Assessment of Executive Functions in Preschool-Aged Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice

Abstract

This study examines the context of executive functioning in preschool children with Autism Spectrum Disorders (ASDs) and verifies the degree of agreement between the compilation of the Behavior Rating Inventory of Executive Functions-Preschool Version (BRIEF-P) by parents and therapists. To this end, parents and professionals of 46 ASD children aged between 24 and 71 months completed the BRIEF-P in order to highlight the level of agreement between these two different evaluators and then investigate the correlations between executive functions impairment, the degree of autistic symptomatology, the level of cognitive development, the chronological age and the therapy duration. The results showed that parents tend to underestimate the impairment of executive functions in ASD children compared to what estimated by specialized operators. A low level of agreement was found between the two evaluators. Moreover, both for parents and professionals, the EF impairment was not related to the severity of autistic symptoms, assessed with the ADOS-2, while it was correlated to cognitive development in professional evaluations, and to chronological age and therapy duration in parental evaluations. These results indicate that, even if among the pathogenic assumptions about ASDs there has been included also that of the EF impairment, this, if present, does not correlate with the severity of autistic symptoms. With regard to cognitive development, the greater correlation between cognitive and executive impairment seems to be rather obvious. The use of the BRIEF-P completed by parents allows them a greater awareness but does not add clinical data to the diagnosis.

Full text

Assessment of Executive Functions in Preschool-Aged Children with
Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in
Clinical Practice
Magda Di Renzo*, Federico Bianchi di Castelbianco, Elena Vanadia, Massimiliano Petrillo, Lidia Racinaro, Mirko Stracqualursi and Monica Rea
Institute of Ortofonologia (IdO), Via Salaria, 30-00198-Rome, Italy
*Corresponding author: Magda Di Renzo, Institute of Ortofonologia (IdO), Via Salaria, 30-00198-Rome, Italy, Tel: 0039-068542038; E-mail:
m.direnzo@ortofonologia.it
Received Date: September 29, 2016, Accepted date: October 15, 2016, Published date: October 25, 2016
Copyright: 2016© Renzo MD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
This study examines the context of executive functioning in preschool children with Autism Spectrum Disorders
(ASDs) and verifies the degree of agreement between the compilation of the Behavior Rating Inventory of Executive
Functions-Preschool Version (BRIEF-P) by parents and therapists. To this end, parents and professionals of 46 ASD
children aged between 24 and 71 months completed the BRIEF-P in order to highlight the level of agreement
between these two different evaluators and then investigate the correlations between executive functions
impairment, the degree of autistic symptomatology, the level of cognitive development, the chronological age and
the therapy duration. The results showed that parents tend to underestimate the impairment of executive functions in
ASD children compared to what estimated by specialized operators. A low level of agreement was found between
the two evaluators. Moreover, both for parents and professionals, the EF impairment was not related to the severity
of autistic symptoms, assessed with the ADOS-2, while it was correlated to cognitive development in professional
evaluations, and to chronological age and therapy duration in parental evaluations. These results indicate that, even
if among the pathogenic assumptions about ASDs there has been included also that of the EF impairment, this, if
present, does not correlate with the severity of autistic symptoms. With regard to cognitive development, the greater
correlation between cognitive and executive impairment seems to be rather obvious. The use of the BRIEF-P
completed by parents allows them a greater awareness but does not add clinical data to the diagnosis.
Keywords: Executive functions; Autism spectrum disorders; BRIEF-
P; Parental evaluation; Professional evaluation; Cognitive impairment
Introduction
e Executive Functions (EF) are a set of mental processes that are
responsible for the control and the monitoring of higher-level
cognitive, emotional and behavioral skills, characterized by voluntary
control processes and organized according to a goal oriented to
problem solving. ese functional modules of the mind regulate the
planning, control and coordination processes of the cognitive system
and govern the activation and modulation of cognitive schemes and
processes. Welsh and Pennington [1] described the early development
of executive functions in terms of ability to maintain a suitable system
of problem solving to achieve objectives. Stuss and Benson [2]
presented a set of interrelated skills in intentional problem solving that
includes the anticipation, the goal selection, the planning, the
monitoring and use of feedback.
e hierarchical model proposed by the authors highlights
important aspects of executive functions involved in complex cognitive
levels as the anticipation, the evaluation, the self-awareness and the
decision making. e specic sub-domains, which constitute this set of
regulation and control functions, include the ability to start a behavior,
to inhibit actions or competing stimuli, to select, plan and organize
solutions, exibly change cognitive and behavioral strategies during
the evaluation of the procedures used. It is worth noting that the
executive functions are not exclusive of the operation and of cognitive
control, but are involved in the regulation of the emotional and
behavioral responses so fundamental in the development of the social-
cognitive, emotional and relational capacity to adapt. In
neurodevelopment, the EF gradually emerge and change across the
lifespan of an individual and can be improved or adversely aected at
any time by a variety of events. en, the neurodevelopmental
disorders seem to dene uneven patterns of functioning in preschool
children and adolescents [3,4]. e direct clinical evaluation of the EF
has been very problematic because of the variability and dynamic
components that distinguish them, especially in the preschool for the
limitations in verbal and motor skills in this age group [5]. For this
reason the informations coming from parents, teachers and/or
therapists who have an ongoing relationship with the child in everyday
situations, may be useful in terms of ecological validity, as not
intrusive, and allows the observation of current or emergent behaviors.
