Brain Injury, December 2007; 21(1314): 13611369

The Frontal Systems Behaviour Scale (FrSBe) as a predictor

of community integration following a traumatic brain injury

STEPHANIE A. REID-ARNDT, CARISSA NEHL, & JOSEPH HINKEBEIN

Department of Health Psychology, University of Missouri-Columbia, Columbia, MI, USA

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(Received 14 August 2007; accepted 4 November 2007)

Abstract
Primary objective: This study examined the relationships between the Frontal Systems Behaviour Scale (FrSBe),
neuropsychological tests and community integration outcomes among individuals with a history of TBI.
Methods: Seventy-six individuals with a history of TBI were consecutively recruited from patients seen in a Neuropsychology
clinic in an academic healthcare setting. Participants completed neuropsychological tests, the FrSBe and the Community
Integration Questionnaire (CIQ) as part of a standard clinical neuropsychological evaluation.
Results: The FrSBe was a significant predictor of community integration (CIQ) outcomes. Specifically, poorer executive
functioning (FrSBe Executive Functioning) predicted lower CIQ Total Scores, while increased apathy (FrSBe Apathy) was
associated with reduced CIQ Productivity. Regarding neuropsychological tests, only Delayed Memory remained as a
predictor: higher scores were associated with enhanced CIQ Total Scores and CIQ Social Integration. Finally, female
gender was associated with superior CIQ Total Scores, CIQ Home Integration and CIQ Productivity.
Conclusions: While neuropsychological tests of executive functioning failed to add predictive power to models of community
integration following TBI with this sample, the FrSBe, a measure of behavioural manifestations of frontal lobe dysfunction,
did predict these important functional outcomes. This suggests that use of the FrSBe may enhance the ecological validity of
information gathered during a clinical neuropsychological assessment.
Keywords: Traumatic brain injury, community integration, neuropsychological, executive functioning, functional status

Introduction
It has been estimated that 1.4 million individuals are
newly affected by a traumatic brain injury (TBI) in
the US each year [1]. Many of these injuries occur
as a result of motor vehicle accidents [1], which
can result in accelerationdeceleration injuries characterized by both cortical contusions and diffuse
axonal injury [2, 3]. The frontal lobes are particularly vulnerable to the mechanisms of injury associated with head trauma [4], resulting in a variety
of cognitive and behavioural changes that can have
significant effects on functional outcomes.
Much work has been done to clarify the roles of
the frontal lobes in human behaviours. In a recent

review, Cicerone et al. [5] identified four domains of

executive functioning that are purportedly associated
with distinct anatomical regions. Executive cognitive
functions include planning, organization and set
shifting and are believed to rely on intact dorsolateral
prefrontal cortex. Behavioural self-regulatory functions,
such as emotional processing and understanding the
consequences of behaviour, can be disrupted by
damage to the inferior medial frontal region. Injury
to the cingulate and superior frontal regions has been
associated with decreased initiation, which Cicerone
et al. [5] conceptualize as activation regulating
functions. Finally, metacognitive processes, including
self-awareness and episodic memory, are attributed
to functioning of the frontal polar region.

Correspondence: Stephanie Reid-Arndt, Health Psychology, University of Missouri-Columbia, One Hospital Dr., DC 116.88, Columbia, Missouri 65212,
USA. Tel: (573) 882-8847. Fax: (573) 884-3518. E-mail: reidarndts@health.missouri.edu
ISSN 02699052 print/ISSN 1362301X online 2007 Informa UK Ltd.
DOI: 10.1080/02699050701785062

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S. A. Reid-Arndt et al.

