Research Paper

British Journal of Occupational Therapy

2019, Vol. 82(10) 618–629
Occupational therapy metacognitive ! The Author(s) 2019
Article reuse guidelines:
intervention for adolescents with ADHD: Teen sagepub.com/journals-permissions
DOI: 10.1177/0308022619860978
Cognitive-Functional (Cog-Fun) feasibility study journals.sagepub.com/home/bjot

Nirit Levanon-Erez1 , Orli Kampf-Sherf2, Adina Maeir1

Abstract
Introduction: Adolescents with attention deficit hyperactivity disorder face neurocognitive impairments that impede their occu-
pational functioning. The Cognitive-Functional model is a metacognitive occupational therapy intervention for individuals with
attention deficit hyperactivity disorder that harnesses self-awareness and strategy behavior to support participation in an indi-
vidualized occupational context. This study explored preliminary feasibility and efficacy of the Cognitive Functional model adapted
for adolescents with attention deficit hyperactivity disorder, the Teen Cognitive-Functional intervention.
Method: A mixed method feasibility study including 22 adolescents with attention deficit hyperactivity disorder and their parents
was conducted. Pre–post assessments included: occupational performance (Canadian Occupational Performance Measure);
executive functioning (Behavior Rating Inventory of Executive Function); self-awareness and strategy behavior (Self-Regulation
Skills Interview).
Results: Modest attrition and high satisfaction from Teen Cognitive-Functional intervention were found. Significant improvements
were reported in adolescents’ occupational performance, executive functioning and strategy behavior. No significant gains were
found in adolescents’ self-awareness. Adolescents’ strategy behavior was correlated with parent-rated occupational performance.
Qualitative analysis of the strategies reported by the adolescents after intervention revealed three categories: “self-determined
choices”; “plan and organize” and “adaptations.”
Conclusion: This study provides initial support for feasibility of the Teen Cognitive-Functional intervention and its potential
efficacy in promoting occupational performance, executive functioning and strategy behavior. Controlled studies are needed to
further validate these findings.

Keywords
ADHD, adolescents, occupational therapy, metacognitive intervention, executive function, self-awareness
Received 15 November 2018; accepted 10 June 2019

