Assessment of Communication and Interaction Skills

1. Abstract

The Assessment of Communication and Interaction Skills (ACIS) is an observational, performance-based clinical measurement tool designed to evaluate an individual’s interpersonal and communicative capabilities within meaningful social contexts. Developed within the conceptual framework of the Model of Human Occupation (MOHO), the ACIS assesses how well a person performs routine communication actions necessary for social engagement, collective occupation, and communal integration. The instrument comprises 20 discrete communication and interaction skills categorized across three developmental and functional domains: Physicality (6 items: Contacts, Gazes, Gestures, Maneuvers, Orients, Postures), Information Exchange (9 items: Articulates, Asserts, Asks, Engages, Expresses, Modulates, Shares, Speaks, Sustains), and Relations (5 items: Collaborates, Conforms, Focuses, Relates, Respects).

Measurement utilizes an authentic 4-point rating scale denoting functional occupational competence: 4 (Competent), 3 (Questionable), 2 (Ineffective), and 1 (Deficit). This scoring paradigm reflects the degree to which observed behaviors support or disrupt the ongoing stream of interpersonal interaction. Extensive psychometric evaluations utilizing both classical test theory (CTT) and Rasch analysis (Many-Facet Rasch Measurement) confirm that the ACIS demonstrates robust structural validity, high inter-rater calibration, acceptable internal consistency across domains (Cronbach’s alpha ranging from .87 to .94), and exceptional sensitivity to changes resulting from therapeutic interventions. The instrument is widely applied across psychiatric, neurorehabilitation, geriatric, and pediatric populations to inform occupational formulation, establish intervention baselines, and evaluate client-centered communicative progress.

2. Keywords

Assessment of Communication and Interaction Skills, ACIS, Model of Human Occupation, MOHO, observational assessment, communication competence, interpersonal interaction, occupational therapy, Rasch measurement, social participation, psychosocial rehabilitation, occupational performance.

3. Authors

The Assessment of Communication and Interaction Skills was originally conceptualized, developed, and validated by:

• Kirsty Forsyth, Ph.D., OTR, FAOTA — Professor of Occupational Therapy and Director of the Center for Person-Centered Practice Research at Queen Margaret University, Edinburgh, United Kingdom; formerly research collaborator with the MOHO Clearinghouse, University of Illinois at Chicago.
• Melanie Salamy, MS, OTR/L — Clinical specialist in psychosocial occupational therapy and clinical researcher, University of Illinois at Chicago.
• Simon Simon, MS, OTR/L — Research associate and occupational therapist affiliated with the Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago.
• Gary Kielhofner, DrPH, FAOTA (1949–2010) — Former Professor and Wade-Meyer Endowed Chair, Department of Occupational Therapy, University of Illinois at Chicago; primary architect and founder of the Model of Human Occupation.

Dutch Standardization and Translation Authors:

• Project Group 1 (2001): M. Moesker, P. van Riet.
• Project Group 2 (2001): T. van Dijken, M. Leusink, I. Vromen.

Inquiries regarding international clearing, authorized manual dissemination, and advanced assessment training are coordinated via the Model of Human Occupation Clearinghouse, Department of Occupational Therapy, University of Illinois at Chicago.

4. Purpose

Human beings are intrinsically occupational and social entities; daily activities, from vocational duties to shared community living, occur within social groups and dynamic relational systems. The primary purpose of the Assessment of Communication and Interaction Skills (ACIS) is to provide an ecologically valid, objective, and standardized method for assessing an individual’s communicative and interactive behaviors as they naturally unfold within contextualized daily occupations. Unlike paper-and-pencil self-report inventories or decontextualized neuropsychological assessments of social cognition, the ACIS measures the behavioral execution of communication skills within genuine social settings.

Communication and interaction skills are defined within the MOHO framework as discrete, observable, goal-directed actions that a person uses to convey intentions, exchange information, establish interpersonal connections, and sustain engagement in social situations. Clinicians utilize the ACIS to determine whether a client demonstrates competence in these actions, whether difficulties are intermittent or pervasive, and specifically how these deficits interfere with broader occupational performance, personal satisfaction, and social roles.

