Weekly Calendar Planning Activity (WCPA): Validating a Measure of Functional Cognition for Adolescents With Attention Deficit Hyperactivity Disorder

Abstract

Importance: Adolescents with attention deficit hyperactivity disorder (ADHD) often experience difficulties with executive function and participation in life roles. Ecologically valid performance-based tests (PBTs) are needed to assess functional cognition in this population.

Objective: To examine the known-groups, concurrent, and ecological validity of a functional cognition PBT, the Hebrew version of the Weekly Calendar Planning Activity (WCPA) Middle/High School Version, among adolescents with and without ADHD.

Design: Cross-sectional between-groups design.

Setting: Community.

Participants: One hundred two adolescents (ages 12–18 yr), with (n = 52) and without (n = 50) ADHD.

Outcomes and Measures: The Hebrew version of the WCPA Middle/High School Version, MOXO™–Continuous Performance Test (MOXO–CPT), Behavior Rating Inventory of Executive Function (BRIEF) parent form, and Child and Adolescent Scale of Participation (CASP).

Results: The results showed significant between-groups differences with medium to large effect sizes for scores on most WCPA measures, with the ADHD group receiving significantly lower scores. Significant correlations in the expected direction were found between scores on the MOXO–CPT Attention and Hyperactivity indices and WCPA measures. Significant correlations were also found between most WCPA measures and the BRIEF Global Executive Composite (GEC) and the CASP. Multiple linear regression on the CASP indicated that the WCPA strategy score and the BRIEF GEC were significant predictors in the model.

Conclusions and Relevance: Results support the known-groups validity of the WCPA Middle/High School Version between adolescents with and without ADHD. Concurrent and ecological validity were supported by significant associations with measures of cognition and participation.

What This Article Adds: These results reinforce the premise that the WCPA Middle/High School Version can be implemented as a valid measure of functional cognition among adolescents with ADHD.

The results of this study reinforce the premise that the Weekly Calendar Planning Activity (WCPA) Middle/High School Version can be implemented as a valid measure of functional cognition among adolescents with attention deficit hyperactivity disorder (ADHD).

Functional cognition is defined as the cognitive ability to perform daily life tasks, and it is conceptualized as incorporating metacognition, executive function (EF), performance skills (e.g., motor skills that support action), and performance patterns (e.g., habits, routines; Giles et al., 2017). It combines the constructs of function and cognition, which refer to the use of cognitive processes in the widest sense, in the context of everyday activities and occupations. Rather than assessing specific cognitive skills (e.g., attention, memory) in isolation from one another, the goal of a functional cognition evaluation is to identify a person’s capacity to perform essential tasks, given the totality of their abilities, including their use of strategies, habits, or routines and contextual and environmental resources (Giles et al., 2020). Performance-based tests (PBTs) of functional cognition examine the how of performance but, unlike neuropsychological tests, are not intended to identify brain dysfunction. PBTs of functional cognition are intended to assess the client’s cognition at the performance level across several functional domains in real-world contexts and to enable therapists to estimate the amount and type of support the client needs to manage the activity demands of their daily life (Giles et al., 2017, 2020).

EFs are defined as an interrelated set of higher level cognitive abilities that are needed to direct and coordinate goal-directed actions. EFs encompass planning, organizing, and problem solving and help people mentally represent goals across time, anticipate future consequences of actions, and make behavioral adjustments when needed (Barkley, 2012). EFs play a critical role in initiating, maintaining, and promoting a healthy lifestyle, and they are a major determinant of healthy behaviors. The current literature shows that many chronic diseases, neurodevelopmental disorders, neurological disorders, and psychopathologies are associated with EF challenges (see Toglia & Katz, 2018, for a review). One of the most common neurodevelopmental diagnoses involving impaired EF is attention deficit hyperactivity disorder (ADHD). A strong relationship exists between EF and ADHD, and many children, adolescents, and adults diagnosed with ADHD exhibit EF challenges that affect their functional performance and participation in life roles (Barkley, 2015; Brown, 2013). Thus, EFs are conceptualized as a significant component of functional cognition among people with ADHD.

Understanding the impact of EFs on daily life is important in determining interventions for people with ADHD, who are required to self-manage their health condition over time. These clients need to learn to adapt to and compensate for their EF challenges in daily life in order to limit their negative impact and enhance participation in life roles (Barkley, 2012, 2015). PBTs that use simulated real-life tasks have the potential to achieve a high level of ecological validity, meaning that the assessment produces data that represent the client’s interactions with their surroundings and provides clinical utility beyond diagnostic utility (Wallisch et al., 2018). The Weekly Calendar Planning Activity (WCPA; Toglia, 2015) is a PBT of instrumental activities of daily living that targets EF processes (e.g., planning, organization, inhibition, working memory, and flexibility) through a complex task that involves scheduling multiple activities on a weekly calendar. Research on the WCPA that compared at-risk adolescents returning to high school after dropping out with community high school students, ages 16 to 21 yr, demonstrated that the at-risk group made more errors, used fewer strategies, and broke more rules. These findings support the use of the WCPA as a PBT of EF (Weiner et al., 2012) and provide support for its discriminant validity with at-risk adolescents and control participants (Toglia & Berg, 2013).

