Developmental Neurorehabilitation

ISSN: 1751-8423 (Print) 1751-8431 (Online) Journal homepage: https://www.tandfonline.com/loi/ipdr20

An Exploratory Study of Executive Function

Development in Children with Autism, after
Receiving Early Intensive Behavioral Training

Erik Winther Skogli, Per Normann Andersen & Jørn Isaksen

To cite this article: Erik Winther Skogli, Per Normann Andersen & Jørn Isaksen (2020):
An Exploratory Study of Executive Function Development in Children with Autism, after
Receiving Early Intensive Behavioral Training, Developmental Neurorehabilitation, DOI:
10.1080/17518423.2020.1756499

To link to this article: https://doi.org/10.1080/17518423.2020.1756499

Published online: 13 May 2020.

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DEVELOPMENTAL NEUROREHABILITATION
https://doi.org/10.1080/17518423.2020.1756499

An Exploratory Study of Executive Function Development in Children with Autism,

after Receiving Early Intensive Behavioral Training
Erik Winther Skoglia, Per Normann Andersenb, and Jørn Isaksenc
a
Innlandet Hospital Trust, Division Mental Health Care, Child and Adolescent Psychiatric Clinic, Lillehammer, Norway; bDepartment of Psychology,
Inland Norway University of Applied Sciences, Lillehammer, Norway; cInnlandet Hospital Trust, Lillehammer, Norway

ABSTRACT ARTICLE HISTORY

Objective: To examine the development of executive functions, in preschool children with autism Received October 28, 2019
spectrum disorders (ASD), receiving early intensive behavioral training (EIBI). Revised April 10, 2020
Method: Executive functions (EF) were assessed with The Behavior Rating Inventory of Executive Accepted April 12, 2020
Function – Preschool Version (BRIEF-P), by parents and preschool teachers at the time of diagnostic KEYWORDS
assessment and after 15 months of EIBI intervention. Ten children with ASD (M = 2.9 years, nine males) Autism; children; early
participated in the study. Reliable Change Index scores were computed for each of the participants in intensive behavioral
order to investigate any significant change in BRIEF-P T-scores. training; executive functions;
Results: Three children showed a significant improvement in EF, based on parent ratings. Four children brief; reliable change index
showed a significant improvement in EF based on preschool teacher ratings.
Conclusion: Findings indicating a reliable improvement in one third of preschool children with ASD
receiving EIBI are encouraging but need to be replicated in larger scale controlled studies.

Introduction ASD and Executive Dysfunction

Autism spectrum disorders (ASD) constitute a group of neuro-
developmental disorders, emerging in childhood, characterized
by pervasive deficits in social behavior and interaction.1 The key
manifestations of ASD are impaired social interaction, commu-
nication deficits and restricted and repetitive patterns of beha-
viors, interests and activities. In the last revision of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), ASD subtypes were eliminated and the social interac-
tion and social communication domains were collapsed into
a single combined domain.2,3 ASD is genetically and phenotypi-
cally heterogeneous with variable degrees of severity, sympto-
matology and different outcomes. However, the common
denominator is that ASD is a life-long persistent neurodevelop-
mental disorder that may cause detrimental functional impair-
ment in school, work and family life, as well as increased levels of
co-morbidity across the lifespan.3,4 With reported worldwide
prevalence estimates ranging between 0.7% and 1.2%, ASD
represent a major public health challenge.5,6 Furthermore, high
levels of heterogeneity with regard to symptom manifestation,
co-morbidity, cognitive function and impairment level, often
cloud the diagnostic picture and may hamper treatment
planning.7 Knowing that behavioral symptoms associated with
ASD are not always stable over time, concerns have been raised
that approaches focusing on behavioral symptoms only, may not
address the range of clinically relevant symptoms in children
with this disorder. Despite high levels of heterogeneity, cognitive
deficits linked to prefrontal and temporal brain regions, which
are crucial for executive functions, have been proposed as one
common hallmark for children and adults with ASD.8
Executive functions (EF) are commonly referred to as a set of
higher order cognitive abilities necessary for goal-directed beha-
vior, including response inhibition, cognitive flexibility and the
maintenance of information in working memory.9 There is an
ongoing debate as to whether single- or multifactor models of EF
best encapsulate the construct. There is, however, ample evi-
dence of a multifactorial model of EF, where a unitary or single-
factor model seem to be more appropriate in preschool
populations.10,11 Preschool years and childhood are character-
ized by rapid changes in EF, 12 and a developmental delay in EF
is considered a central source of the disability associated with
ASD.13–17 Impaired EF, have been associated with poor beha-
vioral, social, educational and occupational outcomes in neuro-
developmental populations, and meta-analyses have found
robust associations between EF impairment and ASD.18,19
Furthermore, EF have been associated with Theory of Mind
(ToM) in children with ASD.20–22 Although EF have been
found to predict changes in ToM abilities in ASD, ToM seems
to have little impact on changes in EF abilities. Impaired EF as
such, may be one putative factor limiting the development of
ToM, causing difficulties in the social functioning of children
with ASD.22–24 Furthermore, EF seem to be a better predictor of
social-communication problems in ASD than ToM.25 Given the
robust associations between EF and functional outcome in ASD,
18,19
it is interesting to note that EF impairments unfolding
throughout childhood, seem to persist in neurodevelopmental
pediatric populations, despite a reduction in symptom
manifestation.26–28 Clearly, the persistence of executive dysfunc-
tions across time, may cause detrimental functional impairment

