Effectiveness of Cognitive–Functional (Cog–Fun)
Intervention With Children With Attention Deficit
Hyperactivity Disorder: A Pilot Study
KEY WORDS
 activities of daily living
 attention deficit disorder with
hyperactivity
 cognitive therapy
 executive function
 treatment outcome
Jeri Hahn-Markowitz, MSc, OTR, is Director of
Continuing Education and Doctoral Student, School of
Occupational Therapy, Faculty of Medicine, Hadassah and
The Hebrew University of Jerusalem, PO Box 20246,
Mount Scopus, Jerusalem 91240 Israel;
jerihahnmarkowitz@gmail.com
Iris Manor, MD, is Medical Director, ADHD Clinic, Geha
Mental Health Center, Petah Tikva, Israel.
Adina Maeir, PhD, OT, is Senior Lecturer, School of
Occupational Therapy, Faculty of Medicine, Hadassah and
The Hebrew University of Jerusalem, Jerusalem, Israel.
384
Jeri Hahn-Markowitz, Iris Manor, Adina Maeir
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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ventions for ADHD symptoms, no intervention has yet been found that deals directly with EFs in daily tasks.
Fourteen children and their parents participated in the Cognitive–Functional (Cog–Fun) program in
occupational therapy, which is tailored to the executive dysfunction of ADHD and focuses on enabling
cognitive strategies for occupational performance. The study included initial assessment of EFs (Behavior
Rating Inventory of Executive Functions; Tower of LondonDX), occupational performance (Canadian Occu-
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
ttention deficit hyperactivity disorder (ADHD) is a neurobiological disorder
that affects the emotions, behavior, and cognitive state of 4%–7% of children
worldwide (Spencer, Biederman, & Mick, 2007). Symptoms include inattention,
impulsivity, and hyperactivity, and they often persist into adulthood. The long-
term emotional, social, educational, and occupational implications of ADHD
are profound and well documented (Cermak, 2005).
Executive functions (EFs) consist of higher order cognitive abilities, including
working memory, planning, and emotional regulation (Barkley, 2004), which
are crucial for complex and dynamic activities of daily living (ADLs; Katz &
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
July/August 2011, Volume 65, Number 4
the Dynamic Interactional Approach (DIA; Toglia, 2005)
and similar applications of strategy-based learning for peo-
ple with cognitive impairments.
Toglia’s (2005) DIA for cognitive rehabilitation
highlights the dynamic interaction among person, task,
and environment regarding problems in occupational
performance. Intervention includes imparting strategies
that are practiced and transferred to different activities
and situations—emphasizing metacognitive strategies of
self-monitoring and self-evaluation—to establish or re-
store balance in occupational functioning ( Josman,
2005). Although this approach has not been applied to
children with ADHD, it has been applied to children and
adults with head injury who experience similar symptoms
(Cermak, 2005).
An intervention for adolescents with ADHD designed
by Ylvisaker and DeBonis (2000) used a global executive
strategy to enable positive changes in everyday routines by
5 middle school students and their parents. Qualitative
findings demonstrated the adolescents’ improved self-
regulated behavior at home.
The Cognitive Orientation to Daily Occupational
Performance (CO–OP; Polatajko & Mandich, 2004)
intervention approach emphasizes metacognitive strate-
gies in an occupational context to guide the motor per-
formance of children with developmental coordination
disorder (DCD). Polatajko and Mandich (2004) pre-
sented a case study of a child with ADHD using CO–OP.
The child, his parents, and his teacher noted improvement
in attaining his set goals, as measured by the Canadian
Occupational Performance Measure (COPM; Law, Baptiste,
et al., 2005). Although the evidence for CO–OP’s effec-
tiveness with children with DCD is ample (Polatajko &
Mandich, 2005; Taylor, Fayed, & Mandich, 2007), aside
from this single case study, no evidence exists for its ef-
fectiveness with children with ADHD. Little is written
in the occupational therapy literature about cognitive ap-
proaches to treating children with ADHD (Cermak, 2005).
