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Assessing Executive Function Skills in School-Based OT


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As an occupational therapist for over a decade, I have witnessed the growing importance of addressing executive functioning (EF) skills in school settings. Executive functioning skills, such as planning, organization, working memory, and cognitive flexibility, play a vital role in a student's ability to succeed academically and participate effectively in daily life activities.


Every educator addresses executive functioning to some degree. However, as school-based OT practitioners, we have a unique opportunity to assess and address EF challenges to support our students' overall well-being and success.

In recent years, the focus on assessing and addressing executive functioning within the school-based OT practice has gained momentum. With a deeper understanding of the impact of Executive Functioning deficits on student performance, we can create more targeted and effective intervention plans.

This essay aims to provide school-based OT practitioners with an overview of structured and unstructured executive functioning assessment tools used in the schools. These tools can help us gain valuable insights into a child's EF skills and guide the development of tailored intervention strategies.


I. Understanding Executive Functioning (EF)


Before delving into the assessment tools, let's first explore what executive functioning entails. Executive functions are a set of cognitive processes that enable individuals to plan, organize, initiate, self-monitor, and complete tasks successfully. These skills are essential for problem-solving, time management, emotional regulation, and flexible thinking.

Children with EF challenges may struggle with following instructions, organizing their school materials, managing time, and adapting to changes in routines. Addressing these challenges early can significantly impact a child's academic success and overall development. Just imagine how difficult it may be for students to complete an assignment if they need help remembering where they placed the instructions.

Per Havard University's Center on the Developing Child, three brain functions impact one's executive functioning. They are working memory, mental flexibility, and self-control.

  • Working memory pertains to the ability to temporarily store and manipulate information in the mind.

  • Mental flexibility is a term used to describe the ability to adapt and adjust to new situations and ideas. The concept that different rules apply to other settings would fit under mental flexibility.

  • Self-control refers to one's ability to set priorities and resist impulses.


These are all skills you have likely worked on with your students and you can likely conclude how these functions could positively (or negatively) impact a student's ability to succeed in a classroom. Here are a few items that come to my mind:


  • Learning and completing the classroom morning routine

  • Following written or verbal instructions to complete an assignment

  • Understanding and accepting that rules may be slightly different in class than they are at recess

  • Tuning out a peer while the teacher is speaking

  • Using a planner to note down the agenda and homework for the day

  • Remembering to complete the homework once at home.


II. The Importance of EF Assessment in School-Based OT Practice:


As is the case with other skills we support, assessing executive functioning skills when warranted is crucial in developing targeted intervention plans. By identifying specific EF strengths and weaknesses, we can set realistic goals for our students and monitor their progress over time. Effective assessments can help us tailor interventions to address individual needs and promote meaningful growth in EF skills.



An image showing a teenager writing in her planner and the title of the blog post


A. The Brief-2 (Behavior Rating Inventory of Executive Function, Second Edition):


Based on my experiences, the Brief-2 is the most commonly used assessment of executive functioning skills by school-based OT practitioners. The Brief-2 relies on rating scales from parents, teachers, and the child. It offers insights into various EF domains, including working memory, inhibition, emotional control, and more. By comparing results from multiple raters, we can gain a comprehensive view of the child's executive functioning skills in different settings.


The ten domains of EF addressed include:

  1. Inhibit: The ability to stop or delay a response when necessary, showing self-control.

  2. Shift: The capacity to move flexibly between tasks or situations, demonstrating cognitive flexibility.

  3. Emotional Control: The regulation of emotions and responses to emotional situations.

  4. Working Memory: The ability to hold and manipulate information mentally to complete tasks efficiently.

  5. Initiate: The ability to begin a task or activity independently without undue hesitation.

  6. Organization of Materials: The capability to manage and arrange one's belongings and work materials effectively.

  7. Plan/Organize: The aptitude to set goals, create plans, and carry out the steps required to achieve them.

  8. Self-Monitor: The skill of self-monitoring one's performance and adjusting strategies when needed.

  9. Task Monitor: The skill of self-monitoring during tasks or activities to ensure they are completed accurately and efficiently.

