Effectiveness of Cognitive–Functional (Cog–Fun)

Intervention With Children With Attention Deficit

Hyperactivity Disorder: A Pilot Study

Jeri Hahn-Markowitz, Iris Manor, Adina Maeir

KEY WORDS The executive function (EF) deficits of children with attention deficit hyperactivity disorder (ADHD) hinder
their performance of complex daily functions. Despite the existing evidence-based pharmacological inter-

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 activities of daily living
ventions for ADHD symptoms, no intervention has yet been found that deals directly with EFs in daily tasks.
 attention deficit disorder with
Fourteen children and their parents participated in the Cognitive–Functional (Cog–Fun) program in
hyperactivity occupational therapy, which is tailored to the executive dysfunction of ADHD and focuses on enabling
 cognitive therapy cognitive strategies for occupational performance. The study included initial assessment of EFs (Behavior
 executive function Rating Inventory of Executive Functions; Tower of LondonDX), occupational performance (Canadian Occu-
 treatment outcome pational Performance Measure), 10 sessions of Cog–Fun intervention with each child–parent dyad, and
postintervention and 3-month follow-up assessments. We found significant improvements with medium to
large effects on outcome measures after intervention, and most effects were maintained at follow-up. The
findings warrant controlled studies examining the effectiveness of this intervention for children with ADHD.

Hahn-Markowitz, J., Manor, I., & Maeir, A. (2011). Effectiveness of cognitive–functional (Cog–Fun) intervention with
children with attention deficit hyperactivity disorder: A pilot study. American Journal of Occupational Therapy, 65,
384–392. doi: 10.5014/ajot.2011.000901

A
Jeri Hahn-Markowitz, MSc, OTR, is Director of ttention deficit hyperactivity disorder (ADHD) is a neurobiological disorder
Continuing Education and Doctoral Student, School of
that affects the emotions, behavior, and cognitive state of 4%–7% of children
Occupational Therapy, Faculty of Medicine, Hadassah and
The Hebrew University of Jerusalem, PO Box 20246, worldwide (Spencer, Biederman, & Mick, 2007). Symptoms include inattention,
Mount Scopus, Jerusalem 91240 Israel; impulsivity, and hyperactivity, and they often persist into adulthood. The long-
jerihahnmarkowitz@gmail.com term emotional, social, educational, and occupational implications of ADHD
Iris Manor, MD, is Medical Director, ADHD Clinic, Geha
are profound and well documented (Cermak, 2005).
Mental Health Center, Petah Tikva, Israel. Executive functions (EFs) consist of higher order cognitive abilities, including
working memory, planning, and emotional regulation (Barkley, 2004), which
Adina Maeir, PhD, OT, is Senior Lecturer, School of are crucial for complex and dynamic activities of daily living (ADLs; Katz &
Occupational Therapy, Faculty of Medicine, Hadassah and
The Hebrew University of Jerusalem, Jerusalem, Israel.
Hartman-Maeir, 2005). Executive dysfunction is a main deficit in ADHD;
therefore, people with ADHD are at risk for significant limitations in occu-
pational functioning (Brown, 2009).
Medications such as methylphenidate are widely used with children with
ADHD, and they have been shown to be effective in reducing symptoms and
increasing academic productivity (Biederman et al., 2004). However, residual
executive dysfunction has been found in medicated children (Safren, 2006). In
addition, a percentage of children with ADHD do not respond to pharmaco-
logical intervention (O’Connell, Bellgrove, Dockree, & Robertson, 2006).
We designed a cognitive–functional intervention program (Cog–Fun)
targeting EF in occupation to improve attainment of occupational goals. This
ecological intervention has a protocol tailored to the unique executive dys-
function of children with ADHD. The Cog–Fun program focuses on acqui-
sition and transfer of cognitive strategies to enable occupational performance in
the child’s natural environments. It is based on the theoretical foundations of

384 July/August 2011, Volume 65, Number 4

the Dynamic Interactional Approach (DIA; Toglia, 2005) tained from the Helsinki Ethics Committee of Geha
and similar applications of strategy-based learning for peo- Hospital. Parents provided informed consent, and chil-
ple with cognitive impairments. dren provided assent.
Toglia’s (2005) DIA for cognitive rehabilitation
highlights the dynamic interaction among person, task, Instruments
and environment regarding problems in occupational Behavioral Rating Inventory of Executive Function. The
performance. Intervention includes imparting strategies Behavioral Rating Inventory of Executive Function
that are practiced and transferred to different activities (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000a) is an
and situations—emphasizing metacognitive strategies of 86-item ecological rating scale (parent, teacher) designed
self-monitoring and self-evaluation—to establish or re- to reflect the neuropsychological constructs of EF in ev-
store balance in occupational functioning ( Josman, eryday situations for children ages 5–18. It comprises
2005). Although this approach has not been applied to eight scales, two indexes, and a Global Executive Com-
children with ADHD, it has been applied to children and posite. The Behavioral Regulation Index includes the Inhibit,
adults with head injury who experience similar symptoms Shift, and Emotional Control scales, and the Metacognitive

