Abstract
Importance:
Early-life stressors related to war have been linked to disruptions in children’s functional cognition, underscoring the need for occupational therapy practitioners to identify and address these difficulties.
Objective:
To compare functional cognition between cohorts of children before a global crisis and during a prolonged war and to test whether cohort differences vary by educational needs (typical vs. special).
Design:
Repeated cross-sectional design.
Setting:
Community-based data collection.
Participants:
Mothers of two cohorts of second- and third-grade children: Cohort 1 (precrisis, 2016–2017; n = 129) and Cohort 2 (during war, 2024–2025; n = 190).
Outcomes and Measures:
Functional cognition was assessed with the Behavior Rating Inventory of Executive Function (BRIEF) Parent Questionnaire. The BRIEF Global Executive Composite, Behavioral Regulation Index (BRI), and Metacognition Index (MI) were analyzed.
Results:
After controlling for gender, age, socioeconomic status, and educational needs, children in the Cohort 2 demonstrated significantly lower functional cognition than children in Cohort 1. Multivariate analysis with cohort and educational needs as independent variables and BRI and MI as dependent variables revealed that children exposed to war and those with special educational needs had functional cognition deficits. A significant interaction between cohort and educational needs indicated that exposure to early-life stressors disproportionately affected children with special educational needs.
Conclusions and Relevance:
War-related early-life stressors are associated with reduced functional cognition, particularly among children with special educational needs. The BRIEF Parent Questionnaire may serve as a practical screening measure to identify functional cognition challenges and guide pediatric occupational therapy interventions during and after crises.
Plain-Language Summary
Functional cognition supports children’s ability to meet the demands of their daily tasks in real-world environments, such as managing daily routines, playing, and participating in school tasks. This study examined how prolonged war-related stress affects children’s functional cognition. The study compared children assessed before a global crisis with children assessed during a prolonged war, all from low socioeconomic backgrounds. Mothers reported on their children’s everyday functional performance with the Behavior Rating Inventory of Executive Function Parent Questionnaire. The findings showed that children exposed to ongoing war-related stress demonstrated lower functional cognition than children assessed before the war. Children with special educational needs were affected most. These findings highlight the importance of identifying functional cognition difficulties during and after crises. For occupational therapy, the results support the use of functional cognition screening in school settings to guide timely, individualized interventions that promote children’s participation in daily activities and learning.
This study examined how prolonged war-related stress affects children’s functional cognition.
The ongoing war in Israel represents a significant environmental stressor that affects the entire population (Dopelt & Houminer-Klepar, 2024; Palgi et al., 2024). For young children, prolonged early-life stressors may cumulatively affect daily occupational performance and routines, with long-lasting consequences for cognitive and functional outcomes (Lampis et al., 2023; Pechtel & Pizzagalli, 2011). These adverse effects have been documented among typically developing children (Lloyd et al., 2023; Ren et al., 2022) and may be even more pronounced among children with special educational needs, who are more vulnerable to disruptions in structured and facilitating routines (Castle et al., 2024; Mete Yesil et al., 2022). In the study reported here, we used a repeated cross- sectional design to examine functional cognition among Israeli children living under ongoing war conditions.
The theoretical framework for this research is based on the Person–Environment–Occupation (PEO) Model of Human Occupation (Kielhofner, 2002), the ecological frame of reference for pediatric practice (O’Brien, 1993), and the Functional Cognition Framework (Maeir & Rotenberg-Shpigelman, 2024). The recently revised Functional Cognition Framework (Rotenberg & Maeir, in press) defines the PEO model as the set of conditions that enables optimal narratives and performances among adolescents and adults. The exclusion of young children from the revised model creates a knowledge gap regarding their occupational performance.
In the current study, the PEO components were explicitly operationalized as follows: Person refers to the children, categorized according to eligibility for special educational needs resources; environment refers to early-life stressors, specifically prolonged exposure to war and pandemic-related lockdowns; and occupation refers to functional cognition, a contemporary construct that replaces the term occupational performance, as measured with the Behavior Rating Inventory of Executive Function (BRIEF) Parent Questionnaire.
