Canadian Journal of Occupational Therapy 80(3) 131-140 DOI: 10.1177/0008417413496060

Article

Executive functioning: A scoping review of the occupational therapy literature

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Les fonctions exe´cutives : une analyse de la porte´e de la litte´rature en ergothe´rapie

Heidi A. Cramm, Terry M. Krupa, Cheryl A. Missiuna, Rosemary M. Lysaght, and Kevin H. Parker

Key words: Assessment; Cognition; Intervention; Literature review; Metacognition. Mots cle´s : cognition; e´valuation; intervention; me´tacognition; revue de litte´rature.

Abstract Background. Increasingly recognized as an important factor in the performance of complex, goal-directed tasks, executive functioning is understood in different ways across disciplines. Purpose. The aim was to explore the ways in which executive functioning is conceptualized, discussed, described, and implied in the occupational therapy literature. Method. A scoping review of the occupational therapy literature was conducted following Levac, Colquhoun, and O’Brien’s (2010) recommended methodology. Results. Executive functioning is described both as a set of performance component skills or processes and as the executive occupational performance inherent in complex occupations. Executive functioning is implicit in occupational performance and engagement, and some health conditions seem to be commonly associated with impaired executive functioning. Assessing executive functioning requires dynamic occupation- and performance-based assessment. Interventions targeting executive functioning are grounded in metacognitive approaches. Conclusion. Executive functioning is a complex construct that is conceptualized with considerable variance within the occupational therapy literature, creating barriers to effective service delivery. Abre´ge´ Description. Bien qu’elles soient reconnues comme un facteur de´terminant du rendement lors de la re´alisation de taˆches complexes et dirige´es vers un but, les fonctions exe´cutives sont de´finies de diffe´rentes fac¸ons d’une discipline a` l’autre. But. Examiner comment les fonctions exe´cutives sont conceptualise´es, discute´es, de´crites et sous-entendues dans la litte´rature en ergothe´rapie. Me´thodologie. Une analyse de la porte´e de la litte´rature en ergothe´rapie a e´te´ re´alise´e, selon la me´thodologie recommande´e par Levac, Colquhoun et O’Brien’s (2010). Re´sultats. Les fonctions exe´cutives sont de´crites a` la fois comme un ensemble de compe´tences ou de processus lie´s a` la composante du rendement, et comme le rendement occupationnel exe´cutif inhe´rent aux occupations complexes. Les fonctions exe´cutives sont contenues implicitement dans le rendement occupationnel et la participation occupationnelle et certains proble`mes de sante´ semblent eˆtre associe´s couramment a` un trouble des fonctions exe´cutives. L’e´valuation des fonctions exe´cutives fait appel a` une e´valuation dynamique du rendement occupationnel. Les interventions ciblant les fonctions exe´cutives sont fonde´es sur des approches me´tacognitives. Conclusion. Les fonctions exe´cutives sont un construit complexe et l’on observe une variance conside´rable face a` la conceptualisation de ce construit dans la litte´rature en ergothe´rapie, ce qui constitue un obstacle a` la prestation de services efficaces.

Funding: The first author received funding from the Canadian Institutes of Health Research, the Canadian Child Health Clinician Scientist Program, and the Canadian Occupational Therapy Foundation. Corresponding author: Heidi A. Cramm, School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George Street, Kingston, ON, Canada K7L 3N6. E-mail: [email protected]

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cross disciplines, the way in which executive functioning (EF) has been understood is changing, as is the frequency with which it is being discussed. EF is considered to be more than the simple ‘‘frontal’’ or ‘‘prefrontal’’ activity with which it has historically been associated, and it impacts populations beyond those who have experienced stroke or traumatic brain injury. Rather, neuropsychologists recognize that many neuronal pathways are considered fundamental to good EF; problems in any of those necessary pathways could lead to EF impairment (Oddy & Worthington, 2009). Moreover, EF is now understood to change with development and diagnosis (P. Dawson & Guare, 2010). As in psychology, the education literature notes the influence of EF on participation and performance in important life domains, such as the student role (Kaufman, 2010; McCloskey, Perkins, & Van Divner, 2009; Meltzer, 2007). The World Health Organization (WHO; 2007) describes EF as ‘‘higher-level cognitive functions’’ that are intimately connected with ‘‘complex goal-directed behaviours’’ (p. 57) across all life domains. Yet, despite the growing recognition of the role of EF on complex behaviours and of its developmental nature, there does not appear to be an accepted definition of EF within or across disciplines. Instead, there are many nuanced conceptualizations about its components and its relation to other constructs (Cooper-Kahn & Dietzel, 2008; Cox, 2007; Zeigler Dendy, 2011). The purpose of this study was to conduct a scoping review to characterize how EF is conceptualized, discussed, described, and implied in the occupational therapy literature. Within this paper, the term executive functioning (EF) will be used to capture the terms executive function/skill/control, dysexecutive, or executive dysfunction. Given the myriad of definitions used across different disciplines, it is important and timely to clarify EF as a construct within occupational therapy. Enhanced clarity can enable discussion and inform health service delivery, assessment, and intervention approaches both within the discipline and in interprofessional collaborations.

