Pacific Northwest Neuropsychological Society, May 12, 2003

Tedd Judd, PhD, ABPP-CN

Diplomate in Clinical Neuropsychology

851 Coho Way, Ste. 301

Bellingham, WA 98225, USA

(360) 734-7310 Ext. 3125

Fax: (360) 647 8336

Learning Objectives:

  1. Participants will be able to identify a 3-pronged approach to testing executive functions, and will be able to give examples of tests for each prong.
  2. Participants will be familiar with the 9 subtests of the Delis-Kaplan Executive Function System and their advantages and limitations.
  3. Participants will be able to identify the advantages and limitations of using adaptive behavior rating scales in the evaluation of executive functions, and will be familiar with examples of these.
Agenda

INTRODUCTION

Assumptions of executive function assessment: intact component skills, “It takes frontal lobes to evaluate frontal lobes (Stuss).”

Challenges and limitations of executive function assessment: inherently low reliability; non-repeatability for many problem-solving tasks; cultural/educational limitations; inconsistency of the problem; inherent structure of the testing situation.

THE THREE-PRONGED APPROACH

Cognitive, emotional/personality, adaptive

THE TESTS

D-KEFS

ABAS

CASL

FrSBe

BRIEF

BDS

RFFT

NEPSY

WJCS-3

TTT

BADS

TOL

NBAP

CASE ILLUSTRATIONS (time permitting)

The D-KEFS consists of 9 independent tests designed to measure quantitative and qualitative aspects of executive functions. Many of the tests are improved versions of older tests, with better standardization, advanced conditions, quantitative scoring of error patterns, and a larger and more representative norm group. Norms are by age, from 8 to 89. Education norms are in development.

THE TESTS
Delis-Kaplan Executive Function System (Psych Corp, $436)

The Trailmaking Test has 5 subtests for probing component skills: Visual Scanning, Number Sequencing, Letter Sequencing, Number-Letter Switching, and Motor Speed.

The Verbal Fluency Test has one minute fluency for FAS, Animals, Boys Names, and Switching between Fruits and Furniture.

Design Fluency involves drawing as many different designs as possible in one minute using 4 straight lines to connect 5 dots, along with other rule constraints.

The Color-Word Interference Test is a version of the Stroop test, with the Color, Word, and Interference conditions similar to the Golden version. In the Interference/Switching condition the person must perform the Interference task, except that some words have a box drawn around them and must be read.

The Sorting Test consists of 6 cardboard tokens with a word written on each. The person must sort these into two groups of 3 items according to some principle, explain the principle, then sort them a different way, for as many different sorts as possible (8 are possible). There is also a category recognition condition. This test measures abstract reasoning and mental flexibility.

The Twenty Questions Test is like the familiar game of the same name and measures abstraction, strategy, and mental flexibility.

The Word Context Test involves inferring what a nonsense word means based on progressive clues. It measures the ability to infer and integrate information.

The Tower Test involves moving 5 concentric rings among 3 different pegs according to rules. It measures planning abilities.

The Proverb Test involves interpreting common and uncommon proverbs and measures the ability to think abstractly. It includes a recognition condition.

Find the “context” for the words of the “Word Context Test” from the D-KEFS:

EXTRA CREDIT:

Sev, prifa, enton, delz, vern, nelzen, gesh, luri, krame, kapla, grot.

The ABAS II is a rating scale completed by the person being evaluated and/or an informant (usually a family member). Each item is rated on a 4-point scale: Is Not Able, Never When Needed, Sometimes When Needed, Always When Needed.

Adaptive Behavior Assessment System II (Psych Corp, $138)

The ABAS covers the 10 adaptive skill areas of the DSM-IV and AAMRD definitions of mental retardation with 20-27 items/area. These are below (with examples of an easy and hard item). There is a General Adaptive Composite score. Norms by age from birth to 89.

Review: Can be used as before and after brain illness. No validity scales; potentially susceptible to response bias. Low ceiling. Cultural values and limitations.

Communication:

States his/her own telephone number. Talks about realistic future educational or career goals.

Community Use:

Finds the restrooms in public places. Uses the local library to check out books, use reference materials, or for other purposes.

Functional Academics:

States the days of the week in order. Budgets money to cover expenses for at least one week.

Home Living:

Operates a microwave oven. Cleans bathroom with proper cleaning supplies.

Health and Safety:

Shows caution around hot or dangerous items. Plans meals in order to get necessary nutrition.

Leisure:

Follows the rules in games and other fun activities. Reserves tickets in advance for activities, for example, concerts or sports events.

Self-Care:

Puts shoes on correct feet. Gets hair cut.

Self-Direction:

Goes out alone in daytime. Calls family or others when late.

Social:

Has one or more friends. Says when he/she feels happy, sad, scared, or angry.

Work:

Attends work regularly. Shows positive attitude towards job.

Comprehensive Assessment of Spoken Language (American Guidance Service, $300)

The CASL is a new measure designed to look not only at how the person understands and expresses language but also how they process linguistic information and use language in the real world. The latter includes measures of how the person can gain meaning from the context rather than from the words themselves, how they interpret ambiguous or nonliteral language, and how they apply language in real situations. Norms for ages 3-21.

SUPRALINGUISTIC

Nonliteral Language

She runs like lightning. What does that mean?

When Alex tried out for the varsity basketball team, the coach told him, “Son, you need a little more rain.” What did the coach mean?

Meaning from Context

When we saw Joe’s riant face, we knew he was enjoying the clown. Explain what riant means.

By means of illation, the detective was able to arrive at the method of the crime after merely examining the room where it took place. Explain what illation means.

