Manual Inventario (BRIEF)

7/28/2019 Manual Inventario (BRIEF)

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PAR Psychological Assessment Resources, Inc. / 16204 North Florida Ave. / Lutz, FL 33549 / 1.800.331.8378 / www.parinc.com

BRIEF : Interpretive Report Copyright 1996, 1998, 2000, 2002 by Psychological Assessment Resources, Inc. All rights reserved. May notbe reproduced in whole or in part in any form or by any means without written permission of Psychological Assessment Resources, Inc.

Version: 1.00 ( 1.00.007 )

Behavior Rating Inventory of Executive Function

BRIEF

Interpretive Report

Developed By

Peter K. Isquith, PhD, Gerard A. Gioia, PhD, and PAR Staff

Client Information

Client Name : Sample Client

Client ID : 123

Gender : Male

Grade: 2 nd.

Age : 8

Birthdate : 01/16/1994

Test Date : 02/12/2002Test Form : Teacher Form

Test Description : Initial Evaluation

Rater Name : Ms. Smith

Relationship to Client : Teacher

Class Taught : Homeroom

Has known student for : 7 months

Knows student : Very Well


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Client: Sample Client Test Date: 02/12/2002

Client ID: 123 Page 2 of 39

The BRIEF was developed to provide a window into the everyday behavior associated with

specific domains of the executive functions. The BRIEF can serve as a screening tool forpossible executive dysfunction. The clinical information gathered from an in-depth profile

analysis is best understood, however, within the context of a full assessment that includes (a) a

detailed history of the child and the family, (b) performance-based testing, and (c) observations

of the childs behavior. A thorough understanding of the BRIEF, including its development andits psychometric properties, is a prerequisite to interpretation. As with any clinical method or

procedure, appropriate training and clinical supervision is necessary to ensure competent use ofthe BRIEF.

This report is confidential and intended for use by qualified professionals only. This reportshould not be released to the parents or teachers of the child being evaluated. If a summary of

the results specifically written for parents and teachers is desired, the BRIEF Feedback Report

can be generated and given to the interested parents and/or teachers.

Tscores are used to interpret the childs level of executive functioning as reported by parentsand/or teachers on the BRIEF rating forms. These scores are linear transformations of the raw

scale scores (M = 50, SD = 10). T scores provide information about an individuals scores

relative to the scores of respondents in the standardization sample. Percentiles, which are alsopresented within the BRIEF-SP, represent the percentage of children in the standardization

sample who fall below a given raw score.

In the process of interpreting the BRIEF, review of individual items within each scale can yield

useful information for understanding the specific nature of the childs elevated score on anygiven clinical scale. In addition, certain items may be particularly relevant to specific clinical

groups. Placing too much interpretive significance on individual items, however, is not

recommended due to lower reliability of individual items relative to the scales and indexes.

Overview

Sample's teacher completed the Teacher form of the Behavior Rating Inventory of ExecutiveFunction (BRIEF) on 02/12/2002. There are no missing item responses in the protocol.

Responses are reasonably consistent. The respondents ratings of Sample do not appear overly

negative. In the context of these validity considerations, ratings of Sample's executive functionexhibited in everyday behavior reveal some areas of concern.

The overall index, the Global Executive Composite (GEC), was elevated (GEC T= 73, %ile =

96). Both the Behavioral Regulation (BRI) and the Metacognition (MI) Indexes were elevated

(BRI T= 71, %ile = 94 andMI T= 71, %ile = 96).

Within these summary indicators, all of the individual scales are valid. One or more of the

individual BRIEF scales were elevated, suggesting that Sample exhibits difficulty with someaspects of executive function. Concerns are noted with his ability to inhibit impulsive responses

(Inhibit T= 70, %ile = 99), adjust to changes in routine or task demands (Shift T= 68, %ile =94), modulate emotions (Emotional Control T = 71, %ile = 94), initiate problem solving or

activity (Initiate T= 69, %ile = 95), sustain working memory (Working Memory T= 74, %ile =

99), plan and organize problem solving approaches (Plan/Organize T= 67, %ile = 94), organizehis environment and materials (Organization of Materials T= 66, %ile = 93), and monitor his

own behavior (Monitor T= 68, %ile = 93).

Sample's scores on the Shift scale and the Emotional Control scale are significantly elevated

compared to age- and gender-matched peers. This profile suggests significant problem-solving


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rigidity combined with emotional dysregulation. Children with this profile have a tendency tolose emotional control when their routines or perspectives are challenged and/or flexibility is

required. In order to develop a better understanding of Sample's difficulties, further

examination of the situational demands that result in such a loss of emotional control would be

helpful.

Current models of self-regulation suggest that behavioral regulation, particularly inhibitorycontrol, underlies most other areas of executive function. Essentially, one needs to be

appropriately inhibited, flexible, and under emotional control for efficient, systematic, andorganized problem solving to take place. Sample's elevated scores on the Inhibit scale, and theBehavioral Regulation and the Metacognition Indexes, suggest that Sample has poor inhibitory

control and/or suggest that more global behavioral dysregulation is having a negative effect on

active metacognitive problem solving. The elevated Behavioral Regulation Index score,however, does not negate the meaningfulness of the elevated Metacognition Index score.

Instead, one must consider the influence of the underlying behavioral regulation issues while

simultaneously considering the unique problems with the metacognitive problem-solving skills.

BRIEF Score Summary Table

Index/Scale Raw Score TScore Percentile 90% C.I.

Inhibit 30 70 99 67 - 73

Shift 22 68 94 63 - 73

Emotional Control 23 71 94 67 - 75

Behavioral Regulation Index (BRI) 75 71 94 69 - 73

Initiate 19 69 95 64 - 74

Working Memory 30 74 99 70 - 78

Plan/Organize 24 67 94 62 - 72

Organization of Materials 17 66 93 62 - 70

Monitor 27 68 93 63 - 73Metacognition Index (MI) 117 71 96 69 - 73

General Executive Composite (GEC) 192 73 96 71 - 75

Scale Raw Score Cumulative Percentile Protocol Classification

Negativity 4 94 Acceptable

Inconsistency 3 98 Acceptable

Note: Male,age-specific norms have been used to generate this profile.

For additional normative information, refer to Appendix A - D in the BRIEF Professional Manual.


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Profile of BRIEFTScores

TScore

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100TScore

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Emotional Working Plan/ Org. of Inhibit Shift Control Initiate Memory Organize Materials Monitor BRI MI GEC

TScore 70 68 71 69 74 67 66 68 71 71 73

Percentile 99 94 94 95 99 94 93 93 94 96 96

Raw score 30 22 23 19 30 24 17 27 75 117 192

Missing 0 0 0 0 0 0 0 0 0 0 0

Note: Male,age-specific norms have been used to generate this profile.For additional normative information, refer to Appendixes A - D in the BRIEF Professional Manual.


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Validity

Before examining the BRIEF profile, it is essential to carefully consider the validity of the data

provided. The inherent nature of rating scales (i.e., relying upon a third party for ratings of a

childs behavior) brings potential bias to the scores. The first step is to examine the protocol formissing data. With a valid number of responses, the Inconsistency and Negativity scales of the

BRIEF provide additional validity indexes.

Missing items

The respondent completed 86 of a possible 86 BRIEF items. For reference purposes, the

summary table for each scale indicates the respondents actual rating for each item. There areno missing responses in the protocol, providing a complete data set for interpretation.

Inconsistency

Scores on the Inconsistency scale indicate the extent to which the respondent answered similar

BRIEF items in an inconsistent manner relative to the clinical samples. For example, a high

Inconsistency score might be associated with marking Neverin response to the item Gets outof control more than friends while at the same time marking Often in response to the item

Acts too wild or out of control. Item pairs comprising the Inconsistency scale are shown in

the summary table below. Tscores are not generated for the Inconsistency scale. Instead, theraw difference scores for the 10 paired items are summed and the total difference score (i.e., the

Inconsistency score) is used to classify the protocol as either Acceptable,Questionable, or

as Inconsistent. The Inconsistency score of 3 falls within the Acceptable range, suggestingthat the rater was reasonably consistent in responding to BRIEF items.

