This is the second post in a series on executive functions by Kavita Murthi.
This post describes how different executive functions are evaluated, results are related to test observations, and the most commonly used batteries of tests and measures. While this post is intended to create awareness, it does not list all the tests and strategies to measure executive functions. Before understanding the different the interventions that are used, it is important to realize that there is no single assessment that completely and fully tests all the executive functions in a child. A complete assessment/ an evaluation strategy will ideally gather information from various sources and bring together materials that provide justification for behavior patterns across places and time. For an assessment to be comprehensive, a range of tools are used in a combination such as observations (observing children in their natural settings like home), data gathering from different people involved with the child (teachers, parents, other caregivers), standardized checklists which are administered in a formal one-one standardized testing environment, and actual work-based testing (which includes assessing the child’s school work).
A child’s behavior in a familiar, natural setting determines the exact nature of difficulties that he/she is facing and this is crucial information as it helps gather data also about the child’s environment. Observations provide a rich collection of information about different executive functions including working memory, planning, organization, inhibition, and time management. They should be carried out in a structured context like a classroom and a less structured context like home/playground. A few examples of executive functions that specialists usually evaluate using observation are:
- Problem-solving skills (eg. Academic problems like sums, comprehension of passages or problems faced while performing household chores like cleaning)
- Inhibition skills (eg. Is the child inhibiting unnecessary noises while solving academic problems or is he/she inattentive?)
- Sustaining attention (eg. Can the child sustain his/her attention in a task despite facing challenges or does the child lose interest easily?)
- Flexibility in thought/ shift of focus (e.g Can the child move easily between two steps in an activity?)
- Working memory (eg. Can the child hold onto the various steps of an activity and manipulate them effectively like remembering to complete five problems one after the other?)
- Organization and time-management (eg. Can the child organize, plan, initiate an activity, and complete it in a timely manner?)
- Theory of mind– is the ability to understand other people’s perspectives, beliefs, notions, knowledge, plans, and the ability to perceive that other people can have different thoughts and ideas. (eg. Can the child understand that other people can think differently or have different thoughts which might not match theirs?)
The data collected through observations can usually be supported through detailed interviews with parents, teachers, caregivers, and the child. Concerns or difficulties can be discussed and this vital chunk of information scaffolds and supports data obtained from observing children in their natural settings. Specialists and therapists extract crucial pieces of information and use this to form the foundation of their intervention program. Both general questions (eg. What concerns do you think your child faces in school?) and specific questions (eg. Can the child sustain his attention while solving math problems? If yes, then for how many?) are subjective in nature. Subjective questions help specialists and therapists to understand areas of concern in depth. Formal assessments also have an interview component but that usually is associated with guidelines from the assessment itself. The time for interviews usually varies and specialists take around 8-15 hours to interview parents and teachers.
A series of standardized tools are available for therapists/specialists to choose from. However, it is crucial to realize that standardized testing can over highlight the severity of issues faced by the child but sometimes the scores cannot be correlated clinically. Hence it is important to understand that these results need to be associated with clinical problems demonstrated by the child. Also, specialists usually compare the child’s progress with same-age peers to provide a comprehensive interpretation of results. Thus, it is important to view these results prudently. Common standardized tests, their description and purpose are described below:
BRIEF (Behavior Rating Index for Executive Function)
This test assesses behaviors associated with executive functioning. It is a widely-used test and is designed to test the capabilities of children (ages 5-18 years, preschool version also available) with a range of developmental challenges including autism, and this test can also be used with parents and teachers. Using a format of 3-point scoring and 86 questions, this test is made to measure eight areas of executive functioning including inhibition, emotional regulation, shift of focus, working memory, organizational skills, organization of materials and monitoring/ task regulation. Scores are given in the format of Global Score, Index Score and Metacognition Index. This test is considered highly consistent (when used repeatedly) and reliable (when used by different test-takers).
TOVA (Test of Variables of Attention)
This test is used for children aged 4 and above and it tests the ability of a child to pay attention while also focusing on inhibition and speed at which information can be processed by a child. It is a 15-20-minute assessment and is computer based. In the original version of the test, different letters pop-up on the screen and the child taking the test presses the spacebar each time letter ‘A’ appears on screen. Not only is inattention measured through this test (e.g. when the child misses the target A), but also, slow processing speed and/or lack of inhibitory control can result in missing targets.
Stroop Color and Word Test
There are 2 versions of this test for children between ages 5-14 and a separate test for teens aged 15 and above. This test measures children’s abilities to restrain their actions and to control themselves by assessing their ability to think before performing an action. This test requires children to read the names of colors which are presented in the form of words. But the color of the ink with which these words are written are different from the words. Eg. The word pink will be presented in blue color font. The child must read a series of words in a prompt manner by ignoring the color of their fonts. For children who can’t read, shapes are presented in different colors and the child has to name the color but not the shape.
WISC (Wechsler Intelligence Test for children)
Two subtypes, the digit span and the spatial span of this test are used to test working memory. While the digit (number) span tests spoken working memory i.e. capability to store spoken information, the spatial (position in space) span is used to assess visual working memory i.e. capacity to store what is seen. For digit span, the child has to repeat the digits presented by the assessor in a reverse manner e.g. 1,2,3 as 3,2,1 and for spatial span, the child is required to touch some blocks in a reverse order as compared to the assessor.
Tower of Hanoi
This test assesses the child’s ability to organize, plan and correctly sequence the required steps from the provided information to solve a problem. Designed for ages 5 and above, this test also assesses working memory and inhibition. A set of instructions is given to the child to follow to construct a tower from beads or disks (e.g. without placing a bigger disk on a smaller disk, completely move tower from position A to position C in 7 steps).
Wisconsin Card Sorting Test
Designed for children aged 7 and above, this test is designed to test a child’s ability to shift from one task to another. This test also assesses formation of ideas and thoughts. This test usually lasts for around 15-20 minutes and the child is presented with a set of stimulus cards and is asked to match cards, but is not provided with rules to match each card (eg. on the basis of color, shape etc.). Each card is different, figures are varied, and the child has to come up with the strategies to match the cards. Only right/ wrong answers are provided by the evaluator.
Apart from these strategies, work samples of children, including but not limited to school work, homework, class projects, drawings and other craft items are also used to analyze the extent of executive dysfunction faced by a child.
These testing strategies are not exhaustive but are just a handful approaches used by specialists to understand the level and intensity of executive dysfunction faced by a child in question. Hence assessments have to be fully understood by parents and caregivers before comprehending their intensity. Also, prudence must be exercised whilst correlating the results of assessments to functional and clinical behaviors. Assessments are not rigid structures that define a child’s future, but rather a yardstick that measures their progress.
The final part of this series will focus on understanding the various intervention approaches used by therapists/specialists to develop and improve executive functions.
About the Author
Kavita Murthi, OTR, FHEA, MSc (OT) is a Board certified Occupational Therapist originally from India. After completing her undergraduate studies she moved to the UK to pursue her Masters in Occupational Therapy from Scotland. She received the title of “Fellow” from the Higher Education Academy, UK for her contributions towards education. Moving back to Mumbai, India, Kavitha worked worked extensively with children with developmental challenges in an outpatient community setting. Here, she worked with children with various developmental challenges and helped provide therapeutic interventions using evidence based strategies. Kavitha recently moved to Boston after getting married and is enjoying her time travelling, writing and volunteering.