Neuropsychological Rehabilitation

An International Journal

ISSN: 0960-2011 (Print) 1464-0694 (Online) Journal homepage: http://www.tandfonline.com/loi/pnrh20

A new approach for assessing executive functions

in everyday life, among adolescents with Genetic
Generalised Epilepsies

Sharon Zlotnik, Aharon Schiff, Sarit Ravid, Eli Shahar & Joan Toglia

To cite this article: Sharon Zlotnik, Aharon Schiff, Sarit Ravid, Eli Shahar & Joan Toglia (2018): A
new approach for assessing executive functions in everyday life, among adolescents with Genetic
Generalised Epilepsies, Neuropsychological Rehabilitation, DOI: 10.1080/09602011.2018.1468272

To link to this article: https://doi.org/10.1080/09602011.2018.1468272

Published online: 30 Apr 2018.

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NEUROPSYCHOLOGICAL REHABILITATION, 2018
https://doi.org/10.1080/09602011.2018.1468272

A new approach for assessing executive functions in

everyday life, among adolescents with Genetic
Generalised Epilepsies
Sharon Zlotnika, Aharon Schiffb, Sarit Ravidb, Eli Shaharb and Joan Togliac
a
Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of
Haifa, Haifa, Israel; bMeyer Children’s Hospital, Paediatric Neurology Unit, Haifa, Israel; cSchool of
Health and Natural Sciences, Mercy College, Dobbs Ferry, NY, USA

ABSTRACT
Studies have characterised relationships between cognitive status and a variety of
clinical epilepsy factors. The aim of this study was to describe a new approach for
assessing executive functions in everyday life and its unique expression in
adolescents with Genetic Generalised Epilepsies (GGEs) compared with typical
peers. Twenty adolescents with a diagnosis of GGEs and 20 typical healthy peers,
matched by age and gender, were studied. Assessment of everyday executive
function was carried out using: (1) the Weekly Calendar Planning Activity (WCPA), a
direct performance based and outcome measure of strategy use and cognitive
performance; and (2) Behavior Rating Inventory of Executive Function (BRIEF)
parental report. Adolescents with GGEs demonstrated significantly less accuracy,
less efficiency and fewer strategies used, as measured by the WCPA. Parents of
adolescents with GGEs rated their child’s daily performance as less efficient
compared with typical peers. Better ratings of executive function (low BRIEF score)
were associated with greater WCPA accuracy in the entered appointments. The
WCPA provides a useful evaluation of cognitive performance for adolescents with
GGEs and a functionally relevant information on task efficiency, self-monitoring and
effective strategy use. Direct observation of performance supplements parental
ratings and has strong potential to guide intervention and measure outcomes.

ARTICLE HISTORY Received 11 June 2017; Accepted 18 April 2018

KEYWORDS Adolescents; Genetic Generalised Epilepsies (GGEs); executive functions; Weekly Calendar Planning
Activity (WCPA)

Introduction
Epilepsy is a common chronic neurological disorder, characterised by recurrent seizures,
which may vary from a brief lapse of attention or muscle jerks to severe and prolonged
convulsions. The seizures are caused by sudden, usually brief, excessive electrical dis-
charges in a group of brain cells. An estimated 2.4 million new cases occur each year
globally; at least 50% of cases begin in childhood or adolescence (WHO, 2017).

CONTACT Sharon Zlotnik sharonzlotnik5@gmail.com Department of Occupational Therapy, Faculty of

Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 31905
© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 S. ZLOTNIK ET AL.

The International Classification of Diseases 10 classifies generalised idiopathic epilep-

