Occupational Therapy & Cognition

Cognition refers to information-processing functions carried out by
the brain that include
- Attention a spotlight that focuses an individual's awareness on a particular facet of their environment, or on
the thoughts in their head.
- Memory the mental capacity or faculty of retaining and reviving facts, events, impressions, etc., or of recalling
or recognizing previous experiences
- Executive functions (i.e., planning, problem solving, self-
monitoring, self-awareness) a set of cognitive processes that are necessary for the cognitive control of
behavior: selecting and successfully monitoring behaviors that facilitate the attainment of chosen goals
- Comprehension and formation of speech calculation ability The ability to
understand something, The process by which thoughts are translated into speech. This includes the selection of
words, the organization of relevant grammatical forms, and then the articulation of the resulting sounds by the
motor system using the vocal apparatus
- Visual perception the brain's ability to make sense of what the eyes see
- Praxis skills neurological process by which cognition directs motor action

Importance of Cognition
- Our cognitive processes are how we make sense of and interact with
the world. They inform everything that we think, feel, say and do.
- Cognitive impairments are major determinants of caregiving needs
and societal health care costs.
- Even mild cognitive impairments can have profound effects on
social participation, academic, employment, emotional wellbeing
and other areas of occupational performance

- Cognitive processes can be conscious or unconscious and often are divided into
basic level skills (e.g., attention and memory processes) and executive functions
- Cognitive dysfunction(or cognitive impairment) can be defined as functioning
below expected normative levels or loss of ability in any area of cognitive
functioning.
- Cognitive dysfunction can be transient or permanent, progressive or static,
general or specific, and of different levels of severity affecting individuals in
different domains of their lives.
- The Occupational Therapy Practice Framework: Domain and Process(2nd ed.,
AOTA, 2008) identifies the underlying factors and areas of occupation that
occupational therapy practitioners consider during the evaluation and
intervention process (i.e., client factors, performance skills, performance patterns,
context and environment, activity demands).
- The interaction between a person’s cognitive functioning and each factor is
transactional in nature and, as such, cognitive functioning is always embedded in
occupational performance and cannot be accurately understood in isolation.

- Occupational therapists examine cognition and performance from multiple
perspectives and use multiple methods during the evaluation process, including
interviewing the client and others (e.g., parent, teacher, caregiver), cognitive
screening, performance-based assessments, environmental assessment, and
specific cognitive measures.
- 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.
- Cognition: “an ongoing product of the dynamic interaction between the
individual (person),the task (occupation) and the environment.
- Consistent with person-environment-occupation models

- 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

- 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

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

Two Levels of Cognitive Processing
- Surface level: memorizing of facts and procedures with no
application
- Deep processing level: new information is connected to current
knowledge by elaborating and organizing the information
- Processing strategies and behavior: “organized approaches,
routines, or tactics that operate to select and guide the processing of
information”
- Strategies are used to acquire information necessary for everyday
activities

- 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
- 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
Definition 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

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

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

Role Occupational Therapist in Dynamic Interactional Approach
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

Evaluation within the Dynamic Interactional Approach
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

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

Components of the Dynamic Interactional Approach
- 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
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

Interventions within the Dynamic Interactional Approach
- 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

Factors to Address for Intervention
Individual factors
- Processing strategies and behaviors
- Metacognition
- Characteristics
Environmental factors:
- Social interaction
- Familiar and new physical and cultural environments
- Multiple contexts
Task factors:
- Surface characteristics
- Number of items
- Complexity
- Familiarity
- Movement and postural requirements
- Arrangement

Factors to Address for Intervention
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
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

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
- OT changes the characteristics of a task or setting so person will
repeat behaviors in multiple contexts

Dynamic Interactional Approach
- 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

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.

What is cognitive rehabilitation?
- Cognitive rehabilitation is a goal-oriented program that aims to
improve cognitive functions (memory, attention, and concentration)
and daily living skills (i.e. using the telephone, managing
medication, and handling money) that may have been affected by
your stroke.
- The rehabilitation program is developed according to each client's
specific needs.
- The goal is to improve performance in tasks that are important to
you.
Two approaches are usually adopted:
- The remedial (or restorative) approach or the compensatory
approach

- Cognitive impairment, a problem involving the mind, is very
common following a stroke.
- There are different kinds of cognitive impairment such as
forgetfulness, confusion and/or disorientation.
- These impairments can interfere with safety, productivity,
independence and personal relationships.

Allen's Cognitive Disabilities Model (CDM)
- The Allen’s Cognitive Disabilities Model (CDM) emphases on the
integration of the cognitive functional ability and the level of
activities that clients are able and willing to perform.
- Interventions using this model can take place individually or in
group.
- When implementing the intervention, therapists consider each
client’s needs and implement changes in task accordingly.
- In group sessions, each client’s cognitive mode of performance is
considered individually and adapted to the modified task with
appropriate level of required cognitive functional ability.

Allen's Cognitive Disabilities Model (CDM)
- To describe the degree of cognitive disability, this model uses six
functional cognitive levels:
- (1) automatic actions
- (2) postural actions
- (3) manual actions
- (4) goal-directed actions
- (5) exploratory actions
- (6) planned actions.

- Each cognitive level consists of modes of performance, and the
overall performance ranges from 0 (generalized reflexive actions) to
6 (normal functioning).
- Assessments on functional history aim to evaluate functional levels
in the domains of ADL, IADL, etc., in order to suggest the level of
cognitive abilities and task performance of specific client.
- Interventions using this model consist of three stages such as post-
acute, rehabilitation, and long-term care.
- Task analysis and activity analysis are mainly used for analyzing
each task to match the demands to the cognitive level to each client
during intervention.
- Short-term goals aim to match to the current mode of performance,
whereas long-term goals are based on prediction of change in
performance modes.

- The ultimate goal of this model is to maintain the client’s existing
skills, and to develop new coping strategies.

Model of neuro-occupation, intention, meaning and perception
- This model aims to describe the symbiotic relationship between
occupation and the brain, as a chaotic, self-organized, and complex
system. It assumes that changes in human condition do not follow a
linear path.
- The model views occupational therapy as a complex intervention and
a result of dynamic integration of several factors and unpredictable
outcomes. The concept of neuro-occupation is complex and holistic,
and aims to help occupational therapists to apply the non-linearity
principles.
- Cognition is a process with dynamic relationships between the three
levels of Intention, Meaning, and Perception that are operated in a
circular feedback loop, which are for adaptation of occupational
performance.

