Revisiting the dynamic comprehensive model of self-awareness: a scoping review and thematic analysis of its impact 20 years later

ABSTRACT

This study aimed to (1) describe the scope of research related to the Dynamic Comprehensive Model of Awareness (DCMA) (Toglia & Kirk, 2000); (2) identify themes and support for key model postulates; and (3) suggest future research directions related to this model. Using PRISMA scoping guidelines, 366 articles were reviewed, and 54 articles met our inclusion criteria. Selected studies were clustered into three themes: (1) the relationship between general and online self-awareness (50%); (2) interventions based on the model (41%); and (3) factors contributing to self-awareness (9%). Most studies were conducted with participants with acquired brain injury (BI) and traumatic BI (68%), most used a cross-sectional design (50%), and most intervention studies utilized a single-subject design (18%), followed by an experimental design (9%). This review provides evidence for the wide application of the DCMA across varying ages and populations. The need for a multidimensional assessment approach is recognized; however, stronger evidence that supports a uniform assessment of online self-awareness is needed. The intervention studies frequently described the importance of direct experience in developing self-awareness; however, few studies compared how intervention methods to influence general versus online self-awareness, or how cognitive capacity, self-efficacy, psychological factors, and context, influence the development of self-awareness.

KEYWORDS:

• Metacognition
• rehabilitation
• anosognosia
• feedback
• brain injury
• cognitive impairment

Introduction

Self-awareness, the ability to understand one’s strengths and limitations as well as to monitor, recognize and evaluate performance errors is crucial to everyday functioning, participation, and rehabilitation outcomes. In clinical populations decreased self-awareness presents a major challenge to rehabilitation and is associated with motivation, functional outcome, caregiver burden, and psychosocial outcomes (Chesnel et al., 2018; Engel et al., 2019; Geytenbeek et al., 2017; Medley & Powell, 2010; Toglia & Foster, 2021). Yet, up to 20 years ago, the field of rehabilitation lacked a comprehensive theoretical framework of self-awareness.

The Dynamic Comprehensive Model of Awareness (DCMA), (Toglia & Kirk, 2000) was developed in an attempt to fill this void by characterizing the multidimensional nature of self-awareness and guiding the development of rehabilitation assessment tools and interventions. The DCMA integrates parallel themes from cognitive psychology, social psychology, and neuropsychology. It proposes a dynamic relationship between knowledge, beliefs, task demands, personal factors, cognitive skills, and the context of a situation.

The DCMA expands upon components introduced by the Pyramid model of awareness (intellectual, emergent, and anticipatory awareness) (Crosson et al., 1989) and highlights the distinction between two main subtypes of self-awareness: Metacognitive knowledge (aka. general awareness), and beliefs that exist outside the context of a task or situation (i.e., offline) or that which is activated within the context of an activity or situation (i.e., online awareness) (emergent and anticipatory awareness based on the Pyramid model). Figure 1 illustrates this particular aspect of the DCMA and includes other terms that are used interchangeably in the literature to refer to these two aspects of awareness. The full model is included in Supplementary file 1.

Figure 1. General vs. online awareness.

This figure shows how general and online self-awareness affect each other reciprocally in a dynamic relationship and are influenced by cognitive skills, emotional state, personality and task variables.

The DCMA argues that general and online awareness is distinct from each other. For example, a person may acknowledge difficulties in activities of daily living (ADL) during an interview yet be unable to use this knowledge about their difficulties to monitor performance while actually performing ADL and vice versa. Furthermore, the DCMA postulates that self-awareness can vary within and across domains (e.g., cognitive, behavioural, social, and functional), depth or level of awareness, and can be influenced by cognitive, task, contextual, personal, and psychological variables. This suggests that self-awareness deficits may be observed in some tasks or situations and not in others. It also implies that self-awareness deficits can be expressed differently in two clients with similar cognitive profiles depending on psychological, task or contextual variables.

Based on these concepts, the DCMA recommended a multidimensional assessment of awareness that examines components of self-awareness across domains, tasks, and levels of specificity. The importance of developing and using online measures that examine self-awareness before, during (at-the-moment error recognition and correction), and immediately after task experiences was emphasized.

The DCMA model describes how general and online awareness affect each other reciprocally in a dynamic relationship. This relationship provides implications for treatment because it explains how self-awareness can change through experience with tasks and describes the mechanism of change. General self-awareness (i.e., pre-existing knowledge and beliefs) is relatively stable and changes slowly through experiences of repeated difficulties and successes across time, while online awareness is variable and is highly dependent on task characteristics, meaningfulness, mood, personality, and other factors (illustrated in Figure 1). Repeated discrepancies between self-appraisal, expectations, and actual task performance outcomes modify one’s online self-awareness that in turn updates and restructures general self-awareness leading to performance adjustments. Inability to update knowledge based on task experiences decreases effective strategy use and can lower self-efficacy or perceived sense of control that can shake one’s sense of self. The DCMA model, therefore, suggests that online self-awareness may be more responsive to the immediate effects of intervention and emphasizes the interplay of self-efficacy and other factors (cognitive, task, contextual, personal, and psychological) with online and general self-awareness.

The DCMA model also draws upon Bandura’s concept of “guided mastery” (Bandura, 2019) and suggests that treatment should be based on guided questions and structured familiar activity experiences to allow the person to discover errors themselves (i.e., self-discovery). Familiar and meaningful tasks are likely to be more effective in facilitating self-awareness because they provide a basis for evaluating and comparing current experiences.

Overall, there are no reviews that have synthesized knowledge based on the DCMA with the aim of identifying major gaps in evidence. Therefore, the main aim of this scoping review was to identify key evidence and gaps and suggest future research needs related to the DCMA. Such scoping review can provide initial evidence related to the conceptualization of self-awareness, which will inform assessment and treatment. This scoping review examines the influence of the DCMA model in research, including the scope of application, how it has been studied and incorporated into clinical assessment and treatment since its publication. Thus the questions that we aimed to answer while conducting this scoping review were: (1) What is the evidence to support the DCMA key themes and what populations have been included? (2) What is the evidence to support the application of DCMA concepts to assessment and treatment? (3) What are the gaps in research and what should be done in future studies to further support the model?

Methods

Scoping reviews are utilized to map an area of study and to determine the need for more studies by helping to identify important evidence gaps and provide a clear indication of the volume of literature and studies available (Mendelsohn et al., 2015). The scoping review used in this research followed the PRISMA guidelines and the steps outlined in Levac et al. (2010). First, we identified the aim and the questions of this scoping review; second, using Google Scholar, PsychInfo, PubMed, and CINAHL we identified relevant studies that cited the DCMA from 2000 through June 2021; third, we selected studies for this review based on the inclusion/exclusion criteria listed below; and, finally, we extracted and tabulated the data. The scope of this inquiry was to identify the current findings related to the DCMA model and areas for future research, with an intended outcome of advancing research and practice of self-awareness within the field of rehabilitation.

Search and selection

The full search strategy was carried out in five main steps which are also illustrated in Figure 2:

1. An initial search in Google scholar using the phrase: “cited by Toglia & Kirk, 2000” OR “Toglia & Kirk, 2000” AND “self-awareness” OR “awareness” OR “model of self-awareness” OR “DCMA” OR “DCMA model” resulted in 521 records.

2. This initial search results were downloaded into excel and duplicates were removed electronically. We then inspected and excluded the non-English records leaving a total of 326 records.

3. Abstract were reviewed in two stages: first, review articles, dissertations, and books or book chapters were excluded. Second, articles that involved surveys of clinicians, treatment protocols, and topics that were completely not related to self-awareness were removed. This review yielded a total of 162 articles

4. Each article was then reviewed for relevancy by considering how well each paper matched and referred to themes and concepts introduced by the DCMA. We opted to exclude articles that did not directly include the DCMA model in their methods, results, and/or discussion, but only mentioned the model as a reference for the definition of self-awareness. Thus, the manuscript that just cited the model without referring to concepts described by the model were excluded; in addition, articles that did not cite the model or the paper describing the model were also excluded.

5. Finally the review included total 54 articles that went through a thematic analysis

Figure 2. Prisma flow chart illustrating the screening and selection of articles.

This figure shows the process of how 512 articles identified were screened and 54 unique articles were selected from the literature.

We reviewed each study at the full-text review stage for distinctions between intervention studies and relationships between main model constructs; any study that incorporated these elements in relation to the DCMA was included. One of two reviewers (JT or YG) made exclusion decisions. Those studies for which exclusion criteria were inconclusive were noted and discussed until a final decision was made. The references-cited list of all included articles identified within the original search was checked for additional relevant citations.

Procedure

The procedure used in this scoping review was a Framework synthesis using a deductive approach (Dixon-Woods, 2011): With this approach, a tentative framework of themes was identified based on the DCMA model. Three main themes were examined in the scoping are (1) General awareness (metacognitive knowledge) and online self-awareness: (1.1) Differences between general and online awareness (1.2) Assessment of online awareness (1.3) Variations of self-awareness across domains and tasks; and (2) Treatment based on the DMCA: (2.1) Effectiveness of familiar or meaningful tasks in improving self-awareness; (2.2) Self-discovery of errors and types of feedback; (2.3) Relationship of strategy use to online awareness. The last theme explored (3) Factors that influence self-awareness.

Using the predefined framework, the reviewers (YG and JT) actively searched for data to support the themes identified. One researcher assigned each study to a primary theme within this framework. As coding progressed, some themes were combined or deleted or new themes were added; previously coded studies were reassessed within the updated framework.

Then, one researcher (YG) assigned primary themes to each study, and the second researcher (JT) validated them. Discrepancies were discussed and resolved. Where appropriate, studies were assigned primary and secondary themes; however, studies were grouped according to the primary theme. Each study was also described according to study aim/s, methodology, population, and key results (See Table 1).

Table 1. Summary of articles included within the scoping review of the DCMA.

