question

What are the three models for cognitive intervention?

answer

Cognitive Retraining Model Neurofunctional Approach Dynamic Interactional Approach

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Who created the Cognitive Retraining Model?

answer

Noomi Katz

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CRM is appropriate for use with?

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adolescents and adults with neurologic and neuropsychological dysfunction (secondary CVA, TBI, learning difficulties)

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Emphasis of CRM?

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first remedial, then adaptive

question

What theories is the CRM grounded in?

answer

neuropsychological, information processing theory, and developmental theory

question

Neuropsychological Rationale

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-Cortex is described as a network of fibers -Interdependency of cortical regions exists, such that every normal act is the result of a dynamic balance among all brain structures -Injury disrupts the balance, thus...a lesion in one area can disintegrate the entire functional system -Intervention aims to re-establish a balance in order to improve function

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Neurobiological Rationale

answer

Neuroplasticity - cortical circuits may be modified following brain injury through experience and learning

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Cognitive retraining OT rationale

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the purpose of cognitive retraining is to (1) improve cognitive deficits and (2) facilitate ability to transfer and generalize these capacities toward the performance of purposeful activities Providing opportunities to learn and experience --> improve ability to evaluate and become aware (metacognition) --> increased independence within any task/context

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What does ot's rationale say about cognitive retraining?

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cog deficits are the primary cause of dysfunction. Functional deficits are caused by cog deficits. Cog retraining would *automatically* result in improved function

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What does the research say about cog retraining?

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There is a relationship between cognitive processes and function An improvement in a cog process does not necessarily predict improvement in function

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How can attentional performance be improved?

answer

By focusing on attention-dependent specific ADLs (ie, driving)

question

Secondary benefits to starting with the remediation approach?

answer

1. Facilitates patient's initial acceptance that a problem exists and promote awareness. 2. Promotes satisfaction with treatment outcome. -Makes it "okay" to choose adaptive compensatory alternatives because you have "tried to fix the problem" first.

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How have cognitive retraining goals changed?

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They have moved from specific cognitive skills to function

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Old model

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Deficit-specific FOCUS: Increase attention Increase memory Increase organization Increase orientation

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Current model

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More holistic FOCUS: Functional outcomes Self-esteem Self-management skills Functionally-oriented cognitive skills

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Evaluation Components

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1. Interview for history and future goals: -Pre-morbid occupational functioning -*Pre-morbid cognition or learning patterns* -Preferences & plans for the future 2. Observe functional ADL 3. Assess sensorimotor functioning -Strength, sensation, coordination, balance 4. *Assess general and specific cognitive-perceptual skills*

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6 specific cognitive-perceptual evaluation areas

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Attention Memory Visual perception Spatial perception Visuo-motor organization Thinking operations

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General Cognitive Assessment Instruments

answer

-Dynamic Loewenstein Occupational Therapy Cognitive Assessment (DLOTCA) -DLOTCA-Geriatric -Loewenstein Occupational Therapy Cognitive Assessment-Functional

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Skills tested by DLOTCA

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Orientation, Visual and Spatial Perception, Praxis, Visuomotor Organization, Thinking Operations, Logical Questions

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Skills tested by DLOTCA-geriatric

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Same as above but shorter and with enlarged items. Memory subtest added.

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Skills tested by Loewenstein Occupational Therapy Cognitive Assessment-Functional

answer

Planning and following directions on a map, organizing tools in a box, and planning a daily schedule

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Specific Cognitive Assessment Instruments

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-Rivermead Behavioral Memory Test - extended -Test of Everday Attention -Behavioral Inattention Test -Behavioral Assessment of Dysexecutive Syndrome -Self-awareness of Deficits Interview

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Rivermead Behavioral Memory Test - Extended

answer

memory

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Test of Everyday Attention

answer

attention (selective, sustained, switching, and divided)

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Behavioral Inattention Test

answer

unilateral spatial neglect

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Behavioral Assessment of Dysexecutive Syndrome

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executive functions

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Self-Awareness of Deficits Interview

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awareness of deficits, disabilities, and ability to set realistic goals

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Graded cognitive exercises

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Present targeted exercises and activities that gradually increase demands on the information processing system. Simple to complex Ability to respond to external environment Ability to manipulate the internal environment

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Tabletop activities

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Worksheets to address specific cognitive skills "Drill and Practice" -repetition and rehearsal are critical -homework is required

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Computer-based exercises

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Benefits: -Optimizes the ability to provide repetition and consistency of administration of cognitive stimuli -Useful for evaluation and measuring treatment outcomes -Can be done at home