  10. Task Completion: The capacity to carry out tasks to completion in a timely and accurate manner.


Additional Information concerning the Brief-2:

  • Age Range: 5 to 18 years. (Self-report form: 11-18 years)

  • Completion Time: 10 to 20 minutes per form (teacher, parent, and self).


Pros:

  • Multiple perspectives from parents, teachers, and the child provide a holistic understanding.

  • Helps identify specific areas for targeted intervention planning.


Cons:

  • Subjectivity from raters may influence results.

  • This is not a task-based assessment. All information is based on reports, which can be skewed.

  • Limited to older children and adolescents, not suitable for younger students.



B. The CKTA (Children's Kitchen Task Assessment):


The CKTA, Children's Kitchen Task Assessment, is a functional and real-life task-based assessment sometimes used by school-based OT practitioners to evaluate executive functioning and adaptive skills. This assessment involves observing the child's performance while they engage in a cooking task to make dough for playing. The CKTA provides insights into a child's ability to plan, organize, and problem-solve during a common IADL.


Domains Assessed:

The CKTA focuses on executive functioning skills related to cooking activities, as well as adaptive skills required for independent meal preparation. The assessment looks into the child's ability to follow multi-step instructions, manage time, and organize materials during the cooking process.


Additional Information:

  • Age Range: 8 to 12 years.

  • Completion Time: 15 to 30 minutes.


Pros:

  • Utilizes a functional, real-life task to assess executive functioning in a familiar context.

  • Offers a practical understanding of a child's EF skills during a daily activity.

  • It can be engaging and motivating for children, making it easier to elicit their best performance.


Cons:

  • Requires access to a kitchen or suitable cooking environment, which may not be available in all school settings.

  • Limited to assessing specific EF skills related to cooking activities and may not cover all EF domains.

  • The CKTA may not apply to students who do not have cooking as part of their education plan.

  • While the assessment is free to download, you will need to obtain the required materials.



C. The Weekly Calendar Planning Activity (WCPA):


The Weekly Calendar Planning Activity (WCPA) is a performance-based assessment that uses the concept of creating a schedule to assess executive functioning. The task involves following and organizing a list of 18 (youth version) appointments or errands into a weekly schedule while keeping track of rules, avoiding conflicts, monitoring the passage of time, and inhibiting distractions. The WCPA is a tool that OT practitioners could use with high school students to understand EF skills better and plan an intervention for supporting organizational goals.


Domains Addressed:

The WCPA is designed to assess executive function domains such as attention and working memory, cognition, and executive functioning through an occupation-based task.


Additional Information:

  • Age Range: 12-89 years

  • Completion time: Approximately 20-30 minutes


Pros:

  • The WCPA is a performance-based assessment that can provide information about both EF skills and the ability to complete a complex scheduling task.

  • It is appropriate for use with adolescents and young adults.

  • The time that it takes to complete the WCPA is reasonable within a school setting.


Cons:

  • Requires the student to have functional writing skills.

  • Not suitable for younger students.

  • Narrow in its scope due to only looking at EF skills related to one particular task.



D. The WCST (Wisconsin Card Sorting Test):


The WCST, Wisconsin Card Sorting Test, is a widely recognized and used standardized assessment tool to assess cognitive flexibility and problem-solving abilities. It requires the child or adolescent to sort cards based on different criteria and adapt to changing rules during the task. It's like playing Solitaire, except with cards designed to be slightly confusing.


Domains Assessed:

The WCST measures the child's ability to adapt to changing conditions, switch mental sets, and problem-solve during the card sorting activity.


Additional Information:

  • Age Range: 6 years and older, including adolescents and adults.

  • Completion Time: 20 to 30 minutes.


Pros:

  • Offers a standardized, objective measure of cognitive flexibility and problem-solving.

