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The Problem of Assessing

Executive Functions
a
Muriel D. Lezak
a
Oregon Health Sciences University and Veterans
Administration Medical Center, Portland, OR, 97201,
USA
Published online: 27 Sep 2007.

To cite this article: Muriel D. Lezak (1982): The Problem of Assessing Executive
Functions, International Journal of Psychology, 17:1-4, 281-297

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 International Journal of Psychology 17 (1982) 281-297 28 1
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THE PROBLEM OF ASSESSING EXECUTIVE FUNCTIONS

Muriel D. LEZAK*
Oregon Health Sciences University, USA

The capacities for formulating goals, planning, and carrying out plans effectively - the executive
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functions - are essential €or independent, creative, and socially constructive behavior. Although
they tend to be vulnerable to brain impairment, they are often overlooked in neuropsychological
and neurological examinations. Reasons why there are few formalized examination procedures for
evaluating executive functions are suggested. Prefrontal contributions and the importance of other
brain areas (e.g., subcortical, right hemisphere) to executive functions are discussed. Assessment
techniques are presented for evaluating four categories of executive capacities: (1) goal formula-
tion, (2) planning, (3) carrying out goal-directed plans, and (4) effective performance. The
Tinkertoy Test", which can provide information about these capacities, is described in some detail.
Need for further exploration in this area is emphasized.

The executive functions comprise those mental capacities necessary for

formulating goals, planning how to achieve them, and carrying out the
plans effectively. They are at the heart of all socially useful, personally
enhancing, constructive, and creative activities. With the executive
functions intact, a person can suffer many different kinds and combina-
tions of sensory, motor, and cognitive deficits and still maintain the
direction of his own life and be productive as well. Impairment or loss
of these functions compromises a person's capacity to maintain an
independent, constructively self-serving, and socially productive life no
matter how well he can see and hear, walk and talk, and perform tests.
Yet crucial as the executive functions are for normal behavior, there
are not many assessment methods generally available for examining
them. With few exceptions we do not have standardized methods for
making objective or reliably replicable estimates of gradations of im-
pairment of these functions, for example, or for making intra- and
interindividual comparisons. Without assessment techniques that can

Author's address: Muriel D. Lezak, Oregon Health Sciences University and Veterans Adminis-
tration Medical Center, Portland, OR 97201, USA.

0020-75 94/82/0000-0000/$02.75 0 1 982 North-Holland

 282 M.D.Lezak / Assessing executive functiom

be standardized and that can produce data subject to statistical analy-

sis, much of our understanding of executive functions will remain at an
anecdotal level.
The assessment of cognitive functions offers a striking contrast. We
have tools for identifying and making fine discriminations between the
various cognitive functions that enable us to describe the neuropsycho-
logical correlates of a number of neurological disorders in terms of
patterns of intellectual strengths and deficits (e.g., Russell 1979; Fuld
1978; Gainotti et al. 1980; McFie 1975), to analyze the components of
many cognitive functions (e.g., Cohen 1957a, b; Guilford 1967; Milner
1974), and that give us agreed-upon words and concepts for discussing
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cognitive phenomena.
A look at some of the important differences between executive and
cognitive functions may help us appreciate why systematic measure-
ment of. the executive functions has lagged so far behind. It also may
suggest some techniques for measuring executive functions and some
dimensions that could be assessed.
One distinction between cognitive and executive functions lies in the
kinds of question each class of functions calls for. Cognitive functions
concern what and how much knowledge, skill, and intellectual equip-
ment a person may possess. When assessing cognitive functions for
neuropsychological purposes we ask such questions as “What are the
patient’s intellectual strengths and weaknesses?”, “What abilities have
remained intact or are particularly well-developed or deteriorated?”,
and “How well can he perform this task compared to that?” Executive
functions have to do with how a person goes about doing something or
whether he does it at all. Questions dealing with executive functions ask
how well the patient maintains a performance rate, how consistently
and effectively he self-corrects, how responsive is he to changes in the
demands of the task, or does he start and stop activities by himself and
if so, how appropriately, and so on.
Our habits of conceptualizing and observing behavior are much more
suited to dealing with questions of cognitive deficits than impaired
executive functions. The familiar three-dimensional classification
scheme for cognitive functions enables us to analyze a person’s intel-
lectual behavior in terms of verbal and configural components; sensory
modalities; perceptual, response, memory, or concept formation and
reasoning activities. Using this scheme, we can make fine discrimina-
tions between different kinds of aphasic disturbances, of perceptual
 M.D.Lezak / Assessing executioe functions 283

disorders, or of defects in reading, writing, or arithmetic for example.

