Individuals with high levels of denial and resistance require a

focus on gaining acceptance and coping with challenges rather than

on increasing awareness. Use of occupation-based activities,
motivational interviewing with an emphasis on the person’s strengths,
and methods for successful management of task challenges can be
effective for some clients (Medley &Powell, 2010).

Exhibit 3.6 Strategies for Managing Denial

• Avoid negative language (problems, difficulties, symptoms, errors).

• Avoid direct feedback and use of prediction or estimation techniques.
• Do not argue, confront, or directly point out errors or problems.
• Be conscious of your tone of voice and nonverbal signals that can convey
disagreement.
• Provide choice and allow control.
• Observe for implicit awareness.
• Focus on task methods, increasing task efficiency, and management of task
challenges rather than deficits.
• Use neutral but relevant activities. Recognize that meaningful activities with high value
and close ties to one’s self-identity may be threatening and elicit more defensive
reactions.
• Develop a close therapeutic alliance first and address other goals (e.g., motor goals) in
the initial phase of treatment. Include cognitive tasks within motor activities but place
the emphasis on motor goals.
• Reinforce (e.g., point out and praise) error recognition and self-correction whenever
observed.
present the right level of challenge. This chapter will focus on the
external factors (activity and environmental demands and
characteristics) that influence cognitive performance, while other
chapters focus on strategy use (Chapter 7), self-awareness, and
metacognitive skills (Chapters 3, 9, 10).

Conceptualization of Cognition

The DIM emphasizes the global capacities of cognition. Limits in

information processing resources, or their inefficient allocation or use,
can underlie many different cognitive performance problems. In the
DIM, cognition is defined as a “person’s capacity to acquire and use
information to adapt to environmental demands” (Toglia, 2018).
Cognitive limitations are operationalized as patterns of behaviors or
performance errors that negatively affect functional performance
across a variety of different activities. For example, a tendency to
overfocus on details, omit key information within an activity, or lose
track of information represent specific cognitive patterns of behavior
that can interfere with functional performance across different
situations. Exhibit 4.1 includes common observable behaviors that can
also be described as signs of specific cognitive deficits such as deficits
in the executive function (EF) components of working memory,
 Exhibit 4.2 Sample Cognitive Performance Errors

• Omissions: misses details, materials, actions, information, or steps

• Incorrect selection: chooses or uses wrong items, materials, or information
• Wrong order: objects, steps, or actions out of sequence
• Repetitions: repeats actions, ideas, steps, or information
• Inaccuracies: steps, actions or information do not match directions or goal
• Incomplete: steps, actions, or information partial or incomplete
• Additions: extra steps, objects, actions, or information added (goal-related)
• Extraneous actions or information: irrelevant items, actions, steps, or information
included (not goal-related)
• Misplacements: items or information in the wrong location

Cognitive performance problems are not always tied to a particular

task or context. For some people, they emerge from cumulative effects
of multiple activities or particular combinations of activities that place
demands on cognitive processing over several hours or a day. A
person may have no difficulty during the first 30-60 minutes of an
activity but may be unable to process information and may experience
Familiarity with activity and environment characteristics that can
increase or decrease demands on specific underlying cognitive
processes is important in analyzing and interpreting functional
cognitive performance. Analysis of performance requires that the
therapist simultaneously consider the activity demands and
environment as well as the person’s skills. Similarly, the ability to
quickly adjust activity features to place either more or less demand on
specific cognitive skills is important in both assessment and
intervention as it can provide insight into the conditions that influence
performance.

The Activity and Cognitive Performance

Activity Characteristics that Influence Cognitive Demand

An understanding of functional cognition requires a thorough analysis

of cognitive activity demands. This includes understanding how slight
The importance of creating a fit between the cognitive abilities of the
person and the activity demands has also been described by
(McCraith &Earhart, 2018).
Table 4.1 summarizes activity characteristics that place low or high
demands on different components of EF. As an example, activities that
are predictable place minimal demands on flexibility, while those that
are unpredictable or involve changing rules or circumstances place
high demands on flexibility. As performance is analyzed, the activity
characteristics that influence specific EF components always needs to
be considered and specified.
In addition to Table 4.1, Appendix A.9 demonstrates how task
features and complexity level can alter the cognitive components
involved in different stages of problem solving. The IDEAL model
(Bransford &Stein, 1993) described in Chapter 2 is used to frame the
characteristics of simple and complex problem-solving tasks. Appendix
A.10 provides examples of different functional cognitive scenarios and
asks readers to analyze the differences. Some scenarios are more
difficult than others. An analysis is included at the end of Appendix A.
These examples illustrate how variations in problems change
complexity and cognitive demands.

