Cognitive Rehabilitation Approach: Toglia's Multicontext Approach

metacognitive strategy training

Explicit teaching, with a focus on activating prior. knowledge, introducing new knowledge and skills, modelling the application of knowledge and skills, and providing ample opportunity for independent practice and reflection

• identify problems

• develop strategies to overcome problems

• implement and evaluate the solution

Metacognitive strategies

Cognitive tools put in place to help learn memorize and problem solve for orientation

• Support learning of performance; acquire new skills make task performance easier

• ability to participate in functional task

• Compensatory technique

• Strategies are used as an end product; adaptive or compensatory

Examples:

•A client uses a list to double check that all steps were completed for a project

•Memorizing groups of words by chunking them together

•ROYGBIV (mnemonics)

•Stopwatch/timer

Strategy Combinations: SING (for reading and listening)

 S = Summarize

 I = Identify main points

 N = Never mind the details

 G = Get the gist

Strategy Combinations: TRAPS (for memory)

 T = Translate into your own words

 R = Repeat to yourself 5x

 A = Associate it with something familiar

 P = Picture it

 S = Self-Test

Strategy Combinations: PQRST (for reading)

P = Preview material

Q = Question self

R = Review

S = Summarize

T = Test self

Strategy Combinations: RIP for memory

Repeat

Imagine

Put it together

Metacognitive strategies

Key elements

• Focus on structured methods and/or strategies for managing multiple step activities

• Self monitoring, self regulation, awareness or goal management, problem solving

• The best strategies are general

  • Strategies are not for a specific activity, but can be applied across activities in daily life

  • Strategies are often developed to overcome error patterns

Different Metacognitive approaches to therapy

•Multicontext Approach**

•Short-term Executive Plus (STEP)

•Goal Management Training

•CogSMART

•Time Pressure Management

Multicontext Approach

•Key elements:

The MC approach can be classified as a metacognitive strategy intervention due to its focus on self-awareness, self-monitoring, and self-regulatory skills.

Population:

• stroke, traumatic brain injury, brain tumor, Multiple Sclerosis, Parkinson's Disease, and Mild Cognitive Impairment (MCI), schizophrenia, ADHD and learning disability.

Focus: On Errors

• Recognizing cognitive error patterns across tasks and reasons for them

• Enhancing self-awareness of task methods and self-monitoring skills

• Increasing strategy generation and effectiveness to manage cognitive errors

Transfer of strategies

3 ingredients for transfer:

• Explicitly help the client make connections (strategy bridging)

• Variability and practice

• Anticipation/self-monitoring and self-evaluation

Near and Far transfer

Near Transfer occurs between tasks that look very much alike and follow the same rules for responding, while a far transfer task is where the same rules apply, but the rules are transferred to a different setting. Far transfer requires us to think more than near transfer.

Activity manipulation

 Small changes in activity characteristics or the environment, such as the instructions, number of items, arrangement of items, or level of familiarity, can influence cognitive performance.

Side ways learning

Activities are not graded up in difficulty until evidence of generalization is observed

Increasing EF Demands

Initiation:

• Ambiguous directions, requires information seeking, asks questions, generates plans or ideas, open-ended, identify goals/choices

Inhibition:

• Rule constraints or criteria for selection; extraneous materials or increased amount of irrelevant information, interruptions, competition

Shifting/Flexibility:

• Tasks requiring alternating, switching actions or attention back and forth between several different sources of information. Changing rules or circumstances, generating alternative ideas, methods, or solutions to obstacles.

Working memory:

• Increased number of items, steps or information to hold onto; decreased external cues, tasks requiring mental tracking, updating or manipulating

Cuing

• General

  • offering encouragement; positive reinforcement of accuracy, not strategy or method; repetition of instructions

• General questioning

• General feedback

• Verbal specific

• Strategy

• Visual Cue

• Therapist demonstrates

• physical Assist

Therapist directed interactions VS Guided training

TD interactions:

• Instruct client on what to do

• Focus on the task and task outcomes

• Improve performance on a specific functional task through fading cues

• Provide direct feedback or assistance

  • Provide strategies

  • Provide additional directions

  • Point out key info

  • Gesture, point

  • Model the strategy

  • Assist with task completion 

Guided Training:

• Enable client to self-discover a strategy or plan how to solve the problem

• Let errors occur

• Socratic questions when necessary