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Title 37 C.F.R., Chapter II, Part 201.14
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 1 2000

ASSESSING THE EXECUTIVE FUNCTION

ABILITIES OF ADULTS WITH
NEUROGENIC COMMUNICATION
DISORDERS
Laura L. Murray, Ph.D.* and Amy E. Ramage, M.S.†

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ABSTRACT—Whereas it is known that executive function abilities are often
impaired in clients having neurogenic communication disorders, few assess-
ments of this cognitive domain are available that consider the speech and lan-
guage deficits of this population. This article provides an overview of current
procedures for assessing executive functions including a discussion of team
approaches to assessment, a review of currently available neuropsychological
and functional tests of executive function abilities, as well as a critique of those
assessment procedures. In addition, suggestions are provided for how best to
use or modify appropriately current tests of executive functioning for clients
having acquired speech and language disorders as a result of brain damage.

KEY WORDS: Executive functions, assessment, neurogenic communication

disorders

Executive function abilities refer to a quently, upon clients’ social, vocational,

collection of high-level, interconnected,
control processes that allow us to generate,
choose, organize, and regulate our goal-
directed, adaptive, and nonautomatic be-
haviors (Phillips, 1997;1 Ylvisaker & Feeney,
19982) or, as Lezak (19953) noted, are skills
that “enable a person to engage successfully
in independent, purposive, self-serving
behavior” (p. 42). Consequently, executive
function impairments can have dire effects
upon the rehabilitation process and, subse-
educational, and rehabilitative outcome
(Chen et al., 19984). As Filley5 noted, adults
with neurogenic communication disorders
such as dementia, traumatic brain injury
(TBI), right hemisphere damage (RHD),
and aphasia may present with varying de-
grees of impairment in a number of execu-
tive functions. Therefore, it is important
that the speech-language clinicians who
work with these individuals be able to iden-
tify the presence, nature, and severity of ex-

*Department of Speech and Hearing Sciences, Indiana University, Bloomington, Indiana, and
†Department of Speech and Hearing Sciences, University of Arizona, Tucson, Arizona

Reprint requests: Dr. L. L. Murray, Department of Speech and Hearing Sciences, Indiana
University, Bloomington, IN 47405.

