CASP 2018 Evidence for Assessment & Intervention with Executive Functions 10/21/2018 Disclosure The Evidence for Executive Function Assessment & Inter

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1 Disclosure The Evidence for Executive Function Assessment & Intervention Harvard Medical School Peter Isquith is co-author of the Behavior Rating Inventory of Executive Function family of instruments (BRIEF), the Tasks of Executive Control (TEC), and the Adaptable Pediatric Neurocognitive Battery, some of which may be discussed at this presentation. Overview Introduction to Executive Function Assessment of Executive Function A Brief History of the BRIEF Clinical Profiles Intervening for executive function problems NASP Data-Based Decision Making and Accountability Relevance: Knowledge of varied models and methods of assessment and data collection for identifying strengths and needs Systematically collecting data form multiple sources and using ecological factors as context for all assessment & intervention decisions Using assessment data to understand students problems and implement evidence-based instructional, behavioral & mental health services Measuring progress & outcomes Evaluate effectiveness and need for modification to school-based interventions 4 Phineas Gage: Cavendish, VT 1848 Phineas Gage: A changed man 3 tamping iron shot through left cheek and exited left frontally Destroyed much of left frontal lobe He is fitful, irreverent, indulging at times in the grossest profanity, impatient of restraint or advice when it conflicts with his desires; at times pertinaciuously obstinate yet capricious and vascillating. His friends and acquaintances said he was no longer Gage Harlow, 1868 Inhibit Shift Emotional Control 1

2 Associations between teacher ratings on the BRIEF-P at 4 years and performance on WJ3 Math Fluency at 6 years Clark, CA, Pritchard, VE & Woodward, LJ. (2010). Preschool executive functioning abilities predict early mathematics achievement. Developmental Psychology, 46, Definition & Models of Executive Function The unity and diversity of executive functions Teuber,

3 Approaches to defining Executive Functions Evolutionary purpose- allow organism to engage in goal oriented purposeful behavior Neuroanatomic substrate- frontal lobe Neurocognitive processes- what tests test Complex skills- what we observe (inhibit, shift, working memory, plan, organize, monitor) Suchy, Y Neuroanatomical Model: Executive Functions & the Frontal Lobes There is no unitary executive function. Rather, distinct processes related to the frontal lobes can be differentiated which converge on a general concept of control functions. Stuss, D.T., & Alexander, M.P. Psychological Research, Neurocognitive Model: The Unity and Diversity of Executive Functions Miyake, Friedman, Emerson, Witzki, Howerter & Wager, 2000 Complex Skills Model: Functional Domains of The Executive Behavior Regulation Gioia, Isquith, Guy & Kenworthy, 2000 Inhibit - stop an action or not react to impulse Self-monitor - attend to behavior/output; revise Emotion Regulation Shift - move from one task or situation to another Emotional Control - regulate emotional response Cognitive Regulation Working Memory/Sustain - hold information actively in mind Initiate - begin task, activity, attention Plan - anticipate future events and develop steps Organize - establish, maintain order Task Monitor- attend to output; revise Three Factor Model Inhibit Self-Monitor Initiate, Working Memory Plan, Organize, Monitor Shift Set Emotional Control 3

4 Unitary vs Multidimensional? results from analyses reveal that the behaviors that are rated on the CEFI represent a single construct: Executive function. Naglieri & Goldstein, 2012 pg 72 Naglieri & Goldstein, 2012 There is no unitary executive function. Stuss, D.T., & Alexander, M.P., EF is an umbrella term encompassing distinct, but interrelated, abilities that contribute to management of goal-directed behaviors. Gioia, Isquith, Guy & Kenworthy, 2000 Both the unity and diversity of executive functions need to be taken into account in developing a theory of executive functions. Miyake et al., 2000 The executive system has multiple subsystems with anatomical & behavioral separation Two Levels of Executive Function Definitions Unity: Evolutionary purpose- allow organism to engage in goal oriented problem-solving Diversity: Neuroanatomy- frontal lobe function Neurocognitive processes- what tests test Complex skills- what we observe (inhibit, shift, working memory, plan, organize, monitor) Unity: Executive Function is the orchestration of basic cognitive processes during goal oriented problem solving Suchy,

