAI) is an interview-based measure of cognition which assesses the impact of cognitive deficits in patients' daily lives. Information obtained from patients and their relatives is integrated into a rater composite score. This study examines the validity of the CAI (adapted to Spanish, CAI-Sp) as a screening instrument for cognitive impairment, compared to an objective test of cognitive functioning. The psychometric properties of the CAI-Sp and its association with clinical dimensions are also explored. Eighty-one patients with a psychotic disorder and 38 healthy controls were assessed using the CAI-Sp and the screen for cognitive impairment in psychiatry (SCIP-S). Patients also underwent a clinical assessment. Poorer cognitive functioning as assessed with the CAI-Sp was associated to illness severity, specifically positive, negative and disorganised syndromes. Binary logistic regression showed that the CAI-Sp was able to detect cognitive impairment in patients, when considering CAI-Sp patient and informant information and CAI-Sp rater scores. The CAI-Sp was found to be a valid and reliable scale to assess cognitive functioning in the context of its impact on daily living. Given its ease and speed of application, the CAI-Sp could prove useful in clinical practice, though not a substitute of objective cognitive testing.

The Daily Activity Report (DAR) a Novel Measure of Functional Outcome for Serious Mental Illness

The assessment of real-world functional outcomes in clinical trials for medications targeting negative symptoms and cognitive impairment is extremely important. We tested the psychometric properties of the Daily Activity Report (DAR), a novel assessment of productive daily activity. We administered the DAR and additional assessments of functional outcome, functional capacity, cognition and symptomatology to 50 individuals with schizophrenia at 2 time points, 1 month apart and to 25 healthy controls. The DAR records a person's daily activity for 7 consecutive days based upon phone calls made 3 times a day. A total score and scores in 3 domains; instrumental activities (ie, independent living), social and work or school related activities are generated for the DAR. Inter-item consistency was high 0.89-0.94 for each domain and 0.88 overall. Test-retest reliability across 1 month for the total DAR score was 0.67,P< .0001. The total DAR score as well as scores for social activity and nondomestic work/school differed significantly between control and patient participants (P< .0001). DAR domain scores were associated with negative symptoms and functional outcomes, but the primary score related to these measures was the work/school dimension of the DAR. DAR scores were only weakly and nonsignificantly related to positive symptoms. This study provides preliminary support for the reliability and validity of the DAR using interviewer administration. The development of a patient reported version of the DAR using smart phone technology with automatic scoring is the next step.

Utility of the UCSD Performance-based Skills Assessment-Brief Japanese version: discriminative ability and relation to neurocognition

The UCSD Performance-based Skills Assessment Brief (the UPSA-B) has been widely used for evaluating functional capacity in patients with schizophrenia. The utility of the battery in a wide range of cultural contexts has been of concern among developers. The current study investigated the validity of the Japanese version of the UPSA-B as a measure of functional capacity and as a co-primary for neurocognion. Sixty-four Japanese patients with schizophrenia and 83 healthy adults entered the study. The Japanese version of the UPSA-B (UPSA-B Japanese version) and the MATRICS Cognitive Consensus Battery Japanese version (MCCB Japanese version) were administered. Normal controls performed significantly better than patients, with large effect sizes for the Total and the subscale scores of the UPSA-B. Receiver Operating Characteristic (ROC) curve analysis revealed that the optimal cut-off point for the UPSA-B Total score was estimated at around 80. The UPSA-B Total score was significantly correlated with the MCCB Composite score and several domain scores, indicating the relationship between this co-primary measure and overall cognitive functioning in Japanese patients with schizophrenia. The results obtained here suggest that the UPSA-B Japanese version is an effective tool for evaluating disturbances of daily-living skills linked to cognitive functioning in schizophrenia, providing an identifiable cut-off point and relationships to neurocognition. Further research is warranted to evaluate the psychometrical properties and response to treatment of the Japanese version of the UPSA-B.

The reliability and validity of the MATRICS functional assessment battery

OBJECTIVES

The Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was designed to encourage the development of cognitive enhancing agents for schizophrenia. For a medication to receive this indication, regulatory agencies require evidence of improvement in both cognition and functional outcome. Functional capacity measures typically used in clinical trials as intermediate measures of functional outcome must be adapted to fit different cultural contexts for use internationally. We examined the psychometric properties of the MATRICS Functional Assessment Battery (MFAB), comprised of 2 subtests from the UCSD Performance-based Skills Assessment (UPSA) and one from the Test of Adaptive Behavior in Schizophrenia (TABS) that were rated by experts in a previous study to be the most appropriate functional capacity assessments across different cultural contexts.

METHOD

Four sites in India administered the MFAB, a brief version of the UPSA, the MATRICS Cognitive Consensus Battery, measures of symptomatology, and a measure of global functional outcome to 141 individuals with schizophrenia at a baseline assessment and at 4 weeks later.

