106 BRIEF- Inventario de funciones Ejecutivas

Esta é uma pré-visualização de arquivo. Entre para ver o arquivo original

106. BRIEF- Inventario de funciones Ejecutivas/Desc. Inventario (BRIEF).pdf
 
►Behavior Rating Inventory of Executive Functions (BRIEF; Gioia, Isquith, 
Guy y Kenworthy, 2000). Es una escala compuesta por dos cuestionarios de 86 
ítems, uno para padres y otro para profesores, diseñados para evaluar el 
funcionamiento ejecutivo en el hogar y en la escuela, respectivamente. Determina 
en qué medida las disfunciones ejecutivas se reflejan en la vida real, es decir, la 
validez ecológica. En esta investigación hemos utilizado la escala BRIEF para 
profesores (ver Anexo II. 12). Una mayor puntuación en esta escala es señal de un 
mayor número de alteraciones en las funciones ejecutivas. Cada ítem tiene tres 
opciones de respuesta: Nunca (1 punto), A veces (2 puntos), Con frecuencia (3 
puntos), según la asiduidad con la que el niño realice las conductas manifestadas 
en cada cuestión. Los ítems se agrupan en 8 dimensiones, a saber: (a) Inhibición, 
(b) Cambio, (c) Control emocional, (d) Iniciativa, (e) Memoria de trabajo, (f) 
Planificación-Organización, (g) Organización de materiales y (h) Control. A 
continuación presentamos una breve descripción de cada una de ellas: 
Inhibición. Esta dimensión evalúa la habilidad para resistir a los impulsos y 
detener una conducta en el momento apropiado. 
Cambio. Esta dimensión mide la habilidad para hacer y tolerar cambios, la 
flexibilidad para resolver problemas y pasar el foco atencional de un tema a otro 
cuando se requiera. 
 
Control emocional. Esta dimensión refleja la influencia de las funciones 
ejecutivas en la expresión y regulación de las emociones. 
Iniciativa. Evalúa la habilidad para iniciar una actividad sin ser incitado a 
ello. Incluye aspectos como la habilidad para generar ideas, respuestas o 
estrategias de resolución de problemas de modo independiente. 
Memoria de trabajo. Mide la capacidad de mantener la información en la 
mente durante un breve periodo de tiempo, con el objetivo de completar una tarea, 
registrar y almacenar información o generar objetivos. Es esencial para llevar a 
cabo actividades múltiples o simultáneas. 
Organización y planificación. Los componentes de esta dimensión son 
importantes para la resolución de problemas. La organización implica la habilidad 
para ordenar la información. Es útil para identificar las ideas principales o los 
conceptos clave en tareas de aprendizaje y para comunicar dicha información, ya 
sea por vía oral o escrita. La planificación supone el planteamiento de un objetivo y 
la elección de la mejor vía para alcanzarlo, con frecuencia a través de pasos 
adecuadamente secuenciados. 
Organización de materiales. Esta dimensión no es más que otro aspecto de 
la organización. Refleja la habilidad para ordenar los elementos del entorno e 
incluye mantener el orden en los elementos de trabajo, juguetes, armarios, 
escritorios u otros lugares donde se guardan cosas, además de tener la certeza de 
que los materiales que se necesitarán para realizar una tarea estén efectivamente 
disponibles. 
 
Control. Esta dimensión comprende dos aspectos; el primero, se refiere al 
hábito de controlar el propio rendimiento durante la realización de una tarea o 
inmediatamente tras finalizar la misma, con el objeto de cerciorarse de que el 
objetivo propuesto ha sido alcanzado satisfactoriamente; el segundo aspecto, que 
los autores llaman autocontrol o conciencia interpersonal (self-monitoring o 
interpersonal awareness), refleja la conciencia del niño acerca de los efectos que su 
conducta provoca en los demás. 
Las dimensiones se agrupan en dos índices principales: (a) Índice de 
Regulación Comportamental (BRI, en sus siglas en inglés) que incluye las 
dimensiones de Inhibición, Cambio y Control Emocional y (b) Índice de 
Metacognición (MI, en sus siglas en inglés) que agrupa las dimensiones de 
Iniciativa, Memoria de Trabajo, Planificación-Organización, Organización de 
materiales y Control. Estos dos índices se agrupan en la llamada Composición 
Ejecutiva Global (GEC, en sus siglas en inglés) (Soprano, 2003). A estas 8 
dimensiones se añaden 13 ítems adicionales, estos ítems no se miden y, por tanto, 
no contribuyen a la puntuación. Su existencia se justifica por la utilidad para 
establecer una intervención funcional y por su relevancia en el estudio de las 
poblaciones clínicas específicas como por ejemplo en el caso del TDAH. Estos 
ítems fueron originalmente asignados a las dimensiones de Inhibición, Planificación-
Organización, Control, Cambio y Memoria de trabajo. 
 Isquith y Gioia (2000) examinaron mediante regresión logística dos de las 8 
dimensiones de este cuestionario, concretamente las escalas de Memoria de 
 
Trabajo y de Inhibición. El objetivo del estudio fue determinar su sensibilidad y 
especificidad a la hora de identificar los subtipos del TDAH en niños referidos 
clínicamente y en aquellos sin este diagnóstico. En las escalas de profesores, la 
escala de Memoria de Trabajo discriminó entre los niños sin TDAH y aquellos con 
los subtipos inatento o combinado del TDAH. La escala de Inhibición distinguió los 
niños con TDAH de tipo combinado de aquellos con el subtipo inatento y del grupo 
de control (“normales”). Las escalas de padres, en la dimensión de Memoria de 
Trabajo, identificaron al 89% de los sujetos del subtipo inatento y al 85% del subtipo 
combinado con medidas T en o por encima del percentil 90, mientras que 
identificaron de forma incorrecta al 16% de los niños del grupo de control. Una 
puntuación de corte en el percentil 90 para la escala de Inhibición identificó 
correctamente al 85% de los niños con diagnóstico del subtipo combinado e 
identificó incorrectamente al 14% sin este trastorno. Las escalas de maestros fueron 
similares en lo que a sensibilidad de refiere, con una puntuación en la escala de 
Memoria de Trabajo en el percentil 90 identificando al 76% de los niños con el 
subtipo inatento pero sólo al 17% de los niños sin un diagnóstico de TDAH. Una 
puntuación en o por encima del percentil 88 en la escala de Inhibición identificó al 
78% de los niños con el subtipo combinado y al 21% de los controles. 
Además de esta utilidad diagnóstica, la escala BRIEF puede delimitar la 
amplitud de las áreas potenciales de la disfunción ejecutiva en el TDAH (e.g. 
organización, planificación, déficits de control, descontrol emocional). En resumen, 
el uso de la escala BRIEF para el diagnóstico clínico del TDAH, mediante las 
 
escalas de Memoria de Trabajo e Inhibición, así como para la definición funcional 
de diversos aspectos de la disfunción ejecutiva, puede añadir información válida 
para la evaluación del TDAH. 
106. BRIEF- Inventario de funciones Ejecutivas/Desc. Inventario (BRIEF-SR).pdf
PAR Psychological Assessment Resources, Inc. / 16204 North Florida Ave. / Lutz, FL 33549 / 1.800.331.8378 / www.parinc.com 
BRIEF®-SR: Interpretive Report Copyright © 1996, 1998, 2000, 2001, 2002, 2003, 2004, 2007, 2008 by Psychological Assessment Resources, 
Inc. All rights reserved. May not be reproduced in whole or in part in any form or by any means without written permission of Psychological 
Assessment Resources, Inc. 
 Version: 3.01.007 
Behavior Rating Inventory of Executive Function
®
 
Self-Report Version 
BRIEF
®
-SR 
Interpretive Report 
 
Developed by 
 
Peter K. Isquith, PhD, Gerard A. Gioia, PhD, Steven C. Guy, PhD, and PAR Staff 
 
Client Information 
 
 Client Name : Sample Client 
 Client ID : SC456 
 Gender : Male 
 Grade: 10th 
 Age : 15 
 Birthdate : 03/15/1992 
 Test Date : 02/29/2008 
 Test Description : Asperger's Disorder 
 
