Occupational Therapy 
Executive Function Disorder
Executive function incorporates various aspects of cognition including attention, working memory, planning, organizing, time management, self-monitoring, cognitive flexibility or adaptation, task initiation, and inhibition. Executive Function Disorder (EFD) or executive dysfunction refers to difficulty with a set of cognitive processes responsible for an individual's thoughts, emotions, and behavioral regulation, resulting in an inability to participate in activities of daily living tasks successfully and independently.
Executive dysfunction can affect the lifespan including the pediatric population to geriatrics. It is also linked to various other conditions including learning disabilities, autism spectrum disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Alzheimer's disease, dementia, brain tumors, depression, stroke, and other neurological conditions.
Common challenges associated with Executive Function Disorder
Individuals with Executive Function Disorder can exhibit varying degrees of challenges that can impact their ability to function successfully in daily life.
Some core challenges involve the following:
- Working memory: Working memory is a limited capacity system that allows us to process, store, and manipulate information in conscious awareness temporarily. Difficulties with working memory can impact following and sequencing multi-step directions. Examples in daily life include registering a long sentence spoken in conversation as we process its meaning and rehearsing a phone number as we prepare to dial.
- Cognitive flexibility: The ability to adapt one's behavior according to the environment and flexible thinking skills. The more flexible your thinking, the better one can adapt to what is happening around you and react to unexpected changes in your situation. Having cognitive flexibility assists with problem-solving skills. Individuals with cognitive flexibility difficulty often have increased stress and anxiety which may result in difficulty in social situations.
- Inhibition control: The ability to control impulses and have emotional regulation. This includes focusing on something that needs your attention and ignoring what doesn’t. People who have difficulty with inhibition control often have difficulty ignoring the thoughts in their head vs. paying attention to what needs to be focused on at the moment.
Other challenges for executive dysfunction include:
- Difficulty starting tasks
- Difficulty sustaining attention to tasks
- Conversations
- Work-related matters
- School-related matters
- Motivation
- Transitioning from one task to another
Occupational therapy evaluation for Executive Function Disorder
Occupational therapists play a crucial role in the evaluation and treatment of Executive Function Disorder. Occupational therapists can also utilize their skilled clinical observation skills by having the individual perform specific ADL tasks or play-based tasks and look for and assess an individual’s attention, working memory, planning, organizing, time management, self-monitoring, cognitive flexibility, task initiation, and inhibition throughout the task.
While there are many assessment methods, some of the common assessment tools that occupational therapists utilize can be found below.
Behavior Rating Inventory of Executive Functioning-2nd Edition (BRIEF-2)
- For ages 5-18
- Available for preschool-age and adults
- Includes parent and teacher forms
- This test is known to dig deeper than similar measures and pinpoints where and why children struggle.
Executive Function Performance Test (EFPT)
- For adolescents ages 13-17, adults 18-64, and elderly adults 65 and over
- Takes 30-45 minutes to administer
- More specific to clients with multiple sclerosis (M.S) and/or stroke
- The EFPT serves three purposes. To determine:
- Which executive functions are impacting function
- An individual’s capacity for independent functioning
- The amount of assistance necessary for task completion
Children’s Kitchen Task Assessment (CKTA)
- For ages 6-12
- Takes 20 minutes to administer
- The test kit is required to be created before assessing
- Assesses executive function by making playdoh
- Tools need to match the photographs. If you are unable to match them, take a photograph and replace the one in the kit.
Assessing working memory for Executive Function Disorder
Many of the assessments that evaluate working memory such as the Wechsler Intelligence Scale for Children, or the Working Memory Index of the NEPSY-II are often utilized by clinical psychologists, school psychologists, and neuropsychologists.
Occupational therapists can use skilled clinical observations to assess working memory by observing how the individual follows multiple-step directions and instructions, organizes their materials, and applies information for task completion. They may also gain valuable insight by having open communication with caregivers or teachers, which provides the therapist with real-world data regarding the challenges an individual is facing.
Assessing cognitive flexibility and inhibitory control for Executive Function Disorder
Some common assessment tools for assessing cognitive flexibility and inhibitory control include the following:
Wisconsin Card Sorting Test (WCST)
- For ages 6.5-89
- Takes about 20-30 minutes to administer
- The client sorts cards but the rules of the assessment change unpredictably, which requires the individual to be flexible.
- WCST allows an OT to assess a client’s strategic planning including organized searching; and ability to utilize environmental feedback to shift cognitive sets, direct behavior toward achieving a goal, and modulate impulsive responding.
Stroop Color and Word Test
- Children ages 5-14 and the adult version is for ages 15-99
- Administration time: 5 minutes
- Useful for screening
- The cognitive dimension tapped by Stroop is aligned with resistance to interference from outside stimuli, cognitive flexibility, psychopathology and creativity – all of which influence an individual's ability to cope with cognitive stress and process output.