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Ultimate goal of intervention

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Improve metacognitive abilities so as to become independent in everyday life

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Underlying assumptions of cognitive intervention

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1. Enhance remaining cognitive abilities 2. Restore/remediate cognitive skills 3. Develop strategies to adapt to environment

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Goals of cognitive retraining model

answer

-Strengthen remaining cognitive abilities -Create new alternative strategies to process information

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Outcome measure of cognitive retraining model

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- Decreasing activity limitations and enhancing participation in everyday activities

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Neurofunctional approach

answer

The focus of this approach is on *retraining real-world skills* rather than retraining specific cognitive processes

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Who developed NFA?

answer

Gordon Giles

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Who is NFA appropriate for?

answer

clients with cognitive impairments from TBI, stroke, anoxia, or infection

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Is NFA remedial or adaptive?

answer

can be both

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What was the development of NFA grounded in?

answer

Learning theory and social psychology

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Occupation-based model of NFA?

answer

"targets function, not impairment" (addresses real-world skill over retraining cognitive processes) "Learning by doing" (highly planned and structured activities; occupation as means and the end) "Improved cognitive function can only occur within the context of specific activities".

question

Assumes generalization ___________(does/does not) readily occur from one situation to another and ________(should/should not) be taken for granted

answer

Assumes generalization does NOT readily occur from one situation to another and should not be taken for granted.

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Underlying assumptions

answer

From continuously practicing a task, over-learning will occur and progress to the point of automaticity

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Why doesn't improvement in cognitive skill predict improvement in functional ability?

answer

Depends on functional resilience of the patient -occupational history -self-awareness -capacity for behavioral self-regulation -life experiences

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What kind of model is the NFA?

answer

PEO model - the therapeutic process attempts to match the contextual demands to the person's capacity to meet them

question

NFA: Primary evaluation

answer

Unstructured/structured observation of occupational performance in contexts closely related to d/c disposition "The therapist's observation skills are most important in identifying the client's problems" (Unsworth, 1999, p. 31).

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NFA: Secondary

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-Standardized tests may supplement if necessary. (A-ONE) -Affective, sensory, motor, perceptual, & cognitive skills are also considered

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A-ONE

answer

-Arnadottir OT-ADL Neurobehavioral Evaluation -Performance-based tool that uses structured observations of UE and LE dressing, grooming, hygiene, feeding, transfers, mobility, and communication -Requires specific training

question

Training should be attempted in ___________________ (different ways/the same way) across functional domains so that _______________(maximal amount/minimal amount) of new learning is required

answer

Training should be attempted in the same way across functional domains so that only a minimal amount of new learning is required

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NFA Integrates use of what?

answer

Reinforcement & skill building Task analysis Chaining Prompts Practice Errorless learning Shaping Antecedent control Over-learning Debriefing

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Reinforcement aids __________

answer

learning

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Primary reinforcement

answer

tangible

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Secondary reinforcement

answer

intangible

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Variance in # of cues related to a client's ability to ___________________

answer

control behavior

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Components of task analysis may be converted to _______________ prompts

answer

visual and/or verbal

question

Chaining

answer

functional tasks are complex stimulus-response chains whereby one tasks sets the stage for the next

question

What method of chaining is most successful with severe TBI?

answer

whole task method

question

Backward chaining

answer

Therapist provides substantial assistance, even hand-over-hand guidance, through the initial steps in the task analysis ...until reaching the last step that the client can't do independently.

question

Benefit of backward chaining

answer

BENEFIT - hardest work at learning a new step occurs near the end of the chain, and leads immediately to the reinforcers associated with completing the whole chain

question

Forward chaining

answer

Therapist teaches the initial step first, with conditioned reinforcement following that first link...and then the therapist usually guides the client through the rest of the tasks.

question

Benefit to forward chaining

answer

Client learns steps in order

question

Whole task chaining

answer

Variation of forward chaining, but with the addition of supplemental reinforcers after each step

question

During whole task chaining, which reinforcer should be the strongest?

answer

Terminal reinforcer should be the strongest (Get points or stickers for each step accomplished, but Disney world is the ultimate reward!)

question

What should be faded over time?

answer

supplemental reinforcers

question

prompts/cues

answer

events that facilitate behavior

question

types of prompts/cues

answer

environmental verbal visual physical gestural

question

Cueing hierarchy

answer

No VC required Non-directive or open-ended cue Directed cue Full cue (answer provided)

question

Practice

answer

Repetition --> Over-learning --> Automaticity --> Integration

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Errorless learning

answer

Errors are prevented from occuring through cues, guidance, etc. Different from trial and error learning where errors are corrected once they occur

question

Who is errorless learning best for?