5 Diversity: Methods of Assessing EF Functions of the Orchestra Functions of the Conductor Perception Attention Inhibit Self-Monitor Micro Molar Macro Language processes Visual-spatial processes Shift Flexibly Modulate Emotions Genetics Structural & Functional Imaging Performance Measures ( tests ) Observations Rating Scales Memory Initiate Sensory inputs Working Memory Motor outputs Plan Knowledge & skills social academic Organize Task-Monitor Performance Measures Advantages of EF Performance Tests: Verbal Fluency / Figural Fluency Stroop Color-Word Interference Test Rey-Osterrieth Complex Figure Tower of Hanoi / Tower of London Wisconsin Card Sorting Test Mazes Trail Making Continuous Performance Tests n back Go/No-go Increased specificity of processes Increased task control and internal validity Decades of research on test behavior Dogmatic adherence to the psychometric tradition of understanding and assessing EF at its most basic cognitive level is grossly inadequate. It provides only a superficial evaluation of even the conventional phenotypic view of EF. It fails to capture entirely the multilevel, concentrically arranged, affectively/motivationally charged, socially important and culturally facilitated nature of the extended phenotype of EF/SR in everyday human activities. Barkley, 2012, pg Recognized need for: external validation, ecological validity for tests Standardized data about everyday executive function Standardized parent / teacher/ self ratings assess multiple aspects of executive functions Time & cost efficiency 5

6 A BRIEF History At a Glance Ages: 5-18 years Administration time: 5 minutes Screening 10 minutes full Parent, Teacher, Self- Report Forms: Paper & pencil iconnect Since publication: Expanded to cover ages 2-90 years More than 1200 peer-reviewed publications More than 50 clinical trials & outcome studies Translated into more than 60 languages Used on 6 continents Enhancements in the BRIEF2 Standardization 1400 Parents 1400 Teachers 800 Students Even across age groups Stratified by gender, ethnicity, parent education, geographic region No meaningful effects of ethnicity, parent education, or geographic region Equivalence with the BRIEF No new items on clinical scales, allowing for consistency of data collection between the BRIEF and BRIEF2 6

7 More concise scales BRIEF Multidimensional Factor structure Shorter by a Quarter Parent Form Confirmatory Factor Analysis Parent Form Profile Analysis New to the BRIEF Inhibit Self-Monitor Shift EC Initiate WM Plan/Org Task-Monitor Materials TD ADHD-C ADHD-I ASD LD Infrequency scale Infrequency scale helps identify unusual responding Parent Form Teacher Form Self-Report Form Forgets his/her name Forgets his/her name I forget my name Has trouble counting to three Has trouble counting to three I have trouble counting to three Cannot find the front door of home Cannot find the front door of I cannot find the front door of school my home 12-item Screening Parent, Teacher and Self-Report Forms quickly indicate whether further assessment is needed Screening Forms Correlate with GEC >.93 7

