Executive Function Performance Test (EFPT)

Evidence Reviewed as of before: 25-02-2013
Author(s): Valérie Poulin, OT, PhD candidate;; Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT
Content consistency: Gabriel Plumier

Purpose

The Executive Function Performance Test (EFPT) is a performance-based assessment of executive function through observation of four Instrumental Activities 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 Activities 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 initiation
  2. Task execution (comprising organization, sequencing, 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

  • Initiation: 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: 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 initiation, organization, sequencing, 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 validity. 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 impairment. 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 stroke (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 aphasia 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 stroke.
Is this a screening 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
Reliability

Internal consistency:

One study reported excellent internal consistency for the EFPT total score and adequate to excellent 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 reliability of the EFPT in a stroke population.

Intra-rater:

No studies have reported on the intra-rater reliability of the EFPT in a stroke population.

Inter-rater reliability:

One study reported excellent inter-rater reliability for the EFPT total score and all tasks.

Validity

Content:

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

Criterion:

Concurrent:

Three studies have examined concurrent validity of the EFPT in patients with acute or chronic stroke and reported an excellent correlation with the Functional Assessment Measure, an adequate to excellent correlation with the Assessment of Motor and Process Skills (AMPS) and the Short Blessed Test, and an adequate 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 validity of the EFPT in a stroke population.

Construct:

Convergent/Discriminant:

No studies have reported on discriminant validity of the EFPT in a stroke population.

Known Groups:

One study reported that the EFPT was able to discriminate between clients with mild and moderate stroke, and between clients with mild stroke and healthy controls.

Floor/Ceiling Effects No studies have reported on floor or ceiling effects of the EFPT in a stroke population.
Sensitivity/ Specificity No studies have reported on sensitivity or specificity of the EFPT in a stroke population.
Does the tool detect change in patients? No studies have reported on responsiveness of the EFPT in a stroke population.
Acceptability The EFPT is comprised of real world tasks. The tool can be administered to individuals of varying ability due to the flexibility 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:

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 stroke. Three studies were identified.

Floor/Ceiling Effects

No studies have reported on the floor or ceiling effects of the EFPT in a stroke population.

Reliability

Internal consistency:

Baum et al. (2008) examined internal consistency of the EFPT with a sample of 73 patients with mild to moderate chronic stroke and 22 age- and education-matched healthy controls. 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 (initiation: r=0.91; organization: r=0.93; sequencing: r=0.88; safety and judgment: r=0.78; task completion: r=0.89).

Test-retest:

No studies have reported on test-retest reliability of the EFPT in a stroke population.

Intra-rater:

No studies have reported on the intra-rater reliability of the EFPT in a stroke population.

Inter-rater:

Baum et al. (2008) examined inter-rater reliability of the EFPT with three trained raters and 10 participants (5 clients with stroke and 5 healthy controls). Inter-rater reliability, calculated using intra-class 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 validity of the EFPT by comparison with functional and neuropsychological tests in a sample of 73 patients with mild to moderate chronic stroke, using Pearson 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 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 validity of the EFPT by comparison with neuropsychological tests in a sample of 20 patients with mild to moderate acute stroke, using Pearson 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 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 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 validity of the EFPT by comparison with the Assessment of Motor and Process Skills (AMPS) in a sample of 23 patients with mild acute stroke, using Spearman’s rank correlation test. The 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 validity of the EFPT in a stroke population.

Construct:

Known Group:

Baum et al. (2008) examined known group validity of the EFPT with a sample of 73 patients with mild (n=59) to moderate (n=14) chronic stroke and 22 age- and education-matched healthy controls. Stroke severity was classified using the National Institutes of Health Stroke Scale (? 5 = mild stroke, 6-15 = moderate stroke). The EFPT was able to discriminate among groups, with healthy controls achieving a lower (better) total score than clients with mild stroke (p<0.05) and moderate stroke (p<0.0001), and clients with mild stroke achieving a lower score than those with moderate stroke (p<0.0001). Significant differences were seen between healthy controls and clients with mild stroke for Cooking (p=0.008) and Paying Bills (p=0.03). Significant differences were seen between clients with mild and moderate stroke 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 stroke for sequencing (p<0.001) and organization (p<0.04). Significant differences between clients with mild and moderate stroke were seen for organization (p<0.0001), sequencing (p<0.001), safety and judgment (p<0.004) and task completion (p<0.01).

Convergent/Discriminant Validity:

No studies have reported on convergent/discriminant validity of the EFPT in a stroke population.

Responsiveness

No studies have examined responsiveness of the EFPT in a sample of patients with stroke, 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).

Sensitivity & Specificity:

No studies have examined responsiveness of the EFPT in a sample of patients with stroke, 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:

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