The appropriateness of the Tower of LondonDX to measure executive skills in children during neuropsychological assessment: a rapid review

Abstract

The aim of the current study was to conduct a rapid review focused on the existing literature to explore the appropriateness of the TOLDX as a measure of executive functioning in children. The research findings of existing scientific literature on the use of the TOLDX as a neuropsychological assessment of executive skills in children were synthesised. A total of four articles (Culbertson & Zillmer, 1998; Donders & Larsen, 2012; Marton, 2008; Solanto et al., 2007) were identified as complying with all the search terms and the eligibility criteria of this study. Four main themes were identified from the analysis of these articles, namely: (1) evidence that the TOLDX has diagnostic/clinical utility; (2) evidence that the TOLDX is a valid and reliable measure in children; (3) evidence that the TOLDX is able to differentiate among age levels; and (4) limitations of the TOLDX. The picture emerged of the TOLDX as a valid and reliable measure of executive functioning in children and appears to have important implications for clinical and diagnostic utility. This was made clear through the consistently superior scores of normally developing children across all scoring variables on the TOLDX contrasted with clinical children. This indicated that the TOLDX demonstrated acceptable and appropriate classification accuracy and clinical utility, particularly when used in conjunction with other neuropsychological measures to optimise diagnostic accuracy. The clinical groups appeared to perform more poorly in observational measures of motor impulsivity while performing cognitive tasks, as well as in visual-spatial working memory when engaged in planning. By assessing executive concept formation, executive problem-solving, and prospective memory, this measure provides supplementary information on individual functioning. The TOLDX appears to be a valid and reliable measure of executive functioning, specifically executive planning and problem-solving abilities in children. The TOLDX appears to offer reliable and valid diagnostic information. The TOLDX appears to be sensitive and capable of differentiating among different age groups in children. The executive planning performance of older children is characterised by greater accuracy, efficiency, and speed of performance. The TOLDX implicates greater executive efficiency as a primary determinant of improved performance on the task Some important limitations of the TOLDX were brought to light. To date, no reliability studies with normal children could be located, and consequently comparable levels of stability on the TOLDX could not be determined. The samples used did not covary for comorbidities, they were not demographically diverse, the number of female participants was too few to compute gender effects, and samples sizes were relatively small. This study presents the findings and thus the implications thereof regarding the necessity for standardisation and normative studies to be conducted in other countries such as South Africa, where the level and quality of education among children vary greatly. The findings highlight the gaps in current research. This is of particular importance and use for all psychologists who engage with neuropsychological practice in South Africa, as well as for teachers and parents who have to make adjustments for the needs of these children during learner support. Some of the key limitations of the present study were that only four articles complied with all the search terms and eligibility criteria. Generalising the findings of this study is therefore not possible. Also, since no studies done in South Africa could be included, it is difficult to form a clear picture of the appropriateness of the TOLDX in the South African context and to make appropriate recommendations in this regard. This study was based on studies of relatively small sample size. As such, it does not represent all data and literature on executive functioning measures and assessments.