666955

research-article2016
JADXXX10.1177/1087054716666955Journal of Attention DisordersHahn-Markowitz et al.

Article
Journal of Attention Disorders

Efficacy of Cognitive-Functional (Cog-Fun)

2020, Vol. 24(5) 655­–666
© The Author(s) 2016
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DOI: 10.1177/1087054716666955
https://doi.org/10.1177/1087054716666955

Children With ADHD: An RCT journals.sagepub.com/home/jad

Jeri Hahn-Markowitz1, Itai Berger1,2, Iris Manor3,4, and Adina Maeir1

Abstract
Objective: To examine the efficacy of a Cognitive-Functional (Cog-Fun) intervention for children with ADHD. Method:
Random allocation of 107 children to study or control groups preceded 10 parent–child weekly Cog-Fun sessions
emphasizing executive strategy training in games and daily activities. Controls received treatment after crossover. Study
participants were followed up 3 months post-treatment. Outcomes included parent/teacher ratings of executive functions,
ADHD symptoms, and parent ratings of quality of life. Results: Eight children withdrew prior to treatment. All children
in both groups who began treatment completed it. Mixed effects ANOVA revealed significant Time × Group interaction
effects on all parent-reported outcomes. Treatment effects were moderate to large, replicated after crossover in the
control group and not moderated by medication. Parent-reported treatment gains in the study group were maintained
at follow-up. No significant Time × Group interaction effects were found on teacher outcomes. Conclusion: Cog-Fun
occupational therapy (OT) intervention shows positive context-specific effects on parent, but not teacher, ratings. (J. of
Att. Dis. 2020; 24(5) 655-666)

Keywords
child ADHD, executive functions (EF), quality of life (QoL), intervention

