FRAMEWORK TO IMPROVE TEACHING-

LEARNING: THE FOUR QUADRANTS

MODEL OF FACILITATED LEARNING
CRAIG GREBER – JENNY ZIVIANI

Apart from being a profession in its own right, teaching is a strategy. Coaches,
trainers, consultants, therapists all use teaching elements to facilitate skill acquisition.
In doing so, they do not reproduce the broad and varied roles of teaching
professionals. Rather, they use effective teaching and learning strategies in ways that
enhance their own competencies in achieving outcomes for the people they work with.
This chapter explores ways occupational therapists can use teaching and learning that
enable their clients to achieve autonomy in the skills that lead to higher professional
performance. In this chapter, the student is the child and the facilitator refers to the
therapist.
Facilitating learning is a complex behavior that includes what we do as well as how we
do it. The four-quadrant model of facilitated learning (4QM) (Greber, Ziviani, & Rodger,
2007a, b) has been proposed as a way to inform the selection of effective learning
strategies based on the changing needs of each learner in the acquisition of a new
skill. Grouped into four broad groups, these strategies provide a scaffold to identify
and assist a child's diverse learning needs throughout the skill acquisition process. In
this chapter, the theoretical basis of the 4qm will define the concepts contained in the
model, function and dysfunction will be identified, and evaluation procedures will be
linked to indicators of function and dysfunction. To establish the relationship between
theory and practice, a case example will illustrate how the 4qm can be used as a
framework to guide teaching-learning interventions in occupational therapy.

THEORETICAL BASIS
This section presents the underlying theoretical basis of 4QM. First, the assumptions
that validate teaching and learning as a useful intervention in occupational therapy will
be examined. Next, the theoretical postulates that illustrate the relationship between
the essential concepts incorporated in 4QM will be described.

Occupational therapists use teaching and learning as an intervention when the

acquisition of skills is seen as an important step in achieving goals at work. To begin to
understand how teaching and learning can be used, it is first necessary to understand
how the fundamental intervention of occupational therapy is. When a therapist
identifies skill learning as a central key to improving a child's work performance,
several interventions are available. When a specific task is difficult to perform, the use
of adaptive equipment could make it easier. Alternatively, when the entire activity is
too difficult for the child, a compensatory approach can be used to find an easier
alternative (for example, a child who is not able to tie shoelaces may more
autonomously use Velcro straps instead. ). In both of these cases, repeated practice
can be used to improve skill acquisition and performance. The acquisition of new skills
is essential in both cases; However, the skills come together in a way that changes the
performance of the initial occupation. Although a degree of teaching and learning is
necessary to acquire these skills, these interventions are slightly different to those in
which the skills are fundamental to occupational performance.
Occupational therapists routinely use teaching and learning as a prominent method of
intervention in pediatric practice to improve self-care, productivity, and leisure (Rodger,
Brown, & Brown, 2005). The effectiveness of teaching and learning depends on the
understanding of the theoretical basis. To do this, it is necessary to become familiar
with the range of strategies used to facilitate learning and which covers the factors that
determine the selection of strategies for an individual in a given task at different stages
of the learning process.
In his seminal work, developmental psychologist Lev Vygotsky proposed a process by
which children with surface competencies could develop skill-orientations through a
facilitator. Vygotsky identified a learning principle called the “zone of proximal
development” (Vygotsky, 1978). The zone of proximal development represents a stage
of learning in which support is necessary for the student to successfully complete a
task. In Vygotsky's theory, progress was made toward possible autonomy through
systematic facilitating supports called "scaffolds." As the student became increasingly
competent, Vygotsky observed the beginning of scaffolding to pass a facilitator to the
child. Vygotsky's person-centered approach to learning provides an appropriate
theoretical framework on which to draw for occupational therapists.
- "Direct instruction teaching methods have been contrasted with more indirect
inductive approaches in conceptualizations of the teaching-learning process (e.g.,
Joyce, Calhoun, & Hopkins, 2002; Woolfolk, 2004) Mosston and Ashworth (2002) )
places a range of teaching styles on a continuum ranging from "command style" at one
end to "self-teaching" at the other, based on the cognitive approach to style. More
direct styles informed the learner of the key elements of the task or response required,
while styles that encouraged the learner to consider barriers to performance facilitated
the learner in arriving at solutions. These latter strategies were observed to involve the
student to a greater extent in the decision-making process.

THE FOUR QUADRANT MODEL OF LEARNING FACILITATION

When therapists choose teaching and learning as an intervention strategy, they
assume the role of facilitator, with the child as a learner. The 4qm provides a means
for understanding, planning and coordinating the use of learning strategies in
occupational therapy, but also lends itself to multidisciplinary use by other people
involved with the child, such as teachers, paraprofessionals and parents.
The 4qm groups of various cognitive and physical learning strategies useful in children
who carry out occupational tasks more autonomously. As Mosston and Ashworth
(2002) theorized, some learning strategies are more direct and open-ended than
others. For example, learning may be based on telling the child what to do or how to
do it. These direct strategies serve the need for knowledge, providing information
about the characteristics of the task, or the response required. Less direct strategies
(such as information provision) engage the learner to a greater extent in the decision-
making process. These strategies encourage the student to be more active in
planning, executing and evaluating performance. Direct strategies can be seen as
being at one end of a continuum of teaching-learning styles, with indirect strategies at
the other end.
Approaches to teaching and learning vary not only in their direct nature, but also on
the basis of the person initiating the strategy. Some learning strategies are initiated by
the person facilitating the learning (in this case, the therapist), while others use the
learner as a source of initiation through discovery methodologies. The source of the
initiation of learning strategies can be seen as a progression in the relationship
between initiated facilitative strategies and initiated learning strategies.
When teaching and learning approaches and the person initiating the strategy are
integrated, four distinct groups of learning strategies become evident, each serving a
different learning need. Those strategies that are direct and initiated by a facilitator
(quadrant 1) specify the characteristics of the task and/or the performance required.
Other strategies that are indirect in nature, and yet facilitator-initiated, fall into quadrant
2. These are useful in encouraging decision making by the student. Quadrant 3
groups of those manifest self-triggered strategies initiated by the student that help him
or her remember key points essential for task performance. A series of self-regulatory
strategies that are not obvious to observers underpin autonomy and these strategies
are grouped in quadrant 4. The 4QM helps a therapist to coordinate the learning
strategies used to promote autonomy by alerting him or her to the learner's needs and
providing a structure that allows the therapist to respond to these needs as skill
acquisition progresses. Within each quadrant, specific learning strategies that
determine the characteristics relevant to that quadrant can be placed. When these are
added, the full 4qm (Figure 8.1) becomes a useful framework to guide therapists in
applying teaching and learning as a method of invention.

