1. Toglia’s Dynamic Interactional Approach to Cognitive Rehabilitation
Dynamic Interactional Model
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Toglia’s Dynamic Interactional Approach to Cognitive Rehabilitation
OT460A
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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
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OT 460A
OT 460A

3. Relevance of Theory To Work with Mentally Ill
Dynamic Interactional Model
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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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OT 460A

4. Dynamic Interactional Model
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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.
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OT 460A
OT 460A

5. Dynamic Interactional Model
Assumptions of the DIA
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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
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OT 460A
OT 460A

6. Contrast with Traditional Approaches
Dynamic Interactional Model
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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 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
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OT 460A
OT 460A

7. DIA Reflects an Information Processing Perspective
Dynamic Interactional Model
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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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OT 460A
OT 460A

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

9. Learner Characteristics in DIA
Dynamic Interactional Model
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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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OT 460A
OT 460A

10. Application of Levels of Awareness
Dynamic Interactional Model
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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….
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OT 460A
OT 460A

11. Application of Levels of Awareness
Dynamic Interactional Model
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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
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OT 460A
OT 460A

12. Two Levels of Cognitive Processing
Dynamic Interactional Model
Two Levels of Cognitive Processing
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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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OT 460A
OT 460A

13. Processing Strategies
Dynamic Interactional Model
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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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OT 460A
OT 460A

14. Processing Strategies
Dynamic Interactional Model
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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 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)
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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
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OT 460A
OT 460A

16. Example: Cognitive Strategies with Women at Gateway
Dynamic Interactional Model
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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:
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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OT 460A

17. Definitions of Cognitive Performance
Dynamic Interactional Model
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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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OT 460A

18. Dynamic Interactional Model
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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 doesn’t have a choice
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OT 460A
OT 460A

19. Dynamic Interactional Model
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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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OT 460A
OT 460A

20. Roles of OT using the DIA
Dynamic Interactional Model
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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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OT 460A

21. Evaluation within the DIA FOR
Dynamic Interactional Model
Evaluation within the DIA FOR
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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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OT 460A
OT 460A

22. Evaluation within the DIA FOR
Dynamic Interactional Model
Evaluation within the DIA FOR
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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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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
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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
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OT 460A

25. Interventions within the DIA
Dynamic Interactional Model
Interventions within the DIA
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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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OT 460A

26. Factors to Address for Intervention
Dynamic Interactional Model
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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
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OT 460A
OT 460A

27. Interventions within the DIA
Dynamic Interactional Model
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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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OT 460A
OT 460A

28. Interventions within the DIA
Dynamic Interactional Model
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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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OT 460A
OT 460A

29. Interventions within the DIA
Dynamic Interactional Model
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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
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OT 460A
OT 460A

30. Dynamic Interactional Model
Contributions of DIA
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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
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OT 460A
OT 460A

31. Dynamic Interactional Model
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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
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OT 460A
OT 460A

32. Treatment in the Dynamic Interactional Approach:
Dynamic Interactional Model
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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.
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OT 460A
OT 460A