Activity Card Sort NL

1. Abstract

The Activity Card Sort Netherlands (ACS-NL) is an ecologically valid, client-centered occupational therapy assessment instrument adapted specifically for Dutch older adults and clinical populations. Rooted in the original American assessment developed by Dr. Carolyn Baum and further refined with Dorothy Edwards, the ACS-NL was culturally adapted and psychometrically validated by Fenna van Nes and Alice Jong (2013). The instrument assesses an individual’s occupational participation, engagement patterns, and longitudinal activity loss across instrumental, leisure, and social domains. By utilizing photographic sorting cards depicting real-world life tasks, the ACS-NL bypasses verbal memory constraints and communication barriers, enabling respondents to classify activities into structured behavioral categories.

The ACS-NL measures engagement across four primary domains: Instrumental Activities of Daily Living (IADL), divided into tasks necessary to maintain oneself and tasks necessary to maintain one’s home and property; Low-Physical-Demand Leisure Activities; High-Physical-Demand Leisure Activities; and Social Activities. Consisting of photographic sorting cards representing culturally tailored occupational tasks in the Netherlands, the assessment is administered via three contextual sorting protocols: the Institutional Version (Form A), the Recovering Version (Form B), and the Community Living Version (Form C). Respondents categorize cards based on whether they currently perform the task, performed it prior to illness or aging, do it less often, or have given it up entirely. The scoring system yields a continuous metric termed the percentage of retained activities, calculated both globally and across subscales.

Psychometric evaluations demonstrate robust properties. The ACS-NL demonstrates high test-retest reliability across clinical and community cohorts (intraclass correlation coefficients ranging from 0.82 to 0.94) and strong internal consistency across its domain categories (Cronbach’s alpha between 0.79 and 0.91). Evidence for construct, convergent, and discriminant validity confirms its sensitivity in differentiating between healthy community-dwelling seniors and individuals experiencing neurocognitive disorders, stroke, or chronic physical impairments. Consequently, the ACS-NL serves as a vital diagnostic and intervention planning instrument within geriatric rehabilitation, neurorehabilitation, and occupational science.

2. Keywords

Activity Card Sort NL, occupational therapy, occupational participation, instrumental activities of daily living, leisure activities, social participation, geriatric assessment, rehabilitation outcome measures, client-centered care, psychometrics

3. Authors

The development and cross-cultural validation of the Activity Card Sort and its specific Dutch adaptation involve key researchers in occupational therapy, rehabilitation science, and geriatric health:

• Carolyn M. Baum, PhD, OTR/L, FAOTA: Professor of Occupational Therapy, Neurology, and Social Work at the Washington University School of Medicine in St. Louis, Missouri, United States. Dr. Baum originated the Activity Card Sort (1995, 2001) as a clinical tool to assess activity engagement in individuals with cognitive decline and Alzheimer’s disease.
• Dorothy F. Edwards, PhD: Professor of Kinesiology and Medicine (Neurology) at the University of Wisconsin-Madison, United States. Co-developer of the standardized second edition of the Activity Card Sort (ACS, 2001).
• Fenna van Nes, PhD, OT: Senior Researcher and Occupational Therapy Scholar, Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences (Hogeschool van Amsterdam), Amsterdam, Netherlands. Lead developer of the cross-cultural adaptation, translation, and standardization of the ACS-NL (2013).
• Alice Jong, MSc, OT: Occupational Therapist, Educator, and Researcher, Faculty of Health, Amsterdam University of Applied Sciences (Hogeschool van Amsterdam), Amsterdam, Netherlands. Co-developer of the Dutch cultural adaptation and psychometric validation protocol (2013).

4. Purpose

The Activity Card Sort NL is designed to provide a comprehensive, objective, and clinically rich inventory of an individual’s engagement in daily life activities. The primary objective is to evaluate how an individual’s occupational repertoire changes across the lifespan as a result of healthy aging, acute trauma (e.g., cerebrovascular accidents, traumatic brain injury), or progressive chronic diseases (such as Parkinson’s disease, multiple sclerosis, or dementia). Within rehabilitation medicine and occupational therapy, quantitative measurements often focus narrowly on basic activities of daily living (BADLs), such as dressing, eating, or personal hygiene. While BADLs are fundamental to basic survival, they fail to capture the holistic scope of human occupation, personal identity, and psychological well-being. The ACS-NL bridges this gap by systematically evaluating instrumental activities, social engagement, and leisure pursuits.

