BRIEFBRIEF®®: : Behavior Rating Behavior Rating

Inventory of Executive Inventory of Executive FunctionFunction®®

Authors: Gerard A. Gioia, PhD, Peter K. Isquith, Authors: Gerard A. Gioia, PhD, Peter K. Isquith, PhD, Steven C. Guy, PhD, and Lauren Kenworthy, PhD, Steven C. Guy, PhD, and Lauren Kenworthy,

PhDPhD

Publisher: PAR, Inc.Publisher: PAR, Inc.

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BRIEF AuthorsBRIEF Authors

Gerard A. Gioia, Children’s National Gerard A. Gioia, Children’s National Medical CenterMedical Center

Peter K. Isquith, Dartmouth Medical Peter K. Isquith, Dartmouth Medical SchoolSchool

Robert M. Roth, Dartmouth Medical Robert M. Roth, Dartmouth Medical SchoolSchool

Steven C. Guy, Independent PracticeSteven C. Guy, Independent Practice Lauren Kenworthy, Children’s National Lauren Kenworthy, Children’s National

Medical CenterMedical Center Kimberly Andrews Espy, Vice Provost, Kimberly Andrews Espy, Vice Provost,

University of Nebraska, LincolnUniversity of Nebraska, Lincoln

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Purpose:Purpose: Assess impairment of Assess impairment of executive functionexecutive function

For:For: Ages 5-18 years Ages 5-18 years Administration:Administration: Individual, 86 items Individual, 86 items Time:Time: 10-15 minutes to administer; 10-15 minutes to administer;

15-20 minutes to score by hand, 15-20 minutes to score by hand, software available for scoring and software available for scoring and interpretationinterpretation

Overview of the BRIEFOverview of the BRIEF

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Overview of the BRIEFOverview of the BRIEF Utilizes parent and teacher input in the Utilizes parent and teacher input in the

evaluation of the child’s behavioral evaluation of the child’s behavioral functioningfunctioning

The BRIEF is useful in evaluating children The BRIEF is useful in evaluating children with a wide spectrum of developmental with a wide spectrum of developmental and acquired neurological conditions, and acquired neurological conditions, such as:such as:

Learning disabilities Learning disabilities Low birth weight Low birth weight Attention-deficit/hyperactivity disorder Attention-deficit/hyperactivity disorder Tourette's disorder Tourette's disorder Traumatic brain injury Traumatic brain injury Pervasive developmental disorders/autism Pervasive developmental disorders/autism

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Interest in Executive Interest in Executive Function in Children Function in Children 5 articles in 19855 articles in 1985

14 articles in 199514 articles in 1995

501 articles in 2005501 articles in 2005

Bernstein & Waber, Bernstein & Waber,

Executive Function in Executive Function in

Education, 2007Education, 2007 0

100

200

300

400

500

600

1985 1995 2005

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Methods of Assessing Methods of Assessing EFEF

MicroMicro MacroMacro

PerformancePerformanceTestsTests

ObservationsObservationsStructural &Structural &Functional Functional

ImagingImaging

GeneticsGenetics

3 4

Goal:

Problem:

Count the number of moves

4045

5055

6065

70

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Measurement of Measurement of Executive FunctionsExecutive Functions Executive functions are dynamic, fluidExecutive functions are dynamic, fluid No formal, single test adequate to No formal, single test adequate to

capture EFcapture EF Many tests are too structured to Many tests are too structured to

adequately assess EFadequately assess EF Need intra-individual approachNeed intra-individual approach ““Executive” is often provided by the Executive” is often provided by the

examinerexaminer

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Limitations of Limitations of Performance TestsPerformance Tests EF tests are molar, tapping several EF and non-EF EF tests are molar, tapping several EF and non-EF

functions that can be disrupted in many waysfunctions that can be disrupted in many ways Differences in cognitive “style” or ability can affectDifferences in cognitive “style” or ability can affect

EF performance regardless of EFEF performance regardless of EF Sensitivity/Specificity limited − Patients who Sensitivity/Specificity limited − Patients who

should have EF deficits do well on EF tests; EF should have EF deficits do well on EF tests; EF performance not sensitive to frontal vs. extra-performance not sensitive to frontal vs. extra-frontal lesionsfrontal lesions

