Executive and nonexecutive demands of constructional measures within a children’s psychiatric inpatient setting

Jane Studeny, Elyssa Weber, Brian C. Kavanaugh, Jennifer A. Dupont- Frechette, Perrin P. Tellock, Isolde D. Maher, Lauren D. Haisley, Kyle McCurdy & Karen A. Holler

To cite this article: Jane Studeny, Elyssa Weber, Brian C. Kavanaugh, Jennifer A. Dupont- Frechette, Perrin P. Tellock, Isolde D. Maher, Lauren D. Haisley, Kyle McCurdy & Karen A. Holler (2019) Executive and nonexecutive demands of constructional measures within a children’s psychiatric inpatient setting, Applied Neuropsychology: Child, 8:1, 40-49, DOI: 10.1080/21622965.2017.1381098 To link to this article: https://doi.org/10.1080/21622965.2017.1381098


This study examined the role of executive functioning in constructional task performance (measured with the Rey Complex Figure Test-Copy Condition [RCFT] and Beery-Buktenica Developmental Test of Visual-Motor Integration [Beery-VMI]) within a children’s psychiatric inpatient setting. A chart review was conducted for 88 children (aged 6–12) who received a neuropsychological evaluation during a psychiatric inpatient hospitalization. Multiple regression analyses investigated the role of executive and nonexecutive demands on RCFT and Beery-VMI performance. Forty-three percent of the sample displayed a constructional weakness. Children with a constructional weakness had lower FSIQ scores and a higher rate of executive dysfunction. Performance on the RCFT was independently predicted by perceptual ability (i.e., Matrix Reasoning; p = .008; β = .340) and attention/executive dysfunction (p = .003; β = −.342; 9.4% of variance), while performance on the Beery-VMI was independently predicted by constructional ability (i.e., Block Design; p = .004, β = .338). Results of this study demonstrate that the RCFT has greater executive demand than the VMI and yields a greater rate of impaired performance in an inpatient child sample as compared to the VMI. Clinical and research practices should consider the distinct differences between various constructional measures to ensure their proper use and interpretation with consideration to their varying executive and nonexecutive demands.


The Beery-Buktenica Developmental Test of Visual- Motor Integration (Beery-VMI; Beery & Beery, 2004) and Rey Complex Figure Test, copy condition (RCFT; Strauss, Sherman, & Strauss, 2006) are two highly valued tasks that are commonly used in pediatric practice to measure visual-constructional abilities (Akshoomoff & Stiles, 1995a, 1995b from Senese, Lucia, & Conson, 2015). Both the Beery-VMI and RCFT are complex drawing tasks that involve constructional, perceptual, spatial, and motor components (Baron, 2004; Fischer & Loring, 2004; Sutton et al., 2011). In addition, the Beery-VMI and RCFT are thought to contain demands on executive functions (EFs). Neuropsychologically, executive functions encompass a range of abilities that are required for goal-directed behavior including inhibitory control, working memory, and cognitive flexibility. Such functions are often related to planning, strategizing, organizing, and executing tasks. A heuristic framework of executive functions argues for the discrimination between hot and cold EFs. Hot EFs are more likely to be elicited by problems that involve the regulation of affect, whereas cold EFs are more likely to be elicited by abstract, decontextualized tasks or problems. Measures of EF generally require a combination of hot and cold EF; however, objective measures of executive functioning that are common in neuropsychological practice typically assess cold EF processes. Alternatively, self-report measures also utilized to assess EF can provide insight into daily tasks and processes that are executively focused and affectively salient (i.e., hot executive functions). Research on the neurocognitive, including the executive functioning, aspects of the Beery-VMI, is limited. Although some studies have used demographic and intellectual measures for predicting visual-motor integration ability (Di Blasi, Elia, Buono, Ramakers, & Di Nuovo, 2007; Memisevic & Sinanovic, 2012; Wuang, Wang, Huang, &, 2008), there is a sparse amount of research that utilizes or suggests the utility of executive measures as predictors of visual-motor integration. One study using the Beery-VMI found that parent-rated executive functions, specifically working memory and monitoring, were associated with Beery-VMI performance in a sample of children with intellectual disability (Memisevic & Sinanovic, 2012). Other studies have demonstrated no association between aspects of executive functions and performance on the Beery-VMI (Schultz et al., 1998). The relationship between executive functions and visual-motor integration is unclear, especially, given the confounding effect of intellectual functioning. As such, the Beery-VMI is more likely associated with broad intellect similar to other tests of visual-motor integration (e.g., clock drawing; Dilworth, Greenberg, & Kusché, 2004), but does not appear to be strongly associated with executive functioning.

