Contribution of rating scales to intervention for executive dysfunction

Clinical Validation of Selected NIH Cognitive Toolbox Tasks in Pediatric Epilepsy

The NIH Toolbox Cognition Battery (NIHTB-CB) is designed to assess cognitive functioning across the lifespan. We aimed to evaluate the clinical validity of two NIHTB-CB tasks as cognitive screening tools in pediatric epilepsy by comparing them to standard neuropsychological measures and their association with epilepsy characteristics. Forty-seven patients with epilepsy ages 5-18, including ten repeat evaluations, were assessed. Correlational analyses and agreement statistics were conducted to validate NIHTB-CB tasks (Flanker Inhibitory Control and Attention test (Flanker) and Pattern Comparison Processing Speed test (Pattern Comparison)) with standard clinical measures. We also examined if performance was related to epilepsy characteristics, including polytherapy, age of seizure onset, seizure type, and history of Electrical Status Epilepticus in Sleep (ESES). The NIHTB-CB tests had moderate to strong correlations with neuropsychological measures of executive functioning, processing speed, and intelligence. Agreement statistics indicated better sensitivity than specificity. Polytherapy and later age of seizure onset were associated with lower performance on Pattern Comparison. ESES patients did not significantly differ in performance on the tests compared to non-ESES patients. Pilot data from a subset of repeated measures indicated a good range of change scores. These two NIHTB tasks are feasible as a screening tool in a clinic given their correlation with clinical measures that assess executive function, processing speed, and IQ. This study supports the use of these tasks as brief, easily accessible screener tools to identify cognitive dysfunction in domains commonly impacted in patients with epilepsy and potential use for monitoring over time.

Psychometric properties of the Behavior Rating Inventory of Executive Function, second edition (BRIEF2) self-report form in Iranian adolescents

BACKGROUND

This study investigated the psychometric properties of a Persian translation of the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) Self-Report form.

METHOD

Participants were 589 typically developing adolescents (336 girls and 253 boys), ages 11-18 years old (M = 15.16; SD = 2.04), in Iran. They completed the Persian version of the BRIEF2 Self-Report form and Teenage Executive Functioning Inventory (TEXI). The Persian translated BRIEF2 psychometric properties were examined via internal consistency, test-retest reliability, convergent validity via associations with TEXI scores, and internal structure using structural equation modeling (SEM) to evaluate fit of the three-factor structure from the original English version BRIEF2.

RESULTS

Findings indicated the Persian version of BRIEF2 Self-Report form yielded scores with robust reliability, with internal consistency ranging from .87 to .93 and test-retest correlations ranging from .89 to .96, and adequate convergent validity, with correlations with the TEXI ranging from .48 to .79. SEM revealed that a three-factor solution was the best fitting model for the seven subscales of the Persian BRIEF2.

CONCLUSION

These findings support the clinical use of the Persian BRIEF2 in Iranian adolescents, including the interpretation of the BRIEF2 three-factor structure, as well as the multidimensional nature of executive functions.

Early and stable difficulties of everyday executive functions predict autism symptoms and emotional/behavioral problems in preschool age children with autism: a 2-year longitudinal study

Introduction

Longitudinal studies of autistic children show that autism symptoms and emotional/behavioral problems vary and change over time. However, the factors that affect this variability remain far from certain and very little is known about what take place in the preschool period and the role of executive functions (EF).

Methods

Here, we test the influence of stable difficulties in everyday executive functioning (EEF) during early childhood across 2 years on autistic symptoms and emotional and behavioral problems. Twenty-nine autistic children (24 males and 5 females) were assessed twice within the space of 2 years. At baseline (M = 29 months, SD =5.6 months), participants were assessed for EEF, cognitive development, autistic symptoms, and emotional/behavioral problems. At follow-up, we repeated the same assessment except for cognitive development.

Results

The group with stable difficulties (across 2 years) in EEF during early childhood showed a worsening in the severity of autistic symptoms and emotional and behavioral problems compared with children without EEF difficulties (p < 0.05), and these effects cannot be attributable to cognitive development.

Discussion

Our results suggest that early and stable EEF plays the role of a modifier by interacting with the core domains of autism, in particular with the social affect domain (SA CSS), influencing social cognition and exacerbating or lessening symptom expression and emotional behavioral problems. These short-term longitudinal and preliminary findings underscore the importance of EEF as necessary target for early intervention in children with autism.

A Validation Study of the BRIEF-2 Among Kindergarteners and First Graders At-Risk for Behavior Problems

Early identification of executive dysfunction and timely school-based intervention efforts are critical for students at risk for problematic behaviors during early elementary school. The original Behavior Rating Inventory of Executive Functioning (BRIEF) was designed to measure real-world behavioral manifestations of executive functioning, neurocognitive processes critical for school success. With the updated BRIEF-2, independent validation is needed with kindergarten and first grade students at risk for emotional and behavioral disorders. Thus, using item level analyses, we examined the factor structure of the BRIEF-2 Teacher Rating form with 1,112 students. Results indicated little evidence for the original three-index model and supported a modified two-index model, with a Cognitive Regulation Index and an overall Behavior-Emotion Regulation Index. Criterion related validity indicated positive relationships with performance-based executive functioning (Head-Toes-Knees-Shoulders) and later internalizing and externalizing behaviors. We discuss implications of findings for early identification and school-based intervention efforts, as well as future research.