 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 2 of 10 
 
 
Introduction 
The Behavior Rating Inventory of Executive Function
®
–Self-Report Version (BRIEF
®
-SR) is 
an 80-item standardized self-report measure developed to capture older children’s and 
adolescents’ (aged
11 to 18 years with a fifth grade or better reading level) views of their own 
executive functions, or self-regulation, in their everyday environment. The BRIEF-SR was 
intended to complement parent and teacher ratings of the adolescent’s executive function on the 
BRIEF
®
 Parent and Teacher Forms in order to meet the need for capturing adolescents’ views 
of their own self-regulatory strengths and weaknesses. In addition to a more comprehensive 
assessment, an understanding of the adolescent’s perspective with respect to difficulties in 
self-control is critical when considering intervention strategies. Explicitly assessing, valuing, 
and providing feedback about his viewpoint can facilitate rapport and the development of a 
collaborative working relationship that can, in turn, serve as a starting point for interventions. 
Indeed, the adolescent’s level of self-understanding and awareness becomes an important factor 
in gauging the amount of support he will require. For those who possess a high awareness of 
their executive/regulatory difficulties and who are eager to ameliorate their struggles, the 
intervention process can be facilitated. For those who lack awareness or acceptance, a much 
higher degree of external support may be required. While response patterns on self-report 
behavior rating scales such as the BRIEF-SR can range from strong agreement with other 
informants to aggressive denial of any problems, rich clinical information can be gleaned from 
directly assessing their opinions. 
As is the case for all measures, the BRIEF-SR should not be used in isolation as a diagnostic 
tool. Instead, it should be used in conjunction with other sources of information, including 
detailed history, parent and/or teacher ratings on the BRIEF
®
, clinical interviews, performance 
test results, and, when possible, direct observation in the natural setting. By examining 
converging evidence, the clinician can confidently arrive at a valid diagnosis and, most 
importantly, an effective treatment plan. A thorough understanding of the BRIEF-SR, 
including its development and its psychometric properties, is a prerequisite to interpretation. 
As with any clinical method or procedure, appropriate training and clinical supervision is 
necessary to ensure competent use of the BRIEF-SR. 
This report is confidential and intended for use by qualified professionals only. This report 
should not be released to the parents or teachers of the adolescent being evaluated or to the 
adolescent himself. If a summary of the results specifically written for parents and teachers is 
desired, the BRIEF-SR Feedback Report can be generated and given to the interested parents 
and/or teachers. If a summary of the results specifically written for the responding adolescent is 
desired and clinically appropriate, the BRIEF-SR Adolescent Feedback Report can be generated 
and given to the adolescent, preferably in the context of verbal feedback and a review of the 
Adolescent Feedback Report with the clinician. 
T scores are used to interpret the adolescent’s self-reported level of executive functioning on the 
BRIEF-SR rating form. These scores are linear transformations of the raw scale scores (M = 
50, SD = 10). T scores provide information about an individual’s scores relative to the scores 
of respondents in the standardization sample. Percentiles, which are also presented within the 
BRIEF-SP, represent the percentage of children in the standardization sample who fall below a 
given raw score. Traditionally, T scores at or above 65 are considered clinically significant; 
however, in the case of the BRIEF-SR, T scores between 60 and 64 on any of the clinical scales 
or indexes, may warrant clinical interpretation. In this report, such scores are described as 
“mildly elevated.” 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 3 of 10 
 
 
In the process of interpreting the BRIEF-SR, review of individual items within each scale can 
yield useful information for understanding the specific nature of the adolescent’s elevated score 
on any given clinical scale. While certain items may be particularly relevant to specific clinical 
groups, placing too much interpretive significance on individual items is not recommended due 
to lower reliability of individual items relative to the scales and indexes. 
Overview 
Sample completed the Self-Report Version of the Behavior Rating Inventory of Executive 
Function (BRIEF-SR) on 02/29/2008. There are no missing item responses in the protocol. 
Responses are reasonably consistent. The respondent’s ratings of his own self-regulation do 
not appear overly negative. In the context of these validity considerations, Sample’s ratings of 
his everyday executive function suggest some areas of concern. 
The overall index, the Global Executive Composite (GEC), was mildly elevated (GEC T = 63, 
%ile = 88). Both the Behavioral Regulation (BRI) and the Metacognition (MI) Indexes were 
mildly elevated (BRI T = 64, %ile = 90 and MI T = 61, %ile = 86). 
Within these summary indicators, all of the individual scales are valid. One or more of the 
individual BRIEF-SR scales were at least mildly elevated, suggesting that Sample reports 
difficulty with some aspects of executive function. Concerns are noted with his ability to 
adjust to changes in routine or task demands (Shift T = 67, %ile = 95) and finish tasks such as 
homework or projects (Task Completion T = 65, %ile = 93). Sample describes his ability to 
inhibit impulsive responses (Inhibit T = 57, %ile = 77), modulate emotions (Emotional Control 
T = 64, %ile = 89), sustain working memory (Working Memory T = 61, %ile = 85), plan and 
organize problem solving approaches (Plan/Organize T = 56, %ile = 77), organize his 
environment and materials (Organization of Materials T = 55, %ile = 73), and monitor his own 
behavior (Monitor T = 61, %ile = 85) as not problematic. 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 4 of 10 
 
 
BRIEF
®
-SR Score Summary Table 
 
Index/Scale Raw Score T Score Percentile 90% C.I. 
Inhibit 23 57 77 54 - 60 
Shift 21 67 95 64 - 70 
Emotional Control 20 64 89 62 - 66 
Monitor 10 61 85 59 - 63 
Behavioral Regulation Index (BRI) 74 64 90 59 - 69 
Working Memory 23 61 85 58 - 64 
Plan/Organize 24 56 77 53 - 59 
Organization of Materials 13 55 73 52 - 58 
Task Completion 21 65 93 62 - 68 
Metacognition Index (MI) 81 61 86 55 - 67 
Global Executive Composite (GEC) 155 63 88 55 - 71 
 
Subscale Raw Score T Score Percentile 90% C.I. 
Behavioral Shift 10 62 88 60 - 64 
Cognitive Shift 11 69 96 67 - 71 
 
Scale Raw Score Cumulative Percentile Protocol Classification 
Negativity 0 98 Acceptable 
Inconsistency 0 98 Acceptable 
Note: Male, age-specific norms have been used to generate this profile. 
For additional normative information, refer to the Appendix in the BRIEF®-SR Professional Manual. 
 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 5 of 10 
 
 
 
Profile of BRIEF
®
-SR T Scores 
T Score
 30
35
40
45
50
55
60
65
70
75
80
85
90
95
 100
T Score
 30
35
40
45
50
55
60
65
70
75
80
85
90
95
 100
Emotional Working Plan/ Org. of Task Behav. Cog.
Inhibit Shift Control Monitor Mem. Org. Mat. Compl. BRI MI GEC Shift Shift
T Score 57 67 64 61 61 56 55 65 64 61 63 62 69
Percentile 77 95 89 85 85 77 73 93 90 86 88 88 96
Raw score 23 21 20 10 23 24 13 21 74 81 155 10 11
Missing n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
 
Note: Male, age-specific norms have been used to generate this profile. 
For additional normative information, refer to the Appendix in the BRIEF®-SR Professional Manual. 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 6 of 10 
 
 
Validity 
Before examining the BRIEF-SR profile, it is essential to carefully consider the validity of the 
data
provided. The inherent nature of rating scales brings potential bias to the scores. The 
first step is to examine the protocol for missing data. With a valid number of responses, the 
Inconsistency and Negativity scales of the BRIEF-SR provide additional validity indexes. 
Missing items 
Sample completed 80 of a possible 80 BRIEF-SR items. There are no missing responses in the 
protocol, providing a complete data set for interpretation. 
Inconsistency 
Scores on the Inconsistency scale indicate the extent to which Sample answered similar 
BRIEF-SR items in an inconsistent manner relative to the combined normative and clinical 
samples. For example, a high Inconsistency score might be associated with marking Never in 
response to the item “I have angry outbursts” while at the same time marking Often in response 
to the item “I have outbursts for little reason.” T scores are not generated for the Inconsistency 
scale. Instead, the raw difference scores for the 10 paired items are summed and the total 
difference score (i.e., the Inconsistency score) is used to classify the protocol as either 
“Acceptable” or as “Inconsistent.” The Inconsistency score of 0 falls within the Acceptable 
range, suggesting that Sample was reasonably consistent in his responses. 
Negativity 
The Negativity scale measures the extent to which the respondent answered selected BRIEF-SR 
items in an unusually negative manner relative to the clinical sample. A higher raw score on 
this scale indicates a greater degree of negativity, with less than 1% of respondents scoring 
above 5 in the clinical sample. As with the Inconsistency scale, T scores are not generated for 
this scale. The Negativity score of 0 falls within the acceptable range, suggesting that 
Sample’s view of himself is not overly negative and that the BRIEF-SR protocol is likely to be 
valid. 
Composite and Summary Indexes 
Global Executive Composite 
The Global Executive Composite (GEC) is an overarching summary score that incorporates all 
of the BRIEF-SR clinical scales. Although review of the Metacognition Index, Behavioral 
Regulation Index, and individual scale scores is strongly recommended for all BRIEF-SR 
profiles, the GEC can sometimes be useful as a summary measure. In this case, the two 
summary indexes are not substantially different, with T scores separated by 3 points. Thus, the 
GEC adequately captures the nature of the overall profile. With this in mind, Sample’s T score 
of 63 (%ile = 88) on the GEC is mildly elevated as compared to the scores of his peers, 
suggesting some difficulty in one or more areas of executive function. 
Behavioral Regulation and Metacognition Indexes 
The Behavioral Regulation Index (BRI) captures the adolescent’s ability to shift cognitive set, 
modulate emotions and behavior via appropriate inhibitory control, and monitor his impact on 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 7 of 10 
 
