Executive Function Performance Test (EFPT)

Purpose

The Executive Function Performance Test (EFPT) is a performance-based assessment of executive function through observation of four Instrumental ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living (I-ADLs).

In-Depth Review

Purpose of the measure

The Executive Function Performance Test (EFPT) is a performance-based standardized assessment of cognitive function using Instrumental ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living (I-ADLs). The EFPT adopts a top-down approach and is performed in an environmental (real-world) context. The EFPT is used to identify an individual’s: (a) impaired executive functions; (b) capacity for independent functioning; and (c) required amount of assistance for task completion (Baum, 2011).

Available versions

The EFPT was developed by Baum, Morrison, Hahn & Edwards (2003) at the Program in Occupational Therapy at Washington University Medical School.

Features of the measure

Description of Tasks:

The EFPT assesses performance of four functional tasks, completed in the following order:

1. Simple cooking (oatmeal preparation)
2. Telephone use
3. Medication management
4. Bill payment

The EFPT assesses the client’s ability to complete three executive function components of the task:

1. Task initiationThe ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)
   
2. Task execution (comprising organization, sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
   , and judgment and safety)
3. Task completion

The EFPT uses a standardized cueing system that enables use with individuals of varying ability (Baum, 2011).

Scoring and Score Interpretation:

The examiner observes the client’s executive functioning during task performance and also records level of cueing required to support task performance.

Executive functions

• InitiationThe ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)
  : beginning the task. The individual moves to the materials table to collect items needed for the task
• Execution: the individual carries out the steps of the task
• Organization: arrangement of the tools/materials to complete the task. The individual correctly retrieves and uses the items that are necessary for the task
• Sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
  : execution of steps in an appropriate order. The individual carries out the steps in an appropriate order, attends to each step appropriately, and can switch attention from one step to the next
• Judgment and safety: avoidance of dangerous situations. The individual exhibits an awareness of safety by actively avoiding or preventing the creation of a situation that would be unsafe.
• Completion: termination of the task. The individual indicates that he/she is finished or moves away from the area of the last step.

Cueing hierarchy:

Cues required	Score
No cues required	0
Indirect verbal guidance	1
Gestural guidance	2
Direct verbal assistance	3
Physical assistance	4
Do for the participant	5

The score is the highest level of cue needed by the client to perform the task.

The EFPT results in three overall scores:

Scores	How is it calculated?	What is the score range?
1. Executive function component score	Sum of the numbers recorded on each of the four tasks for initiationThe ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008) , organization, sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007)) , judgment and completion	Each EF component can range from 0-5, with a total of all four tasks ranging from 0-20
2. Task score	Sum of the five scores for each task	Each task can range from 0-25
3. Total score	Sum ofa the performance on all four tasks	0-100

A higher score indicates that the client requires more cueing and demonstrates more difficulties with executive functions.

Time:

The EFPT takes approximately 30 – 45 minutes to complete.

Training requirements:

While there are no specific training requirements the examiner should have experience delivering cues (as per cue guidance sheet – please see training manual: Baum 2011).

Equipment:

Leave all of the items necessary for all of the tasks in a clear storage box on a table (the “materials table”). Put the box on a lower table or stool if the person is in a wheel chair.

• Hand soap in dispenser (as one would find in a home)
• Paper Towels (if you use cloth they will need to be washed after each use)
• Pan (with handle that gets hot and requires a pot holder)
• Pot holder
• A pad to put beside the burner to set the pan on when finished (have on the table before they start)
• A spoon rest
• Measuring cup (glass) – 1 cup
• Dry measuring cups
• Spoon for stirring
• Rubber spatula
• Old-fashioned Oats
• Bowl
• Spoon for eating
• Salt shaker
• Timer – a timer that can be used for 2 minutes
• Pencil/Paper
• Phone book
• Magnifying Glass
• Medicine bottle with instructions with the person’s name on it – filled with sugar-free candy
• Medicine bottle with instructions with another person’s name on it filled with sugar-free candy
• Crackers
• Claritin (or other over-the-counter version) bottle (non prescription) as a distracter – filled with sugar-free candy
• Drinking cups
• Two bills: one cable (due in 30 days), one phone (due immediately) with pre addressed envelopes mixed with 5 other pieces of mail (letter from credit card company, postcard, flier, letter in a plain white envelope, mail order catalogue) in a Ziploc bag
• Chequebook with person’s name on the check
• Balance sheet (i.e. account book) with a balance $5.00 less than the bills total
• Pen
• Calculator
• Other distracter items
• Tongs
• Pepper shaker
• An enlarged direction sheet for the cooking task as on the oatmeal box (they may not be able to read it in small print). EXCEPTION: Say cook for 2 minutes (so there is time for them to use the timer and be cued if necessary.)
• A stop watch or timer (it is acceptable to use the timer function on a phone)
• Prepare a response card for the pre-test questions.
• Put Bills and distracter mail in a gallon plastic bag
• Put medications in a quart plastic bag

