Read Full Text: Quantitative Evaluation System of Soft Neurological Signs for Children with Attention Deficit Hyperactivity Disorder (ADHD) (Free to access)
Journal: Sensors (Impact Factor 3.031)
Year Published: 2016
Neurological soft signs are a hot topic in OT right now, and I can see why…they are fascinating. And, they confirm what seasoned OT professionals have seen over the years: there is often more going on with our patients, at a biological level, than is readily apparent.
If the term “neurological soft signs” is new to you, no worries. I’m sure your experience and education have taught you more about them than you might imagine.
This week’s article focuses on a specific soft neurological sign, slowed pronation/supination in children with Attention-Deficit/Hyperactivity Disorder (ADHD). The article gives you a window into where the research is at with soft neurological signs—as well as their potential future clinical applications.
(Please note that this article topic is a special request from a Club member—and it does not appear on our 100 most influential articles list, which we will return to next week.)
Quick overview of soft neurological signs (SNS)
“Neurological soft signs,” or “soft neurological signs” (SNS), are observable motor and sensory conditions that cannot be linked to specific brain lesions. (Think: associated movements, involuntary movements, slowed motor skills, etc.)
These soft signs are things we have been noticing in patients for decades—particularly in specific patient populations—but improved brain tracking and standardized assessments are rapidly expanding how we think of them clinically.
I want to clarify that many of these neurological signs are present in infants and young children, but they eventually disappear (or “integrate”) over time. They only become abnormal when they persist longer than they should.
I also want to highlight that the lists I saw of what soft signs could entail varied. Part of this might be the fact that there appears to be a gray area between “soft” and “hard” neurological signs.
Here are examples of soft neurological signs that I found in this article and this article:
- Finger-to-nose
- Finger opposition
- Visual pursuits
- Heel-toe walking
- Pronation and supination
- Associated movements
- Involuntary movements (like choreiform movements)
- Dysrhythmia
- Dysmetria
- Intention tremor
Certain conditions where SNS are found are currently being researched, including:
- Schizophrenia (This is where some of the most prominent research has been done)
- Attention-deficit/hyperactivity disorder (ADHD)
- Autism spectrum disorder (ASD)
- Obsessive-compulsive disorder (OCD)
- Bipolar disorder
- First episode of psychosis
Finally, I think it is super important to mention that the exact origins of SNS are currently unknown, but what authors seem to be suggesting is that they may be caused by a difficulty in integrating the sensory and motor systems. Others have hypothesized that maybe there is some neural circuitry in the subcortical areas of the brain that are being impacted. But, the bottom line is that we simply don’t know their origins.
Why neurological soft signs are important
The development of motor and sensory skills is extremely complex and requires coordination of many parts of the brain. Hence, a delay or impairment in any of these skills can be one of the first indicators that something is developmentally atypical.
It could be the “canary in the coal mine,” so to speak.
For example, motor deficits can be among the earliest and most prominent symptoms of ASD—and they frequently precede core social and communicative symptoms.
Hence, if we can get a better understanding of these early soft signs, it may make a huge difference in early detection and treatment.
ADHD and soft neurological signs
Ok, finally onto the specifics of the article:
Attention-Deficit/Hyperactivity Disorder (ADHD) is typically evaluated by a psychologist by doing the following:
- Reviewing prenatal and perinatal development
- Taking a thorough family history
- Completing a physical and neurological examination using visual inspection of soft neurological signs (SNS). (This often does not use a quantitative method as it uses visual observation and that can be biased.)
The researchers wanted to see if there was a way to better quantify SNS in ADHD beyond the typical visual observation.
How the researchers quantified SNS of pronation/supination
The researchers decided to examine the SNS of pronation and supination response time by using a wireless computer system. The idea was that the system could evaluate more precisely whether this specific SNS in children with ADHD would present differently compared to their typically developing peers.
Researchers used wireless acceleration and angular velocity sensors (which look similar to e-stim pads) placed on both triceps and the tops of both hands. The sensors tracked the children’s movements via bluetooth while the children mimicked guided movements on the computer screen.
The Results
In a nutshell, here were the results:
Spanning from ages 8-11 years old, there were significant differences found in rotation speed, mirror movements, bimanual symmetry, temporal change (or pauses), and compliance with matching the images on the screen. These results indicated that the SNS of motor coordination for pronation and supination function tend to develop several years later in children with ADHD, compared to their typically developing peers.
Further reading:
If this information is relevant to your practice, I highly recommend the 2018 article Scientific Evidence for the Evaluation of Neurological Soft Signs as Atypical Neurodevelopment Markers in Childhood Neuropsychiatric Disorders. Reading it informed much of my thinking on the article, but it is, unfortunately not free to access at this point.
Takeaways for OT practitioners
(These are my personal takeaways, and were not mentioned in the article.)
Neurological soft signs are fascinating—and it’s important for therapists to be aware of them.
As I mentioned before, I think all OTs should have a general awareness of neurological soft signs.
For me, reading about them served as an important reminder that there is so much going on at a biological level that we have yet to understand—not to mention, the fact that our systems are interconnected in ways we are still grasping to understand.
NSS may play an important role in screening, but more research and guidelines are needed.
Screening is a complex topic. I refer you back to our conversation on universal screening for Autism, to get a sense of the complexity.
Basically, you want to be using the best assessments, and not cause unnecessary panic and alarm. Everything I read about NSS indicated that research, although promising, is still in the early stages. No concrete recommendations were given for the use of SNS in screening.
So, it does not seem appropriate to incorporate them as a standard screen, if no neurologic impairment is suspected—at least not at this time.
However, if a certain neurological sign is getting suddenly worse or is especially prominent, it definitely seems important to quantify it to the best of your ability and make an appropriate referral.
I did not see any indicators in research that we should be specifically addressing soft neurological signs in hopes that the intervention would have a broader impact on the condition.
Of course, the question begs itself, if we see something like retained reflexes or delayed motor skills, should we be directly addressing this SNS in our care?
This very topic came up in my supplementary reading on SNS, and I thought it was an important to highlight. I will relay to you the AOTA advice on this, which was found in this 2019 CE article:
Occupational therapists should distinguish between correlation and causality in considering intervention strategies to address learning and behavior problems. The fact that soft signs (such as retained reflexes or poor lateral dominance) are associated with attention and learning problems does not imply they are the cause of these impairments. Intervention approaches claiming to change the brain by establishing lateral dominance, or “integrating” residual reflexes, have little supportive evidence in the scientific literature. Signs are sequelae of brain dysfunction—not causes of it. (pg. 6.)
Listen to my takeaways in podcast form:
Find other platforms for listening to the OT Potential Podcast here.
(Possibly) Earn CEUs/PDUs for reading this article
Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.
And, here’s the full APA citation you many need:
Kaneko, M., Yamashita, Y., & Iramina, K. (2016). Quantitative evaluation system of soft neurological signs for children with attention deficit hyperactivity disorder. Sensors, 16(1), 116.
Now, I just need to get used to your new last name!