Understanding and Evaluating Executive Functioning in ADHD Across the Life Span
SamGoldstein,Ph.D.AssistantClinicalProfessorUniversityofUtahSchoolofMedicine
www.samgoldstein.com
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Disclosure
MyexpensesforthistalkaresupportedbyMulti-HealthSystems.IhavedevelopedtestsmarketedbyMulti-HealthSystems,Pro-EdandWesternPsychologicalServices.
IhaveauthoredbooksmarketedbySpringer,Wiley,Guilford,DoubleDay,McGrawHill,Brookes,KluwerandSpecialtyPress.
IamEditorinChiefoftheJournalofAttentionDisorders(Sage)andCo-EditoroftheEncyclopediaofChildDevelopment(Springer)
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WhatisADHD?
ADHDisabio-psychosocialconditioncharacterizedbycoresymptomsofinattention,hyperactivityandimpulsivityleadingto/interactingwithcognitivedeficitscausingimpairmentinallwalksoflife.
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WhatisADHD?➢ADHDappearstoprimarilyinvolvethebasalganglia,cerebellumandthefrontallobes.
➢Co-morbidityofotherdevelopmental,emotionalandbehavioralconditionswithADHDprobablyconfoundsfindingsfromdifferentstudygroups.(Hendrenetal,JAACP,(2000)39,815-820.
➢ThesymptomsofADHDleadtoanearlyinfinitenumberofconsequences.
CurrentdiagnosticcriteriaspecifythatADHDinvolvesdifficultieswithinattentionand/orhyperactivity/impulsivity.Researchersusingfactoranalysishaveconsistentlyfoundsupportforaninattentionfactorinbothchildrenandadults.Findingshavebeenmixedregardingwhetherhyperactivityandimpulsivityreflectoneortwodimensions(ForReviewseeBarkley,3rdEdition,2005).
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Thepredictionofoutcomesprovidedsupportthatcomplementedconfirmatoryfactoranalysisfortheseparationofthehyperactivityandimpulsivityconstructs.Impulsivityuniquelypredictedmoreoutcomesthanhyperactivityalone.ResultswereconsistentwiththeconceptualizationofADHDasprimarilyadisorderofbehavioralinhibition.Futureresearchusingalternativeoutcomesandclinicalpopulationsshouldbeconducted.(JAD,2012)
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ADHDappearstobeaconditionstemminginpartfrominefficientoperationofEF.
ABitofEFNeuroanatomy
➢Prefrontal➢Richcortical,sub-corticalandbrainstemconnections.
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MoreSpecifically
➢Thedorsolateralprefrontalcortex(DLPFC)isinvolvedwithintegratingdifferentdimensionsofcognitionandbehavior.
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● Thisareaisassociatedwithverbalanddesignfluency,abilitytomaintainandshiftset,planning,responseinhibition,workingmemory,organizationalskills,reasoning,problemsolvingandabstractthinking.
And:
➢Theanteriorcingulatecortex(ACC)isinvolvedinemotionaldrives,experienceandintegration,inhibitionofinappropriateresponses,decisionmakingandmotivation
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● Lesionsinthisareacanleadtolowdrivestatessuchasapathyandmayalsoresultinlowdrivestatesforsuchbasicneedsasfoodordrinkandpossiblydecreasedinterestinsocialorvocationalactivitiesandsex.
AndFinally:
➢Theorbitofrontalcortex(OFC)playsakeyroleinimpulsecontrol,maintenanceofset,monitoringongoingbehaviorandsociallyappropriatebehaviors.
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● Lesionsinthisareacancausedis-inhibition,impulsivity,aggressiveoutbursts,sexualpromiscuityandantisocialbehavior.
AnotherView:HotandCoolEF
➢Cool(metacognitive)–functionsassociatedwithcognitionsuchasplanningandproblemsolving(leadingtoaDorsolateralSyndrome).
➢Hot(emotional/motivational)–functionsassociatedwithcoordinatingandcontrollingemotions(leadingtoanOrbitofrontal/MedialSyndrome).
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WhatdowemeanbythetermExecutiveFunction(s)?