1. General awareness (metacognitive knowledge) and online awareness
1.1. Distinction between general awareness and online awareness
The model clearly differentiates between knowledge and beliefs related to one's self that is pre-existing or stored within long term memory and knowledge and awareness that is activated during a task
Author, Year	Study aim/s	Design and methods	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
Chen and Goverover (2021)	Investigate intellectual and online awareness among pwMS	Cross-sectional:	Ninety-five people with multiple sclerosis (PwMS) and 65 healthy controls	PwMS had impaired intellectual awareness compared to HC but intact online awareness.	Theme 2.1. Familiar tasks are more effective in facilitating awareness (PwMS may benefit from performing a functional task during the assessment and treatment process, which may lead to a more accurate estimate of their abilities).
		Participants and informants completed, 3 self-report inventories, and participants completed an internet task with estimations before and after the task.		Post-task estimates were more accurate than pre-task estimates. Post-task estimates were associated with actual performance but not pre-task predictions.
				Online and intellectual awareness are distinct.	Theme 2.2. Online awareness is more responsive to the immediate effects of experiential feedback
				Components of online awareness (before and after task rating) can be disassociated.
Chen and Toglia (2019)	Explore the relationships among spatial neglect, offline anosognosia, anticipatory Anosognosia for spatial neglect (ASN), and emergent ASN	Cross-sectional:	Fourty-four individuals with right hemisphere stroke.	Severity of neglect was related to online but not to offline self-awareness.	Theme 1.2. Online awareness varies across tasks (novel tasks).
		Questions about functioning asked outside task context.	Inpatient rehabilitation facility.	Offline and online ASN were independent. Online ASN improved after task performance.	Theme 2.1. Experience with familiar and challenging tasks may facilitate emergence of self-awareness.
		Online ratings of certainty and estimated performance were asked immediately before and after a cancellation task, address and sentence copying, telephone dialling, and reading task		There was no task-specific difference in pre-task estimations but there was variation in post-task estimations and pre-post changes across tasks.	Theme 3. Severity of cognitive deficits is related to online awareness
Dean et al. (2017)	Investigate the relationship between a direct (general awareness) and an indirect (online) measure of awareness of Aphasia	Cross-sectional: Participants rated ease of communication activities using a visual analogue scale (general awareness)	Forty-eight people with aphasia	A trend relationship between general and online self-awareness measures.	Theme 3. Both types of awareness were related to overall severity of language impairment
		Self-correction of naming errors of pictures (online awareness)	Left hemisphere acquired brain injury	General awareness (i.e., direct) was associated with language production, while the online (i.e., indirect) measure was associated with comprehension scores. One form of awareness is not based on the other. Both types of awareness were related to overall severity of language impairment, with more severely impaired people being less aware of their difficulties.
Dockree et al. (2015)	Assess the relationship between emergent and metacognitive awareness	Cross-sectional	Sixty-two participants with traumatic brain injury (TBI) and their informants	Found moderate relationship between metacognitive (general) and online awareness, however, a large unexplained variance was found, suggesting that each type of awareness has unique qualities. Patients who reported fewer daily life difficulties compared to significant others had less online awareness of laboratory errors.	Theme 3. Online awareness is more related to executive functioning than general awareness
		Metacognitive awareness was assessed with discrepancy ratings between patients and others on 3 questionnaires.
		Online awareness was assessed through error recognition during laboratory tasks.
Fazeli et al. (2017)	Examine the association between metacognitive knowledge and online awareness and multitasking abilities among older adults living with HIV	Cross-sectional: Participants performed the Everyday Multitasking Test (MT) in which they performed 4 everyday tasks concurrently within a time limit; measures of metacognition regarding their MT performance (e.g., metacognitive knowledge and online awareness in the context of the Everyday MT was administered).	Ninety-nine community-dwelling HIV-infected adults aged 50 years and above	Metacognition (and not online awareness) was a significant partial mediator between neurocognition and everyday MT performance.
				Awareness of cognitive abilities (metacognition) was a strong, independent predictor of everyday multitasking performance.
				Metacognition was associated with Everyday MT.
				More accurate metacognition was correlated with fewer errors, whereas traditional neurocognitive measures were not.
Goverover et al. (2014)	Examine whether experience with a functional task changes the level of online self-awareness; and whether it changes general self-awareness	Cross-sectional study: Intellectual awareness was assessed via discrepancy scores between participants and their informants.	18 pwMS	PWMS had impaired general awareness compared to HC but there were no differences in online awareness. Prediction ratings were correlated with performance but general awareness and post-task ratings were not. Participants were more accurate in post-task assessments than pre-task predictions. Intellectual awareness was not associated with online awareness or with any other outcome variable.	Theme 1.2. Self-awareness cannot be measured using a unidimensional approach to assessment.
		Online Awareness was examined using self-prediction and self-assessment of performance on a functional task.	16 healthy controls (HC)		Indirectly supports treatment theme
					Theme 2.2. Online awareness is more responsive to the immediate effects of feedback intervention, but not general awareness.
Hergert et al. (2020)	Examine the utility of a performance-rating method for assessing awareness of cognitive performance in Huntington's Disease (HD). (General and online awareness)	Cross-sectional:	Fifty-four persons with HD and 47 informants	Patients overestimated actual performance by 20-30% for both pre-test prediction and posttest evaluation. There was a lack of correlation between general and online awareness measures. Patients with severe motor impairment underestimated their problems relative to informant report	Theme 3. Motor impairment was associated with self-awareness
		Participants rated pre and post-performance for each subtest of an assessment battery using the bell curve method (online awareness). Also, patient/informant-report discrepancies of executive functioning (FrSBe) were assessed (general awareness)		Performance rating and patient/informant discrepancies may measure different constructs of awareness (no correlation between these two methods of measurement).
Hoerold et al. (2013)	Examined the awareness correlates of left versus right prefrontal cortex lesions in comparison to left and right posterior lesions	Cross-sectional	Twelve left frontal and seven right frontal, as well as 14, left non-frontal and 12 right non-frontal focal lesion patients (total = 45)	Online and metacognitive awareness were not significantly correlated.
		Assessed general awareness through patient/informant discrepancy using 3 different questionnaires and Online awareness through error monitoring during a laboratory task.
				Distinct neuroanatomical systems may underpin these two types of awareness deficit.
				Lower online awareness with right frontal patients.
			Fifteen healthy controls
Lahav et al. (2014)	Compared and assessed the relationship between handwriting, general self-awareness, online awareness, and handwriting performance.	Cross-sectional: A handwriting evaluation assessment, HAMS, was administered along with self-knowledge and online awareness questionnaires.	Eighty-six middle-school students	Correlations were found between general and online awareness.	Theme 2.2. Self-knowledge is relatively stable and changes slowly with experience; in contrast with online awareness, which can change following experience with an activity
				The correlation between handwriting performance and online awareness was stronger than the correlations between performance and general awareness.
O’Keeffe, Dockree, et al. (2007)	To assess the DMCA in TBI and examine which neuropsychological abilities are associated with awareness	Cross-sectional:	Twenty-seven men and four women with TBI and 31 healthy controls	Metacognitive knowledge did not correlate with Emergent and Anticipatory awareness. The findings differentiate between Metacognitive Knowledge and Online Awareness (Emergent and Anticipatory). TBI group demonstrated impaired awareness of metacognitive knowledge, online-emergent awareness, and online anticipatory awareness, compared to controls.	Theme 3. Low self-awareness was associated with disinhibition, interpersonal problems, and more difficulties in total competency.
		Awareness was assessed in terms of metacognitive knowledge (intellectual awareness) and online emergent awareness (error recognition) and anticipatory awareness (prediction accuracy)
O’Keeffe, Murray et al. (2007)	Investigate awareness of cognitive deficits in frontotemporal dementia (FTD), corticobasal degeneration (CBD), and progressive supranuclear palsy (PSP)	Cross-sectional:	Thirty-five patients (14 FTD, 11 CBD and 10 PSP) and 20 controls	This study differentiates between “metacognitive knowledge” about one’s cognitive abilities and online monitoring of performance during laboratory tasks. All participants had poor online error monitoring and general awareness compared with healthy controls; however, FTD patients were disproportionately more impaired than CBD and PSP patients on error monitoring.	Theme 3. Poor prediction accuracy was associated with higher levels of depression
		Examination of insight deficits in FTD, CBD, and PSP using an awareness interview; discrepancy between patient and informant for three questionnaires to assess general awareness. Online awareness was assessed through error monitoring and prediction accuracy.			Participants showed different cognitive skills related to different aspects of awareness
Robertson and Schmitter-Edgecombe (2015)	Examined four self-awareness variables represented in the DCMA: metacognitive awareness, anticipatory awareness, error-monitoring, and self-regulation.	Cross-sectional and Longitudinal: TBI participants and controls were re-tested after 6 months	Ninety individuals (28 females and 62 males) with moderate-to-severe TBI and 90 age-matched controls	Awareness measures were not correlated with each other except for pre-post memory ratings.	Theme 2.2.
		The Problems in Everyday Living Questionnaire assessed general awareness. Online awareness was assessed with pre-post ratings of memory recall and error-monitoring during two cognitive tasks.		At follow-up, general awareness improved but error monitoring was still impaired	Indirect support for use of feedback interventions to target improvement in error monitoring as a means of facilitating community reintegration following TBI
				Error monitoring was a unique predictor of community integration but other awareness measures were not.
Torres et al. (2016)	Evaluate (a) metacognitive knowledge, pertaining to awareness of one’s own general cognitive functioning; and (b) metacognitive experience, referring to awareness of one’s cognitive performance on a specific, online cognitive task.	Cross-sectional: Assessed (a) global metacognitive knowledge, of awareness of one’s own general cognitive functioning, compared to an average person; and (b) online awareness assessed with post-ratings of memory performance on a list learning recall task.	Fifty clinically euthymic patients with bipolar I disorder and 38 demographically similar healthy controls	Patients showed diminished accuracy in rating their general cognitive ability, implying deficits in metacognitive knowledge. In contrast, patients were accurate in rating their online memory performance (post-ratings), suggesting intact online awareness.
1.2. Assessment of online self-awareness
Measures of awareness that characterize awareness by an overall score, which does not consider the multidimensionality of awareness, are too broad to be useful. Assessment of awareness needs to include systematic methods for examining perception of abilities within the context of a task or situation. The proposed model also implies that assessment of awareness includes both global and specific estimation measures across different tasks and levels of difficulty.