A substantial body of research on executive

functioning has focused on the development and
study of neuropsychological measures designed
to assess executive cognitive functions, such as
planning, set shifting and response inhibition [6].
There is clear evidence that frontal lobe injuries
are associated with impairments on executive functioning tests [2] and research has revealed that
executive dysfunction may be associated with poorer
vocational functioning and community integration.
For example, better performance on measures
of executive functioning are associated with
enhanced community integration and independent
functioning following a TBI [7, 8].
Interestingly, however, a large study utilizing the
National Institute on Disability and Rehabilitation
Research (NIDRR) TBI Model Systems database
failed to find a relationship between frontal lesions,
executive dysfunction and community involvement
at 1-year post-injury [9]. Other studies have similarly
failed to document a relationship between executive
dysfunction and poorer functional outcomes following TBI. One possible explanation is that traditional
neuropsychological measures, such as the tests that
were administered in these studies, are less sensitive
to behavioural changes (e.g. apathy, disinhibition)
that occur secondary to frontal lobe lesions and can
have a significant impact on functional outcomes
[1012].
These findings suggest the need for continued
identification and refinement of tools for evaluating
behavioural aspects of executive functioning.
A recent article [13] provided an in-depth review
of five behavioural executive functioning rating
scales and identified two of these scales as the most
well-validated to date. The Behaviour Rating
Inventory of Executive Functions (BRIEF [14])
and the Frontal Systems Behaviour Scale (FrSBe
[15]) were highlighted as instruments having
adequate norms, good reliability and evidence of
validity based on their ability to discriminate
between individuals who have frontal lobe lesions
from those with lesions in other areas. Both of these
measures have self-report and collateral-report forms
and they generally require 1015 minutes to administer. However, the BRIEF is a measure for
paediatric populations, with normative data for
children up to age 18, while the FrSBe provides
normative data for adults aged 1895 years. Thus,
for adult populations, the FrSBe may have particular
promise for elucidating the nature and severity of
behavioural executive dysfunction secondary to TBI.
The FrSBe [15] is comprised of three sub-scales
measuring Apathy, Disinhibition and Executive
Dysfunction, which can be conceptualized as reflecting functioning of the anterior cingulate, orbital
frontal circuit and dorsolateral prefrontal circuit,

respectively [16]. A factor analysis of the

FrSBe administered to a group of individuals
with a variety of neurological syndromes
(e.g. Huntingtons disease, Alzheimers disease,
Parkinsons disease) and healthy controls revealed
a factor structure that was consistent with these three
identified sub-scales [17].
As further evidence of its psychometric strengths,
the FrSBe has demonstrated sensitivity to executive
functioning deficits in a variety of neurological
populations. For example, studies have noted
increased FrSBe Executive Dysfunction and
Apathy among individuals with multiple sclerosis
[18, 19]; moreover, greater executive dysfunction, as
measured by standard neuropsychological tests, has
been associated with relatively poorer insight into
these deficits [19]. The FrSBe appears to have
utility for identifying early behavioural changes,
particularly apathy and executive dysfunction,
which may occur in individuals with mild cognitive
impairment and early stage Alzheimers disease [20].
In addition, the FrSBe Apathy sub-scale may be
particularly sensitive to differences in behavioural
functioning in individuals with cognitive decline
due to Parkinsons disease [21].
Importantly, research on individuals with
dementia also provides evidence supporting the
functional significance of the behaviours that are
being evaluated by the FrSBe, as scores on the
FrSBe appear to provide insight into factors that can
impact daily functioning. For example, one study
comparing 85 individuals with Alzheimers disease
(AD) or probable AD and 23 healthy controls [22]
demonstrated that FrSBe Apathy was associated
with difficulties managing basic activities of daily
living (ADLs), while FrSBe Disinhibition was
associated with deficits in instrumental ADLs.
Additionally,
other
research
has
revealed
that higher levels of FrSBe-identified behavioural
symptoms among individuals with dementia were
associated with greater caregiver burden [23].
Similar relationships between FrSBe Apathy/
Executive Dysfunction and ability to manage ADLs
have been documented in individuals with
Huntingtons disease [24]. Increased Apathy, as
measured by the FrSBe, has also been associated
with greater impairments in managing basic
and advanced ADLs among individuals diagnosed
with vascular dementia [25]. On the other hand,
scores on the FrSBe were not found to
differentiate individuals who had vascular cognitive
impairment, no dementia from those with vascular
dementia [26].
The FrSBe has also been utilized in research with
psychiatric populations as an index of frontal lobe
functioning. For example, one study of individuals
with schizophrenia [27] found that greater levels

