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OT Cognitive Rehab

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Cognition
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Interrelated processes including the abilities to perceive, assimilate, organize, & manipulate info to enable the person to process info, learn, generalize & produce goal directed action
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Cognition impacts all areas of occupations: Addressed as…
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Process skills, communication/interpersonal skills, mental functions (client factors) & Cognitive skills (UT-III)
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ICF terminologies of mental functions
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Consciousness, orientation, global psychosocial, temperament & personality, Energy & drive, sleep, attention, memory, psychomotor, emotional, perceptual, thought & higher level functions
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General assessment considerations
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1. Assess mental status first: Alertness, arousal, responsiveness to stimuli, orientation 2. Determine presence of perceptual impairments that may impact testing 3. Select culturally familiar or neutral stimuli 4. Separate low level or primary cognitive abilities vs. high level or higher order abilities
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Categories of Cognition: 1. Primary Cognitive Abilities
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Arousal, orientation, attention, memory, recognition/simple comprehension
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Categories of Cognition: 2. Higher Order Thinking
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Problem solving, Abstraction, insight/awareness, judgement, executive functions (planning, organizing, learning/adaptation)
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Arousal
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Neuro-cognitive/wakefulness states: Alert, attentivenessComa, unarousable Generalized by readiness of CNS to respond May fluctuate according to time of day, inner drive, emotional state, positioning, ect
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Glasgow Coma Scale Part 1: Eye opening
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Response: Spontaneous (Score 4) Speech (Score 3) Pain (Score 2) No Response (score 1)
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Glasgow Coma Scale Part 2: Motor Response
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Response: Simple Commands (Score 6) Pulls from pain (with hand, with body) (Score 5, 4) Decorticate posturing (Score 3) Decrebrate posturing (Score 2 No response (Score 1)
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Glasgow Coma Scale Part 3: Verbal Response
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Response: Converses, oriented x 3 (Score 5) Confused or disoriented (Score 4) Makes no sense (Score 3) Incomprehensible sounds (Score 2) No response (Score 1)
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Orientation
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Refers to awareness of self and ones contexts: 1. Lower Level-Awareness & accurate recognition of time, place, other person, situation (“Can you tell me (3 Ws___?”) 2. Higher Level- Deeper awareness of self, situation (“Why are you here?”)
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Arousal: Assessments
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Glasgow coma Scale, JFK Coma Recovery Scale Revised, *Rappaport Scale, *Confusion Assessment Protocol
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Orientation: ASSESSMENT TOOLS
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Mini-MSE, Orientation Log
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Sustained Attention
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Maintain attention during performance over time
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Selective Attention
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Attending to task while ignoring extraneous stimuli
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Divided Attention
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Ability to respond to more than 1 task at a time
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Alternating Attention
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Flexible shifting of attention; multiple engagement & disengagement without breaking the conformity of tasks
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Screening Attention
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Observation & timing of attention in task
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Attention Assessments
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MMSE (Mini mental), CAM, Trail-making, *Cog Log
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Memory
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Involves ability to draw upon past experiences & learn new info
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Short-term memory
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1 minute to 1 hour Related to working memory
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Long-term memory
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Recent- hrs to months post event Remote- ex. Childhood memories Episodic- ex. personal history Semantic- Knowledge of the world
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Memory: Types of Recall
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Free Recall: no specific retrieval cues provided Cued Recall: require cues to facilitate retrieval (ex. assoc./1st letter of item) Recognition: identifying target stimuli from multiple choice or continuous presentation of various stimuli Immediate Recall: recalling target stimuli immd. after presentation (< 60 sec) Delayed Recall: recalling anytime after 1 min to hrs after presentation
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Memory: Phases
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1. Acquisition: Learning or encoding 2. Storage: Holding of info 3. Retrieval: Recognition & recall
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Memory: Screening
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Observation & Interview
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Memory: Assessments
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Mini-MSE, MSE, Hopkins Verbal Learning Test, Contextual Memory Test
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Problem Solving: definition
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Ability to generate a solution to a problem or obsticle
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Steps to COGNITIVE ADAPTATION
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1. Problem identification & definition 2. Generation of Solutions 3. Implementing preferred solution 4. Evaluating outcomes
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Problem Solving: Requirements
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Requires integration of many cognitive & perceptual skills including: 1. Reasoning: a) Drawing inferences or conclusions b) Sequencing & categorization c) Inductive/deductive reasoning 2. Concept Formation-Ideas
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Problem Solving: Assessment Process
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1. Determine specific areas of difficulty 2. Which stage of problem solving that an individual breaks down 3. Analyze underlying factors contributing to decreased performance ie: decreased attention, memory
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Problem Solving: Screening
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Observe task requiring problem solving/error detection, interview (give situation)
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Problem Solving: Assessment tools
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CAM, TCA, Robnett
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Meta-processing abilities: Metacognition
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Knowing one’s own cognitive processing abilities and limitations Being able to plan ahead, adjust to environmental demands, anticipate consequences of one’s actions Self-efficacy is reflected by one’s meta-cognition
