Transcript Dysexecutive Syndrome

Dysexecutive Syndrome
Assessment
Amanda Dam
Shelly Dua
Sandeep Marwaha
OUTLINE
Introduction to Dysexecutive Syndrome
Profile of Executive Control System (Pro-Ex)
Behavioral Assessment of the Dysexecutive
Syndrome (BADS)
Impacts of Assessment Findings on Driving
and Meal Preparation
Guidelines for EF Assessments
Conclusion
WHAT ARE EXECUTIVE
FUNCTIONS?
Executive Functions
goal identification
planning
regulating mood + emotion
organizing behaviors to achieve goals
monitoring goal directed activity
creativity
cognitive flexibility
problem solving
Executive Functions
Common Dysexecutive Symptoms
(Sohlberg & Mateer, 2001)
Rigid and concrete thinking style
Difficulty generating fluent and novel
thoughts
Behavioral and personality changes
Profile of Executive Control
System (Pro-Ex)
Braswell, D., Hartry, A.,
Hoornbeek, S., Johansen, A.,
Johnson, L., Schultz, J., and
Sohlberg, M. M. (1993)
Pro-Ex
Purpose
– To describe a client’s executive control system
– To predict client’s daily functioning
– To educate clients, families, caregivers, and
health professionals about the client’s
impairments and resulting behaviors
Target Population
– Not specified in manual
– Used with adolescents (Proctor et al., 2000)
Pro-Ex: Theoretical Model
Stuss’s (1991) model of executive control
system
Premise
– Executive control results from an interaction
of independent and hierarchical functions
Stuss (1991)
Third Level
METACOGNITION
•Awareness, self-monitoring
Second Level
EXECUTIVE FUNCTIONS
•Adjusts, directs automatic processes from Level 1
First Level
SENSORY/PERCEPTUAL KNOWLEDGE
•Automatic processes forming basis for daily routine behavior
Pro-Ex: Design
Top-down (functional) approach
Intention: to overcome shortcomings of
psychometric/standardized tests
–
–
Psychometric tests tend to over- or under-estimate
cognitive impairment (Sohlberg & Mateer, 2001)
Executive Function Ax: clinicians tend to act as the
client’s “executive control”
Observational assessment, consists of 7
scales
Pro-Ex: Administration
Clinicians can use 3 methods for
assessment
1. Observe client in naturalistic setting
2. Observe client in a simulated setting
3. Interview client, patient, other staff (can be
one or all)
Methods are relatively unstructured
Manual offers suggestions
Pro-Ex: Administration
1. Naturalistic setting
– Multi-step tasks at home (e.g., balancing
chequebook)
2. Simulated setting
– Ask client to perform route-finding task in
hospital
3. Interview
– Ask caregiver scale-specific questions
Pro-Ex: Scales
Observational assessment, consists of 7
scales
Scales derived from:
– Rehabilitation and cognitive science literature
– Clinical experience
Pro-Ex Design
1. Goal Selection
– Ability to generate or choose appropriate future
objectives
– Refers only to ability to select a goal, not to achieve a
goal
– Criticism: Is this a valid scale? Do clients truly select
own goals?
2. Planning/Sequencing
– Ability to develop a scheme to reach intended goals
(objectives)
– Correctly ordering steps involved in generating a plan
Pro-Ex Design
3. Initiation
– To begin an action (behaviourally)
4. Execution
– Carry out or follow through with intended
actions
– Executing plans or organizational schemes
5. Timesense
– Judge and estimate the passage of time
– Complete behaviour within time
Pro-Ex: Design
6. Awareness of deficits
– Level of awareness/understanding of one’s
own deficits
– Knows how deficits will affect daily
functioning
7. Self-monitoring
– To evaluate self
– Modify behaviour with feedback from
environment
– Ability to detect and correct own errors
Pro-Ex: Scoring
Clinicians choose descriptor describing
client’s highest level of functioning most
of the time
Pro-Ex: Critique
Pros
Occupation-based
Observational Ax addresses weaknesses
of psychometric tests
– Psychometric tests tend to over- or underestimate cognitive impairment (Sohlberg &
Mateer, 2001)
– Potentially greater predictive validity
Pro-Ex Critique
Sohlberg & Mateer (2001): Observation Ax
should specify…
1. Behaviors fundamental to activity
– Pro-Ex provides suggestions
2. Compensatory strategies
– manual does not specify
3. Type and frequency of any cues needed for
client to complete task
– Manual does not specify
– Although, there is a “comments” section on score
sheet
Pro-Ex Critique
Cons
Poor inter-rater reliability
– Manual: Standard kappa = 0.35
– Manual: Weighted Kappa = 0.73
high observer bias?