From a clinical perspective, the ACS-NL functions as a shared-decision-making and goal-setting platform. Rather than subjecting clients to passive, abstract interview questionnaires or lengthy behavioral checklists, the ACS-NL employs visual, photographic prompts. The client handles physical cards, sorting them according to their current lived experience. This methodology provides crucial clinical insights into:

• Identifying personal activities that have been preserved, modified, or discontinued due to physical, sensory, or cognitive decline.
• Formulating client-centered, individualized rehabilitation goals directly derived from the occupations the individual wishes to resume or maintain.
• Establishing a quantitative baseline of activity participation, enabling clinicians to objectively track therapeutic efficacy and functional recovery over longitudinal rehabilitation trajectories.
• Providing a structured medium for individuals with language or cognitive deficits—such as expressive aphasia or executive dysfunctions—to express personal occupational histories and aspirations without facing excessive linguistic or working memory barriers.

In scientific research, the ACS-NL provides a standardized outcome measure for clinical trials investigating geriatric lifestyle interventions, occupational therapy programs, neurorehabilitation approaches, and social prescribing initiatives. Occupational science posits that meaningful activity participation is an essential determinant of subjective well-being, cognitive resilience, and overall health-related quality of life. The ACS-NL operationalizes this construct into an empirical, reliable metric: the retained activity score. This metric allows researchers to analyze patterns of occupational disruption, assess the relationship between functional impairment and social participation, and measure the broader impact of chronic conditions on community integration.

5. Psychological Construct

The core construct evaluated by the Activity Card Sort NL is occupational participation, defined within the International Classification of Functioning, Disability and Health (ICF) framework as involvement in life situations and engagement in culturally meaningful everyday activities. The ACS-NL captures occupational participation across several multidimensional subscales:

Instrumental Activities of Daily Living (IADL)

Instrumental activities encompass complex daily tasks that require higher-level cognitive, physical, and organizational skills than basic self-care. In the ACS-NL, IADL tasks are organized into two key operational categories:

• Self-Maintenance IADLs: Tasks required to maintain personal independence and direct physical survival within community environments. Examples include managing personal finances, paying household bills, sorting and taking medications, shopping for personal groceries, and navigating public transportation or driving.
• Environmental/Property Maintenance IADLs: Tasks focused on maintaining one’s living space, immediate social environment, and material possessions. Examples include preparing complex meals, performing routine household cleaning, doing laundry, carrying out minor home maintenance, and caring for household pets or plants.

Low-Physical-Demand Leisure Activities

This dimension encompasses non-obligatory, recreational pursuits that do not require intense physical exertion, cardiovascular fitness, or vigorous motor output. These sedentary or light-energy activities frequently provide cognitive stimulation, creative expression, and emotional relaxation. Typical examples in the Dutch version include reading books or newspapers, solving crossword puzzles, knitting, playing board or card games, watching television or films, engaging in light handcrafts, and using a computer for hobby-related interests.

High-Physical-Demand Leisure Activities

This subscale encompasses active recreational pursuits that require sustained physical endurance, cardiovascular effort, gross motor coordination, and physical stamina. Participation in high-demand leisure is closely linked to physical functional capacity, fall risk, and biological vitality in older adults. Specific examples include bicycling (a pervasive, culturally essential activity in the Netherlands), lap swimming, fitness training, hiking, gardening (involving heavy physical labor), bowling, and dancing.

Social Activities

The social dimension measures an individual’s active engagement with broader social networks, community institutions, friends, and family. Empirical research consistently indicates that social participation is an independent predictor of longevity, cognitive protection, and psychological resilience in older adults. In the ACS-NL, social activities include hosting dinner guests, visiting family or grandchildren, attending church or community meetings, volunteering for charitable organizations, dining out at restaurants, participating in clubs, and traveling on day trips with peers.

6. Theoretical Framework

The Activity Card Sort NL is grounded in established models of occupational therapy and ecological psychology. Its theoretical foundation draws heavily upon two primary frameworks: the Person-Environment-Occupation-Performance (PEOP) Model and the Model of Human Occupation (MOHO).

The Person-Environment-Occupation-Performance (PEOP) Model

Developed by Carolyn Baum and Charles Christiansen, the PEOP Model is a client-centered systems model that views occupational performance and participation as the dynamic outcome of reciprocal interactions between four key components:

• Person (P): The internal neurobehavioral, physiological, cognitive, psychological, and spiritual factors unique to the individual.
• Environment (E): The physical, cultural, socio-economic, and built environments that either facilitate or restrict occupational behavior.
• Occupation (O): The meaningful, goal-directed activities, tasks, and roles that individuals engage in across the life course.
• Performance (P): The actual enactment of occupations leading to active participation and subjective well-being.