sies and epileptic syndromes (code G40.3) as either convulsive or non-convulsive. These
include childhood absence epilepsy, juvenile myoclonic epilepsy, benign myoclonic epi-
lepsy in infancy, etc., and non-specific epileptic seizure (e.g., atonic, clonic, myoclonic,
tonic, etc.; Jette et al., 2015). According to the International League Against Epilepsy
Commission (Berg et al., 2010), generalised epileptic seizures are conceptualised as orig-
inating at some point within, and rapidly engaging, bilaterally distributed networks
which can include cortical and subcortical structures, but do not necessarily include
the entire cortex. The commission recommend that the “‘idiopathic generalised epilep-
sies be called ‘Genetic Generalised Epilepsies’” (GGEs).
Studies have characterised relationships between cognitive status and a variety of
clinical epilepsy factors. The underlying cause of cognitive impairment has been
found to be associated with ethology, age of onset, seizure type, severity, duration,
and antiepileptic medications side effects (Aldenkamp & Arends, 2004; Hermann & Sei-
denberg, 2007; Klinkenberg et al., 2013).
Cognitive impairment, either pervasive or specific, as well as learning disability, may
exist in children with GGEs despite normal intelligence and well-controlled seizures (Kim
& Ko, 2016; Rathouz et al., 2014). Although the severity of cognitive side effects of drug
treatment is generally considered to be mild to moderate for most antiepileptic drugs
(Aldenkamp, Marc De Krom, & Reijs, 2003), it is still debated whether all commonly used
antiepileptic drugs have some impact on cognitive functions and whether some have
less effect (Berg et al., 2010).
Effective executive functions (EFs) are crucial for efficient daily functioning (Rosen-
berg, 2015) and are closely associated with academic achievement, vocational
success, and quality of life throughout life, often more so than IQ or socioeconomic
status (Moffitt et al., 2011). EFs are defined as higher-order cognitive functions that
are needed for performing complex or non-routine tasks (Godefroy, 2003). EF skills
include forming, maintaining, and shifting mental set, corresponding to abilities to (1)
reason and generate goals and plans, (2) maintain focus and motivation to follow
through with goals and plans, and (3) flexibly alter goals and plans in response to chan-
ging contingencies (Josman et al., 2014). Life activities, including risky driving habits and
motor vehicle accidents, resisting substance abuse, making and keeping friends
(Hughes & Dunn, 1998), academic success, getting and keeping a job, as well as
career advancement (Bailey, 2007), have all been related to EF. Therefore, it is particu-
larly important to assess EF in adolescents who may be vulnerable to EF impairments.
An important aspect of EF is the effective use of strategies to learn, remember,
problem solve, or successfully manage challenges that may occur during school, work
or daily life activities. Strategic approaches to tasks include methods or behaviours
that are observable, such as repeating information out loud or checking off items on
a list, as well as those that are not observable, such as talking to oneself or internally
generating a plan of action.
Since strategies are an integral part of performance and involve the process of how
one goes about dealing with task challenges, it is important to understand the range
and type of strategies used by adolescents (Toglia, Rodger, & Polatajko, 2012). There is
very little research, however, on strategies used by adolescents outside the context of
specific academic subjects, despite the recognition that effective strategies are needed
for success in college and work (Conley, Freidhoff, Gritter, & Van Duinen, 2008). There
are no studies to date that have investigated strategy use in adolescents with epilepsy.
 NEUROPSYCHOLOGICAL REHABILITATION 3