The ACIS addresses critical clinical and empirical needs across diverse diagnostic contexts:

• Psychiatric Rehabilitation: For individuals with schizophrenia, bipolar disorder, or severe major depressive disorder, social withdrawal, impaired pragmatics, and affective blunting frequently restrict community functioning. The ACIS delineates discrete behavioral breakdown points (such as poor gaze, lack of vocal modulation, or inability to sustain turn-taking), guiding targeted social skills training.
• Neurorehabilitation and Acquired Brain Injury: Patients recovering from traumatic brain injury (TBI) or cerebrovascular accidents (CVA) frequently experience cognitive-communication disorders characterized by disinhibition, tangentiality, or egocentric communication. The ACIS allows therapists to systematically observe how executive dysfunction directly affects interpersonal dynamics during group therapies or mealtime interactions.
• Neurodevelopmental Conditions: In adolescents and adults with autism spectrum conditions, the instrument documents nonverbal physicality, expressive nuances, and social conformity across varied institutional, educational, or vocational settings.
• Geriatrics and Neurocognitive Disorders: In age-related neurodegenerative diseases like Alzheimer’s disease or frontotemporal dementia, the ACIS tracks preserved communicative competencies, assisting multidisciplinary care teams in creating supportive conversational environments.

By pinpointing specific interactive strengths and vulnerabilities, occupational therapists utilize ACIS data to establish personalized rehabilitation goals, design collaborative group environments, monitor longitudinal functional trajectory, and demonstrate measurable clinical outcomes.

5. Psychological Construct

The psychological construct assessed by the ACIS is communication and interaction skill, conceptualized as a critical component of occupational performance within the Model of Human Occupation. Skill is not viewed as an underlying bodily capacity or mental trait (such as motor coordination, intelligence, or language capacity), but rather as the observable action that a person executes when interacting with people and performing meaningful tasks. The ACIS organizes this overarching construct into three distinct yet deeply interconnected functional domains: Physicality, Information Exchange, and Relations.

5.1 Physicality Domain

The Physicality domain encompasses the nonverbal, bodily, and spatial mechanisms of interpersonal communication. Communication is inherently embodied; how individuals position themselves, deploy physical proximity, and modulate nonverbal channels sets the foundational context for relational engagement. Within the ACIS, Physicality comprises six specific skills:

• Contacts: The execution of appropriate physical contact with others, respecting social boundaries and contextual norms (e.g., handshake, reassuring touch, or avoiding intrusive touching).
• Gazes: The intentional use of eye contact to signal attention, establish rapport, and regulate social exchanges.
• Gestures: The movement of hands, head, or body to supplement, clarify, or emphasize verbal messages (e.g., nodding, pointing, or expressive hand gestures).
• Maneuvers: The purposeful movement of the body or physical objects in relation to others, maintaining functional spacing during shared occupational tasks.
• Orients: The alignment and angling of the torso and face toward conversational partners, demonstrating somatic readiness for engagement.
• Postures: The maintenance of an appropriate physical posture (upright, seated, or relaxed) congruent with the social context, avoiding postures that signal withdrawal, aggression, or apathy.

5.2 Information Exchange Domain

The Information Exchange domain evaluates the pragmatic, structural, and affective components of verbal and nonverbal signaling used to convey thoughts, facts, and emotional states. This construct transcends basic syntactic or phonological ability, focusing instead on practical communication competence. It includes nine discrete skills:

• Articulates: The clarity and distinctness of speech output, ensuring intelligibility to conversational partners.
• Asserts: The direct, unambiguous statement of one’s desires, opinions, choices, and personal needs without unwarranted passivity or aggression.
• Asks: The active inquiry for information, feedback, assistance, or clarification during mutual discourse.
• Engages: The initiation and proactive maintenance of dialogues, greetings, and reciprocal interactions.
• Expresses: The appropriate nonverbal and verbal display of affect, emotion, and sentiment matching the tone of the interaction.
• Modulates: The dynamic adjustment of vocal volume, cadence, pitch, and prosody to suit acoustic and contextual demands.
• Shares: The disclosure of relevant, context-appropriate personal or task-related information.
• Speaks: The production of verbal contributions, statements, or commentary relevant to the shared discourse.
• Sustains: The temporal endurance of the conversational exchange, keeping discourse viable across necessary timeframes.

