Reliability and validity of the Executive Function and Occupational Routines Scale (EFORTS)
Introduction
Daily routines organize everyday life and define roles and responsibilities of family members. They assist the accomplishment of specific concrete goals during the day, such as at mealtimes, bedtime routines, and in leisure time activities (Denham, 2003, Howe, 2002). Children with predictable routines during infancy and preschool are healthier, their behavior is better regulated, and, their parents feel more competent (Fiese et al., 2002). While their management of daily routines is usually significantly supported by parental involvement, some of the children's traits have been recognized as affecting the level of support needed for them to handle their own routines (Early et al., 2010, Fiese et al., 2002, Schuck and Bucy, 1997, Summers et al., 2008).
Managing daily routines effectively requires the ability to relate to temporal dimensions, including pace, turn taking, relating to past events, and projections about the future (Daly, 2002). These faculties require a special form of memory belonging to the mechanism of the executive functions (EF) (Barkley, 1997). EF are central cognitive processes that enable flexible, goal-directed behavior (Brown, 2009, Castellanos et al., 2006). They help the individual to behave and act in a self-directed manner, allowing him to change his own behavior toward better future consequences (Barkley, 2012). Literature suggests varied structures included in the term EF (Castellanos et al., 2006), while there is a general agreement that they are all derived from three core EF: inhibitory control, working memory and cognitive flexibility (Diamond, 2013). Out of all the theories, only Barkley's model (Barkley, 1997) attempts to provide the sequence of EF's development beginning in infancy, suggesting five essential elements of EF: behavioral inhibition, non-verbal working memory, verbal working memory, self regulation of affects/motivation/arousal, and reconstitutions (Dawson & Guare, 2010). EF are most in demand in novel and ambiguous situations that are often lacking in external guidance (Barkley, 2012). When are well developed, they enable children to manage age-related tasks more independently (Dawson & Guare, 2010). However, deficient or delayed EF may cause severe functional impairments (Miller & Hinshaw, 2010), restrict participation in varied life domains (Engel-Yeger, Josman, & Rosenblum, 2009), and predict social and behavioral failure (Hughes, White, Sharpen, & Dunn, 2000).
Since some of daily routines are, indeed, characterized by lack of close external guidance (Daly, 2002), children with EF deficits may be at risk of failing to effectively self-direct themselves in them. For example, it was demonstrated that children with Attention Deficit Hyperactivity Disorder (ADHD), having a high rate of EF deficits (e.g. Barkley, 1997, Shimoni et al., 2012) experience considerable daily challenges in managing morning and afternoon routines, tending to act slowly, forgetting where they put their paraphernalia, and arguing with other family members (Firmin & Phillips, 2009). ADHD belong to a wide group of developmental disorders in which EF deficits have been reported to be involved, such as Learning Disabilities, Specific Language Impairment, Conduct Disorder, and Autistic Syndrome Disorder (Barkley, 1997, Berlin et al., 2004, Gillberg, 2003, Lundervold et al., 2012, Ozonoff and Jensen, 1999, Piek et al., 2007). This suggests that children with all of these diagnoses may also experience difficulties in executive-control during daily occupational routines. Therefore it is important to assess both their daily routines management and their EF, or, alternatively, to use a tool combining both domains.
Although evaluation tools measuring each construct separately are available in existing literature – for example, the Family Routines Inventory (RFI) (Jensen, James, Boyce, & Hartnett, 1983) for daily routines and the Behavior Rating Inventory of Executive Function – Preschool version (BRIEF-P) (Gioia, Espy, & Isquith, 2003), the Childhood Executive Functioning Inventory (Thorell & Nyberg, 2008) and the Barkley Deficits in Executive Functioning Scale – Children and Adolescents (Barkley, 2012) for EF, no instrument in which they were evaluated simultaneously was found. The absence of a tool linking the ability to complete daily routines and the possible contribution of children's EF to them, led to the development of the EFORTS. The tool has been developed as a parents’ report about their child's executive control through daily routines. The purpose of this article is to describe the development process of the EFORTS and to examine its internal reliability and validity among typically developing children.
Section snippets
Phase 1: construction and description of the EFORTS
The questionnaire was originally developed in Hebrew. Two main bodies of knowledge delineated the process of choosing appropriate routines and activities for inclusion in the EFORTS (1) qualitative articles regarding the daily occupational challenges of children with ADHD and their families (Firmin and Phillips, 2009, Segal, 1998); and (2) the information gathered by the first author while interviewing parents regarding occupational referral reasons for intervention. A third source, Barkley's
Exploratory Factor Analysis
A primary factor analysis with oblique rotation was conducted on the 32 items of the EFORTS without pre-determining the number of factors. Results of the analysis revealed three distinct factors. The first two routines, which were assumed theoretically as two different factors, were combined into one factor. The yielded factors were: morning–evening routines (16 items), play and leisure (8 items), and social routines (8 items). All items were loaded on the initial empirical factors. Table 2
Discussion
The aim of this study was to establish the reliability and validity of the EFORTS (Hebrew version), which was developed in light of the importance and absence of a tool for measuring children's executive control in daily routines. Preliminary results suggest that the EFORTS is a reliable and valid tool for assessing children's performance levels in daily routines in the context of EF. Exploratory and confirmatory factor analysis revealed that the EFORTS items are best represented by three
Conclusions
Since the result of the current study validates the EFORTS as a reliable and valid tool, it is recommended for use to measure suspected deficits in executive control during daily routines. This may be applied by conducting further studies utilizing the validated English version (see an example in Appendix A).
Using the EFORTS may assist the parents of children with EF deficits to understand the relationships between these deficits and their child's specific day-to-day occupational challenges. It
Acknowledgments
Authors wish to thank colleagues as well as Netta Gemerman, Ofra Altaras, Rotem Sidan, Yael Froim, Rachel Sorek, Lilian Tator-Khateeb and Michal Kasyi, MA students, who assisted in participant's recruitment. The authors are grateful to all the research participants for devoting their time to the study.
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