Executive dysfunction has been identified in adolescents with GGEs, despite short
duration and benign course of epilepsy, when measured with traditional neuropsycho-
logical assessment of EFs (such as the Verbal Fluency Test, the Five-Point Test, the Trail-
Making Test, Wisconsin Card Sorting Test or the STROOP test; Gelžinienė, Jurkevičienė,
Marmienė, Adomaitienė, & Endzinienė, 2011; Gioia, Isquith, Guy, & Kenworthy, 2000a;
Loughman, Bowden, & D’Souza, 2014; Parrish et al., 2007; Rathouz et al., 2014). In
general, these tests measure habitual response, spontaneous production of words,
speed of attention, sequencing, mental flexibility, visual search, motor function, and
working memory. A systematic review and meta-analysis of cognitive abilities in 26
peer-reviewed, case–control studies published between 1989 and 2014 suggests that
EF deficits may be part of a generalised decrease in cognitive skills in the GGEs syn-
drome, rather than a specific deficit (Rathouz et al., 2014). Although EF impairments
in individuals with GGEs have been previously documented, they remain clinically
under-reported in respect to strategy use. In addition, the functional everyday manifes-
tation of performance in adolescents with GGEs has not been studied through direct
observation.
Everyday EF can be rated by others or directly observed within an activity. Parental
reports using the Behaviour Rating Inventory of Executive Function (BRIEF; Gioia et al.,
2000a) revealed that children and adolescents with recent onset of GGEs demonstrated
significant difficulties in EF when measured by parental rating of their daily performance
(Loughman et al., 2014; Parrish et al., 2007). The BRIEF is based on observations of func-
tion over time and covers a broad array of EF skills. It should be kept in mind, however,
that such subjective ratings of daily performance from caregivers are fraught with chal-
lenges related to informant reports, such as context effects and differences in the way
different observers judge behaviour (Barkley, 2006). On the other hand, a performance-
based assessment is based on a single observation at a particular point in time; however,
it provides the opportunity to provide in-depth information about how one goes about
performing a task. For example, information on strategies used, types of errors, and
ability to recognise and correct errors can be directly observed. This information is par-
ticularly relevant to designing rehabilitation intervention programmes. We suggest that
performance-based and parent report measures of EF provide important but different
perspectives on an individual’s functioning (Toplak, West, & Stanovich, 2013; Toglia,
2015).
The Weekly Calendar Planning Activity (WCPA) is a unique performance-based
measure, comprising a multi-step everyday cognitive task that requires the integrated
use of EF skills and demands the use of a variety of strategies. The WCPA has been
shown to have inter-rater reliability and validity with at-risk adolescents transitioning
to adulthood (Weiner, Toglia, & Berg, 2012) and with college students with ADHD
(Lahav, Ben-Simon, Inbar-Weiss, & Katz, 2015). However, it has not been previously
tested among adolescents with epilepsy.
The purpose of our study was to describe and compare everyday EF performance of
adolescents with GGE with that of age-matched peers, using a newly developed direct
performance based functional measure, the WCPA. Our specific objectives were to: (1)
examine differences between groups in accuracy, number and type of strategies, plan-
ning and completion times and efficiency of a cognitive functional activity (WCPA); (2)
measure differences between groups in parental report of everyday EF skills using the
Behavioral Rating Inventory of Executive Functions (BRIEF); and (3) Examine the relation-
ship between parental report (BRIEF) and a performance measure (WCPA) of EF.
4 S. ZLOTNIK ET AL.

Methods
Participants
Forty adolescents (24 girls, 16 boys; mean age 15.86 years, SD = 1.51) were included in
the study. The study group included 20 adolescents (12 girls, 8 boys; mean age 15.78
years, SD = 1.53) with a diagnosis of GGEs who attended the Paediatric Neurology
Clinic at a tertiary paediatric centre. The diagnosis was based on the criteria of the Inter-
national League against Epilepsy International Classification of Diseases coding (Jette
et al., 2015). The seizures in 16 children were controlled on anti-epileptic therapy (Depa-
lept Chrono; Lamictal; Keppra; Amantadine). Four participants were not receiving any
antiepileptic drugs. The last reported seizure among 11 (55%) participants with GGEs
was between 1 and 24 months previously. Seven (45%) reported having had the last
seizure more than 24 months prior to the study meeting. In the present study no differ-
ences were found between those taking medication and those who were not taking
medication on the sub-scales of the assessments and no correlations were found
between the last reported seizure and the sub-scales of the assessments. Therefore
all participants with GGEs were assigned to one group. The control group included
20 healthy peers (12 girls, 8 boys; mean age 15.94 years, SD = 1.52) with normal devel-
opment, matched to the study group by age and gender. Participants with a learning
disability, additional chronic illnesses and previous reported diagnosis of ADHD were
excluded from the study. Table 1 summarises participant characteristics in each group.

Instruments
The BRIEF Parent Form (Gioia et al., 2000a) consists of 86 items sampled from practising
neuropsychologists, based on theoretical and empirically based definitions of the EF
construct. Parents rate their child’s behaviour on a three-point Likert scale (never, some-
times, often). Eight scales are obtained (Initiate, Working Memory, Plan/Organise,
Organisation of Materials, Monitor, Inhibit, Shift, Emotional Control), along with a Meta-
cognition Index (MCI), Behavior Regulation Index (BRI), and a Global Executive Compo-
site (GEC). Raw scores were converted to a T score with a mean of 50 and a standard
deviation of 10. Higher ratings are indicative of greater perceived impairment. The
BRIEF Parent Form was normed on 1419 control children and 852 children from referred
clinical groups. Factor analytic studies of the normative sample support the existence of
two underlying factors which were used to develop the MCI and BRI. Mean internal con-
sistency ratings reported for clinical populations using the BRIEF Parent Form range

Table 1. Participant characteristics.

