DYSEXECUTIVE SYMPTOM DYSEXECUTIVE SYMPTOM ASSESSMENTSASSESSMENTS

By: Tammy Balaban, Chantal By: Tammy Balaban, Chantal Sampson, and Nykema WrightSampson, and Nykema Wright

AgendaAgenda

Brief overview of executive functionBrief overview of executive function Brief overview of the PRO-EX and BADSBrief overview of the PRO-EX and BADS Rationale and Critique of the assessmentsRationale and Critique of the assessments The impact of dysexecutive symptoms on occupational The impact of dysexecutive symptoms on occupational

performanceperformance

ExecutiveExecutive FunctionFunction

DefinitionDefinition

““Integrative cognitive functions that determine Integrative cognitive functions that determine goal-directed and purposeful behaviour and goal-directed and purposeful behaviour and are superordinate in the orderly execution of are superordinate in the orderly execution of daily life functions”.daily life functions”.

(Cicerone et al., 2002)(Cicerone et al., 2002)

•Dysexecutive Syndrome emanates from frontal lobe Dysexecutive Syndrome emanates from frontal lobe damage.damage.

•Includes symptoms such as decreased attention, increased Includes symptoms such as decreased attention, increased distractibility, impulsivity, perseveration, difficulty with distractibility, impulsivity, perseveration, difficulty with complicated or new tasks, difficulty using feedback, and complicated or new tasks, difficulty using feedback, and behaving inappropriately in social situations. behaving inappropriately in social situations.

Executive Function (2)Executive Function (2)

Executive Function (3)Executive Function (3)

The term ‘Dysexecutive Syndrome’ includes disorders of The term ‘Dysexecutive Syndrome’ includes disorders of planning, organisation, problem solving, setting priorities, planning, organisation, problem solving, setting priorities, and attention and is one of the major areas of cognitive and attention and is one of the major areas of cognitive deficit that can impede functional recovery and the ability deficit that can impede functional recovery and the ability

to respond to rehabilitation programsto respond to rehabilitation programs..

The Profile Of Executive Control The Profile Of Executive Control System (PRO-EX)System (PRO-EX)

Braswell, D., Hartry, A., Hoornbeek, S., Johansen, A., Braswell, D., Hartry, A., Hoornbeek, S., Johansen, A., Johnson, L., Schutlz, J., and Solhberg, M. (1993)Johnson, L., Schutlz, J., and Solhberg, M. (1993)

Used by OTs, SLPs and Psychiatrists involved in Used by OTs, SLPs and Psychiatrists involved in rehabilitationrehabilitation

Purpose:Purpose: To accurately assess executive function and provide a To accurately assess executive function and provide a

classification of executive control behavior components classification of executive control behavior components that will help to organize a clinicians observations of that will help to organize a clinicians observations of executive dysfunctionexecutive dysfunction

Focus of the PRO-EXFocus of the PRO-EX

Provide the clinician with descriptors of executive Provide the clinician with descriptors of executive functions commonly disrupted during brain injuryfunctions commonly disrupted during brain injury

Summarize data gathered from naturalistic activity Summarize data gathered from naturalistic activity observations and interviewobservations and interview

Communicate/educate rehabilitation professionals, Communicate/educate rehabilitation professionals, caregivers, and clients in regards impaired executive caregivers, and clients in regards impaired executive functioningfunctioning

Aid in the design of interventions that will target Aid in the design of interventions that will target improving a client’s occupational performanceimproving a client’s occupational performance

PopulationPopulation

The PRO-EX was tested on 32 subjects 18 and over with a The PRO-EX was tested on 32 subjects 18 and over with a brain injury acquired as an adultbrain injury acquired as an adult

Attributes of brain injury:Attributes of brain injury:

– Sustained, severe closed head injuries with periods of Sustained, severe closed head injuries with periods of post-traumatic amnesiapost-traumatic amnesia

– Post concussional syndromesPost concussional syndromes

ApproachApproach

TOP-DOWN APPROACHTOP-DOWN APPROACH to assessment is used with the to assessment is used with the PRO-EX PRO-EX

