Executive Functions: From
Assessment to Intervention
Presenters: Erin K. Avirett
Jordana E. Mortimer
Contributors: Denise E. Maricle, Ph.D.
OVERVIEW OF EXECUTIVE
FUNCTIONING
What is Executive Functioning (EF)?
•
Globally, EF refers to the array of cognitive abilities
that contribute to make the brain a unique,
organized, sophisticated structure.
•
“The set of processes needed for engaging in
independent, purposeful, goal-directed behaviors.”
(Lezak, Howieson, & Loring, 2004)
•
However, there is no mutually agreed upon definition
or list of EFs, due to much debate regarding their
Popular Viewpoints
•
Some equate EF to the intelligence’s “
g.
”
–
“Conductor of an orchestra,” “Executive of a Company,”
or “Football Coach” view.
Popular Viewpoints, cont.
EF
EF
EF
EF
EF
EF
•Some view EF as a set of supervisory skills,
Popular Viewpoints, cont
•
Others view EF as an umbrella term for a set
complex cognitive skills.
Commonly accepted components
•
response inhibition
•
cognitive flexibility
•
setting and achieving goals
•
task initiation
•
planning, organization, and time management
•
abstract reasoning/ concept formation
•
working memory
•
attentional control
•
controlling emotions and social behaviors
Executive Dysfunction (EDF)
•
EDF may materialize from congenital
abnormalities/ disorders, traumatic/acquired
brain injury, brain lesions, developmental delays,
or unknown etiology.
•
Much of what science has learned about
executive functions is through what is known of
executive dysfunction.
•
EDF can manifest in a multitude of different ways,
typically associated with deficits in EF
EF Component
Associated EDF Area of Weakness
Response Inhibition Difficulty inhibiting responses; May blurt out answers; May seem to act without thinking Cognitive Flexibility Perseveration on thoughts, concepts, or tasks;
Difficulty shifting tasks; Difficulty multitasking Setting and Achieving Goals Difficulty setting appropriate goals and
maintaining course; Difficulty generating individuals strategies for problem solving Task Initiation Reduction in self-generated behaviors;
Procrastination
Planning, Organization, and Time Management Poor planning/ organizational skills; Inefficient use of time
Abstract Reasoning/ Concept Formation Use of concrete thinking; Difficulty
understanding consequences and cause-effect relationships
Working Memory Difficulties accessing knowledge; Forgetfulness Attentional Control Poor attention; Distractibility
Controlling Emotions and Social Behaviors Emotional lability; Poor frustration tolerance; A tendency to blame others
Self-Monitoring and Regulation/ Metacognition Poor self-control; Reduced insight; Difficulty learning from past experiences
Neurophysiology
•
Associated with the prefrontal cortex (PFC).
•
One of the most well-connected parts of the
brain.
•
Three primary cortices/circuits responsible for EF:
–
dorsolateral prefrontal cortex
–
anterior cingulate cortex
Dorsolateral Prefrontal Cortex
•
The last area (45
th
) to fully develop
and myelinate.
•
Typically thought to be responsible
for “classic” EF functions.
–
response inhibition
–
setting and achieving goals
–
organizational and planning strategies
–
sustained/ shifting / divided attention
–
short-term and working memory
–
self-monitoring/ regulation
–
verbal and design fluency
Anterior Cingulate Cortex
•
controls behavioral processes
related to the initiation and
motivation for tasks/ behaviors
•
responsible for:
–
motivation and task initiation
–
behavioral inhibition
–
creativity
–
selective/ divided attention
–
working memory
–
self-monitoring
–
language
Orbitofrontal Cortex
•
Involved with social and cognitive aspects of behavior
that determine the emotional significance and social
appropriateness of behavior.
•
Some of the processes that are controlled by the
orbitofrontal cortex include:
–
tactfulness
–
sensitivity
–
emotional inhibition
–
attention
Stages of Development
•
Development of PFC and EF begins in infancy and
continues through late adolescence/ early
adulthood.