On the other hand, executive defects tend to be supramodal, affecting
the expression of all aspects of behavior. Thus, with the exception of
severe forms of pathological inertia, a condition in which the alert, fully
sentient and motorically capable patient initiates no behavior and
exhibits no interest, defects in executive functions are not readily
observable in themseIves and so rarely become self-evident. Moreover,
lacking a formalized scheme for classifying the executive functions, our
observations tend to be haphazard and our thinking about them tends
to be unsystematic.
Furthermore, unlike cognitive functions that can be readily elicited
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in the formal examination setting, the structure of the usual neurologi-

cal or psychological examination makes it very difficult, if not impossi-
ble, to observe some of the most important executive functions, such as
initiation of complex goal-directed activity, planning such activity, or
carrying out one’s plans. The examiner who wants to observe these
aspects of executive behavior is in a logically absurd position, for by its
very nature the examination places the subject within a structured
situation in which the examiner dictates what the subject is to do, with
what, and when. The examiner who observes the patient only in a
formal examination using only standard neurological or psychological
techniques may see what he calls “disinterest”, “carelessness”, or “im-
pulsivity” on the part of the patient but be unable to appreciate when
these are symptoms of an impaired capacity for self-regulation and
control that compromises all aspects of the patient’s behavior, rather
than simply evidence of negativistic or regressive personality traits.
Unless the patient demonstrates frank cognitive defects, even the ex-
aminer who pays attention to the qualitative aspects of the patient’s test
performance may be as ignorant about the patient’s capacity to take
care of himself and be productive in the real world at the end of a
formal examination as he was at its beginning.
Although executive functions are part and parcel of everything we do
- perhaps because executive functions are part and parcel of everything
we do - relatively few clinicians who deal with brain damaged patients
address this dimension of behavior in their evaluations or their recom-
mendations for care or treatment. Many simply do not seem to appreci-
ate the importance of the executive functions or the psychosocial
incapacitation that can result from their impairments. Those who do
not observe the patient in situations in which he must act on his own
 284 M. D. L a n k / Assessing executive functions

behalf may not be aware that something is missing from the patient’s
behavioral repertoire.
This aspect of the problem of assesssing executive functions was
demonstrated by Hebb who found that loss of even considerable
amounts of frontal lobe tissue had little effect on the scores patients
earned on many highly structured tests of cognitive knowledge and
skills (1942). In reporting his examination of a near-blind 15-year-old
following surgical removal of between 40 to 50% of his right hemis-
sphere and 20% of the left due to multiple abscesses Hebb noted that
on most of the tests he gave (excluding those that required vision), his
patient performed well within the expected range for a young man of
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his age, and better than expected on recall of digits forward and
backward. Hebb concluded that the patient had “unusually good reten-
tion of subjective clarity, responsiveness, memory, and apparent
coherence of thought processes”. He described the patient’s psychologi-
cal status as “exceptionally good’,, basing this in part on his observa-
tion that the young man “seemed normally alert and responsive, and
quite cooperative’. Yet Hebb made nothing of his observation of the
patient’s “inactivity, and apparent willingness to do nothing for rather
long periods”, an observation that suggests seriously impaired executive
functions with a probable future of chronic social dependency.
The most refined and thoughtful observations and formulations
concerning the nature of impaired executive functions have been made
of patients with frontal lobe damage (Damasio 1979; Hecaen and
Albert 1978; Luria 1966, 1973; Seron 1978). As a rule, patients who
have had significant injury or disease of the prefrontal region of the
brain, particularly if the orbital or medial regions have been damaged,
undergo behavioral and personality changes that prevent them from
conducting their lives in a normal, socially responsible manner. Those
with mild injuries may experience changes in drive, in the intensity,
stability, or flexibility of response, or in social sensitivity that di-
minishes their capacity to function as fully and interact socially as they
once had. Since many of the most handicapping changes these patients
undergo involve one or more of their executive capacities, executive
functions generally have been ascribed to the frontal lobes.
However, damage to other areas of the brain can also interfere with
executive functions. Such deficits are part of the clinical picture of
many disorders involving subcortical regions, particularly when limbic
structures are involved, as can be the case in anoxic conditions (Falicki
 M.D. Lerak / Assessing executive functions 285

