week 5: Interventions for cognitive functioning in pediatrics

Importance of Cognition in OT

•Identify Cognitive Deficits to Establish Baseline

•Identify Cognitive Demands in Environment & in Occupations

•Develop intervention to improve cognitive performance for Occupation

Cognitive functioning  affects occupational performance.

Preschool

Progression of ADL & IADL involvement among Children

Home

Morning Routine

Clean up

Prepare cold snack

Make Bed

Outside

Library visit

Community Events

Playground

Controlling Temper/ Impulsive behaviors

Progression of ADL & IADL involvement among Children

middle childhood

Home

Prepare Simple Meals

Take care of Space & needs

Put away Groceries

Completion of homework

Outside

Asist with grocery shopping

Participate in after school programs, community center activities

Follow schedule

Progression of ADL & IADL involvement among Children

younger adolescence

Home

Plan and prepare Simple hot & cold meals

Use of communication devices

Babysit

Manage Medications

Outside

Use public Transportation Independently

Volunteer

Emerging Safety Awareness

Progression of ADL & IADL involvement among Children

older adolescents

Home

Operate kitchen appliances

Home repairs

Outside

Driving

Works Part time

Volunteer

College Readiness

Factors Impacting Cognitive Development

•Sensory

•Psychological

•Physiological

•Environmental

Comorbidities

•Children with DCD →

•Autism →

•Traumatic brain injuries→

•Acquired Brain injury/Genetic Conditions→

•Intellectual disabilities →

•ADHD →

•Down Syndrome →

•Oppositional Defiant Disorder

components of cognition

Memory:

•Short

•Long

•Working

Attention:

•Selective

•Sustained

•Divided

Orientation:

•Alertness

•Arousal

Perception:

•Discrimination of senses

Thought:

•Content

Cognition defined:

“The Child’s ability to acquire and use information in order to adapt to environmental demands.”

Higher Level Components of Cognition: Executive Functioning

•Working Memory

•Inhibitory Control

•Cognitive Flexibility

•Planning and Organization

•Self Regulation

Working Memory

■The ability to hold, update and manipulate information

■Deficits

–Difficulty to remember steps to complete a project

– difficulty following schedule (give 3 step direction)

TBI, ADHD

Inhibitory Control

The ability to inhibit, resist, or not act on impulse

The ability to STOP one’s own behavior at the appropriate time

Deficits:

Intrusiveness

lack of personal safety

ADHD, OCD, ODD

Cognitive Flexibility

The ability to change plans or actions as the circumstances demand

Switching or alternating attention and changing focus

Deficits:

Rigid thinking

Perseverative behaviors

Behavioral/emotional outburst

Plan:

Ability to manage current and future-oriented task demands in context

Anticipation of future events

ability to set goals to meet them,

Develop appropriate steps ahead of time to carry out task or activity

Organization:

Memory component (how one learns and retrieves information) and bringing order to information

Identifying critical steps/groups of information to follow a plan and execute tasks

Deficits: planning and organization

Easily overwhelmed by increased information

Impacts overall learning of content managing assignments

Self Regulation

The ability to control emotions/actions so that goals can be achieved and tasks completed.

EF within the emotional realm

Deficits:

lability (frequent mood changes)

explosiveness (tantrums)

Executive Skills involving Thinking (cognition)

Working Memory

Planning/prioritization

Organization

Time Management

Metacognition

Executive Skills involving doing (behavior)

Response Inhibition

Emotional control

Sustained attention

Task initiation

Goal-directed persistence

Flexibility

Method of Cognitive Assessment

•Observation

•Interview

•Occupational History

•Standardized tests

• Patient Reported Outcome

• Performance based test

•Environmental Assessment

Dynamic occupational therapy cognitive assessment for children

Ages 6-12

Measures cognition and learning potential

Child kitchen task assessment (CKTA)

Ages 8-12

Examines EF through performance

Behavior Rating Inventory of Executive Function (BRIEF-2)

Ages 5-18

Parent/Client Questionnaire

DO- EAT

Ages 5-8

Measures performance on 3 tasks

Making a sandwich

Making chocolate milk

Fill out certificate of outstanding performance for self

Weekly calendar planning activity

12-17

Measures EF by entering appointments and errands in a weekly schedule

Why use Cognitive Approaches?