answer

those with severe memory impairments

question

Shaping

answer

reinforcement of closer and closer approximations to the desired behavior

question

Antecedents

answer

way of controlling behavior by changing cueings events in the environment -alters chances that a desired behavior will occur examples: - checklists or to-do lists - sequenced instructions - other types of cues to inhibit or facilitate behavior

question

NFA Goals

answer

Improve real-world functioning or quality of life Re-establish habits and routines

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NFA Outcome measurement

answer

decreasing activity limitations and enhancing participation in everyday activities

question

Dynamic Interactional Approach (DIA)

answer

Cognition is not static, stable, or fixed; it *changes with our interactions with the external world*; thus it is modifiable under certain conditions

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Who developed the DIA approach?

answer

Toglia

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Who was DIA developed for?

answer

TBI, but applied to all populations

question

Is DIA remedial or adaptive?

answer

both

question

What is DIA grounded in?

answer

Information-processing theory and cognitive psychology

question

What type of model is DIA?

answer

PEO model - the therapist should investigate dynamically the underlying conditions and processing strategies that influence performance

question

Define cognition

answer

Capacity to *acquire* and *use* information to *adapt* to environmental demands

question

What skills does cognition require?

answer

- Information processing skills - Learning - Generalization

question

Acquisition

answer

taking in, organizing, assimilating, & integrating new information with that previously learned *(information processing skills)*

question

Adaptation

answer

using information to plan and structure behavior for goal attainment *(learning)*

question

Application

answer

applying what has been learned to a variety of situations *(generalization)*

question

Summarize cognitive dysfunction

answer

Summarized as representing core *deficiencies* in the ability to -acquire (unable to organize new info) -adapt (unable to access previous knowledge when needed) -apply (cannot flexible apply knowledge and skills to a variety of situation)

question

Static Assessment: Quantitative or Qualitative?

answer

Quantitative

question

Dynamic Assessment: Qualitative or Quantitative?

answer

Qualitative

question

Static or Dynamic Assessment? Answers...Is there a problem? What is it? How severe is it?

answer

Static

question

Static or Dynamic Assessment? Answers...Can performance be changed? What cues or task alterations increase or decrease symptoms?

answer

Dynamic

question

What does a static assessment evaluate?

answer

deficits and degree of severity

question

What does a dynamic assessment evaluate?

answer

process of change and most optimal performance

question

Static assessment tells you how a patient performs ______________________

answer

in comparison to norms

question

Dynamic assessment tells you how a patient performs _______________

answer

when test conditions change

question

What does static assessment examine?

answer

independent performance (examiner is neutral and unbiased)

question

What does dynamic assessment examine?

answer

change with guided assistance or task alteration

question

Examples of static standardized assessments

answer

Line crossing test Star cancellation test Picture scanning test Object search task

question

Dynamic investigative assessments

answer

-Toglia Contextual Memory Test -Dynamic Visual Processing Assessment -Toglia Category Assessment

question

Questions to assess client's self-awareness/ self-perception of abilities PRIOR to task performance

answer

Since your stroke, do you often have trouble finding all the items in a drawer...closet...on a table? Do you tend to miss things on the left side? Do you think your ability to do this sort of activity has changed in any way since your stroke/injury?

question

Ways to facilitate change in performance DURING assessment, while assessing self-awareness

answer

If client has difficulty during an evaluation task, the OTR attempts to facilitate performance by -*Providing a series of cues* (are you sure you found all of the A's on the page?...There are still some remaining, can you find them?) -*Teaching strategies* (Go slower and use your finger to point at each letter) -*Reducing activity demands* (covering up part of the display; providing a perceptual anchor in left margin)

question

Questions for investigating client's self-perception of performance ; strategy use DURING ; AFTER task performance

answer

-How do you think you are doing? - Did you encounter any difficulty while doing this task? Tell me why... - I noticed you began to use your finger to point to each letting in the middle of the task - can you tell me why?

question

Dynamic Visual Processing Assessment

answer

Examiner provides *guidance, encouragement, and feedback* in an attempt to elicit the patient's best performance

question

What is the Dynamic Visual Processing Assessment based on?

answer

Vygotsky's zone of proximal development (diff people can have the same baseline on a static test, but differ in the extent to which they can profit from instruction) AKA "zone of rehabilitation potential"

question

Zone of rehabilitation potential

answer

The difference in what one can do without help vs with help

question

If client's performance is NOT facilitated through repetition and practice, then...

