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

Misunderstood Children.

Participants noted that it is common for adults to misunderstand EF performance issues among children and youth, perceiving them to be lazy, lacking in motivation, or willfully misbehaving. EF performance issues are often “misinterpreted as, ‘this is behaviour’… they’ve got voluntary control … they’re doing it on purpose” (OT07–B). Being able to see past the externalizing behaviors requires that an occupational therapist recognize that EF is a factor in the occupational performance issue, identify its effect, and label it accordingly.

Widespread Effects.

The occupational therapists in the study described the effects of EF issues on occupational performance as negative and widespread, interfering with independence levels and engagement in preferred occupations. From social interaction to self-care routines to the classroom to doing homework, school-aged children with EF issues were consistently described as struggling to get started, to understand what was expected of them, to realize that they needed to ask for help, and to recognize when they were missing information. Making sense out of the task at hand can overwhelm school-aged children’s EF, because “they truly don’t know how to make sense of what they are seeing” (OT13–E).

Core to that difficulty is being able to break the task down into its essential elements, a process that helps define the plan and its sequence, and a sense of the desired product: “You’re stuck before you even start”(OT10–E). Discerning the most salient aspects of a task proves challenging, compounded by deficits in discrete EF performance components such as attention, memory, cognitive rigidity, and impulse control. A child with working memory issues may express, “It’s in my head, I just can’t find it, I know it’s in my head” (OT02–E). Such deficits add significant burden to completing nonroutine tasks. Moreover, with growing age, curriculum and family expectations increasingly tax a student’s EF as projects are introduced, writing becomes less about copying words and more about generating organized and integrated written composition, and increased levels of independence and self-direction are expected at home.

Negative Consequences.

If EF impairments are not recognized and accommodated, children and youth who are struggling will question whether “it’s something wrong and different and bad about them compared to their peers? Because everyone else seems to get it” (OT13–E). Within their primary productivity role as students, children and youth with EF problems increasingly avoid tasks that exceed their EF capacity, such as written composition. School refusal and disengagement from the student role become more and more common with increasing grade level, as do secondary mental health issues such as depression, anxiety, and even suicide. Consequently, participants described foreseeable sequelae: “You either get the outburst behavior or you get the kid that is not engaged. He is just sitting there” (OT08–B). To mitigate these types of negative outcomes, participants emphasized the importance of incorporating an EF lens into the occupational therapy practice repertoire with school-aged children: “It needs to become one of the hypotheses that we generate, we test, we accept, we reject that, you know, the reason he can’t do that” (OT02–E).

Obscured From View.

Occupational therapists in the study consistently reported that consideration of EF within school-aged practice occurs, at best, inadvertently. Many participants remarked that they may not be consciously aware of the presence or influence of EF on occupational performance, attributing the source of performance issues to sensory or motor factors. Difficulties in getting started, for example, may be interpreted as a sensory integrative praxis issue rather than as an EF impairment in initiation. As a result, occupational therapists may directly observe performance-manifesting EF issues, but not recognize them as such: “Executive functioning doesn’t get the—it’s not front and center; for pediatric therapists, in my experience, it’s almost like executive functioning gets labeled as all these other things in kids” (OT03–E).

In addition to the use of different labels, participants noted that it is quite difficult to tease out the role of EF from other contributing factors. For example, specification of task requirements must be confirmed: “Just because you don’t know what’s required of that task does not mean you have a planning problem” (OT04–E). Determining whether anxiety is a primary condition or secondary to disordered doing is akin to sorting out which came first—the chicken or the egg. Consideration of EF issues happens much later in the clinical reasoning process after the “most obvious ones … because it becomes more and more complex” (OT07–B), and it may not be considered at all. That focus may flow from services that have a “pretty narrow focus” (OT02–E) on remediation of the perceived sensory or motor deficit.

Although sensory, motor, or both approaches are necessary, they may not be sufficient to respond to the complexity and depth of the occupational performance issues stemming from EF issues. A seasoned occupational therapist remarked that “we’ve sold ourselves down that river by doing, you know, working on printing and so, when there is so much more a child needs to do to get to school, organizational part or all the life skill stuff is not addressed” (OT05–E). Therapists often feel constrained by their program mandate, which encourages them to focus on specific components. The system may be “set up to not have you go there” (OT03–E).

Feeling Ill Equipped.

Study participants consistently reported that although curriculum covering EF is associated with adult brain injury and commonly considered part of the repertoire of occupational therapy knowledge and skills, therapists do not necessarily integrate or translate that knowledge base beyond the adult population or recognize its relevance across the life span and occupational performance domains. A recent graduate lamented that “no one told us” (OT12–B) that the kids with whom occupational therapy works would have EF issues. Indeed, one participant asserted that occupational therapists with questions about EF “can’t really find those answers in textbooks … executive function needs to be put within a context but they don’t have the context even” (OT04–E). Without this context, psychological reports that identify and describe EF issues may not be used, because their relevance to occupational therapy is unclear.

