7/22/2019 The best executive function tests: a critical overview

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The English Pages Executive function tests: a short introduction

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Executive function tests are a very special kind of neuropsychological tests. They
pretend to measure executive functions or problem solving skills. However, this is
not so easy as one might think. That’s probably the reason there are not that
many executive function tests around.
An executive function test should measure executive functions, that is: planning
ahead, logical thinking, acting in accordance with hypotheses, checking one’s
behavior (self-monitoring) and flexibly changing one’s hypotheses or actions. With
this definition you can easily see that executive functions are always active, no
matter what neuropsychological test is being administered. So this makes it really
difficult to assess executive functions. When a test is measuring all executive
functions, it is usually quite difficult to find out what parts of executive function are
damaged. The most common approach then is to develop multi-faceted tests in
which subtests assess different executive functions.
By definition, executive functions are usually called upon when solving a problem
and that usually takes place whenever you encounter new problems. Old and
familiar problems are normally routinely solved because you already know what to
do. Just as with a small puzzle you already reached a solution and know how to
solve it. One of the main problems with executive tests is that the moment you
know the solution, the test can hardly be administered a second time. Just
because you already know how it should be done. In such cases the test does not
measure any form of executive function anymore. This is one of the main reasons
the test-retest reliability of executive tests is very poor.

On this page I would like to discuss several executive tests that are well-known
Normal brain and and very much used: the Tower of London Test (TOL), the Wisconsin Card
daily life Sorting Test (WCST) and the BADS (Behavioral Assessment of the Dysexecutive
Syndrome). I will also discuss other tests that are extremely useful in assessing
Normal brain executive functions but are usually not used for that.
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Normal Brain
A review of some executive function tests
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As I told you earlier, I can not discuss all available executive function tests used in
brain
neuropsychology. Therefore, I would like to review tests which in my opinion
should be used the most because of their proven ability to measure executive
Brain rehab or function deficits in patients and normal (healthy) persons.
treatment

Brain Training
Tower of London Test (TLT or TOL)
Attention training
To be honest here, I am a bit biased because this test was developed and
Memory training computerized by myself and it is now published by my own company Pyramid
Productions. Nevertheless, it has several qualities worth mentioning and is
Brain injury recovery
therefore used as an example of a fine test. See Figure here to see what test
Best treatment stimulus is like on the computer screen:
fatigue

Fight depression

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7/22/2019 The best executive function tests: a critical overview

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All about
It is a 12-minute computerized planning test in which you have to move small
psychology tests
blocks (a red, yellow and blue one) on 3 different pegs. However, there are
Test psychology several rules to move the blocks and that makes this task difficult. You have to
look carefully and plan before you do your moves. Therefore this TOL test
Tests requires quite a lot of planning (keeping several plans in your working memory
and flexibly chosing between them), some self-monitoring (checking what moves
What is attention? you are making according to your plan), and self-correction (noticing when your
move is wrong and correcting this error). Of course, such a task also requires a
Attention tests good visual perception, a sufficiently large working memory and quite some
concentration and divided attention (attentional control).
Executive function
tests The TLT (copyright Pyramid Productions) originally has been developed by Tim
Shallice, a researcher in Cambridge. Then it was a wooden pegs edition, not
My mission and who computerized yet. My computerized edition strongly follows his original task and I
have added a more useful scoring system. This test is mostly evaluated in a very
I am, and my
positive way by patients as being fun to do, relatively easy and not too long.
columns Clinicians love the computerized edition because of the ease of administration so
that they can observe the patient more fully. This version of the TLT has
About me
reasonable norms for healthy people (n=260) and the largest norm group for
Contact me neurological patients in an executive function test yet (559 stroke patients, 99 TBI
patients and 254 other neurological disorders including hypoxia victims, multiple
My Columns sclerosis and epilepsy). The TLT only requires a Windows based computer and
can be used both stand-alone as in a network.
Analysis of movies
Psychometric characteristics of the TLT have been judged by the Dutch Test
Wake me up - Avicci Committee (COTAN) to be insufficient, referring to the norms and the reliability.
Norway Shooting Content validity actually was sufficient. It does not come as a surprise that I
disagree with the verdict on the norms. Most executive function tests are normed
Connecticut School poorly and you can see for yourself that the TLT has relatively good norms. The
shooting manual is only in Dutch but will be translated in English, probably released this
year. It will become freely available on this page and on my
www.pyramidproductions.nl page as well so everyone can have his own
Legal Stuff judgment.