Introduction behavior in order to support participation. The Cog-

Attention deficit hyperactivity disorder (ADHD) in ado-
lescence is associated with many functional impairments,
including various difficulties in everyday activities and
social interactions and higher rates of academic under-
achievement (Cermak, 2018; Frazier et al., 2007;
Gardner and Gerdes, 2015; Hareendran et al., 2015).
The wide-ranging impact of ADHD in adolescence
calls for the development of intervention programs in
order to minimize functional disability and promote
self-management of challenges over time. Existing inter-
ventions for adolescents with ADHD target specific
skills and behaviors, and result in limited effects on
functional outcomes (Chan et al., 2016). The
Cognitive-Functional (Cog-Fun) intervention model in
occupational therapy for individuals with ADHD
(Maeir et al., 2018) may enable self-management for
adolescents with ADHD. The Cog-Fun targets metacog-
nitive components of self-awareness and strategy
Fun has been validated for children with ADHD
(Hahn-Markowitz et al., 2016, 2018). This study
explored the preliminary feasibility and efficacy of the
Cog-Fun adapted for adolescents with ADHD: the Teen
Cog-Fun.
Literature review
ADHD is a chronic health condition with a wide,
impairing impact on daily life (American Psychiatric
1
School of Occupational Therapy, Hebrew University of Jerusalem,
Jerusalem, Israel
2
Seymour Fox School of Education, Hebrew University of Jerusalem,
Jerusalem, Israel
Corresponding author:
Nirit Levanon-Erez, School of Occupational Therapy, Hebrew University of
Jerusalem, PO Box 24026, Mount Scopus, Jerusalem 91240, Israel.
Email: nirit.Levanon-e@mail.huji.ac.il
Levanon-Erez et al.
Association (APA), 2013). Executive function (EF) def-
icits are considered a central mechanism underlying
functional disability in ADHD (Barkley, 2012).
Executive functions are defined as self-regulatory pro-
cesses that enable self-serving goal-directed behavior,
including behavioral, emotional and cognitive regulation
(Barkley, 2012). In adolescence, the ADHD neurocogni-
tive profile, involving EF deficits, may impair abilities to
cope with developmental challenges and threaten future
adult functioning. Furthermore, impaired self-awareness
and diminished self-efficacy among adolescents with
ADHD (Mazzone et al., 2013; Owens et al., 2007) may
pose additional barriers for adaptive functioning.
The gold standard for ADHD intervention involves
the combination of pharmacological and psychosocial
treatments (National Institute for Health and Care
Excellence (NICE), 2018). Psychosocial treatments
offered for adolescents with ADHD typically combine
skill training, behavioral or cognitive-behavioral techni-
ques (see Chan et al., 2016 for review). Intervention pro-
tocols incorporating behavioral techniques include
defining and selectively reinforcing desired behaviors.
Results of these interventions are mixed, for example
no gains were found in risky driving behaviors
(Fabiano et al., 2016); however, significant improve-
ments were found in organization and planning of aca-
demic tasks (Langberg et al., 2018; Sibley et al., 2016).
Limitations of behavioral management include targeting
specific behaviors and contexts with lack of generaliza-
tion; moreover, behavioral techniques rely heavily on
external control and do not prepare the adolescent for
self-management and coping with ADHD over time.
Cognitive behavior therapy (CBT) protocols for ado-
lescents with ADHD combine skill training with cogni-
tive restructuring aimed at modifying maladaptive
thoughts and beliefs. Results of CBT studies demon-
strate improvements in ADHD symptomatology
(Boyer et al., 2015; Sprich et al., 2016; Vidal et al.,
2015). Vidal and colleagues (2015) also found a reduc-
tion in functional impairment according to parents but
not according to adolescents’ self-reports. Boyer and
colleagues (2015) report improvement in overall level
of functioning (as measured by the Impairment Rating
Scale question: “the overall severity of this child’s prob-
lem in functioning and overall need for treatment”). In
sum, the interventions reviewed above utilize a pre-
scribed approach to skill and behavior acquisition.
Evidence suggests that symptomatology and specific
skills and behaviors can be improved, yet there is limited
evidence of efficacy regarding functional outcomes
(Chan et al., 2016). This review suggests that there
may be a need for a more individualized approach in
order to promote self-management for current and
future functional challenges among adolescents
with ADHD.
Self-management requires metacognitive skills of
awareness to challenges and effective use of strategies
that can bridge the gap between neurocognitive execu-
tive impairment and the demands of daily occupations
619
(Toglia, 2018). Occupational therapy models for cogni-
tive rehabilitation can be utilized to address the cognitive
barriers and limit the impact of ADHD on participation
(Cermak, 2018). The Multicontext Treatment Approach
(Toglia, 2018) targets metacognitive skills of self-
management, promoting (a) awareness to self, task
characteristics and context, and (b) the acquisition of
effective compensatory strategies. Online awareness is
emphasized, which refers to the skills needed to support
effective strategic behavior during task performance
(Toglia, 2018). The Bio–Psycho–Social theory of aware-
ness in neurocognitive rehabilitation (Ownsworth et al.,
2006) delineates the neurocognitive, psychological and
social barriers to awareness, and specifically informs
interventions that target awareness deficiencies.
The Cog-Fun intervention model (Maeir et al., 2018)
is based on the above models of cognitive rehabilitation,
and adapted specifically for individuals with ADHD.
The Cog-Fun focuses on the development of metacogni-
tive skills including adaptive self-awareness and strategic
behavior in daily functioning. Adaptive self-awareness is
defined as the awareness of strengths and resources in
one’s daily life, and the recognition of ADHD symptoms
and their functional implications, together with a sense
of self-efficacy (Levanon-Erez and Maeir, 2014). The
Cog-Fun systematically targets the Bio–Psycho–Social
barriers to awareness (Ownsworth et al., 2006). In
order to address the biological neurocognitive barriers
(attention and EF deficits), the intervention facilitates
learning via the use of structured templates (for example
a monitoring template and session summary) and
hierarchical cueing procedures. In order to address psy-
chological defense mechanisms, the Cog-Fun uses a
client-centered, strength-based approach and intentional
therapeutic relationship techniques (Taylor, 2008). The
social barriers to awareness, mainly stigma and lack of
knowledge regarding ADHD, are addressed through
psychoeducation. Importantly, the metacognitive learn-
ing process, whereby the client develops adaptive
self-awareness, sets the stage for setting personally
meaningful occupational goals. Within the context of
each client’s occupational preferences, strategies that
support occupational performance are acquired.
Strategies include general problem-solving strategies,
which are explicitly taught and repeatedly practiced
(for example goal-setting, planning and monitoring),
and specific strategies that target the client’s personal
EF profile and his occupational requirements (for exam-
ple use of reminders, regulating self-talk, breaking down
tasks). In addition, environmental and/or task adapta-
tions are incorporated, either by client or significant
other (for example parent). Research on the Cog-Fun
for children demonstrates a positive treatment effect
on children’s ADHD symptomatology, EF, quality of
life (QoL) and occupational performance, and on paren-
tal self-efficacy (Hahn-Markowitz et al., 2016, 2018).
The Teen Cog-Fun protocol has been developed to
meet the unique needs of adolescents with ADHD.
The Teen Cog-Fun emphasizes the exploration of
620
occupational identity and the reinforcement of autonomy
by setting occupational goals in line with the adolescent’s
volition and by supporting maximal independence in
decision-making and in self-management (Levanon-Erez
and Maeir, 2014). The purpose of this study is to examine
the preliminary feasibility and efficacy of the Teen Cog-
Fun intervention. The objectives of this study ware to
(a) examine the intervention’s feasibility by evaluating
compliance and the parent’s and adolescent’s satisfaction;
(b) examine preliminary efficacy of the Teen Cog-Fun
intervention on adolescents’ occupational performance,
executive functioning in daily life and metacognition
(awareness to difficulties and strategy behavior), and
(c) explore the potential metacognitive change mechanism
by testing the relation between metacognition and occu-
pational performance gains, and by studying the types of
strategies reported by participants to support their occu-
pational performance following intervention.
Method
Study design
A mixed-methods feasibility study with a one-group pre-
test–posttest design was conducted. The quantitative
methods of the study were used to explore Cog-Fun’s
feasibility and initial efficacy for adolescents with
ADHD. Qualitative content analysis was used to gain
insight into the nature of the strategies reported by the
participants after intervention to support their occupa-
tional performance.
Participants
Convenience sampling of adolescents aged 12–17 years
with ADHD was used. Participants were referred by
neuropsychologists and pediatric neurologists to an
occupational therapy intervention between 2012 and
Table 1. Inclusion and exclusion criteria.
Inclusion criteria
• Valid ADHD diagnosis by neurologist or psychiatrist
• No change in pharmacological status during last 3 months
• Executive dysfunction: clinical impairment (score above
cutoff T > 65) on at least one scale of the Behavior Rating
Inventory of Executive Function (BRIEF) (Gioia et al., 2000a)
• Attendance in a regular educational framework
Note: Hebrew versions of all measures were adapted and published by PsychTech, Ltd.
ADHD: attention deficit hyperactivity disorder.
British Journal of Occupational Therapy 82(10)
2014, within a neurocognitive health center. The neuro-
cognitive health center also offered medical treatments.
See Table 1 for inclusion and exclusion criteria.
Twenty-seven adolescents and their parents partici-
pated in the study. Participants included six girls and
21 boys between the ages of 12 and 17 years (mean:
14.22
1.45), between the seventh and twelfth grade
(mean: 8.67
1.52). Their mean Conners’ Parent Rating
Scales – Revised (CPRS-R) (Conners et al., 1998) total
score was 74.78
9.49. Eighteen of the participants
(66.7%) were medicated. Medication status was stable
for at least 3 months before the intervention, and
remained so during the intervention according to ado-
lescent and parent report.
Procedure
This study was approved by the Institutional Review
Board (Reference ID: 04122011). No payment was
received in return for participation in the study. Six
qualified occupational therapists delivered the interven-
tion protocol. All sessions took place in a designated
clinic on the university campus. Sessions were docu-
mented by video recordings and by a written log.
Treating therapists underwent regular reviews to verify
treatment fidelity. See Figure 1 for study process chart.
Intervention
Participants in Teen Cog-Fun received 17, 1-hour,
weekly sessions. Of those, 13 sessions were conducted
with the adolescent, three sessions were conducted with
the parents, and one final session included the adolescent
and parents together. The protocol includes four modu-
lar units (see Table 2 for a description of the Teen Cog-
Fun intervention protocol content).
Exclusion criteria
• Other neurological disorders diagnosed by neurologist
or psychiatrist
• Psychopathological comorbidity: scores above cutoff for
clinical impairment in total problem, internalizing broad
band score or anxious/depressed or withdrawn/depressed
subscales (T > 63) in parent’s report on Child Behavior
Checklist (CBCL) (Achenbach, 1991)
• Sub-threshold ADHD symptomatology: scores below
cutoff for clinical impairment in both
hyperactivity-impulsivity and inattentiveness
DSM-IV symptoms subscales (<65) in Conners’
Parent Rating Scales – Revised (CPRS-R)
(Conners et al., 1998)
• An estimated IQ below 85: lower than 1 standard
score on Block Design and Vocabulary subtests of
Wechsler Intelligence Scale for Children IV (Wechsler, 2003)
Levanon-Erez et al. 621

Parents of potential participants were contacted by phone

Parents received an explanation of the study and gave oral consent

Screening by parent questionnaires sent by mail

• Conners' Parent Rating Scales-Revised (CPRS-R; Conners et al., 1998)
• Child Behavior Checklist (CBCL; Achenbach, 1991)
• Behavior Rating Inventory of Executive Function (BRIEF; Gioia et al., 2000a)
• Demographic questionnaire

Assessment meeting
Adolescent assessment by a qualified clinical psychologist
• IQ estimation (WISC-IV subtests; Wechsler, 2003)
• DSM-IV diagnosis verification
Parents and adolescents received a detailed explanation of the intervention by the
study coordinator and signed written informed consent.

