7

The Executive Function

Performance Test
CAROLYN M. BAUM, PhD, OTR/L, FAOTA; DOROTHY FARRAR EDWARDS, PhD;
ANNA E. BOONE, MSOT, PhD, OTR/L; AND TIMOTHY J. WOLF, OTD, PhD, OTR/L, FAOTA

LEARNING OBJECTIVES

After completing this chapter, readers should be able to

•  xplain the purpose and the properties of the Executive Function Performance Test,
E
• Discuss the role of functional task performance in the evaluation of cognitive processes,
• Understand how to support performance with the level of cueing that meets the client’s needs,
• Describe an approach to teach a family how to support the client’s successful performance, and
• Understand how to describe the client’s current level of function in documentation.

KEY TERMS AND CONCEPTS

• Completion • Executive Function Performance Test • Executive functions • Initiation • Judgment and safety
• Organization • Sequencing

Introduction People need these EFs to

• Support adaptive behaviors,

The occupational therapist’s lens addresses the complex inter-
actions of biological, psychological, and social capacities of • Generate problem-solving strategies,
those they serve. Furthermore, it focuses on the importance of
• Maintain and update goals,
the fit among the person, the task, and the environment to sup-
port the person’s occupational performance. Before research- • Monitor the consequences of actions, and
ers learned of the role of cognition in everyday performance,
• Apply prior knowledge to anticipate future events
activity analysis primarily concentrated on the movement and
(Miyake & Shah, 1999).
strength necessary to perform functional tasks.
In the 1980s, practitioners recognized that cognitive skills From a performance-based perspective, people need EFs
also play a critical role in occupational performance. This new to make plans, initiate actions, and modify activities as they
understanding required the development of performance-based experience problems or as information from the environment
measures to analyze an individual’s capacity to perform cogni- changes (Fitzpatrick & Baum, 2012).
tively demanding tasks. The Executive Function Performance Chen and colleagues (2006) suggested that EFs are central to
Test (EFPT) is such a measure (Baum et al., 2008). the learning, relearning, and retraining necessary for successful
Executive functions (EFs) are an interrelated set of cogni- rehabilitation of individuals with impaired functional cognition.
tive abilities that organize and direct complex, goal-directed Implementation of effective occupational therapy interventions
activities (Toglia & Katz, 2018). The cognitive components of addressing these deficits is based on comprehensive assessment
EF include working memory, attention, inhibitory control, and of the client’s capacity to perform complex life activities. The
initiation. EFPT provides the information the practitioner needs to guide
  67
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 68  FUNCTIONAL COGNITION AND OCCUPATIONAL THERAPY