- Individuals are asked to name the ink color that spells out the name of the colors. For example, the word is green and it's printed in red.
Trail Making Tests
- A maximum of 5 minutes is allowed
- Part A involves connecting numbers 1-25 in ascending order, and Part B involves connecting numbers and letters in an alternating and ascending fashion.
- Designed for individuals with stroke
Assessing planning and organization skills for Executive Function Disorder
Occupational therapists will often utilize skilled clinical observation to evaluate individual planning and organizational skills specifically during functional ADL tasks. This could include how an individual organizes their materials, manage their time during a specific activity, and follow multiple-step directions. A standardized assessment method that can be used is the weekly calendar planning activity.
Weekly calendar planning activity
- Can be used with children and adults
- Includes organizing a list of appointments and errands into a weekly schedule
- Client keeps track of rules, avoids conflicts, monitors the passage of time, and inhibits distractions
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Interpreting Executive Function Disorder assessment results and developing intervention plans
Interpreting EF assessment results involves data collection review, evaluating each of the domains, and identifying the domains of executive function of greatest need. It is important to consider the age and an individual’s performance with normative data. It is also vital to consider patterns of behavior, education, medical conditions, and strengths as well as weaknesses.
Furthermore, as occupational therapists, it is imperative to identify how the executive function deficits are contributing to an individual's ability to participate successfully in daily life. Intervention strategies should be tailored to address the functional deficits to meet the overall goal.
Some intervention methods could include
- Breaking down multi-step directions into smaller more manageable steps
- Using timers for time management
- Self-monitoring
- Memory games
- Social activities to target cognitive flexibility
- Environmental modifications such as visual schedules, planners, calendars, checklists, or apps designed for planning and organization
It is important to monitor progress and modify and adapt changes as necessary regularly and consistently.
Providing Executive Function Disorder education and support to clients is necessary to empower their abilities to self-monitor and self-advocate. To ensure adequate carryover of skills and to successfully meet goals, it is also vital to collaborate with other professionals such as healthcare team members, teachers, or psychologists.
With a collaborative approach with individuals, and other professionals, and by developing a client-centered approach to intervention, occupational therapists can assist individuals with Executive Function Disorder and improve the overall quality of life.
Future trends in addressing Executive Function Disorder
As there is greater research, development, and understanding of Executive Function Disorder, and as healthcare is increasingly utilizing technology to provide innovative solutions, there are trends that may emerge for the treatment of Executive Function Disorder.
One specific tool may include apps on mobile devices to target more of an individualized approach. Apps may also be focused on managing Executive Function Disorder in different environments such as school or the workplace.
There could also be more of a focus on mind-body interventions such as yoga, mindfulness, breathing, stress management, and cognitive flexibility.
Future trends may also be focused on environmental adaptations and universal designs to incorporate an all-inclusive design to support individuals with varying levels of Executive Function Disorder and conditions associated with Executive Function Disorder.
In addition, there also may be more of a focus on self-advocacy and empowerment via education, seminars, and support networks.
It is essential for therapists to stay up to date on the latest trends, research, and treatment methods.
Therapists can stay informed by having a strong commitment to professional development, engaging in cultural competence education, and having ethical practice methodologies. Engaging in these practices, promotes goal attainment, positive client outcomes, and strengthens the therapeutic relationship between clients, therapists, and the community, as well as contributes to overall effective client-centered care.
Resources
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References
- Behavior Rating Inventory of Executive Function®, Second Edition. PAR. https://www.parinc.com/products/pkey/24
- Children’s Kitchen Task Assessment. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/childrens-kitchen-task-assessment
- Cleveland Clinic Medical. Executive dysfunction: What it is, symptoms & treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/symptoms/23224-executive-dysfunction
- Executive function performance test. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/executive-function-performance-test
- Marvin, MSc. PT, K. Trail-making test (TMT). Stroke Engine. https://strokengine.ca/en/assessments/trail-making-test-tmt/
- Rabinovici, G. D., Stephens, M. L., & Possin, K. L. (2015). Executive dysfunction. Continuum (Minneapolis, Minn.), 21(3 Behavioral Neurology and Neuropsychiatry), 646–659. https://doi.org/10.1212/01.CON.0000466658.05156.54
- Stroop Color and Word Test for Adults Normative Update. PAR.
- Toglia, PhD, OTR/L, FAOTA, J. AOTA. Weekly Calendar Planning Activity. https://myaota.aota.org/shop_aota/product/900369
- Wisconsin Card Sorting Test®. PAR. https://www.parinc.com/Products?pkey=478