and Sep-Kowalik 1969; Jefferson 1976; Muramoto et al. 1979; Pillon et

al. 1977); and may be suspected as a result of inhalation of organic
solvents (Arlien-Shorg et al. 1979; Gregersen et al. 1978; Tsushima
and Towne 1977). Korsakoff patients, whose lesions primarily involve
thalamic nuclei and other subcortical components of the limbic system,
suffer profound disturbances of executive functions. Despite good
retention of both well-learned skills and information and the mental
and physical capacity to perform at least all the activities of normal
daily living, many of these patients are virtually immobilized by apathy
and inertia. The decreased flexibility in regulating movements that
many patients with Parkinson’s disease experience is not always con-
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fined to motor behavior but may be reflected in diminished conceptual

flexibility too (Bowen 1976; Albert 1978). Some Parkinson patients
display impaired initiative and spontaneity as well. Another group of
patients whose executive capacities may be impaired are those with
right hemisphere damage (Lezak 1979). Many of these are patients who
“talk a good game” and are neither inert or apathetic. Yet they may not
be much more active or productive than Korsakoff patients or those
with extensive frontal lobe damage. Their ineffectiveness appears to be
due to inability to conceptualize all elements of a plan, or‘ to organize
all the facets of an activity in an integrated manner so that they are
unable to carry out their intentions.
The definition of the executive functions given at the beginning of
this paper provides a framework for conceptualizing them in terms of
four major classes or functional categories of executive capacities.
These are (1) capacities necessary for formulating goals; (2) capacities
involved in planning; (3) capacities having to do with carrying out
plans to reach the goals; and (4) capacities for performing these
activities effectively. These classes involve distinctive sets of behavior.
All are necessary for appropriate, socially responsible, and effectively
self-serving adult conduct.
The system of executive functions can break down at any stage in the
sequence of behavioral events that make up a planned or intentional
action. Examination of the four classes of executive capacities by means
of interview and observation and by tests and improvised assessment
techniques will usually bring to light executive dysfunctions that may
not have become evident in the usual clinical examination.
Following is a review of the four classes of executive capacities, of
examination techniques that can be useful in identifying some of the
 286 M.D.Lezak / Assessing executiue ftrnctions

ways in which executive functions break down and showing how such
breakdowns interfere with the normal expression of behavior. This
review is intended to be illustrative and provocative; it is far from
exhaustive. I hope that others can use it as a point of departure for their
own explorations into this most subtle and most central realm of
human activity.

1. Goal formulation

The capacity to formulate a goal, or to have an intention, is bound up

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with motivation and with awareness of self and how one’s surroundings
impinge on oneself. Goal-directed motivation differs from the simple
arousal states that spur infants, impulsive adults, and subhuman
animals. Simple arousal states lead automatically to reactive or instinc-
tive activity. In contrast, persons capable of goal formulation not only
can conceptualize their needs and desires before acting upon them but
can entertain motives that may be far removed from organismic drive
states and much more complex than are impulsive acts or automatic
responses to physiological needs or environmental stimuli. The ability
to create motives out of past experiences, out of an appreciation of
physically or temporally distant needs, or out of one’s imagination
requires self-awareness at a number of levels including awareness of
internal states, an experiential sense of self, and self-consciousness
vis-a-vis the social and objective environment. It also requires the
ability to identify those aspects of one’s surroundings that may have
personal relevance.
Persons who lack capacity to formulate goals for themselves may be
unable to initiate activities excepting elementary responses to internal
stimuli such as bladder pressure, or to external stimuli, such as scratch-
ing at a mosquito. It simply does not occur to them to do anything. In
extreme cases, persons fully capable of complex activities, such as using
table utensils in the socially prescribed manner, may not eat what is set
before them without continuing explicit direction and guidance. Less
impaired persons may eat or drink what they see but even when hungry
will not seek nourishment spontaneously.

A surgeon who suffered cardiac arrest with secondary hypoxia during minor elective
surgery drives a delivery truck for his cousin’s business. He can make deliveries
 M.D.Lerak / Assessing executive functions 287

anywhere within his home town so long as he has explicit instructions about where to
go and what to do, but he is unable to handle unexpected situations. When the family
he lives with occasionally leaves him alone on a weekend, he may go for as long as two
days without eating or drinking anything that requires even minimal search or prepara-
tion, although he can make coffee and simple meals when reminded.