Another WCPA study revealed that college students with ADHD had significantly lower WCPA scores than control participants (Lahav et al., 2018). With respect to typically developing adolescents, a recent study demonstrated that the WCPA Middle/High School Version was significantly correlated with parent reports on the Behavior Rating Inventory of Executive Function (BRIEF; Zlotnik & Toglia, 2018), a rating scale of EF in daily life. The literature supports the known-groups validity of the WCPA in detecting challenges among groups with documented evidence-based EF deficits in daily life (Toglia & Katz, 2018), as well as its convergent validity with an ecological EF rating scale. Thus, the WCPA is considered an important PBT of functional cognition for people with EF deficits (Lussier et al., 2019).

Adolescents with ADHD were the focus of the current study. Adolescence has been described as a transitional developmental period distinguished by changes in physical, psychological, and social development, and it is also associated with changes in cognition and EF (Esnaola et al., 2020; Weil et al., 2013). The prevalence of ADHD among adolescents is estimated at about 7% to 13% (Xu et al., 2018), and it is associated with many functional impairments in everyday activities, challenges in social interactions, and academic underachievement (e.g., Biederman et al., 2012; Frazier et al., 2007). In the long term, adolescents diagnosed with ADHD are at risk for more negative outcomes, including substance abuse (Molina et al., 2018) and school dropout (Biederman et al., 2004). Considering their transitional developmental stage, which is characterized by a need for autonomy, and their ADHD-related risks for current and future occupational dysfunction, this population should be targeted for cognitive–functional intervention.

Measures of functional cognition that address the interface between cognition and participation are needed for this population. The WCPA Middle/High School Version is a PBT of functional cognition (Lussier et al., 2019; Toglia, 2015), but its validity has not yet been established among adolescents with ADHD. The use of ecological PBTs has the potential to engage adolescents in a client-centered self-management intervention process because such assessments provide an opportunity to examine performance indicative of real-life strengths and difficulties. Bringing these observations into the clinic is the foundation for exploring awareness and self-management strategies for daily life (Rotenberg & Maeir, 2019; Toglia & Katz, 2018).

The objective of this study was to examine the known-groups, concurrent, and ecological validity of a functional cognition PBT, the WCPA Middle/High School Version, among adolescents with and without ADHD. We hypothesized that adolescents with ADHD would demonstrate worse performance than control participants and that measures of cognition and participation would be moderately correlated with the WCPA Middle/High School Version.

Method

Research Design

This study had a cross-sectional, correlational design. The study was approved by the Helsinki ethics committee of the Haddassah Medical Center (Protocol No. 0366–16-HMO). Participants and their parents signed informed consent. Data were collected at the Hebrew University from 2016 to 2019. Participants in the ADHD group were recruited from neuropediatric clinics in the community and an ambulatory clinic that is affiliated with an academic hospital. Participants in the control group were recruited through convenience sampling and snowball techniques and were age and gender matched to the research group.

Participants

We recruited 102 Hebrew-speaking Israeli adolescents, ages 12 to 18 yr, with (n = 52) and without (n = 50) ADHD who attended regular education schools. Inclusion criteria for the ADHD group were as follows: (1) valid diagnosis of ADHD by a neurologist or psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders (fifth ed.; American Psychiatric Association, 2013), as confirmed by administration by an expert psychologist (Ephraim S. Grossman) of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime (Version 2.0; Kiddie–SADS–PL; Kaufman et al., 1996), and (2) no change in pharmacological status during the past 3 mo. Exclusion criteria for the ADHD group were (1) an estimated IQ <85; (2) a score lower than one standard score on the Block Design and Vocabulary subtests of the Wechsler Intelligence Scale for Children, Fourth Edition (WISC–IV; Wechsler et al., 2004); and (3) on a medication that did not allow for a 24-hr pause (e.g., atomoxetine). Exclusion criteria for the control group were (1) ADHD symptoms, as indicated by a score above the cutoff for clinical impairment on both the Hyperactivity–Impulsivity and Problems/Inattention subscales (T > 65) of the Conners’ Parent Rating Scales–Revised (CPRS–R; Conner, 2000) and (2) no learning difficulties on the basis of parent report. Another exclusion criterion for both groups was an additional major neurological or psychiatric health condition (e.g., autism spectrum disorder, cerebral palsy, epilepsy, intellectual disability), based on parent report.

Procedure

After receiving ethical approval, physicians referred adolescents with ADHD to the researchers. Physicians informed parents of potential participants about the study and gave them an information page and contact information for the primary researcher (Orit Fisher). Control participants were selected from a pool of typically developing Israeli adolescents from a study of the WCPA Middle/High School Version, recruited using convenience and snowball sampling (Zlotnik et al., 2021). Participants who scored above the CPRS–R cutoff score (n = 5) for ADHD or with a parent report of learning difficulties (n = 11) were excluded. The 50 remaining participants were matched by age and gender to those in the ADHD group. The study was described to parents of potential participants who provided consent over the phone and were then invited with their adolescent to the university research lab. ADHD group participants did not take medication on the day of the study.

