Broadening the Occupational Therapy Toolkit: An Executive Functioning Lens for Occupational Therapy With Children and Youth

Cognitive strategies utilised by early learners when writing alphabet-letters from memory

INTRODUCTION

Occupational therapy handwriting studies have shown cognitive instructional techniques are effective methods to assist beginning or challenged handwriters. However, information about how children's cognitive (thinking) skills impact their handwriting development is scarce. This study examined the cognitive strategy efficiency of early learners while writing the alphabet-letters from memory.

METHODS

Participants included 408 mainstream children in their first two years of formal schooling (Year 1 and Year 2). Children were asked to write the 26-lowercase alphabet-letters from memory. Data were collected using alphabet-letters generated by the children and observation of their cognitive strategy use while writing. The measurement tool employed was the Perceive, Recall, Plan, and Perform (PRPP) System of Task Analysis (Stage Two).

RESULTS

The results found that Year 1 and Year 2 children had difficulties applying cognitive strategies across all four PRPP quadrants while writing the lowercase alphabet-letters from memory. Application of the cognitive strategies from the Plan and Recall quadrants showed the most inefficiencies. The lowest PRPP subquadrant scores were observed in Evaluating, Recall Facts, Sensing, and Programming. Except for the Attending subquadrant and the descriptor 'Regulates', Year 2 children were significantly better than Year 1 children at applying cognitive strategies from all other PRPP quadrants and subquadrants.

CONCLUSION

The findings provide beginning evidence that efficient use of cognitive strategies from all four PRPP quadrants is important for children achieving proficiency in accurate and automatic alphabet-letter-writing skills. Recommendations for occupational therapy handwriting assessment and intervention are provided.

PLAIN LANGUAGE SUMMARY

Research suggests that occupational therapists can best help children with handwriting difficulties by using a cognitive approach. This approach involves instructing children how to form letters correctly, encouraging self-evaluation, and providing opportunities to practice handwriting. However, the cognitive (thinking) skills required for children to write alphabet-letters accurately are not well understood. To investigate this, a study was conducted on 408 mainstream children in their first two years of formal schooling (Year 1 and Year 2). The study examined how accurately the children could write lowercase alphabet-letters from memory and which cognitive skills they used to do so. The cognitive skills investigated were related to attention, perception, recalling, planning, and performing. The assumption tested was that mistakes in correctly writing alphabet-letters could be attributed to difficulties in using these cognitive skills effectively. The study found that Year 1 and Year 2 children made errors in over half of the 26-lowercase alphabet-letters they wrote. The cognitive skills, which scored the lowest were children's ability to evaluate their writing, recall how and where to write letters, gather information from their vision, and think carefully to ensure accuracy while writing. This implied that these thinking skills had the most impact on the children's ability to write alphabet-letters correctly. More research is needed to confirm these findings and determine the reliability of the tool used in this study to measure the children's thinking skills.

Inside the Functional Individualized Therapy for Teenagers with Executive Deficits (FITTED): Insights from the Adolescents and Their Parents

This study explores Functional Individualized Therapy for Teenagers with Executive Deficits (FITTED) factors facilitating adolescents' improvement. At each of eight therapy sessions, 41 adolescents with executive function deficits and their parents wrote the primary concept they "took away." Experts categorized their answers by the FITTED model's main factors-goals, strengths, and strategies-adding child's difficulties for the parents' answers. Results describe answer frequencies by factor in each session. Across time, strengths and strategies dominated among adolescents, and strategies and difficulties among parents. Cognitive strategies are integral to the FITTED process for improving the daily functioning of adolescents with executive function deficits.

Anticipatory Awareness and Actual Handwriting Performance Measures among Adolescents with Deficient Executive Functions

This secondary analysis explores differences and correlations between handwriting anticipatory awareness (time estimation, expected performance, and expected difficulty) before a paragraph copying task and actual performance time and legibility among adolescents with executive function deficits (EFD) versus neurotypical adolescents. Eighty-one adolescents (10–18 years old; 41 with EFD and daily functioning difficulties as per parent reports) estimated their time, expected performance, and expected difficulty before the paragraph copying task using the Self-Awareness of Performance Questionnaire (SAP-Q). Time duration was assessed using the Computerized Penmanship Evaluation Tool (ComPET) software, and legibility was scored using the Handwriting Legibility Scale (HLS). Significant between-group differences were found in actual time duration (ComPET), HLS total score and legibility components, and three SAP-Q questions. Both groups estimated significantly more performance time than their actual performance duration. The adolescents with EFD underestimated their performance before the handwriting task. Significant correlations were found between actual performance, anticipatory awareness, and Executive Function (EF) in both groups. Their performance predictions were significantly correlated with their EF and product’s legibility. The results highlight the potential relationships between anticipatory awareness and actual handwriting performance (time duration and legibility) of adolescents with and without EFD. Further studies may analyze the benefits of focusing on both EF and anticipatory awareness for handwriting improvement among populations with EF deficits.