Patients who are only mildly impaired may be able to do household

chores and engage in familiar hobbies or games without prompting but
cannot resume premorbid responsibilities that require appreciation of
long-term or abstract goals, or take on new activities by themselves.
Without direction, once they have completed their routine activities,
they may wander aimlessly or just sit, typically in front of the television
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or at a neighborhood bar or coffee shop.

Reports by the patient’s caretakers, family, and others who may see
him in the normal course of day-to-day livng are the best sources of
information about a patient’s emotionality and motivational capacity.
In the examination situation, the examiner should ask the patient about
his likes and dislikes, what he enjoys doing and what makes him angry.
Most patients whose capacity for motivation is impaired are affectively
flat and do not appear to have strong feelings about anything. When
these patients give a lively and descriptive answer to inquiries about
hobbies or sports, further questioning will usually discover that the
patient is reporting premorbid activities which he no longer pursues.
The surgeon described above reported an interest in hunting and
fishing in the Canadian north woods. Skeptical, I asked, “When did you
last go hunting in Canada?” I was not surprised to learn that he was
reporting what he had done seven years before although he talked
about hunting as if he had just returned from the north woods yester-
day.
Awareness of self and surroundings, too, is best evaluated by means
of observation and report. Lack of self-consciousness, as manifested in
disinterest in appearance and unconcern about childish or crude behav-
ior, reflects impaired self-awareness in once socially functional adults.
The surgeon again provides an example. He had been a stylish bachelor
but, seven years after the cardiac arrest, was still not buying his own
clothes nor did he realize when he needed new ones. He wears what is
put out for him and only changes clothes when told.
Questions about the time of day or the season of the year can test
not only the patient’s orientation but his ability to use environmental
cues spontaneously.
 288 M.D. L e a k / Assessing executive functions

On a cold and blustery April 1, I asked a 68-year-old outpatient suffering from

moderately advanced multi-infarct dementia what the date was. Although he had just
come in from outside - on later questioning he described the weather accurately - and
sat facing the window where he could see a bare-branched tree, he unhesitatingly gave
the date as “July I”.

The Stanford-Binet scales (Terman and Merrill 1973) contain several

items which also test the patient’s ability to use cues to interpret a
situation. In “Problems of Fact”, the patient is told that first a doctor,
then a lawyer, and then a priest were seen going into a house. The
patient is asked, “What do you think is happening there?” The patient’s
ability to infer a story from a picture also may reflect on how well he
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can make sense out of his perceptions. The Cookie Jar picture from the
Boston Diagnostic Aphasia Examination (Goodglass and Kaplan 1972)
is an excellent one for this purpose because it is a simple line drawing
of a number of familiar character types (e.g., mother, mischievous boy)
engaged in familiar activities in a familiar setting. The subject can
devise a single, integrated story that shows he takes account of the
important elements in the picture; he can simply describe the picture on
a piecemeal basis which raises questions about his ability to integrate
what he sees; or he may talk about only one or two items. In
disregarding the rest of the picture he may be demonstrating an
impaired capacity to attend systematically to what he sees.

2. Planning

Several capacities are necessary for planning. Not least of these is the
capacity for sustained attention. In order to plan, a person must also be
able to deal objectively with himself in relation to the environment, and
to view the environment objectively, i.e., to take the abstract attitude
(Walsh 1978b). Planning also requires the abilities to think of alterna-
tives, to weigh and make choices, and to evolve a conceptual framework
or structure which can serve to direct activity.
Defective planning can be identified in patients who have no diffi-
culty formulating goals but lose track of their intentions or activities,
do not generate plans, or come up with plans that are unrealistic if not
simply silly. It also appears, often in a more subtle manner, in a
patient’s inability to create a conceptual structure which can give him
the blueprint and time schedule, so to speak, for carrying out a plan.
 M.D. Lezak / Assessing executive functions 289

These patients may be well energized and prepared to engage in all

kinds of activities but remain virtually immobilized by their inability to
plan. Impulsivity also interferes with planning activity. Far from being
immobilized, impulsive patients tend to act out, but their acting-out
behavior is neither self-serving nor productive.
Again, questioning can bring out defective planning. I usually ask
patients what they plan to do when they leave the hospital, where they
plan to go and how they plan to get there. If they are vague, I press
them for details. However, when asked about familiar activities, a
patient can sound good when in reality he performs poorly. Here, too,
reports from other observers can be invaluable.
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A 35-year old mechanic who had sustained a head injury in a 15-foot fall had not
returned to work in the three years since the accident. In a compensation examination
he reported that he prepares dinner on the days his wife works. When asked to describe
a sample menu, he gave one and included some alternatives, which sounded reasonable.
He also indicated that he did the shopping. When I later asked his wife about his
cooking, she explained that he accompanies her when she shops and that he always
prepares the identical meal exactly the way she had taught him.