Parent and adolescent measures were collected during a 3-hr session. The two PBTs of cognition (WCPA and MOXO™–Continuous Performance Test [MOXO– CPT]; Berger & Goldzweig, 2010) were administered randomly in a counterbalanced order. The ADHD group also completed the WISC–IV, and the expert psychologist administered the Kiddie–SADS–PL to parents. No participants were excluded from the study as a result of the Kiddie–SADS–PL and WISC–IV results. There were no dropouts during the study; all participants completed the study. Parents also completed the BRIEF and Child and Adolescent Scale of Participation (CASP; Bedell, 2004). The study was coordinated by Orit Fisher, an experienced occupational therapist and, at the time of this research, a PhD student.

Instruments

Weekly Calendar Planning Activity Middle/High School Version

The WCPA Middle/High School Version (Toglia, 2015) focuses on EF challenges as reflected in a multiple-step activity. In this study, we used a version of the WCPA Middle/High School Version that was translated to Hebrew and adapted to meet the cultural context of Hebrew-speaking Israeli adolescents (Zlotnik et al., 2021). A randomly ordered list of 18 appointments that need to be scheduled on a 1-wk calendar is displayed to the client. Decision-making is needed to place the appointments in the most accurate space, using effective strategies and adhering to five rules: (1) leave Tuesday free, (2) do not cross out appointments after they are entered onto the calendar, (3) ignore distracting questions from the examiner, (4) inform the examiner when it is a specified time, and (5) inform the examiner when finished. The examiner observes and records the strategies that the client uses during the task and through a semistructured interview conducted after the task is completed. Clients are scored on measures of accuracy (number of accurate appointments scheduled out of 18), number of appointments entered, planning time (time from the beginning of the assessment until the first appointment is scheduled), total time and efficiency score (calculated from the accuracy and total time), error types, number of rules followed, and number and types of strategies used. A high level of interrater reliability for the total accuracy score was established (Weiner et al., 2012), as well as discriminant validity between typically developing and at-risk youth (Toglia & Berg, 2013), college students with ADHD and control participants (Lahav et al., 2018), and typically developing adolescents and those with epilepsy Zlotnik & Toglia, 2018).

MOXO–Continuous Performance Test Adolescent Version

The MOXO–CPT Adolescent Version (Berger & Goldzweig, 2010) is a standardized computerized test designed to evaluate ADHD-related cognitive processes. In this study, it was administered to examine convergent validity regarding the cognitive aspects of the WCPA. The MOXO–CPT requires sustained attention over 17 min to continuous visual and auditory stimuli that vary by load, symbol, and time interval. It includes four indices: Attention, Timing, Impulsivity, and Hyperactivity. Discriminant validity was found between adolescents with ADHD and typically developing control participants (Berger & Cassuto, 2014).

Behavior Rating Inventory of Executive Function, Parent Form

The Behavior Rating Inventory of Executive Function (BRIEF; Gioia et al., 2000) is an ecological rating scale designed to reflect the neuropsychological constructs of EFs in everyday situations. The BRIEF is designed for parents of children and adolescents ages 5 to 18 yr and consists of 86 items. It has eight subscales of main EFs, two indices, and an overall Global Executive Composite (GEC), which was the main score used in this study. The raw scores are transformed into T scores, and the normative mean score is 50 (SD = 10). Clinical threshold scores are indicated by T scores of 65 or higher. Internal consistency, test–retest reliability, and discriminant and convergent validity have been established for people with ADHD (McCandless & O’Laughlin, 2007).

Child and Adolescent Scale of Participation

The Child and Adolescent Scale of Participation (CASP; Bedell, 2004) assesses the extent of children’s participation and restrictions in home, school, and community life situations and activities compared with those of same-age peers, as reported by family caregivers. It consists of 20 items divided into four subsections and provides a total score that was the main measure used in the current study. Scores range from 0 to 100, with higher scores indicating better participation. Test–retest reliability, internal consistency, and construct and discriminant validity have been established for people with acquired brain injury (Bedell, 2004 , 2009) and those with chronic health conditions, including ADHD (De Bock et al., 2019).

Data Analysis

IBM SPSS Statistics (Version 25) was used for data analysis. We used t tests and χ² tests to compare demographic parameters of age, gender, and mother’s educational level. Multivariate analysis of variance (MANOVA) was used to examine differences between groups on scores for six WCPA measures (entered appointments, accuracy score, rules followed, strategy use, total time, and efficiency score). Significance was set at .05, and η_p ² is reported as the effect size for the MANOVA test, with η_p ² = .01 considered a small effect size, η_p ² = .06 a medium effect size, and η_p ² = .14 a large effect size (Richardson, 2011). Further analyses of associations between variables were computed only for the ADHD group. We examined correlations between the WCPA outcome measures and the cognitive instruments (MOXO–CPT and BRIEF parent report), as well as for the participation measure (CASP). One-tailed significance, according to the direction of the hypothesis, was considered. Finally, we performed exploratory multiple regression analyses to examine the unique and combined contributions of the Hebrew version of the WCPA Middle/High School Version and the BRIEF to the explained variance on the CASP.