Method Unlike systematic reviews, which have focused research questions and quality filters (Armstrong, Hall, Doyle, & Waters, 2011), scoping reviews facilitate an understanding of the breadth and range of literature on a topic that is complex or has not been previously reviewed systematically (Mays, Roberts, & Popay, 2001). A scoping review can be effective when a field needs to ‘‘map a wide range of literature’’ (Ehrich, Freeman, Richards, Robinson, & Shepperd, 2010, p. 28). A scoping review methodology was selected as the most appropriate means of mapping the occupational therapy literature because of the need to clarify and contextualize what we know about EF and occupational performance and engagement. Advancing Arksey and O’Malley’s (2005) six-stage scoping methodological framework, Levac, Colquhoun, and O’Brien (2010) delineated clarifications and refinements that would improve methodological rigour; these steps have been followed in this scoping review. Canadian Journal of Occupational Therapy

Identify the Research Question According to Arksey and O’Malley (2005), the research question needs to be wide enough to capture a breadth of knowledge yet be defined clearly enough that database search strategies can be useful. The ultimate purpose of the study, the rationale for selecting a scoping methodology, and the clarity of the research question must be balanced (Levac et al., 2010). The scoping review question was, ‘‘How does occupational therapy literature conceptualize, discuss, describe, and imply executive functioning?’’

Identify Relevant Studies and Study Selection Identifying relevant studies requires a plan that clearly identifies search terms, databases, time frames, and language. Within CINAHL, the most comprehensive database for core occupational therapy publications (Potter, 2010), the original search terms were executive function*/executive skill*/executive control/dysexecutive or executive dysfunction*, combined with occupational therap*. This initial search yielded 37 Englishlanguage results, the vast majority of which had been published since 2001, eliminating the need to search before the database started in 1981. In addition to CINAHL results, hand searching was completed within the American Journal of Occupational Therapy; the British Journal of Occupational Therapy; the Canadian Journal of Occupational Therapy; the Occupational Therapy Journal of Research or OTJR: Occupation, Participation, and Health; and the Australian Occupational Therapy Journal as well as the reference lists of included studies. An additional 27 journal articles and seven book chapters were identified for potential inclusion. Inclusion and exclusion criteria became refined as familiarity with the literature increased (Arksey & O’Malley, 2005). Inclusion criteria were as follows: All articles, books, book chapters, and theses were considered eligible. To be included, occupational therapy and executive functioning had to be found in the title, keywords, abstract, or chapter points. The sources had to be written in English. When an updated edition of a source was available, it was used. Exclusion criteria were as follows: sources were excluded if they used terms associated with but not specifically labelled as EF, such as cognition, metacognition, awareness, and attention. All 71 English titles and abstracts were reviewed. Full source review then ensued with the 49 sources in the final data extraction pool.

Chart the Data, Collate, Summarize, and Report the Results All articles were reviewed, using an analytic data guide, for authors, author disciplines, keywords, year of publication, purpose of the source (e.g., assessment, intervention, etc.), source of literature (e.g., journal article, book chapter, etc.), and key findings relating to how EF is conceptualized, discussed, described, and implied. The data extraction focused on the list of terms used to describe EF and its impact on occupation and a description of the approaches or strategies used to address

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Canadian Journal of Occupational Therapy 80(3) EF within occupational therapy practice. This method of coding is consistent with a process-oriented approach to charting the data, such as understanding how a concept has been used within a larger study (Levac et al., 2010).

Results Explicit discussion of EF has increased dramatically in the occupational therapy literature over the past few years. Of the 49 sources, only three references to EF were located in the occupational therapy literature prior to 2001, whereas almost half were published within 2011. Studies that were included are indicated through an asterisk (*) in the reference list. Sources were mostly peer-reviewed research articles, published predominantly in the United States. Five themes emerged through the charting and analysis process.

Defining Executive Functioning Is Difficult EF as a construct is difficult ‘‘because across disciplines, areas of research, and clinical settings executive function has a different definition and the term often times leads to a great deal of miscommunication’’ (Wolf, 2010, p. 459). EF is sometimes defined in the occupational therapy literature as a set of component processes required for successful engagement in activities or tasks that are complex, non-routine, novel, dynamic, and/or unstructured. Some definitions delineate discrete component processes as if an individual has a finite capacity for each component or process; others explore complex occupational performance contextual requirements that elicit integrated and dynamic EF. Still others combine components and outcomes or blur the distinction between the two. When definitions identify the coordinated set of discrete components that are critical to occupational performance, they use EF as an ‘‘umbrella term’’ (Gillen, 2009, p. 245) to describe performance outcomes. EF is described as complex, higher-level or higher-order abilities, capacities, processes, or functions that draw on, supervise, or manage lower-level, basic, or primary elements of cognition or metacognition. Planning and organizing are commonly cited higher-level processes; the most common descriptors that have been used are outlined in Table 1. Performance of goal-oriented occupations that are sufficiently complex, novel, and dynamic to elicit EF can be considered to be ‘‘executive occupational performance.’’

