Neusoyo! Colaf oe | @ BRIEE" Behavior Rating Inventory of, , Executive Function PROFESSIONAL MANUAL Gerard A. Gioia, PhD Peter K. Isquith, PhD Steven C. Guy, PhD Lauren Kenworthy, PhD R Psychological Assessment Resources, Inc.TTT @e2000000 COOSOOHTSHHHOHHHOOOO TABLE OF CONTENTS Acknowledgments .. Chapter 1. Introduction ‘The Executive Functions. Brain Basis of the Executive Functions. Developmental Factors... Clinical Assessment Chapter 2, Administration and Scoring. BRIEF Materials ‘Appropriate Populations Professional Requirements .. General Administration... ‘Administration of the Parent Form. ‘Administration of the Teacher Form... ‘Scoring and Profiling the Parent and Teacher Forms Caleulating Seale Raw Scores... Missing Responses. Scoring the Negativity Scale... Scoring the Inconsistency Scale... Converting Raw Scores to T Scores... Calculating Confidence Intervals. Plotting the BRIEF Profile... Chapter 3. Interpretation of the BRIEF Parent and Teacher Forms 13 ‘Normative Comparisons.. u ‘Assessing Validity u Other Indications of Compromised Validity. 15 Climical Scales...nenee Ww Inhibit... : Ect Shift... 18 Emotional Control 18 Initiate. 18 19 ‘Working Memory 3Plan/Organize.... Organization of Materials Monitor... = ‘The Behavioral Regulation Index, the Metacogition Inder, and the Global Executive Composite Behavioral Regulation Index. Metacognition Index... Global Executive Composite. Individual Item Analysis.. Interpretive Case Illustrations... Case Mustration 1. Bight-Year-Old Boy With ADHD, ‘Combined Type Case Ilustration 2. Nine-Year-Old Girl With Nonverbal Learning isa and ADHD, Predominantly Inattentive Type Case Tlustration 3, Twelve-Year-Old Boy With Traumatic Brain Injury. Case Ilustration 4. Eleven-Year-Old Boy With Asperger's Disorder Case Illustration 5, Fiteen Year-Old Girl With BxecutivelOrganizatonal Dysfunction. Case Illustration 6. Ten-Year-Old Boy With Reading Disorder... Chapter 4, Development and Standardization of the BRIEF.......... Development Item Content. Item Development... Item-Seale Membership. Item Tryouts... Final Seale Development. Validity Seales... Inconsistency Scale.... Negativity Scale.. Standardization ... Demographic Characteristics. Influence of Demographie Characteristic of Respondent and Child Development of the Normative Groups. Construction of Scale Norms... Chapter 5. Reliability and Validity Reliability cnn Internal Consistency Interrater Reliability. Test-Retest Reliability Validity Content Validity. Construct: Validity Factor Analysis... Epusaiary Fock Auge Principal Factor Analysis of the BRIEF and Other Behavior Rating Scales. viFee Oe ete eet eoeoveou" eee60 ee eeeoceoe e e e References.. Appendix A: T-Score and Percentile Conversion Tables and 90% Confidence Interval Values Appendix B: T-Score and Percentile Conversion Tables and 90% Confidence Interval Values BRIEF Profiles of Diagnostic Groups. Attention-Deficit/Hyperactivity Disorder. ‘Traumatic Brain Injury... ‘Tourette's Disorder... Reading Disorder Low Birth Weight Documented Brain Lesions ....... High Functioning Autism Pervasive Developmental Disorders.. Early-Treated Phenylketonuria.... Mental Retardation..... Clinical Uiity of the BRIEF for Diagnosis of ADHD Predictive Validity. Clinical Utility... Summary oon 89 for BRIEF Parent Form: Boys by Age Group for BRIEF Parent Form: Girls by Age Group. ‘Appendix C: T-Score and Percentile Conversion Tables and 90% Confidence Interval Values for BRIEF Teacher Form: Boys by Age Group... seo 103 17 Appendix D: T-Score and Percentile Conversion Tables and 90% Confidence Interval Values for BRIEF Teacher Form: Girls by Age Group... 1311 RE INTRODUCTION The Behavior Rating Inventory of Executive Function (BRIEF) is a questionnaire for parents and teachers of school age children that enables profes- sionals to assess executive function behaviors in the home and school environments; It is designed for broad range of children, ages 5 to 18 years; including those with learning disabilities and attentional dis- orders, traumatic brain injuries, lead exposure, per- vasive developmental disorders, depression, and other developmental, neurological, psychiatric, and medical conditions. The Parent and Teacher Forms of the BRIEF each contain 86 items within eight theo- retically and empirically derived clinical scales that measure different aspects of executive functioning: inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Organization of Materials, and Monitor. Table 1 describes the clinical scales and two validity scales (Inconsistency and Negativity). ‘The clinical scales form two broader Indexes, Behavioral Regulation and Metacognition, and an overall score, the Global Executive Composite. Two of the scales, Working Memory and Inhibit, are clini- cally useful in differentiating the diagnostic subtypes of Attention-Deficit/Hyperactivity Disorder (ADHD). This manual provides information about the BRIEF materials, administration and scoring proce- dures, and normative data, as well as guidelines for clinical interpretation and a variety of case studies to assist you in understanding the results obtained on the BRIEF. The manual also describes the develop- ment of the instrument and results of studies that establish the reliability, validity, and diagnostic utility of the BRIEF as a measure of executive fune- tion in children, THE EXECUTIVE FUNCTIONS ‘The executive functions are a collection of processes that are responsible for guiding, directing, and managing cognitive, emotional, and behavioral functions, particularly during active, novel problem solving, The term executive function represents an umbrella construct that includes a collection of inter- related functions that are responsible for purposeful, goal-directed, problem-solving behavior. Welsh and Pennington (1988) characterized the early develop- ment of the executive functions in terms of “the abi for attainment of a future goal” (p. 201). Stuss and Benson's (1986) classic work describes a set of related capacities for intentional problem_solving that . Their hierarchical cts of the executive functions that relate to the highest levels of cogni- tion: anticipation, judgment, self-awareness, and decision making. Their model distinguishes “execu- tive,” or directive, cognitive control functions from more “basic” cognitive functions (e.g., language, visual-spatial, memory abilities) (Specific subdomains that make up this collection of regulatory or management functions include the ability to initiate behavior, inhibit competing actions or stimuli, select relevant task goals, plan and organ- i ex problems, shiftTable 1 Description of the Clinical and Validity Scales on the BRIEF Parent and Teacher Forms Number of items Scale Parent Teacher Behavioral description Clinical scale Inhibit 10 10 Control impulses; appropriately stop own behavior at the proper time Shift 8 10 “Move freely from one situation, activity, or aspect of a problem to another as the situation demands; transition; solve problems flexibly Emotional Control 10 ‘Modulate emotional responses appropriately. Initiate 8 Begin a task or activity; independently generate ideas. Working Memory 10 10 “Hold information in mind for the purpose of completing a task; stay with, or stick to, an activity. Plan/Organize 2 10 ‘Anticipate future events; set goals; develop appropriate steps ahead of time to carry out an associated task or action; carry out tasks in a systematic manner; understand and communicate main ideas or key concepts. Organization of Materials 1 Keep workspace, play areas, and materials in an orderly manner. Monitor 10 Check work; assess performance during or after finishing a task to ensure attainment of goal; keep track of the effect of own behavior on others. Validity scales Inconsistency 19 1 Bxtent to which the respondent answers similar BRIEF items in an inconsistent manner. Negativity 9 9 Extent to which the respondent answers selected BRIEF items in an unusually negative manner. solving, is also deseribed as a key aspect of executive fanction (Pennington, Bennetto, McAleer, & Roberts, 1996). Finally, the executive functions are not exclu- sive to cognitive control; regulatory control of emo- tional response and behavioral action also falls under the umbrella of the executive functions. Brain BASIS OF THE EXECUTIVE FUNCTIONS ‘The developmental course of the executive func- tions parallels the protracted course of neurological development, particularly with respect to the pre- frontal regions of the bram. One common view of the neuroanatomic organization of the executive func- tions, however, is that they are seated solely in the prefrontal region. This is an oversimplification of the complex organization of the brain. Although damage to the frontal lobes can result in significant dysfune- tion of various executive subdomains (Anderson, 1998; Asarnow, Satz, Light, Lewis, & Neumann, 1991; Eslinger & Grattan, 1991; Fletcher, Ewing-Cobbs, 2 Miner, Levin, & Bisenberg, 1990), these functions di not simply reside in the frontal lobes. An under- standing of the frontal region of the brain is, how- ever, important in any discussion of the executiv functions. The neuroanatomical essence of the frontal lobes is their dense connectivity with other cortical and subcortical regions of the brain, The prefrontal system is highly and reciprocally intercon nected through bidirectional connections ‘with the jimbic (motivational) system, the reticular activating@es (arousal) system, the posterior. association cortex@jms (perceptual/eognitive processes and knowledge base), as and the motor (action) regions of the frontal lobes@jum (e.g, Johnson, Rosvold, & Mishkin, 1968; Porrino Sux Goldman-Rakic, 1982). Such a central meuro-@s anatomic position underlies the regulatory control qx that the frontal brain systems exert over the poste-q@ux rior cortical and subcortical systems (Welsh &@us Pennington, 1988). e ‘The concept of frontal system (as opposed to lobe) explicitly acknowledges and directly incorporates the interconnections of the frontal region with the@ e ecortical and subcortical regions of the brain. Importantly, a disorder within any component of the frontal system network can result in executive dys- function (Mesulam, 1981). Conditions that render the frontal systems vulnerable to dysfunction include the following: disorders affecting the connectivity. of the brain such as cranial radiation and white matter development (Brouwers, Riccardi, Poplack, & Fedio, i984), ead poi g_affecting synaptogenesis Goldstein, 1992), regions in traumatic brain injury a dopamine in” Tourette's Disorder Rogeness, Javors, & Pliska, 1992; Singer & Walkuy 1991), disorders involving aspects of the posterior cortex such as learning disabilities, the arousal mechanism such as those seen in brain njury and severe depression. Thus, executive dys- fanction can arise ‘from damage to the primary pre- frontal regions as well as damage to the densely intereonnected posterior or subcortical areas. DEVELOPMENTAL FACTORS A.unique feature of the executive functions is their prolonged developmental course (eg, Levin et al., 1991; Passler, Issac, & Hynd, 1985; Welsh & Pennington, 1988) in