1. DYSEXECUTIVE SYMPTOM ASSESSMENTS
By: Tammy Balaban, Chantal Sampson, and Nykema Wright

2. Agenda Brief overview of executive function
Brief overview of the PRO-EX and BADS
Rationale and Critique of the assessments
The impact of dysexecutive symptoms on occupational performance

3. Executive Function Definition
“Integrative cognitive functions that determine goal-directed and purposeful behaviour and are superordinate in the orderly execution of daily life functions”.
(Cicerone et al., 2002)

4. Executive Function (2)
Dysexecutive Syndrome emanates from frontal lobe damage.
Includes symptoms such as decreased attention, increased distractibility, impulsivity, perseveration, difficulty with complicated or new tasks, difficulty using feedback, and behaving inappropriately in social situations.

5. Executive Function (3)
The term ‘Dysexecutive Syndrome’ includes disorders of planning, organisation, problem solving, setting priorities, and attention and is one of the major areas of cognitive deficit that can impede functional recovery and the ability to respond to rehabilitation programs.

6. The Profile Of Executive Control System (PRO-EX)
Braswell, D., Hartry, A., Hoornbeek, S., Johansen, A., Johnson, L., Schutlz, J., and Solhberg, M. (1993)
Used by OTs, SLPs and Psychiatrists involved in rehabilitation
Purpose:
To accurately assess executive function and provide a classification of executive control behavior components that will help to organize a clinicians observations of executive dysfunction

7. Focus of the PRO-EX
Provide the clinician with descriptors of executive functions commonly disrupted during brain injury
Summarize data gathered from naturalistic activity observations and interview
Communicate/educate rehabilitation professionals, caregivers, and clients in regards impaired executive functioning
Aid in the design of interventions that will target improving a client’s occupational performance

8. Population
The PRO-EX was tested on 32 subjects 18 and over with a brain injury acquired as an adult
Attributes of brain injury:
Sustained, severe closed head injuries with periods of post-traumatic amnesia
Post concussional syndromes

9. Approach TOP-DOWN APPROACH to assessment is used with the PRO-EX
Observational Assessment
observe client engaging in tasks requiring use of executive functions such as goal selection, planning/sequencing, initiation, execution, time sense, awareness of deficits, and self-monitoring
35-45 minutes to administer

10. Approach (2) Format of the PRO-EX Assessment
Observing performance on naturalistic tasks: the OT would observe the patients performance on naturalistic tasks under “real life” conditions and make judgments based on these observations
Eliciting samples of executive function (i.e. initiation): set-up specific situations to elicit specific executive control system behaviors and make judgments based on task performance
Interview process Braswell et al., 1993

11. Behavioral Assessment of Dysexecutive Syndrome (BADS)
Alderman, N., Burgess, P., Emslie, H., Evans, J., and Wilson, B. (1996)
Used by OT’s, SLPs and Psychiatrists involved in rehabilitation
Purpose
To assess disorders of planning, organization, and problem solving
To predict everyday problems that arise from Dysexecutive Syndrome (DES) (Alderman et al., 1996)

12. Behavioral Assessment of Dysexecutive Syndrome - Child (BADS-C)
Examines deficits in executive functioning associated with ADD, ADHD, PDD, TBI
Child friendly
Sub-tests are brief, fun, and avoid feelings of failure
Wilson, A, Alderman, N., Burgess, P., Emslie, H., & Evans, J. (1996).

13. Focus of the BADS
It was designed to overcome problems that had arisen from previous test batteries which were not sensitive to problem solving, planning and organizing behavior over a long period of time
BADS is sensitive to frontal lobe damage resulting in executive functioning impairments
Evans et al., (1997) has reported that the BADS is useful in detecting executive dysfunction in closed head injury, schizophrenia and focal frontal damage

14. Population Administered to individuals 16-87 years
BADS-C used for ages 8-16 years
Norms established using a sample of 216 healthy, neurologically sound individuals as controls
Patients consisted of 92 individuals who presented with a variety of neurological disorders
78 of these patients completed all six tests in the BADS

15. Approach BOTTOM UP APPROACH to assessment
standardized testing and set domains
Observe client for the following:
task scheduling
strategy formation
ability to plan
temporal judgment
practical problem solving
cognitive flexibility and inhibition response
Approximately minutes to administer
(Wilson et al., 1996)

16. Approach (2) Dysexecutive Questionnaire (DEX)
Its twenty questions seek to pinpoint:
Impulsivity
Perseveration
Inability to inhibit responses
Distractibility
Apathy, lack of drive
Lack of insight and social awareness
Burgess, P., Alderman, N., Wilson, B., Evans, J., & Emslie, H. (1996)

17. BADS: Six Sub-tests
1. Rules Shift Cards Test: examines clients’ ability to shift rules, follow directions, and change mental sets without perseveration. Use nonpicture playing cards.
2. Action Program Test: examine clients’ problem solving ability. Involves extracting a cork from a tube using various materials.
3. Key Search Test: examines clients’ ability to form a strategy. Clients demonstrate how they would search a field for a set of lost keys. Score according to functionality.

