Validation of the Weekly Calendar Planning Activity With Teenagers With Acquired Brain Injury

PURPOSE AND BACKGROUND: The purpose of this study was to assess the validity of the Weekly Calendar Planning Activity (WCPA) Middle/High School for use as a diagnostic performance-based measure of executive function (EF) in cognitive rehabilitation with teenagers aged 12–18 with acquired brain injury (ABI). EF deficits are estimated to affect up to 38% of teenagers with ABI and can persist for years after injury, profoundly affecting social, emotional, and academic pursuits. Effectively measuring EF deficits may lead to more directive treatment for teenagers with ABI.

Differing approaches are used in rehabilitation to measure EF deficits. Although proxy and self-report tests are useful as one piece of EF evaluation, they are limited by the potential bias of the adolescent, parent, or teacher completing them. Neuropsychological (NP) measures focus on each cognitive construct in isolation and thus have questionable ecological validity—that is, ability to simulate real-world activities and predict real-world performance. Unlike the complex tasks of daily life, NP tests do not require clients to plan and organize behavior or deal with competing tasks, limiting the ability of results to predict teenagers’ success in school and functioning at home and in the community.

Performance-based tests more accurately represent performance of everyday activities of teenagers that require integrated elements of EF such as multitasking, planning, and organization, which often are not picked up by NP tests of isolated constructs. Although validated performance-based assessments of EF exist for use with adults, they have not been tested for use with adolescents. Existing pediatric tests of EF have many limitations; the WCPA does not have such limitations and shows promise for accurate measurement of functional cognition in adolescents with neurological injury.

METHOD: This study had a cross-sectional instrument validation design. The WCPA was compared to gold standard neuropsychological measures and to self- and parent-report questionnaires. Performance of teenagers with ABI was compared to that of age- and gender-matched control participants. We recruited adolescents (N = 14) with ABI (e.g., traumatic brain injury, cerebrovascular accident, neurofibromatosis, meningitis) who were ≥1 mo and <2 yr postinjury from a Midwestern children’s hospital referred by neurologists, neuropsychologists, and therapists. Neurotypical control participants (N = 27) came from the university research registry and convenience sampling.

Each participant completed a 90-min battery of EF tests: NP tests (digit span backwards; Delis–Kaplan Executive Function System Tower Test, Color–Word Interference Test, and Trail Making Test Parts A and B), self- and parent-reported EF behaviors (Behavior Rating Inventory of Executive Function [BRIEF]), and the WCPA. We looked for between-group differences on the WCPA using Mann–Whitney U tests and convergent validity of the WCPA with the NP tests and BRIEF using Spearman rank order correlations.

RESULTS: No significant group differences in demographic characteristics were found. Discriminant validity was established for the WCPA between groups, with total time to take the WCPA greater in the ABI group (U = 102.5, p = .02) and total number of rules followed greater in the control group (U = 114.0, p = .04). The severe ABI subgroup took more time to complete the task (U = 40.5, p = .02), entered fewer accurate appointments (U = 27.5, p = .004), made more errors (U = 46.5, p = .04), and followed fewer rules (U = 52.0, p = .04). The difference in number of strategies used by participants with severe ABI compared with typical adolescents approached significance (U = 48.5, p = .05). Convergent validity with NP tests and the BRIEF and WCPA showed moderate correlations across all measures (rs = .30–.50). Adolescents with ABI reported significantly more deficits than the neurotypical adolescents on the BRIEF and reported more mildly clinically elevated scores than their parents.

CONCLUSION: We established good convergent and discriminant validity of the WCPA in teenagers with ABI. The WCPA can be used to detect EF deficits in adolescents with severe ABI. In this sample, it was not sufficiently sensitive to detect deficits in participants with mild ABI. In addition, participants with severe ABI were found to be good reporters of their own cognition.

IMPACT STATEMENT: The WCPA fills the gap in performance-based assessments of EF for use with adolescents by providing a useful test of functional cognition in adolescents with brain injury. The WCPA is a valid performance-based assessment that occupational therapists can use with adolescents with severe ABI to detect EF deficits, observe strategy use, and guide intervention planning.

References

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Galvin, J., Froude, E. H., & McAleer, J. (2010). Children’s participation in home, school and community life after acquired brain injury. Australian Occupational Therapy Journal, 57, 118–126. https://doi.org/10.1111/j.1440-1630.2009.00822.x

Levin, H. S., & Hanten, G. (2005). Executive functions after traumatic brain injury in children. Pediatric Neurology, 33, 79–93. https://doi.org/10.1016/j.pediatrneurol.2005.02.002

Toglia, J., & Berg, C. (2013). Performance-based measure of executive function: Comparison of community and at-risk youth. American Journal of Occupational Therapy, 67, 515–523. https://doi.org/10.5014/ajot.2013.008482