Discriminant Validity − If EF tasks are impaired in Discriminant Validity − If EF tasks are impaired in several disorders, then EFs are not helpful in several disorders, then EFs are not helpful in distinguishing between disordersdistinguishing between disorders

Pennington & Ozonoff, 1996Pennington & Ozonoff, 1996

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ImpetusImpetus

Clinical need for efficient external Clinical need for efficient external validationvalidation

Collect standardized observational Collect standardized observational reports of everyday functioningreports of everyday functioning

Ecological validity, real-world anchorEcological validity, real-world anchor Common parent descriptions of Common parent descriptions of

everyday executive difficultieseveryday executive difficulties Frustration with available performance Frustration with available performance

teststests

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Purpose: provide a measure Purpose: provide a measure of executive function that is:of executive function that is:

psychometrically sound psychometrically sound sensitive to developmental changessensitive to developmental changes high in ecological validity high in ecological validity sufficiently broad to serve as a screen sufficiently broad to serve as a screen comprehensive in sampling contentcomprehensive in sampling content theoretically coherenttheoretically coherent useful in targeting treatmentuseful in targeting treatment

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The BRIEF consists of two rating formsThe BRIEF consists of two rating forms Parent Parent TeacherTeacher

86 items on both questionnaires86 items on both questionnaires

Purpose of the BRIEFPurpose of the BRIEF

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Additional BRIEF ProductsAdditional BRIEF Products

BRIEF Preschool (Ages 3-5 years)BRIEF Preschool (Ages 3-5 years)

BRIEF Self-Report (Ages 13-18 years)BRIEF Self-Report (Ages 13-18 years)

BRIEF Software (Scoring & Reporting)BRIEF Software (Scoring & Reporting)

BRIEF Adult (Ages 18-90 years)BRIEF Adult (Ages 18-90 years)

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A BRIEF Genealogy

20002000 2003 2003 2004 200420052005

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Meta-Cognition

BehavioralRegulation

Working Memory

Initiate

Plan/Organize

Inhibit

Shift

Emotional Control

Monitor

Organizationof Materials

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Behavioral Definitions for Behavioral Definitions for the Clinical Scalesthe Clinical Scales

Inhibit: Control impulses; stop behaviorInhibit: Control impulses; stop behavior

Shift: Move freely from one Shift: Move freely from one activity/situation to another; transition; activity/situation to another; transition; problem-solve flexiblyproblem-solve flexibly

Emotional Control: Modulate emotional Emotional Control: Modulate emotional responses appropriatelyresponses appropriately

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Behavioral Definitions for Behavioral Definitions for the Clinical Scalesthe Clinical Scales

Initiate: Begin activity; generate ideasInitiate: Begin activity; generate ideas

Working Memory: Hold information in Working Memory: Hold information in mind for purpose of completing a taskmind for purpose of completing a task

Plan/Organize: Anticipate future events; Plan/Organize: Anticipate future events; set goals; develop steps; grasp main ideasset goals; develop steps; grasp main ideas

Monitor: Check work; assess own Monitor: Check work; assess own performanceperformance

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Administering the Administering the BRIEF Parent FormBRIEF Parent Form

Materials: Parent Form and a pen/pencilMaterials: Parent Form and a pen/pencil Parent Form is filled out by a parent; Parent Form is filled out by a parent;

preferably, by both parentspreferably, by both parents Parent must have recent and extensive Parent must have recent and extensive

contact with the child over the past 6 contact with the child over the past 6 monthsmonths

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Administering the Administering the BRIEF Teacher FormBRIEF Teacher Form

Can be filled out by any adult with Can be filled out by any adult with extended contact with the child in an extended contact with the child in an academic setting; typically a teacher, academic setting; typically a teacher, but an aide is acceptable but an aide is acceptable

Minimum familiarity is 1 month Minimum familiarity is 1 month Multiple ratings across classrooms may Multiple ratings across classrooms may

be useful for comparison purposesbe useful for comparison purposes

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Scoring the Scoring the BRIEF Parent/Teacher FormsBRIEF Parent/Teacher Forms

Calculate the raw score by transferring Calculate the raw score by transferring the circled responses to the box for the circled responses to the box for that itemthat item

Sum the scores in each column and Sum the scores in each column and record the sum in the box for that record the sum in the box for that columncolumn

Transfer the summed scores from page Transfer the summed scores from page 1 to the appropriate box on page 2 and 1 to the appropriate box on page 2 and then sum the scores for each scalethen sum the scores for each scale