The three levels are:
- 1. Intention: a state of readiness that enables one to select and define
goal-directed action(s) to fulfil the need and desire.
- 2. Meaning: the actions that have meaning accumulated from
experiences and maintained through one’s history of goal
development and goal-directed actions and choices.
- 3. Perception: Attitudes and Beliefs are shaped, which change
perception and awareness of the person about his or her own
conditions.

- The process begins with hypothesis formulation at the intention
level, then the meaning level (hypothesis will be tested by trial and
error actions in the environment), then eventually at the perception
level (information will be created from the trial and error to modify
or form new perceptions).
- This explains how humans regulate behavior and adapt successfully
to challenging environmental conditions and, by creating meaning
through engagement in occupations, execute complex occupational
performance.
- Perturbance is any condition that causes circular causality to
happen as a response. A person may respond to an internal (i.e.
neurological event) or external perturbance (i.e. significant person
or perceived important situation).

- Perturbance causes a person to move from a steady state of
homeostasis to the edge of chaos, where dynamical change and
adaptation occurs.
- It is where creativity occurs, and these constraints facilitate new
action formation and choice based on circumstances.
- Several factors, such as experiences, genetics, environment, arousal
state, intention state, affect the recognition of perturbance.
- Occupational therapists use personal creativity and accumulated
knowledge of the client, pose an effective perturbance that
challenges, motivates, and directs personal goal formation to client,
and may influence the client’s perception. An intervention based on
what is meaningful to the client may be taken as a perturbance for
restoring hope and motivation.

Human cognition is:
Conscious and unconscious
Concrete or abstract
- Thinking that is focused on the physical world, focused on facts in the here and now, physical objects,
and literal definitions (Concrete thinking)
- A level of thinking about things that is removed from the facts of the “here and now”, and from specific
examples of the things or concepts being thought about (Abstract thinking)
Intuitive and conceptual
- using or based on what one feels to be true even without conscious reasoning; instinctive.
- related to ideas and concepts formed in the mind (Conceptual)
Inductive and deductive reasoning
- Inductive reasoning is a method of reasoning in which the premises are viewed as supplying
some evidence for the truth of the conclusion, this is in contrast to deductive reasoning
- Deductive reasoning, also deductive logic, logical deduction is the process of reasoning from
one or more statements to reach a logically certain conclusion. Deductive reasoning goes in
the same direction as that of the conditionals, and links premises with conclusions.

ICF Mental Functions
Specific Mental Functions:
◦Attention functions
◦Memory functions
◦Psychomotor functions
◦Emotional functions
◦Perceptual functions
◦Thought functions
◦Higher-level cognitive functions
◦Mental functions of language
◦Calculation functions
◦Mental function of sequencing complex movements
◦Experience of self and time function

Higher-level cognitive functions – often called Executive Functions
• Goal-directed behaviors such as decision-making
• Abstract thinking
• Planning and carrying out plans
• Mental flexibility
• Deciding which behaviors are appropriate under what circumstances

Possible Self
Possible selves theory is an extension of self-concept theory.
Similar to other approaches in this tradition, possible selves
theory emphasizes the impact that a student’s self-definition
has on school behavior. Students’ motivation to engage in
effortful learning in school is related to how vividly they can
picture different possible selves, the nature of their possible
selves, and the connections students perceive between school
behavior and either achieving a positive self or avoiding a
negative self.
Possible selves are projections about the future that are
rooted in students’. Both positive and negative possible selves
reflect what students have come to believe are actually
possible for them.

Self-Efficacy
Self-efficacy is an individual’s belief in her or his ability to
achieve particular goals. This means that such individuals
are more likely to believe that they can alter the world by
their actions and are capable of acting effectively on the
world. Consequently, they are more likely to initiate action
proactively, persist during adversity, and show resilience in
the face of failure

Self-Efficacy
Self-efficacy is all about believing in your ability to achieve
particular tasks or goals. This is indispensable for students if
they want to achieve, and especially if they want to achieve at
their highest potential.
People with a strong sense of self-efficacy are highly-
motivated and self-directed. They have the ability to self-
reflect on their experience and learn from it and to self-
regulate their learning and emotions in order to achieve their
goals.

Self Knowledge
The more we know about ourselves, the more we are able to
understand and control our mental processes and behavior
patterns. This in turn enables us to improve how we think
and behave which leads to more substantive learning
outcomes. Students become proficient learners as a result of
reflecting on their own experience and taking action to
improve their ability to control their internal processes.

Metacognitive Awareness: Metacognition is generally defined
as “thinking about thinking.” In other words, students reflect
on the mental processes that influence how they think and
assess the impact of those processes on their learning and
lives.
By recognizing their thinking behavior patters, students can
gain an understanding of what goes on internally when they
learn and how those processes can be improved.
Proficient learners are aware of their metacognitive
processes and how they help or hinder their capacity to learn
and achieve.

Metacognitive Skills: Skill is the ability to do. In terms of our
metacognitive abilities, skill is associated with taking action
to improve based on our metacognitive awareness.
When students, as a result of self-reflection, become aware
that a particular process (e.g., monitoring their progress) is
inhibiting their ability to learn efficiently (acquire knowledge
and successfully apply it in authentic contexts in reasonable
timeframes), they can then take action to improve the process
(develop their skill in executing the monitoring process more
efficiently).
Metacognitive skill development can be taught and learned in
educational contexts, resulting in improved learner outcomes
and higher levels of achievement.

Attribution Styles: Attribution means to explain the causes of
a behavior or an event. Understanding students’ attribution
styles help counselors understand how students explain the
reason for behaviors (their own and of others) and events
that occur and how those explanation impact their learning
and how they view themselves and others.
A good example of understanding students’ attribution style
is how they explain their successes and failures in terms of
their academic performance (e.g., passing or failing a test).
Attributions are often inaccurate or do not reflect the reality
of the situation.

Attribution Styles
Knowing about attribution styles and how to determine them
are important tools for educators to help students improve
their self-image and become more proficient learners.
Understanding how we explain why events and behaviors
occur enables us to make more conscious and accurate
attributions that help us make sense of our lives, the lives of
others and the environment/situations in which we find
ourselves

Casual Attribution: The attributions we make about
behaviors and events explain, or make sense of, the causes
for what occurred.
Causes are generally understood as having to do with locus
of control (e.g., how much control an individual has in the
situation and whether the cause is internal or external),
whether the behavior or event is temporary or if it is
something permanent in the individual (e.g., is failing a math
test a fluke or an inevitable result of taking math courses),
and whether the individual has some degree of control or the
situation is uncontrollable.
The causes assigned by students have a significant influence
on their motivation, self-direction and sense of self-efficacy.