Observational AssessmentObservational Assessment observe client engaging in tasks requiring use of observe client engaging in tasks requiring use of

executive functions such as goal selection, executive functions such as goal selection, planning/sequencing, initiation, execution, time planning/sequencing, initiation, execution, time sense, awareness of deficits, and self-monitoringsense, awareness of deficits, and self-monitoring

35-45 minutes to administer

Approach (2)Approach (2)

Format of the PRO-EX AssessmentFormat of the PRO-EX Assessment1.1. Observing performance on naturalistic tasks:Observing performance on naturalistic tasks: the OT the OT

would observe the patients performance on naturalistic would observe the patients performance on naturalistic tasks under “real life” conditions and make judgments tasks under “real life” conditions and make judgments based on these observationsbased on these observations

2.2. Eliciting samples of executive function (i.e. initiation):Eliciting samples of executive function (i.e. initiation): set-up specific situations to elicit specific executive set-up specific situations to elicit specific executive control system behaviors and make judgments based on control system behaviors and make judgments based on task performancetask performance

3.3. Interview processInterview process Braswell et al., Braswell et al.,

19931993

Alderman, N., Burgess, P., Emslie, H., Evans, J., and Wilson, Alderman, N., Burgess, P., Emslie, H., Evans, J., and Wilson, B. (1996)B. (1996)

Used by OT’s, SLPs and Psychiatrists involved in Used by OT’s, SLPs and Psychiatrists involved in rehabilitationrehabilitation

PurposePurpose To assess disorders of planning, organization, and problem To assess disorders of planning, organization, and problem

solving solving To predict everyday problems that arise from Dysexecutive To predict everyday problems that arise from Dysexecutive

Syndrome (DES) (Alderman et al., 1996)Syndrome (DES) (Alderman et al., 1996)

Behavioral Assessment of Behavioral Assessment of Dysexecutive Syndrome (BADS)Dysexecutive Syndrome (BADS)

Examines deficits in executive functioning associated with Examines deficits in executive functioning associated with ADD, ADHD, PDD, TBIADD, ADHD, PDD, TBI

Child friendlyChild friendly Sub-tests are brief, fun, and avoid feelings of failure Sub-tests are brief, fun, and avoid feelings of failure

Wilson, A, Alderman, N., Burgess, P., Emslie, H., & Wilson, A, Alderman, N., Burgess, P., Emslie, H., & Evans, J. (1996).Evans, J. (1996).

Behavioral Assessment of Dysexecutive Behavioral Assessment of Dysexecutive Syndrome - Child (BADS-C)Syndrome - Child (BADS-C)

Focus of the BADSFocus of the BADS

It was designed to overcome problems that had arisen fromIt was designed to overcome problems that had arisen from previous test batteries which were not sensitive to problem previous test batteries which were not sensitive to problem solving, planning and organizing behavior over a long solving, planning and organizing behavior over a long period of timeperiod of time

BADS is sensitive to frontal lobe damage resulting in BADS is sensitive to frontal lobe damage resulting in executive functioning impairmentsexecutive functioning impairments

Evans et al., (1997) has reported that the BADS is useful Evans et al., (1997) has reported that the BADS is useful in detecting executive dysfunction in closed head injury, in detecting executive dysfunction in closed head injury, schizophrenia and focal frontal damageschizophrenia and focal frontal damage

PopulationPopulation

Administered to individuals 16-87 yearsAdministered to individuals 16-87 years

BADS-C used for ages 8-16 yearsBADS-C used for ages 8-16 years

Norms established using a sample of 216 healthy, Norms established using a sample of 216 healthy, neurologically sound individuals as controlsneurologically sound individuals as controls

Patients consisted of 92 individuals who presented with a Patients consisted of 92 individuals who presented with a variety of neurological disorders variety of neurological disorders

78 of these patients completed all six tests in the BADS78 of these patients completed all six tests in the BADS

ApproachApproach

BOTTOM UP APPROACHBOTTOM UP APPROACH to assessment to assessment– standardized testing and set domainsstandardized testing and set domains