ADHD has been shown to profoundly disrupt functioning
and creates significant barriers to successful participation in
a host of daily activities, including play, learning, self-care,
and social interactions (Cordier, Bundy, Hocking, &
Einfeld, 2010; Dunn, Coster, Cohn, & Orsmond, 2009; Gol
& Jarus, 2005). The persistence of the disorder implies
long-term ramifications on interpersonal relationships, self-
efficacy, activities of daily living, and productivity, signifi-
cantly compromising quality of life (QoL; Maeir,
Hahn-Markowitz, Fisher, & Traub Bar-Ilan, 2014; Stern,
Pollak, Bonne, Malik, & Maeir, 2017). The involvement of
impaired executive functions (EF) is recognized as one of
the central neurocognitive impairments of ADHD (Barkley,
2012). Strong evidence supports the high prevalence of
executive dysfunction in ADHD, which negatively affects
wide-ranging functional outcomes (Barkley, 2012; Stern
et al., 2017). Deficient EF are therefore major intervention
targets for individuals with ADHD.
To enable the child with ADHD to participate in daily
activities, treatment must address factors that hinder per-
formance. A variety of pharmacological, psychosocial,
educational, and computerized treatments to decrease
symptoms of ADHD and to improve behavior and aca-
demic performance exist (Pelham & Fabiano, 2008; Riccio
& Gomes, 2013). Pharmacological treatment has been
shown to be effective in providing temporary relief from
symptoms of ADHD; however, there is little evidence that
medication comprehensively addresses the EF and func-
tional challenges of these children (Biederman et al., 2011;
Smith et al., 2016). Children with ADHD may also be
treated by psychosocial interventions, for example, behav-
ioral programs, psychoeducation for parents, neurofeed-
back, and expressive therapies (Pelham & Fabiano, 2008).
The focus of this study is on an intervention that addresses
the EF cognitive deficit in ADHD; therefore, we limit our
review to cognitive rehabilitation (CR) approaches.
CR approaches to treating children with ADHD include
remedial and compensatory approaches. The remedial
approach purports to improve specific EF by repeated train-
ing, while the compensatory approach aims to provide tools
to cope with impaired EF. These two approaches differ in
1
Hadassah and the Hebrew University, Jerusalem, Israel
2
Neuro-Cognitive Center, Jerusalem, Israel
3
Geha Medical Center, Petah Tikva, Israel
4
Tel Aviv University, Israel
Corresponding Author:
Jeri Hahn-Markowitz, School of Occupational Therapy, Hadassah and the
Hebrew University, P.O. Box 24026, Mt. Scopus, Jerusalem 91240, Israel.
Email: jerihahnmarkowitz@gmail.com
656 Journal of Attention Disorders 24(5)
the degree of contextual factors involved in treatment,
namely, parents and/or teachers, as well as engagement in
daily activities. The compensatory approach usually pro-
vides a “real world,” ecological context in the intervention,
whereas the remedial approach assumes that treatment
gains will transfer spontaneously to real-world tasks and
occupations. The authors of a recent meta-analysis on com-
puterized cognitive training for children with ADHD
(Cortese et al., 2015) found that there were no effects of
working memory training when implemented on its own, on
ADHD symptoms. However, interventions targeting more
than one neuropsychological domain had large effects on
ADHD symptoms in parent-rated outcomes. Six of the 15
studies included parent ratings of EF according to the
Behavior Rating Inventory of Executive Function (BRIEF;
Gioia, Isquith, Guy, & Kenworthy, 2000), with results dem-
onstrating small-to-moderate effect sizes. These authors
suggest that multi-component training models may be more
successful than computerized training for treating ADHD,
given the individualized neuropsychological profile of each
individual, the fact that children may be affected by more
than one deficit, and the complex, heterogeneous nature of
the condition.
A recent randomized control trial (Smith et al., 2016)
evaluated the efficacy of an intervention combining com-
puterized cognitive remediation training, physical exer-
cises, and a behavior management strategy. The effects of
the intervention on EF and components of attention mea-
sured in ratings of ADHD symptoms and neurocognitive
tests were not statistically significant. The authors of this
study suggest that the treatment is insufficient in producing
the desired effects without real-world application and rec-
ommend designing cognitive training to the individual
neurocognitive profiles of children and then tailoring it to
meet their needs in real-world settings or situations (Smith
et al., 2016).
A review of interventions for executive dysfunction in
children and adolescents recommended involving parents
in intervention, as the psychoeducation of parents is a criti-
cal element in their children’s treatment (Riccio & Gomes,
2013). Halperin et al. (2013) conducted a study that aimed
to examine whether cognitive enhancement administered
to preschoolers through play would impact the severity of
their ADHD symptoms. Children attended sessions target-
ing EF, motor control, attention/tracking and visuospatial
abilities. Parents attended separate psychoeducation and
group support sessions. Their role at home was to progres-
sively increase the cognitive and behavioral demands of
games as children mastered necessary skills. Results
pointed to significant reduction of ADHD symptom sever-
ity after treatment, with 3-month maintenance, according
to parent and teacher ratings. Although this intervention’s
efficacy remains to be shown, the program was found to be
feasible and well-accepted by participating parents.
In another study, Tamm, Nakonezny, and Hughes (2014)
taught parents to administer a metacognitive EF training
intervention to their preschool children with ADHD. The
objectives of the study were to establish feasibility of the
intervention and to determine whether it affected EF and
ADHD symptoms. Children participated in small group
activities requiring aspects of EF while their parents
received explanations and modeling of desired actions. The
program was found to be feasible and improvements on
child performance on neuropsychological tasks corre-
sponded to parent ratings of working memory and atten-
tional control on the Metacognitive Index and Global
Executive Composite (GEC) of the BRIEF and on ADHD
inattention symptoms. No significant improvements were
found on teacher ratings. This study used an integrative
approach, with parents employing strategies and specific
praise. Tamm and Nakonezny (2015) implemented their
intervention on a different sample of the same age, finding
significant improvement on BRIEF scales and on the GEC.
The above studies add much merit to the development of
interventions to improve EF among children with ADHD.
The findings support the premise that parents can play an
active role in treatment for affecting child EF.
CR models in occupational therapy (OT) address the
impact of neurologically based cognitive deficits on daily
functioning and QoL among individuals with a variety of
acquired or developmental disorders. The performance of
daily tasks that are meaningful to an individual is the
essence of OT practice for people with cognitive deficits.
Toglia’s Dynamic Interaction Approach for CR in OT high-
lights the dynamic interaction between the person, the task,
and the environment, when addressing problems in perfor-
mance (Toglia, 2011). The Cognitive Orientation to Daily
Occupational Performance (CO-OP; Polatajko, Mandich, &
McEwen, 2011) is an important treatment approach that
includes a major focus on metacognitive strategies within
an occupational context. Moderate-level evidence in con-
trolled studies and case series has shown that these models
have been effective for populations with EF impairment
(Dawson et al., 2009; Goverover, Johnston, Toglia, &
Deluce, 2007; Toglia, Johnston, Goverover, & Dain, 2010).
However, they have not been applied to children with
ADHD. These models provided the basis for the develop-
ment of the Cognitive-Functional (Cog-Fun) OT integrative
intervention for children with ADHD. Cog-Fun targets the
cognitive, emotional, and environmental barriers to partici-
pation as they interact in an occupational context. Cog-Fun
employs learning and practicing executive strategies and
behavioral skills for the child and parent together, within
the context of playful activities and daily functioning.
A pilot study examining the feasibility of Cog-Fun on 14
children diagnosed with ADHD found significant improve-
ments with medium to large effects on measures of EF and
occupational performance after intervention, with most
Hahn-Markowitz et al. 657