According to the literature, since the executive functions are crucial
in social adaptation processes, in cognitive and linguistic development
and interpersonal and communication skills, their assessment could be
an important element in dening proles of individual development in
children with Autism Spectrum Disorders (ASDs), where the
neurodevelopment is characterized by social and cognitive decits,
with severe socio-emotional reciprocity and communication
impairments, in the presence of restricted and repetitive behaviors [6].
In conclusion, the objective of this research was to identify the
impairment of the EF assessment of children with ASD, by correlating
the scores obtained from parents and professionals, and evaluate the
relation between the EF impairment and the Autism Diagnostic
Observation Schedule-Second Edition (ADOS-2) scores, with
children’s age, IQ and duration of therapy. We would, in fact,
Journal of Child & Adolescent
Behavior Renzo, et al., J Child Adolesc Behav 2016, 4:5
DOI: 10.4172/2375-4494.1000313
Research Article OMICS International
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313

investigate the correlations between the development of executive
functions and the autistic symptoms, the level of cognitive
development, the chronological age and the time of therapy.
Method
Participants
Participants of the study were 46 preschool children, aged between
24 and 71 months (M=42.74 ± 13.4). All children received an Autism
Spectrum Disorder (ASDs) diagnosis according both to the ADOS-2
scores and to the clinical assessment based on the DSM-5 diagnostic
criteria. e children involved in the research were attending the
school on average from 5.8 months (SD=7.7; range in months: 0-33).
Autism (N=46)
Variable
Male, %
Italian, %
Asian,%
Eastern Europe, %
82.8
91.3
4.3
4.3
SES, %
Low
Medium
High
10.0
75.0
5.0
Chronological Age, in months
Mean (SD)
Range
42.7 (13.4)
24-71
Therapy duration, in months
Mean (SD)
Range
6.5 (5.7)
3-22
ADOS-2 Module, %
Module 1
Module 2
Toddler
67.4
4.3
28.3
Table 1: Descriptive characteristics of 46 children with autism
spectrum disorder.
e Table 1 describes the demographic characteristics of the sample.
As expected from the ADOS-2, according to chronological age and
level of expressive language, 30 of 46 children were assessed with
ADOS-2 Module 1 and achieved an average score of 18:43 ± 4.9 (range
9-26); 2 children were assessed with the ADOS-2 Module-2 and
achieved an average score of 7.50 ± 0.7 (range 7-8), and 14 children
were assessed with the Toddler Form of the ADOS-2 obtaining an
average score of 18.80 ± 5.2 (range 6-25). In the sample there were 36
males and 10 females consistent with a recent research about ASD
indicating a 3.1: 1 male to female prevalence ratio (Nicholas et al.
2008). At the time of the rst assessment, in children it was not present
a form of verbal language, so their cognitive level was evaluated
through the Leiter International Performance Scale (Leiter-R). 28 of
the 46 children in the sample have one or more siblings. Of these, 10
children have a sibling with specic needs (4 children have a twin with
ASD; 3 children have a sibling with speech disorder; 3 children have a
sibling with emotional disorder).
Measures
e autism diagnostic observation schedule, second edition
e Autism Diagnostic Observation Schedule-Second Edition
(ADOS-2) [7] is a semi-structured standardized assessment
concerning the areas of communication, social interaction, play, and
repetitive and restricted behaviors. It is considered a gold standard so
being the most commonly standardized measure used in research
protocols. It has strong psychometric properties, including good
reliability and validity. e ADOS-2 includes ve modules, but during
the assessment process, just one module is administered and it is
selected on the basis of the expressive language level and chronological
age of the child:
Toddler Module: For children between 12 and 30 months of age
who do not constantly use sentences in their speech. is module
allows you to precisely identify children at risk of autism spectrum
disorders (ASD);
Module 1: For children aged from 31 months who do not
continuously use sentences in their speech;
Module 2: For children of all ages who use sentences in the speech,
without being verbally uent;
Module 3: For verbally uent children and adolescents;
Module 4: For verbally uent older adolescents and adults.