RESULTS

Test-retest reliability based on the intraclass correlation coefficient was significantly better for the UCSD Performance-Based Skills Assessment-Brief (UPSA-B). Pearson correlation coefficients over time were not significantly different for the 2 measures. Only the MFAB was significantly correlated with functional outcome as measured by the Specific Levels of Functioning Scale.

CONCLUSIONS

The psychometric properties of the MFAB and UPSA-B were similar. The MATRICS scientific board chose to translate the MFAB into multiple languages for potential use in studies of novel medications seeking an indication for improving cognition in schizophrenia.

The effect of language on functional capacity assessment in middle-aged and older US Latinos with schizophrenia

The U.S. Latino population is steadily increasing, prompting a need for cross-cultural outcome measures in schizophrenia research. This study examined the contribution of language to functional assessment in middle-aged Latino patients with schizophrenia by comparing 29 monolingual Spanish-speakers, 29 Latino English-speakers, and 29 non-Latino English-speakers who were matched on relevant demographic variables and who completed cognitive and functional assessments in their native language. There were no statistically significant differences between groups on the four everyday functioning variables (UCSD Performance-Based Skills Assessment [UPSA], Social Skills Performance Assessment [SSPA], Medication Management Ability Assessment [MMAA], and the Global Assessment of Functioning [GAF]). The results support the cross-linguistic and cross-cultural acceptability of these functional assessment instruments. It appears that demographic variables other than language (e.g., age, education) better explain differences in functional assessment among ethnically diverse subpopulations. Considering the influence of these other factors in addition to language on functional assessments will help ensure that measures can be appropriately interpreted among the diverse residents of the United States.

Virtual Reality Functional Capacity Assessment In Schizophrenia: Preliminary Data Regarding Feasibility and Correlations with Cognitive and Functional Capacity Performance

INTRODUCTION

Assessment of functional capacity is an intrinsic part of determining the functional relevance of response to treatment of cognitive impairment in schizophrenia. Existing methods are highly and consistently correlated with performance on neuropsychological tests, but most current assessments of functional capacity are still paper and pencil simulations. We developed a computerized virtual reality assessment that contains all of the components of a shopping trip.

METHODS

We administered the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) to 54 healthy controls and to 51 people with schizophrenia to test its feasibility. Dependent variables for the VRFCAT included time to completion and errors on 12 objectives and the number of times that an individual failed to complete an objective. The MATRICS Consensus Cognitive Battery (MCCB) and a standard functional capacity measure, the UCSD Performance-Based Skills Assessment-Brief (UPSA-B) were administered to the patients with schizophrenia.

RESULTS

Patients with schizophrenia performed more poorly than healthy controls on 10/11 of the time variables, as well as 2/12 error scores and 2/12 failed objectives. Pearson correlations for 7 of 15 VRFCAT variables with MCCB composite scores were statistically significant.

CONCLUSION

These results provide support for the possibility of computerized functional capacity assessment, but more substantial studies are required.

Language-dependent performance on the letter fluency task in patients with schizophrenia

Two types of verbal fluency tasks (letter fluency task; LFT, category fluency task; CFT) have been widely used to assess cognitive function in people with psychiatric diseases including schizophrenia. The task demand of the LFT is considered to vary across languages, as the cognitive process largely relies on sound and writing systems. Specifically, a sound unit for a letter (s) and a manner of association between them are assumed to be related with the performance. In the current study, three analyses have been conducted to examine this issue, using Japanese, Turkish, and English-speaking patients with schizophrenia. It was hypothesized that severity of letter fluency impairment would be in the order of Japanese, Turkish, and English speaking patients according to the inflexibility of a word search. First, performance on the LFT and the CFT was compared among Japanese (N=40), Turkish (N=30), and the US (N=31) patients (Analysis 1). A significant difference was found between the US and other two groups only in the LFT. Second, verbal fluency performance was compared between Japanese and Turkish patients by contrasting the degree of disassociations from normal controls (Japanese: N=20, Turkish: N=30) (Analysis 2). In Japanese patients, performance on the LFT was more severely impaired compared to that on the CFT while the opposite trend was found in the Turkish counterpart, suggesting that letter fluency performance was more degraded in Japanese patients. Finally, Analysis 3 was conducted to examine the relative order of letter fluency impairment among Japanese, Turkish and English-speaking patients. Disassociation in English users with schizophrenia was estimated based on previous meta-analytic reviews. The effect size (ES) for the letter fluency deficit was the largest in the Japanese sample, while the other two groups share similar ESs. The results from the three analyses partially supported the hypothesis for the severity of the letter fluency impairment in patients with schizophrenia. The language-dependency of letter fluency impairment was thought to be explained by the theoretical model built on unique properties of sound and writing systems. The considerations presented here would provide useful information for optimizing the portability of cognitive tasks across languages.

