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Toglias Dynamic Interactional

Approach to Cognitive
Rehabilitation
OT460A

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OT 460A

Objectives or what Robin wants you to know


to be a great OT
An understanding of the basic assumptions and principles of this
theory so that you can compare and contrast it to other theories,
especially ones that are logical to do so, like the Cognitive
Disability FOR. This means that you need to be able to:
Contrast the assumptions in this model to more traditional
cognitive models
Describe how the person, task, and the environment and how
modifications within each of these can influence performance
Select appropriate assessments tools
Describe appropriate intervention strategies that can be used
to assist clients
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Relevance of Theory To Work


with Mentally Ill
People with mental illness often have cognitive
deficits:
The theory is an attempt to integrate cognitive
psychology theories about learning with rehabilitation
principles
The principles can be applied to interventions with
persons with chronic mental illness, especially those
people with schizophrenia
It pays attention to the psychological and emotional
parts of a client and their impact on the ability for
meaningful participation in occupation
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Toglias Definitions
Cognition: an ongoing product of the dynamic
interaction between the individual (person),the task
(occupation) and the environment.
Consistent with person-environment-occupation models

Dynamic Interactional Model: a restorative (i.e.,


change can happen!) cognitive rehabilitation
approach used to enhance the functional performance
of persons having a cognitive impairment.
Model can be used to develop cognitive and metacognitive
strategies and uses learner characteristics to increase
occupational performance.

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Assumptions of the DIA


The person is able to learn and improve cognitive
functioning
Adaptations and compensatory approaches may be
needed to improve performance
There are ongoing interactions between the
individual, the task, and the environment that
facilitate or interfere with cognitive processing
required for participation in daily life
A persons dynamic cognitive system is constantly
changing as the person attempts to pay attention to
multiple variables
A persons cognitive abilities are different in different
settings
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Contrast with Traditional Approaches


Traditional
Focuses on separate components of
cognition and is reductionistic
Deficit-specific model
Sub-skills are hierarchically
arranged (like ACLS)
Deficits are identified based on
test performance (like ACLS)
Demands are placed on the
impaired area and there is
repetitive practice of skills in
specific tasks
Focus of intervention is on specific
components, e.g., attention, perception,
memory, knowledge, and problemsolving

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DIA:

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Focuses on how components


work together to do cognitive
processing
Not focused on determining
the absolute level of
performance on tests of
cognitive sub-skills
Learning style, life experience,
difficulty and nature of tasks
and characteristics of the
environment are viewed as
affecting cognition

DIA Reflects an Information


Processing Perspective
Input: information from environment
New information is combined with existing
information and is made sense of
Throughput or elaboration: Judgments and
decisions are made
Output: Decisions are acted upon
Feedback about performance
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Learner Characteristics in DIA


Metacognition: ability to judge abilities in relation
to a task (first question in Togglia Categorization
Test (the forks, spoons, knives assessment!)
Knows cognitive processing abilities and limitations
Is able to plan ahead and adjust to changing task
demands
Is able to predict the likely consequences of ones
actions
Is able to make necessary adjustments for success
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Learner Characteristics in DIA


Three levels of cognitive awareness within
the metacognition domain
Intellectual awareness: ability to understand
that cognitive functioning is impaired
Emergent awareness: ability to recognize
experiencing of a performance problem as it
occurs
Anticipatory awareness: ability to predict or
anticipate where and when there will be a
problem
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Application of Levels of Awareness


Lets be honest: In terms of learning the concepts for
this course, do you
Think of yourself as being impaired in some way?
(Robins answer about herself: It depends upon the time
of day.)
Recognize that at times youre not understanding what
youre reading? (Robins answer about herself: That
happens to me all the time!)
Often predict that you will have difficulty retaining the
concepts? (Robins answer about herself: This was
constant during my work on my dissertation!)
Now You honestly answer the questions.
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Application of Levels of Awareness


Robins experience with multiple women at Gateway:
Intellectual awareness: Most women admit to having
difficulties with cognitive functioning, especially memory
Results from research studies have indicated that there may be
difficulties with concentration, attention span, and problem solving

Emergent awareness: A lot of women dont realize that they


are having problems with completion of a task because they
are unaware of the comprehensive steps to a task
Anticipatory awareness: This is the issue of why the COPM
numbers dont seem to be accurate for a lot of women

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Two Levels of Cognitive Processing


Surface level: memorizing of facts and procedures
with no application:
How many of you do this for a test? If you do, the
downside is that the information is frequently not retained
and therefore not applied. To be an effective OT, you have
to pull on past information to assure that your interventions
are the best for the clients.

Deep processing level: new information is connected


to current knowledge by elaborating and organizing
the information
This is what the faculty want you to do and why we
provide you with contexts for application, e.g., fieldwork.
The upside of this is that leads to long-term retention
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Processing Strategies
Processing strategies and behavior:
organized approaches, routines, or tactics
that operate to select and guide the
processing of information (B & B, p. 272)
Strategies are used to acquire information
necessary for everyday activities
Strategies and behaviors are listed in B & B
Appendix M
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Processing Strategies
Internal: mental activities used to remind
self to do something or to keep on track
Examples: rehearsing, self-cuing, and selfquestioning
Special type of strategy: self-monitoring in
which the person questions, tracks, and/or
evaluates his or her own thoughts or
performance (You did this in OT 311 during
and after group leadership)
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Processing Strategies
External strategies: Reliance on external cues
Examples: To do lists, calendars

Situation strategies: Strategies that are dependent


upon the situation and setting
Non-situational strategies: Strategies used under
diverse circumstances
Examples: Stating steps of a task as it is performed;
visualization; cognitive behavioral techniques

Disruptions of strategies or lack of awareness of


potential strategies can affect self-efficacy
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Example: Cognitive Strategies with


Women at Gateway
Problems with decision-making due to not being
allowed to make decisions, not being taught how
to make decisions, and/or underlying learning
disabilities
Women carry around a card with them that prompts
them to ask themselves questions prior to making a
decision. Questions are individually developed.
Examples:

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Will it hurt me?