Copyright © 2000 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel.: +1(212) 584-4663. 0734-0478,p;2000,21,02,0153,0168,ftx,en;ssl00042x
153
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
ecutive function deficits. To be able to
quantify and qualify executive function
deficits in adults with neurogenic communi-
cation disorders, clinicians must be familiar
with the variety of formal and informal tests
of executive functions that are currently
available. Furthermore, clinicians must be
able to interpret the results of these tests in
terms of reliability and validity. This is par-
ticularly true given that theoretical models
of executive functions have yet to be explic-
itly delineated and that few tests of execu-
tive functions can be administered without
accommodating for the neurogenic com-
munication disorders with which our clients
present.
The purpose of this article is to intro-
duce clinicians to the variety of procedures
that may be used to assess the executive
function abilities of adults with neurogenic
communication disorders. First we address
different degrees of involvement speech-
language clinicians might have in examin-
ing executive functions. Next we review
general types of assessment procedures in-
cluding collection of case history informa-
tion and observational and questionnaire
data, administration of commonly used for-
mal tests of executive functioning, and func-
tional assessment of executive functioning.
Lastly, we discuss limitations associated with
the currently available assessment proce-
dures, as well as provide suggestions for im-
proving tests of executive function abilities
for adults with neurogenic communication
disorders.
THE SPEECH-LANGUAGE
CLINICIAN’S ROLE IN ASSESSING
EXECUTIVE FUNCTIONS
In most clinical settings, whether they
are educational or medical, a team approach
to assessment and treatment has been
adopted. Depending on the team and the
clinical setting, a number of team members
may be capable of and interested in assessing
the executive function abilities of adults with
neurogenic communication disorders. Con-
154 sequently, the first step in assessing the exec-
utive functions of our clients is to determine
who is responsible for this assessment so as to
avoid redundant testing procedures. Ideally,
all team members should directly or indi-
rectly participate in the assessment. Mem-
bers who may be best trained for and most
frequently involved in directly assessing exec-
utive function abilities include the speech-
language clinician, the neuropsychologist
(or psychologist, school psychologist, etc.),
and the occupational therapist.
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Prior to administering tests of executive
functioning, speech-language clinicians should
check with other team members to ensure
that they are not overstepping professional
boundaries. For example, in some states in
the United States and provinces in Canada,
only psychologists are licensed to purchase
and/or administer certain tests of executive
functioning (as well as tests of other cogni-
tive abilities such as memory or attention).
Even under these circumstances, however,
speech-language clinicians should be in-
volved in the executive function assessment
of clients with neurogenic communication
disorders because of our unique expertise in
evaluating and interacting with this popula-
tion of individuals. Whereas other profes-
sionals may have had more training and ex-
perience in administering tests of executive
functioning, speech-language clinicians have
had more training and experience in accom-
modating test procedures for and interpret-
ing the test results of adults with speech and
language impairments.
PROCEDURES FOR ASSESSING
EXECUTIVE FUNCTIONS
Generally, the purposes of an executive
function assessment are to identify not only
impairments but also strengths and to de-
termine whether and how these impair-
ments and strengths contribute to clients’
daily functioning. Ylvisaker et al. (19986)
recommended that a thorough assessment
of executive functioning should “attempt to
understand how effectively an individual
can size up a possibly confusing situation,
decide what to do to achieve meaningful
ASSESSING THE EXECUTIVE FUNCTION ABILITIES OF ADULTS—MURRAY, RAMAGE
goals, plan how to do it, do it and stick to it
until it is done, pay attention to how effec-
tively it was done, and identify a clever way
to do it better if necessary” (p. 223). To
achieve these purposes, a number and vari-
ety of assessment procedures must be com-
pleted including acquiring a case history,
conducting observational and interviewing
procedures, and administering formal tests
of executive function abilities.
Case History
An important initial step to the evalua-
tion of executive function abilities is to re-
view the client’s medical history. First, infor-
mation pertaining to the etiology and
location of brain damage should be ob-
tained because it may provide insight into
whether assessment of executive function
abilities will be necessary. For example,
frontal lobe damage is highly associated
with executive function deficits (Levine et
al., 1998;7 Shallice & Burgess, 19918). Con-
sequently, clients who suffer from traumatic
brain injuries, strokes, tumors, or progres-
sive diseases (e.g., Parkinson’s disease,
Huntington’s disease) that directly or indi-
rectly compromise frontal lobe functioning
might be expected to present with executive
function deficits. A negative history of
frontal lobe involvement, however, does not
dismiss the possibility of executive function
deficits as other neuroanatomical regions
(e.g., limbic system, cerebellum) are also as-
sociated with executive function abilities
(Cummings, 1993;9 Schatz, 199810). Addi-
tional suggestions regarding the identifica-
tion of pertinent medical history informa-
tion are provided by Filley.5
As part of the case history, clinicians
must also collect information concerning
the status of their clients’ speech, language,
attention, memory, sensory (e.g., vision,
hearing), motoric, and mental health func-
tioning (e.g., depression). The results of a
recent, formal assessment of these areas of
functioning should be available and re-
viewed prior to evaluating executive func-
tion abilities so that any existing cognitive,
perceptual, motoric, or emotional problems
can be taken into consideration not only
when choosing and administering tests of
executive functions but also when interpret-
ing test results (Elias & Treland, 199911).
The assessment of executive function abili-
ties will also be guided by information per-
taining to clients’ pre- and postmorbid occu-
pation, residential setting (e.g., community
dwelling, skilled nursing facility), and sup-
port systems (e.g., family, co-workers, home
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health care services). Such information can
help clinicians determine the type and ex-
tent of demands that currently are, or will
be, placed upon their clients’ executive
function abilities (Sbordone, 199612).
Observations and Interviews
In addition to completing formal test-
ing, it is extremely important for clinicians
to observe and interact with clients and to
talk with caregivers and other team mem-
bers to acquire information regarding how
clients interact and function in a variety of
formal and informal social contexts and in
the presence of a variety of daily stressors.
Observational data are critical to evaluating
executive functions because the external
structure that typifies formal testing proce-
dures may mask the executive function
deficits of many clients (Cripe, 1996;13 Dug-
bartey et al., 199914). That is, structured
tasks and the controlled environment asso-
ciated with formal testing procedures may
actually provide the type of support that
many clients need to compensate for their
executive function deficits. Furthermore,
the emotional or personality changes of
clients with executive function deficits are
usually not revealed or quantified by their
formal test performances (Chen et al.,
1998;4 Burgess et al., 199815). As Dugbartey
and colleagues (199914) warned, “to rely ex-
clusively on summary psychometric scores
in the assessment of executive dysfunctions
is a fundamental mistake” (pp. 9–10).
To help organize observational sessions
and to assist in summarizing observational
data, clinicians can use the commercially 155
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
available Profile of Executive Control Sys-
tem (PRO-EX) (Braswell et al., 199216). The
PRO-EX is an observational protocol that
involves observing clients perform daily
tasks and some “set-up” tasks, as well as in-
terviewing clients about their executive
function abilities. Included in the PRO-EX
manual are suggestions regarding unstruc-
tured settings in which to complete observa-
tions (e.g., clients’ home, hospital room,
hospital cafeteria), tasks to elicit executive
function behaviors (e.g., telephone tasks in
which clients are asked to obtain informa-
tion such as how to get a building permit),
and general and specific questions to ask
when interviewing clients, their caregivers,
or both. While collecting the observational
data, clinicians rate their clients’ behaviors
according to seven areas of executive func-
tioning: goal selection, planning/sequenc-
ing, initiation, execution, time sense, aware-
ness of deficits, and self-monitoring. After
all the data have been amassed, clinicians
identify their clients’ highest level of func-
tioning in each area according to the levels
of functioning listed on the PRO-EX Rating
Protocol. For example, in terms of initia-
tion, ratings can vary from the lowest level
in which clients are “Able to initiate only
with physical prompting” to the highest
level in which clients “Independently initi-
ate a variety of complex tasks even if they do
not feel motivated” (Braswell et al., 199216,
p. 2). Braswell et al. reported acceptable in-
terrater reliability when the PRO-EX was
used to observe and rate the executive func-
tion abilities of 32 clients who had suffered
either a TBI or a stroke. Tools such as this
can help verify the reliability of data ob-
tained from fully unstructured observations
of executive function abilities.
To help structure interviews with
clients, caregivers, or other team members,
clinicians might use the Executive Interview
(Royall et al., 199217) or the Dysexecutive
Questionnaire part of the Behavioral Assess-
ment of the Dysexecutive Syndrome test
battery (BADS) (Wilson et al., 199618). The
Dysexecutive Questionnaire documents oc-
currences of 20 of the most frequently re-
156 ported symptoms associated with dysexecu-
tive or frontal lobe syndrome including
changes in emotion or personality (e.g., ag-
gressiveness), motivation (e.g., apathy or
lack of concern), behavior (e.g., impulsive,
distractible), and cognition (e.g., planning
difficulties). Sample questions include
“She/he loses his/her temper at the slight-
est thing,” “She/he seems lethargic, or un-
enthusiastic about things,” and “She/he has
difficulty thinking ahead or planning for
the future.” Two versions of the question-
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naire are used, one to be completed by the
client and one to be completed by a close
caregiver or other team member who has
frequent daily contact with the client. Par-
ticipants are asked to rate each of the behav-
iors on a scale from 0 (i.e., “never”) to 4
(i.e., “very often”) in terms of frequency of
occurrence. It is imperative that clinicians
not rely solely upon the clients’ self-ratings
because individuals with executive function
deficits commonly underestimate the sever-
ity of their deficits (Cripe, 1996;13 Burgess et
al., 1998;15 Wilson et al., 199618). Instead,
clinicians can obtain data concerning their
clients’ insight by comparing self-ratings
with those of caregivers. Importantly, the
Dysexecutive Questionnaire ratings of care-
givers have been found to correlate highly
with the performances of their brain-dam-
aged relatives on tests of executive function
(Burgess et al., 199815).
Observations and interviews completed
prior to formal assessment procedures can
provide valuable information regarding
which components of executive functioning
may be problematic for clients and, conse-
quently, which formal testing procedures
clinicians should select. Observational and
interviewing methods can also be incorpo-
rated into formal testing sessions (Ylvisaker
et al., 1998;6 Levine et al., 1998;7 Dughartey
et al., 199914). For example, prior to admin-
istering a test clinicians might ask clients to
judge whether the test will be easy or diffi-
cult and why and to predict how well they
will perform. Similarly, after the test, clients
might be asked how well they performed
and what type of strategies they used to
complete the test. By including these types
of questions, clinicians will obtain not only
ASSESSING THE EXECUTIVE FUNCTION ABILITIES OF ADULTS—MURRAY, RAMAGE