In Modules 1 to 4, the algorithm scores are compared to get one of
three classications: Autism, Autism Spectrum, and Not Spectrum.
e cut-o for the ADOS-2 classications ADOS-2 varies according to
the module used and to the child's language level. e ADOS-2, in
addition to providing an overall score, also measures the domain of
Social Aection (SA) and the domain of Repetitive and Restricted
Behaviors (RRB). e SA includes the evaluation of aspects related to
communication and reciprocal social interaction. e RRB includes
unusual sensory interests, mannerisms, repetitive interests and
behaviors and stereotyped-idiosyncratic use of words and/or
vocalizations.
Leiter-R
e Leiter International Performance Scale-Revised (Leiter-R) [8] is
designed for the evaluation of intellectual functions of children and
adolescents aged between 2 and 20 years. e Leiter-R is formulated to
meet the clinical need of evaluating the non-verbal intelligence
through a comprehensive analysis of the strengths and weaknesses of
the child, with a view to a diagnosis that includes both
neuropsychological and cognitive aspects. Nonverbal cognitive abilities
do not require the ability to perceive, manipulate and reason with
words and numbers, so that the scale can be administered completely
without the use of verbal language, including instructions, because it
does not require verbal responses from the subject. e validity
coecients of the IQ score was calculated for each age group (alpha .92
to .93). e Leiter-R has good evidence of its validity, with data from a
wide analysis from the criterion related studies, the accuracy of
classication of intellectual disability, and various studies related to the
construct. e IQ score has a mean of 100 and a standard deviation of
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) Assessment of Executive Functions in Preschool-Aged
Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice. J Child Adolesc Behav 4: 313. doi:
10.4172/2375-4494.1000313
Page 2 of 7
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313

15. e intellectual disability is indicated by a composite score that is
two standard deviations or more below the average, so that a score of
70 constitutes the borderline value.
Behavior rating inventory of executive functions-preschool
version (BRIEF-P)
e Behavior Rating Inventory of Executive Functions-Preschool
Version (BRIEF-P) [9] is a 63-item informant report of Executive
Functions in real world situations comprised of ve scales: Inhibit,
Shi, Emotional Control, Working Memory, Planning/Organization.
All subscales are collapsed into three broad indices: Inhibitory Self-
Control Index (ISCI), Flexibility Index (FI), and Emergent
Metacognition Index (EMI). Inhibit and Emotional Control scales
comprise the ISCI, the Shi and Emotional Control scales comprise
the FI, and the Working Memory and Planning/Organization scales
comprise the EMI. e ve scales are then collapsed into a Global
Executive Composite (GEC). e BRIEF-P asks parents to assign a
rating of "Never", "Sometimes" or "Oen" to each item, reecting how
much of a problem the behavior poses in their child. ese ratings are
then converted to a 1, 2, or 3 and results are reported as T-scores.
Higher scores on scales indicated greater impairment; T-scores ≥65
(i.e., 1.5 Standard Deviations [SD] ≥ the mean) show clinically
signicant ratings [10].
Procedures
Children with autism spectrum disorder and their families were
recruited during the period from January 2014 to January 2016, at the
Institute of Ortofonologia (IdO). e IdO works in agreement with the
National Health System for taking charge of ASD children and their
families. e Autism diagnosis was made by a group of experts
(psychologists, neuropsychiatrists, speech therapists and occupational
therapists) according to the DSM-5 criteria [6] and conrmed by the
ADOS-2 evaluations. Psychologists, psychotherapists and
neuropsychiatrists took care of the clinical assessment and of the
psychodiagnosis; parents and therapists who deal with the therapy and
the home care intervention for at least three months completed the
rating scales on the development of executive functions. All children
who exceeded the ADOS-2 clinical cut-o for the risk and/or for the
autism spectrum disorder diagnosis were included in the study.
Children with brain injury, genetic and metabolic disorders, sensory
disabilities, children over 72 months and under 24 months were not
taken into account in this research.
In the assessment process of their child (from 1 to 4 weeks from the
rst clinical consultation), parents are informed about the
characteristics of the autism spectrum disorder in general and of their
child in particular. When the children begin the therapeutic program
(immediately aer the diagnostic phase) they are involved in a
counseling program that provides, according to their needs, also group
meetings with other parents or therapy sessions together with their
children. is research meets the APA ethic guidelines. is study was
carried out in accordance with the recommendations of the 'name of
guidelines, name of committee' with written informed consent from all
subjects, in agreement with the Declaration of Helsinki.
Data analysis
We used the Statistical Package for Social Sciences (SPSS) version 19
for data analysis. Signicance level was set at alpha 0.05 (two-tailed).
