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Toglia’s Dynamic Interactional Approach to Cognitive Rehabilitation

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Presentation on theme: "Toglia’s Dynamic Interactional Approach to Cognitive Rehabilitation"— Presentation transcript:

1 Toglia’s Dynamic Interactional Approach to Cognitive Rehabilitation
Dynamic Interactional Model 9/21/09 Toglia’s Dynamic Interactional Approach to Cognitive Rehabilitation OT460A 9/21/09 OT 460A OT 460A

2 Objectives or what Robin wants you to know to be a great OT
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

3 Relevance of Theory To Work with Mentally Ill
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

4 Dynamic Interactional Model
9/21/09 Toglia’s 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. 9/21/09 OT 460A OT 460A

5 Dynamic Interactional Model
Assumptions of the DIA 9/21/09 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 person’s dynamic cognitive system is constantly changing as the person attempts to pay attention to multiple variables A person’s cognitive abilities are different in different settings 9/21/09 OT 460A OT 460A

6 Contrast with Traditional Approaches
Dynamic Interactional Model 9/21/09 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 problem-solving DIA: 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 9/21/09 OT 460A OT 460A

7 DIA Reflects an Information Processing Perspective
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

8 Learner Characteristics in DIA
Dynamic Interactional Model 9/21/09 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 one’s actions Is able to make necessary adjustments for success 9/21/09 OT 460A OT 460A

9 Learner Characteristics in DIA
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

10 Application of Levels of Awareness
Dynamic Interactional Model 9/21/09 Application of Levels of Awareness Let’s be honest: In terms of learning the concepts for this course, do you… Think of yourself as being impaired in some way? (Robin’s answer about herself: “It depends upon the time of day.”) Recognize that at times you’re not understanding what you’re reading? (Robin’s answer about herself: “That happens to me all the time!”) Often predict that you will have difficulty retaining the concepts? (Robin’s answer about herself: “This was constant during my work on my dissertation!”) Now You honestly answer the questions…. 9/21/09 OT 460A OT 460A

11 Application of Levels of Awareness
Dynamic Interactional Model 9/21/09 Application of Levels of Awareness Robin’s 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 don’t 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 don’t seem to be accurate for a lot of women 9/21/09 OT 460A OT 460A

12 Two Levels of Cognitive Processing
Dynamic Interactional Model Two Levels of Cognitive Processing 9/21/09 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 9/21/09 OT 460A OT 460A

13 Processing Strategies
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

14 Processing Strategies
Dynamic Interactional Model 9/21/09 Processing Strategies Internal: mental activities used to remind self to do something or to keep on track Examples: rehearsing, self-cuing, and self-questioning 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) 9/21/09 OT 460A OT 460A

15 Processing Strategies
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

16 Example: Cognitive Strategies with Women at Gateway
Dynamic Interactional Model 9/21/09 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: 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? 9/21/09 OT 460A OT 460A

17 Definitions of Cognitive Performance
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

18 Dynamic Interactional Model
9/21/09 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 doesn’t have a choice 9/21/09 OT 460A OT 460A

19 Dynamic Interactional Model
9/21/09 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 9/21/09 OT 460A OT 460A

20 Roles of OT using the DIA
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

21 Evaluation within the DIA FOR
Dynamic Interactional Model Evaluation within the DIA FOR 9/21/09 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 9/21/09 OT 460A OT 460A

22 Evaluation within the DIA FOR
Dynamic Interactional Model Evaluation within the DIA FOR 9/21/09 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 9/21/09 OT 460A OT 460A

23 Components of DIA Assessment
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

24 Components of DIA Assessment
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

25 Interventions within the DIA
Dynamic Interactional Model Interventions within the DIA 9/21/09 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 9/21/09 OT 460A OT 460A

26 Factors to Address for Intervention
Dynamic Interactional Model 9/21/09 Factors to Address for Intervention Individual factors Processing strategies and behaviors Metacognition Characteristics Environmental factors: Social interaction Familiar and new physical and cultural environments Multiple contexts Task factors: Surface characteristics Number of items Complexity Familiarity Movement and postural requirements Arrangement 9/21/09 OT 460A OT 460A

27 Interventions within the DIA
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

28 Interventions within the DIA
Dynamic Interactional Model 9/21/09 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 9/21/09 OT 460A OT 460A

29 Interventions within the DIA
Dynamic Interactional Model 9/21/09 Interventions within the DIA Task Analysis and Grading OT’s 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 Toglia’s 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 9/21/09 OT 460A OT 460A

30 Dynamic Interactional Model
Contributions of DIA 9/21/09 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 client-centered philosophies 9/21/09 OT 460A OT 460A

31 Dynamic Interactional Model
9/21/09 Limitations of the DIA It’s complex and challenging to do There’s 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 9/21/09 OT 460A OT 460A

32 Treatment in the Dynamic Interactional Approach:
Dynamic Interactional Model 9/21/09 Treatment in the Dynamic Interactional Approach: Practicing targeted strategies and self-monitoring techniques in a variety of situations and environments Strategy training, metacognitive training, multiple situations, task analysis, learner characteristics. 9/21/09 OT 460A OT 460A


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