Several tests have been widely employed in the examination of

planning ability. The Porteus Mazes (Lezak 1976; Walsh 1978a, b) have
probably had the most extensive use for this purpose. They were
designed to examine processes involved in “choosing, trying, and reject-
ing or adopting alternative courses of conduct or thought” (Porteus
1959) and have a proven sensitivity to frontal lobe damage (Smith
1960). Rey’s Complex Figure Test (Lezak 1976; Messerli et al. 1979;
Rey 1941) also elicits planning behavior. Osterrieth’s (1944) analysis of
approaches to copying the complex figure provides standards for
evaluating how systematic is the patient’s response to this task. A
haphazard or fragmented mode of response may implicate poor plan-
ning. The task of copying all nine Bender-Gestalt designs on one page
is excellent for enabling the examiner to observe whether and how well’
the patient plans the layout of his drawings on the page (Lezak 1976).
The Bender is also more likely to elicit structure-dependent behavior
than most tests used in neuropsychological assessment because it offers
the subject no guidelines, only a blank sheet of paper. The structure-de-
pendent patient may ask what to do (e.g., “Where should I put the
design?”, “Should I count the dots?’), or may simply seek structure by
lining his drawings along the paper’s edge or by hanging one drawing
on another.
 290 M.I). L.eznk / Assessing executive functions

3. Carrying out activities

The translation of an intention or plan into self-serving, productive

activity requires the capacities to initiate, maintain, switch, and stop
sequences of complex behavior in an orderly and integrated manner.
Luria’s (1966,1973) depiction of normal activity as the product of
organized behavioral programs provides a conceptual framework for
studying normal purposive behavior and for understanding the disrup-
tions of purposive behavior that occur with certain kinds of brain
damage.
Disorders in the programming of activity can interfere with a person’s
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ability to carry out reasonable plans regardless of motivation, knowl-

edgeableness, or skill level. They typically thwart intentional activity
but may not interfere with impulsive actions. The patient who is
immobilized by these disabilities may be puzzled and dismayed at
himself as well. He may display a marked dissociation between his
verbilized intentions and plans and his actions.

A 22-year-old man who had successfully completed two years of college before
sustaining a severe head injury in a motor vehicle accident wanted to leave his parents’
home and live in his own apartment. He knew what was needed to make the move,
continued to talk and pester his parents about it, but was unable to undertake even the
simple step of walking to apartment buildings in his neighborhood to make inquiries.

At the level of discrete motor activity, these programming disorders

can show up in perseverations, impersistence, or discontinuities that
interrupt the normal course of sequentially organized activities such as
writing, drawing, or speaking. Some persons who are unable to begin or
carry out large-scale purposive activities can perform discrete behav-
ioral sequences quite normally. However, when disorders of motor
programming affect discrete activities, usually the patient also has
difficulty carrying out purposive behavior.
A programming breakdown at the level of discrete activity may
become evident in the patient’s speech, or any other kind of intentional
performance. Generally, the more open-ended and unstructured the
task, the more likely will impairments in programming become evident.
Thus, tests of verbal fluency (Lezak 1976), free writing or drawing can
be used to assess the patient’s capacity to produce, maintain, and stop
an intended series of responses at will. The ability to shift responses
can be examined at the motor level by having the patient copy and
 M.D.Lezak / Assessing executioe functions 29 1

maintain patterns of alternating hand movements, write letter series

such as mnrnnmn in script, or draw alternating geometric figures in
series (see Christensen 1979; Luria 1966,1973 for examples). A number
of tests have been devised for assessing the capacity to shift at a
conceptual level (Lezak 1976). One of the most interesting and il-
luminating of these is the Wisconsin Card Sorting Test (Milner 1964;
Teuber et al. 1951) which calls upon simple concept formation ability
and - to some extent - immediate memory as well as the capacity for
conceptual flexibility.
Breakdown in the capacity to carry out purposive behavior is often
not seen in the usual structured examination because traditional ex-
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aminations rarely give the patient an opportunity to do much more