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Scoring the Scoring the Negativity ScaleNegativity Scale

To score the Negativity scale, find all To score the Negativity scale, find all of the “N” items that received a score of the “N” items that received a score of 3of 3

Sum the number of “N” items that Sum the number of “N” items that received a score of 3 and record that received a score of 3 and record that number in the Negativity scale box in number in the Negativity scale box in the Scoring Summary/Profile Formthe Scoring Summary/Profile Form

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Scoring the Scoring the Inconsistency ScaleInconsistency Scale

Scoring the Inconsistency scale is Scoring the Inconsistency scale is more complex and requires greater more complex and requires greater attention to detailattention to detail

Inconsistency items have an I in the Inconsistency items have an I in the margin of the scoring sheetmargin of the scoring sheet

Transfer the scores for the 10 item Transfer the scores for the 10 item pairs to the appropriate boxes on the pairs to the appropriate boxes on the Scoring Summary/Profile FormScoring Summary/Profile Form

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Scoring the Scoring the Inconsistency ScaleInconsistency Scale

For each item pair, calculate the For each item pair, calculate the absolute value of the difference for absolute value of the difference for the itemsthe items

Then, sum the difference values for Then, sum the difference values for the 10 pairs to obtain the the 10 pairs to obtain the Inconsistency scale scoreInconsistency scale score

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Obtaining Standard Scores for Obtaining Standard Scores for the BRIEF Parent/Teacher the BRIEF Parent/Teacher FormsForms Once raw scores for all scales are Once raw scores for all scales are

obtained, find the appropriate table in obtained, find the appropriate table in the appendixesthe appendixes

Tables are broken down by form Tables are broken down by form (Parent/Teacher), age, and gender of(Parent/Teacher), age, and gender ofthe childthe child

Standard scores have a mean of 50 Standard scores have a mean of 50 and a and a SDSD of 10; percentile ranks also of 10; percentile ranks also are available in the tablesare available in the tables

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Comparison TablesComparison Tables

Separate normative tables for both the Separate normative tables for both the Parent and Teacher Forms provide Parent and Teacher Forms provide TT scores, percentiles, and 90% scores, percentiles, and 90% confidence intervals for four confidence intervals for four developmental age groups (5-18 developmental age groups (5-18 years) by gender of the childyears) by gender of the child

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JoshuaJoshua

ADHD - Combined TypeADHD - Combined Type

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Computerized ScoringComputerized Scoring

BRIEF Software Portfolio (BRIEF-SP) BRIEF Software Portfolio (BRIEF-SP) provides unlimited scoring and report provides unlimited scoring and report generation for the BRIEF Parent Form, generation for the BRIEF Parent Form, the BRIEF Teacher Form, the BRIEF-SR, the BRIEF Teacher Form, the BRIEF-SR, the BRIEF-P Parent Form, and the the BRIEF-P Parent Form, and the BRIEF-P Teacher Form. Three reports BRIEF-P Teacher Form. Three reports are available − an Interpretive Report, are available − an Interpretive Report, a Feedback Report, and a Protocol a Feedback Report, and a Protocol Summary Report.Summary Report.

Separate software is available for the Separate software is available for the BRIEF-P only and the BRIEF-A only.BRIEF-P only and the BRIEF-A only.

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Interpreting the Interpreting the BRIEF Parent/Teacher BRIEF Parent/Teacher FormsForms All results should be viewed in the All results should be viewed in the

context of a complete evaluationcontext of a complete evaluation

High scores do not indicate “A High scores do not indicate “A Disorder of Executive Function” Disorder of Executive Function”

Problems may be developmental or Problems may be developmental or acquired and, thus, are suggestive of acquired and, thus, are suggestive of differing treatment approachesdiffering treatment approaches

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Steps to BRIEF Steps to BRIEF InterpretationInterpretation Examine validity scalesExamine validity scales

InconsistencyInconsistency NegativityNegativity

Examine clinical scalesExamine clinical scales Examine indexes, Global Executive Examine indexes, Global Executive

CompositeComposite Individual item analysisIndividual item analysis

Within scale itemsWithin scale items Nonscale itemsNonscale items

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InterpretationInterpretation T T scores at the Domain level; higher scores scores at the Domain level; higher scores

suggest a higher level of dysfunction suggest a higher level of dysfunction For the Inconsistency scale, look at scores For the Inconsistency scale, look at scores

≥≥7 as indicative of a high degree of 7 as indicative of a high degree of inconsistency in rater responseinconsistency in rater response

A high Negativity scale score indicates the A high Negativity scale score indicates the degree to which the respondent answers degree to which the respondent answers selected questions in an unusually negative selected questions in an unusually negative manner. “Is information consistent with manner. “Is information consistent with other sources?”other sources?”

