DOI: 10.

1093/brain/awg237 Advanced Access publication July 22, 2003 Brain (2003), 126, 2363±2380

Staying on the job: the frontal lobes control

individual performance variability
Donald T. Stuss,1 Kelly J. Murphy,1,3 Malcolm A. Binns1 and Michael P. Alexander2
1Rotman Research Institute, Baycrest Centre for Geriatric Correspondence to: D. T. Stuss, Ph.D., The Rotman
Care and University of Toronto, Toronto, Ontario, Research Institute of Baycrest Centre, 3560 Bathurst

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Canada, and 2Harvard Medical School, Boston, MA, USA Street, Toronto, ON, M6A 2E1 Canada
E-mail: dstuss@rotman-baycrest.on.ca
3Present address: Psychology Department of Baycrest
Centre for Geriatric Care, Toronto, Ontario, Canada

Summary
The causes of variability of performance by individual
subjects have rarely been investigated, although exces-
sive variability or inconsistency may be a functionally
signi®cant factor for many real-life activities. Our
objective was to determine whether patients with focal
frontal brain lesions have excessive individual perform-
ance variability. Thirty-six patients with focal frontal
(n = 25) or non-frontal (n = 11) lesions were compared
with 12 control subjects on different measures of intra-
individual variability: dispersion within a testing ses-
sion; and consistency across testing sessions. Four reac-
tion time tasks, varying in levels of complexity and
based on a model of detection using feature integration,
were administered. Following the ®rst test session, 22
patients and 10 controls returned for two subsequent
test sessions, which permitted the assessment of consist-
ency of performance. Measures of abnormal dispersion
of performance on these tests were observed in frontal
patients only (except those with exclusively inferior
medial damage). Disturbances in consistency of per-
formance were observed primarily in patients with
frontal lesions. Damage to the frontal lobes impairs the
stability of cognitive performance. Damage to different
frontal regions causes different pro®les of abnormal
variability. Fluctuations in performance of a task may
underlie some of the reported dif®culties in daily tasks
reported by patients with frontal injuries.

Keywords: frontal lobes; reaction time; individual differences; intra-individual variability; attention

Abbreviations: CTL = control; DL = dorsolateral; ICV = intra-individual coef®cient of variation; IIV = intra-individual
variability; IM = inferior medial; ISD = intra-individual standard deviation; LDL = left dorsolateral; NF = non-frontal;
RDL = right dorsolateral; RT = reaction time; SM = superior medial; TBI = traumatic brain injury; TSI = time since
injury.

