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Executive Function and Self-awareness of “Real-world” Behavior and Attention Deficits Following Traumatic Brain Injury

Hart, Tessa PhD; Whyte, John MD, PhD; Kim, Junghoon PhD; Vaccaro, Monica MS

Journal of Head Trauma Rehabilitation: July-August 2005 - Volume 20 - Issue 4 - p 333–347

Objective To investigate the relationship between executive function and awareness of real-world behavioral and attentional dysfunction in persons with moderate and severe traumatic brain injury (TBI) and uninjured controls.

Design Observational 2-group study.

Participants Thirty-six persons with moderate to severe TBI and residual cognitive deficits, recruited from therapy programs and the community, and 30 uninjured control participants of similar age, education, gender, and race.

Measures Eight clinical measures of executive function were combined in a composite score, the Executive Composite (EC). Awareness of behavioral and attentional lapses in everyday life was estimated using Self and Significant Other (SO) ratings on the Dysexecutive (DEX) Questionnaire and the Cognitive Failures Questionnaire (CFQ).

Results Participants with TBI scored significantly worse on the EC than control participants and exhibited impaired self-awareness (ISA) compared to controls. Control participants agreed closely with their SOs on both the DEX and CFQ scales, whereas the SOs of TBI participants reported significantly greater degrees of difficulty on both scales than was endorsed by participants with TBI. Low-EC scorers within the TBI group had significantly worse ISA than controls, lending support to the hypothesis that executive function is related to ISA in chronic, moderate to severe TBI. Executive function and discrepancy scores demonstrated a modest but statistically significant association across the sample.

Conclusion Although executive function was associated with ISA in this sample, further research is needed to determine whether executive function deficits contribute in a causal fashion to ISA, and which of the cognitive operations within executive function are responsible for supporting self-awareness.

Moss Rehabilitation Research Institute, Elkins Park, Pa (Drs Hart, Whyte, Kim, and Ms Vaccaro); and the Department of Rehabilitation Medicine, Jefferson Medical College, Philadelphia, Pa (Drs Hart and Whyte).

Corresponding author: Tessa Hart, PhD, Moss Rehabilitation Research Institute, 1200 W Tabor Rd, Philadelphia, PA 19141 (e-mail:

This work was supported by grant R01NS39163 from the NINDS, NIH. The authors thank Patricia Grieb-Neff, Anthony Risser, Christopher Gantz, Monica Hopson, Joseph Alban, Natosha Bailey, Vonetta Drakes, Kelly Card, Vivian Ly, and Pamela Berretta for their contributions to data collection.

© 2005 Lippincott Williams & Wilkins, Inc.