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(Cermak, 2005). Index includes the Initiate, Working Memory, Plan–
An intervention for adolescents with ADHD designed Organize, Organization of Materials, and Monitor scales.
by Ylvisaker and DeBonis (2000) used a global executive Raw scores are transformed into t scores; children scoring
strategy to enable positive changes in everyday routines by ³65 are considered clinically impaired. Internal consis-
5 middle school students and their parents. Qualitative tency, test–retest reliability (rs 5 .72–.84 for the Parent
findings demonstrated the adolescents’ improved self- Form over 3 wk), and discriminant validity, including the
regulated behavior at home. Hebrew version, have been established for people with
The Cognitive Orientation to Daily Occupational ADHD (Gioia, Isquith, Guy, & Kenworthy, 2000b;
Performance (CO–OP; Polatajko & Mandich, 2004) Linder, Kroyzer, Maeir, Wertman-Elad, & Pollak, 2010;
intervention approach emphasizes metacognitive strate- McCandless & O’Laughlin, 2007).
gies in an occupational context to guide the motor per- Tower of London–Drexel University. The 2nd edition
formance of children with developmental coordination of the Tower of London–Drexel University (TOLDX;
disorder (DCD). Polatajko and Mandich (2004) pre- Culbertson & Zillmer, 2005) is a neuropsychological
sented a case study of a child with ADHD using CO–OP. assessment of EF that identifies impairments in planning.
The child, his parents, and his teacher noted improvement Standard scores are generated for number of moves,
in attaining his set goals, as measured by the Canadian problem-solving time, and rule violations. Test–retest
Occupational Performance Measure (COPM; Law, Baptiste, reliability (r 5 .80 for Total Moves over 20 days), cri-
et al., 2005). Although the evidence for CO–OP’s effec- terion validity, and construct validity of the TOLDX have
tiveness with children with DCD is ample (Polatajko & been established for children with ADHD (Culbertson &
Mandich, 2005; Taylor, Fayed, & Mandich, 2007), aside Zillmer, 1998a, 1998b).
from this single case study, no evidence exists for its ef- Canadian Occupational Performance Measure. The
fectiveness with children with ADHD. Little is written COPM is a semistructured, individualized, client-centered
in the occupational therapy literature about cognitive ap- instrument designed for occupational therapists to help
proaches to treating children with ADHD (Cermak, 2005). clients identify problems and detect change in the per-
The aim of this study was to examine the effectiveness formance of daily occupations. It is a well-validated, reliable
of the Cog–Fun intervention in helping children with (test–retest reliability 5 .80 for Performance over 1–2 wk),
ADHD achieve occupational goals, improve EFs in daily valid, standardized instrument (Law, Baptiste, et al.,
life, and improve self-efficacy. 2005). Law, Majenemer, et al. (2005) used the COPM to
measure occupational performance outcomes before and
Method after an occupational therapy home care program for
children, including children with ADHD. In this study,
Research Design we considered the child’s COPM rating a measure of self-
The study was an uncontrolled, one-group, preintervention– efficacy (Reid, 2002).
postintervention pilot investigation to explore the effects
of the Cog–Fun program on children with ADHD. We Participants
used convenience sampling of children diagnosed in Seventeen children were referred to the first author (Hahn-
a community ADHD clinic. Ethical approval was ob- Markowitz) by the research coordinator of a community

The American Journal of Occupational Therapy 385

ADHD clinic. To be included, children had to be ages 7–8 with ADHD. It supports participation through the
and diagnosed with ADHD (all three subtypes) by a se- learning of specific executive strategies (Stop, Plan, Re-
nior psychiatrist (Iris Manor) on the basis of the criteria view) in a context of achieving occupational goals that
in the Diagnostic and Statistical Manual of Mental Dis- target self-regulation, working memory, and planning. By
orders (4th ed., text revision; American Psychiatric Asso- definition, the goals are meaningful to the child and
ciation, 2000); have reported difficulties in occupational harness motivational and cognitive resources toward goal-
performance; and attend school in a regular educational oriented behavior (Figure 1).
environment. Exclusion criteria were other psychiatric or The program involved ten 1-hr weekly sessions and
neurological disorders and an estimated IQ <80. transfer work facilitated by the parents at home. Each
child–parent dyad chose one occupational goal to work
Procedure toward at home, at school, or in the schoolyard. Goals
Children were referred from the ADHD community clinic were identified by interviewing each child to complete an
in which the study took place. The program was explained activity log of a typical day. Half of the dyads chose a
to parents by telephone, and they and the children signed transfer goal as well. The others could not generate a