ASSUMPTIONS
Many professions use teaching and learning as an approach to their professionals.
Occupational therapists use teaching and learning in ways that are both similar and
different to the way they are used in other professions. The relationship between
teaching and learning and the general theoretical principles of occupational therapy is
fundamental to 4qm. This relationship is based on the assumption that improving a
child's skill repertoire may enable him or her to carry out occupations more
autonomously. By allowing a child to improve his or her occupational skills, the
triangular interaction between the person, his or her occupation, and environment
becomes more congruent, improving occupational performance. Learning key skills
fundamental to the target occupation can be facilitated by either structuring practice
routines to optimize skill mastery, altering the activity to simplify its operation, or
invoking the teaching and learning of specific strategies to facilitate learning essential
skills for occupational performance. Although these three options are sometimes
combined, it is this third aspect that 4qm specifically refers to, the use of specific
teaching and learning strategies to facilitate learning.
 Initiate students

FIGURE 8.1 The four-quadrant model of facilitated learning.

The following assumptions about the development of autonomy are important for 4QM.

● Acquiring key skills is only the first step in improving job performance and
achieving professional goals.
● Improving occupational performance involves more than mastering the skills
necessary for performance. It also requires the ability to adapt and shape skills,
contextual characteristics unique to the target occupation.
● Autonomy, therefore, includes mastery of key competencies, competence in the
use of decision-making procedures that allow generalization, and contextual
competence in incorporating learned skills into occupational performance.
● This framework can be employed only when the child is judged to have the
necessary performance components (e.g., strength and dexterity) to complete
the task in its current form.

FUNDAMENTAL CONCEPTS AND DEFINITIONS

Teaching and learning is the basis of intervention in this framework. The occupational
therapy intervention consists of activity analysis, the teaching-learning encounter, and
generalizations and transfer. Activity analysis supports the acquisition of core
competencies and allows the child to compete in those skills in a real-life context.
While skill acquisition is a central part of this process, teaching and learning as a
therapeutic intervention looks beyond autonomy in skills and towards better
performance in the occupation. The bottom line for the child is occupational
performance.
Activity analysis is useful for establishing intervention priorities when restrictions are
based on a breakdown of performance components, such as strength, dexterity,
and/or sensory processing. Activity analysis helps identify barriers to occupational
performance. Ultimately, this allows the therapist to understand the child's occupations
and the way in which the child creates meaning through purposeful activity.
When selecting teaching-learning methods, therapists often address barriers to
occupational performance created by lack of competence in specific tasks. By allowing
the child to learn the necessary tasks, the components of occupational performance
have not been improved through other therapeutic means. Rather, through teaching
and learning the activities essential to achieving occupational goals are mastered. For
example, when reviewing a child's mealtime occupations, knife and fork use could be a
central activity. Activity analysis helps the therapist to identify the child's ability to
perform specific tasks (such as holding the fork steady, or doing the sawing action with
the knife), what are the possible obstacles to performing the activity and the
performance limit of activities. The teaching-learning approach has the appeal of
guidelines. It requires a deep knowledge of the occupation, the activities that comprise
it, and the tasks that are necessary to facilitate performance. In this approach,
emphasis is not placed on performance components such as strength, dexterity, or
bilateral coordination that could be targeted when using other reference frames.
To help a child acquire a skill, it is first necessary to identify the components of the skill
that require tutoring. Activity analysis is a means by which this can occur and is an
essential skill in occupational therapy. Activity analysis should provide the therapist
with in-depth knowledge of the activity, and the knowledge base to facilitate the child in
learning to perform it. Activity analysis, therefore, constitutes an important basis for
clinical reasoning when using teaching-learning approaches.
The teaching-learning encounter involves the interaction between the therapist and the
child. The therapist can set out to design interventions that support learning, after key
tasks that are barriers to performance have been identified. The teaching-learning
encounter is a complex procedure that requires the therapist to be sensitive to the
changing needs of each student and adapt the strategies used to respond to these
needs. Within this context a number of child and therapist characteristics must be
considered, such as preferred learning style, mode of communication, and
interpersonal factors.
For skill acquisition to occur, the learner must understand task performance
requirements and, engage in effective decisions to modify performance in response to
errors, remember the key elements of successful performance, and monitor
performance through of both concurrent and reflective analyses. Once a skill is
acquired, these processes could be automatic, but during the learning phase,
strategies that establish competence in these processes must be developed.
Therefore, the strategies employed by the therapist during the intervention must match
not only the characteristics of the student, tasks, and the environment, but also to the
learning needs of the child at any point in time. Each child has unique learning needs
that change as skill acquisition progresses, so their needs cannot always be predicted.
Therein lies a challenge for therapists. They are faced with the task of developing an
intervention that depends on high secular persistence of teaching skills and degrees of
knowledge about the teaching-learning process of which they may not have in-depth
knowledge. In this sense, knowledge of effective teaching-learning strategies, and the
ability to match them to a student's needs, is of utmost importance to the child's
outcomes. The 4qm supports therapists' reasoning in this process.
Generalization and transfer of learned skills to the target occupation is a key function
of the therapist. Teaching essential skills in a real-life context minimizes the adaptation
a child needs to make to the contextual features of his or her occupational
performance. For example, teaching a child to use a knife and fork during mealtime
allows the child to generalize those skills to other mealtime environments more easily.
It is preferable that knife and fork teaching be in a game-based environment.
Autonomy in occupational performance is achieved when a child has the necessary
knowledge of the task, decides on an appropriate course of action, and is able to
independently enact, monitor, and mediate performance in such varied contexts as
occupation. could imply.
To illustrate this point, consider a child who has a goal to brush his teeth before going
to bed. The therapist can facilitate learning the fundamental skills for brushing teeth—
putting toothpaste on the brush, holding and manipulating the brush, rinsing, and so on
(Figure 8.2). Then, the child develops autonomous performance in the skills necessary
to brush his teeth. To engage in tooth brushing, however, the child must be oriented to
performance characteristics, such as locating the toothbrush, judging the amount of
toothpaste, the temperature of the water in the rinse, and completing the task in an
amount of appropriate time. Making decisions about these variables involves the child
in procedural autonomy in the transfer of learned skills in the context of real life. The
learning context is closer to that of the target occupation, there are fewer adaptations
necessary. Intervention that takes place in the child's own bathroom, for example,
minimizes the degree of transfer of necessary skills.
Becoming "powerful" is an important stage in the development of autonomy at work, if
the child expects to be reminded to brush his teeth (as often develops when a child
has become dependent on the help of others ), full autonomy has not yet been
achieved. The application of strategies that encourage the child to recognize the
appropriate time to brush their teeth, and the exercise of the profession without asking
can help develop initiative in the use of learned skills. Only when the child begins to
use skills in ways that respond to changing contexts can he or she be truly
autonomous in the target occupation.
FIGURE 8.2 A child putting toothpaste on a pre-hearing toothbrush.

