SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 1999;6:11–20

The ADL Taxonomy—from Individual Categorical Data to Ordinal

Categorical Data
ULLA SONN1, KRISTINA TO8 RNQUIST2 and ELISABETH SVENSSON3
From the 1Department of Rehabilitation, College of Health and Caring Sciences, Göteborg Uni6ersity, Göteborg, 2Department of Caring
Sciences, O8 rebro Uni6ersity, O8 rebro, 3Biostatistics Branch, Department of Mathematical Statistics, Chalmers Uni6ersity of Technology and
Göteborg Uni6ersity, Göteborg, Sweden

Sonn U, Törnquist K, Svensson E. The ADL taxonomy — from indi6idual categorical data to ordinal
categorical data. Scand J Occup Ther 1999; 6: 11–20.

The ADL taxonomy comprises 12 defined activities organized into actions from the easiest to the more
demanding ones. The purpose of the study was to determine whether the actions in the activities have an
ordered, categorical structure, and to compare the distribution of individuals at the levels within each
activity in three different samples. Data were collected by occupational therapists from the following three
samples: (i) persons 65 years or older with home help (n = 684); (ii) patients from different fields of
occupational therapy (n=373); and (iii) patients with stroke (n =226). This study shows that there is an
ordered, categorical structure within each activity defined in the ADL-taxonomy. The median proportion
error of scales was 4%. Some of the activities/actions were redefined and one action was excluded because
of the concentration of errors. People living in their own homes had a significantly higher level of ability in
all activities compared to the other groups. The ADL taxonomy can be used for evaluation at individual as
well as group levels, as every single activity can be used as an ordered scale. Key words: ADL, measurements,
occupational therapy, ordinal data, rating scale.

INTRODUCTION struments are not established in a theoretical frame of

The selection of functional assessment tools for use in
different fields of occupational therapy is a widely
debated issue. One way to assess activities of daily life
(ADL) is to use formalized assessments, that is, more
or less standardized instruments. The instruments
chosen are often used for discriminative, predictive or
evaluative purposes, especially when assessing groups
[1 –8]. Other common purposes at the individual level
might be for clinical decision-making [9], for treat-
ment planning and/or for monitoring programmes.
Today, occupational therapists (OTs) are aware that
there is no widely accepted professional language,
which complicates information between colleagues
and other professionals on the beneficial effect of
occupational treatment on patients’ abilities [9–12].
To cover these needs, OTs often use rating scales, but
these have not always been constructed for this pur-
pose. Choosing the appropriate instrument to suit the
purpose is a difficult task and it is important to
realize that there is no single instrument in the assess-
ment of ADL to meet all these needs.
ADL instruments have often been criticized for
deficient validity and reliability [2, 6, 8]. According to
McDowell & Newell [5], instruments for P-ADL are
less well validated and tested for reliability than
instruments for I-ADL. However, as ADL instru-
ments cannot be tested against a gold standard, the
validity will become a theoretical problem; that is,
one has to question how well an instrument measures
a theoretical concept. Furthermore, most ADL in-
reference and are not built on a theoretical concept of
ADL [13–15]. Today these problems are recognized
by OTs, because they are involved in testing proce-
dures as well as in constructing new instruments from
the perspective of occupational therapy [14–16].
Philosophers often claim that knowledge starts
with naming the different phenomena of interest.
Without terms and concepts—no knowledge [17, 18].
When occupational therapists record those activities
that cause problems in patients, this could be re-
garded as an attempt at categorizing abilities, that is
‘‘to name and frame’’ [19]. According to Stevens [20],
categorical measurements without any order are
called ‘‘categorical’’. Many categorical variables have
an ordered structure, for example no problems,
slight, moderate, severe problems. Such ordered cate-
gorical data are often called ‘‘ordinal’’. The main
property of ordinal data is a distinct order of the
categories, but the concept of distance does not exist.
Therefore, numerical categorical labels are not met-
ric, and arithmetic cannot be applied to ordinal data
[21–24].
THE ADL TAXONOMY
Several studies have shown that OTs have realized
that they lack a refined professional language and
tend to describe the patient’s problem in medical
terms [9, 25–29]. In general, the concepts of ADL
have followed from development of scales in clinical