 
others. It is comprised of the Inhibit, Shift, Emotional Control and Monitor scales. Intact 
behavioral regulation is likely to be a precursor to appropriate metacognitive problem solving. 
Behavioral regulation enables the metacognitive processes to successfully guide active 
systematic problem solving; and more generally, behavioral regulation supports appropriate 
self-regulation. 
The Metacognition Index (MI) reflects the adolescent’s ability to sustain working memory, to 
plan and organize his problem-solving approaches, and to organize his materials and 
environment. It can be interpreted as Sample’s ability to cognitively self-manage tasks. The 
MI relates directly to ability to actively problem solve in a variety of contexts and to complete 
tasks such as school work. It is composed of the Working Memory, Plan/Organize, 
Organization of Materials, and Task Completion scales. 
Examination of the indexes reveals that both the Behavioral Regulation Index (T = 64, %ile = 
90) and Metacognition Index (T = 61, %ile = 86) are mildly elevated. This suggests more 
global difficulties with self-regulation, including the fundamental ability to inhibit impulses, 
modulate emotions, flexibly problem solve, and monitor the impact of his behavior on others. 
These global difficulties extend to metacognitive functions, including the ability to sustain 
working memory, plan and organize, with resulting difficulty completing tasks such as school 
work. 
 
Clinical Scales 
The BRIEF-SR clinical scales measure the extent to which Sample reports problems with 
different behaviors related to the eight domains of executive functioning captured within the 
BRIEF-SR. The following sections describe the scores obtained on the clinical scales and the 
suggested interpretation for each individual clinical scale. 
Inhibit 
The Inhibit scale assesses inhibitory control and impulsivity. This can be described as the 
ability to resist impulses and the ability to stop one’s own behavior at the appropriate time. 
Sample’s T score of 57 (%ile = 77) on this scale is within the expected range as compared to his 
peers. This suggests that he views himself as typically able to resist impulses and consider 
consequences before acting, and generally as “in control” of himself. 
 
 
Shift 
The Shift scale assesses the ability to move freely from one situation, activity, or aspect of a 
problem to another as the circumstances demand. Key aspects of shifting include the ability to 
(a) make transitions, (b) tolerate change, (c) problem-solve flexibly, (d) switch or alternate 
attention, and (e) change focus from one mindset or topic to another. Behavioral aspects of 
shifting, such as making transitions and tolerating change, are captured by the Behavioral Shift 
subscale, while cognitive aspects of shifting, such as problem solving flexibly, are captured by 
the Cognitive Shift subscale. Sample’s score on the Shift scale is significantly elevated as 
compared to like-aged peers (T = 67, %ile = 95).Within the overall scale, both the Behavioral 
Shift (T = 62, %ile = 88) and the Cognitive Shift (T = 69, %ile = 96) subscales are elevated. 
This suggests that Sample is experiencing difficulty with both behavioral and cognitive 
flexibility. Difficulties with shifting can compromise the efficiency of problem-solving. 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 8 of 10 
 
 
Individuals who have difficulty shifting are often described as somewhat rigid and/or inflexible. 
They often prefer consistent routines. In some cases, they are described as being unable to 
drop certain topics of interest or as unable to move beyond a specific disappointment or unmet 
need. In the assessment setting, children or adolescents who report disliking change may need 
additional time to prepare for the evaluation. Sample might benefit from scheduling the 
evaluation in advance and from being reminded as the time approaches of the appointment. If 
not possible, then additional “warm-up” time in the assessment setting might be helpful toward 
facilitating the adjustment to the new setting. On formal assessment, children or adolescents 
with difficulties shifting cognitively may have difficulty changing from one task to the next or 
sometimes from one question to the next. They sometimes require additional explanations or 
demonstration to grasp the demands of a novel task when first presented. They may also “carry 
over” a problem-solving approach, a response style, or information from a previous task that is 
no longer appropriate. This tendency to carry over can be seen as perseverating on content or 
response style from one item to the next within a task. 
 
 
Emotional Control 
The Emotional Control scale measures the impact of executive function problems on emotional 
expression and assesses an individual’s ability to modulate or control his or her emotional 
responses. Sample’s score
on the Emotional Control scale is mildly elevated as compared to 
like-aged peers (T = 64, %ile = 89). This score suggests that he has some concerns about his 
own regulation or modulation of emotions. Sample may overreact to events and may 
demonstrate sudden outbursts, sudden and/or frequent mood changes, and excessive periods of 
emotional upset. 
 
Monitor 
The Monitor scale assesses self-monitoring, or interpersonal awareness. It captures the degree 
to which a child or adolescent perceives himself as aware of the effect that his behavior has on 
others. In this regard, it is somewhat more limited in scope than the Monitor scale included in 
the Parent and Teacher forms of the BRIEF, which capture self-monitoring as well as task 
monitoring. Sample’s score on the Monitor scale is mildly elevated, suggesting some difficulty 
with monitoring his own behavior in social settings (T = 61, %ile = 85). Sample may be 
unaware of the impact his own behavior has on social interactions with others. 
 
 
Working Memory 
The Working Memory scale measures “on-line representational memory;” that is, the capacity 
to hold information in mind for the purpose of completing a task, encoding information, or 
generating goals, plans, and sequential steps to achieving goals. Working memory is essential 
to carry out multistep activities, complete mental manipulations such as mental arithmetic, and 
follow complex instructions. Sample’s score on the Working Memory scale is mildly elevated 
as compared to like-aged peers (T = 61, %ile = 85). This suggests that Sample experiences 
some difficulty holding an appropriate amount of information in mind or in “active memory” 
for further processing, encoding, and/or mental manipulation. Further, Sample’s score suggests 
difficulties sustaining working memory, which has a negative impact on his ability to remain 
attentive and focused for appropriate lengths of time. Caregivers or teachers often describe 
children or adolescents with fragile or limited working memory as having trouble remembering 
things (e.g., phone numbers or instructions) even for a few seconds, losing track of what they 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 9 of 10 
 
 
are doing as they work, or forgetting what they are supposed to retrieve when sent on an errand. 
Such individuals may miss information that exceeds their working memory capacity such as 
instructions for an assignment. Clinical evaluators may observe that such students cannot 
remember the rules governing a specific task (even as he or she works on that task), rehearses 
information repeatedly, loses track of what responses he or she has already given on a task that 
requires multiple answers, and struggles with mental manipulation tasks (e.g., repeating digits in 
reverse order) or solving arithmetic problems that are orally presented without writing down 
figures. 
Appropriate working memory is necessary to sustain performance and attention. Parents of 
children and adolescents with difficulties in this domain often report that he cannot “stick to” an 
activity for an age-appropriate amount of time and frequently switches tasks or fails to complete 
tasks. Although working memory and the ability to sustain it have been conceptualized as 
distinct entities, behavioral outcomes of these two domains are often difficult to distinguish. 
 
 
Plan/Organize 
The Plan/Organize scale measures a respondent’s perceived ability to manage current and 
future-oriented task demands. The scale is comprised of two components: plan and organize. 
The plan component captures the ability to anticipate future events, to set goals, and to develop 
appropriate sequential steps ahead of time in order to carry out a task or activity. The organize 
component refers to the ability to bring order to information and to appreciate main ideas or key 
concepts when learning or communicating information. Sample’s score on the Plan/Organize 
scale is within the expected range as compared to like-aged peers (T = 56, %ile = 77). This 
suggests that Sample perceives himself as able to plan and organize his approach to problem 
solving appropriately and is able to grasp the overall structure or framework of novel 
information that facilitates learning and later recall. 
 
 
Organization of Materials 
The Organization of Materials scale measures orderliness of work and storage spaces (e.g., 
desks, lockers, and backpacks). Sample’s score on the Organization of Materials scale falls 
within the average range relative to like-aged peers (T = 55, %ile = 73). Sample describes 
himself as being able to keep materials and belongings reasonably well organized, as having his 
materials readily available for projects or assignments, and as being able to find his belongings 
when needed. 
 