8 Base rates standardization sample Base rates clinical samples Clinical Groups ADHD-Combined ADHD/Learning Disability Tumor ADHD-Inattentive ASD Epilepsy ADHD-Sluggish Cognitive Tempo Neurofibromatosis type 1 Diabetes TBI Acute lymphoblastic leukemia Anxiety Learning Disability Contingency statistics BRIEF2 interpretation Procedure Example statements Review validity scales Ratings on the BRIEF2 were valid Review T scores and percentiles Parent ratings noted difficulties on the Inhibit, Working Memory, and Plan/Organize scales but typical function on the Emotional Control, Self-Monitor, Initiate, and Task- Monitor scales. Compare to base rates Elevations of this magnitude on the Inhibit and Working Memory scales occur in less than 10% of students his age. Procedure Review profile relative to diagnostic groups Examine inter-rater differences BRIEF2 interpretation (continued) Example statements The pattern is like that seen in students diagnosed with attention disorders. Teacher and parent ratings were in good agreement. Teacher ratings revealed a similar pattern of concerns with inhibitory control and working memory but also suggested problems with self-monitoring in the social setting. Clinical Profiles: ADHD Calculate T score Ratings over time showed a significant decrease in behavior differences; examine regulation concerns, but while there was some decrease in significance of emotion and cognitive regulation scores, the change was not difference. beyond that expected within an 80% confidence interval. 8

9 Executive Function vs ADHD Diagnosis Executive Function & ADHD Dx The diagnosis of ADHD may be better viewed in terms of the underlying executive functions Barkley 1996, 1997, 2000 Executive Function Sustaining working memory Organizing Planning Monitoring (inhibiting) ADHD-Inattentive Symptoms Paying close attention Sustaining attention Listening Forgetful Finishing tasks Organizing Losing materials Distracted Executive Function & ADHD Dx Executive Function Inhibition Motor Verbal Behavioral Social? Emotional? ADHD-Hyp/Imp Symptoms Fidgets Can t stay seated Runs about & climbs Can t play quietly On the go, driven Talks excessively Can t wait turn Interrupts others 83 Studies 3734 ADHD vs 2969 Controls Effect sizes No differences between ADHD- I and ADHD-C Less than ½ with ADHD showed impairment on any EF tasks Tasks: Impaired Stop signal RT 82% CPT Omissions 77% Tower tasks 59% CPT Commissions WCST Perseveration Trails B time Porteus Mazes Rey Complex Figure Sentence Span Digits Backward Toplak et al.,

10 BRIEF2 profiles in ADHD-I BRIEF2 profiles in ADHD-C Inhibit Self-Monitor Shift EC Initiate WM Plan/Org Task-Monitor Materials 40 Inhibit Self-Monitor Shift EC Initiate WM Plan/Org Task-Monitor Materials TD ADHD-I LD N = 159 N = 113 Gioia, Isquith, Guy & Kenworthy, 2015, Behavior Rating Inventory of Executive Function, 2 nd Edition TD ADHD-C ADHD-I LD N = 218 N = 159 N = 113 Gioia, Isquith, Guy & Kenworthy, 2015, Behavior Rating Inventory of Executive Function, 2 nd Edition BRIEF2 WM & Inhibit Predict ADHD Classification TD vs. ADHD ADHD-C vs. ADHD-I Measure Working Inhibit Inhibit Memory T>65 Function 1 a T>65 T>70 Function 2 b Sensitivity Specificity PPV NPV Likelihood Ratio Likelihood Ratio Correct Hit Rate % 83.08% 87.59% 73.68% 68.42% 84.96% a Function 1 = Inhibit, WM, EC b Function 2 = Inhibit, Shift, Initiate n = 1969 clinically referred 5-18 year-olds Isquith, Keneally, Roth & Gioia, 2015, Diagnostic Accuracy of the BRIEF-2 for Children with ADHD Clinical Profiles: ASD n = 1969 clinically referred 5-18 year-olds 10

11 Child Neuropsychology 2014 Troyb et al., 2014 Parent ratings more sensitive than performance tests Troyb et al., 2014 Troyb et al., 2014 BRIEF2 profiles in ASD Inhibit Self-Monitor Shift EC Initiate WM Plan/Org Task-Monitor Materials TD ADHD-C ADHD-I ASD LD N = 262 Gioia, Isquith, Guy & Kenworthy, 2015, Behavior Rating Inventory of Executive Function, 2 nd Edition Classification Accuracy of BRIEF2 in ASD Parent Teacher Classification TD vs. ASD a TD vs. ASD b Measure Shift T>65 Shift T>70 Shift T>65 Shift T>70 Sensitivity Specificity PPV NPV Likelihood Ratio Likelihood Ratio Correct Hit Rate % 83.02% 74.62% 77.83% 69.34% a n = 524; b n = 212; Updated BRIEF Profiles in Children with Autism Spectrum Disorders Y. Granader, P. Isquith, R. Dudley, L. Kenworthy,