Item

1Content 1

Score

1

Item

2Content 2

Score

2Diff.

27 Mood changes frequently 3 26 Has outbursts for little reason 3 0

36 Leaves work incomplete 2 39 Has trouble finishing tasks (chores,homework)

3 1

42 Interrupts others 3 43 Is impulsive 3 0

45 Gets out of seat at the wrong times 3 9 Needs to be told "no" or "stop that" 3 0

46 Is unaware of own behavior when in

a group

3 65 Does not realize that certain actions

bother others

3 0

47Gets out of control more than friends

3 58 Has trouble putting the brakes on

his/her actions

3 0

48 Reacts more strongly to situations

than other children

3 66Small events trigger big reactions

1 2

55 Talks or plays too loudly 3 57 Acts too wild or "out of control" 3 0

57Acts too wild or "out of control"

3 46 Is unaware of own behavior when in a

group

3 0

69 Does not think of consequences

before acting

3 65 Does not realize that certain actions

bother others

3 0

Negativity

The Negativity scale measures the extent to which the respondent answered selected BRIEF

items in an unusually negative manner relative to the clinical sample. Items comprising the

Negativity scale are shown in the summary table below. A higher raw score on this scaleindicates a greater degree of negativity, with less than 3% of respondents scoring above 7 in the


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clinical sample. As with the Inconsistency scale, Tscores are not generated for this scale. TheNegativity score of 4 falls within the acceptable range, suggesting that the respondents view of

Sample is not overly negative and that the BRIEF protocol is likely to be valid.

Item Content Item Response

13 Acts upset by a change in plans Sometimes

14 Is disturbed by change of teacher or class Sometimes24 Resists change of routine, foods, places, etc. Often

32 When sent to get something, forgets what he/she is supposed to get Often

64 Angry or tearful outbursts are intense but end suddenly Sometimes

68 Leaves a trail of belongings wherever he/she goes Often

71 Leaves messes that others have to clean up Sometimes

82 Cannot stay on the same topic when talking Sometimes

84 Says the same things over and over Often

Composite and Summary Indexes

Global Executive Composite

The Global Executive Composite (GEC) is an overarching summary score that incorporates allof the BRIEF clinical scales. Although review of the Metacognition Index, Behavioral

Regulation Index, and individual scale scores is strongly recommended for all BRIEF profiles,

the GEC can sometimes be useful as a summary measure. In this case, the two summaryindexes are not substantially different, with Tscores separated by 0 points. Thus, the GECmay

capture the nature of the overall profile. With this in mind, Sample's Tscore of 73 (%ile = 96)

on the GEC is significantly elevated as compared to the scores of his peers, suggestingsignificant difficulty in one or more areas of executive function.

Behavioral Regulation and Metacognition IndexesThe Behavioral Regulation Index (BRI) captures the rated childs ability to shift cognitive set

and modulate emotions and behavior via appropriate inhibitory control. It is comprised of the

Inhibit, the Shift, and the Emotional Control scales. Intact behavioral regulation is likely to be aprecursor to appropriate metacognitive problem solving. Behavioral regulation enables the

metacognitive processes to successfully guide active systematic problem solving; and more

generally, behavioral regulation supports appropriate self-regulation.

The Metacognition Index (MI) reflects the rated childs ability to initiate, plan, organize, self-monitor, and sustain working memory. It can be interpreted as Sample's ability to cognitively

self-manage tasks and to monitor his performance. TheMIrelates directly to a childs ability to

actively problem solve in a variety of contexts. It is composed of the Initiate, WorkingMemory, Plan/Organize, Organization of Materials, and Monitor scales.

Examination of the indexes reveals that both the Behavioral Regulation Index (T= 71, %ile =

94) and Metacognition Index (T = 71, %ile = 96) are elevated. This suggests more global

difficulties with self-regulation, including the fundamental ability to inhibit impulses, modulateemotions, and to flexibly problem solve. These global difficulties extend to metacognitive

functions, including the ability to sustain working memory, initiate, plan, organize, and self-

monitor.


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Clinical Scales

The BRIEF clinical scales measure the extent to which the respondent reports problems with

different types of behavior related to the eight domains of executive functioning. The following

sections describe the scores obtained on the clinical scales and the suggested interpretation foreach individual clinical scale.

Inhibit

The Inhibit scale assesses inhibitory control and impulsivity. This can be described as the

ability to resist impulses and the ability to stop ones own behavior at the appropriate time.

Sample's score on this scale is highly elevated (T= 70, %ile = 99) as compared to his peers.Children with similar scores on the Inhibit scale typically have marked difficulty resisting

impulses and difficulty considering consequences before acting. They are often perceived as (a)

less in control of themselves than their peers, (b) having difficulty staying in place in line or inthe classroom, (c) interrupting others or calling out in class frequently, and (d) requiring

higher levels of adult supervision. Often, caregivers and teachers are particularly concerned

about the verbal and social intrusiveness and the lack of personal safety observed in children

who do not inhibit impulses well. Such 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 leaping.

In the contexts of the classroom and assessment settings, children with inhibitory controldifficulties often require a higher degree of external structure to limit their impulsive

responding. They may start an activity or task before listening to instructions, before

developing a plan, or before grasping the organization or gist of the situation.

Examination of the individual items that comprise the Inhibit scale may be informative and mayhelp guide interpretation and intervention.

Item Content Item Response9 Needs to be told "no" or "stop that" Often

38 Does not think before doing Often

42 Interrupts others Often

43 Is impulsive Often

45 Gets out of seat at the wrong times Often

47 Gets out of control more than friends Often

57 Acts too wild or "out of control" Often

58 Has trouble putting the brakes on his/her actions Often

59 Gets in trouble if not supervised by an adult Often

69 Does not think of consequences before acting Often

Shift

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

(a) make transitions, (b) tolerate change, (c) problem-solve flexibly, (d) switch or alternate

attention, and (e) change focus from one mindset or topic to another. Sample's score on theShift scale is moderately elevated as compared to like-aged peers (T= 68, %ile = 94). This

suggests that Sample has some difficulties with behavioral shifting, attentional shifting, and/or

cognitive shifting. Difficulties with shifting often compromise the efficiency of problem-


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solving abilities. Caregivers often describe children who have this level of difficulty withshifting as somewhat rigid and/or inflexible. Such children often prefer consistent routines. In

some cases, such children are described as being unable to drop certain topics of interest or

unable to move beyond a specific disappointment or unmet need. On formal assessment,

children with difficulties shifting cognitively are often observed to have difficulty changingfrom one task to the next or sometimes from one question to the next. They sometimes require

additional explanations or demonstration to grasp the demands of a novel task when firstpresented. They may also carry over a problem-solving approach, a response style, orinformation from a previous task that is no longer appropriate. This tendency to carry over can

be seen as perseverating on content or response style from one item to the next within a task.


4 Cannot get a disappointment, scolding, or insult off his/her mind Sometimes

5 Resists or has trouble accepting a different way to solve a problem with

schoolwork, friends, chores, etc.

Sometimes

6 Becomes upset with new situations Never

13 Acts upset by a change in plans Sometimes

14 Is disturbed by change of teacher or class Sometimes

24 Resists change of routine, foods, places, etc. Often

30 Has trouble getting used to new situations (classes, groups, friends) Sometimes

40 Thinks too much about the same topic Often

53 Gets stuck on one topic or activity Sometimes

62 After having a problem, will stay disappointed for a long time Often

Emotional Control

The Emotional Control scale measures the impact of executive function problems on emotional

expression and assesses a childs ability to modulate or control his or her emotional responses.Sample's score on the Emotional Control scale is significantly elevated as compared to like-

aged peers (T = 71, %ile = 94). This score suggests marked concerns with regulation ormodulation of emotions. Sample likely overreacts to events and likely demonstrates suddenoutbursts, sudden and/or frequent mood changes, and excessive periods of emotional upset.