Results

Characteristics and distribution of the participants (N = 102) by age, gender, and parental education level are presented in Table 1. No significant age and gender differences were found between the ADHD and control groups. Significant group differences were found in mother’s years of education, t(99) = 3.68, p = .000; mothers of the control group participants were less educated. No significant associations (all ps > .1) were found between this variable and all other study measures (Hebrew version of the WCPA Middle/High School Version, MOXO–CPT, BRIEF, and CASP). Descriptive statistics for the ADHD group revealed that 63.5% of the participants took ADHD medication, 57.7% had been diagnosed with the combined type of ADHD, and 58.0% had at least one comorbidity in addition to the ADHD diagnosis.

Table 1.

Characteristics of the Study Participants

Characteristic	n (%)
Characteristic	ADHD Group (n = 52)	Control Group (n = 50)
Age, M (SD), range	14.44 (1.58), 12–17.5	14.76 (1.75), 12.08–17.92
Gender
Male	36 (69.0)	32 (64.0)
Female	16 (31.0)	18 (36.0)
Mother’s education, yr, M (SD)	18.29 (3.00)	16.16 (2.81)*
ADHD medication
Yes	33 (63.5)
No	19 (36.5)
ADHD type
Inattentive	18 (34.0)
Impulsive	4 (8.5)
Combined	30 (57.5)
Comorbidities^a
Depression	3 (5.0)
Anxiety	9 (18.0)
Behavioral disorders	23 (44.0)
LD	28 (54.0)
Pure ADHD (no comorbidities)	22 (42.0)

Note. Behavioral disorders include oppositional defiant disorder (33%), conduct disorder (26%), or both. ADHD = attention deficit hyperactivity disorder; LD = learning difficulties.

The overall n for each comorbidity differed because of missing values.

p < .01.

The overall MANOVA group effect between groups on WCPA score was significant, F(6, 90) = 12.527, p < .000, η_p ² = .461. Significant univariate effects with medium to large effect sizes were found for WCPA accuracy score, the number of rules followed, total time, and efficiency score, with the ADHD group scoring significantly lower. In other words, adolescents with ADHD made more mistakes, followed fewer rules, used more time, and used fewer strategies than control participants. Control participants used approximately one strategy more than ADHD participants, but the difference was not statistically significant (Table 2).

Table 2.

Comparing Group WCPA Scores

WCPA Task	M (SD)		F(6, 90)	η² _p
WCPA Task	ADHD Group (n = 52)	Control Group (n = 50)	F(6, 90)	η² _p
Entered appointments	16.82 (2.28)	17.52 (0.81)	3.96*	0.04
Accuracy	12.9 (3.35)	15.18 (1.79)	18.17**	0.16
Rules followed	3.77 (0.91)	4.42 (0.73)	14.20**	0.13
Strategy used	5.00 (2.65)	5.94 (2.14)	3.64	0.04
Total time	33.60 (14.08)	23.18 (7.77)	23.14**	0.20
Efficiency	276.31 (234.27)	111.68 (48.81)	24.39**	0.21

Note. ADHD = attention deficit hyperactivity disorder; WCPA = Weekly Calendar Planning Activity.

p < .05.

p < .001.

Correlations were calculated between the WCPA and (1) cognition as measured by the MOXO–CPT and BRIEF parent report and (2) participation as measured by the CASP (Table 3) for only the ADHD group. Significant correlations in the expected direction were found between the MOXO–CPT Attention and Hyperactivity indices and WCPA appointments entered, accuracy, rules followed, and efficiency. In addition, we found significant correlations between WCPA accuracy and rules followed with the BRIEF GEC score. Regarding the CASP total score, we found significant correlations in the expected direction for all WCPA measures except total time—that is, lower scores on the WCPA were associated with lower scores on participation and vice versa, indicating that cognitive performance and participation in daily life were associated. In other words, according to these findings, the WCPA was found to be a cognitive functional PBT for the ADHD group.

Table 3.

Correlations Between the WCPA and the MOXO–CPT, BRIEF, and CASP for the ADHD Group

Measure	WCPA Task
Measure	Entered Appointments	Accuracy	Rules Followed	Strategy Use	Total Time	Efficiency
MOXO–CPT
Attention	.25*	.22	.12	.01	−.23	−.32*
Timing	−.03	.07	.07	.02	−.21	−.30
Impulsivity	.05	−.16	−.23	.24*	−.01	.04
Hyperactivity	−.12	−.34*	−.34*	−.03	−.11	.15
BRIEF GEC	−.19	−.29*	−.25*	−.15	−.05	.19
CASP Total	.35*	.35*	.29*	.40**	.21	−.26*

Note. n = 47. ADHD = attention deficit hyperactivity disorder; BRIEF = Behavior Rating Inventory of Executive Function; CASP = Child and Adolescent Scale of Participation; GEC = Global Executive Composite; MOXO–CPT = Continuous Performance Test; WCPA = Weekly Calendar Planning Activity.

p < .05.

p < .01.

