ICFA: A new IADL-based assessment of cognitive flexibility for individuals with schizophrenia

Cognitive flexibility deficits contribute substantially to functional disability in individuals with schizophrenia, yet existing neuropsychological measures remain limited in clinical utility, as they lack ecological connection and rarely distinguish spontaneous (sCF) from reactive (rCF) cognitive flexibility. To address this gap, this study developed and validated the Instrumental Activities of Daily Living-context-based Cognitive Flexibility Assessment (ICFA), a novel instrument designed to separately and simultaneously assess both rCF and sCF in real-life contexts.

The ICFA was developed based on literature reviews, then content-validated via the Delphi method. Reliability and validity were subsequently examined in a clinical sample of individuals with schizophrenia (n = 112).

The ICFA demonstrated good internal consistencies (Cronbach's α = 0.83 for sCF and 0.86 for rCF) and moderate to good test-retest reliabilities (ICC_2,1 = 0.73 for sCF and 0.80 for rCF). Adequate criterion, convergent, discriminant, and ecological validities were also supported by moderate to strong correlations between ICFA scores and conceptually relevant references (ρ = 0.29∼0.78). Furthermore, known-groups validity was established through significantly large differences (Cohen's d = 0.81-1.34, p < 0.001) between propensity score-matched samples of individuals with schizophrenia and healthy controls (n = 54 per group).

Our results suggest that ICFA offers a psychometrically sound and ecologically grounded approach to assessing cognitive flexibility in schizophrenia, with direct relevance to real-world functional outcomes. Its ability to distinguish sCF from rCF makes it as an encouraging tool for guiding intervention planning and monitoring recovery.