CONTACT Erik Winther Skogli erik.winther.skogli@sykehuset-innlandet.no Innlandet Hospital Trust, Division Mental Health Care, Child and Adolescent
Psychiatric Clinic, Anders Sandvigsgate 17, 2629 Lillehammer, Norway
© 2020 Taylor & Francis Group, LLC
2 E. W. SKOGLI ET AL.

in school, work and family life. This elucidates the centrality of
targeting these EF deficits to plan intervention and improve
social functioning in children and adolescents with ASD.
Early Intensive Behavioral Intervention
Thorough reviews of research29 and meta-analyses,30,31 have
reported early intensive behavioral intervention (EIBI) to be an
effective and well documented approach in improving current
and future functioning in preschool children with ASD. There is
a growing body of evidence that EIBI may result in significant
improvements in adaptive behavior, language as well as intellec-
tual functioning in preschool children with ASD.29 Using parti-
cipant data,30 reported a reliable positive change in intellectual
functioning (IQ), based on IQ test-scores for 29% of children
with ASD receiving EIBI. With regard to adaptive behavior,30
reported a reliable positive change in adaptive behavior compo-
site scores, based on Vineland Adaptive Behavior Scales32 in 20%
of children with ASD receiving EIBI. Other controlled studies
have reported that approximately 50% of children with ASD
manage school without support, and 40% of children with
ASD show age appropriate language skills after receiving EIBI
in preschool years.30,33 Around 10% show little or no benefit
from EIBI treatment.30,34 Given the strong associations between
EF and IQ,35,36 previous reports are promising findings regard-
ing the potential effects of EIBI on improved EF in children with
ASD. Although there has been a growing interest in behavioral
intervention aiming to improve EF in children with ASD,37 few
studies have investigated EF outcome in children with ASD
receiving EIBI or other behavioral intervention programmes.
In one single-subject design study, addressing working
memory,38 reported improved performance on a counting
span task, using positive reinforcement in three children with
ASD. Further, Cognitive-Functional intervention is reported to
show moderate to large improvements in EF for young children
with Attention Deficit Hyperactivity Disorder (ADHD) after
12 weeks of intervention.39 Parental training programmes aim-
ing to support EF in preschool children with ADHD, have also
reported promising results regarding improved executive func-
tioning in everyday situations.40 Intervention programmes aim-
ing to amend EF in neurotypical children have also reported
improved EF.41–44 One randomized controlled study reported
significantly greater EF improvement in a group of children after
12 weeks of school curricula intervention, relative to the control
group.41 There is also some evidence for improved EF in pre-
school programmes, aimed at improving behavior and emotion
regulation.45,46 Thus, given the strong associations between EF
and IQ,35,36 one hypothesis could thus be, that improved results
in IQ-tests, reported by,30 are mainly driven by improved EF in
children with ASD receiving EIBI. From this perspective, it could
be possible that improved EF in children with ASD who receive
EIBI, simply make these children more able to use their intellec-
tual capabilities and hence improve their scores on intelligence
tests. The aim of this pilot study was, therefore, to examine the
development of EF, in a group of children with ASD, receiving
EIBI. Based on current knowledge we hypothesized that children
with ASD receiving EIBI, will show a greater improvement over-
all in everyday EF, than would be expected, based on the
Behavior Rating Inventory of Executive Functions – Preschool
version (BRIEF-P) T-scores at baseline (T1).
Method
Procedure and Participants
This study included children from three to six years referred in
an ordinary manner to the Division of Habilitation and
Rehabilitation, Innlandet Hospital Trust for an assessment of
ASD. The subjects were recruited as consecutive referrals to the
Habilitation Clinic at Lillehammer, Norway. Ten children parti-
cipated in the study (Table 1). All the children received training
based on EIBI, and had more than 25 hours a week of intensive
behavioral treatment. The treatment met the criterion for quality
treatment described in.47 All children were enrolled in full-time
kindergartens for neurotypical children. They received on aver-
age 15.3 months of intervention between the pre- (T1) – and
posttest (T2) assessment (range 10–19 months).
Measures
All participants underwent a comprehensive assessment according
to common clinical practice. The assessment comprised
a structured diagnostic interview with the parents (Autism
Diagnostic Interview – Revised),48 a diagnostic observation sche-
dule (Autism diagnostic observation schedule–2nd edition),49
a cognitive assessment, an assessment of language functioning
and a medical examination. The diagnostic evaluation with
Autism Diagnostic Interview – Revised (ADI-R) and the Autism
diagnostic observation schedule–2nd edition (ADOS-2) were sup-
plemented with information from the Social Communication
Questionnaire – Current (SCQ-C),50 which covers the DSM-
IV51 and ICD-1052 symptoms for ASD. The SCQ-C was filled