 
Task Completion 
 
The Task Completion scale reflects the ability to finish or complete tasks appropriately and/or 
in a timely manner, emphasizing difficulties with the production of work or performance output. 
Although “task completion” is not commonly considered an executive function, it represents the 
outcome of other executive difficulties including working memory, planning, organization, and 
inhibitory control. Sample’s score on the Task Completion scale is significantly elevated 
compared with like-aged peers (T = 65, %ile = 93). This suggests that Sample views himself as 
having marked difficulties finishing homework or other projects in a timely fashion. 
Examination of other scales may reveal potential sources of difficulty completing tasks, 
including difficulties with working memory, planning, and organization, or ability to inhibit 
task-irrelevant actions. 
Client: Sample Client Test Date: 02/29/2008 
Client ID: SC456 Page 10 of 10 
 
 
 
Executive System Intervention 
 
(This section removed for sample report purposes) 
 
 
End of Report 
106. BRIEF- Inventario de funciones Ejecutivas/Executive Function and ADHD -Single space version.docExecutive Function and ADHD
20
Executive Function and ADHD: Exploration through Children’s Everyday Behaviors
Gerard A. Gioia1,2 & Peter K. Isquith3
1Mt. Washington Pediatric Hospital
2Dept. of Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine
3Dept. of Psychiatry, Dartmouth Hitchcock Medical Center
Accepted for publication in Clinical Neuropsychological Assessment
Abstract
Recent re-examination of Attention-Deficit/Hyperactivity Disorder (ADHD) in terms of the neuropsychological construct of executive function (Pennington & Ozonoff, 1996; Barkley, 1997) provided impetus to explore this relationship using the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy & Kenworthy, 2000). The BRIEF assesses the behavioral manifestations of eight subdomains of executive functions in children aged 5 to 18 years via standardized parent and teacher ratings. The diagnostic utility of the BRIEF for identifying subtypes of childhood ADHD was examined. Two of the eight BRIEF scales - Working Memory and Inhibit - were examined via logistic regression analyses for their predictive validity in identifying clinically referred children with ADHD subtypes versus children with no diagnosis. The Working Memory scale discriminated between children with no ADHD diagnosis and those with either the Inattentive or Combined subtypes, while the Inhibit scale further distinguished between children with the Combined subtype of ADHD and those with the Inattentive subtype or no diagnosis. Additionally, the relationship of the broader construct of executive function to ADHD was examined via factor analysis of the BRIEF with the ADHD Rating Scale-IV (DuPaul, Power, Anastopoulos & Reid, 1998). Specific subscales of the BRIEF were more highly associated with the Inattention syndrome of the ADHD Rating Scale whereas other subscales were associated with the Hyperactive/ Impulsive
syndrome. The findings underscore the importance of executive functions as critical components in the functional definition of ADHD. The underlying functional components of the Inattention subtype include not simply a sustain factor but other metacognitive functions including the ability to initiate, organize and plan an action sequence, as well as to maintain a problem-solving set in active working memory. Similarly, the functional definition of the ADHD Combined subtype includes not only the executive function subdomain of inhibit but also the regulatory functions of flexibility and appropriate emotional control. These findings provide evidence for the strong relationship between executive function and the clinical diagnosis of ADHD. The multi-dimensional neuropsychological construct of executive function is both more specific and comprehensive in highlighting the critical functional aspects of ADHD beyond the traditional triad of symptoms.
Executive Functions and ADHD: Exploration through Children’s Everyday Behaviors
The syndrome of Attention-Deficit/Hyperactivity Disorder (ADHD) has traditionally been defined by three aspects of disordered functioning including sustained attention, impulsivity, and high activity level (DSM-IV, American Psychiatric Association, 1994). The definition of ADHD has been evolving over the last thirty years (Barkley, 1997). More recently, the nature of the disorder has been re-examined and is undergoing further redefinition in terms of a disorder of the executive functions (e.g., Barkley, 1997, 2000; Brown, 1999; Denckla, 1996, 1989; Pennington & Ozonoff, 1996). Various authors have argued that the syndrome of ADHD might better be viewed in terms of the construct of executive function than the traditional triad of symptoms reflected in current diagnostic criteria. Many agree that ADHD is not a unitary disorder, and that difficulties with sustained attention, impulsivity and hyperactivity are not the sole characteristics or areas of difficulty. A model of “attentional” disorders defined by executive function may be both more specific and more inclusive in identifying problematic areas of functioning. Further, viewing the behavioral symptoms of ADHD as ramifications of deficits in executive function provides a more useful neuropsychological model, as executive functions are one step closer to neural substrate than the ADHD diagnosis and provide a more functional framework for research (Barkley, 2000). We propose further that a comprehensive understanding of ADHD requires explicit inclusion of the executive functions in clinical assessment and intervention, as well as in research.
At the outset, it is essential to appreciate the distinction between executive functions and the diagnosis of ADHD: Executive function is a neuropsychological construct inferred from observed behavior, whereas ADHD is a medical diagnosis based on a cluster of observed symptoms (APA, 1994). Although executive functions underlie the symptoms of ADHD, they are not synonymous with a diagnosis of ADHD. The relationships are not yet entirely clear; however, there is general agreement that different aspects of executive dysfunction contribute to the three ADHD subtypes: Predominantly Inattentive Type (ADHD-I), Predominantly Hyperactive-Impulsive Type (ADHD-H), and Combined Type (ADHD-C). Indeed, several authors have recently focused on the relationship between executive function, attention, and the diagnosis of ADHD and its subtypes (Barkley, 1990, 1996; Brown, 1999; Isquith & Gioia, 1999; Pennington and Ozonoff, 1996). 
As can be presumed from the nature of executive function, there is a close link with attentional functioning (Barkley, 1997; Mirsky, 1989). Indeed, executive function deficits may be most noticeable, and perhaps most measurable, as expressed via the attentional system. An intact executive system is necessary to support the ability to initiate, sustain, inhibit, shift and direct the child’s attention (Denckla, 1989). A child who cannot initiate attention or is slow to do so may never manage to focus on what someone is saying or on what he, himself, is doing. Disorders of sustaining attention and performance are characteristic of the inattentive type of ADHD (APA, 1994). Isquith and Gioia (1999) recently demonstrated that initiating, sustaining, planning, organization and working memory are likely functional underpinnings of the inattentive subtype of ADHD, while inhibiting, shifting, self-monitoring and emotional control are strongly related to the combined subtype of ADHD. Barkley (1990, 1997) gives thorough consideration to inhibitory control as a central problem in ADHD, particularly the Combined Type.
While many have explored the relationship between executive function and ADHD (e.g., Barkley 1997; Bayliss & Roodenrys, 2000; Pennington & Ozonoff, 1996), the relationship remains elusive for several reasons, including both definitional and measurement problems with executive functions (Rabbit, 1997). While behavioral criteria are well established for diagnosing ADHD (DSM-IV, American Psychiatric Association, 1994), the same cannot be said for executive function. Definitions and models of executive function abound in the literature (e.g., Barkley, 2000; Brown, 1999; Denckla, 1994; Fuster, 1989; Goldman-Rakic, 1987; Levin et al., 1991; Stuss, 1986; Welsh & Pennington, 1988), with varying degrees of overlap and consensus as to the overall nature of executive function and specific subdomains. Some authors argue, in fact, that it may not be possible to segment the central executive beyond the molar level (Burgess, 1997; Goldman-Rakic 1987). 
To date, attempts to operationalize models of executive function have focused on laboratory or clinical performance tests (Welsh & Pennington, 1988; Welsh, Pennington & Grossier, 1991; Kelly, 2000), although such measures contain inherent problems (Pennington et al., 1996; Rabbit, 1997). For example, Burgess (1997) suggests that most neuropsychological tests alone are inadequate in assessing the executive functions because they attempt to separate integrated functions. Yet executive functions are typically measured by performance on clinical and experimental tests. Indeed, many consider the Wisconsin Card Sorting Task (Heaton, Chelune, Talley, Kay & Curtiss, 1993) the prototypical executive function test, despite the inherently limited focus and scope of any single performance measure. In their comprehensive review of executive function and ADHD studies, Pennington and Ozonoff (1996) cite only a few performance tests that are consistently impaired across studies and note that the Wisconsin Card Sorting Test is not among them. 
Assessment of Attention-Deficit/Hyperactivity Disorder
