Month: March 2016

Brief Psychiatric Rating Scale

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The Benefit(s) of Having a Psychiatrist on a Multidisciplinary Treatment Team

Brief Psychiatric Rating Scale

• Post author By glarehab
• Post date March 31, 2016
• No Comments on Brief Psychiatric Rating Scale

In June 2016, the SABS new definition for catastrophic impairment will take effect.

They will be introducing a new rating method for the combination of physical and mental impairments that includes the use of the 6th edition of the AMA Guides.

The 6th edition method, the rater derives 3 scores by evaluating the client using 3 different scales:

• Brief Psychiatric Rating Scale
• The Global Assessment of Functioning Scale
• The Psychiatric Impairment Rating Scale

In this blog post, we will be discussing the Brief Psychiatric Rating Scale (BPRS).

This scale was first published in 1962 and is one of the oldest, widely used scales to measure psychotic symptoms. The BPRS is measured to have good reliability and validity.

The BPRS is a 24-item scale that measures psychiatric symptoms such as depression, anxiety, hallucinations and unusual behaviour.

The 24 items include the following:

Each symptom is rated on a likert scale from 1 (NOT PRESENT) – 7 (EXTREMELY SEVERE).

The sum of all 24 items is then calculated to a maximum score of 168 (24X7=168).

The higher the score, the more psychiatrically impaired the client is.

The scores are based on the clinician’s interview with the client and observation of the client’s behaviour over 2-3 days. The client’s family should also provide a report on the client’s behaviour to assist with determining the scores.

Some items on this scale are quite specific to bipolar or psychotic disorder, which do not relate to clients in motor vehicle accidents. This eliminates almost 49 points (7 items on the list of 24) from the maximum of 168.

It has been noted that to increase the reliability of ratings, it is recommended that clients be interviewed jointly by a team of 2 clinicians, with the raters either making independent ratings to be later compared, or jointly making ratings through discussion and consensus building.

The strength of this scale is that it is sensitive to change, broad evaluation of a number of different symptoms, and psychometric properties and underlying factor structure is well-established.

The limitations are that the scale focuses mainly on symptoms as opposed to function. In addition, it is often a tool used to measure severity of symptoms of schizophrenia or psychotic disorders, which usually does not relate to motor vehicle accident clients.

The final score out of 168 is then converted to a Whole Person Impairment (WPI) score using the 6th edition of the AMA Guides. You would need a score of at least 3 on the 17 items that do not deal with a psychotic disorder (summed score of 51) to receive a WPI of 30%.

The WPI obtained from the BPRS will then be used in combination of the 2 other scales, the PIRS and the GAF, to obtain the median WPI rating, which will then be combined with the physical WPI rating to obtain the total WPI.

The Global Assessment of Functioning Scale

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The Benefit(s) of Having a Psychiatrist on a Multidisciplinary Treatment Team

The Global Assessment of Functioning Scale

• Post author By glarehab
• Post date March 31, 2016
• No Comments on The Global Assessment of Functioning Scale

In June 2016, the SABS new definition for catastrophic impairment will take effect.

A new rating method for the combination of physical and mental impairments that includes the use of the 6th edition of the AMA Guides is introduced.

The 6th edition method, the rater derives 3 scores by evaluating the client using 3 different scales:

• Brief Psychiatric Rating Scale
• The Global Assessment of Functioning Scale
• The Psychiatric Impairment Rating Scale

In this blog post, we will be discussing the Global Assessment of Functioning Scale (GAF).

The first version of the scale was created in 1962 and subsequently revised in 1976. In 1987, the scale was introduced with the third edition of the Diagnosis and Statistical Manual of Mental Disorder (DSM).

The GAF represents the 5th stage of the assessment process that clinicians may use to determine an individual’s level of psychosocial functioning:

• Axis I – Clinical Disorders
• Axis II – Personality Disorders
• Axis III – General Medical Conditions
• Axis IV – Social and Environmental Problems
• Axis V – Global Assessment of Functioning

The GAF assigns a clinical judgment in numerical fashion to an individual’s overall functioning level. Impairments in psychological, social and occupational/school functioning are considered, but those related to physical or environmental limitations are not.

The scale ranged from 0 to 100, with 100 being “superior functioning”.

The clinician will start at either the bottom or the top of the scale and go up/down the list until the most accurate description of functioning for the individual is reached. The clinician assesses either the symptom severity or the level of functioning, whichever is the worst of the two.

The clinician rates the individual’s GAF in relationship to the “current period”, which may encompass the past week, the past month or the past six months.

Score	Assessment of Symptoms
100-91	No symptoms. Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities.
90-81	Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
80-71	If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social or occupational functioning (e.g., temporarily falling behind on projects).
70-61	Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social or occupational functioning (e.g., theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
60-51	Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers).
50-41	Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social or occupational functioning (e.g., no friends).
40-31	Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., avoids friends, neglects family).
30-21	Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no home or friends).
20-11	Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
10-1	Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
0	Inadequate information.