Legal disclaimers The reliability of the main indice TLTscore range from .58 to .66 (test-retest
reliability) which is only fair, considering it is an executive function test. The
Medical Disclaimer classic AO1 indice has a lower reliability ranging between .48 and .53. When
looking at split-half reliability and Cronbach’s alpha, these reliability coefficients
Copyright notice
are much too low, ranging from .11 to .36. This is a clear indication that in an
executive function test the subitems are hardly related and can not be easily
----------------------------- compared with each other. Due to the main assessment goal of an executive
function test, this does not come as a surprise.
De Nederlandse
pagina's The convergent validity is fair, ranging from .38 to .43. The divergent validity
ranges from .12 to .28. The problem here is that in this study there was only one
Alles over true executive function test that was comparable to the TLT: the WAIS-R Picture
Arrangement task.
hersenletsel

Homepage Large advantages of the computerized TLT are that it is fully standardized with
clear and short instructions to administer. The computer perfectly records all
Nederlands
responses and reliably calculates the two main indices.
Dagelijkse leven
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7/22/2019 The best executive function tests: a critical overview
The TLT is sufficiently patient friendly meaning that all patients can do the test
Hobbies na
without becoming too much frustrated or irritated. The TLT can be administered to
hersenletsel one-handed patients and a large benefit is that it can be used in patients with
aphasia as well.
Hersenletsel
symptomen The costs of the TLT are a bit lower than other executive function tests: 160 euro
ex. VAT for 1 year license on 2 computers. License renewals are 160 euro ex.
Autorijden en
VAT. When sufficiently popular the prices will go down to ensure worldwide use
hersenletsel and distribution.
Geheugenproblemen
Preliminary analysis of the sensitivity and specificity of the TLT shows good
Problemen met zien values, respectively 94.7% and 90.2%. However, this analysis has been done by
using another variable in the test and relying on a very strict cut-off point.
Intimiteit en Sex Therefore, the sensitivity and specificity numbers can be considered to inflated
and must be seen as an indication. Further research is necessary here but won’t
Waarom vermoeid? be easy because there is no ‘gold standard’ test for planning skills. Luckily,
Unterrainer et al. (2005) showed in a nice study of chess players that the TLT had
Opvoeden na
strong correlations with chess. In this way demonstrating that the construct
hersenletsel validity of the TLT is quite sufficient: the TLT does indeed measure planning skills.

Hersen revalidatie of N.B.: NOW (since August 2013) available in English! Manual as well.
behandeling N.B.: TLT can now detect malingering! One of the first executive tests that
checks for symptom validity. Please download and read the manual.
Behandeling
vermoeidheid The TLT is NOW (August 2013) available in Dutch and English!! and can be
downloaded from www.pyramidproductions.nl
Herstel van
Hersenletsel Please download the English manual here: TLT Manual and decide for yourself.
Geheugentraining
Below you see an Evaluation Table for the TLT. Using this Table every
Over depressie
neuropsychological test can be evaluated. See for more information about the
criteria of evaluation my page on Test-Psychology. See this link:
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Go to Test-Psychology
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persoonlijkheid?

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WAIS-R Picture Arrangement

The Picture Arrangement (PA) sub-test of the Wechsler Adult Intelligence Scales
(WAIS) is not really known as an executive test. In the ‘bible’ of
neuropsychological diagnostics, Lezak’s Neuropsychological Assessment (2004),
this test is never described as an executive function test. In the other bible, A
Compendium of Neuropsychological Tests (Strauss, Sherman, & Spreen, 2006), it
is even never mentioned separately! In the Dutch guide for diagnosing executive
functions in which I played a minor role Picture Arrangement is mentioned as one
of the many tests to specifically assess conceptual reasoning skills, as part of the
executive functions. In the international literature, to my knowledge, Picture
Arrangement is almost never mentioned as an executive function test. And that is
at least astonishing, because…it is one of the finest tests of executive function
around!