Learned Optimism: Optimists are more engaged learners and
achieve better results (learning outcomes) than pessimists.
Optimists can benefit from opportunities to learn. The
tendencies toward optimism and pessimism are important
considerations for those seeking to help students learn and
achieve.
Proficient learners are optimists who are motivated to
achieve, engaged in their learning and have a strong sense of
self-efficacy regarding what they are capable of
accomplishing..

Self-knowledge is a key to learning how to learn, plan for
future success, and cope with the challenges of learning and
growing up prepared to enter and thrive in the postsecondary
world.
School counselors are responsible for helping students
become aware of how they learn and how well they control
the mental processes that govern their learning.
Counselors are responsible for guiding students in
developing the skills necessary to improve their learning
processes by bring them up to a conscious level, acting to
change them, monitoring their improvement activities,
evaluating the results and making informed decisions about
the next steps to take to become more proficient at learning.

Self Direction
Self-direction is critical to student learning and the ability of
students to assume ownership of their own learning
processes.
The notion of self-direction can suggest independence rather
than dependence; the ability to make choices independent of
others and manage our actions and lives without external
forces influencing or dictating what we should do. The term
suggests a high degree of autonomy and self-sufficiency in
our thinking and behavior.

Self Direction Sub Constructs
Self-Directed Learning: Individuals direct their own learning
by establish goals, developing and implementing plans,
monitoring progress and evaluating results.
Self-Regulated Learning: Individuals regulate their thinking
and behaviors in order to maximize their potential for
learning and improving their learning outcomes.
Self-Regulation of Emotions: Individuals regulate their
impulses and emotional responses to stimuli and events in
their lives and learning.

Executive Functions: These functions control and manage
the complex processes that enable us to learn and live
balanced lives.
Goal Setting/Action Planning: Individuals have the capacity
to establish goals, develop action plans and then take action
to successfully achieve their goals.
The self-direction construct is inextricably related to
motivation, self-knowledge and relationships. For example,
motivation is the driving force that compels us to make
appropriate choices, establish meaningful goals, and
effectively plan for and achieve desired results by becoming
proficient learners. Motivation drives our desire to direct our
learning in ways that ensure we achieve our goals.

Self-knowledge enables us to understand our abilities and
interests and how o manage and control the mental processes
we use to learn.
Metacognitive awareness, metacognitive skills and self-
efficacy are all critical processes related to self-direction. It
also helps us to make accurate attributions that explain the
causes of our successes and failure, and to recognize our
locus of control as internal rather than external.

Relationships are critical to becoming self-directed as no one
achieves self-direction in isolation.
Others contribute to our understanding of and ability to self-
direct our lives. Self-direction is enhanced in social contexts
and we need social skills to be able to interact with those who
can help us achieve self-direction through supportive
relationships.
Self-direction must also be seen in the context of group
direction where it is important for students to be self-directed
while working in harmony with group-directed activities.

Self Direction
Self-direction is critical to student learning and the ability of
students to assume ownership of their own learning
processes.

Self-Directed Learning: Individuals direct their own learning
by establish goals, developing and implementing plans,
monitoring progress and evaluating results.
Self-Regulated Learning: Individuals regulate their thinking
and behaviors in order to maximize their potential for
learning and improving their learning outcomes.
Self-Regulation of Emotions: Individuals regulate their
impulses and emotional responses to stimuli and events in
their lives and learning

Executive Functions: These functions control and manage
the complex processes that enable us to learn and live
balanced lives.
Goal Setting/Action Planning: Individuals have the capacity
to establish goals, develop action plans and then take action
to successfully achieve their goals.

The self-direction construct is inextricably related to
motivation, self-knowledge and relationships.
For example, motivation is the driving force that compels us
to make appropriate choices, establish meaningful goals, and
effectively plan for and achieve desired results by becoming
proficient learners. Motivation drives our desire to direct our
learning in ways that ensure we achieve our goals.

Self-knowledge enables us to understand our abilities and
interests and how to manage and control the mental
processes we use to learn.
Metacognitive awareness, metacognitive skills and self-
efficacy are all critical processes related to self-direction. It
also helps us to make accurate attributions that explain the
causes of our successes and failure, and to recognize our
locus of control as internal rather than external.

Relationships are critical to becoming self-directed as no one
achieves self-direction in isolation. Others contribute to our
understanding of and ability to self-direct our lives.
Self-direction is enhanced in social contexts and we need
social skills to be able to interact with those who can help us
achieve self-direction through supportive relationships.
Self-direction must also be seen in the context of group
direction where it is important for students to be self-directed
while working in harmony with group-directed activities

Self-Regulated Learners
Learning is a complex process that involves our thinking,
emotions and behaviors. Becoming proficient learners
requires mastery of a set of skills that enable us to effectively
integrate these aspects of our learning into a coherent
approach to achieving positive learning outcomes

Self-regulation requires us to be skilled observers of our own
learning processes and have the ability to determine the
strengths and limitation of our performance, then to improve
the processes.
Self-regulation involves our metacognitive ability to self-
reflect on and regulate the mental processes that influence
our thinking, behavior and emotions.
Self-regulated learning assumes that we are cognizant of how
we learn, how well we learn, what needs to be improved and
how to do it. It assumes a developed capacity to implement
and achieve improvement goals and to evaluate the results of
our efforts. We accomplish this by controlling our learning
processes, being highly motivated, paying attention to details
and regulating our thinking, emotions and behaviors.

Self-Regulation of Emotions
Self regulation of emotions is a critical aspect of student
learning attention to which is part of the core set of
responsibilities for school counselors.

Children need to learn how to direct their own attention and
modulate emotional states related to fear, anxiety, anger and
depression.
By enabling all students to regulate their own attention and
emotional states, school counselors promote the development
of essential skills necessary for learning, persistence,
resilience and effective and satisfying social interactions.

Coping mechanisms are a way to learn how to regulate
emotions and behavior. School counselors can help students
learn how to cope, one of three essential functions in the role
of school counselors: to help students learn how to learn,
how to plan and how to cope).
Coping mechanism such as thinking before acting,
discussing, considering what others are experiencing in
conflict situations can all help to make regulating our
emotions a self-reflective activity that reduces the need to act
out and be out of control.

Can they think of instances when they were out of control or
were having difficulty maintaining control of their emotions?
What can they do to change their behavior patterns? These
can be linked to examples of how uncontrolled emotions are
disruptive to learning (both personally and to classmates) and
the need for students to learn how to better manage their
emotions (e.g., anti-bullying or conflict resolution strategies).

Another approach is to ask students to identify emotional
triggers that interfere with their ability to regulate their
emotions and behaviors, and explore ways to improve their
responses so they regain control.
This requires students to identify in what areas they need to
improve and recognize in what ways they are successful in
regulating their impulses and emotions.
School counselors can help student understand the
consequences of not regulating their emotions and how that
affects their ability to learn and succeed.

