Scandinavian Journal of Occupational Therapy
ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia Helen Ayres & Alexander Panickacheril John To cite this article: Helen Ayres & Alexander Panickacheril John (2015) The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia, Scandinavian Journal of Occupational Therapy, 22:6, 470-477, DOI: 10.3109/11038128.2015.1061050 To link to this article: http://dx.doi.org/10.3109/11038128.2015.1061050
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Date: 07 November 2015, At: 18:48
Scandinavian Journal of Occupational Therapy. 2015; 22: 470–477
ORIGINAL ARTICLE
The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia
HELEN AYRES1,2 & ALEXANDER PANICKACHERIL JOHN1,2 Downloaded by [University of Cambridge] at 18:48 07 November 2015
1
University of Western Australia, Crawley, Australia, and 2Bentley Health Service, Bentley, Australia
Abstract Background: Functional impairments in schizophrenia are substantial, complex, and persistent. Objective measurement of ADL ability, functional capacity and performance is needed for effective intervention planning and outcome evaluation. Objective: To evaluate ADL ability in people with schizophrenia using the Assessment of Motor and Process Skills (AMPS) and to determine the utility of using the AMPS to predict levels of assistance required for successful community living. Method: In a retrospective audit, AMPS ADL measures of a consecutive sample of 64 people with schizophrenia admitted to a mental health facility were compared with normative data and with recommended “cut-off” measures for competency to live independently in the community. Results: Substantial difficulties were measured in both ADL motor (mean z = –1.5) and ADL process ability (mean z = –2.1). AMPS ability measures did not predict problems with independent living for 62.5% of the patients. Conclusion: People with schizophrenia admitted to an inpatient rehabilitation facility experienced significant difficulty performing ADL tasks. AMPS is a useful measure of ADL ability but should be used in conjunction with measures of functional performance in order to plan interventions and supports for people with schizophrenia that reflect the complexity of factors affecting community functioning.
Key words: occupational therapy, mental illness, function, evaluation, activities of daily living
Introduction In spite of advances in biological and psychosocial treatments, many people with schizophrenia continue to experience considerable difficulties in performing the roles and occupations for daily life, not achieving normal milestones in social relationships, productivity, residence, and self-care (1,2). These difficulties are often pervasive and manifest in a variety of activities of daily living (ADL), such as shopping, cooking, cleaning, managing health, finances, and medications, and using transportation, and contribute to low levels of independent living, competitive employment, and community participation (1). Measuring and promoting ability in these areas is increasingly being recognized as important for research and rehabilitation interventions in schizophrenia (3). Function and independence are key concepts of the
profession of occupational therapy (4) and core elements of occupational therapy assessment and rehabilitation interventions in psychiatry (5). Identifying and implementing appropriate interventions requires an understanding of the complex range of factors affecting the person’s ability to function. The World Health Organization International Classification of Functioning, Disability and Health (ICF) describes functioning as referring to all body functions, activities, and participation. ICF further considers what a person with a health condition can do in a standard environment as their level of capacity, and what they actually do in their usual environment as their level of performance (6). When considering functioning in people with schizophrenia, the constructs of capacity and performance have been used to explain the observed differences between what the person is able to do and what the person does do,
Correspondence: Helen Ayres, B.App.Sc. (OT), Bentley Health Service, Mills Street, Bentley, 6102, Australia. E-mail: [email protected] (Received 24 October 2014; accepted 7 June 2015) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1061050
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ADL ability in schizophrenia which may be affected by a range of factors such as mood, negative symptoms (7), confidence, motivation, self-monitoring, societal opportunities, and disincentives (3). Recently, there has been considerable focus on searching for appropriate measures of functional capacity and performance in people with schizophrenia and related conditions (8-10). Whilst a variety of measures such as ratings based on self-assessments, proxy reports from carers and other informants, and direct observation of task performance in the community have been utilized to evaluate functioning in people with schizophrenia, these approaches are associated with a number of methodological issues related to reliability, validity, and ease of administration (11,12). Whilst multiple measures may be required to capture the complexity of abilities and impairments in people with schizophrenia, performance-based measurement of functional capacity is being increasingly acknowledged in academic and clinical settings as a viable option to evaluate real-world functioning, develop treatment and rehabilitation plans, and measure recovery outcomes (9). Our study examines the use of a performance-based measure, the Assessment of Motor and Process Skills (AMPS), to measure the quality of performance of activities of daily living (ADL) in people with schizophrenia. The Assessment of Motor and Process Skills (AMPS) is a standardized, reliable, and valid occupational-therapy-specific observational evaluation that measures accurately the quality of a person’s activities of daily living (ADL) in natural and taskrelevant environments (13). AMPS has been used for research and clinical purpose in a range of health settings in different geographical regions and cultures, such as among people with stroke, dementia, learning disabilities, and other neurological and general medical conditions to measure ADL ability, plan appropriate interventions, evaluate response to treatment, and to determine level of support and assistance required (13). However, studies on the utility of AMPS among patients with severe mental illness such as schizophrenia are sparse (14). A limited amount of research has demonstrated discriminant validity of AMPS motor and process measures between well and psychiatrically ill people (15) and between people with depression and schizophrenia (16). Merritt (17) has explored the option of utilizing AMPS ability measures to predict level of assistance required in the community for people with ADL impairments. Using receiver operating characteristic (ROC) analysis the author found that matched measures of < 1 logits on ADL motor ability and < 0.7 logits on ADL process ability would predict well the need for moderate/maximum assistance in
