Executive Functioning Seminar Notes

 Frontal lobes govern the co-ordination and synthesis of different neuropsychological

functions in order to fulfil a goal or carry out a plan – known as executive functions.
o Involved with the questions of:
 Why do you want to do something?
 Are you accomplishing what you want to do?
 Do you still want to do it?
 (Goldberg, The Executive Brain: Frontal Lobes and the Civilised
Mind)
 Therefore executive function encompasses a broad range of processes or abilities
that enables an individual to successfully engage in independent, purposive, and self-
serving behaviour.
o Includes motivation, goal selection, planning and implementation of action
toward a goal, using information flexibly, sequencing and prioritising
information and behaviour, self-evaluation and monitoring, flexibility of
thinking, hypothesis testing, and reasoning abilities (being able to make
reasonable judgements based on limited information) (Banich, 2004; Mirsky
et al., 1995).
 To this day, frontal lobe damage is difficult for a clinician to diagnose.
o A patient suffering from damage to the frontal lobes may pass many standard
tests for neurological wellness, even though their friends and family will
know that the sufferer ‘isn’t the same person’ they knew before
o Therefore need ecological measures of executive function in order to
determine the applicability of these insults and test results to everyday life.

Why assess executive functioning?

Goldberg believes that:

o “if sensitive measures of executive function can be developed then

progressive brain diseases may be caught much earlier than they can with
traditional cognitive tests”

I’d like to begin today’s seminar by pointing out what is wrong with assessments of
executive functioning so that we can try and determine what is right about them and how
we should try and improve upon it. This will include an overview of clinical and behavioural
observations, standardised assessment, and ecological measures of executive functioning.

What are the applicability of these neuropsychological test results to everyday life?

 If someone is no longer able to take all aspects of a situation into account and
integrate them then they can no longer formulate plans well.
 Emotional lability and proneness to irritability
 Lack of awareness of his mistakes
  Carry out inappropriate and sometimes hazardous plans.

A major obstacle to examining the executive function is the paradoxical need to structure a
situation in which patients can show whether and how well they can make a structure for
themselves!

In formal situations the assessor (NOT THE PATIENT) determines what activity the subject
should do with what materials, when, where, and how. This removes all need for directive
behaviour from the subject.

This is therefore a problem for clinicians who want to examine the executive function. They
somehow need to transfer goal-setting, structuring, and decision-making from the clinician
to the subject within the structured examination.

However, there are a limited number of established examination techniques that give the
subject sufficient leeway to think of and choose alternative as needed to demonstrate the
main components of executive behaviour.

Therefore need techniques that may be useful in exploring and elucidating this most
subtle and central realm of human activity.

Clinical Assessment of Executive Function / Frontal

Lobe Injury

Instruments of Daily Living

o Activities of daily living
o Food purchasing and preparation / housekeeping
o Personal care
o Right hemisphere lesioned patients may give lucid and appropriate answers
to questions involving organisation and planning of impersonal situations or
events
 But show poor judgement by means of unrealistic, confused, often
illogical or nonexistent plans for themselves
 OR lack the judgement to recognise that they need to make plans if
they are to remain independent
 (Lezak, 1994)

Dysexecutive Questionnaire
 20 items
 Samples the range of problems commonly associated with the ‘dysexecutive
syndrome’
o 4 broad areas
 Emotional / personality changes
 Motivational changes
 Behavioural changes
  Cognitive changes
 “I act without thinking, doing the first thing that comes to mind’
 “I have difficulty thinking ahead and planning for the future”
 Each item = scored on a 5 point Likert Scale (0=Never – 4= Very Often)
 2 versions
o 1 to be completed by the patient
o 1 to be completed by the relative / caregiver who has close, daily contact
with them

Both executive function and motor regulation are indicators of frontal lobe functioning.
Psychomotor disturbance may indicate frontal lobe deficit which may lead an assessor to
query whether additional frontal lobe functions such as planning etc are also affected and
therefore lead to further assessment. This is why this test is included.

Simple Finger Opposition

Finger tap test

The patient is asked to tap the table once if the examiner taps the table once, but not to tap
if the examiner taps the table twice. Give adequate demonstration and practice to ensure
comprehension of task. Before proceeding, the examiner asks the patient to describe what
he\she is supposed to do. (Examiner: “If I tap once on the table like this [demonstrate],
could you tap once. If I tap twice on the table like this [demonstrate], please do not tap.”)

Stimulus * * * * ** *

Response

0 - No error

1 - One error

2 - Two or more errors

Fist-edge-palm test
The patient is shown the task and then asked to perform the following: using a smooth and
steady rhythmic pattern, to touch the table with the side of his\her fist, the edge of his\her
hand, and the palm of his\her hand. The patient is to break contact with the surface of the
table between each change in hand position, but not to bring the arm back in full flexion.
The patient is to repeat this sequence of position changes 10 times. (Examiner: “Watch me
do this.” [Demonstrate five times, without verbal instruction.] “Now see if you can do it.”
[Repeat demonstration once if patient fails to perform.])

