Executive Function Performance Test

The EFPT examines the execution of four basic tasks that are essential for self-maintenance and independent living: simple cooking, telephone use, medication management, and bill payment.

Link to Instrument

Area of Assessment

Activities of Daily Living
Behavior
Cognition
Coordination
Executive Functioning
Functional Mobility
Quality of Life

Assessment Type

Administration Mode

Cost

Diagnosis/Conditions

• Multiple Sclerosis
• Stroke Recovery

Populations

Key Descriptions

• The EFPT is a top-down performance assessment designed to examine cognitive integration and functioning.
• The EFPT serves three purposes:
  1) To determine which executive functions are impacting function
  2) To determine an individual’s capacity for independent functioning
  3) To determine the amount of assistance necessary for task completion
• The assessments requires participants to complete the following tasks (in order):
  1) Hand Washing - only use this task if the person has severe cognitive impairment and you want to see if they can follow directions. If they cannot, do not proceed.
  2) Oatmeal Preparation
  3) Telephone
  4) Taking Medication
  5) Paying Bills
• Instructions: Please refer to the training manual available at the Washington University at St. Louis link above for details.

Number of Items

Equipment Required

• Please see the training manual available on the Washington University at St. Louis website link above at "Instrument Details".

Time to Administer

Required Training

Age Ranges

Instrument Reviewers

Updated by Bridget Hahn, OTD, OTR/L; Michelle Sivak, OTS, Megan Westendorf, OTS, Jessi Zuba, OTS; Rush University, 2019.

ICF Domain

Measurement Domain

Considerations

• The EFPT should only be administered once per patient secondary to a learning effect that may confound the results of a second assessment.
• A Korean version of the EFPT, the EFPT-K, was created in order to be more culturally appropriate (Kim, H., Lee, Y., Jo, E., Lee, E., 2017).
• The EFPT has also been translated into Swedish. (Cederfeldt, M., Carlsson, G., Dahlin–Ivanoff, S., & Gosman–Hedstrom, G., 2015).

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Stroke

Cut-Off Scores

Not needed, each person is observed to be independent or need various levels of help.

Normative Data

Chronic Stroke: (Baum et al 2008; n = 73; mean age = 64 (14) years; Barthel Index scores of ≥ 90, Modified Rankin Index scores of ≥ 2; > 6 months post stroke onset)

EFPT Normative Data:

Control

Mild Stroke

Moderate Stroke

NIHSS

EFPT total score

Cooking**

Using Telephone***

Medications***

Paying Bills**

Initiation

Organization***

Sequencing***

Safety & Judgment**

Completion**

Interrater/Intrarater Reliability

Chronic Stroke: (Baum et al, 2008; 3 trained raters rating 10 participants (5 = mild stroke, 5 = healthy controls)

• Excellent Interrater reliability for the overall EFPT (ICC = 0.91)

• Excellent Interrater reliability for EFPT sub-scales
  • Cooking (ICC = 0.94)
  • Paying Bills (ICC = 0.89)
  • Medication (ICC = 0.87)
  • Using Phone (ICC = 0.79)

  Internal Consistency

  Chronic Stroke: (Baum et al, 2008)

  • Excellent: EFPT total sample scores (Cronbach's alpha = 0.94)
  • Excellent: EFPT Cooking subtest (Cronbach's alpha = 0.86)
  • Adequate: EFPT Paying Bills subtest (Cronbach's alpha = 0.78)
  • Excellent: EFPT Managing Medication subtest (Cronbach's alpha = 0.88)
  • Adequate: EFPT Telephone subtest (Cronbach's alpha = 0.77)

  Criterion Validity (Predictive/Concurrent)

  Chronic Stroke: (Baum et al, 2008)

  Concurrent Validity:

  Variable

  EFPT Total Score (r)

  Digits forward

  Digits backward

  Trails A

  Trails B

  Story Recall (Wechsler Memory Scale)

  Animal Fluency

  Short Blessed

  FIM total

  FAM total

  FIM = Functional Independence Measure

  FAM = Functional Assessment

  *adequate correlation; **excellent correlation

  Concurrent Validity:

  Acute Mild Stroke (Cederfeldt, M., Widell, Y., Andersson, E. E., Dahlin-Ivanoff, S., & Gosman-Hedstrom, G., 2011; n = 23, mean age = 72 (10.9) years, mean time since onset of stroke = 4 days)

  • Adequate concurrent validity of the four different tasks of the EFPT at predicting the Assessment of Motor and Process Skills (AMPS) process skills (r=0.54-0.60)
  • Excellent concurrent validity of the total sum of all of the tasks of the EFPT and the Assessment of Motor and Process Skills (AMPS) process skills (r=0.61)

  Construct Validity

  Acute Stroke: (Wolf et al, 2010; n = 20; mean age = 58.8 (13.2) years; mean NIHSS score = 1.5 (2.4); recruited < 1 week post stroke)

  EFPT & other measures of Executive Function

  Measure

  Strength

  DKEFS Sorting adequate

  DKEFS Verbal Fluency

  DKEFS Color-Word Interference adequate

  Short Blessed Test

  DKEFS = Delis-Kaplan Executive Function System

  Chronic Stroke: (Baum et al, 2008)

  Measure

  Control

  Mild Stroke

  Moderate Stroke

  Trails A (seconds)

  Trails B (seconds)***

  Digits Forward**

  Digits Backward**

  Story Recall*

  Animal Fluency***

  note: Values are one-way analyses of variance comparing scores across groups.