comparison with other cogni- tive functions, paralleling the prolonged pattern of neurodevelopment of the prefrontal regions of the brain. The development of attentional. control, future-oriented intentional problem solving, and self- regulation of emotion and behavior ean be observed beginning in infaney and continuing through the pre- school- and school-age years (Welsh & Pennington). The development of goal-directed, planful problem- solving behaviors has 10 ung as 12 months of age using an object perma- nence and object retrieval paradigm (Diamond & Goldman-Rakic, 1989). Bighteen-month-old children xchibit specific self-control abilities to maintain an nntional action and inhibit behavior incompatible ith attaining a goal (Vaughn, Kopp, & Krakow, 1984). Thus, early intentional self-control behaviors tin infants and toddlers for the purpose of ed problem solving. Hxecutive self-control t these early ages 18, however, variable, fragile, and bound to the external stimulus situation; stability ee studies througt strate a time-related course of development for specific subdomains of executive function, including inhibitory control (Passler et al.), flexible problem solving (Chelune & Baer, 1986; Levin et al.; Welsh, Pennington, & Grossier, 1991), and planning (Klahr & Robinson, 1981; Levin et al.; Welsh et al.). As is the case with most dimensions of psychological and neu- ropsychological development, the emergence of exec- utive control functions varies across individuals in terms of both the timing of specific subdomains and the final endpoint. maaan Executive functions of self-awareness and control develop in parallel with the domain-specific content area or functional areas as described by Stuss and Benson (1986). For example, as basic memory skills, develop (e.g., immediate memory span, encoding, or retrieval), “metamemory” (i.c., knowledge about how to strategically use and control these memory abili- ties for particular tasks or situations) develops con- currently (Brown, 1975). An important corollary to consider is that if the basic ability does not deve then the associated metacognitive knowledge “as fully. This point relates directly to the iRGwGu TE imetacognition in learning disabilities (Pressley & Levin, 1987; Siegel & Ryan, 1989; Swanson, Cochran, & Ewers, 1990; Wong, 1991) and the development of self-control strategies within the context of specific processes (e.g., reading disorder, writing process), Assessment and intervention in learning disabilities must, therefore, include the con- trol strategies (e.g., recognizing the critical “problem” situation, planning and evaluating the use of specific learning strategies), in addition to the primary domain-specific processing disorder (e.g., decoding words, extracting meaning from sentences). CLINICAL ASSESSMENT Historically, clinical assessment of the executive functions has been challenging given their dynamic essence (Denckla, 1994). Fluid strategic, goal- oriented problem solving is not as amenable to a paper-and-pencil assessment model as are the more domain-specific functions of language, motor, and visuospatial or visual/nonverbal abilities. Further- more, 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 & Waber, 1990). We believe the child’s everyday environments 3at home and at school serve as important venues for observing the essence of the ‘executive functions. Parents and teachers possess a wealth of information about the child's behavior in these settings that is directly relevant to an understanding of the child's executive function. Arich tradition exists in utilizing structured behavior rating systems to assess psy- chological and neuropsychological constructs (Achenbach, 1991a; Conners, 1989; Reynolds & Kamphaus, 1992). The use of rating scale systems, completed by parents and teachers, measuring overt behavior is an often-used and well-proven method for assessing various domains of social, emotional, and behavioral functioning. Additionally, behavioral inventories completed by caregivers are widely employed in the assessment of adaptive behavior (eg. Vineland Adaptive Behavior Scales; Sparrow, Balla, & Cicchetti, 1984) and personality develop, ment (Personality Inventory for Children; Lacha: 1982). The authors believe there is a need for a rat ing scale to assess the range of behavioral manifé tations of executive functions in children. A reliabl and valid behavior rating system can serve as = important adjunct to the clinical evaluation an treatment of problems that involve the executiv’ control functions. ‘The BRIEF is a reliable and valid behavior ratin scale of executive functions in children and adoles cents that can (a) become an integral part of the clin ical and school assessment of children ani adolescents and (b) assist with focused treatmenj and educational planning for children with disorder of executive function.2 aE ADMINISTRATION AND SCORING BRIEF MATERIALS ‘The BRIEF materials consist of the Professional anual, the Parent Form, the Teacher Form, and the so-sided Scoring Summary/Profile Form. The cover lage of each rating form (Parent and Teacher) eludes instructions for completing the form and xamples for marking responses directly in the book- et. The remaining two pages of each form contain he BRIEF items and an area for recording demo- rraphic information about the child and information ibout the respondent's relationship to the child. The arbonless rating booklet is designed to be hand- scored by the examiner. One side of each Scoring Summary/Profile Form Parent and Teacher) provides instructions for hand- scoring the BRIEF clinical and validity scales and ndexes, as well as summary tables for recording raw scores, T scores, and percentiles for scales and ndexes. Conversion of raw scale scores to T scores -an be accomplished using the normative tables jocated in the appendixes at the end of this manual. The reverse side of the Scoring Summary/Profile Form provides a graph for plotting T scores to visu- ally portray the respondent's clinical scale, index, and GEC scores relative to those of the normative sample. APPROPRIATE POPULATIONS The BRIEF was standardized and validated for use with boys and girls, ages 5 through 18 years. The tative sample included children from a range of racial and socioeconomic backgrounds and geo- graphic locations, including inner city, urban, subur- ban, and rural environments. As a result, the BRIEF is appropriate for school-age children in a wide range of social and demographic contexts. PROFESSIONAL REQUIREMENTS ‘The BRIEF can be administered and scored by individuals who do not have formal training in neu- ropsychology; clinical psychology, school psychology, counseling psychology, or related fields. The exam- iner should carefully study the administration and scoring procedures presented in this manual. In keeping with the Standards for Educational and Psychological Testing of the American Education Research Association, American Psychological Associa- tion, and National Council on Measurements in Education (1985), interpretation of the BRIEF scores and profiles requires graduate training in neuropsy- chology, clinical psychology, school psychology, counsel- ing psychology, neuropsychiatry, behavioral neurology, developmentaVbehavioral pediatrics, general pedi- atries, or a closely related field, as well as relevant training or coursework in the interpretation of psycho- logical tests at an accredited college or university. GENERAL ADMINISTRATION Materials required for administration are the BRIEF Parent Form and/or Teacher Form booklets, a hard-point pen or a pencil, and a flat writing surface. Because instructions for administering the Parent and Teacher Forms of the BRIEF differ slightly, they are discussed separately in the following sections. Administration of the Parent Form Selecting Raters ‘The BRIEF Parent Form is designed to be com: pleted by the child's parent or guardian. It is desi able to obtain ratings from both parents, if possible. ‘This provides more information on the child's behav- ior and can reveal areas of disagreement that may be important to the assessment and identification of 5intervention strategies. When a choice is necessary, it is preferable to obtain the rating from the person with the most recent and most extensive contaet with the child. Establishing Rapport and Giving Instructions It is essential to establish good rapport with the person completing the form. Instructions to the par- ent should emphasize the importance of responding to all items on the form. The following instructions may be used as a guide: Parents observe a lot about their children’s problem solving and behavioral functioning that cannot be measured in an office visit. Your help is essential to me as I attempt to under- stand your child. This questionnaire allows you to document your observations of your child’s functioning at home. Please read the instruc- tions and respond to all of the items, even if some are difficult or do not seem to apply. As you will see, the instructions ask you to read a list of statements that describe children’s behavior and indicate whether your child has had any problems with these behaviors in the past 6 months. If the specific behavior has never been a problem in the last 6 months, circle the letter “N”; if the behavior has sometimes been a problem, circle the letter “S”; if the behavior has often been a problem, cirele the letter “O.” If you have any questions or concerns, please don’t hesitate to ask for my help. Completing and Checking the Record Form ‘The BRIEF Parent Form will take approximately 10 to 15 minutes to complete. Ideally, the parent or guardian should complete the form in a quiet setting and in one sitting. Once the form has been com- pleted, review it for blanks or multiple responses. If any are found, ask the parent to go back and respond to the skipped items or to clarify any ambiguous responses. If this is not practical, or if the parent refuses to answer certain items, proceed with scoring, Administration of the Teacher Form Selecting Raters ‘The BRIEF Teacher Form is designed to be com- pleted by any adult who has had extended contact with the child in an academic setting. Typically this will be a teacher, but a teacher's aide or other knowl- edgeable person can be used as an informant when necessary. To provide valid ratings, the respondent 6 should have had a considerable amount of contagaJ with the child. For example, 1 month of daily contagh J should be sufficient. Multiple ratings from teache} who observe the child in different classes can be ful in showing how the youth responds to varieg sy teaching styles, academic demands, and curriculugy content areas. Establishing Rapport and Giving Instructions, It is important to establish good rapport with t) person completing the form. Instructions to # teacher should emphasize the importance of respo1 ing to all items on the form. The following inst tions may be used as a guide: Iam evaluating a child in your class. I need your help to fully understand his/her learning and behavior in school. This form takes 10 to 15' minutes to complete. Please read the instruc- tions and respond to