answer

Try adaptive approach -Modify the task or environment. -Train specific functional skills

question

If client's performance is facilitated through repetition and practice, then....

answer

Try remedial approach -Train in efficient strategy use -Practice strategies in multi-contexts

question

In this approach, what do we think about the transfer of learning?

answer

it is not assumed! -practice in multiple situations -focus on effective strategy use -incorporate metacognitive training

question

What approach does treatment incorporate?

answer

Multicontextual approach -The *same processing strategy* is practiced across activities ; situations that gradually change. -An emphasis on *self-monitoring ; self-evaluating* performance is embedded throughout treatment. Targets areas that show some evidence of self-awareness ; responsiveness to cues.

question

Generalization

answer

Ability to apply what has been learned in therapy to a variety of NEW situations ; environments Involves a process of decontextualization

question

Decontexualization

answer

Moving from a context-dependent state to a context-independent state example: Using memory notebook for acute rehab schedule sessions and then use it at home for daily school schedule

question

Transfer of learning

answer

Included within the concept of generalization but is narrower in scope Refers to the ability to apply specific strategies to a related task NOT all-or-none; instead, conceptualized on a horizontal continuum that reflects different degrees of transfer of learning

question

The transfer continuum

answer

Represents activities/situations that remain at a similar level of complexity but gradually differ in physical or superficial similarity and provides a guide for the sequence ; progression of treatment activities, based on activity analysis Near --> intermediate --> far --> very far transfer activities

question

Near-transfer activities

answer

appear very similar to each other

question

Intermediate-transfer activities

answer

appear somewhat similar to original activity

question

Far and very far-transfer activities

answer

appear very different from the original activity

question

Near transfer

answer

Occurs when previously acquired knowledge is transferred to new situations that are closely similar to, yet not identical, to the initial learning situation Example: transferring experiences associated with driving a car (manual transmission) to driving a truck (manual transmission)

question

Near transfer learning

answer

Ability to apply strategy across activities that are similar

question

Far transfer

answer

Entails the application of learning to situations that are entirely different to the initial learning Example: Learning about logarithms in algebra class ; applying when assessing growth of bacteria in microbiology class

question

Far or very far learning

answer

ability to apply strategy use across activities that are *very different* in appearance represents far or very far learning (generalization) Example: learning about logariths in algebra class and applying when assessing growth of bacteria in microbiology class

question

Awareness training

answer

Clients will move beyond the cued condition only if they have internalized the ability to *self-monitor ; regulate* performance. *Responsibility* of cueing ; structuring activities is gradually transferred from therapist to client. Need to provide a *non-threatening environment*; convey a positive message rather than a negative one.

question

Clients will move beyond the cued condition only if they have internalized the ability to ______________________________________

answer

self monitor and regulate performance. -Responsibility of cueing ; structuring activities is gradually transferred from therapist to client. -Need to provide a non-threatening environment; convey a positive message rather than a negative one

question

Goal Rating Scale

answer

Reliance on others 1. relies on others for info *majority* of time 2. Relies on others for info *frequently* (~50%) 3. Relies on others for info *some* of time (~25-33%) 4. Relies on others for info *occasionally* (;25% of time) 5. Does not rely on others for info at all

question

Cognitive dysfunction represents core deficiencies in

answer

- information processing strategies - self-monitoring skills

question

The extent to which the core deficiencies are observed depends on what?

answer

Person Environment Task/Occupation

question

Goals

answer

Facilitating optimal skill performance by changing the activity, environment, or person's use of processing strategies for maximizing functional capacity

question

Outcome measurement

answer

Decreasing activity limitation and enhancing participation in everyday activities

question

Limitations of DIA

answer

Cannot be used to measure change over time Requires a high level of expertise from the therapist Needs further research to examine effectiveness of metacognitive training

question

In an ideal world, rehab would look like...

answer

Intensive deficit-specific cognitive retraining using specialized training tasks + Intensive behavior-training in training settings followed by --> intensive generalization training in natural settings with personally meaningful tasks and routines

question

Advantages and disadvantages: Focus on mastering specific deficits until patient is ready to apply this to real-world skill

answer

Maximal repetitions promote neuroplasticity Lack of evidence to support - Does "mental muscle building" translate to everyday functional activities?

question

Advantages and disadvantages: Focus on learning within the real-life context assuming the patient will learn better this way

answer

Highly concrete routines help organize behavior (this does not necessarily mean that is how the patient is dependent on it forever) Difficult to do enough repetitions needed for learning in a natural context

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