Demographic variable Epilepsy (n = 20) Typical (n = 20)
Age (mean, SD) 15.78 (1.53) 15.94 (1.52)
Gender Boys 8 (40%) 8 (40%)
Girls 12 (60%) 12 (60%)
Medication Yes 16 (80%) –
No 4 (20%) 20 (100%)
Last reported seizure Not reported–Last month 2 (5%)–2 (5%)
Last 6 months 3 (7.5%)
6–12 months 2 (5%)
13–18 months 3 (7.5%)
19–24 months 1 (2.5%)
More than 2 years 7 (45%)
 NEUROPSYCHOLOGICAL REHABILITATION 5

from 0.82 to 0.98. Three-week test–retest correlations for clinical populations on the
Parent Form range from 0.72 to 0.84 (Gioia, Isquith, Guy, & Kenworthy, 2000b). For
the purposes of this study, the three main index scores (GEC, BRI, and MCI) were
chosen for analysis.
The WCPA (Toglia, 2015) is a performance measure of EF. The examiner presents par-
ticipants with 18 appointments in a randomly ordered list. Participants are required to
enter the appointments into a 1 week schedule while recognising and managing con-
flicts and adhering to five written rules: (1) leave Wednesday free; (2) do not cross out
appointments once they are entered; (3) inform the examiner when it is a specified time;
(4) do not respond to distracting questions from the examiner; and (5) inform the exam-
iner when finished. The examiner observes and records the strategies that participants
use during the task on a list of 13 pre-identified strategies as listed below. Scores include
total accuracy of appointments entered on the calendar, errors made in appointment
placement, planning time and total task time, number of rules followed, types of strat-
egies used and efficiency score. The assessment’s reliability was established with 38 par-
ticipants; the intra-class correlation for total accuracy score was 0.986, indicating a high
level of inter-rater reliability for total accuracy score (Toglia & Berg, 2013)

List of strategies

(1) Underlines, circles or highlights key words or features.

(2) Uses finger.
(3) Verbal rehearsal: repeats key words or instructions out loud.
(4) Crosses off/checks off or highlights appointments entered.
(5) Re-arranges materials.
(6) Categorises or organises appointments before entering them (coding system,
colour codes, highlights, labels).
(7) Enters fixed appointments first, then flexible.
(8) Uses written plan – makes a rough draft first, or plans out calendar in writing
before entering appointments.
(9) Talks out loud about strategy/method or plan.
(10) Crosses off specified free day.
(11) Self-checks.
(12) Pauses and rereads.
(13) Other.

For detailed description of cognitive strategies please refer to Toglia et al. (2012).

Procedure
Ethical approval of the study was received from the hospital’s IRB committee (no. 0368-
14-RMB). All adolescents and their parents were either recruited by clinic staff or
referred by acquaintances. Parents and adolescents who met the inclusion criteria
and agreed to participate in the study were asked to complete the consent forms.
The adolescents were asked to complete the demographic questionnaire and
perform the WCPA in a quiet room and in the presence of the health professional. Mean-
while, their parents filled in the BRIEF questionnaire outside the room. The same
6 S. ZLOTNIK ET AL.

assessment procedures were followed for the typical control group; however, the
assessment session took place in their homes.

Data analysis
Descriptive statistics (including mean, standard deviation, median, frequency, and per-
centage) were used to characterise selected variables using IBM SPSS version 23. Assump-
tions of linearity, normality, and homogeneity of variance were evaluated prior to
statistical analysis. Since the WCPA sub-scales (efficiency score, number of accurate meet-
ings, and first plan time) were not normally distributed, the non-parametric Mann–
Whitney U and chi-square tests were used to examine differences between the groups.
Correlations between the BRIEF and WCPA scores were measured using the non-
parametric Spearman test. An alpha level of 0.05 was established for all statistical tests.

