By Ellen Braaten, PhD

Posted in: Grade School, Parenting Concerns, Teenagers

Topics: Child + Adolescent Development, Learning + Attention Issues

Executive Functions is one of those “buzzy” terms that teachers use a lot these days. It’s a general term that refers to processes such as:

• planning
• organizational skills
• working memory
• focus – which includes not only the ability to focus and maintain one’s attention, but also ability to know where to focus one’s attention
• the ability to inhibit and monitor one’s behavior.

Twenty years ago, no one talked much about executive function (EF) skills. The term wasn’t very well defined in those days and we didn’t yet realize how important these skills are to successfully navigate the world in which we live. Because we now appreciate the importance of EF, particularly in school-aged children and transitional age youth, we’ve gotten better at assessing EF. We can assess these skills in a variety of ways – by observation, by rating scales that quantify our observations, and by measuring these skills directly using specific tests.

To understand what these tests and observations are measuring, it might be useful to think of EF as similar to the jobs that executive secretaries perform. They keep track of the boss’s calendar, handle and prioritize correspondence, determine which phone calls are necessary for the boss to take, and organize most aspects of the day-to-day running of an office. A good executive secretary must be able to think about many things simultaneously and decide which of these things are most important and which of them can wait.

The frontal lobes of the brain do much the same thing for us. This area of the brain is responsible for planning, future-oriented behavior, attention, and self-regulation. This part of the brain doesn’t fully develop until sometime in late adolescence or early adulthood and is the part of the brain responsible for EF. This is why most kids don’t have perfect EF skills – they haven’t yet developed them.

But what about those kids with significant EF problems?

Brain imaging research has confirmed what neuropsychological tests have indicated, that this part of the brain works somewhat differently in people with Attention Deficit Hyperactivity Disorder (ADHD). Although not all of those with ADHD perform poorly on direct tests of executive functions, most do – and the greater the number of impaired scores on executive function measures, the greater the likelihood that ADHD is present.

Kids with other learning differences such as dyslexia and dyscalculia can sometimes have problems with EF as well, though their impairments are generally milder than those with ADHD. People who have had significant brain injuries, such as a stroke or brain trauma (especially in the prefrontal cortex), can have more significant EF challenges as a result of their injuries.

As you might have surmised by now, EF is a pretty broad concept that can be applied to a wide range of kids (as well as adults). It’s a complex issue, and finding tests that perfectly measure abstract concepts can be tough. It’s one thing to measure a child’s reading skill, but how do you measure his ability to complete complex, open-ended tasks in an unstructured environment?

It’s hard to do that in a typical testing environment where the evaluator is monitoring the child’s academic performance, so sometimes kids who have poor EF skills at school can do well on tests administered in a quiet testing room. That doesn’t mean that they don’t have real EF problems. It just means that their problems are less significant when they are in a structured and quiet setting.

Keeping in mind those challenges, psychologists try their best to use a variety of measures to evaluate EF.  Some of these are formal tests and others are more informal. They include the following elements:

1. A Child’s Development History – We can glean a lot of information from listening to the people who know the child best – usually a child’s parents and teachers. When I interview the parents about EF, I ask them direct question such as How does your child manage his homework? How organized is your child? Does he forget to turn in his homework? Is his room a mess? Does he have trouble remembering what to do? How does he handle his emotions when he is stressed? In older students, in addition to talking to parents and teachers, I’ll ask the student these questions directly. Sometimes the evaluator will observe the child in the classroom and very often the evaluator will ask to see samples of the child’s work such as his writing assignments, tests, and notes.
2. Behavior Checklists – behavior checklists can take the form of a more general checklist that measures many different behaviors (such as social skills, anxiety, attention, hyperactivity) or they can be more specifically focused on EF. Checklists can be completed by the parent, teacher, caregiver, or child/adolescent. They are an important part of the evaluation process as they force the rater to quantify how often a particular behavior occurs and how significant the behavior is. Their ratings are then compared to the typical ratings for a child at that age. Ratings that are far outside of the normal range would be considered to be in the clinically significant range, and provide evidence of significant problems in those particular domains. Some of the more common rating scales that are used include the Behavior Rating Inventory of Executive Functions (BRIEF), the Child Behavior Checklist (CBLC), and the Behavior Assessment System for Children (BASC).
3. Formal Assessment Measures – These include tests that are given to the child by an evaluator who is typically a licensed psychologist. The number of possible tests that can be given is quite large, so I only include a few of the most commonly used tests:
   • Tests that measure a child’s ability to inhibit a response: The Trail Making Test asks a child to connect a series of dots, alternating between a sequence of numbers and letters. It’s a test of motor planning, visual attention, scanning and the ability to shift set (see f below).
   • Tests that measure a child’s working memory skills: The Working Memory Index from the Wechsler Intelligence Scale for Children (WISC) or Wechsler Adult Intelligence Scale (WAIS) ask a child to remember strings of numbers or do mental arithmetic. The California Verbal Learning Test (CVLT) asks a child to remember and recall a shopping list.
   • Tests that measure a child’s ability to sustain attention: The Conners Continuous Performance Test (CPT-3) is a computerized test where letters appear on the screen and the child must press the space bar for all letters except for one specific letter or picture. It measures the ability to remain vigilant, show consistency of attentional focus, to respond quickly and to inhibit responding (see a above).
   • Tests that measure a child’s ability to plan and organize: Tests like the Rey Osterrieth ask the child to copy a very complicated figure or put together a complicated puzzle without directions.
   • Tests that measure a child’s ability to manage time and process information quickly: These include almost any timed tests, but particularly tests like Coding from the Wechsler Intelligence Scales or the Processing Speed Index from the WISC or WAIS.
   • Tests that measure a child’s ability to be flexible in his problem-solving skills: The Wisconsin Card Sorting Test asks a child to play a game with changing rules – requiring the child to be flexible in changing strategies in order to play the game successfully.

A good evaluator will use several measures of executive functions, along with observations and information provided by the parents and teachers. If you’re concerned that your child might be struggling with EF, talk to your child’s teacher and school psychologist. The psychologist can help you determine whether a more formal evaluation is needed, provide a classroom observation, and/or administer questionnaires assessing EF. For children with mild EF weaknesses, a comprehensive assessment that includes many measures is likely unnecessary. For kids with more complex problems that are significantly interfering with the ability to perform successfully in school, and in situations where parents and teachers disagree or are confused about the underlying issues, a more comprehensive assessment is usually beneficial.

Finally, keep in mind that the goal of any assessment is to provide direction for treatment. Regardless of the type of assessment measures used, at the end of the evaluation process you should expect answers to these questions: “What are the EF challenges that my child has?” and “What can we do to help him?”