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ExecutiveFunction(s)
➢In1966AlexandrLuriafirstwroteanddefinedtheconceptofExecutiveFunction(EF)
➢HecreditedBianchi(1895)andBekhterev(1905)withtheinitialdefinitionoftheprocess
141902 - 1977
WhatisExecutiveFunction(s)ThereisnoformalexcepteddefinitionofEF• WetypicallyfindavaguegeneralstatementofEF(e.g.,goal-directedaction,cognitivecontrol,top-downinhibition,effortfulprocessing,etc.).
• Oralistingoftheconstructssuchas● Inhibition,● WorkingMemory,● Planning,● Problem-Solving,● Goal-DirectedActivity,● StrategyDevelopmentandExecution,● EmotionalSelf-Regulation,● Self-Motivation
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DoesExperienceShapeEF?➢TheFamilyLifeProjecthasdemonstratedthatpovertyisassociatedwithelevatedcortisolininfancyandearlychildhood.
➢Thisassociationismediatedthroughcharacteristicsofthehousehold.
➢Parentingsensitivitymediatestherelationshipbetweenpovertyandstressphysiology.
➢IncombinationparentingsensitivityandelevatedcortisolmediatetheassociationbetweenpovertyandpoorEFinchildren.
WhatNeuralActivitiesRequireEF?
➢Thosethatinvolveplanningordecisionmaking.➢Thosethatinvolveerrorcorrectionortroubleshooting.
➢Situationswhenresponsesarenotwell-rehearsedorcontainnovelsequencesofactions.
➢Dangerousortechnicallydifficultsituations.➢Situationsthatrequiretheovercomingofastronghabitualresponseorresistingtemptation.
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Goldstein,Naglieri,Princiotta,&Otero(2013)➢Wefoundmorethan30definitionsofEF(s).➢Executivefunction(s)hascometobeanumbrellatermusedformanydifferentabilities,includingplanning,workingmemory,attention,inhibition,self-monitoring,self-regulationandinitiationcarriedoutbypre-frontalareasofthefrontallobes.
➢
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WhatisExecutiveFunction(s)
1. Barkley(2011):“EFisthusaself-directedsetofactions)”(p.11).
2. Dawson&Guare(2010):“Executiveskillsallowustoorganizeourbehaviorovertime”(p.1).
3. Delis(2012):“Executivefunctionsreflecttheabilitytomanageandregulateone’sbehavior(p.14).
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WhatisExecutiveFunction(s)
4. Denckla(1996):"EF(is)asetofdomain-generalcontrolprocesses…"(p.263).
5. Gioia,Isquith,Guy,&Kenworthy(2000):"acollectionofprocessesthatareresponsibleforguiding,directing,andmanagingcognitive,emotional,andbehavioralfunctions”(p.1).
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WhatisExecutiveFunction(s)
6. Pribram(1973):"executiveprogrammes…tomaintainbrainorganization"(p.301).
7. Roberts&Pennington(1996):EF“acollectionofrelatedbutsomewhatdistinctabilitiessuchasplanning,setmaintenance,impulsecontrol,workingmemory,andattentionalcontrol”(p.105).
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WhatisExecutiveFunction(s)
6. Stuss&Benson(1986):"avarietyofdifferentcapacitiesthatenablepurposeful,goal-directedbehavior,includingbehavioralregulation,workingmemory,planningandorganizationalskills,andself-monitoring"(p.272).
7. WelshandPennington(1988):"theabilitytomaintainanappropriateproblem-solvingsetforattainmentofafuturegoal"(p.201).
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WhatisExecutiveFunction(s)
10. McCloskey(2006):“adiversegroupofhighlyspecificcognitiveprocessescollectedtogethertodirectcognition,emotion,andmotoractivity,including…theabilitytoengageinpurposeful,organized,strategic,self-regulated,goaldirectedbehavior”(p.1)
“thinkofexecutivefunctionsasasetofindependentbutcoordinatedprocessesratherthanasingletrait”(p.2).
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WhatisExecutiveFunction(s)
10. Lezak(1995):"acollectionofinterrelatedcognitiveandbehavioralskillsthatareresponsibleforpurposeful,goal-directedactivity,”…
11. “howandwhetherapersongoesaboutdoingsomething"(p.42).