© 1999 Scandinavian University Press. ISSN 1103-8128

12 U. Sonn et al.
praxis rather than being developed from any theoret-
ical concept or framework [30, 31]. With this back-
ground, we formulated in an earlier study a
theoretical framework for the ADL concept, and
within this framework operationalized the ADL con-
cept to an ADL taxonomy [32], for use by OTs in
clinical situations as a guide for observations and/or
interviews. In Sweden, the ADL taxonomy has be-
come a general accepted way of describing ADL
performance. It is used for different purposes in
clinical work at an individual level, e.g., describing
changes over time (entering hospital, discharge and
follow-up), setting goal profiles, describing differences
between other concepts such as volition, earlier
habits, for showing discrepancies between data col-
lected in different ways (interviews, observations, self-
reports), and/or for assessing performance in
activities in different environments.
The ADL taxonomy was built on the hypothesis
that there is a general ordering of actions based on
stages of human development [33, 34]. The concept of
activities of daily living was defined as frequent com-
mon activities, including self-care, home maintenance
and communication, as these activities often compose
a basis for other occupational forms or areas. The
extent to which a person manages everyday tasks is
largely related to the environment, as these are both
influenced and assumed by the environment [32].
‘‘Daily’’ usually means every day (habit), but this
can also be less often depending on individual needs,
habits and social roles, as well as cultural traditions.
An activity (occupation) means a goal-directed/pur-
poseful and intentional action and consists of an
interaction between a person/subject and a task/ob-
ject in a specific context. This means that the task
itself formulates the demands and influences how a
person performs the specific activity. To perform (to
do) an activity implies that a person has capability
(can do), can meet the demands from the tasks
(know-how), and is able to perform the activity when
it is necessary or needed (wants to do/must do) [32].
The ADL taxonomy is categorized into three lev-
els: occupational forms, activities and actions and
comprises 12 activities, namely: eating and drinking,
mobility, going to the toilet, dressing, personal hy-
giene, grooming, communication, cooking, trans-
portation, shopping, cleaning, and washing. These
activities can be considered common and generic for
most persons and therefore form the basis for activi-
ties of daily living. Each activity has a certain goal/
purpose or intention. The activities comprise a
sequence of actions. For example, the activity eating
and drinking consists of three actions defined as
follows; (i) eating, that is, getting food from a plate
or equivalent into one’s mouth and eating; (ii) drink-
ing, that is, getting liquid from a glass or cup equiva-
lent into one’s mouth and drinking; (iii) getting food
and liquid and cutting up/preparing food. Another
example is the activity of cleaning with two actions;
(i) daily light cleaning, (ii) weekly heavy cleaning [32].
The number of actions within an activity varies, from
two to six, and the actions have been organized in a
logical order from the easiest to the more demanding
ones. As the activities included in the ADL taxonomy
are categorical behaviours, the concept of distance
does not exist [20–22, 35]. The actions are compo-
nents of the activity, and the activity is always some-
thing more than its actions. Assessments of the
performance in the activities as well as its actions can
be presented in a circular graph, where there is addi-
tional space for adding other activities based on
individual needs. The analysis should be based on
each patient’s needs, habits and roles. Each activity
and action has been defined in a manual [32, 36].
So far, the measurement level within each activity
has been regarded as nominal, as the logical order of
the actions within an activity is not verified. This
study will focus on the evaluation of a possible
ordered categorical structure within each activity.
The presence of an ordered structure makes it possi-
ble to discriminate between different levels of ability
in daily life activities and also facilitates the use of the
ADL taxonomy for discriminative, predictive and
evaluative purposes at group level.
The aims of this study were to determine whether
the individual actions have an ordered categorical
structure within each activity in the ADL taxonomy,
to test the ability of the actions and activities in the
ADL taxonomy between different subgroups of pa-
tients/clients.
SUBJECTS AND METHODS
The material used in this study was collected solely
by occupational therapists, and from different fields
of occupational therapy. The assessments using the
ADL taxonomy [32, 36] were made within the OTs’
ordinary work or collected from different projects
(1993–96), where the purpose was to describe and
follow patients’ ability in daily life activities and to
identify rehabilitation needs. Consequently, patient/
clients with different diagnoses are included.
We divided the material into three groups:
Group I consists of a sample of people] 65 years
of age with home help in a social-welfare district
(n = 684). The mean age was 82 years (range 65–102)
[37].
Group II consists of a sample of patients from
different parts of Sweden and from different fields of
occupational therapy (n= 373). The mean age was 73