KEY CONCEPTS AND DEFINITIONS

The 4QM is based on the integration of openness and continuous initiation by detailing
the various learning strategies that can be used to address the needs of the student
from each of the four quadrants. The complete 4QM is illustrated in Figure 8.1. For a
child to acquire a skill, he or she must understand the task, decide on a plan of action,
remember important performance characteristics, and monitor the results of each
effort. When a child finds certain parts of this process problematic, 4QM can help the
therapist identify strategies relevant to the child's needs. Each of these strategies
conceptualizes a scaffolding mode that can be used to achieve successful
performance of the target skill. In the various theories that have been used to inform
the development of 4QM, these concepts have sometimes been given different names
as the many bodies of knowledge refer to the same phenomenon. The labels used in
4QM represent a consolidation of all of these names into the terms best understood by
occupational therapists.
To establish each of the learning strategies in the 4qm as separate and discrete
entities, it is necessary to define and exemplify each one. This allows the distinctions
made between the strategies available to the therapist to enable him or her to select
the most meritorious approach for a student at a given time and on a given task, and
to effectively link or combine the strategies used throughout the process. Learning.

QUADRANT 1 – DIRECT STRATEGIES, INITIATED FACILITATOR

Quadrant 1 uses direct instruction methods to communicate information from the
facilitator to the student, to inform the student of the goal of the task, the requirements
of the task, and/or the nature of the performance. Therapists may use explicit
instruction and explanation, demonstration, physical modeling, and/or lower-order
questioning to provide this information. Each of these strategies involves providing
facilitation to the learner with direct prompts, which provide task-specific information in
a way that encourages the learner to reproduce previously learned responses. They
inform or remind the student what they must do to complete the task.
Explicit instruction and explanation provide the learner with descriptions of various
characteristics of the task itself, and/or the expected response. These strategies can
be used to inform the student of task requirements ("Do this") or key performance
characteristics ("do it this way"). Print and verbal forms, technology-based instruction
can all offer the same type of information, if their purpose is specifically to disseminate
information. A therapist is using explicit instruction and explanation when he or she
says:

● "You have to hold the food still with your fork while cutting to prevent it from
slipping."
● "Push your arm through the sleeve."

● "Turn the paper with your left hand and close the scissors with your right hand."

Explicit teaching and explanation is frequently used in combination with demonstration

to provide the student with a clear understanding of what is required.
Demonstration occurs when a therapist offers an example of the expected response or
performance (Figure 8.3). It can be used to highlight specific points of technique,
clarify ambiguity in verbal instructions, and/or provide a correction reference for the
student's efforts. Demonstration typically uses visual modalities, but can also be used
to model appropriate verbal responses (e.g., in social interaction).

The demonstration can occur when:

● The therapist shows the student how to perform the task.

 ● The student watches a video tape of the task to be performed.

FIGURE 8.3 The therapist demonstrating for a child how to put on a sweater in
quadrant1.
 ● A simulated task is shown using audiovisual technology (e.g., cartoons) as an
example of the expected response.
● The facilitator models verbal response, such as an answer to a question.

Physical Patteming (Greber, Ziviani, & Rodger, 2007a, b) has been used to identify a
specific element of physical manipulation of the student's body. The terms "physical
assistance", "physical guidance" and "manual guidance" have variously been used in
the literature to describe a series of physical facilities, partial prompts to complete the
pattern (Carr and Shepherd, 1998; Chen et al, 2001; Schmidt & Wrisberg, 2000). In
understanding how these strategies might be employed in skill acquisition, it is useful
to make a distinction between those strategies that manipulate the child throughout the
movement modeling, those that direct but do not control the movement (physical
modeling). (Figure 8.4), and strategies that use intermittent tactile and kinesthetic cues
to ensure motor precision (physical prompts) (Figure 8.5). Each of these strategies
involves the student in a different degree in the planning and execution of the
movement, and therefore compatible with different results. These three labels have
been used in 4qm to identify certain learning strategies based on physical input by the
facilitator.

FIGURE 8.4 The therapist uses physical patterns for a writing task in quadrant 1.
FIGURE 8.5 The therapist demonstrating physical aids for a grooming task in quadrant
1

In this strategy, the student does not contribute to the movement, but instead allows
the therapist to manipulate the body part. Physical modeling could be used to establish
the general shape or spatial characteristics of the movement. This could occur when:

● The therapist manipulates the student's limbs to provide an example of

adequate task performance.
● The therapist works hand in hand with the student to complete a task, while the
student remains passive
● The therapist moves the student's limb through the range of motion necessary
to perform the task to provide a general idea for the movement.

“Lower order questions” is a term that describes questions used to assess the
student's understanding of the task and/or performance. This type of questioning
ensures that the student's interpretation of the task is accurate. It can also be used to
focus the student's attention on key aspects of performance by challenging him or her
to remember previously learned material. Examples of lower order questions include
the following:

● "What to do after?"

● "Where to look?"

● "How should you stand?"

The use of questions has received considerable attention in many bodies of literature.
One way to distinguish the different types of questions a therapist might ask a child is
to use a hierarchical system of distinguishing the cognitive skills involved, such as
Bloom's taxonomy (Anderson et al, 2001; Bloom et al., 1956). Several authors have
used this taxonomy to discriminate questions that evoke lower-level processes, such
as remembering and understanding, from those that stimulate higher-order productive
cognitions (e.g., Bissell & Limones, 2006; Johnson, 2000; Marzano, Pickering, " Yes
Pollock, 2001). The use of this taxonomy in the 4qm has resulted in the use of the
labels lower order questions (quadrant 1) and higher order questions (quadrant 2).

QUADRANT 2 – INDIRECT STRATEGIES, INITIATED FACILITATOR

When the student understands the requirements of the task, but is unable to generate
an effective plan for completing the task, different learning tools are necessary. The
strategies that involve the student in decision making have different characteristics
than those that specify the task. Although they are still facilitative initiated, they are
less direct in nature. These strategies are represented in quadrant 2. They involve a
touch of suggestion, rather than specific instruction. Strategies such as higher-order
questioning, feedback, physical prompts, non-verbal prompts, and thinking aloud
model serve this purpose. Each of these approaches encourages the student to make
appropriate decisions about his or her own performance.

