Executive functioning profiles from the BRIEF across pediatric medical disorders: Age and diagnosis factors

The objective of the study was to compare executive functioning (EF) profiles across several pediatric medical conditions and explore the influence of age of diagnosis and evaluation. A retrospective, cross-sectional study of 734 children aged 5 to 18 years was conducted across five medical groups (brain tumor, leukemia [ALL], epilepsy [EPI], neurofibromatosis type 1 [NF1], and ornithine transcarbamylase deficiency [OTC-D]), attention deficit hyperactivity disorder (ADHD) controls, and matched healthy controls. We compared groups across the scales of a parent-completed Behavior Rating Inventory of Executive Functioning (BRIEF) using a repeated measures analysis of variance (ANOVA). Separate ANOVAs were conducted to look at age factors. The results showed that the ADHD group differed from all other groups and had the highest level of reported EF problems. The NF1 and OTC-D groups differed significantly from the healthy comparison group for overall EF problems, while the EPI and cancer groups did not. Working memory was the most elevated scale across medical groups, followed by plan/organize. Children with medical disorders were two to four times more likely than healthy controls to have clinically significant problems in several EF domains. There was a main effect for age at diagnosis and age at evaluation. A subset of children with medical disorders were found to have parent-reported EF difficulties, with particular vulnerability noted in working memory and organizational/planning skills. This has relevance for the development of interventions that may be helpful across disorders. Children with particular diagnoses and earlier age of diagnosis and evaluation had greater reported EF problems.     

Assessment of executive functioning in childhood epilepsy: The Tower of London and BRIEF

Children and adolescents with epilepsy are known to demonstrate executive function dysfunction, including working memory deficits and planning deficits. Accordingly, assessing specific executive function skills is important when evaluating these individuals. The present investigation examined the utility of two measures of executive functions—the Tower of London and the Behavioral Rating Inventory of Executive Functioning (BRIEF)—in a pediatric epilepsy sample. Ninety clinically referred children and adolescents with seizures were included. Both the Tower of London and BRIEF identified executive dysfunction in these individuals, but only the Tower of London variables showed significant relations with epilepsy severity variables such as age of epilepsy onset, seizure frequency, number of antiepileptic medications, etc. Further, the Tower of London and BRIEF variables were uncorrelated. Results indicate that objective measures of executive function deficits are more closely related to epilepsy severity but may not predict observable deficits, as reported by parents. Comprehensive evaluation of such deficits, therefore, should include both objective measures as well as subjective ratings from caregivers.     

Assessment of executive functioning in childhood epilepsy: the Tower of London and BRIEF

Children and adolescents with epilepsy are known to demonstrate executive function dysfunction, including working memory deficits and planning deficits. Accordingly, assessing specific executive function skills is important when evaluating these individuals. The present investigation examined the utility of two measures of executive functions-the Tower of London and the Behavioral Rating Inventory of Executive Functioning (BRIEF)-in a pediatric epilepsy sample. Ninety clinically referred children and adolescents with seizures were included. Both the Tower of London and BRIEF identified executive dysfunction in these individuals, but only the Tower of London variables showed significant relations with epilepsy severity variables such as age of epilepsy onset, seizure frequency, number of antiepileptic medications, etc. Further, the Tower of London and BRIEF variables were uncorrelated. Results indicate that objective measures of executive function deficits are more closely related to epilepsy severity but may not predict observable deficits, as reported by parents. Comprehensive evaluation of such deficits, therefore, should include both objective measures as well as subjective ratings from caregivers.     