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Meta-processing abilities: What in involves
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Involves 2 reciprocal functions 1. Executive functions: skills & abilities that allow us to accomplish goal-directed activities 2. Self-awareness
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Executive functions
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1. Volition: determination of interests, needs or wants (source of motivation) 2. Purposive Action: a) translate plan into a productive activity b) includes ability to initiate, maintain, switch, terminate task 3. Adaptation: monitoring & self-correcting behavioral components
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Executive Functioning: Sample Assessment Process
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Observe daily planning tasks eg., meal prep or home management -ordering items from catalog -Running errand to gift shop -finding out times for religious services -multiple errand tasks over a specified timeframe
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Executive Functioning: Initiation
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-Ability to engage spontaneously in activities -Assess behaviors: appear passive, apathetic, unmotivated, requires prompts to participate
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Executive Functioning: Planning & Organizing
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-Ability to anticipate what needs to be done and carry out those steps in an orderly fashion -Assess behaviors: underestimates time required for a task, fails to plan ahead, over focuses on details, omits steps in task, proceeds by trial & error
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Executive Functioning: Self-Monitoring or Error Detection
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-Ability to realistically evaluate performance on certain tasks -Behaviors: May not notice incorrect actions;impulsive; may not monitor own behavior
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Executive Functioning: Self-Regulation or Error Correction
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-Ability to recognize an error & generate a solution to correct it -Behaviors: Concrete & rigid in approach; Fails to persist to complete task; or may fail to generate alternative solutions to problems
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Awareness: Different types
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1. Anticipatory Awareness 2. Emergent Awareness 3. Intellectual Awareness
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Anticipatory Awareness
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Ability to predict a problem is likely to occur as the result of a deficit
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Emergent Awareness
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The ability to recognize a problem when it is actually happening
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Intellectual Awareness
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The ability to recognize that a particular function is impaired
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Awareness: Assessment
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CMT, interview (probe regarding knowledge of one’s own abilities and problem areas, strategy use, effects of deficits on daily functioning), *Awareness Questionaire
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Awareness Assessment by questioning: Intellectual Awareness questions
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“Have you noticed a change in ___?” “Rate you level of ___ now, vs. prior to injury”
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Awareness Assessment by questioning: Emergent Awareness Questions
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“How difficult is this ___ task?” “Which part of the task, youhad most difficulties with?”
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Awareness Assessment by questioning: Anticipatory Awareness questions
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“If I ask you do more ___ tasks, how much do you think will you be able to accomplish?”
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Cognitive Approaches
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1. Cognitive Behavioral Approach: Remediatory 2. Cognitive Disability Approach: Compensatory & Adaptive 3. Dynamic Interactional Approach: (AKA: Multi-contextual approach) Remediatory, adaptive & compensatory
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Cognitive Behavioral Approach
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Based on humanistic/existential psychology Behavioral control through internalization of cognitive process via: 1. Changing of thoughts-believed to result in or cause specific behaviors 2. Developing knowledge base for problem solving Different from behavioral approaches – Goal is to change behaviors thru reinforcements
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Bandura’s Contribution: Social Learning
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Emphasis on developing self efficacy & competence Makes use of role-modeling and imitation Three types of cognitive reinforcers: 1. External (initial reinforcers) 2. Vicarious (symbolic reinforcers) 3. Self-produced consequences/personal satisfaction
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Cognitive Behavioral: Evaluation and Intervention –> Outcome
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Perceptions, thoughts, attitudes, and beliefs that shape behaviors –> Increased self-knowledge (awareness) & heightened sense of self-efficiacy
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Cognitive Behavioral-Forms: Rational Psychotherapy
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Ellis’ rational emotive therapy (RET) Meichenbaum’s self-instructional training (SIT)
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Cognitive Behavioral-Forms: Coping Skills Therapy
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Suinn & Richardson’s-anxiety management Meichenbaum’s-stress inoculation
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Cognitive Behavioral-Forms: Problem solving therapy
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NO description given
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Cognitive Behavioral-Forms: Elli’s Rationale Emotive Therapy
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ABC theory: Activating event ->irrational belief -> consequence Techniques: bibliotherapy and emotive techniques
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Application to OT
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Targeting change – 4 points of change 1. ENVIRONMENTAL SITUATION: Context in which client feels competent 2. CURRENT THOUGHTS AND ATTITUDES: Awareness of automatic thought processes 3. Reactive behaviors and thoughts: Ask “Why do we react the way we react?” 4. Problem solving skills that client needs to learn
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OT Assessment- Life themes/lifestyles
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Life themes- Listen to verbalizations & ‘rules’ for living -feelings of persecution/victimization -feelings of incapacity/dependency -feelings of lack of self-worth Life theme may convey problem solving strategies that reflect a lifestyle Lifestyle-routines & habits that support of constrain ability to cope
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OT Assessment – Person’s view of self
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Person’s view of self including: -Interests -Personal goals -Degree of flexibility to change -Tolerance with mistakes -Reliance on others for validation -Level of self-exceptance
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OT Assessment – View of Environment
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Person’s view of environment: -Awareness of interests -Perceptions of environment -Reality testing- -Preferred situations or settings -Expectations & tolerance level of others -Does the context of daily occupations enhance or limit function?