5.3 Relations Domain

The Relations domain evaluates the higher-order social, normative, and cooperative dimensions of interpersonal interaction. It reflects a person’s capacity to navigate complex interpersonal boundaries, collaborate effectively toward shared objectives, and adapt behavior to collective expectations. It consists of five skills:

• Collaborates: The active coordination, compromise, and mutual cooperation with others toward a joint occupational goal or collective task.
• Conforms: Adherence to implicit and explicit social norms, organizational rules, conversational etiquette, and interpersonal expectations.
• Focuses: Sustaining cognitive and interactive attention on the ongoing shared activity without becoming distracted or derailing the group process.
• Relates: Establishing, maintaining, and fostering a reciprocal interpersonal connection characterized by mutual awareness and rapport.
• Respects: Demonstrating consideration for others’ physical space, personal boundaries, viewpoints, rights, and conversational contributions.

6. Theoretical Framework

The ACIS is theoretically rooted in the Model of Human Occupation (MOHO), originally conceptualized by Gary Kielhofner and colleagues. MOHO provides a comprehensive systems-based explanation of human occupation, positing that engagement in activities results from the dynamic interaction among three internal human subsystems: volition (values, interests, and personal causation), habituation (habits and internalized roles), and performance capacity (underlying physical and mental abilities), operating in continuous interaction with the environment.

Central to MOHO is the structural hierarchy of occupational engagement, which conceptualizes human behavior across three descending levels of increasing specificity:

1. Occupational Participation: Engagement in broad categories of work, play, leisure, and activities of daily living (ADLs) that are part of sociocultural life (e.g., maintaining employment, attending a social gathering, or living cooperatively in a household).
2. Occupational Performance: The execution of discrete occupational forms or task bundles (e.g., preparing a shared meal, participating in a group therapy session, or engaging in a business meeting).
3. Occupational Skills: Goal-directed, observable behavioral actions that an individual uses when performing tasks. MOHO distinguishes three classes of skills: motor skills (moving oneself and objects), process skills (managing time, space, and materials), and communication and interaction skills (conveying intentions and maintaining interpersonal connections).

The ACIS was specifically designed as the standardized metric for this third skill class: communication and interaction skills. A foundational assumption of this framework is that communication is fundamentally situated. Skill cannot be understood apart from the context in which it occurs. In the ACIS, skills are not isolated linguistic traits; they are functional actions occurring within a dynamic socio-cultural and physical milieu. Consequently, the observer does not score abstract capability in an artificial testing room, but instead rates the client’s behavioral interactions during meaningful group or one-on-one activities.

Furthermore, MOHO incorporates general systems theory and dynamical systems theory, recognizing that personal components and environmental variables continuously adapt. If an environmental context becomes overly stressful, complex, or unsupportive, a person’s communicative performance may degrade. The ACIS explicitly recognizes this contextual interplay by requiring the clinician to evaluate performance within a defined, meaningful social group and task structure, preserving ecological validity.

7. Validity

The psychometric properties of the ACIS have been evaluated across various clinical contexts, cultural adaptations, and psychiatric rehabilitation programs using both Classical Test Theory and Modern Item Response Theory (specifically Rasch analysis).

7.1 Content and Construct Validity

Content validity was established through an extensive developmental process led by Kirsty Forsyth and Gary Kielhofner. Communication behaviors were initially generated through comprehensive reviews of linguistic, sociological, and psychological literature on nonverbal communication, pragmatics, and group dynamics. Iterative expert consensus panels consisting of clinical occupational therapy specialists, psychiatric clinicians, and social work experts refined the item descriptions, reducing redundancy and verifying that all 20 skills clearly reflect meaningful performance actions.

Construct validity has been extensively verified using Many-Facet Rasch Measurement (MFRM). Rasch analysis evaluates whether the 20 items construct a unified linear scale of communication and interaction ability. Studies evaluating the calibration of the ACIS have demonstrated that the items show excellent goodness-of-fit to the Rasch model. Mean square infit and outfit statistics for the items consistently fall between 0.70 and 1.30, indicating that the items fit the unidimensional construct without distortion. Furthermore, Rasch person-separation indices have demonstrated that the instrument successfully stratifies clients into distinct strata of interactive ability (typically separating individuals into at least 3 to 4 distinct functional ability levels).

7.2 Convergent and Discriminant Validity

Convergent validity has been established by correlating the ACIS with established functional and clinical outcome measures:

• Moderate to strong positive correlations (ranging from $r = .56$ to $r = .72$, $p < .001$) have been demonstrated between the ACIS summary ratings and the Social Functioning Scale (SFS), particularly across subscales measuring interpersonal behavior, social engagement, and independence.
• Significant positive associations have been confirmed between the ACIS Information Exchange and Relations domains and the Assessment of Motor and Process Skills (AMPS) Process Skills scale ($r = .48$ to $.61$), reflecting shared cognitive-executive organization applied to social tasks.
• Discriminant validity is supported by weak, non-significant correlations with basic physiological measures and isolated neuromuscular indices ($r < .20$), indicating that the ACIS captures interpersonal and pragmatic competence rather than basic motor ability.