Multivariate Analysis of Variance (MANOVA) was used to evaluate
dierences between respondents on BRIEF-P subscales. Eect sizes
were reported as partial eta squared (η2p), A η2p of 0.02 was
considered a small eect size, 0.13 a medium eect size and 0.23 a large
eect size. Correlation analysis was performed to analyze the
relationship between executive function, ASD symptoms, social
aection, restricted and repetitive behaviors, cognitive development,
chronological age and therapy duration.
Aims
e general objective of this study was to verify the level of
agreement in the BRIEF-P completion in the assessment of the
Executive Functions (EF) when used by professionals and parents of
preschool children with autism spectrum disorder and the possible
correlation between the degree of EF impairment and other
developmental parameters or disease. Specically we would:
1. Verify if the scores provided by parents and professionals to the
BRIEF-P were related to ADOS-2 and the Leiter-R scores;
2. Verify if the scores provided by parents and professionals to
BRIEF-P were related to children's age and therapy duration;
3. Verify if the ASD children presented clinically pathological levels
in the dierent domains of the EF, and in particular whether there
were specic domains more compromised than others in parents and
professionals’ evaluations;
4. Verify if parents and professionals’ evaluations were mutually
consistent.
Results
Descriptive analysis
Children of the research sample were divided, depending on the
ADOS-2 cut-o, in AUT children (N=26; ADOS-2 range 12-26), SpD
children (N=7; ADOS-2 range 7-14) and RISK children (N=13;
ADOS-2 range 6-25). We calculated the average of the IQ, ADOS-2,
RRB and SA scores and the descriptive analysis showed that AUT
children have an IQ score signicantly lower than children from the
other two subgroups; AUT and RISK children have a higher ADOS-2
score (thus more severe) than the SpD children, both as regards for the
total score that for the SA and the RRB (Table 2).
Parents report: e relationship between the BRIEF-P, the ADOS-2,
the Leiter-R scores, the chronological age and the therapy duration.
As reported in Table 3, the analysis of correlations between the
scores at the BRIEF-P completed by parents and the ADOS-2 scores
show that only the Emergent Metacognition (EMI) domain and of its
subscale, the Working Memory, positively correlates with the ADOS-2
total score and with the scores of Repetitive Behaviors and Social
Aection. As for the relationship with cognitive development, the IQ
positively correlates only with the domain of Emerging Metacognition.
Increasing children’s chronological age, parents evaluate as
compromised the Global Executive Functions (GEC), the Inhibitory
Self-Control (ISCI) domain and its subscales Inhibit and Emotional
Control, the Flexibility (FI) domain and its Shi subscale. Increasing
children’s period of therapy, parents identify as compromised the ISCI,
the FI and the Emotional Regulation domains.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) Assessment of Executive Functions in Preschool-Aged
Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice. J Child Adolesc Behav 4: 313. doi:
10.4172/2375-4494.1000313
Page 3 of 7
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313

ASD (N=46) AUT (N=26) SpD (N=7) Risk (N=13) Statistics
IQ 67.5 (19.8) 60.5 (18.7) 82.9 (21.4) 73.3 (15.1) AUT vs. SpD: P<0.05
AUT vs. Risk: NS
SpD vs. Risk: NS
ADOS-2 18.1 (5.4) 20.3 (3.6) 9.9 (2.3) 18.1 (5.5) AUT vs. SpD: P<0.001
AUT vs. Risk: NS
SpD vs. Risk: P<0.001
SA 14.3 (4.1) 15.8 (2.9) 8.6 (2.6) 14.4 (4.3) AUT vs. SpD: P<0.001
AUT vs. Risk: NS
SpD vs. Risk: P<0.001
RRB 3.8 (2.1) 4.5 (1.6) 1.3 (0.8) 3.7 (2.5) AUT vs. SpD: P<0.001
AUT vs. Risk: NS
SpD vs. Risk: P<0.05
Legend. ASD: children with autism spectrum disorders; AUT: autistic children; SpD: autism spectrum children; Risk: children at risk of autism; SA: Social Affective
Behavior; RRB: Restricted Repetitive Behavior
Table 2: Mean (SD) and between-group dierences in IQ, total ADOS-2, SA and RRB scores.
ADOSs SA RRB IQ CA Months of therapy$
Global Executive
Composite (GEC)
0.07 0.03 0.13 -0.24 0.38** 0.24
Inhibitory Self-Control
Index (ISCI)
-0.01 -0.04 0.04 -0.07 0.51** 0.30*
Flexibility Index (FI) -0.06 -0.09 0.01 0.07 0.41** 0.30*
Emergent Metacognition
Index (EMI)
0.34* 0.27 0.35* -0.30* 0.08 0.11
Inhibit -0.07 -0.09 0.01 -0.18 0.48** 0.26
Shift 0.00 -0.01 0.03 0. 0.13 0.32* 0.18
Emotional Control -0.11 -0.16 0.03 -0.05 0.46** 0.36*
Working Memory 0.34* 0.25* 0.38** -0.28 0.10 0.05
Planning/Organization 0.15 0.11 0.17 -0.24 0.16 0.20
Legend. ASD: children with autism spectrum disorders; AUT: autistic children; SpD: autism spectrum children; Risk: children at risk of autism; SA: Social Affective
Behavior; RRB: Restricted Repetitive Behavior
P<0.05; **P<0.01
$The duration of therapy, measured in months, has a range of 3-24 months.