  • Provides valuable information about a child's ability to adapt to changing rules and mental set shifting.

  • Widely recognized and used in neuropsychology, allowing for comparisons with normative data.


Cons:

  • It may be challenging or frustrating for some children, leading to potential performance-related stress.

  • Limited to assessing specific aspects of executive functioning and may not capture the full range of EF skills.



E. The NEPSY-II:


The NEPSY-II is a comprehensive assessment battery used to evaluate various cognitive domains, including executive functions. It provides valuable insights into EF, attention, language, memory, and sensorimotor skills in children. To be frank, I have not heard of OTs using the NEPSY-ll in school-based OT. It seems to be more commonly used by psychologists than OT practitioners. However, as an OT, you may be able to extract data from the tool if your school psychologist has administered it.


Domains Assessed:

The NEPSY-II includes the following subtests:

  • Executive Function and Attention

  • Language

  • Memory and Learning

  • Sensorimotor

  • Visuospatial Processing

  • Social Perception

Several of the six subtests assess executive functioning skills such as inhibition, attention, cognitive flexibility, and working memory, among others.

Additional Information:

  • Age Range: 3 to 16 years.

  • Completion Time: 45 minutes to several hours, depending on the number of subtests. It may take longer while you become familiar with the assessment tool.


Pros:

  • A comprehensive assessment covering multiple cognitive domains, including executive functions.

  • Helpful in identifying developmental delays and cognitive impairments impacting EF.


Cons:

  • Administration time may be lengthy, which could pose challenges in busy school schedules.

  • Requires specific training or expertise to administer and interpret the results accurately.

  • There are reports that this assessment is challenging to administer.



 
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IV. Informal Assessments of EF Skills


While standardized assessment tools like the Brief-2, CKTA, WCST, and NEPSY-II offer valuable insights into executive functioning, school-based OT practitioners can also use informal methods to gather relevant information. These informal ways can provide additional context and complement the formal assessments:


A. Observations:

  • School-based OTs can observe students during classroom activities, transitions, and free play to note how they manage time, follow instructions, and plan tasks.

  • Identifying behaviors such as impulsivity, difficulty switching between tasks, or lack of organization can offer clues about a child's executive functioning abilities.

B. Work Samples and Classwork:

  • Reviewing a student's completed assignments, classwork, and homework can reveal patterns of organization, attention to detail, and task completion.

  • Analyzing the quality of work, consistency, and ability to follow multi-step instructions can provide valuable insights into EF skills.

C. Interviews and Collaborations:

  • Engaging in discussions with teachers, parents, and the student can offer a broader perspective on the child's executive functioning in different settings.

  • Collaborating with educators and support staff can help identify strategies that have been successful or challenging for the student.

D. Checklists and Questionnaires:

  • Using informal checklists or questionnaires focused on executive functioning skills can provide a quick overview of strengths and challenges in specific areas.

  • These tools can be adapted or created to address the individual needs and circumstances of the student.

E. Self-Reports and Student Feedback:

  • Allowing students to self-reflect on their executive functioning abilities through age-appropriate discussions or questionnaires can provide valuable self-awareness and insights.

  • Encouraging students to share their experiences and perspectives can help develop a more holistic understanding of their EF skills.


What assessment tool do you most commonly used to assess executive functioning skills?

  • BRIEF-2

  • The CKTA (Children's Kitchen Task Assessment)

  • The WCPA (Weekly Calendar Planning Activity)

  • The WCST (Wisconsin Card Sorting Test)


Assessing Beyond Executive Functioning


While executive Functioning skills are a crucial focus of school-based occupational therapy, it's important to note that we address a wide range of areas that contribute to students' overall success and participation in the school environment. While EF assessment tools provide valuable insights into working memory, flexible thinking, and self-control, they do not capture the full scope of an OT's expertise and intervention strategies. Here are a few additional areas in which we assess:

  1. Fine Motor Skills: Assessing a student's ability to use and coordinate small muscles in the hands and fingers to perform precise movements required for handwriting, opening containers, and more.