Additional items:

• Pre-test questions
• Script
• Forms B-E
• Cueing chart
• Behaviour assessment chart

What to consider before beginning:

The EFPT is a standardized cognitive assessment; testing procedures should be followed precisely in order to maintain test validityThe degree to which an assessment measures what it is supposed to measure.
. All items must be administered; if a client refuses to perform a task it can be skipped and performed later.

Conversations and verbal feedback are not permitted.

Multiple administrations may result in a learning effect.

Alternative Forms of the measure

There are no other forms of the assessment.

Client suitability

Can be used with:

• Adolescents, adults and elderly adults.
• The EFPT is suitable for use with clients with motor impairmentLoss of strength and coordination, decrease in arm or leg movement
  . Clients are scored according to the cue level required but are not penalized if they ask for assistance because the impairment necessitates physical assistance (Baum et al., 2008).
• The EFPT has been tested on populations with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Baum et al., 2008), multiple sclerosis (Goverover et al., 2005) and schizophrenia (Katz et al., 2007).
• The EFPT has been used with patients with chronic traumatic brain injury (Toglia et al., 2010).

Should not be used with:

• The EFPT is not suitable for use with individuals with severe cognitive impairment who are not able to follow directions.

Note: Assessors should carefully consider the effect of apraxia and aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person's ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person's intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) on performance.

Languages of the measure

The EFPT training manual is available in English. It has been translated and validated in Swedish and Hebrew.

Summary

What does the tool measure?	The EFPT examines executive functions in the context of performing a task.
What types of clients can the tool be used for?	The EFPT can be used with, but is not limited to, clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
What ICF domain is measured?	Activity
Time to administer	30-45 minutes
Versions	An updated EFPT training manual was published in 2011.
Other Languages	The EFPT has been translated and validated in Swedish and Hebrew.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: One study reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. for the EFPT total score and adequate to excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. for tasks. Correlations between the EFPT total score and executive function components were excellent. Test-retest: No studies have reported on test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population. Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population. Inter-rater: One study reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. for the EFPT total score and all tasks.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: The EFPT was developed based on Baum & Edwards’ (1993) Kitchen Task Assessment. Criterion: Concurrent: Three studies have examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the EFPT in patients with acute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and reported an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Functional Assessment Measure, an adequate to excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Assessment of Motor and Process Skills (AMPS) and the Short Blessed Test, and an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Functional Independence Measure, Weschler Memory Scale-Revised Logical Memory Total Recall Test and Digit Span Backward subtests, Animal Naming Test, Delis-Kaplan Executive Function System (DKEFS) Sorting Test, Verbal Fluency Test and Colour Word Interference Test and the Trail Making Test Part B. Predictive: No studies have reported on the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population. Construct: Convergent/Discriminant: No studies have reported on discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess. of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population. Known Groups: One study reported that the EFPT was able to discriminate between clients with mild and moderate strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., and between clients with mild strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and healthy controls.
Floor/Ceiling Effects	No studies have reported on floor or ceiling effects of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	No studies have reported on sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” or specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.
Does the tool detect change in patients?	No studies have reported on responsivenessThe ability of an instrument to detect clinically important change over time. of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.
Acceptability	The EFPT is comprised of real world tasks. The tool can be administered to individuals of varying ability due to the flexibilityThe ability to shift between different thoughts and actions so that when a problem arises, one can draw upon past mistakes and successes and use this knowledge to plan solutions (Anderson, 2008) to provide a hierarchy of cues as required.
Feasibility	The EFPT can be administered in a home or rehabilitation setting. The tool is simple to administer and guidelines are clearly stipulated in the test manual. The EFPT assesses what an individual is able to do rather than what he/she cannot do
How to obtain the tool?	The EFPT is free and can be obtained from Carolyn Baum at baumc@wustl.edu, or online through the following websites: Washington University School of Medicine Program in Occupational Therapy The Practice Change Fellows Program