Higher order questions are used to provoke the student's thinking and attention to the
elements of the skill that need to be considered. This type of question requires the
application of knowledge to engage the student in analysis, problem solving,
reasoning, and/or evaluation. Questions that facilitate cognitive skills in using higher
order, such as "why did it happen?" stimulate the production of new knowledge rather
than the withdrawal of old. For example:

● "What could be the problem here?"

● "How could you do it differently?"

● "Why did that happen?"

 ● "What does that look like?"

Statements like "I wonder why it happened," although not stated as a question, still
imply one. They function to involve the student in analysis, problem solving, and
critical evaluation; Therefore, statements of this type can be considered matters of
higher order.
Feedback (Schmidt & Lee, 2005) can be intrinsic; It may also be provided by others to
support the learner and to guide the use of self-regulation procedures. Therefore
Feedback reports the therapist's observations to the student, but does not instruct the
student what to do, or what to change (this would be similar to explicit instruction). For
example, a therapist might comment:

● "Did it really move smoothly that time."

● "Uh-oh, I think there's a problem."

● "You are leaning a little to the left."

Symbolic representations that record or evaluate performance, such as checklists, can

also provide useful information to learners in a visual form.
Physical aids (Thompson et al., 2004) are tactile aids that promote the initiation of
movement, or provide direction at various points during the response (Figure 8.6).
Such strategies support the student to make successful efforts, without impairing his or
her ability to plan and execute a response. Physical cues may include hitting or
pushing a limb in response to the initiation of delayed movement. With complex
activities, it may be necessary to provide physical cues in several subtasks, and not
just at the beginning of the movement. For example, cues can be used sequentially to
initiate grasping the spoon, picking it up, transporting food to the mouth, and then
replacing the spoon in the bowl. Physical aids challenge the learner to plan, monitor
and execute movements in ways that physical facilitation does not.
Non-verbal messages are the facial expression, gaze and gestures used by the
therapist. Learner Performance can be started, modified, and ended by a series of
non-verbal inputs by the facilitator. For example, a therapist might:

● Give him a quizzical look to indicate the need to reevaluate performance

● Point to a potential danger

● Looking directly at the key objects involved in the task

Think-aloud modeling (Polatajko and Mandich, 2004) is the verbalization of physical
skills and guidance on the use of cognitive strategies. In this strategy, the therapist
audibly describes the decision-making processes that are occurring as he or she
performs the task. While demonstration (from Quadrant 1) of physical skills provides
the student with task-specific information, think-aloud modeling shows the student how
to engage in higher cognitive processes. Dialogue can model error recognition (e.g.,
"Uh-oh,

FIGURE 8.6 The therapist demonstrating physical aids for a dressing task in quadrant
2.

Something has gone wrong"), describes the problem-solving process and/or

exemplifies self-control procedures. A therapist may comment:

● That is not right. What happened there? Maybe if I concentrate on keeping my

hand a little more stable
● What if I put it there? Oh no, it fell. Where else could I put it? Maybe here.
Task performance while describing the associated cognitions combines the use of two
strategies: demonstration (from quadrant 1) and think-aloud modeling (from quadrant
2). The visually represented response is considered demonstration, while verbalization
is modeling thinking aloud.

QUADRANT 3 - DIRECT STUDENT - INITIATING STRATEGIES

Strategies that involve the learner. Remembering what he or she provoked using
strategies that are observable to others is grouped in quadrant3.
Students could use any of several strategies to remember the key points of the task to
be performed successfully, priming strategies, verbal mnemonics - self-instruction,
visual cues and kainesthetic provoking all serve this purpose. It is noteworthy that the
terms “verbal self-orientation” and “memory writing”
They have been used to distinguish two types of conversation strategies encouraged
by occupational therapists working with children. Because both procedures have the
same goal of talking oneself through a difficult task, they are collectively described in
4QM as verbal self-instruction.
Priming is initiated by learners of strategies that involve verbal rehearsal. Priming
differs from strategies that involve repeating procedures that have already been
learned. Priming strategies bring together different skills in a performance as a type of
rehearsal of previously learned procedures to ensure that the intended response is the
correct one. An example of priming is when the child verbally rehearses what he or
she is going to say to a cashier while waiting in line, or doing a “drill” of a task before
performing it. The goal of priming, then, is to prepare for performance rather than
improvement. Priming strategies can use various modalities to organize general
response schemes to meet the demands of impending temporal and contextual
performances. The key element here is priming intention. If the goal is to prime and
optimize the response, rather than providing a path to improving mastery, the strategy
can be considered obscuration. Practice is an opportunity to implement previously
acquired strategies to hone and improve specific skills.
They are a type of associative learning that allows students to increase their ability to
store and retrieve information. Mnemonics help memory of key characteristics,
processes, facts and procedural acts. They include the use of linking words,
acronyms, nonsense searches, and rhymes. Although a facilitator could assist in the
development of a mnemonic, its use becomes the student's responsibility. So it is a
student-initiated strategy, for example, a student might use the nonsense phrase
“every good boy deserves fun” to call for the removal of musical notation notes e, g, b,
d. Alternatively a child could say "nose over toes and away."
Focus on body position during the transition to foot. Mnemonics use simple, symbolic
language to focus on the key elements of the task.
Verbal self-instruction is when a child uses verbal strategies to engage in the problem-
solving process or to remember the steps involved in performance. Complex tasks are
not easily reduced to a few key points represented in a mnemonic prompting the
learner to remember the steps in a task or an action prompt. May include picture cues,
computer-generated visual cues, real-object, concept maps, graphic organizers, visual
displays, and computer-assisted instruction. Mirrors and video recordings can also be
useful visual cues to improve performance. Simple examples of visual cues include
picture cards that remind the student to engage in particular behaviors and a
sequence of photos guides the student through the steps of a task.
Raising kinesthetic strategies improve or direct the child's attention to a certain action
or part of the body during learning. When a child touches or rubs his or her hemiplegic
arm as a reminder to use it to stabilize an object, he or she is using a kinesthetic
posing strategy.