Results
Comparison between adolescents with GGEs and controls on BRIEF variables
A significant difference was found between the epilepsy group in all of the BRIEF sub-
scales (GEC: U = 65.0, Z = −3.52, p = .00; BRI: U = 80.50, Z = −3.08, p = .02; MI: U = 65.0,
Z = −3.51, p = .00).

Comparison between adolescents with GGEs and controls on WCPA

As can be seen in Table 2, significant differences between the epilepsy group and the
typical control group were found for the WCPA efficiency scores (U = 83.0, Z = −3.16, p
< .01), number of accurate meetings (U = 66.0, Z = −3.66 p < .01( and number of strat-
egies, (U = 107.0, Z = −2.38, p < .05). No differences were detected for planning times,
total performance time and number of entered meetings. The control group had signifi-
cantly more accurate meetings and lower (better) efficiency score and used more
strategies.

Differences in distribution of WCPA efficiency and accuracy scores

In order to examine the distribution of accuracy and efficiency scores among the entire
sample, we divided the sample according to high, moderate and low efficiency and accu-
racy scores. The results of a chi-square cross-tabulation test show significant differences
in the distribution of accuracy scores between participants [χ 2 (1, N = 40) = 8.94, p < .01].
Twenty-five per cent of those with high accuracy score were participants with epilepsy,
while 60% of those with high accuracy were participants from the typical group.
A significant difference was also found also in the distribution of efficiency scores
between participants [χ 2 (1, N = 40) = 14.45, p < .01]. Only 15% of those with high effi-
ciency score were participants with epilepsy, while 45% of those in with high accuracy
were participants from the typical group (Table 3).

Correlations between WCPA and BRIEF assessment sub-scales

Significant correlations were found between the WCPA number of accurate meetings
and the BRIEF sub-scales GEC (rs = −0.39, p < .05) and MI (rs = −0.41, p < .05).
Table 2. Comparison between adolescents with GGEs and controls on WCPA.
Epilepsy Control
WCPA M SD Med Min Max Sk Ku M SD Med Min Max Sk Ku U Z p
Entered meetings 15.85 4.24 17 0 18 −3.23 11.01 17.55 1.59 18 17 18 −0.21 −2.18 132 −2.03 NS
Accurate meetings 10.65 4.84 11.5 0 18 −1.13 0.38 15.3 0.51 15 12 18 0.59 −0.49 66 −3.66 p < .01
Number of strategies 2.68 1.45 3 0 5 −0.22 −0.4 3.95 1.43 4 2 6 0.09 −1.21 107 −2.38 p < .05

NEUROPSYCHOLOGICAL REHABILITATION
Efficiency 187.77 196.17 125.97 63.2 932.7 3.24 11.73 86.42 19.91 90.61 53 113 −0.00 −1.43 83 −3.16 p = .01
First plan time, s 32.1 28.25 22.5 7 127 2.31 6.27 114.3 211.02 38 3 720 2.7 6.3 142.5 −1.5 NS
Second plan time, s 93.66 4.58 89.5 12 188 0.77 1.43 110.05 52.95 102 40 217 0.74 −0.18 145.5 −1.0 NS
Total time, s 945.43 303.52 971.7 334.8 1503.6 −0.09 −0.14 1101.85 300.49 1103.1 286 1800 −0.42 2.86 140 −1.6 NS
M = mean; SD = standard deviation; Med = median; Sk = skewness; Ku = kurtosis; U = Mann–Whitney U test; Z = equivalently values.

7
8 S. ZLOTNIK ET AL.

Table 3. Differences in distribution of WCPA efficiency and accuracy scores.

Epilepsy Typical
Participants grouped by accuracy scores
Up to 9 – low accuracy 6 (30%) 0
10–14 – moderate accuracy 9 (45%) 8 (40%)
15–18 – high accuracy 5 (25%) 12 (60%)
Participants grouped by efficiency scores
53–80 – high efficiency 3 (15.8%) 9 (45%)
81–120 – moderate efficiency 6 (31.6%) 11 (55.0%)
121–932 – low efficiency 10 (52.6%) 0

Better ratings of executive function (low BRIEF T score) were associated with greater
accuracy in entered appointments.