Author, Year	Study aim/s	Methods and design	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
Bivona et al. (2020)	Examine the validity of the Self-Awareness Multilevel Assessment Scale (SAMAS), a clinical tool to assess different aspects of awareness: declarative (general), online anticipatory, and emergent.	Cross-sectional	Twenty-five patients with severe acquired brain injury (ABI)	SAMAS scores correlated with clinical expert judgments of awareness for online anticipatory and emergent awareness
		SAMAS was compared to global judgment of awareness by an experienced neuropsychologist who was blinded to scores and 2 existing measures (Patient Competency Rating Scale (PCRS) and Self Awareness Deficits Interview (SADI)		Only the SAMAS (not PCRS or SADI) predicted clinical judgment
(Doig et al., 2017b)	Describe the occupation-based online awareness assessment approach, error classification system and pilot implementation with two adults with severe TBI to evaluate the feasibility of the assessment and inter-rater agreement.	Repeated measurement: Individualized functional assessment tasks were administered repeatedly over 2–3 months and audiovisual recordings were taken.	Two persons with severe TBI	Fair inter-rater agreement between two trained occupational therapists of error behaviour and error correction when using the described occupation-based approach to assessing online awareness (i.e., non-specific vs. specific prompting).
		Independent ratings of two trained occupational therapists were compared using exact percent agreement.		The assessment approach has promise, for providing an in-depth understanding of error behaviour and awareness of errors during meaningful occupations.
		The assessment procedure involves calculating frequency of errors and correction types as well as the amount and types of prompting to correct errors across a variety of functional tasks (eg. cooking, drinking, budgeting).
Krasny-Pacini et al. (2015)	Examine the feasibility of three ways of assessing awareness of executive dysfunction in children with a TBI during a rehabilitation programme based on GMT.	Secondary analysis of an intervention GMT study.	Five single cases of children with severe TBI, aged 8–14, undergoing metacognitive training	Children showed relatively preserved basic intellectual awareness but more difficulty in the higher-order intellectual awareness and online awareness.	Theme 3. Online awareness is associated with executive functions
		Awareness was assessed using three different measures: two measures of metacognitive knowledge/intellectual awareness and one measure of online/emergent awareness (post-task appraisal of task difficulty)
				Using questionnaires and discrepancy scores are not sufficient to assess awareness, because it does not include online error detection, which can be impaired in children, especially those with impaired executive functions
Plutino et al. (2020)	Explore if online awareness assessment can differentiate between Progressive supranuclear palsy (PSP) and behavioural variant frontotemporal dementia – (bv-FTD)	Cross-sectional: Used the Stroop Test, to measure online awareness (scoring any spontaneous self-corrections during the task)	Ninety-three participants (27 FTD, 25 PSP, 42 healthy controls	Findings suggest that different neural networks support different types of self-awareness.
		Patients were selected in the early stage of the disease.		Online error monitoring during a task was the only measure to differentiate between groups
				Different patterns of awareness were found between patients with different types of dementia.
1.3. Variations of self-awareness across domains and tasks
Online awareness or ongoing monitoring and regulation of actual performance varies with the task and the context of a situation and is relatively unstable. However, because online awareness is dependent on the task and the situation, this framework implies that anticipatory and/or emergent awareness may be evident on some tasks and situations but not on others self-monitoring skills may be highly dependent on task characteristics such as familiarity and difficulty level.
Self-awareness can differ in various areas of function: physical, cognitive, perceptual, interpersonal, emotional, and functional domains. Thus, individuals may exhibit “blind spots” may be aware of some areas and not others.
Author, Year	Study aim/s	Methods and design	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
Banks and Weintraub (2008)	Compare differences across groups of people with dementia and healthy controls in insight for 3 domains primarily affected by dementia: Behaviour, Naming, and Memory.	Cross-sectional	Fifty-five participants. 14–15 in each group: patients with Progressive Aphasia, variant (PPA); frontotemporal dementia bvFTD, and probable Alzheimer’s disease (PrAD) and a group of cognitively intact control subjects	Differences observed across domains (cognitive, behavioural, naming) in diff groups BvFTD and PrAD patients were unable to accurately assess Memory. All three groups failed to accurately assess their behavioural symptoms.
		Assessed online awareness using visual analogue scale before and after tasks in 3 domains (1) memory (2) naming (3) behaviour.		Naming ability, in contrast, was either accurately assessed or underestimated in all groups.
Doig et al. (2017a)	Compare online awareness and error behaviour during tasks of meaning and importance to the participants with TBI, using an occupation-based online awareness assessment	Cross-sectional: Participants identified personally meaningful occupations and performed each task on two consecutive occasions.	Two participants with TBI with two matched controls	Participants with TBI demonstrated more frequent errors and poorer self-correction of errors compared to controls.
		Performances were video-recorded and assessed by two OTs to measure the frequency of errors, the percent of self-corrected errors, and the types of error behaviours observed.		Frequency of errors, the ability to self-correct errors, and the types of errors made, varied according to the task being performed.
Goverover et al. (2009)	Assess the relationship between general self-awareness, function, and quality of life in persons with MS	Cross-sectional: Functional Behaviour Profile was completed by both participants and their informants. Participants’ scores were subtracted from those of their informants.	47 pwMS and 26 HC	Self-awareness of functional status was significantly better for the HC group versus the MS group on the total self-awareness score as well as in two self-awareness subscales (task performance and problem-solving), but not in the social integration subscale. Self-awareness is a multidimensional concept that differs cross-domains of function.
		Executive Function Performance Test measured IADL performance; QOL was measured with the Functional
Hurst et al. (2020)	Investigate the evidence for domain-specific self-awareness deficits on the Prigatano Competency Rating Scale (PCRS).	Cross-sectional with within and between-group design using the PCRS	Fifty-six adults with severe TBI and 50 age and gender-matched HC.	Participants displayed significantly poorer self-awareness on the activities of daily living (ADLs) domain in comparison to the interpersonal and emotional domains and compared to controls.	Comment: Limited support for Toglia and Kirk’s model, which proposes that self-awareness varies across functional domains (i.e., was lowest for complex ADLs).
	Examine associations between domain-specific self-awareness and outcomes following severe TBI.			There were no significant between-group differences in other domains.
				Poorer self-awareness in ADLs and cognitive domains were associated with lower independence and occupational functioning, respectively.
Lloyd et al. (2021)	Validate the Paediatric Awareness Questionnaire (PAQ) as a multi-domain measure of self-awareness and investigate domain-specific self-awareness	Cross-sectional study design: Children with TBI and their parents independently completed the PAQ	One-hundred and ninty-seven children and adolescents with mixed causes of ABI (70% with traumatic brain injury) and their parents	Children had poorer self-awareness of cognitive functioning than socio-emotional functioning, ADLs, and communication skills.
Nagele et al. (2021)	Examine domain-specific self-awareness of cognitive ability in TBI, its association with global ISA, and change in self-appraisal of cognitive ability after performance on neuropsychological tests.	Secondary analysis of a cross-sectional cohort study: Grouped participants as underestimators, fair estimators, and overestimators of their memory and executive functioning.	Fifty-nine participants with chronic TBI	Domain-specific groups did not differ on global self-awareness measures. Domain-specific self-awareness distributions varied robustly from the Memory Composite Domain to the Executive Function Domain.
		Compared these groups by global self-awareness measures, and pre- to-posttest change in self-appraisal of cognitive performance		Most participants did not adjust domain-specific self-awareness ratings in response to neuropsychological test performance, despite discrepancies between self-appraisal and objective performance.
Quiles et al. (2020)	To explore whether “online” and “end line” metacognitive awareness assessments lead to comparable results in basic and high-level cognitive tasks	Cross-sectional:	Fifty-nine Healthy adults	No association was found between “online” and “end line” metacognitive awareness scores for memory tests. However, lower end-line metacognitive awareness scores were associated with lower online metacognitive awareness scores for the social cognition test.
		Metacognitive awareness assessments involved rating level of confidence of answers for each item immediately after performance (“Online”) and globally at the end of the test (“end-line”). A memory and social cognition test was used.		Online awareness varies in basic and complex tasks.
		Assess only online awareness: immediately and after the task.		Supports that online awareness differs across domains
Rotenberg-Shpigelman et al. (2014)	Examine online awareness for functional tasks, how it is affected by task experience, and its relationships with neurogenic and psychogenic factors.	Cross-sectional: Online awareness was measured as the discrepancy between subjective ratings of performance and actual performance before and immediately after functional tasks.	Thirty-six adults with ABI	Awareness was found to be task-dependent with significant differences in awareness across tasks. Anticipatory and emergent awareness was found to be significantly more impaired in the IADL tasks compared to the BADL task.
		Participants also completed The Impaired Self-Awareness scale and the Denial of Disability scale		In BADL tasks, participants showed a significant shift from underrating prior to tasks to accurate rating after the task, however, those who initially over-rated performance did not change ratings.
Schoo et al. (2013)	Investigate whether healthy people have differentiated self-awareness for specific cognitive domains; to assess the accuracy of these estimates in relation to the concepts used in clinical neuropsychology, and to determine the grounds on which self-awareness is based	Cross-sectional: Assessed Awareness immediately and after cognitive tasks across different domains (memory, concentration, thinking (executive functioning), and visuoperception) using a vertical visual analogue scale. Assessed general awareness via a short interview	Twenty young males (mean =  21.7); second group of 20 middle-aged males (mean =  52.8)	Dissociations in awareness were found between cognitive domains. The amount of awareness error for visuo-perception was significantly larger than for the memory domain. Self-appraisal after the task was more accurate than initial self-ratings in all domains except attention	Theme 3. Self-awareness is domain-specific, and although it is adaptive to the experience of mental effort, it is most dependent on pre-existing beliefs about one’s own cognitive abilities.
Torres et al. (2021)	Evaluate general and online self-awareness across multiple cognitive domains and investigate the association between metacognition and quality of life.	Cross-sectional	Fifty-seven individuals with bipolar disorder and 55 HC	Disparity of metacognitive inaccuracies was observed across different cognitive domains, thus supporting domain-specific accounts of metacognition. Most metacognitive inaccuracies involved underestimation of cognitive ability.
		Participants rated their performance compared to an average person before and after cognitive tasks. Self-ratings were compared to actual performance.		Individuals with bipolar disorder demonstrate inaccuracies in rating their cognitive functioning and in rating their online cognitive task performance, but only on selected cognitive functions.
		A global cognitive self-rating was compared to a global cognitive test score
