Diagnostic Signs in Recreational Therapy

joan burlingame, CTRS, ABDA, HTR

Question: You have talked about developing and using "signs." What do you mean?

A sign is a non-paper (usually non computer) measurement. A "sign" used by health care providers has two elements: 1. it is a clearly defined, observable and measurable characteristic; 2. which has been shown to have a significant meaning. One of the best known set of signs are vital signs (blood pressure, pulse and temperature).

Two other signs commonly known to recreational therapists are
1. the universal sign for choking (hands placed near throat to indicate a blockage of the individual’s airway)
2. cyanosis, which is a sign of a lack of oxygen.

The field of recreational therapy has many practitioners who are very observant. I believe that during the next decade we will identify numerous characteristics which have significant meaning. But what is the process we need to use to establish signs that have significant meaning to leisure skills and leisure involvement? I believe that there are six steps:
1. Identifying a characteristic (behavior) which seems to fall into a pattern.
2. Write a statement which describes: a. the characteristic (what is observed), b. when it is observed (i.e., during what activity), and c. how it is measured.
3. Hypothesizing about the meaning of the characteristic.
4. Testing the hypothesis.
5. Sharing findings with at least five other facilities who also test the hypothesis.
6. Reporting group findings to the profession through presentations, journal articles and other publications to encourage further testing and use of the sign.

To better understand this process I will share what I call the "porcupine sign." In addition to being president of Idyll Arbor, I keep up with current health care practices by working as a per diem therapist at a large county hospital. One of my favorite units to work on is the locked psychiatric unit. This unit has a very short stay (3 to 14 days) for adults with psychiatric diagnoses who are either a danger to themselves or to others. The functional level of the patients varies significantly, from almost catatonic to hyperawareness with excessive motor activity.

One of the activities I choose to run, because of the broad scope and depth of measurement I can obtain, is "Sticky Spaghetti" (The wRECking Yard of Games and Activities, Alanna. Jones, 1996). The stated "goal" of sticky spaghetti is to see who can build the highest tower using two building materials: large marshmallows and uncooked spaghetti noodles. What I don’t tell the patients is that, usually, to build a tower of more than two levels you need three hands. I do not cue the patients to build a tower after my initial instructions, as I am measuring the patients’ ability to follow instruction and learn from peers. This activity allows me to measure many skills and attributes, including: 1. planning skills, 2. problem solving, 3. attention span, 4. asking for help from a peer (when s/he finally realizes that s/he needs someone else’s help), 5. anger/frustration management, 6. fine motor/gross motor skills, 7. cooperative interaction skills/interpersonal communication, 8. conflict resolution (if the two patients disagree on how to solve problems), 9. leadership/follower skills and 10. ability to learn from others’ successes and failures.

About half of the time I run this activity I have a patient assigned to my activity who makes a "porcupine" instead of a tower. A porcupine is a single marshmallow with multiple (five or more), short, (1 inch to 3 inches) pieces of spaghetti stuck into it over a period of five to ten minutes. After a period of no more than ten minutes the patient abandons this activity and either sits quietly, emotionally withdrawn from the group or gets up and wonders off with little to no ceremony.

So far the characteristics of these patients are very similar. During their intake assessments they tended to be cooperative, providing the therapist with short, generalized answers to questions. On casual observation this group of patients appear to be without noticeable behavioral dysfunction but seem to be on the quiet side. However, when presented with a task, their functional impairments became obvious. These patients do not demonstrate the ability to follow three step commands without cueing, initiation of meaningful leisure activity is significantly impaired, communication tends to be limited to five word answers (frequently less). The demonstrated ability to take a limited risk during activity is moderately to maximally impaired. These patients, who frequently could list two hobbies which they professed skill in, were not able to engage in meaningful activity without verbal support and cueing (1x every 2-5 minutes) for fairly simple, familiar tasks. Their movements become so sluggish they demonstrate a mild to moderate motor retardation, requiring verbal cues to resume activity. This same group of patients usually are able to give shallow, somewhat convincing answers during a brief intake assessment.

I hypothesize that if a patient demonstrates quiet, subdued behavior and is able to report one or two hobbies of interest during the intake assessment but demonstrates the porcupine sign (i.e., builds a porcupine instead of a tower), then that patient will not be independent in the initiation and maintenance of a healthy, independent lifestyle. Therefore, demonstrating the porcupine sign would indicate a need for recreational therapy intervention to reduce isolative and anhedonic behaviors after discharge.

Because I do not work that often at the county hospital, I am not personally able to test my hypothesis.  The hypothesis may be true, may need modification to be true, or may be false. We will only know if a variety of facilities are willing to test it. But wouldn’t it be exciting if recreational therapy had a sign which had significant meaning? This may be a good internship project, master’s thesis or a good quality indicator project for a facility.

As our field becomes more sophisticated with recognizing, defining and using signs, we will be able to divide our signs into three types: 1. constitutional signs (symptoms or measurable characteristics which affect the whole body, such as a high temperature due to an infection), 2. prodromal signs (symptoms or measurable characteristics which are present before the underlying problem is obvious, such as a pain radiating down a patient’s left arm before a heart attack), and 3. local signs (symptoms or measurable characteristics which effect only one part of the body, such as swelling confined to the ankle as a result of a sprain).

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