Comparison of type and strategies used

Figure 1 shows that, amongst adolescents with epilepsy, the most frequent (75%) strat-
egy was “Uses finger”, whereas the most frequent strategy (65%) among age-matched
peers was “Enters fixed appointments first”. Also, the greatest discrepancy of strategy
use was noted in the “Self-checks” strategy; while 60% of the control group used this
specific strategy, only 30% of the epilepsy group used it.
No significant correlations were found between taking medication, the last reported
seizure and the sub-scales of the assessments performance.

Discussion
The aim of this study was to assess executive functions in everyday life among adoles-
cents with GGEs compared with age-matched peers using a newly developed perform-
ance-based measure (the WCPA). Findings from a large US national survey, among
31,897 children aged 6–17 years with special healthcare needs, with and without epi-
lepsy, indicated a higher percentage of children with epilepsy, compared with children
without epilepsy, who presented difficulty in multiple areas of functioning and ADHD
(up to 14%), as well as limitations in school attendance, high prevalence of learning dis-
abilities such as dyslexia (13–32%), dysgraphia (35–56%) or dyscalculia (20–38%) (Dunn,
Austin, Harezlak, & Ambrosius, 2003; Fastenau, Jianzhao Shen, Dunn, & Austin, 2008;
Pastor, Reuben, Kobau, Helmers, & Lukacs, 2015).
The adolescents in our study were mainstream students and according to their
medical files were not reported by their physician as diagnosed with learning disabilities
or special needs; nevertheless, they demonstrated lower EF skills compared with peers
as measured on both the WCPA and parental ratings of everyday executive functions
(BRIEF). Parents of adolescents with GGEs endorsed significantly more EF problems
for their children than parents of adolescents in the control group. The WCPA also dis-
tinguished between adolescents with GGEs and age-matched peers, supporting the dis-
criminative validity of this EF performance-based measure. Adolescents with GGEs were
significantly less accurate and less efficient and used different and fewer strategies on
the WCPA than peers. These results are consistent with previous reports suggesting that
EF is a vulnerable domain of cognition among paediatric epilepsy patients (Lagae, 2006;
Loughman et al., 2014; Parrish et al., 2007). The observed EF difficulties may be one of
 NEUROPSYCHOLOGICAL REHABILITATION 9

Figure 1. Comparison of type and amount of strategies used.

the cognitive problems associated with poorer academic attainment as reported in the
literature.
Performance time or the number of minutes required to complete the WCPA was not
significantly different between groups. According to Lagae (2006), older anti-epileptic
drugs can induce psychomotor slowing of 100–200 ms increase in reaction time. Never-
theless, recent comparison between the side effects of older vs newer anti-epileptic
drugs on psychomotor reaction reveals that the studied new anti-epileptic drugs (leve-
tiracetam = Keppra; lamotrigine = Lamictal; topiramate = Topamax) are safer at the cog-
nitive level in relation to psychomotor processing than the older ones (Lagae, 2006).
These drugs were common among the participants in this present study and, therefore,
no processing delay should be expected.
This study also examined the relationship between the BRIEF and the WCPA. Parental
rating of their children’s daily performance was positively associated with their actual
ability to manage the WCPA. However, the relationship was weak to moderate. This
finding suggests that, although there is some shared variance, each method also pro-
vides information that is different. This is consistent with a previous literature review
by Toplak et al. (2013), who examined the association between performance-based
and ratings measures of executive function across 20 studies of different ages and
populations.
An advantage of the performance-based assessment is that it allows for direct obser-
vation and analysis of strategy use or how a person goes about doing a task. The WCPA
revealed differences between the groups in both the number and type of strategies
used. Amongst adolescents with GGEs the most frequently used strategy was strategy
2, “Uses finger”, whereas the most frequent strategy among the control group was strat-
egy 7 “Enters fixed appointments first”. While more teens in the control group recog-
nised the advantage of entering the fixed appointments first as an efficient method
10 S. ZLOTNIK ET AL.

