This integrative review aimed to explore the conceptual understanding of executive function in occupational therapy literature and how this influences the profession’s approach to assessment. For those unfamiliar with integrative reviews, this methodology enables a holistic synthesis of literature by integrating findings from diverse methodologies—qualitative, quantitative, and theoretical studies.

The researcher chose to explore this topic because scoping reviews have previously noted inconsistency and variation in both the psychological mechanisms and components of executive function because of lack of agreement in research. And secondly because there is evidence from asurvey of 663 occupational therapists found that executive function was rarely addressed, with only 1% using specific performance-based assessments, instead continuing to use impairment-focused assessments not designed for executive function.

Methods

The researcher used an integrative review methodology following PRISMA guidance to ensure rigour. The population included adults with acquired brain injury, whilst excluding mental health-based studies, paediatrics, and elderly/dementia studies. The review included quantitative, qualitative, mixed method, opinion articles, book chapters, integrative reviews, and literature/scoping reviews specific to executive function and occupational therapy published post-2000 in English.

Thirteen papers were ultimately included in the final review, eleven studies, and two book chapters. An adapted version of CASP checklists was used to formalise the process. For synthesising evidence, thematic analysis using ATLAS-ti software was employed, combined with reflexive journalling, to identify themes and patterns across the dataset.

The Results

The analysis generated four overarching themes that reveal significant challenges in how occupational therapists conceptualises and assesses executive function.

Theme 1: Inconsistency in the OT Literature on a Working Definition of Executive Function and Its Components

Of the 13 sources reviewed, six explicitly defined executive function. However, none shared a common definition, and all sourced their definitions from neuropsychological literature rather than occupational therapy-specific frameworks. A shared theme across four studies was conceptualisation of executive function as a group of interrelated cognitive components, with terms like “integrative cognitive skills” or “interplay” of components. In contrast, other studies characterised executive function as a cognitive process enabling behaviours like initiation, organisation, and planning.

The absence of a unified definition contributed to a proliferation of different executive function components. Among the 13 studies, a total of 42 executive function components were identified. Planning emerged as the most frequently cited component, appearing in eight studies, followed by problem-solving in six studies, organisation in five, initiation in five, inhibition in four, and judgement in four. Additionally, 28 components were idiosyncratic, being identified in only a single study.

Semantic overlaps were evident throughout. For example, “goal setting” was identified in three studies, with variations like “goal formulation” in two studies and “establishment of purposeful goals” in another. Self-monitoring was described both as a distinct component and in the context of verifying goal attainment. Planning was described both as a key component or as the ability to “determine effective strategies to facilitate goal attainment.”

An extended semantic analysis by the researcher grouped semantically similar components, reducing the list to 21 components. However, challenges remained in defining what constitutes an executive function component and whether these represent behaviours or cognitive processes.

Theme 2: Executive Function Conceptualised in Singular Complex Tasks in the OT Literature

The terms “complex” and “novel” are frequently used to describe occupations that activate executive function, appearing 83 and 38 times respectively across the 13 studies. Five studies discuss how executive function impairment compromises ability to manage complex activities. However, there’s no consensus on defining complex activities.

The most commonly cited complex tasks included managing finances in four studies, followed by shopping and work in three studies each. Other tasks mentioned included cooking, planning an event, washing, dressing, making coffee, and driving. Interestingly, some studies conceptualise executive function as responding not only to complex tasks but also novel situations requiring adaptation, whilst others present a more simplified view linking executive function primarily to specific tasks.

A consistent issue is the absence of a clear, unified occupational therapy definition of what constitutes a complex activity. Most references to complexity are drawn from neuropsychological literature rather than occupational science. Descriptions remain ambiguous—for example, defining complexity as tasks spanning a “long duration” or occurring in a “dynamic environment” without specifying what these terms mean.

Theme 3: There is Uncertainty on how Normal Executive Function performance is characterised in function

Research highlighted that clinicians felt there was a need for better characterisation of normal executive function performance to accurately interpret assessments. This reflects broader uncertainty regarding when executive function is activated in complex occupations. Clinicians often relied on subjective interpretations of efficient performance rather than using objective error-based assessments.

The lack of clarity surrounding what constitutes normal executive function performance is likely due to scarcity of literature on how executive function components manifest in real-world contexts, particularly when impairments are present. Without universal definition or agreement, interpretation becomes subjective.

In the thematic analysis, 21 executive function components were identified, yet 10 of these lack functional descriptions in the literature. Only two studies provide functional descriptions of any executive function component, whilst seven sources offer no insight into how components present in functional contexts. In the studies that do provide functional descriptions, most rely on neuropsychological literature typically from lab-based settings.

Two studies provided some insight into executive function-related functional performance, but both had significant limitations—small sample sizes, lack of control groups, or being single case studies, making generalisation difficult.

Practical Takeaways

For school-based occupational therapists, this review reveals some sobering truths about how our profession conceptualises and assesses executive function. The findings suggest we’re working with inconsistent definitions borrowed from neuropsychology, an overwhelming proliferation of component terms that overlap semantically, and assessment approaches that may not accurately capture the complexity of real-world occupational performance. I’m finding a very similar pattern in my own PhD work on self-regulation, another term with many differing conceptualisations in the literature.

This lack of clarity has practical implications for assessment. If we’re conceptualising executive function only as an interaction between components, we might identify presence or absence of executive dysfunction, but we cannot accurately conceptualise how it will impact occupational performance context.

This integrative review was conducted by a single researcher as part of a master’s thesis, which introduces certain limitations. The absence of a second researcher to verify thematic analysis may have resulted in some bias or overlooked studies, reducing internal validity. Despite efforts to retrieve all relevant literature, there’s always risk of missing pertinent studies, particularly those published in languages other than English. The exclusion of non-English literature may have limited breadth of perspectives.

This review challenges us to think more critically about how we conceptualise and assess executive function in our practice. It highlights the urgent need for clearer occupational therapy-specific definitions that align with occupational science, better frameworks for creating ecologically valid assessments, and greater focus on personally meaningful occupations rather than generic tasks. Without addressing these gaps, we risk assessments that don’t accurately reflect the real-world impact of executive dysfunction on our students’ occupational performance.

This feasibility study of 11 early childhood teachers implementing POET-T in mainstream classrooms. POET-T is a consultation-based occupational therapy intervention to enhance children’s executive control in educational settings. The programme is over a 6 week period and it showed high acceptance, fidelity, and implementation, and there was an improvement in children’s ability to manage daily routines.

This study of 40 adults with ADHD and 39 controls examined interactions between sensory processing patterns, ADHD symptoms, and executive function performance. Results showed executive function alterations in ADHD and pointed to a potential role of sensory processing in modulating executive function. However the interactions did not remain significant after correction for multiple testing, so the overall results were inconclusive.