Frequency of Scale Elevations and Factor Structure of the Behavior Rating Inventory of Executive Function (BRIEF) in Children and Adolescents With Intractable Epilepsy

The Behavior Rating Inventory of Executive Function (BRIEF) is a standardized rating scale that provides information about the nature and extent of executive function deficits displayed by children and adolescents in daily life. BRIEF protocols completed by parents of 80 children with intractable epilepsy were evaluated with respect to prevalence and severity of scale elevations in the sample, and also with respect to factor structure. Overall, the sample was rated as having significantly more executive function problems than healthy children in the BRIEF standardization sample; elevations on the Working Memory and Plan/Organize scales were most frequently seen. Fully 36% of the sample had four or more significantly elevated scales. However, 31% of the sample had no clinically elevated scales, indicating that executive difficulties, though frequent, are not necessarily characteristic of all children with severe epilepsy. As in the validation studies reported in the manual, a two-factor solution emerged from a principal factor analysis of BRIEF scales. However, the factor structure as given in the manual was not entirely replicated; specifically, the Monitor scale was found to load equivalently on both factors. The results of this study suggest that a substantial proportion of children with intractable epilepsy display significant executive function deficits in daily life. Research into the relationship of BRIEF scores to other measures of executive functioning in children with epilepsy is needed to further clarify its clinical utility.     

Frequency of scale elevations and factor structure of the Behavior Rating Inventory of Executive Function (BRIEF) in children and adolescents with intractable epilepsy.

The Behavior Rating Inventory of Executive Function (BRIEF) is a standardized rating scale that provides information about the nature and extent of executive function deficits displayed by children and adolescents in daily life. BRIEF protocols completed by parents of 80 children with intractable epilepsy were evaluated with respect to prevalence and severity of scale elevations in the sample, and also with respect to factor structure. Overall, the sample was rated as having significantly more executive function problems than healthy children in the BRIEF standardization sample; elevations on the Working Memory and Plan/Organize scales were most frequently seen. Fully 36% of the sample had four or more significantly elevated scales. However, 31% of the sample had no clinically elevated scales, indicating that executive difficulties, though frequent, are not necessarily characteristic of all children with severe epilepsy. As in the validation studies reported in the manual, a two-factor solution emerged from a principal factor analysis of BRIEF scales. However, the factor structure as given in the manual was not entirely replicated; specifically, the Monitor scale was found to load equivalently on both factors. The results of this study suggest that a substantial proportion of children with intractable epilepsy display significant executive function deficits in daily life. Research into the relationship of BRIEF scores to other measures of executive functioning in children with epilepsy is needed to further clarify its clinical utility.     

Profiles of everyday executive function in acquired and developmental disorders.

Executive function profiles were examined within and between several clinical disorders via the multi-domain Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000). Parent ratings of children with Inattentive and Combined types of Attention-Deficit/Hyperactivity Disorder (ADHD-I, ADHD-C), Autistic Spectrum Disorders (ASD), moderate and severe Traumatic Brain Injury (TBI), and Reading Disabilities (RD) were compared with controls. Profile analysis revealed significant (p<.01) and substantial (eta2>.10) differences in global elevations and in profile of scale elevations between diagnostic groups. ASD, ADHD-I and ADHD-C groups exhibited greater elevations across the BRIEF scales than did RD and Severe TBI groups, who were in turn more elevated than Moderate TBI and Control groups. The ADHD-C group was unique in its frequency and severity of inhibitory deficits, while the ASD group was distinguishable by its deficits in flexibility. Within diagnostic groups, relative risk for executive dysfunction was calculated with variability present in the frequency of clinically elevated scales. While the BRIEF captures executive profiles characteristic of specific disorders in the clinical setting, it is not diagnostic in its own right and is best used within the context of a broad based evaluation.     

Attention problems and executive functions in children with spina bifida and hydrocephalus.

This study addressed the incidence of Attention-Deficit/Hyperactivity Disorder (ADHD) subtypes in children with spina bifida meningomyelocele and shunted hydrocephalus (SBH) as well as differences in executive functions among these subtypes. Parent rating scales revealed that 31% of the group with SBH could be identified with AD/HD, mostly the Inattentive type (23%). The group with SBH differed from normal controls on cognitive measures of executive functions, but subtype differences were not significant. Multivariate tests showed that children with SBH were rated with greater difficulties on the Behavior Rating Inventory of Executive Function (BRIEF) compared to controls; those with SBH and any subtype of ADHD differed from those with SBH and no ADHD; and those with ADHD (Combined Type) differed significantly from those with ADHD (Predominantly Inattentive Type). Subtype differences on univariate tests in the latter comparison were significant on the BRIEF Inhibit scale, showing more disinhibition in those with SBH and ADHD (Combined Type), but no significant differences were apparent on the BRIEF Sustain, Shift, and Initiate scales. The results show that the incidence of ADHD in children with SBH exceeds the population rate, is represented by problems with inattention rather than with impulsivity and hyperactivity; and that as with non-brain injured individuals, subtype differences in cognitive function remain to more clearly delineated.     