of approaching the task, most of the adolescents with GGEs mainly used their fingers to
keep track of information.
The clinical importance of this indication is that the strategy of finger pointing to
specific task stimuli can serve to enhance attention to details within a task (Toglia
et al., 2012). Overuse of this strategy may reflect difficulty in focusing on relevant infor-
mation. This difference may also account for less efficient performance. The greatest dis-
crepancy between the groups in strategy use was revealed in the “Self-checks” strategy,
used by most age-matched peers, compared with only one-third of the GGEs group.
Effective cognitive strategy use, such as the “Self-checks” strategy, is a form of self-
regulation of behaviour that involves recognition of performance errors and knowing
when a strategy is not working. The ability to step back and self-evaluate the effective-
ness of strategy use and performance by reviewing, checking, and comparing outcomes
with goals allows one to make corrections and revisions or generate new task methods
for successful performance (Toglia et al., 2012). Self-monitoring and checking one’s work
is an important foundation for problem-solving behaviour and effective strategy use,
which also facilitates awareness of performance. It is also an important skill for
success in school and work. This may account for the significant differences in the accu-
racy of performing the WCPA. This very examination of the patterns of strategy use may
enable a direct and personalised intervention, allowing the therapist to offer specific
guidance as to the needed strategy to enhance performance. Moreover, Toglia and
Kirk (2000) directed therapists in general, and specifically occupational therapists, in
helping clients self-discover their own errors using metacognitive training techniques,
including strategies that focus on self-monitoring skills and guided questions to help
them recognise their own errors. This could support adolescent functional performance
across a wide range of everyday tasks and contexts.

Limitations
The present study was conducted among a relatively small sample size. A larger and
more diverse sample across different settings would allow for greater generalisability
of findings. Also, additional EF measures such as The Zoo Map task (BADS-C) (Baron,
2007) may allow for broader characterisation of EF abilities in this population. Future
studies should also screen for learning disability with respect to other cognitive deficits.

Conclusions
Our study has demonstrated that adolescents with GGEs may have tendency to
decreased EF as reflected in the prevalence of lower scores of functional performance,
compared with their age-matched peers. Taking into consideration that the adolescents
in our study were mainstream students and according to their medical files were not
reported by their physician as diagnosed with learning disabilities or special needs, it
is possible that some had undetected underlying learning disability that were not ident-
ified by their school system. Without additional assessments it is unclear whether the
observed EF problems are the result of broader cognitive deficits prevalent even
among those who attend in regular schools, as reported in the literature by Rathouz
et al. (2014) and also van Iterson & de Jong (2018). However, this could be explored
in future research. Thus, the current findings are particularly significant and suggest
that functional executive skills should be routinely examined in clinical settings and
 NEUROPSYCHOLOGICAL REHABILITATION 11

screened for executive deficits. The WCPA assessment is clinically useful, feasible and
representative of a real-world multi-step activity. It was found to successfully discrimi-
nate differences in executive function performance and strategy use for adolescents
with GGEs. Along with parental rating, the WCPA may serve as a useful in-depth
method for evaluating everyday functional cognition (or executive skills).
Our findings have implications for assessment and intervention of cognitive rehabi-
litation. Early identification of EF weaknesses is important because EF is crucial for
success in creating and maintaining a productive and meaningful across the life span
(de Lima, Moreira, da Gomes, & Maia-Filho, 2014). Rehabilitation methods that
promote effective strategy use within the context of relevant life activities may have
the potential to enhance outcomes for adolescents with GGEs across broad areas of
function. The prerequisites to strategy use and execution should be carefully observed
and assessed during activity performance and probed during pre- and post-activity
interviews.
According to Toglia et al. (2012), promoting an effective strategy use should not only
demonstrate or instruct a person in strategy use, but go beyond “showing and doing”
and help him/her to discover, understand, anticipate, or recognise the need for the
strategy and to know when it is needed. As such, we recommend assessing EF
among adolescents diagnosed with GGEs in order to plan useful intervention strategies
for those who have impaired EFs. We also recommend that further studies with larger
groups of adolescents with GGEs and controls should be performed, targeting measure-
ment of the effectiveness of strategy-based training for adolescents with GGEs and their
impact on daily performance and wellbeing. Everyday EF measures should also be com-
pared with neuropsychological measures of EF impairment, as well as other functional
indicators such as academic performance.

Acknowledgement
We would like to thank all the adolescents and their parents who agreed to participate in this study.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-
profit sectors.

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