Multiple linear regression was computed within the ADHD group to determine the unique contribution to participation (CASP total) of the two ecological measures of cognition: the WCPA and the BRIEF (Table 4). The variables were selected according to the correlation matrix in Table 3. In addition, demographics were entered into the model to control for age and gender effects. The model was significant, F(4, 43) = 16.810, p < .000, accounting for approximately 60% of the explained variance on the CASP (R ² = 63.3, adjusted R ² = 59.5). Both the WCPA strategy score and the BRIEF GEC were significant predictors in the model. Age and gender did not contribute significantly to participation. In summary, these results demonstrate that both ecologically valid EF tests (WCPA and BRIEF) provide a unique contribution to the explained variance in participation among adolescents with ADHD—that is, worse EF predicts less participation.

Table 4.

Multiple Regression Analyses on Participation: CASP Total Parent Report for the ADHD Group

Variables Entered	β	t(43)	p
Age	0.17	1.69	.10
Gender	0.10	0.93	.36
WCPA strategy score	0.24	2.32	.03
BRIEF GEC	−0.67	−6.80	.00

Note. n = 47. F(4, 43) = 16.81, p < .000; R ² = 63.3; adjusted R ² = 59.5. ADHD = attention deficit hyperactivity disorder; BRIEF = Behavior Rating Inventory of Executive Function; CASP = Child and Adolescent Scale of Participation; GEC = Global Executive Composite; WCPA = Weekly Calendar Planning Activity.

Discussion

The aim of this study was to examine the validity of a functional cognition PBT, the Hebrew version of the WCPA Middle/High School Version, among adolescents with ADHD. The results support the known-groups validity of the Hebrew version of the WCPA in differentiating between adolescents with and without ADHD. Moreover, concurrent and ecological validity were supported by significant associations with measures of cognition and participation. These results reinforce the premise that the Hebrew version of the WCPA Middle/High School Version can be implemented as a valid measure of functional cognition among adolescents with ADHD.

Recent literature on comorbidities of ADHD has documented rates of comorbidity similar to those in the current study (Cuffe et al., 2020; Reale et al., 2017). Because comorbidities of ADHD are highly prevalent (e.g., DuPaul et al., 2013; Wilens et al., 2002), it is important to include them when seeking to investigate ecological outcomes. A sample of adolescents diagnosed with pure ADHD (i.e., with no comorbidities) may achieve better scores on all measures. However, the most common clinical representation of the ADHD population is having comorbidities. Therefore, this sample represents the characteristics of adolescents with ADHD in the real world.

When discussing the findings of this study, it is helpful to consider two central dimensions of EF assessment reflecting the interaction between methodology and content in neurocognitive evaluations. The first dimension relates to the method of administration, such as standardized PBTs versus behavioral rating scales, which rely on self-report or significant other report. The second dimension relates to the content of the assessment and represents the neuropsychological versus ecological discourse. The neuropsychological perspective targets isolated EF abilities that can be associated with brain structures and functions, whereas the ecological perspective targets integrated EF skills that are thought to predict real-world functioning.

A large body of literature has shown that children and adolescents with ADHD exhibit significant impairments, with medium effect sizes, on PBTs that measure specific EF abilities, such as response inhibition, working memory, and cognitive flexibility (e.g., Krieger et al., 2019). In this study, specific EF abilities were represented by the MOXO–CPT. However, Barkley and Murphy (2011) undermined the assumption in ADHD research that PBTs of EFs are the gold standard for evaluating EF deficits. They argued that EF behavioral rating scales are more strongly associated with impairment in major life activities. Rating scales, though, are also subject to reporter bias and do not enable objective viewing of the client’s executive processes in the clinic. In this study, EF deficits in daily life were represented by the BRIEF rating scale. PBTs of functional cognition, such as the WCPA used in this study, aim to bridge this gap and provide reliable standardized assessments that can be administered in a clinical setting but are also designed to reflect real-world cognitive challenges.

In the current study, adolescents with ADHD demonstrated significantly lower performance than control participants on most WCPA Middle/High School Version measures of accuracy. These findings can be compared with those of other studies that have examined the WCPA among individuals with known cognitive executive impairments, such as adolescents with genetic generalized epilepsies (GGE; Zlotnik et al., 2020) and college students with ADHD (Lahav et al., 2018). These studies demonstrated lower accuracy scores and use of fewer strategies among target populations compared with control participants. College students with ADHD used significantly more time than controls, whereas time was not significantly longer among adolescents with GGE. Our findings are in line with those of these studies and revealed even more differentiating parameters of the WCPA, whereby adolescents with ADHD made more mistakes, followed fewer rules, used more time, and used fewer strategies than control participants. Taken together, these studies provide strong support for the known-groups validity of the Hebrew version of the WCPA Middle/High School Version among adolescents with expected deficits in EF.