Few, if any, studies examine measure’s
effectiveness
Goal selection scale—validity?
Pro-Ex Conclusion
Ax with potential to overcome
shortcomings of other tests
Provides insight into occupational
performance
Useful to combine with standardized tests
More research examining assessment’s
effectiveness is greatly needed!!!
Behavioral Assessment of
The Dysexecutive Syndrome (BADS)
(Wilson, B., Alderman, N., Burgess, W., Elmsie, H., & Evans, J., 1996)
BADS
Purpose
– Battery of tests aimed at predicting everyday
problems arising from DES
– Describes specificity of impairment
– Designed for psychologists, OT’s, and other
therapists
Target population
– 16 years of age and above
– Individuals with brain injury and schizophrenia
Administration
– 40 minutes
BADS
Design
– Bottom-up approach
Test Kit
– 6 subtests
– Dysexecutive Questionnaire (DEX)
Self and care-giver forms
Scoring
– Profile score calculated for each test
– Overall profile score of all tests is converted to a
standardized score
BADS: Theoretical Models
The Working Memory (Baddeley & Hitch,
1974)
– central executive as an overall controller,
organiser, planner, & allocator of resources
BADS: Theoretical Models
Attention Control System (Shallice, 1982) We have 2
attentional mechanisms:
1. Contention Scheduling:
- routine aspects of attention
2. Supervisory Attention System:
- higher level, more demanding
tasks
SAS
Environment
Sensory
Perceptual
Information
Trigger
Data
Base
Contention
Action
Scheduler
BADS: Rule Shift Cards Test
Evaluates:
– Ability to shift rules
– Follow directions
– Change mental states without perseveration
Task:
– Initially client responds “yes” to a red card & “no” to a
black card
– Later rule is changed & must respond “yes” if card
turned over was the same as previously displayed
card & “no” if previous card was a different colour
Scoring:
– Time taken & number of errors
BADS: Action Program Test
Evaluates:
– Ability to develop a plan of action to solve
a novel problem
Task:
– Client must remove a cork from a plastic
tube using the available equipment
Scoring:
– Number of steps completed without
prompting
Critique:
– Unique & interesting, requiring physical
manipulation of objects
– Not easy to set up & water makes it difficult
to administer
BADS: Key Search
Measures:
–
Ability to plan an effective &
efficient course of action in order
to solve a problem
Task:
–
–
Client receives a piece of paper
with an empty square & a dot
beneath it
Start on dot & diagram how they
would search the field
Scoring:
–
Manual provides complex scoring
Critique:
–
Scoring examples not easy to
follow & task is abstract
BADS: Temporal Judgement Test
Evaluates:
– Ability to make to estimate time to complete a task
Task:
– How long does it take a dentist to do a routine dental
checkup?
– How long does it take to blow up a balloon?
Critique:
– Norms provided do not seem relevant to Canada and
the time estimates don’t seem accurate
– “How long do most dogs live for?” Seems irrelevant
BADS: Zoo Map Test
Evaluates:
– Ability to follow directions, profit from feedback, &
problem solve
Task:
– Indicate the path they would take when visiting a zoo.