  2. Self-Care and Independence: Assessing students' ability to perform daily living tasks, such as dressing and grooming, to enhance independence and functional participation.

  3. Visual Perception and Visual-Motor Skills: Evaluating how students interpret and use visual information for motor planning and coordination, supporting academic performance.

  4. Sensory Processing: Evaluating how students perceive and respond to sensory information to develop strategies for managing sensory challenges and promoting engagement in school activities.

  5. Social-Emotional Skills: Assessing students' social interactions, emotional regulation, self-awareness, and coping strategies to enhance social skills, self-esteem, and emotional well-being, fostering positive relationships and school engagement.

By considering these additional areas and employing comprehensive assessment approaches, we can address the diverse needs of students and support their holistic development, functional participation, and overall well-being in the school environment.


The Final Word


Incorporating informal methods of assessing executive functioning skills alongside standardized assessment tools can enhance the school-based OT practitioner's ability to develop tailored intervention plans.

By leveraging observations, work samples, interviews, and student feedback, OTs can gain a more comprehensive understanding of a child's EF strengths and challenges in real-life contexts. Emphasizing a collaborative and holistic approach will empower school-based OTs to better support students in developing vital executive functioning skills for academic success and daily life activities.


So, do you use any of the assessment tools mentioned above? Let me know by sharing this post on your favorite social media app and tagging @OTSchoolhouse.


Until next time,


👋 Jayson



 
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Additional Resources:


  • Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. Am J Occup Ther August 2020, Vol. 74(Supplement_2), 7412410010p1–7412410010p87. doi: https://doi.org/10.5014/ajot.2020.74S2001

  • Jeri Hahn-Markowitz, Itai Berger, Iris Manor, Adina Maeir; Impact of the Cognitive–Functional (Cog–Fun) Intervention on Executive Functions and Participation Among Children With Attention Deficit Hyperactivity Disorder: A Randomized Controlled Trial. Am J Occup Ther September/October 2017, Vol. 71(5), 7105220010p1–7105220010p9. doi: https://doi.org/10.5014/ajot.2017.022053

  • Heidi Cramm, Terry Krupa, Cheryl Missiuna, Rosemary M. Lysaght, Kevin C. H. Parker; Broadening the Occupational Therapy Toolkit: An Executive Functioning Lens for Occupational Therapy With Children and Youth. Am J Occup Ther November/December 2013, Vol. 67(6), e139–e147. doi: https://doi.org/10.5014/ajot.2013.008607

  • Kristy Rocke, Paige Hays, Dorothy Edwards, Christine Berg; Development of a Performance Assessment of Executive Function: The Children’s Kitchen Task Assessment. Am J Occup Ther September/October 2008, Vol. 62(5), 528–537. doi: https://doi.org/10.5014/ajot.62.5.528

  • Nikki Williamson Weiner, Joan Toglia, Christine Berg; Weekly Calendar Planning Activity (WCPA): A Performance-Based Assessment of Executive Function Piloted With At-Risk Adolescents. Am J Occup Ther November/December 2012, Vol. 66(6), 699–708. doi: https://doi.org/10.5014/ajot.2012.004754

  • Joan Toglia, Christine Berg; Performance-Based Measure of Executive Function: Comparison of Community and At-Risk Youth. Am J Occup Ther September/October 2013, Vol. 67(5), 515–523. doi: https://doi.org/10.5014/ajot.2013.008482

  • Claudia List Hilton, Kristina Cumpata, Cheryl Klohr, Shannon Gaetke, Amanda Artner, Hailey Johnson, Sarah Dobbs; Effects of Exergaming on Executive Function and Motor Skills in Children With Autism Spectrum Disorder: A Pilot Study. Am J Occup Ther January/February 2014, Vol. 68(1), 57–65. doi: https://doi.org/10.5014/ajot.2014.008664











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