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a consent form at assessment. Three assessed children transfer goal and did not agree with the goal suggested by
did not continue to intervention because they did not the occupational therapist. Upon goal attainment, an-
generate or agree to an occupational goal to work toward. other goal was chosen (up to a total of three goals).
A certified psychologist administered four subtests of Task-specific strategies for goal definition, inhi-
the Wechsler Intelligence Scales for Children–Revised bition, planning, and review were used to achieve specific
(Wechsler, 1995) to estimate IQ. The performance mea- occupational goals (e.g., verbalize goal [“What do I want
sures were administered by an experienced occupational to achieve?”]; walk away from provocative sibling; pull
therapist who also carried out the intervention with each chair close to table so that food will not spill; mark
child–parent dyad. All measures were readministered after checklist of items needed in schoolbag). Strategy learn-
intervention by the same occupational therapist and again ing was reinforced at home with two external executive
at a 3-mo follow-up visit. supports. A timer helped each child stop and focus on
thinking about the goal once a day, and a daily planner
Cog–Fun Intervention helped the child plan and monitor goal achievement
(Dawson & Guare, 2004; O’Connell et al., 2006). We
The Cog–Fun intervention is theoretically driven and
also used games and activities that challenge executive
addresses deficient goal-oriented processes in children
components (e.g., Simon Says, card games, planning
a party) in the acquisition and practice of executive
strategies (Table 1).
One parent attended each session to learn about the
intervention, to observe his or her child in an enabling
therapeutic relationship, and to reinforce positive strategy
implementation at home. The occupational therapist pro-
vided parents with information about environmental modi-
fication to facilitate occupation (i.e., lowering shelves) and
about positive, specific feedback. Parents tracked their
child’s transfer of strategy use at home in a Parent’s
Notebook. They received a weekly phone call from the
occupational therapist to report progress or problems,
ask questions, and receive support as needed.

Data Collection
The first author (Hahn-Markowitz) administered the
TOLDX to the children before and after intervention and
at follow-up. She also completed the children’s COPM
and interviewed participants after each goal was agreed
on, at the end of the intervention, and at follow-up. Pa-
Figure 1. Occupational goals chosen by children. rents completed the COPM and BRIEF independently at

386 July/August 2011, Volume 65, Number 4

Table 1. Cognitive–Functional Treatment Protocol
Treatment Aims Activities
1 Set occupational goals. Play game to verify child understands goal concept.
Conduct ocupational interview to identify one occupational goal.
Negotiate and integrate child, parent, and occupational therapist
perspectives.
Occupational therapist ensures feasibility, concreteness, and measurability of goals.
COPM (child, parent)
Provide an avenue for communication Give parent notebook (for use during sessions and at home).
(parents with occupational therapist).
2 Reinforce goal intention. Sign goal contract (harness motivation).
Introduce Stop (inhibition) strategy and practice Stop game: Simon Says.
transferring to occupational goal in clinic. Introduce timer as stop cue.
Practice linking auditory alert with goal intention (verbalize goal when
timer goes off).
Practice transferring Stop strategy to occupational Homework: Practice timer use with goal statement once a day.

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goal in natural context (home).
Provide parental support. Highlight the benefits of positive, specific reinforcement; provide booster
phone call midweek.
3 Reinforce Stop strategy. Review homework and previous session (timer use and demonstration).
Provide organizational device for occupational goal Introduce Daily Occupational Goal Planner (DOGP) and personalize it
attainment and assume ownership. (decorate, write name and goal).
Introduce Plan strategy. Undertake guided discovery of Plan components: actions, materials,
location, time frame.
Play game: Practice Plan strategy for simple and emotionally neutral
hypothetical goal.
Practice transferring Stop strategy to occupational Homework: Practice timer use with goal statement; think about PLAN components
goal in natural context (home). for goal once a day; put smiley sticker on DOGP each day after timer use.
Provide parental support. Reminder to use positive, specific reinforcement; booster phone call midweek.
4 Reinforce Stop strategy; enhance ownership of DOGP. Review homework and previous session (timer use and demonstration; DOGP use).
Practice and transfer Plan strategy Review plan made last session for hypothetical goal.
to occupational goal. Undertake guided discovery toward plan to achieve individual occupational
goal and documentation in DOGP.
Homework: Use timer to initiate plan; use DOGP to document plan
implementation once a day.
Provide parental support.a Reminder to use positive, specific reinforcement; provide environmental
adaptations if appropriate (i.e., lower shelf so child can reach
school materials); make booster phone call midweek.a
5 Reinforce Plan strategy. Review DOGP use.
Introduce review strategy. Undertake guided discovery of review components (what worked, what
did not, and what do I want to change).
Practice transfer of review strategy to game activity Play game: Child observes and then verbally analyzes occupational
in clinic. therapist’s performance of plan made for hypothetical goal of 2 weeks earlier.
Practice transfer of review strategy to occupational Homework: Use timer to implement plan and review strategy to attain
goal in natural context (home). occupational goal once a day; document review in DOGP.
6 Reinforce plan and review strategies used to achieve Review DOGP use and generate additional task-specific strategies
goal and revise plan as needed. to implement goal attainment if necessary.
Play a variety of games that challenge executive skills.
Reinforce all strategies (stop, plan, and review). Homework: Use timer to implement plan revisions (if necessary) and review
strategy to attain occupational goal once a day; document review in DOGP.
7–10 With goal achievement, transfer strategies to COPM for 2nd goal; COPM for 3rd goal. Undertake guided discovery of
new goal. plan and review strategies to achieve occupational goal.
Reinforce all strategies (Stop, Plan, and Review). Play a variety of games that challenge executive skills.
Homework: Use timer to implement plan revisions (if necessary) and review
strategy to attain occupational goal once a day; document review in DOGP.
End of session 10: COPM for each goal, including transfer goal.
Note. COPM 5 Canadian Occupational Performance Measure.
a
Parental support is provided at the end of Sessions 5–10 as well.

