The REAL in Pediatric OT: ADL and IADL Ratings, Scoring, Research, and Reporting Tips

Self care questions come up constantly in pediatric OT. Why can't a 9 year old manage buttons before school? Is a middle schooler ready to ride the bus alone? The Roll Evaluation of Activities of Life, better known as the REAL, is a short caregiver rating scale built for these questions. Here is what it measures, what scores it gives you, how to write it up, and where its limits are.

Why pediatric therapists use the REAL

Most standardized tools we give measure underlying skills like motor coordination or visual perception. They don't tell you whether a child can actually get dressed or pack a backpack. The REAL asks the people who see those routines every day. Pearson describes it as a screening tool for children's ability to care for themselves at home, at school, and in the community, with uses that include determining need for services, educational planning, placement decisions, and program evaluation (Pearson, n.d.-b). For school OTs, it brings home based functional information into an evaluation. For clinic therapists, it documents daily living concerns and supports family centered goals.

What the REAL is

• Authors: Kristin Roll, MA, OTR/L, and William Roll, MA (Pearson, n.d.-b)
• Publisher and year: Pearson, 2013 (Pearson Clinical Australia & New Zealand, n.d.). There is only one edition.
• Ages: 2:0 to 18:11
• Format: Paper and pencil rating form completed by a parent or caregiver, independently or as an interview (Shirley Ryan AbilityLab, 2018). Hand scored; no Q-global option is listed (Pearson, n.d.-b).
• Time: About 15 to 20 minutes (Pearson Clinical India, n.d.)
• Qualification level: B (Pearson, n.d.-b)

What the REAL measures

The rating form has two domains (Pearson, n.d.-b):

• Activities of Daily Living (ADL): 78 statements across six skill areas
• Instrumental Activities of Daily Living (IADL): 58 statements across six skill areas

Pearson's page text doesn't name the skill areas. Database and retailer listings name ADL areas such as dressing, hygiene and grooming, feeding, toileting, and functional mobility, and IADL areas such as housework and chores, managing money and shopping, meal preparation, personal safety, traveling, and school related skills (Shirley Ryan AbilityLab, 2018; Therapro, n.d.). The listings don't agree on the sixth ADL area, so confirm the exact areas in your User's Guide.

Items look at whether the child gets the needed supplies, maintains a safe body position, sequences the steps, and problem solves to make safe choices (Pearson, n.d.-b). That maps nicely onto performance skills OTs already think about.

Caregivers rate each statement from 0 to 3, "Unable" to "Frequently" (Pearson Clinical Australia & New Zealand, n.d.); the database summary lists the points as unable, seldom, occasionally, and frequently (Shirley Ryan AbilityLab, 2018). Statements specific to female dressing and personal care devices are informational and do not count toward the score (Pearson Clinical India, n.d.).

How the REAL is scored

Pearson lists these outputs (Pearson, n.d.-b; Pearson Clinical India, n.d.):

• Raw scores for ADL and IADL. Pearson notes these are relative to their own sections and should not be compared with each other.
• Standard scores, which Pearson describes as having a mean of 100 and a standard deviation of 10. That is a narrower spread than the familiar SD of 15, so confirm the metric in your User's Guide.
• Percentile ranks
• Standard error of measurement, for reporting a range around the observed score

Therapro's listing mentions a combined total standard score (Therapro, n.d.), but Pearson's pages don't, so check your manual before reporting one. Pearson doesn't publish descriptive classification ranges, so none are given here.

Norms come from 786 children without disabilities from 46 states, collected October 2011 to June 2012, with an international comparison group and a clinical group of 164 children with disabilities (Pearson Clinical India, n.d.).

A realistic school example

Maya is an 8 year old third grader with autism. Her teacher reports she needs help with her coat and backpack at dismissal and often leaves the bathroom without washing her hands. Her mother says mornings take over an hour and that Maya eats only if her food is cut for her. For the triennial reevaluation, the school OT sends the REAL home, follows up by phone on items the mother wasn't sure about, observes Maya at arrival, lunch, and dismissal, and gives a fine motor test. The REAL is one piece of the picture.

Sample score summary (FICTIONAL)

These scores are invented for illustration. They assume the mean 100, SD 10 metric Pearson describes, with percentiles estimated from a normal curve. Always take percentiles and SEM bands from your User's Guide norm tables.

• ADL standard score: 84, about the 5th percentile
• IADL standard score: 92, about the 21st percentile

Any ADL versus IADL comparison should use these standard scores, not the raw scores.

How to write it up

Name the rater, the method, and the date. Report standard scores with percentile ranks, and tie the numbers to what the caregiver and staff described.