This failure of not interpreting PA as a very fine example of an executive function

test is exemplary of the sorry state of affairs neuropsychology is in when you
critically consider its arsenal of tests. Not only we still do not have many very
good neuropsychological tests (there is a lot to be concerned about and many
tests need serious improvements), but scientists and clinicians differ considerably
in how to interpret the same neuropsychological test, being either an attention test
or more of an executive function test. In scientific articles researchers usually
echo each other in what they are saying just to be sure to get their article
published. Independent critical thinking is rarely seen. That’s one of the main
reasons that new innovative breakthrough kind of neuropsychological tests are
rare.

I do not want to be extremely critical, that’s destructive talk and doesn’t help
anyone. More constructive is to explain in detail why such a test like Picture
Arrangement can be (and IS) such a fine executive function test. First of all, the
skills for correctly doing this test are all part of what scientists call ‘executive
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functions’. Remember,executive functions are really several different cognitive
functions all humped together: concept formation, formulating a plan (planning),
formulating a goal, sequencing the correct order of steps to take in order to reach
a goal or follow a plan (logical reasoning), executing the steps and monitoring
your own actions, mental flexibility to reformulate a plan and change the actions
to reach your goal/plan and the ability to control your automatic, instinctive or
impulsive reactions in order to follow your action plan consistently. In short,
executive functions are functions that represent goal-directed actions: taking
initiative, planning, executing actions, monitoring and self-correcting those
actions.

And Picture Arrangement has it all. It is a test in which you see for example 5
black-and-white line drawings of cartoon pictures. All are shown in a wrong order
and you have to make up a logical story for these 5 pictures ánd place them in the
(one) correct order. I can not give you a specific example of this test of course
because that is against copyright rules ánd this kind of knowledge can influence
your test score whenever you are confronted with this test (normally only when
you have had a head injury, so let’s not hope so). However, I can give you an
example with a cartoon I borrowed of Zack Thomack, from his website
www.polaroppositescomic.com, with many thanks to him. See the Figure below.

I deleted the text (which was quite amusing by the way) and now your task is to
give the right and ony correct order of the three pictures. Without much effort you
will quickly notice that only the order 2-1-3 is the correct one. You can verify this
on Zack’s website here: www.polaroppositescomic.com (it’s worth looking
around).

This seems like an easy task and normally that is indeed the case. It IS an easy
task. The same goes for the original Picture Arrangement items as well.
Especially when you as a clinician or researcher get rid of the ambiguous items
(the ones where you can have more than one logical order of the pictures and
have more than one logical story). I always use only 7 items of the original WAIS-
R PA: House, Romeo, Louie, Enter, Hunt, Hill, and Robber because these are the
unambiguous items.

The task requires several cognitive processes. First, you have to see all pictures
in clear detail. Then you have to form several ideas about what is going on here.
That’s what neuropsychologists call ‘concept formation’ or ‘formulating a plan’.
Then you have to form a picture in your mind of a sequence of the 3 pictures. Not
randomly, but guided by your plan or idea about what is going on in this story.
Then you have to put these pictures in this planned order and finally you have to
check this whether it matches your plan/ideas. When the sequence is looking
wrong, you will have to correct the order. Remember, in the PA test all pictures
are separate pictures you can move around. I have programmed these pictures
so that they are displayed on a computer screen and can be moved by the
clinician. The patient has only to point at a picture and to point at where it should
go. Accept for planning, sequencing and monitoring cognitive processes like
visual perception, divided attention and memory all work together to do this task
correctly.