2. Studies supporting treatment based on the DMCA:
2.1. Efficacy of familiar or meaningful tasks in improving self-awareness
Author, Year	Study aim/s	Methods and design	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
Chudoba and Schmitter-Edgecombe (2020)	Examine self-awareness, self-monitoring, and a new self-updating construct of insight in amnestic mild cognitive impairment (aMCI).	Cross-sectional: Part of a larger study investigating IADLs in community-dwelling middle-aged and older adults. Participants made predictions (pre-task, post-task, and future predictions) about their performances on a memory list learning task and a simulated functional task (“Day Out” task) that involved carrying out a list of tasks in a campus apartment.	Twenty-six individuals with aMCI and 26 match HC	Individuals with aMCI were able to use task experience to adjust their perceptions about their abilities to perform both memory and functional tasks. Importance of self-monitoring to self-awareness.	Theme 3. Findings suggest that executive functioning abilities may support self-monitoring of skills for individuals with aMCI, thereby contributing to self-updating and self-awareness of limitations
				Better self-awareness to functional tasks than cognitive tasks. For the memory and functional task abilities, individuals with aMCI exhibited intact self-awareness, self-monitoring, and self-updating in comparison to the HC
				Participants update their knowledge after repeated task experience
Dirette (2002)	Explore the development of awareness and the use of compensatory strategies by adults with ABI	A critical incidents, qualitative inquiry.	Three adults with moderate-to-severe ABI resulting from traumatic blunt force injuries	Awareness was developed as a slow process with a comparison of current performance to pre-morbid performance on functional tasks.	Comment: This is not an intervention study but sheds light on the process of self-awareness development.
		In-depth interviews were audiotaped and transcribed for each client and questionnaires completed by clients and therapists with whom they had worked with.		Two of three clients reported increased awareness associated with participation in functional tasks in a familiar environment
Doig et al. (2021)	Determine whether an occupation-based intervention with metacognitive strategy instruction would result in goal achievement and improved online awareness and executive function performance.	A single-case experimental design using a multiple-baseline design across behaviours with repeated measurement of targeted behaviours during multiple, discrete phases of the intervention. The 6-week treatment included pre-task self-prediction, post-task self-evaluation or therapist feedback, video feedback.	Two participants with severe TBI: Four and five years post-injury	The occupation-based intervention with metacognitive strategy instruction led to improvements compared to baseline performance in online awareness and general awareness in one of the participants.	Theme 2.1. Familiar or meaningful tasks improves self-awareness.
		Feedback included either verbal or video including use of “pause, prompt, praise,” strategy instruction/ discussion.			Theme 2.2. Self-discovery of errors and types of feedback
Fleming et al. (2020)	Provide evidence for the effect of verbal feedback on task-specific self-awareness in people with TBI.	A secondary analysis was conducted on selected data extracted from a randomized, assessor-blinded controlled trial.	Thirty-six participants with impaired self-awareness post-TBI	Metacognitive strategy training with verbal or experimental feedback is beneficial to increase self-awareness and ultimately improve occupational performance in individuals with TBI. Post-intervention gains in task-specific self-awareness were not statistically different between groups.	Theme 2.3. Task-specific self-awareness can be improved with verbal and experimental feedback.
				Changes in intellectual awareness were task-specific and did not extend or generalize to the domains appraised by the AQ.
Fleming et al. (2006)	Investigated the effect of an occupation-based intervention programme on self-awareness and emotional status of people after ABI	ABA design-Each participant received a 10-week individualized programme focused on three meaningful occupations, 1–2 hrs per week. Self-awareness outcome measures included the SADI and PCRS.	Four male adults with impaired self-awareness following ABI. 1–4.5 years post-injury	Modest improvements in general self-awareness over the intervention period were observed for all participants	Theme 2.3. Treatment highlights the importance of facilitating self-monitoring using methods that are non-confrontational and respect the individual's desired level of self-disclosure to the therapist.
		Treatment included self-prediction and self-evaluation through pre and post-ratings and multiple feedback methods.		Supports use of “just right Challenge” tasks and structured real-life functional activities that provide experiential feedback.
Goverover et al. (2007)	Investigate the use of an occupation-based intervention that employed self-awareness and verbal self-regulation strategies during the performance of ADL tasks to alleviate difficulties related to SA and SR and to address functional performance outcomes.	Single-blind RCT.	Twenty participants with ABI at least 1-year post-injury	Using familiar IADLs using verbal feedback and guided discovery improved general self-awareness (SRSI) as well as better performance of IADLs.	Theme 2.3. Experience with the task can also be beneficial while providing prompts and verbal feedback.
		Both treatment and placebo control groups performed the same IADL activities across six weekly sessions. The treatment group involving self-prediction and estimation of performance before and after each task was compared with a control group involving conventional practice of tasks		Support awareness treatment embedded within the practice of functional meaningful activities
Miyahara et al. (2018)	Investigate the effectiveness of an awareness occupation-based intervention	“alternating treatments design”,	Four participants 1-year post brain injury (encephalitis, TBI, Cerebral haemorrhage)	Three of the four participants showed significantly better SRSI scores and the details of their responses also indicated higher awareness during the awareness intervention.	Theme 2.3. Findings suggest that experiential and verbal feedback are beneficial for awareness improvement
		Interventions used self-chosen occupations. The awareness intervention (use of anticipation methods before task; and after task self-assessment) was compared to ordinary occupational intervention). Treatment was administered 10 times each (a total of 20 interventions).
(Nagelkop et al., 2021)	Describe the process and procedures for addressing self-awareness and improving strategy use within the context of functional activities	A case report:	One inpatient participant post-stroke	Improved online self-awareness, strategy use, and functional performance were observed, however, no changes were observed on general awareness (a standard Awareness Questionnaire).	Theme 1. Support the difference between online and general self-awareness
		A metacognitive strategy intervention was used with guided questions and prompts to promote identification of task challenges and strategies before the tasks and self-assessment of performance after the task.
					Theme 2.2. Self-discovery of errors: Self-awareness within activities may be more important in contributing to effective strategy use and functional performance compared to verbal acknowledgment in an interview.
O’callaghan et al., (2006)	Exploring factors that help people with TBI gain awareness and individual reactions to gaining awareness	Qualitative, semi-structured interview that was audiotaped, transcribed and analyzed using interpretative phenomenological analysis (IPA)	Ten people with moderate to severe TBI	Themes that emerged included personal discovery that supports the importance of real-life activities and environments in developing self-awareness.	Theme 2.2. Personal discovery was important to develop SA.
Ownsworth et al. (2010)	Evaluate the effects of metacognitive skills training (MST) and behavioural practice on error self-regulation during a naturalistic task.	Single-case study design: Four-session baseline of behavioural practice, two participants received eight MST sessions followed by four maintenance sessions.	Three participants with severe TBI 3–7 years post-injury	The results suggest that error self-regulation on a complex task can improve without more global gains in self-knowledge (Study 1).	Theme 1.1. Difference between online and general self-awareness theme.
		Study 2: participant 3 received 16 sessions of behavioural practice corrections.		Secondly, global self-knowledge can improve without significant developments in error self-regulation.
				Metacognitive techniques can improve self-regulatory behaviour.
Ownsworth et al. (2006)	Assess efficacy of a 16-week intervention targeted error awareness and self-correction in two real-life settings: (a) cooking at home; and (b) volunteer work.	Single-case experimental study: 8 treatment sessions: Systematic feedback techniques involved self-evaluation of performance, anticipation of errors, use of corrective strategies, and “online” self-correction during performance.	Thirty-six-year-old man with a very severe TBI who demonstrated long-term awareness deficits (four years post-injury)	Participants’ ability to independently self-correct errors improved following an introduction of systematic feedback techniques.	Theme 1.1. Provides support for the difference between online and general self-awareness themes.
				Demonstrated a 44% reduction in error frequency and increased self-correction. Participants’ global self-knowledge of deficits assessed by self-report was unchanged after the programme.
					Theme 2.2. Provide support for the importance of feedback during performance of meaningful tasks.
Toglia et al. (2010)	Explore the efficacy of multi-context treatment to improve self-regulation and strategy use	Single-subject design with repeated measures pre and post-intervention Intervention used familiar functional tasks using self-discovery and guided questions and prompts used before, during, and after performance.	Four persons (two male; two female) with difficulty following multi-step directions, 3–5 years post-TBI	Improvement was shown in online awareness, self-regulation, and functional performance in all participants. Improvements were not observed on a standard general awareness measure (AQ)	Theme 1.1. Support the difference between online and general self-awareness.
				Results support a metacognitive strategy intervention embedded within the practice of functional meaningful activities.
					Theme 2.2 and 2.3. Improvement in online awareness and self-discovery of errors
2.2. Intervention: Self discovery of errors and type of feedback
Awareness training techniques, which are geared towards helping patients self-discover their own errors, may be more effective in enhancing awareness than verbal feedback. Treatment needs to be directed towards creating structured experiences where individuals can experience and recognize errors themselves, and at the same time, achieve a sense of control and mastery over performance.
Author, Year	Study aim/s	Methods and design	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
FitzGerald et al. (2019)	Develop and pilot a computer-based training intervention to improve online error awareness that incorporates direct audio-visual feedback-on-error to investigate the effects of the training on metacognitive awareness, transfer of skills	Pre and post-pilot intervention comparing feedback (n = 6) vs. no FB (n = 5)	Eleven adults who sustained a TBI (range from two months to 113 months post-injury)	Error awareness (online) improved significantly in the feedback group and not in the no-feedback group.
		40-minute computer training tasks involving response inhibition and dual attention were conducted twice weekly over four weeks for each participant. Only the intervention group (n = 6) received audio-visual feedback for errors		Gains in emergent awareness during the intervention programme did not transfer to other similar tasks.
Kersey et al. (2019)	Compared metacognitive strategy training with direct skill training	RCT: a secondary analysis. The metacognitive strategy group global metacognitive strategy (i.e., Goal–Plan–Do–Check and guided discovery) was compared to the direct skills group on measures of self-awareness (SRSI and SADI) at 3 and 6 months after intervention.	Forty Participants with acute stroke: 10–25 days post-stroke 21 randomized to strategy training and 22 to direct skill training	Statistically significant and clinically meaningful improvement on the SRSI Strategy Behaviour subscale ONLY for both groups at three months.