Attention Problems and Executive Functions in Children With Spina Bifida and Hydrocephalus

This study addressed the incidence of Attention-Deficit/Hyperactivity Disorder (ADHD) subtypes in children with spina bifida meningomyelocele and shunted hydrocephalus (SBH) as well as differences in executive functions among these subtypes. Parent rating scales revealed that 31% of the group with SBH could be identified with AD/HD, mostly the Inattentive type (23%). The group with SBH differed from normal controls on cognitive measures of executive functions, but subtype differences were not significant. Multivariate tests showed that children with SBH were rated with greater difficulties on the Behavior Rating Inventory of Executive Function (BRIEF) compared to controls; those with SBH and any subtype of ADHD differed from those with SBH and no ADHD; and those with ADHD (Combined Type) differed significantly from those with ADHD (Predominantly Inattentive Type). Subtype differences on univariate tests in the latter comparison were significant on the BRIEF Inhibit scale, showing more disinhibition in those with SBH and ADHD (Combined Type), but no significant differences were apparent on the BRIEF Sustain, Shift, and Initiate scales. The results show that the incidence of ADHD in children with SBH exceeds the population rate, is represented by problems with inattention rather than with impulsivity and hyperactivity; and that as with non-brain injured individuals, subtype differences in cognitive function remain to more clearly delineated.     

Relationships between cognitive and behavioral measures of executive function in children with brain disease.

This study addressed the clinical and construct validity of the Behavior Rating Inventory of Executive Function. (BRIEF: Gioia, Isquith, Guy, & Kenworthy, 2000), a questionnaire designed to tap behavioral aspects of executive functions in children. BRIEF profiles in early treated phenylketonuria (PKU; n=44), early treated hydrocephalus (n=45), frontal focal lesions (n=20) and controls (n=80) were examined. Clinical validity was supported through significant between-group comparisons, especially between the frontal focal lesion group and other groups. To examine construct validity, raw scores on cognitive executive function measures including the Contingency Naming Test (CNT), Rey Complex Figure (RCF), Tower of London (TOL), and Controlled Oral Word Association Test (COWAT), were correlated with BRIEF scale scores. Few significant correlations were found, indicating cognitive and behavioral measures appear to tap different constructs within the executive function domain. A dissociation was found between behavioral and cognitive impairments in the frontal as opposed to PKU and hydrocephalus groups. This is discussed in relation to underlying pathology, the cognitive measures used, and possible limitations in the BRIEF's usefulness for measuring behavioral executive dysfunction in groups only mildly affected by neurological compromise.     

The association between the behavior rating inventory of executive functioning and cognitive testing in children diagnosed with a brain tumor

Pediatric brain tumor survivors (PBTS) suffer from cognitive late effects, such as deteriorating executive functioning (EF). We explored the suitability of the Behavior Rating Inventory of Executive Function (BRIEF) to screen for these late effects. We assessed the relationship between the BRIEF and EF tasks, and between the BRIEF-Parent and BRIEF-Teacher, and we explored the clinical utility. Eighty-two PBTS (8–18 years) were assessed with EF tasks measuring attention, cognitive flexibility, inhibition, visual-, and working memory (WM), and with the BRIEF-Parent and BRIEF-Teacher. Pearson’s correlations between the BRIEF and EF tasks, and between the BRIEF-Parent and BRIEF-Teacher were calculated. The BRIEF-Parent related poorly to EF tasks (rs < .26, ps > .01), but of the BRIEF-Teacher the WM-scale, Monitor-scale, Behavioral-Regulation-Index, and Meta-cognition-Index, and Total-score (rs > .31, ps < .01) related significantly to some EF tasks. When controlling for age, only the WM scale and Total score related significantly to the attention task (ps < .01). The inhibit scales of the BRIEF-Parent and BRIEF-Teacher correlated significantly (r = .33, p < .01). Children with clinically elevated scores on BRIEF scales that correlated with EF tasks performed worse on all EF tasks (ds 0.56–1.23, ps < .05). The BRIEF-Teacher Total and Index scores might better screen general EF in PBTS than the BRIEF-Parent. However, the BRIEF-Teacher is also not specific enough to capture separate EFs. Solely relying on the BRIEF as a screening measure of EFs in BPTS is insufficient. Questionnaires and tasks give distinctive, valuable information.     