The Discrepancy between Actual Performance and Self-Awareness among Adolescents with Executive Function Deficits

Adolescents with executive function deficits (EFD) struggle to perform complex daily activities and have difficulty being self-aware of their performance. This study aimed to compare actual performance with self-awareness of performance among adolescents with EFD before and after a metacognitive intervention. The participants consisted of 41 adolescents aged 10 to 14 years, previously diagnosed with EFD. All performed the Children’s Cooking Task (CCT), and completed the Behavioral Rating Inventory Executive Function—Self-Report (BRIEF-SR) and the Self-Awareness of Performance Questionnaire. Significant positive differences were found in the time duration and the total number of errors from the CCT and three BRIEF-SR subscale scores before and after the intervention. No significant differences were found in self-awareness of performance. After a cognitive intervention, adolescents with EFD improved their performance of a learned skill, but their self-awareness of their performance remained unchanged. These results may imply that EFD inhibits self-awareness development, and that self-awareness may not depend on task performance, but, rather, is influenced by other external factors. The article reports the secondary analysis from the results of the Functional Individualized Therapy for Teenagers with Executive Deficits (FITTED) intervention on human participants.

Exploring the Impacts of Environmental Factors on Adolescents' Daily Participation: A Structural Equation Modelling Approach

Adolescents with neurodevelopmental difficulties struggle to perform daily activities, reflecting the significant impact of executive functions on their participation. This research examines an integrated conceptual model wherein supportive environmental factors in the community, school and home settings explain the children's participation (involvement and frequency) with their daily activities performance as a mediator. Parents of 81 10- to 14-year-old adolescents with and without executive function deficit profiles completed the Participation and Environment Measure for Children and Youth and the Child Evaluation Checklist. A secondary analysis was conducted to examine the structural equation model using AMOS software. The results demonstrated support for the hypothesised model. Supportive environmental demands in school predicted 32% of home participation, and the adolescents' daily performance reflected that executive functions mediated the relationship between them. Together, these findings highlight the school environment as the primary contributor that affects the children's functioning according to their parents' reports and as a predictor of high participation at home in terms of frequency and involvement. This study has implications for multidisciplinary practitioners working with adolescents in general, and in the school setting specifically, to understand meaningful effects of executive functions on adolescents' daily functioning and to provide accurate assistance and intervention.

Daily Performance of Adolescents with Executive Function Deficits: An Empirical Study Using a Complex-Cooking Task

Purpose

To characterize and analyze the performance of adolescents with executive function deficits through the Children's Cooking Task (CCT) as a performance-based complex ecological assessment.

Methods

Participants were 41 adolescents (aged 10–14 years) with normal intellectual function and executive function deficit profiles based on the Behavior Rating Inventory of Executive Function (BRIEF) parent reports and self-reports (BRIEF-SR) and the WebNeuro and 40 controls with typical development matched by age and gender. Participants in both groups performed the CCT, an ecological standardized complex task.

Results

Significant group differences were found for all CCT outcome measures (total number of errors, task duration, and all qualitative rating variables). Significant correlations were found among children with executive function deficit profiles between the CCT performance duration and total number of errors and the BRIEF-SR subscale score. Two separate discriminant function analyses described primarily by the CCT correctly classified the study groups.

Conclusion

The poor performance of adolescents with executive function deficit profiles exhibited through the standardized complex task, as well as the relationships with their executive functions, supplies better insight about their daily confrontations. Identifying how they perform may lead to development of focused interventions to improve these adolescents' daily performance, participation, and wellbeing.

Applied Behavior Analysis, Autism, and Occupational Therapy: A Search for Understanding

Occupational therapists strive to be mindful, competent practitioners and continuously look for ways to improve practice. Applied behavior analysis (ABA) has strong evidence of effectiveness in helping people with autism achieve goals, yet it does not seem to be implemented in occupational therapy practice. To better understand whether ABA could be an evidence-based option to expand occupational therapy practice, the authors conducted an iterative, multiphase investigation of relevant literature. Findings suggest that occupational therapists apply developmental and sensory approaches to autism treatment. The occupational therapy literature does not reflect any use of ABA despite its strong evidence base. Occupational therapists may currently avoid using ABA principles because of a perception that ABA is not client centered. ABA principles and occupational therapy are compatible, and the two could work synergistically.

State of the Journal, 2013

The American Journal of Occupational Therapy (AJOT) has developed into a solid research journal, increasingly disseminating evidence-based research able to inform practice.