formal test results but also qualitative infor-
mation concerning their clients’ self-aware-
ness and self-monitoring abilities.
Formal Tests of Executive
Function Abilities
A variety of commercially available tests
(Table 1) and experimental procedures
(Table 2) may be used to assess the execu-
tests that evaluate a number of these
processes should be administered to delin-
eate which executive functions are problem-
atic and will require remediation (Dug-
bartey et al., 1999;14 Burgess et al., 199815).
Practically speaking, given the current limi-
tations in the amount of time and funding
available for assessment, it is best that for-
mal testing methods should be preceded by
observation and interviewing procedures to
help identify which specific executive func-

tive function abilities of adults with neuro-
genic communication disorders. This as-
sortment of assessment tools can be
categorized into tests or batteries that exam-
ine various executive functions, tests that
aim to evaluate only one or two executive
functions, and tests that yield a so-called
functional appraisal of executive function
abilities. Because executive functioning is
viewed as a corpus of complex, controlling
processes, whenever possible, several formal
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tion behaviors require further, in-depth
evaluation.
Executive Function Test Batteries
As of the writing of this article, only
one test battery, the Behavioral Assessment
of Dysexecutive Syndrome (BADS) (Wilson
et al., 199618), is commercially available for
evaluating executive function abilities. An-
other test battery, the Delis-Kaplan Execu-

TABLE 1. Some Commercially-Available Tests of Executive Function Abilities

Tests Source
Observational/interview tool
Profile of Executive Control Systema Braswell et al. (1992)16
Test battery
Behavioral Assessment of the Dysexecutive Syndromea Wilson et al. (1996)18
Selected tests targeting specific abilities
Booklet Category Testb DeFilippis and McCampbell (1997)19
Color Trails Testb D’Elia et al. (1996)20
Colored Progressive Matricesc Raven et al. (1984)21
Comprehensive Test of Nonverbal Intelligenced Hammill et al. (1996)22
Controlled Oral Word Association Testc Benton et al. (1994)23
Picture Arrangement subtest of the WAIS-3c Wechsler (1997)24
Porteus Maze Testc Porteus (1965)25
Ruff Figural Fluency Testb Ruff (1996)26
Stroop Neuropsychological Screening Testb Trenerry et al. (1989)27
The Category Teste Williams (1994)28
Test of Nonverbal Intelligence—3d Brown et al. (1997)29
Tower of LondonDX: Research Versionf Cullbertson and Zillmer (1999)30
Williams Inhibition Teste Williams (1994)31
Wisconsin Card Sorting Testb Grant & Berg (1993)32
aAvailable from Northern Rehabilitation Services, 117 North Elm Street, P.O. Box 1247, Gaylord, MI 49735. Telephone:
517–732–3866. Internet: www.nss-nrs.com
bAvailable from Psychological Assessment Resources, P.O. Box 998, Odessa, FL 33556. Telephone: 1–800–331–8378. Internet:

www.parinc.com
cAvailable from The Psychological Corporation, 555 Academic Court, San Antonio, TX 78204–2498. Telephone: 1–800–211–8378.

Internet: www.PsychCorp.com
dAvailable from Pro-Ed, 8700 Shoal Creek Boulevard, Austin, TX 78757–6897. Telephone: 1–800–897–3202. Internet: www.

proedinc.com
eAvailable from CoolSpring Software, P.O. Box 130, Woodsboro, MD 21798. Telephone: 301–845–8719. Internet:

users.aol.com/CoolSpring/Cspring.html
fAvailable from Multi-Health Systems, 908 Niagara Falls Blvd., North Tonawanda, NY 14120–2060. Telephone: 1–800–456–3003.