Table 1. Overview of diagnosis, gender, age at assessment, mental age at assessment and duration of treatment for each of the ten participants.
Diagnosis Diagnosis Age in months diagnostic Mental age in Age in months expressive Age in months impressive
Child ICD-10 DSM-IV Gender assessment months language language
1 84.9 299.80 boy 39 *27 *22 *26
2 84.0 299.00 boy 45 *27 *25 *25
3 84.0 299.00 boy 41 *26 - *17
4 84.0 299.00 boy 38 *12 - *9
5 84.0 299.00 boy 33 * 42 *42 *42
6 84.9 299.80 boy 48 ** 25 **13 **14
7 84.1 299.80 boy 33 *39 *37 *36
8 84.0 299.00 boy 24 - - -
9 84.0 299.00 girl 28 - - -
10 84.0 299.00 boy 29 *19 *16 *15
*Bayley Scales of Infant Development-III, cognitive scale, **Psychoeducational Profile-third edition (PEP-3), -Not assessed.

out by parents and preschool teachers. ADI-R interviews with the
parents and ADOS-2 observations with the children, were per-
formed by experienced psychologists, special education teachers
and social educators at the Division of Habilitation and
Rehabilitation, Innlandet Hospital Trust. The ADI-R, ADOS-2
and SCQ-C have shown robust psychometric properties with
regard to the classification of ASD.53–56 Additional information
from preschool teachers with regard to kindergarten functioning
(language development, social and motor function), which is
mandatory on referral, was also incorporated into the diagnostic
evaluation. Diagnoses were considered positive, if, based on
a comprehensive evaluation of the ADI-R, ADOS-2, teacher infor-
mation and rating scales, DSM-IV51 and ICD-1052 criteria were
met. Cognitive functioning was assessed by experienced psychol-
ogists with the Bayley Scales of Infant Development, Third
Edition,57 cognitive scale, or Psychoeducational Profile-third
edition.58 Language development was assessed by experienced
special education teachers with the Bayley Scales of Infant
Development, Third Edition (Bayley-III), impressive and expres-
sive scales. Bayley-III is an individually administered norm-
referenced scale assessing cognitive development, language func-
tion (receptive and expressive communication) and motor func-
tion (gross and fine) in children age 1–42 months.57 Bayley-III is
widely used in both clinical practice and research, and has demon-
strated robust psychometric properties.57 Psychoeducational
Profile-third edition (PEP-3) is another individually-
administered, norm-referenced scale assessing cognitive develop-
ment, language function (receptive and expressive communica-
tion) and motor function (gross and fine) in children from six
months to seven years.58 PEP-3 has demonstrated good internal
consistency and test-retest reliability, with correlations ranging
from .78 to .99.58 Preschool children with ASD were assessed
with The Behavior Rating Inventory of Executive Function –
Preschool Version (BRIEF-P)59 at the time of diagnostic assess-
ment (T1) and after 15 months of EIBI intervention (T2). In the
current study, parents and preschool teachers were asked to com-
plete the written form of the Norwegian version of BRIEF-P60 at
each time point. Exclusion criteria for all participants included
severe head injury (with loss of consciousness) and any disease
affecting the central nervous system.
Attrition
In this study, we initially included 18 children with diagnoses
within the autism spectrum disorders. Eight children were
excluded from the study, due to failure to meet EIBI require-
ments, according to the number of intervention hours or quality
of intervention or incomplete data sets. Only those children
whose treatment met the EIBI requirements and whose test –
retest data were complete, are included in the study.
Intervention
Clinical experience with EIBI together with extensive
research30,31 has led to the preparation of a Norwegian regional
guideline for EIBI. The guideline61 was made available in the
National Health Library in February 2017. This procedure
addresses specialist health services, such as Child Habilitation
Services and Child and Adolescent Psychiatric outpatient
DEVELOPMENTAL NEUROREHABILITATION 3
clinics. In this guideline, procedures are described with regard
to the supervision of municipal employees and parents in the
implementation of highly specialized treatment techniques,
based on the principles of applied behavior analysis. The inter-
vention was supervised and conducted by highly specialized
behavioral analysts, mainly social educators, with considerable
knowledge of EIBI for preschool children with ASD. The
intervention is complex because it is executed in collaboration
with and by means of interaction between the specialist health
services, municipal services, patients and guardians. The EIBI
intervention method involves behavioral training from 20 to
30 hours per week. Children received intervention in multiple
settings including the home, kindergarten and the community.
Each child’s training was delivered by a team of three to four,
trained preschool teachers, teaching assistants and parents.
EIBI treatment goals include all aspects of a child’s functioning,
targeting areas such as compliance skills, joint attention skills,
language and communication skills, play and social skills, self-
help skills and preschool skills. Within these areas, more spe-
cific training programmes are individually tailored to teach the
children skills such as planning, sequencing, initiating, flexibil-
ity in doing and thinking, adaptability, self-evaluation, organiz-
ing and self-regulation. The basis of the intervention comprises
behavior analytic techniques, including numerous reinforce-
ments, instructional, shaping and prompt/prompt fading pro-
cedures. The behavioral programming is inspired by different
treatment manuals.47,62,63 Instruction occurred both during
formal, structured sessions as well as in less structured situa-
tions such as play sessions, both in kindergarten and at a child’s
home including with other children. The preschool teachers are
trained and supervised closely by specialists in behavior analy-
sis and early intervention at the Division of Habilitation and
Rehabilitation, Innlandet Hospital Trust. Initially the preschool
teachers receive supervision on a weekly basis. After two to
three months, when behavioral training has been well estab-
lished, the specialists at the Division of Habilitation and
Rehabilitation supervise the preschool teachers every
fourteenth day. The procedural integrity requirements were
set for the implementation of the individual training pro-
grammes. All preschool teachers were tested for training skills
and had to meet quality requirements, outlined in the
Norwegian regional guideline for EIBI.61
Outcome Measure
The Behavior Rating Inventory of Executive Function – Preschool
Version (BRIEF-P)59 has been developed to assess EF behavior in
children aged two to five years. The BRIEF-P includes 63 items,
each of which is rated on a three-point scale with the values:
1 = Never, 2 = Sometimes and 3 = Often. These 63 items are
composed into five clinical scales (Inhibition, Working Memory,
Shift, Emotional Control, Plan/Organize). These five clinical scales
form three broad classifications of executive functioning –
Inhibitory Self Control Index (ISCI), Flexibility Index (FI),
Emergent Metacognition Index (EMI), as well as an overall
Global Executive Composite (GEC) score.59 The GEC score is
reported in this article. BRIEF-P scores are converted into stan-
dardized T-scores (M = 50, SD = 10). T-scores ≥ 65 (+1.5 SD) are
defined as EF problems in the clinical range.59 BRIEF-P
4 E. W. SKOGLI ET AL.