Table 1.  Description of Study and Control Groups on Mental Disorders (4th ed., text rev.; DSM-IV-TR; American
Demographics at Baseline. Psychiatric Association [APA], 2000) criteria, as assessed by
Study group Control group a certified pediatric neurologist/psychiatrist, including a
(n = 54) (n = 53) semi-structured interview with the child and parents, medi-
n (%) n (%) p cal/neurological/psychiatric examination, and completion
of a ADHD diagnostic questionnaire (DuPaul, Power,
Number male 37 (69) 39 (74) .952
Anastopoulos, & Reid, 1998). The primary inclusion crite-
Pharmacological 36 (67) 34 (64) .894
treatment for ADHD
ria for referral to the study included (a) a score above the
ADHD subtypes clinical cutoff point for ADHD symptoms on the ADHD
 Predominantly 23 (43) 29 (55) .444 Diagnostic and Statistical Manual of Mental Disorders
inattentive (4th ed.; DSM-IV; APA, 1994) Scales (DuPaul et al., 1998;
 Combined 29 (54) 21 (40) Subcommittee on Attention-Deficit/Hyperactivity Disorder,
 Hyperactive- 2 (4) 3 (6) Steering Committee on Quality Improvement and
impulsive Management, 2011) and (b) approval by the pediatric neu-
Marital status of parents rologist/psychiatrist that the child fulfills the criteria as
 Single 2 (4) 1 (2) .766 required by the APA guidelines for ADHD diagnosis.
 Married 50 (93) 49 (92) Additional inclusion criteria included (a) age 7 to 10, in
 Divorced/separated 2 (4) 3 (6) second to fourth grade at first assessment; (b) enrollment in
regular school; (c) stability in medication/no medication
  M ± SD M ± SD  
status and other treatments for ADHD for the previous 2
Child age in years 8.4 ± 0.9 8.6 ± 0.8 .395 months; and (d) executive dysfunction in daily life as
Mother’s education in 16.6 ± 3.8 16.4 ± 2.9 .853 reflected by the score (T-score ≥ 65) of at least one scale on
years the parent version of the BRIEF questionnaire. Exclusion
criteria for all participants were based upon clinical diagno-
sis rendered by treating/referring physician (neurologist/
effects maintained at follow-up (Hahn-Markowitz, Manor, psychiatrist): intellectual disability, other chronic medical/
& Maeir, 2011). In another controlled study of 19 children neurological conditions, and primary psychiatric diagnosis
with a crossover design, significant differences between (e.g., depression, anxiety, psychosis). There was no signifi-
groups in change scores on outcome measures were found cant difference in demographic variables across groups at
before crossover. No significant differences were found in baseline (p > .05; Table 1).
treatment effects after crossover, and significant moderate All participating children gave verbal assent and their
to large treatment effects were found for measures of EF parents provided written informed consent to the study,
and occupational performance (Maeir, Fisher et al., 2014). approved by the Helsinki committees (institutional review
The purpose of this study was to further examine the effi- board [IRB]) of Hadassah-Hebrew University Medical
cacy of Cog-Fun OT intervention for children with ADHD Center, Jerusalem, Israel and Geha Medical Center, Petah
and its effect on EF, ADHD symptoms, and QoL in a ran- Tikva, Israel. The study was registered in a clinical trials
domized controlled crossover study. registry before recruitment (No. NCT01792921).

Method
Setting and Participants
This study was conducted at two ADHD units at major med-
ical centers in two cities in Israel. After receiving ethical
approval from both institutions, the medical directors of these
clinics referred children with ADHD to the study. All partici-
pants were recruited among children referred from tertiary
care university hospitals to the clinics by pediatricians, gen-
eral practitioners, teachers, psychologists, or parents and were
referred over the course of 18 months. The diagnosis of
ADHD was based on the required procedure (Subcommittee
on Attention-Deficit/Hyperactivity Disorder, Steering
Committee on Quality Improvement and Management,
2011), according to Diagnostic and Statistical Manual of
Measures
BRIEF.  The BRIEF (Gioia et al., 2000) is an 86-item eco-
logical rating scale completed by a parent or teacher
designed to reflect the neuropsychological constructs of EF
in everyday situations among children aged 5 to 18 years. It
consists of eight subscales (Inhibit, Shift, Emotional Con-
trol, Initiation, Working Memory, Plan/Organize, Organi-
zation of Materials, and Monitor), two indices (behavioral
regulation index and metacognitive index), and a GEC.
Items are rated 1 (never), 2 (sometimes), or 3 (often). Raw
scores are converted to T-scores, with 65 or above consid-
ered clinically impaired (SD 10). Internal consistency, test–
retest reliability (r = .72-.84 for Parent version over 3
weeks), and discriminant validity have been established for
children with ADHD, as well as convergent and concurrent
658 Journal of Attention Disorders 24(5)
validity (Gioia et al., 2000; McCandless & O’Laughlin,
2007). The GEC is the sum of the eight subscales. The GEC
scores of parents and teachers are reported here.
Conners’ Rating Scales–Revised.  The Conners’ Parent Rating
Scales–Revised (CPRS-R)/Conners’ Teacher Rating
Scales–Revised (CTRS-R; Conner, 2000) are parent and
teacher rating scales of ADHD-related behaviors. The
scales include seven subscales, four indices, and three
DSM-IV subscales. The parent version has 80 items and the
teacher version has 59 items, rated from 0 (not at all) to 3
(very much). Raw scores are converted to T-scores, with 63
or above considered clinically impaired. The scales are
valid and reliable, with test–retest reliability over 6 to 8
weeks ranging from .47 to .92 (teacher version) and .47 to
.85 (parent version; Angello et al., 2003). The Conners’
Global Total Index (CGTI) scores of parents and teachers
are reported here. This index was chosen as it consists of
items that are representative of ADHD symptoms and gen-
eral psychopathology, is considered to be a good indicator
of global concerns about a child’s functioning, and is usu-
ally sensitive to treatment effects (Sparrow, 2010).
The Pediatric Quality of Life 4.0 Generic Core Scales (Ped-
sQL).  The PedsQL is a 23-item measure of pediatric health,
and assesses perceptions of the child’s health-related qual-
ity of life (HRQOL; Varni, Seid, & Kurtin, 2001). It is com-
prised of four generic core scales (Physical, Emotional,
Social, and School Functioning), with parallel child self-
report and parent proxy-report formats. Internal consistency
reliability for the Psychosocial Health Summary score (α =
.86 parent version) was acceptable for group comparisons.
Validity was demonstrated using the known-groups method,
correlations with indicators of morbidity and illness burden,
and factor analysis. The PedsQL distinguishes between
healthy children and pediatric patients with acute or chronic
health conditions. There are five items for each scale,
excepting the Physical Function scale, which has eight
items. Item scores range from 0 (never a problem) to 4
(always a problem). Items are reverse-scored and linearly
transformed to a 0 to 100 scale so that higher scores indicate
better HRQOL. The Physical Health Summary score is the
same as the Physical Function Subscale. The Psychosocial
Health Summary score is the sum of the 15 items (three
other scales) divided by the number of items answered.
Studies have shown the reliability and validity of the Ped-
sQL as a measure of general physical and psychosocial
health in children (McCarthy et al., 2005). The parent Psy-
chosocial Health Summary scores are reported here.
Sample size.  An a priori sample size test of power was per-
formed to identify the probability of detecting clinical
effects in the primary outcome measure, the BRIEF, with
an alpha value of .05 and power of .80, using a minimal
clinically important difference of 7 T points on the post-
intervention score between the intervention and control
waitlist groups. A sample size of 34 participants per group
was needed. Taking into account an expected 30% dropout
rate, 44 participants were needed in each group to detect
clinically significant effects.
Procedure and randomization. Attending physicians briefly
described the study to parents of children they deemed good
candidates, and provided the study coordinator (first author)
with a list of parents who agreed to be contacted. Mothers
of children referred received a telephone explanation by the
study coordinator regarding the conditions of the study and
to determine whether they were interested in participation.
If oral consent was given, they were asked to complete the
BRIEF questionnaire and invited to an interview, where
they received a complete description of the study and pro-
vided written consent. If the scores on the questionnaire
were above cutoff, the family was invited to participate in
the study. Children were assigned randomly to study or con-
trol waitlist group according to blocks of age-group and
gender by the study coordinator, who had prepared the ran-
dom assignment schedule using computer-generated ran-
dom numbers. Parents were asked to give an envelope with
an explanatory letter about the study to the children’s teach-
ers, together with the teacher version of the BRIEF and the
CTRS-R.
Parents and teachers were blinded to group allocation
while completing baseline forms, however, after random-
ization, each family was notified its allocation. Parents and
teachers completed questionnaires independently at all
assessments. Participants in the study group commenced
Cog-Fun treatment after baseline, while those in the control
group received no treatment. Three months later, partici-
pants in both groups underwent Assessment 2, after which
crossover occurred. Assessment 3 (post-intervention for
controls and follow-up for 43 study participants) took place
at the end of an additional 3 months. All participants who
began Cog-Fun treatment completed it and underwent post-
intervention assessment. Figure 1 delineates recruitment,
allocation, and participation in the study.
Intervention
The Cog-Fun is a manualized treatment approach (Maeir,
Hahn-Markowitz, Fisher, & Traub Bar-Ilan, 2012) admin-
istered by licensed OTs with Cog-Fun certification.
Certification is awarded to OTs who successfully complete a
6-month 60-hr theoretical and practical training course. Part
of the training includes 4 months of fieldwork, supervision,
and the presentation of a case study. In the present study,
each of the 12 OTs (three in one clinic and nine in the other)
who treated the child–parent dyads completed a Treatment
Log for each treatment session, which was examined by the
Hahn-Markowitz et al. 659