  Trails A & B from the Trailmaking Test (Reitan & Wolfson, 1995)
  Digit Span Forward and Backward Test from the Wechsler Memory Scale–Revised (Wechsler, 1987)
  Story Recall from the Logical Memory Total Recall Test (Wechsler, 1987)
  Animal Fluency from the Animal Naming test (Barr & Brandt, 1996)

  Content Validity

  The Executive Function Performance Task was developed at the Program in Occupational Therapy at Washington University Medical School based on Carolyn Baum's Kitchen Task Assessment (KTA) measure of functional ability.

  Multiple Sclerosis

  Cut-Off Scores

  Not needed, each person is observed to be independent or need various levels of help.

  Normative Data

  Multiple Sclerosis: (Kalmar, 2008; n = 74 MS & 35 healthy comparison; MS mean age = 44.69 (8.75) years)

  EFPT Performance:

  Variable

  MS-with

  MS-without

  Healthy

  EFPT total score

  Handwashing

  Cooking oatmeal

  Telephone usage

  Medication management

  Bill payment

  Cooking casserole

  ms-with = with cognitive deficits

  ms-without = without cognitive deficits

  Multiple Sclerosis (Voelbel, Goverover, Gaudino, Moore, Ghiaravalloti, & DeLuca, 2011; n = 68, mean age = 44.49 (9.26) years; mean time since onset MS = 13.09 (9.51))

  Test

  MS

  EFPT tasks

  Simple cooking

  Telephone use

  Complex cooking

  Medications

  Bill payment

  EFPT components

  Initiation

  Organization

  Sequencing

  Completion

  Judgement and safety

  Total score

  Criterion Validity (Predictive/Concurrent)

  Multiple Sclerosis (Voelbel et al., 2011)

  • Adequate criterion validity of the EFPT for the bill payment task at predicting TOL-DX total move scores (r = .379).

  Construct Validity

  Multiple Sclerosis: (Goverover et al, 2009; n = 47; men age = 44.8 (8.2) years)

  Self-awareness of Functional Status With the EFPT

  Variable

  Strength

  FBP SA

  BDI

  FAMS

  EFPT = Executive Function Performance Test
  FBP SA = self awareness of functional status
  BDI = Beck Depression Inventory
  FAMS = Functional Assessment of Multiple Sclerosis

  Content Validity

  The Executive Function Performance Task was developed at the Program in Occupational Therapy at Washington University Medical School based on Carolyn Baum's Kitchen Task Assessment (KTA) measure of functional ability.

  Responsiveness

  Multiple Sclerosis: (Voelbel et al., 2011)

  • Statistically significant, lower EFPT scores were found for participants with MS compared to healthy individuals (F_1,103 = 8.69, p = .004).

  Mental Health

  Standard Error of Measurement (SEM)

  Acute Schizophrenia (calculated from Katz, Tedmor, Felzen, & Hartman-Maeir, 2007; n = 30; mean age = 34.13(11.24) years)

  • SEM for entire group (n=30): 1.92

  Chronic Schizophrenia (calculated from Katz et al., 2007; n = 31; mean age = 42.26(10.88) years)

  • SEM for entire group (n=31): 1.35

  Minimal Detectable Change (MDC)

  Acute Schizophrenia (calculated from Katz et al., 2007)

  • MDC for entire group (n=30): 5.32

  Chronic Schizophrenia (calculated from Katz et al., 2007)

  • MDC for entire group (n=31): 3.74

  Normative Data

  Acute and Chronic Schizophrenia (Katz et al., 2007)

  Test

  Acute Schizophrenia

  Chronic Schizophrenia

  EFPT tasks

  Simple cooking

  Telephone use

  Medication management

  Bill payment

  EFPT components

  Initiation

  Planning

  Shifting

  Error detection

  Error correction

  Safety

  Completion

  Total score

  Internal Consistency

  Acute and Chronic Schizophrenia (Katz et al., 2007)

  • Excellent Cronbach’s alpha = .88
  • Pearson correlation coefficients between executive function component and total score: initiation = .71, planning = .81, transfer between stages = .87, error detection = .80, error correction = .88, completion = .53, safe performance = .82

  Criterion Validity (Predictive/Concurrent)

  Acute Schizophrenia (Katz et al., 2007)

  Chronic Schizophrenia (Katz et al., 2007)

  Construct Validity

  Acute versus Chronic Schizophrenia (Katz et al., 2007)

  • A significant overall group effect was found between the acute and chronic schizophrenia groups (F = 12.57, p < .000).

  Responsiveness

  Acute and Chronic Schizophrenia (Katz et al., 2007)

  • Statistically significant differences for all tasks except the EFPT initiation component and telephone task were found among all variables between the two groups (p = .045, .000).