A text messaging intervention and quality of life in adolescents with solid organ transplants

BACKGROUND

Facilitating communication between adolescents and HCP outside of appointments may enhance patient experience and outcomes. The purpose of this study was to determine whether SMS enhances the healthcare experience, QoL, and medication adherence in adolescent SOT patients.

METHODS

This was a prospective observational study of an SMS platform (WelTel Inc) for SOT patients aged 12-19 years. QoL was assessed before and after using the PedsQL™ Transplant Module. Medication adherence was assessed with the frequency of therapeutic tacrolimus levels and variation based on control chart analysis. Patient experience and engagement was evaluated with surveys, response rate to messages, and number of clinical conversations (>2 messages).

RESULTS

Twenty-three patients were included (median age 15.7 years (IQR 13.6-17.1)). Median intervention duration was 13.5 months (range 4.0-16.7 months). There was a 68% response rate (742/1095) with 375 clinical conversations. The majority of patients reported the intervention provided a positive outlook on their health (17/23), was useful (18/23), and improved their connection to HCPs (17/23). Following the intervention, there was no significant difference in the median scaled QoL scores (pre-intervention: 81 (IQR 76.5-93.3), post-intervention: 78 (IQR 76-93); p = .37), mean percentage of therapeutic tacrolimus levels (pre-intervention: 52 ± 25%, post-intervention: 65 ± 17%; p = .07), or variation on control chart analysis of tacrolimus levels.

CONCLUSIONS

The WelTel messaging platform provided supplemental clinical care for a group of adolescent SOT patients that enhanced their healthcare experience. Patient QoL and adherence were unchanged following the intervention and remained at a high level.

A randomised controlled trial (MindChamp) of a mindfulness-based intervention for children with ADHD and their parents

BACKGROUND

Family mindfulness-based intervention (MBI) for child attention-deficit/hyperactivity disorder (ADHD) targets child self-control, parenting and parental mental health, but its effectiveness is still unclear.

METHODS

MindChamp is a pre-registered randomised controlled trial comparing an 8-week family MBI (called 'MYmind') in addition to care-as-usual (CAU) (n = 55) with CAU-only (n = 48). Children aged 8-16 years with remaining ADHD symptoms after CAU were enrolled together with a parent. Primary outcome was post-treatment parent-rated child self-control deficits (BRIEF); post hoc, Reliable Change Indexes were explored. Secondary child outcomes included ADHD symptoms (parent/teacher-rated Conners' and SWAN; teacher-rated BRIEF), other psychological symptoms (parent/teacher-rated), well-being (parent-rated) and mindfulness (self-rated). Secondary parent outcomes included self-ratings of ADHD symptoms, other psychological symptoms, well-being, self-compassion and mindful parenting. Assessments were conducted at post-treatment, 2- and 6-month follow-up.

RESULTS

Relative to CAU-only, MBI+CAU resulted in a small, statistically non-significant post-treatment improvement on the BRIEF (intention-to-treat: d = 0.27, p = .18; per protocol: d = 0.33, p = .11). Significantly more children showed reliable post-treatment improvement following MBI+CAU versus CAU-only (32% versus 11%, p < .05, Number-Needed-to-Treat = 4.7). ADHD symptoms significantly reduced post-treatment according to parent (Conners' and SWAN) and teacher ratings (BRIEF) per protocol. Only parent-rated hyperactivity impulsivity (SWAN) remained significantly reduced at 6-month follow-up. Post-treatment group differences on other secondary child outcomes were consistently favour of MBI+CAU, but mostly non-significant; no significant differences were found at follow-ups. Regarding parent outcomes, significant post-treatment improvements were found for their own ADHD symptoms, well-being and mindful parenting. At follow-ups, some significant effects remained (ADHD symptoms, mindful parenting), some additional significant effects appeared (other psychological symptoms, self-compassion) and others disappeared/remained non-significant.

CONCLUSIONS

Family MBI+CAU did not outperform CAU-only in reducing child self-control deficits on a group level but more children reliably improved. Effects on parents were larger and more durable. When CAU for ADHD is insufficient, family MBI could be a valuable addition.

Caregiver-reported executive functioning and associated adaptive and challenging behaviour in children with histories of developmental delay

BACKGROUND

Deficits in executive functioning (EF) have been measured in individuals with developmental disabilities, such as autism spectrum disorder and attention-deficit/hyperactivity disorder, through the use of behaviour rating scales and performance-based assessment. Associations between EF and variables such as challenging and adaptive behaviour have been observed; however, limited research exists on EF profiles in children with heterogeneous developmental delay or with intellectual disability (ID) or the impact of EF on adaptive and challenging behaviour with this population.

METHODS

The present study sought to examine the EF profile of 93 children (75 male and 18 female) previously identified with developmental delay in early childhood. EF was assessed using the Behaviour Rating Inventory of Executive Function, Second Edition (BRIEF-2). Children were categorised into an ID group (n = 14) or no ID group (n = 79) based on scores from cognitive and adaptive behaviour assessments. EF profiles were investigated and compared by group. In addition, the impact of EF on both adaptive behaviour and challenging behaviour was measured using hierarchical linear regressions.