18. BADS: Six Sub-tests (2)
4. Temporal Judgment Test: examines clients’ ability to determine how long certain activities take in real life. Four questions are asked.
5. Modified Six Elements Test: examines clients’ ability to organize, plan task schedule, and monitor performance. For this test the clients must dictate, complete arithmetic problems and name pictures.
6. Zoo Map Test: this test measures clients’ ability to follow directions, profit from feedback and problem solve. Clients are to indicate the path they would take on a map when visiting the zoo (i.e. plan a route to visit 6 of 12 locations in a zoo).

19. Dysexecutive Questionnaire (DEX)
20 - item questionnaire administered to client and a person close to the client (independent rater)
5 - point scale
Four Broad areas:
EMOTIONAL
PERSONALITY CHANGES
MOTIVATIONAL CHANGES
BEHAVIORAL CHANGES
COGNITIVE CHANGES

20. Rationale for PRO-EX
The use of formal standardized test for assessing executive function present some challenges that question the ability of the test to provide an accurate and valid assessment of executive function
The authors identified that there was a need for an assessment tool that could describe and classify the range of associated behaviours that might be affected due to brain injury
(Braswell, D. et al, 1993)

21. Rationale (2)
Executive control system impairment may be augmented by the structured nature of standardized testing situations.
Act of testing executive control functions may mask an existing impairment making it difficult to assess the actually integrity of the executive control system.
Client may appear higher functioning in a structured testing situation.
(Braswell, D. et al, 1993)

22. Rationale (3)
Therefore, the only methods to fully evaluate the executive control system is through observation of performance and or interview in real life situations
The PRO-EX provides a taxonomy of executive control system behaviour/components which will assist in organizing the clinician’s observations of patient performance.
Top-down assessment that uses observation and/or interview in some cases in addition to or instead of formal testing
(Braswell, D. et al, 1993)

23. Model Executive Control System Model (Stuss, 1991)
Hierarchical Model with three levels to describe executive control system
Based on premise the premise that the executive control system consists of a hierarchy of independent but interactive functions
First Level: Sensory/Perceptual or Knowledge-based information
-includes automatic or unconscious processes that form the basis for daily routine

24. Model (2) Second Level: Executive Functions
-associated with the executive control or supervisory function of the frontal lobes
-based on sensory/perceptual information from level one, it adjusts and directs the more automatic processes

25. Model (3)
Third Level: Metacognitive Functions (under control of prefrontal cortex)
-Awareness: understanding of the relationship of the self to the environment
-Metacognition: ability to reflect on a process
All three are organized as a feedback control system

26. PRO-EX and the Model (Braswell et al, 1993)
PRO-EX has seven scales that are consistent with the executive control systems model by D.T. Stuss (1991)
For example,
Goal Selection:
-at all three levels intact goal selection would require the basic knowledge of the appropriate steps to reach a particular goal
-anticipation and goal articulation are also necessary for goal selection
-client needs to have some awareness of their situation in order to select appropriate goals

27. PRO-EX and the Model (2) Awareness of Deficits and Self-monitoring:
-more reflected in Metacognition with an inability to self-criticize or self-monitor
Planning/Sequencing, Initiation, Execution, Time-sense:
-reflected in second level of executive functions because these domains are dependent on information from level one where it adjusts and directs the more automatic processes so that behaviour can be guided toward a goal

28. PRO-EX and other Theories
(Banich, M, 2003)
Goal Selection:
The selection of this skill area is important because many theories emphasize the role that frontal regions play in guiding behaviour towards a goal
Planning/Sequencing, Initiation, Execution, Time-sense, Self-monitoring:
Theories about working memory emphasize the linkage between working memory and executive function.

