The Cog-Fun Approach: The Cog-Fun intervention approach is an ecologically-based occupational therapy approach developed to promote quality of life and participation in life roles for individuals with ADHD. Cog-Fun intervention targets cognitive, emotional, and environmental barriers as they manifest in the occupational context. In addition to promoting quality of life and participation, the Cog-Fun approach aims to promote the development of a positive occupational identity and self-management throughout life for individuals with ADHD.
Addressing the complex bio-psycho-social barriers that hinder desired quality of life and participation, the approach utilizes four key channels of change, drawn from principles derived from the cognitive rehabilitation and psychiatric occupational therapy:
- Metacognitive learning
- Environmental supports
- Occupational-centered assessments and interventions
- Positive engagement
Metacognitive Learning: The channel of metacognitive learning focuses on developing self-awareness and promoting the acquisition of management strategies to bridge the gap between task demands and unique executive function deficits. This component is based on Toglia's ecological approach (2011). Current qualitative research on management and coping of adults with ADHD supports the utility of awareness and compensatory strategies such as external supports, anchors, and organization methods. Findings have linked self-awareness and strategy use to improved functioning in adults with ADHD and have also indicated that the use of strategies during childhood predicts continued use in adulthood (Bjerum, Pedersen, & Larsen, 2017; Kysow, Park, & Johnston, 2017). The Cog-Fun approach places a strong emphasis on promoting these factors through iterative and recursive processes of guided discovery and task-based awareness, efficacy of strategies, individual strengths, and identification of ecologically situated difficulties. These are gradually achieved through real-time experiential learning with self-reflection and structured external feedback. These reflective processes are also supported by the Occupational Performance Experience Analysis (OPEA) tools developed by Meir, Fisher, and colleagues (2016).
- Metacognitive learning within a comprehensive intervention process emphasizes the balance between internal strategies that require significant internal resources and external strategies that draw on environmental resources.
- The internal strategy "Stop and..." is critical for transitioning from automatic reactive modes to goal-directed initiation and behavior. While this process is effortful and requires internal resources, it is essential and emphasized across all age groups. External strategies may include lists, reminders, neutralizing distractors, and organizing aspects of the individual's physical and human environment. This component includes learning and integration of interpersonal skills and self-advocacy skills. Alongside these, there is a psycho-educational channel, addressing the promotion of intellectual awareness through shared learning about the diagnosis of ADHD, its biological underpinnings, including, among other things, deficits in executive functions, and how these difficulties manifest in the individual's life. This learning aims to outline the unique profile of the individual.
This learning process, ideally done in collaboration with a medical professional, aims to promote the management of the individual's health condition alongside pharmacological support. The learning process is reinforced through a summary of each therapeutic session in a structured format. This summary includes: What did I learn about myself? What were the task demands? What were the environmental factors? And which strategies were used to support occupational performance? This metacognitive learning process forms the foundation for setting future goals that utilize the acquired strategies, understanding and analyzing task demands, and identifying individual strengths alongside monitoring the individual's difficulties.
Due to deficits in self-awareness in individuals with ADHD, setting functional goals will be more effective if they emerge from the developing metacognitive knowledge of the client. Therefore, the summary of the therapeutic session ends with "mini-goals," which are small exercises linking new strategic knowledge learned to occupational context (e.g., I will stop and take a deep breath before entering the house at the end of the workday). Metacognitive learning is adapted to the developmental level, where with younger children, there is limited use of management strategies (for example, "Stop," "Check," "Recruit Effort," "Plan," "Calm," "Social"), and more extensive use of strategies, both in variety and complexity, such as monitoring and reporting, self and social advocacy, etc., for adolescents and adults.