The assessment of Attention-Deficit/Hyperactivity Disorder is a complex process given the genetic, neurological, neuropsychological, developmental, behavioral, familial, and social aspects of the disorder (Shelton & Barkley, 1990). Several levels of assessment are recommended in considering these factors, including a medical examination, clinical interviews, and careful behavioral assessment (Goldstein & Goldstein, 1990). The behavioral assessment can be accomplished via direct observational methods and the collection of ratings of the child’s behavior via standardized behavior rating scales. The administration of tests has proven less useful for the specific diagnosis of ADHD (Barkley & Grodzinsky, 1994; Pennington & Ozonoff, 1996) although it can be critically important for examining underlying executive deficits (Pennington et al., 1996) and comorbid cognitive or social-emotional conditions (Shelton & Barkley, 1990). A medical examination should be considered given the underlying neurobiological basis of ADHD and the various conditions that can contribute to poor attention, impulse control, and high activity level (e.g., prenatal alcohol/ drug exposure, exposure to neurotoxins, perinatal or postnatal hypoxia, traumatic brain
injury) or co-exist with ADHD (e.g., motor incoordination, enuresis/ encopresis, allergies). Careful clinical interview of the parent and child seeks to understand factors associated with the child’s birth and developmental history; genetic history of psychiatric, medical or developmental disorders; social and family factors that may contribute positively or negatively to the child’s adaptive functioning; and school performance and functioning. Finally, the use of well-standardized and validated child behavior rating scales in the assessment of ADHD has become an essential component in order to measure the degree to which the problematic behavior falls outside of the norm for children of the same age and gender (Barkley, 1990; American Academy of Child and Adolescent Psychiatry, 1997; American Academy of Pediatrics, 2000). Such information is typically gathered from parents and teachers in order to understand the child’s behavioral functioning in the home and school settings, respectively. Many different behavior rating scales are now available including those that assess the broad spectrum of behavioral, social, emotional and attentional functioning (e.g., Child Behavior Checklist, Achenbach, 1991; Behavior Assessment System for Children (BASC), Reynolds & Kamphaus, 1994), as well as those that assess specific behaviors associated with ADHD (e.g., ADHD Rating Scale - IV, DuPaul, Power, Anastopoulos & Reid, 1998; Brown Attention Deficit Disorder Scales, 1996; SNAP-IV, Swanson, Nolan & Pelham, 2000).
Assessment of Executive Function
The assessment of the executive functions is equally as complex as the assessment of ADHD (Anderson, 1998). The clinical assessment of the executive functions is quite challenging given their dynamic essence (Denckla, 1994). Any assumption that the executive functions are a static set of abilities simply amenable to traditional testing is false. The fluid strategic, goal-oriented problem-solving involved in the executive functions is not as amenable to a paper-and-pencil assessment model as are the more domain-specific functions of language, motor, and visual/nonverbal abilities (Gioia, Isquith & Guy, 2001). Furthermore, the structured nature of the typical assessment situation often does not place a high demand on the executive functions, reducing the opportunity for observing this important domain (Bernstein and Waber, 1990). In considering whether or not a child has difficulty in the executive domain, suspected executive difficulties need to be viewed within the larger context of a neuropsychological framework (Bernstein and Waber, 1990). That is, in many testing situations, the examiner provides the structure, organization, guidance, and plan, as well as cueing and monitoring necessary for optimal performance by the child, thus serving as that child’s external executive control (Stuss & Benson, 1986; Kaplan, 1988). A child with significant executive dysfunction can perform appropriately on well-structured tasks of knowledge where the examiner is allowed to cue and probe for more information, thus relieving the child of the need to be strategic and goal-directed. Comprehensive assessment of executive function should include information gathered from testing, focused observations, standardized behavioral ratings, and clinical interview. In addition, problems in other domain-specific functions such as attention, language, visual/nonverbal processing, sensory inputs, motor outputs, and learning and memory must be understood. A clear understanding of the differences between assessment of the “basic” domain-specific content areas of cognition (e.g., memory, language, visuospatial) and the domain general or “control” aspects of cognition and behavior is essential. PRIVATE 
 By necessity, there is always a “domain-specific” content area regulated by the executive control process. Teasing apart executive functions from domain-specific functions is part of the challenge of the neuropsychological assessment (Gioia et al., 2001).
A paradox in the assessment of the executive functions is that some individuals with significant deficits in specific executive function subdomains may, in fact, perform appropriately on many purported "tests of executive function" yet have significant problems making simple real-life decisions (Stuss and Buckle, 1992). All tests are multi-factorial, with greater or lesser degrees of domain-specific content knowledge and thereby demanding varying degrees of organization, planning, inhibitory control, or flexibility. For example, a child may be able to perform appropriately on the Wisconsin Card Sorting Test (Heaton et al. 1993), which requires flexibility in problem-solving, yet fail miserably in strategically modifying his/her approach to completing a set of math problems in the classroom or in solving social problems. In a formal testing situation, one may not be collecting the relevant data to document the full essence of strengths and weaknesses in the array of executive functions.
Assessment of the executive functions requires a multi-modal approach to characterize fully the child’s profile. The examiner must (1) obtain systematic observations of ways the child manages task demands within the context of the assessment situation, (2) recruit reliable reports of critical problem-solving behaviors in the child’s “real world”, and (3) provide psychometrically and developmentally appropriate tests for direct observation of executive problem-solving performance. 
The notion of ecological validity is particularly relevant in the assessment of the executive functions (Burgess, Alderman, Evans, Emslie & Wilson, 1998). In this context, ecological validity is defined as the ability of an assessment instrument to validly measure a behavior, function or process that is representative of the functioning of the individual in their everyday world. In addition to discussions regarding the ecological validity of tests, the artificial nature of the test environment has been questioned in terms of its ability to reflect the test-takers natural environment (Burgess, 1997). Efforts to better tap real-world environments and behaviors in the assessment of executive function have been made by various authors (e.g., Shallice & Burgess, 1991; Wilson, 1996; Burgess et al., 1996). 
We believe the everyday environment of the child at home and school serves as an important venue for observing the essence of the executive functions in children. Parents and teachers possess a wealth of information about the child’s behavior in these settings that is directly relevant to an understanding of his executive function. As previously noted, a rich tradition exists in utilizing structured behavior rating systems in the assessment of psychological and neuropsychological constructs (Achenbach, 1991; Conners, 1989; Reynolds & Kamphaus, 1994). Given the difficulties and complexities involved in test-based assessment of executive function, an ecologically valid system of assessing the everyday self-regulatory behaviors of children serves as an important adjunct to the clinical evaluation and treatment of executive dysfunction. One such measure, the Behavior Rating Inventory of Executive Function (BRIEF), was designed to assess the behavioral manifestations of executive functions in children aged 5 to 18 years (Gioia, Isquith, Guy & Kenworthy, 2000). The BRIEF assesses 8 interrelated subdomains of executive function within two general domains - Behavioral Regulation (Inhibit, Shift (Flexibility), Emotional Control) and Metacognitive problem-solving (Initiation, Task Organization/Planning, Environmental Organization, Self-Monitoring, Working Memory). Items were generated primarily from parent and teacher behavioral descriptions of executive difficulties, ensuring good ecological validity. The BRIEF demonstrates appropriate internal consistency and test-retest reliability, a consistent factor structure, convergent and discriminant validity with other behavior
rating scales, and different profiles of dysfunction with a variety of populations (Gioia et al., 2000).
In relying upon more ecologically valid parent and teacher ratings of children’s everyday executive and attentional behavior, we offer a different perspective of the relationship between executive function and ADHD. The present studies focus on two aspects of the relationship between ADHD and executive function. First, we explore the relative predictive value of parent and teacher ratings of inhibitory control and working memory in detecting the diagnosis of ADHD subtypes via logistic regression. Second, we examine the relationship between subdomains of executive function and the traditional symptomatology of ADHD through factor analysis of parent ratings. Both studies offer a different methodology than those of many previous reports by relying on observed behaviors presumed to reflect executive function. An ecologically-sensitive assessment of the everyday self-regulatory behaviors in children with the diagnosis of Attention-Deficit/ Hyperactivity Disorder (ADHD) can contribute significantly to the clinical evaluation and treatment process. 