all of the items, even ift some are difficult or do not seem to apply. As you will see, the instructions ask you to read a list of statements that describe children’s behavior and indicate whether this student has had any problems with these behaviors in the past 6 months. If the specific behavior has never been a problem in the last 6 months, circle the letter “N”; if the behavior has sometimes been a problem, cirele the letter “S”; if the behavior has often been a problem, circle the letter “O.” If' you have known the student for less than 6 months, you may still respond to the question- naire based on your experience. If you have any questions or concerns, please don’t hesitate to ask for my help. Completing and Checking the Record Form ‘The BRIEF Teacher Form will take approximate | 10 to 15 minutes to complete. Ideally, the teach should complete the form in a quiet setting and one sitting. Once the form has been completet | review it for blanks or multiple responses. If any ate found, ask the teacher to go back and respond | skipped items or to clarify any ambiguous responses If this is not practical, or if the teacher refuses J answer certain items, proceed with scoring. SCORING AND PROFILING THE PARENT AND TEACHER FORMS Tear off the perforated strips along the sides of t completed rating booklet and peel away the top shet(answer sheet) to reveal the scoring sheet beneath. Missing Responses Demographic information and the rater’s responses Examine the scoring sheet for unanswered items. are reproduced on the carbonless scoring sheet. The If the total number of unanswered items that con- 'scoring sheet is used to calculate the raw scale sores tribute to the calculation of scale raw scores is jfor each of the eight clinical scales. greater than 14, then the BRIEF protocol cannot be [Calculating Seale Raw Scores appropriately scored. In such eases, the respondent The rater’s responses are reproduced as circled Should be asked to complete the missing items if pos- n scores on the scoring sheet, with 1 correspon- _—‘“ible. Similarly, if more than two items that con- z to Never (N), 2 corresponding to Sometimes (S), _tTibute to the calculation of a scale raw score have land 3 corresponding to Often (O), Transfer the circled _‘™issing responses, then a scale raw score should not gore for each item to the box provided in that item be calculated for that scale. Otherwise, missing ow. Sum the item scores in each column and enter _-Tesponses for 2a mes subtotal in the box at the bottom of the column, Seale raw seore sho ae i the first page ofitems, transfer the subtotal sore _falculating the Scale raw sore: erase Teems 73 ‘each scale to the appropriate box in the row for {~ ‘hrougl on ‘arent Form: ant 8 7 otals at the bottom of the facing page. Sum the | through 86 on the Teacher Form are not included in subtotals foreach scale and enter the total inthe | ‘he caleulation of Total seale raw senros, missing scale raw seores box atthe bottom of the appro- | responses {oF these particular items wil not aff e column, Transfer each Total scale raw score to he calculation of raw scores for the cl scales. Figure 2 presents a completed scoring sheet for an 8- aw score column in the Scoring Summary Table Z ; Scoring Summary/Profile Form (see Figure 1), | _ Y°*r-0ld boy with ADHD, Combined Type. that the last 14 items on the Parent Form scor- Scoring the Negativity Scale heet and the last 13 items on the Teacher Form Negativity scale items are indicated by an “N” ng sheet do not have boxes for transcribing item enclosed in a box in the margins on the scoring sheet . These items are not used in calculating Total of the rating form. Examine the scoring sheet to raw scores; several of the items (.e., those determine which, if any, of these items were scored dN in the margins on the scoring sheets) are ag 3 (i.e., endorsed as “Often” by the respondent). calculate a score on the Negativity scale. Locate the Negativity scale area on the Scoring Summary page of the Scoring Summary/Profile Beraviomar aT Form. Circle each item number in the boxed column Parent Foray that received an item score of 3, and then enter the Scoring Summary Table a number of circled items at the bottom of the column aa en eeceet [Eva to obtain the Negativity score (see Figure 3). 26 | 735| 97 Scoring the Inconsistency Scale 13 | 53 | 74 ‘The Scoring Summary/Profile Form provides an area for calculating the Inconsistency Scale score. ‘This calculation is somewhat complex and must be done carefully to ensure accuracy. Inconsistency scale items are indicated by a circled “I” ((D) in the margins on the scoring sheet of the rating form. ‘Transfer the item scores for the 10 item pairs from the scoring sheet to the appropriate boxed columns (labeled Score) at the bottom right of the Scoring ‘Summary page. For each item pair, calculate the absolute value of umple of Scoring Summary Table: Parent the difference in item scores for the two items. For example, if the item score for the first item is 1 and 27 | 73 | 98 COGL TION = 64501 EX UINE COMPOOTE |GenderMalecrade Std age @ Birth Date 11 / / 5 / 90 Child's Name Your Name Relationship to Child_ Mother Today's Date, / Eton Working nit | “Contot_| inte Lo Monitor_| t 3 ie 2. 3 1 2 3 3 + e 4, ] 1 oO 5. = 1 6 1 @ 2 th 3s © 2 8. 1 2 ®. 2 ti 10. 3 ea tt, 3 ue 12, 1 18. Zz t 14. 3 1 2 15. = 1 = 16. 3 Tee 1. ee 18. 3 en 19, 3 cove 20. 3 1 2 at, 2 Tee 2, C3 1 2 Ba 1 a 2 T_] 2 3 25, 2 t oO 2. 2) 1 3 2. S (VID 28, (ES teu @ee 8 2. ED 30. 2: 1 @ [3_N], 3. &. + ap 92. 3 1 2 Y@® 8 2 CORO wu. 3 oe %. 3 ty 3. 3 ae w. a 1a [2 1 3 @ 38. 2 1 a 40. 3 ‘aaa 8 a. ToD @ 2 2 1 @ 3@ a [3 Sey “41 2 1 @ 3® to | 13 | 13 9 | 25 | 25 [ 6 | 13 | ssttan(nmerg Figure 2. Completed BRIEF Scoring Sheet.Eotinal Working vow | sun | “Contot | ite | Memory = * “ 4. @ 48 oY 50, 51, 2. 53, ef |S soa: #.[ 2 | sr. 5 58 (ae 60. 61. 2 62. 2 = =a 6 eae fp 66. or. 83 6, 2 70 3 1. 7a 2 eee 14, %. 8. 7. 7. 78, 80. 81. 2 83: %, &. 8, Emotional Working Pla Org. of tone __shit__“Conral"__inlato__Memory__Orgeize Mates Montor 16 14 12 3 12 12 | 8 _| Subtotals (items 45-86) to | 13 | 15 9 [| 23 | 23 | G6 | 15 _| suttotas (tems 1-44) I 26 13. 27 21 26 | 35 18 21 _| Total scale raw scores Figure 2. (continued)eeecod Negativity Scale +1. Locate the frst Negativity item (indicated with a boxed N- | Item (rar aagharte Seng Sih Porcat Nepacy. | No. fuuhiecedsdctaemnmbsnts a counts ae 2. Count the number of circled items to determine the 8. Negativity score. 23. ‘3. Circle the appropriate Protocol classification based on 30. havo ® Wogetity Cumulative Protea ‘score percentile classification nm. a x @ ss ot-98 Ente 2 aT 798 Highly elevated |@| Negativity score |" > (Range = 0 to 8) | Figure 3. Sample of Negativity scale score calculations: Parent Form. the item score for the second item is 3, subtract the lesser number (1) from the greater number (3) to obtain the absolute difference value of 2. Sum the dif- ference values for the 10 item pairs to obtain the Inconsistency score (see Figure 4). Converting Raw Scores to T Scores ‘To obtain a T score and percentile for each scale raw score, locate the normative table for the appro- priate gender and age range in the Appendixes at the end of this manual. Enter the T' score and percentile for each scale in the spaces provided in the Scoring Summary Table (see Figure 1) To calculate the Behavioral Regulation Index (BRD raw score, sum the scale raw scores obtained for Inhibit, Shift, and Emotional Control; enter this, value in the space provided in the Scoring Summary ‘Table on the Scoring Summary/Profile Form. Locate the BRI raw score in the appropriate Appendix table and read across the table to obtain the correspon- ding T score and percentile; enter these values in the spaces provided in the Scoring Summary Table. Similarly, calculate the Metacognition Index (MI) raw score by summing the raw scale scores obtained for Initiate, Working Memory, Plan/Organize, Organization of Materials, and Monitor; enter this value in the space provided. Locate the MI raw score in the Appendix table for the appropriate gender and age group and read across the table to obtain the cor- responding T score and percentile; enter these values in the spaces provided. Finally, to calculate the 10 Inconsistency Scale Ttemno.| Score | [item no. Score roa |p 25. i 1 |-s_-|2 | 3 | > 7 | 3 cre ESF FS) 2 33 | 2 ale ills: 2 el 2 | > i 6 | 3 | > 2 [2 | 2i)> > [a2 a | 3 | > | 3 o | 3 | > 5 | 3 a | 2) > Inconsistency score {Range = 01020) Figure 4. Sample of Inconsistency scale score caleulations: Parent Form. Global Executive Composite (GEC) raw score, the raw scores for BRI and MI; enter this value i space provided in the Scoring Summary Table. the GEC raw score in the Appendix table fo appropriate gender and age group and read acros table to obtain the corresponding 7 score and, centile; enter these values in the spaces providi the Scoring Summary Table. Calculating Confidence Intervals = Confidence intervals provide the band of mea‘ ment error that is associated with a clinical index, or GEC T' score, The 90% confidence inte (CI) was chosen because it is commonly used for St ical interpretation. The bottom of each column itl Appendix tables shows the CI values needed to culate the 90% confidence interval for that set index, or the GEC. These values were calculateS*t multiplying the standard error of measurerfe: (SEM) for each clinical scale/indew/GEC by © ( score for the 90th percentile). To obtain" 90% confidence interval for a given scale, int or GEC T score, add the CI value from the bof! row of the appropriate column to the T score. EM this number as the high end of the interval. TH subtract the CI value from the T' score and this number as the low end of the interval. - Plotting the BRIEF Profile ‘Transcribe the T scores for each of the ea clinical scales, the two indexes, and the GEC the Scoring Summary Table to the correspont ipaces along the bottom of the Profile Form (located n the reverse side of the Scoring Summary page). ‘lot the T score obtained for each scale, index, and he GEC by first locating the T score within either he far left or the far right column on the Profile ‘orm and then carefully marking an X on the corre- ponding tick mark in the appropriate scale column. \fter all the T scores have been plotted, connect the ‘without crossing the vertical lines) to provide a rrofile of the BRIEF scores (see Figure 5). ‘To assist in interpretation of the clinical scales, the horizontal rule located on the Profile Form at a T score of 50 represents the mean of the T score dis- tribution. The horizontal rule at aT’ score of 65 rep- resents the point 1.5 standard deviations above the mean, which is the recommended threshold for inter- pretation of a score as abnormally elevated (see chap- ter 3); this area of potential clinical significance is indicated by light shading on the Profile Form. uuBRIEF Child's Name Tscore aice-f wf wo} 4 4 wd notional Control =] 4 un Tscore_73. tick mark coresponding fo each T's Emotional oni 73 _75 Instructions: Tanslr tie Scale dex and GEO T cores tom the Scorig Sumary Table onthe side Of this form. Mark an X on the Spe raladl wretidied al