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The frontal systems behaviour scale

of FrSBe Apathy, Executive Dysfunction and
Disinhibition were associated with poorer adaptive
functioning. Other research has also provided
evidence that the FrSBe is sensitive to frontal
system behavioural deficits in poly-substance abusers [28, 29]. Furthermore, one of these studies [29]
noted that severity of marijuana abuse was associated with greater Apathy and Executive
Dysfunction, while extent of cocaine use was
associated with greater Disinhibition. In other
research by the same group [30], the FrSBe
documented frontal system behavioural problems
in substance-dependent individuals, revealing an
association between poorer frontal system functioning and greater addiction severity.
Finally, studies of non-clinical populations have
also suggested that the FrSBe may document
variability in frontal lobe functioning that can be
associated with maladaptive behaviours in the
absence of a clinical disorder. For example, based
on the premise that eating disorders are associated
with dysfunction in the prefrontalsubcortical systems, one study [31] documented a significant
relationship between FrSBe Executive Dysfunction
and maladaptive eating behaviours (disinhibited
eating and greater food cravings) among healthy
individuals. Similarly, in an evaluation of the
hypothesis that prefrontalsubcortical systems are
associated with guiding financial decisions, Spinella
et al. [32] found that higher levels of FrSBe
Executive Dysfunction were associated with more
substantial credit card debt after controlling for
demographic and income variables.
Despite evidence of increasing use of the FrSBe to
document frontal system functioning in clinical and
non-clinical populations, there is limited research
addressing the potential utility of the FrSBe in
clarifying the behavioural executive dysfunction that
may occur secondary to TBI. In fact, the authors are
aware of only two studies employing the FrSBe
with individuals having a history of TBI.
OKeefe et al. [33] used the FrSBe along with
several other self-report measures to assess
self-awareness of deficits; they determined that
individuals with low self-awareness evidenced
greater impairments in behavioural functioning and
overall competency, but not in neuropsychological
test performance. Another study [34] utilized the
FrSBe to understand functional outcomes among
individuals with a history of TBI. In this research,
121 individuals with mild TBI evidenced significant
executive dysfunction as measured by the FrSBE;
however, FrSBe scores did not remain in the model
predicting success in returning to work.
Thus, the present study was designed to assess the
utility of the FrSBe as a predictor of functional
outcomes among individuals with a history of TBI.

1363

Consistent with a growing body of research assessing

outcomes following TBI [9, 3537], the primary
outcome measure for this study was the Community
Integration Questionnaire [38]. To briefly review,
this scale assesses the degree to which individuals are
independently able to participate in a range of daily
activities via questions regarding involvement in
home, social and work/school functions. The validity
of this measure has been suggested by several
studies, including one evaluating a large sample of
individuals with TBI [39] and another specifically
assessing the measures reliability and validity [40].
On the other hand, the CIQ has also been the
subject of some criticism. For example, rating scale
analyses have resulted in low reliabilities suggestive
of poor item coherence [41] and observations have
been made that the CIQ fails to account for non-TBI
factors that may influence scores, such as pre-injury
activity levels [42] and gender [43]. Despite this,
results from a comparison of several outcome
measures suggested that, of currently available
instruments, the CIQ may be the most effective
measure of rehabilitation outcomes following a
TBI [44].
Utilizing the CIQ as the primary outcome
measure, it was hypothesized that poorer performance on neuropsychological tests measuring executive functioning would predict relatively poorer
community integration among a group of individuals
with a history of TBI. Moreover, it was predicted
that the FrSBe sub-scales, particularly Executive
Dysfunction and Apathy, would add predictive
value to the model, accounting for additional
variance in community integration outcomes.

Method
Participants
Participants were 76 individuals consecutively
recruited from a clinical population of individuals
referred for testing in a Neuropsychology clinic
located in a Midwest academic healthcare setting.
All participants had a self-reported history of TBI.
Specific demographic information can be found in
Table I.

Table I. Participant demographics (n 76).

Age
Education (years)
Months since TBI
Gender (% male)
Marital status (% married)
Percentage currently employed

M (SD)

Range

35.1 (12.8)
12.9 (2.6)
35.4 (67.0)
71.1%
38.2%
32.9%

1864
622
0408

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S. A. Reid-Arndt et al.

