COGNITIVE DISABILITY FRAME OF REFERENCE

              

                             COGNITIVE DISABILITY FRAME OF REFERENCE

1.      THEORY:

·         The theory of cognitive disabilities, developed by OT Claudia Kay Allen, focuses on the effect of impaired cognition—a frequent symptom of psychiatric disorders—on task performance

·         Allen states: “just as physical disabilities restrict the physical ability to do a voluntary motion action, a cognitive disability restricts the cognitive ability to do a voluntary motor action”

·         Allen originally defined six cognitive levels (of ability and disability) related to task performance.

·         These range from level 1 (severe impairment) to level 6 (no impairment).

·         Persons functioning at levels 1 through 4 have difficulty living unassisted in the community because they cannot perform the necessary routine tasks, such as paying bills, obtaining adequate nourishment, and finding their way to an unfamiliar place.

2.      DEFINITION:

·         Allen defined cognitive disability  as a restriction in voluntary motor ation originating in the physical or chemical structures of the brain and producing observable limitation in routine task behavior

3.      FUNCTION:

·         This definition implies Function is competence which means the ability  to handle ones own affairs where competence or incompetence is generally based on the ability to make sound judgment and reasonable decision about activities that the individual intend to do  

·         Competence here denotes that function is ability to use motor action to engage in activities ,guided by cognition that enable one to performance of task effectively and safely

·         To make judgment and decision and to guided motor and speech function in a changing environment, leading to adaptation

4.      DYSFUNCTION:

·         Dysfunction may be conceptualized as restriction in motor function that originates from a deficiency of cognitive abilities due to structural damage of the brain resulting from physical injury, degeneration  of the brain organs, or chemical imbalance in the Central nerve system

5.      ASSUMENTION:

·          A mental disorders severity can be judged by the consequence it has on a person capacity to think do and learn

·         Mild mental disorder can be compensated for by learning psychological substitutes

·         Severe mental disorder can be associated with limited mental abilities that cannot be corrected by what the person says or does

·         Severe mental disorders can be compensated for by providing environmental substitutes for normal mental processes and identifying normal processes that still be used

·          The remaining mental abilities can be engaged to do realistic activities that are meaningful to the client practical for caregivers and sustainable over time

·         When people are to learn to use  psychological compensation effectively environmental compensation can improve the quality of life of persons with cognitive disabilities and their long term care givers 

6.      PROPOSTION :

                Allen’s theory of cognitive disabilities is summarized in nine propositions

·         The observed routine task behavior of disabled patients will differ from the observed behavior of nondisabled populations.

·         Limitations in task behavior can be hierarchically described by the cognitive levels.

·         The choice of task content is influenced by the diagnosis and the disability.

·         The task environment may have a positive or a negative effect on a patient’s ability to regulate his or her own behavior.

·         People with cognitive disabilities attend to those elements of the task environment that are within their range of ability

·         Therapists can select and modify a task so that it is within the person’s range of ability through the application of task analysis

·         An effective outcome of occupational therapy services occurs when successful task performance is accompanied by a pleasant task experience

·         Steps in task procedures that require abilities above a person’s level of ability will be refused or ignored

7.      COGNITIVE LEVEL ASSESMENT:

·         Cognitive level is assessed by observing the motor actions the person performs during a task and by inferring the sensory cue that the person was paying attention to at the time.

·         The therapist watches what the person does (motor action) and tries to identify what sensory information provoked or started that action.

·         The sensory cues progress from internal at the lowest cognitive levels to external and more complex and abstract at the higher levels. Motor actions are automatic at the lowest level and become more refined at higher levels.

