The Behavior Rating Inventory of Executive Function (BRIEF), a caregiver-report questionnaire, was used to measure changes in executive function in the first year after traumatic brain injury (TBI) in a study of children, aged 5 to 15 years, at University of Minnesota, Minneapolis, and Johns Hopkins University School of Medicine, Baltimore, MD. BRIEF reports were obtained at baseline (retrospectively), and at 3 months and 1 year after injury in 330 children with mild-to-severe TBI and in 103 controls with orthopedic fractures. Children with TBI had more dysfunction than controls on the Global Executive Composite at 3 months after injury, and on the Behavioral Regulation Index, Metacognition Index, and Global Executive Composite at 1 year after injury. Between 18% and 38% of children with TBI had significant executive dysfunction in the first year after injury, children with more severe TBI having the greater dysfunction. Only 8% to 10% of children with orthopedic fractures showed executive dysfunction in the year after in jury. The working memory scale was the only scale to discriminate between controls and all 3 TBI severity groups at both 3 and 12 months after injury. Predictors of greater Global Executive Composite dysfunction were preexisting learning/behavior problems, lower respondent education, and poor family functioning. More systematic screening for executive dysfunction after TBI is recommended to increase recognition of cognitive disability, especially in patients with preinjury learning and behavior disorders and in dysfunctional families. [1]

COMMENT. Executive functioning, or the ability to perform sustained, goaldirected, multiple-step skills while inhibiting inappropriate behavior, is dependent on intact frontal-striatal brain circuits. Executive functioning is impaired following TBI that interrupts these frontal lobe connections; the more severe the injury, the greater the degree of executive dysfunction. The BRIEF questionnaire is more valid than performance-based, distraction-free measures of executive function, since the caregiver observes the child during unstructured daily activities. The test requires 10 minutes to administer and may be completed from the physician's office. When reports are suggestive of executive dysfunction, a more extensive neuropsychological evaluation is indicated to define the symptoms of ADHD and signs of cognitive dysfunction, the frequent sequelae of TBI. Several articles connecting symptoms of ADHD and learning disorders with TBI are cited in the literature.