1. hobbies and interests
2. games
3. gambling

International Journal of Neuroscience, 122, 500–505, 2012
Copyright © 2012 Informa Healthcare USA, Inc.
ISSN: 0020-7454 print / 1543-5245 online
DOI: 10.3109/00207454.2012.673516
Self-Reported Differences on Measures of Executive
Function in a Patient Sample of Pathological Gamblers
Rory C. Reid, Heather L. McKittrick, Margarit Davtian, and Timothy W. Fong
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
Patients seeking help for pathological gambling often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with gambling. Some of these characteristics
are also common among patients presenting with neurological pathology associated with executive deficits.
Evidence of executive deficits have been confirmed in pathological gamblers using objective neurocognitive
tests, however, it remains to be seen if such findings will emerge in self-report measures of executive control.
These observations led to the current investigation of differences between a group of pathological gamblers
(n = 62) and a comparison group (n = 64) using the Behavior Rating Inventory of Executive Function–Adult Version (BRIEF-A). Significant differences between the groups emerged over all nine subscales of executive functioning with the most dramatic differences on BRIEF-A subscales Inhibit, Plan/Organize, Shift, Emotion Control,
Self-Monitor, and Initiate among the pathological gamblers. These results provide evidence that support findings
among pathological gamblers using objective neuropsychological measures and suggest that the BRIEF-A may
be an appropriate instrument to assess possible problems with executive control in this population.
KEYWORDS: assessment, executive functioning, pathological gambling
Executive Functions and Pathological
Gambling
Pathological gambling is estimated to affect 1%–3%
of North American adults at some point in their lifetime
[1, 2] and creates a constellation of issues for the gambler, the gambler’s family, and society. Consequences
include a diminished quality of life for the gambler [3]
as well as financial problems, high divorce rates, legal
challenges, and interpersonal problems [4]. Suicide attempts are common in this population, with rates as high
as 12%–24% [5, 6]. Patterns of impulsivity, poor judgment, impaired decision making, and emotional lability
commonly found among pathological gamblers have led
to studies examining executive functioning in this population. Such studies help to illuminate whether there
are underlying neurocognitive deficiencies implicated in
pathological gambling that might provide greater information about the etiology, maintenance, or treatment of
patients seeking help for gambling problems.
Executive functions refer to a set of higher order cognitive abilities that enable an individual to inhibit, shift,
plan, and organize information in order to achieve a
desired goal in an efficient and acceptable way. Cognitive processes theoretically linked to executive functions include the ability to inhibit behavior and impulses,
process nonverbal and verbal working memory stimuli,
and regulate affect, motivation, and arousal. Executive
functions are also important in allowing an individual
to adapt to and manipulate external cues in the environment by facilitating processes involved in planning,
organization, decision making, judgment, task monitoring, attention, problem solving, hypothesis generation,
abstract thinking, and cognitive flexibility [7, 8, 9, 10].
There is evidence to suggest that disruptions in brain
areas important for the proper functioning of executive
tasks (e.g., prefrontal cortex) generate a wide range of
behavioral disturbances manifested by impulsive, exaggerated, or extreme behaviors [11]. It has, therefore,
been proposed that deficits in executive functions predate the onset and maintenance of addictive behaviors,
including pathological gambling [12]. As such, understanding executive functioning in pathological gamblers
Received 19 January 2012
Funding sources: NIDA Grant 5K23DA019522-04
Address correspondence to Rory C. Reid, Ph.D., Semel Institute for
Neuroscience and Human Behavior, Department of Psychiatry and
Biobehavioral Sciences, University of California, Los Angeles, 760 Westwood
Boulevard, Suite 38-260, Los Angeles, CA 90024, USA. E-mail:
[email protected]
500
Executive Functioning and Gambling
can facilitate a more comprehensive assessment of the
disorder and may even have implications for whether an
individual can benefit from specific treatment interventions [13, 14].
Previous research examining executive functioning
in pathological gamblers shows evidence of diminished
performance on objective neuropsychological measures
[13–18]. For example, pathological gamblers have
slower stop signal reaction times and greater difficulty
inhibiting responses to incongruent stimuli when compared to healthy controls, suggesting impaired inhibition
in pathological gamblers [14]. Effective decision making, an important facet of executive control, also appears
to be compromised in pathological gamblers when measured by objective neuropsychological testing [15–17].