Internet: www.mhs.com
157
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
TABLE 2. Some Experimental Procedures for Assessing
Executive Function Abilities
Test
Observational/interview tools
Executive Function Self-Rating Scale
Executive Interview (EXIT25)
Functional tests
American Multiple Errands Test
Photocopy Tasks
Route-Finding Test
Wheelbarrow Test
Selected tests targeting specific abilities
Antisaccade Task
Behavioral Dyscontrol Scale
CLOX: An Executive Clock Drawing Task
Everyday Problem Solving Inventory
Mental Dice Task
Six Elements Test
Strategy Application Test
Stuck-in-Set Test
Tinkertoy Test
Tower of Toronto
Twenty Questions Test
tive Function System (Delis et al.38) is under
development and will be ready for retail in
the latter part of 2000.
The BADS (Wilson et al., 199618) was
designed to determine whether clients have
impairments of one or several executive
functions and whether these impairments
compromise their daily functioning. This
test battery consists of the following seven
subtests which were devised to assess a spec-
trum of executive function abilities:
1. Rule Shift Cards Test: assesses cognitive
flexibility and inhibition by requiring
clients to respond correctly to one rule
for a period of time (i.e., say “yes” when
the card is red and “no” when the card
is black) and then to a new rule (i.e., say
“yes” if the previous card was red and
“no” if the previous card was black) in
the second part of the task.
2. Action Program Test: examines planning
and problem solving by having clients
figure out how to get a cork out of a tube
using a variety of objects and materials
and following a small set of rules.
3. Key Search Test: evaluates planning and
self-monitoring by requiring clients to
158 draw the route they would take to
Source
Coolidge and Griego (1995)31
Royall et al. (1992)32
Aitken et al. (1993)33
Crepeau et al. (1997)34
Boyd and Sautter (1993)35
Butler et al. (1989)36
Guitton et al. (1985)37
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Grigsby et al. (1992)38
Royall et al. (1998)32
Cornelius and Caspi (1987)33
Brugger et al. (1996)34
Shallice and Burges (1991)7
Levine et al (1998)6
Sandson and Albert (1987)35
Lezak (1995)3
Saint Cyr and Taylor (1992)36
Laine and Butters (1982)37
search for a lost set of keys in a large
field (represented by a square on a
piece of paper).
4. Temporal Judgment Test: assesses prob-
lem solving or reasoning by asking
clients four questions about the length
of time required for commonplace oc-
currences for which there is no exact
answer (e.g., “How long do most dogs
live for?”).
5. Zoo Map Test: evaluates planning and
cognitive flexibility by having clients
draw out the route they would follow to
visit a number of prescribed locations
on a map of a zoo while also adhering to
a number of prescribed rules.
6. Modified Six Elements Test: examines
planning, organizing, and self-monitor-
ing by requiring clients to complete
three tasks, each of which has two parts,
and by imposing the rule that clients
must perform these tasks without com-
pleting the two parts of the same task
consecutively.
7. The Dysexecutive Questionnaire (as
previously described), which identifies
the presence and frequency of a variety
of symptoms associated with impaired
executive functioning.
ASSESSING THE EXECUTIVE FUNCTION ABILITIES OF ADULTS—MURRAY, RAMAGE
Several of these subtests represent adapta-
tions of previously published tests. Gener-
ally, these adaptations were made to bring
the tests more in line with real-life activities
and to increase the variety of clients for
which the tests might be appropriate.
The BADS was normed for 216 non-
brain-damaged, healthy control individuals
who ranged in age from 16 to 87 years
(mean = 47 years) and 78 individuals with
brain damage related to various etiologies
(i.e., TBI, stroke, dementia, infection, and
anoxia) who ranged in age from 19 to 76
years (mean = 39 years) (Wilson et al.,
199618). Specific information pertaining to
the speech and language abilities of the
brain-damaged individuals was not pro-
vided. It might be anticipated, however, that
clients with moderate to severe language
comprehension deficits would have diffi-
culty understanding the directions to many
of the subtests (e.g., Action Program, Zoo
Map) and that clients with moderate to se-
vere language production deficits would
have difficulty completing the subtests re-
quiring verbal responses (e.g., Rule Shift,
Modified Six Elements). In terms of psycho-
metric properties, the BADS accurately dif-
ferentiated the performances of brain-
damaged and non-brain-damaged individu-
als; more recently, it was successful in dis-
criminating between the performances of
schizophrenic and non-brain-damaged indi-
viduals (Evans et al., 199739). In addition,
caregivers’ ratings of executive problems
were predicted by the BADS performances
of their brain-damaged relatives (i.e., brain-
damaged individuals with executive func-
tion problems were distinguished from
brain-damaged individuals without execu-
tive function problems) (Wilson et al.,
199618). High interrater reliability has been
reported, but test-retest reliability was only
moderate with a trend toward improvement
on subsequent testing. Because a crucial as-
pect of testing executive function abilities is
novelty, (Phillips, 1997;1 Ylvisaker & Feeney,
19986), Wilson et al.18 conjectured that this
test-retest performance pattern could be re-
lated to the reduction of novelty that occurs
on repeated administrations.
Tests of Specific Executive Function Abilities
As previously discussed, executive func-
tioning has been hypothesized by some to
be a multidimensional construct consisting
of a number of separate, controlling func-
tions or domains (Burgess, 199740). Present-
ly, however, there is no consensus on the
vernacular or composition of these execu-
tive domains (Phillips, 19971). Therefore, in
an attempt to provide some organization to
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the numerous tests of executive functioning
available, we chose to arrange tests into the
following executive domains most fre-
quently encountered in the literature: (1)
planning or the ability to formulate a strat-
egy and sequence the steps of that strategy
in order to meet intended goals; (2) organi-
zation or the ability to structure or catego-
rize incoming information as well as one’s
own responses; (3) inhibition or the ability