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Interpretive OptionsInterpretive Options

Professional Manual Professional Manual

Computer Scoring and Interpretive Computer Scoring and Interpretive ReportingReporting

Integrated ReportingIntegrated Reporting

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BRIEF BasicsBRIEF Basics

BRIEFBRIEF BRIEF-PBRIEF-P BRIEF-SRBRIEF-SR BRIEF-ABRIEF-AItems / Items / ScalesScales

86/886/8 63/563/5 80/880/8 75/975/9

αα .80-.90s.80-.90s .80-.90s.80-.90s .80-.90s.80-.90s .93-.98s.93-.98s

RetestRetest .80-.90s.80-.90s .80-.90s.80-.90s .80-.90s.80-.90s .94-.96s.94-.96s

Inter-Inter-raterrater

Parent – Parent – TeacherTeacher

rr = .30 = .30

Parent – Parent – TeacherTeacher

rr = .17 - .28 = .17 - .28

Self – Parent Self – Parent = .50= .50

Self –Teacher Self –Teacher = .25= .25

Self–Informant = Self–Informant = .64.64

CovaryCovary BASC, CBCL, BASC, CBCL, ADHD-IVADHD-IV

CBCL, CBCL,

ADHD-IVADHD-IVCBCL, BASC, CBCL, BASC,

ADHD-IV, CHQADHD-IV, CHQBDI, FrSBe, DEX, BDI, FrSBe, DEX,

CAD, STAICAD, STAI

Clinical Clinical groupsgroups

ADHD, LD, TS, ADHD, LD, TS, ASD, Frontal ASD, Frontal

lesion, lesion, PKU,TraumaPKU,Trauma

ASD, ADHD, ASD, ADHD, Language, LBWLanguage, LBW

ADHD, ASD, ADHD, ASD, Anx/Dep,Anx/Dep,DM (T1)DM (T1)

ADHD, MCI, TBI, ADHD, MCI, TBI, MS, Epilepsy MS, Epilepsy

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ReliabilityReliability

High internal consistency (High internal consistency (αα = .80-.98) = .80-.98)

Test-retest reliabilityTest-retest reliabilityrrs = .82 for parents and .88 for s = .82 for parents and .88 for teachers; teachers; moderate correlations between moderate correlations between teacher and parent ratings (teacher and parent ratings (rrs s = .32-.34) = .32-.34)

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ValidityValidity

Convergent validityConvergent validity established with established with other measures: inattention, other measures: inattention, impulsivity, and learning skills impulsivity, and learning skills

Divergent validityDivergent validity demonstrated demonstrated against measures of emotional and against measures of emotional and behavioral functioning behavioral functioning

Working Memory and Inhibit Working Memory and Inhibit scalesscales differentiate among ADHD differentiate among ADHD subtypessubtypes

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Standardization PopulationStandardization Population

Normative data based on child ratings Normative data based on child ratings from 1,419 parents and 720 teachers from 1,419 parents and 720 teachers from rural, suburban, and urban areas, from rural, suburban, and urban areas, reflecting 1999 U.S. Census estimates reflecting 1999 U.S. Census estimates for SES, ethnicity, and gender for SES, ethnicity, and gender distribution distribution

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Clinical Standardization Clinical Standardization PopulationPopulation Clinical sample included children with Clinical sample included children with

developmental disorders or acquired developmental disorders or acquired neurological disorders (e.g., reading neurological disorders (e.g., reading disorder, ADHD subtypes, TBI, disorder, ADHD subtypes, TBI, Tourette's disorder, mental Tourette's disorder, mental retardation, localized brain lesions, retardation, localized brain lesions, high functioning autism) high functioning autism)

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Diagnostic Group StudiesDiagnostic Group Studies Reading DisordersReading Disorders

Working Memory: Reading > ControlsWorking Memory: Reading > Controls Plan/Organize: Reading > ControlsPlan/Organize: Reading > Controls

– B. Pratt, F. Campbell-LaVoie, P. Isquith, G. Gioia, & S. B. Pratt, F. Campbell-LaVoie, P. Isquith, G. Gioia, & S. GuyGuy

Extremely Low Birth Weight vs VLBWExtremely Low Birth Weight vs VLBW Monitor, WM, Shift, Inhibit, Init, Plan/Org: Monitor, WM, Shift, Inhibit, Init, Plan/Org:

ELBW > ControlsELBW > Controls Initiate & Plan/Org: ELBW > VLBWInitiate & Plan/Org: ELBW > VLBW

– G. Taylor, et al.G. Taylor, et al.