The ACS-NL directly operationalizes the PEOP framework. When disease or aging impacts the Person factors (such as cognitive decline following a stroke or motor limitations from osteoarthritis), the harmony within the person-environment-occupation nexus is disrupted. The ACS-NL allows clinicians and researchers to isolate and quantify the occupational consequences of this disruption by examining which activities have been retained, altered, or abandoned, and how environmental adaptations can restore occupational balance.

The Model of Human Occupation (MOHO)

Formulated by Gary Kielhofner, the Model of Human Occupation conceptualizes human beings as open, dynamic systems that continuously adapt through three interconnected subsystems: volition (the motivation for occupation, guided by personal values, interests, and personal causation), habituation (the organization of occupational behavior into recurring daily routines and social roles), and performance capacity (the underlying mental and physical abilities needed for action). The card-sorting format of the ACS-NL assesses the individual’s habituation and volition. By presenting photographs of concrete activities, the tool prompts respondents to reflect on their occupational identity—the composite sense of who one is and wishes to become through their occupations.

Cultural Adaptation Paradigm

The theoretical necessity of the Dutch adaptation (ACS-NL) is grounded in cross-cultural occupational science. Occupations are culturally embedded phenomena; the daily activities of community-dwelling older adults in the United States do not fully align with those of older adults in the Netherlands. Everyday transportation, leisure pursuits, culinary traditions, and social conventions vary substantially. For instance, cycling is an essential mode of daily utilitarian transport and social life in the Netherlands, carrying different functional and cultural weight compared to suburban American car-dependent environments. Van Nes and Jong (2013) adapted the card deck by systematically substituting culturally incongruous activities with authentic Dutch occupational practices, ensuring high ecological and content validity.

7. Validity

The validity of the Activity Card Sort NL has been examined across several methodological frameworks to ensure that its photographic items accurately measure occupational participation in Dutch populations.

Content and Face Validity

The cross-cultural development of the ACS-NL followed rigorous translation and adaptation guidelines. Van Nes and Jong (2013) engaged expert panels comprising occupational therapy clinicians, researchers, and community-dwelling older adults. An initial pool of activity items underwent cultural screening to eliminate non-relevant American activities (such as playing baseball or specific home maintenance tasks uncommon in Dutch housing) and to integrate common Dutch activities (such as specific board games, local public transit use, regional gardening tasks, and cycling). Photographs were staged and captured within typical Dutch domestic and community settings to ensure authentic visual representation. The resultant card set achieved strong face validity, as older adults reported that the photographs were instantly recognizable, culturally authentic, and accurately reflected their daily lives.

Construct and Convergent Validity

Construct validity for the ACS-NL has been supported by evaluating correlations with standardized instruments measuring functional independence, cognitive status, and quality of life. The ACS-NL percentage of retained activities correlates significantly with:

• Canadian Occupational Performance Measure (COPM): Moderate-to-high positive correlations (r = 0.54 to 0.68, p < 0.001) with both performance and satisfaction scales, demonstrating that retained activities align with subjective functional performance and self-rated satisfaction.
• Barthel Index (BI): Significant positive correlations (r = 0.42 to 0.58) in inpatient and post-acute rehabilitation cohorts, indicating that basic functional independence supports broader community activity retention.
• Functional Independence Measure (FIM): Moderate positive correlations (r = 0.46 to 0.61) with the FIM motor and cognitive subscales.
• Short Form-36 Health Survey (SF-36): Moderate positive associations with the Physical Functioning (r = 0.52) and Social Functioning (r = 0.48) subscales, demonstrating that physical and social well-being correspond directly to activity retention.

Discriminant and Known-Groups Validity

Known-groups comparisons demonstrate the instrument’s capacity to differentiate between distinct functional cohorts. Studies indicate statistically significant differences (p < 0.001) in the percentage of retained activities between:

• Healthy community-dwelling older adults (mean retained activity percentage typically exceeding 80–85%).
• Individuals living in the community after a stroke or with mild neurocognitive impairment (retained activity levels frequently dropping to 50–65%).
• Individuals residing in assisted living or residential nursing facilities (retained activity levels often falling below 40%).

These findings demonstrate that the ACS-NL is sensitive to the functional disruption caused by acute clinical events, chronic degenerative conditions, and institutional placement.

8. Reliability

The psychometric evaluation of the Activity Card Sort NL confirms high reliability across clinical and community settings.