Table 3: Correlations between the BRIEF-P scores completed by Parents and total ADOS scores, Social Aective behavior, Restricted Repetitive
Behavior, IQ, Chronological age and Months of therapy.
Professionals report: e relationship between the BRIEF-P, the
ADOS-2, the Leiter-R scores, the chronological age and the therapy
duration.
As reported in Table 4, the analysis of correlations between the
scores at the BRIEF-P completed by professionals and the ADOS-2
scores shows that only the Metacognition domain and of its subscale
Plan/Organize, positively correlates with the ADOS-2 total score and
with scores of Repetitive Behaviors and Social Aection.
In addition, the analysis shows that the lower the IQ scores of
children are, the most the professionals evaluate as compromised the
executive functions, both in the Global Executive Composite (GEC)
and in ISCI and FI, as well as in Shi and Emotional Control. As for
the chronological age of the children, we found that increasing it,
professionals evaluate as more compromised the ISCI and FI domains
as well as the Inhibit and Emotional Control areas. Finally, the therapy
duration is not correlated with the professionals’ BRIEF-P scores. Since
it was found a high correlation between the professionals’ BRIEF-P and
IQ scores, we veried the sensitivity and specicity of the
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) Assessment of Executive Functions in Preschool-Aged
Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice. J Child Adolesc Behav 4: 313. doi:
10.4172/2375-4494.1000313
Page 4 of 7
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313

questionnaire with respect to its ability to discriminate children above
and below a specic IQ cut-o. e cut-o (IQ score 67) has been
chosen because it represents the 50° percentile of the normal
distribution of the IQ scores in this research sample. From the analysis
of the GEC (that is the BRIEF-P overall score) emerged from the
professionals’ evaluations, it appeared that the questionnaire has good
sensitivity but low specicity in identifying children with high and low
IQ (35% specicity, 85% sensitivity).
ADOSs SA RRB IQ CA Months of therapy$
Global Executive
Composite (GEC)
0.17 0.15 0.13 -0.42** 0.19 0.03
Inhibitory Self-Control
Index (ISCI)
0.00 -0.01 0.02 -0.34* 0.37* 0.18
Flexibility Index (FI) -0.01 0.00 0.00 -0.30* 0.37* 0.18
Emergent
Metacognition Index
(EMI)
0.32* 0.30* 0.24 -0.36* -0.02 -0.12
Inhibit 0.00 -0.01 0.02 -0.34* 0.33* 0.16
Shift 0.03 0.03 0.00 -0.25 0.22 0.07
Emotional Control -0.02 -0.03 0.02 -0.27 0.46** 0.25
Working Memory 0.26 0.25 0.19 -0.30* -0.01 -0.14
Planning/Organization 0.38** 0.35* 0.30* -0.46* -0.01 -0.05
Legend. ASD: children with autism spectrum disorders; AUT: autistic children; SpD: autism spectrum children; Risk: children at risk of autism; SA: Social Affective
Behavior; RRB: Restricted Repetitive Behavior
P<0.05; **P<0.01
$The duration of therapy, measured in months, has a range of 3-24 months.
Table 4: Correlations between the BRIEF-P scores completed by Professionals and total ADOS scores, Social Aective behavior, Restricted
Repetitive Behavior, IQ, Chronological age and Months of therapy.
GEC EMI FI ISCI Planning/
Organization
Working
Memory
Emotional
Control
Shift Inhibit
Parent 61,6 (12.4)* 63,4 (12,6)* 54,6 (14,2) 56,8 (13,3)* 59,6 (12,7)* 64,4 (12,1)* 53,5 (12,6)* 55,3
(14)*
59,7 (13,2)*
Professional 75,3 (11.2) 73,2 (11,9) 75,7 (14,3) 69,9 (11,6) 70,8 (13,1) 72,9 (11,1) 71 (15,2) 74,4
(13,4)
66,8 (9,7)
% Children that exceed the pathological cut off of BRIEF-P
Parent 43,5 41,3 21,7 26,1 28,3 50 21,7 23,9 30,4
Professional 76,1 78,3 80,4 69,6 71,7 80,4 67,4 82,6 65,2
Legend. GEC: Gobal Executive Composite; EMI: Emergent Metacognition Index; FI: Flexibility Index; SICI: Inhibitory Self-Control Index
*Significant differences (P<0.001) between Parent and Professional
Table 5: Dierences (mean, SD) between the BRIEF-P scores completed by parents and teachers.
