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    The omportmental Learning Disabilities of Early Frontal Lobe Damage   (Article begins on next page)  The Harvard community has made this article openly available.Please share how this access benefits you. Your story matters. Citation Price, Bruce H., Kirk R. Daffner, Robert M. Stowe, and M. Marsel Mesulam.1990. “The Comportmental Learning Disabilities of Early Frontal LobeDamage.” Brain 113, no. 5: 1383–1393. Published Version doi:10.1093/brain/113.5.1383  ccessed January 14, 2018 12:21:49 PM EST Citable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:12605379 Terms of Use This article was downloaded from Harvard University's DASH repository,and is made available under the terms and conditions applicable to OtherPosted Material, as set forth at http://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAA  Brain  (1990), 113, 1383-1393 THE COMPORTMENTAL LEARNING DISABILITIESOF EARLY FRONTAL LOBE DAMAGE by  BRUCE H. PRICE, KIRK R. DAFFNER, ROBERT M. STOWE  and M. MARSEL MESULAM  From the Bullard and Denny-Brown Laboratories, the Division of Behavioral Neurology andNeuroscience of  the  Harvard Neurology Department and the Charles A. Dana Research Institute ofthe Beth Israel Hospital, Boston, USA) SUMMARYTwo adult patients are described who suffered bilateral prefrontal damage early in life and who subse-quently came to psychiatric attention because of severely aberrant behaviour. A battery of developmentalpsychology paradigms (not previously used to assess neurologically impaired individuals) showed that socialand moral development of these 2 patients was arrested at an immature stage. In comparison with othertypes of brain damage which disrupt cognitive development, frontal damage acquired early in life appearsto provide the neurological substrate for a special type of learning disability in the realms of insight, foresight,social judgement, empathy, and complex reasoning.INTRODUCTION Most of the available literature on the behavioural affiliations of the human frontal lobeis based on the clinical examination of patients with lesions acquired during adulthood(Ackerly, 1935; Brickner, 1936; Hebb, 1945; Benton, 1968; Milner, 1982; Eslingerand Damasio, 1985; Lhermitte, 1986; Lhermitte  etal.,  1986). Comparatively littleinformation is available about the behavioural outcome of lesions acquired early in lifeor in the course of embryogenesis. Such information could help to identify the behavioursthat depend on the frontal lobes for their acquisition and development.This report describes 2 individuals who sustained severe frontal lobe damage earlyin life and subsequently displayed major behavioural abnormalities as adults. Theseobservations suggest that the frontal lobe plays an essential role in the maturation ofcomplex comportmental skills, formal operational thought, social conduct and moraljudgement. CASE REPORTS Case I G.K. is a 31-yr-old right-handed man who has been given multiple diagnoses, including antisocial orborderline personality, atypical psychosis, and paranoid schizophrenia. Because of increased headcircumference over the first 7 days of life, bilateral ventricular punctures were performed which yielded10 ml of subdural haematoma fluid. Air was injected after aspiration and an irregular collection in theleft frontal lobe was demonstrated. He was discharged 7 wks after birth when his head circumference hadstabilized and he was thriving.Correspondence to: Dr Bruce H. Price, Neurological Unit, Beth Israel Hospital, 330 Brookline Avenue, Boston,MA 02215, USA.Dr Stowe is now at the Veterans Administration Medical Center, Pittsburgh, Pennsylvania, USA.©  Oxford University Press  1990   a  t  H a r  v a r  d L i   b r  a r  y onM a  y2 1  ,2  0 1 4 h  t   t   p :  /   /   b r  a i  n . oxf   or  d  j   o ur n a l   s  . or  g /  D o wnl   o a  d  e  d f  r  om  1384 B. H. PRICE AND OTHERS Detailed history from multiple sources revealed that he was always considered immature  but  that seriousbehavioural difficulties were first identified  by  the  age of  8  yrs. He  did not  respond  to  parental discipline,always sought gratification  of his  immediate needs, never developed adequate friendships,  and  blamedhis difficulties  on  others. Though gregarious,  he was  irresponsible, tended  to  wander,  and  consistentlyfell under  the  influence  of  other deviant children. Under firm guidance  and  after  two  school transfers,he graduated from high school.  He  joined  the  Marine Corps  but was  dishonourably discharged  6 wks later. Over the next  1 yrs,  he  was hospitalized  27  times  in  psychiatric institutions  and  imprisoned  8  timeson charges  of  assault, forgery (using his father's cheque book), grand larceny, drug involvement  and  lewdbehaviour. Inappropriate behaviours were numerous. While walking  by a  gas station  he saw an  unattendedtaxi with keys  in the  ignition.  He  jumped  in and  drove  off,  ripping  the  hose from  the gas  pump, onlyto  be  captured several blocks away. When restricted  for  inappropriate behaviour  by a  ward attendant,  he escaped from  the  locked psychiatric unit, scratched  the  attendant's  car  with broken glass, signed  his own name,  and  re-entered  the  ward. When confronted, he denied his involvement. The only 2 people he claimedas friends were involved with  him in  abusing marijuana, alcohol, LSD,  and  phencyclidine.  He  was chargedwith arson  of two  public buildings.  He is an  active bisexual, often trades cigarettes  for  oral  sex, and masturbates  in  public.  