(range 18–97) years. In some assessments (3%), infor-
mation on age was missing.
Group III consists of a sample of patients with
stroke, collected within a stroke project (n = 226),
mean age 73 years (range 32 – 93) years [38].
Only those activities in the ADL taxonomy [32, 36]
where all actions have been assessed were included in
the analysis. Thus, the number of assessments in the
different activities varies. As information on gender
was missing in some assessments, only the total group
was analysed.
The recording within each action was dichotomous
(binary) and labelled (+ ) for ability to perform
(actually do) the actions and (− ) for disability (actu-
ally not do) the actions.
Given a complete ordered structure, all individuals
can be ordered from the most able to the most
disabled. For an activity with four actions, the or-
dered structure (see Table I) defines a hierarchical
conditional scale having five ordered levels of ability.
The five categories are labelled A, B, C, D, E (see
Table I). All other combinations of binary responses
define lack of perfect hierarchical order, and define
the errors of scale. The proportion of such un-or-
dered classifications is determined.
In order to test the ability of the scales to discrim-
inate between a wide range of ability/disability levels,
three different subsamples were used in the scaling
procedure. Possible differences in categorical distribu-
tions between the subsamples in each activity were
analysed by the Kruskal-Wallis one-way analysis of
variance by ranks, corrected for ties [39]. In this
analysis, individuals with errors of scale were ex-
cluded.
In order to obtain an overall significance level of at
least 5%, the Bonferroni – Holm stepwise adjustment
for multiple tests was performed [40].
RESULTS
Evaluations of the ordered structure of actions are
presented separately for each activity, and for each of
the subsamples (see Table II). The activities shopping
Table I. The ordered structure in an acti6ity compris-
ing four actions
Actions
1 2 3 4 Categories
+ + + + A 5.5%. In the ADL taxonomy, this last action ‘‘getting
+ + + − B to and from the hygiene room’’ should be excluded.
+ + − − C
+ − − − D This type of mobility is already included in the
− − − − E activity mobility, action number 3 (see Appendix).
The ADL taxonomy — ordered categorical data 13
and cleaning have an ordered categorical structure
with three levels (A–C); eating and drinking, per-
sonal hygiene, cooking and washing have four or-
dered levels (A–D); going to the toilet has five levels
(A–E); dressing, grooming, communication and
transportation six levels (A–F); and, finally, mobility
has seven ordered levels (A–G).
The errors of scale in the activity eating and drink-
ing were less than 2.5%, and the majority of individu-
als were able both in eating and drinking (levels A
and B).
Thirteen different types of errors were found in the
activity mobility with no tendency towards a system-
atic pattern. Thirty-seven percent of the errors (n=
38) can be explained by the fact that persons used
wheelchairs for mobility, and most of them belonged
to the stroke group (III). Moving from one floor to
another caused substantial problems in all groups.
Few persons had problems in the activity mobility
indoors among those receiving help from the social
services (I) compared to the other groups where
mobility in bed also caused problems.
In the activity going to the toilet the errors of scale
were almost 14%. Ten different types of error without
any systematic pattern were identified. The last ac-
tion, i.e. ‘‘getting to and from the bathroom’’, has a
low impact on the ordered structure of the scale
(levels B and C). As this type of mobility is different
from what is defined in mobility, action number 3
(walking or moving from one room to another), in
that it is mobility under stress (one must be able to
get to the bathroom in time), it can be of clinical
value to assess this form of mobility separately. The
definition should be more precise to indicate this
difference (see Appendix).
In the activity dressing, the errors of scale were less
than 11%. Thirty-one of the errors of scales con-
cerned persons who were able in all activities but not
in pulling on stockings or shoes, and 20 errors con-
cerned those who were disabled in all actions but not
in dressing the upper trunk.
Four actions were included in the activity personal
hygiene. The first analysis showed 32% errors of scale
in the total material. These errors were found in all
three groups and were systematically concentrated
(87%) in the last action, that is, getting to and from
the hygiene room. Furthermore, this action did not
contribute to any discrimination between ability and
disability in this activity. When this action was omit-
ted, the errors of scale were reduced to less than
When this action was excluded, three types of errors
14 U. Sonn et al.

Table II. Relati6e frequency distribution on ordered categories of actions in the acti6ities of the ADL Taxonomy
for each of the three samples (I =persons li6ing at home with home-help; II=persons from different fields of
occupational therapy; III = persons with stroke)