Executive Functioning Impacts Broadly on Occupational Performance and Engagement The literature is in agreement about the pervasive and critical impact that EF can have on occupational performance and engagement. Individuals living with deficits in their EF ‘‘typically demonstrate difficulties with instrumental activities of daily living (IADL), employment, and social functioning, leading to a reduction in their full participation in community life’’ (Maeir, Krauss, & Katz, 2011, p. S39). EF is considered the

133 ‘‘most critical cognitive function that affects participation’’ (Wolf & Baum, 2011, p. 42). With participation affected by impaired EF, roles can be restricted, and community living, independence, and quality of life may be affected (e.g., Erez, Rothschild, Katz, Tuchner, & Hartman-Maeir, 2009; Foster & Hershey, 2011). Impairments in EF can disrupt complex occupations that involve dynamic and simultaneous task demands, such as household management, mothering, and driving (e.g., Gutman et al., 2004; Stapleton & Connelly, 2010). Returning to work after acquiring EF deficits is described as challenging; individuals living with EF issues experience difficulties in work, with higher rates of work disruption, underemployment, and lower social economic status (e.g., Bade, 2010; Nadeau & Buckheit, 1995; Precin, 2010; Tan, 2009). Social occupations—exceedingly complex because of the constant perception and interpretation of social cues, selection and inhibition of appropriate responses, and ongoing monitoring and adaptation of responses—are ‘‘inherently linked with executive functioning’’ (Connor & Maeir, 2011, p. S4) and to higher rates of peer and familial conflict (e.g., Cermak & Maeir, 2011). When impaired EF leads to difficulties in performing novel and complex tasks, compromised decision making, and selfregulation issues, school and academic performance are negatively impacted across the life span, and individuals become frustrated with their ineffectual and unsuccessful efforts and unsatisfactory outcomes (e.g., Connor & Maeir, 2011; Ziviani, Copley, Ownsworth, Campbell, & Cummins, 2008).

Multiple Populations Are at Risk for Impaired Executive Functioning The majority of occupational therapy literature targeting EF has focused on acquired and traumatic brain injury (e.g., DePoy, Maley, & Stanraugh, 1990; Wilson, 2001) and stroke (e.g., Cederfeldt, Widell, Elgmark Andersson, Dahlin-Ivanoff, & Gosman-Hedstrom, 2011; Korner-Bitensky, Barrett-Bernstein, Bibas, & Poulin, 2011). However, EF issues have more recently been identified in other vulnerable populations: It is now known the person can experience executive dysfunction even in the absence of frontal lobe injury. Almost any diagnosis that affects the brain can potentially affect to a greater or lesser extent executive functioning. (Wolf & Baum, 2011, p. 43)

EF issues are commonly experienced among individuals living with schizophrenia (e.g., Josman, 2011; Katz & Keren, 2011), multiple sclerosis (e.g., Preston, 2010; Voelbel et al., 2011), and mild cognitive impairment (e.g., Kizony, DemayoDayan, Sinoff, & Josman, 2011). Moreover, EF issues may go unnoticed, as impaired executive performance can occur in the absence of a diagnosis and in the absence of other identified impairments traditionally associated with EF deficits (e.g., Wolf & Baum, 2011), such as Parkinsonian disorders. The occupational therapy literature cited studies from other disciplines that recognize that EF is vulnerable to disruption

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Table 1 Most Common Descriptors of Executive Functioning in Occupational Therapy Literature Literature reference

Descriptor

Bade, 2010 Bottari, Dassa, Rainville, & Dutil, 2010 Bottari & Dawson, 2011 Cederfeldt, Widell, Elgmark Andersson, Dahlin-Ivanoff, & Gosman-Hedstrom, 2011 Cook, 2008 Connor & Maeir, 2011 D. Dawson et al., 2009 DePoy, Maley, & Stanraugh, 1990 Erez, Rothschild, Katz, Tuchner, & Hartman-Maeir, 2009 Foster & Hershey, 2011 Gillen, 2009 Hahn-Markowitz, Manor, & Maeir, 2011 Hartman-Maeir & Katz, 1997 Josman, Berney, & Jarus, 2000 Josman & Birnboim, 2001 Josman & Rosenblum, 2011 Katz, Baum, & Maeir, 2011 Katz & Maeir, 2011 Katz, Tadmor, Felzen, & Hartman-Maeir, 2007 Kizony, Demayo-Dayan, Sinoff, & Josman, 2011 Levy & Burns, 2011 Lipskaya, Jarus, & Kotler, 2011 Maeir, Krauss, & Katz, 2011 Matheson, Dodson, & Wolf, 2011 Nadeau & Buckheit, 1995 Precin, 2010 Preston, 2010 Rocke, Hays, Edwards, & Berg, 2008 Stapleton & Connelly, 2010 Tan, 2009 Toglia, Goverover, Johnston, & Dain, 2011 Voelbel et al., 2011 Wolf, 2010 Wolf & Baum, 2011 Ziviani, Copley, Ownsworth, Campbell, & Cummins, 2008