Measures

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Community
Integration
Questionnaire.
The
Community Integration Questionnaire (CIQ [38])
is a 15-item scale designed to assess the extent to
which individuals are integrated in their community
following a TBI. The CIQ is composed of three subscales: Home Integration, Social Integration and
Productivity. The Home Integration sub-scale
assesses the level of independence that individuals
achieve with regard to domestic activities. The Social
Integration sub-scale looks at the level of participation in social activities. Finally, the Productivity
sub-scale assesses the degree to which individuals are
participating in productive activities (i.e. work or
school). Higher scores indicate greater involvement
in these various activities.
Frontal Systems Behaviour Scale. The Frontal
Systems Behaviour Scale (FrSBe [15]) is a 46-item
scale designed to assess behavioural symptoms
common to individuals with frontal lobe damage.
For each statement, ratings are made to indicate
how often an individual engaged in a particular
behaviour, both before and after the onset of an
illness or injury. Responses are made on a 5-point
scale. Self- and other-rated forms of the FrSBe are
available; the self-rated post-injury scores were used
in the current study. The FrSBe is composed
of three sub-scales: Apathy, Disinhibition and
Executive Dysfunction. A total score is also computed. Raw scores are converted to age and
education corrected t-scores, which were used in
the current study.
Neuropsychological assessment. Participants were
administered a standard, comprehensive neuropsychological assessment during a clinic visit.
Neuropsychological measures used in the current
study include: Wechsler Memory Scale-3rd ed
(WMS-III [45]), Trail Making Test [46], Wechsler
Adult Intelligence Scale-3rd ed (WAIS-III) Digit
Span [47] and Booklet Category Test [46].
All variables were converted to standard scores and
z-scores based on applicable normative data, which
included corrections for age, gender and education.
To aid in data reduction, summary scores were
created for identified cognitive domains (Delayed
Memory, Attention and Executive Functioning)
by computing an average of z-scores for all tests
within each domain. These three cognitive domains
were specifically selected for inclusion in analyses
based on prior evidence that, relative to other
neuropsychological skills, deficits in these
domains were most highly correlated with community integration and psychosocial outcomes [8, 48].
See Table II for a listing of tests comprising each
domain.

Table II. Tests comprising each cognitive domain.

Summary scores

Included measures

Delayed Memory

WMS-III Auditory Delayed

WMS-III Visual Delayed
Trails-A
WAIS-III Digit Span
Trails B
Booklet Category Test

Attention
Executive Functioning

Traumatic brain injury variables. It was hypothesized

that time since TBI may have a significant effect on
community integration outcomes, as individuals
with more recent injuries may be experiencing
more acute cognitive deficits and/or may have
had less of an opportunity to re-establish their
community involvement. Information regarding
time since TBI (in months) was gathered via selfreport from the participants. As the range of months
since injury was quite broad (i.e. 0408 months),
this variable was converted to a categorical variable.
Two groups were formed: individuals with a TBI
that occurred less than 24 months before they
completed neuropsychological testing and those
with a TBI that occurred 24 months or more prior
to testing.
Efforts were made to obtain information
regarding injury severity, including duration of loss
of consciousness (LOC) and post-traumatic
amnesia (PTA). Because this data could be reliably
ascertained from only 58% of the participants
(n 44), it was determined that these variables
could not be used in the regression analyses.
However, Pearson correlation analyses were computed with the available data to determine whether
injury severity was associated with community
integration outcomes in this sample.
Demographic variables. Gender was selected for
inclusion in the present study based on prior
research of its impact on Community Integration
Questionnaire (CIQ) scores [41, 49].
Procedure
Participants were administered the neuropsychological battery and completed the self-report questionnaires as part of a standard clinical
neuropsychological evaluation. All participants
gave their written informed consent to allow their
data to be used for the current study, following
applicable institutional review board guidelines.
Data analysis
All data was analysed using SPSS. For the sub-set of
participants who were able to provide injury severity

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The frontal systems behaviour scale

Table III. Regression equations predictor variables.
Variable categories

Table IV. Correlations* between injury severity variables and

CIQ sub-tests.