Categories
Range of Errors of scale
Activity catagories Group n A B C D E F G %

Eating and Drinking A–D I 678 89.1 9.6 0.1 0.4 0.7
II 373 59.5 30.0 0.5 8.6 1.3
III 226 46.5 37.6 0.9 12.8 2.2
Mobility A–G I 645 54.9 6.7 9.8 16.4 0.6 1.8 2.0 7.8
II 367 21.5 5.2 4.1 19.1 6.0 10.6 25.3 8.2
III 220 12.7 3.6 4.5 23.6 5.4 6.8 33.1 10.0
Going to the toilet A–E I 679 78.8 0.6 0.3 2.2 4.0 14.0
II 373 45.6 2.4 1.3 19.8 22.5 8.3
III 226 39.8 1.8 1.8 19.9 27.9 8.8
Dressing A–F I 631 76.7 1.0 1.6 0.3 0.3 13.6 6.5
II 367 35.1 4.6 3.0 7.4 2.2 37.3 10.3
III 220 31.4 2.7 1.4 2.3 2.7 48.6 10.9
Personal hygiene A–D I 655 50.1 4.1 30.8 11.1 3.8
II 368 26.9 3.5 42.1 22.8 4.6
III 224 18.3 2.7 41.9 31.7 5.4
Grooming A–F I 568 29.7 17.8 11.6 13.4 2.8 7.6 17.1
II 350 16.8 16.3 22.3 14.3 8.3 16.9 5.1
III 214 14.0 13.6 24.8 10.3 10.7 22.9 3.7
Communication A–F I 580 74.3 6.4 2.6 4.1 1.5 1.5 16.3
II 348 46.5 8.0 5.4 11.5 6.6 10.6 11.2
III 208 34.6 9.1 4.8 9.6 9.6 15.9 16.3
Transportation A–F I 588 0.5 0.3 13.6 8.3 57.3 15.6 4.2
II 257 4.3 0 2.3 5.1 25.7 59.9 2.7
III 195 3.1 0 1.0 1.5 21.0 71.8 1.5
Cooking A–D I 679 52.7 16.8 7.1 20.8 2.6
II 275 20.4 21.1 6.9 49.1 2.5
III 203 10.3 20.1 7.9 59.6 2.0
Shopping A–C I 662 15.5 23.0 61.0 0.4
II 261 5.4 14.6 80.0 0
III 200 3.0 7.5 89.5 0
Cleaning A–C I 663 8.4 34.1 56.9 0.6
II 259 6.6 23.5 69.9 0.4
III 199 4.5 16.6 78.9 0
Washing A–D I 656 12.6 4.7 33.5 46.2 2.9
II 249 5.6 6.4 12.4 72.7 2.8
III 195 3.6 4.1 9.7 81.5 1.0

remained and the most common of them concerned
‘‘able in all actions’’ but ‘‘disabled in washing the
body’’.
In the activity grooming, each action contributed to
a step-wise explanation of increasing ability in the
ordinal scale. The errors were low, except for 17.1%
in the sample of persons living at home with home
help, where 29% of the errors concerned ‘‘able in all
actions’’ but not in shaving/make-up. This could be
due to the fact that the action is not relevant or
necessary for all persons to perform.
In the activity communication, the number of errors
of scale was pronounced (16%) in groups I and III. In
patients with stroke and group II, most of the errors
concerned those persons who could not use the tele-
phone, whereas in group I, most of the errors of scale
were in reading. Rates for persons displaying inability
in all actions with the exception of writing were
 The ADL taxonomy — ordered categorical data 15

Table III. The acti6ities of the ADL taxonomy and the median (Md) le6el of actions within each acti6ity in three
subsamples (indi6iduals not categorized due to errors of scale are excluded)
Activity Categories Group I (Md) Group II (Md) Group III (Md)

Eating and Drinking A–D A A B

Mobility A–G A D E
Going to the toilet A–E A B D
Dressing A–F A D F
Personal hygiene A–D A C C
Grooming A–F B C C
Communication A–F A A B
Transportation A–F E F F
Cooking A–D A A D
Shopping A–C C C C
Cleaning A–C C C C
Washing A–D C D D