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OT assessment – Learning style
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Person’s learning style: – Active initiator vs. observer -Presence of mentor or authority figure -Personal identification with others -Reinforcers -Physical & social contexts of learning -Strategies that assist learning -Ability to generalize learning
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OT Assessment: Future Environment
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Demands of future environment: -Knowledge & skills needed -Availability of cues, models, reinforcers -Which strategies work best? -Can new strategies be incorporated in past lifestyle of living?
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Assessment tools/methods
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Task Checklist-to assess competence Depression & Anxiety scales Stress Management Scales Assessment of primary cognitive abilities Interviews that address assmnt areas
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OT Intervention: Principles
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-Overarching goal: re-establish an individuals self regulating abilities -Change way of thinking 1st before Behaviors change can happen -Focus on shared authority -Client centered
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OT Intervention: Examples of Goals
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-Client will provide a realistic identification of strengths and weaknesses in interpersonal skills (awareness of self) -Client’s will identify situations when assertiveness skills are needed (awareness of environment) -Client will demonstrate proficiency in identifying various scenarios & selecting scenarios that best fit his situation (brainstorming strategy)
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Levels of change: 1) Peripheral Change
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Using strategies learned in daily living tasks/routines
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Levels of change: 2) Deep change
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-Remodeling of personal identity -Involves connecting the past with the present and relating the person’s thoughts to such issues as trust, dependency, aggression, avoidance, over-compliance, ect.
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Treatment strategies – 1
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-Socratic Dialogue (Use of self) -Listening for Must-developing person’s awareness of expectations on self and others -Homework and bibliotherapy-short articles, brochures, handouts -Modeling and Role playing -Assertiveness Training-learning about rights
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Treatment strategies – 2
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Teaching problem-solving skills -Creative problem-solving (CPS): identifying & measuring the problem, owning & identifying the need to solve the problem, identifying resources to solve the problem, & incubation: sitting on an a problem/issue (“wait-and-see”)
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Treatment strategies – 3
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Brainstorming: -identifying all possible scenarios (divergent) -choosing the best scenario (convergent thinking) by process of elimination Thinking Aloud Protocol: -What is my problem? -What is my plan? -Am I using my plan? -How did I do?