				Increases in strategy behaviour were observed after six months in the metacognitive group (but not the direct skills group)
(Ng et al., 2018)	To examine how participants’ predictions and performance change with task experience on Retrospective memory (RM) and Prospective memory (PM) tasks	Cross-sectional	One hundred and seventy-eight community-dwelling older adults	Hierarchical multiple regressions revealed that metacognitive awareness acquired during the RM and PM tasks influenced how older adults’ modified their predictions of subsequent task performance. Support the DCMA in that individuals compare ongoing performance to expectations based on metacognitive knowledge, such that a discrepancy between actual and expected performance may influence online emergent awareness.	Theme 2.3.
		Participants predicted performance on both a word list recall task (RM) and a laboratory task involving PM embedded within a word categorization task			Anticipatory awareness influence a person’s performance
		A novel data analysis strategy was used that included latent growth curve modelling of prediction and performance.
Ownsworth et al. (2008)	Explore how an individual perceived and reacted to different components of an awareness intervention (based on DMCA model) in the context of a return to work.	Case study and use of multiple data sources to understand the phenomenon in-depth including questionnaire data, observation field notes by the research clinician, and ongoing interviews with the participant about his programme experiences.	Thirty-three-year-old males following a right thalamic stroke 4-years post-stroke.	Participant preferred and benefited from learning through practical experience. Participant noted that sessions were useful when they involved making predictions about “real life.”	Theme 2.1. Use of familiar and meaningful activities
		The intervention provided structured opportunities for the client to learn about the effects of his stroke and develop self-regulatory strategies		Supports use of experimental feedback and just right challenge level of the task.
Richardson et al. (2015)	Examined the relationship between the nature of feedback provided by close others and self-awareness in individuals with TBI	Cross-sectional design	Sixty-nine individuals with mild-to-severe TBI (between three months and 20 years post-injury) and their informants	There was no relationship between frequency of feedback by close others and self-awareness.	Theme 1.1. Supports distinction and the relationship between online and metacognition.
		Participants and their close-others were invited to complete a brief interview and questionnaires including feedback about cognitive difficulties from close others and the Awareness Questionnaire (AQ)		60% of participants were reported to detect an error once they received feedback, but they showed low levels of acceptance/acknowledgment in response to feedback. Thus, pointing out errors does not enhance awareness.
				Results suggest a person may be made aware of an error during performance of a task but this does not necessarily translate into an enhanced “metacognitive” understanding of their deficits.
(Schmidt et al., 2013)	To evaluate the effectiveness of feedback interventions for improving online awareness in individuals with TBI.	Randomized, assessor-blinded trial with concealed allocation:	Fifty-four participants with TBI and impaired self-awareness 1–8 years post-injury	Providing video feedback in addition to verbal feedback significantly improved online awareness compared with verbal feedback and experiential feedback alone. Verbal feedback and experimental feedback affected online awareness similarly. The video feedback group showed more improvement in intellectual awareness compared with the other groups.	Theme 1.1. Improvements in online awareness can occur independently of changes in intellectual awareness
		All participants completed a meal preparation task on 4 occasions, with 2–4 days between tasks		Verbal and experimental feedback improves online awareness while video feedback improved intellectual.	Theme 2.3. Treatments that improve online awareness
		Comparisons were made with 3 types of feedback interventions:
		(1) Video plus verbal feedback, (2) Verbal feedback, and (3) Experiential feedback
(Toglia & Chen, 2020)	Examined the effect of a brief 20–30-min session of spatial exploratory strategy training.	Randomized controlled study: Both groups participated in a series of visual object search tasks. The treatment group received a metacognitive strategy intervention during search tasks that included guided prompts and questions focused on helping the patient self-discover, monitor, and self-manage errors.	Forty patients with left-sided neglect after right brain stroke, in-patient setting	The intervention improved online self-awareness within the search task, which in turn, appeared to help patients recognize the need to use strategies to attend to the left side of space.	Theme 1.1. Dissociation between general and online awareness theme
				General awareness was not associated with improvement in online awareness.
2.3. Relationship of strategy use to online awareness
Accurate task appraisal or judgment of task difficulty level is related to recognition of the need for strategies and self-monitoring
Author, Year	Study aim/s	Methods and design	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
Casaletto et al. (2016)	Examined the effectiveness of goal management training (GMT) alone or GMT as part of a metacognitive training among HIV/SUD individuals with executive dysfunction.	Single-blinded procedure (examiner not blinded to condition)	Ninety HIV/SUD individuals	Post-hoc analyses showed that GMT and GMT + Meta groups demonstrated small benefits (compared to the control arm) but did not differ from one another.	Online awareness was responsive for training.
		Experimental design: three groups (1) GMT with metacognitive strategy vs (2) GMT only (3) active control group. Treatment was a 15 minutes session		Online Awareness showed a significant positive trend across the study conditions.
				Task appraisals are important executive skills needed for accurate metacognition.
(Levanon-Erez et al., 2019)	Examined the feasibility and efficacy of the Cognitive Functional model adapted for adolescents with attention deficit hyperactivity disorder, the Teen Cognitive-Functional intervention	A mixed-methods feasibility study with a one-group pretest-posttest design using the Cog-Fun treatment (metacognitive strategy approach) for 17 one-hour sessions. Awareness and strategy use were measured by SRSI	22 adolescents with attention deficit hyperactivity disorder and their parents	Significant improvements were reported in adolescents’ occupational performance, executive functioning, and strategy behaviour. “The differential association found between awareness components and functioning, whereby awareness and use of strategies, and not awareness of deficits, correlated with occupational performance further validates this model (DCMA)” (pp. 626–627).
van Erp and Steultjens (2020)	Explore the difference in cognitive strategy use during observed occupational performance between and within different levels of impaired awareness of deficits of individuals with acquired brain injury (ABI).	Quasi-experimental and cross-sectional design.	Twenty-four individuals with ABI	This study showed significant differences in cognitive strategy application during task performance in individuals with emergent or anticipatory awareness deficits
		Cognitive strategy use during occupational performance of daily activities was measured with the perceived, recall, plan, and perform (PRPP) and compared with awareness levels as measured by the self-regulation skill interview.
3. Factors that influence self-awareness (e.g., Cognitive severity, denial, self-efficacy)
Although knowledge and understanding of one’s deficits may not be related to severity of cognitive-perceptual deficits, the ability to anticipate, recognize and self-correct errors within the context of current task performance may be related to the severity of cognitive-perceptual deficits
Author, Year	Study aim/s	Methods and design	Sample size and participants	Summary of key findings related to DCMA	Other supporting themes/comments
(Medley et al., 2010)	Examine subjective beliefs about TBI among individuals undergoing neurorehabilitation, and examine the interplay between such beliefs, self-awareness, and coping responses.	Cross-sectional:	Thirty-seven persons with TBI	Cluster analysis confirmed 3 groups that showed different patterns of beliefs that also had between-group differences in awareness and coping strategies. The high salience group was characterized by beliefs about serious consequences of the injury and greater self-awareness and reported a greater range of coping strategies. The other two groups showed lower levels of awareness but differed in coping styles, with the low control/ambivalent group showing a trend towards more avoidance coping against a background of lower perceived control. Important to understand subjective perceptions, coupled with individually tailored rehabilitation tasks to promote mastery, self-efficacy, and perceived control.
		All participants were administered questionnaires measuring subjective beliefs about TBI, awareness, and coping strategies.
		Cluster analysis was used to identify subgroups of participants who shared similar profiles of injury beliefs, and between-group comparisons were performed to explore differences in coping strategies, self-awareness, and psychological distress.
(Morton & Barker, 2010)	Measured the contribution of injury severity, IQ, mood state, executive and implicit functions to awareness in head-injured patients assigned to moderate/severe head-injured groups.	Cross-sectional	34 participants moderate (n = 11) and severe (n = 23) head-injured groups	The executive function of response monitoring (number of errors made) was the largest unique predictor of metacognitive awareness.
		Participants completed several awareness measures (SADI, AQ, DEX, SSRI), neuropsychological tests, and implicit experimental measures in a counterbalanced order.
				Executive functioning measures of concept formation and response monitoring were the strongest unique predictors of emergent/anticipatory awareness. Implicit learning also made a significant contribution to emergent awareness.
				The severe group had greater impairments on most executive function, awareness, and implicit measures.
Ownsworth et al. (2007)	Identify groups of individuals according to neuropsychological and psychological factors related to awareness deficits and compare emotional adjustment and psychosocial outcomes at the initial assessment and 12-month follow-up.	Longitudinal: participants were assessed initially on awareness, psychosocial and neuropsychological measures.	Eighty-four persons with ABI	A hierarchical cluster analysis distinguished four awareness subgroups. There were differences between awareness groups in patterns of outcomes. For example, poor self-awareness and high symptom groups experienced poorer outcomes than the high defensiveness and good self-awareness group.	Comment: Highlights the need to tailor interventions according to the nature of awareness deficits.
		Awareness subgroups were identified using cluster analysis during initial assessment. Awareness groups were compared on emotional adjustment and psychosocial/functional outcome measures after 12 months.		Awareness can be characterized on a spectrum with levels of awareness and levels of emotional defensiveness.
Villalobos et al. (2020)	Explore the predictive value of cognitive abilities on the level of self-awareness once the cognitive rehabilitation is completed.	The participants were assessed with a semi-structured awareness interview and neuropsychological measures twice: before admission and after discharge from an inpatient rehabilitation centre	Sixty-nine participants (44 men and 25 women) with ABI	Verbal fluency (i.e., executive measure) was the best predictor of self-awareness, both at admission and discharge. In addition, inhibition and cognitive flexibility, as well as episodic memory were significant predictors of post-rehabilitation self-awareness
				Different cognitive abilities may have differential contributions to self-awareness at different stages of recovery.
(Villalobos et al., 2020)	Explore whether SA may play a moderator role in the relation between memory, executive functions, and functional independence.	Prospective observational study, cross-sectional.	Sixty-nine adults with a diagnosis of moderate or severe ABI	Deficits in executive function were associated with poorer functional outcomes only in participants with low levels of SA.
		All participants were administered Lawton IADL scale, general awareness measures (semi-structured interview and SADI), IADL, and tests of executive and declarative memory, 1–2 weeks before discharge from a brain injury rehabilitation programme		Self-awareness is associated with cognitive abilities