Study 1. Working Memory and Inhibit as Predictors of ADHD Subtypes
In the first study, parent and teacher ratings of everyday executive behaviors in separate samples of clinically referred children with ADHD subtypes were compared with parent and teacher ratings for matched groups of non-referred children. Theoretically, working memory deficits contribute substantially to the primarily inattentive subtype of ADHD, while inhibitory control deficits account for the cluster of symptoms comprising the hyperactive/impulsive subtype (Barkley, 1996; Isquith & Gioia, 1999; Pennington & Ozonoff, 1996). While children with ADHD may exhibit problems in several areas of executive function (e.g., planning, organization, self-monitoring), we focused on the most direct theoretical relationships. We hypothesized that children with the inattentive subtype of ADHD and those with the combined type of ADHD would show marked problems with working memory, but that only the latter type would show significant problems with inhibitory control.
Methods
Participants 
Children referred to a hospital-based outpatient pediatric neuropsychology practice who met DSM-IV criteria for either ADHD, Predominantly Inattentive Type (ADHD-I) or ADHD Combined Type (ADHD-C) participated in the study. ADHD diagnosis was based on interview, observation, parent and teacher ADHD-specific and broad behavior rating scales (e.g., CBCL, BASC) and neuropsychological evaluation as per clinical routine. No ADHD, Predominantly Hyperactive-Impulsive Type, diagnostic group was included because this diagnosis occurs infrequently in our clinical practice in school-age children. Most children who meet the hyperactivity and/or impulsivity criteria for the ADHD diagnosis also meet the inattention criteria, warranting the diagnosis of ADHD, Combined Type. Children with comorbid diagnoses (e.g., Conduct Disorder, Oppositional Defiant Disorder, Reading Disorder) were excluded from the study. The control groups were comprised of children selected from original standardization samples of the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy & Kenworthy, 2000) without identified attentional, learning, or behavioral concerns and matched for age, gender, ethnicity and parental education to the clinical groups. The standardization samples were collected from a broad range of schools in terms of socioeconomic and geographic variables. Separate clinical and control groups were recruited for parent and teacher ratings on the BRIEF. Table 1 presents sample sizes and essential demographics for the parent and teacher samples.
Insert Table 1 about here
Procedures
Parents and teachers completed the BRIEF as part of either the standardization sample via schools or as part of a clinical evaluation. The BRIEF is an 86-item questionnaire designed to assess executive functions via ratings of children’s everyday behaviors. Of the eight non-overlapping BRIEF scales, two- Working Memory and Inhibit -served as the dependent measures. While the remaining six scales may be of interest in this population (i.e., Initiate, Plan/Organize, Organization of Materials, Monitor, Emotional Control, and Shift), for the purposes of this study we focused on Working Memory and Inhibit for the strong theoretical relationship to ADHD symptoms (Barkley, 1997). The BRIEF Working Memory and Inhibit scales have demonstrated strong psychometric properties: internal consistency, stability over short periods of time, and interrater (teacher-parent) agreement in the appropriate range. The Working Memory scale correlates in a logical fashion with a variety of attention scales, such as those included within the BASC (Reynolds & Kamphaus, 1994), CBCL/TRF (Achenbach, 1991), Conners’ Rating Scales (Conners, 1989), and the ADHD Rating Scale IV (DuPaul, Power, Anastopoulos & Reid, 1998), providing evidence for convergent validity. The Inhibit scale correlates strongly with measures of restlessness, impulsivity, overactivity, behavior problems, and aggression, and demonstrates secondary correlations with attention problem scales. Both the Working Memory and Inhibit scales correlate moderately with scales reflecting social difficulties, consistent with the observation that children who have attention and, in particular, impulse control problems, also have social difficulties. Equally important are the low correlations with a variety of scales that reflect behavioral and emotional difficulties that should not be related to inattention, impulsivity, and hyperactivity. The pattern of low correlations with scales measuring somatic complaints, anxiety, and depression provide evidence of discriminant validity for the Working Memory and Inhibit scales.
RESULTS
Group Differences
Parent and teacher ratings on the BRIEF Working Memory and Inhibit scales were submitted to two separate (parent, teacher) one-way (Control, ADHD-I, ADHD-C) multivariate analyses of variance. Tables 2 and 3 present mean scale T scores for ADHD-I, ADHD-C, and matched control groups on the parent and teacher forms, respectively. The T scores have a mean of 50 and a standard deviation of 10. Of interest, both samples of control groups were above the mean of 50 but within one standard deviation. This likely reflects sampling error and causes the significance tests to be more conservative. Still, the omnibus multivariate analyses of variance were significant for each form, indicating large overall effects of diagnostic group membership. The Working Memory and Inhibit scale univariate between-groups tests were significant for the parent ratings with large effect sizes as reported in Table 2: Working Memory F(2, 127) = 50.9, p < .001, Eta2 = .45; Inhibit F(2, 127) = 31.2, p < .001, Eta2 = .33. Results of the teacher ratings analysis, reported in Table 3, were similar: Working Memory F(2, 218) = 75.1, p < .001, Eta2 = .41; Inhibit F(2, 218) = 45.1, p < .001, Eta2 = .29. 
Insert Table 2 about here
Insert Table 3 about here
Post-hoc comparisons (Scheffe, p < .05) between diagnostic groups for the parent and teacher samples revealed similar patterns for each form. Children with both subtypes of ADHD (i.e., ADHD-I and ADHD-C) were rated by teachers and parents as significantly higher (i.e., more impaired) on the Working Memory scale than controls. There was no significant difference between ADHD-I and ADHD-C groups on Working Memory. Children diagnosed with ADHD-C were rated significantly higher by parents and teachers on the Inhibit scale than children in the ADHD-I and control groups. The ADHD-I group was somewhat elevated on the Inhibit scale, but significantly less elevated than the ADHD-C group. [see tables 2 and 3]
Predicting Diagnosis
Prediction of diagnostic group membership for the BRIEF Working Memory and Inhibit scales was then
examined via logistic regression. Parent ratings on the BRIEF Working Memory and Inhibit scales were entered separately as predictor variables in logistic regression equations with diagnostic group membership as the criterion variable. Data were examined for the ADHD-I versus control groups, separately for the ADHD-C versus control groups, and finally for the ADHD-I versus ADHD-C groups. The same analyses were conducted for teacher BRIEF ratings.
Table 4 presents results of the logistic regression analyses predicting ADHD-I versus control group membership for the parent and teacher Working Memory and Inhibit scales. Parent ratings on the Working Memory scale predicted 81% of diagnostic group membership correctly, whereas ratings on the Inhibit scale correctly predicted 78%. Group membership was similarly predicted by teacher ratings: Working Memory correctly predicted 83% and Inhibit correctly predicted 70%.
Insert Table 4 about here
Table 5 shows the same analyses conducted with the ADHD-C diagnostic group versus matched controls for the Working Memory and Inhibit scales. Again, the percentage of correctly predicted group membership was acceptable: Parent ratings on the Working Memory scale predicted 84% and ratings on the Inhibit scale predicted 85% of group membership accurately. Teacher ratings on the Working Memory scale predicted 80% and ratings on the Inhibit scale predicted 79% correctly.
Insert Table 5 about here
The Working Memory scale was not helpful in distinguishing between ADHD-I and ADHD-C diagnostic groups, either in isolation or in concert with the Inhibit scale. Recall that both groups demonstrated elevated scores on the Working Memory Scale. The Working Memory scale was not predictive of ADHD-I vs ADHD-C group membership, and did not add significantly to the predictive power when included with the Inhibit scale. The Inhibit scale in isolation, however, was useful in distinguishing children diagnosed with ADHD-C from children diagnosed with ADHD-I, such that 68% of group membership was accurately predicted. Teacher ratings predicted 65% of group membership. Table 6 shows the logistic regression analyses for Working Memory and Inhibit scales for the ADHD-I and ADHD-C groups. 
Insert Table 6 about here
Discussion
In essence, children with either Inattentive or Combined types of ADHD were rated by parents and teachers significantly, indeed substantially, higher than children without an ADHD diagnosis on the BRIEF Working Memory scale. Parents and teachers also rated children with the combined type of ADHD significantly higher on the Inhibit scale than children with the inattentive type of ADHD, who were in turn rated higher on the same scale than children with no diagnosis. Both BRIEF forms predicted ADHD-I and ADHD-C group membership (vs. no diagnosis) adequately. The Working Memory scale did not distinguish between subtypes of ADHD, whereas the Inhibit scale distinguished some 65% to 68% of cases.
This study supports the notion that deficits in domains of executive function underlie the behavioral symptom clusters that characterize the diagnosis of ADHD. Specifically, working memory deficits are characteristic of attention problems in both subtypes of ADHD, however failure of inhibitory control was a stronger contributor to the hyperactive/impulsive symptoms of ADHD, Combined Type.