QUADRANT 4 INDIRECTS, INITIATED LEARNER STRATEGIES

Internalized strategies for monitoring and evaluating performance are not observable
to bystanders, but are necessary for autonomous functioning; Because they are not
overtly observable, these strategies can be considered indirect in nature. Such
strategies and processes are assessable only by self-reported students, making the
content of the strategies in quadrant 4 somewhat speculative. Sinha and Sharma
describe a series of cognitive processes in silverware that underpin autonomous
performance such as self-instruction, self-questioning, and self-control.
Additionally, mental images help in preparing for performance, as well as overcoming
barriers.
To solve, they use the term "automaticity" to describe a final stage of learning that is
independent of the cognitive processes that mark previous stages. This label has been
adopted in 4QM.
Self-instruction of using internal speech to direct students' actions is a symbol of the
internalization of verbal self-instruction strategies. Where verbal self-instruction is an
observable learning strategy, self-instruction provides no signs of commitment. Self-
instruction helps identify and direct the use of problem-solving strategies.
It is particularly useful in remembering procedural measures involved in a
performance.
Self-questioning uses internal dialogue to analyze information and regulate the use of
cognitive strategies through reflective thinking.
The distinction between self-instruction and questioning is academic because neither
process.
It is obvious to the observer. Reports from the learner can be used to identify
characteristics of self-talk if it is likely to be useful to the learning process and if the
learner has sufficient knowledge to distinguish the strategies used, as with self-
instruction, self-talk can be used to engage in silent feedback. operation, development
and criticism of action plans and clarification of goals
Self-monitoring supports the appropriate use of specific strategies, analyzes their
effectiveness, critiques performance, and evaluates the need for modification. Self-
monitoring allows the child to evaluate the extent to which his or her performance
matches the expected response. Once again this is an internal process that is not
observable.

Intermediate Quadrant Strategies

Those strategies exhibiting characteristics of adjacent quadrants can be considered
intermediate strategies. It can perform dual functions, or link the content of one
quadrant to another. Three forms of intermediate strategies are discernible: main
strategies (bridging quadrant 1 and quadrant 2), orienting strategies (linking to
quadrant 2 and quadrant 3) and fading strategies (judging from quadrant 3 to quadrant
4) (Figure 8.1)

FIGURE 8.7 A child demonstrating automaticity in quadrant 4.

The main strategies are question forms, incomplete statements, and physical direction
reflect the characteristics of both task specification (quadrant 1) and facilitation of
solving processes (quadrant 2). These strategies can provide effective links between
the information-giving strategies of Quadrant 1 and the cognitive processes of
Quadrant 2. Some examples of the main strategies:
● "A reading comprehension test that involves the person supplying a word that has
been systematically removed from the text (merriam webster on-line retrieved
06/01/07) (incomplete statements), such as" below, is required.. . (Pause)"
● Guide a child's reach and wrist positioning to enable understanding of an object for
hand-to-hand work (physical direction)
● Questions that simulate higher and lower order cognitive processes (eg, "What
part of your body should be used when overcoming that problem?")
● Partial demonstration of the expected answer

Cuing strategies include verbal and nonverbal strategies that do not provide
information to the child other than a reminder to use self-cueing procedures. These
strategies have the characteristics of Quadrant 2 (student participation in decision-
making process) and Quadrant 3 (remembering key performance characteristics),
which help guide students to the need for self-regulated instruction. For example, a
therapist may guide a child to use verbal self-instruction strategies with the question
"What could I say to remember what to do next?" or directly to a visual cue by pointing
to the child's prompt photo card.
Fading is a gradual process that involves the internalization of Quadrant 3 open self-
regulation strategies. Some forms of self-prompting may be less obvious to observers,
however, they are not representative of Quadrant 4 covert self-instruction. Strategies
such as subvocalization (whispering) are on the margin of the two quadrants. Similarly,
when a child begins to orient only some of the steps in a sequence of images, it is
clear that the child is internalizing some of the procedures, but is not yet able to do so
without the visual symbol. In these cases, the fading of manifest self-triggered
strategies is occurring.

Theoretical postulates
4QM introduces Vygotsky's notion of the zone of proximal development as a period in
which learning skill acquisition and performance can scaffold oneself and others. The
relationships between the quadrants allow the scaffolds to be systematically reduced
as the learner progresses toward skill acquisition. As Vygotsky (1978) theorized,
learning and performance can be activated through the provision of appropriate
learning supports.
In 4QM, these supports are specific learning strategies that are appropriate to the
needs of students at a given point in time.

● In the early stages, the learner's efforts are shaped by information from the
facilitator (quadrant 1).
 ● Stimuli are used to drive appropriate decisions about performance (Quadrant
2).
● Later stages of mastery are characterized by the gradual internalization of self-
mediated cues (quadrants 3 and 4).
● Intermediate strategies are used to move the child from one quadrant to
another and from an initiated facilitator to an initiated student.
● A learning facilitator must respond to the needs of the child in a way that is fluid
and adaptable.

Within 4QM, specific learning strategies are grouped based on the needs of the
students they support. At the same time, strategies in one quadrant are closely related
to those in other quadrants. For example, the physical pattern in quadrant 1 is aligned
with physical aids in quadrant 2 and self-elicited kinesthetic aids in quadrant 3.
Similarly, explicit teaching and explanation (quadrant 1) has similarities to think-aloud
modeling in quadrant 2 and verbal self-instruction in quadrant 3. In this way, learning
strategies are used in different parts of the learning process that can be coordinated.

CONTINUITY OF FUNCTIONS-DYSFUNCTION
As a child develops competence in the key skills that underpin occupational
performance, the type of scaffolding to enable performance changes. Four broad types
of scaffolding have been described above: task specification, decision making, key
points, and autonomy. Each of these corresponds to a different quadrant in 4QM, and
illustrates various levels of function and dysfunction of the skills to be achieved. These
indicators are analyzed below. It is important to keep in mind that the student may
enter the meeting exhibiting a learning need for all or some of these scaffolds.
Although he or she might generally be expected to move through the quadrants
sequentially, in practice, this might not be the case. The learner could quickly move
towards autonomous performance after the task and the corresponding performance
explained. Alternatively, some learners might require different levels of scaffolding in a
single learning encounter, or even in a single trial. For some children, performance will
always be marked by the need for facilitative support or overt self-mediation. These
children can never develop autonomy in the task.
The 4QM has a function-dysfunction continuum, the execution of autonomous tasks
(Table 8.1). The functional end of the continuum is able to perform successfully and
autonomously, while the dysfunctional end of the continuum would be unable to
perform a task without facilitator-initiated strategies. It should be noted that while the
identified points of function and dysfunction mark two ends of the process, there are
actually two groups of behaviors in between these two end points. They are,
respectively (in moving from function to dysfunction) the ability to use externally
obvious self-mediation strategies for successful performance and the need for external
facilitation to stimulate successful performance. In the 4qm, the continuum is not truly
linear; when moving from dysfunction to function, the path is more like a Z, as
illustrated in Figure 8.8.
Within the one continuum, four groups of behaviors indicate characteristics of function
and dysfunction, based on the discussion above. These characteristics can be used as
a basis for evaluating the autonomy of the capabilities to be achieved.
A child cannot demonstrate all the behaviors in one quadrant.

