understanding and evaluating executive …...understanding and evaluating executive functioning in...

Understanding and Evaluating Executive Functioning in ADHD Across the Life Span

SamGoldstein,Ph.D.AssistantClinicalProfessorUniversityofUtahSchoolofMedicine

www.samgoldstein.com

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Disclosure

MyexpensesforthistalkaresupportedbyMulti-HealthSystems.IhavedevelopedtestsmarketedbyMulti-HealthSystems,Pro-EdandWesternPsychologicalServices.

IhaveauthoredbooksmarketedbySpringer,Wiley,Guilford,DoubleDay,McGrawHill,Brookes,KluwerandSpecialtyPress.

IamEditorinChiefoftheJournalofAttentionDisorders(Sage)andCo-EditoroftheEncyclopediaofChildDevelopment(Springer)

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WhatisADHD?

ADHDisabio-psychosocialconditioncharacterizedbycoresymptomsofinattention,hyperactivityandimpulsivityleadingto/interactingwithcognitivedeficitscausingimpairmentinallwalksoflife.

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WhatisADHD?➢ADHDappearstoprimarilyinvolvethebasalganglia,cerebellumandthefrontallobes.

➢Co-morbidityofotherdevelopmental,emotionalandbehavioralconditionswithADHDprobablyconfoundsfindingsfromdifferentstudygroups.(Hendrenetal,JAACP,(2000)39,815-820.

➢ThesymptomsofADHDleadtoanearlyinfinitenumberofconsequences.

CurrentdiagnosticcriteriaspecifythatADHDinvolvesdifficultieswithinattentionand/orhyperactivity/impulsivity.Researchersusingfactoranalysishaveconsistentlyfoundsupportforaninattentionfactorinbothchildrenandadults.Findingshavebeenmixedregardingwhetherhyperactivityandimpulsivityreflectoneortwodimensions(ForReviewseeBarkley,3rdEdition,2005).

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Thepredictionofoutcomesprovidedsupportthatcomplementedconfirmatoryfactoranalysisfortheseparationofthehyperactivityandimpulsivityconstructs.Impulsivityuniquelypredictedmoreoutcomesthanhyperactivityalone.ResultswereconsistentwiththeconceptualizationofADHDasprimarilyadisorderofbehavioralinhibition.Futureresearchusingalternativeoutcomesandclinicalpopulationsshouldbeconducted.(JAD,2012)

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ADHDappearstobeaconditionstemminginpartfrominefficientoperationofEF.

ABitofEFNeuroanatomy

➢Prefrontal➢Richcortical,sub-corticalandbrainstemconnections.

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MoreSpecifically

➢Thedorsolateralprefrontalcortex(DLPFC)isinvolvedwithintegratingdifferentdimensionsofcognitionandbehavior.

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● Thisareaisassociatedwithverbalanddesignfluency,abilitytomaintainandshiftset,planning,responseinhibition,workingmemory,organizationalskills,reasoning,problemsolvingandabstractthinking.

And:

➢Theanteriorcingulatecortex(ACC)isinvolvedinemotionaldrives,experienceandintegration,inhibitionofinappropriateresponses,decisionmakingandmotivation

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● Lesionsinthisareacanleadtolowdrivestatessuchasapathyandmayalsoresultinlowdrivestatesforsuchbasicneedsasfoodordrinkandpossiblydecreasedinterestinsocialorvocationalactivitiesandsex.

AndFinally:

➢Theorbitofrontalcortex(OFC)playsakeyroleinimpulsecontrol,maintenanceofset,monitoringongoingbehaviorandsociallyappropriatebehaviors.

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● Lesionsinthisareacancausedis-inhibition,impulsivity,aggressiveoutbursts,sexualpromiscuityandantisocialbehavior.

AnotherView:HotandCoolEF

➢Cool(metacognitive)–functionsassociatedwithcognitionsuchasplanningandproblemsolving(leadingtoaDorsolateralSyndrome).

➢Hot(emotional/motivational)–functionsassociatedwithcoordinatingandcontrollingemotions(leadingtoanOrbitofrontal/MedialSyndrome).

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WhatdowemeanbythetermExecutiveFunction(s)?