Study 2. Factor Analysis of ADHD Rating Scale and BRIEF
Next, we examined the relationship between the broader neuropsychological construct of executive function and aspects of the clinical syndrome of ADHD by comparing the BRIEF scales with a published measure of ADHD symptoms based on the DSM-IV diagnostic criteria, the ADHD Rating Scale-IV (DuPaul et al., 1998). The ADHD Rating Scale-IV is a behavior rating questionnaire, with separate home and school versions, that consists of 18 items reflecting the nine DSM-IV Inattention criteria and the nine Hyperactivity/ Impulsivity criteria of the diagnosis of ADHD. The respondent is asked to indicate the frequency of the behavior on a 4-point Likert scale (ranging from “Never or rarely” to “Very Often”). The home and teacher versions of the scale have high internal consistency, good test-retest and inter-rater reliability, and demonstrated criterion validity and clinical utility. We hypothesized that the subdomains of executive function, as measured by the BRIEF, would be associated with ADHD symptomatology in specific and differential ways based on earlier work (Isquith & Gioia, 1999). More specifically, we predicted that difficulties with sustained attention and performance would be associated with difficulties initiating problem-solving activity, organization, planning and working memory. These metacognitive functions would, therefore, load more significantly with the “cognitive”/ inattention symptoms than the impulsive and hyperactive behaviors. In contrast, we predicted that hyperactive/ impulsive behaviors would be associated with greater difficulties regulating behavior including inhibiting and shifting behavior, as well as emotional control and self-monitoring.
Method
Participants
Parents of 81 clinically referred children completed the BRIEF along with the ADHD Rating Scale –IV: Home Version as a routine part of a neuropsychological evaluation. Responses were collected for 51 boys and 30 girls with the DSM-IV diagnosis of ADHD, aged 5 to 17 years (M = 9.2, SD = 2.8). The sample was subdivided into diagnostic subtype groups as follows: Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type (n=50; 30 boys, 20 girls) and Attention-Deficit/Hyperactivity Disorder, Combined Type (n=31; 21 boys, 10 girls. Overall intellectual functioning of the sample was at the lower end of the Average range (Mean Full Scale IQ = 91.3, SD = 16.6). There were no differences between the diagnostic groups for age or IQ.
Results
Raw total score ratings for each of the eight BRIEF scales were correlated with raw total scores for the Inattention and Hyperactivity/Impulsivity scales of the ADHD Rating Scale-IV (Table 7). Inattention was most strongly related to Initiate, Plan/Organize, Working Memory, and Monitor. Hyperactivity/Impulsivity was most strongly related to Inhibit, Shift, and Emotional Control.
Insert Table 7 about here
 In order to clarify the relationships between the various scales in Table 7, the correlation matrix was submitted to exploratory principal factor analysis (PFA) with oblique rotation to allow for the intercorrelation of factors. Factor loadings greater than .40 were retained on a factor. Two-, three- and four-factor solutions were examined. A two-factor solution was determined to be the most parsimonious based on the analysis of the scree plot and the clinical/ theoretical meaningfulness of the solution. Table 8 presents the rotated pattern matrix. The factor structure of the BRIEF scales was identical to the structure found in the normative sample (Gioia et al., 2000). Factor 1 was defined by the five BRIEF Metacognition scales (Initiate, Plan/Organize, Working Memory, Organization of Materials, and Monitor) loading with the ADHD Rating Scale-IV Inattention scale, accounting for 59% of the variance. Factor 2 was defined by the three BRIEF Behavioral Regulation scales (Emotional Control, Inhibit, and Shift) loading with the ADHD Rating Scale-IV Hyperactive/Impulsivity scale, accounting for an additional 13% of the variance. The two factors were moderately correlated (r = -.53). 
_____________________
Insert Table 8 about here
_____________________
Discussion
The findings of the factor analysis highlight the relationship between eight subdomains of executive function, as measured by the BRIEF, and the symptom components of the ADHD syndrome. Specific scales of the BRIEF were associated more highly with Inattention symptoms whereas other scales were associated with Hyperactive/ Impulsive symptoms. The Inattention symptoms were highly related to the metacognitive domains
of task initiation, organization and planning, working memory, monitoring, and organizing one’s materials. The Hyperactive/ Impulsive symptoms were more highly related to the behavioral regulation aspects of executive function including inhibitory control, emotional control, and problem-solving flexibility. These findings extend the viewpoint of executive function as a critical component, together with inattention and hyperactivity/ impulsivity, of the ADHD diagnosis. These findings suggest that executive functions, as a neuropsychological construct, are a set of regulatory subdomains that characterize the functional components underlying the clinical syndrome of ADHD. The present results suggest the underlying functional elements of the Inattention subtype include not simply inattention behaviors in the narrow sense but also the executive ability to initiate, organize, plan, and monitor an action sequence and to maintain this problem-solving set in active working memory. Similarly, the behaviors within the ADHD Combined subtype would include the executive function subdomain of inhibit, consistent with Barkley’s (1997) model, as well as the ability to flexibly shift problem-solving set, and maintain appropriate emotional control.
Conclusions
The findings of these two studies provide evidence for the strong relationship between the neuropsychological construct of executive function and the clinical diagnosis of Attention-Deficit/Hyperactivity Disorder, consistent with the viewpoints expressed by Barkley (2000), Brown (1999), and Denckla (1996). Additionally, specific relationships between the traditional symptoms of ADHD and subdomains of executive function are suggested. We concur that executive function is a more useful framework for understanding the behavioral characteristics captured as the triad of ADHD symptoms. The multi-dimensional construct of executive function is both more specific in highlighting the multiple functional components within the subtypes of ADHD and more comprehensive in expanding the critical behavioral symptoms beyond the traditional triad. 
The first study highlights the relevance and utility of the specific executive function behaviors of inhibitory control and working memory in the diagnosis of the subtypes of ADHD. These two executive function domains, as assessed by the BRIEF, demonstrate good ability to detect the ADHD subtypes of Predominantly Inattentive Type and Combined Type. The second study supports the “redefinition” of the ADHD diagnostic components within an executive function framework. Barkley (1994) and others (Conners & Wells, 1986; Douglas, 1999) have long held inhibitory self-control as the fundamental symptom of ADHD. Redefining the critical diagnostic behaviors in terms of the neuropsychological construct of inhibition is supported. The construct of working memory has also been proposed as a possible underlying element of ADHD (Barkley, 1997). In fact, the “attention” in ADHD has been questioned as a discriminating aspect of ADHD (Gordon, 1995) and suggested to be the secondary consequence of other more primary underlying functions (e.g., inhibition). Thus, the present redefinition of attention in the ADHD symptom complex in terms of executive function has prior support.
Not only do specific components of executive function serve to redefine the diagnosis of ADHD but we also demonstrate the importance of considering the broader metacognitive and behavioral/ emotional regulatory aspects of executive function as well. We believe this inclusive application of the executive function construct to ADHD has clinical support when one considers the types of everyday problems that are often reported by parents and teachers. Although “not paying attention” and “not thinking before he acts” are frequent concerns, reports of “disorganized thinking and performance”, “poor planning”, “not checking his work”, and “difficulty accepting other strategies” are also expressed quite frequently. The formal assessment of these critical aspects of executive function is necessary in functional diagnosis and treatment planning for children with ADHD symptoms. Articulating the particular behavioral subdomains of executive function allows for a more specific targeting of behavioral and cognitive/ academic treatment methods toward those deficient areas. Following an executive function rubric, the clinician would not be asking questions only about the inattention of the child but would also be formally inquiring about the child’s ability to initiate, plan, organize, and monitor task and social behavior, as well as hold the information actively in working memory. Furthermore, rather than pursuing information primarily in terms of overactive or impulsive behavior, assessment questions regarding the broader aspects of inhibitory control (including cognitive inhibition), as well as problem-solving flexibility and control of emotional responses, would be addressed.
An ecologically relevant method of assessing the executive functions in children suspected of ADHD is consistent with the current approach to assessing this behavioral diagnosis. This paper demonstrates a reliable and valid method, via standardized parent and teacher behavior ratings, of assessing these critical component behaviors. 