The American Journal of Occupational Therapy 387

all assessment points. The BRIEF was delivered to the trend: Effect sizes were slightly smaller than on the
teachers for completion at all assessment points and re- Parent BRIEF. Teacher BRIEF results were slightly worse
turned to the occupational therapist. at follow-up than at postintervention.

Data Analysis TOLDX

We analyzed the data with nonparametric statistics (Wilcoxon TOLDX scores showed statistically significant improve-
signed-ranks tests) using SPSS Version 16 (SPSS, Inc., ment after intervention. The means of the raw scores
Chicago). We computed effect size using Hedge’s g be- showed a decrease (improvement) by 14.69 total moves
cause of the small sample size (Lion, 2008). (p 5 .018); 1 rule violation (p 5 .012); and 180 s in total
time (p 5 .012), with predominantly large effect sizes.
Results Scores were slightly worse at follow-up than at post-
intervention, other than total time.
The sample included 14 children ages 7 yr, 0 mo, to 8 yr,
8 mo (mean [M] 5 7 yr, 5 mo; standard deviation [SD] 5 Canadian Occupational Performance Measure

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4.18); the male:female ratio was 9:5. Nine children (64%)
were diagnosed with combined-type ADHD, and 5 Parents’ Ratings of Their Children’s Performance. The
children (36%) were diagnosed with inattentive type ADHD, parents’ ratings of their children’s performance of goals
in accordance with the prevalence reported in the literature and transfer goals after intervention reflected statistically
(Solanto et al., 2007). Four of the 14 treated children were significant improvements (mean difference score 5
medicated for ³6 mo before participation in this study 4.1 points, p 5 .001, and 3.86 points, p 5 .017, re-
and continued this intervention throughout follow-up. One spectively) with a large effect size. At follow-up, 5 pa-
child began medication after postintervention assessment rents reported further improvement in their child’s
and therefore was not followed up. Mother’s education performance of goals, 2 parents reported that their child
ranged from 12 to 25 yr (M 5 15.14, SD 5 3.82). Four maintained the performance level achieved at postinter-
fathers and 10 mothers participated in the program vention, and 5 parents reported a decrease of an average
(Table 2). Results on all outcome measures are shown in of 1.33 points in their child’s performance level from
Table 3. postintervention.
Children’s Ratings on the COPM. We found a statisti-
BRIEF cally significant improvement in the means of the child-
ren’s ratings on the COPM goals and transfer goals after
Analysis of the changes on the Parent BRIEF revealed
intervention (ps 5 .001 and .014, respectively). Average
statistically significant improvements after intervention in
self-scoring on goal performance decreased slightly from
the mean Global Executive Composite and on both the
postintervention to follow-up.
indices and four of the eight scales. The largest effect size
was found for the Plan–Organize scale. The frequencies of
Intervention Fidelity
individual BRIEF Global Executive Composite Parent pro-
files revealed that after intervention, the scores improved The occupational therapist who carried out the program
(decreased) for 12 children. At follow-up, improvements kept a log of all sessions to support fidelity of intervention
on the indexes and Global Executive Composite were and to obtain qualitative information, which was checked
maintained. by investigator Adina Maeir.
Teachers of 13 children completed the BRIEF before
intervention, and teachers of 10 children completed it after Discussion
intervention. Examination of the results revealed a similar We examined the effectiveness of a cognitive–functional
Table 2. Participant Sample (N 5 14)
intervention to improve the EF of children with ADHD.
The aim was to examine whether children would acquire
Participant Characteristics Boys Girls % Total
executive skills and improve their performance on mean-
Age 7 yr, 0 mo–7 yr, 11 mo 6 2 57 8
ingful occupations that were targeted, as well as occupa-
Age 8 yr, 0 mo–8 yr, 8 mo 3 3 43 6
Inattentive ADHD type 3 2 36 5
tions not directly targeted, in intervention (i.e., transfer of
Combined ADHD type 6 3 64 9 EFs). Assessments were chosen to reflect EF and occupa-
Medication 2 2 29 4 tional components of the intervention. Findings showed
No medication 7 3 71 10 significant improvement on the outcome measures, and
Note. ADHD 5 attention deficit hyperactivity disorder. many of the gains were maintained at follow-up.