Poor emotional control is often expressed as emotional lability, sudden outbursts, or emotional

explosiveness. Children with difficulties in this domain often have overblown emotional

reactions to seemingly minor events. Caregivers and teachers of such children frequentlydescribe a child who cries easily or laughs hysterically with small provocation, or a child who

has temper tantrums of a frequency or severity that is not age appropriate.


1 Overreacts to small problems Often

7 Has explosive, angry outbursts Often

26 Has outbursts for little reason Often

27 Mood changes frequently Often

48 Reacts more strongly to situations than other children Often

51 Mood is easily influenced by the situation Sometimes

64 Angry or tearful outbursts are intense but end suddenly Sometimes

66 Small events trigger big reactions Never

72 Becomes upset too easily Often


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Initiate

The Initiate scale reflects a childs ability to begin a task or activity and to independently

generate ideas, responses, or problem-solving strategies. Sample's score on the Initiate scale is

moderately elevated as compared to like-aged peers (T= 69, %ile = 95). This suggests that

Sample may have difficulties beginning, starting or getting going on tasks, activities, and

problem-solving approaches appropriately. Poor initiation typically does not reflectnoncompliance or disinterest in a specific task. Children with initiation problems typically want

to succeed at and complete a task but they have trouble getting started. Caregivers of suchchildren frequently report difficulties with getting started on homework or chores along with a

need for extensive prompts or cues in order to begin a task or activity. Children with initiation

difficulties are at risk for being viewed as unmotivated. In the context of psychologicalassessment, initiation difficulties are often demonstrated in the form of difficulty with word and

design fluency tasks as well as a need for additional cues from the examiner in order to begin

tasks in general. Alternatively, initiation deficits may reflect depression, and this should be

examined particularly if this finding is consistent with the overall affective presentation of thechild.


3 Is not a self-starter Often

10 Needs to be told to begin a task even when willing Often

19 Does not show creativity in solving a problem Often

34 Has problems coming up with different ways of solving a problem Often

50 Has trouble getting started on homework or chores Often

63 Does not take initiative Sometimes

70 Has trouble thinking of a different way to solve a problem when stuck Sometimes

Working Memory

The Working Memory scale measures on-line representational memory; that is, the capacityto hold information in mind for the purpose of completing a task, encoding information, or

generating goals, plans, and sequential steps to achieving goals. Working memory is essential

to carry out multistep activities, complete mental manipulations such as mental arithmetic, and

follow complex instructions. Sample's score on the Working Memory scale is significantlyelevated as compared to like-aged peers (T= 74, %ile = 99). This suggests that Sample has

substantial difficulty holding an appropriate amount of information in mind or in active

memory for further processing, encoding, and/or mental manipulation. Further, Sample's scoresuggests difficulties sustaining working memory, which has a negative impact on his ability to

remain attentive and focused for appropriate lengths of time. Caregivers describe children with

fragile or limited working memory as having trouble remembering things (e.g., phone numbers

or instructions) even for a few seconds, losing track of what they are doing as they work, orforgetting what they are supposed to retrieve when sent on an errand. They often miss

information that exceeds their working memory capacity such as instructions for an assignment.Clinical evaluators may observe that a child cannot remember the rules governing a specific

task (even as he or she works on that task), rehearses information repeatedly, loses track of what

responses he or she has already given on a task that requires multiple answers, and struggles

with mental manipulation tasks (e.g., repeating digits in reverse order) or solving arithmeticproblems that are orally presented without writing down figures.

Appropriate working memory is necessary to sustain performance and attention. Parents of

children with difficulties in this domain report that the children cannot stick to an activity for


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an age-appropriate amount of time and frequently switch tasks or fail to complete tasks.Although working memory and the ability to sustain it have been conceptualized as distinct

entities, behavioral outcomes of these two domains are often difficult to distinguish.


2 When given three things to do, remembers only the first or last Often

8 Has a short attention span Often18 Has trouble concentrating on chores, schoolwork, etc. Often

21 Is easily distracted by noises, activity, sights, etc. Often

25 Has trouble with chores or tasks that have more than one step Often

28 Needs help from an adult to stay on task Often

31 Forgets what he/she was doing Often

32 When sent to get something, forgets what he/she is supposed to get Often

39 Has trouble finishing tasks (chores, homework) Often

60 Has trouble remembering things, even for a few minutes Often

Plan/Organize

The Plan/Organize scale measures the childs ability to manage current and future-oriented taskdemands. The scale is comprised of two components: plan and organize. The plan component

captures the ability to anticipate future events, to set goals, and to develop appropriatesequential steps ahead of time in order to carry out a task or activity. The organize component

refers to the ability to bring order to information and to appreciate main ideas or key concepts

when learning or communicating information. Sample's score on the Plan/Organize scale ismoderately elevated as compared to like-aged peers (T= 67, %ile = 94). This suggests that

Sample has some difficulty with the planning and the organization of information which has a

negative impact on his approach to problem solving. Planning involves developing a goal orend state and then strategically determining the most effective method or steps to attain that

goal. Evaluators can observe planning when a child is given a problem requiring multiple steps

(e.g., assembling a puzzle or completing a maze). Sample may underestimate the time requiredto complete tasks or the level of difficulty inherent in a task. He may often wait until the lastminute to begin a long-term project or assignment for school, and he may have trouble carrying

out the actions needed to reach his goals.

Organization involves the ability to organize oral and written expression as well as to

understand the main points expressed in presentations or written material. Organization alsohas a clerical component that is demonstrated, for example, in the ability to efficiently scan a

visual array or to keep track of a homework assignment. Sample may approach tasks in a

haphazard fashion, getting caught up in the details and missing the big picture. He may havegood ideas that he fails to express on tests and written assignments. He may often feel

overwhelmed by large amounts of information and may have difficulty retrieving material

spontaneously or in response to open-ended questions. He may, however, exhibit betterperformance with recognition (multiple choice) questions.


12 Does not bring home homework, assignment sheets, materials, etc. Often

17 Has good ideas but cannot get them on paper Often

23 Forgets to hand in homework, even when completed Often

29 Gets caught up in details and misses the big picture Often

35 Has good ideas but does not get job done (lacks follow-through) Often

37 Becomes overwhelmed by large assignments Sometimes


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41 Underestimates time needed to finish tasks Sometimes

49 Starts assignments or chores at the last minute Sometimes

52 Does not plan ahead for school assignments Never

56 Written work is poorly organized Sometimes

Organization of Materials

The Organization of Materials scale measures orderliness of work, play, and storage spaces(e.g., desks, lockers, backpacks, and bedrooms). Caregivers and teachers typically can provide

an abundance of examples describing a childs ability to organize, keep track of, and/or clean up

their belongings. Sample's score on the Organization of Materials scale is moderately elevatedrelative to like-aged children (T= 66, %ile = 93). Sample is described as having a moderatedegree of difficulty with (a) keeping his materials and his belongings reasonably well organized,

(b) having his materials readily available for projects or assignments, and (c) as having

difficulty finding his belongings when needed. Children who have difficulties in this area oftendo not function efficiently in school or at home because they do not have their belongings

readily available for use. Pragmatically, teaching a child to organize his or her belongings can

be a useful, concrete tool for teaching greater task organization.Item Content Item Response

11 Loses lunch box, lunch money, permission slips, homework, etc. Sometimes

16 Cannot find clothes, glasses, shoes, toys, books, pencils, etc. Sometimes

20 Backpack is disorganized Often

67 Cannot find things in room or school desk Often

68 Leaves a trail of belongings wherever he/she goes Often

71 Leaves messes that others have to clean up Sometimes

73 Has a messy desk Sometimes

Monitor

The Monitor scale assesses two types of monitoring behaviors: Task-oriented monitoring or

work-checking habits and Self-monitoring or interpersonal awareness. The task monitoring

portion of the scale captures whether a child assesses his or her own performance during orshortly after finishing a task to ensure accuracy or appropriate attainment of a goal. The self

monitoring portion of the scale evaluates whether a child keeps track of the effect that his or her

behavior has on others. Sample's score on the Monitor scale is moderately elevated, suggestingsome difficulty with monitoring (T= 68, %ile = 93). Examination of the task-monitoring and

self-monitoring clusters of individual items that comprise the Monitor scale reveals stronger

endorsement of self-oriented monitoring items but an average level of endorsement of task-oriented items. Children with similar patterns tend to be less aware of their own behavior and

the impact this behavior has on their social interactions with others. The task-oriented itemssuggest, however, that Sample is reasonably cautious in his approach to tasks or assignments

and that he tends to notice and/or check for mistakes.