The results of the correlation analyses address the associations of the WCPA with other measures of EF— PBTs, such as the MOXO–CPT (but not ecological) and ecological rating scales, such as the BRIEF, that are designed to capture EFs in daily life. The relationship between the WCPA and the MOXO–CPT revealed small to moderate correlations in the expected direction, pointing to some commonalities between each measure but also to their unique aspects, reflecting different levels of cognitive analyses. The MOXO–CPT was designed to capture discrete and isolated cognitive functions, whereas the WCPA measures integrated cognitive skills. Both measures share the same basic cognitive constructs, but the WCPA assesses an integration of these constructs in a complex activity. This pattern of association is similar to that found in other measures of functional cognition, whereby small to moderate correlations were found with neuropsychological measures of isolated cognitive functions.

For example, the Executive Function Performance Test was found to correlate with neuropsychological measures of working memory, verbal fluency, and attention (Baum et al., 2008), and the Multiple Errands Test (MET) correlated with attention, memory, processing speed, and EFs (Burns et al., 2019 ; Hansen et al., 2018). Regarding ecological measures of cognition, small correlations in the expected direction were found between the WCPA accuracy and rules scores and the BRIEF GEC. These correlations reflect a shared variance of both ecological measures, yet the small effect size points to the disparity between them, which can be attributed to the different measurement contexts. The BRIEF, an ecological rating scale, reflects everyday manifestations of EFs over time, whereas the WCPA relies on a one-time observation of performance of a complex task targeting EFs in a standardized setting. This finding is in accordance with Burns et al. (2019), who found a similar pattern of correlations between the MET and the Dysexecutive Rating Scale. Similar findings were also found among adolescents with epilepsy (Zlotnik & Toglia, 2018), with moderate correlations between WCPA accuracy score and BRIEF GEC. This finding also demonstrates the shared but unique pattern of variance between types of EF ecological measures, suggesting that these measures capture different aspects of EF in daily life. Indeed, the results of the regression analyses support the contention that both the WCPA and the BRIEF each provide a unique contribution to the explained variance in participation among adolescents with ADHD.

Limitations and Recommendations for Future Research

This study has several limitations. The sample was not sufficiently powered to examine the additional impact of ADHD characteristics found in the general population, such as level and type of symptoms, use of medication, gender, and presence of other neurodevelopmental conditions (e.g., learning disorders) and comorbidities that may mask EF abilities. Further studies are needed with larger and more representative samples to examine possible effects on WCPA performance. Moreover, we used the Hebrew version of the WCPA Middle/High School Version, which limits the generalizability of the findings to other cultural contexts.

Implications for Occupational Therapy Practice

The findings of this study may have the following implications for occupational therapy practice:

The Hebrew version of the WCPA Middle/High School Version may be used to diagnose EF deficits among adolescents with ADHD and, accordingly, redirect treatment goals and achieve them.

The Hebrew version of the WCPA Middle/High School Version provides unique information with respect to participation beyond that accounted for by the BRIEF cognitive functional rating scale.

Conclusions

This study contributes to the body of knowledge about adolescents with ADHD and addresses the EF challenges that affect their participation. The Hebrew version of the WCPA Middle/High School Version provides unique performance-based information on EFs in daily life. In addition, when supplemented with EF rating scales, its use may lead to a better understanding of cognitive functional challenges, defining more precise and effective targets for occupational therapy intervention.

Footnotes

Acknowledgments

We sincerely thank the parents and adolescents who participated in this study for their trust and for allowing us to learn from their experiences.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Barkley

R. A.

(2012). Executive functions: What they are, how they work, and why they evolved. Guilford Press.

Barkley

R. A.

(2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Guilford Press.

Barkley

R. A.

, & Murphy

K. R.

(2011). The nature of executive function (EF) deficits in daily life activities in adults with ADHD and their relationship to performance on EF tests. Journal of Psychopathology and Behavioral Assessment , 33 , 137–158. https://doi.org/10.1007/s10862-011-9217-x

Baum

C. M.

Connor

L. T.

Morrison

Hahn

Dromerick

A. W.

, & Edwards

D. F.

(2008). Reliability, validity, and clinical utility of the Executive Function Performance Test: A measure of executive function in a sample of people with stroke. American Journal of Occupational Therapy , 62 , 446–455. https://doi.org/10.5014/ajot.62.4.446

Bedell

G. M.

(2004). Developing a follow-up survey focused on participation of children and youth with acquired brain injuries after discharge from inpatient rehabilitation. NeuroRehabilitation , 19 , 191–205. https://doi.org/10.3233/NRE-2004-19303

Bedell

(2009). Further validation of the Child and Adolescent Scale of Participation (CASP). Developmental Neurorehabilitation , 12 , 342–351. https://doi.org/10.3109/17518420903087277

Berger

, & Cassuto

(2014). The effect of environmental distractors incorporation into a CPT on sustained attention and ADHD diagnosis among adolescents. Journal of Neuroscience Methods , 222 , 62–68. https://doi.org/10.1016/j.jneumeth.2013.10.012

Berger

, & Goldzweig

(2010). Objective measures of attention-deficit/hyperactivity disorder: A pilot study. Israeli Medical Association Journal , 12 , 531–535.