0 - Normal

1 - One or two minor mistakes, slow or clumsy (e.g., gross presence of associated
movements in other parts of the hand and forearm), but no major disruption of movements
2 - Major disruption (e.g., total loss of rhythm or precision) or repeated breakdowns of
sequence

Standardised Assessment of Executive Function /

Frontal Lobe Injury

Executive Function Assessment of Volition

Volition

 Complex process of determining what one needs / wants & conceptualising some
kind of future realisation of that need / want
 Capacity for intentional behaviour
 Deficits = unable to initiate activity except in response to internal stimuli (bladder
pressure) or external stimuli (annoying mosquito)
 People with volitional deficits can be fully capable of performing complex activities
o BUT will not carry them out unless instructed to do so
 Can still use eating utensils but will not eat something that is set
before them without explicit instruction

o Assessing Motivational Capacity

 Motivation = necessary precondition for volitional behaviour
 Direct examination of likes and dislikes, what they enjoy and what
makes them angry
 Volitionally impaired patients = apathetic with diminished / absent
capacity for emotional response
 ALSO, patient’s behaviour – no spontaneous and appropriate
conversation / questions. Do not participate actively in examination
proceedings by e.g. putting caps back on pens or turning test cards
themselves
 Serious volitional impairment = volunteer little or nothing EVEN when
responsive to what the examiner says or does
 Assessment: Heilman & Watson (1991)
 Scatter pennies on the table in front of patients
 Blindfold patients and tell them to pick up as many pennies as
they can.
 Task = exploratory behaviour which is impaired in patients
with defective initiation / volition / motivation
o Capacity for Self-Awareness
 Assessment = dependent on observations and interviews
  Integration of a number of aspects
 Awareness of Physical Status
o Assessment: human figure drawing (e.g. draw-a-
person)
 Inaccurate body images
 Distortions
 Perceptions of more severe impairment than is
the case
o Impaired or absent appreciation of one’s physical
strengths and limitations
 Defective self-awareness in vocation
 Blind person who wants to be a pilot
 Awareness of Environment or Situational Context
o Reflected in use of environmental cues
o Questions re: time of day, temporal events / situational
circumstances
 E.g. Brief Cognitive Status Exam (WMS-IV)
 Orientation
 Time Estimation
 Clock drawing
 Cookie Theft Picture
 Complexity and richness of responses
may show rich integration of items in
picture or bit-by-bit description of the
picture that shows little integration of
environmental / situational cues.
 Awareness of Social Context
o Observations and interviews
o Dressing and grooming
o Relating to examiner, staff, family and friends
o Collateral interviews = NB to establish premorbid
behaviour
o Lack of adult ‘self-consciousness’ may = seen in childish
and crude behaviour
o Conversely, patients can become excessively polite

Executive Function Assessment of Planning

Planning – can be determined through patient’s handling of many of the standard
psychological tests (provide insight into the status of these important conceptual activities)

Porteus Maze / Mazes

 Assesses planning (and possible visuomotor scanning and speed)
 Designed to yield data about the highest levels of mental functioning involving
planning and foresight
 “process of choosing, trying, and rejecting or adopting alternative courses of conduct
or thought”
 Ideal approach: find a path through the maze by making a preliminary investigation
(plan) of the maze in order to envisage a path that does not go down blind alleys
 E.g. Porteus Maze Test (Porteus, 1959, 1965)
o Successful trial: subject must trace the maze without entering any blind alleys
o Range in difficulty from simplest at year III to the most complex for adults.
o Discontinuation criteria varies with level of difficulty (no. of fails)
o Test is not timed (can take some subjects an hour or more to complete all the
mazes given to them)
o Scores = reported in terms of TA (test age) – age level of the most difficult
maze the patient completes successfully minus a half-year for every failed
trial.
 Upper score = 17 for success on the adult level
o 8 qualitative error scores
 1st 3rd errors, last 3rd errors, wrong direction, cut corner, cross line, lift
pencil, wavy line & total qualitative errors.
o Number of repeated entries into the same blind alley can measure
perseverative tendencies
o Quite sensitive to brain disorders (Smith, 1960).
o Successfully predicted severity of brain disease (Meier, Ettinger & Arthur,
1982)
 Stroke study: TA of VIII or higher during first week after a stroke made
significant spontaneous gains in lost motor functions
 Those whose TA fell below VIII showed relatively little
spontaneous improvement
o Has been known to be associated with visuospatial and visuomotor tasks
(Ardila & Rosselli, 1989) so results must be interpreted with other measure of
planning.
o Practically:
 can substitute with WISC-III shorter maze test with a time limit and an
error scoring system
 format and time limit make mazes easier to administer
 = satisfactory and practical substitute for the lengthier Porteus
test (which isn’t timed) (Lezak, 2004).
 most difficult item = almost as complex as the most difficult item in
the Porteus series
 highest norms (15y10m) allow for examiner to make rough estimate
of the adequacy of the adult patient’s performance
o Ecological validity:
 Maze test performances including both brain damaged and intact
subjects correlated significantly (r = .77) with scores on actual driving
tasks (Sivak et al., 1981).
  Alzheimers patients (mild to moderate) TA scores correlated with
ratings on activities of daily living scale

Tower Tests
 Assesses planning
 Note: correlation between London and Hanoi = low (r = .37)
o This suggests that they do not measure precisely the same thing
 LONDON
 Assesses planning
 HANOI
 Assesses inhibition (of a prepotent response – e.g. goal,
subgoal)
o Study: Miyake et al., 2000
o Response inhibition contributes to performance
 Working memory
 Information speed processing
 Problem Solving