rehabilitation interventions and family education designed to on standard neurocognitive measures. The EFPT cueing system
support the client’s occupational performance in context. Use is standardized and relates to the degree of cognitive impairment
of the EFPT helps to determine the client’s ability to live inde- affecting task performance. The cueing system gives the test
pendently, the level and frequency of cues they need for inde- administrator a straightforward assessment of the assistance the
pendence, and specific EF components supporting or inhibiting individual requires to perform tasks; thus, it is a clinically useful
performance. test that can be used in practice and research.
The EFPT was developed to provide a performance‐based, The initial version of the EFPT examines the execution of
standardized assessment of cognitive function (Baum & 4 basic tasks that are essential for self‐maintenance and inde-
Edwards, 1993). EFs traditionally have been measured by stan- pendent living:
dard neuropsychological evaluations, but the functional cogni-
1. Simple cooking
tion necessary to perform in daily life is often missed, because
neuropsychological tests are administered in a simplified, 2. Telephone use
structured, and supportive environment (Lezak et al., 2004;
3. Medication management
Prigatano, 1999). Neuropsychological tests gather information
about specific aspects of cognition, such as memory, attention, 4. Bill payment (Baum et al., 2008).
or planning. The EFPT
The tasks included in the EFPT were selected because they
• Assesses the person’s ability to initiate, organize, and represent complex activities needed for independence in com-
sequence actions; munity settings (i.e., cooking, making a phone call, taking med-
ication, paying a bill).
• Measures the person’s ability to use judgment and com-
An alternate version (aEFPT) has been developed with
plete a task; and
slight modifications to the task demands of the original 4 tasks
• Records how cognition functions support the person’s (i.e., cooking pasta instead of oatmeal, calling a physician’s
performance of daily activities. office instead of a grocery store, sorting medications instead
of taking medications, ordering items from a catalogue instead
The EFPT does not examine what individuals cannot do. Rather,
of paying 2 bills; Hahn et al., 2014). Rand and colleagues
it identifies what they can do and how much assistance they
(2018) also developed alternate, Internet-based forms of the
need in accomplishing those actions.
Bill Pay and Telephone Use tasks. A more complex version of
There are several ecologically valid, performance-based
the EFPT, the EFPT–Enhanced, is currently undergoing psy-
IADL assessments that measure the capacity of a person to per-
chometric evaluation among persons with stroke and with
form a structured everyday life activity, some of which are dis-
cancer-related cognitive impairment.
cussed in this text. Although these measures reveal problems in
The EFPT assesses an individual’s ability to complete 5
cognitive and processing skills, most do not record the person’s
executive components within each subtask (see Exhibit 7.1).
capabilities when they are provided with progressive levels of
Using the definitions in Exhibit 7.1, the test administrator can
support, although such information is necessary to developing
record the EFs that are involved in each task by identifying the
a treatment plan. The EFPT (Baum & Wolf, 2013; Baum et al.,
level of guidance (cueing) the person needs to perform the task.
2008) was developed to identify supports needed to help those
The levels of assistance are scored as follows:
with executive dysfunction perform daily tasks, and it fills a
gap that many other currently available assessments do not • No cue required (0)
address.
Performance-based tests yield specific understanding of • Indirect verbal guidance (1)
the impact that a cognitive problem is having on the tasks that • Gestural guidance (2)
are central to daily life. A screening tool such as the Montreal
Cognitive Assessment (MoCA; Nasreddine et al., 2005) can • Direct verbal assistance (3)
indicate whether a client is experiencing severe cognitive diffi- • Physical assistance (4)
culties, but performance-based tests provide a more direct eval-
uation of functional–cognitive deficits for clients who score as • The test administrator does the step for the person (5).
cognitively intact or show only mild impairment on the MoCA These levels of cues make it possible to record the degree
(Nasreddine et al., 2005; Toglia et al., 2017). of assistance required by even someone with severe cognitive
impairment, yet the measure is sensitive enough to identify
an individual who requires only minimal cues. Knowledge of
EFPT Structure what cueing support the client needs to function safely and
how cognitive components are integrated in functional per-
By using a cueing system as part of the assessment process, prac- formance informs treatment planning and family education
titioners can capture a wider range of abilities among people pre- related to maintaining client engagement (Baum & Edwards,
viously assumed to be untestable because of poor performance 2003; see Exhibit 7.2).

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 CHAPTER 7. THE EXECUTIVE FUNCTION PERFORMANCE TEST   69

EXHIBIT 7.1. Executive Function Components Assessed in Each Subtask of the EFPT

EXECUTIVE FUNCTION
COMPONENT DEFINITION

Initiation The start of motor activity that begins a task.

Organization The physical arrangement of the environment, tools, and materials to facilitate efficient and effec-
tive performance of the steps required to complete the task. The individual correctly retrieves and
uses the items that are necessary for the task.

Sequencing The coordination and proper ordering of the steps that compose the task. A proper allotment
of attention to each step is required. The individual carries out the steps in an appropriate order,
attends to each step appropriately, and can switch attention from 1 step to the next.

Judgment and safety The use of reason and decision-making capabilities to intentionally avoid physically, emotionally, or
financially dangerous or problematic situations. The individual exhibits an awareness of danger by
actively avoiding or preventing the creation of a dangerous or problematic situation.

Completion The inhibition of motor performance, driven by the knowledge that the task is finished. The person
does not perseverate and instead terminates task performance by indicating verbally or by physi-
cally moving away from the area of the last step.

Note. EFPT = Executive Function Performance Test.

Source. Adapted from Executive Function Performance Test Manual, by C. M. Baum and T. J. Wolf, 2013, St. Louis: Washington University in St. Louis. In the
public domain.