Observe client for the following:Observe client for the following:– task schedulingtask scheduling– strategy formationstrategy formation– ability to planability to plan– temporal judgmenttemporal judgment– practical problem solvingpractical problem solving– cognitive flexibility and inhibition responsecognitive flexibility and inhibition response– Approximately 35-45 minutes to administerApproximately 35-45 minutes to administer

(Wilson et al., 1996)(Wilson et al., 1996)

Approach (2)Approach (2)

Dysexecutive Questionnaire (DEX)Dysexecutive Questionnaire (DEX) Its twenty questions seek to pinpoint:Its twenty questions seek to pinpoint: Impulsivity Impulsivity PerseverationPerseveration Inability to inhibit responsesInability to inhibit responses DistractibilityDistractibility Apathy, lack of driveApathy, lack of drive Lack of insight and social awarenessLack of insight and social awarenessBurgess, P., Alderman, N., Wilson, B., Evans, J., & Emslie,

H. (1996)

BADS: Six Sub-testsBADS: Six Sub-tests

1. 1. Rules Shift Cards Test:Rules Shift Cards Test: examines clients’ ability to shift examines clients’ ability to shift rules, follow directions, and change mental sets without rules, follow directions, and change mental sets without perseveration. Use nonpicture playing cards.perseveration. Use nonpicture playing cards.

2. 2. Action Program Test:Action Program Test: examine clients’ problem solving examine clients’ problem solving ability. Involves extracting a cork from a tube using ability. Involves extracting a cork from a tube using various materials.various materials.

3. 3. Key Search TestKey Search Test:: examines clients’ ability to form a examines clients’ ability to form a strategy. Clients demonstrate how they would search a strategy. Clients demonstrate how they would search a field for a set of lost keys. Score according to field for a set of lost keys. Score according to functionality.functionality.

BADS: Six Sub-tests (2)BADS: Six Sub-tests (2)

4. 4. Temporal Judgment TestTemporal Judgment Test: : examines clients’ ability to examines clients’ ability to determine how long certain activities take in real life. Four determine how long certain activities take in real life. Four questions are asked.questions are asked.

5. 5. Modified Six ElementsModified Six Elements Test: Test: examines clients’ ability to examines clients’ ability to organize, plan task schedule, and monitor performance. For organize, plan task schedule, and monitor performance. For this test the clients must dictate, complete arithmetic this test the clients must dictate, complete arithmetic problems and name pictures.problems and name pictures.

6. 6. Zoo Map Test:Zoo Map Test: this test measures clients’ ability to follow this test measures clients’ ability to follow directions, profit from feedback and problem solve. Clients directions, profit from feedback and problem solve. Clients are to indicate the path they would take on a map when 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 visiting the zoo (i.e. plan a route to visit 6 of 12 locations in a zoo).a zoo).

Dysexecutive QuestionnaireDysexecutive Questionnaire(DEX)(DEX)

20 - item questionnaire administered to client and 20 - item questionnaire administered to client and a person close to the client (independent rater)a person close to the client (independent rater)

5 - point scale5 - point scale

Four Broad areas:Four Broad areas:– EMOTIONALEMOTIONAL– PERSONALITY CHANGESPERSONALITY CHANGES– MOTIVATIONAL CHANGESMOTIVATIONAL CHANGES– BEHAVIORAL CHANGESBEHAVIORAL CHANGES– COGNITIVE CHANGESCOGNITIVE CHANGES

Rationale for PRO-EX Rationale for PRO-EX

•The use of formal standardized test for assessing The use of formal standardized test for assessing executive function present some challenges that question executive function present some challenges that question the ability of the test to provide an accurate and valid the ability of the test to provide an accurate and valid assessment of executive functionassessment of executive function

•The authors identified that there was a need for an The authors identified that there was a need for an assessment tool that could describe and classify the range assessment tool that could describe and classify the range of associated behaviours that might be affected due to of associated behaviours that might be affected due to brain injurybrain injury

(Braswell, D. (Braswell, D. et al, 1993)et al, 1993)

Rationale (2)Rationale (2)

•Executive control system impairment may be augmented by Executive control system impairment may be augmented by the structured nature of standardized testing situations. the structured nature of standardized testing situations.