The PEO model, often presented in a linear sequence, is fundamentally a circular and dynamic framework in which the three components, person, environment, and occupation, can be viewed from multiple directions. The central focus of this study is the impact of early-life environmental stressors on functional cognition and the ways in which this relationship interacts with special educational needs as a person-level factor. For this reason, the literature review does not follow the traditional PEO order. Instead, it begins with the environmental context of early-life stressors, proceeds to their influence on functional cognition, and then examines person- related moderators. This structure reflects the conceptual priorities of the study while remaining grounded in the PEO model.
Operationalizing PEO Model Components Among Children Exposed to Stressors
Environment: Environmental Stressors in Early Life
The environment directly shapes children’s development, particularly when they experience crises at the family, community, national, or global level. From an ecological perspective, Bronfenbrenner (1975) emphasized that children are embedded within multiple interacting environmental systems, and disruptions at any of these levels can influence developmental outcomes. This ecological framing aligns with research on adverse childhood experiences (Felitti, 2009; Felitti et al., 1998) and with resilience and contextual models of trauma (Ungar, 2013), all of which highlight how environmental conditions become biologically embedded.
Within this broader ecological context, threat and deprivation represent two core dimensions of adverse environmental experience that have distinct effects on neural development (Sheridan et al., 2017; Sheridan & McLaughlin, 2014). Threat refers to atypical experiences involving actual or potential harm to one’s physical integrity, consistent with the definition of traumatic events in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013). Deprivation, in contrast, reflects the absence of expected cognitive or social inputs, such as those experienced by some children growing up in low-socioeconomic-status (SES) environments.
Children in Israel are currently experiencing environmental threats that began with the brutal October 7, 2023, attacks and have continued throughout the subsequent, ongoing Iron Swords War and Operation Roaring Lion, beginning in March 2026. At the onset of the war, most resources were directed toward securing safe shelters for families and individuals directly affected by the war and those who were in immediate danger. However, war also affects broader circles, and, to some extent, the entire Israeli population has been functioning in a prolonged state of survival. Studies show that direct and indirect wartime threats generate secondary trauma responses among individuals who do not directly witness combat or violence (Pfefferbaum et al., 2020). Perceived threats to personal safety can elicit significant psychological distress among children, who often lack the developmental tools or coping mechanisms to regulate acute stress responses (Powell et al., 2021; Smith & Pollak, 2020).
The cohort of children exposed to war at the time of the study had already experienced a different environmental stressor, namely the coronavirus disease 2019 (COVID-19) pandemic. The pandemic-imposed lockdowns disrupted routines for all children and exposed some children to illness, bereavement, and long-term health effects (Ghanamah et al., 2024; Hammerstein et al., 2021; Paryente & Gez-Langerman, 2023). Such adverse experiences were particularly challenging for children with special educational needs (for a comprehensive review, see Castle et al., 2024).
Low SES is an additional environmental stressor for young children. Executive functions and learning are sensitive to socioeconomic and other contextual factors (Blair, 2010; Deer et al., 2026; Doebel, 2020; Hollander et al., 2025; Munakata & Michaelson, 2021; Obradovic et al., 2019; Sheridan & McLaughlin, 2014). For example, lower maternal education, a commonly used indicator of SES, has been shown to affect the initial learning phase of children’s graphomotor and verbal skill acquisition (Hollander & Adi-Japha, 2021). These foundational learning abilities constitute core components of children’s functional cognition.
Occupation: Children’s Functional Cognition and Executive Function Behavior
Functional cognition is the application of cognitive processes in everyday activities and occupations. It emphasizes the observable performance of everyday activities that results from the dynamic interaction among a person’s abilities, the demands of the activity, and the task environment (Wesson et al., 2019). Among children, functional cognition refers to the cognitive skills required to accomplish the primary occupations of childhood, including basic activities of daily living, play, and productive occupations, such as preschool and school readiness skills (Dumas & Grajo, 2021). In general, the network of functional cognitive abilities enables individuals to engage effectively in real-world contexts (Barkley, 1997; Benson et al., 2013; Cortés Pascual et al., 2019; Diamond et al., 2007; Gioia et al., 2010; Hoskyn et al., 2017; Tzuriel, 2021). Functional cognition is linked to a wide range of distinct aspects of academic performance from preschool through adulthood (Cortés Pascual et al., 2019; Diamond, 2013; Koenen et al., 2003; McClelland et al., 2013). Functional cognition, therefore, incorporates executive functions, metacognition, and other cognitive skills within the context of the demands of the activity and environment (Giles et al., 2020).