He was a  suspect  in the  rape  of 2  female ward patients. Neither individualpsychotherapy  nor  trials  on  multiple psychoactive agents were effective.The patient  has 5  younger brothers.  One  suffers from mild mental retardation  of  unknown aetiology.Four siblings  are  college graduates,  1 is a  lawyer.  His  father successfully operates  a  landscape business.His mother was trained  as a  nurse and suffers from depression  and  alcoholism. There  is  no other significantfamily psychiatric history.  The  family environment  was not  particularly chaotic  or  stressful.Neurological examination revealed  an  overly familiar, impulsive,  but  cooperative man.  He  showed littleinsight  or  empathy  and  felt victimized  by  others. Other than  a  minimal left central facial paresis,  the examination  was  unremarkable, without grasp, suck  or  root reflexes. Formal neuropsychological testingrevealed  a  WAIS-Revised verbal  IQ of  102, Performance  IQ of  90,  and  Full-Scale  IQ of  96 (Wechsler, 1981).  No  primary memory, language  or  visuospatial difficulties were demonstrated. Deficits were confinedto attentional, organizational,  and  mental flexibility skills.  For  example, severe deficits were seen  on  PartB  of  the Trail Making Test (Reitan, 1958), Stroop Interference (Stroop, 1935), Wisconsin Card Sorting(Berg, 1948), Luria hand-motor sequences (Luria, 1973), auditory go-no-go (Luria, 1973),  and the  visual-verbal test (Feldman  and  Drasgow, 1959). Word list generation (Benton  and de  Hamsher, 1976),  and traditional office tests  of  abstraction  and  proverb interpretation were normal (Table  1). General medical examination, laboratory tests,  and  routine  EEG  were normal. Axial  MRI  images usingTl  and  T2-weighted sequences revealed bilateral lesions extending from cortex  to  the caudate nuclei, moreon  the  left than  the  right. There  was  mild  ex  vacuo enlargement  of the  right lateral ventricle  fig. 1). TABLE I. NEUROPSYCHOLOGICAL PROFILE OF CASE 1 Test Score WAIS-RVerbal  IQ Performance  IQ Full Scale  IQ Digit SpanWord Generation (F/A/S)Stroop InterferenceTrails  B Wechsler Memory ScaleBoston Naming TestHooper Visual Organization TestVisual-Verbal Test10290967 forward/4 backward17/7/11143  s/6  errors 86* 54/6014/150/5AverageAverageAverageMild inattention57th percentile<  1st  percentile<  1st  percentile18th percentile31st percentileNormalAbnormal* Although  the  Wechsler Memory Scale suggests  low  average memory,  no  memorydifficulties were apparent  in his  daily living activities.   a  t  H a r  v a r  d L i   b r  a r  y onM a  y2 1  ,2  0 1 4 h  t   t   p :  /   /   b r  a i  n . oxf   or  d  j   o ur n a l   s  . or  g /  D o wnl   o a  d  e  d f  r  om  EARLY FRONTAL LOBE DAMAGE1385 FIG.  1.  Case I.  Axial MRI scan showing bilateral frontal lobe lesions. The left side of the head is on the right ofthe scan. Left involvement is greater than right. The lesions extend from cortex to the caudate nuclei. Mild ex vacuoenlargement of the right lateral ventricle can be seen. Case 2 M.H. is a 26-yr-old ambidextrous woman who was referred by the Massachusetts Department of SocialService for inappropriate behaviour and negligent care of her 2'/2-month-old infant. She was developingappropriately until 4 yrs of age, when she was struck by an automobile. She was unconscious for 48 hand suffered bilateral skull fractures and a right frontal haematoma.Over the next year she began to exhibit temper outbursts when frustrated. She became verbally andphysically assaultive in an abrupt, unpredictable, and short-lived manner. She hit her brother, threw herfather over a table, and cut her sister with glass. Family members lived in constant terror and once calledthe police when she threatened them at knife point. She repeated the first and second grades and was givenspecial tutorials in English, social studies, and reading. She graduated from high school at age 20 yrs.Since her early teens, she was known for her sexual promiscuity and bravado. She intermittently engagedin heavy alcohol and marijuana use. She had no sustained friendships.After high school graduation, she held several temporary menial jobs where infrequent outbursts againstcoworkers or customers occurred. Although free of major depressive symptoms, she impulsively attemptedsuicide twice, once with an overdose of hypnotics, and another time  by  jumping out of a second floor window.At age 17 yrs, she was raped while wandering through a local cemetery, but returned to the scene andwas raped again by the same man. Her first pregnancy was terminated by an elective abortion, anotherended in miscarriage, and her third accidental pregnancy yielded a daughter despite her parents' andboyfriend's pleas for an abortion. She under-dressed the baby in inclement weather, fed her erraticallyand left her unsupervised for lengthy periods of time. There were suspicions of physical assault. At 20days of age, the patient's daughter was placed in foster care. This intervention infuriated the patient whosaw nothing wrong with her child care. She attacked the social worker, and threatened to kill membersof the social service agency. At her last follow-up visit in our unit, she was pregnant again but was uncertainwho the father might be. Individual psychotherapy did not significantly alter her behaviour nor did a prolongedtrial of anticonvulsant agents.   a  t  H a r  v a r  d L i   b r  a r  y onM a  y2 1  ,2  0 1 4 h  t   t   p :  /   /   b r  a i  n . oxf   or  d  j   o ur n a l   s  . or  g /  D o wnl   o a  d  e  d f  r  om
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