Parental Ratings of Children with Fetal Alcohol Spectrum Disorder on the Behavior Rating Inventory of Executive Function (brief)

Children with FASD typically display deficits on cognitive measures of executive functioning, but the goal of this study was to examine performance of children with FASD on a behavioral measure of executive function using the Behavior Rating Inventory of Executive Function (BRIEF). Participants were 64 children (aged 5 to 16 years) with FASD. These children showed significant deficits on the BRIEF, with mean scores on all scales reaching clinical significance. A distinctive pattern was also found, with the children showing most difficulty on Inhibit, Working Memory, and Initiate scales and least difficulty on Organization of Materials. Females demonstrated substantial difficulty with inhibition and older children had more difficulty (relative to the norm) than younger children on scales measuring working memory and initiation. The BRIEF appears to be a useful tool for evaluating behavioral, social, and emotional aspects of executive functioning in children with FASD. etal Alcohol Spectrum Disorder (FASD) is an umbrella term used to refer to individuals who may have physical, mental, behavioral, and learning disabilities as a result of maternal alcohol consumption. Understanding the neurobehavioral deficits associated with FASD is particularly important for both diagnosis and treatment of FASD. Some of the primary neurobehavioral impairments associated with FASD involve deficits in memory, attention, visual-spatial abilities, declarative learning, planning, cognitive flexibility, processing speed as well as language and motor delays. These children tend to score lower on measures of IQ and academic achievement, specifically in mathematics.Executive functioning, which has been defined as higher-order psychological abilities involved in goal-oriented behavior under conscious control, is a significant deficit in individuals with FASD. Executive functioning involves cognitive, emotional, and behavior components and refers to abilities such as planning, organized search, inhibition, working memory, set-shifting, strategy employment, and fluency. The executive function deficits in FASD have been documented on tests of cognitive flexibility, inhibition, planning and strategy use, concept formation and verbal reasoning, set shifting, working memory measures, and fluency. The bulk of this previous research has been on cognitionbased or ‘cool’ executive functioning tests. More recently researchers have started examining emotion-related or ‘hot’ executive function in FASD. Hot executive function is thought to be involved in response to reward and punishment stimuli and involves regulation of motivated and emotional behavior. Hot and cool executive functions are associated with different areas of the fontal cortex; the orbitofrontal cortex and the dorsolateral prefrontal cortex, respectively. In one study, children with FASD were found to be impaired on emotion-related or hot executive function, however, very few researchers have examined hot executive functioning in FASD and even less have looked at ‘real-world’ executive functioning behaviors in FASD. One test that aims to evaluate a child’s executive functioning behaviors in a real-world setting is the Behavior Rating Inventory of Executive Function, or BRIEF. The arrival of the BRIEF has provided a welcome alternative to prevailing neuropsychological tests that are largely modified versions of adult measures. Unlike these traditional tests, which are administered under regulated laboratory conditions, the BRIEF is a parental and teacher rating scale of a child’s executive functioning behaviors in everyday situations and settings, measured across eight domains/subscales (Inhibit, Shift, Emotional F Parental ratings of children with fetal alcohol spectrum disorder on the behaviour rating inventory of executive function (BRIEF) J FAS Int 2007;5:e2 –February 5, 2007 © Hospital for Sick Children 2007 2 Control, Initiate, Working Memory, Plan/Organize, Organization of Materials, and Monitor). The BRIEF appears to uniquely evaluate a set of metacognitive, behavioral, and emotional abilities that go beyond common psychopathology and behavioral disturbances measured by other behavior rating scales. Both Baron and Donders attest to the BRIEF’s sound psychometric properties and believe it has potential clinical utility for capturing areas of dysfunction not currently measured by alternative instruments. Some researchers have suggested that the behaviors measured on the BRIEF may be involved in the brain area that is important for emotional and behavior skills (i.e., hot executive functions) rather than areas more related to cognition-based or cool executive function. Anderson et al. looked at the relationship between traditional cognitive executive functioning tests and the BRIEF among children with early treated Phenylketonuria (PKU), Hydrocephalus, and frontal focal lesions. All children showed significant dysfunction on the BRIEF, but the children with frontal lobe damage exhibited the greatest executive dysfunction. These results indicate that the BRIEF may tap into behavioral symptoms specific to frontal lobe systems, which are thought to be involved in executive functioning. Very low correlations between behavioral and cognitive instruments were also found, suggesting that cognitive and behavioral measures may be tapping