The cognitive functions that support children’s primary occupations are core components of executive functions. Executive functions can be viewed as the underlying mechanisms required to effectively perform and participate in directed, complex, and nonroutine activities in various situations and environments (Josman & Meyer, 2019). Executive functions, including cognitive flexibility, inhibitory control, and self-regulation, support emotion–behavior–performance regulation. They also include metacognitive components such as working memory, initiation, planning, organization, sequencing, and task maintenance, which start to develop in infancy and early childhood (Best et al., 2009; Diamond et al., 2007).
Person: Children Entitled to Special Educational Needs Resources
Children who are entitled to special educational needs resources (defined in the Methods section) from governmental support services tend to demonstrate lower executive function behaviors compared with their peers, as documented in previous research (Bar-Ilan et al., 2018; Frisch et al., 2020; Rhodes-Sanders, 2020; Shin & Brunton, 2024).
Executive function deficits are common among children with attention disorders, learning disabilities, motor coordination difficulties, communication challenges, and emotional or psychological conditions. These children often experience frustration, low self-efficacy, and perceived incompetence, which manifest behaviorally as inflexibility, poor adaptability, and misalignment with environmental demands (Fogel et al., 2020). These deficits hinder performance across all occupational domains, including daily functioning, education, leisure, and social participation, and significantly impede developmental progress and integration into various life settings.
Environmental stressors in early life are strongly linked to executive functions within the framework of functional cognition and specifically to metacognitive and emotional–behavioral aspects (Bos et al., 2009; Sheridan & McLaughlin, 2014; Shin & Brunton, 2024; Zhou et al., 2022). However, little is known about the impact of war on young children’s functional cognition, and even less is known about its effect on children with special educational needs.
Measuring Functional Cognition and Executive Functions of Children With Special Educational Needs
Screening tools aim to capture a child’s functional cognition, identify risks, and guide occupational therapy interventions, which are critical during or after stressful events. During the current wars in Ukraine and Israel, several studies have examined children with special educational needs who were directly exposed to war-associated early-life stressors. These studies described treatment methods for panic attacks (Vovchenko, 2023) and the effect of war on children with autism spectrum disorder and psychological distress (Shaked-Ashkenazi et al., 2025). However, the impact on children who were only indirectly exposed to war remains largely unexplored. In addition, existing studies have not examined children’s participation in daily occupations in real-life contexts; cognitive skills have been assessed primarily in isolation (Dumas & Grajo, 2022; Giles et al., 2020).
Ylvisaker, as discussed in Gioia et al. (2010) and Ylvisaker and Feeney (1998), emphasizes that assessments should capture a child’s everyday functioning in the context of real-world demands and that interventions must improve real-world performance. His pragmatic model has shaped how researchers and clinicians measure executive functions as an ecological aspect of functional cognition and develop interventions for children with executive function deficits. Baum et al. (2023) helped establish the occupational therapy profession’s role in evaluating and treating deficits of functional cognition in adults. They suggest that functional cognition, along with fluid and crystallized cognitions, contribute hierarchically to a general cognitive factor and argue that functional cognition is a unique cognitive construct that is distinct from executive function. The extent to which executive function tests predict real-life functioning is unclear, and even less clear for children, underscoring the need for ecologically valid, performance-based assessments in occupational therapy (Baum et al., 2023; Josman & Meyer, 2019).
The BRIEF Parent Questionnaire (Gioia et al., 2000, 2010) applies an ecological approach to assessing children’s behavioral manifestations of executive control functions in real-world contexts. Maternal perspectives on children’s executive function behaviors are recognized as reliable and valid measures (Budman & Maeir, 2022; 2024; Frisch et al., 2020). Therefore, this questionnaire can serve as a validated instrument for measuring children’s functional cognition performance. The BRIEF Parent Questionnaire has demonstrated reliability and validity for school-age and preschool-age children (Bar-Ilan et al., 2018; Hendrickson & McCrimmon, 2019; Singh & Floyd, 2023).