EXHIBIT 7.2. Cueing Principles for the EFPT

• The test administrator delivers the cues necessary to help the test taker avoid errors and complete the tasks. Even individuals
with severe cognitive loss who require multiple step-by-step cues or physical assistance may complete the EFPT.
• During performance difficulty, the test administrator must wait to give the test taker time to process before giving a cue, but
they must also time the cues to prevent the test taker from making an error.
• Unless the participant is in danger (e.g., putting a hot pad on the burner, touching the burner to see whether it is on), the test
administrator does not intervene until the test taker shows they are not processing to move to the next step.
• The test administrator gives 2 cues of each kind before progressing to the next cueing level.
• If the test taker is still unable to perform a step in a task after gestural and verbal assistance, the test administrator should do the
step for the test taker, who should then be cued back to the next step in the task sequence.
• If the test taker needs direct verbal cues in 1 aspect of the observation (organization, sequencing, judgment, and safety), the test
administrator should provide the verbal cues to finish the task without starting back through the level sequence each time.
• Test administrators will often find themselves accidentally combining different levels of cues. The score for degree of assistance
must reflect the highest level of cueing used to facilitate task completion.
• The test administrator should not initiate conversations during the test, and “cheerleading” is to be avoided (i.e., do not give
positive or negative feedback).

Note. EFPT = Executive Function Performance Test.

Source. Adapted from Executive Function Performance Test Manual, by C. M. Baum and T. J. Wolf, 2013, St. Louis: Washington University in St. Louis. In the
public domain.

Psychometric Properties ate impairment in stroke (Baum et al., 2008), MS (Kalmar et al.,
2008), schizophrenia (Katz et al., 2007), and TBI (Baum et al.,
The EFPT has been translated into Hebrew, Swedish, French, 2017).
Italian, and Spanish. It has been validated for people with a vari- Test–retest reliability has not been established because
ety of conditions affecting cognitive performance (e.g., stroke, of the learning effect inherent in performance-based tests of
multiple sclerosis [MS], schizophrenia, traumatic brain injury cognition. Good to excellent interrater reliability has been
[TBI]). The EFPT has demonstrated good discriminant validity demonstrated among patients with stroke for
between healthy adults and persons with mild cognitive impair-
• The overall EFPT (intraclass correlation [ICC] = .91),
ment from stroke (Baum et al., 2008), MS (Kalmar et al., 2008),
and TBI (Baum et al., 2017). The EFPT has also been found to • Cooking (ICC = .94),
discriminate between groups of people with mild and moder-
• Bill Pay (ICC = .89),

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 70  FUNCTIONAL COGNITION AND OCCUPATIONAL THERAPY

• Medication Management (ICC = .94), and Administration

• Telephone Use (ICC = .79).
Practitioners should consult the EFPT test manual for test
Adequate internal consistency of the measure has been evalu- administration guidelines and a list of required supplies. The
ated among persons with stroke (Cronbach’s α = .77–.94) and manual includes the forms, the labels to personalize the tasks,
among persons with schizophrenia (Cronbach’s α = .88). and the script for the administration of the EFPT. The EFPT
The EFPT has moderate correlations with neurological itself and the training manual are free and available online
tests known to be measures of EF, including the Delis–Kaplan (http://www.ot.wustl.edu/about/resources/executive-function-
Executive Function System’s Trail Making subtest (Delis et al., performance-test-efpt-308). The materials include all of the
2001), the Wisconsin Card Sorting Test (Heaton et al., 1993), assessment forms and a scoring sheet that can be placed in the
and the National Institutes of Health Toolbox’s Fluid Cogni- individual’s medical record. Some hospital systems have asked
tion and Crystalized Cognition composite scores (Weintraub that the scoring sheet be included in their electronic medical
et al., 2014). Excellent correlations exist with the Assessment of record; this is possible because the tool is in the public domain.
Motor and Process Skills (Cederfeldt et al., 2015; Fisher & Jones, The EFPT tasks can be administered in a clinic’s life skills
2010). Correlation coefficients between the EFPT and the total area or in a home. Three of the tasks—Bill Pay, Medication Man-
Behavioral Assessment of the Dysexecutive Syndrome profile agement, and Telephone Use—can be administered in a hospital
revealed moderate to high correlations (Katz et al., 2007). Pre- room. In the absence of a kitchen, practitioners can administer
dictive validity was determined in a sample of persons with TBI, the test using a portable burner and water from a pitcher. All of
with the EFPT total task score predicting self-reported inde- the items to administer the assessment are placed in a box and
pendence (Baum et al., 2017; Wilson et al., 1996). can be used at the point of testing.
Psychometric testing with the aEFPT has revealed the tasks The training manual includes all of the test materials, such
to be reliable, with no significant differences demonstrated in as the script, labels, and bills; however, the test administrator
performance on the EFPT tasks compared with the aEFPT will need to purchase items necessary for the tasks and the
tasks. Furthermore, performance on the aEFPT demonstrated distractors. The items are listed and can be purchased at any
moderate to high correlations with neuropsychological cogni- grocery or general merchandise store for less than $50. The
tive assessments (Hahn et al., 2014). Reliability of the form has instructions to administer the test are listed in Exhibit 7.3, but
also been demonstrated with Internet-based versions of the readers should review the test manual for details regarding
Bill Pay task and Telephone Use task (Rand et al., 2018). cueing. Video 7.1 provides an example of the instructions for
the cooking subtest as well as an example of the cueing pro-
vided to the participant.
Target Population