15 Does not check work for mistakes Often

22 Makes careless errors Sometimes

33 Is unaware of how his/her behavior affects or bothers others Often

36 Leaves work incomplete Sometimes

44 Does not notice when his/her behavior causes negative reactions Sometimes


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46 Is unaware of own behavior when in a group Often

54 Has poor understanding of own strengths and weaknesses Often

55 Talks or plays too loudly Often

61 Work is sloppy Often

65 Does not realize that certain actions bother others Often

Additional Clinical Items

The BRIEF Parent and Teacher Forms both contain additional items of clinical interest that are

not included in any of the clinical scales. Although these items are not scored and therefore do

not contribute to the BRIEF scale raw scores, they were retained because of their directrelevance to functional intervention programming and their relevance to specific clinical

populations (e.g., Pervasive Developmental Disorders, Traumatic Brain Injury, and Attention

Deficit/Hyperactivity Disorder). Careful review of these individual items can assist the

examiner in identifying and targeting areas of concern for intervention and can further reinforceinterpretation of the findings from the clinical scales by providing additional evidence of

difficulties in the particular domain of executive function. The item summary table below

includes the item numbers, item content, and the raters item responses, as well as the BRIEFscale to which the item was originally assigned.


74 Has trouble waiting for turn (Inhibit) Often

75 Does not connect doing tonight's homework with grades (Plan/Organize) Often

76 Tests poorly even when knows correct answers (Plan/Organize) Sometimes

77 Does not finish long-term projects (Plan/Organize) Sometimes

78 Has poor handwriting (Monitor) Sometimes

79 Has to be closely supervised (Inhibit) Often

80 Has trouble moving from one activity to another (Shift) Sometimes

81 Is fidgety (Inhibit) Often82 Cannot stay on the same topic when talking (Working Memory) Sometimes

83 Blurts things out (Inhibit) Never

84 Says the same things over and over (Shift) Often

85 Talks at the wrong time (Inhibit) Sometimes

86 Does not come prepared for class (Plan/Organize) Sometimes

Comparison of BRIEF Working Memory and Inhibit Scales to

ADHD Groups

The BRIEF Inhibit and Working Memory scales may be helpful in identifying children with

suspected Attention-Deficit/Hyperactivity Disorder (ADHD). Theoretically, inhibitory controlenables self-regulation, and working memory enables sustained attention. It is important at the

outset, however, to appreciate the distinction between executive functions and the diagnosis of

Attention-Deficit/Hyperactivity Disorder (ADHD): Executive functions are neuropsychologicalconstructs whereas ADHD is a neuropsychiatric diagnosis based on a cluster of observed

symptoms. Although executive functions underlie the symptoms of ADHD, executive

dysfunction is not synonymous with a diagnosis of ADHD. There is general agreement that

different aspects of executive dysfunction contribute to the behaviors that characterize ADHD.


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The Inhibit and Working Memory scales exhibit good predictive validity and good sensitivityand specificity for detecting a likely diagnosis of Attention-Deficit/Hyperactivity Disorder

(ADHD) Inattentive Type or Combined Type. In clinical samples, the Working Memory scale

discriminated between children with no ADHD diagnosis (healthy controls) and those with

either the Inattentive or Combined types of ADHD. The Inhibit scale further distinguishedbetween controls and children with the Combined Type of ADHD. Please refer to pages 76

through 84 in the BRIEF Professional Manual for further detail. While the BRIEF may be ahelpful and efficient tool in assessing for ADHD, it is important that all relevant data beconsidered in the context of clinical judgment before reaching a diagnostic decision.

In this particular profile, Teacher ratings of Sample's working memory (T= 74, %ile = 99) and

inhibitory control (T= 70, %ile = 99) are moderately elevated. This suggests that Sample may

have characteristics of executive dysfunction that are often seen in children diagnosed withADHD. It is important to appreciate, however, that some children with similar elevations do

not meet the criteria for ADHD.

As with any diagnostic decision, consideration of all relevant clinical assessment data is

essential and clinical judgment is of paramount importance. Teacher and parent rating scales,

such as the BRIEF, can add valuable information to a more comprehensive assessment forADHD.


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Executive System Intervention

A General Framework

Given the unique nature of the executive functions in playing a command role in terms ofguiding and regulating thought and behavior, the approach to intervention must be considered

globally. First, one must consider the end goal or outcome ofgood executive function for the

child. The following executive outcomes for children are proposed:

Demonstrating purposeful, goal-directed activity

Displaying an active problem-solving approach

Exerting self-control

Demonstrating maximal independence

Exhibiting reliable and consistent behavior and thinking

Demonstrating positive self-efficacy

Exhibiting an internal locus of control

The general principles of an intervention model for the executive functions used here are based

largely on the work of Mark Ylvisaker and colleagues (Ylvisaker, 1998; Ylvisaker & Feeney,1998; Ylvisaker, Szekeres, & Feeney, 1998) who advocate an ongoing (a) contextualized (i.e.,

in the childs real world), (b) collaborative (i.e., together with the child, parents, teachers, and

peers), and (c) hypothesis-testing (i.e., generating and implementing testable methods)assessment and treatment approach. The reader is referred to these excellent resources as well

as Marlowe (2001) and Levine et al. (2000) for further discussion of executive function

intervention issues and methods.The ultimate goal of executive function interventions is to establish regular behavioral/cognitiveroutines to maximize independent, goal-oriented problem solving and performance. A critical

feature of any intervention is to establish external environmental preconditions that will enable

the child to develop, and, ideally, will enable the child to make automatic behavioral/cognitiveroutines. For individuals just starting to learn executive control behaviors, for young children,

or for individuals with extreme executive dysfunction, the focus of intervention may need to be

more externalized or environmental (i.e., to organize and structure the external environment and

to organize and provide cuing for behavioral strategies and routines). Many such children donot have the internal resources available to initiate behaviors without significant individualized

structuring, cuing, and reinforcement. They often need help to know when and how to apply

the appropriate problem-solving behavioral routine. Direct rewards and positive incentives areoften necessary to motivate the child to attend to and practice new behavioral routines. Because

of the nature of the childs executive dysfunction, these organizational routines may initially be

experienced as quite stressful by many children and adolescents. Therefore, establishing suchroutines may require explicit rewards. Once these behavioral routines are established, positive

cuing becomes the crucial factor; cuing can then be faded, as the childs autonomy increases.

It is possible to have an executive system focus in any and all activities, including classroom

activities, therapy activities, social/recreational activities, and activities of daily living at home.


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Furthermore, this may take little time or effort, once parents and school staff have developedappropriate habits in this area. For example, any activity can include

Goal setting: An initial decision about or choice of a goal to pursue. (What do I need toaccomplish?)

Self-awareness of strengths/weaknesses: Recognition of ones stronger and weaker

abilities, and a decision about how easy or how difficult it will be to accomplish thegoal. (How easy or difficult is this task/goal? Have I done this type of task before?)

Organization/Planning: Development of an organized plan. (What materials do weneed? Who will do what? In what order do we need to do these things? How long will it

take?)

Flexibility/Strategy use: As complications or obstacles arise while working toward the

goal, planned (e.g., staff ensure that problems arise) or unplanned coaching of the

individual in flexible problem solving/strategic thinking. (When or if a problem arises,what other ways should I think about in order to reach the goal? Should I ask for

assistance?)

Monitoring: A review of the goal, plan, and accomplishments at the end. (How did I

do?)