Results

The search yielded a total of 366 articles, 54 of which were included in this review. (Fig. 2 describes the exclusion process). These were clustered according to three primary themes: (1) relationship between general and online self-awareness (n = 27); (2) research studies related to interventions (n = 22); and (3) factors influencing self-awareness (n = 5). It should be noted that some studies could be categorized under more than one theme (indicated in Table 1).

Theme 1. General awareness (metacognitive knowledge) and online self-awareness

Twenty-seven studies examine directly and indirectly the difference and the relationship between metacognitive knowledge, that is, knowledge of task characteristics and knowledge of one’s own capabilities and online self-awareness. The majority of the studies in this theme utilized a cross-sectional design. Only two studies utilized a longitudinal design.

Most studies in this theme consisted of samples of persons with traumatic brain injury (TBI) (n = 9; including two studies with children with TBI), dementia (n = 4), and acquired brain injury (ABI) (n = 4). Two of the studies (within the ABI and dementia sample) were done with participants with aphasia. Additionally, studies were done with adults with Huntington disease (n =  1), bipolar disorder (n = 2), multiple sclerosis (n = 3), and persons with HIV (n = 1), as well as middle-school children (n = 1) and healthy adults (n = 2).

Three subthemes were identified within this main theme: (1.1) the difference and relationship between general and online self-awareness; (1.2) Assessment of online awareness; and (1.3) Variations of self-awareness across domains and tasks.

1.1 Distinction between general and online self-awareness

The model “clearly differentiates between knowledge and beliefs related to one’s self that are pre-existing or stored within long-term memory and knowledge and awareness that is activated during a task”. (Toglia & Kirk, 2000, p. 59)

This theme was assigned to any study that measured both general self-awareness and online self-awareness. The theme included 13 studies describing the distinction and the relationship between online self-awareness and general self-awareness (AKA metacognitive knowledge or general awareness). Table 2 describes the different self-awareness components assessed in the studies reviewed. Only three studies assessed all components of online awareness (before, during, and following task performance), four studies used functional tasks to assess online self-awareness; six studies assessed general and anticipatory self-awareness (before task), and six studies assessed general self-awareness and error monitoring (during task performance).

Table 2. Studies examining different components of self-awareness.

	General self-awareness	Online self-awareness before	Online self-awareness during	Online self-awareness after	Type of task: functional/laboratory
(Chen & Goverover, 2021)	●	●		●	●
(Chen & Toglia, 2019)	●	●		●	●
(Dean et al., 2017)	●		●			●
(Dockree et al., 2015)	●		●			●
(Fazeli et al., 2017)	●	●	●	●	●
(Goverover et al., 2014)	●	●		●	●
(Hergert et al., 2020)	●	●		●	●
(Hoerold et al., 2013)	●		●			●
(Lahav et al., 2014)	●			●	●
(O’keeffe et al., 2007)	●	●	●			●
(O’keeffe et al., 2007)	●	●	●			●
(Robertson & Schmitter-Edgecombe, 2015)	●	●	●	●		●
(Torres et al., 2016)	●			●		●

The method used to assess general self-awareness was quite unified. Most studies used a discrepancy score between self and informant ratings or a self-rating of one’s own intellectual, emergent, and anticipatory self-awareness during a semi-structured interview. The method used to assess online awareness, on the other hand, was less unified. Studies differed in the components of online awareness assessed, the rating format, specificity of ratings, type and number of tasks used, and scoring methods For example, some studies used verbal reports to mark the number of recognized or corrected errors in a laboratory-based task (e.g., Dockree et al., 2015) while other studies used self-evaluation immediately after a series of functional tasks which were compared to actual performance (e.g., O’keeffe et al., 2007). The variations in online assessment methods are further summarized in Table 3.

Table 3. Online awareness methods: Examples of variations in online assessment methods.

Performance ratings (Before and/or after Tasks)
• Global performance rating using visual analogue scales (eg. vertical line from low to high or from below to above average), before and/or after tasks.
• Bell Curve Method – specify performance ratings on a bell curve compared to the mean or average person (before and/or after task).
• Comparison of objective performance ratings (% accurate, scores, time for completion) to the person’s actual performance. (before and/or after task).
• Discrepancy between therapist and client ratings of actual performance (eg. difficulty level, degree of challenge, efficiency, level of independence) (after task).
• Pre-task, task appraisal: Verbal formulation of plan.
• General therapist rating of awareness level based on observations.
• Therapist rating of awareness based on responses to a semi-structured interview or questions about performance, immediately after a task.
Error monitoring within tasks.
• Number of errors corrected out of total errors with and without prompts.
• Verbal self-reports of errors during performance.
• Observed behavioural indicators of spontaneous error recognition.
• Confidence ratings for each item or answer during tasks.

Results indicated that some sample populations showed greater impairment in general self-awareness (MS, bipolar) (Chen & Goverover, 2021; Goverover et al., 2014; Torres et al., 2016), while persons with dementia, TBI, stroke (including neglect) and Huntington’s disease appeared to have more impairment in online self-awareness than in general self-awareness (Chen & Toglia, 2019; Hoerold et al., 2013; O’Keeffe et al., 2007).

Studies did not demonstrate consistent results regarding the association between general and online self-awareness. Some studies showed that online and general self-awareness were not correlated linearly. For example, O’Keeffe et al. (2007) investigated the relationship between online and general self-awareness in persons with TBI. They found that metacognitive knowledge did not correlate with emergent and anticipatory self-awareness. Similar findings were demonstrated in persons with bipolar disorder (Torres et al., 2016), Huntington’s disease (Hergert et al., 2020), frontal lesions (Hoerold et al., 2013), and aphasia (Dean et al., 2017). In contrast, Dockree et al. (2015) found a positive relationship between metacognitive knowledge (over-estimation of daily life) and emergent self-awareness of errors during laboratory tasks. Lahav et al. (2014) also found a positive correlation between self-knowledge and online self-awareness, while online self-awareness was more closely associated with actual performance. Lastly, a study comparing general and online self-awareness in HIV found that general self-awareness was more significantly associated with task performance than was online self-awareness (Fazeli et al., 2017). However, in this study, general self-awareness included assessment of prediction accuracy of performance. Prediction accuracy has been used as an indicator of online awareness in other studies (Casaletto et al., 2016; Fazeli et al., 2017; Quiles et al., 2020).

1.2 Assessment of online self-awareness

Measures that characterize awareness by an overall score do not consider the multidimensionality of awareness and, therefore, are too broad to be useful. Assessment of awareness needs to include systematic methods for examining perception of abilities within the context of a task or situation … . The proposed model also implies that assessment of awareness should include both global and specific estimation measures across different tasks and levels of difficulty. (Toglia & Kirk, 2000, p. 68)

Four studies specifically examined the use of clinical assessment tools that were developed based on the DCMA. The first study (Bivona et al., 2020) proposed a new clinical tool to assess self-awareness at its various levels based on the DCMA. They examined the validity of the Self-Awareness Multi-Level Assessment Scale (SAMAS) to assess impairment of self-awareness after severe acquired brain injury. The authors found that SAMAS allows the assessment of emergent and anticipatory self-awareness, as long as it is completed within the context of accurate clinical observation.

The second study (Doig, et al., 2017a), examined a new task analytic approach to assessing online self-awareness involving observation and classification of errors during meaningful activities (e.g., cooking, drink-making, organization of time, budgeting, and use of an iPad application). The authors concluded that the assessment was feasible and provided important information about error behaviour and correction; however, since it requires a time investment in training and planning, it would be best suited to be performed in clinical practice by occupational therapists.

The third study (Krasny-Pacini et al., 2015) examined the feasibility of three ways of assessing self-awareness of executive dysfunction in children with TBI during a rehabilitation programme, based on goal management training. Their study also called for the assessment of both online and metacognitive knowledge when assessing self-awareness. Importantly, they point to relevant ways to use specific stimuli when evaluating children’s self-awareness suggesting using stories to assess intellectual self-awareness and real cooking tasks to assess online self-awareness.

An additional study (Plutino et al., 2020) provided evidence of the need to assess online self-awareness during evaluation. In that study, an online self-awareness assessment differentiated between groups of patients with dementia above and beyond executive function. It concluded that online self-awareness error monitoring was the only measure to differentiate between groups. Table 3 summarizes the methods used to measure online awareness across research studies.

1.3. Variations of self-awareness across domains and tasks: online self-awareness varies across tasks and contexts and general self-awareness varies across domains

Online awareness or ongoing monitoring and regulation of actual performance varies with the task and the context of a situation and is relatively unstable. However, because online awareness is dependent on the task and the situation, this framework implies that anticipatory and/or emergent awareness may be evident on some tasks and situations but not on others. (Toglia & Kirk, 2000, p. 59)

Self-monitoring skills may be highly dependent on task characteristics, such as familiarity and difficulty level (p. 62). Self-awareness can differ in various areas of function: physical, cognitive, perceptual, interpersonal, emotional and functional domains. Thus, individuals may exhibit blind spots’and may be aware of some areas and not others (Toglia & Kirk, 2000, p. 60).

Ten articles were clustered within this theme. Of the six articles that only assessed general self-awareness, five demonstrated that metacognitive or general self-awareness varies across domains (Banks & Weintraub, 2008; Goverover et al., 2009; Hurst et al., 2020; Lloyd et al., 2021; Schoo et al., 2013; Torres et al., 2021). For example, Hurst et al. (2020), showed that participants with TBI displayed significantly poorer self-awareness in the activities of daily living (ADLs) domain than in the interpersonal and emotional domains. Goverover et al. (2009) found that among persons with MS, self-awareness of problem-solving and task performance was lower than self-awareness of social interaction. Schoo et al. (2013) found that self-awareness for the visuoperception domain was significantly worse than for the memory domain. Only Hurst et al. (2020) provided limited support for domain-specific deficits in general self-awareness. Nagele et al. (2021) assessed both general and online self-awareness. Similar to Hurst et al, they also found no difference in general self-awareness between domains, but they did find that online self-awareness distribution (measured by a visual analogue) varied robustly from the memory composite domain to executive function. They concluded that when assessing self-awareness, measures should assess both general and online self-awareness.

Three studies examined online self-awareness across tasks and contexts. Rotenberg-Shpigelman et al. (2014) found that anticipatory and emergent self-awareness were significantly more impaired in the instrumental ADL (IADL) tasks compared to basic ADL tasks. Quiles et al. (2020) noted that online self-awareness was different for memory tasks in comparison to social cognitive tasks. Lastly, Doig, Fleming, and Lin (2017a) compared online self-awareness and error behaviour during tasks of meaning and importance in participants with TBI. They found that error behaviours (i.e., frequency of errors, the ability to self-correct errors, and the types of errors made) may vary according to the nature and complexity of the activity and its relevance to the individual. In addition, error behaviour varied according to the characteristics of the task being performed.