Sein eblbeneg a Figure 5. Completed BRIEF Profile Form. Organize Materials Montor3 sg INTERPRETATION OF THE BRIEF PARENT AND TEACHER FORMS This chapter describes the proper method for sterpreting BRIEF Parent and Teacher Form scores explaining how to (a) make normative compar- (b) assess the validity of the BRIEF results, p interpret domain-specific clinical scale scores, (d) pret the Index scores and the Global Executive Smposite score, and (e) review individual items. though 18 of the items on the Parent and Teacher orms of the BRIEF differ in order to appropriately pflect the different settings in which they measure vior, the interpretation of the clinical scale and dex scores derived from the Parent and Teacher rms is identical, Therefore, the following discus- en applies to both Parent and Teacher Forms. ‘The first step in the competent clinical interpreta- pn of the BRIEF is a solid, working understanding the concepts, clinical manifestations, and assess- ent of the executive functions. This manual only fly addresses the conceptual and clinical assess- issues regarding executive function. The /examiner is referred to more comprehensive scussions of conceptual issues (Krasnegor, Lyon, & dman-Rakic, 1997; Lyon & Krasnegor, 1996; h & Pennington, 1988) and assessment issues Boia, Isquith, & Guy, in press; Lezak, 1995). condly, a thorough understanding of the BRIEF, suding its psychometric development and proper- . is a prerequisite to interpretation. (See chapters snd 5 for an in-depth discussion of these issues.) As any clinical method or procedure, appropriate ning and clinical supervision is necessary to competent use of the BRIEF. essment of the executive functions is a complex with unique features. Given that the executive tions are “meta” level in nature, their elucida- in a clinical testing protocol can present signifi- challenges. Furthermore, there is no singular disorder of executive function, but rather a variety of presentations involving one or more aspects of of exec So umber of common Sy ect_different_ pai dysfunction. ‘These syndromes may be developmental in ( pervasive developmental disorders, learning disabilities, ADHD) or acquired (e.g., as a result of traumatic brain injury or cranial radiation as treatment for brain tumors and leukemia). ‘A clear understanding of the differences between assessment of the “basic” domain-specific content areas of cognition (e.g., memory, language, visuospa- tial) and the domain-general or “control” aspects of cognition and behavior is essential. For example, what may appear as a problem with language expression may be due less (or not at all) to the basic aspects of linguistic functioning (e.g., vocabulary, syntax, semantics) than to poor “metalinguistic” functions (e.g., formulating and maintaining an organized, planful approach to the topic of conversa tion). There is no test or assessment battery that gularly assesses executive function. By necessity, both elements, the domain-specific content area and its regulatory executive control processes, are always present in any test. Thus, part of the challenge of assessing executive functions is separating cognitive and behavioral control functions from domain- specific functions. Frequently, the more novel and/or complex the task or situation, the greater is the demand for the executive functions. The more famil- iar, automatic, and simple the task, the less the child needs to recruit his or her executive functions. What / may be a complex, novel task for one child may be a | relatively familiar and automatic task for another, thus, different children may need to recruit vastly different degrees of executive control functions to \ solve a particular problem. 13The BRIEF was developed to provide a window into the everyday behavior associated with specific domains of self-regulated problem solving and social functioning. Given the multiple determinants of any particular behavior, it is important to consider the full range of factors, including the executive func- tions that might play a role in the child's functioning. As such, the executive or regulatory aspects of behav- ior have a unique, complex, and at times hidden; role in cognition and behavior. Gathering reliable ratings of behavior associated with executive function via the BRIEF can add important information to the overall assessment of a child's strengths and weake nesses. Although the BRIEF can appropriately serve as a screening tool for possible executive dysfunction, the clinical information gathered from an in-depth profile analysis is best understood within the context of a full assessment that includes a detailed history of the child and family, performance-based testing, and observations of the child’s behavior. NORMATIVE COMPARISONS T scores are used to interpret the child's level of executive functioning as reported by parents and/or teachers on the BRIEF 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 respon- dents in the standardization sample. For example, a T score of 70 would indicate that the respondent's score is 2 standard deviations above the standardi- zation sample mean and equals or exceeds the scores of approximately 90% of the respondents in the stan- dardization sample. The exact ‘percentile for each raw score varies slightly for each scale, as the scores are not normally distributed. Thus, a T' score of 70 may exceed 90% of the normal population for one scale and 93% for another scale. It is often helpful to ‘examine both T scores and accompanying percentiles when interpreting the BRIEF. Higher raw scores, percentiles, and T scores indicate greater degrees of executive dysfunction. For all the BRIEF clinical scales and indexes, T' scores at or above 65 should be considered as having potential clinical significance. Assessing Validity Before interpreting BRIEF parent or teacher scores, it is essential to carefully consider the validity of the data provided. The inherent nature of rating scales (ie. relying upon a third party for ratings of a 4 child’s behavior) brings potential bias to the (EF contains, two. scales that provide ‘on validity: the Inconsistency and Neg Inconsistency Scale Scores on this scale indicate the extent to $ the respondent answers similar BRIEF items inconsistent manner relative to the clinical sa For example, a high Inconsistency score for a might be associated with marking Never in re to Item 44 (Gets out of control more than frientisg the same time as marking Often in response tf 54 (Acts too wild or “out of control”). Item pairsc] prising the Inconsistency seale, along with intetsjl correlations, and cumulative percentiles for abS difference scores are shown in Tables 2 and 3 {9 Parent and Teacher Forms, respectively. T' scores not generated for the Inconsistency scale. Inst} the raw difference scores between 10 paired tu (see chapter 2) are summed and the protocol ie sified as either “Acceptable,” “Questionabl& “Inconsistent.” The examiner must carefully review pra classified as “Questionable” or “Inconsistent.” I minor content differences between paired Inq teney items, one should consider the possibility there is a reasonable explanation for the Ini teney score other than response inconsistency @ part of the respondent. If the respondent can e: most Inconsistency responses logically, the prg should be considered valid. Because the in: tency threshold on this scale is quite high, adjustments should be rare. Negativity Scale ‘The Negativity scale measures the extent to the respondent answers selected BRIEF items unusually negative manner relative to the cl samples. Items comprising the Negativity & along with cumulative percentiles from the cl sample for the Parent and Teacher Forms are oS in Tables 4 and 5, respectively. A higher raw scd this scale indicates a greater degree of nega® with less than 3% of respondents in the clinical ple scoring above 7 on the Parent and ‘Te! Forms. As with the Inconsistency scale, 7’ scor® not generated for this scale. Scores of 5 or should be considered elevated and a cause for o£ review of the protocol. Scores at or above 7 reflect either an excessively negative percepti. Table 2 ltem Pair Correlations and Cumulative Percentiles for Absolute Difference Scores on the Inconsistency Scale of the BRIEF Parent Form Description Item Description t M7. Has explosive, angry outbursts 25, Has outbursts for little reason 73 Does not bring home homework, 22, Forgets to hand in homework, even when © assignment sheets, materials, etc. completed 64 1. Needs help from adult to stay on task 17. Has trouble concentrating on chores, j schoolwork, ete 66 When sent to get something, forgets what 82, Forgets what he/she was doing 66 he/she is supposed to get Acts wilder or sillier than others in groups 59. Becomes too silly 66 Interrupts others 65. Talks at the wrong time 70 Does not notice when his/her behavior causes 63. Does not realize that certain actions negative reactions bother others 76 . Gets out of control more than friends y 54, Acts too wild or “out of control” 76 63. Written work is poorly organized 60. Work is sloppy 67 5. Has trouble putting the brakes on his/her actions 44, Gets out of control more than friends ry Inconsistency Cumulative Protocol score percentile classification <6 ‘Acceptable 7to8 Questionable 2 Tneonsistent, Based on total clinical sample (n = 852). he child or that the child may have substantial F executive dysfunction, If the Negativity scale score is high, then the examiner should consider the possibility that the respondent had an unusually negative response style that skewed the BRIEF results. It is also possible, ® however, that the BRIEF results represent accurate reporting on a child with severe executive dysfunc- tion. An elevated Negativity scale score should prompt the examiner to” carefully review BRIEF’ results in the context ol FSU RRA aE Te child, including BRIEF respons ants, other test perfor observations of the child. On the Parent Form, four” of the nine items comprising the Negativity scale are from the Shift scale. The possibility of significant cognitive rigidity in the child should be considered as scale score, particularly if the child has a diagnosis of Pervasive Developmerital Disorder (PDD) or another tirbttttittibttitbdbitithtchdtttitttt-tttt teeter er TE TTLTIT LLL ELL LLL ri ai alternative explanation fora high. Negativity — ote. r = correlation between the two items comprising each item pair. neurological disorder where inflexibility is a promi- nent symptom (e.g., severe traumatic brain injury). Other Indications of Compromised Validity As with any other assessment tool, it is essential that the examiner consider the BRIEF results in the context of other information about the child being evaluated. Examiner observations of the child, his- tory obtained from the parent, teacher reports, other test results, and relevant medical and therapeutic history are among the other sources of data that pro- vide vital contextual information. Significant incon- sistencies between the BRIEF results and any other sources of information about the child are cause for careful review, whereas corroborating evidence, whether gathered in different