Table 8.1 Indicators of Autonomous Function and Dysfunction of Task Performance

Autonomous Performance Performance Requires Direct Facilitation
GUIDE FOR EVALUATION
Activity analysis can be useful both in identifying the main tasks that must be mastered
to improve performance at work, and also in establishing the person's current
performance characteristics. Importantly, a person's performance can change not only
from one occasion to the next, but even during sustained execution of the same task
(for example, when maintaining balance while transferring from the toilet). Through the
process of activity analysis, the therapist must ensure that the child has the necessary
performance components, such as strength and dexterity, to successfully complete the
task.
In establishing the learning strategies that may be most appropriate for a child, the
therapist must maintain a fluid view of the child's learning needs, systematically
guiding him or her to think through various stages of the learning process.
Understanding the performance characteristics that indicate learners' needs leads the
therapist to select the strategies most likely to enable successful learning
performance. This dynamic approach to using activity analysis leads to the
coordinated utilization of learning strategies, which is essential in the development of
autonomy. A therapist might ask specific questions in assessing a child's learning
needs as outlined in Figure 8.9. The answer to each question helps establish the
child's learning status, and therefore the quadrant from which appropriate learning
strategies could be established. Repeated use of these questions throughout the
learning encounter ensures that the child's learning needs are met and skill
acquisitions are optimized.
While the child's performance characteristics may be indicative of the quadrant most
likely to serve his or her needs, activity analysis provides other important information.
 Learning started
FIGURE 8.8 The characteristics of function and dysfunction in 4QM

The characteristics of the task itself can determine the approach a learning strategy
should take. Motor, cognitive, and social activities each have unique characteristics
that require the selection of optimal learning strategies. For example, while physical
tasks lend themselves to physical demonstration and facilitation, cognitive and verbal
tasks may be better served by higher-order questioning and think-aloud modeling.
In several cases, the physical environment may or may not support the use of certain
learning strategies. For example, it may not be socially appropriate to use verbal self-
instruction strategies if the environment is an inherently calm one. Likewise, visual
cues such as sequences of images may not be able to be used in environments that
do not have a location for placing them. Consideration of the environments in which
the occupation takes place allows the therapist to select strategies that are socially
valid.
 Learning started
FIGURE 8.9 Guidelines for assessing learning needs

A synthesis of these factors provides the therapist with the basis for selecting and
using learning strategies that are appropriate to the needs of the learners,
characteristics of the environment, and the target occupation.

POSTULATES OF CHANGE REGARDING

At the center of the 4qm framework are general postulates about change:
1. Learning can be enhanced by appropriately scaffolding performance so that the
learner achieves a successful outcome. In this way, the social environment can
 be manipulated to improve performance and learning in the way proposed by
Vygotsky (1978).
2. When a therapist seeks dually to facilitate skill acquisition and maximize self-
meditation he or she will be more effective in moving from the strategies that
the facilitator initiated and engage the child in reproductive cognitions (quadrant
1) toward those that are covert and the learner starts (quadrant 4).
3. To enable a child to progress through the stages of skill acquisition, and
therefore move through the quadrants, it is useful to employ intermediate
strategies that fall into two quadrants.

Specific postulates related to change

The various learning strategies in 4QM have been described and defined above. In
order to put general postulates above action, they must be linked to providing a path
towards autonomy, while at the same time maintaining the flexibility to respond to
individual learning needs on a temporal and contextual basis. This can be achieved
effectively by using the concepts in 4QM in a well-directed and coordinated manner.
Accepting general postulates about change to be true, several specific postulates
about change allow 4QM to implement.
1. If the therapist employs facilitative methods initiated such as explicit explanation of
instruction, physical modeling, and lower order questioning, then the child will be able
to understand the characteristics of the task and/or the performance required.
2. If the therapist employs additionally initiated facilitative methods, such as higher-
order questions, feedback, physical prompts, no verbal prompts, and thinking aloud
modeling, then the child is encouraged to make decisions about the task.
3. If the therapist encourages the child to engage in initiated learning strategies such
as priming, mnemonics, verbal self-instruction, visual cues and kinesthetic self-elicited,
then the child will be able to remember key points essential to the task. performance.
4. If the therapist encourages the child to use initiated learning strategies such as
mental imagery, self-instruction, self-questioning, self-monitoring, problem solving and
automaticity, then the child will be able to perform the task autonomously.
5. If the therapist uses intermediate strategies to move the child from Initiated
Facilitator to Initiated Learners and from direct strategies to indirect strategies, then
the child will be able to move the shape one quadrant to another quadrant.

APPLICATION TO PRACTICE
This framework can be employed only when the child is judged to have the necessary
performance components (eg, strength, dexterity) to complete the task in its current
form. Each strategy in the 4qm reflects a set of knowledge about the way learning
occurs, and has been validated as an effective method to facilitate learning. These are
grouped into distinct quadrants based on shared characteristics.
To provide only the amount of scaffolding as needed. It may be necessary for the
therapist to work backwards to determine where to begin the intervention. A therapist
should first allow enough time for a child to perform the task autonomously, and if that
is not possible, use guidance strategies to remind the child of the self-promotion
strategies in Quadrant 3. If the child still does not embraces, in quadrant 3 strategies,
the therapist should use indirect prompts, employing more direct prompts only, as
necessary. This process eliminates the likelihood of dependent behaviors that can
develop when therapists anticipate failure, assume the need for guidance, and provide
scaffolding that is not necessary.
When using the 4QM framework, the therapist integrates knowledge of the task, the
children, the environment, and their own skills to develop specific learning strategies
that will result in improved occupational performance for the child. One way to
approach the task of developing specific strategies for a child is to begin by identifying
the characteristics of autonomous performance. Using knowledge of the child's
characteristics, and those of the environment and the task itself, the therapist can work
backwards through the mode to identify effective strategies in earlier quadrants that
will be helpful in establishing autonomy.
It is helpful to use a “What if?” scenario to frame the development of intervention
strategies. The strategy works backward from quadrant 4 to quadrant 1 to identify
where the child is having a problem with the task. For example, with a child learning to
tie her shoelaces (quadrant 4) the therapist might ask, "What could she do to remind
herself if she forgot the sequence of movements?" (Quadrant 3). Next, the therapist
might ask, "What would she do if she was internalizing self-triggering strategies?"
(Fade strategy). After that, he or she might ask, "What could you say if you forget your
directions?" (Strategy orientation). Subsequently, you could ask: "What will I do to help
you decide what to do if she doesn't use self-provoking?" (Quadrant 2), and then,
"What am I going to do if he forgets what he was supposed to do and can't figure it
out?" (Quadrant 1). Finally, the therapist might ask, "What could I do if she is reluctant
to attempt the task without asking directly?" (Leadership strategy). Armed with these
questions, the therapist can construct an individualized set of strategies that directly
relate to a barrier to occupational performance in a coordinated and sequential
manner.
To understand how 4QM might apply in practice, it is useful to consider its application
in the following procedure example:

The implementation of 4QM: A case study

The image is of a young woman who lives with her mother in an apartment block in the
inner city.
She is in her first year of schooling and enjoyed school immensely. Because the
mother works full time, mornings are a very busy time. Although she is left to prepare
for school on her own, in the picture she has a difficult dressing room and her mother
usually does this activity for her. Delayed development of images has led to difficulties
in mastering some of the basic skills required in dressing. Her occupational therapist
responds to the image and her mother's request to target her dressing skills as a way
to improve self-care activities in preparing for school.
The occupational therapist begins by analyzing the occupation. Preparing for school
participates with the image in a variety of self-care occupations. She finds meaning in
being able to perform these occupations independently. Getting dressed, however,
has led to ongoing difficulties and repeated failure, and she has become less
enthusiastic about completing the task unless her mother helps her. Although the
image has indicated her desire to learn how to dress, she has also indicated some
doubt that she will be able to develop the necessary skills.
An analysis of the activity identifies that the image can in fact perform most of the
tasks necessary for dressing. She can guide the garments and put them on, and she is
able to put on her shoes slip-on without problems. In fact, only two barriers limit their
ability to prepare for school independently: Difficulty with buttons and problems
aligning the two sides of the garment. Because she prefers to wear open front blouses
it has become a constant source of frustration over an image, and this frustration has
led to the belief that she cannot dress herself. At this stage, she refuses to try and
waits for her mother to make the buttons for her.
The therapist considers several directions for intervention. She could encourage the
image in which she is wearing only her sweater: However, this probably limits the
performance of other occupations in the images such as in dresses when buttons were
essential. The therapist could encourage the mother with imagery to put buttons on
blouses as she puts them away, allowing the image to simply slide the garment over
her head. However, you have identified the image that you would like to learn to dress
independently because all of your friends are able to do it. With these factors in mind,
the therapist observes the buttoning attempts in the images and believes that fine
motor strength and dexterity are sufficient to learn the skill of buttoning. The therapist
decides to facilitate the acquisition of the imagery in the skill so that she can learn to
button her blouse independently when dressing for school.
To intervene in this case, the therapist identifies the following three key theoretical
postulates:
1. That image lacks the necessary dressing skills
2. That their strength, endurance, fine and gross motor skills are sufficient to
perform the tasks of dressing
3. That with the appropriate use of teaching-learning strategies, the image will be
able to master the skills necessary for dressing and generalize those skills to
the home environment when preparing for school
The therapist specifically focuses on two tasks that she perceives as barriers to
occupational performance: Aligning the two sides of the blouse buttons and fastening
them.
This leads her to select 4QM as a framework to guide teaching-learning strategies.
The therapist uses a series of questions to determine the needs in the learning
images.
 ● Do you know what to do and how to start buttoning?

● Are you aware when you have inserted the button into the wrong buttonhole?

● Is the choice of tactics appropriate for grabbing and manipulating the buttons?

● Can she remember the steps of buttoning, skip/repeat some steps?

● Are you using all the obvious strategies to remember how to use the buttons
effectively?
● Are there signs that require self-initiation?

Additionally, the therapist uses other questions to guide the selection of appropriate
strategies in each quadrant of the 4QM.

● What type of activity is this? Physical? Verbal? Cognitive? Sensory?

● What are the characteristics of the student (physical, cognitive, verbal)?

● Are there environmental characteristics that make it difficult to use particular

strategies (e.g., space, noise, distraction)?
● What physiological factors should be considered (e.g., learned disability,
attribution of success/failure, risky behaviors, response to praise)?
The occupational therapy service available image allows therapy to take place in the
home environment, although it is not possible in the time sessions that correspond
with preparing for school, home therapy sessions will help you minimize the transfer of
skills necessary for the objective skill. The characteristics of the environment in which
the therapy takes place will be consistent with those inherent in the performance of the
occupation; However you will still have to manage time restrictions on school
mornings.
With these factors in mind, the therapist develops several coordinated learning
strategies and records them in each quadrant of the 4QM. She does this by working
backwards through the starting model in Quadrant 4, linking each of the learning
strategies directly to the objective skill.
Quadrant 4 represents autonomous performance. The therapist begins by identifying
what the characteristics of autonomous performance will be. Like physical activity, it
will be easy to observe performance when using only covert self-provoked
performance. Working at home will allow the therapist to identify potential sources of
distraction. The therapist collaborates with the image to identify several core
performance characteristics. The picture will correctly locate and align each button
with the buttonhole, and then grab the button with the index finger and thumb of your
right hand and open the hole by pushing your left thumb partially through. The picture
then is to press the hole button, grab it between your index finger and left thumb, and
pass through. To engage in autonomous performance, the image will need to have a
clear image of the task, and covertly instruct and monitor its own performance. The
therapist will also observe images in response to the difficulties encountered, and
review the use of reinforcements if necessary. By identifying what autonomous
functioning will look like, the therapist is able to identify the main characteristics of the
performance that must be mastered (Figure 8.10, quadrant 4).
Quadrant 3 strategies are useful in helping the student remind himself of key
performance characteristics. In developing strategies appropriate for quadrant 3, the
therapist takes into account the strength of images in verbal memory, particularly of
simple rhymes and songs. She enjoys dance and action songs that link physical
activities, verbal announcement. This suggests that she will be able to use verbal self-
cueing strategies. First, the therapist identifies a verbal self-instruction strategy to
button. The image will say out loud, "Are the two sides aligned?" In collaboration with
the image, the therapist will develop a simple mnemonic rule
That image can say to itself like the buttons on your blouse: "4 P: pinch, push, push,
pull." This jingle encapsulates all the key points of the task identified in Quadrant 4:
understanding the button, opening the buttonhole, passing it through the key, and then
pulling it out the other side. Although the use of verbalization may be intrusive (and
even embarrassing) in some settings, objective skill occurs at home, so these
strategies are more appropriate in this case. If the image does not spontaneously use
your mnemonic, the therapist can use quick guidance such as "What could I say to you
to help you remember?" As the image moves openly to the self-provoking strategies of
Quadrant 3, to the secrets of Quadrant 4, you may naturally choose to whisper the
jingle rather than say it out loud (Fade Out). Quadrant 3, Targeting and fading
strategies which are all detailed in Figure 8.10.