More research has focused on the broader neurocognitive demands and executive demands of RCFT performance (Kirkwood, Weiler, Bernstein, Forbes, & Waber, 2001; Sami, Carte, Hinshaw, & Zupan, 2003; Schwarz, Penna, & Novack, 2009; Senese et al., 2015; Smith & Zahka, 2006; Watanabe et al., 2005). The RCFT is often used to assess visual-perceptual organization (Lezak, Howieson, & Loring, 1995; Waber & Holmes, 1986), visuospatial perception and orientation (Akshoomoff & Stiles, 1995a; Shorr, Delis, & Massman, 1992), and behavioral planning, organization, and sequencing (Deckersbach et al., 2000; Waber & Holmes, 1986). In one related study, measures of executive functions accounted for 11% of the variance in the copy trial of the RCFT (Schwarz et al., 2009). However, such findings are frequently related to the use of more executively-focused RCFT scoring criteria, such as the Developmental Scoring System (DSS; Bernstein & Waber, 1996) and Boston Qualitative Scoring System (BQSS; Stern et al., 1999). More traditional scoring systems such as the original 36-point scoring system (Osterrieth, 1944) and the revised 18-point Taylor scoring system (Duley et al., 1993) are most commonly used in clinical and research practices because they are well-defined, quantitative scoring approaches that yield greater reliability than more idiographic scoring systems such as the more recently proposed executively-focused qualitative scoring systems.

Although the RCFT and Beery-VMI are widely used, only a few studies to date have investigated the role of executive and nonexecutive skills in the drawing abilities of children, and have focused almost exclusively on the RCFT in normative child samples. Senese et al. (2015) investigated cognitive predictors of RCFT performance in a sample of 277 typically developing children between the ages of 7 to 10 and found that cognitive flexibility, working memory, visual perception, and mental rotation were all predictive of the RCFT copy condition. According to their study of a neurologic adult sample, Westervelt, Somerville, Tremont, and Stern (2000) summarized that higher order executive functions—namely planning and organization—directly impact copy performance and, subsequently, immediate recall performance on the RCFT. Deficits in attention, perception, or executive functioning were related to inadequate copy performance on the RCFT (Budd, Houtz, & Lambert, 2008). Interestingly, subsequent studies including the RCFT and Beery-VMI found that fine motor coordination was not associated with performance on either task (Klein, Guiltner, Sollereder, & Cui, 2011; Schwarz et al., 2009). There is a reciprocal link between environmental experiences and children’s development of core neurocognitive capacities (Brocki & Bohlin, 2004). Children’s construction skills are known to be impacted by exposure to trauma (e.g., De Bellis, Hooper, Spratt, & Woolley, 2009), while executive functions have been found to be impacted by institutionalization and post-institutionalization (e.g., Merz, Harlé, Noble, & McCall, 2016). Executive functions are impaired in many psychiatric disorders including addictions (Baler & Volkow, 2006; Smith et al., 2014), attention deficit hyperactive disorder (AD/HD; Diamond, 2005; Lui & Tannock, 2007), oppositional- defiant disorder/conduct disorder (Fairchild et al., 2009; Ogilvie et al., 2011), major depressive disorder (Taylor-Tavares et al., 2007), bipolar disorder (Snyder, Miyake, & Hankin, 2015), obsessivecompulsive disorder (Penades et al., 2007), and schizophrenia (Barch, 2005). Executive deficits have been identified in groups of individuals with panic disorder, social anxiety disorder, and generalized anxiety disorder (Airaksinen, Larsson, & Forsell, 2005; Mantella et al., 2007). Although not entirely conclusive, preliminary studies suggest that executive functions are impaired in persons with post-traumatic stress disorder (Polak et al., 2012). A meta-analytic review of childhood disorders by Willcutt et al. (2008) identify and highlight the significance of the executive functioning deficits associated with diagnoses of AD/HD, autism, and childhood onset schizophrenia. Although milder, associations between executive deficits and juvenile bipolar disorder, oppositional-defiant disorder/conduct disorder, and Tourettes syndrome and other tic disorders are also observed in children (Willcutt, Sonuga-Barke, Nigg, & Sergeant, 2008).


Download Full Article