 Tower of London
o Subject must look ahead to determine the order of moves necessary to
rearrange three coloured rings / balls from their initial position on 2 of 3
upright sticks to a new set of predetermined positions on 1 / > of the sticks
o 12 test items of graded levels of difficulty
 Levels of difficulty depend on number & complexity of subgoals
required to achieve the desired arrangement
o Correct score = solution is achieved with the minimum number of moves
necessary.
o 3 trials allowed for each problem
o Constraints:
 only 1 piece may be moved at a time
 each piece may be moved only from peg to peg
 only a specified number of pieces may be left on each peg at a time
o Factors
 test = typically used to assess planning BUT
 other factors = NB for successful performance
o working memory
o response inhibition
o visuospatial memory
 (refs: Carlin et al., 2000; Phillips et al., 1999;
Welsh et al., 2000)
o Laterality:
 Shallice, 1982; Shallice & Burgess, 1991
 Brain injured persons
 Scoring criteria = no. of correct solutions
 left anterior lesions = performed least well
 right anterior lesions = performed less well than controls ONLY on the
most difficult problems (5 move)
  either left / right posterior lesions = performed as well as controls
 indicates prefrontal cortex during task performance (functional
imaging studies corroborate – Baker et al., 1996; Lazeron et al., 2000)
 patients with focal lesions STILL MADE MORE moves, used
trial and error strategy, slower to arrive at solutions
 patients with frontal lobe dementia made more moves, more
rule violations (disinhibition and dysregulation), more
incorrect solutions, & = slower in executing moves
 HD = impaired
 TBI with anterior lesions performed at essentially the same
level as control (Levin, Goldstein, Williams & Eisenberg, 1991)
o Shows relative insensitivity of test to cognitive
impairment associated with TBI

 Tower of Hanoi
o More complex than London
o Instead of same size pieces, objects to be arranged are 5 rings of varying sizes
o Only one ring may be moved at a time
o Cannot remove rings from pegs that aren’t being moved
o Any number of rings are allowed on a peg BUT
 A larger ring may not be placed on a smaller ring
o Multiple forms (7 rings and up) and computerised
o Requires establishment of
 Subgoals
 A move that = essential for the solution of the puzzle but does
not place a ring into its goal position
 a counterintuitive back-move

 Tower tasks show age-related decline = faster in problem solving than in some
forms of memory (Davis & Klebe, 2008)
 Anterior lesions = poorer performance than posterior lesions (again showing the
implication of the frontal lobes in executive functions)
o Frontal lesions = more errors and appeared to have difficulty choosing a
counterintuitive backward move to reach a subgoal

 Tower of Toronto
o A fourth ring = added
o Rings = same size but different colours (white, yellow, red, black)
o Keep lighter coloured rings on top of darker ones
o Used to examine planning (strategy formation), learning & memory for
previously developed strategies
 Initial set of 5 trials = followed by second 5 trial set 1.5 hours later
o Parkinson’s patients: slow to develop solution – take and learning an
inefficient path that led to correct solution
o Amnesic patients = performed normally on both trials
 o Late stage HD = defective performances on both sets of trials

 TAT
o Reflect patient’s handling of sequential verbal ideas
 Stories told may be complex & highly organised OR have simple & straight
story lines

 Picture Arrangement & Block design

o How patient addresses highly structured tests such as these = provide
information about whether they order and plan ahead naturally and
effectively
 OR plan laboriously, inconsistently or not at all

 Sentence Arrangement
o = good opportunity to see whether patients can organise their thoughts into
a sensible and linguistically acceptable construct

ROCFT
o Elicits planning behaviour through analysis of how people copy the complex
figure
o Questions how systematic a person’s approach is versus how haphazard /
fragmented
 Beginning with the basic structure = systematic
o Coloured pencils, marking lines etc.

Ecological Assessment of Planning

The abstract nature of many standard tests = different from the planning requirements of
ordinary daily activities (e.g. planning to meet friends, to prepare a meal, to accomplish a
set of errands).

These activities represent important challenges to many patients with brain disorders.

Methods to assess real-life everyday planning skills of patients:

 Chanon & Crawford (1999)

o Videotapes and stories of everyday awkward situations (e.g. negotiating a
solution with a neighbour about a problem dog)
o Anterior lesion patients = more impaired than posterior lesioned patients in
 generating a range of possible solutions to solve the problem
 quality of solutions = poor

 Goel, Grafman, Tajik et al. (1997)

o Patients with focal prefrontal cortex lesions were asked to plan a response
for a hypothetical couple engaged in real-world financial decisions
 o Lesioned patients took much longer to identify information that was missing
from the problem scenario and spent less time on the problem-solving phase
o Showed poor judgement regarding the adequacy and completeness of their
plans

 Goel & Grafman (2000)

o Examined an architect with right prefrontal lesions
o Performed well on most standard problem-solving tests
 = more structured
 = have definite rules
o Gave him architectural task to develop a new design for lab space
o Concluded that patient = impaired in ability to explore possible alternatives
for solutions because of the imprecise and ambiguous characteristics of the
design problem
o This shows the NB of ecological assessment as it can find real-world
implications of insult or deficits and illustrate the impracticality of returning
to specific jobs or the inherent danger in doing so for certain individuals.

 Satish et al. (1999)

o Patient – moderate TBI
o Devise emergency management plan in case of weather-related flooding for
hypothetical country
o Elaborate interactive computer simulation assessed variety of executive skills
= assessed
o Patient = able to plan short-term goals
 But decision making and strategy use impaired overall performance
o Responses on this simulation appeared to explain her post-injury vocational
failures and demonstrated specific difficulties that limited her potential.