Previous investigators have hypothesized that specific
executive functions play an important part in risky decision making associated with pathological gambling and
the maintenance of the disorder [17]. Evidence for such
hypotheses has been observed in studies where diminished capacity for effective problem solving, as measured
by the Wisconsin Card Sorting Test, has been noted in
problem gamblers compared to healthy controls [18].
Collectively, these results suggest that executive deficits
as measured by neuropsychological tests are common in
pathological gamblers.
Rationale for this Study
Although objective neuropsychological tests are one approach to assessing executive control in patients, some
researchers criticize the ecological validity of these tests
because they are conducted in controlled settings that
often do not generalize to real world situations [9, 19].
Furthermore, the ecological validity of such tests may
vary significantly, even when using the same outcome
measure [20]. As a result, some have suggested that selfreported assessment of executive functioning may provide a more accurate picture of real world deficits encountered among various clinical populations. In some
cases, self-report measures of executive control have discovered deficits that neurocognitive instruments failed
to identify [21].
In the present study, we sought to assess whether
findings of executive deficits measured by neuropsychological tests in pathological gamblers could be replicated
when limited to subjective measures of self-report. We
were also interested in whether pathological gamblers
would detect executive deficits not previously identified
where objective testing had been employed. Finally, the
utility of self-reported assessment of executive functioning is more cost effective and more feasibly conducted in
a clinical setting. Thus, if self-report assessment of executive functioning parallels findings where objective neu
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2012 Informa Healthcare USA, Inc.
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ropsychological testing is employed, our results could
offer clinicians more cost effective and efficient ways of
assessing the strengths and limitations of pathological
gambling patients. At a minimum, a self-report instrument could be considered as a screener to assess whether
additional neuropsychological testing of executive functioning is indicated for a given patient.
METHODS
Participants
The patient sample used in this study consisted of 62
subjects (male = 38) recruited from an outpatient clinic
that specialized in the treatment of pathological gamblers. These participants were selected consecutively
based on (a) a primary complaint of problem gambling
reported during intake and assessment and (b) willingness to participate in research, as reflected in consent
provided at the outset of the treatment process. Ethnic
representation among the patient sample included Asian
(n = 11), Hispanic (n = 6), Native American (n = 1),
African American (n = 5), and Caucasian (n = 39), and
participants ranged from 21 to 66 years of age (M =
45.3, SD = 11.4). Relationship status included never
married (n = 27), first marriage (n = 13), remarried (n
= 1), divorced (n = 12), separated (n = 5), cohabitating
(n = 3), and widowed (n = 1). Education among the
gambling sample included high school education (n =
17), some college (n = 20), bachelor’s degree (n = 18),
master’s degree (n = 5), and doctorate degree (n = 2).
A total of 64 control (male = 40) subjects were drawn
from a group of individuals who sought help for distress
associated with minor relationship issues (e.g., communication problems) or a life transition issue (e.g., starting a new job) at an outpatient community clinic that
provided brief counseling. These subjects were assessed
by a clinical psychologist and determined to be void
of meeting criteria for any mental health illness. Ethnic representation among the control sample included
Asian (n = 5), Hispanic (n = 8), and Caucasian (n = 51),
and participants ranged from 23 to 62 years of age (M
= 37.1, SD = 8.7). Relationship status included never
married (n = 17), first marriage (n = 33), remarried (n =
3), divorced (n = 6), separated (n = 2), and cohabitating
(n = 3). Education among the control sample included
high school education (n = 5), some college (n = 34),
bachelor degree (n = 23), master degree (n = 3), and
doctorate degree (n = 4).
Measures
Behavior Rating Inventory of Executive
Function–Adult Version (BRIEF-A)
The BRIEF-A is a self-report measure composed of
75 items with nine distinct empirically derived clinical
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R.C. Reid et al.
Problem gambling behaviors
Executive function processes
Difficulties controlling gambling behaviors
Inhibition, impulse control
Motivational deficits to change behavior
Motivation, task initiation, decision making, sustained attention
Alexithymia, emotion dysregulation, rumination
Emotional control, cognitive flexibility, inhibition
Choose gambling despite negative consequences
Decision making, judgment, inhibition, impulse control
Preoccupation and rumination about gambling
Attention, behavior inhibition, cognitive flexibility
FIGURE 1 Hypothesized correlates of pathological gambling and executive functions.
scales that measure various aspects of executive functioning: Inhibit, Self-Monitor, Plan/Organize, Shift,
Initiate, Task Monitor, Emotional Control, Working
Memory, and Organization of Materials. The clinical
scales form two broader indices: the Behavioral Regulation Index (BRI) and the Metacognition Index (MI).