between 6% and 9%. It is a matter for discussion
whether the definition of writing and reading should
be changed and be more precise in the future. For
example, writing should be changed to include both
writing by hand or with a word-processor, and read-
ing could be changed to reading a message in the
form of a short newspaper article or/and a letter (see
Appendix).
In the activity transportation, the errors of scale
were small 4.2%. Ten types of errors of scale were
found, but with no systematic patterns. Few persons
had full ability in all actions. The criterion of full
ability (level A) is ‘‘driving a car/motorcycle’’, which
explains why the proportion of individuals with full
ability in all actions in this sample of elderly persons
was limited.
In the activity cooking, the errors of scale were less
than 3%, and four types of errors of scale were
identified. Most of the errors concerned those persons
who could not prepare a cold or hot meal, but could
heat up liquid or prepare food.
In the activity shopping, few errors of scale were
found, because only two actions were included in the
activity. There is a floor effect, as most of the subjects
are categorized as disabled. Accordingly, making
plans for shopping was included in the definition and
is assessed as the first action in the order (see Ap-
pendix).
In the activities cleaning and washing, the same
patterns were shown with less than 3% errors of scale
and with no systematic pattern of errors (Table II).
In conclusion, it was found that the actions within
each activity have an ordered categorical structure.
The evaluation of the errors of the ordered structure
showed that the median proportion of individuals
that did not fit into this ordered structure of all
activities and the subsamples was 4.6% (95% confi-
dence intervals 2.7 to 7.8%). As the errors of scale
showed a wide variety of patterns, combining two
central categories would not substantially decrease
the proportion of errors.
Considering the fact that this scaling evaluation is
based on heterogeneous material with regard to indi-
viduals, occupational therapists and environment, the
proportion of error of scales is acceptable. Thus, the
levels of ability in each activity have an ordered
structure and can be measured by the constructed
ordered categorical scales.
There were significant differences in the distribu-
tions of the level of ability in each activity of the
ADL taxonomy between the subsamples (pB
0.00001). The individuals in group I showed a signifi-
cantly higher level of ability in all activities compared
with the other groups (II and III) although the me-
dian levels were the same (Table III). This sample
was comprised of people living in their own homes
with home help, while the individuals in the other
groups were patients with stroke or patents with
other diagnoses from different fields of occupational
therapy.
Eating and drinking, going to the toilet, dressing
and communication were those activities that seemed
to be easiest to perform, as they were ranked in the
five highest or the five lowest relative frequencies
when full ability was assessed (level A). When full
disability was assessed, washing, cleaning, shopping,
and transportation seemed to be the most difficult
activities for all groups, as they were ranked in the
five highest or the five lowest relative frequencies.
DISCUSSION
This study has shown that there is an ordered cate-
gorical structure within each activity defined in the
ADL taxonomy. Each ordered categorical structure
was tested in three samples with a range of 1040–
16 U. Sonn et al.
1277 assessments. Furthermore, the ordered structure
is absolute, that is, no degree of freedom in the
ordered structure was allowed. Only assessments of
actual performance in daily life were included and
with a strict definition of ability according to the
manual [9, 32, 36]. This study includes three different
samples with assessments collected by occupational
therapists in their ordinary work or in their on-going
projects, from different fields of occupational therapy
and in different stages of the rehabilitation process.
This was done, however, without strict control of the
sampling procedures, which means that the evalua-
tion of the instrument is tested under difficult condi-
tions. Despite this, the results showed that the
ordered structure within the activities was stable in all
three groups studied. This indicates that the instru-
ment has good stability and might not be influenced
by external factors, and that it can be used in unstan-
daridized situations in clinical practice.
The study results are based on data from both men
and women and from different study groups in order
to obtain a general applicability. All assessments are
based on each person’s habits or roles. This indicates
that only activities that are relevant for the individual
are included in the analyses. Thus, in future research
the ADL taxonomy is suitable for use in the evalua-
tion of different patterns of ADL performance, at-
tributable, for example, to gender, diagnoses or
treatment.
The frequency distributions of ability in different
activities differed between the groups studied, persons
with stroke being more disabled than those living in
their own homes. In group II, the differences were
not so evident, as this group comprised persons with
different diagnoses collected from different areas of
the healthcare system. This indicates that the ADL
taxonomy can be used to compare different groups
and to distinguish between levels of ability within the
sample.
In all three groups, all scale steps were used, which
indicates a good discriminatory validity. In an earlier
study, the construct and content validity of the ADL
taxonomy was tested [32]. In the present study, the
content validity was confirmed further as there is an
ordered categorical level of the actions. However,
adjustment of the definitions might further improve
the validity of the ADL taxonomy.
In five activities, 10% or more of the assessments
did not fit into the ordered categorical structure, and
in the activity communication it was shown in all the
samples.
In hygiene it was obvious that the action defined
‘‘getting to and from the hygiene room’’ could not be
ordered into an ordinal scale with the other actions.
Thus, moving from one room to another is already
included in the activity mobility, and it is more logical
if this type of mobility is assessed only once to fulfil
the principles of logical correctness in the ADL tax-
onomy [41].
In the activity shopping, ‘‘make plans for shop-
ping’’ is included in the definition and is also assessed
as the first action in order to meet the new technolog-
ical development introduced for persons with disabili-
ties. For instance, technology in terms of systems for
ordering groceries has already been introduced for
elderly persons as a form of home shopping [42].
The activities included in the ADL taxonomy de-
scribe relevant areas for assessing ability and disabil-
ity within the ADL concept, and can therefore be
recommended as a general instrument as well as for
different diagnoses in occupational therapy when as-
sessing adults. How the actions are ordered and how
relevant it is to use the ADL taxonomy in children,
we do not know, but studies to investigate these
issues are in progress.
Occupation is a highly cultural concept, with
meanings of specific occupations differing with re-
spect to culture and age. Occupation refers to groups
of activities and tasks of everyday life, which are
named, organized and given value by individuals and
culture. This taxonomy has been built on an everyday
language as well as on action theory. The ordered
structure verifies that one can talk meaningfully
about actions to build up an activity [43]. Further-
more, there is logical meaning, so that each action
represents progress in ability. The findings in this
study show that the ability can be described at levels
of actions, and it is not necessary further to divide
actions into smaller measurement units. The concept
of activity can be distinguished from the concept of
function in several respects; an activity or action
means a goal directed/purposeful and intentional ac-
tion and consists of an interaction within a person/
subject and a task/object in a specific context.
Furthermore, activities and actions are performed at
the personal level in contrast to function, which is
limited to the organ level [6]. Our definition of the
concept can be identified in other common disable-
ment models either as functional limitations or dis-
abilities [44–47]. According to the models, both P-
and I-ADLs are defined at the disability level, while
parts of communication as well as mobility can be
related to both functional limitations and/or disabil-
ity level. In the ADL taxonomy, the actions are not
defined as capacities, e.g., to stand, to grip, to hear
(functional limitations), but rather as abilities defined
as intentional and voluntary actions which a person
manages in every day tasks. Our ADL taxonomy fits
well into the new versions of ICIDH-2, (International
Classifications of Impairments, Activities and Partici-