Theme 2. Studies supporting treatment based on the DMCA

Studies focusing directly or indirectly on improving self-awareness were assigned the intervention or treatment theme. We distinguished between treatment studies designed to directly improve awareness versus those that support awareness treatment concepts but did not directly attempt to improve awareness. From the 22 studies reviewed in this cluster, 16 studies intended to improve awareness directly. These studies are presented in each section relevant to the theme.

Most of the studies in this theme utilized a single subject design (n  = 7) to assess treatment efficacy, five studies utilized experimental design, and the rest used qualitative or mixed design (n = 3), cross-sectional and secondary analysis (n = 3), and quasi-experiment (n = 2).

Twenty studies in this theme were done with persons with TBI and ABI (primarily stroke; one study focused on people with ABI and unilateral neglect); one study was with adolescents with ADHD; another was with community-dwelling older adults.

Studies related to treatment based on the DMCA were clustred into three subthemes (2.1) Efficacy of familiar or meaningful tasks in improving self-awareness used familiar, occupation-based, or functional tasks to improve self-awareness, (2.2) intervention that emphasized self-discovery of errors or type of feedback, and (2.3) Studies that examined the relationship between strategy use and online awareness.

2.1. Efficacy of familiar or meaningful tasks in improving self-awareness

Familiar tasks may be more effective in facilitating awareness than remedial or unfamiliar tasks because they provide a basis for evaluating current experiences. Familiar tasks should be simplified and structured (feedback) so that they match the individual’s information processing abilities. (Toglia & Kirk, 2000, p. 65)

From the 12 studies reviewed, one used RCT, six utilized single-subject designs, one utilized data from a previous RCT to conduct a secondary analysis, one used a cross-sectional design, one used a case report, and two used qualitative methodology to provide more information on the development of self-awareness following brain injury. Studies in this theme were done with samples of persons with TBI and ABI. Each of the studies presented a unique approach or support for treatment to improve self-awareness, but the common theme of these studies was the use of familiar functional, occupation-based tasks to improve self-awareness.¹

From these 12 studies, nine were designed specifically to improve self-awareness and therefore were classified as direct studies and are listed in Table 4. For example, Fleming et al. (2006) and Fleming et al. (2020) provided initial support for the use of familiar occupation-based tasks in facilitating participants’ online and general self-awareness. Thus, studies listed under this theme all based their treatment on the performance of functional everyday tasks. Of these, four provided full support and another three provided partial support to the use of functional everyday tasks in improving online self-awareness. As for general self-awareness, two studies provided full support for improvement, four partial support, and three provided no support. The studies listed in Table 4, Section 2.1, provide initial support for using familiar, meaningful tasks while providing treatment to directly improve self-awareness. However, it is important to note the numerous variations in type and methods of self-awareness assessment, as seen in Tables 3 and 4. For example, some studies did not assess online self-awareness (Fleming et al., 2006; Miyahara et al., 2018), and most studies used a single-subject design to examine the efficacy of the treatments.

Table 4. Studies that support treatment based on the DMCA.

2.1 Direct treatment to improve self-assessment using familiar, occupational-based tasks
	Type of treatment task	Treatment/ type of FB	Improvements in Online awareness	Improvements in General Awareness	Improvement in Function
(Doig et al., 2020)	Functional	Verbal or video FB
(Fleming et al., 2020)	Functional	Metacognitive strategy training with verbal or experimental FB
(Fleming et al., 2006)	Functional	verbal FB delivered in the sandwich format, and videotape FB.	-		-
(Goverover et al., 2007)	Functional	Self-evaluation and ratings of performance, structured journaling.
(Miyahara et al., 2018)	Functional	Experiential and verbal feedback	-		-
(Nagelkop et al., 2021)	Functional	Verbal Metacognitive strategy approach
(Ownsworth et al., 2010)	Functional	role reversal, audio-visual feedback and use of non-specific or specific prompts.
(Ownsworth et al., 2006)	Functional	Systematic FB techniques (i.e. Pause, Prompt, and Praise Role reversal, video review of performance)
(Toglia et al., 2010)	Functional	self-discovery and verbal feedback
2.2 Intervention: Self-discovery of errors and type of feedback
Direct
(FitzGerald et al., 2019)	Computer-based abstract tasks	Direct FB with errors during task, use of audio visual F/B (alerting tone with errors)			-
Kersey et al., (2019)	Functional	a global metacognitive strategy (i.e., Goal–Plan–Do–Check) and guided discovery	-		-
Ownsworth et al., (2008)	Functional	Predictions, Role reversal, video review, pre-post discussions
Schmidt et al., (2013)	Functional	(1) Video plus verbal feedback, (2) Verbal feedback, and (3) Experiential feedback
Toglia & Chen, (2020)	Object search task	Verbal Metacognitive strategy approach; self-discovery		-	-
Indirect
(Ng et al., 2018)	word-list learning task	Verbal and experiential FB		-	-
(Richardson et al., 2015)	-	Verbal feedback by informant	-		-
2.3 Strategy use is related to online self-awareness
Direct
(Casaletto et al., 2016)	laboratory-based function task,	Goal management training combined with verbal feedback
(Levanon-Erez et al., 2019)	Functional	Cog-Fun	-

 = Partial support;  = No Support;  = Full support; -  = not measured. Note. Some studies that are listed in one category could fit also the others as can be seen in the table.

Three studies in this group were not designed directly to improve self-awareness. Two studies (Dirette, 2002; O’callaghan et al., 2006) explored the process of developing self-awareness. Both studies presented that, in addition to using familiar tasks, participants should be given the chance to “discover” their strengths and limitations while performing familiar tasks. Lastly, Chudoba and Schmitter-Edgecombe (2020) support the use of familiar occupations in improving self-awareness. In fact, they found that people with Mild Cognitive Impairment (MCI) showed intact self-updating while performing functional but not memory tasks, indicating that the ability to self-update knowledge may differ depending on the task.

2.2. Intervention: self-discovery of errors and type of feedback

Awareness training techniques, which are geared towards helping patients self-discover their own errors, may be more effective in enhancing awareness than verbal feedback (p.65). Treatment needs to be directed towards creating structured experiences where individuals can experience and recognize errors themselves and, at the same time, achieve a sense of control and mastery over performance. (Toglia & Kirk, 2000, p. 66)

Seven articles were categorized into this theme that emphasizes how to provide feedback during treatment sessions to improve self-awareness (Table 4, Section 2.3). Note that there is some overlap between treatment studies as some presented in the other sections also used a self-discovery approach (Toglia et al., 2010). However, some of them were not classified into this theme because they did not fully describe how prompts or questions were provided, or they fit better to another theme.

Kersey et al. (2019) conducted a secondary analysis of data collected from a randomized controlled trial, in which treatment consisted of a performance of activities and identifying barriers to performance. The treatment was based on prompting questions, as well as workbooks to facilitate learning and aid the participants in implementing the strategy. The treatment resulted in improvement of strategy behaviour immediately after treatment for both groups, however, only the treatment group showed continued improvement at six months post-treatment. Toglia and Chen (2020) based the intervention on the DCMA. The therapist provided supportive feedback and semi-structured guidance to promote strategy learning and self-discovery of omission errors. This intervention resulted in improved online awareness. In a cross-sectional study with community-dwelling older adults, Ng et al. (2018) found that metacognitive awareness acquired during the retrospective and prospective memory tasks influenced how older adults’ modified their predictions of subsequent task performance. Thus awareness that emerged from experiential feedback or ongoing task experiences helped to shape predictions of later tasks.

Ownsworth et al. (2008) used predictions, role reversal, and video review interventions to improve self-awareness. Participants preferred and benefited from experimental feedback and from working on tasks that were optimally challenging. FitzGerald et al. (2019) used direct audio-visual feedback consisting of an alerting tone whenever participants made an error. They concluded that while performing a computerized attention task, individuals may become aware of their own errors through experiential feedback that is structured, planned, and supported.

Schmidt et al. (2013) conducted the only study that compared three types of feedback: video combined with verbal, verbal, and experiential. The study demonstrated that multi-modal feedback was superior to solely experiential practice or experiential practice paired with post-task verbal feedback. Furthermore, their study found that video feedback paired with verbal feedback improved both online and intellectual self-awareness.

Richardson et al. (2015) was the only study that was not designed to directly improve self-awareness but instead studied the relationship between the nature of feedback and self-awareness in individuals with TBI through retrospective reports from their informants. Their study supports various types of feedback but emphasizes the value of experimental feedback.

2.3. Relationship of strategy use to online awareness

Accurate task appraisal or judgment of task difficulty level is related to recognition of the need for strategies and self-monitoring. (Toglia & Kirk, 2000, p. 62)

Three studies presented findings related to this category. See Table 4, Section 2.4 for a description of these studies. Levanon-Erez et al. (2019) examined a treatment programme using the Cog-Fun treatment to improve functional performance in children with ADHD. The Cog-Fun treatment included structured reflection on occupational experiences and teaching general problem-solving strategies – goal-setting, planning, and self-monitoring. The authors found a positive significant correlation between occupational functioning gains and strategy behaviour and concluded that children with better online self-awareness tended to use strategies and have better occupational performance.

Casaletto et al. (2016) used goal-management methods (stop, define, list/outline, learn/apply, check) while providing feedback on executive function impairment prior to task performance. They found that those with HIV who completed the goal management strategy training had better online self-awareness compared to a control group. Although strategy use was not directly measured, it suggests that those with better online awareness may be effectively applying the strategy learned during the study.

Lastly, van Erp and Steultjens (2020) concluded that lower levels of self-awareness seem to be associated with low motivation to persist and complete the activity. This latter study is not listed in Table 4 as it was observational and did not report an intervention. Thus, online awareness appears to be important for effective strategy use. However, literature in this area is limited.

All in all, participants were able to benefit from treatment designed to improve self-awareness; more specifically, online self-awareness appeared to be more responsive to treatment than general self-awareness. For example, across all studies described in Table 4, there were 13 studies providing support for improvements in online awareness (10 = full and 3 = partial) and 8 studies supporting improvement in general awareness (3 = full, 5 = partial).

Theme 3. Factors that influence self-awareness (e.g., cognitive severity, denial, and self-efficacy)

Although knowledge and understanding of one’s deficits may not be related to severity of cognitive-perceptual deficits, the ability to anticipate, recognize and self-correct errors within the context of current task performance may be related to the severity of cognitive-perceptual deficits. (Toglia & Kirk, 2000, p. 65)

Five studies discussed this theme of the model. Morton and Barker (2010) and Villalobos et al. (2020) found that executive functions are significant contributors to metacognition and self-awareness. These studies emphasize that the ability to anticipate, recognize, and self-correct errors within the context of current task performance may be related to the severity of cognitive-perceptual deficits; furthermore, self-monitoring, which is part of executive function, is crucial for self-awareness. Villalobos et al. (2020) further stressed the role of self-awareness as a mediator between cognitive functions of memory and executive functions.