388 July/August 2011, Volume 65, Number 4

Table 3. Outcome Measures Before and After Treatment (N 5 14)
Measures Pretreatment M (SD) Posttreatment M (SD) z (p) Hedge’s g Follow-up; M (SD)
COPM
Parent (performance of goals) 3.71 (1.57) 7.81 (1.03) 23.30 (.001) 3.00 7.04 (1.21)
Parent (performance of transfer goal; n 5 7) 4.14 (2.04) 8.00 (3.32) 22.12 (.017) 1.36 6.80 (3.11)
Child (performance of goals) 3.77 (1.86) 8.46 (3.36) 23.18 (.001) 1.68 7.78 (2.02)
Child (performance of transfer goal; n 5 7) 4.86 (1.68) 8.43 (3.36) 22.21 (.014) 1.30 8.00 (3.34)
BRIEF (T score)
Parent BRI 64.07 (11.11) 57.93 (12.11) 22.83 (.003) 0.51 57.75 (11.00)
Parent MI 66.86 (8.73) 59.64 (10.07) 22.91 (.002) 0.74 59.33 (12.98)
Parent GEC 67.14 (8.87) 58.57 (12.05) 22.99 (.002) 0.82 59.33 (12.03)
Teacher BRI 56.82 (10.08) 51.82 (5.90) 22.25 (.008) 0.58 53.60 (8.07)
Teacher MI 59.10 (7.20) 53.36 (8.00) 22.40 (.016) 0.73 54.20 (6.63)
Teacher GEC 57.82 (8.13) 52.10 (6.70) 22.49 (.007) 0.74 54.20 (6.99)
TOLDX (standard score)

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Total moves 89.38 (18.41) 106.00 (13.74) 22.06 (.020) 0.99 99.38 (13.55)
Rule violations 83.85 (18.86) 96.71 (16.78) 22.11 (.035) 0.70 92.62 (20.12)
Total time 86.62 (21.31) 104.77 (17.81) 22.20 (.014) 0.90 104.92 (17.04)
Note. BRI 5 Behavioral Regulation Index; BRIEF 5 Behavior Rating Inventory of Executive Functions; COPM 5 Canadian Occupational Performance Measure;
GEC 5 Global Executive Composite; M 5 mean; MI 5 Metacognitive Index; SD 5 standard deviation; TOLDX 5 Tower of London–Drexel University.

The significant improvements with medium to large and after receiving methylphenidate twice daily for 16 wk
effect sizes found on the BRIEF parent and teacher reports and found no improvement on the TOLDX. This compar-
are encouraging, suggesting a possible intervention effect on ison may represent an advantage for cognitive–functional
EF in daily life. The teachers reported better EF in school intervention on planning abilities. An exhaustive literature
than the parents reported for home, concurring with the search did not generate articles on nonpharmacological
findings of Drechsler et al. (2007), who used the BRIEF studies using the TOLDX as an outcome measure; therefore,
when evaluating neurofeedback training for children with this premise could not be further explored.
ADHD. Several explanations are possible for the discrep- We found a strong positive change in the parents’
ancy between parent and teacher reports on children’s EF. and children’s rating of occupational performance on
The fact that some children were on medication while in trained and untrained goals, as reflected in the COPM
school ( Jarratt et al., 2005) and that the classroom envi- preintervention–postintervention scores. Previous studies
ronment is structured (Mares, McLuckie, Schwartz, & have shown that a change of ³2 points on the COPM is
Saini, 2007) may account for teachers’ witnessing more considered a moderate to large change and a clinically
organized and controlled behavior than parents witnessed important difference as judged by clients and their fam-
at home. In other studies, teachers reported higher ilies (Phipps & Richardson, 2007). According to Toglia
(worse) BRIEF scores than parents ( Jarratt et al., 2005; (2005), multitask activities in a variety of settings should
McCandless & O’Laughlin, 2007; Mares et al., 2007). be included in therapy to facilitate the acquisition and
Differences between informants may be the result of transfer of strategies in a multitude of contexts. In this
cross-situational discrepancies in expectations and per- study, the transfer goals chosen were not addressed di-
ceptions. Future studies should examine the source of rectly in the therapeutic process. The improved COPM
these differences with the aid of an independent infor- scores on the transfer goals could reflect the success of the
mant who would observe the child in both environments program in facilitating transfer of strategy use.
(Mares et al., 2007). Despite this study’s positive results, caution is needed
On the TOLDX, the children completed the tasks in in accounting for the effect of potential human bias on
less time, with fewer moves and fewer rule violations, after the part of respondents on rating scales (Draper, 2002).
intervention, with medium to large effects. This finding The actual size of effects will need to be determined in
could reflect more efficient strategic planning, similar to further controlled, blinded studies.
that reported on the BRIEF. The established test–retest
reliability supports this interpretation and reduces the Mechanisms of Change in Intervention
likelihood of a practice effect. These results are unlike The positive results of this study raise questions as to what
those of Yang, Chung, Chen, and Chen (2004), who com- contributed to change. Notwithstanding the possibility
pared 6- to 12-yr-old Taiwanese children with ADHD before of bias, we hypothesized that the strategies acquired in