These two indices generate an overall Global Executive
Composite (GEC) score. Standard scores are calculated
for the clinical scales, the indices, and the summary
composite score. Comparisons to a normative sample of
1050 self-reports and 1200 informant reports generate
T scores for each scale, with higher scores reflecting
greater difficulties and levels of impairment. The
BRIEF-A also includes three validity scales: Negativity,
Infrequency, and Inconsistency [22]. Internal consistency for the self-report form yielded alpha coefficients
ranging from 0.80 to 0.94 for the clinical scales and
0.96 to 0.98 for the index scores. The BRIEF-A has also
shown reliability over time with test–retest correlations
among the clinical scales ranging from 0.91 to 0.94
over a 4–week period. The BRIEF-A has been shown to
be sensitive to subtle executive changes in a population
with mild cognitive impairment and older adults with
significant cognitive complaints when standardized neuropsychological tests failed to detect any decline [23].
27]. Participants who answered positively to five or more
items are classified as pathological gamblers.
Mini International Neuropsychiatric Interview
(MINI 6.0)
The MINI is a structured diagnostic clinical interview used to assess DSM-IV-TR psychopathology along
the Axis I domains and includes a module that assesses for adult Attention Deficit Hyperactivity Disorder (ADHD). It is widely used, and the psychometric
properties have been established and reported in the literature [24].
DATA ANALYSIS AND RESULTS
National Opinion Research Center DSM Screen
for Gambling Problems (NODS)
National Opinion Research Center DSM Screen for Gambling Problems (NODS) is a short brief structured interview based on the DSM-IV criteria [25] and has been
demonstrated to be a valid, reliable, and clinically useful tool to screen for gambling related disorders [26,
Procedure
All subjects signed informed consent, completed a demographic survey, and research measures at the outset
of their participation in counseling. All participants
received an Axis I diagnostic interview by a clinical psychologist. Participants also received a diagnostic clinical
interview to assess for Axis I disorders, including adult
ADHD. The structured diagnostic interviews were
conducted using the Mini International Neuropsychiatric
Interview and were administered by two doctoral level
clinicians with 8+ years of experience. One clinician
was trained in neuropsychology; the other in psychiatry.
Exclusion criteria included any history of head injury,
concussion, color-blindness, cortical neurotoxins,
stroke, or alcohol or drug abuse. Participants with any
history of a neurological or neuropsychiatric condition
or adult ADHD were also excluded given these confounds might better account for executive deficits. All
study procedures were approved by the Institutional Review Board at the University of California, Los Angeles.
Group Comparisons
The overall MANOVA for the subscales of the BRIEF-A
revealed significant differences between the two groups
(Wilks’ λ = 0.702, F(9, 116) = 5.48, p = 0.001).
As shown in Table 1, post-hoc univariate tests showed
significant differences between the groups on all of
the nine subscales of the BRIEF-A. The magnitude of
the differences was most pronounced for the Inhibit,
Plan/Organize, and Shift subscales, where pathological
gamblers reported significantly higher scores.
Clinically Meaningful Elevations
In practice, we are usually interested in clinically
meaningful elevations to determine whether patients
International Journal of Neuroscience
Executive Functioning and Gambling
503
TABLE 1. Means, standard deviations, and group differences on study variables
Executive function
Variables
BRIEF-A
Inhibit
Shift
Emotion control
Self-monitor
Initiate
Working memory
Plan/organize
Task monitor
Organization of materials
∗
Controls
Gamblers
n = 64
n = 62
Effect size
M
SD
M
SD
F
52.6
53.8
48.9
49.8
52.1
55.4
52.3
52.6
49.8
8.2
7.9
8.4
7.3
8.6
9.5
8.8
8.3
10.3
61.6
61.8
56.7
57.1
61.2
61.9
61.5
59.9
53.8
10.4
10.2
9.8
9.4
12.5
10.5
10.6
10.9
11.7
29.19∗∗
24.35∗∗
23.17∗∗
23.19∗∗
23.67∗∗
13.21∗∗
27.99∗∗
17.41∗∗
4.09∗
η2
.19
.16
.16
.16
.16
.09
.18
.12
.03
p < .05, ∗∗ p < .001.
fall within various groups. That same principle can
be applied to understand how frequently pathological
gamblers produce BRIEF-A elevations that are diagnostically significant (usually regarded as T ≥ 65). To
better understand how often such elevations are found
in gamblers versus the control group, frequencies of
participants falling above and below this threshold
on the BRIEF-A subscales were computed (see Table
2). For these data, 71% of the gamblers had at least
one clinical elevation, with 56% having two or more
clinically elevated scales and 45% having three or
more elevated scales. As shown in Table 2, scales with
the most frequent elevations among the gamblers are
Plan/Organize (44%), Working Memory (42%), Shift
(39%), Initiate (37%), and Inhibit (36%). As can be
seen, the control sample exhibits some elevations, but
overall, they occur much less frequently among this
group than among gambling patients.