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Treatment strategies – 4
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Self-instruction-self talk -Let client describe procedures while in the act of doing -Therapist intervenes and then lets client do it again by saying the procedures aloud again
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Stress Inoculation
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Conceptualization of stressful event & it’s psychological & somatic consequences Skill Acquisition & Practice Phase -Identify source of stress -Apply methods to reduce physical arousal: ex. autogenic breathing -Channel internal discomfort to a creative output -Alleviate internal discomfort by inoculation -Listen to internal dialogue -Select internal verbal responses
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Cognitive Disability Model
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Developed by Claudia Kay Allen in 1982 Theoretical foundation: Vygotsky Basic premises: -Activities as tools for change -“Task Equivalence”-what you do represents your cognitive functioning -Cognitive operations and means of address needs of the cognitively disabled are unique
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Overarching Principles
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-Assess cognitive level of the client -Identify activities where clients can succeed -Advise professionals & caregivers about cognitive limitations on functional performance -Make environmental modifications -Cognitive skill-building initially thought of as NOT a realistic goal
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*Cognitive Levels*: LEVEL 1
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Automatic Actions: -Awake but unaware -Engages habitual actions -Responds to internal stimuli only
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*Cognitive Levels*: LEVEL 2
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Postural Actions: -Confused but motivated by comfort
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*Cognitive Levels*: LEVEL 3
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Manual Actions: -Responds to manual cues -Learns simple tasks with repetitive actions
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*Cognitive Levels*: LEVEL 4
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Goal-directed Actions: -Responds to & relies on visual cues -Performs well in set routines
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*Cognitive Levels*: LEVEL 5
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Exploratory Actions: -Operates by overt trial & error -Does well with predictable situations, but has difficulty planning
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*Cognitive Levels*: LEVEL 6
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Planned Actions: -Able to plan ahead, anticipate results -Able to problem solve, internalize strategies
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Cognitive Disability Model: Preliminary Assessment
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Medical History includ. medications Occupational profile
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Cognitive Disability Model: Initial Assessment
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Low Cognitive Level Test-clap test Allen’s Cog. Level Screen (ACLS)-leather lacing task to assess learning ability Routine Task inventory (RTI)-Observe ADL’s, IADL’s Cognitive Performance Test (CPT) Allen’s Diagnostic Modules (ADM)-sensory kits & craft projects to verify ability to function (3’s to low 5’s)
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Cognitive Disability Intervention
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Goal: “Making life with disability as normal as possible Management component: Create least restrictive environment; educating caregivers Therapeutic Groups FOr Change: a. must use similar cognitive levels b. safety c. skills training at level 5 & 6
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Dynamic Interaction Model: Background
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Developed by Joan Toglia in early 1900’s Departs from “static” impairment specific models Combines cog. psychology (eg. info processing models) & rehab sciences (ei. remediation, compensation, adaptation) AKA “Multi-contextual Approach” Defines Cognition as: ” ongoingproduct of the dynamic interaction between the individual, task (occupation), and the environment.”
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Dynamic Interaction Model: Function/dysfunction Continuum
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Contextual in nature Adequate//competent cognitive function Impaired performance-mismatch between the person, task & environment
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Dynamic Interaction Model: Therapist’s Roles
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Detective-careful observation and analysis of performance in context Collaborator Mediator-must know/understand “zone of proximal developmental”
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Comparison:Traditional Models*
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-Deficit focused, cognition broken into subcomponents -Sub-skills are hierarchically arranged, primary skills must be addresses first -Intervention involves repetition and practice of sub-skill components that are usually non-contextual in nature
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Comparison: Dynamic Interactional*
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-Focuses not on the specific areas of cognition but on dynamic processing -Cognition consists of multiple interrelated processes -Restorative rehab approach in context:client has capacity to learn
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Evaluation Process
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GOAL: Identify specific conditions that greatly influence performance Use of dynamic assessments: -includes awareness questioning, strategy investigation, impact of cues and task grading EX. CMT, TCA -May also modify current “Static” assessments to cover awareness, strategy investigation & response to cues/grading
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Intervention Process
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FOCI: Building awareness & developing meta-cognitive strategies *Use of self: THerapeutic Cueing -Level of task difficulty -Time needed to complete task -Factors that may support/interfere with performance -Strategies used to complete task -Self-monitoring
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Hierarchy of Cueing: Level 1
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Minimal, non-verbal or verbal type of cue (reflective pause, raising eye-brow, slowed cadence of speech, tone of voice)
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Hierarchy of Cueing: Level 2
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Indirect cue that does not tell the patient what to do or how to do it (action cue)
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Hierarchy of Cueing: Level 3
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Utilize a direct question or hint to provide a prompt for the pt that allows them to do some processing
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Hierarchy of Cueing: Level 4
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Verbalize directly what to do
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Hierarchy of Cueing: Level 5
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Show and tell the patient what to do
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Examples for using the Hierarchy of Cueing
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Activity: Scanning sheet Behavior: Impulsive 1. Hmm? With a questioning look 2. Wow! That was quick 3. Did you find everything you were looking for? 4. You’ve made many mistakes, try using your finger as a guide 5. You’ve made many mistakes, let me show you how its done 6. Provide hand over hand assistance and give verbal instructions at the same time
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Affolter Approach (TX approach)
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Use with inattention & apraxia Link b/t tactile/kinesthetic input & problem solving skills Requires nonverbal guidance (hand-over-hand) to facilitate perceptual cognitive interaction Appropriate input rather than successful output
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Intervention Process: Teach Strategies of
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-Anticipation: Looking for potential problems -Self-prediction: To address overestimation -Self-checking/evaluation -Self-questioning: Assess own progress while engaged in task -Time monitoring
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Intervention: Strategies to increase generalization/transfer of learning
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-Near (simple context) -> Intermediate -> Far (Multi-/complex context) -Task grading/segmentation: number of steps/rules task details, objects used, familiar task to novel task