Study Aim and Hypotheses
The purpose of this study was to measure functional cognition and its impact on the lives of young children from low-SES backgrounds who have been exposed to prolonged war-related stressors and to assess whether outcomes differ by educational need (typical vs. special). Specifically, we compared functional cognition performance outcomes, as measured with an informant- based tool (the BRIEF Parent Questionnaire), of two cohorts of second- and third-grade children in Israel. Cohort 1 was assessed in 2016–2017, before a global crisis (the COVID-19 pandemic); Cohort 2 was assessed in 2024–2025 and included children who were experiencing ongoing war at the time of the study and had been exposed to the COVID-19 pandemic when they were ages 3 to 5 yr. Both cohorts included children with typical educational needs and children with special educational needs. Using the BRIEF Parent Questionnaire as a functional cognition-specific screening tool to assess functional cognition performance in children exposed to environmental stressors is a novel approach.
The study was based on mothers’ perceptions of their children’s general executive function behavior (functional cognition performance). A shuffled PEO order was applied to the study hypotheses. First, the Environment component was centered by comparing a cohort of children exposed to cumulative early-life stressors with a cohort of children who were not. Second, the Occupation component was examined by testing which executive function–related behaviors differed between cohorts. Finally, the Person component examined whether the effects of stressors were modified by children’s eligibility for special educational needs resources.
We tested the following hypotheses. We hypothesized that children in Cohort 2 would demonstrate significantly greater deficits than children in Cohort 1 on the BRIEF Global Executive Composite, Behavioral Regulation Index, and Metacognition Index and that these differences would remain significant after controlling for key background variables, including age, gender, SES, and eligibility for special educational needs resources. We also hypothesized that differences between cohorts would vary across the eight BRIEF executive function scales. In addition, we hypothesized that in both cohorts children with special educational needs would score higher on the three BRIEF composite scores than children with typical educational needs. We further hypothesized an interplay between early-life stressors and educational type (special vs. typical), such that the negative impact of early-life stressors on functional cognition, measured by executive function behavior outcomes, would be greater for children with special educational needs. Accordingly, we analyzed a multivariate analysis of covariance (MANCOVA) with the Metacognition Index and Behavioral Regulation Index as dependent variables and an analysis of covariance (ANCOVA) for the Global Executive Composite.
Method
Study Design
We used a repeated cross-sectional design to compare two independent, age-matched cohorts from 2016–2017 and 2024–2025. This was completed to detect population-level changes in functional cognition associated with the early-life stressors of COVID-19 lockdowns and exposure to an ongoing war. Repeated cross-sectional studies are an established method for documenting changes in prevalence and associations across time because they allow direct comparison of cohorts sampled from the same target population and measured with identical instruments while controlling for measured covariates (Pan, 2021). This design enabled us to compare two cohorts of children of similar ages sampled 8 yr apart and to isolate the impact of exposure to prolonged stressors from age-related developmental progression. The study provides robust evidence of shifts in group-level functioning that can justify and guide the development of targeted screening and intervention strategies (Bann et al., 2022; Levin, 2006; Pérez-Guerrero et al., 2024).
Data were collected from mothers of children ages 7.5 to 9.5 yr (second and third grades). Cohort 1 (precrisis; 2016–2017) included 59 children with typical educational needs and 70 children entitled to various special educational needs resources, including remedial, emotional, occupational therapy, speech therapy, and small classroom settings. Data were collected from 129 mothers. Cohort 2 (during and postcrisis; 2024–2025) included 139 children with typical educational needs and 51 children entitled to special educational needs. Data were collected from 190 mothers. (See Table 1 for full cohort characteristics.)
Characteristics of Study Participants (N = 319)
Inclusion and Exclusion Criteria
The study included children in second or early third grade (considered the oldest age in early education), living in Israel, from Orthodox Jewish communities, from a middle- or low-SES city or school, as classified by national rankings. Children from other religious or cultural backgrounds were excluded from the study to maintain group homogeneity.
