Executive Functioning in School‑Based Occupational Therapy: Assessment and Intervention Through an Occupational Lens

Dr. Pauline Kelly, OTD, OTR/L

Dr. Debra Misrahi, DrOT, OTR/L

The school‑based occupational therapy practitioner (SBOTP) is charged with supporting students’ engagement in their role as “student.” This encompasses a range of occupational performance patterns as outlined by the Occupational Therapy Practice Framework, Fourth Edition (OTPF‑4; AOTA, 2020). Within many special education eligibility categories, difficulties with executive functioning (EF) may serve as a significant barrier to performance of this role, however. Tanis and Erb (2021) reported that school‑based occupational therapists identified EF difficulties at rates comparable to handwriting, fine motor, and sensory‑motor challenges; however, EF was assessed significantly less frequently than these other areas. How can executive dysfunction be identified? Which aspects of executive functioning fall within the SBOTP scope of practice, and how can they be addressed in schools?

Understanding Executive Functioning through an Occupational Lens. 

Barkley (2012) noted that there is no single, universally accepted definition of executive function, nor a gold‑standard method for its assessment. A user‑friendly conceptualization was proposed by Dawson and Guare (2018), who describe an 11‑skill model that includes inhibition, working memory, emotional control, sustained attention, task initiation, planning and prioritization, organization, time management, flexibility, metacognition, and stress tolerance (Dawson & Guare, 2018). These terms lend themselves to the school environment and frame EF in terms of performance skills that can be addressed by the Individualized Education Plan (IEP) process or through a 504 Accommodation plan. Through an occupational performance lens, these terms can also be seen as a good fit with the OTPF-4 classification of EF as body functions of higher level cognitive mental functions (AOTA, 2020).

Executive functioning skills begin to emerge in infancy and continue to develop through adolescence and young adulthood (Dawson & Guare, 2018). Early interactions between the infant and the environment serve as the foundation for EF development. As task demands increase, EF skills mature to support adaptive responses. For example, preschool students must navigate classroom routines and behavioral expectations, while older students face increasing demands for independence in task initiation, organization, and time management.

How do executive functioning difficulties impact school performance for the student with an IEP or 504 plan? 

Attention‑deficit/hyperactivity disorder (ADHD), one of the most common educational eligibilities associated with EF dysfunction, falls under the Exceptional Student Education (ESE) category of Other Health Impaired (OHI) in the state of Florida (Florida Department of Education, 2009). Lambek et al. (2010) estimated that approximately 50% of students with ADHD experience EF difficulties. These challenges are not exclusive to ADHD; Schultz‑Krohn (2019) identified EF deficits among students with autism spectrum disorder, developmental coordination disorder, intellectual disabilities, learning disabilities, sleep disturbances, and histories of trauma.

EF deficits affect a wide range of occupational performance patterns and skills across the school years. In preschool, difficulties with response inhibition may interfere with social participation, such as waiting for a turn. In elementary school, students may struggle with task initiation, assignment completion, and organization. As students progress to middle and high school, EF demands increase, requiring effective time management, planning of multi-step projects and organization across changing schedules. These challenges are often addressed as Priority Educational Needs within an IEP or through accommodations on a 504 plan. For example, the preschooler described above may benefit from an IEP goal such as: 

When a preferred toy is unavailable, the student will use a self‑regulation strategy (e.g., deep breathing or counting) and a functional phrase (e.g., “My turn next?”) to request the item, waiting up to 60 seconds in 4 of 5 opportunities, as measured by teacher observation.

A high school student with organizational challenges with a 504 plan may benefit from an accommodation such as:

        Use a color‑coded system to organize materials for A/B day schedules.

What role does the SBOTP play in the assessment of EF? 

The hallmark of any school-based occupational therapy assessment is the occupational profile, and this is where the gathering of data to reflect EF and its impact on school performance begins. A clear understanding of the educational environment and how EF impacts student performance is essential to frame the occupational profile (Schultz-Krohn, 2019).  Skilled observations of the student in multiple educational contexts and interviewing educational staff on the student’s ability to:

• Attend to tasks 
• Initiate, sustain, and complete tasks (including level of assistance required) 
• Complete classroom routines 
• Arrive prepared with necessary materials 
• Self‑regulate during periods of stress or disappointment

may provide the basis for the occupational profile and drive further assessments. 

Observations should include more than one school environment (classroom, cafeteria, PE field or playground) as different levels of structure and environmental inputs can affect EF abilities. The built environment can also be observed (desk and bookbag organization, time management objects, organizers including agendas, graphic organizers for writing assignments, etc.) (Dawson & Guare, 2018).

Work samples can also offer a guide to a student’s EF abilities. A writing assignment or a multi-step project can shine light on many EF skills including organization, time management, working memory.