Pre-intervention measures
Assessment by treating therapist
• Canadian Occupational Performance Measure (COPM; Law et al., 2005), for
parent and adolescent (separately)
• Self-Regulation Skills Interview (SRSI; Ownsworth et al., 2000), for adolescent

Intervention: 17 weekly sessions (13 with adolescent, 3 with parents, 1 with both)

Post-intervention measures
Parent questionnaire
• Behavior Rating Inventory of Executive Function (BRIEF; Gioia et al., 2000a)
Assessment by therapist not involved in the intervention
• Canadian Occupational Performance Measure (COPM; Law et al., 2005), for
parent and adolescent (separately)
• Self-Regulation Skills Interview (SRSI; Ownsworth et al., 2000), for adolescent
• Patient satisfaction questionnaire, for parent and adolescent (separately)

Figure 1. Study process chart.

DSM-IV: Diagnostic and Statistical Manual, 4th Edition.

Measures 8 weeks ranging from .47–.85 (Angello et al., 2003).

Screening measures. Conners’ Parent Rating Scales-
Revised (CPRS-R) (Conners et al., 1998). The CPRS-
R is a parent rating scale of ADHD-related behaviors.
Items are based on the American Psychiatric
Association’s Diagnostic and Statistical Manual
(DSM-IV) diagnostic criteria of ADHD and common
comorbid problems/disorders. There are 80 items,
rated from 0 (not at all) to 3 (very much). Raw scores
are converted to T scores, with 65 or above considered
clinically impaired. The scales include seven subscales,
four indices and three DSM-IV subscales. The scales are
valid and reliable, with test–retest reliability over 6–
For the purpose of this study, the DSM-IV subscales
of hyperactivity-impulsivity and inattentiveness symp-
toms were used.
Achenbach System of Empirically Based Assessment
(ASEBA) Child Behavior Checklist 6-18 (parent version)
(CBCL) (Achenbach, 1991). The ASEBA is a system of
questionnaires designed to empirically identify psycho-
pathological symptoms. The questionnaires contain
100 statements, and the informant rates how true
each statement is on a 0 (never true) to 2 (always true)
scale. Items are summed and converted into a standard-
ized T-score based on age and gender norms (M ¼ 50,
622 British Journal of Occupational Therapy 82(10)

Table 2. Description of Teen Cog-Fun intervention protocol content.

Session Content

1 Evaluation. Parent interview, reviewing the occupational profile of their child, discussing parents’ concerns and goals.
2 Evaluation. Teenager occupational and awareness interview.
3–6 Unit A. Adaptive self-awareness. Exploring occupational identity and promoting awareness of strengths, values, ADHD and EF
challenges.
Methods:
Guided reflection on occupational experiences; online monitoring of task experiences; questionnaires probing interests and
values; psychoeducation about ADHD.
8–13 Unit B. Strategy acquisition. Developing self-management in the context of occupational goal-attainment.
Methods:
Teaching general problem-solving strategies: goal-setting, planning and monitoring.
Structured reflection on occupational experiences in order to discover specific strategies and identify environmental resources
to bridge the gap between occupational demands and individual EF deficits.
7, 14 Unit C. Parent guidance. Collaborating with parents in order to design supports tailored to their teenager’s needs.
15–17 Unit D. Consolidation. Summarizing metacognitive learning and presenting it to parents in order to promote transfer and
generalization.
Methods:
Teenager prepares a project that summarizes his/her individual profile, goals and strategies, and presents it to his/her parents
at the final session.
ADHD: attention deficit hyperactivity disorder; EF: executive function.

SD ¼ 10). Its reliability and validity have been docu-
mented in many populations and cultures (Achenbach
et al., 2008). For the purpose of this study, the total
problem, internalizing broad band score, anxious/
depressed and withdrawn/depressed subscales were used.
score of two or more is considered clinically significant
(Law et al., 2005). The reliability, validity and respon-
siveness of the COPM are satisfactory to excellent
(Carswell et al., 2004; Law et al., 2005). Both adolescents
and parents completed the COPM separately.

Screening and pre–post measure Metacognition. The Self-Regulation Skills Interview