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the community. The author also observed that people with ADL measures of 1.5 logits and more on the motor scale and 1.0 logits and more on the process scale were unlikely to require much support to live independently in the community. Further work by Merritt (18) explored more specifically the predictive validity of AMPS ADL ability measures in relation to diagnoses. Using a recommended cut-off measure of 1.5 logits motor ability and 1.0 logit process ability to predict the need for assistance, for people with mixed psychiatric diagnoses, the author found that while the motor ability cut-off measure had a poor discriminating value, the process ability cut-off measure was more accurate, with a fair discriminating value. Whilst assessment using AMPS can have a wide range of clinical utility for people with severe mental illness, due to the limited number of research studies and methodological limitations of these studies there are significant knowledge gaps. Studies on people with schizophrenia are limited, mostly involving older people with a mean age around 50 (16,19), which is much higher than the typical age of onset of this condition. Methodological issues of previous studies include using non-homogeneous diagnoses (15,20), small sample sizes (20), samples drawn from the same database for different studies (15-17), and case reports involving very small numbers (21). Studies truly representative of people with schizophrenia seen in specialized treatment and rehabilitation settings of public mental health services are sparse. To the best of our knowledge there are no published studies on the utility of AMPS as a functional assessment tool among a representative sample of people with schizophrenia admitted to an in-patient treatment and rehabilitation psychiatry setting. In view of this, we decided to study the use of the AMPS to measure ADL ability in a sample of people with schizophrenia admitted to our facility. Material and methods This study is a retrospective medical records audit of ADL task performance measured using the AMPS, in people with schizophrenia at the time of admission to a tertiary care, medium length of stay, psychiatric treatment and rehabilitation facility. This 12 bed in-patient public psychiatry facility provides integrated pharmacological and evidence-based psychosocial interventions to enable people with severe mental illness to achieve optimal outcome in various domains of their health, function, and personal goals. The large majority of people admitted to the facility were people with schizophrenia. Referral criteria to the facility are for people who would benefit from intensive rehabilitation to enable them to live in the community, and to function at their optimal level. It
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can therefore be reasonably assumed that all of our sample population would require some support or assistance to live in the community at the time of admission. For the purpose of this study we analysed the AMPS ADL motor and process ability measures of consecutive people admitted with a diagnosis of schizophrenia between December 2010 and March 2014. All people with diagnosis of schizophrenia admitted to the facility within that time and who had agreed to undertake an AMPS evaluation as part of their routine clinical care were included in the study. People with a diagnosis of other related conditions such as schizoaffective disorder or other non-organic psychoses were not included. Psychiatric diagnoses were made on admission to the facility after a detailed semi-structured clinical interview by a senior consultant psychiatrist utilizing DSM-IV criteria (22). AMPS evaluations were conducted soon after admission for baseline rehabilitation planning. During the time frame of the study, two senior occupational therapists were employed at the facility; both had attended a five-day training course and were calibrated as valid and reliable AMPS raters. Approval was obtained from the Area Health Service’s Human Research Ethics Committee for the study, which was conducted in accordance with the ethical standards of that committee and with the Helsinki Declaration of 1975, as revised in 1983.
questionable, ineffective, or deficient. Motor skills relate to how the person moves him/herself, tools, and materials during the task, such as walking, bending, lifting, and manipulating items. Process skills relate to applying knowledge, organizational ability, and adaptation when problems occur, such as logically sequencing steps of the task, heeding the goal, and organizing the workspace. After scoring each ADL motor and process skill, the occupational therapist entered raw scores into the AMPS9 computer scoring software. This software adjusted the raw scores for complexity of the task observed and the severity of the rater, and converted them into linear measures of ADL ability (logits) using many-faceted Rasch analyses. Additionally, the software compared the logit measures of our sample with a sample of agematched well people available through the AMPS standardization sample (23, Table 9-2, p9-4), to obtain standardized z-scores. The AMPS standardization sample of well people (n = 12.773) was obtained by AMPS International through a database of evaluations conducted by occupational therapists in various world regions, on “healthy, well persons with no apparent problems or history of medical, psychiatric, physical or cognitive conditions” (12, p15-3).
Instruments
ADL motor and ADL process measures and the standardized z-scores were entered into a spreadsheet and range, mean, and standard deviation (SD) values were calculated. The ADL motor and process ability measures of our sample were demarcated into the various categories based on the competency cut-off ADL motor and ADL process ability scores proposed by Merritt (17). Standardized z-scores were examined to compare the ADL ability in our sample to the normative range for well people available through the AMPS International standardization sample (22).
The Assessment of Motor and Process Skills. The Assessment of Motor and Process Skills measures the quality of a person’s task performance as they carry out chosen, familiar, and life-relevant ADL tasks (13). These tasks may be related to self-care, such as showering, brushing teeth, dressing, and eating; or domestic, such as cooking, housework, gardening, and shopping. The occupational therapists who administered the AMPS worked within the multidisciplinary facility and had the opportunity to engage well and build a therapeutic relationship with the person prior to the AMPS evaluation. Standard administration procedures as outlined in the AMPS manual (23) were followed. Each person chose two tasks that they were willing to perform, which matched their ability, needs, interests, and cultural background. After observing the person perform each task, the occupational therapist scored the overall quality of performance, in terms of effort, efficiency, safety, and independence. Using the criterion of competence, the occupational therapist then rated each of 16 ADL motor and 20 ADL process skills using a four-point rating scale, identifying each skill item as being competent,
Data analysis
Participants Sixty-four out of 78 consecutive people with schizophrenia admitted to the facility during the study period had agreed to an AMPS evaluation. Of the 14 who were not evaluated, seven declined to participate, one could not tolerate the full evaluation, three were discharged soon after admission, and three were not assessed as the calibrated occupational therapist was on leave. Our sample of 64 people comprised 48 males (75%) and 16 females (25%). Their ages ranged from 18 to 52 years with a mean of 29.9 years (SD 8.4).