12 BRIEF Scale Profiles in Peds TBI Children with history of TBI show deficits on the BRIEF 5-10 years later, with a linear trend in severity on the BRIEF related to severity of injury. N = 48 Vriezen & Pigott, 2002, Child Neuropsychology BRIEF Ratings in Students with TBI 80 BRIEF Index Scores for Controls and Children with PKU, Hydrocephalus, and Frontal Lesions Anderson, Anderson, Northam, Jacobs & Mikiewicz, Percentage of BRIEF Scores T > Inhibit Shift EC Initiate WM Plan/Org Monitor Materials TD LD ADHD-I ADHD-C ASD TBI Gioia, Isquith, Kenworthy & Barton, Typical PKU Hydrocephalus Frontal Lesion BRI MI Cortical Thickness Correlated with BRIEF Working Memory in Pediatric Moderate-Severe TBI 16 TBI (age: 9 16 years, 3.1 ± 2.4 years post-injury) and 16 demographically matched controls Several regions of less cortical thickness in the TBI group Cortical thickness not correlated with Glasgow Outcome Scale Worse BRIEF Parent report working memory correlated with abnormal thickness in key working memory brain regions Regions of significant cortical loss in TBI Longitudinal Changes in Cortical Thickness Correlated with BRIEF in Pediatric Moderate-Severe TBI Cortical thickness at ~ 3 and 18 months post-injury in 20 children with moderate-to-severe TBI (age: years) and 21 with orthopedic injury (age: years). BRI and Emotional Control higher in TBI than OI (only variables used) In TBI group, worse BRI (A) associated with greater thickness of medial left frontal lobe, and worse Emotion Regulation (B) with greater thickness of right medial frontal and right anterior cingulate gyrus over time. Interpreted as failure to undergo normal cortical thinning or adaptive change in the TBI group over time. Merkley et al. (2008, J Neurotrauma) Wilde et al. (2012, Int. J. Devl Neuroscience) 12

13 Neuroanatomical correlates of behavioral rating vs performance measures of working memory in typically developing children and adolescents Faridi, Karama, Burgaleta, White, Evans, Fonov, Collins & Waber, NIH Brain Development Cooperative Group. (2014). Method Longitudinial data from NIH MRI study N=347, 6-16 years, 54.3% girls Race, ethnicity, SES census matched Correlated lobar, amygdala, hippocampus, basal ganglia volumes with: BRIEF WM EC INH scales WISC-III Digit Span CANTAB Spatial Working Memory Faridi, Karama, Burgaleta, White, Evans, Fonov, Collins & Waber, NIH Brain Development Cooperative Group. (2014). Learning Executive Function 1965 BRIEF WM & PHG Digit/Visual Span & Hippocampus Interventions: General Findings Working Memory Training Diamond, A. & Lee, K. (2011) Science, Most studied intervention Narrow Transfer: Gains do not generalize beyond WM Some evidence of gains in classroom Gains maintained at six months Gains more limited at 1 year 13