Executive functioning. The Behavior Rating Inventory
of Executive Function (BRIEF) (Gioia et al., 2000a) is an
ecological rating scale designed to reflect the neuropsycho-
logical constructs of EF in everyday situations. The
BRIEF is designed for parents of children and adolescents
aged 5–18 years, and comprises 86 items. Each item is a
short statement that reflects a behavioral manifestation of
EF deficit in daily life. The informant marks “never,”
“sometimes” or “always” based on their children’s behav-
ior, over the past 6 months. Items form eight clinical
scales. Scales are combined to form two indices – the
Behavioral Regulation Index (BRI) and the
Metacognition Index (MI) – as well as an overall Global
Executive Composite (GEC). Raw scale scores are trans-
formed into T scores, with 65 or above considered clini-
cally impaired (SD ¼ 10). Internal consistency, test–retest
reliability, and discriminant and convergent validity have
been established in individuals with ADHD (Gioia et al.,
2000b; McCandless and O’Laughlin, 2007).
Pre–post measures
Occupational performance. The Canadian
Occupational Performance Measure (COPM) (Law
et al., 2005) is a standardized client-centered measure
designed to identify client-specific occupational issues
in daily functioning and measure change in a client’s
self-perception of occupational performance over time.
A 10-point scale is used to measure self-rated levels of
performance and satisfaction with performance, with a
higher score indicating better performance. A change
(SRSI) (Ownsworth et al., 2000) is a semi-structured
interview that assesses metacognition related to difficul-
ties in life. The SRSI is composed of six items that assess
the following skills: emergent awareness, anticipatory
awareness, self-rated readiness to change, strategy
awareness, strategy use and strategy effectiveness. Each
question is scored on a 10-point rating scale. Scores are
summed and averaged within two subscales: awareness
of difficulties (emergent and anticipatory) and strategy
behavior (strategy awareness, use and effectiveness)
ranging from 0 to 10, with lower scores indicating
better awareness. The readiness to change domain was
not used in this study. The measure has good inter-rater
(r ¼ 0.81–0.92) and test–retest (r ¼ 0.69–0.91) reliability
(Ownsworth et al., 2000). The interview was translated
into Hebrew with permission from the authors, and
internal reliability Cronbach’s alpha in our study was
.89 and .88 (pre- and post-intervention). The interviews
were videotaped and transcribed. All identifying infor-
mation was removed to enable rating that is blinded to
time of evaluation (pre–post) by an independent rater
not involved in the intervention. In addition, post-
intervention interviews were qualitatively analyzed by
the authors (see statistical analyses section).
Post-intervention measure
Patient satisfaction. Parents and adolescents provided
ratings of satisfaction at post-intervention using a ques-
tionnaire developed for this study. Respondents indicat-
ed their degree of satisfaction regarding relations with
Levanon-Erez et al.
Table 3. Demographic characteristics in enrolled group, completers and non-completers.
Enrolled (n ¼ 27)
M (SD)
Age (years) 14.22 (1.45)
Grade (years) 8.67 (1.52)
CPRS-R total 74.78 (9.49)
n (%)
Female 6 (22.2)
ADHD medication 18 (66.7)
Data are M (SD), CPRS-R total: Conners’ Parent Rating Scales – Revised (CPRS-R) total score.
a
Mann–Whitney test
b
Chi-square test
therapist, the impact of the intervention on adolescent’s
awareness of strengths and difficulties, knowledge of
strategies and their use in daily life. Parents also rated
their satisfaction regarding the impact of intervention on
their own knowledge, skills and parental efficacy. The
questionnaires consisted of 10 (parent version) or six
(adolescent version) items that were scored on a 10-
point Likert scale (1 ¼ not at all satisfied to 10 ¼ highly
satisfied). The internal reliability Cronbach’s alpha for
this scale was .82 for the parent version and .80 for the
adolescent version.
Statistical analyses
Quantitative analysis. Baseline sociodemographic
(age, grade, gender) and clinical characteristics (CPRS-
R and medication status) were compered between com-
pleters and non-completers using chi-square (for gender
and medication status) and Mann–Whitney (age, grade
and CPRS-R) tests. All outcome variables met
Kolmogorov–Smirnov test criteria for normal distribu-
tion >.05 except for the SRSI strategy score at time 1,
therefore paired t-test analyses were computed between
pre and post measures for all variables except for strat-
egy score, for which the non-parametric Wilcoxon sign
rank was computed. Effect sizes (ES) Cohen’s d were
calculated. Bonferroni correction for multiple compari-
sons was performed. Spearman correlation analysis was
computed to examine correlations between SRSI and
COPM improvement.
Qualitative analysis. The SRSI interviews were video
recorded and transcribed. In addition to the standard
quantitative scoring, participants’ post-intervention
interviews were analyzed using a directed approach to
content analysis (Hsieh and Shannon, 2005). In the
directed approach, existing theoretical concepts guide
the coding process (Hsieh and Shannon, 2005).
Strategy behavior (Ownsworth et al., 2000) was the spec-
ulated enabler of occupational performance in this
study, thus this construct was explored. The authors
read each interview, highlighted by hand all statements
representing strategy behavior, extracted codes and
assigned descriptive labels. Labels were consolidated
623
Completers (n ¼ 22) Non-completers (n ¼ 5) p
M (SD) M (SD)
14 (1.38) 15.2 (1.48) .093a
8.45 (1.44) 9.6 (1.67) .141a
74.45 (9.2) 76.2 (11.76) 1.00a
n (%) n (%)
4 (18.2) 2 (40) .303b
15 (68.2) 3 (60) .553b
into categories, and then re-examined and revised several
times through discussion, until a consensus was reached.
Results
Study population and feasibility
Forty-four adolescents were recruited to the study.
Parents provided oral consent and completed the screen-
ing measures. Eleven applicants were excluded due to
scores above/below cutoffs on the CBCL (n ¼ 6),
CPRS-R (n ¼ 4) and BRIEF (n ¼ 1). Six participants
did not show up for the initial evaluation session. The
final sample comprised 27 participants who enrolled in
the Teen Cog-Fun intervention (see Table 3 for demo-
graphic characteristics in enrolled group, completers and
non-completers). Twenty-two (81%) participants com-
pleted the intervention. Three participants withdrew
due to technical reasons (moved away, therapist child-
birth) and two participants had difficulty with compli-
ance. There were no significant differences between
completers and non-completers in all demographic and
clinical variables (p>.05).
The mean overall satisfaction rate from the interven-
tion was high for both parents (M ¼ 9.08, SD ¼ 1.25)
and adolescents (M ¼ 8.58, SD ¼ 1.18). The highest sat-
isfaction for both parents and adolescents was reported
on “relationship with therapist” (parent: M ¼ 9.6,
SD ¼ 0.63; adolescent: M ¼ 9.17, SD ¼ 0.88). The
lowest reported mean satisfaction was found for parent
ratings of the impact of the intervention on parental self-
efficacy (M ¼ 6.87, SD ¼ 2.27). Parents’ and adolescents’
mean ratings of satisfaction with the impact of the inter-
vention on adolescents’ awareness, strategy acquisition
and strategy effectiveness in daily life were all high rang-
ing, from M ¼ 7.71 (SD ¼ 2.03) to M ¼ 9.17 (SD ¼ 0.94).
Preliminary efficacy of the Teen Cog-Fun
intervention
Participants of the study set on average 2.5 occupational
goals each, with 55 goals set overall. Goals represented a
variety of occupational categories (instrumental activi-
ties of daily living, education, leisure, social participa-
tion and family participation). The category with the
624
Table 4. Number (n) of goals per occupation category and examples of the goals set (total goals: n ¼ 55).
Occupation category Goals, n (%)a
IADL 16 (29)
Medication management
Time management
Material organization
Task organization
Education (school) 26 (47)
Tasks
Behavior
Leisure 5 (9)
Social participation 2 (4)
Family participation 6 (11)
a
n ¼ goals (%) of total goals per category
IADL: instrumental activities of daily living.
highest number of goals (47%) was education (school)
functioning (see Table 4).
Teen Cog-Fun intervention outcomes are presented
in Table 5. Comparison of baseline to post-treatment
scores revealed significant improvements in adolescent
and parent ratings on the COPM (p<.001) with very
large ES (d >1.0), in parent ratings on the BRIEF (p<
.001) with large ES (d>.7) and in adolescents’ strategy
behavior (p<.001) with very large ES (d ¼ 1.24). No sig-
nificant improvement was found in the awareness to dif-
