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Introduction

When it comes to traumatic brain injuries or clients with cognitive impairments, what helps ease the mind of the client and the caregiver is modifying the environment to where it is comfortable and productive for the client. Cognitive Adaptation Training, or CAT, uses the modification of the environment and compensatory strategies to support individuals with cognitive impairments and promote and improve physical and mental function to help individuals operate in their daily lives (Allott et al., 2017).

Theory

As a model the PEO was created to examine the interaction of the person, environment, and occupation and the ways in which they influence occupational performance (Maclean, 2012). The person functions within their environment and their behavior cannot be separated from the context in which they find themselves. Using an intervention that enhances and creates an environment that supports the person will positively influence occupational performance.

Evidence

A review of the literature reveals a lack of evidence for the use of Cognitive Adaptation Training (CAT) for use in the population of youth in foster care. However, there is strong evidence in the literature for the use of CAT as an intervention in the population of individuals suffering from schizophrenia. In a review conducted by researchers at the University of Texas Health Science Center of previous studies evaluating CAT as an intervention to bypass the cognitive effects of schizophrenia there was found to be strong positive evidence for the improvement of functional outcomes specifically in medication adherence (Maples & Velligan, 2008). Other evidence indicates that improvement in functional outcomes using CAT compared to generic environmental supports and treatment as usual persists up to 24 months post intervention (Fredrick et al., 2015). A randomized controlled trial in medication maintenance included 166 individuals with schizophrenia and concluded that CAT alone produced more favorable outcomes than either cognitive behavioral therapy (CBT) alone or CAT and CBT combined (Velligan et al., 2015). The strong evidence for positive outcomes in the use of CAT as an intervention in schizophrenia provides hope for its use in other areas including foster care.

Case Study

James is a 17-year-old male, currently in the foster care system. James was recently in an altercation with one of his house-mates and suffered a severe TBI. He was hospitalized for 3 months and in a coma for 2 months. He came out of his coma 1 month ago. He was evaluated by an OT and was determined to be at a 3.4 Claudia Allen  Cognitive level. James is at 54% cognitive assistance, and 10% physical assistance. He has issues with fine motor tasks, and is at risk for wandering around and getting lost. He needs 24 hour assistance with all ADLS due to his difficulty with sequencing. He is able to learn new things with repetition.

Intervention Plan 

Problem Statement

Client is unable to complete dressing tasks due to inability to sequence tasks, secondary to traumatic brain injury

Long term goals

• Client will able to complete lower body dressing, demonstrating proper sequencing independently  by discharge
• Client will be able to don dress shirt, demonstrating proper sequencing, independently by discharge.

Short term goals

• Client will be able to demonstrate appropriate way to don/doff shirt using appropriate sequencing 3 out of 5 times by 4/15/2018.
• Client will be able to select appropriate dress pants for outing 1 out of 2 choices 3/3 trials by 4/15/2018 using verbal cues .
• Client will be able to use dressing mirror for donning and doffing shorts in 1 week using simple verbal cues
• Client will be able to locate items of clothing in drawers for dressing in 2 weeks using tactile cues

Supplies

• Dressing mirror
• dress pants
• dress shirts
• shorts

Agenda

Set up safe learning environment (5 minutes)

• Review treatment goals with James
• Assess client’s readiness to learn

Implement Cognitive Assessment Training (20 minutes)

• Help client develop checklist to don/doff clothes with 3 sequence step tasks
• add visual cues on drawers to mark location of clothing items to aid in proper sequencing.
• Add visual cues such as tags to clothes
• Use tactile and hand over hand when necessary
• Execute donning/ doffing of clothing techniques

Evaluate learning outcomes (5 minutes)

• Ask client to return demonstrate don/doff

SOAP

S: Client would repeat “I am sad” during the treatment session. Nurses mentioned the client experiences crying spells throughout the day.

O: Client was had difficulty putting on his shirt with buttons. Client took 10 minutes to button his first button with the use of a button hook with 7 encouraging, simple verbal cues. Client was observed putting on his underwear over his pants and his undershirt over his shirt.

A: Client was having difficulty buttoning his shirt due to difficulty with bilateral fine motor tasks and his inability to sequence properly and aligning the buttons to the proper holes. He was displaying a sense of frustration when attempting to use a button hook on the first button. He also has difficulty determining the order that his clothes are donned as evidenced by him putting on his undergarments over his outerwear. He needs visual and verbal cues to locate and donn clothes properly. Colored tags are needed  on his clothing (undergarments and outer garments) to aid him with sequencing. Client would continue to benefit from OT services

P: Client will continue to work on sequencing for upper and lower body dressing with  adaptive equipment. Client will be seen 3x per week for 45 minute sessions.

References

Allen, C.K., Earhart, C.A., & Blue, T. (1995) Understanding Cognitive Performance Modes Ormond Beach FL: Allen Conferences

Allott, K. A., Killackey, E., Sun, P., Brewer, W. J., & Velligan, D. I. (2017). Improving vocational outcomes in first-episode psychosis by addressing cognitive impairments using Cognitive Adaptation Training. Work, 56(4), 581-589. doi:10.3233/WOR-172517

Fredrick, M. M., Mintz, J., Roberts, D. L., Maples, N. J., Sarkar, S., Li, X., . . . Turkington, D. (2015). Is cognitive adaptation training (CAT) compensatory, restorative, or both? Elsevier B.V.10.1016/j.schres.2015.06.003 Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edselp&AN=S0920996415003187&site=eds-live http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edswsc&AN=000355993800010&site=eds-live

Maples, N. J., & Velligan, D. I. (2008). Cognitive adaptation training: Establishing environmental supports to bypass cognitive deficits and improve functional outcomes. American Journal of Psychiatric Rehabilitation, 11(2), 164-180. Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=105732202&site=eds-live 

Maclean F, Carin-Levy G, Hunter H, Malcolmson L, Locke E (2012) The usefulness of the Person-Environment-Occupation Model in an acute physical health care setting. British Journal of Occupational Therapy, 75(12), 555-562. DOI: 10.4276/030802212X1354895554553

Velligan, D. I., Roberts, D. L., Maples-Aguilar, N., Brown, M., Mintz, J., Tai, S., & Turkington, D. (2015). A randomized controlled trial comparing cognitive behavior therapy, cognitive adaptation training, their combination and treatment as usual in chronic schizophrenia Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edswsc&AN=000355993800010&site=eds-live