Adult Psychiatric Sensory Integration Evaluation

The Schroeder Block Campbell Evaluation

The adult psychiatric sensory integration evaluation

Covers sensory & motor responses; developmental history; & various neurologic soft signs Various evaluation procedures normed for children are used informally by clinicians for adult clients with brain damage

Historical development San Diego Veteran’s Administration Medical Center 15 clients with chronic schizophrenia, paranoid schizophrenia, & hyperkinetic adult syndrome Tested both on & off medications SBC evaluation & 11 subtests from the Southern California Sensory Integration Tests by Ayres Rationale: To have an objective numerical score of a patient’s ability to perform at any given point in time When reliability, validity & norms are established, it is possible to objectively evaluate: An individual client over time The effects of medication, or other forms of treatment, both acutely & over time Groups of clients by diagnosis or by other criteria

Benefits to the client: The physician & treatment team have a better understanding of their client’s physical ability to interact with his environment The client himself better understands his physical abilities & disabilities An increased understanding of the neurologic components of psychiatric

Literature review Focuses primarily on measurable perceptual & motor changes in schizophrenia Many methodological & technical flaws in the reported results. Any research on perception is as complicated as the perceptual response itself

Literature review - neurochemistry Neuroregulators are thought to be primarily under genetic control but responsive to stress. Given enough of a specific stress, the neurochemical mechanisms are altered, initiating changes in perception & behavioral responses which are then labeled to as a psychiatric disorder. Disordered dopamine transmission in schizophrenia Lowered MAO platelet activity & a corresponding low platelet activity in 1st degree relatives Reported correlation between lowered MAO inhibitors, platelet activity, increased incidence of abnormal EEG, & presence of auditory hallucinations High level of endorphins in schizophrenia The report or an exciting finding & then difficulty in replicating the results has plagued schizophrenia research

Literature review – vestibular system Leach study – schizophrenic groups showed diminished reactivity, with the greatest deficits occurring under conditions of weak stimulation, & were relatively more normal with increased stimulation. Some studies report transitory hyporeactivity Some studies, acute & chronic schizophrenic clients demonstrate normal vestibular responses Holtzman observed eye tracking dysfunctions in schizophrenic patients & their relatives. The vestibular system plays a significant role in perception, & is intricately interconnected to many brain structures, some of which are known to be affected by dopamine More research needs to be done to clarify which subtypes, in any, of schizophrenic clients show vestibular involvement.

Literature review – psychomotility Involves processing information & responding to stimulation Psychomotor changes parallel the course of clinical improvement, & clients responding favorably to tranquilizing drugs do significantly better on psychomotor tests before & after drug administration Weaver & Brooks – high association between good or poor psychomotor performance & release from the hospital; 75% accurate prediction of patient outcome was made based on psychomotor

Literature review – body image Almost all reports of body image refer to figure drawings Despite problems of validity & reliability, body image is included because it tells so much about the quality of the client’s perception of himself.

Literature review – anatomical changes Marsden reports cerebral atrophy & cognitive impairment observed Johnstone – cerebral ventricular size is highly significant in relation to cognitive impairment Other anatomical changes: Motor end plate alterations or branching & sprouting of nerve twigs, abnormal electromyograms, Increased electrical activity of skeletal muscles at rest Increased incidence of morphological

Literature review – laterality Gur study – left sidedness on laterality scores Flor-Henry – increased EEG foci in the left temporal lobe of schizophrenics Other researchers found less eye & hand congruence in schizophrenics than normals

Literature review – abnormal movements Movement disorders in schizophrenia have been reported before the advent of drugs, & includes stereotypic mannerisms, hypo & hyperkinesia Also involuntary ocular movements (deviant eye tracking, gaze disturbance, altered blink rates, eye deviation, abnormal saccadic movements & failure to converge) Can occur from side effects of neuroleptic medication due to toxicity, hypersensitivity, & long term use Can be affected by a subject’s anxiety, by interpersonal contact, & by physical contact with persons Dyskinesias are involuntary movements & are thought to occur in older psychotic patients in whom long term treatment with the anti-psychotic drugs of phenothiazine & butyrohenone groups has occurred.

