Understanding and Evaluating Executive …...Understanding and Evaluating Executive Functioning in...
Transcript of Understanding and Evaluating Executive …...Understanding and Evaluating Executive Functioning in...
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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87.5
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102.5
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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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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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87.5
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102.5
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Parent Teacher Self-Report
LDControl
CEFIScales:SLD(Naglieri&Goldstein,2013)
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GroupDifferences:MoodDisorders(Naglieri&Goldstein,2013)
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87.5
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102.5
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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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Copyright © 2017, Multi-Health Systems, Inc. All rights reserved.
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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