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ExecutiveFunction(s)

➢In1966AlexandrLuriafirstwroteanddefinedtheconceptofExecutiveFunction(EF)

➢HecreditedBianchi(1895)andBekhterev(1905)withtheinitialdefinitionoftheprocess

141902 - 1977

WhatisExecutiveFunction(s)ThereisnoformalexcepteddefinitionofEF• WetypicallyfindavaguegeneralstatementofEF(e.g.,goal-directedaction,cognitivecontrol,top-downinhibition,effortfulprocessing,etc.).

• Oralistingoftheconstructssuchas● Inhibition,● WorkingMemory,● Planning,● Problem-Solving,● Goal-DirectedActivity,● StrategyDevelopmentandExecution,● EmotionalSelf-Regulation,● Self-Motivation

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DoesExperienceShapeEF?➢TheFamilyLifeProjecthasdemonstratedthatpovertyisassociatedwithelevatedcortisolininfancyandearlychildhood.

➢Thisassociationismediatedthroughcharacteristicsofthehousehold.

➢Parentingsensitivitymediatestherelationshipbetweenpovertyandstressphysiology.

➢IncombinationparentingsensitivityandelevatedcortisolmediatetheassociationbetweenpovertyandpoorEFinchildren.

WhatNeuralActivitiesRequireEF?

➢Thosethatinvolveplanningordecisionmaking.➢Thosethatinvolveerrorcorrectionortroubleshooting.

➢Situationswhenresponsesarenotwell-rehearsedorcontainnovelsequencesofactions.

➢Dangerousortechnicallydifficultsituations.➢Situationsthatrequiretheovercomingofastronghabitualresponseorresistingtemptation.

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Goldstein,Naglieri,Princiotta,&Otero(2013)➢Wefoundmorethan30definitionsofEF(s).➢Executivefunction(s)hascometobeanumbrellatermusedformanydifferentabilities,includingplanning,workingmemory,attention,inhibition,self-monitoring,self-regulationandinitiationcarriedoutbypre-frontalareasofthefrontallobes.

➢

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WhatisExecutiveFunction(s)

1. Barkley(2011):“EFisthusaself-directedsetofactions)”(p.11).

2. Dawson&Guare(2010):“Executiveskillsallowustoorganizeourbehaviorovertime”(p.1).

3. Delis(2012):“Executivefunctionsreflecttheabilitytomanageandregulateone’sbehavior(p.14).

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WhatisExecutiveFunction(s)

4. Denckla(1996):"EF(is)asetofdomain-generalcontrolprocesses…"(p.263).

5. Gioia,Isquith,Guy,&Kenworthy(2000):"acollectionofprocessesthatareresponsibleforguiding,directing,andmanagingcognitive,emotional,andbehavioralfunctions”(p.1).

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WhatisExecutiveFunction(s)

6. Pribram(1973):"executiveprogrammes…tomaintainbrainorganization"(p.301).

7. Roberts&Pennington(1996):EF“acollectionofrelatedbutsomewhatdistinctabilitiessuchasplanning,setmaintenance,impulsecontrol,workingmemory,andattentionalcontrol”(p.105).

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WhatisExecutiveFunction(s)

6. Stuss&Benson(1986):"avarietyofdifferentcapacitiesthatenablepurposeful,goal-directedbehavior,includingbehavioralregulation,workingmemory,planningandorganizationalskills,andself-monitoring"(p.272).

7. WelshandPennington(1988):"theabilitytomaintainanappropriateproblem-solvingsetforattainmentofafuturegoal"(p.201).

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WhatisExecutiveFunction(s)

10. McCloskey(2006):“adiversegroupofhighlyspecificcognitiveprocessescollectedtogethertodirectcognition,emotion,andmotoractivity,including…theabilitytoengageinpurposeful,organized,strategic,self-regulated,goaldirectedbehavior”(p.1)

“thinkofexecutivefunctionsasasetofindependentbutcoordinatedprocessesratherthanasingletrait”(p.2).

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WhatisExecutiveFunction(s)

10. Lezak(1995):"acollectionofinterrelatedcognitiveandbehavioralskillsthatareresponsibleforpurposeful,goal-directedactivity,”…

11. “howandwhetherapersongoesaboutdoingsomething"(p.42).