•
Development of EF skills generally moves from
external skills (i.e. goal directed behavior) to
internal skills (i.e. metacognition).
•
Development occurs in age dependent growth
spurts:
–
Birth to 2 years
–
6 to 9 years
Development – Birth through 2 years
•
Basic EF processes, such as simple memory and
attention, are apparent in early infancy.
•
Infants rapidly learn new strategies and motor planning
skills that aid in getting crucial needs fulfilled. The
following associated EF processes are used:
–
Organized search
–
Goal directed behavior
–
Response inhibition
–
More advanced memory
and attentional skills
–
Social skills/ nonverbal
signals
Development - Early and Middle
Childhood
•
Most significant period of EF development.
•
Many EF processes related to the control of
goal-directed behavior develop during this
time, these include:
–
basic inhibitory skills
–
planning
–
organizational strategies
–
concept formation
–
creative problem solving
–
working memory
•
Adult level maturation of these skills might not fully
Development - Late Childhood,
Adolescence, and Early Adulthood
•
Maturation of the prefrontal cortex should be reached
during this time.
•
Some processes that may develop during this time
include:
–
the advanced coordination of working memory and
inhibition
–
complex planning and
foresight
–
visual working memory
–
verbal fluency
–
processing speed
–
motor sequencing
–
Self-monitoring regulation
Disorders that Commonly Manifest EF
Dysfunction
•
EDF is strongly associated with components of the
following childhood disorders:
–
ADHD (attention and inhibition)
–
SLD (self-regulation and monitoring, cognitive flexibility, and
organizing and prioritizing tasks, problem solving)
–
NVLD (cognitive flexibility, fluently shifting tasks/environments,
adapting to novel situations, working memory, self-regulation,
attentional control )
–
AU/ ASD (cognitive flexibility, fluently shifting attention to novel
tasks, planning, appropriately responding to social cues,
regulating social interactions, and nonverbal behaviors )
–
Tourette’s Syndrome (inhibition)
–
Sleep Disorders/ sleep deprivation
When is an EF Assessment
Appropriate?
Children with:
•
Known or Suspected Neurological Disorder
•
Past or Recent Head Injury w/ Academic of Behavioral Difficulties
•
Acquired or Congenital Brain Damage
•
Neuromuscular Diseases
•
Brain Tumors
•
Central Nervous System Infection or Compromise
•
Hydrocephalus
•
Neurodevelopmental Risk Factors
•
Prenatal Exposure to Drugs and/or Alcohol
•
ADHD
•
SLD/ NVLD
•
AU/ASD
Assessment of Executive
Functions
Tests and Abbreviations
•
Behavior Rating Inventory of Executive Function (BRIEF)
•
Continuous Performance Test (CPT)
•
Das-Naglieri Cognitive Assessment System (DN: CAS)
•
D-KEFS (Delis Kaplan Executive Function System)
•
Kaufman Assessment Battery for Children – Second Edition (KABC-II)
•
NEPSY-II A Developmental Neuropsychological Assessment (NEPSY-II)
•
Neuroprocessing Concerns Checklist (NPCC; Miller, 2007)
•
Test of Everyday Attention for Children (TEA-Ch)
•
Test of Memory and Learning (TOMAL)
•
Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV)
•
Wide Range Assessment of Memory and Learning – Second Edition
(WRAML-2)
•
Wisconsin Card Sorting Test (WCST)
History of EF Assessment
•
Traditional roles in clinical
neuropsychology.
•
Tend to be used in adults
rather than children.
•
Tests often do not address the application of
executive capacities directly to academic skill
development.
Principles of EF Assessment
•
All EF tasks also measure other information
processing capacities.
•
All measures of information processing and/or
academic skills are also indirect measures of EF
functions.
•
No measure purely assesses the use of only one
self-regulation executive function capacity.
•
The amount and nature of executive functions
that are involved in a task will vary greatly.
Principles of EF Assessment cont’d
•
EF embodies a wide array of processes that are seen
only when brought into play by multiple measures.