Summarizing: What worked and what didn't work? What was easy and what wasdifficult, and why?

An executive function intervention model includes at the outset an appropriate assessment. Thisincludes defining the relevant profile of executive strengths and weaknesses, associated domain-

specific abilities or deficits, and an analysis of the everyday person, task, and situational

demands that increase or decrease appropriate executive functioning. Determination of thedevelopmental level of the child and the age-appropriate expectations for executive function are

also necessary.

Several basic tenets are also advocated, including

Teaching a goal-directed, problem-solving process.

Implementing the process within positive, meaningful everyday routines.

Providing real-world relevance and application of strategies and routines.

Involving everyday people (parents, teachers, and peers) as models and coaches.

Including the child in the design of the intervention as much as possible.

Most individuals with executive dysfunction do not yet possess the age-appropriate internalized

skills needed for well-regulated problem solving. Therefore, intervention often begins from anexternal support position with active and directive modeling, coaching, and guidance by

important everyday people, which gradually transitions into an internal process of fading and

cuing as follows

External modeling of multistep problem-solving (i.e., executive) routines.

External guidance with the development and implementation of everyday executiveroutines.

Practice the use of executive routines in everyday situations.


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Fade external support and cue internal generation and use of executive routines.

Support internal control in the generation and use of specific problem-solving routine(s).

With external guidance, promote generalization to new situation(s).

Accumulate experience and examine conditions for the selective use of various

executive routines. Provide feedback (external and internal) throughout the process.

In structuring an executive function intervention program, we advocate the use of everydayexecutive routines within the context of a general approach to executive problem solving as

opposed to merely teaching specific skills out of context. In addition, given the difficulties with

working memory that many individuals with executive dysfunction possess, the use of a written

copy of the active multistep executive routine is often necessary. The child should becomeincreasingly more active in formulating and carrying out the plans and reviewing his

performance, thus promoting internal executive control. The goal of executive function

intervention is maximal independence and self-sufficiency, which necessitates the active

involvement of the child.

Goal-Plan-Do-Review System

The use of a general executive problem-solving routine that promotes (a) systematic goal

definition, (b) planning, (c) action, (d) self-monitoring/evaluating, and (e) flexible, strategic

adjustment of plans and actions may serve as a central framework or vehicle within whichspecific executive function intervention methods and strategies can be incorporated. The Goal-

Plan-Do-Review (GPDR) method is one such system (Ylvisaker, Szkeres, et al., 1998). Other

goal-oriented problem-solving methods can also be considered (Levine et al., 2000; Marlowe,2001). The complexity of the problem-solving routine should be adapted to the competency

level of the child. The GPDR system is presented in Figure 1.In developing interventions for the executive functions, it is important to appreciate what they

are not. Executive function interventions are not

Specific, isolated sets of skills or information that are unidirectionally taught to thechild.

Mere lists of steps that are taped to the childs desk or bedroom door.

Simple behavior modification(s) to increase motivation in the absence of critical

antecedent conditions (setting variables, problem-solving routines).

Just a list of treatment/IEP goals without attention to the how, who, where, and when

of the intervention delivery system.

To cue individuals responsible for implementing the executive function interventions (e.g.,

parents, teachers, and therapists), the following intervention checklists for general executivesystem impairment (see Figure 2) and specific organizational impairment (see Figure 3) can be

helpful (Ylvisaker, Szekeres, et al., 1998). These checklists provide an important set of

questions to help guide implementation of specific interventions, supports, andaccommodations.

Within the context of a collaborative, contextualized problem-solving model utilizing the

everyday routines of the child and delivered within a method such as the Goal-Plan-Do-Review


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system, some specific recommendations for interventions and accommodations are offeredaccording to the specific area of functional impairment. While the efficacy of each intervention

has not been empirically demonstrated, the majority are common interventions, and they are

likely to be familiar methods to the intervention team. These recommendations are general and

are intended here as suggestions or ideas that may be tailored to suit Sample's needs. As withany intervention, clinical judgement is paramount.


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GOALWhat do I want to accomplish?

PLANHow am I going to accomplish my goal?

MATERIALS/EQUIPMENT STEPS/ASSIGNMENTS1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

PREDICTIONHow well will I do? How much will I get done?

Self-rating 1 2 3 4 5 6 7 8 9 10

Other Rating 1 2 3 4 5 6 7 8 9 10

DO

PROBLEMS ARISE? FORMULATE SOLUTIONS!1. 1.

2. 2.

3. 3.

REVIEWHow did I do?

Self-rating 1 2 3 4 5 6 7 8 9 10

Other Rating 1 2 3 4 5 6 7 8 9 10

What worked? What didnt work?1. 1.

2. 2.

3. 3.

What will I try differently next time?

Note: From Cognitive Rehabilitation: Executive Functions, by M. Ylvisaker, S. Szekeres, and T. Feeney, Traumatic Brain

Injury Rehabilitation: Children and Adolescents (2nd ed., p. 244), by M. Ylvisaker (Ed.), 1998, Boston: Butterworth-Heinemann. Copyright 1998 by Butterworth-Heinemann. Adapted with permission.

Figure 1. Goal-Plan-Do-Review Problem-Solving System.


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General Considerations

V Is intervention in the areas that fall into the category of executive functions structured around the individuals

meaningful goals?

V Is intervention infused into everyday activities? Are all everydaypeople oriented to how they can facilitate

improved executive functions? Are all everyday people aware of the dangers oflearned helplessness?

V Are everyday people aware of the strategies that the individual is being taught or is expected to use?

V Is successful performance in the areas classified as executive functions richly and naturally rewarded? Is the

individual held responsible for effective strategic performance?

V Is the individual given ample opportunity to identify and solve his or her own problems (with guidance, if

necessary)?

V For individuals who are young or very concrete thinkers, are executive function tasks structured around

concrete physical activities (versus abstract or purely cognitive activities)?

V Do everyday people in the environment routinely model expert use of executive functions?

V Is the individual given sufficientpractice so that strategic behavior becomes automatic?

V Are everyday people in the environment supportive of strategic or compensatory ways to accomplish tasks?

V Does the individual respecta strategic or compensatory approach to everyday problems? If not, is appropriate

help or counseling provided?

V Are everyday people in the individuals environment fully aware of possible limitations in the individualsexecutive functions (especially initiation and inhibition) so that they do not misinterpret behavior?

Appropriateness

Level of Development

V Preschoolers: Are preschoolers introduced to relevant vocabulary, including difficultor easy to do;plan; do

something special; review; what works and what doesnt work? Are they actively engaged in identifying what

is difficult and easy for them (especially physical activities)? Are they richly and naturally rewarded for

clever solutions to difficult everyday problems?

V Grade-school-age children: Are grade-school-age children actively engaged in identifying what is difficult

and easy for them (including cognitive and academic activities)? Are they actively engaged in identifying

clever ways to accomplish difficult tasks? Are they actively encouraged to seek help on their own when tasks

are difficult? Are they richly and naturally rewarded for clever solutions to difficult everyday problems? Are

they encouraged to help one another solve problems?V Older students and adults: See entire checklist.

Level of Recovery

V People who are minimally responsive: Is the individual prompted (physically, if necessary) to engage in

familiar activities (e.g., activities of daily living), so that he or she is acting, not just being acted on? Has

every attempt been made (e.g., remote switch control) to enable the individual to control meaningful events?

Do everyday people in the environment respond to the individual as an agent?

V People who are alert but confused: Is the individual given choices whenever possible (short of increasing

confusion)? Is the individual thoroughly oriented to the purposes of intervention activities? Do staffnegotiate

activities with the individual? Does the individual have opportunities to experience natural consequences of

choices?

V People who are no longer seriously confused: See entire list.

Figure 2. A checklist for intervention for individuals with executive system impairment.


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Self-Awareness of Strengths and Needs

V Is the individual maximally engaged in identifying what is easy and difficult to do and in determining what

makes activities easy or difficult?

V Is the individual given opportunities to compare performance when an activity is completed in a usual way

versus when it is completed with special strategic procedures?