RESULTS

Statistically significant differences in caregiver-reported EF were not observed between groups; however, both the ID and the no ID group scores were elevated as reported by their caregivers. For the overall sample, caregiver-EF accounted for significant variance in both adaptive (22%) and challenging (68%) behaviour after accounting for child age and sex.

CONCLUSIONS

Results indicated deficits in EF for children with and without ID. The significance of EF was accounted for in both adaptive and challenging behaviour for all children in the sample. Future research could elucidate the role of adaptive and challenging behaviour in understanding EF variability among children with histories of developmental delay.

Behavioral aspects of executive functions in young adults with well-controlled epilepsy

Executive function (EF) skills involve higher-level cognitive functions, such as planning, goal formation, goal-directed behavior, and effective performance. Previous research has shown that these aspects of EF are essential for successful functioning in everyday life. This study aimed to examine differences in the behavioral aspects of EF between young adults with epilepsy and healthy controls. The study involved 62 young adults, aged 18 to 30 years, divided into two groups: a study group of young adults with well-controlled epilepsy and a control group of healthy young adults. The groups were matched according to basic sociodemographic characteristics. The Behavior Rating Inventory of Executive Function - Adult version was used to assess the behavioral aspects of executive functions. A significant difference between groups was only observed on the Organization of Materials scale, where the group with epilepsy achieved better performance. Our findings suggest that self-assessed behavioral control of EF is almost the same in healthy young adults and young adults with epilepsy who have no comorbidities and have good control of the disease as well as preserved intellectual ability and functionality in everyday activities.

Enhanced interpretation of the BRIEF2: multivariate base rates of elevated scores in the standardization samples

The Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) is a standardized rating (self, parent, and teacher) scale of executive functioning in children and adolescents. Here, we provide multivariate base rate (MBR) information (for the Self, Parent, and Teacher forms), which is not included in the BRIEF2 Professional Manual. Participants were children and adolescents for the BRIEF2 Self-Report (ages = 11-18; N = 803), Parent-Report (ages = 5-18; N = 1,400), and Teacher-Report (ages = 5-18; N = 1,400) standardization samples. We focused on cumulative (e.g., % of sample with oneor more elevated scores) MBRs across scales, which were examined at three elevation levels on each form: T≥ 60, ≥65, and ≥70. Across forms, MBRs predictably decreased with increasing number of elevated scores and at higher cutoffs. The cumulative MBR of having at least one score at T≥ 60 was common (37.5-42.2%), but less frequent at T≥ 70 (15.4-17.4%). The probability of having elevated scores on all scales was very low, irrespective of form, age, or elevation threshold (T≥ 60 = 2.4-4.4%; T≥ 65 = 1.0-1.4%; T≥ 70 = 0.0-0.7%). There was no clinically meaningful relation between demographic factors (age, gender, race, and parental education) and MBRs. These data provide clinicians and researchers with an enhanced way of concurrently interpreting multiple BRIEF2 scales.

Behavior regulation skills are associated with adaptive functioning in children and adolescents with prenatal alcohol exposure

Children with prenatal alcohol exposure (PAE) experience a range of adverse outcomes that impact multiple domains of functioning, including cognitive, physical, mental health, behavioral, social-emotional, communication, and learning. To inform tailored clinical intervention, the current study examined the relation between caregiver-reported cognitive skills (executive function; EF) and adaptive functioning. The study conducted a secondary analyses of data provided by caregivers of 87 children and adolescents (aged 5-18 years, M = 11.7; 52% male) with confirmed PAE, including a subset (n = 70) with Fetal Alcohol Spectrum Disorder (FASD), who reported on their child's EF (Behavior Rating Inventory of Executive Function) and adaptive function (Adaptive Behavior Assessment System, 2nd Edition) skills. Findings from the current study showed that caregivers reported significantly poorer EF and adaptive functioning skills for children with PAE as compared to normative samples. Poorer behavior regulation skills were associated with all aspects of adaptive functioning (i.e., practical, conceptual, and social skills). Specifically, shifting skills emerged as the best predictor of adaptive functioning among children with PAE. These results highlight the possibility that targeting particular EF domains among individuals with PAE may benefit behavior regulation, which may also extend to adaptive skills. This highlights the need to develop EF interventions for children and adolescents who have been prenatally exposed to alcohol.

Investigation of the Clinical Utility of the BRIEF2 in Youth With and Without Intellectual Disability

OBJECTIVE

Executive function (EF) difficulties are commonly found in youth with intellectual disability (ID). Given mixed results from studies using performance-based EF measures, the EF profile has not been well characterized for this population. No published work has examined the clinical utility of the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) in distinguishing EF in ID. We hypothesized that the BRIEF2 would show greater elevations in youth with ID compared to the Average IQ comparison group.

METHODS

Participants included a large sample of 504 youth (157 in ID group; aged 8-18 years) referred for (neuro)psychological evaluation (2015-2019) and identified as meeting criteria for either ID or Average IQ comparison group.