·         Allen cognitive levels:

Ø  Automatic actions automatic motor responses and changes in autonomic nervous system minimal conscious response to external environment

Ø  Postural reactions

       Testing: unable to imitate running stitch movement is associated with comfort some awareness of large objects in environment may assist caregiver with simple tasks

Ø  Manual actions

       Testing: able to imitate running stitch, 3 stitches use of hands to manipulate objects may be able to perform a limited number of tasks with long-term repetitive training (ie: ADLs)  

Ø  Goal directed action 

      Testing: able to imitate whip stitch, 3 stitches ability to carry out simple tasks through completion relies heavily on visual cues may be able to perform established routines but cannot cope with unexpected events

Ø  Exploratory actions

      Testing: able to imitate single cordovan stitching using overt (physical) trial-and-error, 3 stitches new learning occurs may be usual level of function for 20% of population

Ø  Planned actions

      Testing: able to imitate single cordovan stitch using covert (mental) trial-and-error absence of disability think of hypothetical situations, plan ahead to prevent mistakes

LEVEL	ACTION
	Spontaneous motor action	Imitated motor action	Example of motor action	Attention to sensory cues{inferred from observation}	Examples of sensory cues
Automatic actions	Automatic	None	Sniffing, Walking, Swallowing	Subliminal {dimly conscious awareness}	Hunger Thirst Discomfort
Postural reactions	Postural	Approximate imitation	Gesturing, Calisthenics	Proprioceptive movement {movement and position of the body}	Posture Motion Gesture
Manual actions	Manual (but not goal directed)	Manual or manipulative	Picking up, Touching objects, Stringing beads	Tactile {touchable cues}	Texture Shapes
Goal directed action	Goal directed	Copy or reproduction of an example	Chopping carrots, Standing wood	Visible {what is not in plain sight is ignored}	Color , Size  or discomfort
Exploratory actions	Exploratory {experimentation and trial and error }	New steps are imitated	Spacing of tile, Blending of makeup colors	Related{relationship between two visible cues}	Overlapping , Color mixing, And spatial relationships
Planned actions	Planned	Often unnecessary –action can be initiated without demonstration	Budgeting , Building a project from a diagram	Symbolic {abstract or intangible	Evaporation , Electrical current, Heat , Time, Gravity

8.      EVALUATION:

·         Allen maintains that the proper roles of occupational therapy are to

Ø  Identify the cognitive level through evaluation, 

Ø  Monitor changes in cognitive level that may result from other treatments such as medications

Ø  Adapt the environment to help the person compensate for or accommodate to his or her disability

·         Instruments

Ø  Routine Task Inventory

Ø  Allen cognitive level test

Ø  Lower cognitive level test

Ø  Routine Task Inventory Expanded (RTI-E)

Ø  Cognitive Performance Test (CPT) 

Ø  Allen Cognitive Level Screen-5 (ACLS-5) test

Ø  Large Allen Cognitive Level Screen-5 (LACLS-5)

Ø   Allen Diagnostic Module, 2nd Edition (ADM-2).

9.      THERAPEUTIC INTERVENTION:     

·         Three concept regarding performance based on the  cognitive disability model guide intervention to help client function optimally and safely in their environment

Ø  What a client can do is determined by biological factors and specifically the cognitive level of functioning  as measured on the allen cognitive levels

Ø  What he or she will do is related to psychological factors such as motivation belief in personal abilities ,meaningfulness of the task

Ø  What the client may do depends on support system available in the environment to facilitates ability to engage in task with in once capability and interest given residual cognitive abilities   

·         Three intervention strategies are proposed

Ø  Expectant {in which the therapist tracks remission of a clients symptoms through observation of his  or her engagement in various task }

Ø  Supportive {using diversional activities to support the client during the acute phase of illness}

Ø  Compensatory {changing the task or environment to facilitate the client optimal performance within the environment}

·         Intervention is divided into phase according to progression of the disease

Ø  Acute phase the client evaluated to determine the cognitive level. Further intervention may consist of alleviation of discomfort through positioning for the clients in lower cognitive level and supportive activities for those at higher level

Ø  Expectant phase intervention is mostly palliative. Care takers educated regarding how to cue the client for optimal performance. Monitoring cognitive changes continues hand in hand with recommendations to care taker for the level of assistance needed during this phase

Ø  Residual {rehabilitation} phase the therapist determines the current level of cognitive function that is expected to remain stable and plans discharge accordingly. Emphasis is on optimizing performance  by provided assistive devices, modifying the environment, and training caregivers on how to cue the client for optimal safe functioning