V Does the individual keep ajournal in which strengths and needs are recorded?

V Is the individual given opportunities to identify strengths and needs in others and strategic procedures that

others may use (e.g., peer teaching)?

V Is the individual given appropriate informativefeedback(e.g., peer feedback, video feedback, confrontational

feedback, if appropriate)?

Goal Setting

V Is the individual routinely asked topredicthow well he or she will do on activities?

V Are predictions recorded in journals and comparedwith actual performance?

V Does the individual maximally participate in rehabilitation and special education goal setting? Is adequate

support provided if this is difficult?

V Are intervention activities structured around the individuals personal goals?

Planning

V Does the individual participate maximally in planning his or her intervention activities?

V Is aplanning guide available, if needed?

V Does the individual begin the day by preparing a plan on a planning board or in a journal? Does the

individual begin each activity by preparing a plan?

V Do therapeutic activities include attempts to plan meaningful complex events (e.g., parties, outings)?

V Does the individual participate maximally in long-term future planning, rehabilitation planning, anddevelopment of the individualized plan?

Organizing See the organization checklist in Figure 3.

Self-InitiatingV Do everyday people give the individual opportunities to initiate and then wait an appropriate length of time?

Are signals available to remind the individual to initiate activities?

V Do the activities in which the individual engages make appropriate demands on the individuals ability to

initiate? (For example, board games may require little initiation, whereas conversations may require much

initiation.)

V Are all forms of institutional learned helplessness avoided?

V Areprosthetic initiators available if needed (e.g., alarm watch, NeuroPage)?

V If inhibition cues are necessary, are they as subtle as possible and provided as much as possible by peers as

opposed to staff? Is nagging avoided?

Figure 2 (continued). A checklist for intervention for individuals with executive system impairment.


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Self-Inhibiting

V Do everyday people give the individual opportunities to inhibitimpulsive or inappropriate behavior that are

realistic in their demands?

V Do the activities in which the individual engages make appropriate demands on the individuals ability to

inhibit? (For example, unstructured and unfamiliar activities in a distracting environment require considerable

inhibition.)

V If inhibition cues are necessary, are they as subtle as possible and provided as much as possible by peers as

opposed to staff? Is nagging avoided?

Self-Monitoring and Evaluating

V Do everyday people give the individual opportunities to self-monitor and evaluate performance? If cues are

necessary, are they subtle? Is nagging avoided?

V Is the individual maximally involved in charting his or her own performance, in keeping a journal which

performance is recorded, and in graphing performance?

V Is the individual routinely asked to fill in a form regarding his or her own performance; What works and what

doesnt work?

Problem Solving and Strategic ThinkingV Is the individual maximally involved in solving everyday problems as they arise? Are everyday people

thoroughly oriented to the importance of problem solving?

V Is the individual maximally engaged in selecting strategies to overcome obstacles and achieve important

goals?

V Is there an appropriate amount of external support for strategic thinking?

V Does the individual have aform that cues the appropriate kind of strategic thinking?

V Do everyday people in the environment expect and cue strategic performance?

V Do everyday people in the environment avoid learned helplessness: That is, do they resist solving all of the

individuals problems?

V Is there consistency among staff and family members in how problem-solving tasks are presented and in the

kinds of external problem-solving supports that are provided? Is there consistency in reducing external

supportas the individual becomes increasingly independent in problem solving?

Note: From Cognitive Rehabilitation: Executive Functions, by M. Ylvisaker, S. Szekeres, and T. Feeney, Traumatic Brain

Injury Rehabilitation: Children and Adolescents (2nd ed., p. 260-262), by M. Ylvisaker (Ed.), 1998, Boston: Butterworth-Heinemann. Copyright 1998 by Butterworth-Heinemann. Adapted with permission.

Figure 2( continued). A checklist for intervention for individuals with executive system impairment.


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V

V Are the individuals life experiences adequately organized?

V Is there thematic or other organization within therapeutic or instructional sessions? Is the organization of

the session obvious to the individual?

V Is there thematic or other organization across therapeutic or instructional sessions? For example, are the

activities in speech therapy or occupational therapy related in a clear way to activities in academic

instruction or vocational intervention?

V

Is there thematic or other organization from day to day? Is the individual involved in activities or projectsthat require integrating information over several days or weeks?

V Is the individuals life organized around well-understood routines?

V

V Is thecontent that is used for organizational tasks personally meaningful or directly related to social,

academic, or vocational success?

V

V Are organizing tasks correctly placed on the continuum of involuntary (incidental) to deliberate

(strategic) learning tasks?

V For the concretely thinking person, is there a concrete, meaningful goal that he or she wishes to

accomplish and that requires organizational thinking?

V If appropriate, is the individual engaged in trying to understand the concept of organization and what he or

she can do to organize more effectively?

V

V

Is there an appropriate amount ofexternal organizational support for individuals who have difficultyorganizing?

V Are advance graphic organizers available for complex tasks? That is, is the task mapped out in a way that

makes it easy to follow (e.g., sequence of photographs or drawings, written outline, flowchart, or

checklist)?

V Does the organization of the advance organizers correctly capture the way in which the information should

be organized in the head of the learner?

V Is a log book, day planner, or memory book available that contains schedules, maps, photographs of

critical people, assignments, and other important information needed to stay organized?

V Are plans illustrated in appropriately concrete ways (e.g., photographs)?

V If organizational reminders must be provided by other people, are they presented in a way that is not

perceived as nagging?

V If the individual is confused about his or her past life, is a visually clear life line available, representing

important events in that persons life?

V

V Is thereconsistency among staff and family members in how tasks and information are presented and in

the kinds of external organizational support that are provided?

V

V Doall everyday people understand how to use everyday activities to facilitate improvement inorganizational functioning?

V

V Is there consistency inreducing external organizational support as the individual becomes increasingly

organized?

V

V Is the individual as engaged as possible in

V Determining the goal of activities?

V Creating a plan to achieve the goal?

V

Monitoring performance during the activity?V Evaluating success of the activity?

V Determining what worked and what did not work in the plan?

Note: From Cognitive Rehabilitation: Executive Functions, by M. Ylvisaker, S. Szekeres, and T. Feeney, Traumatic BrainInjury Rehabilitation: Children and Adolescents (2nd ed., p. 217), by M. Ylvisaker (Ed.), 1998, Boston: Butterworth-Heinemann. Copyright 1998 by Butterworth-Heinemann. Adapted with permission.

Figure 3. A checklist for intervention for individuals with organizational impairment.


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Inhibit

External Structuring and Modifications

A student with inhibitory control difficulties often requires additional structure in his

environment at the outset in order to maintain more appropriately controlled behavior. Sample

might need a more explicit, extensive, and/or clear set of rules and expectations, and might needthese reviewed with him regularly.

Often, it is important to limit distractions that are problematic for a student with inhibitorycontrol difficulties. This might include visual and auditory distractions as well as other students

or activities that can pull Sample's attention away from a task.

Environmental structure can be an important consideration for children like Sample. Openclassroom settings often have too many distractions and too many opportunities for impulsive

behaviors.

A student like Sample often benefits from careful placement in the classroom. This is not

necessarily in the front and center, but might be close to the center of activity to help him feel

more involved or in a place where frequent eye contact with the teacher is likely.

Disinhibited children often require more frequent redirection and more frequent limit-setting

from the teacher. Placement in close proximity of the teacher can facilitate greater interaction

without disturbing other students.

Sample might benefit from sitting with or near more well-controlled and more focused peerswho can serve as models and can resist his distracting tendencies.

A lower student-to-teacher ratio may be necessary to allow for more frequent interaction

between Sample and his instructors. The inclusion of aids, parent helpers, or other

paraprofessionals within the classroom can help provide the additional external structureSample needs to remain more appropriately controlled.

Often a child with impulse control difficulties finds typical homework loads daunting. Sample

may need his homework requirements reduced to within his capabilities at the outset, with

stepwise increases in expectations as he demonstrates success.

Student-Based Interventions

Response delay techniques can be helpful for some students. Sample might be taught strategies

such as counting to 5 or 10 before responding verbally or physically.