Working Memory and Executive Functioning

 Executive processes include various kinds of judgements made on stimuli held in
short-term memory and active retrieval of information from memory
 The frontal lobes play a key role in the functioning of memory.
 Working Memory = governed by the frontal lobes
o The process of retrieving and retaining task-relevant information
 Frontal lobes DO NOT store out memories but rather, they know WHERE in the brain
to find them.
o Activate a memory while it is needed for a specific step in a task and then
release it for the next step.
o CEO example
 Frontal lobes have to bring different types of memories ‘on-line’ at each stage of
problem-solving
o Brain must switch to different types of tasks throughout the day.
o More difficult if these tasks are going in parallel.
 Dementia = affects working memory
 ‘inane’ tasks – take dishes to the bedroom or look for gloves in the
refrigerator
 Could be early indicators of executive dysfunction so
important ecological indicators
 Assessment: Verbal and Non-verbal assessments of working memory
o Digit span, RCFT, RAVLT

DIGIT SPAN
o Repetitions of number forwards and backwards
 NOTE: (Lezak, 2004).
o Repetitions made by patients whose abilities for mental and motor flexibility
are intact but who have difficulty keeping track of immediately previous /
ongoing actions (deficits in working memory) ARE NOT PERSEVERATIONS and
should not be labelled as such.
o This kind of repetition occurs most frequently in formalised testing on word
generation tasks such as verbal fluency (COWAT) or learning ability (word list
learning (RAVLT)).
 Patients repeat a word when they have forgotten they have said it 10
to 20 seconds ago (lost out of short-term / working memory).
 Cannot perform a mental task and keep track of what they are doing
at the same time.
o Repetitions will typically differ qualitatively from perseverations as the latter
appear in repeated repeating of one word or several, or repeated use of the
same word or action with stimuli similar to those that initially elicited the
word / action.

Executive Function Assessment – Purposive Action

Translation of intention into action.

Requires ability to initiate, maintain, switch, and stop sequences of complex behaviours in
an orderly and integrated manner.

Inertia = dysfunction

Disturbances in programming of activity can thwart the carrying out of reasonable plans
regardless of motivation, knowledge, or capacity to perform the activity.

Called ‘purposive action’ because impulsive action is likely to remain intact as it bypasses
the planning stages in the action sequence. Difference between impulsive and consciously
deliberate actions.

 Shallice (1982)
o Programming functions = necessary when performing non-routine tasks but
are not needed when action is familiar, routine, or overlearned.
 o THEREFORE such routine / overlearned behaviour = less vulnerable to
impaired brain functioning than novel / non-routine activities –
PARTICULARLY WHEN THE IMPAIRMENT INVOLVES THE FRONTAL LOBES.
 Disturbance in programming action = patients show MARKED DISSOCIATION
between verbalised intentions / plans and their actions.

Tinkertoy Test
 Purposive Action – Lezak (2004)
 Patients must initiate, plan, and structure a potentially complex activity and carry it
out independently
 These functions = absolutely essential to the maintenance of social independence in
a complex society
o BUT typically remain unexamined as they are normally carried out by the
examiner / are made unnecessary by the structured nature of the test
material / the restricted number of possible responses in most tests of
cognitive functions
 Gives the patient an opportunity to make a ‘free’ construction without the
constraints of a model to copy / predetermined solution
 Administration:
o 50 pieces of a tinkertoy set are placed on a clean surface in front of the
subject
o Told “make whatever you want with these. You will have at least 5 minutes
and as much more time as you wish to make something” (be careful of
perseveration)
 5 minute minimum time limit = used to stop competitive minded
people from thinking it is a speed test
 Poorly motivated / self-deprecating patients give us easily (volition)
 May stop handling materials after 2 / 3 minutes and
THEREFORE must be allowed to sit for several minutes before
being asked whether they have finished with the material
 Amount of time taken may vary regardless of neuropsychological
status.
 Encouragement = given as needed
 Only blind patients OR sighted patients who cannot manipulate small
objects with both hands are unable to take this test
o When completed the examiner asks what the construction represents
 If it does represent something (e.g. a named object like car or ladder)
the construction = evaluated for its appropriateness to the indicated
name (concept formation)
 Original scoring system:
o
 Ecological validity
o Bayless et al. (1989) & Cicerone & De Luca (1990)
o Correlated tinkertoy test performance with employment status

Executive Function Assessment - Self-Regulation

Lezak divides self-regulation into the assessment of productivity, flexibility and the capacity
to shift, and perseveration. I have included inhibition.

Self-Regulation Assessment - Productivity

 Reduced / erratic productive due to dissociation between intention (volition) and
action (inertia?)
 Slowed responding
o Probably most common cause of low productivity in people with brain
disorders
 Weak / absent development of intentions
 Planning defect
 Individuals may talk about performing an action and even give details of what needs
to be done but do not carry out what they verbally propose
o Talk the talk but cannot walk the walk
 Clinical observations:
o Initiation of action may be slow / require a series of preparatory motions
o May make stuttering sounds preparatory to speaking
o May display agitation in the body part that will be undertaking the intended
activity before it becomes fully activated
o NB – NOT an intention defect
 Rather = defect of translation from thought to action
 Can usually be observed during interview / tests of other functions
o Examiner must be alert to qualitative aspects of behaviour
 E.g. stuttering that heralds the onset of speech
 Comments about an error without a correction (not perseveration just
a failure to correct something despite knowledge of it – doesn’t mean
they will continue to perform the action incorrectly)
 Assessment:
o Slowed responding can occur on almost any kind of test
o NB to note whether performances are slowed generally / only when certain
kinds of functions or activities = called upon
o Slowing should be documented
 Provides clues to the nature of a disorder which is not apparent in the
patient’s test responses themselves