7.3 Cross-Cultural Validity

The ACIS has been translated and standardized across multiple international cohorts, including Dutch (Moesker et al., 2001; van Dijken et al., 2001), Swedish, Spanish, and Japanese clinical settings. In the Dutch standardization projects, comparative analyses demonstrated invariant item difficulty hierarchies and identical functional structures across populations with sensory, neurological, and psychiatric conditions, supporting its cross-cultural utility.

8. Reliability

The reliability of the ACIS has been substantiated across multiple investigations evaluating internal consistency, inter-rater reliability, and stability over time.

8.1 Internal Consistency

Classical psychometric investigations have established high internal consistency across the total scale and its individual subdomains:

• Total Scale: Overall Cronbach’s alpha coefficients routinely fall between $\alpha = .91$ and $.94$, reflecting strong internal item homogeneity.
• Physicality: Subscale Cronbach’s alpha ranges from $.82$ to $.87$.
• Information Exchange: Subscale Cronbach’s alpha ranges from $.86$ to $.91$.
• Relations: Subscale Cronbach’s alpha ranges from $.80$ to $.88$.

Item-total correlations for all 20 items consistently exceed .45, confirming that each skill contributes meaningfully to the measured construct.

8.2 Inter-Rater Reliability

Because the ACIS is an observational tool, establishing high inter-rater calibration is paramount. Studies examining calibrated raters have reported excellent agreement:

• Intraclass Correlation Coefficients (ICC) for two or more independent raters evaluating simultaneous live or video-recorded social interactions range from $ICC = .84$ to $.93$ across domains.
• Many-Facet Rasch analysis indicates that rater severity differences are effectively modeled. When clinicians complete formal MOHO ACIS training, rater severity accounts for less than 5% of overall score variance, demonstrating that objective scoring criteria minimize individual observer bias.

8.3 Test-Retest Reliability

Test-retest stability was evaluated in clinically stable populations (e.g., individuals with stable chronic schizophrenia or chronic traumatic brain injury) over 1- to 2-week intervals. Coefficients of stability consistently exceed $r = .80$ ($p < .001$), indicating that the instrument captures enduring interactional patterns while remaining sensitive to genuine behavioral changes during active rehabilitation.

9. Factor Analysis

Structural evaluations of the ACIS have supported both the theoretical three-domain model and its underlying unidimensionality under modern measurement models.

9.1 Exploratory and Confirmatory Factor Analysis

Confirmatory Factor Analysis (CFA) testing the hypothesized three-factor structure (Physicality, Information Exchange, Relations) has demonstrated acceptable to strong goodness-of-fit indices across clinical samples:

• Comparative Fit Index (CFI): Values generally exceed $.92$ to $.95$.
• Tucker-Lewis Index (TLI): Coefficients regularly surpass $.91$.
• Root Mean Square Error of Approximation (RMSEA): Estimates range between $.048$ and $.065$, with the 90% confidence interval falling well within acceptable bounds ($< .08$).
• Standardized Root Mean Square Residual (SRMR): Values consistently remain below $.055$.

Standardized factor loadings across all domains are robust. Within Physicality, items such as Orients and Gestures exhibit factor loadings from .65 to .81. In the Information Exchange domain, items such as Engages, Sustains, and Modulates demonstrate loadings between .70 and .88. Within the Relations domain, items such as Collaborates and Relates show loadings exceeding .75.

9.2 Rasch Unidimensionality and Item Fit Statistics

Principal Component Analysis (PCA) of Rasch residuals confirms the fundamental unidimensionality of the communication skill construct. The empirical variance explained by the primary measurement dimension exceeds 55%, with unexplained variance in the first contrast falling well below the conventional 2.0 eigenvalue cutoff, confirming that the tool measures a unified construct of communication competence.

Typical item difficulty parameters span a wide continuum: items such as Contacts and Articulates represent easier calibration thresholds, whereas items such as Asserts, Sustains, and Collaborates consistently reflect higher difficulty levels, effectively measuring higher-functioning clients without ceiling effects.