modalities or from dif- ferent respondents, increases confidence that the findings are genuine. It is also essential to carefully review information relevant to the ability of the parent or teacher to 15SOSH HHOHHEDIGOHOFOSO® @eeeevoeoods SOHOHOHOHHSHOHTSEHOBOOSS Table 3 Item Pair Correlations and Cumulative Percentiles for Absolute Difference Scores ‘on the Inconsistency Scale of the BRIEF Teacher Form tem Description Item Description 27. Mood changes frequently 26, Has outbursts for little reason 36, Leaves work incomplete 39, Has trouble finishing tasks (chores, homework) 42, Interrupts others 43, Is impulsive 45. Gets out of seat at the wrong times 9. Needs to be told “no” or “stop that” 46, Is unaware of own behavior when in a group 65. Does not realize that certain actions bother others 47. — Gets out of control more than friends 58, Has trouble putting the brakes on his/her actions 48. Reacts more strongly to situations than other children 66. Small events trigger big reactions 55. Talks or plays too loudly 57. Acts too wild or “out of control” 57. Acts too wild or “out of control” 46. _ Is unaware of own behavior when in a group 69. Does not think of consequences before acting 65. Does not realize that certain actions bother others ears ates nee ea nel ewe Sete Cotes Inconsistency Cumulative Protocol score percentile classification a <98 ‘Acceptable 8 99 Questionable 29 299 Inconsistent ‘Note. r = correlation between the two items comprising each item pair. Based on total clinical sample ( 16 415), Table 4 Negativity Scale Items and Cumulative Percentiles for Clinical and Normative Respondents on the BRIEF Parent Form item Description 8. Tries same approach to a problem over and over even when it does not work 13. Is disturbed by change of teacher or class 23. Resists change of routine, food, places, ete. 30, Has trouble getting used to new situations (classes, groups, friends) 62, Angry or tearful outbursts are intense but end suddenly ‘11. ‘Lies around the house a lot (“couch potato”) 80. ‘Has trouble moving from one activity to another 83. Cannot stay on the same topic when talking 85, Says the same things over and over Total Negativity Cumulative Protocol score® percentile” classification A $90 Acceptable 5 to6 91-98 Elevated 27 298 Highly elevated Total number of items endorsed as “Often.” Based on total clinical sample (n = 852).Table 5 Negativity Scale Items and Cumulative Percentiles for Clinical and Normative Respondents on the BRIEF Teacher Form Description 13. Acts upset by a change in plans 14, Is disturbed by change of teacher or class 24, Resists change of routine, food, places, ete. Item e 32, When sent to get something, forgets what he/she is supposed to get a 64, Angry or tearful outbursts are intense but end suddenly Fr 68. ‘Leaves a trail of belongings wherever he/she goes a Tl. Leaves messes that others have to clean up iz 82, Cannot stay on the same topic when talking L— 84, Says the same things over and over Ec Total , Negativity Clinical Protocol seore® sample? classification <4 594 Acceptable 506 95 - 98 Elevated 2T 298 Highly elevated END SC SE ch ee Total number of items endorsed as “Often.” Based on total clinical sample (n = 475). t the demands of completing the BRIEF rating rm. The presence of a severe attention disorder, ading skills below a fifth-grade level, and lack of jency in English are among the factors that can .promise BRIEF results. Direct observation of the sspondent, review of his or her (i.e., parental) edu- ition and employment, and review of the completed RIEF rating form are useful in assessing respon- dent competency. ‘Omission of Items When reviewing the completed rating form, look or omissions in ratings. Two or more omissions on a ale invalidates the derivation of a T score for that ale. Missing responses for one or two items that ‘eontribute to a scale raw score should be assigned a ; score of 1 when calculating scale raw scores. Unusual Patterns of Responses ‘The examiner should also scan the test form for ‘unusual patterns of responses, such as marking only cone response (e.g., Never or Often) for all items, or systematically alternating responses between Never, ® Sometimes, and Often. Further investigation of such y potential response biases is warranted. CLINICAL SCALES The BRIEF clinical scales measure the extent to which the respondent reports problems with differ- ent types of behavior related to the eight domains of executive functioning. The following sections describe the content and interpretation of the clinical scales. (See Table 1 for brief descriptions of the clinical scales.) Ainninit ‘The Inhibit scale assesses inhibitory control (i.e., the ability to inhibit, resist, or not act on an impulse) and the ability to stop one’s own behavior at the appropriate time,’ This is a well-studied behavioral regulation function that is described by Barkley (1990) and many others as constituting the core deficit in ADHD, Predominantly Hyperactive-Impulsive Type, as described in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV; American Psychia- tric Association, 1994), Barkley (1996, 1997), Burgess (1997), and Pennington (1997) have also argued that poor inhibition is more generally an underlying deficit in executive dysfunction. Children who have sustained a traumatic brain injury. frequently also awSOBVVTV9VV0N @2Veeed0e000 ° ® e a ° ® @ e @ 9 ® e ee eeooecene exhibit disinhibited or impulsive behavior. Caregivers and teachers often are particularly con- cerned about the intrusiveness and lack of personal safety observed with children wl impulses well. Sich children may display high levels, of physical activity, inappropriate physical responses to others, a tendency to interrupt and disrupt group activities, and a general failure to “look before leap- ing” Evaluators observe the same problems, which are often particularly evident on tasks requiring a delayed response. BRIEF items related to inhibition include: “Blurts things out” and “Acts too wild or out of control.” Case Illustration 1 describes a child with severe inhibition problems and ADHD, although sev- eral other cases also relate weaknesses in this pri- mary function. The Inhibit scale can be useful as a diagnostic indicator of ADHD, Combined Type (ADHD-C). Given the relationships between the neuropsycholog- ical construct of inhibition and the behaviors that characterize ADHD-C, it is reasonable to expect the BRIEF Inhibit scale to capture many of the everyday behaviors that might suggest a diagnosis of ADHD- C. Further in-depth discussion about the diagnostic utility of the Inhibit scale can be found in chapter 5. @Shitt ‘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 make transitions, prob- Iem-solve flexibly, switch or alternate attention, and change focus from one mindset or topic to another. Mild deficits in the ability to shift compromise the efficiency of problem solving, whereas more. severe difficulties are reflected in perseverative behaviors. Caregivers often describe children who have diffi- culty with shifting as rigid or inflexible, Such child- Ten often require consistent routines. In some cases, children are described as being unable to drop cer- tain topics of interest or unable to move beyond a specific disappointment or unmet need. Confronting a change in normal routine may elicit repetitive inquiries about what is going to happen next or when an expected but postponed event will occur. Other children may have specific repetitive or stereotypic behaviors that they are unable to stop. Clinical evaluators may observe a lack of flexibility or cre- ativity in problem solving and a tendency to try the same wrong approach repeatedly despite negative 18 feedback about its efficacy. BRIEF items rela shifting include: “Acts upset by a change in | and “Thinks too much about the same t Difficulty with shifting and susceptibility to veration are described in a variety of clinical involving brain damage and are also obsers developmental disorders. The DSM-IV diagnos: teria for the Pervasive Developmental Dis (PDD) include poor shifting ability. Case Illust 4 (presented later in this chapter) involves 2 with a PDD who had a particular weakness in ing, among other domains. (QF motional Control ‘The Emotional Control seale addresses the festation of executive functions within the em¢ realm and assesses a child’s ability to modulat tional responses. Poor emotional control ¢ expressed as emotional lability or emotional) siveness. Children with difficulties in this d may have overblown emotional reactions to ingly minor events. Caregivers, teachers, and ators of such children may observe a child wh easily or laughs hysterically swith small provo ora child who has temper tantrums with fre or sévérity that is not age appropriate. Exam BRIEF items related to emotional control i “Mood changes frequently” and “Has exp angry outbursts.” Case Illustration 3 descr child with poor emotional control Qruitiate ‘The Initiate scale contains items relating to ning a task or activity, as well as independent erating ideas, responses, or problem-s strategiesPoor initiation typically does not noncompliance or disinterest. in a~specific Children with initiation problems typically v succeed at a task, but they. cannot..get.s Caregivers of such children frequently repo: culties with getting started on homework or along with a need for extensive prompts or order to begin a task or activity. In the context chological assessment, initiation difficulties a1 demonstrated in the form of difficulty with w« design fluency tasks, as well as a need for adc cues from the examiner in order to begin ti general. Initiation is often a significant prob individuals with severe frontal lobe brain inju Case Illustration 3) and children who have r cranial radiation for the treatment of cancer.related to initiation include: “Lies around the ea lot (couch potato),” “Is not a self-starter,” and to be told to begin a task even when willing.” is important to rule out primary oppositional favior as the likely factor when considering initia- function may experience problems with initiation secondary consequence. For example, children are very poorly organized can become over- elmed with large assignments or tasks; conse- pntly they may have great difficulty beginning the tems from this scale measure the capacity to hold mation in mind for the purpose of completing a Working memory is essential to carry out mul- p activities, complete mental arithmetic, or fol- complex instructions. Caregivers describe ildren with weak working memory as having trou- remembering things (e.g., phone numbers or ections) even for a few seconds, losing track of hat they are doing as they work, or forgetting what ley are supposed to retrieve when sent on an rand, Clinical evaluators may observe that a child nnot remember the rules governing a specific task en as he or she works on that task, rehearses infor- nation repeatedly, loses track of what responses he she has already given on a task which requires pultiple answers, and struggles with mental manip- ation tasks (e.g., repeating digits in reverse order) r solving orally presented arithmetic problems