e BRIEFF-A Wr Behavior Rating Inventory of |, Executive Function— Adult Version PROFESSIONAL MANUAL Robert M. Roth, PhD Peter K. Isquith, PhD Gerard A. Gioia, PhDDedication ‘To my sons, Matthew and Frederik, and my wife, Patricia, for encouraging me to use my frontal lobes, and to my parents, Louis and Veronica, for their unwavering support (kiszinéml). J offer my heartfelt thanks to Peter Isquith and Gerry Gioia for inviting me to contribute to the BRIEF family of tests—RMR. To my father, Alan J., who taught me that science was fun, and my mother, V. Judith, who taught me that writing was worth the effort—PET Ai first, we celebrated the younger generations and their development of executive functions; now we dedicate this work to our “adult” executive mentors. To Vito and Pat, my parents, who through their everyday life behavior, skillfully demonstrated an executive approach to managing a large tribe while also promoting independent executive function development in yours truly —GAG It is our hope that this measure will enhance the lives of adults by increasing their participation in the evaluation of their executive functions. By explicitly seeking and valuing their views, we hope to build a bridge of communication and awareness through mutual understanding of their everyday experiences. Such a collaborative partnership in the assessment process provides a starting point for a more comprehensive evaluation of cognitive strengths and weaknesses, as well as a more successful intervention in the world outside the assessment office. PAR - 16204 N. Florida Ave. * Lutz, FL 33549 1.800.331.8378 + wwnw.parinc.com ‘Copigtt © 1996, 1898, 2000, 2001, 2003, 2004, 2005 by PAR. Al ights reserved, May not bo roroduco in whoo or in prt in any fom: or by any rere ston pocrission of AA, 987654921 earder 190-5748Sg Acknowledgments p The magnitade of this project required the support and participation of many individuals, both professional sive oftheir time. We thank all of the participants and ‘heir informants (whether relatives, friends, or col- leagues) who provided a wealth of knowledge of exec- vive funetion in the everyday world and participated in ‘he development of the Behavior Rating Inventory of * Faculty and staff of the Neuropsychology Program and Brain Imaging Laboratory at Dartmouth Medical School under the direction of Andrew Saykin, PhD, ABCN, for their generous support and collaborative spirit including Laura Flashman, PhD, ABCN, Arthur Maerlender, PhD, Thomas MeAllister, MD, Brenna McDonald, PhD, and Heather Wishart, PhD, as well as Mariana Borgos, PhD, Cameron Brewer, MA, Franklin Brown, PhD, Howard Cleavinger, PhD, Jennifer Crawford, PhD, Mary Hynes, RN, Nancy Koven, PHD, John MacDonald, MA, Katherine Nutter- Upham, BA, Nadia Pare, PhD, Heather Pixley, BA, Laura Rabin, PhD, Ariel Rosen, BA, Dorothy Sullivan, RN, June Vance, and John West, 3A. Joseph Biederman, MD, Ronna Fried, EdD, Megan -Aleardi, Anya Potter, and Roselinde Kaiser of The Clinical and Research Programs in Pediatrie Psychopharmacology and Adult ADHD at Massachusetts General Hospital for their generos- ityin sharing data, Stephen Michlovitz, Director of Curriculum, Instruction and Assessment, and Meg Gallagher, © Superintendent of the Windsor Supervisory ‘Administrative Unit, and Anne Koop, Kelley Cherington, Iynn MeMorris, Holly Morse, Marion. Withum, Patricia Davenport, Dana Peterson, and Johanna Harpster, Principals within the Windsor Supervisory Administrative Unit school system, for thelr assistance with data collection. Rosalind Jones, PhD, Caitlin Mccaulay, PhD, Ronna Fried, EdD, Leslie Baxter, PhD, Peter Giancola, PD, Ellen Popenoe, PhD, Mary 1. MacNamee, EdD, Henry J. Rierdan, PhD, and Frank Wolkenburg, PhD, for applying their expert Knowledge to the categorization of the entire item pool into scales. Debra Bergeron, Sarah Smith, and Brian Potter, doctoral students in Clinical Psychology at Antioch New England Graduate School, for their conceptual, analytical, and research inputs Chad Johnson, Carolyn Parma, Viana Turcios, Lucinda Leung, and Shaffer Boder of the Department of Psychological and Brain Sciences at Dartmouth College, for their assistance throughout the data collection and development processes. ‘Mark Yivisaker, PHD, of the College of St. Rose, “defender of the real world” to whom we are ‘grateful for sharing his views on