Referred to study
(n=124) Excluded (n=17)
Did not meet inclusion
criteria (n=3)
Declined (n= 14)
Randomized and
assessed (n=107)

Allocated to intervention (n=54) Allocated to wait list control (n=53)

Received intervention and Assessment Completed wait period and Assessment
Intervention-Wait Period

2 (Post-intervention) (n=50) 2 (Pre-intervention) (n=51)

Did not received allocated intervention Did not complete wait period (n=2)
(n=4) Unwilling to wait (n=1)
Withdrew from study (n=2) Found alternative intervention (n=1)
Lack of child compliance (n=1)
Suspected severe psychiatric
comorbidity (n=1)

Crossover: Wait period (n=50) Crossover: Intervention (n=49)

Completed wait period and Assessment Received intervention and Assessment
3 (Follow-up) (n=43) 3 (Post-intervention) (n=49)
Crossover

Lost to follow-up (n=7) Did not receive intervention (n=2)

Began medication (n=4) Withdrew from study (n=1)
Refused follow-up (n=3) Suspected severe psychiatric
comorbidity (n=1)

Analyzed after intervention (n=50) Analyzed after wait period (n=51)

Analysis

Analyzed at follow up (n=43) Analyzed after intervention (n=49)

Excluded from analysis (n=0) Excluded from analysis (n=0)

Figure 1.  Participant flow diagram for cognitive-functional.

study coordinator to verify treatment fidelity. The Log
included a checklist to ensure that treatment was adminis-
tered according to Cog-Fun principles, as well as space allot-
ted for details such as description of activities, executive
strategies learned, goals defined, and significant interper-
sonal interactions. Each therapist was initially blind to group
allocation.
Cog-Fun is an integrative intervention in which the use
of effortful executive strategies is supplemented by envi-
ronmental adaptations to facilitate success, which serves as
positive reinforcement, motivating the child to continue try-
ing to attain personal goals by using strategies. Basic strate-
gies (inhibition, effort, monitoring, and planning) are
learned in a playful setting, practiced according to individu-
alized functional goals that are meaningful to the child and
parents. The strategies were designed to compensate for the
neurocognitive barriers to participation rather than to reme-
diate them in a cognitive training model. For example, the
“inhibit” strategy is acquired in games such as Simon Says,
simulated in a social context identified as challenging to the
child.
Parents learn to provide necessary supports (i.e., positive
verbal mediation, daily planner, timer, checklists) and mod-
ifications (i.e., preparing materials in advance, reducing
clutter and distractions) for their child in the home environ-
ment to promote transfer of strategies and successful occu-
pational performance at home. These are based on the
neurofunctional training (NFT) approach to CR (Guiles,
2011), which uses environmental resources to minimize
frustration and EF demands and enable successful perfor-
mance during the learning process. The supports and adap-
tations are designed to facilitate function and participation
by modifying factors in the client’s surroundings and to
supplement executive strategy acquisition, the former often
aiding to boost motivation, the latter being a more effortful
process. In Cog-Fun, these methods are exemplified by
structured treatment sessions, by adapting activities to the
child’s abilities and by using cues. The therapist models
660 Journal of Attention Disorders 24(5)