The aim of this study was to examine the effectiveness
of the Cog–Fun intervention in helping children with
ADHD achieve occupational goals, improve EFs in daily
life, and improve self-efficacy.
Method
Research Design
The study was an uncontrolled, one-group, preintervention–
postintervention pilot investigation to explore the effects
of the Cog–Fun program on children with ADHD. We
used convenience sampling of children diagnosed in
a community ADHD clinic. Ethical approval was ob-
The American Journal of Occupational Therapy
tained from the Helsinki Ethics Committee of Geha
Hospital. Parents provided informed consent, and chil-
dren provided assent.
Instruments
Behavioral Rating Inventory of Executive Function. The
Behavioral Rating Inventory of Executive Function
(BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000a) is an
86-item ecological rating scale (parent, teacher) designed
to reflect the neuropsychological constructs of EF in ev-
eryday situations for children ages 5–18. It comprises
eight scales, two indexes, and a Global Executive Com-
posite. The Behavioral Regulation Index includes the Inhibit,
Shift, and Emotional Control scales, and the Metacognitive
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Index includes the Initiate, Working Memory, Plan–
Organize, Organization of Materials, and Monitor scales.
Raw scores are transformed into t scores; children scoring
³65 are considered clinically impaired. Internal consis-
tency, test–retest reliability (rs 5 .72–.84 for the Parent
Form over 3 wk), and discriminant validity, including the
Hebrew version, have been established for people with
ADHD (Gioia, Isquith, Guy, & Kenworthy, 2000b;
Linder, Kroyzer, Maeir, Wertman-Elad, & Pollak, 2010;
McCandless & O’Laughlin, 2007).
Tower of London–Drexel University. The 2nd edition
of the Tower of London–Drexel University (TOLDX;
Culbertson & Zillmer, 2005) is a neuropsychological
assessment of EF that identifies impairments in planning.
Standard scores are generated for number of moves,
problem-solving time, and rule violations. Test–retest
reliability (r 5 .80 for Total Moves over 20 days), cri-
terion validity, and construct validity of the TOLDX have
been established for children with ADHD (Culbertson &
Zillmer, 1998a, 1998b).
Canadian Occupational Performance Measure. The
COPM is a semistructured, individualized, client-centered
instrument designed for occupational therapists to help
clients identify problems and detect change in the per-
formance of daily occupations. It is a well-validated, reliable
(test–retest reliability 5 .80 for Performance over 1–2 wk),
valid, standardized instrument (Law, Baptiste, et al.,
2005). Law, Majenemer, et al. (2005) used the COPM to
measure occupational performance outcomes before and
after an occupational therapy home care program for
children, including children with ADHD. In this study,
we considered the child’s COPM rating a measure of self-
efficacy (Reid, 2002).
Participants
Seventeen children were referred to the first author (Hahn-
Markowitz) by the research coordinator of a community
385
ADHD clinic. To be included, children had to be ages 7–8
and diagnosed with ADHD (all three subtypes) by a se-
nior psychiatrist (Iris Manor) on the basis of the criteria
in the Diagnostic and Statistical Manual of Mental Dis-
orders (4th ed., text revision; American Psychiatric Asso-
ciation, 2000); have reported difficulties in occupational
performance; and attend school in a regular educational
environment. Exclusion criteria were other psychiatric or
neurological disorders and an estimated IQ <80.
Procedure
Children were referred from the ADHD community clinic
in which the study took place. The program was explained
to parents by telephone, and they and the children signed
a consent form at assessment. Three assessed children
did not continue to intervention because they did not
generate or agree to an occupational goal to work toward.
A certified psychologist administered four subtests of
the Wechsler Intelligence Scales for Children–Revised
(Wechsler, 1995) to estimate IQ. The performance mea-
sures were administered by an experienced occupational
therapist who also carried out the intervention with each
child–parent dyad. All measures were readministered after
intervention by the same occupational therapist and again
at a 3-mo follow-up visit.