Relationships Between Cognitive and Behavioral Measures of Executive Function in Children With Brain Disease

This study addressed the clinical and construct validity of the Behavior Rating Inventory of Executive Function. (BRIEF: Gioia, Isquith, Guy, & Kenworthy, 2000), a questionnaire designed to tap behavioral aspects of executive functions in children. BRIEF profiles in early treated phenylketonuria (PKU; n = 44), early treated hydrocephalus (n = 45), frontal focal lesions (n = 20) and controls (n = 80) were examined. Clinical validity was supported through significant between-group comparisons, especially between the frontal focal lesion group and other groups. To examine construct validity, raw scores on cognitive executive function measures including the Contingency Naming Test (CNT), Rey Complex Figure (RCF), Tower of London (TOL), and Controlled Oral Word Association Test (COWAT), were correlated with BRIEF scale scores. Few significant correlations were found, indicating cognitive and behavioral measures appear to tap different constructs within the executive function domain. A dissociation was found between behavioral and cognitive impairments in the frontal as opposed to PKU and hydrocephalus groups. This is discussed in relation to underlying pathology, the cognitive measures used, and possible limitations in the BRIEF's usefulness for measuring behavioral executive dysfunction in groups only mildly affected by neurological compromise.     

Brief report: Relationship between performance testing and parent report of attention and executive functioning profiles in children following perinatal arterial ischemic stroke

Children with perinatal arterial ischemic stroke (PAIS) have increased rates of attention and executive functioning (EF) weaknesses. Research in other pediatric disorders has documented poor consistency between parent report of these skills and performance-based measures. We compared these data sources in children with PAIS. Forty full-term (≥37 weeks) children ages 3–16 (median = 7.2 years; 58% male) with PAIS completed neuropsychological testing and composite scores were created for seven attention and EF domains (Processing Speed; Attention; Working Memory; Verbal Retrieval; Inhibitory Control; Flexibility/Shifting; Planning). Parents completed “real-world” functioning questionnaires (ADHD Rating Scale-IV, BRIEF). Correlational analysis were used to compare parent and performance measures. Correlations between ADHD Rating Scale-IV scores and the performance-based Attention and Inhibition composite scores were nonsignificant. Significant negative correlations were found between the BRIEF GEC and performance-based Verbal Retrieval and Processing Speed composites, but remaining GEC/composite comparisons were nonsignificant. Analyses between parent report BRIEF index scores and the corresponding performance-based domain identified one significant negative correlation between the BRIEF Working Memory Index and the Working Memory composite score. While children with PAIS demonstrate difficulties in attention and EF on both parent report and performance measures, little significance was found in comparisons of these two types of measures. There may be several explanations for this dissociation: measures assessing different aspects of the same underlying construct; performance-based measures lacking ecological validity; and parents underestimating/underreporting their child’s deficits. Thus, multiple sources of informant and performance data are necessary to make more accurate conclusions about functioning in these domains.     