RESULTS

Significant elevations were found across BRIEF2 indices and scales. Only mild elevations were noted in selective cognitive regulation scales within the Average IQ group. Groups differed significantly across all EF dimensions, with greater differences observed in behavioral regulation (Self-Monitoring, Inhibition), Shift, and Working Memory. An elevated but less variable pattern of index scores was noted in ID, while the overall pattern of scaled scores appeared similar between groups.

CONCLUSIONS

The less variable and consistently elevated profile may suggest fewer EF dimensions in individuals with ID than the model proposed in the test manual. Similar profiles between groups may reflect differences in severity, rather than differences in constructs measured by the EF factors, per se. Additional examination is needed to confirm potential structural differences in EF for youth with ID as measured by BRIEF2, with a clinical implication for greater efficiency of EF assessment in this population.

Adolescents with solid organ transplant: Using the BRIEF2 parent-report and self-report to measure parent-child agreement and everyday executive function

Agreement between parent and adolescent ratings of executive function (EF) is not known in adolescents with solid organ transplant (SOT), even though pressing concerns about EF deficits are being raised in this population. The current study investigated EF in adolescents with SOT using parent and self report. Twenty-five adolescents (M = 15.51 years) with SOT and their parent completed a behavior rating scale assessing EF within everyday context using the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2). Parents and their adolescents demonstrated moderate to excellent agreement across the BRIEF2 clinical and index scores, higher than previous research with a typical sample. Adolescent males had higher agreement with their parents than female adolescents. Both parents and adolescents reported significantly higher mean T scores on various BRIEF2 indices and domains, in addition to higher rates of clinically elevated executive dysfunction than their peers. Assessment of EF and targeting specific EF domains for intervention may be useful in this population.

Relationship between Executive Functions, Mindfulness, Stress, and Performance in Pediatric Emergency Simulations

Over the past decade, high-fidelity medical simulation has become an accepted and widely used teaching method in pediatrics. Both simulation and work in the real conditions of emergency departments are accompanied by stress that affects the executive functions of participants. One of the methods for reducing stress among medical students and healthcare professionals is the practice of mindfulness. The aim of this study was to examine whether executive functions, mindfulness, and stress are related to the technical and non-technical skills of medical students participating in medical simulations in pediatrics. The study included 153 final-year medical students. A total of 306 high-fidelity simulations of life-threatening situations involving children were conducted. Results: Stress and the coping mechanism of the participants were correlated to their skills during pediatric simulations. Some components of mindfulness, such as non-judgment and conscious action, were positively related to the skills of medical team leaders. Executive functions correlated with the non-technical skills and mindfulness of the medical students. Conclusions: Stress, mindfulness, and executive functions modeled the behavior and skills of medical students during pediatric simulations of life-threatening events. Further research in this area may prove whether mindfulness training will improve learning outcomes in pediatric emergency medicine.

Cognitive control deficits in pediatric frontal lobe epilepsy

Executive dysfunction and behavioral problems are common in children with epilepsy. Inhibition and shifting, both aspects of cognitive control, seem related to behavior problems and are thought to be driven mainly by the frontal lobes. We investigated if inhibition and shifting deficits are present in children with frontal lobe epilepsy (FLE). Secondly, we studied the relationship between these deficits and behavior problems. Thirty-one children were administered the Stroop Color Word Test and a digital version of the Wisconsin Card Sorting Test (WCST). Parents completed the Behavioral Rating Inventory for Executive Function (BRIEF) and the Achenbach scale (Child Behavior Checklist (CBCL)). About 20% of the children displayed significant low results on the Stroop Effect. About 60% showed shifting problems on the WCST. Parents reported cognitive control and behavioral deficits in about a third of the children. Also, behavioral problems and deficits in inhibition and shifting in daily life (BRIEF) seem to be related. There were no correlations between questionnaires and the Stroop and the WCST. Only in the group of children with many perseverative errors there were especially high correlations between Inhibit of the BRIEF.

Executive functions

First, executive functions are defined. Then the development of executive functions in children, from infancy to 10-11 years of age, is briefly described. The relation between the speed of processing and the development of executive functions is addressed. Finally, tools and pointers for evaluating executive functioning in younger and older children are discussed. A cautionary note is sounded, in that almost no executive function measure requires only one executive function. A child might fail a working memory task because of problems with inhibitory control (not working memory), fail an inhibitory control task because of working memory problems, or fail a cognitive flexibility, planning, or reasoning task because of problems with inhibitory control or working memory.

Promoting Executive Functioning in Children with Autism Spectrum Disorder Through Mixed Martial Arts Training

The present study evaluated the effectiveness of a mixed martial arts (MMA) intervention in improving executive functions (EFs) in a sample with autism spectrum disorder (ASD). School-aged children with ASD were randomly assigned to a MMA intervention group or a waitlist control (WLC) group. The intervention featured a 26-class program over a 13-week period; the WLC group did not participate in any martial arts between pre- and post-test. Results indicated that the MMA group had significantly better EFs at post-test compared to the WLC group. The intervention appeared to be efficacious in meeting its goals of improving the executive functioning of children with ASD. The present study extends the current literature on the malleability of EFs among children with ASD.