Considering that quadrant 3 strategies are initiated by the child, in quadrant 2 the
strategies involve the facilitator (in this case the therapist) to provide the necessary
impetus for learning.
The strategies in this quadrant should be congruent with those in quadrant 3, so that
the natural way of carrying the child should be more self-directed. In quadrant 3 the
strategies involve the child in decision making, fostering the cognitive skills necessary
to select, organize and monitor a course of action. Although the skill of buttoning is
physical, the therapist notes that difficulties are often the result of not understanding
what to do, rather than not having the physical skills to perform the task. The therapist
chooses two strategies that allow in the image they must learn the procedures for
buttoning their blouse. First, the therapist plans a think-aloud modeling strategy, when
she will perform the task herself, describing out loud the image of the decisions she
makes, as she aligns the buttons and makes Blouse.
She'll say things like, "Are those two sides of the blouse still?" Oh yeah. Now I'm ready
for the button. Where is the buttonhole? If I push my thumb through, I'll be able to see
it better. That's it now, push through! Wow that's a little clumsy, I'm going to pinch with
my finger and thumb. Better. Now pinch, open, push, and pull it through. There,
everything done. "This strategy will be used to emphasize key points, such as gripping
the button, and also making the decision that the next error occurs.
The other strategy used in quadrant 2 will be higher order questions. The therapist
recognizes the value of questioning and encouraging imagery to make decisions and
judgments about the appropriate task. She will ask, "How will you know if the button is
in the hole on the right?" and "Is the grip on the button the same with both hands?"
She will also ask him, "Why do you think it happened?" if an error occurs (Figure 8.10,
quadrant 2). The therapist is aware that images have long been difficult to solve the
task, making it difficult to answer these questions, so he also develops a series of
simple questions, structures images, responding to possible reluctance. Developing a
supportive and non-judgmental relationship will be important in building images, and
answering questions even when you are sure of the correct answer.
Strategies in quadrant 1 provide information about either the task itself or the
anticipated response. Although you have tried buttoning on previous occasions, your
understanding of the critical performance characteristics may be poor. The therapist
establishes a series of strategies to clarify the characteristics of the task. The home
environment, like a safe and secure, is optimal for the use of more direct learning
strategies. Although this is a physical task, the therapist's experience in teaching fine
motor skills leads her to believe that little will be gained in this case from physical hand
facilitation. Furthermore, from her observations, she believes that Image has a general
understanding of the parameters of the task. However, the demonstration associated
with the direct instruction that the image will provide, with a clear picture of the critical
characteristics of buttoning on which success depends. The therapist decides that it
would be necessary to demonstrate how to button the blouse, clearly showing how to
line up the two sides, hold the buttons down, open the buttonhole, and pass through.
She develops a concise description of each step to accompany the manifestation.
Lower-order questions, such as, "How should you hold down the button?" o How do
you know when the holes are aligned?" can be used after the demonstration to check
standing. With Quadrant 1 strategies established, the therapist develops some leading
Quadrant 1 and Quadrant 2, such as the freedom to say "I pinch the button with my
finger and... (Pause)" and "Push the button through and then... (Pause)." The image
will consider the process and identify the next step when the therapist pauses. These
strategies are identified in Figure 8.10, in quadrant 1.
The therapist has now developed a comprehensive 4QM that will guide you through
the intervention process.
The therapist's Intervention takes place in the environment. The house begins by
establishing images of the knowledge of the task. She watches the image trying to
button her blouse and asks questions about the procedure ("What should you do
first?"), the technique ("What do you think is the best way to hold the button down?"),
and the result ("Why do you need to make the right buttons in the right holes? ").
The images give an indication of the orientation of the task. The answers to these
questions indicate that, although you understand the image and task at a general
level, you have not gained an appreciation of the key characteristics of the task that
determine success, such as the importance of aligning the two sides first, and the
patterns of various graphics required.
The therapist uses concurrent demonstration and explanation to draw attention with
imagery to the need to keep the two sides of the blouse equal (Figure 8.11), and to
use the pincer grip to hold and manipulate the buttons (Figure 8.12). Answers to lower-
order questions indicate which image is able to remember key features when
prompted.
FIGURE 8.11 The therapist demonstrates aligning both sides of the blouse and
fastening the buttons.

FIGURE 8.12 Therapist demonstrates the pincer grip necessary for buttoning.
The therapist begins to use incomplete instructions (blank spaces) during his
manifestations, and images capable of completing them.
The therapist then switches demonstrations to illustrate the decision-making process,
rather than critical physical skills, by using think-aloud models. The image is able to
see not only how the task is performed, but also the essential cognitive skills that
underpin performance. The image then takes a turn to buttoning the blouse. The
therapist poses higher order questions to simulate decision making. After some
practice, the image is able to perform the task with ongoing support from the therapist,
but continues to have difficulty remembering how to carry out specific stages of the
task. Over the course of a few sessions, the image is again able to use self-initiated
strategies (quadrant 3) to instruct itself to align the garment, and a mnemonic rule to
remember key aspects of the buttoning task (Figure 8.13). . Occasionally, she forgets
to use these strategies, and the therapist uses a coaching strategy to remind her what
to say to herself. Over time, the image begins to whisper these instructions to itself,
becoming able to button its blouse independently.
At these points, the image demonstrates autonomy in carrying out some key tasks
(Figure 8.14). When they rush to complete the activity, however, as happens when
preparing for school, this performance breaks down. Using the strategies detailed in
4QM the mother, the Images, and others involved with the image, can easily take on
the role of facilitator, using consistent learning strategies to promote skill acquisition.
FIGURE 8.13 In the image, practice lining up both sides of the blouse.

The use of quadrant 3 (self-prompting) strategies, and exposure to higher-order

questions (quadrant 2), enable the image to make astute decisions about the
contextual demands of the occupation. When the task became difficult due to time
constraints, by dressing a different garment with slightly smaller buttons, the image
could retreat to its previously learned dependent patterns, waiting for its mother to
dress it or help it through the problem. Instead, your mother uses strategy guidance to
encourage you to use the image of self-mediation strategies (quadrant 3) to think and
talk your way through difficult situations, demonstrating the ability to initiate processes
that enable occupational performance. As the result of a carefully thought out
intervention process, the image has been able to learn the skills necessary to dress
itself without assistance when getting ready for school. Through attention to the
numerous factors that influence the mastery and generalization of skills, your therapist
has used the 4QM as a framework to enable you to develop autonomy at work.
FIGURE 8.14 In the image, practice buttoning the buttons of the blouse.