Planning (n ¼ 30) p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p

‘‘even with mild neurological injury and many chronic health conditions’’ (Wolf & Baum, 2011, p. 42). Neurodegenerative diseases, such as dementia (e.g., Katz, Tadmor, Felzen, & Hartman-Maeir, 2007; Levy & Burns, 2011); acquired neurological conditions (Wolf & Baum, 2011); mental health disorders, such as bipolar disorder; neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD; e.g., Hahn-Markowitz, Manor, & Maeir, 2011); autism spectrum disorder (e.g., Gentry, 2005); and natural processes associated with aging (e.g., Josman & Rosenblum, 2011) are increasingly alluded to in the literature. There is also literature that addresses EF issues associated with cognitive disabilities (e.g., Hartman-Maeir, Katz, & Baum, 2009). Recently, the term ‘‘atypical brain development’’ (Josman & Rosenblum, 2011, p. 223) was used to capture a group of Canadian Journal of Occupational Therapy

Mental/cognitive Goal-directed flexibility Organize behaviour Initiate/Start Monitor (n ¼ 15) (n ¼ 13) (n ¼ 20) (n ¼ 20) (n ¼ 17) p p p p p p p p p p

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diagnoses—learning disability, ADHD, developmental coordination disorder, and specific language impairment—in which EF is described as a common issue with children. Only a few articles have explicitly discussed EF in children who were not described as having specific diagnoses (e.g., Josman & Jarus, 2001; Rocke, Hays, Edwards, & Berg, 2008; Weintraub, Yinon, Hirsch, & Parush, 2009; Ziviani et al., 2008).

Assessing Executive Functioning Is Inherently Challenging Administered with clear cueing protocols, standardized assessments of EF components are structured to prompt the beginning and end of the test, task duration, and task sequence and to target isolated cognitive skills associated with EF. The testing

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Canadian Journal of Occupational Therapy 80(3) location is quiet and free of distraction, creating conditions quite disparate from regular daily living. These conditions interfere with the elicitation of EF issues in performance situations, raising concern as to their relevance for occupational therapy (e.g., Baum, Foster, & Wolf, 2009). Designed to capture optimal performance on tasks assessing EF performance components, such assessments do not accurately estimate an individual’s capacity for performance of occupations in real-life tasks, which may be underestimated or overestimated by the assessment results (e.g., Bottari, Dassa, Rainville, & Dutil, 2010; Wolf, Barbee, & White, 2011). Gillen (2009) summarizes this challenge: People living with executive function impairment may perform normally on pen and paper tests of cognition but unfortunately present catastrophic everyday problems that are particularly evident in situations requiring multitasking and planning. (p. 248)

In keeping with occupational therapy’s domain of concern, observational, performance-based occupational therapy assessment is frequently described (e.g., Baum & Katz, 2011). The Executive Functions Performance Test is the most frequently cited performance-based assessment of EF within occupational therapy (e.g., Connor & Maeir, 2011). The administration protocol involves a systematic hierarchy of therapist cueing to determine what an individual can accomplish successfully. It also clarifies the nature of support required from the environment. This is a dynamic approach to assessment, one that is increasingly identified as useful for assessing EF performance in a developmentally sensitive manner (e.g., Ziviani, Rodger, Pacheco, Rootsey, Smith, & Katz, 2004). Dynamic performance analysis (Polatajko, Mandich, & Martini, 2000)—also referred to as dynamic assessment and dynamic interactional assessment—explores how a person responds to complex new tasks and clarifies the conditions under which performance can be successful. As such, it may reveal patterns of errors and self-correction strategies used and outlines what conditions or modifications are required for effective performance of a complex task. Dynamic performance analysis allows the therapist to discern what an individual can do independently and to compare it with what can be done when the experience is mediated by the therapist (e.g., D. Dawson et al., 2009).

Intervention Paradigms May Target Executive Functioning Occupational therapy is challenged to provide ‘‘theoretically driven, evidence-based interventions that will enable participation and improve the health and well-being of these individuals’’ (Connor & Maeir, 2011, p. S6). Remedial, compensatory, and environmental approaches were described. Remedial approaches that emphasize restoration of impaired EF components have historically been used. Compensatory task and environmental interventions for EF involve accommodations, such as day planners and checklists that support performance, and modifications, such as reduced task complexity and increased structure, as well as the resources available to provide such accommodations in the environment (e.g., Cook, 2008; Gardner, 2002). In addition