Construct Validity of Parent Ratings of Inhibitory Control

Recent literature has emphasized the need to examine executive functions (EF) in children using multiple sources, including both parent rating and performance-based measures. Computerized Go/No-Go tests, including commercially available continuous performance tests (CPTs), represent one of the most commonly used methods of assessing inhibitory control—a variable central to the executive function construct. We examined the relationship between parent ratings of inhibitory control and CPT performance in two mixed clinical samples. Experiment 1 examined 109 children ages 6–18 using the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) and the Conners' CPT-II (Conners, 2000). In this sample, ratings on the BRIEF Inhibit scale (mean T-score?=?62.3) were significantly higher than the CPT-II commissions score (mean T-score?=?50.7; p < .0001); and the BRIEF and CPT-II scores were not highly correlated (r?=???.12). Experiment 2 examined a sample of 131 children ages 7–18 using the BRIEF and the Tests of Variables of Attention (TOVA; Greenberg, 1996). In this sample, parent ratings on the BRIEF Inhibit scale (mean T-score?=?56.8) were similar to TOVA commissions scores (mean T-score?=?58.6; p?=?.33), although still poorly correlated (r?=??.02). Factor analyses exploring covariance between BRIEF scales CPT-II variables (Experiment 1) and between BRIEF and TOVA (Experiment 2) yielded similar findings. In both experiments, all eight BRIEF scales loaded on a single factor, with no overlap with either the CPT-II or the TOVA. In mixed outpatient clinical samples, the BRIEF appears to measure different elements of inhibitory control than those assessed by computerized continuous performance tests.     

Construct validity of parent ratings of inhibitory control.

Recent literature has emphasized the need to examine executive functions (EF) in children using multiple sources, including both parent rating and performance-based measures. Computerized Go/No-Go tests, including commercially available continuous performance tests (CPTs), represent one of the most commonly used methods of assessing inhibitory control - a variable central to the executive function construct. We examined the relationship between parent ratings of inhibitory control and CPT performance in two mixed clinical samples. Experiment 1 examined 109 children ages 6-18 using the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) and the Conners' CPT-II (Conners, 2000). In this sample, ratings on the BRIEF Inhibit scale (mean T-score = 62.3) were significantly higher than the CPT-II commissions score (mean T-score = 50.7; p < .0001); and the BRIEF and CPT-II scores were not highly correlated (r = - .12). Experiment 2 examined a sample of 131 children ages 7-18 using the BRIEF and the Tests of Variables of Attention (TOVA; Greenberg, 1996). In this sample, parent ratings on the BRIEF Inhibit scale (mean T-score = 56.8) were similar to TOVA commissions scores (mean T-score = 58.6; p = .33), although still poorly correlated (r = -.02). Factor analyses exploring covariance between BRIEF scales CPT-II variables (Experiment 1) and between BRIEF and TOVA (Experiment 2) yielded similar findings. In both experiments, all eight BRIEF scales loaded on a single factor, with no overlap with either the CPT-II or the TOVA. In mixed outpatient clinical samples, the BRIEF appears to measure different elements of inhibitory control than those assessed by computerized continuous performance tests.     

Parent and self-report ratings of executive function in adolescents with myelomeningocele and hydrocephalus.

Parent and self-report ratings were obtained for 28 adolescents with myelomeningocele and congenital hydrocephalus using the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1998a, 1998b) and the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000; Guy, Gioia, & Isquith, 1998). Parents rated their children as having significantly more problems, compared to published norms, on the BRIEF but not the BASC. Adolescents rated themselves as having significantly more problems, compared to parent ratings, on scales comprising the BRIEF Behavioral Regulation Index; but not on common scales of the BASC. Parents also reported more problems on the BRIEF Global Executive Composite than on all three primary BASC indices, and more problems on the BRIEF Metacognition Index than on the BRIEF Behavioral Regulation Index. We conclude that the BRIEF captures salient executive dysfunction among individuals with myelomeningocele and hydrocephalus, and may be useful in identifying needs for intervention that might not be identified by broad-band behavior rating scales alone.     

Parent and Self-Report Ratings of Executive Function in Adolescents with Myelomeningocele and Hydrocephalus

Parent and self-report ratings were obtained for 28 adolescents with myelomeningocele and congenital hydrocephalus using the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1998a, 1998b) and the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000; Guy, Gioia, & Isquith, 1998). Parents rated their children as having significantly more problems, compared to published norms, on the BRIEF but not the BASC. Adolescents rated themselves as having significantly more problems, compared to parent ratings, on scales comprising the BRIEF Behavioral Regulation Index; but not on common scales of the BASC. Parents also reported more problems on the BRIEF Global Executive Composite than on all three primary BASC indices, and more problems on the BRIEF Metacognition Index than on the BRIEF Behavioral Regulation Index. We conclude that the BRIEF captures salient executive dysfunction among individuals with myelomeningocele and hydrocephalus, and may be useful in identifying needs for intervention that might not be identified by broad-band behavior rating scales alone.     

