DYNAMIC INTERACTIONAL FRAME OF REFERENCE Cognitive Rehabilitation

1. DYNAMIC INTERACTIONALFRAME OF REFERENCE(Cognitive Rehabilitation) THEORISTS: Joan Toglia & Beatrice Abreu Reference: Cole & Tufano, Chapter 15

3. AKA: Dynamic Interactional Model of Cognitive Rehabilitation New title given to Joan Toglia�s recent work in this area Beatriz Abreu has developed the theory in a different direction. She calls her approach the �Quadraphonic Approach: Holistic Rehabilitation for Brain Injury� Note: We will cover Abreu�s approach only briefly

4. FOCUS Persons with damage to the CNS who experience perceptual and cognitive deficits (CVA & TBI primarily, also MH) Perceptual processes (integration of sensations into meaningful information through sensory detection and analysis, hypothesis formation, and response). Cognitive processes (processing, storage, retrieval, and manipulation of information; involves attention, memory, initiation, planning, reflection, and adaptive problem solving).

5. BASIC ASSUMPTIONS 1- Neuroscience Luria�s theory of brain functioning Information Processing research Systems approach Brain Plasticity 2- Occupation-based approach Person Activity Contexts

6. NEUROSCIENCE - Aleksandr Luria, Russian physiologist- Brain functions as a whole to produce the following: Orientation Attention Visual Processing Motor Planning Cognition Occupational Behaviors Effort

7. Information Processing Because humans can only process a limited amount of information at a time, the system must structure and organize the information in 3 steps (may occur simultaneously): 1. Registration 2. Analysis 3. Hypothesis formation

8. Information Processing Registration: Involves receiving sensory stimuli & selecting only relevant data. Analysis: Clustering or grouping information together into categories. Hypothesis formation: Matching incoming information with memories of similar previous experience in which the person actively constructs an account of what the information is telling & how it can be interpreted.

9. Information Processing, cont. The process of perceiving operates in two styles of responding to sensory information: Data-driven response relies on detailed analysis of the sensory data, (such as reacting to a ringing telephone) Conceptually driven response is a symbolic interpretation process that begins with an internal expectation (e.g., when I turn the key, the car will start so I can drive to church).

10. Systems Approach Current evidence suggests that cognition works as a system and cannot be broken down into sub-skills. Therefore Luria�s skills (orientation, attention, visual, motor planning, cognition, occupational performance & effort) may not be separated when facilitating occupational performance in OT.

11. Brain Plasticity Research shows that the brain forms new neural pathways to replace lost ones. After brain damage, functions are not lost, but are often Slower, because brain must re-learn the relevant skills Less efficient, until new pathways can be established for accomplishing tasks.

12. Occupation-Based Concepts Performance in occupations is based on the ability to perceive and evaluate sensory information and the ability to conceive of, plan, and execute purposeful action. Included are aspects of the person, the task, and the environment or context.

13. PERSON Personal context includes age, gender, stage of life, and emotional or motivational factors that strongly influence occupational performance Awareness, or self-knowledge has recently been identified as key to the success or failure or OT rehabilitation.

14. Person, cont. Toglia identifies two types of awareness: 1. Self-concept includes a relatively stable knowledge of one�s abilities, strengths & weaknesses, including how illness may have changed one�s abilities (insight) 2. On-line awareness refers to the application of such knowledge while anticipating, planning, and performing tasks or occupations.

15. ACTIVITY Activity demand focuses on the cognitive capacities & skills required to do a task. More complex tasks require the use of multiple cognitive strategies. Familiarity with the physical & social context increases the efficiency of occupational performance. In OT, tasks need to be practiced in the client�s natural or familiar settings. Cognitive strategies for performing tasks are best analyzed in client�s natural settings, where OT can better observe & understand the conditions that cause occupational performance difficulties.

16. ENVIRONMENT Social context � may be structured to facilitate performance and learning (as a teacher does in a classroom through variety of input). Zone of proximal development (Vygotsky, 1978) refers to the distance between unaided performance and guided performance. OT teaches care givers to provide guidance to achieve client�s best occupational performance.