Cookie Theft Picture:

 Typically used to evaluate linguistic attributes
 BUT, Mendez and Ashla-Mendez (1991)
o timing the rate of responding (words per minute)
demonstrated significant differences between patients
with multi-infarct dementia, those with probably
Alzheimer’s and elderly controls
 responsive sluggishness = shows up in correct but over-time
responses on timed tasks (e.g. picture completion, picture
arrangement, block design etc)
 normally appears in first 1 / 2 items of a new test (after which
patients perform quite well)
  THEREFORE – observe the timing correctly and make a note of
it as it may indicate executive dysfunction in self-regulation
o Patients who = slow to develop a set but whose
cognitive functions are intact may achieve quite
respectable test scores

RAVLT – Working and Long-Term Memory, Learning, Recognition, Forgetting proactive and
retroactive interference

 slowed patients = likely to have a relatively limited recall on the first

trial
 but will do well on the interference list since by this time they
are familiar with the format

Verbal Fluency
 COWAT – verbal production & fluency: people displaying slowed responses may
produce only few words on the first trial but perform other trials well
o Note: dwindling responses = NB to observe too.
 Patient begins performing tasks at a ‘rapid’ rate but loses speed and
may ultimately stop responding altogether in the course of a trial / set
of trials
 Thurstone’s Word Fluency Test

Self-Regulation Assessment: Cognitive Flexibility, Set-Shifting, Inhibition,

and Effective Performance

Flexibility extends through cognitive, behavioural and response dimensions.

Deficits in flexibility results in perseveration.

 Deficits in mental flexibility show up perceptually in defective scanning (such as

cancellation tasks), and an inability to change perceptual set easily (sorting tasks)
 Deficits in conceptual flexibility appear in rigid or concrete approaches to
understanding and problem-solving and stimulus-bound behaviour (cannot
dissociate their responses or pull their attention away from whatever is in their
perceptual field / current thoughts) (sorting, stroop, copying)
 Deficits in response flexibility results in perseverative, nonadaptive behaviour and
difficulties in regulating and modulating motor acts (e.g. copying and drawing –
RCFT, Bender)

An efficient examination should be different for each patient as the examiner follows up on
the unique set of dysfunctional responses displayed at each step.
  If a subtle deficit is suspected then examiner may give a series of tasks of
increasing length or complexity.
 If a broad, very general defect is suspected, may be unnecessary to give long,
complex tasks but rather – for planning and rehabilitation – to expose patient to
a wide range of tasks.

Sorting Tasks
 Most sorting tests assess abstraction and concept formation as well as cognitive
shift and response inhibition
 Observations will clarify whether the individuals primary difficulty is in sorting or I
shifting
 Must augment numerical data with behavioural descriptions in order to determine a
holistic assessment that is ecologically valid
 Dysfunction = perseveration
 Frontal-lobe patients frequently perseverate on responses in tests in which there are
changing demands

WCST
 Best example of this phenomenon = WCST
 WCST = one of standard clinical tests of frontal-lobe injury
 First earned its reputation as a measure of frontal lobe dysfunction in studies by
Brenda Milner (1963, 1964)
o Neuroimaging studies have supported the major role of the frontal lobes in
performing this task
 Administration:
o Double pack of 128 cards
 Allows for optimal number of 11 runs of ten correct sorts each
o Subject = presented with four stimulus cards, bearing designs that differ in
colour, form, and number of elements.
o One irrelevant stimulus dimension – placement of symbols on the card
o Subject = required to sort the cards into piles in front of one or another of the
stimulus cards
o Only help given to subject = told whether the choice is correct / incorrect
(yes / no)
o 1st sort = colour, 2nd sort = form, 3rd sort = number of elements
o When subject = correctly identified the sort the correct solution changes
without warning
o Most adults (under age of 75) achieve at least four categories
o Discontinue after 30 / 40 incorrect placements
 Scoring:
o Most widely used scores are for
 categories achieved
 number of correct runs of ten sorts
 ranges from 0 (patient who never gets the sort criteria) to 6
(point at which test = discontinued)
 perseverative responses
  a correct response may be classified as a perseverative
response if it also matches a previously correct category
 perseverative errors
 useful in documenting problems in forming concepts, profiting
from correction, and conceptual flexibility
 Shifting response strategies = particularly difficult for people with frontal lesions
o May perseverate by continue to respond to the original stimulus for as many
as 100 cards until testing = terminated
o Subjects may realise they are perseverating and comment on it e.g. “form is
probably the correct sort now so this sort will be wrong, and this will be
wrong, and this will be wrong”
 Frontal lesioned patients produce more perseverative and loss-of-set errors than
patients with posterior lesions (Stuss et al., 2000)
 Principle locus of card-sorting effect appears to be roughly around Brodmann’s area
9 in the left hemisphere (Kolb & Whishaw, 2009).
o Lesions elsewhere in the left frontal lobe and often in the right frontal lobe
will also produce a deficit on this task, although an attenuated one
 Has been used with success in MS, Parkinson’s disorder and alcoholics to determine
executive functioning

Other examples are the:

Card Sorting Task (D-KEFS)

 Will be discussed in the battery

Rule Shift Cards (BADS)