Test-Retest Reliability

Test-retest stability was evaluated by administering the ACS-NL to stable cohorts across a 7-to-14-day interval. Because daily activity repertoires are generally stable over short durations in the absence of acute health changes, high temporal stability is expected:

• Total Score: The overall percentage of retained activities demonstrated excellent stability, with intraclass correlation coefficients (ICC) typically ranging between 0.88 and 0.94 (p < 0.001).
• IADL Subscale: ICC values consistently range from 0.84 to 0.91.
• Leisure Subscales: Low-physical leisure demonstrated ICCs between 0.82 and 0.88; high-physical leisure yielded ICCs between 0.85 and 0.92.
• Social Subscale: ICC values ranged from 0.80 to 0.87, reflecting acceptable temporal stability despite occasional weekly fluctuations in social calendars.

Internal Consistency

Although the ACS-NL is a broad behavioral checklist rather than a unidimensional psychometric scale, internal consistency calculations across the subscale domains reveal acceptable to high Cronbach’s alpha coefficients:

• Instrumental Activities of Daily Living: Cronbach’s α = 0.83 to 0.89
• High-Physical-Demand Leisure: Cronbach’s α = 0.80 to 0.86
• Low-Physical-Demand Leisure: Cronbach’s α = 0.74 to 0.81
• Social Activities: Cronbach’s α = 0.78 to 0.84
• Total Scale: Cronbach’s α = 0.89 to 0.93

Inter-Rater Reliability

Because the ACS-NL relies on photographic sorting and objective mathematical scoring formulas rather than subjective clinician interpretation, inter-rater reliability is exceptionally high. When two independent therapists score identical sorting distributions from recorded sessions, ICCs consistently exceed 0.96.

9. Factor Analysis

Structural evaluations of the original Activity Card Sort and its cultural adaptations, including the ACS-NL, have examined the construct validity of its domain categorization using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

Exploratory Factor Analysis (EFA)

Early factor analyses of the ACS card inventory typically employed principal component analysis (PCA) with varimax rotation to examine activity clustering. While the tool was originally constructed based on clinical consensus into IADL, low-demand leisure, high-demand leisure, and social domains, empirical factor solutions frequently identify 4 to 5 major underlying dimensions that closely mirror these conceptual groupings:

• Factor 1: High Physical/Recreational Demand (accounting for 18–24% of the total variance; high factor loadings [0.55–0.82] for cycling, swimming, heavy yard work, and long-distance walking).
• Factor 2: Domestic & Household Management (IADLs) (accounting for 14–19% of variance; loadings [0.50–0.78] for cooking, cleaning, laundry, and grocery shopping).
• Factor 3: Passive/Sedentary Cognitive Pursuits (accounting for 10–14% of variance; loadings [0.48–0.75] for reading, watching television, listening to music, and needlework).
• Factor 4: Interpersonal & Community Engagement (accounting for 8–12% of variance; loadings [0.45–0.72] for hosting gatherings, attending community groups, dining out, and visiting relatives).

Confirmatory Factor Analysis (CFA)

Confirmatory factor analyses evaluating the theoretical 4-factor model have demonstrated acceptable to good model fit across clinical rehabilitation cohorts, particularly when allowing for residual covariances among items within the same environmental domain (e.g., related household cleaning tasks). Representative fit indices from structural analyses include:

• Comparative Fit Index (CFI): Values between 0.91 and 0.95, indicating acceptable comparative model fit.
• Tucker-Lewis Index (TLI): Values between 0.90 and 0.94.
• Root Mean Square Error of Approximation (RMSEA): 0.048 to 0.058 (90% CI [0.042, 0.064]), well below the standard 0.08 cutoff indicating good parameter fit.
• Standardized Root Mean Square Residual (SRMR): 0.051 to 0.062.

Item loadings across target factors generally range from 0.45 to 0.81. Items with lower loadings (below 0.40) typically reflect activities that bridge multiple categories—such as volunteering, which combines social participation with high organizational or physical demands.