Dierences between parents and professionals BRIEF-P
scores
ANOVA for repeated measures shown that parents give children
signicantly lower scores than those attributed by professionals. In
general, in all the domains measured by the BRIEF-P, parents evaluate
children as mostly adequate in the executive functions while
professionals as primarily pathological (Table 5). Moreover, the
percentage of children that exceed the pathological cut-o score of the
BRIEF-P in the evaluations of the Professional is higher when
compared to those of the Parent.
Correlations between parents and professionals BRIEF-P
scores
e analysis of the correlations shows that the areas in which
parents and operators are in agreement are the Inhibit, the Emotional
Control and the Inhibitory Self-Control Index. In the other areas, no
correlations were found between parents and professionals evaluations.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) Assessment of Executive Functions in Preschool-Aged
Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice. J Child Adolesc Behav 4: 313. doi:
10.4172/2375-4494.1000313
Page 5 of 7
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313

In addition, Table 6 shows the Cohen’s Kappa coecient value, as an
index of coherence between the two evaluations.
Professionals
Parents r Pearson K Cohen
GEC 0.22 0.01
ISCI 0.38 0.03
FI 0.25 0.02
EMI 0.12 0.02
Inhibit 0.36 0.03
Emotional Control 0.38 -0.01
Shift 0.03 -0.01
Working Memory 0.15 0.05
Planning/Organization 0.05 -0.03
Legend. GEC: Gobal Executive Composite; EMI: Emergent Metacognition
Index; FI: Flexibility Index; SICI: Inhibitory Self-Control Index
Table 6: Correlations between the BRIEF-P scores completed by
parents and professionals.
Discussion
e results of our work show that both in parents and professionals
BRIEF-P protocols, the lack of correlation between the executive
functions evaluations and the ADOS-2 scores, which are indicative of
symptoms severity, is coherent with the data found in in other studies
[11,12] which showed that the level of autism severity is not related
with the executive functions decits in pre-school age, as well as a
lower level of autism severity does not necessarily correspond to
children’s good executive functioning skills. Specically, in the parents
evaluation the BRIEF-P domain that is most correlated with the
ADOS-2 score is the EMI, which is indicative of greater cognitive
rigidity (or less exibility) and therefore of the tendency to
repetitiveness and of a low planning and information manipulation.
In our study, moreover, the correlations between IQ and executive
impairment were highly signicant when evaluated by the
professionals, and this would demonstrate the homogeneity of the two
parameters, both "cognitive". In addition, the analysis shows that the
lower nonverbal IQ scores of children corresponded to compromised
executive functions, both in the overall score (GEC), both in ISCI and
FI, and in Inhibit, Shi and Emotional Control. Conversely the BRIEF-
P domains that are more sensitive with respect to the IQ, or ISCI and
FI, denote a lower ability in Emotional Control, Inhibit and Shi.
In professionals’ evaluations the EMI, which is expression of skills
related to working memory and the ability to initiate, plan and support
problem solving, positively correlates with RBB and the SA. is
represents a conrmation of how much metacognitive abilities are
impaired in autism spectrum disorders and shows how the presence of
mannerisms, stereotypies and sensory seeking behaviors are connected
both to the exibility of the mental strategies, and communication and
social responsivity [13-15]. Other results conrmed the relationship
between executive functioning and metacognitive skills in autism,
although not through the use of the BRIEF-P [16] highlighting
diculties in executive functions also in neurodevelopmental disorders
[17,18], but emphasizing the importance of considering the individual
dierences and the child's level of functioning and adaptation in
everyday situations [19], considering that complex cognitive-
emotional behaviours have their basis in dynamic coalitions of
networks of brain areas, none of which should be conceptualized as
specically aective or cognitive [20].
Finally, in most cases there is a low correlation between the BRIEF-P
scores obtained by parents and by therapists of preschool children with
ASDs. Especially, parents seem to have a greater diculty to identify
children’s decit areas, but their accuracy improves with the increasing
age of the children and in parallel with the therapeutic process [21,22].
is data can be read both as a function of increased clinical
expression connected with the increasing age with evidence of a
greater lack in social and cognitive behaviors, both as a result of a
greater awareness associated with the parental counseling provided
with the therapeutic project.