The American Journal of Occupational Therapy 389

intervention would play a significant role in improved Which Children Benefited Most From
performance on outcome measures. This hypothesis is the Intervention?
based on findings of previous studies in which metacognitive The therapist observed several trends. One common de-
strategy training was used and beneficial for children nominator among the children with the greatest gains was
with ADHD. having a mother who was actively supportive of her child
Thompson and Thompson (1998) taught children and worked with him or her at home, communicated with
with ADHD metacognitive strategies related to academic the therapist, and was consistent in coming to weekly
tasks. Symptoms lessened after intervention, and aca- sessions. In addition, qualitative information from the
demic performance improved. The results of a study to therapist’s log revealed that children who showed large
determine the effectiveness of the CO–OP approach with improvements may be characterized by a high level of
children with DCD (Taylor et al., 2007) supported motivation. These observations are anecdotal and could
metacognitive strategy training; however, the CO–OP not be examined statistically; however, they form the
approach was not studied among children with ADHD. basis for further questions regarding the characteristics of
This study supports a metacognitive approach for chil- participants who may benefit most from this program.

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dren with ADHD, with positive results found for occu- We did not observe different intervention outcomes for
pational performance measures. children with different subtypes of ADHD.
The positive atmosphere in the clinic may have Factors that may have influenced a lack of im-
contributed to enhanced motivation, which, in turn, may provement among other children include emotional
have influenced a change in performance (Ylvisaker & problems, family problems, lower IQ, inconsistent atten-
DeBonis, 2000). In the Model of Human Occupation, dance at sessions, and parents’ inadequate understanding of
Kielhofner (1995) asserted that volition is a key factor in their role and assuming it, which may have led to in-
determining a person’s level of participation in an occu- adequate parental support while working toward goals
pation because it guides one’s choice of occupational at home. In addition, the therapist was less successful in
behavior on the basis of level of enjoyment and degree of enlisting fathers who attended sessions with their child to
engagement. The results of this study are in line with the communicate what took place with their spouses and to
preceding findings and reinforce the importance of the support their child in managing his or her goals on a daily
role of harnessing motivation. We did not specifically basis than in enlisting mothers.
measure motivation as an outcome; however, it may have
been an important element of the program’s success. Limitations of the Study
Future studies should measure motivation.
The lack of a control group may have contributed to
Another intervention component central to this study
a placebo effect; change may have resulted from factors
was the participation of a parent in all sessions and the
other than intervention. The study sample was small,
parent’s role in facilitating change. In the family-centered
and participants were referred from one center and may
approach, occupational therapists work with parents to
not represent the general population. In addition, the oc-
empower and enable them in the intervention process
cupational therapist administered the assessment measures.
(Chu & Reynolds, 2007; Law et al., 2007). We did not
Despite her qualifications, she could have been biased.
specifically measure the parents’ participation in this
Future studies should use a larger controlled and randomized
study; however, future studies should examine parents’
sample with sufficient representation of ADHD subtypes
level of awareness, knowledge of the intervention process,
and medication use.
role in facilitating transfer of strategy use at home, and
degree of support they offered to their children, as me-
diating factors. Conclusion
We hypothesize that that the combination of the This pilot intervention study demonstrated improvements
children’s metacognitive skills training (with adaptations in EFs and occupational performance in children who
for ADHD), the clinical setting that fostered motivated received cognitive–functional occupational therapy with
engagement in therapy, and the parental role contributed their parents present. The positive mechanism underlying
to the positive outcomes. Regarding the findings at follow- these effects may be related to the provision of cognitive
up, the scores on most measures demonstrate that inter- and motivational tools for performing complex daily
vention gains were maintained, yet did not continue to occupations that require EF. If similar findings can be
improve, suggesting that children and parents may benefit further shown in randomized, controlled studies, then
from periodic booster sessions. this intervention may be a feasible, ecological, and