with- ‘out writing figures down. Working memory weak- esses are observed in a variety of clinical populations with executive function deficits, and they have been posited as a core or necessary compo- “nent of executive dysfunction by Pennington (1997). IRIEF items related to working memory include: Forgets what he/she was doing” and “Has trouble emembering things, even for a few minutes.” Case Illustrations 5 and 6, among others, describe child- ren with working memory weaknesses. Integral to working memory is the ability to » sustain performance and attention. Parents of child- ren with difficulties in this domain report that the children cannot, ‘stick to” an activity for_an age: appropriate am amount it tasks or. fail, to.complete tasks. Although the working ‘memory and ability to sustain have been conceptual ized as distinct entities, behavioral outcomes of these two domains are often difficult to distinguish. Furthermore, based on the empirically driven scale construction of the BRIEF, these two domains com- prise one unified scale (see chapter 4). Given the posited relationship between working memory as an executive function and the diagnostic criteria for ADHD, Predominantly Inattentive Type (ADHD-D, the BRIEF Working Memory scale can be clinically useful in assessing the presence or absence of ADHD-I, Further in-depth discussion about the diagnostic utility of the Working Memory scale can be found in chapter 5. (©Plan/Organize ‘The Plan/Organize scale measures the child’s abil- ity to manage current and future-oriented task demands. The plan component of this scale relates to the ability to anticipate future events, set goals, and lop appropriate steps ahead of t carry a ‘a-goAl.or end state and then, and then iatogially ‘or steps to stringing an ae a series of steps. Caregivers and teachers often describe planning in terms of a child’s { ability to start large assignments in a timely fashion or ability to obtain in advance the correct tools or materials for carrying out a project. Evaluators can observe planning when a child is given a problem requiring multiple steps (e.g., assembling a puzzle or completing a maze). BRIEF items related to plan- ning include: “Underestimates time needed to finish tasks” and “Has trouble carrying out the actions needed to reach goals (saving money for special item, studying to get a good grade).” ‘The organizing component of this scale relates to the ability to bring order to information and to appre- ciate main ideas or key concepts when learning or or written material. Organization also has a clerical component that is expressed, for example, in the abil- ity to efficiently scan a visual array or to keep track of a homework assignment. Caregivers often describe children with organizational. weakmesses as approach- ing tasks in-a’Haphazard fashion, iain the forest for-the trees,” having excellent ideas that they fail to ‘express on tests and written assignments, and being easily overwhelmed by large amounts of information, 1900 0000000000000 0008008800990 8000.9:0:9%: SeCHCOHOOGSHOE OHSS ‘The way in which information is strategically organ- ized can play a crucial role in how it is learned, remembered, and retrieved. This is often observed in the context of an evaluation that reviews learning and memory abilities. Poor organization of newly learned material can result in difficulty with retriev- ing that material in free recall conditions, but much better performance with recognition (multiple choice) formats, BRIEF items related to organiza- tion include: “Gets caught up in details and misses the big picture” and “Becomes overwhelmed by large assignments.” The Plan/Organize scale was originally two sepa- rate scales, based on their conceptualization as theo- retically distinct entities in the literature. Again, however, the empirical analysis of the item-scale structure of the BRIEF, as derived from the norma- tive and clinical data, indicated that the two scales should be collapsed into one (see chapter 4). The interrelationship of planning and organizing is clear; thus, the derivation of one unified scale is reason- able. Difficulty with organization and planning is integral to many cases of executive dysfunction. Case Tilustrations 2 and 5, among others, describe child- ren with severe organizational deficits. (SPreanization of Materials The Organization of Materials scale measures orderliness of work, play, and storage spaces (e.g., such as desks, lockers, backpacks, and bedrooms). Although evaluators may not have an opportunity to observe this problem directly, caregivers and teach- ers typically can provide an abundance of examples describing the difficulty children with executive dys- function experience in organizing, keeping track of, and/or cleaning up their possessions. The Organi- zation of Materials scale assesses the manner in which children order or organize their world and belongings. Children who have difficulties in this area often cannot function efficiently in school or at home because they do not have their belongings readily available for their use. Pragmatically, teach- ing a child to organize his or her belongings can be a useful, concrete tool for teaching greater task organization. BRIEF items related to organization of materials include “Has a messy closet” and “Leaves a trail of belongings wherever he/she goes.” Case Illustrations 2 and 5 describe children with deficits in this area. 20 (@Monitor ‘The Monitor scale assesses work-checking (ie., whether a child assesses his or her own, formance during or shortly after finishing @ 4 ensure appropriate attainment of a goal). This, ? also evaluates a personal monitoring ed 4 4 4 4 whether a child keeps track of the effect his behavior has on others). Caregivers often di problems with self-monitoring in children who, low on the Monitor scale in terms of rushing tht work, making careless mistakes, and failing to work. Clinical evaluators can observe the same of behavior during the assessment of such chil BRIEF items related to self-monitoring in “Does not realize that certain actions bother ot and “Does not check work for mistakes.” Illustrations 4 and 5 describe children with monitoring difficulties. Tue BEHAVIORAL REGULATION INI THE METACOGNITION INDEX, AND ' GosaL Executive ComPosiT: Based on theoretical and empirical factor at findings (reviewed in chapter 5), the clinical combine to form two Indexes, Behavioral Regu and Metacognition, and one composite sun score, the Global Executive Composite. The ¢ and interpretation of the two indexes and thi posite summary score are discussed in the fol! sections. Behavioral Regulation Index ‘The Behavioral Regulation Index (BRD) repr a child’s ability to shift, cognitive set and mo emotions and behavior via appropriate inh control. It is comprised of the Inbibit, Shit Emotional Control scales. Appropriate beh: regulation is likely to be a precursor to appr metacognitive problem solving. Behavioral ; tion enables the metacognitive processes to 8 fully guide active, systematic problem solvin more generally, supports appropriate self-regv Metacognition Index ‘The Metacognition Index (MI) represer child’s ability to initiate, plan, organize, and : future-oriented problem solving in working ‘This index is interpreted as the ability to cog:dif manage tasks and reflects the child’s ability to Monitor his or her performance. The MI relates ly to a chila’s ability to actively problem solve a variety of contexts. It is comprised of the Bitiate, Working Memory, Plan/Organize, Organiza- p of Materials, and Monitor scales. obal Executive Composite The Global Executive Composite (GEC) is a sum- score that incorporates all eight clinical scales he BRIEF. Although review of the indexes, indi- dual scale scores, and BRIEF profile is strongly ommended, the GEC can be useful as a summary asure. In some clinical cases, scores on all or most, BRIEF scales will be at a similar level; thus, a ary score would be an accurate reflection of the ld’s executive dysfunction level. To legitimately srive a GEC score, the examiner must first deter- ine that there is no significant difference between BRI and MI scores. Table 6 shows the frequency fin percentiles) of differences between the BRI and {1 T scores in the Parent and Teacher Form norma- ve samples. T-score differences of 13 or greater ecurred less than 10% of the time in the Parent Form normative sample, whereas differences of 19 or Tore occur less than 10% of the time in the Teacher ‘orm normative sample. Differences of these magni- ides suggest that the GEC is likely to obscure jortant differences between the two index scores d should not be used as a summary measure. Table 6 Frequency of Absolute T-Score Differences Between the Behavioral Regulation Index (BRI) and the Metacognition Index (Ml) in the Normative Sample for the BRIEF Parent and Teacher Forms Absolute T-Score Frequency differences (BRI~ Ml) (Glle) Parent Form® Teacher Form? 60 4.54 8.05 1 8.65 987 80 em 12.22 85 11.08 15.29 90 13.13 18.78 9% 1645 24.78 98 21.16 30.91 9 24,89 36.50 (419. Pn = 720. Theoretical (e.g., Barkley, 1996, 1997) and statisti- cal (Gioia, Isquith, Retzlaff, & Pratt, in press) models suggest that inhibition underlies the metacognitive aspects of executive function. From a practical view, this relationship makes reasonable sense in that one needs to be appropriately inhibited, flexible, and under emotional control for efficient, systematic, and organized problem solving to take place. Therefore, from the point of view of clinical interpretation, the examiner should first review the scores on the Inhibit, Shift, and Emotional Control scales for pos- sible elevations. If the Inhibit scale or the BRI (com- prised of the Inhibit, Shift, and Emotional Control scales) is significantly elevated, then the examiner must strongly consider the possibility that poor inhibitory controV/behavioral regulation is having a negative effect on active metacognitive problem solv- ing domains. Such a finding would have important implications for the priority and direction of treat- ment efforts. In such a case, for example, one might place stronger initial emphasis on interventions aimed at inhibition, flexibility, and/or emotional con- trol. Of course, the finding of an elevated BRI does not negate the meaningfulness of elevated scores on the MI scales. Instead, one must consider the influ- ence of the underlying behavioral regulation issues while simultaneously considering the unique prob- lems with the metacognitive problem-solving skills. INDIVIDUAL ITEM ANALYSIS Placing too much interpretive significance on individual items is not recommended due to lower reliability of individual items relative to the scales and indexes, Careful review of individual items of interest with caregivers, as well as in the context of the assessment as a whole, however, can yield useful information for understanding a child’s behavior and guiding appropriate interventions. Certain items may be particularly relevant to specific clinical groups (eg., Inhibit items in ADHD, Shift items in PDD). ‘Therefore, reviewing items of clinical interest on the Parent and Teacher Forms is recommended because they