The major limitation of the GAF is the conflation of symptom severity with functional impairment.

For the majority of MVA cases, a GAF score of between 31-40 is unlikely, implying a maximal mental WPI as 20%.

The score of the GAF will convert to a WPI rating, which will then be used in combination of the 2 other scales, the PIRS and the BPRS, to obtain the median WPI rating which will then be combined with the physical WPI rating to obtain the total WPI.

The Kings Outcome Scale for Childhood Head Injury (KOSCHI)

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The Benefit(s) of Having a Psychiatrist on a Multidisciplinary Treatment Team

The Kings Outcome Scale for Childhood Head Injury (KOSCHI)

• Post author By glarehab
• Post date March 5, 2016
• No Comments on The Kings Outcome Scale for Childhood Head Injury (KOSCHI)

According to the article, “A practical outcome scale for paediatric head injury” 1, The KOSCHI was created by Crouchman and colleagues “due to the lack of evaluation of active and rehabilitation therapies after TBI.” It is meant to be an adaptation of the original Glasgow Outcome Scale (GOS) for adults.

Inter-rater reliability studies show that even with an apparently simple scale, some training for assessors may be required to maintain reliability.

Head injury accounts for 5% of all paediatric hospital admission and is the commonest cause of acquired brain disability in childhood, with an estimated 3000 children acquiring significant new neurological or cognitive disability as a result of TBI every year in the UK1.

There is a lack of pediatric descriptors of outcomes in this field and this was the main reason why the KOSCHI was developed.

Information from 200 head injured children admitted to the pediatric ward of King’s College Hospital between 1990-1997 was explored.  More than 90% of the items in the research had severe injury with abnormal intracerebral radiological findings on imaging1.

The 5 categories of the KOSCHI include:

1 –Death

2 –Vegetative – The child is breathing spontaneously and may have sleep/wake cycles.

3 -Severe disability – The child is at least intermittently able to move part of the body/eyes to command or make purposeful spontaneous movements. Implies a continuing high level of dependency, but the child can assist in daily activities; for example, can feed self or walk with assistance or help to place items of clothing.

4 –Moderate disability – The child is mostly independent but needs a degree of supervision/actual help for physical or behavioural problems. The child is age appropriately independent but has residual problems with learning/behaviour or neurological sequelae affecting function/

5 –Good recovery – This should only be assigned if the head injury has resulted in a new condition which does not interfere with the child’s wellbeing and/or functioning. Implies that the child has made a complete recovery with no detectable sequelae from the head injury.

There is potential for ambiguity in such a simple instrument. For example, a child with a minor head injury, who has a partial spinal cord injury, might place him in category 4, irrespective of complete recovery of the brain injury.

According to the “A practical outcome scale for paediatric head injury” 1 article, the evaluator needs to make sure that they are taking into account the sequelae of the child’s brain injury, rather than that of other injuries.

Another issue is that for a child with premorbid learning and/or behavioural problems, assignment to a category should be based on change in function following TBI.

In June 2016, the SABS definition for catastrophic impairment is changing.

The new SABS states the following conditions for Catastrophic Designation under childhood brain injury:

If the insured person was under 18 years of age at the time of the accident, a traumatic brain injury that meets one of the following criteria:

• The insured person is accepted for admission, on an in-patient basis, to a public hospital named in a Guideline with positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.
• The insured person is accepted for admission, on an in-patient basis, to a program of neurological rehabilitation in a paediatric rehabilitation facility that is a member of the Ontario Association of Children’s Rehabilitation Services
• One month or more after the accident, the insured person’s level of neurological function does not exceed category 2 (Vegetative) on the King’s Outcome Scale for Childhood Head Injury
• Six months or more after the accident, the insured person’s level of neurological function does not exceed category 3 (Severe disability) on the King’s Outcome Scale for Childhood Head Injury.
• Nine months or more after the accident, the insured person’s level of function remains seriously impaired such that the insured person is not age-appropriately independent and requires in-person supervision or assistance for physical, cognitive or behavioural impairments for the majority of the insured person’s waking day.

As you can see above, criterion #3 and #4 take into consideration the KOSCHI assessment and score.

After one month following the accident, if the child scores a 2 – Vegetative on the KOSCHI, they are CAT.

After six months following the accident, if the child scores a 3- Severe Disability on the KOSCHI, they are CAT.

The SABS does not provide any guidance of who should do the KOSCHI assessment.

However, when we read the definition of a Severe Disability, it notes that the child needs a “high level of dependence”. How can this be measured?

Obviously, it cannot be measured by a quick interview with the child and caregiver, as the evaluator must observe the child’s actual capabilities to determine the level of independence.