•Act of testing executive control functions may mask an Act of testing executive control functions may mask an existing impairment making it difficult to assess the actually existing impairment making it difficult to assess the actually integrity of the executive control system. integrity of the executive control system.

•Client may appear higher functioning in a structured testing Client may appear higher functioning in a structured testing situation. situation.

(Braswell, D. et al, 1993)

Rationale (3)Rationale (3)

•Therefore, the only methods to fully evaluate the executive Therefore, the only methods to fully evaluate the executive control system is through observation of performance and or control system is through observation of performance and or interview in real life situations interview in real life situations

•The PRO-EX provides a taxonomy of executive control The PRO-EX provides a taxonomy of executive control system behaviour/components which will assist in organizing system behaviour/components which will assist in organizing the clinician’s observations of patient performance. the clinician’s observations of patient performance.

•Top-down assessment that uses observation and/or Top-down assessment that uses observation and/or interview in some cases in addition to or instead of formal interview in some cases in addition to or instead of formal testingtesting

(Braswell, D. et al, 1993)

Model Model

Executive Control System Model (Stuss, 1991)Executive Control System Model (Stuss, 1991)•Hierarchical Model with three levels to describe executive Hierarchical Model with three levels to describe executive control systemcontrol system

•Based on premise the premise that the executive control Based on premise the premise that the executive control system consists of a hierarchy of independent but interactive system consists of a hierarchy of independent but interactive functionsfunctions

First Level: Sensory/Perceptual or Knowledge-based First Level: Sensory/Perceptual or Knowledge-based informationinformation-includes automatic or unconscious processes that form the -includes automatic or unconscious processes that form the basis for daily routinebasis for daily routine

Model (2)Model (2)

Second Level: Executive FunctionsSecond Level: Executive Functions-associated with the executive control or supervisory function of -associated with the executive control or supervisory function of the frontal lobesthe frontal lobes

-based on sensory/perceptual information from level one, it -based on sensory/perceptual information from level one, it adjusts and directs the more automatic processesadjusts and directs the more automatic processes

Model (3)Model (3)

Third Level: Metacognitive Functions (under control of Third Level: Metacognitive Functions (under control of prefrontal cortex)prefrontal cortex)

-Awareness: understanding of the relationship of the self to the -Awareness: understanding of the relationship of the self to the environmentenvironment

-Metacognition: ability to reflect on a process-Metacognition: ability to reflect on a process

•All three are organized as a feedback control systemAll three are organized as a feedback control system

PRO-EX and the ModelPRO-EX and the Model

(Braswell et al, 1993)(Braswell et al, 1993)•PRO-EX has seven scales that are consistent with the PRO-EX has seven scales that are consistent with the executive control systems model by D.T. Stuss (1991)executive control systems model by D.T. Stuss (1991)

For example,For example,Goal Selection: Goal Selection: -at all three levels intact goal selection would require the basic -at all three levels intact goal selection would require the basic knowledge of the appropriate steps to reach a particular goalknowledge of the appropriate steps to reach a particular goal-anticipation and goal articulation are also necessary for goal -anticipation and goal articulation are also necessary for goal selectionselection-client needs to have some awareness of their situation in order to -client needs to have some awareness of their situation in order to select appropriate goalsselect appropriate goals

PRO-EX and the Model (2)PRO-EX and the Model (2)

•Awareness of Deficits and Self-monitoring:Awareness of Deficits and Self-monitoring:-more reflected in Metacognition with an inability to self--more reflected in Metacognition with an inability to self-criticize or self-monitorcriticize or self-monitor

•Planning/Sequencing, Initiation, Execution, Time-sense: Planning/Sequencing, Initiation, Execution, Time-sense: -reflected in second level of executive functions because these -reflected in second level of executive functions because these domains are dependent on information from level one where it domains are dependent on information from level one where it adjusts and directs the more automatic processes so that adjusts and directs the more automatic processes so that behaviour can be guided toward a goalbehaviour can be guided toward a goal

PRO-EX and other TheoriesPRO-EX and other Theories

(Banich, M, 2003)(Banich, M, 2003)Goal Selection:Goal Selection: The selection of this skill area is important because many The selection of this skill area is important because many theories emphasize the role that frontal regions play in guiding theories emphasize the role that frontal regions play in guiding behaviour towards a goalbehaviour towards a goal

Planning/Sequencing, Initiation, Execution, Time-sense, Self-Planning/Sequencing, Initiation, Execution, Time-sense, Self-monitoring:monitoring: Theories about working memory emphasize the linkage between Theories about working memory emphasize the linkage between working memory and executive function.working memory and executive function.