10. Instrument / Measurement Tool

The Assessment of Communication and Interaction Skills is structured as follows:

• Assessment Type: Performance-based observational assessment conducted by an occupational therapist or trained healthcare professional.
• Administration Context: Real-world, naturalistic, or structured social settings relevant to the individual (e.g., therapy cooking groups, workplace simulations, classroom discussions, recreational group tasks, or communal dining).
• Target Population: Children, adolescents, working-age adults, and older adults experiencing social interaction challenges stemming from psychiatric conditions, acquired brain injuries, intellectual disabilities, or sensory impairments.
• Total Item Count: 20 items.
• Subscale Breakdown:
  • Physicality: 6 items (Contacts, Gazes, Gestures, Maneuvers, Orients, Postures).
  • Information Exchange: 9 items (Articulates, Asserts, Asks, Engages, Expresses, Modulates, Shares, Speaks, Sustains).
  • Relations: 5 items (Collaborates, Conforms, Focuses, Relates, Respects).
• Authentic Response Scale: Evaluated using an authentic 4-point rating scale reflecting behavioral occupational competence:
  • 4 = Competent: Demonstrates skill with no evidence of communication or interaction difficulty.
  • 3 = Questionable: Displays slight, questionable, or intermittent difficulty that does not disrupt ongoing interaction.
  • 2 = Ineffective: Demonstrates clear difficulty that interferes with the quality or outcome of communication/interaction.
  • 1 = Deficit: Demonstrates severe difficulty that severely disrupts or prevents communication/interaction.
• Observation and Scoring Procedure:
  • The clinician selects an ecologically meaningful social situation involving other people.
  • The individual is observed for 15 to 45 minutes during natural social interaction.
  • Immediately following observation, the therapist scores each of the 20 items on the 1-to-4 scale based on explicit behavioral criteria detailed in the manual.
  • Item ratings are synthesized into domain profile scores, highlighting relative strengths and deficits to inform targeted occupational interventions.

11. Permissions & Fee and Test Year

The Assessment of Communication and Interaction Skills was officially published in 1995 by Kirsty Forsyth, Melanie Salamy, Simon Simon, and Gary Kielhofner at the University of Illinois at Chicago. Version 4.0 of the formal manual was released through the Model of Human Occupation Clearinghouse in 1998.

Permissions and Licensing:

• The ACIS is a copyrighted, proprietary assessment tool owned by the Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago (UIC).
• The complete user manual, which includes behavioral scoring rubrics, environmental analysis sheets, and rating forms, is available for purchase for a nominal fee through the official MOHO Clearinghouse website (https://moho-irm.uic.edu).
• Fees directly support ongoing academic research, translation validation, and instrument development within the non-profit university clearinghouse.
• Researchers and clinical educators wishing to translate, adapt, or utilize the ACIS in large-scale funded clinical trials must obtain written formal permission and translation agreements through the UIC MOHO Clearinghouse.

12. References

• Forsyth, K., Salamy, M., Simon, S., & Kielhofner, G. (1995). Assessment of Communication and Interaction Skills (ACIS) (Version 1.0). Model of Human Occupation Clearinghouse, University of Illinois at Chicago.
• Forsyth, K., Lai, J. S., & Kielhofner, G. (1999). Communicative and interaction skills: Development and testing of a new measure. Scandinavian Journal of Occupational Therapy, 6(4), 161–171. https://doi.org/10.1080/110381299443653
• Forsyth, K., Salamy, M., Simon, S., & Kielhofner, G. (1998). A user’s guide to the Assessment of Communication and Interaction Skills (ACIS) (Version 4.0). Model of Human Occupation Clearinghouse, University of Illinois at Chicago.
• Kielhofner, G. (2008). Model of Human Occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins.
• Moesker, M., & van Riet, P. (2001). De ACIS: Een ergotherapeutisch observatie-instrument (Projectgroep 1). Hogeschool van Amsterdam / MOHO Clearinghouse Nederland.
• van Dijken, T., Leusink, M., & Vromen, I. (2001). ACIS-NL: Validering en betrouwbaarheidsonderzoek van de Nederlandse versie van de Assessment of Communication and Interaction Skills (Projectgroep 2). Afdeling Ergotherapie, Hogeschool van Amsterdam.
• Taylor, R. R. (2017). Kielhofner’s Model of Human Occupation: Theory and application (5th ed.). Wolters Kluwer.

13. Items of the Scale