Feasibility and Preliminary Efficacy of an Adapted Transdiagnostic Treatment for Children With Executive Function Deficits

Few psychological interventions exist to target executive function difficulties in children and adolescents. The current study modified the Unstuck and On Target! intervention protocol for use in an outpatient clinic setting with a diagnostically diverse group of participants. Participants engaged in a 10-week child and parent group treatment with assessment measurement at pre- and post-treatment. Assessments consisted of parent-report questionnaires, clinician-administered tasks, and treatment fidelity ratings. Results suggest that the modified intervention was delivered with high fidelity and is feasible and acceptable in a transdiagnostic sample. Although preliminary, efficacy appears promising and suggests that parent-rated executive function, as well as behavioral and emotional challenges, are amenable to change as a result of intervention participation. The results imply that the modified intervention has merit, and should be further explored within the context of larger studies.

Executive Function Profiles at Home and at School in 11-Year-Old Very Low Birth Weight or Very Low Gestational Age Children

OBJECTIVE

Executive function (EF) problems of children born at very low birth weight (VLBW; ≤1500 g) or very low gestational age (VLGA; <32 gestational weeks) may present differently at school compared to the home environment. Ecological assessment of EF including parent- and teacher-rated profiles and associated risk factors of 11-year-old children born at VLBW or VLGA was evaluated.

METHODS

A total of 125 VLBW or VLGA children and 132 controls were assessed using the Behavior Rating Inventory of EF, which includes 8 subscales that form the Behavioral Regulation and Metacognition Indexes. For VLBW or VLGA children, full-scale intelligence quotient (IQ) was assessed using the Wechsler Intelligence scale for Children, Fourth Edition. Neonatal data were collected systematically.

RESULTS

VLBW or VLGA children with full-scale IQ ≥ 70 had clinically significant problems in the Working Memory subscale at school. Although they had clinically significant problems at home in the Behavioral Regulation Index, the difference disappeared when adjusted for paternal education. Lower gestational age, lower birth weight z-score, surgical necrotizing enterocolitis, low paternal and maternal education, and lower full-scale IQ were identified to be risk factors for higher scores in ecological assessment of EF.

CONCLUSION

VLBW or VLGA children in this cohort exhibit fewer EF problems in ecological assessment of EF compared to previous literature. EF problems of this study population vary by home and school setting and are emphasized in working memory at school. Screening for EF problems in school environment is recommended to target the support.

Epilepsy Journey: A proof of concept trial of a Web-based executive functioning intervention for adolescents with epilepsy

OBJECTIVE

To examine the preliminary feasibility and acceptability of a Web-based program, Epilepsy Journey, to improve executive function behaviors in adolescents with epilepsy.

METHODS

We conducted a proof of concept single-arm pilot trial of Epilepsy Journey with 31 adolescents (average age = 15.3 ± 1.3 years) who had an epilepsy diagnosis and executive function (EF) deficits on the caregiver-report version of the Behavior Rating Inventory of Executive Function (BRIEF). Epilepsy Journey coupled a gamified problem-solving website comprised of 10 learning modules targeting EF deficits (eg, working memory, organization, problem-solving) with Skype sessions with a trained therapist. Outcomes included feasibility (attrition, sessions completed) and acceptability (satisfaction ratings). Exploratory analyses examined changes in caregiver-, self-, and teacher-reported BRIEF scores from baseline to posttreatment and at 2- and 5-month follow-ups.

RESULTS

Seventy-nine percent of participants completed the program. Satisfaction was high, with 97% of caregivers and adolescents rating the program as helpful and indicating they would recommend it to others. Caregivers and adolescents reported global improvements on the BRIEF, with caregivers reporting significant improvements on all BRIEF subscales. EF symptoms rebounded slightly between the 2- and 5-month follow-ups for some of the self- and caregiver-reported BRIEF scales. Notably, clinically meaningful improvements (eg, clinical/subclinical to normative levels) were reported for several caregiver-reported BRIEF subscales, including the Global Executive Composite (62% to 33-34%) and Metacognitive Index (74% to 41-42%) from baseline to 2- and 5-month follow-up.

SIGNIFICANCE

Findings suggest that a Web-based problem-solving intervention tailored to EF deficits for adolescents with epilepsy is both feasible and acceptable and may contribute to improvements in EF behaviors across domains.

Working memory in pediatric frontal lobe epilepsy

Thirty-two children with frontal lobe epilepsy (FLE) were assessed using different working memory measures. In addition, parents and teachers completed the working memory scale of the Behavioral Rating Inventory of Executive Functioning (BRIEF) to assess the children's "daily life behavior." Results suggested minimal working memory deficits as assessed with performance-based measures. However, the BRIEF showed more working memory deficits suggesting that, on a daily life level, working memory problems seem to be associated with FLE. We discuss why the results of the performance-based measures are not consistent with results of the BRIEF.HighlightsParents as well as teachers report working memory dysfunction in daily life to the same extent.Performance based measures show minimal deficits of working memory.Correlation between working memory tasks and proxy measures are low.