The Roll Evaluation of Activities of Life (REAL), a standardized caregiver rating scale of activities of daily living (ADL) and instrumental activities of daily living (IADL), was completed by Maya's mother through a phone interview with this therapist. Maya earned an ADL standard score of 84 (5th percentile) and an IADL standard score of 92 (21st percentile). Her mother reported that Maya is unable or seldom able to manage fasteners, cut her own food, or complete handwashing without reminders. This is consistent with school observations, where Maya required hand over hand help with her coat zipper and verbal prompts for each step of unpacking. Results suggest that dressing and feeding skills are an area of need affecting her independence in school routines.

From there, write goals around the school routines that matter most, like managing outerwear at dismissal or following a handwashing visual checklist.

What the research says

The evidence base is thin. Nearly all published psychometric data come from the authors' User's Guide, as summarized by the Shirley Ryan AbilityLab Rehabilitation Measures Database (Shirley Ryan AbilityLab, 2018):

• Test retest reliability: r = .98 for both ADL and IADL in children without disabilities.
• Internal consistency: Cronbach's alpha = .94 for ADL and .96 for IADL. The database labels these as interrater reliability, but alpha is an internal consistency statistic.
• Content validity: Based on clinical experience and the AOTA Practice Framework, with item wording reviewed by OTs, a COTA, PTs, and SLPs.
• Criterion validity: Not well established. The authors compared REAL and PEDI mean standard scores but did not report correlations.
• The clinical group of children with disabilities scored lower on average than the normative sample.

The database concludes that the REAL is simple and quick, may work best as a screening tool, should be combined with other assessments, and has limited psychometric information. A review appears in the Twentieth Mental Measurements Yearbook (Buros Center for Testing, n.d.). We did not find independent peer reviewed validation studies of the REAL.

Practical cautions

• It is a proxy report. Family routines, cultural expectations, and how much help a family usually gives all shape ratings. Pair it with your own observation.
• No teacher form. If you need a school perspective, add a tool that has one.
• Watch the metric. With an SD of 10, a score of 85 is 1.5 SD below the mean, not 1 SD as on most tests.
• Narrow coverage. Social participation, rest and sleep, leisure, play, and work are not assessed (Shirley Ryan AbilityLab, 2018).
• Norms date to 2011 to 2012. Expectations for some IADLs, like handling money, may have shifted.

How it compares with related tools

• PEDI-CAT: Computer adaptive caregiver or clinician report for ages 1 month to 20 years 11 months, covering Daily Activities, Mobility, Social/Cognitive, and Responsibility. It yields age percentiles and T scores plus criterion referenced scaled scores for tracking change, administered through Q-global (Pearson, n.d.-a).
• Vineland-3: Birth to 90 years, with Interview, Parent/Caregiver, and Teacher forms covering Communication, Daily Living Skills, and Socialization (Pearson, n.d.-c). Broader and longer; a better fit when overall adaptive behavior is the question.
• REAL: Shorter, focused on self care and IADLs, inexpensive, and hand scored. Good for a quick, OT focused caregiver snapshot.

Bottom line

The REAL is a quick, low cost caregiver rating of ADLs and IADLs for ages 2 to 18 that gives standard scores and percentile ranks to anchor a functional discussion. Use it as a screener or one part of a broader evaluation, pair it with observation and a performance based or teacher report measure, and confirm the score metric and skill areas in your User's Guide.

References

Buros Center for Testing. (n.d.). Roll Evaluation of Activities of Life (The) [Test review]. University of Nebraska-Lincoln. https://marketplace.unl.edu/buros/roll-evaluation-of-activities-of-life-the.html

Pearson. (n.d.-a). Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT). https://www.pearsonassessments.com/store/usd/p/100002037.html

Pearson. (n.d.-b). The Roll Evaluation of Activities of Life (REAL). https://www.pearsonassessments.com/store/en/usd/p/100000762

Pearson. (n.d.-c). Vineland Adaptive Behavior Scales, Third Edition (Vineland-3). https://www.pearsonassessments.com/en-us/Store/Professional-Assessments/Behavior/Adaptive/Vineland-Adaptive-Behavior-Scales-%7C-Third-Edition/p/100001622

Pearson Clinical Australia & New Zealand. (n.d.). The REAL: The Roll Evaluation of Activities of Life. https://www.pearsonclinical.com.au/store/en/p/P100010197

Pearson Clinical India. (n.d.). The REAL: The Roll Evaluation of Activities of Life [Product overview]. https://pearsonclinical.in/?p=14026

Shirley Ryan AbilityLab. (2018). Roll Evaluation of Activities of Life. Rehabilitation Measures Database. https://www.sralab.org/rehabilitation-measures/roll-evaluation-activities-life

Therapro. (n.d.). The Roll Evaluation of Activities of Life (REAL). https://www.therapro.com/The-Roll-Evaluation-of-Activities-of-Life.html

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