Functional–cognitive changes occur frequently in chronic neu­

Scoring
rologic and metabolic diseases, including Alzheimer’s disease
(Baum & Edwards, 1993); Parkinson’s disease (Cahn et al., 1998;
The individual task sheets and the final scoring sheets are
Klepac et al., 2008); MS (Birnboim & Miller, 2004); TBI (Gov-
in the test manual located online. For each task, the test
erover & Hinojosa, 2002); stroke (Baum et al., 2008); spinal cord
administrator calculates the highest level of cueing in the 5
injury (Hanks et al., 1999); and psychiatric disorders, in par-
domains:
ticular schizophrenia (Katz et al., 2007; Rempfer et al., 2003)
and depression (Brown et al., 2014). More recently, deficits in 1. I nitiation (i.e., the start of motor activity that begins a
functional cognition have been recognized as secondary con- task)
sequences of cancer treatment (Nieuwenhuijsen et al., 2009) as
2. O
 rganization (i.e., the physical arrangement of the en-
well as in diabetes (Gaspar et al., 2016), chronic obstructive pul-
vironment, tools, and materials to facilitate efficient and
monary disease (Dodd et al., 2010), and kidney disease (Zammit
effective performance of the steps required to complete
et al., 2015).
the task)
Functional–cognitive issues also require attention among
people with autism; children with known sensory-processing 3. S
 equencing (i.e., the coordination and proper ordering of
problems; people with eating disorders (Dohle et al., 2018); and the steps that compose the task)
adults with behavioral conditions, including substance abuse
4. J
 udgment and safety (i.e., the use of reason and decision-
(Perry, 2016; Rezapour et al., 2015). The EFPT may be applied
making capabilities to intentionally avoid physically,
in any of these populations or others in which there are sus-
emotionally, or financially dangerous or problematic
pected functional–cognitive deficits. The EFPT is particularly
situations)
useful for those with mild to moderate cognitive deficits, which
might not be adequately detected with often-used neuropsy- 5. C
 ompletion (i.e., the inhibition of motor performance
chological quick-screen measures (Toglia et al., 2017). driven by the knowledge that the task is finished).

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 CHAPTER 7. THE EXECUTIVE FUNCTION PERFORMANCE TEST   71

EXHIBIT 7.3. Step-by-Step Instructions for Administering the EFPT

1. Begin the EFPT with the script and all of the pretest questions (see the EFPT manual).
2. Leave all of the items necessary for all of the tasks in the box on a table (the “materials table”). Put it on a lower table or stool if the
person sits in a wheelchair. (Bills and other mail should be mixed together in a sealable plastic bag. The account book or check-
book should have checks included inside. All other items are loose in the box.)
3. Ask the person to begin the task (use the script available in the EFPT manual).
4. Offer assistance only after the participant has made a good attempt to process the actions necessary to carry out the step. Use
the cueing guidelines.
5. Complete the cueing chart and behavior assessment chart for each task.
6. Time each of the tasks, and write down in minutes and seconds the time the test taker spends on each task on the task sheet.
7. Complete the score sheet with the information from each task sheet.

Note. EFPT = Executive Function Performance Test.

Source. Adapted from Executive Function Performance Test Manual, by C. M. Baum and T. J. Wolf, 2013, St. Louis: Washington University in St. Louis. In the
public domain.