12. Luria(1966):“…abilitytocorrectlyevaluatetheirownbehaviorandtheadequacyoftheiractions”(p.227).

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JackA.Naglieri,Ph.D.GeorgeMasonUniv,Fairfax,VA22030.naglieri@gmu.edu

ExecutiveFunctions

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AndFinally....

AnNICHDpanelin1994identified33EFsbyconsensus!

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TheTopSixWere:

➢Self-regulation➢Sequencingofbehavior➢Flexibility➢Responseinhibition➢Planning➢Organizationofbehavior

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WhatistherelationshipofEFtoADHDandotherdefineddisorders?

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EFandADHD

EFdeficitsarenotnecessarilyuniquetoADHD.TheyareneithernecessarynorsufficienttomakeadiagnosisofADHD.WhenEFimpairmentsaremeasuredinchildrenwithADHDtheytendtoreflectspecificratherthanglobalimpairments.

EFandOtherDisruptiveDisorders(ODD&CD)

EarlyreviewsreportedthatEFdeficitswerenotcharacteristicofchildrenandadolescentswithODDandCDafterco-morbidADHDwasfactoredout.Morerecentstudies,however,suggestthatinhibitiondeficitsmaybecharacteristicofbothADHDandCDbutwhetherchildrenwithCDdisplayimpairmentsonadditionalEFmeasuresisequivocal.

EFandTourette’s

DistinctandrobustimpairmentsinEFdonotappeartobecharacteristicofchildrenwithTD.

EFandAnxietyDisorders

EFdeficitsinset-shifting,cognitiveflexibility,conceptformation,interferencecontrol,andverbalfluencyhavebeendocumentedamongchildrenwithseparationanxietydisorder,overanxiousdisorder,andPTSD.EFinOCDhasnotbeenwelladdressed.

EFandDepression

ScantresearchhasbeenconductedontheEFabilitiesamongyouthwithdepression.StudiesthathaveincludedolderadolescentshavesuggestedsomedegreeofsensitivityofEFtasksinidentifyingunipolardepression,butlessspecificity.

EFandBi-PolarDisorderThereisagrowingconsensusaboutthenatureofBDamongchildren.SeveralstudieshavetargeteditsEFconcomitants.Althoughresultsoftenhavebeenconfoundedwithsignificantco-morbidityissues,childrenandadolescentswithBDreliablyhavedemonstratedimpairmentsrelativetothosewithoutanyhistoryofmooddisordersonseveralEFmeasures(e.g.workingmemory,setshifting).

EFandTraumaticBrainInjury

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EFDeficitsandASD

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EFandLearningDisabilities

IfalloftheseconditionsarestatisticallyrelatedtobehaviorsandabilitiesreflectingEFthanacommondenominatormustexist.

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AnexaminationofolderfactoranalyticstudiesexaminingEFinchildrenfindsonlyasinglefactor-planning–commontoallstudies.

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Anderson, 2002 Clin. Neuropsych.

Executive ExecutiveFunction Functions

● EFisaunitaryconstruct(e.g.,Duncan&Miller,2002;Duncan&Owen,2000).

● EFisunidimensionalinearlychildhoodnotadulthood.

● Bothviewsaresupportedbysomeresearch(Miyakeetal.,2000),--EFisaunitaryconstruct…butwithpartiallydifferentcomponents.

● EFhasthreecomponents:inhibitorycontrol,setshifting(flexibility),andworkingmemory(e.g.,Davidson,etal.,2006;Miyakeetal.,2000).

● EFhasindependentabilities(Wiebe,Espy,&Charak,2008).

● ExecutiveFunctionsisamultidimensionalmodel(Friedmanetal.,2006;Miyakeetal.,2000).

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ExecutiveFunction(s)

➢GivenallthesedefinitionsofEF(s)wewantedtoaddressthequestion…ExecutiveFunctions…or

ExecutiveFunction?

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ExecutiveFunction(s)

➢OnewaytoexaminethisissueistoresearchthefactorstructureofbehaviorsrelatedtoEF(s)

➢Todoso,weexaminedthefactorstructureofanationallyrepresentativesampleofchildren.

➢Weconductedaseriesofresearchstudiestoanswerthefollowingquestion:• WhatistheunderlyingstructureofEFbehaviors?• IsthereisjustoneunderlyingfactorcalledExecutiveFunction),ordothebehaviorsgrouptogetherintodifferentconstructssuggestingamultidimensionalstructure?