into different dimensions of executive functioning. Similar to Zelazo and Muller, Anderson et al. suggest that cognitive aspects of executive functioning are associated with the dorsolateral prefrontal cortex, whereas the orbito-frontal regions of the cortex mediate the emotional and social aspects of executive functioning. Anderson et al. also suggest that the low correlations may be due to the different test administrations used. For instance, cognitive tests are typically given in a structured laboratory setting, whereas the BRIEF involves naturalistic observations of the child’s day-to-day behavior. Vriezen and Pigott found that among children with moderate to severe traumatic brain injury (TBI), BRIEF scores did not correlate with impairments on performance-based measures of executive functioning. More children were found to be impaired based on the BRIEF than on any other performance-based executive functioning tests indicating that children can perform relatively well on highly structured neuropsychological tests and still have great difficulties in daily life. The authors suggest that the BRIEF measures a unique aspect of executive functioning. The BRIEF has been validated as a multidimensional measure of executive functioning abilities for a mixed diagnosis clinical group, which allows for broad generalization. However, Gioia, Isquith, Kenworthy and Barton also believe that with further study of specific clinical populations the BRIEF may help achieve “disorder-specific executive profiles.” The BRIEF has thus far been useful in identifying differences in disorders such as ADHD, autism spectrum disorder (ASD), reading disabilities, and TBI. The BRIEF shows great promise in highlighting differences between different neurodevelopmental profiles without being a diagnostic tool per se. Although there is ample research on the use of the BRIEF for children with other neurodevelopmental disorders, to our knowledge, there has only been one published study on the BRIEF and FASD. In this previous study, children with FASD displayed considerable deficits on the BRIEF. The BRIEF was not the focus of this study (it was one of many neurobehavioral measures) and the sample size was relatively small (n=31), which did not allow for a detailed analysis of the data. Nevertheless, some interesting, albeit preliminary, patterns emerged with children showing most difficulty on the Plan/Organize and Working Memory scales on the BRIEF and least difficulty on Organization of Materials. Also, girls tended to have higher scores (indicating more difficulty relative to their peers) than boys. Age effects were not observed but this analysis may have been constrained by the small sample size over a large age range. This research provided initial evidence regarding patterns of performance of children with FASD on the BRIEF and calls for a more detailed study specially examining the BRIEF among a larger sample of children with FASD. The goal of the current study was to conduct a more detailed examination of performance on the BRIEF among 64 children (aged 5 to 16 years) with FASD, who were a different sample of children as in Rasmussen et al. First, we wanted to determine whether children with FASD showed deficits on the BRIEF, and more importantly, whether they showed a distinctive pattern of strengths and Parental ratings of children with fetal alcohol spectrum disorder on the behaviour rating inventory of executive function (BRIEF) J FAS Int 2007;5:e2 –February 5, 2007 © Hospital for Sick Children 2007 3 weaknesses on scales of the BRIEF. This is important for determining whether there are aspects of executive functioning that are particularly difficult for children with FASD, or conversely whether there are areas of strength within the domain of executive functioning. Such information is important for developing instruction and remediation that can target specific areas of weakness or build upon areas of strength. Given that working memory is a significant area of difficulty for children with FASD and was one of the lowest scales on the BRIEF in Rasmussen et al., we hypothesized that the working memory subscale would be a significant area of deficit on the BRIEF among this sample. Second, we examined whether gender and age were related to performance on the BRIEF. We hypothesized that, similar to Rasmussen et al. girls, would have higher scores (indicating more difficulty) than boys, but in the current study we also examined the specific subscales of the BRIEF that are responsible for this gender effect. This comparison will help us determine which aspects of executive functioning are particularly difficult for girls with FASD. Although we did not observe age effect in Rasmussen et al., in a recent study we found that on a cognitive-based assessment of executive functioning, older children with FASD showed more difficulty (relative to the norm) than younger children on some tests, suggesting that some executive functioning deficits may become pronounced with age in FASD. Thus, we hypothesized that children with FASD will show more difficulty with age (relative to normative scores) on a behavioral measure of executive functioning, in accordance with the findings of Rasmussen and Bisanz with a cognition-based executive functioning test. This comparison is important for understanding the developmental trajectory of executive function deficits in FASD, which has strong implications for diagnosis and remediation.