135 to an active and motivated client, supportive individuals in the person’s environment seem to be associated with improved outcomes (e.g., Cermak & Maeir, 2011). While improvements have been reported within all of these approaches, it appears that participants who engage in strategy-based approaches may benefit more than those who engage in skill-based remedial intervention (e.g., Toglia, Goverover, Johnston, & Dain, 2011). Framed more as a continuum of interventions (e.g., Katz & Maeir, 2011), different approaches may be selected based on the severity of the deficit, the individual’s awareness of the deficits and emotional state, and the nature and availability of environmental resources (e.g., Connor & Maeir, 2011). Alternatively, approaches have been categorized as ecological, dynamic, or cognitive and may be used in combination (e.g., Josman & Rosenblum, 2011). Regardless of the approach selected for intervention, the role of metacognition has been described as critical to managing EF issues (e.g., Hartman-Maeir & Katz, 1997). Global metacognitive strategies can act as integrators of the combination intervention approach. External compensatory strategies gradually become internalized, blurring the line between improvement in an EF deficit and effective strategic use of a compensatory approach (e.g., D. Dawson et al., 2009) such that ‘‘both arguments are valid’’ (Toglia et al., 2011, p. S58). Metacognitive approaches help clients to develop their capacity to use their strengths to optimize performance and to self-manage a spectrum of EF issues (e.g., Cermak & Maeir, 2011). When a metacognitive framework is used as part of the intervention, a structured and systematic process should be explicitly implemented to support understanding, practice, and transfer of the strategies to contextualize the need for and purpose of strategies and accommodations (e.g., Gillen, 2009; Toglia et al., 2011). That framework can then be systematically deployed, consistently embedded across activities, and structured while clients are learning the framework (e.g., Cook, 2008). Intervention tasks should be sufficiently novel, challenging, and complex to provide real-world opportunities to engage in strategic action (e.g., Hartman-Maeir & Katz, 1997). Vygotsky’s (1978) zone of proximal development has been cited frequently to suggest that mediation may be a useful cognitive technique. Mediation involves the clear and structured presentation of information in a manner that helps the individual to attend to and discern the most salient features in order to make connections and enrich the learning experience (Cermak & Maeir, 2011). Global metacognitive or executive strategy frameworks, such as the Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Polatajko & Mandich, 2004), have been described as useful for supporting executive occupational performance, involving verbal self-instruction techniques, goal management training, and/or problem-solving training in clinical applications with individuals who have EF difficulties (e.g., Cook, 2008; D. Dawson et al., 2009).

Discussion The purpose of this scoping review was to examine how EF is implied, described, discussed, and conceptualized in the

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occupational therapy literature. The ways in which occupational therapy understands and approaches EF draw on literature and research from other fields yet offer a perspective uniquely relevant to occupational therapy and its domain of concern. The literature speaks to the importance of EF and its effect on occupational performance, the role of the occupational therapist in addressing EF, and assessments or practice interventions that are used when working with clients who have EF difficulties. Five themes emerged from the literature: (a) defining executive functioning is difficult, (b) executive functioning impacts broadly on occupational performance and engagement, (c) multiple populations are at risk for impaired executive functioning, (d) assessing executive functioning is inherently challenging, and (e) intervention paradigms may target executive functioning. Points of tension and the implications of these findings for occupational therapy practice and research are discussed, as are future directions.

evaluates the level of occupational performance itself (e.g., Josman & Birnboim, 2001). Top-down, occupation-based performance assessments that demand observation of the occupational performance in context affords the occupational therapist insight into contextual and task demands as well as into the difficulties that a client may have with execution of complex occupations (e.g., Bottari et al., 2010; Hartman-Maeir et al., 2009; Rocke et al., 2008; Ziviani et al., 2008). Intervention approaches are similarly polarized between interventions that focus on remediating components and a growing trend toward the systematic use of a metacognitive framework to provide structure and context for strategies developed and accommodations that will be required. Metacognitive frameworks, such as the CO-OP (Polatajko & Mandich, 2004), initially used as an intervention for children with motor learning problems, are finding broader application and promising efficacy among individuals with EF issues.

Points of Tension

Future Directions

EF is conceptualized with considerable variance. Overall, the literature suggests that EF is a complex process involving many interrelated factors. The myriad of terms associated with EF in the occupational therapy literature are entangled, shifting and overlapping in meaning and in relation to other constructs under discussion. For example, self-awareness, awareness, monitor, self-monitor, self-regulate, and self-correct are all used, sometimes as distinct constructs (e.g., Cederfeldt et al., 2011) and sometimes with overlapping meaning (e.g., Matheson, Dodson, & Wolf, 2011). Decision making is discussed as both a discrete entity (e.g., Stapleton & Connelly, 2010) and as a factor in problem solving (e.g., Gillen, 2009). Terms are also used with varying levels of precision. Without consensus on a definition of EF, barriers to understanding and communicating about the role of EF in occupational performance are reinforced (Wolf, 2010). While recognition of the effect of EF on performance is critical, assessment is equally so. If occupational therapy services are structured to assess specific performance components or less complex aspects of performance, such as routine self-care tasks, performance issues associated with EF may not be detected (e.g., Josman & Rosenblum, 2011). There is a call for the development of ecologically valid assessments of EF that respond to these issues (e.g., Josman & Birnboim, 2001). The literature suggests that, without explicitly considering EF and its relation to occupational performance, occupational therapists may be neither identifying the issues accurately nor addressing them in an effective way (e.g., Connor & Maeir, 2011). Discussion of assessment of EF is split into a focus on EF components, such as memory and attention, versus executive occupational performance. The key distinction appears to be assessing the EF component deficit versus the effect of that EF deficit on occupational performance (e.g., Wolf et al., 2011). This assessment issue underscores the polarity of a bottom-up orientation to practice that emphasizes correcting performance components and a top-down orientation that