Environmental Supports/Implementation Anchors
Environmental adaptations refer to the supports and adjustments provided by factors external to the individual, aimed at enabling participation, and they can be realized as the use of anchors within a specific context. Individual use of strategies alone is insufficient to enable full participation in life roles, and adaptations are formulated as additional resources required to bridge the gap between the individual's resources and the demands of tasks and roles. Supports include temporal, physical, and emotional environment (such as creating routines, reducing distractions, shifting from self-blame to insight, and using empathy); providing cues to support function; or changing tasks and/or their requirements. The nature of supports varies with development. In children, parental role is central in providing supports in challenging environments to promote function. Parents are guided to create challenges tailored to the child's level (just right challenge) to experience self-capabilities in using strategies acquired to achieve meaningful goals (e.g., encouraging the child to stop and check the shopping list before leaving the store). As the client grows older, the level of support decreases, and greater emphasis is placed on self-management as well as on managing the person's available external resources. Significant others such as parents and other meaningful individuals are encouraged to openly use managerial language such as: "Let's stop and think. What's happening here?"; "Stop. How do you feel about it?"; "Important. What are your options?"; "Is this serving you? Does it work for you?". Additionally, close/significant others are encouraged to attribute difficulties to deficits in managerial functions, identify the individual's strengths and resources, and set realistic expectations.
Occupation-Centered Assessment and Intervention
In the Cog-Fun approach, occupation is central, and engagement during intervention and assessment is linked to occupations (Fisher, 2014). Assessment is occupation-based and involves analyzing the quality of occupational performance and expression of daily management functions. Intervention is also occupation-based and allows effective learning through engagement in occupations such as play, simulated activities of daily living (ADLs), and structured reflection using the OPEA template. Resource discovery occurs concurrently with the performance of these activities, which are both enjoyable/significant to the individual and functional. Activity-based learning fosters real-time awareness and then explicitly transfers to occupational goals, from specific contexts to multiple contexts. In Cog-Fun, occupation-based performance is reflected through the connection between intervention-acquired strategies and "occupational mini-goals." Balancing occupations and managing health are explicit goals of intervention. There is a drive to promote personal balance and well-being through the analysis and exploration of occupations that provide enjoyment and productivity (Alter, 2015). Consistent examination of these dimensions assists in understanding occupational balance or its absence. Given the understanding that there is a constant involvement of processes related to deficits in managerial functions in chronic cognitive impairments, it is crucial to consider these factors. It is very common to find individuals with ADHD who invest all their resources in the productivity dimension and neglect self-care and enjoyment, paradoxically impairing productivity in the long run.
Positive Engagement
Positive engagement in therapy is difficult to define but represents a significant change channel in interventions among individuals with ADHD in Cog-Fun, drawing on models of human occupation and mental health recovery (Ennals & Fossey, 2009; Kielhofner, 2008; Mueser, et al, 2006). This channel aims to promote positive occupational identity, including exploration of aspiration - areas of interest and enjoyment alongside promoting a sense of self-worth (the individual's belief in their ability to fulfill personally meaningful goals). This is attempted through a therapeutic relationship system that incorporates acceptance, empowerment, connection, enjoyment, and client engagement, alongside addressing their negative beliefs through self-compassion, a vital component in this process (Neff & Faso, 2015).
Living with a chronic health condition can be challenging, requiring constant resource use to compensate for deficits and manage life roles. Therefore, cognitive-behavioral learning, requiring effort, must be balanced with positive therapeutic support. In child therapy, this is achieved through a family-focused process in a triadic system - therapist-child-parent, attempting to support and empower each side of the triad. In interventions with adolescents and adults, support and empowerment are provided individually to the adolescent or adult. Efforts are also made to support the caregiver - the adolescent's parent or partner. Borrowing from the Intentional Relationship Model (IRM, Taylor, 2008), principles of deliberate and self-aware use as a therapist with clinical thinking are employed. Deliberate and flexible use of therapeutic interaction styles (encouraging, empathetic, collaborative, problem-solving, instructional, and confrontational) according to the client's needs, to promote positive engagement in therapy.
In summary, the Cog-Fun model is an integrative model addressing central change channels drawn from central models in occupational therapy. These models draw from the world of therapeutic relationship, aspiration, and human occupation approaches to the rehabilitation of people with cognitive disabilities and psychiatric rehabilitation models in occupational therapy. Hence, the change channels aim to:
- Create a positive family-focused therapeutic environment - this therapeutic environment is conceptualized through conscious self-use, interpersonal thinking, therapeutic communication, and family focus, based on The Intentional Relationship Model (Taylor, 2008).
- Intervene in the child and their family's aspiration system - the Model of Human Occupation emphasizes the centrality of the aspiration system (interest, enjoyment, and capacity) (Kielhofner, 2008) and cultivates an adaptive and positive occupational identity.