 Assesses shift and response inhibition
 Will be discussed in the battery

Self-Regulation Assessment - Inhibition

Stroop
 Assesses cognitive flexibility, switching and response inhibition.
 Further demonstrates the loss of response inhibition subsequent to frontal-lobe
damage
 Many formats
o Number of trials runs from 2 – 4
o Increased complexity such as seen in the D-KEFS
 Word reading
 Colour naming
 Colour-word interference
 (assesses inhibition) – traditional stroop measure
 Inhibition / switching task (rectangular blocks around 20 of the blocks
in which the WORD must be read and not the colour
 (assesses cognitive flexibility and inhibition)
 o Dodrill, Golden, Trenerry formats
 2 trials = sufficient to illicit slowing response but may require more if
looking for subtle deficit / want to illicit cognitive inflexibility
o 3, 4, or 5 colours
o Scoring = time, error, correction / both and contrast scores between trials
o Stroop formats have satisfactory reliability
o Age effects on colour-word interference trial
o L.H. patients take 2x as long as control subjects to perform each trial
 BUT interference effect = similar for both right and left hemisphere
lesioned patients (Nehemkis & Lewisohn, 1972)
o Sensitive to closed head injury
 Patients with ‘good recovery’ 5 months / > after accident = stilled
slowed on stroop
o Important the patients has visual competence
o Test = very unpleasant for patients with concentration problems

Trail-Making Test
 A few forms available
o Trail B = switching task (cognitive flexibility)
o D-KEFS = visual cancellation (condition 1) and cognitive flexibility (condition
4)
 Visual cancellation tasks often elicit deficits in mental flexibility
 show up perceptually in defective scanning (such as
cancellation tasks)
 Scoring = time with optional error scores.
 Careful observation of how patients get off track, and the kind of mistakes they make
can provide insight into the nature of their neuropsychological deficits
 Ecological validity:
o Pontius & Yudowitz (1980)
o Relationship between trail making performance and self-reported criminal
behaviour
o Youths displayed inability to switch ongoing activity in Trail B (untimed) also
reported they were unable to make appropriate shifts in the ‘principle of
action’ during the commission of the crime (e.g. if something went wrong /
the plan needed to change somehow – could follow a plan but not flexibly)

Self-Regulation Assessment - Decision Making Assessment

(e.g. Dysregulation: emotional and functional)

Veridical vs Adaptive Decision Making

o Veridical
 Checking balance, dentist’s telephone number, Boss’s wife’s name
 A single correct answer, all others = false.
 o Adaptive
 What shall I wear today? Where should I go on vacation? What should
I order for dinner? (actor-centered problem solving)
 No intrinsically right answer that you could look up or solve for
(mathematically)
 To find an answer requires knowledge of internal and external
contexts
 Facility for adaptive decision making lies in FRONTAL LOBE
FUNCTIONING
 Governs the interplay of external environment (social context,
industry, culture etc) with inner personality, vision, and goals
of individual / leader.
 BUT
 How do you assess actor-centered adaptive decision making
when there is no correct answer?

Goldberg & Podell: Cognitive Bias Task

o Captures some of the nature of adaptive decision-making
o Subject = shown large geometric (target) design, followed by two other
designs
 “look at the target and then select from the two other design choices
the choice you like best”
o Repeat task over 5 trials: differ in shape (circle / square), colour (red/blue),
number (one / two identical components), size (large / small), and contour
(outline / filled with homogenous colour).
o Two design choices = ALWAYS have DIFFERENT degrees of similarity to the
target – one is always more similar to the target shape.
 Therefore: no right / wrong answers
 Healthy people (intact frontal lobes without insult) tend to
make either context-dependent or context-independent
strategy choices
o Context-dependent:
 Choose the most similar shape to the target
 Males tend to choose this approach.
o Context-independent:
 Choose a shape based on some stable
preference (e.g. colour or shape)
 Females tend to choose this approach.
 Differences in laterality of lesions
 Males
o Right frontal lesions
 Produced-target driven responses
o Left frontal lesions
 Responses = made on perceptual preferences
independent of the target.
 Females:
 o Both left and right frontal lesioned women produced
more target-driven responses than control subjects
o Low / high similarity scores indicate that individual allowed the target to
influence their choice (context-dependent vs independent)

Similarly, how do you assess emotion-based decision making in individual with executive
dysfunction or frontal lobe insults?

Many conventional executive function tests appear to stress the formal and deliberate
processes associated with ‘reasoning’ operations. (e.g. cognitive estimates)

Emotion-Based Decision Making (Risk Taking and Rule Breaking)

 Emotional dysregulation and ‘non-formal’ reasoning operations
o We’re only human after all
o Emotion versus intuition
 Standard administration procedure
o Subjects = given $2000 worth of ‘money’
o 4 decks of cards
 2 decks = advantageous (based on frequency of rewards and
punishments)
 2 decks = disadvantageous
o 100 card selections
 Divided into 5 blocks of 20 cards each
 Often shows slow learning initially and then substantial improvement over the
five blocks
 Bechara et al. (1998)
o Dorso-lateral frontal lesions + working memory disorders = performed
WELL on IGT
o Ventro-mesial lesions = performed POORLY but retained good working
memory

How does this apply to ‘real life’?

 Gambling – what happens if someone with frontal lobe injury goes to a casino and
not only cannot make adequate social adjustments for their behaviour, but fails to
determine the consequences of actions and perseverates with playing until all their
money has run out?