ADL ability in schizophrenia Table I. Logit and norms-based AMPS ADL ability measures of 64 people with schizophrenia. ADL motor ability
ADL process ability
Mean (SD) in logits
2.18 (0.52)
1.16 (0.47)
Range in logits
0.52–3.32
0.47–2.36
Mean (SD) in standardized z-score
–1.51 (1.05)
–2.1 (1.15)
Range in standardized z-score
–5.2–0.7
–5.5–0.7
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Results Table I describes the AMPS ADL motor and process ability measures of our sample using ADL ability measures (logits) and norm-based perspectives (standardized z-scores). The mean AMPS ADL motor and process ability measures were just above the criterion-based competence cut-off. However, when our sample was compared with age-matched well people their mean ADL motor ability measure was 1.5 SD below and ADL process ability measure 2.1 SD below well people. Further analysis revealed that a range of ADL ability in both motor and process measures was evident among our sample and a significant proportion (64.1% and 62.5%) had measures above the competence cut-off on ADL motor and process ability respectively. However, using age-standardized normative data (standardized z-scores) 28.1% and 46.9% of participants had z-scores two SD below the norm for ADL motor and process ability respectively, suggesting moderate to severe impairments. While in normal distributions 95% of people are expected to measure within two SD of the norm, among our sample only 71.9% and 53.1% measured within two SD of the norm for ADL motor and process ability respectively. Further, very low numbers of people in our sample measured above the mean, 7.81% and 1.56% for ADL motor and process ability respectively. The details of the proportion of our sample deemed as requiring support and assistance for community
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living based on ADL motor and process ability measures cut-off as proposed by Merritt (17) are given in Table II. Our data suggest that 40 people (62.5%) in our sample could be determined as capable of living independently in the community based on ADL motor and process measures and only one person was considered as requiring moderate to maximal assistance utilizing both motor and process cut-off measures (Table II). However, utilizing solely ADL process ability measure cut-off of 0.7 logit when the ADL motor and process measures were not both below cut-off, an additional 11 people in our sample were identified as requiring moderate to maximal assistance.
Discussion Our study examined ADL ability measures in people with schizophrenia and the use of cut-off measures to predict need for assistance to live in the community. The study revealed that people with schizophrenia treated at a public psychiatric in-patient treatment and rehabilitation facility exhibited a range of ADL motor and process ability. Whilst more than 60% performed above the competence cut-off measures, when compared with age-matched data of well people a considerable proportion had moderate to severe deficits. The deficits in ADL process ability were more pronounced compared with motor ability, which is significant as ADL process ability is a stronger predictor of the need for assistance in people with psychiatric diagnoses (18). In addition, only a negligible proportion had ADL ability measures at or above age-standardized norms. Comparable studies using AMPS to measure ADL functions in people with schizophrenia are limited. However, some comparison can be made to the works published by Girard et al. (16) and K. Moore et al. (19) who examined people with schizophrenia from the AMPS International database and Fossey, Harvey, Plant, & Pantelis (24) who evaluated a sample
Table II. Participant ADL motor and ADL process ability measures presented in relation to AMPS cut-off measures (n = 64). Number of participants
ADL motor and process ability measures
Clinical interpretation
39 (60.9%) 1 (1.6%)
Motor ability ‡ 1.5 logits and process ability ‡ 1.0 logit Motor ability < 1.5 logit but process ability ‡ 1.0 logit
Best prediction of independence in the community
9 (14%) 3 (4.7%)
Motor ability ‡ 1.5 and process ability < 1.0 logit but ‡ 0.7 logit Motor ability < 1.5 and process ability < 1.0 logit but ‡ 0.7 logit
Risk zone. Further information required to predict independence in the community
11 (17.2%)
Process ability below 0.7 when motor measure not below 1.0 logit
May need maximal assistance to live in the community
1 (1.6%)
Motor ability below 1.0 logit and process ability below 0.7 logit
May need maximal assistance to live in the community
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Table III. Comparison of studies of AMPS ADL motor and process measures in people with schizophrenia. Our study (n = 64)
Girard et al. (n = 43)
Fossey et al. (n = 43)
Moore et al. (n = 200)
Mean age in years (SD)
29.9 (8.4)
49 (17)
35.09 (7.31)
50.00 (15.2)
Mean ADL motor ability (SD)
2.18 (0.52)
1.9 (0.8)
1.76 (0.41)
1.97 (0.71)
Range: motor scores
0.52–3.32
0.00–3.8
0.99–2.55
Not reported
Mean ADL process ability (SD)
1.16 (0.47)
0.5 (0.7)
0.89 (0.47)
0.81 (0.6)
Range: process ability
0.47–2.36
–1.1–1.6
–0.7–1.67
Not reported
of people with schizophrenia living either in fully supported public residential rehabilitation facilities or at their home supported by an assertive community team (Table III). Unlike our study, these researchers found that the mean motor and process measures in their sample were below the competence cut-off. Similarly, deficits were more pronounced on the process measure. However, all the studies, including ours, observed that a range of ADL ability measures are present in people with schizophrenia, with a significant proportion having considerable impairments. The difference in ADL ability measures among our sample compared with other studies could be partly explained by inclusion of a younger cohort. Our treatment and rehabilitation service caters for people with schizophrenia at various stages of illness, including first episode, and the mean age of our population was younger than the other studies. ADL ability in well people has been shown to reduce with ageing (13). However, together all these studies point towards significant impairment in ADL motor and process ability among a significant proportion of people with schizophrenia. It is unclear whether ADL ability among people with schizophrenia is different from other severe mental illnesses. ADL ability impairments in several domains have been reported in people with bipolar disorder and depression (16,19). Researchers who have analysed data drawn from the AMPS project database have reported differing findings. One study revealed that people with schizophrenia had greater deficits on ADL motor and process measures compared with people with depression (16), whilst another found no clinically significant differences in the mean AMPS motor and process measures among people with schizophrenia, bipolar mania, and bipolar depression (19). Studies involving people recruited without selection bias from the same setting with different diagnoses would give a clearer picture on the extent of ADL ability deficits in these severe mental illnesses. In this study we have not analysed the raw scores of the 16 ADL motor and 20 ADL process skills individually. Cognitive deficits, negative symptoms, and