  Brain Injury

  Normative Data

  Mild/Moderate TBI (Baum et al., 2017; n=83; mean age = 44.2 (2.05) years; mean time post injury = 3 years)

  Severe TBI (Baum et al., 2017; n=99; mean age = 34.9 (1.44) years; mean time post injury = 5 years)

  Test

  Mild/Moderate TBI

  Severe TBI

  EFPT tasks

  Simple cooking

  Telephone use

  Medication management

  Bill payment

  EFPT components

  Initiation

  Organization

  Sequencing

  Safety and Judgement

  Completion

  Total score

  Criterion Validity (Predictive/Concurrent)

  Predictive validity:

  Severe TBI (Baum et al., 2017)

  • Adequate predictive validity of total task score independence with beta of −0.53 (p < .006).

  Construct Validity

  Construct validity:

  Entire TBI group (Baum et al., 2017; n=182)

  • Adequate construct validity of the EFPT and the Total Composite Score of the NIH Toolbox Cognitive Function Battery (r=-.479).
  • Adequate construct validity between the EFPT and the NIH Toolbox Cognitive Function Battery Crystallized Tests (r = −.479).
  • Adequate construct validity of the EFPT and the Total Composite Score of the NIH Toolbox Cognitive Function Battery Fluid Tests (r = −.420).

  Discriminant validity:

  Entire TBI group (Baum et al., 2017)

  • The total task score significantly discriminated the control, mild/moderate TBI, and severe TBI groups (p < .001).
  • A significant and moderate group effect was found between the control and mild/moderate TBI groups (Cohen’s d = -0.562, p < .01).
  • A significant and large group effect was found between the control and severe TBI groups (Cohen’s d = -1.041, p < .01).
  • A significant and moderate group effect was found between the mild/moderate TBI and severe TBI groups (Cohen’s d = -0.486, p < .01).

  Responsiveness

  Mild/Moderate and Severe TBI: (Baum et al., 2017)

  • Statistically significant differences between mild/moderate and severe TBI were found for total EFPT scores, cooking, telephone use, organization, and sequencing (p < .01, .01, .05, .01, .05 respectively).
  • Statistically significant differences between mild/moderate TBI and control group were found for total EFPT scores, medications, sequencing, and safety and judgement (p < .01, .01, .05, .01 respectively).
  • Statistically significant differences between severe TBI and control group were found for total EFPT scores, cooking, telephone use, medications, paying bills, organization, sequencing, and safety and judgement (p < .01, .01, .01, .01, .05, .01, .01, .01 respectively).

  Bibliography

  Baum, C., Connor, L., et al. (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. Find it on PubMed

  Baum, C., Morrison, T., et al. (2007). "Executive Function Performance Test: Test protocol booklet." Unpublished program in Occupational Therapy Washington University School of Medicine, St. Louis, MO.

  Baum, C. M., Wolf, T. J., Wong, A. W. K., Chen, C. H., Walker, K., Young, A. C., Carlozzi, N. E., Tulsky, D. S., Heaton, R. K., & Heinemann, A. W. (2017). Validation and clinical utility of the executive function performance test in persons with traumatic brain injury. Neuropsychological Rehabilitation, 27(5), 603–617.Find on PubMed

  Cederfeldt, M., Widell, Y., Andersson, E. E., Dahlin-Ivanoff, S., & Gosman-Hedstrom, G. (2011). Concurrent validity of the executive function performance test in people with mild stroke. British Journal of Occupational Therapy, 74(9), 443. Retrieved from http://lup.lub.lu.se/record/2179988

  Goverover, Y., Chiaravalloti, N., et al. (2009). "The relationship among performance of instrumental activities of daily living, self-report of quality of life, and self-awareness of functional status in individuals with multiple sclerosis." Rehabil Psychol 54(1): 60-68. Find it on PubMed

  Kalmar, J. H., Gaudino, E. A., et al. (2008). "The relationship between cognitive deficits and everyday functional activities in multiple sclerosis." Neuropsychology 22(4): 442-449. Find it on PubMed

  Katz, N., Tadmor, I., Felzen, B., & Hartman-Maeir, A. (2007). Validity of the Executive Function Performance Test in individuals with schizophrenia. OTJR: Occupation, Participation and Health, 27(2), 44–51.

  Kim, H., Lee, Y., Jo, E., Lee, E. (2017). Reliability and validity of culturally adapted executive function performance test for koreans with stroke. Journal of Stroke and Cerebrovascular Diseases, 26(5). Find on PubMed

  Voelbel, G. T., Goverover, Y., Gaudino, E. A., Moore, N. B., Ghiaravalloti, N., & DeLuca, J. (2011). The relationship between neurocognitive behavior of executive functions and the EFPT in individuals with multiple sclerosis. OTJR: Occupation, Participation and Health, 31(Suppl 1), S30–S37. Find on PubMed.

  Wolf, T., Stift, S., et al. (2010). "Feasibility of using the EFPT to detect executive function deficits at the acute stage of stroke." Work: A Journal of Prevention, Assessment and Rehabilitation 36(4): 405-412. Find it on PubMed

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