ficulties subscale of the SRSI (see Table 5). Regarding
the BRIEF clinical categories, 67% of the participants
were in the clinically impaired category (GEC T-score-
> 65) pre-intervention and 32% post-intervention.
Metacognitive change mechanism
Correlations between change scores (pre–post-interven-
tion) of the SRSI and COPM scores revealed a positive
moderate correlation between change in strategy behav-
ior subscale of the SRSI and change in parent-rated
COPM (r ¼ .459, p<.05), whereas no significant correla-
tion was found with change in adolescent-rated COPM
(r ¼ –.164). In addition, no significant correlations were
found between the change in awareness to difficulties
subscale of the SRSI and change in parent or
adolescent-rated COPM scores (r ¼ –.024, –.083).
Qualitative analysis of strategy types. Qualitative analysis
of the strategies that were reported in the SRSI after
intervention revealed three overarching strategy catego-
ries supporting occupational performance, which further
divided into several subcategories (see Table 6). The first
category, “self-determined choices,” includes statements
reflecting the use of strategies that express the choice of
occupational goals that stem from values, self-efficacy
beliefs and interests. This category comprised two
British Journal of Occupational Therapy 82(10)
Examples of occupational goals
Remember to take ADHD medication
Get up on time in the morning on my own
Be on time (to school/to leisure activity)
Tidy my room
Organize my travel pack
Remember to do my chores
Study for tests on my own
Do my homework
Listen and participate in science class
Stop disrupting the class
Participate in leisure activities other than TV
Go to the gym twice a week
Meet more friends
Meet friends more often
Make a joint decision with my parents
Interact respectfully with my family during dinner
subcategories addressing strategies used for the initial
choice to engage in an occupation and the subsequent
choosing of a starting point, that is, where to begin the
activity (for example components that require less
effort). The second category, “plan and organize,” com-
prises statements reflecting a strategic approach to task
performance: “analyze task requirements and barriers,”
“prioritize,” “organize,” “sequence steps” and “time
scheduling.” The third category, “Adaptations,”
includes strategic self regulation and adapting task and
environmental factors supporting occupational
performance.
Discussion
This study sought to examine the feasibility of the Teen
Cog-Fun intervention for adolescents with ADHD, and
to test the potential effects of this metacognitive inter-
vention embedded in daily occupations. The compliance
rate was acceptable and participants that completed the
intervention reported high rates of satisfaction (both
teens and parents). Pre–post measures demonstrated sig-
nificant gains in occupational performance, EF and
strategy behavior. Moreover, a positive significant cor-
relation was found between gains in occupational per-
formance and strategy behavior. Qualitative findings
point to participants’ use of three types of strategies to
support their occupational performance: “self-deter-
mined choices,” “plan and organize” and “adaptations.”
These positive preliminary findings provide a rationale
for further controlled research on the Teen Cog-Fun
intervention. The current study is unique in its focus
on functional outcomes as represented by the individu-
alized occupational goals as well as standardized meta-
cognitive outcomes and ecological measures of EF in
daily life.
Levanon-Erez et al.
Table 5. Teen Cog-Fun intervention outcomes (n ¼ 22).
Pre M (SD) Post M (SD)
COPM performance
Parent 2.56 (1.34)
Adolescent 4.29 (1.97)
COPM satisfaction
Parent 2.70 (1.58)
Adolescent 4.99 (1.92)
BRIEF (parent)
Global executive composite 68.91 (6.8) 60.41 (8.13)
Behavioral regulation index 63.91 (11.3) 55.82 (9.89)
Metacognitive index 69.36 (6.43) 61.32 (7.91)
SRSI
Awareness of difficulties 6.47 (2.18)
Strategy behavior 7.08 (1.98)
COPM: Canadian Occupational Performance Measure; BRIEF: Behavior Rating Inventory of Executive Function (T scores); SRSI: Self-Regulation
Skills Interview; ES: Cohen’s d effect size.
*
Wilcoxon signed rank Z statistic, since variable did not meet criteria for normal distribution.
Bonferroni correction for multiple comparisons p ¼ 0.05/9 ¼ .005.
Considering the low adherence of adolescents with
ADHD to any treatment (Bussing et al., 2012), the attri-
tion rate of this study was reasonable, with 81% of par-
ticipants completing the intervention. Importantly, of
the five adolescents that dropped out of treatment, two
dropped out due to therapist childbirth, not willing to
continue with another therapist. This may reflect the
centrality of the therapeutic relationship as supported
by the high satisfaction rates for relationship with ther-
apist. The Cog-Fun protocols place an explicit emphasis
on the therapeutic alliance, utilizing communication
modes (Taylor, 2008) to create the accepting and
empowering environment necessary for the development
of adaptive self-awareness (Maeir et al., 2018). Further
studies should examine the features of the therapeutic
relationship in the Teen Cog-Fun and their influence
on treatment gains.
Satisfaction rates regarding the impact of intervention
on awareness, strategy acquisition and strategy effective-
ness in daily life were high according to both parents and
teens. This finding is encouraging, supporting feasibility
of the intervention. On the other hand, lower satisfaction
was reported regarding parents’ own gains in parental
self-efficacy. It is reasonable to assume that the two ses-
sions with the parents were not sufficient to address the
substantial parental challenge of raising an adolescent
with ADHD (Theule et al., 2013). This finding can be
compared to the significant gains in parental self-
efficacy that were found among the parents of young
children that participated in a full dyadic Cog-Fun inter-
vention, where parents attend all sessions (Hahn-
Markowitz et al., 2018). Due to the unique autonomy
issues of adolescents it was decided not to include parents
in sessions with their teens; however, the results suggest
that, in further development of the Teen Cog-Fun inter-
vention, it might be advisable to consider offering parents
additional guidance and support.
Participants of this study set goals concerning varied
occupations, possibly reflecting the comprehensive effect
625
t (1,21) p ES
5.33 (2.11) –5.50 .000 1.57
8.19 (1.12) –10.95 .000 2.43
5.57 (2.24) –5.86 .000 1.50
7.94 (1.22) –6.85 .000 1.83
4.43 .000 1.13
3.90 .001 0.76
4.14 .000 1.12
5.78 (1.96) 1.60 .126 0.12
4.70 (1.87) –3.73* .000* 1.24
of ADHD in adolescents’ lives (Cermak, 2018;
Hareendran et al., 2015). The high number of goals
related to school functioning may echo the struggle
that adolescents with ADHD experience in this
domain (Frazier et al., 2007), and the high value they
attribute to school success (Levanon-Erez et al., 2017).
In line with this, many interventions for adolescents with
ADHD focus on school functioning (Langberg et al.,
2018; Sibley et al., 2016). However, the substantial
number of goals in non-academic domains calls for
expanding the scope of interventions to meet the broad
occupational needs and concerns of adolescents with
ADHD. The significant improvement, with large effect
sizes in the occupational performance of adolescents’
goals according to both parents and adolescents, pro-
vides initial support for intervention efficacy.
Nevertheless, the gains in occupational functioning
should be interpreted cautiously since the COPM mea-
sure used in this study does not represent overall func-
tional impairment, but rather represents specific
functioning in individually desired occupations. The
positive findings may indicate that functional impair-
ment is modifiable but the potential extent of this func-
tional gain needs to be further examined.
The participants’ EF in daily life, as measured by
BRIEF, demonstrated significant improvements follow-
ing intervention, with the average score shifting from the
clinical to non-clinical range. These positive findings rep-
licate those found among children receiving the Cog-Fun
intervention (Hahn-Markowitz et al., 2016), reflecting
the potential for change among adolescents as well as
children in this important area. However, caution is war-
ranted considering that parent report may have been
biased due to participation in the study. Future studies
should add more objective informant reports or
performance-based measures of EF in daily life.
To the best of our knowledge this is the first study of
an occupation-based intervention for adolescents with
ADHD that included a metacognitive measure of
626 British Journal of Occupational Therapy 82(10)