10.

Biederman

Monuteaux

M. C.

Doyle

A. E.

Seidman

L. J.

Wilens

T. E.

Ferrero

, . . . Faraone

S. V.

(2004). Impact of executive function deficits and attention-deficit/hyperactivity disorder (ADHD) on academic outcomes in children. Journal of Consulting and Clinical Psychology , 72 , 757–766. https://doi.org/10.1037/0022-006X.72.5.757

11.

Biederman

Petty

C. R.

Woodworth

K. Y.

Lomedico

Hyder

L. L.

, & Faraone

S. V.

(2012). Adult outcome of attention-deficit/hyperactivity disorder: A controlled 16-year follow-up study. Journal of Clinical Psychiatry , 73 , 941–950. https://doi.org/10.4088/JCP.11m07529

12.

Brown

T. E.

(2013). A new understanding of ADHD in children and adults: Executive function impairments. Routledge. https://doi.org/10.4324/9780203067536

13.

Burns

S. P.

Dawson

D. R.

Perea

J. D.

Vas

Pickens

N. D.

, & Neville

(2019). Development, reliability, and validity of the Multiple Errands Test Home Version (MET-Home) in adults with stroke. American Journal of Occupational Therapy , 73 , 7303205030. https://doi.org/10.5014/ajot.2019.027755

14.

Conner

K. C.

(2000). Conner’s Rating Scales—Revised. Multi-Health Systems.

15.

Cuffe

S. P.

Visser

S. N.

Holbrook

J. R.

Danielson

M. L.

Geryk

L. L.

Wolraich

M. L.

, & McKeown

R. E.

(2020). ADHD and psychiatric comorbidity: Functional outcomes in a school-based sample of children. Journal of Attention Disorders , 24 , 1345–1354. https://doi.org/10.1177/1087054715613437

16.

De Bock

Bosle

Graef

Oepen

Philippi

, & Urschitz

M. S.

(2019). Measuring social participation in children with chronic health conditions: Validation and reference values of the Child and Adolescent Scale of Participation (CASP) in the German context. BMC Pediatrics , 19 , 125. https://doi.org/10.1186/s12887-019-1495-6

17.

DuPaul

G. J.

Gormley

M. J.

, & Laracy

S. D.

(2013). Comorbidity of LD and ADHD: Implications of DSM–5 for assessment and treatment. Journal of Learning Disabilities , 46 , 43–51. https://doi.org/10.1177/0022219412464351

18.

Esnaola

Sesé

Antonio-Agirre

, & Azpiazu

(2020). The development of multiple self-concept dimensions during adolescence. Journal of Research on Adolescence , 30(Suppl. 1), 100–114. https://doi.org/10.1111/jora.12451

19.

Frazier

T. W.

Youngstrom

E. A.

Glutting

J. J.

, & Watkins

M. W.

(2007). ADHD and achievement: Meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students. Journal of Learning Disabilities , 40 , 49–65. https://doi.org/10.1177/00222194070400010401

20.

Giles

G. M.

Edwards

D. F.

Baum

Furniss

Skidmore

Wolf

, & Leland

N. E.

(2020). Health Policy Perspectives—Making functional cognition a professional priority. American Journal of Occupational Therapy , 74 , 7401090010. https://doi.org/10.5014/ajot.2020.741002

21.

Giles

G. M.

Edwards

D. F.

Morrison

M. T.

Baum

, & Wolf

T. J.

(2017). Health Policy Perspectives—Screening for Functional Cognition in Postacute Care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. American Journal of Occupational Therapy , 71 , 7105090010. https://doi.org/10.5014/ajot.2017.715001

22.

Gioia

G. A.

Isquith

P. K.

Guy

S. C.

, & Kenworthy

(2000). Behavior Rating Inventory of Executive Function (BRIEF). Psychological Assessment Resources.

23.

Hansen

De Amicis

N. K.

Anderson

N. D.

Binns

M. A.

Clark

A. J.

, & Dawson

D. R.

(2018). Cognitive contributors to Multiple Errands Test (MET) performance. American Journal of Occupational Therapy , 72 , 7206205050. https://doi.org/10.5014/ajot.2018.025049

24.

Kaufman

Birmaher

Brent

Rao

, & Ryan

N. D.

(1996). Kiddie–SADS–PL. Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center.

25.

Krieger

Amador-Campos

J. A.

, & Gallardo-Pujol

(2019). Temperament, executive function, and attention-deficit/hyperactivity disorder (ADHD) in adolescents: The mediating role of effortful control. Journal of Clinical and Experimental Neuropsychology , 41 , 615–633. https://doi.org/10.1080/13803395.2019.1599824

26.