Specific variables included

LOC

Demographics/injury
characteristics

Neuropsychological
summary scores

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FrSBe (self-report)

PTA

Gender
Time since TBI
(<24 months, 24 months)
Delayed Memory
Attention
Executive Functioning
Apathy
Disinhibition
Executive Functioning

data (LOC and PTA), Pearson correlations were

computed to assess the relationship between injury
severity and community integration outcomes. Next,
regression analyses were used with the complete set
of participants to evaluate the relationship between
neuropsychological and self-report indices of current
functioning and community integration. For all
regression analyses, variables of interest and potential confounding variable were entered simultaneously into the analysis. Variables entered into the
models included demographic variables, neuropsychological summary scores and Frontal Systems
Behaviour Scale-self report (FrSBe) scores (see
Table III for a listing of all predictor variables).
Residuals for all models were graphically examined
and showed approximately normal distributions and
fairly consistent variances. Condition indexes and
variance-decomposition proportions were calculated
and revealed no evidence of colinearity.

Results
Frontal Systems Behaviour Scale
Individual scores for the FrSBe were converted to
gender, age and education corrected t-scores based
on the norms published in the administration
manual. The scores suggest that individuals in the
current sample exhibited elevated post-injury scores
on the FrSBe compared to normative samples.
Specifically, mean t-scores for Apathy (M 71.08,
SD 20.75),
Executive
Dysfunction
(M 72.18, SD 20.56) and FrSBe Total Score
(M 76.29, SD 26.83) were in the clinically
elevated range. The mean score for the
Disinhibition sub-scale was also elevated; however,
it was not in the clinically significant range
(M 62.72, SD 20.18).
Injury severity variables
Pearson correlations were computed utilizing data
from a sub-set of participants who provided injury

CIQ
CIQ
CIQ
CIQ

Home Integration
Social Integration
Productivity
Total Score

0.08,

0.01,

0.01,
0.04,

p 0.67
p 0.98
p 0.96
p 0.84

0.21,

0.10,

0.21,

0.29,

p 0.20
p 0.55
p 0.20
p 0.08

*Pearson two-tailed correlations.

Table V. Hierarchical regression model for CIQ-Total Score
(Adjusted R2 0.38).

Gender
Time since TBI
Delayed Memory
Attention
Executive Functioning
FrSBe Apathy
FrSBe Disinhibition
FrSBe Executive Dysfunction

t-Score

p-Value

4.07

0.85
2.86

0.65

0.05

1.29
0.82

1.84

<0.01
0.40
<0.01
0.52
0.96
0.20
0.42
0.07

severity data (LOC and PTA) to assess the relationship between community integration, LOC and
PTA. As shown in Table IV, there were no
significant correlations between indicates of injury
severity and CIQ scales. However, the correlation
between CIQ Total Score and PTA approached
significance (r
0.21, p 0.08), with a trend
suggesting that longer duration of PTA was associated with relatively lower CIQ Total Scores.
Overall, these findings provided support for proceeding with subsequent regression analyses that did
not include these injury severity variables.
Predictors of community integration
A regression analysis was performed to identify
predictors of CIQ Total Scores. As noted above,
gender was included based on results of previous
research; time since injury, neuropsychological
summary scores and FrSBe sub-scales were also
included. The overall model accounted for a
statistically significant amount of variance in CIQTotal Score (Adjusted R2 0.38, F(8, 67) 6.60,
p < 0.0001). In this model, greater reported executive dysfunction was associated with poorer integration, while female gender and better delayed
memory skills were associated with better overall
integration. See Table V for specific details.
Regression analyses assessing predictors of the
CIQ sub-scales were also completed. The overall
model predicting CIQ Home Integration was significant (Adjusted R2 0.12, F(8, 67) 2.29,
p < 0.05). Dependent variables remaining in the

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S. A. Reid-Arndt et al.