Maternal Executive Functioning and Scaffolding in Families of Children with and without Parent-Reported ADHD

Parental scaffolding robustly predicts child developmental outcomes, including improved self-regulation and peer relationships and fewer externalizing behaviors. However, few studies have examined parental characteristics associated with a parent’s ability to scaffold. Executive functioning (EF) may be an important individual difference factor associated with maternal scaffolding that has yet to be examined empirically. Scaffolding may be particularly important for children with attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorder (DBD) symptoms due to their core difficulties with inattention, disorganization, EF, and self-regulation, their need for greater parental structure, and higher-than-average rates of parental EF deficits. Yet, little research has examined child ADHD in relation to parental scaffolding. This cross-sectional study examined: (1) the association between maternal EF (as measured by the Hotel Test, Barkley’s Deficits in Executive Functioning Scale, and Digit Span) and observed scaffolding, (2) the association between parent-reported child ADHD/DBD symptoms and scaffolding, and (3) the interaction between child ADHD/DBD symptoms and maternal EF in predicting scaffolding. In a sample of 84 mothers and their 5–10 year-old biological children (62% male) with and without parent-reported ADHD, we found that maternal EF, as measured by Digit Span and the Hotel Test, predicted observed maternal scaffolding. However, child ADHD/DBD symptoms did not significantly predict maternal scaffolding controlling for child age, maternal education, and maternal EF, nor did the interaction of maternal EF and parent-reported child ADHD/DBD symptoms. Working memory and task shifting may be key components of parental EF that could be targeted in interventions to improve parental scaffolding.     

Verbal and nonverbal predictors of executive function in early childhood

The study of executive function (EF) has become increasingly popular in multiple areas of research. A wealth of evidence has supported the value of EF in shaping notable outcomes across typical and atypical development; however, little evidence has supported the cognitive contributors to early EF development. The current study used data from a large longitudinal sample of healthy children to investigate the differential influence of verbal and nonverbal cognition on later EF. Participants were assessed at 2 years of age using the Mullen Scales of Early Learning, and Mullen scores were used to calculate nonverbal and verbal developmental quotients. Executive function was measured at 6 years using assessments from the Stanford-Binet, Cambridge Neuropsychological Test Automated Battery, and the Behavior Rating Inventory of Executive Function. Results suggested that early nonverbal cognition was a better predictor of 6-year EF as measured by task-based laboratory assessments, whereas verbal cognition was a better predictor of parent-reported EF. Findings are discussed in regard to EF development and characteristics of EF measurement.     

Caregiver ratings and performance-based indices of executive function among preschoolers with and without maltreatment experience

Despite the well-documented impact of early maltreatment on children’s executive function (EF), there has been limited consensus about how to best assess this neurocognitive domain in high-risk, vulnerable preschool-aged children. Relevant studies have generally utilized either performance-based tests or caregiver ratings of EF, yet multi-method research has been rare. This study examined the EF profiles of preschoolers exposed to maltreatment, as indexed by the Behavior Rating Inventory of Executive function – Preschool Version (BRIEF-P), and investigated associations between caregiver ratings and performance-based measures (Happy–Sad Stroop, Tapping Test, and Dimensional Change Card Sort – DCCS) of EF in this population. Maltreatment status was further tested as a moderator of associations between these measures. Participants were (n = 107) children aged 4–5 years (M = 4.75; SD = 0.57; 39% female), with various levels of exposure to maltreatment. Children exposed to maltreatment were found to exhibit significantly more caregiver-rated deficits in EF than non-maltreated children, with greater fluctuations apparent across all scales of the BRIEF-P. Consistent with previous research in neurologically impaired children, there were only limited and weak to moderate correlations between BRIEF-P scales and performance-based measures of EF. Furthermore, maltreatment status was found to moderate the association between scores on the BRIEF-P Inhibit Scale and the DCCS, such that the association between these indices was weaker among children exposed to higher levels of maltreatment.