Goal Setting/Action Planning
Imagine life without goals. We would have no sense of
direction, lack any motivation to accomplish something
meaningful, would be unable to make any plans and would
have very little, if any, control over our lives.
Our ability to set goals and develop plans to achieve them is
essential to our sense of self-efficacy and ability to achieve.

Goal Setting/Action Planning
.

Goal setting and action planning are fundamental to the
human experience.
Constructs, goal setting and action planning are critical to
our motivation to achieve, and to envisioning and realizing
our future possible selves.
Self-direction would be impossible without the ability to
establish goals and develop plans. Our executive functions
would be rendered non-functioning. Without goal setting and
action planning we would not be able to use the knowledge
we have about our metacognitive abilities to make plans to
improve the processes by which we learn. And relationships
would never be able to develop and deepen if we were unable
to plan for our future with others.

Goal setting and action planning
As humans we rely on goal-setting in every aspect of our
lives, therefore it is critical for our educational systems to
teach goal-setting and action planning as core learning
opportunities for students.
We do not wait for our children to enter school before helping
them to understand the need to set goals and develop plans,
nor are goal-oriented learning opportunities limited to the
PreK-12 learning continuum.
Goal setting and action planning are life-long learning skills
that we introduce early and continue to reinforce and refine
as we age.

Goal setting and action planning
The development of individual learning plans by students
where they set academic, career and person/social goals
places school counselors at the forefront of school’s efforts to
help students be college and career ready by the time they
graduate from high school.
Whether students are creating short, intermediate or long-
term goals, school counselors are positioned to strongly
influence how well students learn and apply goal-setting and
action planning to their learning and lives. Plus school
counselors are in a position to help students understand the
connection between goal setting and action planning and
their motivation, self-efficacy, self-regulation, thinking
processes, behavior patterns and achievement.

Metacognitive Awareness
Metacognitive awareness involves self-reflecting on these
learning processes in order to understand and improve them.
This focus on metacognition is in contrast to an emphasis on
cognitive content knowledge which until recently has
dominated educational theory, policies and practice. Recent
research demonstrates that both cognitive and metacognitive
abilities are critical to student learning and achievement.

Hacker, et al (2009) defines metacognition as consisting of
“two complementary processes: 1) the knowledge of cognition
and 2) the regulation of cognition.”

Awareness (knowledge of cognition) focuses on our knowing
the metacognitive factors that influence our learning and
performance, knowing various appropriate strategies to
improve our learning processes, and knowing which
strategies to select to increase our ability to control and
manage our mental processes.
Regulation focuses on applying what we know and taking
action to improve our learning processes and hence improve
our learning outcomes. This involves goal-setting, planning,
implementing the plan and monitoring progress, and
evaluating the results of our efforts to improve our learning.

Our metacognitive abilities enable us to reflect on what
controls our learning processes and take action to improve
them. Development of our metacognition is a pathway to
improved learner outcomes and as such needs to be a strong
focus in the work of school counselors.
There is also a strong relationship between CBA constructs
and sub-constructs, metacognitive abilities and social-
emotional learning. The CASEL (Collaborative for Academic,
Social and Emotional Learning) “The short-term goals of
SEL programs are to (1) promote students’ self-awareness,
social awareness, relationship, and responsible-decision-
making skills and (2) improve student attitudes and beliefs
about self, others, and school.”

Metacognition is a fundamental part of human experience as
it deals with our ability to be aware of how we function and
what we can do to more effectively control and manage our
mental processes.
Traditionally, counselors have helped students develop
metacognitive awareness of their interests, values, abilities,
learning styles, temperament and personality, all of which
promote effective learning, self-direction and decision-
making.

Understanding metacognition and how to teach students to
improve their metacognitive abilities are a core responsibility
of school counselors and an essential component of
comprehensive school counseling programs.
Helping students become aware of their own selves and
ability to regulate their own metacognitive and social-
emotional processes are central to the design of a CBA and
the core mission of school counseling programs. By focusing
on metacognition as a central component of what we teach
students, we are helping them to become more proficient
learners and progress toward achieving at their highest
potential.

The effective use of CBA school counseling standards and
competencies, which serve as primary learning targets in the
CBA counseling curriculum, all depend on helping students
develop their metacognitive abilities. This includes helping
students reflect on their own thinking processes and behavior
patterns, assessing how these processes and patterns
influence their learning, plan to improve their processes and
patterns, implement their plan and monitor progress and
evaluate the results. We want to help students be aware of
their own mental processes and take charge of regulating
these processes in ways that improve their learning outcomes.
By doing so we are making a significant contribution to
students’ ability to achieve in school and succeed in life.

Metacognitive Skills
“Metacognitive skills” and “metacognitive strategies.” The
meanings of both terms are useful in understanding what we
do once we are aware (have knowledge about) our
metacognitive processes. Both terms suggest that we act on
our awareness, that we use our knowledge to effect change in
the way we control and manage our mental processes.
Becoming skilled at dealing with our metacognition denotes
that we have achieved a level of proficiency or expertise in
improving a metacognitive process. Using a metacognitive
strategy indicates that we have selected an appropriate
approach and developed a plan to improve a metacognitive
process.

“Metacognitive Awareness” , there are two key aspects of
metacognition: “awareness of cognition” (which allows us to
identify what is influencing our learning and performance)
and the “regulation of cognition” (which allows us to select
appropriate responses for specific situations in order to
improve the way we control our learning processes and
analyze the results).
Develop metacognitive awareness (knowledge about their
own mental processes) so they can actively control their
learning processes, academic and career development, and
social relationships.. The majority of sources will focus on
processes such as self-reflection, planning, monitoring
progress and evaluating the results of implementing one’s
plan.

Attributional Styles
Three sub-constructs (attribution styles, causal attribution,
learned optimism) are all part of our metacognitive
functioning and critical to our ability to learn and live
productive and fulfilling lives.
A significant aspect of the human experience is the need to
understand why something has happened. Behaviors and
events need to make sense to us and we accomplish this
through attributions we make regarding the cause of what
occurred.

Attributional Theory
The conceptual framework used to study the processes by
which we make judgments and attribute causes to what
happened is called attribution theory. We attribute (assign a
reason for) the cause of the behavior or event in terms that
make sense to us. Attribution theory is also called explanatory
theory because this process represents our efforts to explain
the causes of what occurred

Attribution theory was first proposed by Fritz Heider and
later expanded upon by Bernard Weiner, among others.
These psychological theorists have provided the foundational
concepts for attribution theory and have established the
importance of the attributional process to education because
of the strong influence attributions have on students’ feelings
of success and failure and on their emotions, and future
motivation and emotional state.