than what he is told to do. In order to put executive responsibility in
the patient’s hands so it could be subjected to a standardized examina-
tion with reliably objective scoring, I have been asking patients to
“make whatever you want” with 50 Tinkertoy” pieces, (see table 1)-
Tinkertoys are children’s play materials consisting of brightly colored
wood and plastic knobs, dowels, and connecting pieces of varying sizes
that can be combined into many different constructions yith a mini-
mum of effort in five or ten minutes at most. Most patients enjoy the
task and do not seem to feel that it is beneath their dignity. On
completion of a construction, I ask the patient to tell me what it is.
The Tinkertoy constructions of 35 unselected patients and of a group
of ten normal control subjects were scored for number of pieces used
( n p ) and also given a “complexity” score (comp) based on seven
construction variables (see table2). On the basis of history, records, or
family interviews, 18 patients who required total support and supervi-
sion were classified as Dependent (D), and 17 were classified as Not
Dependent (ND) because they all could manage daily routines on their
own and five of them were capable of working independently. The two
patients groups did not differ in age, education, or their scores on the
Information subtest of the WAIS (Lezak 1980). The control subjects
were younger and better educated than the patients.
Both the np and comp scores differentiated the constructions of the
three groups (see table3). Moreover, with a single exception, Depen-
dent patients used less than 23 pieces, those who were Not Dependent
used 23 or more, and half of the control group used all 50 pieces. The
np and comp scores of the 19 patients who had age-graded scaled scores
of 10 or higher on the WAIS Information or Block Design subtests
 292 M.D.Lezak / Assessing executive functions

Table 1
Items used in the Tinkertoy Test.

Wooden dowels Wooden rounds Plastic pieces

Green (18.9 cm) 4 Knobs 10 CoMectors 4

Red (12.6 cm) 4 Wheels 4 Caps 4
Blue (8.3 cm) 4 Points 4
Yellow (5.3 cm) 6
Orange (3.2 cm) 6
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were also compared to see whether the differences between the patient
and control groups might be due to cognitive deficits. This comparison
yielded significant differences between the groups on both the np
( t = 3.58, df = 27, p < 0.01) and the comp ( t = 4.58, df = 27, p < 0.001)
scores. The lower Tinkertoy Test scores of the patients whose cognitive
performances were relatively intact suggest that this test measures more
than cognitive abilities. Moreover, patients with high Block Design
scores (nine or better) and those with Block Design scores of eight or
less did not differ significantly in tendencies to achieve'high or low np
scores (30 or more, 29 or less) using Fisher's exact probabilities test
(Finney et al. 1963). These data suggest that level of performance on
the Tinkertoy Test is not dependent on constructional ability.

Table 2
Scoring for complexity.

Variable Scoring criteria Total possible

n >20= 1, >30=2, 4
>40=3, =50=4
nome +=1
mar mobile= 1, moving parts = 1
vm X2-1, X4=2
3d 3-dimcnsional= 1
stand free-standing= 1
mode constmtion(s) any combination of pieces= 1
error one or more error -1
---------
Highest score possible 12
Lowest score possible -1
 M.D. k z a k / Assessing exenrtioe functions 293

Table 3
Comparisons between groups on np and complexity scores.

Measure Group

Patient Control

Dependent Non-dependent F

“P
Mean (S.D.) 13.5 (9.46) 30.24 (1 1.32) 42.2 (10.03) 26.91‘
Range 0 to 42 9 to 50 23 to 50
Cornplexiv
Mean (S.D.) 2.22 (2.10) 5.47 (1.77) 7.8 (1.99) 28.27‘
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Range -1 to8 2 to 9 5 to 12

a One-way ANOVA, p KO.001

High scoring constructions appeared to involve a number of execu-

tive functions, including capacities to formulate a goal and plan as well
as initiate and carry out complex activity in pursuit of that goal. There
has not yet been adequate opportunity to investigate whether this
examination technique may be used to pinpoint the nature of the
defects of poorly executed constructions. However, these early observa-
tions suggest that patients who have difficulty initiating or carrying out
purposive activities tend to use relatively few pieces although they may
make a recognizable and appropriately named construction. Those
whose deficits are in formulating goals or planning may use relatively
more pieces but their constructions are more likely to be unnamed or
inappropriate for their names. Patients with extensive impairment in-
volving all aspects of the executive functions use very few pieces to
make unnamed or unplanned constructions or to pile pieces together
without attempting to cdmbine any. Patients who are pathologically
inert usually can be coaxed into responding to at least some standard
test items but are most likely to do nothing at all with the open-ended
task of Tinkertoy construction.