17. Environment, cont. Cultural context influences cognitive recovery through attitudes about deviation from the norm, role expectations, and acceptable levels of support for client functioning during the rehabilitation process (e.g., Is it okay to use short cuts when preparing a meal when the old way was too complex or time consuming?).

18. Environment, cont. Physical context provides a backdrop of potential facilitators or barriers. OT uses physical context to discuss with client ways to better structure the physical environment for improved performance.

19. FUNCTION Client is able to: Process information: Ability to receive, elaborate, and monitor incoming information Generalize learning: Flexibility to use & apply one�s analysis of information across task boundaries Use Metacognitive Skills: (higher level skills or executive functions) including self awareness, goal formation, planning, & monitoring during task performance.

20. Function, cont. Metacognition includes the following: Anticipatory awareness Intellectual awareness Intention Planning Monitoring Strategic Problem solving

21. DYSFUNCTION Toglia identifies the inability to: Use efficient processing strategies to organize incoming information (perception) Anticipate, monitor, & verify the accuracy of performance (awareness) Access previous knowledge (memory) Apply knowledge & skill to a variety of situations (generalization)

22. Dysfunction, cont. Areas of disability may apply to specific client factors, such as visual processing or motor planning, or may occur over a broader range of functioning. Issues cause problems with task performance. Issues cause problems with social participation. Disability defined within client, task, and contextual domains.

23. CHANGE Cognitive change depends on one�s ability to learn & generalize. Response to cues for doing tasks & guidance strategies determine type of assistance needed for learning. Therapeutic use of self assists client in dealing with barriers to awareness. Self-observation may be assessed with the use of daily logs or journals.

24. Change: Processing Strategies Processing strategies are small units of behavior which can increase the effectiveness and efficiency of occupational performance: Surface level � e.g., memorization Deep level � e.g., reflection on meaning, conceptual understanding Internal � e.g., self-cues, mental repetition External � e.g., using a timer Specific � applies to steps of a task Non-specific � applies to many situations, such as pacing oneself or visualizing consequences

25. Change: Transfer of Learning Multiple contexts: application of learning increases when cognitive strategies are practiced in a variety of situations. Near to far transfers: OT interventions progress along a continuum which gradually places more demands on the use of targeted strategies.

26. Near to Far Transfer Continuum Near transfer: similar situations Number cancellation: cross out all 5�s Intermediate: somewhat similar 4 rows of coins: pick out all nickels Far: physically different situations Spice rack: pick all jars that need to be refilled Very far: include broad range of everyday life situations Find the Aspirin in a crowded medicine cabinet Find the Lipton�s onion soup mix on a grocery store shelf

27. Change, cont. Even if permanent damage is present, the individual can be taught to: Capitalize on existing potentials & strengths Use strategies to substitute or compensate for limitations. Performance can be enhanced if the environment or the task is modified to accommodate limitations.

28. ASSESSMENT A range of standard tests and informal procedures exist for evaluating cognitive and perceptual deficits. Standardized tests may provide only limited information about the client's functioning, because there is not a perfect relationship between perceptional and cognitive deficits and actual occupational performance. Because such deficits cannot be observed directly, therapists must infer the deficits from their effects on occupational performance tasks.

29. Treatment, cont. Treatment goals are set to match as closely as possible the expected roles and requirements of the person�s home or work environment. Collaborative goal-setting increases client effort & motivation in therapy.

30. Treatment/Intervention Four approaches Functional approach Remediation Multicontextual Quadraphonic

31. 1. Functional Approach The functional or adaptive approach does not rely on achieving changes in the underlying cognitive-perceptual capabilities, but seeks to enable persons to function optimally despite limitations. Focuses on assets & strengths

32. Functional approach, cont. Functional task training in natural contexts � rote repetition Adaptation of task & environment Good place to start when client & caregiver (family) express strong preferences or specific goals Involves assistance & training of care giver

33. Functional Approach, cont. When tasks are too difficult, compensation strategies are used Modify method of performing the task Client must be capable of learning new strategies Expectations for performing task may need to change Requires awareness & ability to generalize

34. 2. Remediation Remedial training is used to promote the reorganization of impaired CNS functions through repetition & practice. The assumption underlying this approach is that learning will be beyond the particular task, because it increases the underlying cognitive or perceptual skill. Research on brain plasticity supports this view.