Attribution theory is a primary focus of social psychology.
Locus of control is divided into internal vs. external, or
whether the cause can be attributed to ourselves (internal) or
to others or the environment (external). Stability relates to
whether causes are temporary or permanent. Controllability
refers to the amount of control individuals perceive they have
over a behavior or event.

The particular combination of styles (characteristics) can be
conducive to or inhibit our learning potential.
Attribution styles can be used to understand how and why
individuals respond to behaviors and situations. It can also be
used to describe behavior in social contexts that impact the
relationships we have, how we interact with other groups,
understand our national identify and the role of our country
in a global context.

Attributions styles are affected by a combination of personal
and environmental, or situational, factors. Attributions that
we make in the past influence our future thinking and
behavior. This is especially important in education where
students’ attributions related to learning successes and
failures can have a significant impact on their learning as
they progress along the PreK-12 learning continuum.
Students’ perceptions about causes of their successes and
failures can be more powerful than the actual causes because
students’ future attributions are influenced by their past
perceptions which are not always an accurate assessment of
the actual cause.

Attributional Biases
Another set of important concepts in attribution theory
address attributional biases. A bias is a judgment that people
make or believe to be true that is based on preconceived ideas
or beliefs but in reality are not true.

Attributional biases are very important in understanding both
individual and group explanations of behaviors and events.
They can be used to explain in-group and out-group beliefs
wherein people in the in-group (we or us) believe that certain
negative characteristics of entire out-groups (they or them)
are accurate perceptions.

The literature identifies many types of attributional biases.
Some of the more common are the fundamental attribution
error, self-serving bias, actor-observer bias, just world
hypothesis and the self-centered bias.
What all the biases have in common: they are all inaccurate
attributions that we can examine, challenge, clarify and
change by reflecting on the processes that explain behaviors
and events.

Attributions are an integral part of our daily lives and highly
impactful in terms of how students learn, are motivated to
learn and develop their ability to self-direct their learning.
Because they are part of our metacognitive processes,
attributions can be examined and changed, resulting in
improved learning processes and learner outcomes.
Self-knowledge about the mental processes associated with
attributions is an area of human experience that must be
controlled and effectively managed both by students and the
adults who are helping them to learn. It is therefore a
responsibility of school counselors to be able to understand.

The essential nature of attributions and how they are
constructed.
Attributional errors that can be made and how they affect
individuals in the learning environment.
How to recognize their own attributional styles and what their
personal attributions are communicating to students.
How to teach students to recognize and examine their
attributions, and challenge the causes they assign to
behaviors and events.
How to teach students to determine the positive and negative
influence attributions have on their self-image, potential for
learning, motivation, achievement and relationships.

How to help students develop their ability to assign accurate
explanations for their successes and failures in school and
life.
How to help students develop their ability to change and more
effectively control their attributional processes.
How to help other adults engaged in helping students learn
understand their own attributions and the potential impact of
what they are communicating to students.

Causal Attribution
Attributions have a major influence on students’ perception
about their ability to learn, how they approach learning tasks,
and whether they are motivated to stay focused on tasks to
completion.
Attribution theory describes three causal dimensions related
to how we make attributions (internal vs. external, stability vs.
instability, controllable vs. uncontrollable)

Causal Attribution
Students can be taught to examine their attributions as being
accurate or inaccurate, and recognize how the attributions
they make have affected their performance and learning
outcomes.
For example, a student may attribute failure on a test or in a
course to have been caused by a lack of ability when the
actual cause was a lack of effort.
By helping students make accurate attributions about the
causes of their low performance or failures, school
counselors can help improve students’ motivation and ability
to understand and successfully complete learning tasks.

Causal Attribution
The ability to reflect on the attributions students make that
are related to learning outcomes involves metacognitive
awareness, skill development and enhancement of their
executive functions.
Counseling curriculum activities should emphasize the need
for students to be critical thinkers and critically ask questions
about their own thinking and behavior patterns rather than
simply accepting what other may say are the causes of their
outcomes, or assigning an inaccurate attribution without
investigating what the real cause may be.

Causal Attribution
Inaccurate causal attributions regarding one’s successes and
failures at achieving learning tasks influence students’
motivation, self-awareness, self-direction and self-efficacy.
Enhancing these attributes lead to more engaged students
who are capable of achieving at higher levels. Teaching
students about causal attribution is a critical component of
school counseling programs and function of school counselor
practice.
By doing this, school counselors are helping to promote and
sustain a learning environment focused on achievement
rather than a fear of failure.

Learned Optimism
These tendencies toward negative or positive perceptions are
generally referred to as optimism and pessimism

Learned Optimism
These tendencies toward negative or positive perceptions are
generally referred to as optimism and pessimism
One of the key things to remember about our tendencies to be
optimistic or pessimistic is that we can, through critical self-
reflection, challenge our attributions and replace negative
thinking patterns with positive ones.
Optimists have a stronger belief that they are in control of, or
have some control in, situations and that their actions can
influence the outcomes. They are more highly motivated to
achieve because they have the opportunity to influence the
results.

Learned Optimism
Pessimists feel less in control or feel like they have no control
at all over the outcomes, hence they question why they should
even try.
Optimists are more successful at becoming self-directed
learners because their thinking is future-oriented based on
past experiences of success.
Since optimist feel a sense of control, the decisions they make
and actions they take can be controlled by them to maximize
their potential for achieving future goals.

Learned Optimism
Pessimists, based on past experiences of failure, or lack of
success in controlling situations, view the future as merely a
continuation of past performance, thereby diminishing any
sense of hope that outcomes will change because of their
efforts. This is also crucial in students’ ability to envision,
prepare for and realize their future selves.
Optimists have a strong sense of self-efficacy. They believe in
their ability to set goals and achieve specific tasks. The
success they experience in completing these goals builds their
confidence and self-concept and increases their motivation to
achieve at higher levels.

Learned Optimism
Self-confidence leads to decisive decision-making and
persistence in working to successfully complete tasks.
Pessimists do not think very highly of their ability to succeed
at specific tasks, let alone achieve their life’s goals. They lack
confidence in themselves and will avoid trying to achieve at
higher levels simply because they do not believe they can.

Learned Optimism
The opposite of learned optimism is learned helplessness, a
theory that suggests that the feeling of helplessness can
become a learned trait, and once a person has accepted their
helpless state, they can remain trapped by the negative
attributions they keep using to explain why things are
happening to them.
When students feel they have no control over their lives or
their happiness and feel they are incapable of performing
tasks, it can lead to low self-esteem and depression and
severely diminish their motivation and desire to achieve.