Table 6. Qualitative analysis of the strategies reported after intervention in the SRSI.
Strategies category Strategies sub-category Examples

Self-determined choices The initial choice of goals and sub-goals “First, I have to think it’s important to me”
“I decide, ‘this is what I want’”
Choosing to begin with task “[When I have to read a boring text] I look for something in
components that are most that text that I can connect to [emotionally]”
interesting/easiest “I look for the easiest question [in the test] to start with”
Plan and organize Analyze task requirements and barriers “I write down what I need, physically and mentally,
in order to begin”
“I need to understand the obstacles, in order to minimize them”
Prioritize “[when] I have a 10-minute recess, I think of all the things
I have to do. . . then I do the important things first”
Organize “I summarize the material [for exam], shorten it, divide
it to subcategorize”
Sequence steps “In order to be on time to seminar, I need to go to sleep
earlier and arrange my clothes and bag before I go to sleep”
Time scheduling “I have a weekly timetable, so I know what I should do every day”
Adaptations Self:
External actions (food; deep breathing; “If a eat before [I study] I’m more concentrated, less hyperactive”
engage, slow down) “I take a deep breath [to calm down]”
“In order to stay focused [in class] I ask questions,
answer questions”
“When I don’t understand [what I read] I need to read
it again, much slower”
Internal self-talk: stop, motivate, calm down “To stop [teasing] . . . I say things in my heart instead
of saying out loud”
“To go to the gym, I remind myself of its beneficial
effect on my health”
“To calm down I tell myself, ‘you don’t have to finish first
[the exam]’. . . or ‘it’s all right not to get 100’”
Task:
Break it down to parts “I break it down to small parts. . . for example I had an
annual trip, one day I checked what I needed, the second
I bought things, two days before the trip I packed”
Change task demands “In order to read a book, I’ll read a book with short stories”
“I had to memorize a boring text, I turned it into a literary
analysis which was interesting and fun and
I remembered it better”
Environment:
Social: Asking for support “I ask my parents to help me monitor task completion,
they ask me, ‘did you do it?’. . . I won’t lie to my parents,
I’ll do it. . . when I self-monitor, I may cheat”
“I tell my teacher, ‘when you notice I start interrupting class,
tell me to go out, wash my face and come back’”
Physical: Adapting environmental features “I prefer studying at the kitchen table, away from
my computer, I also listen to music”
Using adaptive aids “I use reminders in my cell (phone)”
SRSI: Self-Regulation Skills Interview.