demonstrated high internal consistency (Cronbach’s α = .80 − .97) Table 3. Teacher rated BRIEF-P Global Executive Composite (GEC) T-scores at
baseline (T1) and 15 months follow up (T2). Change status and RCIs for each of
and good test-retest reliability (r = 0.78–0.90).64 These values are the ten participants.T-scores are based on the original norms. Elevated BRIEF-P
at the same level as Cronbach’s α, reported in the original BRIEF T-scores indicate a higher degree of impairment.
manual (.80 − .98).65 In the current study, parents and preschool Child T1 T2 Change RCI
teachers are asked to complete the written form of the Norwegian 1 65 57 −8 −1.63
translation of BRIEF-P.60 T-scores are based on the original 2 78 60 −18 −3.67*
3 76 43 −33 −6.74*
norms and elevated BRIEF-P T-scores indicate a higher degree 4 84 81 −3 −0.61
of impairment. 5 87 75 −12 −2.45*
6 88 65 −23 −4.70*
7 80 81 1 0.20
8 81 83 2 0.41
Data Analyses 9 56 71 15 3.06*
10 82 77 −5 −1.02
BRIEF-P data are presented in Tables 2 and 3 as composite
BRIEF-P; Behavior Rating Inventory of Executive Function-Preschool version. *RCI
T-scores at the baseline (T1) and at the 15 months follow up values ≥ ±1.96 indicate a reliable change at a 95% confidence level (p-value ≤
(T2) for each of the ten participants. Parent ratings are reported 0.05). Positive change scores indicate increasing EF problems. Negative change
in Table 2. Preschool teacher ratings are reported in Table 3. In scores indicate decreasing EF problems.
order to investigate any significant change in BRIEF-P T-scores
across time, a Reliable Change Index (RCI)66 was computed for
each of the participants. The RCI is a statistical technique, a chance of above 95% of detecting a genuine effect should
designed to test whether any observed difference between two one exist and not explained by a measurement error.
or more time points have occurred by chance, or not. The
advantage of this approach is that RCI can provide an evi- x2  x1
RCI ¼ rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
dence-based analysis of change within individuals, across time
or conditions.67 In line with the original publication by,66 we 2ðSD 1  rxx Þ2
computed an RCI for each of the participants, by dividing
BRIEF-P change scores (T2 – T1) by the standard error of Hence, we used this approach to test and reject the hypothesis that
the difference (Sdiff) for each of the participants. observed differences within each participant in EF from T1 to T2
x2  x1 have occurred by chance. Furthermore, by applying age adjusted
RCI ¼ T-scores instead of raw scores, T-scores allow us to detect sig-
Sdiff
nificant changes in each individual that are not due to maturation.
Decreasing T-scores indicate a lower degree of impairment from
In order to estimate the standard error of the difference T1 to T2, while increasing T-scores indicate a higher degree of
(Sdiff), we calculated the standard error (Se), using impairment from T1 to T2. Unchanged T-scores from T1 to T2
a standard deviation of ten (SD), a test-retest reliability of indicate an unchanged level of impairment from T1 to T2, in
0.90 (parent rating) and 0.88 (teacher rating) from the nor- which the children display a maturation of EF-skills as expected,
mative sample of BRIEF-P.59 relative to neurotypical children. RCI-scores based on the original
qffiffiffiffiffiffiffiffiffiffiffiffi proposals by,66 may also be calculated using the RCI-calculator,
Sdiff ¼ 2ðSe Þ2 developed by,68 http://daniel-zahra.webs.com/publications.htm

pffiffiffiffiffiffiffiffiffiffiffiffiffiffi
Se ¼ SD 1  rxx Ethics
RCI values ≥ ±1.96 are considered to indicate a reliable The study was approved by the Norwegian Center for
change at a 95% confidence level [p-value ≤ 0.05), i.e., Research Data (project number: 51533) and conducted in
accordance with the Helsinki Declaration of the World
Table 2. Parent rated BRIEF-P Global Executive Composite (GEC) T-scores at Medical Association Assembly. According to the Regional
baseline (T1) and 15 months follow up (T2). Change status and RCIs for each Committee for Medical Research Ethics in Eastern Norway
of the ten participants.T-scores are based on the original norms. Elevated BRIEF-
P T-scores indicate a higher degree of impairment. (REK), this study did not require REK-approval (REK ref.
Child T1 T2 Change RCI
2017/72). The study is also registered in the www.isrctn.com
1 53 56 3 0.67
clinical trial register (ISRCTN registry – 33010). The parents
2 66 57 −9 −2.01* of all the children were informed about the research project
3 84 73 −11 −2.46* both in person and in writing, and they were asked if they
4 72 72 0 0.00
5 66 68 2 0.45 agreed to allow the data from the EIBI intervention to be used
6 80 70 −10 −2.24* for research purposes. Participants were also asked whether
7 96 94 −2 −0.45
8 63 64 −1 0.22 they could be contacted again 12 months after intervention
9 39 75 36 8.05* had been terminated, for a follow-up evaluation with the
10 78 73 −5 −1.12 BRIEF-P. Subjects who did not wish to participate in the
BRIEF-P; Behavior Rating Inventory of Executive Function-Preschool version. *RCI research project were provided the same clinical assessment
values ≥ ±1.96 indicate a reliable change at a 95% confidence level (p-value ≤
0.05). Positive change scores indicate increasing EF problems. Negative change and offered the same intervention method as those participat-
scores indicate decreasing EF problems. ing in the study.