29. PRO-EX and other Theories (2)
Self-monitoring, Awareness of Deficits:
theories similar to Stuss (1991) emphasize the critical role of the frontal lobes for controlled versus automatic processing
damage to this area leaves actions to be governed by the automatic processing system

30. PRO-EX and Neuroanatomy
Dorsolateral Prefrontal Cortex:
-represents goals and the means to achieve them
-typically see goal neglect when this area is damaged
-interference with ability to keep goal in mind
-impaired orientation
-impaired working memory
-poor organization and planning
-poor monitoring of performance

31. PRO-EX and Neuroanatomy (2)
Ventromedial Pre-frontal Cortex
- decreased ability to spontaneously initiate and complete activities
Orbital Frontal Cortex:
- poor control/regulation of behavior and emotions
- neurological lack of awareness

32. Ease of Use and Scoring
The scoring is simple to complete and involves placing a letter on the scale corresponding to the skill area that was being assessed.
Each letter contains a description so that the clinician is able to assess the client’s level of functioning.
The summary sheet provided allows the clinician to compare each skill area assessed to see which areas of executive function are interfering with the clients daily living

33. Psychometrics
There is barely any literature discussing the use of the PRO-EX and any limitations inherent in the assessment making it difficult to make a sound judgement as to whether it is a useful assessment for assessing dysexecutive function
Inter-rater reliability using standard and weighted Kappa’s appears acceptable.
(Braswell, D. et al, 1993)

34. Advantages
alternative to structured approaches to assessment (especially because executive functions are difficult to quantify)
provides a taxonomy to organize observations of the client and this make it easier to identify priority areas that the client is having the most issues so the clinician gets a good sense of how to structure treatment

35. Advantages (2)
able to assess twice and compare the result to see if any improvements have been made by the client
allows for observation and interview of the client and caregiver which provides the therapist with a lot of information
therapists have reported that it is easy to use in the clinical setting (very user-friendly, easy to understand and administer)

36. Disadvantages
no literature/studies done on the PRO-EX so this affects the justification for its use in the clinical setting
inter-rater and test-retest reliability are not that great
OT really has to know the client and also needs skill in this area because you need to know what executive functions are to know what to look for

37. Rationale of BADS
The inspiration for the BADS originated from the belief that existing assessment tools were limited by brevity and single task orientation
Patients with DES are likely to be impulsive, distractible, have problems utilizing feedback and behave inappropriately in social situations
They are not easy to assess because the individual component skills of executive functioning i.e. the building blocks may be intact. For example, it may seem like they have normal IQ even when DES exists. Wilson et al, (1996)

38. Rationale (2)
The authors have provided a brief review of other measures in the field and argue that most measures, like the Wisconsin Card Sorting Test, focus on a specific (and myopic) sample of behaviour (i.e., problem solving with cards), and do not require life-related problem-solving.
the authors have presented this measure as an ecologically valid and clinically useful tool to assist in the diagnosis of the DES (Wilson, 1993).

39. Theory Based on two theoretical models:
1) Working Memory Model (Baddeley & Hitch, 1974) with its hypothetical construct of central executive
This CE an be conceived as an overall controller, organizer, planner, and allocator of resources
2) Attentional Control System (Shallice, 1982) with two attentional mechanisms
Contention scheduling system: responsible for more routine aspects of attention
Supervisory attentional system: responsible for higher level, more demanding attentional tasks

40. Theory (2)
According to Shallice, clients may have few problems with tasks involving contention scheduling system, but have great difficulty with tasks involving supervisory attentional systems. Thus, clients demonstrate problems with executive functioning when doing tasks that require more thinking and planning.

41. Psychometrics
Interrater reliability and test-retest reliability demonstrate a high degree of consistency among raters lending credence to the notion of easy, consistent scoring of the subtests of the BADS
Test-retest reliability measures indicated for normal subjects to perform slightly better on second testing than the first.
Spreen, O., & Strauss, E.(1998)

42. Psychometrics (2) Vailidity:
Study concluded that the BADS accurately discriminated between the two groups and that subtest scores accurately reflected subjective measures of impairment.
Additional studies are needed before it can be recommended for general clinical use, but for research purposes the measure seems promising.
Wilson, B., Evans, J., Emslie, H., Alderman, N., & Burgess, P. (1998).

43. Critique of BADS
More research on how the BADS discriminates among persons with varying severity of impairment would be highly useful
The utility of this assessment tool in diverse settings (e.g., out-patient vs. in-patient settings) cannot be adequately determined without such information
Chevignard, M, Pillon, B., Pradat-Diehl, Taillefer, C., Rousseau, S., Le Bras, C., & Dubois, B. (2000).