To be included in the special educational needs group, a child had to be entitled to government special educational needs funding and either enrolled in a special educational classroom or learning in a mainstream classroom with extra special educational support. Children studying in special education schools were excluded from this study.
According to Israeli law, for a child to be entitled to special educational needs resources, parents are required to provide diagnostic documentation from a registered physician, a neurologist, psychiatrist, clinical psychologist, or neuropsychologist or documentation of a valid learning disability diagnosis from another registered professional. The governmental ring system for children with special educational needs support considers the child’s type of disability and level of functioning. Accordingly, classification was based solely on eligibility versus noneligibility for educational support within educational frameworks. Therefore, children in Cohorts 1 and 2 were defined as having special educational needs if they required general or specific assistance in mainstream schools.
Recruitment and Research Approval
The work with Cohort 1 was approved by the Ethics Committee of the Chief Scientist of Israel, Ministry of Education (7883/054 10.32), and the Ethical Committee of Bar-Ilan University. The work with Cohort 2 was approved by the Ethical Committee of the Michlalah Jerusalem (05.02.24/023) and the Ethics Committee of the Chief Scientist of the Israel, Ministry of Education (14082). For Cohort 1, the principal investigator, Chagit Hollander, collected the data from schools with a low-SES background in a city in Israel. For Cohort 2, Hollander returned to the same schools in the same city, accompanied by early childhood education students who assisted in collecting the data. The sample was expanded to additional cities with similar cultural backgrounds by occupational therapists from the Ministry of Education Regional Municipal Support Centers (known as MATYA). Therefore, in Cohort 2, additional mothers of children from other schools with a low-SES background were included. The researchers provided the participants with an explanation of the study’s aims and procedure. All participants signed a standard Ministry of Education consent form.
Study Setting
Data were collected in the community, directly from the mothers. Researchers contacted school principals, presented the study, and asked for their consent to contact and recruit mothers of children in second and third grades. For Cohort 1, Hollander contacted the mothers by telephone. Mothers completed the questionnaires while seated in a quiet room at their child’s school, using either a printed or an electronic form on the researchers’ computer. For Cohort 2, mothers had the option to complete the questionnaires online or at their child’s school, similar to Cohort 1.
Measures
The SES questionnaire is a seven-factor index based on Hollingshead (1975) and Duncan and Magnuson (2003), adapted for Israeli culture by Korat et al. (2007, 2008; α = .90). It assesses parents’ education, occupation and professional qualifications, number of children, number of rooms in the home, and family income. Occupation and qualifications are rated from 1 (unskilled workers and menial laborers) to 5 (upper-level executives and professionals). Respondents also rank family income relative to the national average (1 = much below, 5 = much above). To calculate an SES value, data were transformed to a 5-point scale (1 = low, 5 = high), and SES z scores were averaged to adjust for differences in the scales and distributions across variables (Korat et al., 2007, 2008). Because of some participants’ ultra-Orthodox cultural background, where many fathers’ foremost role is studying the Torah, fathers’ education and profession were excluded to avoid bias.
The BRIEF Parent Questionnaire (Gioia et al., 2000) is an 86-item ecological rating scale for children ages 5 to 18, completed by a parent. The Hebrew version of the BRIEF (Gioia et al., 2000/2007; Linder et al., 2010) was used and coded through the PTech online research platform, which was developed by Psychtech in Israel. The BRIEF consists of eight scales, two indexes, and a Global Executive Composite. Raw scale scores are converted to T scores, with a score of ≥65 indicating clinical impairment and a score of 55 to 65 indicating a risk of clinical impairment. The BRIEF shows high reliability (α = .80–.98; test–retest r = .82). In the current study, T scores were used in all analyses.
Statistical Analysis
Descriptive statistics and distributional analyses were performed for all study variables. Participant characteristics were compared between cohorts using χ2 tests for categorical variables and independent-samples t tests for continuous variables. To address the study hypotheses, we first used independent-samples t tests to compare scores on the BRIEF scales between cohorts. A MANCOVA was then conducted with the two BRIEF indexes, the Behavioral Regulation Index and the Metacognition Index, as dependent variables; cohort and special educational needs as independent variables; and chronological age (months), gender, and standardized SES as covariates. Before conducting the MANCOVA, we tested and confirmed that all the statistical assumptions were met. In addition, we conducted a separate ANCOVA on the Global Executive Composite because it is commonly reported in BRIEF research and provides a valuable measure for comparison with published studies and is thereby considered a global functional cognition score. Effect sizes were reported using η2 p to indicate the proportion of variance in functional cognition explained by the independent variable, after accounting for covariates. All analyses were performed using IBM SPSS Statistics (Version 29). Statistical significance was defined as p < .05.
