Pacific Northwest
Neuropsychological Society, May 12, 2003
Tedd Judd, PhD,
ABPP-CN
Diplomate in Clinical Neuropsychology
851 Coho Way, Ste. 301
Bellingham, WA 98225, USA
(360) 734-7310 Ext. 3125
Fax: (360) 647 8336
Learning Objectives:
INTRODUCTION
Assumptions of executive
function assessment: intact component skills, “It takes frontal lobes to
evaluate frontal lobes (Stuss).”
Challenges and
limitations of executive function assessment: inherently low reliability;
non-repeatability for many problem-solving tasks; cultural/educational
limitations; inconsistency of the problem; inherent structure of the testing
situation.
THE THREE PRONGED APPROACH
Cognitive,
emotional/personality, adaptive
THE TESTS
D-KEFS
ABAS
CASL
FrSBe
BRIEF
BDS
RFFT
NEPSY
WJCS-3
TTT
BADS
TOL
NBAP
CASE ILLUSTRATIONS (time permitting)
THE TESTS
The
D-KEFS consists of 9 independent tests designed to measure quantitative and
qualitative aspects of executive functions. Many of the tests are improved
versions of older tests, with better standardization, advanced conditions,
quantitative scoring of error patterns, and a larger and more representative
norm group. Norms are by age, from 8 to 89. Education norms are in development.
The Trailmaking Test has 5 subtests for
probing component skills: Visual Scanning, Number Sequencing, Letter
Sequencing, Number-Letter Switching, and Motor Speed.
The Verbal Fluency Test has one
minute fluency for FAS, Animals, Boys Names, and Switching between Fruits and
Furniture.
Design Fluency involves drawing as many different designs as possible in one minute
using 4 straight lines to connect 5 dots, along with other rule constraints.
The Color-Word Interference Test is a
version of the Stroop test, with the Color, Word, and Interference conditions
similar to the Golden version. In the Interference/Switching condition the
person must perform the Interference task, except that some words have a box
drawn around them and must be read.
The Sorting Test consists of 6 cardboard
tokens with a word written on each. The person must sort these into two groups
of 3 items according to some principle, explain the principle, then sort them a
different way, for as many different sorts as possible (8 are possible). There
is also a category recognition condition. This test measures abstract reasoning
and mental flexibility.
The Twenty Questions Test is like the
familiar game of the same name and measures abstraction, strategy, and mental
flexibility.
The Word Context Test involves inferring
what a nonsense word means based on progressive clues. It measures the ability
to infer and integrate information.
The Tower Test involves moving 5 concentric
rings among 3 different pegs according to rules. It measures planning
abilities.
The Proverb Test involves interpreting
common and uncommon proverbs and measures the ability to think abstractly. It
includes a recognition condition.
EXTRA CREDIT:
Find the “context” for the words of the “Word Context Test” from the
D-KEFS:
Sev, prifa, enton, delz, vern, nelzen, gesh, luri, krame, kapla, grot
The ABAS II is a rating scale
completed by the person being evaluated and/or an informant (usually a family
member). Each item is rated on a 4-point scale: Is Not Able, Never When Needed,
Sometimes When Needed, Always When Needed.
The ABAS covers the 10 adaptive
skill areas of the DSM-IV and AAMRD definitions of mental retardation with
20-27 items/area. These are below (with examples of an easy and hard item). There is
a General Adaptive Composite score. Norms by age from birth to 89.
Review: Can be used as before and after brain illness. No validity scales;
potentially susceptible to response bias. Low ceiling. Cultural values and
limitations.
Communication
States his/her own telephone number. Talks about realistic
future educational or career goals.
Community Use
Finds the restrooms in public places. Uses the local library
to check out books, use reference materials, or for other purposes.
Functional Academics
States the days of the week in order. Budgets money to cover
expenses for at least one week.
Home Living
Operates a microwave oven. Cleans bathroom with proper
cleaning supplies.
Health and Safety
Shows caution around hot or dangerous items. Plans meals in
order to get necessary nutrition.
Leisure
Follows the rules in games and other fun activities.
Reserves tickets in advance for activities, for example, concerts or sports
events.
Self-Care
Puts shoes on correct feet. Gets hair cut.
Self-Direction
Goes out alone in daytime. Calls family or others when late.
Social
Has one or more friends. Says when he/she feels happy, sad,
scared, or angry.
Work
Attends work regularly. Shows positive attitude towards job.
Comprehensive Assessment of
Spoken Language (American Guidance Service, $300)
The CASL is a new measure designed to look not only at how the person
understands and expresses language but also how they process linguistic
information and use language in the real world. The latter includes measures of how the person can gain meaning from
the context rather than from the words themselves, how they interpret ambiguous
or nonliteral language, and how they apply language in real situations. Norms
for ages 3-21.
She runs like lightning. What does that mean?
When Alex tried out for the varsity basketball team, the coach told him,
“Son, you need a little more rain.” What did the coach mean?