The studies presented in this article are only a first step in the re-examination of ADHD as a disorder of the executive functions. As suggested by Barkley (2000), this reformulation may prove particularly useful in further research and clinical model development. For example, he speculates that an executive function model of ADHD would predict secondary executive function deficits due to the primary deficit in response inhibition. Attention deficits are also redefined as “intention deficits” (p. 1067) from an executive function perspective. The relationship between executive function and ADHD as demonstrated by the current set of studies provides support for future model-building. We advocate a behavioral phenotype paradigm with an executive function model at its core to further specify the full nature of the regulatory disorder now known as Attention-Deficit/Hyperactivity Disorder. The causal relationships among the subdomains of the executive functions, as posited by Barkley, could be investigated further with structural equation modeling. Preliminary support for the primary underlying role of inhibitory control with respect to the other executive functions has been reported in a sample of children with ADHD (Gioia, Isquith, Retzlaff & Pratt, 2000). Finally, the redefinition and refinement of our understanding of ADHD may promote better clinical treatment of individuals with this disorder. A more specific executive function model of ADHD would be useful for targeting appropriate cognitive/ academic, social, and behavioral treatments.
References
Achenbach, T. (1991) Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry.
American Academy of Pediatrics (2000). Clinical practice guideline: Diagnosis and evaluation of the child with Attention-Deficit/Hyperactivity Disorder, Pediatrics, 105, 1158-1170.
American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder (1997). Journal of the American Academy of Child and Adolescent Psychiatry, 36, 85s-121s.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington, DC: American Psychiatric Association.
Anderson, V. (1998) Assessing executive functions in children: Biological, psychological and developmental considerations. Neuropsychological Rehabilitation, 8, 319-349.
Barkley, R.A. (1990) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York, NY: The Guilford Press.
Barkley, R.A.
(1994) Impaired delayed responding: A unified theory of attention deficit hyperactivity disorder. In D.K. Routh (Ed.) Disruptive behavior disorders in childhood: Essays honoring Herbert C. Quay (pp.11-57). New York: Plenum.
Barkley, R.A.& Grodzinsky, G.M. (1994) Are tests of frontal lobe functions useful in the diagnosis of attention deficit disorders? Clinical Neuropsychologist, 8, 121-139
Barkley, R.A. (1996). Linkages between attention and executive functions. In G. R. Lyon & N. A. Krasnegor (Eds.), Attention, memory and executive function (pp. 307-326). Baltimore: Paul H. Brookes.
Barkley, R.A. (1997) ADHD and the Nature of Self-Control. New York: Guilford Press.
Barkley, R.A. (2000) Genetics of Childhood Disorders: XVII. ADHD, Part 1: The executive functions and ADHD. Journal of American Academy of Child and Adolescent Psychiatry, 39, 1064-1068.
Bayliss, D.M. and Roodenrys, S. (2000) Executive processing and attention deficit hyperactivity disorder: An application of the supervisory attentional system. Developmental Neuropsychology, 17, 161-180.
Bernstein, J.H. & Waber, D.P. (1990) Developmental neuropsychological assessment: The 
systemic approach. In A.A. Boulton, G.B. Baker & M. Hiscock (Eds.) Neuromethods: Vol. 17 Neuropsychology (pp. 311-371). Clifton, N.J.: Humana.
Brown, T.E. (1996) Brown Attention Deficit Disorder Scales. San Antonio, TX: The Psychological Corporation.
Brown, T.E. (1999) Does ADHD Diagnosis require impulsivity-hyperactivity?: A response to Gordon & Barkley. ADHD Report, 7, 1-7.
Burgess, P.W. (1997) Theory and methodology in executive function and research. In P. Rabbitt (Ed.) Methodology of frontal and executive function. (pp.81-116). Hove, U.K.: Psychology Press.
Burgess, P.W., Alderman, N., Evans, J., Emslie, H., & Wilson, B.A. (1998) The ecological validity of tests of executive function. Journal of the International Neuropsychological Society, 4, 547-558.
Conners, C.K. (1989) Manual for Conners’ Rating Scales. North Towanda, NY: Multi-Health Systems, Inc.
Conners, C.K., & Wells, K.C. (1986). Hyperkinetic children: A neuropsycholosocial approach. Beverly Hills: Sage Publications.
Denckla, M.B. (1989) Executive function, the overlap zone between attention deficit hyperactivity disorder and learning disabilities. International Pediatrics, 4, 155-160.
Denckla, M.B. (1994) Measurement of executive function. In G.R. Lyon (Ed.) Frames of reference for the assessment of learning disabilities: New views on measurement issues (pp.117-142). Baltimore: Paul Brookes Publishing Co. 
Denckla, M.B. (1996) A theory and model of executive function: A neuropsychological perspective. In G.R. Lyon & N.A. Krasnegor (Eds.) Attention, memory and executive function (pp. 263-278). Baltimore, Md: Paul H. Brookes Publishing Co.
Douglas, V.I. (1999) Cognitive control processes in attention-deficit/hyperactivity disorder. In H.C. Quay and A. Horgan (Eds.), Handbook of Disruptive Behavior Disorders (pp. 105-138). New York: Plenum Press.
DuPaul, G.J., Power, T.J., Anastopolous, A.D., & Reid, R. (1998). ADHD Rating Scale IV: Checklist, norms and clinical interpretation. New York, Guilford Press.
Fuster, J.M. (1989) The prefrontal cortex: Anatomy, physiology, and neurophysiology of the frontal lobe. New York: Raven Press.
Gioia, G.A., Isquith, P.K. & Guy, S.C. (2001) Assessment of executive functions in children with neurological impairment. In R.S. Simeonsson & S. Rosenthal (Eds.) Psychological and Developmental Assessment. New York: Guilford Press.
Gioia, G.A., Isquith, P.K., Retzlaff, P.D., & Pratt, B.M. (2000) Modeling Executive Functions with Everyday Behaviors: A Unitary or Fractionated System? Paper presented at the 10th Annual Rotman Institute Conference, Toronto, Ontario. 
Gioia, G.A., Isquith, P.K. & Guy, S.C. (1998) The regulatory role of executive control processes in children’s behavioral, social, and emotional functioning. The Journal of Neuropsychiatry and Clinical Neurosciences, 9, 663.
Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. (2000). Behavior Rating Inventory of Executive Function. Lutz, FL: Psychological Assessment Resources, Inc.
Gordon, M. (1995) How to operate an ADHD clinic or subspecialty practice. Syracuse, NY: GSI Publications.
Goldman-Rakic, P. (1987) Circuitry of primate prefrontal cortex and regulation of behavior by representational memory. In F. Plum (Ed.), Handbook of Physiology: The Nervous System (pp. 373-417). NY: Oxford University Press.
Goldstein, S. and Goldstein, M. (1998) Managing attention deficit hyperactivity disorder in children: A guide for practitioners (2nd ed.). New York: John Wiley & Sons.
Heaton, R., Chelune, G., Talley, J., Kay, G., and Curtiss, G. (1993). Wisconsin Card Sorting Test Manual. Lutz, FL: Psychological Assessment Resources.
Isquith, P. K., & Gioia, G. A. (1999). The nature of executive function in ADHD [Abstract]. The Clinical Neuropsychologist, 13, 222.
Isquith, P.K., Guy, S., Pratt, B., & Gioia, G. (1999). Initial clinical validity of the Behavior Rating Inventory of Executive Function. Journal of the International Neuropsychological Society, 5, 117.
Kaplan, E. (1988) A process approach to neuropsychological assessment. In T. Boll and B.K. Bryant (Eds.) Clinical Neuropsychology and Brain Function: Research, Measurement and Practice (pp. 125-167). Washington, D.C.: American Psychological Association.
Kelly, T.P. (2000) The development of executive function in school-aged children. Clinical Neuropsychological Assessment, 1, 38-55.
Levin, H. S., Culhane, K. A., Hartmann, J., Evankovich, K., Mattson, A. J., Harward, H., Ringholz, G., Ewing-Cobbs, L., & Fletcher, J. M. (1991). Developmental changes in performance on tests of purported frontal lobe functioning. Developmental Neuropsychology, 7, 377-395.
Lyon, R. & Krasnegor, N. (1996). Attention, Memory and Executive Function. Baltimore: Paul H. Brookes Publishing Co.
Mirsky, A.F. (1989) The neuropsychology of attention: Elements of a complex behavior. In E. Perecman (Ed.) Integrating Theory and Practice in Clinical Neuropsychology (pp. 75-91). Hillsdale, NJ: Lawrence Erlbaum Associates.
Passler, M.A., Isaac, W., and Hynd, G.W. (1985) Neuropsychological development of behavior attributed to frontal lobe functioning in children. Developmental Neuropsychology, 1, 
349-370.
Pennington, B.F. & Ozonoff, S. (1996) Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry, 37, 51-87.
Pennington, B.F., Bennetto, L., McAleer,O.K. and Roberts, R.J. (1996) Executive functions 
and working memory: Theoretical and measurement issues. In G.R. Lyon and N.A. Krasnegor (Eds.) Attention, Memory and Executive Function (pp. 327-348). Baltimore: Paul H. Brookes Publishing Co.
Rabbitt, P. (1997). Introduction: Methodologies and models in the study of executive function. In P. Rabbitt (Ed.), Methodology of frontal executive function (pp. 1-38). East Sussex, UK: Psychology Press.
Reynolds, C.R. and Kamphaus, R.W. (1994) Behavior Assessment System for Children. Circle Pines, MN: American Guidance Service, Inc.
Shallice, T. & Burgess, P.W. (1991) Deficits in strategy application following frontal lobe damage in man. Brain, 114, 727-741.
Shelton, T. & Barkley, R.A. (1990) Clinical, developmental, and biospychosocial considerations. In R.A. Barkley (Ed.) Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (pp. 209-231). New York: Guilford Press.
Stuss, D.T. & Benson, D.F. (1986) The frontal lobes. New York: Raven.
Stuss, D.T. and Buckle, L. (1992) Traumatic brain injury: Neuropsychological deficits and 
evaluation at different stages of recovery and in different pathologic subtypes. Journal of Head Trauma Rehabilitation, 7, 40-49.
Swanson, J.M., Nolan, W., Pelham, W.E. (2000). The Swanson, Nolan and Pelham (SNAP) Rating Scales. (Web: WWW.ADHD.net).