metabolic problems are common among people with schizophrenia (25). It will be interesting to explore the relationship of these variables with the ADL motor and ADL process measures and with the individual 16 motor and 20 process items. The observation that a substantial proportion of our sample could be determined as capable of independent living at the time of admission, if using only the AMPS ADL measures to inform a judgement, does not reflect well the reality that people were referred to our unit for difficulty living in the community. Functional capacity and real-world community functional performance can be quite divergent among many people with severe mental illness (7,25,26). Some researchers have found that AMPS ADL measures were only moderately useful in predicting home safety for people with mental illness (20). It is likely that in complex conditions such as severe mental illness, a range of clinical, risk, and psychosocial factors will determine treatment setting and support needs rather than assessment based on a single instrument. Numerous other researchers have also opined that AMPS should be used in conjunction with other measures of functional ability (13,14,18). There are two constructs relating to function in schizophrenia: capacity and performance (6,7). Searches for valid and reliable measurement of these for clinical and research purposes are prominent in schizophrenia literature (8-10,27) and we consider the contribution that an AMPS evaluation may make. Although not directly measuring functional capacity, AMPS objectively demonstrates the impact on ADL ability, which is an important predictor of independent living (2). In considering that AMPS evaluates the quality of performance of ADL tasks on a single testing occasion in optimal circumstances, it allows insights into ADL capacity. Additional information on the person’s usual abilities in daily life is required in order to determine the need for assistance. We use AMPS in conjunction with other information to determine what is limiting the person’s ability to live a personally satisfying life in the community, such as the effects of active psychotic, negative, and mood symptoms, cognitive impairments, metabolic
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ADL ability in schizophrenia symptoms, environmental opportunities/disincentives, and availability of supports. Since commencing using the AMPS in December 2010 we have found it to be a clinically useful tool in measuring ADL ability, one component of the person’s ability to live independently in the community. In a health setting where resources are limited, we have found AMPS to be a useful tool to prioritize need for interventions such as skills training for independent living. In addition, we have initiated studies exploring the possible reasons for lower measures on ADL motor and process ability in people with schizophrenia, studying other variables such as positive and negative symptoms, cognition, metabolic problems, and medication side effects. In general, we have found people with schizophrenia to be accepting of the AMPS evaluation when carried out during routine clinical care and rehabilitation planning. Only one person entered into and was unable to continue the assessment and less than 10% declined to participate. Initially we were concerned that the intense scrutiny and note taking by the observing occupational therapist during the task performance would be off-putting for people, particularly those with anxiety or paranoia; however, the vast majority reported that this was not so. We have found that the client-centred nature of task selection has contributed to a willingness to participate. Occupational therapists are skilled in the observation and assessment of personally meaningful activities and observing the person performing real tasks in relevant environments provides “rich information” (5, p 164). The NIMH-MATRICS and VALERO studies in schizophrenia have recommended other performance-based measures of functional capacity and real-world outcomes for treatment studies and clinical purposes (27,28). However, the value of occupational therapy observational assessment in real environments using tools such as the AMPS must remain prominent in treatment settings and in the literature if occupational therapists are to remain recognized as experts in functional assessment and interventions for schizophrenia. There have been recent calls for occupational therapists to use more consistently standardized assessments such as AMPS to measure outcomes following interventions (29) and there has been a small pilot study using the AMPS to measure functional changes in people with schizophrenia following treatment and rehabilitation interventions (30). We intend a similar follow-up study describing the use of AMPS as a functional outcome measure for people with schizophrenia, utilizing data collected from our sample with additional evaluation following interventions. Our study has a number of methodological advantages such as including a sample with homogeneous
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diagnosis and avoiding selection bias by studying consecutive admissions. The occupational therapists were working within the unit, and had engaged well and established therapeutic relationships with each person prior to the AMPS evaluation. However, our sample size was relatively small at 64 and there was an attrition rate of 18%. In addition, being a single-site study, extrapolation of the results to other settings should be done with caution. Though the ratings were done by two different occupational therapists, both were trained and certified as valid and reliable AMPS raters. AMPS has robust psychometric properties and has extensive reliability and validity established through research for assessment of ADL ability properties (13, ch15). Conclusions There is an increasing emphasis worldwide on recognising functional impairments in schizophrenia, which are substantial, complex, and persistent. We have implemented the AMPS, a performance-based evaluation of ADL ability, at our in-patient treatment and rehabilitation facility. The AMPS has been demonstrated to be a valid and reliable instrument for use in people with schizophrenia. It is clinically useful in treatment, rehabilitation, and discharge planning for people admitted to the facility. Results were largely consistent with other studies and have emphasized that people with schizophrenia exhibit a range of ADL motor and process ability, but as a group have significantly poorer motor and process ADL ability compared with the well population. It is possible to speculate whether older cohorts with more longstanding illness are likely to have further deterioration in their ADL ability. The relationship between ADL motor and process ability and other domains of symptoms such as cognitive deficits, negative symptoms, and co-morbidities such as metabolic syndrome in schizophrenia warrants further study. High levels of need for assisted community living were expected, given the facility’s referral criteria was that a person could benefit from intensive rehabilitation to enable community living. Predicted need based on AMPS ADL measures was not consistent with this, however, indicating the complexity of factors influencing functional performance that should be considered when planning assessment, services, and supports for people with schizophrenia. Implications for occupational therapy practice Mental health occupational therapists contribute to meeting the need, currently identified in the psychiatric community, for improved measurement of cognitive and functional outcomes for people with
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schizophrenia. Occupational therapy expertise in functional assessment and tools with strong psychometric properties such as the AMPS should be used and reported prominently. Further studies are indicated into the relationships between functional capacity, cognitive impairments, and physical health factors in people with schizophrenia to identify those factors most impacting on functional performance and real-world outcomes. There is an increasing emphasis on standardized outcome measures that determine the effectiveness of rehabilitation interventions to improve community functioning in people with schizophrenia. Mental health occupational therapists are able to contribute prominently to this research.
Acknowledgements Emma Harrison is acknowledged for contributing to the conduct of AMPS evaluations in routine clinical assessment and rehabilitation planning. Declaration of interest: The authors received no payments for this study and declare that there are no conflicts of interest in relation to the subject of this study.