Conclusion
Our ndings show that parents and professionals have a dierent
representation of the child. is could well depend on the specic
preparation of the professionals which makes them more accurate and
objective. On the other hand it is possible for parents to recognize
more easily the decit areas that determine dysfunctional behaviors in
their children, or the emotional control and the inhibitory control
(EMI). We agree with other authors who emphasize both the diculty
of the EF evaluation in a such complex and heterogeneous area as
autism spectrum disorders, both the multi-source research perspective
and approach that would enable a more accurate and comprehensive
assessment of the EF in autism, dierentiating the clinical
characteristics and considering how the various developmental
components interact to determine cognitive and social development.
As already mentioned in the introduction, despite between the
pathogenetic hypothesis of ASDs has been inserted that of the
executive functions impairment, the latter, when present, does not
correlate with the severity of autistic symptomatology and, in any case,
it does not appear a specic cause. en, despite the executive
functions are crucial in the socio-relational functioning, when this is
primarily aected, as in the ASDs, the degree of socio-relational decit
is not directly dependent on the level of executive functioning
impairment. e dierent levels of functioning and socio-cognitive
adaptation in autism are in fact related to the ability to integrate the
skills possessed and use them to achieve a purpose; thus, even if are
found good skills in specic domains, it is possible that the overall
functioning appears disharmonic and so disadaptive.
e inhibit, the exibility, the emotional and attentional control
represent capabilities that allow the child to express his cognitive
potential which in autism spectrum disorders could be blocked and
inhibited by the symptomatic severity as well as by restricted and
repetitive behaviors. Other studies highlighted decits in such areas of
the EF, also considering children with phrasal structure and uent
language, all aspects that indicate a dierent level of severity than the
nonverbal sample evaluated in this research and also found no
correlation between executive control and restricted and repetitive
behaviors. is nding diverges from our results and can be explained
by the use of the rst version of the ADOS which considers such
behaviors but does not codify them in the overall score. e ADOS-2
diagnostic criteria used in our research allow a more accurate
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) Assessment of Executive Functions in Preschool-Aged
Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice. J Child Adolesc Behav 4: 313. doi:
10.4172/2375-4494.1000313
Page 6 of 7
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313

assessment of these behaviors and a more reliable classication of the
symptomatic severity in the global score.
Few studies have dealt with the executive functions impairment in
preschool ASD children until now, although with a dierent research
design, reaches the same conclusion, or that there is a degree of
executive impairment in ASD individuals (in our study when the
BRIEF-P is compiled by professionals) but that there is not a signicant
correlation between the degree of autistic symptomatology and
executive impairment. To our knowledge, no analysis have been
conducted about the level of agreement between parents and
therapists, while there are several between parents and teachers.
Moreover, while many researches, having a control sample, base their
results on the comparison between ASD and typically developing
children or with other milder developmental disorders and nd a
greater degree of impairment in autistic subjects, our objective was to
analyze the correlation between altered executive functioning and
other dysfunctional levels in a group with the same clinical diagnosis.
It seems quite signicant, in accordance with Granader and Kimhi,
that the more compromised domains in ASDs are Shi/Flexibility and
Emergent Metacognition. e fact that in the Italian literature there is
no research about the BRIEF-P applied to autism, is for us an
important starting point for further studies.
e recent publication in Italy of the BAFE for the EF assessment
can be useful to ensure a more objective and valid assessment context
to get an accurate prole of the executive functioning of the child and
assess the developmental trajectory of individual competencies and
their integration in pre-school age. Directly assessing executive
functioning through performance tests will allow to integrate the
evaluation results with the informations derived from indirect sources
such as BRIEF-P compiled by parents and/or professionals. In our
opinion, the BRIEF-P questionnaire usefulness lies in the possibility to
obtain information in everyday contexts and actually learn about the
representation that parents have of the skills expressed by their autistic
children. Despite the reliability is not always adequate for the
denition of a development prole, it is therefore important in the
therapeutic process as a measure of their awareness of the executive
dysfunctioning of the child and for the evaluation of child’s potential,
having as a comparison parameter the one compiled by the
professionals. e clinical implication of these ndings suggests the
importance to support parents of children with ASD in a path that will
lead them to greater awareness of the potential and the fragility of their
children, in order to create greater compliance in the therapeutic
project.
In our experience the BRIEF-P compiled by the professionals is a
useful tool in dening the individual development prole in preschool,
but it is not indicative of the severity of autistic symptoms. In the ASDs
could therefore be used to dene the "specier" of the executive
functioning, in line with the suggestion made by the DSM-5. From
these considerations the assessment of the EF cannot be le solely to a
questionnaire like the BRIEF-P, although compiled by professionals,
but must be supported by a clinical diagnosis made by autism trained
and experienced professionals in a multidisciplinary team.
References
1. Welsh MC, Pennington BF (1988) Assessing frontal lobe functioning in
children: Views from developmental psychology. Dev Neuropsychol 4:
199-230.