awareness of difficulties and strategy behavior. The
strength of the study is that the SRSI interviews were
rated by a blinded rater that did not participate in the
intervention. Positive gains were found in strategy
behavior but, contrary to our expectation, gains in
awareness of deficits were not found. These findings
can be compared to other metacognitive occupation-
based interventions with adults with traumatic brain
injury (Toglia et al., 2010), which found improvements
in both awareness and strategy behavior on the SRSI. It
is possible that awareness of deficits among adolescents
with a neurodevelopmental disorder, as opposed to an
acquired injury, is less modifiable. According to the Bio–
Psycho–Social model of awareness, these factors may
have prevented adolescents’ full recognition of their
dysfunctions (Ownsworth et al., 2006). Adolescents
evolving identity may be specifically vulnerable and
thus psychogenic defense mechanisms may be highly
influential, despite explicit therapeutic attempts to iden-
tify and capitalize on strengths in order to reduce the
need for defensive denial.
In contrast to awareness of deficits, strategy behavior,
comprising strategy awareness, use and effectiveness,
was shown to be more responsive to intervention in
our study. The differential effect of intervention on
awareness of deficits and awareness of strategies can be
understood by the multidimensional nature of aware-
ness. According to the Dynamic Comprehensive Model
of Awareness (DCMA) (Toglia and Kirk, 2000), aware-
ness is a complex construct compromising several
Levanon-Erez et al.
distinct components. The differential association found
between awareness components and functioning, where-
by awareness and use of strategies, and not awareness of
deficits, correlated with occupational performance fur-
ther validates this model.
The positive significant correlation that was found
between occupational functioning gains and strategy
behavior is encouraging. Correlation does not prove
causality, yet this finding is in line with the assumption
that utilization of strategies may be a key component of
adaptive coping with neurocognitive challenges (Toglia,
2018). Our correlational findings support the recent find-
ings of Kysow and colleagues (2017), whereby the use of
strategies had a beneficial effect on functioning in
employment, education and parenting of adults with
ADHD. Interestingly, Kysow and colleagues (2017)
also found a significant correlation between childhood
and adulthood use of strategies. The long-term benefits
of strategy behavior gains following Teen Cog-Fun
should be further explored. Of note, the correlation
between strategy behavior and occupational perfor-
mance was found only with parent-rated occupational
performance and not with adolescents’ ratings. The dif-
ference in correlations may reflect adolescents’ overesti-
mation of performance, as demonstrated in other studies
(Owens et al., 2007). However, comparing between self-
report and informant report was not the focus of this
study, therefore further inquiry is needed.
Qualitative analysis of the types of strategies that
adolescents reported in order to support their occupa-
tional performance provides a more in-depth account of
the strategy change mechanism. Adolescents reported
utilizing three types of strategies: “self-determined choic-
es,” “plan and organize” and “adaptations.” Employing
“self-determined choices” may reflect their recognition
of the impact of internal motivation. Explicit linking
of motivation to action is considered a powerful enabler
for effort recruitment and regulation among individuals
with ADHD (Barkley, 2015). The use of motivational
techniques like motivational interviewing and self-
chosen goals is reported in other psychosocial interven-
tions for adolescents with ADHD (Boyer et al., 2015;
Vidal et al., 2015). The Teen Cog-Fun emphasis on
addressing adolescents’ volition, first by comprehensive
exploration of occupational identity, discussing values,
strengths and challenges in occupational contexts, and
then by setting goals arising from adolescents’ self-
determination, may have contributed to adolescents’
perception of motivation as a valuable enabler.
Adolescents reporting the use of “Plan and organize”
strategies supports positive findings of other interven-
tions targeting these skills (Langberg et al., 2018;
Sibley et al., 2016), indicating that adolescents with
ADHD are able to acquire them. Planning and organiz-
ing can be conceptualized as compensating for various
EF dysfunctions, and is thus important for ADHD self-
management. Other interventions have imparted plan-
ning and organizing skills in specific academic contexts
(Langberg et al., 2018; Sibley et al., 2016) and the
627
findings of this study suggest these skills can be acquired
in other occupational contexts as well.
The varied adaptation strategies reported by adoles-
cents may suggest that their challenges can be compen-
sated for by using many different individualized
strategies, as opposed to the “one size fits all” approach
of other interventions (Langberg et al., 2018). The Teen
Cog-Fun intervention is specifically designed to develop
self-management skills. General problem-solving strate-
gies of goal-setting, action planning and monitoring are
explicitly taught and systematically practiced during the
intervention. On the other hand, specific strategies and
modifications are not given by the therapist, encourag-
ing the adolescent to generate or discover his own
(Maeir et al., 2018). It is hypothesized that strategy gen-
eration skills would promote adolescent ability to stra-
tegically approach future challenges, thus supporting
self-management of ADHD over time. Of note, goal-
setting and use of resources have been referred to as
components of proactive coping that promote wellbeing
in the face of upcoming stressors (Sohl and Moyer,
2009). Based on our findings, there is a possibility that
the Teen Cog-Fun may enhance proactive coping.
Limitations
Participants who completed the intervention reported
high satisfaction, yet the 19% dropout rate may reflect
more variation in overall satisfaction than was mea-
sured. Regarding outcomes, the use of subjective out-
come measures with a lack of performance-based
measures may limit the validity of findings, since one
cannot rule out the possibility of a placebo or therapeu-
tic alliance effect. Finally, regarding the strategy catego-
ries found in the qualitative analysis, caution is required
in attributing these strategies to the intervention since
pre-intervention influences were not controlled for in
this study (for example prior interventions,
family practices).
Conclusion, clinical implications and
future directions
The current study provides preliminary evidence regard-
ing the feasibility and efficacy of Teen Cog-Fun within a
clinical setting. Participants were satisfied with the inter-
vention. The adolescents’ occupational performance, EF
and strategic behavior improved. Following interven-
tion, participants reported using a variety of self-
determined, planning and specific adaptation strategies,
suggesting that adolescents are able to acquire a self-
management approach to their challenges. The correla-
tion found between gains in adolescent-reported strategy
behavior (awareness use and effectiveness of strategies)
and parent-reported occupational functioning suggests
that functioning can be improved by training metacog-
nitive skills.
There is a need for future randomized controlled
studies in order to validate these findings. Studies
628
should include long-term follow-up in order to examine
the speculated benefits of metacognitive abilities on
managing ADHD over the lifespan.
Key findings
• The Teen Cog-Fun intervention resulted in improve-
ment in adolescents’ occupational performance, exec-
utive functioning and strategy behavior.
• Following the intervention, adolescents’ strategy
behavior was correlated with parent-rated occupa-
tional performance.
What the study has added
This study initially supports the feasibility and effica-
cy of the Teen Cog-Fun, an occupational therapy
metacognitive intervention, for promoting the occu-
pational performance, executive functioning and stra-
tegic behavior of adolescents with ADHD.
Acknowledgments
The authors deeply thank the parents and adolescents who partic-
ipated in this study for their trust and for allowing us to learn from
their experiences. We would also like to express our strong appre-
ciation and thankfulness for the occupational therapists that imple-
mented the intervention, Orit Fisher, Tamar Paley-Altit, Adi Caspi,
Nufar Grinblat and Osnat Alon, for their professional and caring
implementation, for precision in data collection and for sharing
their constructive feedback. Special thanks to Ruthie Traub Bar-
Ilan for her valuable contribution to the Teen Cog-Fun protocol
and for helping in post-intervention data collection, to Shiri
Davidovich, MA child clinical and school psychology student, for
assisting with the screening phase of the study, and to Inbal
Kelmm, graduate occupational therapy student, for her devoted
attention to the trustworthiness rating of the SRSI data.
Research ethics
Ethical approval was obtained from the Institutional Review Board
of the Hebrew University of Jerusalem in 2011 (Reference