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Table VI. Hierarchical regression

Integration (Adjusted R2 0.12).

model

for

CIQ-Home

t-Score

p-Value

Gender
Time since TBI
Delayed Memory
Attention
Executive Functioning
FrSBe Apathy
FrSBe Disinhibition
FrSBe Executive Dysfunction

3.27

1.90
1.15
0.57

0.64
1.22

0.57

0.053

<0.01
0.06
0.25
0.57
0.52
0.23
0.57
0.60

Table VII. Hierarchical regression

Integration (Adjusted R2 0.23).

model

Gender
Time since TBI
Delayed Memory
Attention
Executive Functioning
FrSBe Apathy
FrSBe Disinhibition
FrSBe Executive Dysfunction

for

CIQ-Social

t-Score

p-Value

1.66

0.79
2.46

0.77

0.46

1.65
1.07

1.45

0.10
0.43
0.02
0.45
0.65
0.10
0.29
0.15

equation included gender and time since TBI (see

Table VI). Specifically, individuals who had more
recent injuries were more involved with home
activities. Similarly, female gender was also associated with increased engagement in home activities.
The overall regression equation for CIQ
Social Integration was significant (Adjusted
R2 0.23, F(8, 67) 3.72, p < 0.005). Delayed
Memory was the sole predictor in the final model,
revealing that stronger delayed memory skills were
associated with increased involvement in social
activities. Additional information is provided in
Table VII.
Finally, the overall model for CIQ Productivity
was
also
significant
(Adjusted
R2 0.27,
F(8, 67) 4.48, p < 0.0005). As shown in
Table VIII, independent variables remaining in the
final model include gender and FrSBe Apathy,
indicating that males and individuals demonstrating
greater apathy were reporting lower levels of
productivity.
Post-hoc analyses
Although findings of gender effects were consistent
with prior research showing that women may have
higher scores on the CIQ compared to men [49],
additional post-hoc analyses were undertaken to
evaluate whether there were gender differences in
terms of demographics or injury severity that might
contribute
to
these
findings.
Specifically,

Table VIII. Hierarchical regression model for CIQ-Productivity

(Adjusted R2 0.27).

Gender
Time Since TBI
Delayed Memory
Attention
Executive Functioning
FrSBe Apathy
FrSBe Disinhibition
FrSBe Executive Dysfunction

t-Score

p-Value

1.89
1.57
1.55

1.28
1.18

2.50
0.98

1.17

0.06
0.12
0.13
0.20
0.24
0.02
0.33
0.25

Table IX. Independent samples t-test comparisons of males

vs. females.

Age
Education
Loss of Consciousness
Post-traumatic Amnesia

df

Sig. (2-tailed)

0.59
0.07

0.85
0.18

74
73
26
37

0.56
0.94
0.40
0.86

independent samples t-tests were conducted comparing male vs female study participants in terms of
age, education, length of loss of consciousness and
duration of post-traumatic amnesia. Results revealed
no evidence of significant group differences on any of
these injury severity variables (see Table IX).
Similarly, correlations were computed to determine
whether injury severity variables might account for
the observed effect of age on CIQ Home Integration.
These post-hoc analyses revealed no significant
relationship between age and length of altered
consciousness (r 0.06, ns) or between age and
duration of post-traumatic amnesia (r
0.27, ns).

Discussion
The present study evaluated the relative contributions of gender, neuropsychological deficits and
behavioural indices of frontal lobe dysfunction to
community integration outcomes among individuals
with a history of TBI. Regarding gender, women
were reporting better overall community integration,
higher levels of involvement in home activities
and higher levels of productivity. Importantly,
these findings did not appear to be accounted
for by differences in age, education or brain
injury severity. Instead, they are consistent with
other research suggesting that women score higher
on measures of community integration relative
to men [40, 41, 49, 50] and they provide support
for the proposition that items used to evaluate
community integration in the CIQ may be affected

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The frontal systems behaviour scale