The administrator then sums these values to create a score In this example, the report would include that the client was
for each subtask. They may calculate EF domain scores (e.g., administered the EFPT, a standardized functional–cognitive
initiation) by summing each of the domain components across assessment, and that the client required verbal cues in initiating,
tasks (e.g., all initiation components). organizing, sequencing, and being safe in performing tasks. The
client’s occupational performance indicates that they may pose
a safety risk. The occupational therapy practitioner could use
Documentation an example from the EFPT to illustrate this. The client required
a direct verbal cue to turn off the stove, required a direct verbal
Table 7.1 shows EFPT scoring for an example client, on the cue to avoid paying a bill when there were insufficient funds in
basis of the test material available online. A short summary the account, and had to be cued to take their medication rather
of the client’s test results is given. The occupational therapy than another person’s.
practitioner could report this information at a case conference The report should indicate the level of assistance the cli-
and include it in the client’s record to document the cognitive ent is likely to require (e.g., the client requires a caregiver
problems the client is having in performing tasks and the level who can provide direct cues to help with instrumental tasks).
of cueing needed. If the client is independent or requires only limited help with
organization, that can also be reported. The report might
TABLE 7.1. Example EFPT Scoring Representation also include a statement regarding the client’s efficiency in
MEASURED ITEM CONTROL CLIENT the tasks. Finally, through comparison with the client’s pre-
dictions of performance or recall of performance, the practi-
Task tioner may draw conclusions regarding self-awareness.
Cooking 4.03 7

Bill Pay 0.38 5 Interpretation and Intervention Considerations

Medication 1.82 4
Management The EFPT provides information regarding the functional–
cognitive capabilities of the client. If clients are respond-
Telephone Use 0.92 14
ing to cues in the assessment, they will likely respond best to
strategy-based intervention methods. For example, Cognitive
Cognitive construct Orientation to daily Occupational Performance involves appli-
cation of a global problem strategy, generation of domain-
Initiation 0.50 8
specific strategies, and use of guided discovery methods (Dawson
Organization 0.47 10 et al., 2017). If the client consistently requires physical assistance,
a skill- or habit-training approach, such as the Neurofunctional
Sequencing 1.63 18
Approach, may be indicated (Clark-Wilson et al., 2014).
Judgment and safety 0.61 18 In both situations, the family will need to learn strategies
to support the client in full engagement outside of the ther-
Completion 0.60 1
apy environment. After the family observes the level of cueing
Note. EFPT = Executive Function Performance Test. provided by the occupational therapist, it is essential that the

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 72  FUNCTIONAL COGNITION AND OCCUPATIONAL THERAPY

therapist give them the opportunity to be successful in provid- Clark-Wilson, J., Giles, G. M., & Baxter, D. M. (2014). Revisiting the Neuro­
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rehabilitation of everyday living skills. Brain Injury, 28, 1646–1656.
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phens, 1989; Lawton et al., 1991). Orientation to daily Occupational Performance in Occupational
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 CHAPTER 7. THE EXECUTIVE FUNCTION PERFORMANCE TEST   73

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 8
Weekly Calendar Planning Activity
ALEXIS LUSSIER, MS, OTR/L; MEGHAN DOHERTY, OTD, OTR/L;
AND JOAN TOGLIA, PhD, OTR/L, FAOTA

LEARNING OBJECTIVES

After completing this chapter, readers should be able to

•  escribe the background, purpose, and aims of the Weekly Calendar Planning Activity (WCPA) to assess executive
D
function;
• Describe the administration, utility, and clinical applications of the WCPA;
• Identify quantitative and qualitative information obtained from the WCPA; and
• Discuss how the results of the WCPA can be used to guide treatment planning.

KEY TERMS AND CONCEPTS

• Cognitive strategy • Executive function • Instrumental activity of daily living • Self-awareness

• Weekly Calendar Planning Activity

Introduction Specific EF demands placed on the test taker during this

activity include
The Weekly Calendar Planning Activity (WCPA) is a
• Planning,
performance-based measure of functional cognition (Toglia,
2015a). This tabletop assessment asks the test taker to perform • Organization,
an instrumental activity of daily living (IADL) task. IADLs
• Inhibition,
are “activities that support daily life within the home and com-
munity and that often require more complex interactions than • Working memory, and
those used in ADLs” (American Occupational Therapy Associ-
• Flexibility.
ation, 2014, p. S43).
The WCPA requires the test taker to enter a 10- to 18-item Additionally, successful adherence to a provided set of rules
list of fixed and flexible appointments into a blank weekly engages prospective memory, mental tracking, and problem
schedule while adhering to rules, monitoring time, and recon- solving.
ciling conflicting task demands. During the task, demands are The test administrator or occupational therapist observes
placed on the test taker’s executive function (EF) processes, the client’s use of cognitive strategy, which can be defined as
which can be described as “an inter-related set of abilities “a mental plan of action that helps a person to learn, problem
responsible for directing and coordinating cognitive control solve, and perform” (Toglia et al., 2012, p. 227). The activity part
and goal directed actions” (Toglia & Katz, 2018, p. 129). of the assessment is followed by a semistructured interview,

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