Will it hurt my children?
Will it make my children and me unsafe?
Will it stop me from prioritizing my child?
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Definitions of Cognitive Performance


Adequate cognitive function: able to use knowledge and
take in and process information that enables successful
participation in desired occupations
Impaired performance: outcome of conflict or
mismatch between the person, task, and environment
Dysfunction: lack of processing and metacognitive
strategies and the inability to self-monitor performance
Competent Cognitive Performance: ability to use
information, strategies, and problem-solving behaviors
for participation in occupations
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Task Issues
Processing skills used are based on the
complexity of the task
OT analyzes the cognitive demands of the task
OT grades tasks up or down

Context of the task affects performance


OT determines best environment for learning,
e.g., natural versus simulated, but often doesnt
have a choice
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Environmental Issues
Involves the social, cultural, and physical
natures of the environment
Togglia believes that higher level skills are
influenced by social interaction
Togglia believes that familiar environments
can provide cues and are very important

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Roles of OT using the DIA


Detective
Uncover clues that identify factors that account for the
ability to function or for not being successful in
situations

Teacher: Work with client, family, and others to:


Modify conditions or attributes of the task or setting
Teach cognitive strategies that can be used in multiple
situations

Collaborator: Mediation to facilitate problem


solving
Provide the just right match that is challenging and
can facilitate development of skills and strategies
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Evaluation within the DIA FOR


Static Assessments:
Standardized cognitive screening tools that identify
cognitive deficits

Dynamic interactional assessments:


Used to identify and specify the conditions that have the
greatest influence on performance
When client is unable to perform a task item, OT may make
modifications
Can be based on observance of performance of occupations
Examples: Togglia Category Assessment, Contextual
Memory Test

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Evaluation within the DIA FOR


Goals of Dynamic Interactional Assessment
are to determine if the client:

Has adequate knowledge


Can use knowledge
Uses strategies during task performance
Can use some modifications initiated by OT that
will enhance performance Analyze the person,
task, and environmental issues
Has awareness of abilities and limitations

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Components of DIA Assessment


Awareness: recognition of strengths and
limitations regarding the three types of awareness
(intellectual, emergent, and anticipatory)
Strategy Investigation: Observes and probes client
to determine process for task performance
Cuing and Task Grading: Determine response to
these strategies that include task modification and
verbal cues
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Components of DIA Assessment


Observe performance of occupations
Determine the level of cognitive functioning
Examine the extent to which performance
might be improved by determining possible
modifications for the person, task, or
environment

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Interventions within the DIA


Individualized treatment approach: There is no set,
predetermined treatment sequence
Therapy is delivered in a reactive mode, i.e, as
strengths and limitations arise
There is an emphasis on the OT-client relationship
Performance of occupations is based on occupation
as a means and an ends
Cognitive skills used during performance can be
generalized
Familiar tasks enhance metacognition
Learning transfer can happen within a continuum of
transfer, e.g., near, intermediate, far, and very far transfer
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Factors to Address for


Intervention
Individual factors

Task factors:

Processing strategies and


behaviors
Metacognition
Characteristics

Surface characteristics
Number of items
Complexity
Familiarity
Movement and postural
requirements
Arrangement

Environmental factors:
Social interaction
Familiar and new physical
and cultural environments
Multiple contexts

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Interventions within the DIA


Awareness Building & Metacognitive
Strategy Training
OT cues client for identification of awareness
and strategies
Goal is for client to self-initiate these cues in
future

Strategies to Promote Generalization


Teach cognitive processing strategies that can
be used in multiple situations

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Interventions within the DIA


Processing Strategies
OT determines where the problems are and
identifies and teaches one to two strategies that
the client can use
The same strategies are practiced in multiple
contexts
Example: task segmentation: OT teaches client
to analyze a task for component parts and then
to work in an organized manner
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Interventions within the DIA


Task Analysis and Grading
OTs task analysis helps to determine tasks in which a
strategy will be used for success (Now you hopefully
know why I made you do the detailed task analysis!)
As performance improves, the OT adjusts the cues for
continued success
Refer to Toglias Three Levels of Activity on B & B, p.
289

Transfer of Learning
OT changes the characteristics of a task or setting so
person will repeat behaviors in multiple contexts

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Contributions of DIA
Over a decade spent in development
Model increases our understanding of cognitive
processing and behavioral principles and their
relationships to task and occupational performance
Facilitates view of cognitive processing as dynamic
where multiple functions work together
Supports the use of meaningful activity as method
for improving cognitive processing
It provides a holistic, non-reductionistic view
It is consistent with occupation-based and clientcentered philosophies
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Limitations of the DIA


Its complex and challenging to do
Theres been minimal studies of the efficacy of teaching
self-monitoring strategies to persons with brain injuries
There is not hard evidence about its use improving
transfer of learning and therefore, performance in
multiple contexts
It has been minimally applied to clients with
schizophrenia or other populations and leaves OTs
wondering about the best approach with these
populations

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Treatment in the Dynamic


Interactional Approach:
Practicing targeted strategies and selfmonitoring techniques in a variety of
situations and environments
Strategy training, metacognitive training,
multiple situations, task analysis, learner
characteristics.

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