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

PRO-EX and other Theories (2) PRO-EX and other Theories (2)

PRO-EX and NeuroanatomyPRO-EX and Neuroanatomy

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

PRO-EX and Neuroanatomy (2)PRO-EX and Neuroanatomy (2)

Ventromedial Pre-frontal CortexVentromedial Pre-frontal Cortex - decreased ability to spontaneously initiate and complete activities- decreased ability to spontaneously initiate and complete activities

Orbital Frontal Cortex:Orbital Frontal Cortex: - poor control/regulation of behavior and emotions- poor control/regulation of behavior and emotions - neurological lack of awareness- neurological lack of awareness

Ease of Use and ScoringEase of Use and Scoring

The scoring is simple to complete and involves placing a letter The scoring is simple to complete and involves placing a letter on the scale corresponding to the skill area that was being on the scale corresponding to the skill area that was being assessed. assessed.

Each letter contains a description so that the clinician is able to Each letter contains a description so that the clinician is able to assess the client’s level of functioning. assess the client’s level of functioning.

The summary sheet provided allows the clinician to compare The summary sheet provided allows the clinician to compare each skill area assessed to see which areas of executive function each skill area assessed to see which areas of executive function are interfering with the clients daily livingare interfering with the clients daily living

Psychometrics Psychometrics

There is barely any literature discussing the use of the PRO-EX There is barely any literature discussing the use of the PRO-EX and any limitations inherent in the assessment making it difficult and any limitations inherent in the assessment making it difficult to make a sound judgement as to whether it is a useful assessment to make a sound judgement as to whether it is a useful assessment for assessing dysexecutive functionfor assessing dysexecutive function

Inter-rater reliability using standard and weighted Kappa’s Inter-rater reliability using standard and weighted Kappa’s appears acceptable.appears acceptable.

(Braswell, D. (Braswell, D. et al, 1993)et al, 1993)

AdvantagesAdvantages

alternative to structured approaches to assessment (especially alternative to structured approaches to assessment (especially because executive functions are difficult to quantify)because executive functions are difficult to quantify)

provides a taxonomy to organize observations of the client and provides a taxonomy to organize observations of the client and this make it easier to identify priority areas that the client is 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 having the most issues so the clinician gets a good sense of how to structure treatment to structure treatment

able to assess twice and compare the result to see if any able to assess twice and compare the result to see if any improvements have been made by the clientimprovements have been made by the client

allows for observation and interview of the client and caregiver allows for observation and interview of the client and caregiver which provides the therapist with a lot of information which provides the therapist with a lot of information

therapists have reported that it is easy to use in the clinical therapists have reported that it is easy to use in the clinical setting (very user-friendly, easy to understand and administer)setting (very user-friendly, easy to understand and administer)

Advantages (2)Advantages (2)

DisadvantagesDisadvantages

no literature/studies done on the PRO-EX so this affects no literature/studies done on the PRO-EX so this affects the justification for its use in the clinical settingthe justification for its use in the clinical setting

inter-rater and test-retest reliability are not that greatinter-rater and test-retest reliability are not that great

OT really has to know the client and also needs skill in this OT really has to know the client and also needs skill in this area because you need to know what executive functions area because you need to know what executive functions are to know what to look forare to know what to look for

The inspiration for the BADS originated from the The inspiration for the BADS originated from the belief belief that existing assessment tools were limited by brevity and that existing assessment tools were limited by brevity and single task orientationsingle task orientation

Patients with DES are likely to be impulsive, distractible, Patients with DES are likely to be impulsive, distractible, have problems utilizing feedback and behave inappropriately have problems utilizing feedback and behave inappropriately in social situationsin social situations