35. Remediation, cont. Affolter Approach to sensory motor deficits Uses tactile/kinesthetic input to guide client through the motions of a task hand over hand Example: peeling a banana Look for signs of learning during actual task performance Good alternative for persons with apraxia or aphasia

36. Remediation, cont. Specific skill training follows hierarchy (6 steps): Orientation Attention Visual processing Motor planning, sequencing Memory, categorization, concept formation Problem solving in task performance Uses graded or computerized exercises

37. Remediation Groups Use practice exercises together Helps build awareness & insight See each other�s mistakes Learn from each others� strengths Share ideas for application of skills Example: Picture memory test

38. Attention Exercise: Connect alternate letters & numbers, check each other

39. Example Group Skill training: Memory tray Cover objects until instructions are given. Ask each member to estimate how many of 20 objects he/she will remember. Allow to view tray for 1 minute. Each member writes down as many items as can remember. Compare actual score with prediction (builds realistic view of own ability/deficits).

40. Suggested Introduction for Persons with Brain Injury After brain injury, it is common to have changes in the ability to quickly think and organize information. It takes time to sort things out and to recognize the changes that have occurred. The first step in getting better is recognizing and knowing your limits. As you do activities (in group) we will ask you to identify errors and difficulties so that we can help (each other) build strategies to improve your functioning and help you do the things you want to do.

41. 3. Multicontextual Approach: Example Visual scanning strategies to: Find the light switch in the room. Find the milk in the fridge Reading road signs while driving Finding the Kraft marshmallows at the grocery store Complete Word-find puzzles

42. Multicontextual, cont.Generalization & Transfer of Learning Different applications of a processing strategy represent different levels of generalization or transfer of skills Transfer of skills may be near, intermediate, far, or very far depending on how similar the tasks are to one another

43. Generalization, cont. Similarity of tasks may be determined by the number of characteristics that are different. Tasks differ in terms of: Surface Characteristics (rules, steps, types of stimuli, environment, etc.) Underlying concepts (skills required, strategies required, memory required, etc.) Example of near transfer: Sorting color cards, sorting laundry Example of far transfer: Finding a street on a map, finding a street while driving

44. Metacognition Toglia defines metacognition as, �insight or the degree of awareness one has regarding one�s own cognitive or physical capacities� Metacognitive skills include: Evaluating task difficulty Predicting consequences of action Formulating goals Planning for anticipated problems Monitoring one�s own performance Recognizing errors Demonstrating self-control

45. Without metacognition, persons are unable to initiate and use either remedial or compensatory strategies. Techniques for increasing metacognition include: Self-instruction � verbalize plan before execution Self-estimation � rate task difficulty & compare with actual performance Role-reversal � watch OT making errors & correctly identify Self-questioning � �Am I using _ strategy?� Self-evaluation � check own work for results

46. In the multicontextual approach, Remediation and compensation are not separate but both contribute to task performance. Typical strategies might be: Self-prediction Specific goal ratings/checklists Videotaping Self-evaluation & self-questioning Journaling

47. Treatment Groups Occupational therapists typically use group treatment using Toglia�s principles. Groups can maximize the social learning and support aspects of group interaction to increase generalization & metacognition

48. RESEARCH Relevant research includes development of assessments & the relationship of cognitive�perceptual deficits to occupational performance problems

49. Quadraphonic Approach - Abreu Integrated model, mixes & matches Uses micro perspective: impairment Uses macro perspective: occupational performance 2 phases: remedial exercises & adaptation of environment Activity performance while practicing targeted strategy or subskill

50. The End Let�s Practice: Tray of 20 items Predict how many you will remember. View 1 minute Cover/ Write down as many as you can remember Scores? Compare with predictions. Compare strategies.