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ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia Helen Ayres & Alexander Panickacheril John To cite this article: Helen Ayres & Alexander Panickacheril John (2015) The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia, Scandinavian Journal of Occupational Therapy, 22:6, 470-477, DOI: 10.3109/11038128.2015.1061050 To link to this article: http://dx.doi.org/10.3109/11038128.2015.1061050
Published online: 01 Jul 2015.
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Date: 07 November 2015, At: 18:48
Scandinavian Journal of Occupational Therapy. 2015; 22: 470–477
ORIGINAL ARTICLE
The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia
HELEN AYRES1,2 & ALEXANDER PANICKACHERIL JOHN1,2 Downloaded by [University of Cambridge] at 18:48 07 November 2015
1
University of Western Australia, Crawley, Australia, and 2Bentley Health Service, Bentley, Australia
Abstract Background: Functional impairments in schizophrenia are substantial, complex, and persistent. Objective measurement of ADL ability, functional capacity and performance is needed for effective intervention planning and outcome evaluation. Objective: To evaluate ADL ability in people with schizophrenia using the Assessment of Motor and Process Skills (AMPS) and to determine the utility of using the AMPS to predict levels of assistance required for successful community living. Method: In a retrospective audit, AMPS ADL measures of a consecutive sample of 64 people with schizophrenia admitted to a mental health facility were compared with normative data and with recommended “cut-off” measures for competency to live independently in the community. Results: Substantial difficulties were measured in both ADL motor (mean z = –1.5) and ADL process ability (mean z = –2.1). AMPS ability measures did not predict problems with independent living for 62.5% of the patients. Conclusion: People with schizophrenia admitted to an inpatient rehabilitation facility experienced significant difficulty performing ADL tasks. AMPS is a useful measure of ADL ability but should be used in conjunction with measures of functional performance in order to plan interventions and supports for people with schizophrenia that reflect the complexity of factors affecting community functioning.
Key words: occupational therapy, mental illness, function, evaluation, activities of daily living
Introduction In spite of advances in biological and psychosocial treatments, many people with schizophrenia continue to experience considerable difficulties in performing the roles and occupations for daily life, not achieving normal milestones in social relationships, productivity, residence, and self-care (1,2). These difficulties are often pervasive and manifest in a variety of activities of daily living (ADL), such as shopping, cooking, cleaning, managing health, finances, and medications, and using transportation, and contribute to low levels of independent living, competitive employment, and community participation (1). Measuring and promoting ability in these areas is increasingly being recognized as important for research and rehabilitation interventions in schizophrenia (3). Function and independence are key concepts of the
profession of occupational therapy (4) and core elements of occupational therapy assessment and rehabilitation interventions in psychiatry (5). Identifying and implementing appropriate interventions requires an understanding of the complex range of factors affecting the person’s ability to function. The World Health Organization International Classification of Functioning, Disability and Health (ICF) describes functioning as referring to all body functions, activities, and participation. ICF further considers what a person with a health condition can do in a standard environment as their level of capacity, and what they actually do in their usual environment as their level of performance (6). When considering functioning in people with schizophrenia, the constructs of capacity and performance have been used to explain the observed differences between what the person is able to do and what the person does do,
Correspondence: Helen Ayres, B.App.Sc. (OT), Bentley Health Service, Mills Street, Bentley, 6102, Australia. E-mail: [email protected] (Received 24 October 2014; accepted 7 June 2015) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1061050
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ADL ability in schizophrenia which may be affected by a range of factors such as mood, negative symptoms (7), confidence, motivation, self-monitoring, societal opportunities, and disincentives (3). Recently, there has been considerable focus on searching for appropriate measures of functional capacity and performance in people with schizophrenia and related conditions (8-10). Whilst a variety of measures such as ratings based on self-assessments, proxy reports from carers and other informants, and direct observation of task performance in the community have been utilized to evaluate functioning in people with schizophrenia, these approaches are associated with a number of methodological issues related to reliability, validity, and ease of administration (11,12). Whilst multiple measures may be required to capture the complexity of abilities and impairments in people with schizophrenia, performance-based measurement of functional capacity is being increasingly acknowledged in academic and clinical settings as a viable option to evaluate real-world functioning, develop treatment and rehabilitation plans, and measure recovery outcomes (9). Our study examines the use of a performance-based measure, the Assessment of Motor and Process Skills (AMPS), to measure the quality of performance of activities of daily living (ADL) in people with schizophrenia. The Assessment of Motor and Process Skills (AMPS) is a standardized, reliable, and valid occupational-therapy-specific observational evaluation that measures accurately the quality of a person’s activities of daily living (ADL) in natural and taskrelevant environments (13). AMPS has been used for research and clinical purpose in a range of health settings in different geographical regions and cultures, such as among people with stroke, dementia, learning disabilities, and other neurological and general medical conditions to measure ADL ability, plan appropriate interventions, evaluate response to treatment, and to determine level of support and assistance required (13). However, studies on the utility of AMPS among patients with severe mental illness such as schizophrenia are sparse (14). A limited amount of research has demonstrated discriminant validity of AMPS motor and process measures between well and psychiatrically ill people (15) and between people with depression and schizophrenia (16). Merritt (17) has explored the option of utilizing AMPS ability measures to predict level of assistance required in the community for people with ADL impairments. Using receiver operating characteristic (ROC) analysis the author found that matched measures of < 1 logits on ADL motor ability and < 0.7 logits on ADL process ability would predict well the need for moderate/maximum assistance in