pation). The activity (A) dimension deals with a
person’s activities associated with everyday life, i.e.,
the integrated activities expected of a person as per-
formed in daily tasks. The activity dimension is
based solely on activities of the ‘‘person’’, and is
defined in the broadest sense to capture everything
that a person does at any level of complexity [48].
The A code gives a profile of an individual’s per-
formance in terms of activities from simple activi-
ties to complex ones [48: 11].
The ADL taxonomy has been developed in close
contact with occupational therapists, and is based
on the professional language they use as well as on
common everyday language [9, 29]. Thus, it is im-
portant to communicate rehabilitation outcome in
such a way that it is relevant to involve the patient
in the rehabilitation process. From this understand-
ing the patient/client can more readily formulate
his/her own goals and make priorities, thereby feel-
ing involved in and taking responsibility for the
rehabilitation process. This is a fundamental princi-
ple in occupational therapy, which is based on pa-
tient volition and interest [16, 19, 49]. Furthermore,
it is important to communicate in an easy way with
relatives as community-based rehabilitation will be-
come more common in our society. In studies of
occupational therapy practice, it is rarely of interest
to get a total score of ability. Conversely, it is more
relevant to analyse ability in relation to specific ac-
tivities, to focus on different dimensions of ability
(capability, motivation, preferences, environmental
requirements) [9, 37].
This way of defining a hierarchical conditional
scale within the ADL taxonomy gives us a valuable
instrument for group evaluations. It should be
stressed that the measurement level is ordinal within
each activity and that the different activities should
be analysed separately with appropriate statistical
methods for ordinal categorical data. A model for
analysis change within each activity of the ADL
taxonomy at group and individual level will be pre-
sented in a forthcoming paper [50].
ACKNOWLEDGMENTS
This study was supported by grants from the County
Council Association and Göteborg University, College of
Health Sciences.
REFERENCES
1. Shah S, Cooper B, Maas F. The Barthel Index and
ADL evaluation in stroke rehabilitation in Australia,
Japan, the UK and the USA. Aust Occup Ther J
1992; 39: 5–13.
The ADL taxonomy — ordered categorical data 17
2. Law M, Letts L. A critical review of scales of activi-
ties of daily living. Am J Occup Ther 1989; 43: 522–
528.
3. Eaking P. Assessment of activities of daily living: a
critical review. Br J Occup Ther 1989; 52: 11 – 15.
4. Eaking P. Problems with assessments of activities of
daily living. Br J Occup Ther 1989; 52: 50 – 54.
5. McDowell I, Newell C. Measuring health: a guide to
rating scales and questionnaires. Oxford: Oxford Uni-
versity Press, 1987.
6. Granger CV. A conceptual model for functional as-
sessment. In: Granger CV, Gresham GE, eds. Func-
tional assessment in rehabilitation medicine.
Baltimore: Williams & Wilkins, 1984; 14 – 25.
7. Bowling A. Measuring health: a review of quality of
life measurement scales. Philadelphia: Open Univer-
sity Press, 1995.
8. Wade DT. Measurement in neurological rehabilita-
tion. Oxford: Oxford University Press, 1992.
9. Törnquist K. Att fastställa och mäta förmåga i dag-
liga livets aktiviteter (ADL) (Verifying and measuring
the ability to perform activities of daily living) [disser-
tation]. Göteborg: Department of Social Work,
Göteborg University, Sweden, 1995.
10. Lundgren Pierre B, Sonn U. Occupational therapy as
documented in patients’ records. Part I. A content
analysis of occupational therapy records at an occu-
pational therapy department. Scand J Occup Ther
1996; 3: 79 – 89.
11. Baum CM, Law M. Occupational therapy practice:
focusing on occupational performance. Am J Occup
Ther 1997; 51: 277 – 288.
12. Nelson DL. Therapeutic occupation: a definition. Am
J Occup Ther 1996; 50: 775 – 782.
13. Unsworth CA. The concept of function. Br J Occup
Ther 1993; 56: 287 – 292.
14. Fisher AG. Functional measures. Part I. What is
function, what should we measure, and how should
we measure it? Am J Occup Ther 1992; 46: 183 –185.
15. Fisher AG. Functional measures. Part II. Selecting
the right test, minimizing the limitations. Am J Occup
Ther 1992; 46: 278 – 281.
16. Kielhofner G. A model of human occupation. Theory
and application, 2nd ed. Baltimore: Williams &
Wilkins, 1995.
17. Wittgenstein L. Tractatus Logico-Philosophicus 1921.
Swedish translation. Helsingborg, 1982.
18. Wittgenstein L. Filosofiska undersökningar. Stock-
holm, 1978.
19. Yerxa EJ. Seeking a relevant, ethical and realistic
way of knowing for occupational therapy. Am J Oc-
cup Ther 1991; 45: 189 – 204.
