TRAA: About the Card Game
joan burlingame, CTRS, ABDA, HTR
Question: My residents are having trouble seeing the cards in the TRAA? Am I allowed to use different cards so they can be distinguished more easily?
Idyll Arbor, Inc. acquired the Therapeutic Recreation Activity Assessment (TRAA) about five or so years ago from Mary Ann Keogh Hoss. We felt that she had done an outstanding job developing the constructs of the TRAA, had demonstrated good inter-rater reliability and was able to draw meaningful data from the results.
The original cards used with the TRAA (the ones seen in the training video) were problematic for us for two reasons. First, they could not be duplicated with good color quality, which is important for the test's construct reliability. (One of the test's strength is that everyone uses the exact same materials; the ball is the same size, the cards as consistent color and weight, the board is washable, the basketball hoop a standard size, and the wood chips the same size within a reasonable tolerance). The second, and most significant problem for me with the pictures, was that they all came from a white, Christian cultural background. Many of my clients did not come from the same cultural background.
When the clinicians at Idyll Arbor began to look for a replacement for the cards (with consultation from Mary Ann), we decided to use old fashioned post cards whose theme was old time advertising. We were able to buy hundreds of each print and carefully selected for a range of colors and shapes on the cards to allow individuals with some visual impairment multiple cues to tell the cards apart. The TRAA has sold far better than we first anticipated and we found that our ten year supply of cards ran out in four years. When we contacted the company which made our original post cards, we found that some of the cards had gone out of print. So our clinical staff went back to the "drawing board" to establish another set of post cards for the TRAA. We used the same criteria as the first time, carefully picking pictures which offered the various characteristics we wanted. We purposely selected post cards from the same general topic (top 1000 best known paintings).
This detail about why we have the cards we do today may not be of interest to you. What is important is for you to know that each picture post card was carefully chosen for specific attributes. Some time in the future, the TRAA, after further research, should be able to give us even more detail about patient function because the pictures were so carefully chosen.
If some of the pictures are too dark for your residents, this observation is a clinically significant finding! First check to see if your lighting is too low. (100 watt bulbs, while not approved for new household lamps, should be okay in industrial lamps.) Florescent lighting may not be enough for the eyes of a person who is older. If your residents cannot see the pictures because the pictures are too dark, I would ask their physician to check for cataracts. Not being able to see the pictures is a true physical impairment, one which should be noted as a result of the test. All programming for clients who cannot see the pictures because the pictures are too dark needs to have the environment adapted for them (e.g., better lighting). This should be written right into their care plan.
The matching of the post cards to the post cards on the board (the matching game) has several significant functional skills which are being measured. First, the therapist can observe whether the client is aware it is his/her turn, or if s/he needs cueing. If s/he needs cueing, what type of cueing is needed? Also, does the client need cueing the second time around? When the client picks up the post card, what type of grasp does s/he use? (You can find pictures of the different types of grasps in the Assessment Tools for Recreational Therapy, Red Book 1, Second Edition on page 37.) Does the client actually turn over the card and look at the picture, or does s/he look at the back of the card? The instructions in the video tape show the therapist demonstrating and verbally explaining the task one time. This task involves a three step command.
Here are some of the observations you can make about clients during the card game that will help you understand what will be required for developing a program for this client. Can the client remember all three steps and carry them out in order, as requested? Does the client learn from the other clients who are also playing the matching game, or does their performance confuse the client? How does this impact his/her performance the second time around? Does the client demonstrate good control (both fine motor and gross motor) of his/her upper body during this three step task? Does the client demonstrate appropriate motor quietness while waiting for his/her turn, or does the client exhibit extra motor behavior? Is the client able to wait for his/her turn? What type of social communication does the client exhibit during the matching game?