390 July/August 2011, Volume 65, Number 4

economic complement to pharmacological intervention neurofeedback training of slow cortical potentials in chil-
with children with ADHD. s dren with attention deficit/hyperactivity disorder (ADHD).
Behavior and Brain Functions, 3, 35.
Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L.
Acknowledgments (2000a). Behavior Rating Inventory of Executive Function
(BRIEF). Odessa, FL: Psychological Assessment Resources.
We thank the families who took part in this study and
Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L.
Shlomit Rozen for her assistance in enlisting their par- (2000b). Test review: Behavior Rating Inventory of Exec-
ticipation. We also thank Aviva Yochman for her helpful utive Function. Child Neuropsychology, 6, 235–238.
comments after reading the manuscript. This study was Jarratt, K. P., Riccio, C. A., & Siekierski, B. M. (2005). Assess-
supported by Grant 3–00000–5472 from the Chief Sci- ment of attention deficit hyperactivity disorder (ADHD)
entist’s Office of the Ministry of Health, Israel. Using the BASC and BRIEF. Applied Neuropsychology, 12,
83–93. doi: 10.1207/s15324826an1202_4
Josman, N. (2005). The Dynamic Interactional Model for
References children and adolescents. In N. Katz (Ed.), Cognition
American Psychiatric Association. (2000). Diagnostic and statistical and occupation across the life span: Models for intervention

Downloaded from http://research.aota.org/ajot/article-pdf/65/4/384/63632/384.pdf by UCBL 1- (I-894) user on 05 November 2022

manual of mental disorders (4th ed., text rev.). Washington, in occupational therapy (2nd ed., pp. 261–276). Bethesda,
DC: Author. MD: AOTA Press.
Barkley, R. A. (2004). Attention-deficit/hyperactivity disorder Katz, N., & Hartman-Maeir, A. (2005). Awareness and exec-
and self-regulation: Taking an evolutionary perspective on utive functions enabling engagement in occupation. In
executive functioning. In R. F. Baumeister & K. D. Vohs N. Katz (Ed.), Cognition and occupation across the life
(Eds.), Handbook of self-regulation (pp. 301–332). New span: Models for intervention in occupational therapy (2nd ed.,
York: Guilford Press. pp. 3–25). Bethesda, MD: AOTA Press.
Biederman, J., Monuteaux, M. C., Doyle, A. E., Seidman, L. J., Kielhofner, G. (1995). A Model of Human Occupation: Theory
Wilens, T. E., Ferrero, F., et al. (2004). Impact of executive and application (2nd ed.). Baltimore: Lippincott Williams
function deficits and attention-deficit/hyperactivity disorder & Wilkins.
(ADHD) on academic outcomes in children. Journal of Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko,
Consulting and Clinical Psychology, 72, 757–766. H., & Pollock, N. (2005). The Canadian Occupational Per-
Brown, T. E. (2009). ADD/ADHD and impaired executive formance Measure (4th ed.). Ottawa, Ontario, Canada:
function in clinical practice. Current Attention Disorders CAOT Publications.
Reports, 1, 37–41. doi: 10.1007/s12618-009-0006-3 Law, M., Darrah, J., Pollock, N., Rosenbaum, P., Russell, D.,
Cermak, S. (2005). Cognitive rehabilitation of children with Walter, S. D., et al. (2007). Focus on function—A ran-
attention-deficit/hyperactivity disorder. In N. Katz (Ed.), domized controlled trial comparing two rehabilitation in-
Cognition and occupation across the life span: Models for terventions for young children with cerebral palsy. BMC
intervention in occupational therapy (2nd ed., pp. 277– Pediatrics, 7, 31.
302). Bethesda, MD: AOTA Press. Law, M., Majnemer, A., McColl, M. A., Bosch, J., Hanna, S.,
Chu, S., & Reynolds, F. (2007). Occupational therapy for Wilkins, S., et al. (2005). Home and community occupational
children with attention deficit hyperactivity disorder (ADHD). therapy for children and youth: A before and after study.
Part 1: A delineation model of practice. British Journal of Canadian Journal of Occupational Therapy, 72, 289–297.
Occupational Therapy, 70, 372–383. Linder, N., Kroyzer, N., Maeir, A., Wertman-Elad, R., &
Culbertson, W. C., & Zillmer, E. A. (1998a). The construct Pollak, Y. (2010). Do ADHD and executive dysfunctions,
validity of the Tower of LondonDX as a measure of the measured by the Hebrew version of Behavioral Rating
executive functioning of ADHD children. Assessment, 5, Inventory of Executive Functions (BRIEF), completely
215–226. doi: 10.1177/107319119800500302 overlap? Child Neuropsychology, 16, 494–502.
Culbertson, W. C., & Zillmer, E. A. (1998b). The Tower of Lion, G. (2008). Beyond p value: Effect size. Retrieved January
LondonDX: A standardized approach to assessing executive 5, 2010, from www.slideshare.net./gaetanlion/effect-size-
functioning in children. Archives of Clinical Neuropsychol- presentation
ogy, 13, 285–301. Mares, D., McLuckie, A., Schwartz, M., & Saini, M. (2007).
Culbertson, W. C., & Zillmer, E. A. (2005). Tower of London: Executive function impairments in children with attention-
Drexel University technical manual (2nd ed.). North To- deficit hyperactivity disorder: Do they differ between school
nowonda, NY: Multi-Health Systems. and home environments? Canadian Journal of Psychiatry, 52,
Dawson, P., & Guare, R. (2004). Executive skills in children 527–534.
and adolescents: A practical guide to assessment and interven- McCandless, S., & O’Laughlin, L. (2007). The clinical utility
tion. New York: Guilford Press. of the Behavior Rating Inventory of Executive Function
Draper, S. W. (2002). The Hawthorne, Pygmalion, placebo and (BRIEF) in the diagnosis of ADHD. Journal of Attention
other effects of expectation: Some notes. Retrieved December Disorders, 10, 381–389. doi: 10.1177/1087054706292115
25, 2009, from www.psy.gla.ac.uk/zsteve/hawth.html O’Connell, R. G., Bellgrove, M. A., Dockree, P. M., & Robertson,
Drechsler, R., Straub, M., Doehnert, M., Ehinrich, H., Steinhausen, I. H. (2006). Cognitive remediation in ADHD: Effects of
H., & Brandeis, D. (2007). Controlled evaluation of a periodic non-contingent alerts on sustained attention to