Cog–Fun Intervention
The Cog–Fun intervention is theoretically driven and
addresses deficient goal-oriented processes in children
Figure 1. Occupational goals chosen by children.
386
with ADHD. It supports participation through the
learning of specific executive strategies (Stop, Plan, Re-
view) in a context of achieving occupational goals that
target self-regulation, working memory, and planning. By
definition, the goals are meaningful to the child and
harness motivational and cognitive resources toward goal-
oriented behavior (Figure 1).
The program involved ten 1-hr weekly sessions and
transfer work facilitated by the parents at home. Each
child–parent dyad chose one occupational goal to work
toward at home, at school, or in the schoolyard. Goals
were identified by interviewing each child to complete an
activity log of a typical day. Half of the dyads chose a
transfer goal as well. The others could not generate a
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transfer goal and did not agree with the goal suggested by
the occupational therapist. Upon goal attainment, an-
other goal was chosen (up to a total of three goals).
Task-specific strategies for goal definition, inhi-
bition, planning, and review were used to achieve specific
occupational goals (e.g., verbalize goal [“What do I want
to achieve?”]; walk away from provocative sibling; pull
chair close to table so that food will not spill; mark
checklist of items needed in schoolbag). Strategy learn-
ing was reinforced at home with two external executive
supports. A timer helped each child stop and focus on
thinking about the goal once a day, and a daily planner
helped the child plan and monitor goal achievement
(Dawson & Guare, 2004; O’Connell et al., 2006). We
also used games and activities that challenge executive
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-
rents completed the COPM and BRIEF independently at
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Table 1. Cognitive–Functional Treatment Protocol
Treatment Aims
1 Set occupational goals.
Provide an avenue for communication
(parents with occupational therapist).
2 Reinforce goal intention.
Introduce Stop (inhibition) strategy and practice
transferring to occupational goal in clinic.
Practice transferring Stop strategy to occupational
goal in natural context (home).
Provide parental support.
3 Reinforce Stop strategy.
Provide organizational device for occupational goal
attainment and assume ownership.
Introduce Plan strategy.
Practice transferring Stop strategy to occupational
goal in natural context (home).
Provide parental support.
4 Reinforce Stop strategy; enhance ownership of DOGP.
Practice and transfer Plan strategy
to occupational goal.
Provide parental support.a
5 Reinforce Plan strategy.
Introduce review strategy.
Practice transfer of review strategy to game activity
in clinic.
Practice transfer of review strategy to occupational
goal in natural context (home).
6 Reinforce plan and review strategies used to achieve
goal and revise plan as needed.
Reinforce all strategies (stop, plan, and review).
7–10 With goal achievement, transfer strategies to
new goal.
Reinforce all strategies (Stop, Plan, and Review).
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
Activities
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)
Give parent notebook (for use during sessions and at home).
Sign goal contract (harness motivation).
Stop game: Simon Says.
Introduce timer as stop cue.
Practice linking auditory alert with goal intention (verbalize goal when
timer goes off).
Homework: Practice timer use with goal statement once a day.
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Highlight the benefits of positive, specific reinforcement; provide booster
phone call midweek.
Review homework and previous session (timer use and demonstration).
Introduce Daily Occupational Goal Planner (DOGP) and personalize it
(decorate, write name and goal).
Undertake guided discovery of Plan components: actions, materials,
location, time frame.
Play game: Practice Plan strategy for simple and emotionally neutral
hypothetical goal.
Homework: Practice timer use with goal statement; think about PLAN components
for goal once a day; put smiley sticker on DOGP each day after timer use.
Reminder to use positive, specific reinforcement; booster phone call midweek.
Review homework and previous session (timer use and demonstration; DOGP use).
Review plan made last session for hypothetical 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.
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
Review DOGP use.
Undertake guided discovery of review components (what worked, what
did not, and what do I want to change).
