Executive Functioning and Frontal Lobe Challenges After Coma

Executive Functioning: Betty Part Eight

Betty suffered a subdural hematoma in her frontal lobe injury, requiring brain surgery.  It is in her frontal lobe functioning that she shows the most significant ongoing deficits with her executive functioning.   Her frontal lobe deficits include social and emotional issues and executive functioning problems.  Certain aspects of all of the issues we have discussed previously relate to frontal lobe injury, such as her challenges in conversation.  She also has problems with impolitic speech, impatience and independence.    She talks too much about her own TBI, particularly in social settings where that much familiarity isn’t appropriate.  Her inability to make even small decisions can cause her brain to overload, then shut down.

Executive functioning:

“Executive functions are the neurocognitive operations that enable purposeful behavior as it unfolds in time.” Evaluation and Treatment of Mild Traumatic Brain Injury” Varney,Roberts, page 133.  The executive functions relate to three primary purposes, goals, organization of time and flexibility.

• 1. A person or organization must be able to set goals;
• 2. Likewise, in order to achieve those goals, a person or organization must organize how time and effort are allocated to a plan; and
• 3.  An person or an organization must have sufficient flexibility to shift the methods of enacting the plan, when change or miscalculations require it.

Think of the brain as the quarterback of a football team.  The team has overall goals of winning the game, going to the playoffs, winning the Super Bowl.  The quarterback has smaller goals on each play, each drive.  Prior to the game, the coaches of the team will create a game plan, to achieve those goals, with each player assigned his tasks, in temporal sequence, to carry out the game plan.  But ultimately, the success or failure of the short term and long term goals, will depend upon the ability of the quarterback to implement the game plan.  Even if all other parts of the team are working fine, if the executive of the team (the quarterback during the game) is unable to coordinate all of the various activities of the other players – in time sequence and with the flexibility to change the play –  the team will fail.

The team that can’t make a plan will fail. The quarterback who can’t coordinate the time sequence of his other 10 players in carrying out a play will fail. The quarterback who can’t call the audible, will fail.

Some of Betty’s executive functioning challenges fit neatly into quarterback analogy.  But the frontal lobes also control behavior, emotions and are where we learn to become adults.  Becoming an adult requires a generation long inlay of subtle social cues, inhibitions and development of independence upon the cerebral cortex of the brain.  Subtle damage can set back that process for years.  Significant damage can not only erase the neural networks but eliminate the neurons upon which a new set of social mores could be imprinted.

In our next blog, we will elaborate upon the particular frontal lobe deficits and executive functioning Betty identified in her own behavior.

For Part  Nine, Click here.