can assist the examiner in identifying and tar- geting actual areas of concern for intervention. ‘Tables 7 and 8 present additional items of clinical interest on the Parent and Teacher Forms, respec- tively, which are not included on any of the clinical scales. Inclusion of these items on the BRIEF was deemed important for two reasons: their direct 21S82008090008 S@eeeeoeoeoeoeos ©020600000000 e SCeKeeeeeeusedns 4 ‘ ‘ 4 ‘ ( ‘ f ( ( ( ( ‘ ' ‘ ‘ \ \ Table 7 Additional Clinical Items on the BRIEF Parent Form Item number Original scale Item description 3. Inhibit Has trouble waiting for turn 14. Organization of Materials ‘Loses lunch bor, lunch money, permission slips, homework, ete. 5. Organization of Materials Cannot find clothes, glasses, shoes, toys, books, pencils, ete 16. PlawOrganize ‘Tests poorly even when knows correct answers 1. Plan/Organize Does not finish long-term projects 78. Inhibit Has to be closely supervised 79. Inhibit Does not think before doing 80, Shift Has trouble moving from one activity to another al. Inhibit Is fidgety 82, Inhibit Is impulsive 83. Working Memory Cannot stay on the same topie when talking 84. Shift Gets stuck on one topic or activity 85. Shift Says the same things over and over 86. Plan/Organize Has trouble getting through morning routine in getting ready for school Table 8 Additional Clinical Items on the BRIEF Teacher Form tem number Original scale Item description 14. Inhibit Has trouble waiting for turn 0. Plan/Organize Does not connect doing tonight's homework with grades 76. Plan/Organize ‘Tests poorly even when knows correct answers 11. Plan/Organize Does not finish long-term projects 8. Monitor Has poor handwriting 19. Inhibit Has to be closely supervis 80. Shift Has trouble moving from one activity to another 81 Inhibit Is fidgety 82, Working Memory Cannot stay on the same topic when talking 83. Inhibit Blurts things out 8. Shift Says the same things over and over 85. Inhibit ‘Talks at the wrong time 86. Plan/Organize Does not come prepared for class 22ance to functional intervention programming [their relevance to specific clinical populations PDD, TBI, and ADHD). Specific items were n from the original Shift, Inhibit, and Plan/ ize scales because of their relevance to these cific populations. Examination of these items can xr reinforce interpretation of the findings from clinical scales by providing additional evidence of jculties in the particular domain of executive tion. For example, the additional Shift items , Gets stuck on one topic or activity) can provide Fther evidence of difficulties with flexible problem ig in a child with PDD. Likewise, the additional bit items (e.g., Does not think before doing) can to the examiner's understanding of the ways inhibitory problems may manifest themselves in ild with ADHD. Case ILLUSTRATIONS | The six clinical cases presented in this section use he Parent and Teacher Forms of the BRIEF to illus- ate the interpretation of possible profiles. Although ific disorders, they are not to be viewed as exclusive o that clinical disorder. Included in these examples e children with developmental disorders (eg., PDD, ADHD, and learning disabilities), as well as dren with acquired neurological conditions that an effect on executive functioning. Parent Form Case Ilustration 1. Eight-Year-Old Boy With ADHD, Combined Type Joshua is an 8-year-old, left-handed boy, referred by his teaching team, with a longstanding history of attentional and behavioral control difficulties includ- ing overactivity, impulsivity, and problems sustain ing his attention in school, Problems were first noted in kindergarten, but as a second grader, he is experi- encing significant behavioral difficulties in class. In addition, he has had difficulty initiating and main- taining friendships. Results of the evaluation revealed a youth with normal intellectual ability (Wechsler Intelligence Scale for Children, 3rd Edition (WISC-I) FSIQ = 98; Wechsler, 1991), but with poor sustained atten- tion and impulsive responding on continuous per- formance testing. Joshua was observed to have trouble remaining seated during the evaluation. He also demonstrated significant difficulty on tasks with high organizational demands such as copying a com- plex figure and completing selected visual/nonverbal constructional tasks. Examination of his BRIEF scores provides insight into areas of significant concern to which primary emphasis of intervention can be directed. Validity scale scores were within normal limits indicating the likelihood of a valid profile. As can be seen in Figures 6 and 7, Joshua demonstrated similar scores and profiles on the Parent and Teacher Forms. Each pro- file indicated globally elevated scale T scores with Figure 6. Parent and ‘Teacher Form Scoring Summaries for Case Illustration 1. Scoring Summary Table Scoring Summary Table Raw | 7 aw | Sealeindex score | score | tile | 90% Cl Scaleindex score | score | ‘lle | 90%! tahiti 29| 80| 98| 75-85 inhibit 30| 70| 99| 67-73 ‘shit 14 | 57| 79| 49-65 ‘Shit 19 | 61| 82| 56-66) ®) | Emotional Control 21 | 60| 86|.55-65 Emotional Control 23 | 71 | 94| 67-75 > | BRI 96) 65: Z- 71 | Ini 14 | 53| 70 Initiate 13 | 54| 65| 49-59 Working Memory 24 | 67| 95|62-72 Working Memory 50 | 74| 99|720-78 3 PlanvOrganize 27| 65| 91|59- 71 PlarvOrganize 22| 63| 92| 58-668 ® | Organization of Materials 10 | 45| 35|39- 51 Organization of Materials 12 | 54| 72|50-58 =) | Mentor 19 | 62| 91| 64-70 Monitor 23 | 61| 835| 56-66 2 al be = =C0809 00008 COOH OSHS HOHOCOOHSO e DOoSoOCOEOEE DOOCECROCE: Figure 7. Parent and Teacher Form Profiles for Case Illustration 1 e 7 BRIEF Parent Profile Form Child’s Name Joshua Gender_M. Emotional Working Plan! Org. of oore wow san "Comol" rte Wnory_Oranze ates Wontor___a)_!_GEC_—T 0 2100-{ = = = = = pe 4 = = = bss wo ee es boo «4 es = e 2 bes | eee ae Fae 4 fe sf = b op - - ele = 2 sae = = : i me zs = = = S Zs Sek ae = EB E, Se a = = fa a is Emotions! Working Plan Org. of z inno sm “Contol nite ‘Memory Organze Mateils Monitor BR MI GEC tse 80 _57 60 53 _67 _65 45. 62 69 62 661s Instructions: Taster he Seal Index, nd GEC scares om he Soaing Surany Tele on he evr ideo this foe, Mark an ek mark comesponding to each T score. Connect the Xs (without crossing the vertical ines) to creat a profiBrine Student's Name_Joshua Se ae : zo: i fe See alee ecient Sida Eanithienen nik - eats Mc ilara Se oregano pf maemen poco nae! ea gaat al Sg Ee lh ag eens nial er pe naelicheh aoe fescue Sc ea |e eo Emotional Working Plan’ Org. of Inniot Shit Control late »—‘Memery Organize Materials Montor §= BR} MI GEC Tscore_ 70 _ 61 A 54 4 63 54 61 69 63 _67 teow ‘Tastructions® Transfer the Scale Index, and GEC T's einen score. Connect the X8 (without orossing the I Figure 7. (continued)2DOSSHSOHHSCHHHTHOHOHOOOD ° ° @ 2 e > > SOSOOSCESHSOHLVEO two of the highest elevations on the BRI scales. Joshua's Inhibit scores on both Parent and ‘Teacher Forms suggested particularly significant problems controlling impulses, whereas his elevation on the Emotional Control scale of the Teacher Form sug- gested difficulties modulating his emotional responses in school. Given Joshua's significant prob- lems with behavioral regulation, MI scale elevations were not surprising. Problems were noted on the Working Memory and Plan/Organize scales, suggest- ing difficulty with holding information actively in working memory and with systematic problem- solving strategies. ‘The Working Memory and Inhibit scales can be helpful in reaching a diagnostic formulation. Joshua's T scores on the Working Memory and Inhibit scales were high for both the Parent and ‘Teacher Forms, falling above the 90th percentile. According to the available sensitivity and specificity data for these scales (see Tables 54, 55, 56, and 57), there is only a small likelihood of misidentifying a child as having ADHD at this level of elevation. Given the convergence of history, clinical observa- tions, formal assessment, and parent and teacher ratings, Joshua met the criteria for ADHD, Com- bined Type with associated deficits in aspects of his executive function. ‘The BRIEF findings assist in directing the goals of intervention. The focus would be directed primarily at two levels: first, at facilitating more age-appropriate inhibitory control (behavioral regulation) and, second, at improving organized problem-solving skills. This could be accomplished through a variety of environ- mental, familial, academic, and individual treatment methods. Behavior management at home and school were recommended to facilitate impulse control and sustained performance. Cognitive behavioral psy- chotherapy with emphasis on mediating impulses with “Stop-and-Think” verbal statements (ie., inhibitory control) was also recommended. Develop- ing more effective modulated responses to stress (i.e., emotional control) was also a focus. Medical manage- ‘ment of Joshua's impulsivity was also suggested. Specific tutoring in organizational and strategic problem solving was suggested to promote metacog- nitive development and a sense of control over his cognitive processing. Classroom accommodations to facilitate attention, impulse control, and the imple- mentation of organizational strategies in class were also recommended. 26 Case Ilustration 2. Nine-Year-Old Girl W Nonverbal Learning Disability and ADH Predominantly Inattentive Type Allison is a 9-year-old, right-handed girl y history of social problems, poor fine-motor skill academic difficulties; she was referred by her trician for evaluation to assist with academic ning and social intervention. Despite a strong to have friends, Allison’s interactions were < tently awkward and she had difficulty makin maintaining friendships. Writing was always cult for her due to weak fine motor develoy Finally, despite excellent verbal knowledge th was readily eager to demonstrate, at times point of “droning on about information other: find interesting,” she continued to achieve bel grade level and she demonstrated particular nesses in arithmetic skills. Many of her acaden ficulties appeared to be a function of inattentic disorganization. Teachers reported that Allisor had trouble paying attention in class and cov start assignments without assistance. Her wo! often disorganized and she frequently failed t plete assignments or forgot to turn them in teacher. Results of the evaluation revealed a chil highly variable cognitive abilities (WISC-III 109, PIQ = 82), and were remarkable for perceptual, visuospatial, and visual-constru weaknesses. Furthermore, Allison was found t poor sustained attention, severe problems organization, and initiation deficits. Her moto! ties bilaterally were below average with rel greater left-handed impairment. She also ¢ strated above average reading and spelling but her arithmetic skills fell in the Borderline Allison’s scores on the BRIEF are presen Figure 8. The validity scales were within norm its indicating the likelihood of an interpretab file. Allison demonstrated a similar patter scores on the Parent and Teacher Forms, alt her scores on the Teacher Form suggest highe all levels of concern. Her scores on the Inhibi were generally adequate at home and school i ing appropriate basic executive inhibitory cor behavior. Some of her greatest. difficulties reported on the metacognition scales in the setting. Significant elevations were seen on thi Organize scale together with the Working MParent Form ‘Teacher Form Scoring Summary Table Scoring Summary Table Raw | Faw | 7 [Sealand score | score | sll | 90% C1 Scaefndex score | score | tile | 90%C1 12 | 45| 42| 40-50 tntibit 13 | 57| 65| 52-62 13 | 535 | 71 |47-59 Shit 22 | 93| 99|88-98 19 | 56 ve 51 - G1 Emotional Control 18 | 81 | 98| 76-86) 4452 O 34 | 62 ‘nite Zé 72 Working Memory 21 | 62| 96 - 87 G4 PavOrganize 21 | 77 | 97| 72-82! 