•
No single measure will provide an accurate estimate of
an entire person’s executive function capacities.
•
Behavioral checklists, when used singularly, tend to
overestimate executive impairments. Keep in mind that
these are opinions of an individual’s EF.
•
EF assessments should be assessed in tandem with
other abilities and skills.
•
A multifaceted, comprehensive assessment is required
to obtain the best understanding of an individual’s
functioning.
Approaches to Assessment
•
No two EF tasks exactly measure the same EF
construct.
•
Examples:
–
Inhibition
•
CPT vs. Tower tasks
–
Motor Programming
•
Fingertip tapping vs. Hand Movements (KABC-II)
•
Completing a task analysis is imperative .
Conducting an EF Assessment:
How is it different?
•
Semi-structured interview
–
Generate hypotheses from information and how to collect
data
–
What additional questions should be asked that are
related to EF functioning
•
Parent, Teacher, Self Report Inventories
–
Global behavioral rating scales
–
EF inventories (BRIEF, Neuropsychological Processing
Concerns Checklist)
–
How can these
supplement
your EF assessment?
•
Standardized Measures
EF Component
Associated EDF Area of Weakness
Response Inhibition Difficulty inhibiting responses; May blurt out answers; May seem to act without thinking Cognitive Flexibility Perseveration on thoughts, concepts, or tasks;
Difficulty shifting tasks; Difficulty multitasking Setting and Achieving Goals Difficulty setting appropriate goals and
maintaining course; Difficulty generating individuals strategies for problem solving Task Initiation Reduction in self-generated behaviors;
Procrastination
Planning, Organization, and Time Management Poor planning/ organizational skills; Inefficient use of time
Abstract Reasoning/ Concept Formation Use of concrete thinking; Difficulty
understanding consequences and cause-effect relationships
Working Memory Difficulties accessing knowledge; Forgetfulness Attentional Control Poor attention; Distractibility
Controlling Emotions and Social Behaviors Emotional lability; Poor frustration tolerance; A tendency to blame others
Self-Monitoring and Regulation/ Metacognition Poor self-control; Reduced insight; Difficulty learning from past experiences
EF Assessment Areas
•
Concept Generation
•
Inhibition
•
Motor Programming
•
Planning, Reasoning, Problem Solving
•
Set Shifting
•
Retrieval Fluency
•
Attention
Measures of Concept Generation
•
D-KEFS: Card Sorting Test
•
WCST
•
WJCOG –III: Concept Formation
Measures of Inhibition
•
Go-No-Go Tasks
•
NEPSY-II
–
Auditory Attention and Response Set
–
Inhibition
–
Statue
•
Stroop Color-Word Test
–
Similar tasks in D-KEFS and
Measures of Motor Programming
•
Dean-Woodcock Sensory-Motor Battery
–
Fingertip Tapping
•
NEPSY-II
–
Manual Motor Movements
•
KABC
Measures of Planning, Reasoning, and
Problem Solving
Traditional EF tests
•
Category Tests
•
Tower Tests
•
Trail-Making Tests
•
D-KEFS
–
20 Questions
–
Tower
–
Proverbs
–
Word Context
•
NEPSY-II
–
Tests of Cognitive Abilities
•
KABC-II
– Conceptual Thinking – Pattern Reasoning – Rover – Triangles•
WJIII-COG
– Concept Formation – Planning – Pair Cancellation – Analysis-Synthesis•
WISC-IV
– Block Design – Matrix Reasoning – Picture Completion – Picture ConceptsMeasures of Set Shifting
•
Category Tests
•
D-KEFS
–
Color-Word Interference Test (Condition 4)
–
Design Fluency (Condition 3)
–
Trail Making (Condition 4)
–
Verbal Fluency (Condition 3)
•
NEPSY-II
–
Auditory Attention & Response Set (Response Set portion)
–
Inhibition (Condition 3 – Switching)
–
Animal Sorting
•
Stroop Tests
•
Trail-Making Tests
Trail Making Test
Condition 4 – Number/Letter Sequencing
–
Assesses complex mental processes of cognitive flexibility,
multi-tasking, simultaneous processing, and divided
attention.