Session Unit Content

1 1 Evaluation: Parent Cognitive-Functional interview on EF in daily life and parental concerns and goals
2 1 Evaluation: Introduction to Cog-Fun setting (session routine and treatment tools- games and activities) and establishing a
therapeutic alliance with the child
3-4 2 Strategy acquisition and practice: ‘Inhibit’ strategy in multiple activities (games requiring use of ‘inhibit’, e.g., Red Light
Green Light) and transfer to functional activities requiring ‘inhibit’ (e.g., waiting one’s turn)
5-6 3 Strategy acquisition and practice: ‘Effort recruitment’ strategy in multiple activities (games requiring use of ‘effort re-
cruitment’, Tug of War) and transfer to functional activities requiring ‘effort recruitment’ (e.g., remain engaged in game
with friend)
7 4 Home visit: Transfer of learning: practicing strategies in home-based activities
8 5 Strategy acquisition and practice: ‘Monitoring’ strategy in multiple activities (games requiring use of ‘monitor’, e.g.,
Rush Hour) and transfer to functional activities requiring ‘monitoring’ (e.g., preparing schoolbag according to list)
9 - 10 6 Strategy acquisition and practice: ‘Planning’ strategy in multiple activities (games requiring use of ‘plan’, e.g., Rush
Hour) and transfer to functional activities requiring ‘planning’ (e.g., planning birthday party)
11 7 Final session with parent-child dyad: summarizing strategy learning
12 7 Summary session with parents: consolidating parents’ tools for on-going implementation

Figure 2.  Cog-Fun OT intervention content.

Note. The progression between “inhibit,” “effort,” “monitoring,” and “planning” strategies is tailored to child’s progress. Not all strategies need to be
achieved. Cog-Fun = cognitive-functional; OT = occupational therapy; EF = executive functions.

these techniques for the parents, who are encouraged to use
them to help their child at home and in the community. The
structure provides the necessary clarity and supports to
enable effective learning for families with ADHD, while
flexibility provides for the unique individual executive and
functional profile of each client. Treatment is administered
in weekly 1-hr sessions with child and parent over 12
weeks. If a session is missed, it is made up so that the full
program is received by all participants.
In light of the fact that many parents of children with
ADHD report experiencing a sense of being burdened with
managing their child’s ADHD, there are no required “home-
work” assignments, nor are parents rated on what they do at
home with their child. Rather, the therapist recommends
that parents encourage strategy implementation in daily
activities at home, including during play with their child.
Likewise, they are encouraged to praise their child’s attempt
at using the strategies in the appropriate contexts. The pro-
tocol comprises seven intervention units: an evaluation
unit, four units of executive strategy acquisition, a home
visit, and a summary unit (Figure 2).
Hypotheses
It was hypothesized that
Hypothesis 1: There would be significant Time × Group
(study and waitlist control) interaction effects on all out-
comes measuring EF, ADHD symptomatology, and QoL
from baseline to Assessment 2.
Hypothesis 2: There would be significant time effects
on all measures after crossover (replication of the treat-
ment effect), with no Time × Group interaction.
Hypothesis 3: There would be maintenance of the treat-
ment effects at follow-up for the study group, with no
significant changes.
Statistical Analyses
All statistical analyses were conducted by using SPSS for
Windows 19 (SPSS Inc, Chicago, Illinois). Descriptive sta-
tistics were generated for demographic and clinical vari-
ables and are reported as means and SD values, as well as
those of the BRIEF GEC score, CGIT score, and the PedsQL
Psychosocial Health Summary score. Because the primary
research goal was the study of a new treatment, we chose to
use a non-intent-to-treat (non-ITT) approach to measure the
effect of the treatment (Ten Have et al., 2008). To compare
between the study and control groups on various personal
characteristics, t tests were performed (Table 1). Mixed
effects ANOVA with the within subject main effect of time
and the between subject main effect of group was performed
to examine the effect of treatment compared with waitlist
control on outcome measures. Significance was set at a
level of .05. Estimates of effect sizes and 95% confidence
intervals (CIs) were calculated. The effect sizes are repre-
sented by partial eta squared, while η2 < .04 is considered a
minimum effect size representing a clinically significant
effect, .04 < partial η2 < .25 is considered a moderate effect,
and partial η2 > .25 is considered a strong effect size
(Ferguson, 2009).
Results
The data were collected from April 2013 through June
2015. One hundred seven children were randomized and all
Hahn-Markowitz et al. 661

Table 2.  T-Scores at Baseline and at Assessment 2 on Outcome Measures (Group × Time Interaction Effect).