Results
Participants
The study included 319 participants: n = 129 in Cohort 1 (precrisis, 2016–2017) and n = 190 in Cohort 2 (during the Iron Swords War, 2024–2025). Sample characteristics are presented in Table 1. There were no statistically significant differences between cohorts in mean age or SES. However, the gender distribution and proportion of children with special educational needs differed significantly between the cohorts, with a higher proportion of boys and children with special educational needs in Cohort 1 compared with Cohort 2.
Although a cross-sectional design does not establish causality, it can identify patterns and support future researchers in generating hypotheses and developing more robust study designs. Using this design, we were able to determine associations between exposure to early-life stressors and functional cognition at the population level. Moreover, examining culturally homogeneous cohorts within a cross-sectional design minimized potential confounders and enabled identification of cohort-related effects.
Comparison of Executive Function Domains Between Cohorts
Independent-samples t tests indicated significant differences between cohorts across several BRIEF- assessed executive function domains. Table 2 summarizes mean scores for all BRIEF index composite and scale scores. Scores on the Behavioral Regulation Index, Metacognition Index, and the Global Executive Composite were significantly higher in Cohort 2, reflecting greater executive dysfunction compared with Cohort 1.
Comparison of BRIEF Composite Indexes and Scales Scores Between Cohorts (N = 319)
Note. BRIEF = Behavior Rating Inventory of Executive Function.
aBehavioral Regulation + Metacognition.
At the scale level, children in Cohort 2 scored significantly higher on six of the eight BRIEF scales. Scores on the Working Memory scale were similar across the two cohorts, whereas scores on the Plan/ Organize scale were slightly higher in Cohort 2, approaching significance and in the same direction. Because these initial comparisons describe cohort differences, we next evaluated cohort and educational needs effects while adjusting for demographic covariates.
Effect of Educational Needs and Cohort on BRIEF Indexes
We conducted a MANCOVA to examine cohort and special educational needs as predictors of executive function behaviors while accounting for demographic covariates. Significant multivariate effects emerged for cohort, Wilks’s λ = .935, F(2, 311) = 10.746, p < .001, η2 p = .065, and special educational needs, Wilks’s λ = .949, F(2, 311) = 8.364, p < .001, η2 p = .051, along with a significant Cohort × Educational Needs interaction, Wilks’s λ = .966, F(2, 311) = 5.495, p = .005, η2 p = .034. These results reflect small to medium reliable multivariate effects. Adjusted mean T scores for the BRIEF indexes are shown in Figure 1.
Effect of early-life stressors on BRIEF scores of children with typical and special educational needs
Follow-up univariate ANCOVAs are presented in Table 3. Children in Cohort 2 scored significantly higher than children in Cohort 1 on both the Behavioral Regulation Index and the Metacognition Index, and children with special educational needs scored significantly higher on both indexes than children with typical educational needs. The Cohort × Educational Needs interaction was also significant for each BRIEF index. This interaction, observed at both the multivariate and the univariate levels, indicates that cohort differences were disproportionately larger among children with special educational needs after controlling for sociodemographic characteristics.
Effect of Educational Needs and Cohort on BRIEF Indexes and Composite
Note. The model included the covariates age (in months), gender, and standardized socioeconomic status. BRI = Behavioral Regulation Index; GEC = Global Executive Composite (the Functional Cognition Score); MI = Metacognition Index.
In addition, we conducted a separate ANCOVA on the Global Executive Composite, which we considered a global functional cognition score. Although this composite is derived from the two indexes, we report it here as a summary composite score of the BRIEF (Table 3). Among the three covariates tested, gender and age did not have a significant effect on the BRIEF indexes and composite. Standardized SES had a significant impact on the Global Executive Composite, F(1, 312) = 4.5, p = .036, η2 p = .014, and the Metacognition Index, F(1, 312) = 4.0, p = .044, η2 p = .013, but not on the Behavioral Regulation Index. Taken together, these findings indicate consistent cohort differences in BRIEF outcomes, including a Cohort × Educational Needs interaction, which we address next.