1
Start
2
3
4
5
End
A
B
C
D
E
Measures of Retrieval Fluency
Non-verbal
•
D-KEFS
–
Design Fluency (Conditions 1
& 2)
•
NEPSY-II
–
Design Fluency
Verbal
•
D-KEFS
–
Verbal Fluency (Conditions 1
& 2)
•
NEPSY-II
–
Verbal Fluency
•
WJIII-COG
Design Fluency Test
Condition 1 – Filled Dots
–
Assesses aspects of non-verbal
productivity/creativity and visual-perceptual
speed.
Connect empty dots only.
Use a different design in each square.
Use only 4 straight lines to connect dots.
EF Assessment of Attention
•
Selective
–
D-KEFS Color
Word
Interference
Test
–
NEPSY –II
Auditory
Attention &
Response Set
–
WISC-IV Coding
& Symbol
Search
–
WJIII-COG
Auditory
Attention
–
TEA-Ch
•
Sustained
–
Continuous
Performance
Tests
–
NEPSY –II
Auditory
Attention &
Response Set
–
TEA-Ch:
Score!; Score
DT; Walk
Don’t Walk
–
WISC-IV
Cancellation
• Shifting
-D-KEFS: Trail
Making (C-4);
Verbal Fluency
(C-3);
Color-Word
Interference
Test (C-4);
Design
Fluency (C-3)
- NEPSY-II
Response Set
(Auditory
Attention)
-Wisconsin
Card Sort Test
-TEA-Ch
Measures of Working Memory
•
WISC-IV
–
Digit Span
–
Letter-Number Sequencing
•
WISC-IV Integrated
–
Digit Span: Backward
–
Letter-Number Sequencing Process Approach
–
Spatial Span: Backward
•
WJIII:COG
–
Numbers Reversed
–
Auditory Working Memory
•
TOMAL
–
Digits Backward
–
Letters Backward
•
WRAML-2
–
Symbolic Working Memory
–
Verbal Working Memory
Examples of EF Problems in Reading
Skills
•
Reading Decoding – poor use of one or more
self-regulation EF’s (lack of attention to
specific letters in words).
•
Rapid Automatic Naming – poor executive
control of language fluency processes.
•
Reading Comprehension – poor direction of EF
processes when reading for meaning.
Examples of EF Problems in Writing
Skills
•
Poor graphomotor control and
lack of automaticity for handwriting.
•
Poor organization of written material.
•
Poor retrieval cueing or poor generation
cueing (idea generation or idea fluency when
writing).
•
Inability to use multiple self-regulation EF’s at
one time (hold, manipulate, retrieve,
Examples of EF Problems in
Mathematics
•
Poor cueing and monitoring when doing
calculation routines.
•
Poor ability to organize, manipulate, and
retrieve when setting up calculations or
problems.
•
Poor ability to execute when
learning or applying rote
knowledge.
1
16
+17
Important Considerations for EF
Interventions
•
Typical EF development should be taken into
account when designing interventions for EF.
•
Since developmental progression of EF skills
moves from the external to the internal,
interventions should match.
–
A lot of external support (i.e. preferential seating,
reinforcements) may be needed at first, but should
gradually fade out.
•
EF skills can be intervened in one of two ways
–
at the level of the environment, or
Environmental Interventions
•
Environmental supports
–
Increased supervision
–
Preferential seating/ placement
–
Daily rules & routines
–
Visual & verbal cues
–
Incentive systems
•
Task Modification
–
Breaking tasks into pieces, with breaks
–
Using close-ended tasks
Person-Centered Interventions
•
Generally speaking, EF difficulties are associated
with suboptimal brain function.
•
Interventions may be:
–
Compensatory strategies that are used for dealing
with EF deficits
–
Teaching EF skills that have not yet developed
–
Rehabilitating damaged EF skills
•
Brain function can be altered through intervention.
•
Interventions can activate the use of intact brain
function.