Non-verbal Fluency
 Design Fluency
o Non-verbal counterpart of Thurstone’s Word Fluency Test
o 1st condition – invent drawings
 Drawings do not represent actual objects / nameable forms
 Must not be scribbles either
 o Subject = shown acceptable vs non-acceptable drawings by the examiner and
then given 5 minutes to make up as many different kinds of drawings as they
can (‘many’ and ‘different’ = emphasised in manual)

Dysregulation:
Defects in self-regulation

Perseveration (inertia of termination)

 Observation
o if perseveration / inability to move smoothly through a movement, drawing,
speaking sequence is noted than that is evidence enough of a deficit in self-
regulation.
 Assessment:
o copying / repetition tasks tend to elicit perseverative tendencies in
individuals with executive dysfunction
 Therefore:
 RCFT
 Copying and Drawing Tasks that contain repeated
elements tend to elicit perseverative tendencies
 Perseveration in response set
o True / false
 Response Set Tasks elicit ‘acquiescent
perseveration’ as patients with cerebral
damage tend to have more runs of 4 / >
True responses
 Multiple choice

Battery Assessment of Executive Functions

Behavioural Assessment of the Dysexecutive Syndrome (BADS)
o Wilson, Alderman et al. (1996)
o Developed to examine performance on a wide range of real-world tasks
o 5/6 tests = question & answers / paper & pencil tests
 Rule Shift Cards
 Assesses cognitive flexibility & inhibition
 Deficit = perseveration & cognitive inflexibility
 Subjects view playing cards and respond under 2 ‘rule’
conditions:
o 1st – instructed to say ‘yes’ if presented with a red card
and no if presented with a black card
o 2nd – after series of cards = shown then instructions
change to ‘yes’ if card = same colour as PREVIOUS card
and ‘no’ if not the same colour
 Action Program Test
  Assesses planning (including abstract / conceptual thinking
(strategy formation)).
 Subjects must figure a way to get a cork out of a tube with a
variety of objects at their disposal.
o Need to develop a plan, and manipulate materials such
as water in a beaker and a metal hook to try and get
the cork out.
 Key Search Test
 Assesses planning (strategy formation)
 Subject is asked to draw a plan for finding a lost key in a
square-shaped area
 Temporal Judgement Test
 Assesses cognitive estimation and prediction
 Asks four questions concerning estimations on how long
activities take
 Zoo Map Test
 Assesses planning
 Subject must plan an effective route through a zoo in order to
visit certain sites
 Modified Six Elements Test
 Assesses planning and priority setting
 Subjects = instructed to complete as many paper-and-pencil
tasks (e.g. simple calculations / naming pictures) as possible in
a brief time while attempting at least something from each of
the test’s six parts
 Performance = judged by how well subjects organise their time
 Dysexecutive Questionnaire
 20-item checklist for patient and collateral source
 Not formally part of the BADS
o Not used in the calculation of the profile score for the
battery
o Reliability and validity
 emphasis in many of the BADS subtests is on requiring the client to
impose structure on the tasks and to engage in forward planning.
 One potential danger in using unstructured tasks is that inter-rater
reliability will be low, however, the inter-rater reliability coefficients
for all BADS subtests are more than adequate.
o BADS = high inter-rater reliability (.88 – 1.00)
o Test-retest reliability = best on Action Program, Key Search, and Temporal
Judgement (r = .64-.71). Lower for other tests.
o Ecological Validity:
 Another impressive feature of the BADS, shared with other tests from
the same stable, is its demonstrated convergence with observational
ratings of everyday problems in the same domain. (good ecological
validity)

Delis-Kaplan Executive Function System (D-KEFS)
o Delis, Kaplan & Kramer, 2001.
o Set of 9 tests – each designed to stand alone. No overall score
o Ages 8 – 89
o 9 tests – most = variations on the most commonly used tests purporting to
examine executive function
 Trail Making Test
 Verbal Fluency (letter and category)
 Design Fluency
 Colour-Word Interference Test
 Sorting Test
 5 conditions
o Visual scanning
o Number sequencing
o Letter sequencing
o Number-Letter Switching
o Motor Speed
 Twenty Questions Test
 Word Context Test
 Tower Test
 Proverb Test
o Advantage = norms (1750 participants ranging in ages 8-89)
o Alternate form = available
o Many of ‘standard’ tests have been lengthened to avoid ceiling and floor
effects
o Subtests breakdown performance into fundamental components required for
success on these tasks
 Provides large number of scores
 Principal scores = acceptable reliability
 Additional scores = low reliability
o Internal consistency varies from test to test

Ecological / Naturalistic Assessment of Executive

Functions
The ecological validity of tests indicates the degree to which the test is predicitive of
everyday real-world behaviour. There is a growing concern among testing professionals that
most, if not all, psychological tests and standardized assessments introduce environments and
stimuli that people never encounter and tasks that often do not emulate life situations or
vocational requirements.

Many individuals with deficits in specific areas of EF are passing through NP assessments, and
even vocational and functional assessments, without clinicians having a clear understanding of
their deficits.

The ecological validity of cognitive tests has become an increasingly important issue with
the developing role of neuropsychologists in rehabilitation settings. The clinician wants to
determine whether an injury has affected a person’s ability to manage their affairs, live
independently, or return to work. Many tests were not designed to make such predictions,
and it has been argued that existing test’s ability to do so is limited.