Mental RetardationMental Retardation Working Memory: MR > ControlsWorking Memory: MR > Controls

– B. Pratt & T. ChapmanB. Pratt & T. Chapman

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Diagnostic Group StudiesDiagnostic Group Studies

High Functioning AutismHigh Functioning Autism All BRIEF scales: HFA > ControlsAll BRIEF scales: HFA > Controls

– R. Landa & M. GoldbergR. Landa & M. Goldberg

Pervasive Developmental DisordersPervasive Developmental Disorders All BRIEF scales: PDD > ControlsAll BRIEF scales: PDD > Controls

– L. Kenworthy & S. GuyL. Kenworthy & S. Guy

Frontal vs. Extrafrontal LesionsFrontal vs. Extrafrontal Lesions All scales: Frontal & Extrafrontal > ControlsAll scales: Frontal & Extrafrontal > Controls Inhibit:Inhibit: Frontal > Extrafrontal > ControlsFrontal > Extrafrontal > Controls

– R. Jacobs, V. Anderson, & S. HarveyR. Jacobs, V. Anderson, & S. Harvey

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Case ExampleCase Example

Joshua:Joshua: 8-year-old left-handed male8-year-old left-handed male Attention-Deficit/Hyperactivity Attention-Deficit/Hyperactivity

Disorder, Disorder,

Combined TypeCombined Type

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JoshuaJoshua

ADHD - Combined TypeADHD - Combined Type

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JoshuaJoshua

ADHD - Combined TypeADHD - Combined Type

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BRIEF Clinical Studies ADHD - - Jarratt et al., 2005; Loftis, 2005; Viechnicki, 2005; Lawrence et al., Jarratt et al., 2005; Loftis, 2005; Viechnicki, 2005; Lawrence et al.,

2004; Blake-2004; Blake- Greenberg, 2003; Palencia, 2003; Kenealy, 2002; Mahone et Greenberg, 2003; Palencia, 2003; Kenealy, 2002; Mahone et al., 2002.al., 2002.

Reading disorders - Gioia et al., 2002; Pratt, 2000.- Gioia et al., 2002; Pratt, 2000. Autism spectrum disorders - Gilotty et al., 2002; Gioia et al., 2002.- Gilotty et al., 2002; Gioia et al., 2002. Bipolar disorder vs. ADHD - Shear et al., 2002.- Shear et al., 2002. Tourette’s syndrome - Mahone et al., 2002; Cummings et al., 2002.- Mahone et al., 2002; Cummings et al., 2002. Traumatic brain injury - - Landry et al., 2004; Brookshire et al., 2004; Landry et al., 2004; Brookshire et al., 2004;

Gioia et al., 2004; Mangeot et al., 2002; Vriezen et al., 2002; Jacobs, 2002.Gioia et al., 2004; Mangeot et al., 2002; Vriezen et al., 2002; Jacobs, 2002. Media violence exposure - Kronenberger et al. 2005.Kronenberger et al. 2005. Spina bifida and hydrocephalus - - Burmeister et al., 2005; Brown, Burmeister et al., 2005; Brown,

2005; Mahone et al., 2002.2005; Mahone et al., 2002. Obstructive sleep apnea - Beebe, 2004, 2002.Beebe, 2004, 2002.

Galactosemia - - Antshel et al., 2004.Antshel et al., 2004.

Childhood onset MS - McCann et al., 2004.McCann et al., 2004. Sickle cell - Kral et al., 2004. - Kral et al., 2004. 22q11 deletion - - Kiley-Brabeck, 2004.Kiley-Brabeck, 2004. PKU - - Antshel et al., 2003.Antshel et al., 2003. Frontal lesions, PKU & hydrocephalus - - Anderson et al., 2002.Anderson et al., 2002.