Compensatory Strategies
•
Strategies that an individual with neurological
deficits uses to improve performance and
behavioral skills.
–
Self-talking through steps of an assignment;
Thinking out loud
–
Using planners/ schedules/ checklists/ lists
–
Rehearsal strategies for memory
Teaching EF skills
•
Some children require more than
“incidental learning” to master EF skills
•
Directly teaching EF skills involves several
broad steps:
1.
Describe the problem behaviors to child
2.
Describe what target behavior/ skill “looks
like”
3.
Set a goal
4.
Set a procedure for reaching the goal
5.
Supervise the child following the procedure
6.
Evaluate process and make changes as
necessary
Rehabilitating EF skills
•
Attempting to alter brain function by
specifically targeting suboptimal functioning
–
Game-based approaches
–
Play-based approaches
–
Book therapy
–
Art therapy
How does RtI fit in?
•
Which intervention is used at what tier depends
on the specific needs of the classroom, small
group, and individual child.
•
Interventions should be based on very specific
goals and interim goals.
•
Data/ progress monitoring
–
This also gives the student a very concrete image of
how they are progressing towards their goals.
References
•
Anderson, V., Levin, H.S., & Jacobs., R. (2002). Executive functioning after frontal
lobe injury: A developmental perspective. In Stuss, D.T. & Knight, R.T. (eds.)
Principles of Frontal Lobe Function
(pp. 504-527). New York: Oxford University
Press.
•
Avirett, E. & Maricle, D. (in press). Executive Function. In S. Goldstein & J. Naglieri
(Eds.)
Encyclopedia of Children Behavior and Development
. New York, NY: Springer.
•
Avirett, E. & Maricle, D. (in press). Executive Dysfunction. In S. Goldstein & J.
Naglieri (Eds.)
Encyclopedia of Children Behavior and Development
. New York, NY:
Springer.
•
Bradshaw, J.L. (2001).
Developmental disorders of the frontostriatal system:
Neuropsychological, neuropsychiatric, and evolutionary perspectives.
East Sussex:
Psychology Press, LTD
•
Cooper-Kahn, J., & Dietzel, L. (2008).
Late, lost, and unprepared: A parents’ guide
to helping children with executive functioning.
Woodbine House, Inc.: Bethesda,
MD.
•
Dawson, P. & Guare, R. (2004).
Executive Skills in Children and Adolescents: A
Practical Guide to Assessment and Intervention.
Guilford Press: New York.
•
Dawson, P., & Guare, R. (2009).
Smart but Scattered.
Guilford Press: New York.
•
Goldberg, E. (2002).
The executive brain: Frontal lobes and the civilized mind.
New
References, cont.
•
Hale, J. B. & Fiorello, C. A. (2004).
School Neuropsychology: A Practitioner’s
Handbook.
Guilford Press: New York.
•
Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004).
Neuropsychological assessment
(4
thed). New York: Oxford University Press.
•
Maricle, D., Bauman, W., & E. Avirett. (2010). Best practices in the assessment of
executive functioning in children. In D. Miller (Ed.).
Best practices in school
neuropsychology: Guidelines for effective practice, assessment, and
evidenced-based intervention.
New York: John Wiley & Sons, pp. 599-640.
•
McCloskey, G., Perkins, A., & Divner, B.V. (2009).
Assessment and Intervention for
Executive Function Difficulties
. Routledge: New York.
•
Meltzer, L. (ed.). (2007).
Executive function in education: From theory to practice
.
The Guilford Press: New York.
•
Miller, D. C. (2007).
Essentials of School Neuropsychological Assessment.
John
Wiley & Sons: New Jersey. (Can get NPCC from book)
•
Stuss, D.T., & Alexander, M.P. (2000). Executive functions and the frontal lobes: A
conceptual view.
Psychological Research, 63
, 289-298.
•
Welsh, M.C., Pennington, B.F., & Groisser, D.B. (1991). A normative-developmental
study of executive function: A window of prefrontal function in children.