Other factors can also influence online awareness and self-monitoring abilities such as … , motivation, beliefs, emotional state …  … .. (Toglia & Kirk, 2000, p. 60)

Ownsworth et al. (2007) sorted individuals into four groups according to neuropsychological and psychological factors related to self-awareness deficits and compared emotional and psychosocial adjustment. Interestingly, they found that the group with poor self-awareness and high symptom reporting experienced poorer outcomes than did the highly defensive and self-aware group. In fact, this study differentiates between psychological and neuropsychological self-awareness.

Lastly, Medley et al. (2010) characterized three groups of TBI participants, based on profiles of subjective beliefs about TBI. This study and that of Ownsworth et al. (2007) are unique in that they show the importance of understanding subjective perceptions, coupled with individually tailored rehabilitation tasks to promote mastery, self-efficacy, perceived control, and self-awareness.

Discussion

This scoping review demonstrates that the multidimensional nature of self-awareness highlighted in the DCMA has been well-established over the past 20 years since its initial publication. In this discussion, we present the findings of this scoping review, connect these findings with the main concepts and postulates presented by the DCMA model, and discuss what requires further evidence.

General and online self-awareness

The DCMA distinguishes between general awareness of abilities that are offline or independent of tasks and online self-awareness that is activated within the context of task experiences. The disassociation between general and online self-awareness has been demonstrated across a wide range of clinical populations (e.g., TBI, ABI, MS) and ages (children and adolescents to community-dwelling older adults). Importantly, one study provided evidence for neuroanatomical areas that are responsive to these two types of awareness, further supporting this disassociation (Plutino et al., 2020). However, cross-sectional studies investigating both general and online awareness are limited in number and hampered by variations in assessment methodology. Studies comparing general and online awareness frequently used measures that differed in domains of cognition or functional tasks (Robertson & Schmitter-Edgecombe, 2015). For example, general self-awareness may have been assessed using questions related to activities of daily living, or social participation while online awareness was measured in relation to a cognitive abstract task (Dockree et al., 2015). In this review, only two studies assessed both general and online awareness in relation to the same context, within and outside the context of performance (Chen & Toglia, 2019; Lahav et al., 2014). If awareness can vary across domains and tasks, it is also important to compare general and online awareness with similar domains or tasks within the same study (Merchán-Baeza et al., 2020).

This review suggests that further clarification and consensus is needed about the concepts of general and online self-awareness. For example, some studies included prediction accuracy as a measure of general self-awareness and verbal formulation of a plan as a measure of task appraisal or anticipatory awareness (Fazeli et al., 2017). Although it can be argued that prior to a task, individuals use their stored knowledge and beliefs to appraise task difficulty, most studies used prediction accuracy as an online awareness measure. Also, many studies assessed selected components of online awareness such as error recognition, prediction accuracy, or post-performance ratings but did not examine all aspects of online self-awareness (e.g., Chen & Goverover, 2021; Dockree et al., 2015).

Additional ambiguities and discrepancies were noted in the literature about what constitutes an online self-awareness measure. For example, some authors included the Self-Regulation Strategy Interview (SRSI) as a measure of online self-awareness (e.g., Kersey et al., 2019), while others included it as a measure of general self-awareness (Toglia et al., 2010). The SRSI is categorized as a measure of general and not online self-awareness because it includes anticipation and error recognition questions outside the context of activities (Toglia & Kirk, 2000). A person can say all the right things during an interview but fail to assimilate this knowledge during actual task performance. Therefore, the DMCA would not classify an interview outside the context of an activity as being a measure of online self-awareness. Differences found within the results between the SSRI and other self-awareness questionnaires may be related to the specificity, content, and format of the questions (Goverover et al., 2007).

These differences observed with both general and online measures of self-awareness add to the confusion within the research literature and make it difficult to draw definitive conclusions about comparisons and relationships between online and general self-awareness.

Need to include online self-awareness within assessment

Despite the variations observed in the literature regarding assessment methodology for online self-awareness, a consensus exists of the importance to measure online self-awareness and incorporate it into everyday clinical evaluation (Bivona et al., 2020). The DCMA describes different components of online self-awareness immediately before (anticipation and task appraisal), during (error recognition and correction), and after-task performance (self-evaluation and appraisal) and suggests that these online self-awareness components involve different skills. A few recent papers provide clinical guidelines for assessing some components of online self-awareness (Bivona et al., 2020; Doig, Fleming, Ownsworth, et al., 2017); however, the investigation of standardized clinical tools that provide a comprehensive assessment of online self-awareness is limited.

Online self-awareness varies across tasks and contexts; general self-awareness varies across domains

The majority of studies reviewed in this paper support that both general and online self-awareness can vary within and across domains. However, cross-sectional research studies that include online self-awareness have primarily used abstract tasks restricted to specific cognitive domains. Further systematic investigation is warranted on online self-awareness across everyday tasks that differ in complexity, perceived importance, or meaningfulness; also needed is an identification of the task conditions under which the individual shows the highest levels of emergent and anticipatory self-awareness.

Studies supporting treatment based on the DMCA

The DCMA inspired occupation-based metacognitive interventions that include experiences with relevant everyday tasks. The majority of intervention studies demonstrate the effectiveness of incorporating familiar tasks into treatment so that the person has a basis for evaluating current abilities (Chudoba & Schmitter-Edgecombe, 2020; Doig et al., 2021). As Dirette (2002) describes, self-awareness is a slow process in which participants compare current performance to pre-morbid performance on functional tasks. Although a few studies have observed and documented the relationship between strategy use and online self-awareness of performance, more studies are needed to empirically investigate this (Dirette, 2002; Nagelkop et al., 2021).

Treatments that improve online self-awareness

The DCMA suggests that online self-awareness is less stable than metacognitive knowledge and, therefore, is more susceptible to change. Overall, studies demonstrate that online awareness appears to be more responsive to treatment than general self-awareness. However, treatment varied in terms of dose, method, and frequency, while assessments varied across studies, making it difficult to generalize findings and draw valid conclusions.

The DCMA suggests using training methods that help people self-discover their own errors rather than directly pointing out their errors; however, detailed guidelines for therapists on how to use guided prompts and structure-activity experiences have only recently been published (Toglia & Foster, 2021). The literature generally supports the use of feedback (FitzGerald et al., 2019) in increasing online self-awareness, specifically, experiential feedback (Ownsworth et al., 2008, 2010) and systematic feedback (Ownsworth et al., 2006); however, direct comparison between types of feedback or between guided methods and direct feedback in enhancing online awareness is needed.

Systematic examination of changes in self-efficacy as a result of intervention is a missing component across the self-awareness intervention literature. The DCMA suggests that self-awareness intervention should involve simultaneously building self-efficacy and a sense of control and mastery over performance as self-awareness emerges. Although self-efficacy is occasionally mentioned within the context of case examples, a greater focus on self-efficacy is needed within intervention studies.

Support for the relationship between executive function and self-awareness exists, but it is unclear whether the severity of executive function deficits differentially impacts general versus online self-awareness or response to treatment. Initial research on the interplay between psychological factors and self-awareness has been conducted by Medley et al. (2010), who explored belief schematas with measures of awareness and coping, and Ownsworth et al. (2007), who examined self-awareness typologies based on neuropsychological and psychological measures, including the level of defensiveness. However, no empirical research focuses on how the interplay of these factors impacts response to treatment. Areas needing more attention include the process of emergence of online and general self-awareness – how they are influenced by personal, psychological, cognitive, and contextual variables, and how they change across treatment and recovery.

Limitations

Only studies citing or referring directly to the DCMA and its main concepts or methodology were included in this review. Many studies were not included that could support some of the postulates because they did not cite the DCMA model directly (i.e., they cited papers that cited the DCMA model). These papers were also not included in this review. Therefore, multiple components that were discussed in the original paper (Toglia & Kirk, 2000) were not addressed in this scoping review (e.g., implicit self-awareness, depth of self-awareness).

Conclusion

Over the past 20 years, the literature has supported the multi-dimensional and dynamic nature of self-awareness proposed by the DCMA model. Multiple studies identified differences between general and online self-awareness across different diagnostic and age groups. This current review sheds light on the need to understand how general and online self-awareness influence each other and change with repeated experiences and feedback. Additionally, across the studies reviewed, online awareness was a modifiable outcome, however, because of the variation in the operational conceptualization of online awareness, it is hard at this time to draw a definitive conclusion about the assessment, outcome, and intervention related to online awareness.

In the area of treatment, numerous studies demonstrate promise and support for occupation-based interventions or the use of familiar and meaningful task experiences that provide experiential feedback to increase self-awareness, as emphasized in the DCMA model. However, a comparison of treatment methods or activities was not found, and comparison of feedback methods is limited. Additionally, the relationship between online awareness and strategy use requires further study within the treatment context.

The DCMA also discussed the importance of task variables, personality characteristics, self-efficacy, methods of interaction, emotional reactions, and the context of the person’s life (e.g., understanding the client’s personality, values, and way of life). These concepts add complexity to the study of self-awareness and were not addressed in the majority of studies reviewed. A wider focus on how personal and psychosocial factors influence self-awareness is needed (e.g., Ownsworth et al., 2007).

Overall, this review highlights the need to think more broadly about patterns of variables that interact and impact the person’s reactions to task challenges or performance difficulties as a foundation for both assessment and treatment. For example, self-awareness may be best understood by creating self-awareness profiles or by simultaneous consideration of self-awareness components with other task and psychological variables as described above, to allow for analysis of patterns across multiple variables. Going forward, greater attention on the interplay and dynamic relationship between areas of self-awareness and key factors (i.e., contextual, personal-psychological, and task variables) influencing aspects of self-awareness is needed.

Acknowledgement

The authors would like to acknowledge and thank Carolina Herrera for her assistance.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 In addition, several studies, noted in Table 4, Sections 2.2 and 2.3, also used functional and familiar activities for treatment, with positive results, and these studies even though not listed in this section also provide support for the use of functional tasks for self-awareness improvement.