Discussion
The functional cognition of young schoolchildren from lower-SES backgrounds (deprivation) who were exposed to war-related risks (threats) and prolonged early-life stressors was compared with that of young schoolchildren from similar SES backgrounds before the occurrence of a global crisis.
Findings, as measured with the BRIEF, revealed significant differences between the cohorts after controlling for background variables, indicating lower functional cognition abilities in Cohort 2 of the current study. By age 9, children from Cohort 2 had been exposed to cumulative environmental stressors and demonstrated lower scores across all indexes and nearly all scales. These findings strengthen the study’s assumptions and are consistent with the conclusions of previous studies. First, early childhood is considered a critical period for the development of core executive functions (Haimov et al., 2022; Lampis et al., 2023). Second, early-life stressors are strongly associated with executive functions (Shin & Brunton, 2024; Zhou et al., 2022). Global threats, when combined with deprivation, have been shown to exert a substantial influence on emotional and behavioral outcomes (for a comprehensive review, see Wade et al., 2022), such as depression and reduced quality of life in adolescents (Lass-Hennemann et al., 2024). However, this represents a much broader discussion that is beyond the scope of the current study.
Furthermore, the study’s findings indicate that children with special educational needs from lower-SES backgrounds are particularly susceptible to environmental challenges (Mete Yesil et al., 2022). In the current study, children with special educational needs demonstrated lower executive function behaviors, as measured with the BRIEF, compared with children with typical educational needs, in line with the existing literature (Bar-Ilan et al., 2018; Frisch et al., 2020). Notably, the results revealed a significant interaction between cohort and educational type (special vs. typical), indicating that cumulative stressors affect children with special educational needs to the greatest extent.
Children’s functional cognition performance is influenced by their baseline functioning, and there were differences between children with special educational needs and those with typical educational needs before, during, and postcrisis. The present study is an observational study that describes the situation, not a causal study, and thus cannot explain these differences; causal inference requires a different study design. Despite these findings, empirical knowledge regarding the impact of war on the functional cognition of young children with special educational needs remains limited and warrants further investigation. Additional appropriate causal or longitudinal designs are recommended to examine the long-term impact of war-related crises on functional cognition.
As expected, differences were not observed across all executive function scales of the BRIEF. Cohort 2 demonstrated higher mean scores than Cohort 1 on most BRIEF scales, except for the Working Memory and Plan/Organize scales, which showed comparable scores across cohorts. The unique nature of working memory is thought to involve more core components and greater cognitive complexity than other executive function behaviors assessed with the BRIEF. Current research provides compelling evidence that working memory functions as a flexible mental workspace, enabling the temporary storage of information for immediate task completion as well as the manipulation and maintenance of information during complex cognitive operations (Tzuriel et al., 2026). Some researchers further suggest that working memory may be more appropriately conceptualized as a fluid rather than a functional cognitive process (Baum et al., 2023).
The present findings suggest that children’s working memory behaviors in daily routines, as measured before, during, and postcrisis, do not necessarily follow the same patterns as other executive functions, possibly because environmental challenges may foster the development of certain abilities rather than uniformly impair cognitive functioning (Young et al., 2018). The apparent “resilience” of the Plan/Organize and Working Memory scale components to stressful events represents an important finding; however, it should be interpreted with caution and warrants further investigation. Increasing awareness of the effects of environmental stressors on children’s occupational performance components, through direct observation of functional behavior, may support the development of targeted professional intervention.
Readers should note the limitations of this study. The sample was drawn from a homogeneous population of Orthodox Jewish Israeli communities. Therefore, the generalizability of our findings requires further investigation. Future studies that sample children from other religious groups and cultural backgrounds may provide critical insights into tailoring interventions for those populations (Golos et al., 2021). Integration of the findings in different populations could be used to draw more general conclusions.