These examples further illustrate that cognitive components such

as working memory, inhibition, flexibility, organization, or problem
solving are not all or none but depend on activity demands. Functional
cognition requires understanding how activity characteristics impact
cognitive performance as well as analyzing the fit between the
person’s abilities and the activity demands (Wesson &Giles, 2019).
Manipulating Activity Characteristics to Influence Cognitive Performance

Knowledge and skill in adjusting activities to vary cognitive demands

and thus impact performance provide a foundation for both
assessment and intervention. It allows the therapist to identify the
types of activities that a person might need supports for, as well as
guides the selection, sequence, and grading of treatment activities.
Table 4.2 illustrates how specific functional tasks such as packing a
lunch or making coffee can be modified to place different demands on
different EF skills by changing key activity characteristics. As in the
preparing lunch examples above, the “same” activity can present
different cognitive demands and produce different performance
problems depending on the directions, set-up, or other activity
characteristics.
On the other hand, different activities (e.g., packing a lunch and
making coffee or tea) can present similar cognitive demands, thereby
resulting in similar cognitive performance errors. For example, in Table
4.2, working memory directions that emphasize “keeping track” are
used in two different activities (packing a lunch and making tea). A
person that has difficulty keeping track of information will likely show
similar errors across both tasks. Therefore, strategies such as using a
written list or verbal rehearsal that help a person to keep track would
be beneficial for both tasks.

The cognitive skills and type of cognitive strategies required for

efficient performance change if the activity or environmental demands
change. If the directions are modified so that they are now ambiguous,
greater demands are placed on the ability to initiate ideas, ask
questions, and seek information (see Table 4.2). With ambiguous
directions, the strategy of verbal rehearsal that was effective with more
explicit directions that emphasized keeping track is no longer beneficial
because strategies that promote generation of ideas or information
seeking are now needed.
Table 4.3 demonstrates a detailed analysis of how activity demands
can be manipulated to place demands on key aspects of EF using a
table setting task. It shows how the activity of setting the table can
place more or less demand on the components of EF, depending on
how the activity is presented. For example, increasing the number of
distractors or interruptions places greater demands on inhibition by
increasing competition and disrupting the flow of actions, whereas
increasing the number of steps or items needed can place more
demands on the ability to keep track of information.
Table 4.3 also illustrates that the same task can result in different
types of performance errors, depending on how the task is presented
as well as the person’s cognitive difficulties. The last row of the table
illustrates how the strategies that help a person in an activity may differ
depending on the performance error. A blank form for use with other
activities is included in Appendix A.13. Analysis of performance errors
and strategies are discussed in more depth in Chapters 5 and 7,
respectively.
Tables 4.2 and 4.3 illustrate that the same activity can be used in
many ways depending on activity characteristics, cognitive difficulties,
or performance errors. Blank activity analysis forms are included in
Appendix A.12-A.13 and can be used to practice manipulating the
cognitive demands of everyday activities.
Integrating Cognition into Motor-Based Activities
 Functional cognitive performance should always be examined
under a variety of conditions, including at the person’s highest motor
level. Of course, the therapist should consider and ensure a person’s
safety in these dual-tasking situations. Similarly, cognitive demands
can be reduced within motor activities to support performance if dual
tasking is a problem for the person.

Functional Cognitive Activity Modules

 Varying Directions (on cards)
• Find the items on this list that are also on the schedule.
• Study the list and remember as many items as you can from the list at one time.
• Underline the Exercise Activities and circle all the Classes.
• Using a blue marker, put a on the games; using a green marker, place an on the
Exercise Activities; and using a red marker, circle the Classes.
• For each Exercise Activity, place an in the same location on the blank schedule using
a red marker.
• For each Game, place a in the same location on the blank schedule #2, using a blue
marker.

Similar to activity demands, environmental characteristics can also

be manipulated to increase or decrease demand on cognitive skills
and, thus, to influence cognitive performance. Table 4.5 includes
examples of environmental characteristics that can increase demands
on EF skills. These environmental characteristics need to be
considered simultaneously with activity characteristics to interpret
functional cognitive performance.
If environmental characteristics are influencing cognitive functional
performance, adaptations or changes in the environment can be
considered to minimize cognitive demands. Care partners can be
instructed on ways to change the environment or the therapist can help
the client learn how to modify environmental features themselves.