What executive function tests do you include in your school based occupational therapy evaluation? Do school based OT’s even need to include tests of executive function into our evaluations?
Executive function is woven into every single school based occupation.
As school-based occupational therapy practitioners(OTP’s), our responsibility is to identify both the barriers and bridges that impact a student’s ability to engage, participate and perform within the educational system.
Executive functioning skills encompass a range of cognitive processes essential for goal-oriented behavior.
They include inhibition, initiation, self regulation, organization, time management, sustained attention and working memory, which are all prerequisites of institutional education and learning.
Therefore determining whether a student has the necessary executive function development to meet the demands of their environment is a crucial aspect of our evaluation.
When it comes to assessing a student’s executive functions in a school setting, occupational therapy practitioners (OTPs) have a multitude of options. In this article, we will explore the various executive function tests for use in the school environment.
Executive Functions in ADHD
Students with ADHD typically struggle with executive function and self-regulation. Researchers estimate that the child’s executive age may be up to 30% behind neurotypical peers.
ADHD does not impact intelligence, so that means your highly intelligent 5th grader may have the impulse control, working memory, cognitive flexibility, task initiation and emotional regulation skills of a 1st -2nd grader, making it extremely difficult for this student to meet classroom expectations, complete routines and demonstrate their knowledge.
Lagging executive function skills are not limited to students with ADHD. Executive function challenges are often present in children with various developmental and neurological differences including but not limited to autism, dyslexia, TBI, anxiety disorders, depression, Obsessive Compulsive Disorder and trauma.
Clinical vs Contextual Assessments of Executive Function Skills
Standardized tests of executive function used in neuropsychological evaluations measure clinical, non-contextual performance. For students with ADHD, performance on standardized tests in a highly novel, controlled testing environment may not replicate their day to day function in the classroom.
While information from these tests helps the practitioner create a comprehensive pattern of strengths and weaknesses, these assessments must be viewed with caution as they do not accurately represent a child’s performance within the unique context of a school environment. Below we list some of the common standardized tests used to measure executive function, this is not an exhaustive list.
Standardized Tests that Measure Executive Function
- Wechsler Intelligence Scale for Children (WISC) is widely used by school psychologists. The Working Memory Index , the Coding or the Processing Speed Index are useful in determining executive function strengths and weaknesses.
- The NEPSY-II is widely used by school psychologists and neuropsychologists, to assess children, ages three to sixteen. It provides comprehensive assessment over six functional domains: Attention/Executive Functioning, Language, Sensorimotor Functions, Visuospatial Processing, Memory and Learning, and Social Perception
- Delis-Kaplan Executive Function System (D-KEFS)-assesses the key components of executive functions with nine stand-alone tests within verbal and spatial modalities.
- The Wisconsin Card Sorting Test is used primarily to assess perseveration and abstract thinking. This test assesses strategic planning; organized searching; and ability to utilize environmental feedback to shift cognitive sets, direct behavior toward achieving a goal, and modulate impulsive responding
- The Comprehensive Trail Making Test asks a child to connect a series of dots, alternating between a sequence of numbers and letters. It’s a test of motor planning, visual attention, scanning and the ability to shift sets.
- The Stroop Color and Word Test (SCWT) -is widely known and used to measure response inhibition in learners with proficient reading skills.
Contextually Based Rating Scales of Executive Function
It is crucial to consider both the environment and the child’s executive function profile when assessing and planning interventions. Performance exists within the intersection of the person and the environment.
Symptom expression of ADHD is contextually dependent. And the context contains an infinite number of factors that on any given day can act as a bridge or barriers to this learners ability to access, perform and participate in their education.
Using contextually based checklists, across multiple environments home/school or favorite class/ least favorite class will provide the school based practitioner with more information about the student than the “Tower of London”.
The BRIEF-2 is a norm referenced checklist that assesses a child’s executive function skills in various areas, including inhibition, shifting, emotional control, working memory, planning/organizing, and monitoring. Both the child’s teacher and parent/caregiver can complete it.
The online version at Pari-Connect offers a quick and easy administration that provides instant scoring and interpretation, making it a preferred choice for many therapists.
Quick tip, email yourself a copy then forward to the teacher to avoid getting lost in the spam filters in schools.
The BRIEF-2 is:
- Suitable for students aged 5-18
- Has a preschool version available for students aged 2 to 5.11 years.
- Offers comprehensive evaluation with behavioral, emotional, and cognitive indexes.
- Identifies unusual responses through the infrequency scale.
- Pinpoints specific areas and reasons for a child’s struggles, facilitating informed interventions in schools and therapy.
- Provides an interpretive report with in-depth analysis, including clinical scale, index, and composite scores, along with validity indicators.
- Spanish versions are also available.
The Brown Executive Function/Attention Scales helps screen and assess a range of executive functioning categories.
It aligns with Brown’s Models of Executive Function. Test items are specific and contextual, and ask about difficulties in a specific context (e.g., difficulty remembering what has been read).