20. Stevens SS. On the theory of scales of measurement.
Science 1946; 103: 677 – 680.
21. Svensson E. Analysis of systematic and random dif-
ferences between paired ordinal categorical data [dis-
sertation]. Göteborg: Göteborg University, Sweden,
1993.
22. Merbitz C, Morris J, Grip JC. Ordinal scales and
foundations of misinference. Arch Phys Med Rehabil
1989; 70: 308 – 312.
23. Silverstein B, Fisher WP, Kilgore KM, Harley JP,
Harvey RF. Applying psychometric criteria to func-
tional assessment in medical rehabilitation: I. Explor-
ing unidimensionality. Arch Phys Med Rehabil 1991;
72: 631 – 637.
18 U. Sonn et al.
24. Silverstein B, Fisher WP, Kilgore KM, Harley JP,
Harvey RF. Applying psychometric criteria to func-
tional assessment in medical rehabilitation: II. Defin-
ing interval measures. Arch Phys Med Rehabil 1992;
73: 507–518.
25. Rogers JC. Elinor Clarke Slage Lectureship 1983;
clinical reasoning: the ethics, science and art. Am J
Occup Ther 1983; 37: 601–616.
26. Thornton G, Rennie H. Activities of daily living: an
area of occupational therapy expertise. Aust Occup
Ther J 1988; 35: 49–58.
27. Yerxa EJ. Research in occupational therapy. In:
Willard & Spackman’s Occupational Therapy. Hop-
kins HL, Smith HD, editors. 7th ed. Philadelphia: JP
Lippincott, 1988; 171–177.
28. Lysett R. Well, what is occupational therapy? An
examination of the definition given by occupational
therapists. Br J Occup Ther 1991; 54: 411–414.
29. Sonn U, Lundgren Pierre B, Klippe Németh A. Att
beskriva ADL: en undersökning av vilka ord arbet-
sterapeuter vanligtvis använder när de dokumenterar
ADL. [To describe ADL. A study of the words occu-
pational therapists commonly use in documentation
of ADL). Arbetsterapeuten 1993; 11: 16–21.
30. Halpern AS, Fuhrer MJ, editors. Functional assess-
ment in rehabilitation. London: Paul H Brookes,
1984.
31. Smith RO. The science of occupational therapy as-
sessment. Occup Ther J Res 1992; 12: 3–15.
32. Törnquist K, Sonn U. Towards an ADL taxonomy
for occupational therapists. Scand J Occup Ther
1994; 1: 69–76.
33. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe
MW. Studies of illness in the aged. The Index of
ADL: a standardized measure of biological and psy-
chosocial function. J Am Med Ass 1963; 185: 914 –
919.
34. Lawton MP. The functional assessment of elderly
people. J Am Geriatr Soc 1971; 19: 465–481.
35. Østerberg D. Tolkande sociologi. Göteborg: Bokför-
laget Korpen, 1989.
36. Sonn U, Törnquist K. ADL-taxonomi: analys av
ADL-förmåga. Nacka; Förbundet Sveriges Arbetster-
apeuter, 1993.
37. Borell L, Lilja M, Carlsson-Alm S, Törnquist K.
Community-based occupational therapy: a study of
elderly people with home help in a social-welfare dis-
trict in Stockholm. Scand J Occup Ther 1995; 2:
138–144.
38. Selander E. Redovisning av social -och neurorehabili-
tering. Uppföljning av slaganfallspatienter inom A8 del.
O8 rebro Läns Landsting, 1996.
39. Siegel S, Castellan NJ. Nonparametric statistics for
the behavioral sciences, 2nd ed. New York: McGraw
Hill, 1988.
40. Holm S. A simple sequentially rejective multiple test
procedure. Scand J Statist 1979; 6: 65 – 70.
41. Laserfeld PF, Barton AH. Qualitative measurement in
social sciences: classification, typologies, and indices.
In: Lerner D, Lasswell HD, eds. The policy sciences.
Standford: University Press, 1951.
42. O8 stlund B. Gammal är äldst: en studie av teknik i
äldre människors liv [dissertation]. Institute of Tema
Research, Linköping University, Sweden, 1995.
43. Haglund L, Henriksson C. Activity — from action to
activity. Scand J Caring Sci 1995; 9: 227 – 234.
44. Nagi SZ. The disabled and rehabilitation services: a
national overview. Am Rehabil 1977; 2: 26 – 33.
45. World Health Organization: International classifica-
tion of impairments, disabilities, and handicaps: a
manual of classification relating to the consequences
of disease. World Health Organization, Geneva, 1980.
46. Verbrugge LM, Jette A. The disablement process. Soc
Sci Med 1994; 38: 1 – 14.
47. Nordenfelt L. On the notions of disability and handi-
cap. Scand J Soc Welfare 1993; 2: 17 – 24.
48. ICIDH-2: International classification of impairments,
activities and participation: a manual of dimensions
of disablement and health. htpp://www.who.ch/pro-
grammes/mnh/mnh/ems/icidh/introduction.htm, 12th
Aug, 1997.
49. Enabling occupation: an occupational therapy per-
spective. CAOT, 1997, Ottowa, Ontario.
50. Sonn U, Törnquist K, Svensson E. Analysis of
change in ADL performance measured by the ADL-
taxonomy (in manuscript).
Accepted July 14, 1998
Address for correspondence:
Ulla Sonn
Göteborg University, College of Health and Caring
Sciences
Department of Rehabilitation
P.O. Box 111
SE-405 30 Göteborg
Tel:+ 46 31 773 57 33
Fax: +46 31 773 57 23
E-mail: ulla.sonn@ufhs-gu-se
 The ADL taxonomy — ordered categorical data 19