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Executive Function Performance Test (EFPT). While this assessment can be used with various populations, this module addresses the psychometric properties of the measure specifically when used with patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Three studies were identified.

Floor/Ceiling Effects

No studies have reported on the floor or ceiling effects of the EFPT in a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Baum et al. (2008) examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the EFPT with a sample of 73 patients with mild to moderate chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and 22 age- and education-matched healthy controls. Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency., calculated using Cronbach’s alpha, was excellent for the total score (?=0.94) and adequate to excellent for test items (cooking: ?=0.86; paying bills: ?=0.78; managing medication: ?=0.88; telephone use: ?=0.77). Correlations between the EFPT total score and executive function components were excellent (initiationThe ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)
: r=0.91; organization: r=0.93; sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
: r=0.88; safety and judgment: r=0.78; task completion: r=0.89).

Test-retest:
No studies have reported on test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

Intra-rater:
No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

Inter-rater:
Baum et al. (2008) examined inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the EFPT with three trained raters and 10 participants (5 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 5 healthy controls). Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
, calculated using intra-class correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients (ICCs) was excellent for the total score (ICC=0.91) and all test items (cooking: ICC=0.94; paying bills: ICC=0.89; managing medication: ICC=0.87; telephone use: ICC=0.79).

Validity

Content:

The EFPT was developed at the Program in Occupational Therapy at Washington University Medical School.

The EFPT was developed based on Baum & Edwards’ (1993) Kitchen Task Assessment.

Criterion:

Concurrent:
Baum et al. (2008) examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the EFPT by comparison with functional and neuropsychological tests in a sample of 73 patients with mild to moderate chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Functional tests included the Functional Assessment Measure and the Functional Independence Measure (FIM). Neuropsychological tests included the Weschler Memory Scale-Revised (WMS-R) Logical Memory Total Recall, Digit Span Forward and Digit Span Backward subtests, Animal Naming Test, Short Blessed Test and Trail Making Test. The EFPT showed an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Functional Assessment Measure (r=-0.68), and adequate correlations with the FIM (r=-0.40), WMS-R Logical Memory Total Recall Test (r=-0.59) and Digit Span Backward (r=-0.49) subtests, Animal Naming Test (r=-0.47), Short Blessed Test (r=0.39) and the Trail Making Test Part B (r=0.39). Correlations with cognitive tests that are not considered to assess executive function were not significant (Trail Making Test Part A, WMS-R Digit Span Forward).

Wolf et al. (2010) examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the EFPT by comparison with neuropsychological tests in a sample of 20 patients with mild to moderate acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. The EFPT total score showed adequate correlations with the Short Blessed Test (p=0.548) and the Delis-Kaplan Executive Function System (DKEFS) Sorting Test (p=-0.511), Verbal Fluency Test (p=-0.474) and Colour Word Interference Test (p=-0.566), but not the Trail Making Test. The EFPT Cooking task showed adequate correlations with the DKEFS Sorting (1: p=-0.498; 2: p=-0.587) and Verbal Fluency (p=0.527) Tests, and an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Short Blessed Test (p=0.710). The EFPT Bill Payment task showed adequate correlations with DKEFS Sorting, Colour Word Interference and Trail Making Tests (p=-0.484 to -0.594). The EFPT Telephone task showed an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the DKEFS Colour Word Interference Test (p=-0.499). There were no significant correlations between the EFPT Medication Management task and other neuropsychological tests.

Cederfeldt et al. (2011) examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the EFPT by comparison with the Assessment of Motor and Process Skills (AMPS) in a sample of 23 patients with mild acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
test. The correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the EFPT total sum of all tasks and AMPS process skills was excellent (rho=0.61). Correlations between the four EFPT tasks and AMPS process skills were adequate to excellent (rho=0.54 – 0.60).