Adapting and evaluating a social cognitive remediation program for schizophrenia in Arabic

Although growing evidence supports the efficacy of social cognitive training interventions for schizophrenia, nearly all studies to date have been conducted in Westernized countries. In the current study, we translated and adapted an existing social cognitive skills training (SCST) program into Arabic and conducted a preliminary efficacy evaluation in schizophrenia outpatients in Egypt. Twenty-two patients were randomized to 16 sessions of group-based SCST and 20 were randomized to a format- and time-matched illness management training control condition. Pre- and post-intervention assessments included a primary social cognition outcome measure that assessed four branches of emotional intelligence and a battery of neurocognitive tests. The SCST group demonstrated significant treatment effects on total emotional intelligence scores (F=24.31, p<.001), as well as the sub-areas of Identifying Emotions (F=11.77, p<.001) and Managing Emotions (F=23.27, p<.001), compared with those in the control condition. There were no treatment benefits for neurocognition for either condition, and both interventions were well-tolerated by patients. These initial results demonstrate the feasibility of implementing social cognitive interventions in different cultural settings with relatively minor modifications. The findings are encouraging regarding further efforts to maximize the benefits of social cognitive interventions internationally.

A qualitative assessment of cross-cultural adaptation of intermediate measures for schizophrenia in multisite international studies

In this substudy of the Measurement and Treatment Research to Improve Cognition in Schizophrenia we examined qualitative feedback on the cross-cultural adaptability of four intermediate measures of functional outcome (Independent Living Scales, UCSD Performance-Based Skills Assessment, Test of Adaptive Behavior in Schizophrenia, and Cognitive Assessment Interview). Feedback was provided by experienced English-fluent clinical researchers at 31 sites in eight countries familiar with medication trials. Researchers provided feedback on test subscales and items which were rated as having adaptation challenges. They noted the specific concern and made suggestions for adaptation to their culture. We analyzed the qualitative data using a modified Grounded Theory approach guided by the International Testing Commission Guidelines model for test adaptation. For each measure except the Cognitive Assessment Interview (CAI), the majority of subscales were reported to require major adaptations in terms of content and concepts contained in the subscale. In particular, social, financial, transportation and health care systems varied widely across countries-systems which are often used to assess performance capacity in the U.S. We provide suggestions for how to address future international test development and adaptation.

Clinical instruments to evaluate and guide treatment in schizophrenia

Treatment research in schizophrenia is focused on the development of pharmacological agents that are effective for improving community functioning and decreasing disability. As a result of this recent focus, there has been substantial activity for developing instruments that can measure functioning as well as the psychopathological domains that are related to functioning. Issues in selecting measures of real-world functioning include ensuring that the instrument measures the full range of possible outcomes and differentiating symptoms from functioning. For many treatment studies it is unrealistic to expect a change in actual functioning. Most treatment trials are too brief to permit subjects to change their level of vocational or social functioning. In addition, real-world functioning is influenced by factors such as an individual's financial status or the availability of community services. This has led to the use of functional capacity measures which monitor an individual's ability to perform functionally meaningful tasks even if they do not complete these tasks. Attention has also focused on interview-based measures of cognition and negative symptoms. Both of these psychopathological domains are related to functioning and both are the focus of drug development.Recent drug development has focused on the development of agents that target domains of psychopathology that may lead to improved functioning. This focus contrasts with the development of first and second-generation antipsychotics; these drugs were considered effective when they treated psychotic symptoms such as auditory hallucinations, suspiciousness, delusions, and disorganized behaviors. Treating these symptoms was important for reducing suffering and for allowing many patients to live in their communities. On the other hand, these agents had relatively modest effects on the ability of patients to function in their communities. This new focus on functioning has led to the development of new instruments for measuring functioning as well as the psychopathological domains that appear to be related to impaired functioning. This review will discuss the challenges that instrument developers have faced in designing these new instruments as well as the current state of the field. The measurement of typical psychopathology-particularly psychosis will not be discussed.

International assessment of functional skills in people with schizophrenia

Disability is very common in schizophrenia and is related to cognitive impairments, some illness symptoms, and deficits in skills needed to function in the everyday environment (i.g., functional capacity). Research on measurement of the ability to perform the skilled acts required for successful everyday functioning has advanced considerably in the past five years. However, different environmental situations require different skill sets, and one of the major challenges in research on functional capacity is identification of the differences in skills that are required across environments. This article reviews the challenges associated with international measurement of functional capacity. The authors present their perspectives on what can be done with existing measures and what needs to be done in the future. As America becomes more multicultural, these challenges will also occur close to home as well.