Play game: Child observes and then verbally analyzes occupational
therapist’s performance of plan made for hypothetical goal of 2 weeks earlier.
Homework: Use timer to implement plan and review strategy to attain
occupational goal once a day; document review in DOGP.
Review DOGP use and generate additional task-specific strategies
to implement goal attainment if necessary.
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.
COPM for 2nd goal; COPM for 3rd goal. Undertake guided discovery of
plan and review strategies to achieve occupational goal.
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.
387
all assessment points. The BRIEF was delivered to the
teachers for completion at all assessment points and re-
turned to the occupational therapist.
Data Analysis
We analyzed the data with nonparametric statistics (Wilcoxon
signed-ranks tests) using SPSS Version 16 (SPSS, Inc.,
Chicago). We computed effect size using Hedge’s g be-
cause of the small sample size (Lion, 2008).
Results
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
4.18); the male:female ratio was 9:5. Nine children (64%)
were diagnosed with combined-type ADHD, and 5
children (36%) were diagnosed with inattentive type ADHD,
in accordance with the prevalence reported in the literature
(Solanto et al., 2007). Four of the 14 treated children were
medicated for ³6 mo before participation in this study
and continued this intervention throughout follow-up. One
child began medication after postintervention assessment
and therefore was not followed up. Mother’s education
ranged from 12 to 25 yr (M 5 15.14, SD 5 3.82). Four
fathers and 10 mothers participated in the program
(Table 2). Results on all outcome measures are shown in
Table 3.
BRIEF
Analysis of the changes on the Parent BRIEF revealed
statistically significant improvements after intervention in
the mean Global Executive Composite and on both the
indices and four of the eight scales. The largest effect size
was found for the Plan–Organize scale. The frequencies of
individual BRIEF Global Executive Composite Parent pro-
files revealed that after intervention, the scores improved
(decreased) for 12 children. At follow-up, improvements
on the indexes and Global Executive Composite were
maintained.
Teachers of 13 children completed the BRIEF before
intervention, and teachers of 10 children completed it after
intervention. Examination of the results revealed a similar
Table 2. Participant Sample (N 5 14)
Participant Characteristics Boys Girls % Total
Age 7 yr, 0 mo–7 yr, 11 mo 6 2 57
Age 8 yr, 0 mo–8 yr, 8 mo 3 3 43
Inattentive ADHD type 3 2 36
Combined ADHD type 6 3 64
Medication 2 2 29
No medication 7 3 71
Note. ADHD 5 attention deficit hyperactivity disorder.
388
trend: Effect sizes were slightly smaller than on the
Parent BRIEF. Teacher BRIEF results were slightly worse
at follow-up than at postintervention.
TOLDX
TOLDX scores showed statistically significant improve-
ment after intervention. The means of the raw scores
showed a decrease (improvement) by 14.69 total moves
(p 5 .018); 1 rule violation (p 5 .012); and 180 s in total
time (p 5 .012), with predominantly large effect sizes.
Scores were slightly worse at follow-up than at post-
intervention, other than total time.
Canadian Occupational Performance Measure
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Parents’ Ratings of Their Children’s Performance. The
parents’ ratings of their children’s performance of goals
and transfer goals after intervention reflected statistically
significant improvements (mean difference score 5
4.1 points, p 5 .001, and 3.86 points, p 5 .017, re-
spectively) with a large effect size. At follow-up, 5 pa-
rents reported further improvement in their child’s
performance of goals, 2 parents reported that their child
maintained the performance level achieved at postinter-
vention, and 5 parents reported a decrease of an average
of 1.33 points in their child’s performance level from
postintervention.
Children’s Ratings on the COPM. We found a statisti-
cally significant improvement in the means of the child-
ren’s ratings on the COPM goals and transfer goals after
intervention (ps 5 .001 and .014, respectively). Average
self-scoring on goal performance decreased slightly from
postintervention to follow-up.