Baseline, M Assessment 2, Partial eta squared

± SD M ± SD M [95% CI] p time p interaction interaction
Parent measures
  Executive functions: .38 .00 .08
BRIEF GEC
   Study group (n = 50) 67.8 ± 9.3 61.9 ± 8.8 −5.9 [−8.5, −3.3]  
   Control group (n = 51) 66.5 ± 9.5 65.7 ± 7.3 −0.8 [−2.8, 1.7]  
  ADHD symptomatology: .02 .00 .14
CPRS-R GIT
   Study group (n = 45) 67.1 ± 10.5 61.6 ± 9.9 −5.5 [−8.3, −2.7]  
   Control group (n = 47) 67.2 ± 10.8 68.6 ± 11.1 1.4 [0.6, 3.4]  
  Quality of life: .01 .00 .08
PedsQL psychosocial health
summary score
   Study group (n = 45) 59.6 ± 11.8 68.1 ± 12.1 8.5 [3.7, 13.1]  
   Control group (n = 47) 60.1 ± 12.2 61.2 ± 12.6 1.1 [−3.9, 1.8]  
Teacher measures
  Executive functions: .63 .73 .03
BRIEF GEC
   Study group (n = 19) 58.9 ± 8.8 60.6 ±9.7 1.7 [−1.7, 5.1]  
   Control group (n = 17) 58.1 ± 12.7 57.8 ± 13.0 −0.3 [−4.9, 5.5]  
  ADHD symptomatology: .75 .65 .47
CTRS-R GIT
   Study group (n = 18) 55.9 ± 10.8 57.1 ± 7.2 1.2 [−2.8, 5.3]  
   Control group (n = 14) 56.0 ± 10.6 55.8 ± 12.4 −0.2 [−5.5, 5.1]  

Note. Lower scores signify improvement on BRIEF (65 ≥ indicates executive dysfunction) and CPRS-R (63 ≥ indicates dysfunction). Higher scores signify
improvement on PedsQL. CI = confidence interval; BRIEF = Behavioral Rating Inventory of executive functions; GEC = global executive composite;
CPRS-R = Conners’ Parent Rating Scales–Revised; GIT = global index total; PedsQL = Pediatric Quality of Life 4.0 Generic Core Scales; CTRS-R =
Conners’ Teacher Rating Scales–Revised.

completed the baseline assessment. Compliance was high,
with 99 children receiving intervention and eight leaving
the study prior to intervention. Five participants left the
study and one was excluded after baseline, one more left the
study and another was excluded after Assessment 2. All
children who commenced treatment completed it; however,
seven children were not followed up due to change in medi-
cation status (four) or lack of availability (three). There
were no significant differences between children who
received treatment and those that left the study before treat-
ment, nor between those followed up and those who were
not, on all demographic and ADHD variables (age, gender,
mother’s education, ADHD subtype, medication status,
study location).
All participating mothers had at least high school
degrees, with the majority having higher education. The
majority of parents (>94%) were married. The mean age
of participating children was 8.5 years, including 72 chil-
dren aged 7 to 8 years and 35 children aged 9 to 10 years.
The majority of children (67%) received medication for
ADHD during their participation in the study. Eleven chil-
dren in the study group and 10 children in the control
group were receiving ongoing additional treatments for
ADHD (art therapy, equestrian therapy, remedial educa-
tion, psychotherapy, homeopathy, animal therapy, drama
therapy).
Outcomes
Time × Group interaction effects on measures from baseline to
Assessment 2. There were significant interaction effects
between the study and control groups from baseline to
Assessment 2 on all parent- reported measures. Mean scores
for both groups at baseline were worse (higher) than the
cutoff scores for significant impairment on the BRIEF (T ≥
65) and the CPRS-R (T ≥ 63), and PedsQL Psychosocial
Health Summary was one standard deviation below reported
norms (Varni et al., 2001). At Assessment 2, mean scores
for the study group improved by 5.9 and 5.5 points, respec-
tively (equivalent to >.5 SD) on the BRIEF and CPRS-R
and by 8.5 points on the PedsQL (equivalent to >.5 SD),
whereas mean scores for the control group remained essen-
tially unchanged (Table 2).
The interaction effects between the study and control
groups from baseline to Assessment 2 on both teacher mea-
sures were not significant. The low teacher response rate
662 Journal of Attention Disorders 24(5)

Table 3.  Outcome Comparisons After Crossover (Intervention Effect).

Pre-treatment, Post-treatment, Partial eta squared

M ± SD M ± SD M [95% CI] of time effect p time p interaction
Parent measures
  Executive functions:  
BRIEF GEC
   Study group (n = 50) 67.8 ± 9.3 61.9 ± 8.8 −5.9 [−8.5, −3.3] .39 .00 .38
   Control group (n = 49) 65.4 ± 9.5 58.0 ± 8.6 −7.4 [−9.4, −5.3]  
ADHD symptomatology:
CPRS-R GIT
   Study group (n = 45) 67.1 ± 10.5 61.6 ± 9.9 −5.5 [−8.3, −2.7] .27 .00 .61
   Control group (n = 46) 68.0 ± 10.9 61.4 ± 11.4 −6.6 [−9.5, −3.6]  
  Quality of life:
PedsQL psychosocial health summary score
   Study group (n = 45) 59.6 ± 11.8 68.1 ± 12.1 8.5 [3.7, 13.1] .17 .00 .14
   Control group (n = 46) 62.0 ± 12.1 66.2 ± 12.5 4.2 [0.7, 7.6]  
Teacher measures
  Executive functions: .002 .803 .245
BRIEF GEC
   Study group (n = 19) 58.9 ± 8.8 60.6 ± 9.7 1.7 [−1.7, 5.1]  
   Control group (n = 13) 57.7 ± 10.0 56.5 ± 12.5 −1.2 [−5.4, 2.9]  
  ADHD symptomatology .02 .962 .393
   Study group (n = 18) 55.9 ± 10.8 57.1 ± 7.3 1.2 [−2.8, 5.3]  
   Control group (n = 11) 57.5 ± 13.1 56.2 ± 11.4 −1.3 [−3.2, 6.0]  

Note. Lower scores signify improvement on BRIEF (65 ≥ indicates executive dysfunction) and CPRS-R (63 ≥ indicates dysfunction). Higher scores signify
improvement on PedsQL. CI = confidence interval; BRIEF = Behavioral Rating Inventory of executive functions; GEC = global executive composite;
CPRS-R = Conners’ Parent Rating Scales–Revised; GIT = global index total; PedsQL = Pediatric Quality of Life 4.0 Generic Core Scales; CTRS-R =
Conners’ Teacher Rating Scales–Revised.