Predictive:
No studies have reported on the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the EFPT in a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population.

Construct:

Convergent/Discriminant:
No studies have reported on convergent/discriminant validityThe degree to which an assessment measures what it is supposed to measure.
of the EFPT in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

Known Group:
Baum et al. (2008) examined known group validityThe degree to which an assessment measures what it is supposed to measure.
of the EFPT with a sample of 73 patients with mild (n=59) to moderate (n=14) chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 22 age- and education-matched healthy controls. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. severity was classified using the National Institutes of Health StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale (? 5 = mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., 6-15 = moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.). The EFPT was able to discriminate among groups, with healthy controls achieving a lower (better) total score than clients with mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (p<0.05) and moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (p<0.0001), and clients with mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. achieving a lower score than those with moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (p<0.0001). Significant differences were seen between healthy controls and clients with mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. for Cooking (p=0.008) and Paying Bills (p=0.03). Significant differences were seen between clients with mild and moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. for Paying Bills (p=0.01), Managing Medication (p=0.001) and Telephone Use (p=0.0001). Analysis of test EF components showed significant differences between healthy controls and clients with mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. for sequencing"The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step" (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
(p<0.001) and organization (p<0.04). Significant differences between clients with mild and moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. were seen for organization (p<0.0001), sequencing"The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step" (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
(p<0.001), safety and judgment (p<0.004) and task completion (p<0.01).

Responsiveness

No studies have examined responsivenessThe ability of an instrument to detect clinically important change over time.
of the EFPT in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001; Bot et al., 2004; MacDermid & Tottenham, 2004; Schmitt & Di Fabio, 2004).

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
& SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
No studies have examined responsivenessThe ability of an instrument to detect clinically important change over time.
of the EFPT in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001).

References

• Baum, C.M. (2011). Executive Function Performance Test: training manual. St. Louis, MO: Washington University.
• Baum, C.M. & Edwards, D. (1993). Cognitive performance in senile dementia of the Alzheimer’s type: the Kitchen Task Assessment. The American Journal of Occupational Therapy, 47, 431-6.
• Baum, C.M., Morrison, T., Hahn, M., & Edwards, D.F. (2003). Test manual: Executive Function Performance Test. St. Louis, MO: Washington University.
• Baum, C.M., Tabor Connor, L., Morrison, T., Hahn, M., Dromerick, A.W., & Edwards, D.F. (2008). Reliability, validity, and clinical utility of the Executive Function Performance Test: a measure of executive function in a sample of people with stroke. The American Journal of Occupational Therapy, 62(4), 446-455.
• Cederfeldt, M., Widell, Y., Elgmark Andersson, E., Dahlin-Ivanoff, S., & Gosman-Hedström, G. (2011). Concurrent validity of the Executive Function Performance Test in people with mild stroke. British Journal of Occupational Therapy, 74(9), 443-9.
• Goverover, Y., Kalmar, J., Gaudino-Goering, E., Shawaryn, M., Moore, N.B., Halper, J., & DeLuca, J. (2005). The relation between subjective and objective measures of everyday life activities in persons with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 86, 2303-8.
• Katz, N., Tadmore, I., Felzen, B., & Hartman-Maeir, A. (2007). Validity of the Executive Function Performance Test in individuals with schizophrenia. Occupational Therapy Journal of Research, 27, 1-8.
• Toglia, J., Johnston, M.V., Goverover, Y., & Dain, B. (2010). A multicontext approach to promoting transfer of strategy use and self regulation after brain injury: an exploratory study. Brain Injury, 24(4), 664-77.
• Wolf, T.J., Stift, S., Tabor Connor, L., Baum, C., & The Cognitive Rehabilitation Research Group. (2010). Feasibility of using the EFPT to detect executive function deficits at the acute stage of stroke. Work: Journal of Prevention, Assessment & Rehabilitation, 36(4), 405-12.

See the measure

How to obtain the assessment?

The EFPT can be obtained from Carolyn Baum at baumc@wustl.edu, or online through the following websites:

• Washington University School of Medicine Program in Occupational Therapy
• The Practice Change Fellows Program