Cognitive, or "Top-Down", Approaches to Intervention

For a variety of reasons, pediatric therapists have begun to investigate the possibility of using cognitive approaches during intervention with children with neurodevelopmental disabilities. While these approaches have a long history in the disciplines of education and psychology, they are relatively new to most therapists in rehabilitation. The purpose of this Keeping Current is to familiarize therapists with some of the terminology that is used in the cognitive literature and to provide an overview of a few key concepts so therapists can make educated decisions about instructional courses that may be offered. Therapists who receive training and utilize these approaches may also find this document helpful to share with families. What do we mean by "top-down" and "bottom-up" approaches to intervention? Therapists are beginning to explore the feasibility of moving from "bottom-up" approaches - those that emphasize remediating children's motor deficits - to "top-down" approaches, focusing on the performance difficulties that children with disabilities experience everyday. "Bottom-up" therapies are based upon the assumption that, if foundational motor skills are developed, motor control will emerge and task performance will be improved. "Top-down" approaches assume that the motor requirements for any task are variable and that motor control for a particular task becomes more efficient when children understand what is expected. These "top-down" approaches are often referred to as cognitive approaches since the emphasis in therapy is upon assisting a child to identify, develop and utilize cognitive strategies to manage daily tasks more effectively. Conducting a literature search on cognitive approaches is usually not helpful to the therapist who is unfamiliar with this area due to the vast amount of literature on "cognitive therapies", "cognitive treatment methods", "cognitive mechanisms", "cognitive-behaviour modification", "cognitive strategy research" and studies of "metacognition". In this issue, we will define some of these terms and provide an overview of the key concepts that are needed for a therapist to understand and think about using "top-down" interventions with children.