It is included in the Pearson Q global digital assessments, takes 10 -15 minutes and is norm referenced for ages 3 – adult.
Delis-Rating of Executive Functions (D-REF) for ages 5:0–18:11, therapists can quickly and easily administer, score, and report the frequency of observed behaviors that identify executive function problems in children and adolescents.
The D-REF assesses these constructs within four broad areas of global executive function: Attention/Working Memory (AWM), Activity Level/Impulse Control (AIC), Compliance/Anger Management (CAM), and Abstract Thinking/Problem Solving (APS).
D-REF include three core indexes and a total composite score based on behavioral, emotional, and cognitive functioning.Includes parent, teacher, and self-ratings with 36 items that are answered as: Seldom/Never, Monthly, Weekly, or Daily. Available digitally on Q Global.
The Barkley Deficits in Executive Functioning Scale—Children and Adolescents (BDEFS-CA)
The Barkley Deficits in Executive Functioning Scale—Children and Adolescents (BDEFS-CA), by Russel Barkley, is an empirically based tool for evaluating child and adolescent executive functioning.
The BDEFS-CA measures capacities involved in time management, organization and problem solving, self-restraint, self-motivation, and self-regulation of emotions.
Informal Rating Scales of Executive Function
Executive Skills Questionnaire (ESQ)
The ESQ was developed by Dawson and Guare and is available and described in a number of their books on executive skills including their titles : Executive Skills in Children and Adolescents, Smart but Scattered, Smart but Scattered Teens.
The scales and interviews are used to identify and compare executive function strengths and weakness within a person, not measure compared to peers. Many people, have made alternate versions of checklists based off of these tools suited for specific populations, linked below.
The ESQ-R is a Dawson and Guare’s, self-report online survey, that students grade 3 and older can complete to help understand their executive skill strengths and challenges. The 25 items on this survey yield scores in 5 domains of executive skills, that the authors call skill areas.
- Plan Management
- Time Management
- Emotional Regulation
- Behavioral Regulation
The lower the total score in each area ( 0-3) the stronger the student is in that skills area. Items scored with a 2 or higher are viewed as problematic for the individual.
The Smart but Scattered website provides a pdf of the results that you can download and save. The online version is linked here ,you can use it to grab an immediate profile.
The CHEXI is a rating instrument for parents and teachers designed to measure executive functioning in children aged 4-12. Additionally, a teenage version called the Teenage Executive Functioning Inventory (TEXI) was introduced in March 2020. These quick tools are available online for free, without normative data.
Classroom Observations of Executive Functions
Observation of the child in the natural context is an important part of the occupational therapy evaluation. It is often difficult to determine the difference between compliance and completion.
Is it that the student “does not follow classroom rules and procedures” or are they are having difficulty with the executive function skills needed to complete the classroom procedures? The procedural checklist can help OTP’s with classroom observations.
Evaluating Executive Functions is Best Practice
As school-based occupational therapists, understanding and assessing executive function skills is paramount to facilitating functional performance in the school environment.
Executive function is woven into every single school based occupation. Every student will have unique strengths and weaknesses within their executive function profile.
An effective assessment of executive functions will include a variety of measures including, information from formal one to one assessment, standardized rating scales, contextual based executive function checklists, observations, interviews and work samples.
OTP’s can look at the students performance on standardized tests that have executive function components including:
- Wechsler Intelligence Scale for Children (WISC) – Working Memory Coding and Processing Speed Index’s
- The NEPSY-II
- Delis-Kaplan Executive Function System (D-KEFS)
- Wisconsin Card Sorting Test
- Comprehensive Trail Making Test
- Stroop Color and Word Test (SCWT)
They can use standardized norm referenced rating scales including:
- Behavior Rating Inventory of Executive Function-2 (BRIEF-2)– Digital
- Brown Executive Function/Attention Scales– Digital
- Delis-Rating of Executive Functions-(D-REF)– Digital
- Barkley Deficits in Executive Functioning Scale—Children and Adolescents (BDEFS-CA)
And they can use informal measures of executive function through self report, and parent/teacher interview including :
- Executive Skills Questionnaire (ESQ)Student
- Executive Skills Questionnaire (ESQ)Grade 1-3
- Executive Skills Questionnaire (ESQ) Grade 4-5
- Executive Skills Questionnarre (ESQ) Grade 6-8
- Executive Skills Questionnaire (ESQ)Teen
- ESQ-R – Student grade 3 and above Self Report
- Childhood Executive Functioning Inventory (CHEXI)-Parent /Teacher
- Teenage Executive Functioning Inventory (TEXI)- Teen
- Procedural Performance Questionnaire
- Contextual Support Checklist
From these, OTP’s can develop an executive function profile that provides valuable insights to guide intervention, develop goals and provide support tailored to each student’s unique profile of strengths and needs.
BRIEF (Behavior Rating Inventory of Executive Function) – By Gerard A. Gioia, PhD, Peter K. Isquith, PhD, Steven C. Guy, PhD, and Lauren Kenworthy, PhD.
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