executive func- tion in the everyday world. Erin Bigler, PhD, at Brigham Young University, Catherine Kuiter, PhD, at the White River Junction VA Medical Center, Antonietta Russo, PhD, at Intermountain Health Care and Brigham Young University, and Cheryl Weinstein, PhD, ABPP/CN at the Beth Israel Deaconess Hospital, for their valuable recommendations and feedback as beta examiners, Wealso wish to acknowledge the significant contribu- tons and support of Drs. Travis White, Michelle Widows, and R. Bob Smith, I, of Psychological Assessment Resources, Inc., publisher of the BRIEF-A. Gratitude is extended to PAR staff members who contributed to the production of the BRIEF-A: Richard Brummer, Scott Murphy, Lisa Doelling, Linda Jennings, Penny Smith, Becky Haines, Sherrie St. James, and Mark Wallner. Robert M. Roth, PhD Peter K. Isquith, PhD Gerard 4. Gioia, PhD October 2005owledgments pter 1. Introduction.. Calculating Seale Raw Scores.. ompleting the Scoring Summaxy/Proile Form. BY Compicting the Scoring Summary Table and Calculating Index Raw Scores fF Scoring the Inconsistency Scale... F Plotting the BRIEF-A Profile hapter 3. Interpretation of Scores on the BRIEF-A Respondent Competen Omission of Item Responses... Unusual Patterns of Responses. 8 8 8 8 8 9 8 8 8 8 8 3Introduction Behavior Rating Inventory of Executive Adnlt Version (BRIEF-A) is a standardized rt measure that captures adults’ views of their ive functions, or self-regulation, in their environment. It is designed to be completed ts between the ages of 18 and 90 years with a in fifth-grade reading level, including those with ‘atiety of developmental disorders and systemic, gical, and psychiatric ilinesses such as attention Tearning disabilities, autism spectrum disor- f simatic brain injury, multiple sclerosis, depres- als. The BRIEF also includes thrve validity egatvty, frequency, and Inconsistency. Table 1 es form two broader indexes—the Behavioral Index (BRI) and the Metacognition Index an overall summary score, the Global Bre Composite (GEC). The BRIEF-A has demor- fessional Manual provides information SRIEF-A materials, administration and scor- lures, normative data, guidelines for clinical ion, and a variety of case studies to assist the understanding results obtained with the sThis Professional Manual also describes the ‘of the BRIEF-A and results of studies that reliability, validity, and clinical utility as a The Executive Functions Executive funetions are a set of interrelated control processes involved in the selection, initiation, execu- tion, and monitoring of cognition, emotion, and behay- ior, as well as aspects of motor and sensory functioning ‘The term “executive function” represents an umbrella construct reflecting self-regulatory functions that organize, direct, and manage other cognitive activities, emotional responses, and overt behaviors (Gioia, Isquith, & Guy, 2001; Stuss & Alexander, 2000). Siuss and Benson (1984) described a set of related capacities for intentional problem solving that include anticipa- tion, goal selection, planning, monitoring, and use of feedback. Their hierarchical model highlights impor- tant aspects of the executive functions that relate to the highest levels of cognition such as anticipation, judg ment, selawareness, and decision making, Their model distinguishes “executive,” or higher order cognitive con- trol functions, from more “basic” cognitive functions (eg, language, visuospatial, memory abilities) ‘The operational definition of executive functions, as well as the specific cognitive processes subsumed under this umbrella term, has varied somewhat among authors (Lezak, 1995; Stuss & Benson, 1984; Tranel, Anderson, & Benton, 1994). However, several processes are commonly regarded as regulatory or management, functions, inchiding the ability to initiate behaviors, {inhibit competing actions or stimuli, select relevant task goals, plan and organize a means to solve complex problems, shift problem-solving strategies flexibly when necessary, regulate emotions, and monitor and evaluate behavior. Working memory capacity, whereby {information is actively held “online” so that it may be ‘manipulated and transformed in the service of planning ~ and guiding cognition and behiavior, is also described as a key aspect of executive function (Baddeley, 2008 Goldman Rakic, 1987).Table 1 Description of the Clinical and