ID: 04122011).
Consent
All participants, parents and adolescents provided written informed
consent for participation in Teen Cog-Fun intervention
and research.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship and/or publication of this article.
Contributorship
Nirit Levanon-Erez and Adina Maeir researched literature, devel-
oped the intervention protocol and applied for ethical approval.
Orli Kampf-Sherf contributed to subject recruitment and to screen-
ing for inclusion/exclusion criteria. Nirit Levanon-Erez and Adina
Maeir supervised data collection and carried out the statistical anal-
ysis. All authors interpreted the data. Nirit Levanon-Erez and
British Journal of Occupational Therapy 82(10)
Adina Maeir wrote the first draft of the manuscript. All authors
reviewed and edited the manuscript and approved the final version.
ORCID iD
Nirit Levanon-Erez https://orcid.org/0000-0001-9984-7436
References
Achenbach TM (1991) Manual for the Child Behavior Checklist
4–18 and 1991 Profile. Burlington: University of Vermont.
Achenbach TM, Becker A, D€ opfner M, et al. (2008)
Multicultural assessment of child and adolescent psychopa-
thology with ASEBA and SDQ instruments: Research find-
ings, applications, and future directions. Journal of Child
Psychology and Psychiatry 49(3): 251–275.
American Psychiatric Association (APA) (2013) DSM:
Diagnostic and Statistical Manual of Mental Disorders, 5th
edn. Washington, DC: American Psychiatric Association.
Angello LM, Volpe RJ, Diperna JC, et al. (2003) Assessment of
attention-deficit/hyperactivity disorder: An evaluation of six
published rating scales. School Psychology Review
32(2): 241–262.
Barkley RA (2012) Executive Functions: What they Are, How
they Work, and Why they Evolved. New York:
Guilford Press.
Barkley RA (2015) Attention-Deficit Hyperactivity Disorder: A
Handbook for Diagnosis and Treatment, 4th edn. New York:
Guilford Press.
Boyer BE, Geurts HM, Prins PJM, et al. (2015) Two novel
CBTs for adolescents with ADHD: The value of planning
skills. European Child and Adolescent Psychiatry
24(9): 1075–1090.
Bussing R, Koro-Ljungberg M, Noguchi K, et al. (2012)
Willingness to use ADHD treatments: A mixed methods
study of perceptions by adolescents, parents, health profes-
sionals and teachers. Social Science and Medicine
74(1): 92–100.
Carswell A, Mccoll MA, Law M, et al. (2004) The Canadian
Occupational Performance Measure: A research and clinical
literature review. Canadian Journal of Occupational Therapy
71(4): 210–222.
Cermak SA (2018) Cognitive rehabilitation of children and
adults with attention deficit hyperactivity disorder. In:
Katz N and Toglia J (eds) Cognition Across the Lifespan,
4th edn. Bethesda: AOTA Press, pp.189–217.
Chan E, Fogler JM and Hammerness PG (2016) Treatment of
attention-deficit/hyperactivity disorder in adolescents: A
systematic review. JAMA – Journal of the American
Medical Association 315(18): 1997–2008.
Conners CK, Sitarenios G, Parker JD, et al. (1998) The revised
Conners’ Parent Rating Scale (CPRS-R): Factor structure,
reliability, and criterion validity. Journal of Abnormal Child
Psychology 26(4): 257–268.
Fabiano GA, Schatz NK, Morris KL, et al. (2016) efficacy of a
family-focused intervention for young drivers with
attention-deficit hyperactivity disorder. Journal of
Consulting and Clinical Psychology 84(12): 1078–1093.
Frazier TW, Youngstrom EA, Glutting JJ, et al. (2007) ADHD
and achievement. Journal of Learning Disabilities
40(1): 49–65.
Gardner DM and Gerdes AC (2015) A review of peer relation-
ships and friendships in youth with ADHD. Journal of
Attention Disorders 19(10): 844–855.
Levanon-Erez et al.
Gioia GA, Isquith PK, Guy SC, et al. (2000a) Behavior Rating
Inventory of Executive Function (BRIEF). Odessa:
Psychological Assessment Resources.
Gioia GA, Isquith PK, Guy SC, et al. (2000b) Test review
Behavior Rating Inventory of Executive Function. Child
Neuropsychology (Neuropsychology, Development and
Cognition: Section C) 6(3): 235–238.
Hahn-Markowitz J, Berger I, Manor I, et al. (2016) Efficacy of
Cognitive-Functional (Cog-Fun) occupational therapy
intervention among children with ADHD: An RCT.
Journal of Attention Disorders. Epub ahead of print 16
September 2016. DOI: 10.1177/1087054716666955.
Hahn-Markowitz J, Berger I, Manor I, et al. (2018) Cognitive-
Functional (Cog-Fun) dyadic intervention for children with
ADHD and their parents: Impact on parenting self-efficacy.
Physical and Occupational Therapy in Pediatrics
38(4): 444–456.
Hareendran A, Setyawan J, Pokrzywinski R, et al. (2015)
Evaluating functional outcomes in adolescents with
attention-deficit/hyperactivity disorder: Development and
initial testing of a self-report instrument. Health and
Quality of Life Outcomes 13(1): 1–14.
Hsieh HF and Shannon SE (2005) Three approaches to qual-
itative content analysis. Qualitative Health Research
15(9): 1277–1288.
Kysow K, Park J and Johnston C (2017) The use of compen-
satory strategies in adults with ADHD symptoms. ADHD
Attention Deficit and Hyperactivity Disorders 9(2): 73–88. D
Langberg JM, Dvorsky MR, Molitor SJ, et al. (2018)
Overcoming the research-to-practice gap: A randomized
trial with two brief homework and organization interven-
tions for students with ADHD as implemented by school
mental health providers. Journal of Consulting and Clinical
Psychology 86(1): 39–55.
Law M, Baptiste S, Carswell A, et al. (2005) The Canadian
Occupational Performance Measure, 4th edn. Ottawa:
CAOT Publications ACE.
Levanon-Erez N and Maeir A (2014) The Teen Cog-Fun model
of intervention for adolescents with ADHD. In: Berger I
and Maeir A (eds) ADHD – A Transparent Impairment,
Clinical, Daily-life and Research Aspects in Diverse
Populations. New York: Nova Science Publishers, pp.17–34.
Levanon-Erez N, Cohen M, Traub Bar-Ilan R, et al. (2017)
Occupational identity of adolescents with ADHD: A
mixed methods study. Scandinavian Journal of
Occupational Therapy 24(1): 32–40.
McCandless S and O’Laughlin L (2007) The clinical utility of
the Behavior Rating Inventory of Executive Function
(BRIEF) in the diagnosis of ADHD. Journal of Attention
Disorders 10(4): 381–389.
Maeir A, Traub-Bar Ilan R, Kastner L, et al. (2018) An inte-
grative cognitive functional (Cog-Fun) intervention model
for children, adolescents and adults with attention deficit
hyperactivity disorder (ADHD). In: Katz N and Toglia J
(eds) Cognition across the Lifespan, 4th edn. Bethesda:
AOTA Press, pp.335–351.
629
Mazzone L, Postorino V, Reale L, et al. (2013) Self-esteem
evaluation in children and adolescents suffering from
ADHD. Clinical Practice & Epidemiology in Mental
Health 9(1): 96–102.
National Institute for Health and Care and Excellence (2018)
Attention Deficit Hyperactivity Disorder: Diagnosis and
management. Available at: nice.org.uk/guidance/ng87
(accessed 15 November 2018).
Owens JS, Goldfine ME, Evangelista NM, et al. (2007) A crit-
ical review of self-perceptions and the positive illusory bias
in children with ADHD. Clinical Child and Family
Psychology Review 10(4): 335–351.
Ownsworth T, Clare L and Morris R (2006) An integrated
biopsychosocial approach to understanding awareness def-
icits in Alzheimer’s disease and brain injury.
Neuropsychological Rehabilitation 16(4): 415–438.
Ownsworth TL, McFarland K and Young RM (2000)
Development and standardization of the Self-Regulation
Skills Interview (SRSI): A new clinical assessment tool for
acquired brain injury. The Clinical Neuropsychologist
(Neuropsychology, Development and Cognition: Section D)
14(1): 76–92.
Sibley MH, Graziano PA, Kuriyan AB, et al. (2016) Parent-
teen behavior therapy plus motivational interviewing for
adolescents with ADHD. Journal of Consulting and
Clinical Psychology 84(8): 699–712.
Sohl SJ and Moyer A (2009) Refining the conceptualization of
a future-oriented self-regulatory behavior: Proactive coping.
Personality and Individual Differences 47(2): 139–144.
Sprich SE, Safren SA, Finkelstein D, et al. (2016) A random-
ized controlled trial of cognitive behavioral therapy for
ADHD in medication-treated adolescents. Journal of Child
Psychology and Psychiatry and Allied Disciplines
57(11): 1218–1226.
Taylor RR (2008) The Intentional Relationship: Occupational
Therapy and the Use of Self. Philadelphia: F. A. Davis.
Theule J, Wiener J, Tannock R, et al. (2013) Parenting stress in
families of children with ADHD: A meta-analysis. Journal
of Emotional and Behavioral Disorders 21(1): 3–17.
Toglia J (2018) The dynamic interactional model and the multi-
context approach. In: Katz N and Toglia J (eds) Cognition
across the Lifespan, 4th edn. Bethesda: AOTA
Press, pp.355–385.
Toglia J and Kirk U (2000) Understanding awareness deficits
following brain injury. NeuroRehabilitation 15(1): 57–70.
Toglia J, Johnston MV, Goverover Y, et al. (2010) A multi-
context approach to promoting transfer of strategy use and
self regulation after brain injury: An exploratory study.
Brain Injury 24(4): 664–677.
Vidal R, Castells J, Richarte V, et al. (2015) Group therapy for
adolescents with attention-deficit/hyperactivity disorder: A
randomized controlled trial. Journal of the American
Academy of Child and Adolescent Psychiatry 54(4): 275–282.
Wechsler D (2003) Wechsler Intelligence Scale for Children—
4th Edition (WISCIV). San Antonio: Harcourt Assessment.