by baseline gender differences in home/community
involvements.
In terms of neuropsychological variables, despite
the use of a comprehensive battery of neuropsychological tests, only Delayed Memory remained as a
significant predictor. Not surprisingly, individuals
with greater memory deficits reported experiencing
more difficulties functioning effectively in social
activities and they also endorsed relatively poorer
community integration overall. While these findings
were consistent with other research reporting the
adverse effect of memory deficits on functional
outcomes [51], the absence of a relationship between
neuropsychological measures of frontal lobe functioning and community integration was contrary to
the studys hypothesis. One possible explanation for
these findings is that the battery of tests did not assess
a sufficiently broad sampling of the types of cognitive
skills associated with frontal lobe functioning.
Perhaps with additional measures of neuropsychological skills associated with frontal lobe functioning,
relationships between test performance and community integration would have been identified.
On the other hand, as noted previously, others
have also failed to document a relationship between
neuropsychological measure of executive functioning
and functional outcomes [9], possibly pointing to
limitations of relying solely on these measures as
indices of frontal lobe functioning. As Sbordone
[52, 53] has noted, neuropsychological tests were
designed to document cognitive deficits resulting
from neurological changes rather than to predict
real-world functioning. He has proposed that this
lack of ecological validity is a limitation of traditional
neuropsychological testing that can be addressed
with detailed clinical interviews and observations of
activities in real-life settings [52]. Additionally, the
present research suggests that behavioural measures
of executive functioning such as the FrSBe may
similarly serve to enhance the ecological validity of
information gathered during a clinical neuropsychological assessment.
Specifically, while tests of executive functioning
failed to add predictive power to models of community integration following TBI with this sample, the
present study revealed that the FrSBE, a measure of
behavioural manifestations of frontal lobe dysfunction, did indeed predict these important functional
outcomes. As used in this research, the FrSBe is a
brief self-report measure that is easy to administer
and has demonstrated reliability and construct
validity [13]. Furthermore, this study provides
evidence of predictive validity, as data revealed that
FrSBe indices of Apathy and Executive Functioning
were predictors of community integration outcomes
among this sample of individuals with TBI. These
findings parallel results from studies with other

1367

neurological populations reviewed above that have

demonstrated the utility of the FrSBe as a measure
of behavioural features of frontal lobe functioning.
Furthermore, they are unique in demonstrating the
potential value of the FrSBe for understanding
factors that impact community integration outcomes
in individuals with TBI.
In considering implications of these data, limitations of the present study deserve mention. First,
while preliminary analyses with data from a sub-set
of study participants suggested that injury characteristics were not related to community integration
outcomes in this sample, having medical records to
confirm self-reported data regarding injury severity
(e.g. LOC and PTA) for all participants would have
allowed for further assessment of the role of these
variables in predicting the outcomes of interest. On
the other hand, it is perhaps worth noting that this
lack of data reflects the reality of many clinic
settings, where patients report a history of TBI and
yet do not present with medical records to specifically document the nature of the injury. Thus, at a
minimum, it appears that, under these circumstances, the FrSBe can provide additional useful
information regarding behavioural functioning that
may have an impact on functional outcomes.
A second limitation of the study is the reliance on
self-report FrSBe scores. While these data did
underscore the roles that apathy and executive
dysfunction may have in community involvement, it
could be argued that limited self-awareness of deficits
may hamper the utility of the FrSBe Self-Report
version. Nevertheless, it is notable that, despite
possible under-reporting of symptoms secondary to
metacognitive deficits that may occur with TBI, in
this study the FrSBe still added predictive power to
models of community integration outcomes. Thus,
use of the Family Report version of the FrSBe may
result in the identification of additional deficit, which
it is hypothesized would also be associated with
functional outcomes in the same manner that was
observed in this research with the Self-Report form.
In sum, despite some limitations resulting from
the use of participants identified through clinic
referrals, the present study provides support for the
utility of the FrSBe in documenting behavioural
symptoms of frontal lobe dysfunction that occur as a
result of a TBI. Moreover, it appears that these selfreport indices of Apathy and Executive Dysfunction
measure behaviours that have significant consequences for community integration among individuals with a history of TBI.
Subsequent to this study, directions for future
research include further evaluation of the relationship between the FrSBe and other self-report,
informant report and neuropsychological measures
of frontal lobe dysfunction among individuals with

1368

S. A. Reid-Arndt et al.

a history of TBI. It would be informative to

determine the relationships between injury variables
(e.g. severity as suggested by LOC and PTA,
neuroanatomical location of lesions), the FrSBe
and community integration outcomes. Additionally,
research evaluating the predictive validity of the
FrSBe for other important outcomes (e.g. vocational
functioning, family functioning, emotional status)
would further our understanding of the neurobehavioural factors that need to be addressed to improve
these outcomes for individuals with a history of TBI.

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