Of course, this example given was a simple one. There are more items and it
becomes more difficult meaning that you have to make up more different ideas for
how the story really goes. Then you have to match this with the correct
sequences according to your ideas. Finally, you will find only one correct
sequence and one correct story. Failing to do so can have several reasons: a. not
making up the correct plan, b. not using the correct logical reasoning, c. not
checking carefully all details against your ideas, d. not being able to hold several
different story lines all at once in your attentional span (working memory). As you
have figured out by now, all executive functions are tested with this simple task.
And indeed, in my clinical experience (I have administered this task in about 2500
patients by now) it is a very sensitive task indeed to detect brain injury, especially
right hemisphere damage and errors in logical reasoning and problems with
insightful reasoning. Of course, you have to take into account that low intellectual
capacities do also lead to poor performances on this test. But then again: poor
intellectual capacity is another way of saying that there are serious problems in
problem solving, in executive functions.
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Unfortunately, the psychometric test characteristics of such a test like PA are not
that good. Only to be understood because it IS an executive function test that
suffers from a relatively poor test-retest reliability. In Lezak (2004) she notes
reliability coefficients ranging from .66 to .82. Furthermore, significant practice
effects hinder the repeated administration of this test, just as with any other
executive function test.

However, despite the mentioned disadvantages (psychometrically spoken) of the

PA, I would like to call upon all clinicians and scientists to use this test much
more. Especially in the way I have programmed this test, on a computer screen,
because only then it resembles very much a planning task like the Tower of
London Test. Indeed, in my normative study (see the Manual of the Tower of
London Test) I could find a correlation coefficient between TLT and PA of .43 in a
sample of n=232 neurological (mostly stroke) patients. A factor-analysis using
only 79 neurological patients showed a factor that was represented fairly well by
the TLT, PA and another logical reasoning and planning test, the Wisconsin Card
Sorting Test (although this last one loaded much lower than the other two tests).

Below you will find the evaluation Table of the Picture Arrangement test for the
paper and pencil version because this version is the most widely used and
available.

Wisconsin Card Sorting Test (WCST)

One of the most used neuropsychological tests is the Wisconsin Card Sorting
Test. I do not want to imply here that I am very fond of this test, just because a lot
of scientists and clinicians use this test. I want to explain here why it still is a very
interesting test to use but you have to be very careful in interpreting its results. Let
me first tell you what kind of test it is.

There are four stimulus cards, placed in front of the subject, each having different
symbols (1 to 4, triangle, star, cross, or circle). No two cards are identical and
there are 64 cards (original version of 1948 had 128 cards, more identical cards).
The figure below (from Wikipedia.com) shows some stimulus cards.

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Unfortunately, on the Internet you can find very detailed descriptions about the
test and the strategy that is being used to administer the test. As I said in my
introduction earlier I do not want to give so much information about a
neuropsychological test that a patient can prepare himself for a test
administration. Everyone publishing such kind of information on the Internet can
face prosecution by large test publishers and rightly so. Because it can seriously
hinder good neuropsychological assessment.

The WCST originally was developed in 1948 to study ‘abstraction ability’ and ‘the
ability to shift cognitive strategies’. It is still considered to be an executive function
test and yes it is. To perform correctly in this test you have to plan, execute your
plans, monitor your actions and feedback, and change your hypothesis (plan). In
fact, it is a very simple test but astonishingly, a lot of healthy students perform
rather disappointingly as well. Just as a lot of patients. So, in theory the test
seems very easy but in clinical practice you see quite a lot of patients who score
very poorly on this test. That is why the WCST should never be used alone: it has
to be administered with other executive tests as well. This advice applies to all
neuropsychological tests, I know, but it is extremely valid for executive tests. One
of the largest problems with executive tests is that they depend on only a few
several cognitive strategies. If you know these few strategies, you will perform
excellent on such a test. That’s also the reason that most executive tests can not
be administered twice: once a patient knows the strategy (i.e. how to do the test),
he performs very good on the test. In other words, then you have a ceiling effect
and the test can not be used as a diagnostic instrument.