12. Luria(1966):“…abilitytocorrectlyevaluatetheirownbehaviorandtheadequacyoftheiractions”(p.227).
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JackA.Naglieri,Ph.D.GeorgeMasonUniv,Fairfax,[email protected]
ExecutiveFunctions
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AndFinally....
AnNICHDpanelin1994identified33EFsbyconsensus!
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TheTopSixWere:
➢Self-regulation➢Sequencingofbehavior➢Flexibility➢Responseinhibition➢Planning➢Organizationofbehavior
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WhatistherelationshipofEFtoADHDandotherdefineddisorders?
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EFandADHD
EFdeficitsarenotnecessarilyuniquetoADHD.TheyareneithernecessarynorsufficienttomakeadiagnosisofADHD.WhenEFimpairmentsaremeasuredinchildrenwithADHDtheytendtoreflectspecificratherthanglobalimpairments.
EFandOtherDisruptiveDisorders(ODD&CD)
EarlyreviewsreportedthatEFdeficitswerenotcharacteristicofchildrenandadolescentswithODDandCDafterco-morbidADHDwasfactoredout.Morerecentstudies,however,suggestthatinhibitiondeficitsmaybecharacteristicofbothADHDandCDbutwhetherchildrenwithCDdisplayimpairmentsonadditionalEFmeasuresisequivocal.
EFandTourette’s
DistinctandrobustimpairmentsinEFdonotappeartobecharacteristicofchildrenwithTD.
EFandAnxietyDisorders
EFdeficitsinset-shifting,cognitiveflexibility,conceptformation,interferencecontrol,andverbalfluencyhavebeendocumentedamongchildrenwithseparationanxietydisorder,overanxiousdisorder,andPTSD.EFinOCDhasnotbeenwelladdressed.
EFandDepression
ScantresearchhasbeenconductedontheEFabilitiesamongyouthwithdepression.StudiesthathaveincludedolderadolescentshavesuggestedsomedegreeofsensitivityofEFtasksinidentifyingunipolardepression,butlessspecificity.
EFandBi-PolarDisorderThereisagrowingconsensusaboutthenatureofBDamongchildren.SeveralstudieshavetargeteditsEFconcomitants.Althoughresultsoftenhavebeenconfoundedwithsignificantco-morbidityissues,childrenandadolescentswithBDreliablyhavedemonstratedimpairmentsrelativetothosewithoutanyhistoryofmooddisordersonseveralEFmeasures(e.g.workingmemory,setshifting).
EFandTraumaticBrainInjury
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EFDeficitsandASD
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EFandLearningDisabilities
IfalloftheseconditionsarestatisticallyrelatedtobehaviorsandabilitiesreflectingEFthanacommondenominatormustexist.
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AnexaminationofolderfactoranalyticstudiesexaminingEFinchildrenfindsonlyasinglefactor-planning–commontoallstudies.
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Anderson, 2002 Clin. Neuropsych.
Executive ExecutiveFunction Functions
● EFisaunitaryconstruct(e.g.,Duncan&Miller,2002;Duncan&Owen,2000).
● EFisunidimensionalinearlychildhoodnotadulthood.
● Bothviewsaresupportedbysomeresearch(Miyakeetal.,2000),--EFisaunitaryconstruct…butwithpartiallydifferentcomponents.
● EFhasthreecomponents:inhibitorycontrol,setshifting(flexibility),andworkingmemory(e.g.,Davidson,etal.,2006;Miyakeetal.,2000).
● EFhasindependentabilities(Wiebe,Espy,&Charak,2008).
● ExecutiveFunctionsisamultidimensionalmodel(Friedmanetal.,2006;Miyakeetal.,2000).
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ExecutiveFunction(s)
➢GivenallthesedefinitionsofEF(s)wewantedtoaddressthequestion…ExecutiveFunctions…or
ExecutiveFunction?
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ExecutiveFunction(s)
➢OnewaytoexaminethisissueistoresearchthefactorstructureofbehaviorsrelatedtoEF(s)
➢Todoso,weexaminedthefactorstructureofanationallyrepresentativesampleofchildren.
➢Weconductedaseriesofresearchstudiestoanswerthefollowingquestion:• WhatistheunderlyingstructureofEFbehaviors?• IsthereisjustoneunderlyingfactorcalledExecutiveFunction),ordothebehaviorsgrouptogetherintodifferentconstructssuggestingamultidimensionalstructure?