Impairments of executive function in young children referred to child psychiatric outpatient clinic

Few studies have reported on the quantity and quality of executive function (EF) deficits in young children referred to child psychiatric outpatient clinic with multiple psychiatric symptoms. We evaluated the EF deficits with the Attention and Executive Function Rating Inventory-Preschool (ATTEX-P) filled out by day care teachers for 4- to 7-year-old clinical group ( n = 171) and reference group ( n = 709). Family background information was collected from all families by parent questionnaire. Diagnoses of the referred children were collected from medical records. Clinical group exhibited higher mean ranks across the ATTEX-P Total score and all nine subscales than reference group ( p < .001). Most of the children in the clinical group (58.5%) showed a significant amount of EF deficits (ATTEX-P Total score over clinical cut-off) including distractibility (55.6%) and impulsivity (53.8%) regardless of their diagnoses. In a multiple logistic regression model (controlling for age, gender and parental education), children in the clinical group had increased risk (odds ratio (OR)) = 10.6, 95% confidence interval (CI) = [6.88, 16.2], p < .001) for scoring over the clinical cut-off point on the ATTEX-P Total score. Assessment of EFs should be a routine part of the treatment plan in young children referred to child psychiatric outpatient clinic as it may guide the treatment choices.

Pattern of executive functioning in adolescents with epilepsy: A multimethod measurement approach

Youth with epilepsy demonstrate deficits in executive functioning (EF), the skills necessary for goal-directed behavior (e.g., problem-solving, initiating, monitoring, organization, planning, and working memory). Despite 30-50% of youth with epilepsy demonstrating EF deficits, no extant studies have utilized both performance and questionnaire-based measures to examine the pattern of EF deficits in adolescents with epilepsy. Study aims were to 1) identify the pattern of EF deficits in adolescents with epilepsy and 2) identify which assessment tools are most sensitive to EF deficits in this population (adolescents, ages 13-17, with epilepsy). An exploratory aim was to examine group differences on measures of EF by epilepsy type. Standard performance-based neuropsychological measures (Wechsler Intelligence Scale for Children - Version V or Wechsler Adult Intelligence Scale Working Memory Index-Version IV, Delis Kaplan Executive Functioning System, NIH Toolbox, Test of Everyday Attention for Children) and the Behavior Rating Inventory of Executive Functioning (BRIEF) comprised the multimethod assessment battery. Depending on the measure, 30% of adolescents with epilepsy had deficits in working memory, 17% in cognitive flexibility/problem solving, 6% in inhibition, and 18% in planning/organization. Attention was a significant problem for 15% of adolescents with epilepsy. Correlations among the various EF measures were quite poor. Across various EF domains, results indicated that adolescents with localization-related epilepsy demonstrated better EF skills compared to adolescents with unclassified epilepsy. Overall, our findings suggest that executive functioning deficits are selective and different from those observed in other neurological populations (e.g., attention deficit hyperactivity disorder (ADHD), traumatic brain injury) where problems with self-regulation (i.e., inhibition, planning/organization) are more pronounced. These findings support utilizing multiple measures, including both performance-based neuropsychological tests and parent- and self-reports, to assess executive functioning difficulties in adolescents with epilepsy as they are uniquely sensitive to executive functioning domains. Adolescents with unclassified epilepsy also appear to be at higher risk for EF deficits and thus represent an important group to target for intervention.

Mechanisms behind distracted driving behavior: The role of age and executive function in the engagement of distracted driving

Performing secondary tasks, such as texting while driving, is associated with an increased risk of motor vehicle collisions (MVCs). While cognitive processes, such as executive function, are involved in driving, little is known about the relationship between executive control and willingness to engage in distracted driving. This study investigated the relationship between age, behavioral manifestations of executive function, and self-reported distracted driving behaviors. Executive difficulty (assessed with the BRIEF-A) as well as demographics (age and gender) was considered as possible predictors of engagement in distracted driving behaviors. Fifty-nine young, middle, and older adults self-reported executive difficulty and weekly engagement in distracted driving behaviors. Results revealed that while partially accounted for by age, global executive difficulty was uniquely related to engagement in distracted driving behaviors. Older age was associated with fewer weekly self-reported distracted driving behaviors while higher self-reported executive difficulty was associated with more frequent weekly engagement in distracted behavior. No significant differences were found between young and middle-aged adults on distracted driving behaviors. Findings conclude that distracted driving is a ubiquitous phenomenon evident in drivers of all ages. Possible mechanisms underlying distracted driving behavior could potentially be related to deficits in executive function.

The test-retest reliability of the latent construct of executive function depends on whether tasks are represented as formative or reflective indicators

This study investigates the test-retest reliability of a battery of executive function (EF) tasks with a specific interest in testing whether the method that is used to create a battery-wide score would result in differences in the apparent test-retest reliability of children's performance. A total of 188 4-year-olds completed a battery of computerized EF tasks twice across a period of approximately two weeks. Two different approaches were used to create a score that indexed children's overall performance on the battery-i.e., (1) the mean score of all completed tasks and (2) a factor score estimate which used confirmatory factor analysis (CFA). Pearson and intra-class correlations were used to investigate the test-retest reliability of individual EF tasks, as well as an overall battery score. Consistent with previous studies, the test-retest reliability of individual tasks was modest (rs ≈ .60). The test-retest reliability of the overall battery scores differed depending on the scoring approach (r_mean = .72; r_{factor_score} = .99). It is concluded that the children's performance on individual EF tasks exhibit modest levels of test-retest reliability. This underscores the importance of administering multiple tasks and aggregating performance across these tasks in order to improve precision of measurement. However, the specific strategy that is used has a large impact on the apparent test-retest reliability of the overall score. These results replicate our earlier findings and provide additional cautionary evidence against the routine use of factor analytic approaches for representing individual performance across a battery of EF tasks.