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EXPLORATORYFACTORANALYSES

➢Bothitem-levelandscale-levelexploratoryfactoranalyses(EFA)wereconducted.

➢Thenormativesamplesforparents,teacher,andselfratingswererandomlysplitintotwosamplesandEFAconductedusing• theitemrawscores• ninescales’rawscores

➢WeusedastandardizationsamplefromourinstrumenttheComprehensiveExecutiveFunctioningInventory(CEFI).

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CEFIStandardization

➢Samplewasstratifiedby• Sex,age,race/ethnicity,parentaleducationlevel(PEL;forcasesratedbyparents),geographicregion

• Race/ethnicityofthechild(Asian/PacificIslander,Black/AfricanAmerican/AfricanCanadian,Hispanic,White/Caucasian,Multi-racialbytherater

• ParentsprovidedPELofbothparents● Thehigherofthetwolevelswasusedtoclassifytheparentaleducationlevelofthechild.

• Allraterscompletedthequestionnaireviapaper-and-penciloronlinemethods.

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EXPLORATORYFACTORANALYSES

➢Forthefirsthalfofthenormativesampleusingitemscores:EFAofthe90itemswasconducted

➢Thescreeplottestandtheverysimplesolutioncriterionbothindicatedthatonlyonefactorshouldberetained.

➢Theratioofthefirstandsecondeigenvalueswasgreaterthanfourforallthreeforms,whichisacommonruletosupportaonefactorsolution.

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EXPLORATORYFACTORANALYSES

➢Itemlevelfactoranalysisclearlyindictedthatonefactorwasthebestsolution

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EXPLORATORYFACTORANALYSES

➢UsingthesecondhalfofthenormativesampleEFAwasconductedusingrawscoresfortheAttention,EmotionRegulation,Flexibility,InhibitoryControl,Initiation,Organization,Planning,Self-Monitoring,andWorkingMemoryscales

➢BoththeKaiserrule(eigenvalues>1)andtheEigenvalueRatiocriterion(>4)unequivocallyindicatedonefactor.

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EXPLORATORYFACTORANALYSES

➢FactoranalysisoftheCEFIScalesalsoclearlyindicatedaonefactorsolution

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EXPLORATORYFACTORANALYSES

➢CoefficientsofCongruence–allveryhigh

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EXPLORATORYFACTORANALYSES

➢Conclusions•Whenusingparent(N=1,400),teacher(N=1,400),orself-ratings(N=700)basedonbehaviorsobservedandreportedforanationallyrepresentativesample(N=3,500)aged5to18yearsExecutiveFunctionnotfunctionsisthebesttermtouse.

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Naglieri&Goldstein,2012

➢ExecutiveFunctionis:howefficientlyyoudowhatyoudecidetodo.

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Naglieri&Goldstein,2012➢ExecutiveFunctionis:howefficientlyyoudowhatyoudecidetodo.

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Modify the Solution as

Needed

Star

t with

a

Goa

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Gather

Information

Consider Solutions

Select a Plan

Apply the P

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Monitor the

PlanModify the Plan

If Goal is

Met

Problem Solved

LatentclassanalysisoffrontallobetasksstronglysuggestsageneralEFthatreflectstheefficiencyandperhapsautomaticityoftheexecutivemanagementsystem.

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Miyake, Friedman, et al 2008 Cognitive Psychology

EFskillsmaydevelopindifferenttracksbutmergeinfunctionaschildrendevelop.

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Wasserman and Wasserman, 2013 Applied Neuropsych. Child

EFappearstobeaunitary,moredomainspecificprocessinchildren

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Wiebe, Scheffield, et al, 2011 J. Of Exp. Child Psych.

ConclusiveevidenceconcerningthedevelopmentaltrajectoriesinchildrenofthedifferentEFcomponentsonneuropsychologicaltestshasyettobeestablished.

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Huizinga, Dolan et al, 2006 Neuropsyhologica

CEFIScoresbyDiagnosis➢WeexpectedthatindividualswithADHD,mooddisorders,andAutismSpectrumDisordersmightearnalowscoresonthismeasureofEFbehaviors.