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the community. The author also observed that people with ADL measures of 1.5 logits and more on the motor scale and 1.0 logits and more on the process scale were unlikely to require much support to live independently in the community. Further work by Merritt (18) explored more specifically the predictive validity of AMPS ADL ability measures in relation to diagnoses. Using a recommended cut-off measure of 1.5 logits motor ability and 1.0 logit process ability to predict the need for assistance, for people with mixed psychiatric diagnoses, the author found that while the motor ability cut-off measure had a poor discriminating value, the process ability cut-off measure was more accurate, with a fair discriminating value. Whilst assessment using AMPS can have a wide range of clinical utility for people with severe mental illness, due to the limited number of research studies and methodological limitations of these studies there are significant knowledge gaps. Studies on people with schizophrenia are limited, mostly involving older people with a mean age around 50 (16,19), which is much higher than the typical age of onset of this condition. Methodological issues of previous studies include using non-homogeneous diagnoses (15,20), small sample sizes (20), samples drawn from the same database for different studies (15-17), and case reports involving very small numbers (21). Studies truly representative of people with schizophrenia seen in specialized treatment and rehabilitation settings of public mental health services are sparse. To the best of our knowledge there are no published studies on the utility of AMPS as a functional assessment tool among a representative sample of people with schizophrenia admitted to an in-patient treatment and rehabilitation psychiatry setting. In view of this, we decided to study the use of the AMPS to measure ADL ability in a sample of people with schizophrenia admitted to our facility. Material and methods This study is a retrospective medical records audit of ADL task performance measured using the AMPS, in people with schizophrenia at the time of admission to a tertiary care, medium length of stay, psychiatric treatment and rehabilitation facility. This 12 bed in-patient public psychiatry facility provides integrated pharmacological and evidence-based psychosocial interventions to enable people with severe mental illness to achieve optimal outcome in various domains of their health, function, and personal goals. The large majority of people admitted to the facility were people with schizophrenia. Referral criteria to the facility are for people who would benefit from intensive rehabilitation to enable them to live in the community, and to function at their optimal level. It
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can therefore be reasonably assumed that all of our sample population would require some support or assistance to live in the community at the time of admission. For the purpose of this study we analysed the AMPS ADL motor and process ability measures of consecutive people admitted with a diagnosis of schizophrenia between December 2010 and March 2014. All people with diagnosis of schizophrenia admitted to the facility within that time and who had agreed to undertake an AMPS evaluation as part of their routine clinical care were included in the study. People with a diagnosis of other related conditions such as schizoaffective disorder or other non-organic psychoses were not included. Psychiatric diagnoses were made on admission to the facility after a detailed semi-structured clinical interview by a senior consultant psychiatrist utilizing DSM-IV criteria (22). AMPS evaluations were conducted soon after admission for baseline rehabilitation planning. During the time frame of the study, two senior occupational therapists were employed at the facility; both had attended a five-day training course and were calibrated as valid and reliable AMPS raters. Approval was obtained from the Area Health Service’s Human Research Ethics Committee for the study, which was conducted in accordance with the ethical standards of that committee and with the Helsinki Declaration of 1975, as revised in 1983.
questionable, ineffective, or deficient. Motor skills relate to how the person moves him/herself, tools, and materials during the task, such as walking, bending, lifting, and manipulating items. Process skills relate to applying knowledge, organizational ability, and adaptation when problems occur, such as logically sequencing steps of the task, heeding the goal, and organizing the workspace. After scoring each ADL motor and process skill, the occupational therapist entered raw scores into the AMPS9 computer scoring software. This software adjusted the raw scores for complexity of the task observed and the severity of the rater, and converted them into linear measures of ADL ability (logits) using many-faceted Rasch analyses. Additionally, the software compared the logit measures of our sample with a sample of agematched well people available through the AMPS standardization sample (23, Table 9-2, p9-4), to obtain standardized z-scores. The AMPS standardization sample of well people (n = 12.773) was obtained by AMPS International through a database of evaluations conducted by occupational therapists in various world regions, on “healthy, well persons with no apparent problems or history of medical, psychiatric, physical or cognitive conditions” (12, p15-3).
Instruments
ADL motor and ADL process measures and the standardized z-scores were entered into a spreadsheet and range, mean, and standard deviation (SD) values were calculated. The ADL motor and process ability measures of our sample were demarcated into the various categories based on the competency cut-off ADL motor and ADL process ability scores proposed by Merritt (17). Standardized z-scores were examined to compare the ADL ability in our sample to the normative range for well people available through the AMPS International standardization sample (22).
The Assessment of Motor and Process Skills. The Assessment of Motor and Process Skills measures the quality of a person’s task performance as they carry out chosen, familiar, and life-relevant ADL tasks (13). These tasks may be related to self-care, such as showering, brushing teeth, dressing, and eating; or domestic, such as cooking, housework, gardening, and shopping. The occupational therapists who administered the AMPS worked within the multidisciplinary facility and had the opportunity to engage well and build a therapeutic relationship with the person prior to the AMPS evaluation. Standard administration procedures as outlined in the AMPS manual (23) were followed. Each person chose two tasks that they were willing to perform, which matched their ability, needs, interests, and cultural background. After observing the person perform each task, the occupational therapist scored the overall quality of performance, in terms of effort, efficiency, safety, and independence. Using the criterion of competence, the occupational therapist then rated each of 16 ADL motor and 20 ADL process skills using a four-point rating scale, identifying each skill item as being competent,
Data analysis
Participants Sixty-four out of 78 consecutive people with schizophrenia admitted to the facility during the study period had agreed to an AMPS evaluation. Of the 14 who were not evaluated, seven declined to participate, one could not tolerate the full evaluation, three were discharged soon after admission, and three were not assessed as the calibrated occupational therapist was on leave. Our sample of 64 people comprised 48 males (75%) and 16 females (25%). Their ages ranged from 18 to 52 years with a mean of 29.9 years (SD 8.4).