With the growing awareness of the effect and pervasiveness of EF on occupational performance comes recognition that occupational therapists must be cognizant of the possibility of EF issues when assessing occupational performance. Yet, at present, regardless of medical condition, EF deficits may not be recognized, even among individuals who have had a stroke, a diagnosis that has traditionally been associated with executive dysfunction (Wolf et al., 2011). By extension, EF may be identified even less frequently in practice areas that have not been concerned typically with impairments of EF. Wolf and Baum (2011) stress that ‘‘executive dysfunction is an occupational performance problem and not a diagnosis specific problem’’ (p. 43). When deficits in EF are not recognized, their effect on daily occupational performance compounds and can cascade into secondary issues (Bade, 2010; Wolf, 2010):

Canadian Journal of Occupational Therapy

A maladaptive cycle may begin. This disabling cycle, triggered by negative occupational experiences due to executive function deficit, may have broad implications for overall health and well-being, including reduced self-efficacy, occupational withdrawal, social isolation, and deterioration in mental and physical health. (Connor & Maeir, 2011, p. S5)

To mitigate and possibly prevent this cycle, enhanced recognition of EF in the context of occupation will be required. To develop the profession’s capacity to recognize and address EF, future research is needed to identify occupational therapists’ knowledge and skills regarding awareness of the presentation and elicitation of EF issues, along with its developmental and diagnostic trajectories. Training and system issues must also be considered with assessment and intervention. A focus on impairment may persist in some areas of occupational therapy practice rather than on the activity and participation dimensions described in the WHO’s (2007) International Classification of Functioning, Disability and Health—Children & Youth Version. The level of skill required for clinicians to be able to accurately assess

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Canadian Journal of Occupational Therapy 80(3) performance errors in naturalistic contexts remains to be ascertained. Bottari and Dawson (2011) have shown that neither total years of practice nor years of practice with individuals with neurological issues were significantly correlated with accuracy of performance-based observations of EF.

Study Limitations Scoping reviews are not intended to evaluate study quality and, therefore, cannot draw conclusions about the methodology or rigour of the sources. It is possible that use of different databases may have yielded an increased number of sources. The process of analysis and summarizing the data is iterative and may have been organized differently by another research team. Including the consultation step of the scoping review methodology may have enhanced the scoping review. It is possible that occupational therapists are implicitly discussing EF in the literature without using the term explicitly. Based on the inclusion criteria, some sources were excluded (e.g., Leew, 2001; Missiuna, Mandich, Polatajko, & MalloyMiller, 2001) that likely were dealing with issues of EF. Sources that discussed diagnoses, such as acquired brain injury and ADHD, both known to be highly correlated with EF issues, but that did not expressly use the term EF, were also excluded (e.g., Chu & Reynolds, 2007; Jones & Drummond, 2005). Nevertheless, the exclusion of these sources was required to better clarify how occupational therapy literature is explicitly describing EF.

Conclusion A scoping review methodology was used to explore how the occupational therapy literature describes EF. Although the rate and frequency with which EF is discussed have recently surged, lack of consensus remains about the construct itself. There is growing recognition of the connection between occupational performance and EF that extends well beyond the traditional diagnostic identification of EF impairment in stroke or traumatic brain injury. Given the breadth of EF issues across client groups and ages, occupational therapists need to consider EF in holistic, occupation-based assessment, which requires a dynamic analysis of performance. The literature appears to be shifting away from a remedial orientation with current interventions combining compensatory environmental and metacognitive frameworks to promote effective and efficient occupational performance. Occupational therapy education and training may be required for occupational therapists to become more familiar with how EF affects occupational performance as well as with assessment and intervention approaches that are effective in targeting occupational performance that is affected by EF.

Key Messages 

Executive functioning is a complex construct that refers to both components of executive functioning as well as the execution of complex occupations.

137  Executive functioning has broad implications for occupational performance and engagement across diagnostic and developmental populations.  Holistic, occupation-based assessment requires dynamic analysis of performance in real life context, followed by a blend of compensatory environmental and metacognitive frameworks to enable occupation.