Results
Parent Report
Ten children with ASD (M = 2.9 years, nine males) were rated
with BRIEF-P at the time of diagnostic assessment and after
15.3 months of EIBI intervention. The results are presented in
Table 2. Based on computed Reliable Change Indexes (RCI)
for each of the participants and comparing GEC T-scores at
T1 and T2, three children showed a reliable decrease in GEC
T-scores from T1 to T2 (child two T1: 66, T2: 57, RCI: −2.01;
child three T1: 84, T2: 73, RCI: −2.46; child six T1: 80, T2: 70,
RCI: −2.24). Six children showed no significant change in
GEC T-scores from T1 to T2 (child one T1: 53, T2: 56, RCI:
0.67; child four T1: 72, T2: 72, RCI: 0.0; child five T1: 66, T2:
68, RCI: 0.45; child seven T1: 96, T2: 94, RCI: −0.45; child
eight T1: 63, T2: 64, RCI: 0.22, child ten T1: 78, T2: 73, RCI:
−1.12). One child displayed increased GEC T-scores from T1
to T2 (child nine T1: 39, T2: 75, RCI: 8.05.)
Preschool Teacher Report
The results are presented in Table 3. Based on computed
Reliable Change Indexes (RCI) for each of the participants
and comparing GEC T-scores at T1 and T2, four children
showed a reliable decrease in GEC T-scores from T1 to T2
(child two T-score T1: 78, T2: 60, RCI: −3.67; child three T1:
76, T2: 43, RCI: −6.74; child five T1: 87, T2: 75, RCI: −2.45;
child six T1: 88, T2: 65, RCI: −4.70). Five children showed no
significant change in GEC T-scores from T1 to T2 (child one
T1: 65, T2: 57, RCI: −1.63; child four T1: 84, T2: 81, RCI:
−0.61; child seven T1: 80, T2: 81, RCI: 0.20; child eight T1: 81,
T2: 83, RCI: 0.41, child ten T1: 82, T2: 77, RCI: −1.02). One
child showed increased GEC T-scores from T1 to T2 (child
nine T1: 56, T2: 71, RCI: 3.06)
Discussion
Parent Report
We found that three out of ten children with ASD receiving
EIBI, showed a significant improvement in EF (GEC
T-scores) from T1 to T2, based on parent ratings. Six of the
children displayed no significant change in EF from T1 to T2.
The parents of one child reported a significant increase in EF
problems from T1 to T2. Age adjusted T-scores allowed us to
detect an improvement in EF beyond that which could be
expected due to maturation. A significant decrease in BRIEF-
P T-scores might thus reflect a development in EF skills and
beyond age expected maturation from T1 to T2 for three of
the ten participants.59 When inspecting BRIEF-P T-scores for
the three children showing a reliable improvement from T1 to
T2, one child no longer displayed EF problems in the clinical
range, i.e., T-score < 65 at T2. The other two children still
struggled with EF problems in the clinical range at T2, but at
a significantly lower level compared to age-referenced norms
at T1.59 Furthermore, results showing no reliable change in
six of the children, indicated no improvement in EF-problems
relative to age-referenced norms from T1 to T2. Nonetheless,
no reliable change in EF-problems indicated that six of the
DEVELOPMENTAL NEUROREHABILITATION 5
children with ASD showed no increase in EF-problems from
T1 to T2. Interestingly, no reliable change in EF-problems for
six of the children may thus indicate an age adequate matura-
tion of EF in more than half of the children with ASD
receiving EIBI.59 Our findings showing a reliable EF improve-
ment in three out of ten children, are somewhat correspond-
ing to previous studies reporting a reliable change in IQ for
29% of children with ASD receiving EIBI, and a reliable
change in adaptive behavior for 20% of the children with
ASD receiving EIBI.30,34 Unfortunately, parents of one child
reported elevated levels of EF-problems at T2 compared to
T1. Although empirical evidence has found EIBI to be an
effective treatment for children with ASD, a minority of
children with ASD (10%) are reported to show little or no
benefit from the treatment with regard to adaptive behavior,
language or intellectual functioning.30,34 Clearly, it is possible
that EF-problems will persist in some children with ASD
receiving EIBI. One explanation may be that parents receive
information regarding their children’s difficulties at the time
of their diagnostic assessment and later in EIBI treatment
meetings. Improved knowledge regarding the children’s diffi-
culties, may thus make some parents more sensitive to EF
problems, leading to elevated scores on BRIEF-P question-
naires at T2.
Preschool Teacher Report