In order to describe “functional level” and the amount of assistance a child requires, an OT will have to visit the child in their home and observe how they interact with their family, their peers and in the community.

To learn more about the KOSCHI, please do not hesitate to contact us.

1 M. Crouchman et al, “A practical outcome scale for paediatric head injury” Arch Dis Child 2001; 84:120-124 [the “KOSCHI article”].

The Psychiatric Impairment Rating Scale (PIRS)

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The Benefit(s) of Having a Psychiatrist on a Multidisciplinary Treatment Team

The Psychiatric Impairment Rating Scale (PIRS)

• Post author By glarehab
• Post date March 1, 2016
• No Comments on The Psychiatric Impairment Rating Scale (PIRS)

In June 2016, the SABS will be introducing the 6th edition of the AMA Guides in order to combine the physical with mental/behavioural for CAT determination.

On the OCF 19, the mental and behaviour criterion states:

“A mental or behavioural impairment, excluding traumatic brain injury, determined in accordance with the rating methodology in Chapter 14, Section 14.6 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 6th edition, 2008, that, when the impairment score is combined with a physical impairment described in paragraph 6 in accordance with the combining requirements set out in the Combined Values Table of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 percent or more impairment of the whole person”.

In the 6th edition method, the rater derives three scores by evaluating the client using 3 different scales:

• Brief Psychiatric Rating Scale (BPRS)
• The Global Assessment of Functioning Scale (GAF)
• The Psychiatric Impairment Rating Scale (PIRS)

In this blog post, we are going to explore the PIRS a bit further.

The PIRS is a rating scale from 0-5 used to measure functional impairment including:

• Activities of daily living
  • Self-care and personal hygiene
  • Social and recreational activities
  • Travel
• Social functioning
• Concentration, persistence and pace
• Employability and resilience

Each functional impairment receives a rating from 0-5. For example, the Self-Care and Personal Hygiene category looks like the following:

SELF CARE AND PERSONAL HYGIENE

Class 1: No deficit, or minor deficit attributable to the normal variation in the general population

Class 2: Mild impairment: Able to live independently, looks after self adequately, although may look unkempt occasionally, sometimes misses a meal or relies on take-away food.

Class 3: Moderate impairment: Can’t live independently without regular support. Needs prompting to shower daily and wear clean clothes. Does not prepare own meals, frequently misses meals. Family member or community nurse visits (or should visit) X 2-3 per week to ensure minimum level of hygiene and nutrition.

Class 4 Severe impairment: Needs supervised residential care. If unsupervised, may accidentally or purposefully hurt self.

Class 5 Totally impaired: Needs assistance with basic functions, such as feeding and toileting.

Once a class score has been arranged for all 6 areas of functioning, the six scores are arranged from lowest to highest.

For example, 2, 2, 3, 3, 4, 5.

The median is then calculated by averaging the 2 middle scores. In this example, the median class = 3. If a score falls between 2 class, for example, 3, 4, then it is rounded up to the next class.

Each median class score represent a range of impairment:

Class 1 = 0 -3%

Class 2 = 4 -10%

Class 3 = 11-30%

Class 4 = 31-60%

Class 5 = 61-100%

In order to determine an exact percentage of impairment, an aggregate score needs to be calculated.

For example, using the numbers of 2, 2, 3, 3, 4, 5, that we used above, the aggregate score would be,

2 + 2 + 3 + 3 + 4 + 5 = 19

Using the Conversion Table provided in the assessment, it is then converted to a percentage score. In this example, it would convert to 24% (considering a Median Class of 3). The 24% was found by following the Class 3 level with the 19 aggregate score to the number of 24. If it was a Class 2 level with the same aggregate score of 19, the percentage of impairment would be different. The Conversion Table shows that the same aggregate score can lead to different percentages of impairment in different Median Classes.

This rating scale can only be completed by a Psychiatrist. However, as described above, the scale relates mainly to the function of the individual. This level of functioning can be very difficult to obtain from 1 or 2 sessions of subjective information provided by the client.

The Occupational Therapist will play a large role in obtaining the information used to decide on scores in the scale. An OT’s job revolves around “function” and activities of daily living, including but not limited to personal care, work, play, leisure, social participating and IADLS.

Through sessions in the client’s own home and community environment using objective information, the OT will be able to report and comment on all areas of functioning considered in the PIRS. This information from the OT can then be passed on to the Psychiatrist on the file to assist with determining a rating score.

The OT can play a vital part with this new scale in assisting with determining if a client is catastrophic or not.

Please look out for our blogs next month on the 2 additional scales, the Brief Psychiatric Rating Scale (BPRS) and The Global Assessment of Functioning Scale (GAF).

If you have any more questions about these scales or would like GLA to host a Lunch & Learn to educate you about the new upcoming changes to the SABS, please contact us. We would be happy to provide you with more information.