References References marked with an asterisk indicate studies included in the scoping review. Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8, 19–32. doi: 10.1080/1364557032000119616 Armstrong, R., Hall, B., Doyle, J., & Waters, E. (2011). ‘‘Scoping the scope’’ of a cochrane review. Journal of Public Health, 33, 147– 150. doi: 10.1093/pubmed/fdr015 *Bade, S. (2010). Cognitive executive functions and work: Advancing from job jeopardy to success following a brain aneurysm. Work: A Journal of Prevention, Assessment and Rehabilitation, 36, 389– 398. doi: 10.3233/WOR-2010-1038 *Baum, C., Foster, E., & Wolf, T. (2009). Addressing performance and participation in occupational therapy: The importance of cognition. British Journal of Occupational Therapy, 72, 143. *Baum, C., & Katz, N. (2011). Introduction to the special issue on cognition and executive function. OTJR: Occupation, Participation and Health, 31, S2–S2. doi:10.3928/15394492-20101108-01 *Bottari, C., Dassa, C., Rainville, C., & Dutil, E. (2010). The IADL Profile: Development, content validity, intra- and interrater agreement. Canadian Journal of Occupational Therapy, 77, 90–100. doi: 10.2182/cjot.2010.77.2.5 *Bottari, C., & Dawson, D. (2011). Executive functions and realworld performance: How good are we at distinguishing people with acquired brain injury from healthy controls? OTJR: Occupation, Participation and Health, 31, S61, S61–S68. doi:10.3928/ 15394492-20101108-10 *Cederfeldt, M., Widell, Y., Elgmark Andersson, E., Dahlin-Ivanoff, S., & Gosman-Hedstrom, G. (2011). Concurrent validity of the Executive Function Performance Test in people with mild stroke. British Journal of Occupational Therapy, 74, 443–449. doi: 10. 4276/030802211X13153015305673 *Cermak, S., & Maeir, A. (2011). Cognitive rehabilitation of children and adults with attention deficit hyperactivity disorder. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 249–276). Bethesda, MD: American Occupational Therapy Association. Chu, S., & Reynolds, F. (2007). Occupational therapy for children with attention deficit hyperactivity disorder (ADHD), part 1: A delineation model of practice. British Journal of Occupational Therapy, 70(9), 372–383. *Connor, L., & Maeir, A. (2011). Putting executive performance in a theoretical context. OTJR: Occupation, Participation and Health, 31, S3–S7. doi:10.3928/15394492-20101108-02

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*Cook, C. (2008). An exploration of the neural control of multitasking and the implications for practice. British Journal of Occupational Therapy, 71, 241–247. Cooper-Kahn, J., & Dietzel, L. (2008). Late, lost, and unprepared: A parent’s guide to helping children with executive functioning. Bethesda, MD: Woodbine House. Cox, A. (2007). No mind left behind: Understanding and fostering executive control. The eight essential brain skills every child needs to thrive. New York, NY: Penguin Group. *Dawson, D., Gaya, A., Hunt, A., Levine, B., Lemsky, C., & Polatajko, H. (2009). Using the Cognitive Orientation to Occupational Performance (CO-OP) with adults with executive dysfunction following traumatic brain injury. Canadian Journal of Occupational Therapy, 76, 115–127. doi: 10.1177/000841740907600209 Dawson, P., & Guare, R. (2010). Executive skills in children and adolescents: A practical guide to assessment and intervention (2nd ed.). New York, NY: Guilford Press. *DePoy, E., Maley, K., & Stanraugh, J. (1990). Executive function and cognitive remediation: A study of activity preference. In J. A. Johnson (Ed.), Occupational therapy approaches to traumatic brain injury (pp. 101–114). Binghamton, NY: Haworth Press. Ehrich, K., Freeman, G., Richards, S., Robinson, I., & Shepperd, S. (2010). How to do a scoping exercise: Continuity of care. Research Policy and Planning, 20, 25–29. *Erez, A. B., Rothschild, E., Katz, N., Tuchner, M., & HartmanMaeir, A. (2009). Executive functioning, awareness, and participation in daily life after mild traumatic brain injury: A preliminary study. American Journal of Occupational Therapy, 63, 634–640. *Foster, E., & Hershey, T. (2011). Everyday executive function is associated with activity participation in Parkinson disease without dementia. OTJR: Occupation, Participation and Health, 31, S16– 22. doi:10.3928/15394492-20101108-04 *Gardner, M. (2002). In the clinic. Using speech dictation software as an occupational therapy medium. OT Practice, 7, 20–21. *Gentry, T. (2005). A brain in the palm of your hand: assistive technology for cognition. OT Practice, 10, 10–13. *Gillen, G. (2009). Cognitive and perceptual rehabilitation: Optimizing function. St. Louis, MO: Mosby. *Gutman, S. A., Diamond, H., Holness-Parchment, S. E., Brandofino, D. N., Pacheco, D. G., Jolly-Edouard, M., & Jean-Charles, S. (2004). Enhancing independence in women experiencing domestic violence and possible brain injury: An assessment of an occupational therapy intervention. Occupational Therapy in Mental Health, 20, 49–79. doi: 10.1300/J004v20n01_03 *Hahn-Markowitz, J., Manor, I., & Maeir, A. (2011). Effectiveness of cognitive-functional (cog-fun) intervention with children with attention deficit hyperactivity disorder: A pilot study. American Journal of Occupational Therapy, 65, 384–392. doi:10.5014/ajot. 2011.000901 *Hartman-Maeir., & Katz, N. (1997). Occupational performance and metacognition. Canadian Journal of Occupational Therapy, 64, 53–62. doi: 10.1177/000841749706400201 *Hartman-Maeir, A., Katz, N., & Baum, C. (2009). Cognitive functional evaluation (CFE) process for individuals with suspected cognitive disabilities. Occupational Therapy in Health Care, 23, 1–23. doi:10.1080/07380570802455516 Canadian Journal of Occupational Therapy