14 Inhibition Training More limited success No evidence of transfer beyond computer Martial Arts Executive Training? Martial arts training with mindfulness associated with improved attention, emotion regulation, and behavior regulation vs regular PE Yoga with mindfulness resulted in better EF Aerobics? Physical /Cognitive Training Physical training alone did not improve EF People who are more physically active and fit have better executive functions Meta-analyses of aerobic exercise alone in older adults showed little to no EF benefits 2 of 3 studies in children found little to no EF change Cognitive training with physical activity improved EF Oswald et al., 2006; Moreau et al., 2015 Few studies (no studies?) have examined EF benefits in sports with mindfulness ADHD Medication Intervention Studies using Rating Scale Measures Other Biderman et al., 2011 Tourette s: Cummings et al., 2002 DuPaul et al., 2012 TBI: Beers et al., 2005 Findling et al., 2009 Depression: Roth et al., 2012; Madoo et al., 2014 Maziade et al., 2009 Hypertension (lande et al., 2010 Turgay et al., 2010 Yange et al.,

15 Effect of Lisdexamphetamine Dimesylate (Vyvanse) in Adults with Executive Dysfunction and Partial or Full remission of Major Depression DSM-IV dx of MDD- recurrent, no psychotic features Executive Dysfunction defined as BRIEF-A GEC T > 60 MADRAS < 18 at screening and baseline DuPaul et al., 2012 Madhoo et al. (2014) Neuropsychopharmacology Non-medication interventions using Rating Scales as Outcome Measures Liver transplant: Sorenson et al., 2011 Chemotherapy: Kesler et al., 2011; McDonald et al., 2013 Corticosteroids: Mrakostsky, 2012 Family Problem Solving; Wade et al., 2004, 2005 Cognitive Remediation: Beck et al., 2010; Hahn-Markowitz 2011, Toglia 2010 Flexibility in ASD: Kenworthy et al., children with mod-severe TBI 32 non-injured children Participated in problem solving skills training to teach metacognitive awareness and problem solving 15

16 A Collaborative Problem-Solving Model of Everyday Executive Function Intervention Mark Ylvisaker & Tim Feeney Teach goal-directed problem-solving process, within everyday meaningful routines, having real-world relevance and application, using key people as models & coaches Goal-Plan-Do-Review GOAL What do I want to accomplish? PLAN How am I going to accomplish my goal? MATERIALS/ EQUIPMENT STEPS/ASSIGNMENTS PREDICTION: HOW WELL WILL I DO? Self rating Other Rating How much will I get done? DO PROBLEMS SOLUTIONS REVIEW: HOW DID I DO? Self rating Other rating WHAT WORKED? WHAT DIDN'T WORK WHAT WILL I TRY NEXT TIME? Tools of the Mind Preschool curriculum based on Vygotsky s notions of development Pretend play requires inhibition, flexibility, and working memory Children involved in Tools program showed better performance on range of EF tasks When Tools was used as an add-on, gains were limited and narrow When incorporated across the school day, gains were much larger and replicated BUT children with no EF risks showed minimal gains Children with low SES showed marked gains Blair & Raver, 2014; Diamond et al.,

17 Real-World Collaborative Problem- Solving Intervention for EF in ASD Unstuck Philosophy: Principles of Remediation 1. Teach by Doing Coaching Model: Support, Fade, Generalize 2. Talk Less Self-regulatory scripts 3. Be consistent 4. Provide visual cues 5. Collaborate, use humor, have fun Lauren Kenworthy & Laura Anthony, Children s National Ylvisaker & Feeny, 1998; Feeny & Ylvisaker, 2008 Real World, Well-Matched Methods 67 3 rd -5 th grade children in 14 schools randomized Children met full criteria for diagnosis and were already receiving services Existing school staff led interventions Interventions matched on number of sessions (28) and training: Interventionists: Manual, 7 training sessions, 2 fidelity observations with feedback Parents: Manual, 2 training sessions, visual supports Mainstream Teachers: 1 training session, visual supports Parent & Teacher BRIEF Shift Higher score = Less flexible Take Aways: Direct EF training may improve an EF skill in isolation but transfer is narrow How an EF activity is presented is as important as the activity (i.e., coaching or mentoring) EF s need to be continually challenged Those with problems benefit more Training across the curriculum has greater benefit Parent Cohen s d=-0.64; Teacher Cohen s d=