Best practice of the school-based occupational therapy assessment emphasizes a top-down, student-centered and strengths-based approach (Frolek-Clark & Rioux, 2019). Furthermore, IDEA (2004) requires a "variety of assessment tools," which can include a combination of parent input, teacher observations, ecological assessments, standardized measures to determine eligibility for special education and related services (34 CFR § 300.304[b][2]). Although school psychologists often administer standardized EF measures as part of a psychoeducational battery, such as the Behavior Rating Inventory of Executive Function–Second Edition (BRIEF‑2; Gioia et al., 2017), SBOTPs should prioritize assessment methods grounded in occupation (Clark & Rioux, 2019). When standardized or criterion‑referenced tools are indicated, those focused on occupational performance are most appropriate, such as the Children’s Kitchen Task Assessment (Rocke et al., 2008) and the Weekly Calendar Planning Activity (Toglia, 2015).

What are the ways in which the SBOTP supports students with barriers to performance related to EF deficits? 

Although EF can be a major barrier to performance for students in the school setting, the ability of the SBOTP to address the impact of these barriers can contribute to the multi-disciplinary team’s ability to promote successful school performance.

According to Schultz-Krohn (2019) there are several evidence-based intervention approaches that can be used to address EF dysfunction in the school setting. These include:

• Cognitive Orientation to Daily Occupational Performance (CO-OP) (Polatajko & Mandich, 2004) . This approach teaches students to use problem solving approaches and self-regulatory strategies to address self-selected goals. The hallmark of this approach is the Goal, Plan, Do and Check approach. Some EF skills that can be addressed with this intervention approach include task initiation, planning/prioritization, organization, and time management.
• Cognitive-Functional (Cog-Fun). This approach was used by Hahn-Markowitz et al. (2011, as cited in Schultz-Krohn, 2019) to develop EF skills among 7–8-year-olds with ADHD. The approach involved environmental adaptations in addition to specific skill development including those that fall into the self-regulation area. 

When viewed through an occupational performance lens, executive functioning plays a critical role in students’ ability to engage in the occupation of “student.” EF skills develop across the lifespan and significantly influence academic performance, routines, self‑regulation, and independence, particularly for students with IEPs and 504 plans. Although EF difficulties are prevalent, school‑based occupational therapists assess these skills less frequently than other performance areas. Through occupational profiles, observations, work samples, and collaboration with multidisciplinary teams, SBOTPs are well positioned to identify and address EF‑related barriers to school performance.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process(4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), Article 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

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

Dawson, P., & Guare, R. (2018). Executive skills in children and adolescents: A practical guide to assessment and intervention (3rd ed.). Guilford Press.

Florida Department of Education. (2009). Exceptional student education eligibility for students with other health impairment (Rule 6A-6.030152, Florida Administrative Code). https://www.fldoe.org/academics/exceptional-student-edu/ese-eligibility/other-health-impairment-ohi.stml

Frolek‑Clark, G., & Rioux, J. (2019). Best practices in school‑based occupational therapy evaluation. In G. Frolek‑Clark & S. C. Cohn (Eds.), School‑based occupational therapy (pp. 331-339). AOTA Press.

Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. (2017). Behavior Rating Inventory of Executive Function–Second Edition (BRIEF®2). Psychological Assessment Resources. https://www.wpspublish.com/brief-2-behavior-rating-inventory-of-executive-function-second-edition

Hahn-Markowitz, J., Manor, I., Maeir, A., & Engel-Yeger, B. (2011). Effectiveness of cognitive-functional (Cog-Fun) intervention among children with ADHD: A pilot study. American Journal of Occupational Therapy, 65(4), 384–392. https://doi.org/10.5014/ajot.2011.001073

Individuals with Disabilities Education Act, 20 U.S.C. § 1400 (2004).

Lambek, R., Sonuga-Barke, E., Tannock, R., & Mies, G. W. (2010). Are there distinct executive function profiles in ADHD? Journal of Attention Disorders, 13(5), 496–504. https://doi.org/10.1177/1087054709333661

Polatajko, H. J., & Mandich, A. (2004). Enabling occupation in children: The Cognitive Orientation to daily Occupational Performance (CO-OP) approach. AOTA Press.

Rocke, K., Hays, P., Edwards, D., & Berg, C. (2008). Development of a performance assessment of executive function: The Children’s Kitchen Task Assessment. American Journal of Occupational Therapy, 62(5), 528–537. https://doi.org/10.5014/ajot.62.5.528

Schultz-Krohn, W. (2019). Executive function in school-based practice. In J. Case-Smith & J. C. O’Brien (Eds.), Occupational therapy for children and adolescents (7th ed., pp. 557–575). Elsevier.

Tanis, E. S., & Erb, J. (2021). School-based occupational therapists’ assessment of executive function. Journal of Occupational Therapy, Schools, & Early Intervention, 14(2), 184–198. https://doi.org/10.1080/19411243.2020.1775997

Toglia, J. (2015). Weekly Calendar Planning Activity (WCPA). AOTA Press.