Literature review – neurologic soft signs Soft signs are chronic, & non-life threatening & can refer to any neurologic deviation: motor, sensory, or integrative Manifestations: Delay in reaching developmental milestones Difficulty in acquiring simple athletic skills Learning problems Organic indicators on mental status exams

Behaviors assessed

Behaviors assessed Scoring is based on a 0-3 scale (0 is normal, 1,2,3 are the degrees of divergence from normal) It is an evaluation tool consisting of definite procedures, observations, scoring, work sheets,& summary sheets Dominance Eye, hand & foot dominance Eye: subject asked to look through a paper tube at an object on the wall; paper tube is replaced by a piece of cardboard which has a ¼ inch hole in its center; key ring Hand: write his name on top of the paper Foot: asked to hop on 1 foot 3x; kick softly a ball in front of

Behaviors assessed Posture Stand in relaxed position; therapist runs the fingers down the spine for lordosis, kyphosis, scoliosis, asymmetrical posture, inward rotation of the shoulders

Neck rotation Rotate head first clockwise, then counter-clockwise; smooth or jerky? Full ROM?

Gait Walk away from the therapist & return; associated arm movements? Shuffling?

Hand observations Place hands palms down, and then turn palms up to look for abnormal hand structure

Grip strength Dynamometer assessment

Fine motor control Use of tapping board to tap as fast as he can using the index finger of the dominant & non-dominant hands

Diadochokinesis Alternately pronates & supinates both hands simultaneously for 10 seconds; smoothness & synchronization of movement?

Behaviors assessed Finger-thumb opposition Touch each finger of one hand to the thumb; smoothness of movement? Speed? Coordination? Ability to perform without visual cues?

Visual pursuits Visually track a penlight without moving the head

Bilateral coordination – upper extremity Draw two circles simultaneously on a blackboard, one with each hand; eye-hand coordination? Ability to coordinate the motor use of both Ues?

Cross the midline Draws a line from his left to his right on the blackboard & retraces it; subject crosses? Avoids crossing? Line irregular?

Stability of the upper extremity Clasp his hands in front of his chest, therapist places one hand above & one hand below the subject’s hands, then pushes & pulls; keep hands within 8 inches of his chest?

Stability of the trunk Stand & hold his body still, he is then pushed FW, side to side, BW; ability to cocontract trunk? Steps to avoid losing his balance? Excessive fluidity?

Classical Romberg Test for balance; walk a line on the floor without looking at the line, then to retrace

Behaviors assessed Sharpened Romberg Cross his arms over his chest & place his feet in the tandem walking position, subject holds this position for 30 seconds with eyes open, 30 seconds with eyes closed

Overflow movements Stand with both arms extended at shoulder height with fingers extended & slightly apart; with eyes closed, he is asked to hold position for 30 seconds; movements exceed 3 inches?

Neck righting Same as used to test overflow movements; First rotates subject’s head to the right, then to the left; trunk & arms tend to align with the head?

Rolling Subject’s ability to rotate his trunk; roll on a mat to his left, then to his right

Asymmetrical tonic neck reflex Quadruped position, making sure that his elbows are clearly visible; head turned to the right, held for 5 seconds, then turned to the left & held for 5 more seconds

Symmetrical tonic neck reflex Examiner extends subject’s neck & holds it for 5 seconds, then lowers the head towards the chest & holds it for 5 more seconds

Tonic labyrinthine reflex Pivot prone position & hold it for 30 seconds

Behaviors assessed Protective extension Upsets balance by pushing him to the front & to the sides, & by pulling him backwards; reaction slow? Adequate? Absent?

Seated equilibrium Wear a safety belt, to straddle an inflatable, & to rock side to side without holding on to the inflatable; right his head & trunk when rocking? Ease to do the task? Balance?

Body image Draw a complete picture of a person; size of the drawing? Anatomy indicators?

Abnormal movements 2 types: those that show upon activation & those that show spontaneously Automatic obedience – extends the subject’s arm over his head, holding it for 30 seconds Cogwheel rigidity – flexing the subject’s arm & feeling for intermittent contraction of either biceps or triceps Tongue protrusion – protrude his tongue, timing it for 30 seconds

Self-reported childhood history Developmental history is taken to see if the subject has had any