With regard to preschool teacher reports, four out of ten
children displayed a significant improvement in EF skills
from T1 to T2. Five out of ten children showed no significant
change in EF, while one child showed a significant increase in
EF problems from T1 to T2. Intra-class correlations show
a good to moderate inter-rater reliability between parent and
preschool teacher reports at T1 (ICC: 0.71) and T2 (ICC: 0.56)
indicating the same tendency in parent and preschool teacher
reports at T1 and T2. Preschool teachers, however, seem to
report a reliable improvement in more cases than the parents.
Furthermore, preschool teachers seem to report larger RCI
effects for those children showing a reliable improvement in
BRIEF-P ratings, compared to parent reports (see Tables 2
and 3). When inspecting T-scores at T1 and T2, preschool
teachers, in general, report greater EF impairment at T1
compared to parent ratings (T1: parent mean 69.7, teacher
mean 77.7; T2: parent mean 70.2, teacher mean 70.3). Larger
RCIs in preschool teacher ratings compared to parent ratings,
may thus be driven by higher ratings of EF-problems at T1 by
preschool teachers. Challenges in everyday EF may be more
demanding in a kindergarten setting than at home. Preschool
teachers may thus be more susceptible to detecting subtle
differences in children’s EF over time. By comparison, pre-
vious research on the parent-teacher agreement reveals that
parents of neurotypical children rate their children as having
more EF difficulties than preschool teachers.64 However, the
children in our study were all diagnosed with ASD and this
may represent a greater challenge in kindergarten than at
home. This is in line with the findings of,69 with regard to
children with ADHD. The participants in our study were very
young (age range 24 to 48 months) and problems with emo-
tional self-regulation, impulse-control and attention, will
6 E. W. SKOGLI ET AL.
often be interpreted as age appropriate behavior at this stage
of development. Often preschool teachers will have a better
opportunity than parents to compare the developmental levels
of children of the same age. This could make preschool
teachers more sensitive to EF-problems when behavior man-
ifestations are difficult to understand in young children.
Nevertheless, direct observations could be more sensitive to
subtle behavior changes than indirect observations like
BRIEF-P ratings.70 Consequently, inferior sensitivity in indir-
ect observations compared to direct observations, may be one
possible explanation of our results, indicating a reliable
improvement in only a minority of the participants. The
child reported to show more EF-problems at T2 according
to parent ratings, was also reported to show elevated levels of
EF problem behavior at T2 by preschool teachers.
Interestingly, parents report this aggravation in EF problems
as being on a much larger scale than preschool teachers
(parent report RCI 8.05, preschool teacher report RCI 3.06).
As previously discussed, parents’ increased knowledge regard-
ing the children’s functioning at T2 may be one potential
explanation of larger RCI effects in parent reports, by com-
parison with preschool teacher reports for the same child.
Development of EF in Children with ASD Who Receive EIBI
In this exploratory study we wanted to investigate the develop-
ment of EF in children with ASD who receive EIBI. Based on
parent ratings before intervention (T1), seven out of ten children
with ASD displayed EF problems in the clinical range (T-scores
≥ 65) on the Global Executive Composite. Based on preschool
teacher ratings, nine out of ten children displayed EF problems
in the clinical range on the Global Executive Composite at T1.
Thus, the majority of children with ASD participating in this
study, displayed clinical levels of EF problems. These findings
corresponded to previous studies reporting impaired EF in
pediatric populations with ASD,18 as well as in other neurode-
velopmental populations.71,72 In this exploratory study, we
wanted to test the hypothesis that children with ASD who
receive EIBI will show a greater overall improvement in everyday
EF, than would be expected based on BRIEF-P T-scores at T1.
Our findings indicated a significant decrease in EF problems in
three to four of the children with ASD after 15 months of EIBI
treatment. Five to six children showed no reliable decrease or