Introduction
Analysis of quantitative neuropsychological tests requires
consideration of performance variability on the tests. There
are different types of variability and they have different
consequences for analysis of different methods of control.
Diversity is the variation of performance between subjects in
a group; it is inter-individual variability and is usually viewed
as `noise'. Diversity is sometimes successfully controlled by
methodological techniques: using a consistent test environ-
ment; creating homogeneous groups; the extreme example
being single subject studies; or using very large groups
(Cronbach, 1957).
Brain 126 ã Guarantors of Brain 2003; all rights reserved
Variation of performance of an individual subject may also
contribute `noise'. It may also be a source of considerable
information (Flugel, 1928; Philpott, 1933; Fiske and Rice,
1955; Cronbach, 1957; Barratt, 1963) and there is a substan-
tial history of studying intra-individual variability (IIV) as the
dependent measure of interest (Stuss et al., 1989). IIV is
short-term ¯uctuation in performance, not the durable and
systematic change due to practice, learning, developmental
growth, trait alterations or, in clinical practice, improvement
or progression of the medical problem. There are two general
types of IIV. Dispersion is the oscillation of performance by
2364 D. T. Stuss et al.
an individual during a single continuous task. Consistency is
the degree of variability of an individual between adminis-
trations on the same test either within the same testing
session, or over separate sessions of testing. The foci of the
present study are dispersion and consistency.
Factors affecting variability of performance
It is dif®cult to generate detailed predictions about the causes
of IIV from prior studies because of differences in working
de®nitions of variability, task demands, statistical methods
and subject populationsÐsome normal and others clinical.
There are, however, some factors that have been identi®ed as
possible contributors to IIV. Increased age is frequently cited
as a cause of greater variability of performance and of
inconsistency (Fozard et al., 1994; Shammi et al., 1998;
Anstey, 1999), but this aging effect is task or measurement
dependent (Foster et al., 1995; Lindenberger and Baltes,
1997; Shammi et al., 1998). Normal aging (Salthouse, 1993,
1996; Fozard et al., 1994) and many neurological disorders
(van Zomeren and Brouwer, 1994; Whyte et al., 1995; Collins
and Long, 1996; Bleiberg et al., 1998; Leth-Steensen et al.,
2000) produce a general slowing on numerous reaction time
(RT) tasks, and overall RT slowing may be accompanied by
variability of RT. The association is not suf®cient to account
for all variability in RT performance. In some experiments,
no association has been found between overall RT and IIV
(Benton and Blackburn, 1957; Bruhn and Parsons, 1971;
Schwartz et al., 1989; Hetherington et al., 1996). In other
reports, the correlation between overall RT and IIV has been
quite inconsistent depending on the exact variability measure
(Shammi et al., 1998).
Tasks that appear to require more active control of
attention are often labelled `complex', although complexity
can surely be generated along many task dimensions. Perhaps
because of differences in working de®nition, complexity has
had a mixed effect on performance variability. In some
studies, task complexity increased IIV (Stuss et al., 1994b;
Shammi et al., 1998; West et al., 2002b) but, in others, it did
not (Bruhn and Parsons, 1971; Zahn et al., 1991; Foster et al.,
1995).
Whether the mechanism of increased IIV is due to some
aspect of complexity or to slower overall responses or to some
other fundamental psychophysiological process, it has been
observed for many years that brain damage causes increased
IIV (Head, 1926; Goldstein, 1942; Benton and Blackburn,
1957). This variability may be of two general types. There
may be increased IIV that is speci®c to a discrete cognitive
process, and probably always associated with impairment to
that process. Thus, patients with right brain damage and
spatial neglect show increased variability on bisection tasks
(Anderson et al., 2000) and patients with left brain damage
and aphasia appear to show increased IIV on lexical decision
tasks (Milberg et al., 2003). There may also be increased IIV
due to a general de®cit in regulation of attention to any task.
The general de®cit would not be associated with any distinct
cognitive domain, and this form of increased IIV has been
most consistently described in patients with `executive'
impairments, with or without overt demonstration of focal
frontal lesions.
Trauma
Since the initial report of Goldstein (Goldstein, 1942)
demonstrating increased IIV (and overall slow RT), numer-
ous studies have con®rmed increased dispersion or reduced
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consistency in patients with traumatic brain injury (TBI) at all
levels of severity, with or without focal frontal lesions (Stuss
et al., 1989, 1994b; Whyte et al., 1995; Collins and Long,
1996; Hetherington et al., 1996; Spikman et al., 1996;
Segalowitz et al., 1997; Bleiberg et al., 1997, 1998; Zahn and
Mirsky, 1999).
Dementia
Patients with a variety of dementing illnesses are also
reported to be more variable in performance than normal
elderly (Hultsch et al., 2000). There is an apparent ordering of
the level of variability in different dementing disorders.
Patients with Lewy body disease exhibit the greatest ¯uctu-
ation of performance, followed by vascular dementia and then
Alzheimer's disease (Walker et al., 2000; Ballard et al.,
2001). Murtha et al. (2002) showed that patients with frontal±
temporal dementia have more IIV than those with
Alzheimer's disease.
Miscellaneous
Increased IIV has also been reported in schizophrenia (but not
affective disorders) (Schwartz et al., 1989), and in attention
de®cit disorder and conduct disorder (Zahn et al., 1991; Leth-
Steensen et al., 2000).
In both normal subjects and clinical groups, IIV is sensitive
to `executive control'. In normal subjects, IIV is sensitive to
the demand for executive control (Shammi et al., 1998; West,
1999a). In normals, West et al., (2002b) concluded that
increased IIV was limited `almost exclusively' to task
conditions requiring the active demands of such executive
control processes. In TBI, IIV is closely associated with
impaired maintenance of consistent `top-down' attentional
processes (Stuss et al., 1989, 1994b; Stuss, 1991). The
hierarchy of IIV in dementias parallels the relative frontal
system damage; individuals with Alzheimer's disease have
the least involvement of the frontal lobes and the least IIV.
There have been no direct experiments to determine
whether lesions in any focal region of the frontal lobes are
critical in the production of increased IIV, but there is indirect
evidence that suggests that right dorsolateral (RDL) lesions
may be particularly likely to increase IIV. Right frontal
lesions impair top-down attentional control (Fink et al.,
1997). Patients with right frontal lesions make excessive
errors due to a lowered inhibition to distracting information
 Individual variability in reaction time 2365