Validity Scales on the BRIEF-A Self-Report and Informant Report Forms ‘Number of items/pairs Salt-Report Form Informant Roport Form Behavioral description Clinical Inhibit stun. Emotional Control SaleMonitor Initiate ‘Working Memory PlawvOrganize ‘Task Monitor Organization of Materials Validity Negativity Infrequency Inconsistency Control impulses; appropriately stop owm behavior af the proper time. ‘Move freely from one situation, or aspect of a problem, to another as needed; solve problems flexibly ‘Modulate emotional responses appropriately Keep track of the effeet of own behavior on others; atend to ‘own behavior in the social context. Begin a task or activity; fluidly generate ideas. Hold information in mind for the purpose of completing a task; slay with, or stick to, an activity Anticipate future events, set goals; develop appropriate steps to ‘cary Out an associated action cary out tasks ina systematic manner, understand main ideas. (Check work, assess performance during or after finishing a task to ensure atiainment of goal. Keep workspace, living areas, and materials in an orderly ‘Extent to which the respondent answers selected BRIEF-A items. ‘in an unusually negative manner. Extent to which the respondent answers additional items in an uusual and infrequent direction. Extent to which the respondent answers similar BRI in an inconsistent manne. -A items Brain Basis of the Executive Functions ‘The developmental course of the executive functions parallels the protracted course of neurological develop- ‘ment, particularly with respect to the frontal regions of the brain (Krasnegor, Lyon, & Goldman-Rakic, 1997). One common view of the neuroanatomical organization of executive functions, however, is that they are sub- served solely by the frontal lobes. This view is an-over- simplification of the complex organization of the brain. Although damage to the frontal lobes can result in sig- nificant dysfunction of various executive subdomains (Miller & Cummings, 1999; Petrides & Milner, 1982; Robbins, 1996; Stuss & Knight, 2002), these complex, higher order processes are not solely a product of frontal activity. Nevertheless, an understanding of the frontal region of the brain is important in any diseus- sion of the executive functions. The frontal lobes are ily and reciprocally interconnected, through numer- ous neuroanatomical pathways, with other cortical and subcortical regions of the brain such as the limbiq (motivational/mnemonic) system, the reticular activa ing (arousal) system, the posterior association corty (perceptual/cognitive processes and knowledge base and the motor (action) regions of the frontal lobed (Alexander, Crutcher, & DeLong, 19%; Barbas, 200 Cummings, 1995; Goldman-Rakic, 1987; Gloanni, Dégénétais, & Glowinski, 2000). Sueh a cent ‘neuroanatomical position underlies the regulatory explicitly acknowledges and directly incorporates intereonnections of the frontal region with other es Importantly, a disorder within any component of| frontal system network, inciuding white matter pé ways, can result in executive dysfunction (Jahans et al, 2002; O'Brien et al, 2002; van der Wert et 1999). Stateofthe-art functional neuroimaging stualso repeatedly demonstrated contributions to funetions from other cortical and subcortical is-within the frontal system (Belger et al, 1008; eval, 2004, Rao et.al, 1997). Numerous conditions ender the frontal systems vulnerable to dysfimc- Jnluding disorders affecting the connectivity of ain such as cranial radiation and multiple sclero- [tes & Saykin, 2001; Wishart et al, 2004); direct, ato the prefrontal regions of the brain (Levine, Boutet, Schorartz, & Stuss, 2000; McAllister, Flashman, & Saykin, 2001; McDonald, & Saykin, 2002); Attention-Deficit/ Eeractvity Disorder (ADHD) (Murphy, Barkley, & | 2001; Roth & Saykin, 2004; Seidman, Biederman, Hatch, & Faraone, 1998; Woods, Lovejoy, & Ball, 5 substance use disorders (Fein, Di Sclafani, & off, 2002; Giancola & Moss, 1998; Sullivan, Rosenbloom, & Pfefferbaum, 2002); schizophre- is et al, 1997; Roth, Flashman, Saykin, , & Vidaver, 2004; Townsend, Malla, & 2001); neurodegenerative disorders such as disease and Alzheimer’s disease (Lewis, bins, Barker, & Owen, 2003; Owen eta, 1992; (tr, Grace, & Cakn-Weiner, 2008); and mild cog: raiment (Saykin eta, 2004), a condition asso- Developmental Factors quse of their cornplex, higher