The second limitation of the study is the use of the BRIEF Parent Questionnaire as the sole assessment instrument. Although the BRIEF is widely used and well validated, reliance on a single measure introduces the risk of informant bias and limits the scope of cognitive functioning assessed. In future research, it is recommended to incorporate, in addition to the BRIEF Parent Questionnaire, direct assessment of the children themselves. This approach would strengthen the findings of the current study by providing additional evidence that children who are eligible for special education resources indeed experience difficulties in functional cognition within the domain of learning.
It is also important to note that the current study used BRIEF rather than the revised version (BRIEF–2). Although the BRIEF is relatively complicated and time consuming for mothers to complete, the BRIEF–2 has not yet been translated into Hebrew or validated. In future studies, other validated questionnaires for occupational routine may be considered, such as the Executive Function and Occupational Routines Scale (Frisch & Rosenblum, 2014) and the Childhood Executive Function Inventory (CHEXI; Catale et al., 2015), which are shorter and may reduce respondent burden.
Implications for Occupational Therapy Practice
Measuring functional cognition is a priority for pediatric occupational therapists, and its assessment should be incorporated into a routine practice for children in school settings. The BRIEF has recently been used to assess functional cognition of adolescents and adults (Rotenberg & Maeir, in press), as well as of critically ill children (Dumas & Grajo, 2021). One of the key novelties of the current study lies in the application of this assessment approach to young schoolchildren exposed to war-related experiences and early-life stressors.
Many children are exposed to early-life stressors that may occur at multiple systemic levels (Bronfenbrenner, 1975), including within the home and the community and at the national and global levels, such as during the COVID-19 pandemic and armed conflicts. Armed conflicts, in particular, can exert wide-ranging and long-lasting effects that extend beyond those directly involved in combat, affecting children and families far from the front lines. Given the central role occupational therapists play in supporting young children’s daily functioning, especially in the context of extraordinary stressors such as war, it is essential to recognize this need and actively provide intentional, proactive support.
This study has the following implications for occupational therapy: ▪ Occupational therapists in school-based settings should enhance their awareness and attend more closely to children’s functional cognition as reflected in their primary roles of play, learning, and independence. ▪ Practitioners should examine children’s capacity to participate functionally in essential occupations by considering the totality of their abilities in context (Dumas & Grajo, 2021) rather than assessing cognitive skills in isolation (Giles et al., 2020), especially during times of crisis. ▪ Practitioners should select and use appropriate school-based assessment tools, such as the BRIEF, to support an evaluation process that incorporates valid and reliable measures to define group intervention goals, especially those aimed at improving functional cognition (Josman and Meyer, 2019), given the growing and critical need to assess functional cognition. ▪ Occupational therapy practitioners should strengthen the researcher–practitioner partnership and create boundary-crossing roles, ensuring that (1) the most pressing needs of young children in the early school years are systematically studied and (2) that evidence-based approaches, such as the multicontext approach used with children and adolescents with learning difficulties (Cermak & Toglia, 2018; Toglia & Foster, 2021), are effectively translated into school and home contexts to support children’s lives (Landi, 2023).
Conclusion
This study provides timely evidence that young children exposed to cumulative environmental stressors, such as ongoing war and COVID-19 lockdowns, exhibit lower functional cognition than children not exposed to similar stressors. Children with special educational needs are at greater risk for reduced functional cognition and are disproportionately affected by cumulative environmental stressors. The findings underscore the need for evidence-based interventions tailored to children’s individual needs, with particular attention to children with special educational needs from low-SES backgrounds. Such interventions are essential to help children regain, maintain, and ideally improve their ability to perform and participate in everyday activities at home and in school, both during and after periods of crisis.
Footnotes
Acknowledgments
We express our gratitude to the mothers of the children who participated in this study and generously contributed their valuable time to support this research. We also extend our appreciation to the students from the Early Childhood Education Department at Michlalah Jerusalem, as well as to the occupational therapists at the Ministry of Education, who assisted in data collection during the Iron Swords War.
We gratefully acknowledge the financial support provided for this study by the National Institute for Psychobiology in Israel, founded by The Charles E. Smith Family (Award No. 15-25-26), and the Research Authority of Gordon College of Education.