increase in EF problems after 15 months of EIBI treatment. One
child displayed more severe EF problems after 15 months of EIBI
treatment. In summary, our findings revealed that a minority of
children with ASD receiving EIBI, showed increasing levels of EF
problems in everyday situations. These are potentially interest-
ing findings regarding the centrality of EF problems in children
with ASD18,19 and the detrimental effects EF deficits may have
on social-, educational- and occupational function across the
lifespan.13–17 By comparison, intervention programmes aiming
to improve EF through learning and behavioral interventions in
neurotypical children have reported improved EF.41–44,73 In an
RCT-intervention study with school age children,41 reported
a significantly greater improvement in global EF and improved
behavior regulation skills after 12 weeks of school curricula,
aiming to enhance EF (Art of Learning) in those children receiv-
ing intervention (n = 66) compared to the control group
(n = 37). Other intervention programmes aiming to enhance
EF and learning in preschool and school age children, have
reported similar findings with a reduction in problem behavior,
improved emotion-regulation and better social problem-solving
skills, after being enrolled in different kindergarten and school
curricula programmes.46,74,75 Previous research with neurotypi-
cal children elucidates the centrality of improved emotional and
behavioral regulation when aiming to improve EF through dif-
ferent intervention programmes. Furthermore, as previous
research has reported behavior regulation to be closely linked
to social function in children with ASD,76 these findings may
indicate that the key advantage of such intervention pro-
grammes are related to children’s social function, rather than
academic outcome.41 Improved social function may boost test
performance in intelligence tests and academic outcome, as
better social competencies enhance the co-operation needed
for solving many of the tasks given in school settings.41
Our results, which indicate a reliable improvement in
a minority of the participants, raises the question whether
BRIEF-P is sufficiently sensitive to change in preschool chil-
dren with ASD. Previous studies have reported that neurop-
sychological EF test results are only tenuously linked to the
symptom severity in neurodevelopmental disorders, with up
to 50% of children and adolescents with ADHD or ASD
performing normally on EF tests.26,77–79 These findings have
raised a concern regarding the ecological validity of EF test
results.80 Where traditional neuropsychological EF tests seem
to capture “best estimates” in an ideal setting,81 the Behavior
Rating Inventory of Executive Function (BRIEF) was designed
to assess EF performance in ecologically valid situations.65 In
clinical practice, the BRIEF has proven to be a valuable addi-
tional assessment tool for the identification of impaired EF in
school-aged children, demonstrating better sensitivity in the
assessment of EF problems than neuropsychological EF tests.-
80,82–84
As such, BRIEF-P may seem more suited to detecting
EF-change in preschool children with ASD, than neuropsy-
chological tests. Furthermore, other intervention studies with
pediatric populations have reported inconsistent results, using
BRIEF as an outcome measure,85 reported lesser treatment
effects based on BRIEF-P as an outcome measure in preschool
children with cerebral palsy, compared to the BRIEF-P
T-score changes in our study. Results from one study by,39
supports the effectiveness of cognitive-functional (Cog-Fun)
intervention on improved BRIEF and BRIEF-P scores in chil-
dren with ADHD. Promising results have also been reported
from parental training programmes, aiming to support EF in
preschool children with ADHD when assessed with BRIEF
and BRIEF-P.40 Thus, in spite of inconsistent findings, the
results of our study indicating a reliable change in approxi-
mately one third of the participants, as well as findings
reported by,39,40 and may support the use of BRIEF-P when
assessing EF change in preschool children with ASD.
Limitations and Future Directions
The lack of a control group represents a major limitation in this
exploratory study. Consequently, we investigated EF change
within individuals across time, and applied RCI analyses in
order to investigate any reliable change from T1 to T2. A small