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EXPLORATORYFACTORANALYSES
➢Bothitem-levelandscale-levelexploratoryfactoranalyses(EFA)wereconducted.
➢Thenormativesamplesforparents,teacher,andselfratingswererandomlysplitintotwosamplesandEFAconductedusing• theitemrawscores• ninescales’rawscores
➢WeusedastandardizationsamplefromourinstrumenttheComprehensiveExecutiveFunctioningInventory(CEFI).
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CEFIStandardization
➢Samplewasstratifiedby• Sex,age,race/ethnicity,parentaleducationlevel(PEL;forcasesratedbyparents),geographicregion
• Race/ethnicityofthechild(Asian/PacificIslander,Black/AfricanAmerican/AfricanCanadian,Hispanic,White/Caucasian,Multi-racialbytherater
• ParentsprovidedPELofbothparents● Thehigherofthetwolevelswasusedtoclassifytheparentaleducationlevelofthechild.
• Allraterscompletedthequestionnaireviapaper-and-penciloronlinemethods.
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EXPLORATORYFACTORANALYSES
➢Forthefirsthalfofthenormativesampleusingitemscores:EFAofthe90itemswasconducted
➢Thescreeplottestandtheverysimplesolutioncriterionbothindicatedthatonlyonefactorshouldberetained.
➢Theratioofthefirstandsecondeigenvalueswasgreaterthanfourforallthreeforms,whichisacommonruletosupportaonefactorsolution.
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EXPLORATORYFACTORANALYSES
➢Itemlevelfactoranalysisclearlyindictedthatonefactorwasthebestsolution
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EXPLORATORYFACTORANALYSES
➢UsingthesecondhalfofthenormativesampleEFAwasconductedusingrawscoresfortheAttention,EmotionRegulation,Flexibility,InhibitoryControl,Initiation,Organization,Planning,Self-Monitoring,andWorkingMemoryscales
➢BoththeKaiserrule(eigenvalues>1)andtheEigenvalueRatiocriterion(>4)unequivocallyindicatedonefactor.
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EXPLORATORYFACTORANALYSES
➢FactoranalysisoftheCEFIScalesalsoclearlyindicatedaonefactorsolution
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EXPLORATORYFACTORANALYSES
➢CoefficientsofCongruence–allveryhigh
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EXPLORATORYFACTORANALYSES
➢Conclusions•Whenusingparent(N=1,400),teacher(N=1,400),orself-ratings(N=700)basedonbehaviorsobservedandreportedforanationallyrepresentativesample(N=3,500)aged5to18yearsExecutiveFunctionnotfunctionsisthebesttermtouse.
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Naglieri&Goldstein,2012
➢ExecutiveFunctionis:howefficientlyyoudowhatyoudecidetodo.
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Naglieri&Goldstein,2012➢ExecutiveFunctionis:howefficientlyyoudowhatyoudecidetodo.
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Modify the Solution as
Needed
Star
t with
a
Goa
l
Gather
Information
Consider Solutions
Select a Plan
Apply the P
lan
Monitor the
PlanModify the Plan
If Goal is
Met
Problem Solved
LatentclassanalysisoffrontallobetasksstronglysuggestsageneralEFthatreflectstheefficiencyandperhapsautomaticityoftheexecutivemanagementsystem.
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Miyake, Friedman, et al 2008 Cognitive Psychology
EFskillsmaydevelopindifferenttracksbutmergeinfunctionaschildrendevelop.
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Wasserman and Wasserman, 2013 Applied Neuropsych. Child
EFappearstobeaunitary,moredomainspecificprocessinchildren
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Wiebe, Scheffield, et al, 2011 J. Of Exp. Child Psych.
ConclusiveevidenceconcerningthedevelopmentaltrajectoriesinchildrenofthedifferentEFcomponentsonneuropsychologicaltestshasyettobeestablished.
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Huizinga, Dolan et al, 2006 Neuropsyhologica
CEFIScoresbyDiagnosis➢WeexpectedthatindividualswithADHD,mooddisorders,andAutismSpectrumDisordersmightearnalowscoresonthismeasureofEFbehaviors.