Learned Optimism
From a school counseling perspective, it is the responsibility
of school counselors to help students critically self-reflect on
their thinking processes and behavior patterns, examine the
attributions they make about them their ability and
performance, and develop plans to improve these processes
and patterns in ways that replace negative self-attributions
with positive ones.
Optimists feel more personal responsibility that bad things
are temporary or isolated and that good things will continue
to happen. Pessimists are negative thinkers, which things are
their own fault and that bad things will continue to happen to
them

Learned Optimism
From what we have learned about the causal dimension of
attributions, school counselors can reinforce students’ self-
esteem by focusing on self-confidence and high expectations
and learning how to construct attributions that are internal,
unstable and controllable.
The capacity to learn optimism depends on openness to
change and a willingness to expend effort to look at one’s
circumstances and the world around them in more positive
ways. School counselors can communicate optimistic and
controllable attributions, such as giving positive feedback to
students on what they do well and helping them understand
what they can do to improve their learning outcomes.

Relationships
This construct is important because we do not live in total
isolation from the influences of others, therefore we need to
become proficient in interacting with other individuals and
groups. Areas like social interaction and cultural competence
are critical traits that can be learned and developed over time
in school environments.

Relationships
Social Skills. Individuals live in social contexts. In order to
benefit from the social interactions and networks in which we
participate, it is important to become skilled in interacting
with others.
This can take many forms such as communication,
cooperation, collaboration, teamwork, group involvement and
sharing belief systems.
Being skilled in social interaction is one of the central
requirements for success in the modern world.

Help Seeking. The ability to seek help is critical to the
learning process. Completing challenging learning tasks is
inevitably going to require seeking assistance to gather
additional information or solve problems.
A critical skill that all students should develop is the ability to
identify what they know and do not know, and to access
experts and people knowledgeable in their fields to guide
them through difficult learning tasks.
One of the significant benefits of seeking and getting help
from others is that it develops one’s own expertise and in time
those who at one point needed to seek help become the
experts to whom those who need help come for advice and
guidance.

Critical Consciousness. The world is filled with oppressive
systems where basic human rights are ignored. One only has
to listen to the news to see that there are people who are
oppressed in this world.
Critical consciousness raises our awareness of oppressive
systems and commits us to act to change them. Education is a
primary tool for helping students understand the structure
and consequences of oppression in our midst and learn that it
is a human responsibility to work to counteract its influence

Social Justice. Injustices are evident everywhere in our
society and world (e.g., racism, sexism, xenophobia, income
inequality) and it is important for school counselors to be
aware of the injustices and help student become aware of
them and act to resolve them.
By focusing on social justice issues and the need to effectively
address them, school counselors are helping students mature
in ways that help contribute to a just society and the well
being of our world.

One of the responsibilities of school counselors is to help
guide students in developing meaningful relationships that
contribute to individual growth and the building of
sustainable communities. Research indicates that there is a
strong link between social competence and academic
achievement.
School counseling programs help students understand and
build relationships from basic respect of others to working for
a more equitable and just world.

To learn and to live effectively requires good social skills.
To learn effectively, students need to establish and maintain
productive, collaborative, social relationships with teachers
and with peers.
Students need to learn how to work in classrooms,
workgroups and teams to achieve common goals that can be
achieved through shared experience.
Social skills have also repeatedly been identified as an
essential component of work and career success.

Individual achievement needs to be grounded in social
interest and a commitment to working to improve one’s local,
national and global communities. Otherwise, the pursuit of
individual achievement can lead to self-absorption and the
unbridled pursuit of self-interest at the expense of others.
Consequently, the CBA suggests that all students need to
develop the broader social understanding that allows them to
recognize current inequities in society and the need for
individual commitment to work for a more equitable and just
world.

The CBA indicates that all students should develop the ability
to understand diversity, recognize inequity and act in ways to
promote a more just society. Given the current state of the art,
this will require practicing counselors to use the existing
research base to develop the effective social justice education
interventions.
Relatedly, school counseling researchers ought to be involved
in researching the effectiveness of these interventions and
assessing the value of and benefits associated with students’
participation in social justice education in schools.

Help Seeking
Successful learning requires individual effort and the help of
others. Help seeking is an essential contributor to
achievement and success in school.

Help Seeking
Help seeking is part of self-directed and self-regulated
learning as students need to self-initiate the process of
seeking help from others.
Successfully seeking and using the help of others establishes
a life-long learning skill that improves with subsequent
requests for assistance.

Help Seeking
Seeking help does not come naturally for many students.
They are afraid to ask for help for a variety of reasons, all of
which cause them to not speak to anyone about their
problems.
This is especially critical when the problems are inhibiting
the student’s ability to learn or to effectively cope with the
barriers to their learning.
Fear of coming to school or fear of taking tests or fear of
being bullied are all serious issues that must be addressed,
but many students do not feel comfortable asking anyone to
help them, thus exacerbating the problem and in the long
term making it more difficult to resolve.

Help Seeking
Another aspect of help seeking in educational contexts is
teachers asking school counselors for help in deepening their
understanding of individual students, help with diagnosing
problems, suggesting appropriate strategies, and having
students referred to them for help.
Likewise, parents can be help seekers when they need
assistance in helping resolve issues they have with their
child’s learning. Even though this perspective on help seeking
is not directly on students asking for help, the fact that adults
are seeking the help of counselors increases the potential for
increased learning and achievement in the school and in
school-home relationships.

Critical Consciousness
Raising people’s consciousness is a developmental process
that makes people aware of social, economic and political
systems that oppress people. Awareness leads to action to
against oppressive systems.
The theory of critical consciousness assumes that oppression
is a reality world-wide and it is in the best interest of people to
fight to remove it from our midst. One of the key components
of the theory of critical consciousness is that it frees both
oppressors and the oppressed, that the problem of oppression
can be as much structural as it is personal.

Critical consciousness is viewed as a transformational
process because it has the power to change the way we look at
our world and how people are treated, and strengthens
human resolve to make the world a better place for all to live.
A critically conscious society would change the way we relate
to each other.
When individuals exercise critical consciousness they explore
questions related to human dignity, freedom, authority, social
responsibility and personal purpose.

School counselors help students develop critical
consciousness by teaching them about the contextual nature
of the interconnectedness of life and the importance of the
sanctity of life achieved through human rights.
A primary goal of school counseling programs must be to
help students engage in a self-reflective process that leads to
their own development of critical consciousness and sense of
personal and social responsibility and empowerment.