4. Effective performance

The effectiveness of behavior depends on the performer’s ability to

monitor, to self-correct, and to regulate the tempo, intensity, and other
qualitative aspects of delivery.
 294 M . D.Lezak / Assessing executive functions

Erratic performance is one of the hallmarks of impaired executive

functions. It is also a common phenomenon among brain-damaged
patients since the integrity of self-correcting and self-monitoring abili-
ties is vulnerable to many different kinds of brain damage. Some
patients do not perceive their mistakes and therefore cannot correct
them. More interesting are those patients with pathological inertia who
perceive their errors, may even point them out and talk about them, but
still do nothing to change them. Self-monitoring defects can comprom-
ise the worthiness of any kind of performance, from pushing buttons
through button holes so forcibly that they tear off, to unpunctuated
monotonic speech, to cramped writing that leaves little or no space
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between words and wanders far from the horizontal.

Assessment of these capacities usually depends upon the observer’s
sensitivity to them. Scores alone do not tell about the presence or
nature of errors and whether the patient was aware of them or tried to
correct any of them. Nor do scores reveal performance idiosyncracies
that may not lower the number of points earned on a test but, as in the
case of cramped writing, could reduce the patient’s effectiveness. The
examiner can only learn about the patient’s effectiveness by watching
and listening to him and inspecting his products.
Constructional or drawing tasks in which more of the solution
process is overt than is the case with tasks calling for a verbal response
can be particularly instructive in bringing to light how the patient errs,
self-corrects or not, and monitors his performance. Walsh (1978a) has
developed an electrically activated maze, the Austin Maze, to study
self-correcting behavior. This test requires the subject to learn a long
pathway through a series of buttons that light up green for correct steps
and red for incorrect steps along the pathway. Initially, the maze must
be traversed by trial and error. The subject’s goal is to go through the
pathway without any errors, i.e., learn the maze. This device enables the
examiner to observe the patient as he works to reduce errors. Observa-
tion and comparisons with the patient’s performance on learning tests
help the examiner determine whether poor performance is due to
learning or to executive disabilities.

* * *

Over the last decade in particular, the goals of clinical neuropsycholo-

gists have evolved from simply being able to identify the presence of
 M. D.Lezak / Assessing executive functions 295

brain damage to understanding the behavioral correlates of brain

dysfunction and of brain-behavior relationships generally. The rela-
tively recent upsurge of concern about the often tragic psychosocial
consequences of brain damage and what role neuropsychology can play
to ameliorate them reflects the continuing maturation of our discipline.
As we increasingly come to appreciate that the brain functions we study
are always the functions of somebody’s brain and that that somebody
has a life outside of our examining rooms and laboratories, we also
become increasingly aware of how disorders of the executive functions
debase the quality of the patient’s life and the lives of the persons
around him. I anticipate that the psychosocial problems attendant upon
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impaired executive functions will soon become a major concern for

neuropsychologists. I suspect that the intractable nature of executive
dysfunctions will keep them on our center stage for a long time to
come.

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 M.D.Lezak / Assessing executioe functions 291

Etre capable de formuler des buts, elaborer des plans et les executer effectivement sont “les
fonctions executives” essentieUes a l’existence de conduites autonomes, creatives et socialement
constructives. Bien que ces fonctions soient vulnkables en cas d’atteintes cerebrales, elles sont
souvent neghgizs dans les examens neurologiques et neuropsychologiques. Les raisons de cette
carence au Nveau de 1’8valuation formelle sont evcquks. La contribution des aires prefrontales e t
d’autres aires cerebrales (par ex. les structures souscorticales, himispheriques droites) aux “fonc-
tions exkutives” est tgalement discutte. On presente des procMQ d’evaluation pour quatre
catkgories de capacitt exkutives: (1) la formulation d’un but; (2) la planification de I’action; (3)
l’exhtion orientte du plan; et (4) la performance effectivement realisk.On d k r i t en outre et en
detail le Tinkertoy test@, qui semble capable de fournir des informations en relation avec ces
capacitis. Enfin, la nkessite &explorations futures dans ce domaine est soulignk.
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