Several stop and think methods are available that teach students to inhibit their initial

response, to consider the potential consequences of their behaviors, and to further develop aplan of approach to a situation. Some are cognitive-behavioral strategies, and others are

available as games for guidance counseling or therapy.

If Sample demonstrates an impulsive approach to tasks, he might be asked to verbalize a plan of

approach before starting work. This places a short time period between the impulse and theaction and can allow for better planning and a more strategic approach. Sample's teacher or

parent can ask him to explain how he will approach a task, including his goals for accuracy and

time.

It is often helpful to require a student like Sample to develop and express more than one plan ofapproach to a task before starting. This helps him to focus his attention on possible

consequences, and alerts him to alternative strategies.


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A child like Sample often needs more frequent breaks, particularly with motor activity. Breakscan be a reward for work completed and only need to be one or two minutes in duration.

Sample might be asked to complete some independent desk work within his capabilities before

running an errand, taking a bathroom break, or simply bringing his work to the teacher for

review.

It is often important to set goals for accuracy of work when a child tends to rush through hiswork. Acknowledging the speed with which Sample completes his work can help him feel good

about his accomplishments; increasing accuracy or neatness might be suggested as additionalgoals.

Behavior programs are often a necessary component for addressing impulse control difficulties,particularly when there are behavioral problems (e.g., the child acts in a physically or socially

impulsive fashion). It is important to appreciate that, by definition, a child with inhibitory

control difficulties cannot consider potential consequences of his actions in the moment, eventhough he may demonstrate appropriate knowledge of consequences. Therefore, behavioral

programs geared toward controlling stimuli that precede or lead to impulsivity are likely to be

more successful than those that focus on the consequences following an impulsive action.

Controlling antecedents, or what occurs prior to an impulsive behavior, is often an importantmethod of reducing problematic behaviors. Parents and teachers can likely anticipate times

when Sample is likely to act in a disinhibited manner. Intervening at that point may be more

effective than attempting to apply consequences during or after a problem. Limiting stimuli orsituations where Sample might be impulsive can be important, or discussing the likelihood of

impulsive behaviors and expectations may also be helpful. For example, if Sample has

difficulty with behavioral control on the playground, he might meet with the teacher for a few

minutes before joining his peers to discuss expectations and actions that Sample or his teachermight take to avoid problems.

Consequence based systems may be an effective support for Sample. While he may have

difficulty considering consequences at the moment, reinforcement for appropriate behaviors andresponse costs for inappropriate behaviors may be helpful and necessary.

It is usually important that any behavior program be implemented across settings for

consistency. Sample's parents, teachers, and other involved individuals should be consistent in

their use of behavioral techniques.

Ongoing behavioral consultation is often important. Behavioral interventions typically requireongoing adjustments to address new situations or challenges, to modify reinforcers and

consequences as needed, and to ensure consistency. Often counselors, a behavioral specialist,

or a therapist can serve as the behavior program manager.

Social difficulties often become apparent for a child with inhibitory control difficulties. A child

who behaves impulsively with peers may say or do inappropriate things and peers will learn tokeep their distance. It is important to intervene early to avert social difficulties and the negative

effects on Sample's self-esteem. Some suggestions include

Employing cross-age tutoring or mentoring with an older student who can explain and

model appropriate social behaviors can be an effective means of increasing socialsuccess.

Sample might benefit from small group activities with more focused and well-controlled

peers. His peers can serve as role models, but may need adult guidance in ways to

respond to Sample's impulsive behaviors.


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Guided observations of peer interactions may be helpful for Sample as a means of

learning more appropriate social skills. A teacher or parent might meet with him brieflyat the outset of an activity and discuss how other children are behaving.

Sample may need more limited time in unstructured activity in order to maintain

appropriate behavior. He might join an activity with a prearranged expectation that he

will take a break from the activity after a set period of time. This break time can be usedto review his successes and any areas of difficulty before returning to the activity.

Shift


Remaining consistent is an important aspect of structured, systematic teaching, and it promotes

learning and generalization across settings and time. Consistency in teaching and management

does not imply rigidity, but rather a systematic form of teaching and dependable, predictableenvironments. Increased consistency is often necessary at the outset for a child with difficulties

shifting or adjusting to changes in routine, schedule, or activity. This may include the use of

teaching and behavioral strategies that remain the same across time, environments, and people.

Often a child's preference for sameness or insistence on routines and sameness reflect the degreeof anxiety and distress he experiences with change. While respecting Sample's need for the

comfort which his routines may provide, the learning and home environments can gradually and

incrementally introduce minor changes, one at a time.

A child with difficulties shifting can often adjust to changes in schedule or routine with the useof visual organizers such as pictures, schedules, planners, and calendar boards. This will let

Sample know the order of activities for the day, and can alert him to variations in the usual

sequence of events before they occur.

Adherence to routines and resistance to change may reflect Sample's need for predictability inhis environment. An essential tenet of intervention is to facilitate feelings of security by

maintaining a set of basic routines, then adjusting routines slightly in a stepwise fashion. Larger

steps may provoke resistance and distress.

Displaying a daily schedule and reviewing it at the outset of the day can help a student likeSample anticipate the sequence of events and can serve as a useful reminder of any changes in

his daily routine.


For a child who benefits from routines or who rigidly adheres to routines, development of

positive routines and a set of alternative routines can be functional. Essentially, Sample's day

can be viewed as a sequence of routines, such as a morning routine, a school routine, and anevening routine. These can be further broken down into several subroutines, such as brushing

teeth, washing up, getting dressed, and packing a backpack for school. Sample may then beable to learn alternative subroutines, such as different ways to get to school, that can be

practiced and swapped in and out of the larger routines. This can build in the appearance of

flexibility.

A child like Sample with difficulties shifting attention and cognitive set often needs to focus ononly one task at a time. Presenting one task at a time and limiting choices to only one or two

may be helpful.


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Sample might benefit from practice with shifting attention and cognitive set. Working with twoor three familiar tasks and rotating them at regular intervals can build in the appearance of

greater flexibility and help Sample become more accustomed to shifting.

Some children can benefit from external prompting to shift attention, behavior, or cognitive set

from one activity or focus to the next.

One of the most effective strategies for a child with difficulty adjusting to change in routine isthe use of the 2-minute warning. Teachers and parents can alert Sample that one activity is

about to end and another will begin. Allowing a few minutes ofdown time or leisure activitybetween the end of one activity and the beginning of the next can also facilitate transitions.

Making the change in activity another form of routine may be helpful. That is, it may be useful

to indicate a change and to complete the change of activity in a similar fashion each time. Forexample, giving a 2-minute warning that the activity is about to change, providing a signal to

indicate that the activity is changing, and putting away materials for one task then bringing out

the next can make the change itself a comfortable routine.

Any changes in scheduled activities, persons, or events can be placed on Sample's schedule and

called to his attention with as much advance notice as possible. This provides more time forhim to adjust to the change.

Some children can benefit from set time limits for each task before a shift to the next task is

required. Sample might work on one activity or assignment for a set period then an alternativeactivity for the next period. Use of a timer can facilitate Sample's adjustment to change in

activity.

Developing a routine for when the usual routine changes can assist the child in adapting to

unanticipated change. Anticipating possible changes in the childs everyday routine (e.g., whenthe childs favorite cereal is not available for breakfast) and building in a new routine (e.g.,

reviewing a preestablished menu of other breakfast foods) can reduce the chances of a crisis and

can promote more adaptive response to change.Sometimes working in small groups or pairs with peers can help a child like Sample shift hisfocus or cognitive set. Peers can model that it is time to change, cuing Sample by their

behavior.

Emotional Control


It may be useful to manage stimuli or antecedents that appear to produce emotional changes oroutbursts in Sample. Some situations, peers, or tasks may need to be initially avoided or limited

until he experiences more success in managing his emotional expression.

It may be helpful for Sample's parents and teachers to model appropriate emotional modulation.

