What tools and questions are used to assess insight and executive function in a patient with Traumatic Brain Injury (TBI), and how does the information from a relative differ from the patient's self-report?

Assessment of Insight and Executive Function in Adolescent TBI

Tools for Assessing Executive Function and Insight

Use the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) with both patient self-report and collateral informant report, as this dual approach is essential for capturing the discrepancy between self-awareness and actual functional deficits in TBI patients. 1, 2

Standardized Assessment Battery

• Administer the BRIEF-A to both the 16-year-old patient and a relative/caregiver, as this instrument captures real-world behavioral manifestations of executive dysfunction across multiple domains including metacognition, behavioral regulation, and emotional regulation 3, 4

• Include the Frontal Systems Behavior Scale (FrSBe) with both before-injury and current ratings from patient and collateral, as this provides critical information about premorbid functioning versus current status 2, 5

• Conduct formal neuropsychological testing including 9 subtests designed to assess executive functions (cognitive flexibility, inhibition, planning, problem solving) appropriate for ages 8-89 years 1

• Evaluate everyday executive skills using 7 subtests that assess planning and temporal judgment through everyday activities (e.g., key search task), which includes questionnaires completable by both patient and caregiver 1

• Assess attention domains including auditory and visual sustained, selective, and divided attention, as well as attention switching, using validated instruments with good psychometric qualities 1

• Test memory functions comprehensively including auditory and visual immediate and delayed memory, and visual working memory, using age-appropriate batteries (Adult 16-69 years) 1

Cognitive Process Scores

• Obtain process-oriented scores from standard tests, particularly California Verbal Learning Test II (CVLT-II) intrusions and repetitions, and Letter Fluency (FAS) intrusions and repetitions, as these cognitive process scores are stronger predictors of behavioral dysfunction than traditional scores 5

• Document qualitative errors during testing including perseverations, rule violations, and self-monitoring failures, as these provide insight into executive control deficits not captured by summary scores 5, 6

Critical Differences Between Patient and Relative Reports

Collateral informant ratings from relatives consistently indicate more executive dysfunction than patient self-ratings, with this discrepancy being larger for current post-injury status than for premorbid functioning, reflecting impaired self-awareness (anosognosia) as a core feature of TBI-related executive dysfunction. 2

Specific Discrepancy Patterns

• Pre-injury ratings from collaterals are significantly more reliable over time compared with patients' self-ratings, making relative reports the preferred source for establishing baseline premorbid functioning 2

• At 3 months post-injury, the difference between patient and collateral ratings of current status is substantially larger than the difference relating to premorbid status, indicating that patients retain some ability to rate themselves from a pre-injury perspective but have impaired awareness of current deficits 2

• For all rating contexts (before injury, after injury, and compared to healthy controls), collateral ratings consistently indicate more abnormality than comparable self-ratings, suggesting that evaluating one's own executive behavior is inherently difficult and is exacerbated by TBI effects 2

Interpretation Framework for This 16-Year-Old

• Given the 8-year interval since injury (age 8 at injury, now 16), the patient's self-ratings of "pre-injury" function are unreliable because they cannot accurately recall executive functioning from early childhood, making collateral report from parents/caregivers essential for establishing developmental baseline 2

• The relative can provide critical information about developmental trajectory including whether executive function deficits have persisted, improved, or worsened during the critical developmental period from childhood through adolescence 1, 2

• Premorbid psychiatric history strongly predicts higher BRIEF-A scores (reflecting more perceived problems) on all three factors (Metacognition, Behavioral Regulation, Emotional Regulation), so relatives should be specifically queried about any pre-injury behavioral or psychiatric concerns 4

• Educational attainment and academic performance data from relatives provide objective markers of executive function over time, as lower educational attainment associates with higher Behavioral Regulation factor scores 4

Specific Questions for Relative Interview

Ask the relative structured questions about specific executive function domains in daily life, focusing on concrete behavioral examples rather than general impressions, as this yields more reliable functional assessment data. 1, 3

Daily Functioning Domains

• Planning and organization: "Does your child have difficulty planning ahead for school assignments, breaking down multi-step tasks, or organizing materials needed for activities?" 1

• Cognitive flexibility: "Does your child get stuck on one way of doing things, have difficulty switching between activities, or become upset when routines change?" 1

• Inhibition and impulse control: "Does your child act without thinking, interrupt conversations, have difficulty waiting their turn, or make impulsive decisions?" 1

• Working memory: "Does your child forget instructions while carrying them out, lose track of what they're doing mid-task, or need frequent reminders?" 1

• Initiation: "Does your child have difficulty starting tasks independently, require prompting to begin activities, or appear unmotivated?" 1

• Self-monitoring: "Does your child recognize when they make mistakes, adjust their approach when something isn't working, or seem unaware of how their behavior affects others?" 1

Comparison Questions

• "How did your child function in these areas before the injury at age 8 compared to same-age peers?" This establishes developmental baseline 2

• "How has your child's functioning in these areas changed over the past 8 years?" This captures trajectory and identifies persistent versus resolved deficits 2

• "In what specific situations do you notice the biggest differences between your child's abilities and those of their peers?" This identifies ecologically relevant functional impairments 3

Common Pitfalls and How to Avoid Them

• Do not rely solely on patient self-report, as impaired self-awareness is a core feature of executive dysfunction, particularly in adolescents with childhood-onset TBI who lack accurate memory of premorbid functioning 2, 3

• Do not interpret normal performance on office-based neuropsychological tests as indicating intact real-world executive function, as standardized tests often fail to capture the unstructured, complex demands of daily life where executive deficits become apparent 3, 6

• Do not attribute all discrepancies between patient and relative reports to poor insight alone, as premorbid psychiatric history, depression, and injury severity all contribute to rating patterns and must be systematically assessed 4, 5

• Do not assume that 8 years post-injury represents complete recovery, as executive function deficits can persist chronically and may become more apparent as environmental demands increase during adolescence and young adulthood 5, 6

• Do not overlook cognitive process scores (intrusions, repetitions, perseverations) in favor of only traditional summary scores, as process scores are stronger predictors of real-world behavioral dysfunction 5