- Intervene in functional difficulties against the background of functional management barriers.
- Develop adaptive and healing awareness and acquire management strategies. This cognitive-behavioral learning process is based on a multi-context treatment approach in cognitive rehabilitation (Toglia, 2011) and involves several stages. In the first stage, the child experiences the need for managerial strategy use and uses it in a variety of activities (e.g., practicing delayed response need based on the "stop" strategy practiced in a running and stopping game, such as "red light, green light"). Then, the child assigns a name to the strategy and creates a tangible symbol (e.g., a visual, auditory, and/or kinesthetic-sensory symbol of the "stop" concept) that is transferred to various clinic and home activities and contexts. These managerial strategies are practiced with the child and parent and subsequently transferred to functional goals. Playful activities and occupational goals are aimed at being enjoyable and engaging resources of motivational and cognitive abilities for purposeful behavior. The cognitive-behavioral learning process includes gradual development of self-awareness: progressive development of awareness of the need for strategy use during and in relation to occupational performance (Online awareness), and self-intellectual awareness of strengths and challenges. Adaptive self-awareness promotes strategic occupational ability, facilitating engagement in meaningful occupations (as opposed to non-adaptive awareness, which may decrease self-capability and limit participation).
- It is important to remember - the goal of acquiring managerial strategies is to promote self-ability in occupational performance. In order for these strategies to be internalized, they must be part of the child's occupational context and "language," enjoyable activities worth striving for. These activities aim to be relevant and meaningful to the child, important and significant to them. It should be noted - the process of acquiring managerial strategies is an effortful process, thus requiring a therapeutic process that promotes ability, with family mediation of language and tools and encouragement of self-attribution and encouragement for effort.
- The acquisition process is carried out in a variety of contexts - initially, in the familiar context of the clinic and the home, subsequently expanding to the school and social contexts. The child's managerial ability is tested in diverse situations and various contexts to generalize learning. The strategy is then used and internalized in a variety of occupational situations.
- Intervention objectives vary according to the developmental level and the needs of the child. Goals and objectives are updated over time according to progress and needs. The concept of dynamic evaluation is central to intervention planning (Fisher, 2014).
- The level of support provided by the therapist and the family also changes according to the child's developmental level. Initially, a significant amount of support is required from parents and therapists, which gradually decreases, with an emphasis on self-ability.
- Ongoing evaluation and analysis of intervention outcomes are important. Evaluation is performed through a variety of means: observing occupational behavior, structured analysis of cognitive, emotional, and behavioral aspects of function, interviews with children, parents, and significant others, and use of standardized tools. Evaluation is conducted to examine the effectiveness of intervention strategies and revise goals and objectives as needed.
- Environmental Adaptations, Anchors, and Learning Functionality. This component is based on the Neuro-Functional Rehabilitation approach (Guiles, 2011), which relies on behavioral learning, environmental resources, and reducing frustration during the learning process. The goal of these applications is to promote motivation and self-capacity in a short period of time, in order to support the need for cognitive-learning, which is a more strenuous process.
In summary, therapeutic intervention among children, adolescents, and adults with ADHD addresses the broader implications of the disorder from a person-occupation-environment paradigm, which relates to barriers in bio-psycho-social participation, quality of life, and well-being. Cog-Fun is an occupation-focused, client-focused, and family-focused intervention targeting cognitive and emotional difficulties of children, adolescents, and adults with ADHD. The channels for improving function and quality of life are through therapeutic interaction with the child and their parents, cognitive-learning, functional learning, and environmental adaptation.
This approach has been researched and supported by evidence (Hahn-Markowitz, Berger, Manor, & Maeir, 2016; Hahn-Markowitz, Berger, Manor, & Maeir, 2017a; Hahn-Markowitz, Berger, Manor, & Maeir, 2017b; Hahn-Markowitz, Berger, Manor, & Maeir, 2018; Hahn-Markowitz, Manor, & Maeir, 2011; Maeir, Fisher, Traub Bar-Ilan, Boaz, Berger, & Landau, 2014; Maeir, Hahn-Markowitz, Fisher, & Traub Bar-Ilan, 2014).