When planning route certain rules must be followed
– First trial is a high demand version of the task in
which client must plan in advance the order in which
the designated locations will be visited
BADS: Modified Six Elements Task
Measures:
–
–
–
Ability to plan, organize,
and monitor behaviour
Ability to manage diverse
elements of a task under
time constraints
Taps prospective memory
Task:
–
–
Dictate, complete arithmetic
problems, & name pictures
10 min to complete and
must switch between tasks
during time period
Scoring:
–
Number of tasks completed
& number of rule breaks
BADS: DEX Questionnaire
20 Item questionnaire measures:
–
–
–
–
Emotional personality changes
Motivational changes
Behavioural Changes
Cognitive Changes
Two versions:
–
–
Client
Relative or caregiver
Scoring:
–
–
Impairment score
Insight score
BADS: Critique
Reliability
– Manual
– High inter-rater reliability
– Test-retest data is unclear
Clinical Utility
– Limited info on interpreting test scores or how
to scores on tests with DEX questionnaire
– Some materials not readily available in all
settings
BADS: Critique
Validity:
–
–
–
–
–
–
–
–
Consists of a number of tests that test for DES
Subtest scores may be used individually but the overall battery
is most sensitive
Statistical analyses show that BADS subcomponents are
related
BADS profile score differentiates those with brain injury from
controls
Validity with other measures of similar purpose (e.g. Wisconsin
Card Sorting Task)
Better predictor of everyday skills than other measures
Performance of subjects over age 65 poorer
Has a distinctively British flavour
BADS: Conclusion
Ecologically valid test
Bridges laboratory and observational
measures
Good for assessing non-routine everyday
problems
More research needed to look at how
useful BADS is for planning & evaluating
rehabilitation
IMPACTS OF PRO-EX AND BADS FINDINGS
ON DRIVING
PRO-EX
SUBTESTS
BADS SUBTESTS
SKILLS BEING
ASSESSED
OCCUPATIONAL
PERFORMANCE
EXAMPLE
Goal Selection
Zoo Map Test
Key Search Task
Choosing
appropriate future
objectives
Exiting off of a
freeway
Planning/
Sequencing
Action Program Test
Key Search Task
Zoo Map Test
Modified 6 Elements
Generating a plan
and sequencing
steps to reach an
intended objective
Planning steps
before exiting
freeway
Initiation
Modified 6 Elements
Ability to
independently
begin an action
Timesense
Temporal Judgment
Modified 6 Elements
Ability to estimate
passage of time
Amount of time it
will take to reach an
exit off the freeway
Self-monitoring
Rule Shift Test
Ability to selfevaluate and
modify own
behavior
Constantly
checking your
speed, mirrors and
space cushion
Key Search Task
Modified 6 Elements
Changing lanes
IMPACTS OF PRO-EX AND
BADS FINDINGS ON MEAL
PREPARATION
PRO-EX
SUBTESTS
BADS SUBTESTS
SKILLS BEING
ASSESSED
OCCUPATIONAL
PERFORMANCE
EXAMPLE
Goal Selection
Zoo Map Test
Key Search Task
Choosing
appropriate future
objectives
Making a pizza for
dinner at 6pm
Planning/
Sequencing
Action Program Test
Key Search Task
Zoo Map Test
Modified 6 Elements
Generating a plan
and sequencing
steps to reach an
intended objective
Planning specific
steps involved in
making the pizza
Initiation
Modified 6 Elements
Ability to
Regularly
independently begin checking the oven
an action
Timesense
Temporal Judgment
Modified 6 Elements
Ability to estimate
passage of time
Self-monitoring
Rule Shift Test
Key Search Task
Ability to selfMonitoring amount
evaluate and modify of spices
own behavior
Modified 6 Elements
Estimating time it
takes to prepare
and cook a pizza
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
BADS
1. Be free from
Picks up
ceiling and floor subtle
effects
differences in
planning &
organization,
particularly in
those who are
cognitively well
preserved
Pro-Ex
Depends on
clinicians’
expertise—can
they notice
subtle
differences?
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
BADS
2. Be
comparable in
multilingual
settings
Pro-Ex
Questionnaire Could be used
and tests have with people who
a British flavour speak different
languages
Has been
translated into
Cantonese
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
BADS
3. Should test
Tests
planning,
planning,
purposive
purposive
action, attention action, &
attention
Pro-Ex
Tests planning
and purposive
action
(execution)
Does not test
attention
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
BADS
Pro-Ex
4. Be short and
Approximately Observational
easily
40 minutes to
tasks tend to be
administered
administer
lengthy
Interviews can
also be lengthy
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
5. Be culturally
agreeable
BADS
Pro-Ex
Temporal
Judgment Test
has British
cultural content
DEX
suggested to be
sensitive to
impairments in
Hong Kong
Chinese clients
Its
observational/
functional basis
potentially
affords it crosscultural
applicability
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
BADS
6. Outcome
measures that
are sensitive to
mild and severe
EF impairments
Pro-Ex
Total profile
Scale implies
score is converted mild to severe
into a
impairment
standardized
But sensitivity
score allowing for
classification from is questionable
impaired to very
severe
Guidelines for EF Assessments (Ylikoski &
Hanninen, 2003)
7. Include
various tests
BADS
Pro-Ex
Contains 6
subtests
DEX
questionnaire
contains selfrating &
caregiver rating
forms
Does not
include different
tests
Though
different
domains of
testing are
suggested
Conclusion
Dysexecutive Syndrome is difficult to
assess
Pro-Ex and BADS provide two approaches
for assessment
Using both assessments can compensate
for weaknesses in each assessment