They are not easy to assess because the individual They are not easy to assess because the individual component skills of executive functioning i.e. the building component skills of executive functioning i.e. the building blocks may be intact. For example, it may seem like they blocks may be intact. For example, it may seem like they have normal IQ even when DES exists.have normal IQ even when DES exists. Wilson et al, (1996)Wilson et al, (1996)

Rationale of BADSRationale of BADS

Rationale (2)Rationale (2)

The authors have provided a brief review of other The authors have provided a brief review of other measures in the field and argue that most measures, like measures in the field and argue that most measures, like the Wisconsin Card Sorting Test, focus on a specific (and the Wisconsin Card Sorting Test, focus on a specific (and myopic) sample of behaviour (i.e., problem solving with myopic) sample of behaviour (i.e., problem solving with cards), and do not require life-related problem-solving.cards), and do not require life-related problem-solving.

the authors have presented this measure as an ecologically the authors have presented this measure as an ecologically valid and clinically useful tool to assist in the diagnosis of valid and clinically useful tool to assist in the diagnosis of

the DES (Wilson, 1993the DES (Wilson, 1993).).

TheoryTheory

Based on two theoretical models:Based on two theoretical models:

1) Working Memory Model (Baddeley & Hitch, 1974) with its 1) Working Memory Model (Baddeley & Hitch, 1974) with its hypothetical construct of central executivehypothetical construct of central executive– This CE an be conceived as an overall controller, organizer, planner, This CE an be conceived as an overall controller, organizer, planner,

and allocator of resourcesand allocator of resources

2) Attentional Control System (Shallice, 1982) with two 2) Attentional Control System (Shallice, 1982) with two attentional mechanismsattentional mechanisms– Contention scheduling system: responsible for more routine aspects Contention scheduling system: responsible for more routine aspects

of attentionof attention

– Supervisory attentional system: responsible for higher level, more Supervisory attentional system: responsible for higher level, more demanding attentional tasksdemanding attentional tasks

Theory (2)Theory (2)

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

PsychometricsPsychometrics

Interrater reliability and test-retest reliability demonstrate a Interrater reliability and test-retest reliability demonstrate a high degree of consistency among raters lending credence high degree of consistency among raters lending credence to the notion of easy, consistent scoring of the subtests of to the notion of easy, consistent scoring of the subtests of the BADSthe BADS

Test-retest reliability measures indicated for normal Test-retest reliability measures indicated for normal subjects to perform slightly better on second testing than subjects to perform slightly better on second testing than the first. the first.

Spreen, O., & Strauss, E.(1998)

Psychometrics (2)Psychometrics (2)

Vailidity:Vailidity:

– Study concluded that the BADS accurately Study concluded that the BADS accurately discriminated between the two groups and that subtest discriminated between the two groups and that subtest scores accurately reflected subjective measures of scores accurately reflected subjective measures of impairment.impairment.

Additional studies are needed before it can be recommended Additional studies are needed before it can be recommended for general clinical use, but for research purposes the for general clinical use, but for research purposes the measure seems promising.measure seems promising.

Wilson, B., Evans, J., Emslie, H., Alderman, N., & Burgess, Wilson, B., Evans, J., Emslie, H., Alderman, N., & Burgess, P. (1998). P. (1998).

Critique of BADSCritique of BADS

More research on how the BADS discriminates among More research on how the BADS discriminates among persons with varying severity of impairment would be persons with varying severity of impairment would be highly usefulhighly useful

The utility of this assessment tool in diverse settings (e.g., The utility of this assessment tool in diverse settings (e.g., out-patient vs. in-patient settings) cannot be adequately out-patient vs. in-patient settings) cannot be adequately determined without such informationdetermined without such information

Chevignard, M, Pillon, B., Pradat-Diehl, Taillefer, C., Rousseau, S., Le Bras, C., & Dubois, B. (2000).

Advantages Advantages

Executive functions are difficult to quantify, so it is Executive functions are difficult to quantify, so it is positive to observe people doing task or set of activities positive to observe people doing task or set of activities and have a structured way to score and record information and have a structured way to score and record information on how the client is going about taskon how the client is going about task

Good that in scoring Good that in scoring there are ratings for average, below there are ratings for average, below average, high average—so there is a range of average, high average—so there is a range of classifications. classifications.