to suppress automatic, routine, or irrelevant
processing or responding; (4) cognitive
flexibility or the ability to change or adapt
one’s response set in the event of failure;
(5) problem solving or the ability to iden-
tify the problem and the ability to generate
and select solutions to the problem; and
(6) self-monitoring or the ability to evalu-
ate and regulate one’s own performance
and behavior on the basis of environmental
feedback, including the ability to identify
one’s own mistakes and deficits. We ac-
knowledge that other domains of executive
functioning may exist, that cognitive
processes within these domains may over-
lap, and that most tests can plausibly fit into
more than one domain. Still, we hope that
our categorization of tests provides clini-
cians with a framework for selecting tests to
ensure that a spectrum of their clients’ ex-
ecutive function abilities are evaluated
(Tables 1 and 2).
“Planning” Tests. Tower tests, clock
drawing, and maze completion are often de-
scribed as planning tests because they re-
quire clients to sequence and plan ahead,
taking into consideration the consequences
of certain responses. Tower tests such as the
Tower of London DX: Research Version
(TOL:RV) (Cullbertson & Zillmer, 199930), 159
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
the original Tower of London (Shallice,
198241), and the Tower of Toronto (Saint
Cyr & Taylor, 199236) involve deriving the
most efficient solution (i.e., use the fewest
moves) to a particular spatial arrangement.
For example, the TOL:RV, which has been
normed for children and adults, requires
that individuals plan ahead to determine
the order of moves necessary to arrange col-
ored wooden beads from their starting posi-
tion on two of three towers to a target con-
figuration on another tower. Configuration
difficulty depends on the number and com-
plexity of steps necessary to rearrange the
beads. Tower tests can be scored in terms of
number of moves as well as number of cor-
rect solutions and have been used with a
variety of neurogenic communication-
disordered populations (Glosser & Good-
glass, 1990;42 Lawrence et al., 199643).
Clock drawing tasks have been used
since Luria44 to assess executive functions.
In addition to planning skills, clock drawing
or setting tasks have been hypothesized to
tap the executive functions of organization,
inhibition, and self-monitoring (Freedman
et al., 1994;45 Royall et al., 199832). These
tasks can be administered in one or both of
the following conditions: (a) a free-drawn
condition in which clients are given a blank
piece of paper and a pen and asked to
“Draw a clock, put in all the numbers, and
set the hands to . . .” or (b) a pre-drawn con-
dition in which clients are given a piece of
paper with a circle representing a clock and
asked to put in the numbers and set the
hands to a specified time (usually “ten past
eleven”). Scoring for clock drawing is not
standardized and many different scoring
systems have been devised. For example,
Freedman et al.45 created a comprehensive
scoring system in which they defined each
element needed to construct a well-formed
clock including specifics about the clock
contour, numbers, and hands. Rather than
solely relying on these scoring systems, clini-
cians should also observe clients while draw-
ing the clock to make note of planning
strategies (e.g., placing anchor numbers—
12, 3, 6, and 9—before placing other num-
160 bers) or areas of particular difficulty as evi-
denced by overwriting or latencies. In addi-
tion, clinicians should note when clients ask
for repetition of instructions, possibly indi-
cating a confounding memory deficit. Not
only does clock drawing provide useful
qualitative and quantitative information
about clients’ executive function abilities, it
is also a quick and easy task that can be ad-
ministered in the acute as well as other ther-
apeutic settings.
“Organization” Tests. The Wisconsin
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Card Sorting Test (WCST) is the most
widely used and readily accepted test of ex-
ecutive functioning (Grant & Berg, 199332).
It requires clients to develop a strategy to
sort or categorize a set of cards, to maintain
that strategy, to utilize feedback to change
the strategy, and to inhibit impulsive re-
sponses to achieve accurate responses
(Phillips, 19971). Consequently, in addition
to organizational skills, the WCST assesses a
number of other executive functions such
as cognitive flexibility and inhibition (Pen-
nington et al., 199646). For the test, clients
are given a deck of 128 cards; on each card
is printed one to four symbols (circles, trian-
gles, stars, and crosses) in red, green, yel-
low, or blue, and therefore the cards can be
sorted by form, number, or color. Clients
are then asked to place the cards, one by
one, under four stimulus (key) cards ac-
cording to the category that they deduced
from the pattern of the clinicians’ feedback
(i.e., “correct” or “incorrect”). After 10 con-
secutive correct sorts, the category by which
clients can sort and receive credit is
changed; clients are not blatantly told that it
has changed but rather have to deduce
again from the pattern of the clinicians’
feedback that it has changed. The WCST
takes approximately 20–30 minutes to ad-
minister to healthy adults but can be ex-
tremely frustrating and time consuming for
brain-damaged as well as non-brain-dam-
aged clients (Parker & Crawford, 199247).
The Modified Wisconsin Card Sorting Test
(MWCST) (Nelson, 197648) was devised to
cut time by using only 48 cards, reducing
the requirements for task discontinuation,
and eliminating cards that shared more
than one attribute with the key cards to
ASSESSING THE EXECUTIVE FUNCTION ABILITIES OF ADULTS—MURRAY, RAMAGE
minimize confusion and make the sorting
principle more obvious. The MWCST has
been used in research studies and, like the
original WCST, has been found to be sensi-
tive to problems with organization and cog-
nitive flexibility (Lezak, 1995;3 Glosser &
Goodglass, 199042).
“Inhibition” Tests. These tests require
clients to ignore extraneous, irrelevant in-
formation that may conflict with a goal. In-
hibition can play a role at multiple levels of
cognitive processing such as inhibiting a
response to allow for response formula-
tion, inhibiting attention to irrelevant por-
tions of a task, and inhibiting previous re-
sponses or task requirements that are no