Performance Based approach to assist the child in identifying, developing, & utilizing cognitive strategies to increase occupational performance:

•Motivation

•Generalization

•Facilitate Lifelong Development

Cognitive Rehabilitation Models:Dynamic Model of Cognition

Based on Dynamic Systems theory (individual, task and environment)

Integrates info. on learning from cognitive & educational psych with OT practice (Ex. Vygotsky, Bandura)

• Discovery learning (construct knowledge from past experiences and direct experiences)

• Metacognition

Cognitive and occupational performance change based on personal as well as task and environmental factors

The ability to effectively use strategies learned depends on personal factors & external factors

Provides broad view of cognition and therefore supports multiple intervention approaches

• Improve self awareness, modify external factors

• Emphasis on Ability to apply cognitive strategies & be self directed in improving performance vs completing the task itself

Guidelines for Cognitive Intervention

Design environment rich with opportunities to practice EF & cognitive skills

• Complex and progressive to facilitate cog. Challenge

• Variability in practice

• Intensity and frequency of practice is important

Support child’s development of self-awareness at all stages of intervention

Wean external supports when appropriate

• Prompt hierarchy (ex. CKTA)

Help family and others involved to have reasonable expectations

• Simple directions; Environmental Set up

• Education on Arousal & SP

Cognitive Rehabilitation Models: remedial: MAIN DIFF

Main focus is on retraining and restoring impaired areas of cognition

Targets core components such as memory, attention, EF, etc. that cause the deficit

Cognitive Rehabilitation Models: Adaptive/functional: MAIN DIFF

•Main focus is on facilitating functional participation despite cognitive deficits

•Main goal is to adapt the environment/task to individual’s abilities

Cognitive Rehabilitation Models: Remedial/Restorative

Emphasis on evaluating & restoring impaired cognitive skills

Follow hierarchy (higher cortical skills vs. lower level skills)

No evidence that practice of cognitive components in isolation will generalize to task requiring these skills

Connect to Occupation

Examples:

• Cognitive computer-based training programs,

• Remedial: focused on specific cognitive components

Remedial Cognitive Intervention: Attention & Working Memory

Divided Attention

Visual Scanning (Driving)

Following Directions

Sequencing

example: Goal: Carlos will prepare 2 cold snacks/meals (sandwich, cereal, fruit), gathering then putting away all needed materials, independently for 3 sessions to demonstrate age-appropriate meal preparation.

Cognitive Rehabilitation Models: Adaptive/Functional Models

Emphasizes the ability to successfully perform everyday tasks and routines by building on the person’s assets and/or residual skills

•Indirect Approach:

• Caregiver Education

• Environmental  Modifications

•Domain Specific Strategies:

• External Sensory &Environmental

• Mental of Self Verbalization Strategies

• Task Modification  & Specification Strategies

Domain Specific Strategies: Mental & Verbalization

Role Script: A pattern of words to help guide a sequence of actions

“Stab, Slice, Saw”

goal: Carlos will utilize a knife and fork to cut tough  foods with min verbal cues for 75% of relevant opportunities

Domain Specific Strategies: Task Modification for Task Completion

Stimuli Reduction: Reading Bar

Organization: Restructure for Logic

Pacing Strategies: Assist with Timing: Tapping foot, humming, timer

Attention to Doing: Relevant Cue

Task Modifications– Organization & Planning

Task Simplification

organization:

Task Specification: Place Backpack Here

Cognitive Intervention For Organization

Verbalization: Self Questioning:

Indirect Education:

Task Modification:

goal example: Per parent report, Carlos will be prepared when time to leave for school (books in backpack, have lunch, etc.) with the use of a checklist or visual reminder for 3/5 days of the school week.

Cognitive Rehabilitation Models:Cognitive Strategies

CO-OP (Cognitive Orientation to Daily Occupational Performance Approach)

External control

• visual checklist

Internal control

• Self awareness training

• E.g. Zones, video modeling, self-talk, etc.

Problem Solving Strategies

Cognitive Intervention - Time Management

Goal: Per parent report, Iris will demonstrate improved time management and attention to complete all steps of her morning routine with min VC to redirect attention to task 3/5 days per week

Cognitive Intervention: Cognitive Flexibility & Self Regulation

Group Intervention (Speech and Social Work)

Peer Dyads

Cognitive Strategy ->Zones of Regulation

Teletherapy Ideas

Meal Preparation

Scavenger Hunts!

Planning An Obstacle Course

Visual Schedules

Online Boardgames

Battleship

Chess

Connect 4

Puzzles

Dice games

Executive Function Intervention: Collaboration with Speech Therapists

Auditory Processing

• Ex Lennox Gastaut syndrome

  • Safety

Receptive Understanding

• Ex. Yes/No Questions

• Wh Questions

• Spatial Concepts

• Aphasia

Expressive Speech

• Gestalt Language Processer

  • Ex. It's a red car!”

Use of Communication Device

Executive Function Intervention: Collaboration with Speech Therapists

nova chat

Applications to Support EF

Applications to Google Keep

Google Read and Write

Sticky Notes

Day board Site Blocker

To Do list

Homework Tracker

Sometimes in school setting you may need to advocate for extensions to be allowed on laptop to promote school organization, plannings, attention etc.