Moreover, even when therapists did identify that EF is an issue, they reported feeling ill-equipped to address this “murky” (OT12–B) area. Requiring more information about what EF issues might look like from a performance perspective, as well as the developmental trajectories of typical and atypical EF across the life span, participants described needing more information about assessments, theories, models, and frameworks that explicate EF and its relation to occupational performance: “I don’t have a framework that I refer to and I don’t even know if there is one… . I’ve got ideas and feelings and some evidence about it” (OT09–E). Therapists reported similar concerns about interventions. Therapists wondered whether organizational strategies such as checklists and visual timers were little more than common sense as they “just seem so basic… . I’m a highly trained professional, I shouldn’t, you know, surely, I have more to offer than that” (OT02–E). Cognitive strategies used to mediate a child’s performance on a task garnered a similar response, as participants seemed unsure whether their prompts were merely helpful or actually part of an intervention framework.

Politics of Change.

Several study participants speculated that occupational therapists may be less assertive and confident than other health care professionals in explicitly addressing EF. Therapists are feeling as though they need

Participants also broached the notion that therapists may prefer certain approaches to practice because of a comfort level with certain types of practice models or may prefer enacting a prescriptive rather than a collaborative role with clients. In addition, pressures within occupational therapy practice contexts may impede the broadening of how the occupational therapists’ expertise is deployed. One occupational therapist speculated that broadening the lens to include EF may create considerable resistance from educators who are used to a particular pattern of occupational therapy interventions:

This situation creates a complex climate for incorporating an additional lens into practice. Indeed, occupational therapists who have integrated EF into their practice perspective reported tension and conflict with other occupational therapists. For instance, one participant described an experience of being challenged by another occupational therapist: “It was—very confrontational and it was very, ‘What? You have no right to even address this. This isn’t handwriting!’” (OT13–E). As a result, there may be forces at play within the profession and practice contexts to maintain the status quo of traditional approaches.

Interprofessional Relationships.

The role of interprofessional relationships was reported as critical to acquiring an EF lens, but it depended on “whether you get exposed to it or not” (OT11–E). Having established EF language, frameworks, and models, education and psychology colleagues, in particular, played significant roles in enabling occupational therapists to being able to see EF. Opportunities to engage in interprofessional dialogue were described as enlightening and formative, allowing occupational therapists to gain skills such as understanding and interpreting psychological assessment reports.

Participants also championed the transformative power of mentorship from outside of the profession, citing highly experienced professionals with knowledge and experience with EF who, as one participant noted, “have the education and who they themselves can identify that that’s what the issue is. So people that understand that piece to it, I think, how they would address things from that point of view” (OT09–E). Participants who had had access to these kinds of mentors and interprofessional relationships recognized that their experiences were exceptional and outside of what is generally available.

Working With Clients.

Digging deeper to reveal the role of EF seems to happen when traditional approaches are not effective in resolving the occupational performance issues with clients who have conditions such as ADHD. Therapists reflected that their personal shifts were precipitated by “feeling like lots of the other component-based bottom-up approaches are not particularly effective” (OT03–E) and that “what I was doing wasn’t making a whole lot of difference” (OT02–E). Participants noted that incorporating EF into their clinical reasoning aligned closely with their individual and the profession’s shift toward top-down, occupation-based practice, enabling a shift toward attending to the “how” of occupational performance and engagement: The focus on execution of occupational performance implicit with the EF lens is “so perfectly OT because, you know, it’s part of that whole, ‘why can’t they do it’” (OT11–E).

Explicitly considering EF and its relation to occupational performance “gives OT a whole new way of looking at this stuff that it’s always been there but we haven’t really put words to or put a lot of value to” (OT09–E). Teasing out these EF performance issues requires observing performance of daily occupations and dynamic performance analysis that will reveal “where the glitch is” (OT13–E) and lay the foundations for the intervention plan. Furthermore, participants reported that systematic trial of a variety of interventions can help to expose the source of the performance issue such that “the intervention starts to explain the problem, rather than the problem the intervention” (OT04–E).

Also helpful was the opportunity to make connections between standardized assessments and real-life performance. The degree to which the practice context afforded the occupational therapist the opportunity to do just that was highly variable. Participants who had worked in various practice contexts with school-aged children reported that working within clients’ homes laid bare the daily challenges the child and family face when managing EF difficulties. Working in community settings “makes you see the reality really quickly” (OT09–E) in a way that a more defined, school-based role may not.