10. Instrument / Measurement Tool

The Activity Card Sort NL consists of structured photographic sorting cards, standardized sorting category labels, and a dedicated scoring matrix:

• Assessment Type: Performance-based visual card-sorting interview; clinician-administered or self-administered under clinician guidance.
• Target Population: Community-dwelling older adults, individuals undergoing physical or neurological rehabilitation (e.g., post-stroke, traumatic brain injury), and individuals with mild-to-moderate neurocognitive disorders.
• Administration Modality: Standardized physical cards (or authorized digital adaptations). Each card features a monochrome or color photograph depicting an adult performing an activity in a typical Dutch environment, with a concise descriptive label printed underneath in Dutch.
• Administration Forms:
  • Form A (Institutional Version): Used when the client resides in a nursing home, assisted living, or long-term inpatient facility. Cards are sorted into: Done prior to illness/admission vs. Done since admission.
  • Form B (Recovering Version): Designed for individuals recovering from an acute medical event, surgery, or active rehabilitation phase. Cards are sorted into categories reflecting pre-injury performance versus current status.
  • Form C (Community Living Version): Used with community-dwelling older adults to map general occupational trajectories across the lifespan.
• Sorting Categories (Form B/C standard):
  • Never Did / Niet van toepassing: The client has never participated in this activity during their adult life. (Excluded from the scoring denominator).
  • Continue to Do / Doe ik nog steeds: The client currently performs the activity at the same frequency and engagement level as before. (Scored as 1.0).
  • Do Less / Doe ik minder: The client continues to perform the activity, but at a reduced frequency, duration, or intensity. (Scored as 0.5).
  • Gave Up / Gestopt: The client participated in the activity in the past but has completely discontinued it due to health, environmental, or social changes. (Scored as 0.0).
  • New Activity / Nieuwe activiteit: Activities initiated recently or since the onset of impairment. (Added to the retained activity numerator).
• Scoring Algorithm:
  • The clinician sums the numeric scores for current participation (1.0 for each current activity, 0.5 for each “do less” activity, and 1.0 for each new activity) to yield the Current Activity Sum.
  • The Previous Activity Sum is calculated by tallying all activities previously engaged in (current + do less + stopped). Activities categorized under Never Did are excluded entirely from both the numerator and denominator.
  • The core metric, the Percentage of Retained Activities, is calculated using the formula:
    
    Percentage Retained = (Current Activity Sum / Previous Activity Sum) × 100
  • Scores can be calculated as a global composite metric (0–100%) and broken down across the individual subscales: Instrumental Activities of Daily Living, Low-Physical Leisure, High-Physical Leisure, and Social Activities.

11. Permissions & Fee and Test Year

• Year of Initial Release: The original American Activity Card Sort was introduced by Carolyn Baum in 1995, followed by the standardized 2nd Edition (Baum & Edwards) in 2001. The Dutch version (ACS-NL) was published and validated by Fenna van Nes and Alice Jong in 2013.
• Copyright & Intellectual Property: The original ACS is copyrighted by the American Occupational Therapy Association (AOTA) and Washington University in St. Louis. The Dutch cultural adaptation (ACS-NL) is protected under copyright by the adapting authors (van Nes & Jong) and their collaborating publishing partners/academic institutions (including the Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences).
• Licensing & Access: The complete manual, photographic card sets, sorting labels, and score sheets are proprietary clinical instruments. They must be purchased through authorized occupational therapy distributors or university research portals. They are not freely distributed in the open public domain. Qualified healthcare professionals (occupational therapists, clinical neuropsychologists, geriatricians) may purchase and utilize the instrument in clinical practice and clinical research protocols.

12. References

• Baum, C. M. (1995). The Activity Card Sort. Washington University School of Medicine, St. Louis, MO.
• Baum, C. M., & Edwards, D. F. (2001). Activity Card Sort (ACS): Test manual. Washington University School of Medicine, St. Louis, MO.
• Baum, C. M., & Edwards, D. F. (2008). Activity Card Sort (ACS): 2nd Edition. AOTA Press.
• Christiansen, C. H., Baum, C. M., & Bass, J. D. (Eds.). (2014). Occupational therapy: Performance, participation, and well-being (4th ed.). SLACK Incorporated.
• Edwards, D. F., Hahn, M., & Baum, C. (2006). The Activity Card Sort with stroke survivors: A measure of participation. American Journal of Occupational Therapy, 60(4), 386–394. https://doi.org/10.5014/ajot.60.4.386
• Kielhofner, G. (2008). Model of human occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins.
• van Nes, F., & Jong, A. (2013). Handleiding Activity Card Sort – Nederland (ACS-NL). Hogeschool van Amsterdam, Domein Gezondheid, Opleiding Ergotherapie.
• van Nes, F., Jonsson, H., Hirsch, F., & Depla, M. (2012). Language, culture, and occupational participation: The process of adapting the Activity Card Sort for the Netherlands. Scandinavian Journal of Occupational Therapy, 19(4), 365–374. https://doi.org/10.3109/11038128.2011.603352
• World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). World Health Organization.

13. Items of the Scale