Overtly profound changes in behaviour that are behaviourally observed are sometimes
missed in a highly structured exam.

This means that family and friends may report that the person is ‘different’ or ‘not
themselves’ but the formal assessment may not pick this up!

Therefore many tests were designed to assess cognitive impairments, the results of which
have little applicability to rehabilitation or everyday life settings.

Certain tests are inherently ‘ecologically valid’ since they are little more than formalised
versions of real world activities.

Route- Finding Task

o Boyd & Sautter, 1993
o Subjects must find their way from a starting point to a predetermined
destination within the building complex in which the examination is given
o Practical level of difficulty:
 Final destination must be a minimum of five choice points and one
change in floor level away from the starting place
 Ideally there will = signs giving directions for the destination
o Assessor
 accompanies the examiner and records the path taken and how the
patient gets there
 answers questions
 gives encouragement and advice as needed
 makes note of any questions or advice required
o performances = rated on 4 point scale to measure the degree to which the
patient was dependent on the examiner for:
 understanding the task
 seeking information
 remembering instructions
 detecting errors
 correcting errors
 ability to stick with the task (on-task behaviour)
o high inter-rater reliability (r = .94)
o Study by Spikman et al. (2000)
 (r > .90)
 Patients with documented frontal lesions = more difficulty than those
without frontal damage
 Only one of a number of executive tasks on which the patients
performed significantly worse than control subjects
 Test sensitivity = due to lack of structure and need for participant’s to
seek information and to detect and correct errors on their own.
 (motivation, cognitive shift, etc).
Behavioural Assessment for Vocational Skills (BAVS): Wheelbarrow Test
o Butler & Anderson et al., 1989
o Naturalistic examination technique
o Subject must assemble parts of a mail-order wheelbarrow within a 45
minutes period.
 Assessors = play role of ‘job supervisors’
 Offer little guidance / structure
 BUT can become more directive if subject limitations require
help to stay on task / complete it.
 Offers 1 constructive criticism in response to an error to see how the
subject deals with criticism.
o Distractibility problems = elicited by interjecting a ‘brief alternate task’ and
then redirecting the subject’s attention back to the wheelbarrow
o Performance: rated on 5 point scale for 16 vocationally relevant aspects
 e.g. following directions, problem solving, emotional control,
judgement, and dependability.
o Although this test doesn’t correlate significantly with WCST, it did PREDICT
the levels of 3 categories of work performance (in 20 TBI patients in
volunteer work settings)
 Work quantity (r = .74)
 Work quality (r = .75)
 Work-related behaviour (r = .64)
 All correlations were significant at p < .01

Hamburger Turning Task

- Shugars, 2007
- Vocational simulation task
- Shown a video of a person verbally explaining each step while performing the HTT
- The subjects can use any strategy they wish to remember this information
- Once video is concluded the person is introduced to the HTT props
o Faux grill, spatula, salt, faux hamburgers
- They are familiarised with the props and told to treat the props as if they were real. i.e.
the grill is hot, the hamburgers are uncooked
o Therefore if you rest your hand on the grill, it is a rule break and scored as such.
o Told to concentrate on accuracy rather than speed

- Administrator videotapes this process to allow for accurate post-scoring

- When subject has completed the HTT they are asked to fill out a self-assessment of how
they felt they did in the task
o Provide insight into the participant’s ability to implement strategies, self-
evaluate and problem solve.
o HTT Self-Assessment:
 Consists of four questions that the participant is asked to fill out at the
conclusion of the HTT (see Appendix C).
  Each answer was scored as accurate 2, moderately accurate 1, or
completely wrong 0.
 A score of all 2’s would reflect a person who has exhibited accurate self-
awareness, is able to evaluate their performance accurately, and has
created a strategy for completing the HTT.
 A score of all 0’s would reflect a person who was completely inaccurate
in their self-assessment, was unable or unwilling to complete the answer,
and did not generate a strategy for the task.
 Those whose scores were primarily 1’s would fall in-between complete
awareness and those who were unaware.
 For example; individual A only made three mistakes on the HTT and rated
himself as “good”; he would have been scored as a 2. Individual B made
multiple mistakes and broke three rules during the HTT and rated himself
as “excellent”; he was scored as a 0. Individual C did not make any
mistakes on the HTT but only scored himself as “good”; he was not
completely accurate, but he was also not completely wrong.

HTT scoring:

- This 15 page form scores a correct step with a 2, skipped steps -1, rule breaks -1, added
steps-1, and self-corrected improper sequence (but correct action) is 1.
- HTT has been found to be an ecologically valid measure in the following areas: 1) ability
to initiate and persistence, 2) attention and concentration, 3) memory functions, and 4)
executive functioning.
- What aspects of EF are measured by HTT. These include: 1) the ability to sequence, 2)
following rules, 3) forgetting steps (omission), 4) adding steps (co-mission), 5) self-
evaluation and use of strategies (on the post self-assessment), 6) memory and 7)
procedure.
- The results of this investigation indicate that the HTT may be useful as a functional
evaluation for certain aspects of executive functioning in a real-world setting.

The significant relationship between the HTT and the behavioral data indicates that
performance on the HTT is related to how well an individual functions everyday, according
to the five levels of executive functioning on the behavioral rating scale (maintain initiation
and persistence, attention and concentration, memory and executive functions).

These preliminary results suggest that the HTT is able to be reliably scored and has a
standardized administration protocol that allows it to be a useful measure of executive
functioning of everyday behavior.