They might talk aloud through a situation that provokes feelings of anger or sadness and explainhow they will deal with their feelings.

If Sample responds with emotional outbursts to school work, it may be helpful to return to

mastery or success levels and to adjust academic demands.

Clear rules and expectations for behavior, including emotional modulation, both in theclassroom and at home, may be important for Sample. Such explicit expectations can provide


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predictability and a feeling of control over the situation, which in turn can facilitate betteremotional modulation.


Children with executive difficulties, particularly with fragile inhibitory control and/or

difficulties adapting to change in their home and school environments, may express their

feelings more strongly and more directly than most children. This can make them seem moreangry, irritable, sad, or silly than their peers. Such emotional expression should prompt

evaluation to rule out mood or affective difficulties. When difficulties with modulation ofaffect occur in the context of other self-regulatory problems, management of the childs

executive difficulties may be helpful.

Difficulties with emotional control can often be viewed as one expression of disinhibition.Thus, techniques for supporting inhibitory control and reducing impulsivity may be helpful.

Sample might benefit from opportunities to discuss upcoming situations or events that may

provoke an emotional outburst. Increasing his awareness of the potential for emotional

reactivity and the likely consequences to follow may help him modulate more effectively in the

moment.Processing situations that have led to emotional outbursts with Sample in a nonthreatening

setting and manner is important. Choose a situation where he is relaxed and therefore more

receptive to objective analysis of what happened. This can help Sample gain better controlwhile increasing his awareness of his reactions.

Peer modeling may be helpful for Sample. Placing him in activity-focused, small groups with

well-controlled peers may help him emulate their behavior.

Sample might benefit from learning response delay techniques, similar to those used to helpwith inhibitory control (e.g., practice leaving the situation, counting before responding, and/or

developing two or more possible responses). Also, thinking through potential ramifications of

his responses may reduce the frequency or intensity of an immediate emotional reaction.

A child with strong emotional responses to events or situations may benefit from learning aconcrete, simple metaphor to help increase emotional monitoring and increase the likelihood of

a more appropriate response. For example, Sample might work in therapy or with a counselor

to develop a thermometer or speedometer metaphor for measuring anger or distress. He

might label each temperature or speed to reflect degrees of anger, such as 10 = normal, 20 =irritated, 30 = getting mad,. 100 = out of control. Each level can then be tied to a specific

concrete behavior, such as counting to delay responses, terminating the conversation, seeking

adult intervention, or immediately leaving the situation.

Sample might benefit from increased awareness of the strength of his emotional reactions and

the impact this has on others. Discussing a recent situation with Sample when he is calm is oneway to help increase his awareness, while also considering other ways he might approach a

similar situation in the future. Peer group counseling can provide an opportunity for feedbackfrom peers. Methods for increasing self-monitoring of behavior may be appropriate.

Some children with difficulty modulating affect require psychotherapy to help them develop a

clear, practical, affective vocabulary. Such work can help them differentiate and label complex,

overwhelming feelings ofupset into more specific feeling states (i.e., angry, nervous, sad) aswell as practice alternative ways of expressing emotions. He might benefit from learning an

emotional vocabulary or scripts for dealing with situations that provoke strong emotions.


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A child who experiences difficulty with emotional control often needs short breaks or a coolingoff period to consider his response to an event or situation. This is best taken before an

emotional outburst occurs. Sample might be given permission to take a time out when needed

or to leave the situation and seek an identified adult with whom he can discuss his feelings. It is

important to avoid viewing time out as a punishment, and to reward Sample for removinghimself from a situation independently.

Behavioral programs that are designed to support independent use of coping skills can be an

important aid. Reinforcing Sample's ability to identifying stress-inducing situations ahead oftime, his use of relaxation methods, or his implementation of more modulated forms ofemotional expression (e.g., verbalizing feelings associated with a stress response or verbalizing

the impact of the stressor) may be helpful.

Initiate


It may be helpful to appreciate that children with initiation difficulties have trouble getting

going or starting. This can be exhibited in a number of ways: (a) behaviorally, such that theycannot get started on physical activities such as getting up; (b) socially, such that they have

difficulty calling friends or going out to be with friends; (c) academically, such that they have

trouble getting started on homework or assignments; or (d) cognitively, such that they havedifficulty coming up with ideas or generating plans. Deficits in primary initiation are

relatively rare and are often associated with significant neurological disorders (e.g., traumatic

brain injury, anoxia, radiation). More commonly, initiation deficits are the secondaryconsequence of other executive problems (e.g., disorganization) or emotional disorders (e.g.,

depression, paralyzing anxiety). Basic tenets of intervention include providing additional

external structure, prompting and cuing, and helping with organization and planning.

Increased structure in the environment or in an activity can help with initiation difficulties.Building in routines for everyday activities is often important, as routine tasks and their

completion become more automatic, reducing the need for independent initiation. For example,

the morning routine can be broken down into a sequence of steps, and these steps can be writtendown on index cards or a simple list. Sample might then follow the list of steps each day with

supervision as needed until the routine becomes automatic. Sample can learn to use such lists

as prompts.

External prompting may be necessary to help Sample get started. Sample's teacher might stopby his desk at the outset of each task and prompt him to start his work, or perhaps demonstrate

the first problem of a worksheet. At home, his parents might need to similarly prompt him to

get started on homework, to perform chores, or to go out with friends.

Peers can often help serve as models to help Sample get started on tasks. Working in pairs or insmall groups may be helpful, as Sample's peers will serve as external cues. Cooperative

projects may be most useful as the interaction with peers will continuously prompt Sample.

Some children benefit from having time limits set for completing a task. Use of a timer may

facilitate increased initiation and speed of task completion.

Many children with initiation difficulties are viewed as unmotivated. It is important toreframe the problem as an initiation difficulty rather than lack of motivation.


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Problems with initiating may be exacerbated by the childs sense of being overwhelmed with agiven task. Tasks or assignments that seem too large can interfere with Sample's ability to get

started. Breaking tasks into smaller, more structured steps may reduce his sense of being

overwhelmed and increase initiation.

Methods designed to increase overall level of arousal or basic energy level can be useful for

children like Sample who have difficulty initiating on their own. Physical activity, groupinteraction, frequent short breaks with motor activity, and variation of pace or stimulation may

be explored as means of increasing arousal and supporting initiation.

Guidance through the first problem of a set for deskwork or homework will often support

greater initiation. Stopping by Sample's desk and demonstrating the procedures for the firstproblem of a worksheet will help him get going on the remainder of the problems.

It is often helpful to provide examples or work samples that serve as a model of what is

expected. Sample can then follow the example to help cue what is next.

Provide Sample with realistic opportunities for initiating a task with appropriate wait time that

allows for the child to recruit their plan and skill for the particular activity or task.

Provide appropriate supportive signals or cues that remind the child to initiate an activity (e.g.,cues by caretaker, cues by devices such as alarm watch, personal digital assistant). Use natural

cues whenever possible, including peers in social or academic situations when appropriate.

It is important to appreciate that different tasks place varying demands on Sample's ability toinitiate. Tasks that are inherently motivating often require less internal initiation than tasks that

are less motivating. Similarly, more complex tasks may require greater initiation.

Those who work with Sample should be aware of the natural tendency to do things for him,

rather than support his own participation. It is important to support independent task initiation,thus avoiding the risk oflearned helplessness. This requires a balance, however, as constant

or repeated prompting may feel like nagging to Sample.


Children like Sample who demonstrate difficulties thinking of ideas may benefit from learning a

structured, systematic approach to idea generation. They can be taught idea generationstrategies to help develop ideas for topics, for performing activities, or for ways to approach

problems.

Providing to do lists on paper or index cards can be a method of developing automatic

routines and can serve as external cues to begin an activity. Some children benefit fromkeeping a binder or cookbook with lists of steps for each activity. They can look up a page

with steps for completing a specific task, and use the list to guide their activity.

As with any executive difficulty, it can be helpful to increase Sample's awareness of hisdifficulty with initiation. As he becomes metacognitively aware of his own difficulties gettingstarted, he can then participate more act

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