When we saw Joe’s riant face, we knew he was enjoying the clown.
Explain what riant means.
By means of illation, the detective was able to arrive at the
method of the crime after merely examining the room where it took place.
Explain what illation means.
Mother called to four-year-old Sondra, “Be sure to bring your bathing suit. And don’t
forget your shovel and bucket.” Where were they going?
After examining the figures on annual car purchases, the American
automobile industry asked for a quota to be placed on foreign car imports. Why?
Tell two different meanings for these sentences:
It is light.
Janet offered to drive her many times.
Karen studied very hard last night for the big test she’s taking today.
Karen’s mom says “good-bye” to her as she leaves for school. What else can her
mom say to her?
The new teacher says to the first grade class, “I will greatly appreciate
it if you remain in the seated position while I absent myself.” The children do
no obey. Why?
Frontal Systems Behavior Scale (PAR, $165)
The FrSBe measures Apathy, Disinhibition, and Executive Dysfunction through self and informant ratings before the injury and currently. 46 items, 5-point scale from almost never to almost always. Age 18-95. Norms are by age, gender, rater, and education.
Apathy
Sits around doing nothing. Starts things but fails to
finish them, “peters out.”
Disinhibition
Talks out of turn, interrupts others in conversation. Laughs or cries too easily.
Executive Dysfunction
Is disorganized. Cannot do two things at once (for
example, talk and prepare a meal).
Overreacts to small problems. Has explosive, angry outbursts.
Is not a self-starter. Needs to be told to begin a task even when willing.
When given three things to do, remembers only the first or last. Is easily distracted by noises, activity, sights, etc.
Has good ideas but cannot get them on paper. Forgets to hand in homework even when completed.
Leaves playroom a mess. Cannot find things in room or school desk.
Global Executive Composite
Behavioral Dyscontrol Scale (experimental, see me)
On the BDS the person is asked to learn and carry out a number of motor sequences and tasks, and also to count aloud alternating with saying the alphabet. The highest possible score is 19. The BDS is still under research. The BDS is sensitive to difficulties in response organization and inhibition, and is a good predictor of ability to carry out common, everyday activities. Designed for the elderly. Low ceiling. Norms are by age.
Ruff Figural Fluency Test (Psych Corp, $103)
On the RFFT the person must draw as many
different designs as possible in one
minute within the constraints of set rules. Five trials are given. The test
requires the generation of new, non-verbal ideas and the formulation and use of
strategies. It is normed by age and
education. Designed to be non-verbal analog of verbal fluency. Shown to be
sensitive to right frontal injury.
NEPSY, a Developmental
Neuropsychological Assessment (Psych Corp, $598; PAR, $639)
The NEPSY is a neuropsychological battery for ages 8-13 and is normed by age.
Attention
/ Executive Functions Domain: The Tower Test measures the executive functions of
planning, monitoring, self-regulation, and problem solving by asking the child
to use a certain number of moves to re-arrange colored balls in a set
pattern. Design Fluency involves
rapidly drawing unique designs following general rules. The Statue subtest
measures persistence, distractibility, and impulse control, and involves
standing perfectly still with eyes closed for 75 seconds in spite of
distracting noises. Knock and Tap measures self-regulation and involves
responding to the examiner’s movements in a rule-bound, non-imitative manner.
The new scales have improved executive
function subtests
The person is given a
set of Tinkertoys and is instructed to build something. The result is rated by
number of pieces, mobility, name, 3-dimensionality, and free-standing. Measures
initiation, creativity, and planning. Correlated with independent adaptive
functioning.
Behavioural Assessment of the Dysexecutive
Syndrome (Thames Valley, £275; Psych Corp $655)
British test with cognitive tasks involving
planning, flexibility, time judgment, and multitasking. Also a rating
questionnaire. Norms age 16-87.
Temporal Judgment—estimation of how long it
takes to complete various events (e.g., routine dental appointment).
Rule Shift Cards—like Wisconsin Cart Sort
Action Program—practical problem solving in
extracting a cork from a tube.
Key Search—How would you search a field to
find lost keys?
Zoo Map—visit six locations following certain
rules.
Modified Six Elements—Schedule time for working
on six tasks in 10 minutes.
Dysexecutive Questionnaire—20 items, self and
informant, emotional or personality changes, motivational changes, behavioural
changes, cognitive changes.
Tower of London (Psych Corp, $259)
Three pegs of different heights, 3 balls of
different colors, move from one configuration to another according to rules and
a certain number of moves. A measure of planning. Norms age 7-60+.
Neuropsychology Behavior and Affect Profile (PAR, $120)
Before and Now rating by self and other. 106
items. Choices of Agree and Disagree. Age 15 and older. Scales of Indifference,
Inappropriateness, Pragnosis (communication pragmatics deficit), Depression,
and Mania. Compares to dementia, stroke, traumatic brain injury, and elderly
control groups, but no comprehensive norms available.