Intervention Fidelity
The occupational therapist who carried out the program
kept a log of all sessions to support fidelity of intervention
and to obtain qualitative information, which was checked
by investigator Adina Maeir.
Discussion
We examined the effectiveness of a cognitive–functional
intervention to improve the EF of children with ADHD.
The aim was to examine whether children would acquire
executive skills and improve their performance on mean-
8
ingful occupations that were targeted, as well as occupa-
6
5
tions not directly targeted, in intervention (i.e., transfer of
9 EFs). Assessments were chosen to reflect EF and occupa-
4 tional components of the intervention. Findings showed
10 significant improvement on the outcome measures, and
many of the gains were maintained at follow-up.
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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
effect sizes found on the BRIEF parent and teacher reports
are encouraging, suggesting a possible intervention effect on
EF in daily life. The teachers reported better EF in school
than the parents reported for home, concurring with the
findings of Drechsler et al. (2007), who used the BRIEF
when evaluating neurofeedback training for children with
ADHD. Several explanations are possible for the discrep-
ancy between parent and teacher reports on children’s EF.
The fact that some children were on medication while in
school ( Jarratt et al., 2005) and that the classroom envi-
ronment is structured (Mares, McLuckie, Schwartz, &
Saini, 2007) may account for teachers’ witnessing more
organized and controlled behavior than parents witnessed
at home. In other studies, teachers reported higher
(worse) BRIEF scores than parents ( Jarratt et al., 2005;
McCandless & O’Laughlin, 2007; Mares et al., 2007).
Differences between informants may be the result of
cross-situational discrepancies in expectations and per-
ceptions. Future studies should examine the source of
these differences with the aid of an independent infor-
mant who would observe the child in both environments
(Mares et al., 2007).
On the TOLDX, the children completed the tasks in
less time, with fewer moves and fewer rule violations, after
intervention, with medium to large effects. This finding
could reflect more efficient strategic planning, similar to
that reported on the BRIEF. The established test–retest
reliability supports this interpretation and reduces the
likelihood of a practice effect. These results are unlike
those of Yang, Chung, Chen, and Chen (2004), who com-
pared 6- to 12-yr-old Taiwanese children with ADHD before
and after receiving methylphenidate twice daily for 16 wk
and found no improvement on the TOLDX. This compar-
ison may represent an advantage for cognitive–functional
intervention on planning abilities. An exhaustive literature
search did not generate articles on nonpharmacological
studies using the TOLDX as an outcome measure; therefore,
this premise could not be further explored.
We found a strong positive change in the parents’
and children’s rating of occupational performance on
trained and untrained goals, as reflected in the COPM
preintervention–postintervention scores. Previous studies
have shown that a change of ³2 points on the COPM is
considered a moderate to large change and a clinically
important difference as judged by clients and their fam-
ilies (Phipps & Richardson, 2007). According to Toglia
(2005), multitask activities in a variety of settings should
be included in therapy to facilitate the acquisition and
transfer of strategies in a multitude of contexts. In this
study, the transfer goals chosen were not addressed di-
rectly in the therapeutic process. The improved COPM
scores on the transfer goals could reflect the success of the
program in facilitating transfer of strategy use.
Despite this study’s positive results, caution is needed
in accounting for the effect of potential human bias on
the part of respondents on rating scales (Draper, 2002).
The actual size of effects will need to be determined in
further controlled, blinded studies.
Mechanisms of Change in Intervention
The positive results of this study raise questions as to what
contributed to change. Notwithstanding the possibility
of bias, we hypothesized that the strategies acquired in

The American Journal of Occupational Therapy 389

intervention would play a significant role in improved
performance on outcome measures. This hypothesis is
based on findings of previous studies in which metacognitive
strategy training was used and beneficial for children
with ADHD.
Thompson and Thompson (1998) taught children
with ADHD metacognitive strategies related to academic
tasks. Symptoms lessened after intervention, and aca-
demic performance improved. The results of a study to
determine the effectiveness of the CO–OP approach with
children with DCD (Taylor et al., 2007) supported
metacognitive strategy training; however, the CO–OP
approach was not studied among children with ADHD.