BADS may be useful for picking up problems in those BADS may be useful for picking up problems in those people who appear to be cognitively well-preserved and people who appear to be cognitively well-preserved and functioning well in structured settings.functioning well in structured settings.

Sohlberg, M. & Mateer, C. (2001). Sohlberg, M. & Mateer, C. (2001).

Advantages (2)Advantages (2)

Clear instructions for administering and scoringClear instructions for administering and scoring Can administer without knowing client that wellCan administer without knowing client that well Gives an indication of difference between individuals’ Gives an indication of difference between individuals’

perceptions of functioning and his or her caregiver perceptions of functioning and his or her caregiver Combined structured interviews with standard Combined structured interviews with standard

questionnaires may reveal most information about adaptive questionnaires may reveal most information about adaptive functioningfunctioning

Sohlberg, M. & Mateer, C. (2001).Sohlberg, M. & Mateer, C. (2001).

Disadvantages Disadvantages

Can be used with a broad range of clients, but experiences Can be used with a broad range of clients, but experiences suggest that it is not usually sensitive to executive function suggest that it is not usually sensitive to executive function impairments in relatively high functioning individualsimpairments in relatively high functioning individuals

Score is only on six tests--therefore issues like initiation, Score is only on six tests--therefore issues like initiation, planning are not scored specifically-just alluded to from planning are not scored specifically-just alluded to from results from BADS six subtest.results from BADS six subtest.

If the client has trouble with DES, the fact that the BADS If the client has trouble with DES, the fact that the BADS is so structured can lead to improved performance is so structured can lead to improved performance regardless of deficits—e.g. patient given explicit task to regardless of deficits—e.g. patient given explicit task to solve and examiners can prompt.solve and examiners can prompt.

Sohlberg, M. & Mateer, C. (2001). Sohlberg, M. & Mateer, C. (2001).

Disadvantages (2)Disadvantages (2)

The utility of BADS in diverse settings (e.g., out-patient The utility of BADS in diverse settings (e.g., out-patient vs. in-patient settings) hasn’t been adequately determined.vs. in-patient settings) hasn’t been adequately determined.

Six specific tests-- DES is seen most in novel situations, Six specific tests-- DES is seen most in novel situations, and the BADS is not necessarily demonstrative of novel and the BADS is not necessarily demonstrative of novel taskstasks

On the DEX, which is looked at with the BADS, the On the DEX, which is looked at with the BADS, the questionnaire of patient is disregarded and only the questionnaire of patient is disregarded and only the caregivers’ answers are factored in—is this really caregivers’ answers are factored in—is this really CLIENT-CENTRED???CLIENT-CENTRED???

Sohlberg, M. & Mateer, C. (2001). Sohlberg, M. & Mateer, C. (2001).

The Impact of Dysexecutive Symptoms on The Impact of Dysexecutive Symptoms on Occupational PerformanceOccupational Performance

Behavioral Assessment of Dysexecutive SystemBehavioral Assessment of Dysexecutive SystemDressingDressing

1. 1. Rule Shift Cards Test:Rule Shift Cards Test: goal of this test is to examine the goal of this test is to examine the client’s ability to respond correctly to a rule and shift from client’s ability to respond correctly to a rule and shift from one rule to anotherone rule to another– client would may have difficulty recognizing that an client would may have difficulty recognizing that an

under shirt is put on before an outer top and socks go under shirt is put on before an outer top and socks go on before shoeson before shoes

2. 2. Key Search Test:Key Search Test: goal of this test is strategy formation goal of this test is strategy formation– where to look in their room for certain accessories like a where to look in their room for certain accessories like a

shirt, skirt, pants , socks, watchshirt, skirt, pants , socks, watch– tying shoelacestying shoelaces

The Impact of Dysexecutive Symptoms The Impact of Dysexecutive Symptoms on Occupational Performance (2)on Occupational Performance (2)