longer appropriate (i.e., stuck-in-set perse-
veration) (Barkley, 1996;49 Sandson & Al-
bert, 198735). One well-known test of inhi-
bition is the Stroop Test (Trenerry et al.,
198927) for which clients either read color
names or name the color in which the
word is written (e.g., the word “blue” writ-
ten in red ink). The greatest interference
(i.e., difficulty inhibiting irrelevant infor-
mation) typically occurs when the color
and written word are conflicting (Mac-
Leod, 199150); this interference is particu-
larly problematic for clients with left hemi-
sphere damage, RHD, or closed head
injury (Nehemkis & Lewisohn, 1972;51
Stuss et al., 198552). Obviously, the Stroop
Test would be difficult for clients with spo-
ken language or reading deficits. For these
individuals, a more appropriate, nonverbal
test of inhibition is the Antisaccade Task,
(Guitton et al., 198537) which requires
them to focus on a center fixation point on
a computer monitor. Cues are randomly
flashed on the right or left side of the
screen and clients are instructed to make
an eye movement in the direction opposite
to the cue; that is, clients must inhibit the
natural response of directing their eyes in
the same direction as the abrupt visual cue.
This task is difficult and even non-brain-
damaged adults make incorrect saccades
around 30% of the time, suggesting that
there is a continuum of performance
decrement from normal to disordered
functioning (Parker & Crawford, 199247).
“Cognitive Flexibility” Tests. Cognitive
flexibility is necessary when performing
tasks that require a shift from one thing to
another when feedback (either internal or
external) indicates the need to change.
Cognitive flexibility may subsume or be de-
pendent upon attentional skills and also is
closely related to inhibition (Sohlberg &
Mateer, 198953). One popular test of cogni-
tive flexibility is the Trail Making Test, (Rei-
tan & Wolfson, 198554) which requires
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clients to connect digits (Part A) or to con-
nect digits and letters in an alternating se-
quential order (Part B). This test is easily
administered, as long as clients understand
the instructions, has published normative
data for elderly adults (Spreen & Strauss,
199155), and has been found to be sensitive
to even the subtle deficits observed in mild
TBI (Brooks et al., 199956). A variation of
this test is the Color Trails Test (D’Elia et al.,
199620) in which colors (i.e., bright pink
and yellow) are substituted for letters, mak-
ing it more appropriate for clients with neu-
rogenic communication disorders, particu-
larly those who are aphasic. A number of
other cognitive flexibility tasks that are de-
scribed in the research literature and are
quick and simple to administer include
repetitive graphomotor tasks such as copy-
ing alternating figures or letters and repeti-
tive sequential hand movements (e.g.,
rapidly alternating hand pronation and
supination; alternating fist-edge-palm)
(Luria, 1973;44 Grigsby et al., 1992;38 Shatz,
199857). Clinicians also may refer to
Rende58 for a more detailed description of
cognitive flexibility and its assessment.
“Problem Solving” Tests. The Raven’s
Progressive Matrices (RPM) (Raven et al.,
197659) and the Colored Progressive Matri-
ces (Raven et al., 198421) are described as
measures of nonverbal problem solving and
thus are useful when assessing clients with
neurogenic communication disorders.
These tests also tap visuoperceptual skills
and cognitive flexibility as clients search for
a solution. Verbal demands are minimal as
the instructions can be pantomimed by clin-
icians and clients indicate their response by
pointing. In brief, clients are shown a de- 161
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
sign with a piece missing from it and are re-
quired to choose from an array of possibili-
ties the piece that correctly completes the
design. Kertesz and McCabe60 found that
RPM scores were not correlated with apha-
sia severity scores, indicating that this test
measures problem solving independent of
the language impairment observed in that
population. In contrast, others have found a
relation between test performance and
aphasia severity (Grigoroiu & Mihailescu,
197961), suggesting that some individuals
may use verbal mediation to arrive at solu-
tions (Lezak, 19953).
“Self-Monitoring” Tests. Fluency tasks
are often used as executive function mea-
sures as they require clients to monitor the
exemplars they have already produced
while continuing to generate new exem-
plars. Many fluency tasks are verbal in na-
ture, requiring the generation of words
beginning with a certain letter or belong-
ing to a particular semantic category (e.g.,
animals, grocery store items). The most
widely used and standardized letter flu-
ency task is the FAS test (also referred to as
Controlled Oral Word Association Test)
(Benton et al., 199423) for which clients
are given 1 minute to produce as many
words as they can beginning with the letter
F, then a minute for A, and a minute for S.
Clients are instructed to avoid giving
proper names or numbers. Normative data
for other letter fluency tasks are provided
in Lezak.3 Another option for clients with
speech and language deficits is the Ruff
Figural Fluency Test (Ruff, 199626), a stan-
dardized, nonverbal fluency task. During
this test, clients are given a piece of paper
that has 40 squares each filled with a set of
five dots. Clients are asked to generate as
many unique designs as possible within 1
minute by connecting each set of dots with
straight lines. This test can be scored by
calculating the number of unique draw-
ings and perseverative errors to examine
clients’ ability to initiate, plan, and inhibit
their drawing responses (see also
Sohlberg62 for an in-depth discussion of
the concept and assessment of self-moni-
162 toring abilities).
Functional Tests of Executive Function Abilities
With respect to the World Health Orga-
nization63 (WHO) model of health condi-
tions and disablement, an executive func-
tion assessment should quantify and qualify
impairments of structure or function (e.g., poor
self-awareness, decreased inhibition), limi-
tations of personal activities (e.g., problems
cooking, difficulty using public transporta-
tion), and restrictions in participation in society
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(e.g., social isolation, loss of one’s job). Cur-