➢Wecomparedgroupsmatchedongender,race/ethnicity,andparentaleducation(Naglieri,J.A.,&Goldstein,S.(2013).ComprehensiveExecutiveFunctioningIndex.Toronto:MultiHealthSystems.)
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GroupDifferences:ADHD(Naglieri&Goldstein,2013)
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80
87.5
95
102.5
110
Parent Teacher Self-Report
ADHDControl
CEFIScales:ADHD(Naglieri&Goldstein,2013)
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Parent
TeacherSelf Report
Parent
Self ReportTeacher
GroupDifferences:ASD(Naglieri&Goldstein,2013)
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80
85
90
95
100
Parent Teacher
General Population
ASD
CEFIScales:ASD(Naglieri&Goldstein,2013)
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Parent
Teacher
Teacher
Parent
GroupDifferences:LearningDisabilities(Naglieri&Goldstein,2013)
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80
87.5
95
102.5
110
Parent Teacher Self-Report
LDControl
CEFIScales:SLD(Naglieri&Goldstein,2013)
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GroupDifferences:MoodDisorders(Naglieri&Goldstein,2013)
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80
87.5
95
102.5
110
Parent Teacher Self-Report
MoodControl
CEFIScales:MoodDisorders(Naglieri&Goldstein,2013)
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HowcanwereliablyandvalidlyevaluateEF?
HowtoMeasureExecutiveFunction(s)
ArecentreviewbyWeyandtetal(2012)found168measuresusedtoevaluateEF.
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From
Wey
andt
et
al, 2
012
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IngeneralsingleEFtestsshareatmost10%ofthevariancewithEFratingsandobservationsofeverydaybehavior.
BatteriesofcombinedEFtestsfareabitbettersharingupto20%ofthevariancewithobservationandreportedbehavior.
ThemoretestsinanEFbatterythemorefactorsidentifiedinbothexploratoryandconfirmatorystudies.
EFRatingScales
➢Measuresrealworldbehavior➢Abletosamplemultiplesources(self,parents,teachers)
➢EfficientwaystoevaluateEF➢However• self-ratingsmaybelimitedbyimpairedself-awareness• Observersmaynotbegoodatobserving!
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AttentionMeasureshowwellanadultcanavoiddistractions,concentrateontasks,andsustainattention
InhibitoryControlReflectsanadultscontroloverbehaviororimpulses
PlanningReflectshowwellanadultdevelopsandimplementsstrategiestoaccomplishtasks
EmotionRegulationMeasuresanadult’scontrolandmanagementofemotions
InitiationDescribesanadult’sabilitytobegintasksorprojectswithoutbeingprompted
Self-MonitoringDescribesanadult’sself-evaluationofhis/herperformanceorbehavior
FlexibilityDescribeshowwellanadultcanadapttocircumstances,includingproblemsolvingabilities
OrganizationDescribeshowwellanadultmanagespersonaleffects,workormultipletasks
WorkingMemoryReflectshowwellanadultcankeepinformationinmindthatisimportantforknowingwhattodoandhowtodoit
ExecutiveFunctionFullScale
CEFI:WISC-IV,CAS,andWJIII
➢DatafromtheNeurology,LearningandBehaviorCenterinSaltLakeCity,UT
➢ChildrengiventheCEFI,WISC-IV(N=43),CAS(N=62),andtheWJIIIachievement(N=58)aspartofatypicaltestbattery.
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CEFI,WISC-IV,CAS,Achievement
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CEFI,WISC-IV,CAS,Achievement
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Table 8.27 CEFI Manual
CEFI&WISC-IV
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CEFI&CAS
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CEFI&WJ-IIITotalAchievement
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CEFI&WJ-IIIReading
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CEFI&WJ-IIIBroadMath
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CEFI&WJ-IIIWrittenLanguage
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Conclusions
➢TheconceptofEFisevolving.➢DatafromtheourStandardizationSampleindicatethatwhenmeasuredusingobservablebehaviorsthetermExecutiveFunctionissupported.
➢GoodresearchcanprovideawellnormedmeasureofEFthathasdemonstratedreliability&validity.
➢Thereisalsoemergingevidencethatchildrencanbetaughttobemorestrategic–animportantindicationofefficientEF.
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