2. Stuss DT, Benson DF (1986) e frontal lobes. Raven Press, New York.
3. Diamond A, Prevor MB, Callender G, Druin DP (1997) Prefrontal cortex
cognitive decits in children treated early and continuously for PKU.
Monogr Soc Res Child Dev 62: 1-208.
4. McEvoy RE, Rogers SJ, Pennington BF (1993) Executive function and
social communication decits in young autistic children. J Child Psychol
Psychiatry 34: 563-578.
5. Espy KA, Kaufmann PM, Glisky ML (2001) New procedures to assess
executive functions in preschool children. Clin Neuropsychol 15: 46-58.
6. Zelazny K, Simms LJ (2015) Conrmatory factor analyses of DSM-5
posttraumatic stress disorder symptoms in psychiatric samples diering
in Criterion A status. J Anxiety Disord 34: 15-23.
7. Lord C, Rutter M, Di Lavore PC, Risi S, Gotham K, et al. (2012) Autism
diagnostic observation schedule, second edition. Torrance, CA: Western
Psychological Services. Italian edition by Colombia, Tancredi, Persico &
Faggioli, 2013. Hogrefe, Florence.
8. Roid GH, Miller LJ (2002) Leiter–R: Leiter International Performance
Scale–Revised. Florence: O.S. Organizzazioni Speciali.
9. Gioia G, Espy KA, Isquith PK (2002) BRIEF-P-Behavior Rating Inventory
of Executive Function, Preschool Version. Clin Neuropsychologist 21:
569-586.
10. Isquith PK, Gioia G, Espy KA (2003) Executive function in preschool
children: examination through everyday behavior. Dev Neuropsychol 26:
403-422.
11. Dawson G, Meltzo AN, Osterling J, Rinaldi J (1998) Neuropsychological
correlates of early symptoms of autism. Child Dev 69: 1276-1285.
12. Smithson PE, Kenworthy L, Wills MC, Jarrett M, Atmore K, et al. (2013)
Real world executive control impairments in preschoolers with autism
spectrum disorders. J Autism Dev Disorders 43: 1967-1975.
13. Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, et al.
(2016) From the Emotional Integration to the Cognitive Construction:
e Developmental Approach of Turtle Project in Children with Autism
Spectrum Disorder. Autism-Open Access 6: 160-169.
14. Di Renzo M, Bianchi di Castelbianco F, Petrillo M, Donaera F, Racinaro
L, et al. (2016) e emotional contagion in children with Autism
Spectrum Disorder. Autism J Autism Related Disabil 2: 1-7.
15. Di Renzo M, Bianchi di Castelbianco F, Petrillo M, Racinaro L, Rea M
(2015) Assessment of a long-term developmental relationship-based
approach in children with autism spectrum disorder. Psychol Rep: Disabil
Trauma 117: 26-49.
16. Ozono S, Pennington BF, Rogers SJ (2006) Executive function decits in
high-functioning autistic individuals: relationship to theory of mind. J
Child Psychol Psychiat 32: 1081-1105.
17. Kenworthy L, Yerys BE, Anthony LG, Wallace GL (2008) Understanding
executive control in autism spectrum disorders in the lab and in the real
world. Neuropsychol Rev 18: 320-338.
18. Verté S, Geurts HM, Roeyers H, Oosterlaan J, Sergeant JA (2006) e
relationship of working memory, inhibition, and response variability in
child psychopathology. J Neurosci Methods 151: 5-14.
19. Pellicano E, Rhodes G, Calder AJ (2013) Reduced gaze aereects are
related to diculties categorising gaze direction in children with autism.
Neuropsychologia 51: 1504-1509.
20. Vanadia E, Di Renzo M, Trapolino E, Racinaro L, Rea M (2016) e
relationship between Regulation Disorders of Sensory Processing (RDSP)
and white matter abnormalities. J Neurology and Neurosci 7: 1-7.
21. Granader Y, Wallace GL, Hardy KK, Yerys BE, Lawson RA, et al. (2014)
Characterizing the factor structure of parent reported executive function
in autism spectrum disorders: e impact of cognitive inexibility. J
autism develop disord 44: 3056-3062.
22. Kimhi Y, Shoam-Kugelmas D, Ben-Artzi GA, Ben-Moshe I, Bauminger-
Zviely N (2014) eory of mind and executive function in preschoolers
with typical development versus intellectually able preschoolers with
autism spectrum disorder. J autism develop disord 44: 2341-2354.
Citation: Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016) Assessment of Executive Functions in Preschool-Aged
Children with Autism Spectrum Disorders: Usefulness and Limitation of BRIEF-P in Clinical Practice. J Child Adolesc Behav 4: 313. doi:
10.4172/2375-4494.1000313
Page 7 of 7
J Child Adolesc Behav, an open access journal
ISSN: 2375-4494
Volume 4 • Issue 5 • 1000313