ADL ability in schizophrenia Table I. Logit and norms-based AMPS ADL ability measures of 64 people with schizophrenia. ADL motor ability
ADL process ability
Mean (SD) in logits
2.18 (0.52)
1.16 (0.47)
Range in logits
0.52–3.32
0.47–2.36
Mean (SD) in standardized z-score
–1.51 (1.05)
–2.1 (1.15)
Range in standardized z-score
–5.2–0.7
–5.5–0.7
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Results Table I describes the AMPS ADL motor and process ability measures of our sample using ADL ability measures (logits) and norm-based perspectives (standardized z-scores). The mean AMPS ADL motor and process ability measures were just above the criterion-based competence cut-off. However, when our sample was compared with age-matched well people their mean ADL motor ability measure was 1.5 SD below and ADL process ability measure 2.1 SD below well people. Further analysis revealed that a range of ADL ability in both motor and process measures was evident among our sample and a significant proportion (64.1% and 62.5%) had measures above the competence cut-off on ADL motor and process ability respectively. However, using age-standardized normative data (standardized z-scores) 28.1% and 46.9% of participants had z-scores two SD below the norm for ADL motor and process ability respectively, suggesting moderate to severe impairments. While in normal distributions 95% of people are expected to measure within two SD of the norm, among our sample only 71.9% and 53.1% measured within two SD of the norm for ADL motor and process ability respectively. Further, very low numbers of people in our sample measured above the mean, 7.81% and 1.56% for ADL motor and process ability respectively. The details of the proportion of our sample deemed as requiring support and assistance for community
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living based on ADL motor and process ability measures cut-off as proposed by Merritt (17) are given in Table II. Our data suggest that 40 people (62.5%) in our sample could be determined as capable of living independently in the community based on ADL motor and process measures and only one person was considered as requiring moderate to maximal assistance utilizing both motor and process cut-off measures (Table II). However, utilizing solely ADL process ability measure cut-off of 0.7 logit when the ADL motor and process measures were not both below cut-off, an additional 11 people in our sample were identified as requiring moderate to maximal assistance.
Discussion Our study examined ADL ability measures in people with schizophrenia and the use of cut-off measures to predict need for assistance to live in the community. The study revealed that people with schizophrenia treated at a public psychiatric in-patient treatment and rehabilitation facility exhibited a range of ADL motor and process ability. Whilst more than 60% performed above the competence cut-off measures, when compared with age-matched data of well people a considerable proportion had moderate to severe deficits. The deficits in ADL process ability were more pronounced compared with motor ability, which is significant as ADL process ability is a stronger predictor of the need for assistance in people with psychiatric diagnoses (18). In addition, only a negligible proportion had ADL ability measures at or above age-standardized norms. Comparable studies using AMPS to measure ADL functions in people with schizophrenia are limited. However, some comparison can be made to the works published by Girard et al. (16) and K. Moore et al. (19) who examined people with schizophrenia from the AMPS International database and Fossey, Harvey, Plant, & Pantelis (24) who evaluated a sample
Table II. Participant ADL motor and ADL process ability measures presented in relation to AMPS cut-off measures (n = 64). Number of participants
ADL motor and process ability measures
Clinical interpretation
39 (60.9%) 1 (1.6%)
Motor ability ‡ 1.5 logits and process ability ‡ 1.0 logit Motor ability < 1.5 logit but process ability ‡ 1.0 logit
Best prediction of independence in the community
9 (14%) 3 (4.7%)
Motor ability ‡ 1.5 and process ability < 1.0 logit but ‡ 0.7 logit Motor ability < 1.5 and process ability < 1.0 logit but ‡ 0.7 logit
Risk zone. Further information required to predict independence in the community
11 (17.2%)
Process ability below 0.7 when motor measure not below 1.0 logit
May need maximal assistance to live in the community
1 (1.6%)
Motor ability below 1.0 logit and process ability below 0.7 logit
May need maximal assistance to live in the community
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Table III. Comparison of studies of AMPS ADL motor and process measures in people with schizophrenia. Our study (n = 64)
Girard et al. (n = 43)
Fossey et al. (n = 43)
Moore et al. (n = 200)
Mean age in years (SD)
29.9 (8.4)
49 (17)
35.09 (7.31)
50.00 (15.2)
Mean ADL motor ability (SD)
2.18 (0.52)
1.9 (0.8)
1.76 (0.41)
1.97 (0.71)
Range: motor scores
0.52–3.32
0.00–3.8
0.99–2.55
Not reported
Mean ADL process ability (SD)
1.16 (0.47)
0.5 (0.7)
0.89 (0.47)
0.81 (0.6)
Range: process ability
0.47–2.36
–1.1–1.6
–0.7–1.67
Not reported
of people with schizophrenia living either in fully supported public residential rehabilitation facilities or at their home supported by an assertive community team (Table III). Unlike our study, these researchers found that the mean motor and process measures in their sample were below the competence cut-off. Similarly, deficits were more pronounced on the process measure. However, all the studies, including ours, observed that a range of ADL ability measures are present in people with schizophrenia, with a significant proportion having considerable impairments. The difference in ADL ability measures among our sample compared with other studies could be partly explained by inclusion of a younger cohort. Our treatment and rehabilitation service caters for people with schizophrenia at various stages of illness, including first episode, and the mean age of our population was younger than the other studies. ADL ability in well people has been shown to reduce with ageing (13). However, together all these studies point towards significant impairment in ADL motor and process ability among a significant proportion of people with schizophrenia. It is unclear whether ADL ability among people with schizophrenia is different from other severe mental illnesses. ADL ability impairments in several domains have been reported in people with bipolar disorder and depression (16,19). Researchers who have analysed data drawn from the AMPS project database have reported differing findings. One study revealed that people with schizophrenia had greater deficits on ADL motor and process measures compared with people with depression (16), whilst another found no clinically significant differences in the mean AMPS motor and process measures among people with schizophrenia, bipolar mania, and bipolar depression (19). Studies involving people recruited without selection bias from the same setting with different diagnoses would give a clearer picture on the extent of ADL ability deficits in these severe mental illnesses. In this study we have not analysed the raw scores of the 16 ADL motor and 20 ADL process skills individually. Cognitive deficits, negative symptoms, and