Lahav

Ben-Simon

Inbar-Weiss

, & Katz

(2018). Weekly Calendar Planning Activity for university students: Comparison of individuals with and without ADHD by gender. Journal of Attention Disorders , 22 , 368–378. https://doi.org/10.1177/1087054714564621

27.

Lussier

Doherty

, & Toglia

(2019). Weekly Calendar Planning Activity. In Wolf

Edwards

D. F.

, & Giles

G. M.

(Eds.), Functional cognition and occupational therapy: A practical approach to treating individuals with cognitive loss (pp. 75–89). AOTA Press.

28.

McCandless

, & O’Laughlin

(2007). The clinical utility of the Behavior Rating Inventory of Executive Function (BRIEF) in the diagnosis of ADHD. Journal of Attention Disorders , 10 , 381–389. https://doi.org/10.1177/1087054706292115

29.

Molina

B. S. G.

Howard

A. L.

Swanson

J. M.

Stehli

Mitchell

J. T.

Kennedy

T. M.

, . . . Hoza

(2018). Substance use through adolescence into early adulthood after childhood-diagnosed ADHD: Findings from the MTA longitudinal study. Journal of Child Psychology and Psychiatry, and Allied Disciplines , 59 , 692–702. https://doi.org/10.1111/jcpp.12855

30.

Reale

Bartoli

Cartabia

Zanetti

Costantino

M. A.

Canevini

M. P.

, . . . Bonati

; Lombardy ADHD Group. (2017). Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. European Child and Adolescent Psychiatry , 26 , 1443–1457. https://doi.org/10.1007/s00787-017- 1005-z

31.

Richardson

J. T. E.

(2011). Eta squared and partial eta squared as measures of effect size in educational research. Educational Research Review , 6 , 135–147. https://doi.org/10.1016/j.edurev.2010.12.001

32.

Rotenberg

, & Maeir

(2019). The Cognitive–Functional Evaluation Framework. In Wolf

Edwards

D. F.

, & Giles

G. M.

(Eds.), Functional cognition and occupational therapy: A practical approach to treating individuals with cognitive loss (pp. 39–46). AOTA Press.

33.

Toglia

J. P.

(2015). Weekly Calendar Planning Activity (WCPA): A performance test of executive function. AOTA Press.

34.

Toglia

, & Berg

(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

35.

Toglia

, & Katz

(2018). Executive functioning: Prevention and health promotion for at-risk populations and those with chronic disease. In Katz

& Toglia

(Eds.), Cognition occupation, and participation across the lifespan: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (4th ed., pp. 129–142). AOTA Press.

36.

Wallisch

Little

L. M.

Dean

, & Dunn

(2018). Executive function measures for children: A scoping review of ecological validity. OTJR: Occupation, Participation and Health , 38 , 6–14. https://doi.org/10.1177/1539449217727118

37.

Wechsler

Kaplan

Fein

Morris

Kramer

J. H.

Maerlender

, & Delis

D. C.

(2004). The Wechsler Intelligence Scale for Children—Fourth Edition Integrated. Psychological Corporation.

38.

Weil

L. G.

Fleming

S. M.

Dumontheil

Kilford

E. J.

Weil

R. S.

Rees

, . . . Blakemore

S. J.

(2013). The development of metacognitive ability in adolescence. Consciousness and Cognition , 22 , 264–271. https://doi.org/10.1016/j.concog.2013.01.004

39.

Weiner

N. W.

Toglia

, & Berg

(2012). Weekly Calendar Planning Activity (WCPA): A performance-based assessment of executive function piloted with at-risk adolescents. American Journal of Occupational Therapy , 66 , 699–708. https://doi.org/10.5014/ajot.2012.004754

40.

Wilens

T. E.

Biederman

Brown

Tanguay

Monuteaux

M. C.

Blake

, & Spencer

T. J.

(2002). Psychiatric comorbidity and functioning in clinically referred preschool children and school-age youths with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry , 41 , 262–268. https://doi.org/10.1097/00004583-200203000-00005

41.

Strathearn

Liu

Yang

, & Bao

(2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997–2016. JAMA Network Open , 1 , e181471. https://doi.org/10.1001/jamanetworkopen.2018.1471

42.

Zlotnik

Doherty

Fisher

, & Tal-Saban

(2021). Adaptation and cross-cultural comparison of the Adolescents Weekly Calendar Planning Activity (WCPA) Middle/High School Version. Israeli Journal of Occupation Therapy , 30 , E6–E24.

43.

Zlotnik

, & Toglia

(2018). Measuring adolescent self-awareness and accuracy using a performance-based assessment and parental report. Frontiers in Public Health , 6 , 15. https://doi.org/10.3389/fpubh.2018. 00015

44.

Zlotnik

Schiff

Ravid

Shahar

, & Toglia

(2020). A new approach for assessing executive functions in everyday life, among adolescents with genetic generalised epilepsies. Neuropsychological Rehabilitation , 30 , 333–345. https://doi.org/10.1080/09602011.2018. 1468272