(36/99 BRIEF and 32/99 CTRS-R questionnaires were
returned) must be noted. Mean scores for both groups at
baseline were better than the cutoff scores for significant
impairment on the BRIEF and on the CTRS-R. At
Assessment 2, mean scores for the study group slightly
worsened and for the control group slightly improved.
Time effect for both groups on outcomes after crossover. Rep-
lication of the treatment effects was found on all parent
measures after crossover, and interactions between groups
were not significant (all p > .05; Table 3). Within subject
comparisons between times revealed significant differ-
ences before and after intervention on all measures.
Effect sizes were large for the BRIEF GEC and the CGIT
and moderate for the PedsQL psychosocial health sum-
mary score. The treatment effects on teacher measures
were not significant in both groups, with very small
effect sizes, and interactions between groups were not
significant. The low teacher response rate (32/99 BRIEF
and 29/99 CTRS-R questionnaires were returned) must
be noted.
Medication status and treatment effects.  No interaction was
found between medication status and treatment effects (pre-
post-intervention) on parent measures. Parent BRIEF GEC
medicated 66.9-59.9, not medicated 65.8-60.2, p = .381;
CGIT medicated 68.9-61.5, not medicated 65.0-61.2; p =
.123; PedsQL medicated 63.8-68.2, not medicated 58.2-
65.1, p = .314. Regarding teacher measures, a significant
Time × Medication status interaction was found on the
CGIT, F(1, 27) = 5.236 p = .03, whereby the scores of non-
medicated children (n = 9) improved after intervention
(63.7-59.4), whereas the scores of medicated children (n =
20) slightly worsened (53.3-55.6). A similar but not signifi-
cant trend was found for the teacher BRIEF GEC (medi-
cated 54.9-57.5, not medicated 62.0-60.2), F(1, 30) = 3.010,
p = .093.
Three-month follow-up for study group.  The treatment effects
on the study group were maintained at the 3-month follow-
up assessment on all measures (Table 4). On the BRIEF
GEC, there was an additional significant improvement with
a moderate effect size (ES = .11). Post-treatment results
were maintained on the CGIT and the PedsQL psychosocial
healthy summary score, with no significant change. Teacher
reports were not analyzed at follow-up due to the small
number of questionnaires returned (nine BRIEF, 16
CTRS-R).
No adverse events or side effects occurred among par-
ticipants in either group.
Hahn-Markowitz et al. 663
Table 4.  Parent Outcome Comparisons for Study Group at Post-Intervention and Follow-Up.
Post-intervention,
M ± SD
Executive functions: 60.8 ± 7.3
BRIEF GEC (n = 43)
ADHD symptomatology: 60.7 ± 9.7
CPRS-R GIT (n = 40)
Quality of life: 69.1 ± 12.3*
PedsQL psychosocial health
summary score (n = 38)
Note. Lower scores signify improvement on BRIEF (65 ≥ indicates executive dysfunction) and CPRS-R (63 ≥ indicates dysfunction). Higher scores signify
improvement on PedsQL. CI = confidence interval; BRIEF = Behavioral Rating Inventory of executive functions; GEC = global executive composite;
CPRS-R = Conners’ Parent Rating Scales–Revised; GIT = global index total; PedsQL = Pediatric Quality of Life 4.0 Generic Core Scales.
Discussion
The findings suggest that Cog-Fun in OT shows positive
effects for improving EF, QoL, and decreasing symptoms
among children with ADHD as perceived by their parents.
Significant Time × Group interactions were found on all
parent outcomes, demonstrating that these effects cannot be
attributed to time, as the controls did not improve and, in
some cases, worsened at Assessment 2. The positive treat-
ment effects in the study group were replicated among the
controls after crossover. Therefore, the effects cannot be
attributed to one sample, to a random occurrence, to treat-
ment site, or to a particular therapist, as findings were con-
sistent across both sites and for all therapists. Treatment
gains were maintained for the study group 3 months after
completion of treatment. These results substantiate the find-
ings of previous studies (Hahn-Markowitz et al., 2011;
Maeir, Fisher et al., 2014) and establish the impact of Cog-
Fun on parent-reported outcomes.
In Cog-Fun, parents are central “change agents,” helping
to transfer treatment principles so that the child is better
able to monitor his or her behavior and performance outside
the clinic. Executive strategies, especially those designed to
address behavioral and emotional regulation, are taught and
practiced in treatment. The BRIEF GEC scores after treat-
ment reflect the parents’ perceptions of their children’s
improved ability to self-regulate in the context of daily
challenges in home and community settings. The higher
psychosocial health summary scores on the PedsQL provide
evidence that the treatment emphasis on changing psycho-
social components affected the children’s QoL positively.
The improved scores on CGIT, which consists of items
reflecting symptoms and general psychopathology (i.e.,
restlessness, impulsiveness, inattention, emotional out-
bursts), lend further evidence to the efficacy of Cog-Fun.
Riccio and Gomes (2013) conducted a review of inter-
ventions for executive dysfunction in children and ado-
lescents and recommended involving parents in the
intervention, as psychoeducation of parents is a critical
Follow-up, Partial eta
M ± SD M [95% CI] squared p time
58.5 ± 7.8 −2.3 [−4.3, 0.3] .11 .02
59.9 ± 14.1 −0.8 [−4.6, 2.9] .00 .63
67.5 ± 14.1* −1.6 [−2.4, 5.7] .02 .41
element. To this end, the studies of Halperin et al. (2013),
Tamm et al. (2014), and Tamm and Nakonezny (2015) add
much merit to intervention development for children with
ADHD. Results of these studies are in line with those of the
present study, supporting the role of parents for effective
impacting of positive outcomes.