44. Advantages
Executive functions are difficult to quantify, so it is positive to observe people doing task or set of activities and have a structured way to score and record information on how the client is going about task
Good that in scoring there are ratings for average, below average, high average—so there is a range of classifications.
BADS may be useful for picking up problems in those people who appear to be cognitively well-preserved and functioning well in structured settings.
Sohlberg, M. & Mateer, C. (2001).

45. Advantages (2) Clear instructions for administering and scoring
Can administer without knowing client that well
Gives an indication of difference between individuals’ perceptions of functioning and his or her caregiver
Combined structured interviews with standard questionnaires may reveal most information about adaptive functioning
Sohlberg, M. & Mateer, C. (2001).

46. Disadvantages
Can be used with a broad range of clients, but experiences suggest that it is not usually sensitive to executive function impairments in relatively high functioning individuals
Score is only on six tests--therefore issues like initiation, planning are not scored specifically-just alluded to from results from BADS six subtest.
If the client has trouble with DES, the fact that the BADS is so structured can lead to improved performance regardless of deficits—e.g. patient given explicit task to solve and examiners can prompt.
Sohlberg, M. & Mateer, C. (2001).

47. Disadvantages (2)
The utility of BADS in diverse settings (e.g., out-patient vs. in-patient settings) hasn’t been adequately determined.
Six specific tests-- DES is seen most in novel situations, and the BADS is not necessarily demonstrative of novel tasks
On the DEX, which is looked at with the BADS, the questionnaire of patient is disregarded and only the caregivers’ answers are factored in—is this really CLIENT-CENTRED???
Sohlberg, M. & Mateer, C. (2001).

48. The Impact of Dysexecutive Symptoms on Occupational Performance
Behavioral Assessment of Dysexecutive System
Dressing
1. Rule Shift Cards Test: goal of this test is to examine the client’s ability to respond correctly to a rule and shift from one rule to another
client would may have difficulty recognizing that an under shirt is put on before an outer top and socks go on before shoes
2. Key Search Test: goal of this test is strategy formation
where to look in their room for certain accessories like a shirt, skirt, pants , socks, watch
tying shoelaces

49. The Impact of Dysexecutive Symptoms on Occupational Performance (2)
3. Temporal Judgement Test: assess subjects ability to estimate how long various events last (time-sense)
if getting ready for an appointment, being able to prepare items and gage how long it will take to get dressed
i.e. the individual may want to iron clothes before hand or polish shoes
4. Zoo Map Test: follow directions, problem solve, feedback
planning the appropriate dress for specific occasions
where to locate items for dress (drawers, closet)
deciphering appropriate dress for weather conditions
matching items (i.e. tops with bottoms)

50. The Impact of Dysexecutive Symptoms on Occupational Performance (3)
5. Modified Six Elements Test: test of planning, task scheduling, and performance monitoring
being aware of what dress items have been already laid out (i.e. scarf, hat, gloves, and boots) and what is necessary for that days weather conditions
keep track of what needs to be put
6. Action Program Test: goal in mind is developing a plan of action in order to solve a problem
if having trouble buttoning a shirt or tying laces on shoes, being decide other alternatives to dressing

51. The Impact of Dysexecutive Symptoms on Occupational Performance (5)
Profile of Executive Control System
Meal Preparation
1. Goal Selection:
find it difficult to plan the steps required to prepare dinner with regards to choosing the food items and the utensils that will be used, and the procedure for which the food is to be cooked
2. Initiation:
inability to start the simple tasks of assembling the items necessary to cook

52. The Impact of Dysexecutive Symptoms on Occupational Performance (6)
3. Time sense:
impaired ability to manage time to cook the meal (i.e. how long it takes to cook a dish, or cook a particular food item)
unable to gage time between items being prepared simultaneously so that items are not forgotten, over-cooked, or burned
4. Awareness of deficits:
may deter the client from returning to meal preparation in fear of creating an accident or motivate them to find strategies to cope with deficits
person may be negligent of deficits and attempt meal preparation

53. The Impact of Dysexecutive Symptoms on Occupational Performance (7)
5. Self-monitoring:
an inability to self-monitor can lead to the client injuring self while at the stove or using a cutting utensil
inability to manage multiple tasks that come with meal preparation (i.e. making a salad or setting the table while monitoring pots on the stove)