TABLE 2. Prevalence rate comparisons for clinically elevated
BRIEF-A scores
Percent with T-scores > 65
BRIEF-A scales
Inhibit
Shift
Emotion control
Self-monitor
Initiate
Working memory
Plan/organize
Task monitor
Organization of
materials
Gamblers
Controls
χ2
36%
39%
19%
18%
37%
42%
44%
21%
21%
6%
5%
5%
0%
9%
19%
14%
2%
8%
16.43∗∗∗
21.65∗∗∗
6.46∗∗
12.44∗∗∗
13.65∗∗∗
8.04∗∗
13.42∗∗∗
12.01∗∗∗
4.45∗
Note: p values for χ 2 based on Fisher’s Exact Test.
∗
p < .05, ∗∗ p < .01, ∗∗∗ p < .001.
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2012 Informa Healthcare USA, Inc.
DISCUSSION
In examining self-reported executive deficits in this
study, pathological gamblers scored higher than controls
across all nine indices as measured by the BRIEF-A.
The magnitude of the effect sizes for the group differences was large for the majority of executive functioning indices. The most notable differences occurred on
the BRIEF-A subscales of Inhibit, Plan/Organize, Shift,
Emotion Control, Self-Monitor, and Initiate, providing
a number of insights about difficulties encountered by
pathological gamblers.
Clinically speaking, these elevated indices among the
gambling group suggest a number of executive deficits
experienced by this population. In particular, cognitive rigidity in problem solving and making transitions
(Shift), as well as the ability to modulate or control
one’s own emotional responses (Emotional control), independently begin a task, generate ideas, responses, or
problem-solving strategies (Initiate), and manage current and future-oriented task demands (Plan/Organize)
appear to be problematic domains for gamblers. Not
surprisingly, the ability to inhibit, resist, or delay gratification by not acting on an impulse (Inhibit) and selfmonitoring of one’s own social behavior and the effect
of his or her behavior on others are also executive domains that gamblers appear to struggle with significantly
more than healthy controls. Collectively, these executive
deficits contribute to difficulties regulating thoughts,
urges, and behaviors leading to a constellation of consequences for pathological gamblers and their loved ones.
An important finding from this study is that a selfreport measure of executive functioning yields similar results among pathological gamblers compared to
studies that employ objective neuropsychological tests.
Thus, the BRIEF-A may provide clinicians a more
cost effective way to assess executive deficits among
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R.C. Reid et al.
pathological gamblers. At a minimum, the BRIEF-A
could be used to screen candidates for more comprehensive neuropsychological testing.
Limitations to this study include the use of self-report
instruments and lack of standardized clinical neuropsychological test batteries to collaborate the use of the
BRIEF-A (although such testing was conducted in the
development of the BRIEF-A). Inferences about the
findings beyond those listed in this study should be
made with caution, in part, because this study was crosssectional in nature and thus causal conclusions cannot
be drawn from these data.
Future studies may consider using other comparison
groups such as a chemically dependent population or
recreational gamblers. Furthermore, collaborating elevations on the BRIEF-A specifically with a sample of
pathological gamblers would be a desirable way to assess the classification accuracy in this population.
CONCLUSIONS
The present study investigated differences between a
sample of pathological gamblers and a comparison
group on indices of executive functioning as measured
by self-report. On an average, the gambling group experienced significantly greater degrees of deficits in executive functions as measured by the BRIEF-A, with
the most dramatic differences on the subscales Inhibit,
Plan/Organize, Shift, Emotion Control, Self-Monitor,
and Initiate. The findings of executive deficits noted in
this study parallel those found in other studies utilizing
objective neuropsychological tests and suggest that the
BRIEF-A may be a cost-effective way to assess or screen
for possible executive deficits in pathological gamblers.
Declaration of interest: The authors of this
manuscript indicate they have no conflict of interest to
declare nor do they have any financial interest in the
publication of this manuscript.
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