order nature, the dion and development of executive functions is lowitz, & Davies, 2004; Zelazo, 2004). This developmental course parallels the prolonged neurodevelopment of the frontal regions of including dramatic growth in synaptic con- zor et al, 1997; Miller, 1999; Thompson et al, development of executive functions such as of emotion and behavior begins in Panagiotides, Klinger, & Hill, 1992) ues through the preschool period (Diamond 1996; Espy et al, 2002; Kerr & Zelazo, 2004; 2003) through adolescence and early adult- a, Ridderinkhof, & van der Molen, 2004; van 2000; Zelazo, Craik, & Booth, 2004), Decline in the use of executive functions in later adulthood and ‘old age is also observed, though decline is found neither {for all executive functions nor forall healthy individuals and tends to be modest (Daigneanlt, Braun, & Whitaker, 1902; De Luca et al., 2003; Verhaeghen & Cerella, 2002; Wecker, Kramer, Wisniewski, Delis, & Kaplan, 2000). As is found for many dimensions of psychological and neu- ropsychological functioning, the decline of executive functions varies across individuals in terms of the age of onset, rate of decline, and actual proficiency level at any given age. Several variables have been associated with age-associated decline in executive funetions such as changes in the structural integrity of white matter pathways and neurodegenerative changes in frontal lobe grey matter, as well as genetic factors (Carmell, Swan, DeCarli, & Reed, 2002; Jemigan et al., 2001; OBrien et al, 2002; Valenmela et al., 2000). Clinical Assessment Historically, clinical assessment of the executive functions has been challenging because of their dynamic essence (Stuss & Alexander, 2000; Tranel etal, 1904). Fluid, strategic, goal-oriented problem solving is not as amenable to a paperand-peneil assessment ‘model as are the more domain-specific functions of lan- guage, motor, and visuospatial abilities. Furthermore, the structured, wellorganized nature of the typical assessment situation often does not place sufficiently high demands on the executive functions, reducing the opportunity for directly observing this important domain (HolmesBemstein & Waber, 1990). In addi- tion, commonly employed performance measures developed specifically for assessing executive func- tions do not always yield expected results; adults may score in the normal range on these measures within the context of the evaluation, despite reports of severe executive deficits in everyday functioning (Eslinger & Damasio, 1985; Goldstein, Bernard, Fenwick, Burgess, & McNeil, 1993; Meyers, Berman, Scheibel, & Hayman, 1992). Burgess (1997) has suggested that most neu- ropsychological tests alone are inadequate for assessing the executive functions because they attempt to sepa- rate integrated functions into component parts. Current performance-based tests are constructed to measure individual components of executive functions over a short time frame, not the integrated, multidimensional, relativistic, priority-based decision-making that is often demanded in real-world situations (Goldberg & Podell, 2000, Shallice & Burgess, 1991). As a resuli, narrow- band, component tests may be necessary, but not . |sufficient, to capture more complex, day-to-day exect- tive problem solving. The need exists for complemen- tary, ecologically valid tasks that capture the broader, molar aspects of comples, everyday, problert-solving demands, This need has led to increased attertion to eco- logical validity in assessment of executive function across the age spectrum and in a variety of clinical con- ditions (Alderman, Burgess, Knight, & Henman, 2003; Burgess, Alderman, Evans, Emslie, & Wilson, 1998; Chaytor & SchmitterEdgecombe, 2003; Farias, Harrell, ‘Neumann, & Hout, 2003; Gioia & Isquith, 2004; Goldberg & Podell; Ready, Stierman, & Paulsen, 2001; Semkovska, Bedard, Godbout, Limoge, & Stip, 2004). A central aspect of most psychological and neu- ropsychological evaluations is the gathering of data that permitpredictions to be made about an adult's fanction- ing in the everyday environment. Such predictions play ‘vital role in guiding the construction of practical ree- ‘ommendations made by the professional, as well as the dovelopment. and implementation of specific effective interventions and accommodations employed to maxi- mize the functioning of the adult in his or