So why am I still using the WCST in my daily practice as a clinical

neuropsychologist, even though there are a lot of normal healthy persons who
can not do this test adequately? Well, it really tells you something about executive
functions, and especially one aspect of executive functioning. Namely, the ability
to flexibly and logically think things through. In fact, this is the planning aspect of
executive functions. In order to correctly perform in the WCST you have to look
carefully to the feedback that is given after every single step you take and you
have to take the initiative to logically form several hypotheses and then test each
hypothesis consequently (according to your plan/hypothesis). If you do not do
that, you don’t ‘stop and think’, then you will perform poorly on this test. The ability
for self-correction= changing your course of action in the light of correcting
feedback is very clearly tested in the WCST. Much more challenged than in any
other executive test I know. Thát’s probably the reason the WCST is still being
used today, even after more than 60 years. Unfortunately, not every clinician or
scientist does seem to be really aware of this fundamental aspect of the test.

Another fundamental aspect of the WCST is highly related to the above

mentioned changing your actions: sufficient focus on the right hypothesis. By that
I mean that a logical hypothesis should be maintained long enough in working
memory to put it to the test. Research by Barceló for example showed that
patients really had trouble in maintaining their hypothesis (set) in working
memory, either due to interference from other cards (distraction) or other reasons
yet unknown. In other words: a low performance on the WCST is not just simply a
real perseverative symptom (unless the number of Perseverative Erros is very
high), but can also be related to simply a very weak concentration or executive
attentional control (cognitive control).

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There are several versions of the WCST and that makes comparison of scientific
studies quite difficult. There is the original 128 cards version in which there are
more similar cards. Heaton (1981) standardized the test instructions and scoring
procedures and later refined this in the 1993 manual. He was the first to really
publish the task as a clinical instrument. I myself use the shortened 64 card
version and have programmed the Milwaukee version of Osmon & Suchy(1996).
However, the Milwaukee version in which patients had to tell beforehand why they
chose a specific card, seemed promising but could not make much difference in
clinical practice so I discontinued using it.

Because the paper and pencil version of the WCST is quite difficult to score
correctly, even in very experienced clinicians, so it is really advisable to use the
computerized editions of the WCST. Furthermore, using the computer total test
time is seriously reduced.

The norms of the WCST are available but they are from 1993, so quite old.
N=899 American population ranging 6 to 89 years. However, there is also a
relatively recent meta-analysis of 34 studies consisting of about 3000 healthy
adults. The two main variables of the WCST are Number of Categories achieved
(range: 0-6) and Number of Perseverative Errors. The meta-analysis shows an
age-effect on the WCST: 55 years or older have a Mean Categories of 3.99
(SD=1.83) and 20-35 yrs have a mean score of 5.58 (SD=1.1) (Strauss et al.,
2006). The most important and statistically most usable variable is the Number of
Perseverative Errors. The older age group had a mean of 15.85 errors
(SD=11.44) and the younger group a mean of 6.92 (SD=5.04). Heaton’s norms
are less stringent and talk about an average of 11 perseverative errors as being
average in a young group, and 21 in an older (70-74 yrs) group. This already
shows that even ‘normal’ healthy controls do show quite some perseverative
errors on the WCST. Furthermore, the higher age groups perform less well on the
WCST and I do NOT think this should be considered normal. To be precise:
although it may seem average for an older age group, a larger number of errors in
such a very simple task does mean that the flexibility in changing cognitive sets is
less than in younger adults. As a neuropsychologist I would not simply conclude
that this is normal, although it may be average compared to older adults.

Other norms are available for healthy Canadian children (n=685), aged 9 to 14
years, more preferable than the Heaton norms because of a higher representative
nature and more recent (1996; for the norms see Strauss, Sherman, & Spreen). A
major problem with all these norms is that they are valid for the paper and pencil
version of the 128 cards version of the WCST but not for the computerized
versions. Furthermore, caution is advised when using the 64-card version
because of a lower sensitivity to more subtle cognitive problems.

The test-retest reliability scores in healthy adults are disappointingly low for the
main variables in the WCST. The difficulty is also that there are different studies
with most of the time only small test-retest groups (< 100) and using different
WCST variables. From what I’ve read so far test-retest reliability is usually less
than .63. Furthermore, there are doubts about the second administration of the
test because whenever people know the strategies and 3 rules, the WCST does
not seem to measure problem-solving anymore.