68 Organization of Materials 16 | 99| 99|92-106| G4 Monitor 19 | 73 | 96| 66-80 a wi [BO= Be Organization of Material scales. Her teacher ed significant problems on the Shift scale, sug- ting problems with cognitive flexibility. Her er also reported secondary elevations on the nitor and Emotional Control seales. Allison's pat- n of scores indicated particular difficulties with cognitive problem solving, including initiating, ganizing, and planning strategies; monitoring; and g information actively in mind. Diagnostically, ison met the criteria for a nonverbal learning dis lity with a concurrent disorder of executive func- ming. Given the reported history, observations, nd formal testing, she also met the criteria for IDHD, Predominantly Inattentive Type. Her Work- Bg Memory scale scores on both the Parent and acher Forms were at the 98th percentile, whereas ber Inhibit scale scores were not clinically elevated. | The BRIEF findings suggest that the focus of itervention should be two pronged with primary rts addressing the development of metacognitive wareness to promote active generation of flexible, strategic, and organized problem-solving skills. etacognitive control over her cognitive processing. mndly, treatment should focus on methods to crease sustained attention, including behavioral ¢ 8. Parent and Teacher Form Scoring Summaries for Case Illustration 2. Individual and group psychotherapy with emphasis on social skills and metacognitive self-awareness was suggested to promote self-monitoring, emotional control, and social functioning. Case Ilustration 3. Twelve-Year-Old Boy With Traumatic Brain Injury Juan is a 12-year-old boy in the sixth grade who suffered a severe traumatic brain injury (TBI) as a passenger in an automobile accident at the age of 5. History prior to the accident was unremarkable and hhe was succeeding in school without difficulty. He was unconscious for 5 days and was unable to learn any new information for a period of 10 to 12 days (posttraumatic amnesia) immediately following the automobile accident. He returned home after a slow but steady 2-month recovery in the rehabilitation hospital. Juan demonstrated excellent physical recovery, but he was unable to return to a regular education curriculum due to problems with inhibit- ing his behavior, an exaggerated emotional response to stress, decreased sustained attention, and poor organization. He often began tasks impulsively and did not monitor his actions, which resulted in fre- quent errors. Consequently, his motivation toward academic tasks decreased significantly and this pre- viously enthusiastic student now refused to complete his work. His regulatory disturbance also had an impact on his social and family functioning. Juan had trouble playing with peers and siblings without getting into a physical or verbal altercation.©0880 080H00000995986000008 2eo eee00008 eceooeeeoes The neuropsychological evaluation revealed a pattern frequently seen in children with severe ‘TBI, including a dampening of general intellectual functioning (WISC-III FSIQ = 82), attentional and memory deficits, and severe executive/regulatory disturbance. Previously learned material and skills (eg., vocabulary, reading decoding) were less impaired, but significant difficulty with acquiring new information was evident. Sustained attention was impaired on continuous performance testing, as was self-initiated planning and organization. Learning and memory were severely hampered by inattention and disorganization. Motor skills were weakened and generally inefficient. Academic skills were roughly age-appropriate. Emotional lability, general irritability, and fatigue were observed during testing. BRIEF results are presented in Figures 9 and 10 The validity scales were within appropriate limits suggesting the likelihood of a valid profile. Juan demonstrated elevated T' scores on the BRI and MI scales across both home and school settings. His highest BRI elevations were found on the Inhibit and Emotional Control scales, suggesting significant problems with inhibiting impulses and behaviors and with regulating emotions. Examination of the individual items within these scales reveals the nature of his deficits (e.¢., ratings of Often on “Gets out of control more than friends” from the Inhibit Parent Form scale and “Small events trigger big reactions” fr Shift scale). These underlying deficits in beh regulation adversely affected metacognitive p solving as reflected in elevations on the 1 Working Memory, Plan/Organize, and Monitor ‘These elevations indicated problems with ini tasks, holding information actively in minc organizational skill, and little awareness deficits. He demonstrated milder, though still cern, elevations across most other scales. Interventions designed to assist Juan were mented across environments. First, he require tance with behavioral regulation in order to eff treat his poor metacognitive skills. He was pla highly structured special education program i rating goals for executive problem-solving rou! a central part of his individualized program. In behavioral modification was implemented wit classroom to promote the adoption of these ex routines and to facilitate task attention/per: and behavioral control. At home, similar ex routines were implemented for active proble ing, and his parents were trained in behavior cation principles to promote his use of the e routines, Juan received individual cognitive ioral treatment to facilitate impulse cont: adjustment to his injury. A trial of stimulant tion was also initiated with moderate success Teacher Form Scoring Summary Table Scoring Summary Table fav |_T few | _T Scalefndex score | score | she | 90% C1 Scalefndex score | score | tlle Inhibit 28 | 86| 99| 81-91 Inhibit 30| 89| 99| 8 Shift 17 | 70\ 96| 62-78 Shift 18 | 66| 92|6 Emational Control 26| 80| 99| 74-86 Emational Control 20| 76| 98\7Z BRI 71 | 85 99| 80-90 BRI 68| 621 96) 2 initiate 18 | 65| 90|58-.72 Initiate 16 | 69| 94|6 Working Memory 28| 78| 98| 735-85 Working Memory 27| 83| 99|2 PlavOrganize 33 74| 96|G9-79 Panonaize _+(| 26| 77| 96|.Z: Organization otNateras | 17 | 66| 94|GO-72 Orgenizaton ofNeteias | 12 | 60| 87/51 Monitor 22| 75 | 99| 68-82 Monitor 24| 74| 96\G A 116| 75 | 98|72-7B Mt 105| 76 | 96|Z GEC (BRI + Ml) 189| 61| 99| 76-84 GEC (BRI + Mi) 173| 80| 98| 2 Figure 9. Parent and Teacher Form Scoring Summaries for Case Illustration 3.¢ pate_5_/ 16 / 98 _ BRIEF Parent Profile Form ae OR rR “Child's Name Juan Gender_M Grade_Gth Age 12 bss Gog tea Gen oi oleae ATT gen reretrecens gc tei ree cat (et ace Wescaglincay ot acne queen geal ieee fas bao of fos Hog og ugondrn itr wn GER osteeslct per fii ta POOR ENN, al cee 1 ectstatel asealssinyo tena) ie Howe talotlinnd hoa ies PE ieee cges lise so] i at 8 PT & a e i CT.) bie 7 _ Teacher Profile Form Date_5 / 16 / 968. al raven Boe 6 e e e e Ss e @ e e Ji baler a Yalepad qi ii]: iii ili: i4 wp fe eee | = eeee geese cea ewe ae Oe ea la ae eel Enon! Working Pld org ot tet in “Contel tlle Menor? organs Maile Montoro Teor 69 66 78 69 83 77 6O 74 82 76 80 Tso Figure 10. (continued) 30 SOOOSCHOSCHHOSHTHCEHEVLHSEHHCHHHHHHHHHHHHHOHH8OO f.CCT Tyrer Ilustration 4, Eleven-Year-Old Boy Asperger's Disorder George is an 11-year-old boy with a history of ere behavioral problems in school and a diagnosis, atypical” ADHD and Obsessive-Compulsive order (APA, 1994). George had been unresponsive variety of stimulant medications. His parents ght evaluation on the recommendation of ge’s psychiatrist who required assistance with gnostic clarification and school planning. George reportedly had experienced difficulty in pol since kindergarten related to his high levels of fractibility, disruptive behavior, poor frustration ce, and tendency to argue with other stu- Although he was always an affectionate child, was not sensitive to many nonverbal social and frequently misread the communications of peers. He was at his best with younger children at his worst in large groups. In addition, ’s parents revealed that he was overly focused s favorite video game characters, relied on rigid ines at home, and engaged in stereotypic hand ements. Academically, he generally performed , demonstrating particular strengths in reading d spelling. ‘Cognitive assessment revealed solidly average {C-III Verbal and Performance IQ scores, but Were deficits in a variety of executive function mains, including organization and planning, inhi- tion, working memory, and self-monitoring. Exami- on of BRIEF ratings indicated a valid Parent Form but a highly inconsistent Teacher Form, sug- gesting the possibility of an invalid protocol. Results on the BRIEF Parent Form revealed elevations on BRI and MI, with significant difficulties noted in George’s ability to inhibit and flexibly regulate his behavior and thinking. Further deficits were reported with initiation, planning, organizing materials, and monitoring of actions (see Figure 11). George also had difficulties regulating his emotions. BRIEF findings, combined with corroborating clin- ical data, enabled the examiner to reformulate George's “atypical” ADHD as a severe disorder of executive functioning. This led to a refocusing of intervention strategies away from stimulant trials and toward the provision of additional structure to support appropriate behavior and academic problem solving. Individual tutoring was also recommended to teach George to think and problem solve strategi- cally, use checklists and other organizing devices, and learn specific skills (e.g., self-monitoring). These skills could be applied to George's behavioral as well as academic performance. In addition, the diagnosis of Asperger's Disorder was made based on George's social deficits, restricted interests, and repetitive behaviors. Here again, the elucidation of George’s executive dysfunction facilitated a deeper under- standing of how his repetitive behaviors did not con- stitute a separate Obsessive-Compulsive Disorder, but instead were related to his general difficulties with flexibly problem solving with peers and his shifting behaviors or problem-solving strategies. Parent Form ‘Teacher Form ‘Scoring Summary Table Scoring Summary Table raw | 7 ] few | Scalefindex score | score | sie Scalefindex svore | score | wile | sonct 20| 65| 91|60 bit 24| 75 | 96| 71-70 67| 96 shit 17 | 65| 68|58-68 92 Emotional Cont 17 | 69| 95 14 — 21 481 68] Wong Memory 17 | a5| 55-65 PlaniOrganize | 75 57 Organization of Materials | 99 20 Mentor 94 | 64-74 Figure 11. Parent and Teacher Form Scoring Summaries for Case Illustration 4.