“Motivation is defined as the process that initiates, guides,
and maintains goal-oriented behaviors. Motivation is what
causes us to act….It involves the biological, emotional,
social, and cognitive forces that activate behavior.”
Achievement Motivation: Humans have an innate drive to
achieve, to accomplish something significant in their lives.
Plan to achieve it, implement and monitor the progress,
evaluate the results and use the results to inform their next
steps.

Intrinsic and Extrinsic Motivation: Individuals are
intrinsically motivated to do things simply because we enjoy
doing them, without any external factors influencing our
decisions to act.
Individuals are extrinsically motivated to do things because
we get something from it (e.g., a reward or praise or because
of the fear of consequences for failing to achieve what is
expected of us).
We are often extrinsically motivated because someone else
has defined it as something that is expected of us and
because there are consequences to doing or not doing it

Self-Determination: Individuals need to understand that we
have a choice to think and behave based on our own volition.
The right to self-determination can be seen in a variety of
contexts (e.g., individual, social, political).
Possible Selves: An integral part of the learning process is
envisioning who we might be and what we might be doing in
the future. These possible selves help provide direction for
our lives and enable us to set goals that direct our thinking,
behavior and actions.

Self-Efficacy: This involves the belief individuals have in
their ability to successfully complete specific tasks. This is
important in education as students achieve at higher levels
the more they believe in their ability complete the tasks which
allow them to achieve at the higher levels.
Help students understand the importance of self-efficacy,
examine how strongly they believe in their ability to
accomplish particular learning tasks, and learn effective
strategies for building their confidence and successfully
completing what is required to succeed.

What is metacognition?
Metacognition is often referred to as “thinking about
thinking.” But that’s just a quick definition. Metacognition is
a regulatory system that helps a person understand and
control his or her own cognitive performance.
Metacognition allows people to take charge of their own
learning. It involves awareness of how they learn, an
evaluation of their learning needs, generating strategies to
meet these needs and then implementing the strategies.
(Hacker, 2009)

What is metacognition?
Learners often show an increase in self-confidence when
they build metacognitive skills. Self-efficacy improves
motivation as well as learning success.
Metacognitive skills are generally learned during a later
stage of development. Metacognitive strategies can often (but
not always) be stated by the individual who is using them.
For all age groups, metacognitive knowledge is crucial for
efficient independent learning because it fosters forethought
and self-reflection.

The Two Processes of Metacognition
According to theory, metacognition consists of two
complementary processes:
1) the knowledge of cognition and
2) the regulation of cognition.
Knowledge of cognition has three components: knowledge of
the factors that influence one’s own performance; knowing
different types of strategies to use for learning; knowing
what strategy to use for a specific learning situation.
Regulation of cognition involves: setting goals and planning;
monitoring and controlling learning; and evaluating one’s
own regulation (assessing results and strategies used).

Metacognition and Expertise
Many experts cannot explain the skills they use to elicit
expert performance. (Perhaps this is due to the automatic
functioning of the expert.)
Metacognitive strategies often separate an expert from a
novice. For example, experts are able to plan effectively on a
global level at the start of a task—a novice won’t see the big
picture.
Some adults with expertise in one domain can transfer their
metacognitive skills to learn more rapidly in another domain.
On the other hand, some adults do not spontaneously
transfer metacognitive skills to new settings and thus, will
need help doing so.

Examples of Metacognition Skills You May Use
Successful learners typically use metacognitive strategies
whenever they learn.
Knowing the limits of your own memory for a particular task
and creating a means of external support.
Self-monitoring your learning strategy, such as concept
mapping, and then adapting the strategy if it isn’t effective.
Noticing whether you comprehend something you just read
and then modifying your approach if you did not
comprehend it.

Choosing to skim subheadings of unimportant information to
get to the information you need.
Repeatedly rehearsing a skill in order to gain proficiency.
Periodically doing self-tests to see how well you learned
something.
Metacognitive and learning Strategies
Metacognitive strategies facilitate learning how to learn. You
can incorporate these, as appropriate, into eLearning
courses, social learning experiences, pre- and post-training
activities and other formal or informal learning experiences.

Ask Questions. During formal courses and in post-training
activities, ask questions that allow learners to reflect on their
own learning processes and strategies. In collaborative
learning, ask them to reflect on the role they play when
problem solving in teams.
Foster Self-reflection. Emphasize the importance of personal
reflection during and after learning experiences. Encourage
learners to critically analyze their own assumptions and how
this may have influenced their learning.
Encourage Self-questioning. Foster independent learning by
asking learners to generate their own questions and answer
them to enhance comprehension. The questions can be
related to meeting their personal goals

Teach Strategies Directly. Teach appropriate metacognitive
strategies as a part of a training course.
Promote Autonomous Learning. When learners have some
domain knowledge, encourage participation in challenging
learning experiences. They will then be forced to construct
their own metacognitive strategies.
Provide Access to Mentors. Many people learn best by
interacting with peers who are slightly more advanced.
Promote experiences where novices can observe the
proficient use of a skill and then gain access to the
metacognitive strategies of their mentors.

Solve Problems with a Team: Cooperative problem solving can
enhance metacognitive strategies by discussing possible
approaches with team members and learning from each other.
Think Aloud. Teach learners how to think aloud and report
their thoughts while performing a difficult task. A
knowledgeable partner can then point out errors in thinking
or the individual can use this approach for increased self-
awareness during learning.
Self-explanation. Self-explanation in writing or speaking can
help learners improve their comprehension of a difficult
subject.

Provide Opportunities for Making Errors. When learners are
given the opportunity to make errors while in training, such
as during simulations, it stimulates reflection on the causes
of their errors.

Cognition can be broken down into 5 components:
1. Attention
2. Visual Processing
3. Information Processing
4. Memory
5. Executive Functions

Causes of Cognitive Deficits
1. Human genetics and/or development
e.g. chromosomal abnormalities (Downs Syndrome),
environmental deprivation, Fetal Alcohol Syndrome, Autism,
ADHD
2. Neurologic disease, events, injuries and disorders
e.g. Stroke, TBI, Dementia, Multiple Sclerosis
3. Mental Illness e.g. Schizophrenia, Major Depressive
Disorder, Bipolar Disorder
4. Transient or continuing life stresses or changes e.g. stress-
related disorders, pain syndromes, anxiety disorders, grief
and loss

Why is it important to know the cause of cognitive
dysfunction?
• To appreciate prognosis including impact of comorbidities
and other complications
• To enables us to educate client and family
• Enable our clinical reasoning →choose most appropriate
evidence-based intervention
• To inform realistic goal setting