All in all there are a few advantages in using the WCST, especially the computer
version. It definitively is a sensitive test for executive function, especially for
assessing the ability for self-correction. I know of no other test that measures
this ability so clearly. Especially when the number of perseverative errors is 11 or
more. However, there are also quite a few disadvantages of the WCST that
make the test results really difficult to interpret correctly. First of all, although the
Number of Perseverative Errors is the most viable and logical variable to use in
interpreting the test, there are at least several explanations possible accounting
for a high number of PEs. So it is not really certain what exactly is the patient’s
problem. It can be a failure to focus attention or maintain a set, but it can also
indeed be a serious problem in flexible thinking (shifting set). Therefore, it is
strongly recommended not to use the WCST alone as an indication for executive
functions. Several executive function tests have to be administered as well to try
to find a specific pattern of functioning. Another disadvantage of the paper and
pencil version of the WCST is the difficult scoring system, although Lezak (2004)
suggests some helpful tricks (p. 588). My advice would be to use a computerized
version, however, take caution in interpreting the results because norms are
based on the paper and pencil versions. Thirdly, the long 128-card version is
usually too long for clinical patients and highly stressful. When constantly
confronted with negative feedback, a lot of patients do not want to continue the
test. Therefore I only use the 64-card version on the computer. Fourth, it is not
really sure how the Heaton (american) norms can be compared to European
populations. My guess is that there should be not much difference in caucasian
American and European people, but nevertheless caution in interpreting norms is
advised. Fifth, the WCST has low test-retest reliabilities in a normal population.

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Not surprisingly, because most healthy people do perform at a ceiling effect level.
The reliabilities in clinical populations is more reassuring so retesting a patient
with sufficient time in-between administrations (say at least 3 months) should be
possible. But whenever the WCST is done almost perfectly, there is no reason at
all to do a retest. That makes the test quite useless in research designs.

The WCST is available at all major test publishers. Links are provided below:

Psychological Assessment Resources: Psychological Assessment Resources

(PAR, Inc.): for the Modified Wisconsin Card Sorting Test using only 48 cards. 10
minutes to administer, 3 minutes to score. N=327 healthy people, age range 18-
90 yrs (so not children).

With the same company you can order the original WCST but computerized and
64-cards version. It is easy to administer (10-15 min) and to score (10 min). The
software is for unlimited use and costs 575,00 $. Highly recommended is the Card
version Professional Manual for an additional 114,00 $.
For anti-computer clinicians you can order the 64-card paper and pencil version
as well for just 288,00 $ excluding the Card version Professional Manual.

Western Psychological Services (WPS) is a bit cheaper:

Western Psychological Services For the 64-card version of the WCST you pay
here: 295,00 $, paper and pencil version. They have different norms (18 to 89 yrs)
and (6 to 17 yrs), probably Heaton’s norms.
The original Heaton 128-card version, paper and pencil version can be purchased
for 389,00 $. Heaton norms (1993).

For some very interesting articles about the WCST see the following links:

Nyhus&Barceló2009CriticalUpdate
Barceló&Knight2002

Below you will find the Test-Evaluation Table for the WCST. It was very difficult to
compose because most research had been done with the paper and pencil 128-
card version of the WCST. Furthermore, there are many different studies with very
different brain injury type patients, in different languages as well.

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Summary: what is the best executive function test?

I really don't know. I have only reviewed 3 tests, commonly seen as executive
function tests. However, their total points are disappointing, ranging from 23 to 19.
Although I do feel that the TOL is a rather good executive function test, I feel this
even more strongly for the Picture Arrangement. Although this test is used for
executive function assessment, it is not used much. Strauss et al. (2006)
recommend using more measures and also use questionnaires to assess
executive functions. Interviews with caregivers and/or partners is highly
recommended as well.

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whenever there is any news to share, being either about brain injury, emotional
problems, abnormal behavior or other morality issues. Click on the link below:

Als u wilt kunt u me ook op Twitter volgen. Ik tweet eigenlijk alleen serieuze
zaken, of dat nu nieuws is over hersenletsel, emotionele problemen, abnormaal
gedrag of andere ethische zaken. Klik op onderstaande link:

https://twitter.com/fckovacs

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Last modified: 30 December 2018

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