The American Journal of Occupational Therapy 391

 response. Neuropsychological Rehabilitation, 16, 653–665. bidities, and neurobiology. Journal of Pediatric Psychology,
doi: 10.1080/09602010500200250 32, 631–642. doi: 10.1093/jpepsy/jsm005
Phipps, S., & Richardson, P. (2007). Occupational therapy Taylor, S., Fayed, N., & Mandich, A. (2007). CO–OP inter-
outcomes for clients with traumatic brain injury and stroke vention for young children with developmental coordina-
using the Canadian Occupational Performance Measure. tion disorder. OTJR: Occupation, Participation and Health,
American Journal of Occupational Therapy, 61, 328–334. 27, 124–130.
doi: 10.5014/ajot.61.3.328 Thompson, L., & Thompson, M. (1998). Neurofeedback
Polatajko, H., & Mandich, A. (2004). Enabling occupation in combined with training in metacognitive strategies: Effec-
children: Cognitive orientation to daily occupational perfor- tiveness in students with ADD. Applied Psychophysiol-
mance. Ottawa, Ontario, Canada: CAOT Publications. ogy and Biofeedback, 23, 243–263. doi: 10.1023/A:
Polatajko, H., & Mandich, A. (2005). In N. Katz (Ed.), Cog- 1022213731956
nition and occupation across the life span: Models for inter- Toglia, J. P. (2005). A dynamic interactional approach to cog-
vention in occupational therapy (2nd ed., pp. 237–260). nitive rehabilitation. In N. Katz (Ed.), Cognition and
Bethesda, MD: AOTA Press. occupation across the life span: Models for intervention in
Reid, D. T. (2002). Benefits of a virtual play rehabilitation envi- occupational therapy (2nd ed., pp. 29–72). Bethesda,
ronment for children with cerebral palsy on perceptions of self- MD: AOTA Press.

Downloaded from http://research.aota.org/ajot/article-pdf/65/4/384/63632/384.pdf by UCBL 1- (I-894) user on 05 November 2022

efficacy: A pilot study. Pediatric Rehabilitation, 5, 141–148. Wechsler, D. (1995). Wechsler Intelligence Scale for Children–
Safren, S. (2006). Cognitive–behavioral approaches to ADHD Revised manual. New York: Psychological Corporation.
treatment in adulthood. Journal of Clinical Psychiatry, 67, Yang, P., Chung, L., Chen, C., & Chen, C. (2004). Rapid
46–50. improvement in academic grades following methylpheni-
Solanto, M. V., Gilbert, S. N., Rau, A., Zhu, J., Pope-Boyd, S., date treatment in attention-deficit hyperactivity disorder.
Stepak, B., et al. (2007). Neurocognitive functioning in Psychiatry and Clinical Neurosciences, 58, 37–41. doi:
AD/HD, predominantly inattentive and combined sub- 10.1111/j.1440-1819.2004.01190.x
types. Journal of Abnormal Child Psychology, 35, 729–744. Ylvisaker, M., & DeBonis, D. (2000). Executive function
doi: 10.1007/s10802-007-9123-6 impairment in adolescence: TBI and ADHD. Topics in
Spencer, T. J., Biederman, J., & Mick, E. (2007). Attention- Language Disorders, 20, 29–57. doi: 10.1097/00011363-
deficit/hyperactivity disorder: Diagnosis, lifespan, comor- 200020020-00005

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