Inference

Mother called to four-year-old Sondra, “Be sure to bring your bathing suit. And don’t forget your shovel and bucket.” Where were they going?

After examining the figures on annual car purchases, the American automobile industry asked for a quota to be placed on foreign car imports. Why?

Ambiguous Sentences

Tell two different meanings for these sentences:

It is light.

Janet offered to drive her many times.

Pragmatic Judgment

Karen studied very hard last night for the big test she’s taking today. Karen’s mom says “good-bye” to her as she leaves for school. What else can her mom say to her?

The new teacher says to the first grade class, “I will greatly appreciate it if you remain in the seated position while I absent myself.” The children do no obey. Why?

Frontal Systems Behavior Scale (PAR, $165)

The FrSBe measures Apathy, Disinhibition, and Executive Dysfunction through self and informant ratings before the injury and currently. 46 items, 5-point scale from almost never to almost always. Age 18-95. Norms are by age, gender, rater, and education.

Apathy:

Sits around doing nothing. Starts things but fails to finish them, “peters out.”

Disinhibition:

Talks out of turn, interrupts others in conversation. Laughs or cries too easily.

Executive Dysfunction:

Is disorganized. Cannot do two things at once (for example, talk and prepare a meal).

Brief Rating Inventory of Executive Function (Psych Corp, $164)

The BRIEF is a series of scales that can be completed by parents, teachers, or students themselves to rate the child’s behavior in areas of self-control and metacognition. Designed for ADHD. Ages 5-18. Norms are by age and by who does the rating. A brief BRIEF is in development.

Inhibit:

Gets out of seat at the wrong times. Gets in trouble if not supervised by an adult.

Shift:

Becomes upset with new situations. Tries the same approach to a problem over and over even when it doesn’t work.

Emotional Control:

Overreacts to small problems. Has explosive, angry outbursts.

Initiate:

Is not a self-starter. Needs to be told to begin a task even when willing.

Working Memory:

When given three things to do, remembers only the first or last. Is easily distracted by noises, activity, sights, etc.

Plan/Organize:

Has good ideas but cannot get them on paper. Forgets to hand in homework even when completed.

Organization of Materials:

Leaves playroom a mess. Cannot find things in room or school desk.

Monitor:

Does not check work for mistakes. Makes careless errors.

INDEXES

Behavioral Regulation – Inhibit, Shift, Emotional Control

Metacognition – Initiate, Working Memory, Plan/Organize, Organization of Materials, Monitor

Global Executive Composite

Behavioral Dyscontrol Scale (experimental, see me)

On the BDS the person is asked to learn and carry out a number of motor sequences and tasks, and also to count aloud alternating with saying the alphabet. The highest possible score is 19. The BDS is still under research. The BDS is sensitive to difficulties in response organization and inhibition, and is a good predictor of ability to carry out common, everyday activities. Designed for the elderly. Low ceiling. Norms are by age.

Ruff Figural Fluency Test (Psych Corp, $103)

On the RFFT the person must draw as many different designs as possible in one minute within the constraints of set rules. Five trials are given. The test requires the generation of new, non-verbal ideas and the formulation and use of strategies. It is normed by age and education. Designed to be non-verbal analog of verbal fluency. Shown to be sensitive to right frontal injury.

NEPSY, a Developmental Neuropsychological Assessment (Psych Corp, $598; PAR, $639)

The NEPSY is a neuropsychological battery for ages 8-13 and is normed by age.

Attention / Executive Functions Domain: The Tower Test measures the executive functions of planning, monitoring, self-regulation, and problem solving by asking the child to use a certain number of moves to re-arrange colored balls in a set pattern. Design Fluency involves rapidly drawing unique designs following general rules. The Statue subtest measures persistence, distractibility, and impulse control, and involves standing perfectly still with eyes closed for 75 seconds in spite of distracting noises. Knock and Tap measures self-regulation and involves responding to the examiner’s movements in a rule-bound, non-imitative manner.

OTHER NEW TESTS (I don’t have direct knowledge of these)

Woodcock-Johnson Cognitive Scales – III

The new scales have improved executive function subtests.

Tinkertoy Test (Toys R Us, see Lezak)

The person is given a set of Tinkertoys and is instructed to build something. The result is rated by number of pieces, mobility, name, 3-dimensionality, and free-standing. Measures initiation, creativity, and planning. Correlated with independent adaptive functioning.

Behavioural Assessment of the Dysexecutive Syndrome (Thames Valley, £275; Psych Corp $655)

British test with cognitive tasks involving planning, flexibility, time judgment, and multitasking. Also a rating questionnaire. Norms age 16-87.

Temporal Judgment – estimation of how long it takes to complete various events (e.g., routine dental appointment).

Rule Shift Cards – like Wisconsin Cart Sort

Action Program – practical problem solving in extracting a cork from a tube.

Key Search – How would you search a field to find lost keys?

Zoo Map – visit six locations following certain rules.

Modified Six Elements – Schedule time for working on six tasks in 10 minutes.

Dysexecutive Questionnaire – 20 items, self and informant, emotional or personality changes, motivational changes, behavioural changes, cognitive changes.

Tower of London (Psych Corp, $259)

Three pegs of different heights, 3 balls of different colors, move from one configuration to another according to rules and a certain number of moves. A measure of planning. Norms age 7-60+.

Neuropsychology Behavior and Affect Profile (PAR, $120)

Before and Now rating by self and other. 106 items. Choices of Agree and Disagree. Age 15 and older. Scales of Indifference, Inappropriateness, Pragnosis (communication pragmatics deficit), Depression, and Mania. Compares to dementia, stroke, traumatic brain injury, and elderly control groups, but no comprehensive norms available.