Importance of Client-Centered Goal Setting
● Increase motivation and resilience
● Increases engagement with and ownership of therapy goals
● Improves therapy outcomes
● Provide baseline and can be used as an outcome measure
● Important to include family and significant others
● Shared goals encourages inter-disciplinary working in teams

Goal Setting- Additional Considerations
● Importance of establishing therapeutic alliance
● Goals tend to be more therapist-driven in hospital setting and
more client-centered in community setting
◦ Note client and family may have limited knowledge of the
real world impact of condition, when in the acute hospital
phase
● Goals need to be prioritized and continually reviewed
● Long-term goals need to be broken down into smaller
achievable goals- “Just right challenge”

Goal Setting- a 2 stage process
1. Goal Identification
● Detailed assessment
● Observation of performance
● Discussion with client and significant others
◦ Consider: COPM Activity Sort Card
Patient Specific Functional Measure- see handout
Discussion following standardized, non-standardized
Assessment
2. Goal Negotiation
● GAS
● SMART

Activity Card Sort (ACS)
The ACS measures a range of activities that
adults do and includes:
● 20 instrumental activities
● 35 low-physical-demand leisure activities
● 17 high-physical-demand leisure activities, and 17 social
activities
It also reflects the client's level of engagement with each
activity and whether or not that activity has been discontinued,
guiding the clinician to find out why

Goal Attainment Scale (GAS)
● Objective way to document and assess progress with
individualized goals
● High interrater reliability and good concurrent
validity with other outcome measures
● Can be rated by client/family
● 5-point scale
● Can account for multiple goals with weighting to reflect
overall progress

GAS (Kiresuk, & Sherman, 1968)
5 point scale:
+2 – Much greater than expected outcome
+1 – Greater than expected outcome
0 – Expected outcome
-1 – Less than expected outcome
-2 – Much less than expected outcome

Case example – GAS procedure
Step 1- Goal identification Through the process of:
●Detailed assessment
●Observation of performance
●Discussion with client and significant others
Goal Identification
David will remember to plug in his iPhone to charge each
night over the next 4 weeks.

● Step 2- Specify the nature and parameters as precisely as
possible (SMART)
● How will this goal be measured?
● Behavior to measure
● What is the set up/context of the task? What materials are
needed?
Case example
● David needs to plug his Iphone into his charger (located by
his bed) by 10pm each night (7 nights per week) without any
prompting

Step 3- Determine the most realistic expected outcome
● e.g. David will remember to plug in his phone 3 nights of the
week without prompting
● expected level is recorded in the middle level “0 level”

Step 4- Set other levels - They should be realistically attainable
+2 – David will remember to plug in his phone 6-7 nights of
the week without prompting
+1 – David will remember to plug in his phone 4-5 nights of
0 – David will remember to plug in his phone 3 nights of the
week without prompting
-1 – David will remember to plug in his phone 1-2 nights of
-2 – David will not remember to plug in his phone any night of
the week or requires prompting after 10pm each night

Step 5- Specify a time for review
Case Example
David to review progress towards his goal with his community
OT in 4 weeks time.
● The focus of GAS is on process “evaluating change” not
product “determining status”
In other words:
● GAS should not be considered a general outcome of post-
treatment status but rather a sensitive measure of treatment–
induced change

OT Assessment
Discharge Planning
• Safety considerations
• Home visit
• Referral to hospital Rehab or Community Services
Rehab Intervention
• Goal setting
• Education
• Remedial
• Compensatory
• Occupation based
Evaluation
• Review/Set new goals
• Discharge Planning – see above
OT not indicated
• Fully recovered
• End of life care
Improved Quality of Life / Occupational Participation
F

Models of OT
- Cognitive Disabilities Model (Allen, Earhart, & Blue, 1992)
- Cognitive Orientation to Daily Occupational Performance
Model (CO-OP; Polatajko, Mandich, & McEwen, 2011)
- Cognitive Rehabilitation Model (Averbuch & Katz, 2011)
- Dynamic Interaction Approach (Toglia, 2011))
- Neurofunctional Approach (Giles, 2010, 2011)
- Occupational Performance Model Australia (OPMA)(Chapparo
& Ranka 2011)F

Remedial/Restorative Vs Compensatory/Adaptive Approach
Remedial/Restorative
- Intervention targeting at restoring the underlying performance
Components
- Reliant on neuroplasticity and the brains ability to “rewire”.
Either restoring neural pathways or creating new ones
Compensatory
- Finding “work arounds” to allow task performance and
“compensate” for lost performance components/cognitive
functions
- Treatment should encompass attempts at restoration of lost
function at the same time as teaching compensatory strategies to
minimize the impact of cognitive impairment(s).

Remedial/Restorative Vs Compensatory/Adaptive Approach
Remediation or compensation should not be considered an
either/or approach.
Both approaches should be utilized as clinically reasoned to be
most effective in enabling individuals to achieve optimal
occupational performance.
Examples
1. Attention
a) Practicing reading book with increasing levels of distraction
b) Reading books for short time periods in a quiet area
2. Memory
a) Repeating and visualizing grocery items needed
b) Using a list to aid grocery shopping

3. Executive Functions
a) Completing computer simulated driver training programs
b) Using public transport as not safe to drive
Bottom-up Vs Top down approach
Bottom-up
- Examines the small, separate components of client skills to
enable intervention targeted at the underlying
performance components.
- The idea being that improvements in these components
would in turn improve overall occupational performance.
This approach links more with the body structures and
functions level of ICF

Top-down
- Takes a global approach, links more with activity and
participation aspects of ICF. This approach addresses
desired occupations and practicing these occupations with
the necessary compensations to achieve desired occupation
- The Top-down approach has received a lot of support for
being more occupational focused but a multidirectional
approach can ensure your treatment is targeting the
underlying cause of the dysfunction, whilst also being

Cognitive Rehabilitation Therapy
“Cognitive Rehabilitation Therapy (CRT) is the process of
relearning cognitive skills that have been lost or altered as a
result of damage to brain cells/chemistry.
If skills cannot be relearned, then new ones have to be
taught to enable the person to compensate for their lost
cognitive functions.”

Many OT intervention interventions are multimodal, where
OTs can select a range of interventions for a client
depending on their individual needs.
Different approaches can be may be selected to address
different areas of Occupational performance in the same
client

Cognitive Rehab Therapy (CRT)
The 4 Approaches:
1. Education
2. Process Training (Remedial/Restorative)
3. Strategy Training (Compensatory/Adaptive)
4. Functional Activities Training (Can be both)
- Best outcome if all 4 approaches used
- To be used simultaneously, not sequentially
The degree to which each these approaches are utilized
depends on:
- Cause of cognitive impairment
- Individual client factors

Occupational Therapy & Cognition

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