metabolic problems are common among people with schizophrenia (25). It will be interesting to explore the relationship of these variables with the ADL motor and ADL process measures and with the individual 16 motor and 20 process items. The observation that a substantial proportion of our sample could be determined as capable of independent living at the time of admission, if using only the AMPS ADL measures to inform a judgement, does not reflect well the reality that people were referred to our unit for difficulty living in the community. Functional capacity and real-world community functional performance can be quite divergent among many people with severe mental illness (7,25,26). Some researchers have found that AMPS ADL measures were only moderately useful in predicting home safety for people with mental illness (20). It is likely that in complex conditions such as severe mental illness, a range of clinical, risk, and psychosocial factors will determine treatment setting and support needs rather than assessment based on a single instrument. Numerous other researchers have also opined that AMPS should be used in conjunction with other measures of functional ability (13,14,18). There are two constructs relating to function in schizophrenia: capacity and performance (6,7). Searches for valid and reliable measurement of these for clinical and research purposes are prominent in schizophrenia literature (8-10,27) and we consider the contribution that an AMPS evaluation may make. Although not directly measuring functional capacity, AMPS objectively demonstrates the impact on ADL ability, which is an important predictor of independent living (2). In considering that AMPS evaluates the quality of performance of ADL tasks on a single testing occasion in optimal circumstances, it allows insights into ADL capacity. Additional information on the person’s usual abilities in daily life is required in order to determine the need for assistance. We use AMPS in conjunction with other information to determine what is limiting the person’s ability to live a personally satisfying life in the community, such as the effects of active psychotic, negative, and mood symptoms, cognitive impairments, metabolic
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ADL ability in schizophrenia symptoms, environmental opportunities/disincentives, and availability of supports. Since commencing using the AMPS in December 2010 we have found it to be a clinically useful tool in measuring ADL ability, one component of the person’s ability to live independently in the community. In a health setting where resources are limited, we have found AMPS to be a useful tool to prioritize need for interventions such as skills training for independent living. In addition, we have initiated studies exploring the possible reasons for lower measures on ADL motor and process ability in people with schizophrenia, studying other variables such as positive and negative symptoms, cognition, metabolic problems, and medication side effects. In general, we have found people with schizophrenia to be accepting of the AMPS evaluation when carried out during routine clinical care and rehabilitation planning. Only one person entered into and was unable to continue the assessment and less than 10% declined to participate. Initially we were concerned that the intense scrutiny and note taking by the observing occupational therapist during the task performance would be off-putting for people, particularly those with anxiety or paranoia; however, the vast majority reported that this was not so. We have found that the client-centred nature of task selection has contributed to a willingness to participate. Occupational therapists are skilled in the observation and assessment of personally meaningful activities and observing the person performing real tasks in relevant environments provides “rich information” (5, p 164). The NIMH-MATRICS and VALERO studies in schizophrenia have recommended other performance-based measures of functional capacity and real-world outcomes for treatment studies and clinical purposes (27,28). However, the value of occupational therapy observational assessment in real environments using tools such as the AMPS must remain prominent in treatment settings and in the literature if occupational therapists are to remain recognized as experts in functional assessment and interventions for schizophrenia. There have been recent calls for occupational therapists to use more consistently standardized assessments such as AMPS to measure outcomes following interventions (29) and there has been a small pilot study using the AMPS to measure functional changes in people with schizophrenia following treatment and rehabilitation interventions (30). We intend a similar follow-up study describing the use of AMPS as a functional outcome measure for people with schizophrenia, utilizing data collected from our sample with additional evaluation following interventions. Our study has a number of methodological advantages such as including a sample with homogeneous
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diagnosis and avoiding selection bias by studying consecutive admissions. The occupational therapists were working within the unit, and had engaged well and established therapeutic relationships with each person prior to the AMPS evaluation. However, our sample size was relatively small at 64 and there was an attrition rate of 18%. In addition, being a single-site study, extrapolation of the results to other settings should be done with caution. Though the ratings were done by two different occupational therapists, both were trained and certified as valid and reliable AMPS raters. AMPS has robust psychometric properties and has extensive reliability and validity established through research for assessment of ADL ability properties (13, ch15). Conclusions There is an increasing emphasis worldwide on recognising functional impairments in schizophrenia, which are substantial, complex, and persistent. We have implemented the AMPS, a performance-based evaluation of ADL ability, at our in-patient treatment and rehabilitation facility. The AMPS has been demonstrated to be a valid and reliable instrument for use in people with schizophrenia. It is clinically useful in treatment, rehabilitation, and discharge planning for people admitted to the facility. Results were largely consistent with other studies and have emphasized that people with schizophrenia exhibit a range of ADL motor and process ability, but as a group have significantly poorer motor and process ADL ability compared with the well population. It is possible to speculate whether older cohorts with more longstanding illness are likely to have further deterioration in their ADL ability. The relationship between ADL motor and process ability and other domains of symptoms such as cognitive deficits, negative symptoms, and co-morbidities such as metabolic syndrome in schizophrenia warrants further study. High levels of need for assisted community living were expected, given the facility’s referral criteria was that a person could benefit from intensive rehabilitation to enable community living. Predicted need based on AMPS ADL measures was not consistent with this, however, indicating the complexity of factors influencing functional performance that should be considered when planning assessment, services, and supports for people with schizophrenia. Implications for occupational therapy practice Mental health occupational therapists contribute to meeting the need, currently identified in the psychiatric community, for improved measurement of cognitive and functional outcomes for people with
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schizophrenia. Occupational therapy expertise in functional assessment and tools with strong psychometric properties such as the AMPS should be used and reported prominently. Further studies are indicated into the relationships between functional capacity, cognitive impairments, and physical health factors in people with schizophrenia to identify those factors most impacting on functional performance and real-world outcomes. There is an increasing emphasis on standardized outcome measures that determine the effectiveness of rehabilitation interventions to improve community functioning in people with schizophrenia. Mental health occupational therapists are able to contribute prominently to this research.
Acknowledgements Emma Harrison is acknowledged for contributing to the conduct of AMPS evaluations in routine clinical assessment and rehabilitation planning. Declaration of interest: The authors received no payments for this study and declare that there are no conflicts of interest in relation to the subject of this study.
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