3. 3. Temporal Judgement TestTemporal Judgement Test: assess subjects ability to : assess subjects ability to estimate how long various events last (time-sense)estimate how long various events last (time-sense)– if getting ready for an appointment, being able to if getting ready for an appointment, being able to

prepare items and gage how long it will take to get prepare items and gage how long it will take to get dressed dressed

– i.e. the individual may want to iron clothes before hand i.e. the individual may want to iron clothes before hand or polish shoesor polish shoes

4. 4. Zoo Map TestZoo Map Test: follow directions, problem solve, feedback: follow directions, problem solve, feedback– planning the appropriate dress for specific occasionsplanning the appropriate dress for specific occasions– where to locate items for dress (drawers, closet)where to locate items for dress (drawers, closet)– deciphering appropriate dress for weather conditionsdeciphering appropriate dress for weather conditions– matching items (i.e. tops with bottoms)matching items (i.e. tops with bottoms)

The Impact of Dysexecutive Symptoms The Impact of Dysexecutive Symptoms on Occupational Performance (3)on Occupational Performance (3)

5. 5. Modified Six Elements Test:Modified Six Elements Test: test of planning, task test of planning, task scheduling, and performance monitoringscheduling, and performance monitoring– being aware of what dress items have been already laid being aware of what dress items have been already laid

out (i.e. scarf, hat, gloves, and boots) and what is out (i.e. scarf, hat, gloves, and boots) and what is necessary for that days weather conditionsnecessary for that days weather conditions

– keep track of what needs to be put keep track of what needs to be put

6. 6. Action Program Test:Action Program Test: goal in mind is developing a plan goal in mind is developing a plan of action in order to solve a problemof action in order to solve a problem– if having trouble buttoning a shirt or tying laces on if having trouble buttoning a shirt or tying laces on

shoes, being decide other alternatives to dressingshoes, being decide other alternatives to dressing

The Impact of Dysexecutive Symptoms The Impact of Dysexecutive Symptoms on Occupational Performance (5)on Occupational Performance (5)

Profile of Executive Control System Profile of Executive Control System Meal PreparationMeal Preparation

1. 1. Goal Selection:Goal Selection: – find it difficult to plan the steps required to prepare find it difficult to plan the steps required to prepare

dinner with regards to choosing the food items and the dinner with regards to choosing the food items and the utensils that will be used, and the procedure for which utensils that will be used, and the procedure for which the food is to be cookedthe food is to be cooked

2. 2. Initiation:Initiation:– inability to start the simple tasks of assembling the inability to start the simple tasks of assembling the

items necessary to cookitems necessary to cook

The Impact of Dysexecutive Symptoms The Impact of Dysexecutive Symptoms on Occupational Performance (6)on Occupational Performance (6)

3. Time sense:3. Time sense:– impaired ability to manage time to cook the meal (i.e. impaired ability to manage time to cook the meal (i.e.

how long it takes to cook a dish, or cook a particular how long it takes to cook a dish, or cook a particular food item)food item)

– unable to gage time between items being prepared unable to gage time between items being prepared simultaneously so that items are not forgotten, over-simultaneously so that items are not forgotten, over-cooked, or burnedcooked, or burned

4. Awareness of deficits:4. Awareness of deficits:– may deter the client from returning to meal preparation in fear of may deter the client from returning to meal preparation in fear of

creating an accident or motivate them to find strategies to cope creating an accident or motivate them to find strategies to cope with deficitswith deficits

– person may be negligent of deficits and attempt meal preparationperson may be negligent of deficits and attempt meal preparation

The Impact of Dysexecutive Symptoms The Impact of Dysexecutive Symptoms on Occupational Performance (7)on Occupational Performance (7)

5. Self-monitoring:5. Self-monitoring:– an inability to self-monitor can lead to the client injuring self while an inability to self-monitor can lead to the client injuring self while

at the stove or using a cutting utensilat the stove or using a cutting utensil– inability to manage multiple tasks that come with meal preparation inability to manage multiple tasks that come with meal preparation

(i.e. making a salad or setting the table while monitoring pots on (i.e. making a salad or setting the table while monitoring pots on the stove)the stove)