Toglia’s Dynamic Interactional

Approach to Cognitive
Rehabilitation
OT460A

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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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 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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 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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 Assumptions of the DIA
• 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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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
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• 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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 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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 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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 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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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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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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Two Levels of Cognitive Processing
• 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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 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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 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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 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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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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 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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 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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 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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 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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 Evaluation within the DIA FOR
• 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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 Evaluation within the DIA FOR
• 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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 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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 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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 Interventions within the DIA
• 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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 Factors to Address for
Intervention
• Individual factors • Task factors:
– Processing strategies and • Surface characteristics
behaviors • Number of items
– Metacognition • Complexity
– Characteristics • Familiarity
• Environmental factors: • Movement and postural
– Social interaction requirements
– Familiar and new physical • Arrangement
and cultural environments
– Multiple contexts

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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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 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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 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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 Contributions of DIA
• 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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 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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 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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