This study supports a metacognitive approach for chil-
dren with ADHD, with positive results found for occu-
pational performance measures.
The positive atmosphere in the clinic may have
contributed to enhanced motivation, which, in turn, may
have influenced a change in performance (Ylvisaker &
DeBonis, 2000). In the Model of Human Occupation,
Kielhofner (1995) asserted that volition is a key factor in
determining a person’s level of participation in an occu-
pation because it guides one’s choice of occupational
behavior on the basis of level of enjoyment and degree of
engagement. The results of this study are in line with the
preceding findings and reinforce the importance of the
role of harnessing motivation. We did not specifically
measure motivation as an outcome; however, it may have
been an important element of the program’s success.
Future studies should measure motivation.
Another intervention component central to this study
was the participation of a parent in all sessions and the
parent’s role in facilitating change. In the family-centered
approach, occupational therapists work with parents to
empower and enable them in the intervention process
(Chu & Reynolds, 2007; Law et al., 2007). We did not
specifically measure the parents’ participation in this
study; however, future studies should examine parents’
level of awareness, knowledge of the intervention process,
role in facilitating transfer of strategy use at home, and
degree of support they offered to their children, as me-
diating factors.
We hypothesize that that the combination of the
children’s metacognitive skills training (with adaptations
for ADHD), the clinical setting that fostered motivated
engagement in therapy, and the parental role contributed
to the positive outcomes. Regarding the findings at follow-
up, the scores on most measures demonstrate that inter-
vention gains were maintained, yet did not continue to
improve, suggesting that children and parents may benefit
from periodic booster sessions.
390
Which Children Benefited Most From
the Intervention?
The therapist observed several trends. One common de-
nominator among the children with the greatest gains was
having a mother who was actively supportive of her child
and worked with him or her at home, communicated with
the therapist, and was consistent in coming to weekly
sessions. In addition, qualitative information from the
therapist’s log revealed that children who showed large
improvements may be characterized by a high level of
motivation. These observations are anecdotal and could
not be examined statistically; however, they form the
basis for further questions regarding the characteristics of
participants who may benefit most from this program.
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We did not observe different intervention outcomes for
children with different subtypes of ADHD.
Factors that may have influenced a lack of im-
provement among other children include emotional
problems, family problems, lower IQ, inconsistent atten-
dance at sessions, and parents’ inadequate understanding of
their role and assuming it, which may have led to in-
adequate parental support while working toward goals
at home. In addition, the therapist was less successful in
enlisting fathers who attended sessions with their child to
communicate what took place with their spouses and to
support their child in managing his or her goals on a daily
basis than in enlisting mothers.
Limitations of the Study
The lack of a control group may have contributed to
a placebo effect; change may have resulted from factors
other than intervention. The study sample was small,
and participants were referred from one center and may
not represent the general population. In addition, the oc-
cupational therapist administered the assessment measures.
Despite her qualifications, she could have been biased.
Future studies should use a larger controlled and randomized
sample with sufficient representation of ADHD subtypes
and medication use.
Conclusion
This pilot intervention study demonstrated improvements
in EFs and occupational performance in children who
received cognitive–functional occupational therapy with
their parents present. The positive mechanism underlying
these effects may be related to the provision of cognitive
and motivational tools for performing complex daily
occupations that require EF. If similar findings can be
further shown in randomized, controlled studies, then
this intervention may be a feasible, ecological, and
July/August 2011, Volume 65, Number 4
economic complement to pharmacological intervention
with children with ADHD. s
Acknowledgments
We thank the families who took part in this study and
Shlomit Rozen for her assistance in enlisting their par-
ticipation. We also thank Aviva Yochman for her helpful
comments after reading the manuscript. This study was
supported by Grant 3–00000–5472 from the Chief Sci-
entist’s Office of the Ministry of Health, Israel.
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