Behavior Rating Inventory of Executive Function Adult Version in Patients with Neurological and Neuropsychiatric Conditions: Symptom Levels and Relationship to Emotional Distress

OBJECTIVES

The present study explored the level of self-and informant reported executive functioning in daily living using the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) in a large sample comprising healthy adults and patient cohorts with neurological and neuropsychiatric disorders. The relationship to neuropsychological test performance and self-reported emotional distress was explored, as well as the applicability of U.S. normative data.

METHODS

Scores on the self- and informant reported BRIEF-A are presented, along with scores on standardized cognitive tests, and on rating scales of self-reported emotional distress in a Norwegian healthy comparison group (n=115), patients with severe traumatic brain injury (n=125), focal frontal lobe damage (n=29), focal cerebellar lesion (n=24), Parkinson's disease (n=42), attention deficit hyperactivity disorder (n=34), type II bipolar disorder (n=21), and borderline personality disorder (n=18).

RESULTS

Strong associations were observed between the BRIEF-A and emotional distress in both the healthy group and in neurological groups, while no or weak relationships with IQ and performance-based tests of executive function were seen. The relationship between BRIEF-A and emotional distress was weaker in the neuropsychiatric patient groups, despite high symptom load in both domains. Healthy participants tended to have BRIEF-A scores 1/2-3/4 SD below the U.S. normative mean of T score=50.

CONCLUSIONS

The study demonstrates the need to interpret BRIEF-A results within a broad differential diagnostic context, where measures of psychological distress are included in addition to neuropsychological tests. Uncertainty about the appropriateness of U.S. normative data in non-U.S. countries adds to the need for interpretive caution. (JINS, 2016, 22, 682-694).

Childhood Maltreatment Exposure and Disruptions in Emotion Regulation: A Transdiagnostic Pathway to Adolescent Internalizing and Externalizing Psychopathology

Child maltreatment is a robust risk factor for internalizing and externalizing psychopathology in children and adolescents. We examined the role of disruptions in emotion regulation processes as a developmental mechanism linking child maltreatment to the onset of multiple forms of psychopathology in adolescents. Specifically, we examined whether child maltreatment was associated with emotional reactivity and maladaptive cognitive and behavioral responses to distress, including rumination and impulsive behaviors, in two separate samples. We additionally investigated whether each of these components of emotion regulation were associated with internalizing and externalizing psychopathology and mediated the association between child maltreatment and psychopathology. Study 1 included a sample of 167 adolescents recruited based on exposure to physical, sexual, or emotional abuse. Study 2 included a sample of 439 adolescents in a community-based cohort study followed prospectively for 5 years. In both samples, child maltreatment was associated with higher levels of internalizing psychopathology, elevated emotional reactivity, and greater habitual engagement in rumination and impulsive responses to distress. In Study 2, emotional reactivity and maladaptive responses to distress mediated the association between child maltreatment and both internalizing and externalizing psychopathology. These findings provide converging evidence for the role of emotion regulation deficits as a transdiagnostic developmental pathway linking child maltreatment with multiple forms of psychopathology.

Teacher Ratings of Executive Function Difficulties in Finnish Children with Combined and Predominantly Inattentive Symptoms of ADHD

School-age children with difficulties in executive functions (EFs) are at risk for substantial academic impairment and poorer developmental outcome. Although Attention Deficit Hyperactivity Disorder (ADHD) is generally associated with weaknesses in EFs, a relatively minimal amount is known about school-related EF difficulties and differences between ADHD subtypes. The present study examined teacher ratings of EF behaviors in 7- to 15-year-old Finnish children with combined symptoms of ADHD (ADHD-C; n = 189), predominantly inattentive symptoms (ADHD-I; n = 25), and no ADHD (n = 691). The teacher ratings showed that both ADHD groups had more EF difficulties than controls. Ratings also indicated specific EF profiles for the ADHD subtypes, students with ADHD-I having more wide-ranging EF difficulties in attention as well as initiation, planning, and execution of actions than children with ADHD-C. According to the present findings, the school-related EF difficulties of children with ADHD-I need to be specifically acknowledged. Teacher ratings seem to be sensitive indicators of EF difficulties and distinguish between different kinds of EF profiles. In clinical practice, rating scales with reliable psychometric properties and normative data relevant to the specific cultural environment should be employed.

Association Between Executive Function and Problematic Adolescent Driving

OBJECTIVE

Motor vehicle collisions (MVCs) are one of the leading causes of injury and death for adolescents. Driving is a complex activity that is highly reliant on executive function (EF) to safely navigate through the environment. Little research has examined the efficacy of using self-reported EF measures for assessing adolescent driving risk. This study examined the Behavior Rating Inventory of Executive Function (BRIEF) questionnaire and performance-based EF tasks as potential predictors of problematic driving outcomes in adolescents.