➢Wecomparedgroupsmatchedongender,race/ethnicity,andparentaleducation(Naglieri,J.A.,&Goldstein,S.(2013).ComprehensiveExecutiveFunctioningIndex.Toronto:MultiHealthSystems.)

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GroupDifferences:ADHD(Naglieri&Goldstein,2013)

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80

87.5

95

102.5

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Parent Teacher Self-Report

ADHDControl

CEFIScales:ADHD(Naglieri&Goldstein,2013)

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Parent

TeacherSelf Report

Parent

Self ReportTeacher

GroupDifferences:ASD(Naglieri&Goldstein,2013)

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80

85

90

95

100

Parent Teacher

General Population

ASD

CEFIScales:ASD(Naglieri&Goldstein,2013)

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Parent

Teacher

Teacher

Parent

GroupDifferences:LearningDisabilities(Naglieri&Goldstein,2013)

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80

87.5

95

102.5

110

Parent Teacher Self-Report

LDControl

CEFIScales:SLD(Naglieri&Goldstein,2013)

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GroupDifferences:MoodDisorders(Naglieri&Goldstein,2013)

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80

87.5

95

102.5

110

Parent Teacher Self-Report

MoodControl

CEFIScales:MoodDisorders(Naglieri&Goldstein,2013)

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HowcanwereliablyandvalidlyevaluateEF?

HowtoMeasureExecutiveFunction(s)

ArecentreviewbyWeyandtetal(2012)found168measuresusedtoevaluateEF.

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From

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al, 2

012

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IngeneralsingleEFtestsshareatmost10%ofthevariancewithEFratingsandobservationsofeverydaybehavior.

BatteriesofcombinedEFtestsfareabitbettersharingupto20%ofthevariancewithobservationandreportedbehavior.

ThemoretestsinanEFbatterythemorefactorsidentifiedinbothexploratoryandconfirmatorystudies.

EFRatingScales

➢Measuresrealworldbehavior➢Abletosamplemultiplesources(self,parents,teachers)

➢EfficientwaystoevaluateEF➢However• self-ratingsmaybelimitedbyimpairedself-awareness• Observersmaynotbegoodatobserving!

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Copyright © 2017, Multi-Health Systems, Inc. All rights reserved.

AttentionMeasureshowwellanadultcanavoiddistractions,concentrateontasks,andsustainattention

InhibitoryControlReflectsanadultscontroloverbehaviororimpulses

PlanningReflectshowwellanadultdevelopsandimplementsstrategiestoaccomplishtasks

EmotionRegulationMeasuresanadult’scontrolandmanagementofemotions

InitiationDescribesanadult’sabilitytobegintasksorprojectswithoutbeingprompted

Self-MonitoringDescribesanadult’sself-evaluationofhis/herperformanceorbehavior

FlexibilityDescribeshowwellanadultcanadapttocircumstances,includingproblemsolvingabilities

OrganizationDescribeshowwellanadultmanagespersonaleffects,workormultipletasks

WorkingMemoryReflectshowwellanadultcankeepinformationinmindthatisimportantforknowingwhattodoandhowtodoit

ExecutiveFunctionFullScale

CEFI:WISC-IV,CAS,andWJIII

➢DatafromtheNeurology,LearningandBehaviorCenterinSaltLakeCity,UT

➢ChildrengiventheCEFI,WISC-IV(N=43),CAS(N=62),andtheWJIIIachievement(N=58)aspartofatypicaltestbattery.

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CEFI,WISC-IV,CAS,Achievement

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CEFI,WISC-IV,CAS,Achievement

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Table 8.27 CEFI Manual

CEFI&WISC-IV

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CEFI&CAS

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CEFI&WJ-IIITotalAchievement

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CEFI&WJ-IIIReading

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CEFI&WJ-IIIBroadMath

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CEFI&WJ-IIIWrittenLanguage

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Conclusions

➢TheconceptofEFisevolving.➢DatafromtheourStandardizationSampleindicatethatwhenmeasuredusingobservablebehaviorsthetermExecutiveFunctionissupported.

➢GoodresearchcanprovideawellnormedmeasureofEFthathasdemonstratedreliability&validity.

➢Thereisalsoemergingevidencethatchildrencanbetaughttobemorestrategic–animportantindicationofefficientEF.

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