APPENDIX A: Operational definitions of activities and actions included in the ADL taxonomy. Adjustments
in the definitions are printed in italics

ACTIVITIES ACTIONS

Eating and drinking
Defined as getting food from the table, to eat
and drink. The activity comprises the following
actions:
Mobility
Defined as goal-directed mobility of the body
from one place to another. The activity
comprises the following actions:
Going to the toilet
Defined as getting to the toilet room in time and
performing the necessary elimination. The
activity comprises the following actions:
Dressing
Defined as getting the necessary clothes and
shoes, dressing and undressing. The activity
comprises the following actions:
1. Eating, that is, getting food from a plate or
equivalent into one’s mouth and eating
2. Drinking, that is, getting the liquid from a
glass or cup or equivalent into one’s mouth and
drinking
3. Getting food and liquid and cutting
up/preparing food
1. Transfer in bed, that is, changing positions,
turning over and sitting up
2. Transferring the body from bed to chair or
between two chairs
3. Walking or moving from one room to
another (the same floor)
4. Walking or moving from one floor to another
5. Walking or moving in and out of the house
6. Walking or moving in the neighbourhood
1. Bowel and urine elimination volitional
2. Getting on and off the toilet and cleaning
one’s self after elimination
3. Arranging clothes and equipment such as
pads and sanitary towels, washing hands
4. Getting to and from the toilet room in time
1. Undressing
2. Dressing upper trunk
3. Dressing lower trunk
4. Pulling on stockings/pantyhose/shoes
5. Getting necessary clothes from closets and
drawers

Personal hygiene 1. Washing hands and face

Defined as (getting to and from the hygiene 2. Washing body/bathing/showering
room) washing hair and body and getting dry. 3. Washing one’s hair
The activity comprises the following actions: (4. getting to and from the hygiene room)

Grooming 1. Combing one’s hair

Defined as other hygiene activities concerning 2. Brushing teeth
one specific part of the body. The activity 3. Shaving/make-up
comprises the following actions: 4. Manicuring
5. Pedicuring
20 U. Sonn et al.

Communication
Defined as transferring information between a 1. Calling for attention/communicate
transmitter and a receiver and managing actual 2. Taking part in a conversation
equipment. The activity comprises the following 3. Using the telephone
actions: 4. Reading
5. Writing by hand and/or using a
word-processor

Transportation 1. Going by car

Defined as getting to, in and out of public or 2. Going by bus/tram/tube
private transportation. The activity comprises 3. Going by train, boat/aeroplane
the following actions: 4. Riding bicycle/moped
5. Driving car/motorcycle

Cooking 1. Preparing a cool meal

Defined as planning, and taking out equipment, 2. Heating up liquid or prepared food
preparation, cooking, laying the table and washing 3. Cooking a hot meal
the dishes. The activity comprises the following
actions:

Shopping 1. Making plans for shopping

Defined as making plans for shopping, getting (shoppinglist/order)
to the store, taking out groceries, paying for them 2. Daily or small quantity shopping in
and bringing them home. The activity comprises the neighbourhood shop
following actions: 3. Weekly or large quantity shopping

Cleaning 1. Daily light cleaning

Defined as light cleaning= making the bed, ‘‘clearing 2. Weekly heavy cleaning
away/tiding up’’, wiping off, dusting;
heavy cleaning= vacuum cleaning/washing floors, washing
toilet- and bathroom. The activity comprises the following
actions:
Washing 1. Light washing by hand
Defined as transportation of laundry to and from 2. Light washing in washing machine
the washing place, sorting, washing up, hanging 3. Heavy washing in washing machine (e.g.
up, folding up/ironing/mangling the laundry. The sheets)
activity comprises the following actions:
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