rently, the vast majority of formal tests of ex-
ecutive function assess for problems at only
the impairment level of the WHO model.
This inordinate focus on impairments is
problematic because there is no apparent
one-to-one correspondence among the
WHO concepts of impairment, activity, and
participation; that is, it is difficult to antici-
pate whether and how executive function
impairments might be manifest as personal
activity or social participation limitations
(Burgess, 199740).
Consequently, tests such as the Ameri-
can Multiple Errands Test (AMET) (Aitken
et al., 199333) and the BADS (Wilson et al.,
199618) were developed to assess executive
function abilities in daily activities and set-
tings. These test procedures are described
as ecologically valid in that most are simply
formalized variants of daily activities. For ex-
ample, the AMET consists of a set of 16 tasks
that revolve around buying six items as
promptly and cheaply as possible in a real
shopping environment while adhering to
six prescribed rules. Clients must also mail a
postcard with certain information on it to
clinicians as well as meet the clinician at a
certain time and place. Prior to arriving at
the shopping area, clients receive instruc-
tions pertaining to the tasks and the rules.
Clients are allowed to use only the small
amount of money provided and their
watches; all other personal belongings and
money are temporarily taken away until
client completion of the AMET. At the shop-
ping area, task instructions are repeated
and then clinicians observe and record
their clients’ performance (e.g., successful
task completion, rule breaks, inefficient
ASSESSING THE EXECUTIVE FUNCTION ABILITIES OF ADULTS—MURRAY, RAMAGE
strategies). In terms of executive function
abilities, the AMET provides information
concerning daily problem-solving and plan-
ning abilities. Although further research
into the psychometric properties is needed,
initial findings indicated that the AMET
performances of adults with TBI were signif-
icantly worse than those of non-brain-
damaged adults and were related to care-
givers’ ratings of the TBI adults’ functional
abilities (McCue, 199564). Interestingly, no
strong associations were found between the
TBI group’s AMET performance and their
performance of more traditional, planning
and problem-solving tests (e.g., Trail Mak-
ing Test, The Category Test), indicating that
the AMET identified executive function
deficits missed by standard psychometric
evaluation. This result underscores that re-
liance on more formal and structured tests
of executive functioning may lead to under-
estimation of the degree of difficulty clients
will have in real-world contexts (Ylvisaker et
al., 1998;6 Braswell et al., 199216).
CURRENT LIMITATIONS IN
EXECUTIVE FUNCTION PROCEDURES
Although a variety of assessment tools
and methods have been developed to exam-
ine executive function abilities, there are
psychometric weaknesses and procedural
limitations associated with many of these
tests. A primary weakness of current execu-
tive function tests relates to the psychomet-
ric property of validity. Generally, validity
refers to a test’s ability to measure what it
contends to measure (Carmines & Zeller,
197965). There are several types of validity
including content validity, the extent to
which a test measures all of the behaviors it
should be measuring, and predictive valid-
ity, the accuracy with which a test predicts
whether individuals have the target deficit.
Unfortunately, both of these types of validity
are inadequate in most presently available
tests of executive functioning. For example,
the content validity of most executive func-
tion tests is suspect because they have been
developed without providing a clear opera-
tional definition of what executive function
or functions are being assessed and without
stipulating the specific model of executive
functioning upon which test construction
was based (Phillips, 1997;1 Pennington et
al., 199646). For example, although Tower
tests (e.g., Tower of London) are commonly
proposed to assess planning ability, statisti-
cal examination of Tower test performances
indicates that many additional cognitive
skills such as spatial working memory are in-
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volved and, consequently, assessed (Robbins
et al., 199866). Therefore, without addi-
tional testing, clinicians cannot be sure that
their clients’ poor performance on a Tower
test represents planning difficulties, spatial
working memory deficits, or both.
In addition, few executive function
tests have been shown to possess acceptable
ecological validity, a type of predictive valid-
ity that examines the extent to which indi-
viduals’ test performances predict their be-
havior in real-world settings (Sbordone,
199612). That is, with respect to the WHO
model of health conditions, few executive
tests will help clinicians reliably predict
which of their clients are at risk for daily ac-
tivity limitations, social participation restric-
tions, or both (Cripe, 1996;13 Dugbartey et
al., 1999;14 Braswell et al., 199216). Collec-
tively, these validity problems indicate that
future research is necessary to specify which
processes are tapped by each existing test of
executive functioning and to determine
whether there are meaningful relations be-
tween performances on these tests and our
clients’ daily functional outcome and status
(see Miyake et al.67 for a more detailed dis-
cussion of the validity of executive function
tests).
Another psychometric weakness of
many tests of executive functioning is their
low level of test-retest reliability (Phillips,
1997;1 Pennington et al., 199646). Test-retest
reliability refers to the extent to which a test
yields similar results across repeated admin-
istrations under similar testing conditions:
the more consistent the repeated measure-
ments are, the more reliable the test
(Carmines & Zeller, 197965). As noted previ-
ously, at least part of the poor test-retest reli- 163
 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
ability of executive tests may relate to the re-
duction of novelty that occurs on repeated
administrations (Wilson et al., 199618). It
has been argued that executive tests must
include some type of novelty (i.e., novel
content or task) so that when completing
these tests, participants use nonroutine, ef-
fortful processes that are representative of