However, according to teachers’ reports, no significant
treatment effects were found in the classroom except for
non-medicated children, for whom teachers reported moder-
ate improvement in ADHD symptoms after treatment. These
findings may indicate minimal transfer of treatment from the
clinic to the school environment, indicating the context-spe-
cific nature of Cog-Fun. These results are similar to those of
Malik, Rooney, Chronis-Tuscano, and Tariq (2017) from a
study examining the preliminary efficacy of a behavioral
parent training program for children with ADHD in which
teacher ratings of symptoms and impairments showed no
improvement after treatment, while parent ratings did. Those
authors noted that such findings are consistent with other
intervention studies targeting the home environment and not
the classroom in which ADHD behavioral treatment effects
do not usually generalize beyond the treatment setting
(Malik et al., 2017). In a different vein, it is important to note
that prior to intervention teachers reported less EF deficits
and less severe ADHD symptoms than parents reported, to
the point where mean teacher scores were below (not
impaired) cutoff for both measures. This finding is in line
with other studies (Goulardins et al., 2015; McCandless &
O’Laughlin, 2007) in which overall agreement between par-
ents and teachers on measures of problems related to ADHD
is low. McCandless and O’Laughlin’s findings suggest that
discrepancies in parent and teacher reports may be due to
their observing different types of behaviors in the home and
school settings. Goulardins et al. (2015) suggested that the
structured framework of the classroom may account for chil-
dren being more regulated there than they are at home.
Parent–teacher discrepancies may also be due to the fact that
some of the children were taking medication for ADHD dur-
ing school hours (Jarratt, Riccio, & Siekierski, 2005). Our
664 Journal of Attention Disorders 24(5)
data support this as medicated children were rated signifi-
cantly better than non-medicated children at baseline by
teachers (53.3 vs. 63.7), as opposed to parent ratings, where
they rated medicated children as worse than non-medicated
children (68.9 vs. 65.0). Interestingly, teachers reported that
non-medicated children improved more than medicated chil-
dren after intervention, suggesting that more impaired chil-
dren benefited from Cog-Fun. However, this finding must be
viewed with caution due to the low teacher response rate
and the fact that there were only nine children in the non-med-
icated group. It is possible that low teacher compliance was due
to lack of involvement in the treatment process. Further research
is required to examine the interaction of medication status on
teachers’ reports as well as to examine the effect of Cog-Fun on
teacher ratings of the child in the classroom.
Cog-Fun is an integrative cognitive behavioral approach,
harnessing executive strategies, learned and practiced in
treatment, together with parental supports at home. Being
equipped with tools (parental support, cognitive strategies)
acquired in treatment may aid children with ADHD to meet
daily challenges as they develop and mature. The results of
this study add to the body of cognitive behavioral interven-
tions with a focus on executive cognitive outcomes in eco-
logical settings. Cog-Fun can impact on everyday functioning
and QoL, and can be implemented by OTs in a relatively brief
time span.
The study has several limitations. The intervention was
compared with waitlist controls and not to another treat-
ment. The sample comprised primarily educated, married
parents who were willing and able to commit to participa-
tion in treatment with their child and to working with them
at home, and therefore may not be representative of the gen-
eral population of children with ADHD. There was no con-
trol for children who received ongoing additional treatments.
Teacher ratings were not used as inclusion criteria, and low
teacher return rates may have influenced the results of the
study. Findings may also have been affected by potentially
biased responding on the part of parents and teachers.
Future studies that analyze Cog-Fun’s change agents,
such as the therapeutic interaction with parents and child,
the process of strategy acquisition, and increased aware-
ness, are recommended. In addition, the interaction of Cog-
Fun with medication status should be further examined. A
study with a larger sample in a more diverse population is
called for as well. Finally, the development of an adapted
Cog-Fun program in school settings is recommended in
which teachers can support children with ADHD as they
acquire and learn to implement executive strategies in the
classroom.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was supported by the Milton Rosenbaum Endowment Fund
for Research in Psychiatric Sciences, the Martin Levin Institute for
Child Development, and the Rama Shoval Foundation.
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Author Biographies
Jeri Hahn-Markowitz, MSc, OTR, is a doctoral student at the
Hadassah-Hebrew University School of Occupational Therapy,
Jerusalem, Israel. She is also a member of the school’s Neurocognitive
Rehabilitation laboratory.
Itai Berger, MD, is director of the Neuro-Cognitive Center,
Pediatric Wing, Hadassah and Hebrew University Medical Center,
Jerusalem, Israel.
Iris Manor, MD, is director of the ADHD Unit, Geha Medical
Center, Petah Tikva, Israel and Sackler School of Medicine, Tel
Aviv University, Israel.
Adina Maeir, PhD, is a professor, school chair, and director of
graduate studies, School of Occupational Therapy, Faculty of
Medicine of Hadassah and Hebrew University of Jerusalem,
Israel. She is also director of the school’s Neurocognitive
Rehabilitation laboratory.