Jones, P., & Drummond, A. (2005). Occupational therapy for children with acquired brain injury: A review of the literature. British Journal of Occupational Therapy, 68, 324–330. *Josman, N. (2011). The dynamic interactional model in schizophrenia. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 203–221). Bethesda, MD: American Occupational Therapy Association. Josman, N., Berney, T., & Jarus, T. (2000). Evaluating categorization skills in children following severe brain injury. Occupational Therapy Journal of Research, 20(4), 241–255. *Josman, N., & Birnboim, S. (2001). Measuring kitchen performance: What assessment should we choose? Scandinavian Journal of Occupational Therapy, 8, 193–202. *Josman, N., & Jarus, T. (2001). Construct-related validity of the Toglia Category Assessment and the Deductive Reasoning Test with children who are typically developing. American Journal of Occupational Therapy, 55, 524–530. *Josman, N., & Rosenblum, S. (2011). A metacognitive model for children with atypical brain development. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation and models of intervention in occupational therapy (3rd ed., pp. 223–247). Bethesda, MD: American Occupational Therapy Association. Katz, N., Baum, C., & Maeir, A. (2011). Introduction to cognitive intervention and cognitive functional evaluation. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 3–12). Bethesda, MD: American Occupational Therapy Association. *Katz, N., & Keren, N. (2011). Effectiveness of occupational goal intervention for clients with schizophrenia. American Journal of Occupational Therapy, 65, 287–296. doi:10.5014/ajot.2011.001347 *Katz, N., & Maeir, A. (2011). Higher-level cognitive functions enabling participation: Awareness and executive functions. In N. Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 13–40). Bethesda, MD: American Occupational Therapy Association. *Katz, N., Tadmor, I., Felzen, B., & Hartman-Maeir, A. (2007). Validity of the Executive Function Performance Test in individuals with schizophrenia. OTJR: Occupation, Participation and Health, 27, 44–51. Kaufman, C. (2010). Executive function in the classroom: Practical strategies for improving performance and enhancing skills for all students. Baltimore, MD: Brookes. *Kizony, R., Demayo-Dayan, T., Sinoff, G., & Josman, N. (2011). Validation of the Executive Function Route-Finding Task (EFRT) in people with mild cognitive impairment. OTJR: Occupation, Participation and Health, 31, S47–S52. doi:10.3928/1539449220101108-07 *Korner-Bitensky, N., Barrett-Bernstein, S., Bibas, G., & Poulin, V. (2011). National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. Australian Occupational Therapy Journal, 58, 241–250. doi:10. 1111/j.1440-1630.2011.00943.x

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Author Biographies Heidi A. Cramm, PhD, OT Reg. (Ont.), is Assistant Professor, Queen’s University, School of Rehabilitation Therapy, Louise D. Acton Building, 31 George Street, Queen’s University, Kingston, ON, Canada K7L 3N6. At the time of this study,

Heidi was a doctoral candidate in the Rehabilitation Science program at Queen’s University, Kingston, ON. Terry M. Krupa, PhD, OT Reg. (Ont.), FCAOT, is Professor, Queen’s University, School of Rehabilitation Therapy, Louise D. Acton Building, 31 George Street, Queen’s University, Kingston, ON, Canada K7L 3N6. Cheryl A. Missiuna, PhD, OT Reg. (Ont.), is Professor, McMaster University, School of Rehabilitation Science, 1400 Main Street West, IAHS 414, Hamilton, ON, Canada L8S 1C7. Rosemary M. Lysaght, PhD, OT Reg. (Ont.), is Professor, Queen’s University, School of Rehabilitation Therapy, Louise D. Acton Building, 31 George Street, Queen’s University, Kingston, ON, Canada K7L 3N6. Kevin H. Parker, PhD, is Director, Queen’s University Psychology Clinic, 184 Barrie Street, Kingston, ON, Canada K7L 3K1.

Book Review Danto, Ayelet H. and Pruzansky, Michelle. (2011). 1001 Pediatric Treatment Activities: Creative Ideas for Therapy Sessions. Thorofare, NJ: Slack. 283 pp. $48.95. ISBN: 978-1-55642-968-2 DOI: 10.1177/0008417413481952

Written by two paediatric occupational therapists, this book was intended to enhance resources available to occupational and physical therapists. It is divided into seven sections on sensory integration, visual system, dissociation activities, hand skills, body strengthening and stability, cognitive and higherlevel skill building, and social skills. Each section has multiple chapters that include a description and explanation of the importance of the skills, compensatory strategies, a list of treatment ideas and activities, and examples of commercially available products. There is an abundance of photographs of children (although in black and white) demonstrating the activity and/or equipment. The equipment and supplies needed

Canadian Journal of Occupational Therapy

for the treatment sessions are inexpensive and readily available. The list of commercially available products is appropriate; however, a description of these products with a picture, manufacturer, and age range would be useful if purchasing. The 62-page appendix is composed of worksheets that are designed to support the development of visual perceptual skills, scissor skills, visual motor skills, and visual skills. Permission is granted to reproduce material only after a fee is paid. This book would be helpful for therapists working in the school system as well as in other settings. The activities can be followed through by a therapist, assistant, or parent (with guidance); therefore, the material is a useful resource for developing home programs. To make it more user-friendly and time efficient, permission to copy parts of the book would be useful.

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Beverly Franchuk

Executive functioning: a scoping review of the occupational therapy literature.

Increasingly recognized as an important factor in the performance of complex, goal-directed tasks, executive functioning is understood in different wa...
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