sample size is another limitation. A larger sample size could have
allowed for more replications of the results in this study, which
could have strengthened the findings. However, a well-powered
RCT would strengthen the quality of the findings in future
studies, investigating the effect of EIBI on EF outcomes in
children with ASD. Another potential limitation is that the
sample was drawn from a clinical population and represents
those parents who are willing to seek help for their children.
Although the participants were recruited as consecutive referrals
to the Habilitation Clinic at Lillehammer, Norway, only ten of
the initial 18 children were included in the study. This relatively
high attrition rate might hamper our findings in this study.
Furthermore, the lack of neuropsychological assessment of EF
may be another limitation in this study. Modest correlations
between BRIEF and neuropsychological EF tests, indicate that
the BRIEF and neuropsychological EF tests are complimentary
rather than similar instruments.84 EF questionnaires like BRIEF-
P, assess the parents’ and teachers’ impressions of the children’s
EF behavior in everyday situations, but not necessarily whether
EF behavioral problems are manifestations of the children’s
underlying cognitive function.86 A neuropsychological assess-
ment with EF tests would as such provide more reliable informa-
tion about the children’s EF. Furthermore, one potential
explanation for the reported upswing of intelligence test results
in children with ASD receiving EIBI29 is that test performance in
intelligence tests are mainly driven by improved EF after EIBI
intervention, and are not an effect of improved IQ per se. This
potential causality between improved EF and enhanced intellec-
tual capabilities needs to be demonstrated more directly in future
studies. Finally, a single subject design, based on direct observa-
tions, may allow for a more fine-grained analysis of behavior
change compared to group designs.87 This will, in particular, be
advantageous when evaluating intervention programmes in het-
erogeneous populations such as ASD.88 Hence, single subject
designs based on direct observations should be taken into con-
sideration in future studies evaluating EF in children with ASD
receiving EIBI.
Implications and Conclusion
Given the detrimental effect EF deficits may have on social-,
educational- and occupational function across the lifespan,3,89
our results showing a reliable improvement in one third of
preschool children with ASD receiving EIBI are encouraging,
however, they need to be replicated in larger scale controlled
studies. As EF have been reported to be a robust predictor for
later adaptive behavior in children and adolescents with
ASD,90 it is of great interest to evaluate whether EIBI could
improve EF at preschool age, and in the long run improve
prognosis, functional outcome and quality of life in persons
with ASD.
Acknowledgments
The authors wish to thank the parents, children and staff at the
Habilitation Clinic at Lillehammer, Norway for their contributions to
making this project possible.
DEVELOPMENTAL NEUROREHABILITATION 7
Disclosure statement
The authors declare no conflict of interest with respect to the authorship
or publication of this article.
Funding
Skogli’s authorship was supported financially by the Innlandet Hospital
Trust (grant number 150610). Andersen’s efforts were supported by the
Inland Norway University of Applied Sciences.Isaksen’s efforts were
supported by the Innlandet Hospital Trust and Inland Norway,
University of Applied Sciences.
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