her everyday world. As such, the everyday environment of an adult can provide an important venue for observing the exec- tive functions “in action.” Tn this context, the authors previously developed parent and teacher rating scales to enhance the understanding of executive functions in preschool and schooF-aged children and adolescents, a8 ‘well as a selfreport inventory for adolescents to rate ‘their executive functions in their everyday lives. The Behavior Rating Inventory of Executive Function (GRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000), the Behavior Rating Inventory of Executive Function- Preschool Version (BRIEF-P; Gioia, Espy, & Isquith, 2008), and the Behavior Rating Inventory of Executive Fimetion-Self Report (BRIEF-SR; Guy, Isquith, & Gioia, 2004) have demonstrated reliability, validity, and clini cal utility for assessing the behavioral manifestations of ‘executive dysfunction in children from preschool through adolescence (Anderson, Anderson, Northam, Jacobs, & Mikiewicz, 2002; Gioia, Isquith, Kenworthy, & Barton, 2002; Isquith, Gioia, & Bspy, 2004; Mahone, Hagelthom, et al, 2002), with particular attention to ‘ecological validity (Gioia & Isquith, 2004). ‘An adult's report of his or her experience of his or her own executive functioning can add critical informa: tion to enable assessment and intervention. An adult ‘possesses an abundance of information about his or her own daly activities that is directly relevant to an under- standing of his or her executive capabilities. Selfxeport ‘methodology is commonly used in clinical assessment to capture the adult’s perspective of his or her function: ing, Explicitly assessing, valuing, and providing fect | ack about his or her viewpoint can facilitate rapport ‘and the development of a collaborative working rela tionship with an adult that can, in turn, serve as a star jing point for interventions. Many Self-report measures are included in standard clinical assessment protocels, such as the Beck Depression Inventory (BDI; Beck, 1987), the StateTrait Anxiety Inventory (STAI: Spielberger, Gorsnch, & Lushene, 1970), and the Personality Assessment Inventory (PAI; Morey, 1981). ‘These measures assess emotional, behavioral, and per- sonality characteristics but do not focus on executive function. The BRIEF-A was developed in order to meet the neod for capturing an adult's views of the strengths ‘and weaknesses of his or her own executive functions. ‘The level of self understanding and awareness shown by adults with respect to thelr executive fictions is an important factor in ganging the amount of support they ‘will require. For clients who possess 2 high awareness of their executive difficulties and who are eager to arnelio- rate their struggles, the intervention process can be facllitated. For those who lack awareness or acceptance (Flashman, 2002; Flashman & Roth, 2004; Ott et al, 1906), a much higher degree of extemal support may be required. Although an adult’s response patterns ot behavior rating scales such as the BRIEF-A can range from strong agreement with other informants to aggres: sive denial of any problems, rich clinical information can ‘be gleaned from directly assessing his or her opinions. ‘To facilitate this process, there is a need fora self-report rating scale for measuring the range of behavioral mant festations of executive functions in adults. Because awareness of the integrity of an adult's own ‘executive functions can vary among both healthy ind ‘viduals and those with a variety of illnesses, an infor ‘mant’s report on the same executive functions provides ‘an empirical basis from which to begin identifying prob- lems of avrareness. For example, poor awareness of bs or her executive dysfimetion in an individual with ‘Alsheimer’s disease may increase the possibility that he or she might engage in certain risky behaviors. In add tion, selfreport of executive functions may not be reat ily or validly obtained froma some adults, such as thos ‘with limited reading skils or those with cognitive impai ments that affect their ability to understand or otherwise respond in a reliable and valid manner to written infor: ‘mation (eg, advanced stages of dementia, severe devel ‘opmental disorders). Obtaining reports from informants (eg, spouse, caregiver, adult child, friend, nurse, mes tal health worker) about the executive functions of a