executive functioning abilities (Phillips,
1997;1 Ylvisaker & Feeney, 19986). When ex-
isting executive tests are readministered,
part of the novelty is lost, and subsequent
test completion places fewer demands upon
executive function abilities. Consequently,
there is a need to develop tests that can be
repeatedly administered without significant
practice effects or that have alternate forms
so that clinicians can quantify the effects of
rehabilitation programs aimed at remediat-
ing or accommodating for executive func-
tion deficits (Elias & Treland, 1999;11 Dug-
bartey et al., 199914).
Another problem with most tests of ex-
ecutive functioning is that they were not
specifically developed for clients with neu-
rogenic communication disorders. Conse-
quently, there are various cognitive, sensory,
motoric, and demographic variables that
may affect this population’s performance
and thus obscure assessment of their execu-
tive function abilities. Possible confounding
variables include (1) aphasia that may inter-
fere with understanding task instructions or
with completing tasks that have specific ver-
bal output or input demands; (2) visuoper-
ceptual problems such as hemianopsia that
may interfere with perceiving visual stimuli
or with completing tasks that require
drawn, written, or visuoconstruction re-
sponses; (3) motoric impairments such as
hemiparesis, tremor, and rigidity that may
interfere with completing tasks that involve
hand or limb movements (e.g., object ma-
nipulation, pointing, drawing, writing); (4)
motor speech impairments such as dysar-
thria and apraxia of speech that may inter-
fere with completing tasks that require spo-
ken responses; and (5) the client’s age
(particularly 70 years or older) and ethno-
cultural background, which may be incom-
164 patible with test norms.
Therefore, when assessing executive
functioning in clients with neurogenic com-
munication disorders, it is important to se-
lect tests that are or can be adapted to be
compatible with their cognitive, sensory,
and motoric abilities as well as their demo-
graphic characteristics. For example, to
identify executive function impairments in
clients with aphasia, clinicians should
choose tests that have minimal language de-
mands (e.g., clock drawing, Tower tests).
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Clinicians also could use nonstandardized
administration of verbal, executive tests in
an attempt to accommodate for their apha-
sic clients’ language deficits (e.g., present-
ing verbal, written, and gestural test instruc-
tions; allowing written rather than, or in
addition to, verbal responses; substituting
test stimuli with items that the client can
name or understand). Of course, these
types of accommodations might negate the
use of test norms but may still provide use-
ful information about the aphasic client’s
executive function abilities. To improve the
accuracy and reliability with which clini-
cians can assess the executive function abili-
ties of clients with neurogenic communica-
tion disorders, future research must focus
on (1) developing novel tests of executive
functioning that minimize linguistic, vis-
uoperceptual, or motoric demands; (2)
standardizing adaptations of existing tests
to accommodate for linguistic, visuopercep-
tual or motoric deficits; and (3) extending
the normative data of existing tests to repre-
sent the increasing age and ethnocultural
diversity of our client population (Sbor-
done, 199612).
CONCLUSIONS
Currently, the numerous procedures
available to examine executive functioning
abilities of clients with neurogenic communi-
cation disorders require further refinement
and development. Nonetheless, by looking
for converging evidence across the data ac-
quired from both qualitative (e.g., observa-
tions, interviews) and quantitative (e.g., for-
mal tests) assessment methods, clinicians
 ASSESSING THE EXECUTIVE FUNCTION ABILITIES OF ADULTS—MURRAY, RAMAGE
should be able to obtain an accurate deter-
mination of the presence, nature, and sever-
ity of executive function deficits of their
clients (Cripe, 199613). Unfortunately, with
the possible exception of clients with TBI,
clients with neurogenic communication dis-
orders (e.g., dementia, aphasia, cognitive-
communicative disorders associated with
RHD, Parkinson’s disease) probably rarely
receive assessment for executive function
deficits despite evidence that the extent of
executive deficits can predict their func-
tional outcome and abilities (Chen et al.,
1998;4 Grigsby et al., 199238). We have tried
to provide a sufficient review and description
of the variety of formal tests of and proce-
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 SEMINARS IN SPEECH AND LANGUAGE—VOLUME 21, NUMBER 2 2000
ARTICLE FIVE
SELF-ASSESSMENT QUESTIONS
1. Executive functions are difficult to as-
sess because:
(a) they are a composite of several dif-
ferent cognitive domains.
(b) many current tests measure more
than one executive function, mak-
ing it difficult to delineate exactly
what is being measured.
(c) many current tests were standard-
ized on populations that are not
representative of the current neuro-
genic communication population.
(d) valid assessment procedures have
not been developed.
(e) all of the above
2. Executive functions can be assessed by:
(a) neuropsychologists
(b) occupational therapists
(c) speech-language pathologists
(d) all of the above
(e) a and c only
3. Executive function ability may be over-
estimated with classic, standardized
tests because:
(a) they do not measure these functions.
(b) clients may have poor insight to
their disorders.
168
(c) the testing environment may actu-
ally facilitate better performance.
(d) none of the above
(e) all of the above
4. Caregivers may be valuable in an execu-
tive function assessment by providing
information about:
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(a) premorbid functional abilities
(b) the home environment
(c) expectations for treatment outcomes
(d) personality changes since event
(e) all of the above
5. Retesting executive functions in clients
is particularly difficult because:
(a) clients get too tired after an entire
evaluation session.
(b) changes in test scores are probably
secondary to spontaneous recovery.
(c) tests are no longer novel after be-
ing administered once.
(d) the tests are too time consuming
and insurance will not pay for the
outcome information.
(e) all of the above