METHODS

Forty-six adolescent drivers completed the (1) BRIEF, (2) Trail Making Test, (3) Backwards Digit Span, and (4) self-report on 3 problematic driving outcomes: the number of times of having been pulled over by a police officer, the number of tickets issued, and the number of MVCs.

RESULTS

Greater self-reported difficulty with planning and organization was associated with greater odds of having a MVC, whereas inhibition difficulties were associated with greater odds of receiving a ticket. Greater self-reported difficulty across multiple BRIEF subscales was associated with greater odds of being pulled over.

CONCLUSION

Overall findings indicated that the BRIEF, an ecological measure of EF, showed significant association with self-reported problematic driving outcomes in adolescents. No relationship was found between performance-based EF measures and self-reported driving outcomes. The BRIEF could offer unique and quick insight into problematic driving behavior and potentially be an indicator of driving risk in adolescent drivers during clinical evaluations.

Performance-based tests versus behavioral ratings in the assessment of executive functioning in preschoolers: associations with ADHD symptoms and reading achievement

The early assessment of the executive processes using ecologically valid instruments is essential for identifying deficits and planning actions to deal with possible adverse consequences. The present study has two different objectives. The first objective is to analyze the relationship between preschoolers' performance on tests of Working Memory and Inhibition and parents' and teachers' ratings of these executive functions (EFs) using the Behavior Rating Inventory of Executive Function (BRIEF). The second objective consists of studying the predictive value of the different EF measures (performance-based test and rating scales) on Inattention and Hyperactivity/Impulsivity behaviors and on indicators of word reading performance. The participants in the study were 209 children in the last year of preschool, their teachers and their families. Performance-based tests of Working Memory and Inhibition were administered, as well as word reading measures (accuracy and speed). The parents and teachers filled out rating scales of the EF and typical behaviors of attention deficit hyperactivity disorder (ADHD) symptomatology. Moderate correlation values were found between the different EF assessments procedures, although the results varied depending on the different domains. Metacognition Index from the BRIEF presented stronger correlations with verbal working memory tests than with inhibition tests. Both the rating scales and the performance-based tests were significant predictors of Inattention and Hyperactivity/Impulsivity behaviors and the reading achievement measures. However, the BRIEF explained a greater percentage of variance in the case of the ADHD symptomatology, while the performance-based tests explained reading achievement to a greater degree. The implications of the findings for research and clinical practice are discussed.

A t(3;9)(q25.1;q34.3) translocation leading to OLFM1 fusion transcripts in Gilles de la Tourette syndrome, OCD and ADHD

Gilles de la Tourette syndrome (GTS) is a neuropsychiatric disorder with a strong genetic etiology; however, finding of candidate genes is hampered by its genetic heterogeneity and the influence of non-genetic factors on disease pathogenesis. We report a case of a male patient with GTS, obsessive compulsive disorder, attention-deficit/hyperactivity-disorder, as well as other comorbidities, and a translocation t(3;9)(q25.1;q34.3) inherited from a mother with tics. Mate-pair sequencing revealed that the translocation breakpoints truncated the olfactomedin 1 (OLFM1) gene and two uncharacterized transcripts. Reverse-transcription PCR identified several fusion transcripts in the carriers, and OLFM1 expression was found to be high in GTS-related human brain regions. As OLFM1 plays a role in neuronal development it is a likely candidate gene for neuropsychiatric disorders and haploinsufficiency of OLFM1 could be a contributing risk factor to the phenotype of the carriers. In addition, one of the fusion transcripts may exert a dominant-negative or gain-of-function effect. OLFM1 is unlikely to be a major GTS susceptibility gene as no point mutations or copy number variants affecting OLFM1 were identified in 175 additional patients. The translocation described is thus a unique event, but further studies in larger cohorts are required to elucidate involvement of OLFM1 in GTS pathogenesis.

Large-scale brain systems and subcortical relationships: practical applications

This article describes an interactive paradigm for understanding brain functioning. This model requires both explicit and implicit learning processes. This paradigm is illustrated through the interpretation of practical examples of behavior. Applications of current neuropsychological tests are presented within this interactive paradigm. The development of new neuropsychological tests is presented, as derived from experimental test paradigms that evaluate implicit learning processes.

Much ado about norming: the Behavior Rating Inventory of Executive Function

The Behavior Rating Inventory of Executive Function (BRIEF) is a rating scale designed to assess executive functions in everyday life that is widely used in school and clinical settings and in research studies. It has been recently suggested, however, that the limited geographic stratification of the standardization sample renders the measure overly sensitive. We evaluated this hypothesis by examining BRIEF scores across studies of typically developing children and adolescents. Thirty-nine studies were identified that included at least one of three possible index scores. Mean scores across studies were (a) within one to two T-score units from the standardization sample mean of 50, (b) tended to be slightly lower than 50, and (c) were unrelated to geographic location (US Census regions or internationally). These findings refute recent claims that the BRIEF is overly sensitive and further add to the large body of literature supporting the validity of the measure.