Table 1 Aetiology, lesion location, lesion size*, time since injury and handedness within patient groups
Subject Aetiology Lesion location Lesion size (%) TSI (months) Handedness

LDL frontal
1019 Trauma DL, ACG, IM, polar 0.87 31.1 Right
1021 Stroke DL 1.03 2.8 Right
1027 Stroke DL, polar, medial 3.76 18.3 Right
1029 Stroke DL 1.76 24.0 Left
1053 Trauma DL 0.92 291.1 Right
2012 Tumour DL, SM, ACG 1.46 3.8 Right

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RDL frontal
1017 Stroke DL, parietal 3.04 1.3 Left
1041 Lobectomy DL, IM 2.92 4.2 Right
1054 Tumour IM, DL, ACG 2.55 24.7 Right
1055 Stroke SM, DL 5.09 10.9 Right
1067 Stroke DL 0.84 21.0 Right
2001 Stroke DL, striatal 3.26 5.3 Right
2024 Stroke DL, striatal 1.74 2.5 Right

IM
1023 Stroke Striatal, caudate, IM(L), ACG(L) 0.85 26.7 Both
1056 Stroke IM, ACG 1.60 33.1 Both
1059 Trauma IM, DL, ACG 4.47 34.1 Left
1065 Trauma IM 1.30 15.6 Right
1069 Tumour IM 0.22 2.5 Right
2013 Stroke IM, septal, ACG 0.07 8.9 Right

SM (+ IM)**
1011 Trauma Medial, DL(L), ACG 7.17 13.9 Right
1044 Stroke IM, polar, ACG, SM(L) 3.20 118.9 Right
2002 Stroke Medial, DL, ACG(L) 1.19 4.6 Right
2011 Stroke SM, ACG 1.60 3.6 Right
2045 Stroke Medial, septal, ACG 7.43 59.8 Right
2167 Tumour Medial, polar 5.46 6.0 Right

NF
1049 Tumour Temporal (Left) NA 17.8 Right
1058 Stroke Parietal (Left) NA 3.5 Right
2028 Stroke Temporal, occipital (Left) 0.95 28.5 Right
2032 Lobectomy Temporal (Left) 1.60 49.6 Right
2036 Lobectomy Temporal (Left) NA 91.3 Right
2038 Lobectomy Temporal (Left) 1.17 144.7 Right
2040 Lobectomy Temporal (Right) 2.06 89.3 Right
2043 Stroke Occipital (Right) 0.48 36.3 Right
2054 Lobectomy Temporal (Left) NA 142.6 Right
2057 Lobectomy Temporal (Right) 2.66 134.6 Right
2103 Stroke Parietal, occipital (Right) 0.74 34.6 Right

*Percentage lesion size of total brain volume for certain patients varied across studies by a minimal amount due to re®nements in
measurement. The variations do not alter any group differences. **See caption for Fig. 1. ACG = anterior cingulate gyrus; NA = not
available.

(Knight et al., 1981; Woods and Knight, 1986; Alivisatos and
Milner, 1989; Stuss et al., 1999) or as if sustaining control
over distinctive criteria between targets and non-targets is lost
(Stuss et al., 2002b). Lesions of the right frontal area have
been correlated with de®cits in a number of tasks requiring
sustained attention (Woods and Knight, 1986; Deutsch et al.,
1987; Stuss et al., 1987; Wilkins et al., 1987; Glosser and
Goodglass, 1990). In summary, if focal lesions result in
increased IIV, there is considerable evidence to suggest the
importance of the frontal lesions, particularly on the right.
This possibility has never been directly tested.
To assess the effects of focal lesions on IIV, we used RT
tasks designed to allow serial analyses of reaction times and
errors moving from simple RT to increasingly more complex
RT tasks, including the ability to analyse the effect of
redundant information. Four different types of RT tasks were
administered (Stuss et al., 2002b). The theoretical framework
for task design was detection using feature integration.
Complexity was de®ned by the type and number of features
that had to be analysed. The higher level of task included the
mental operations of the previous task, plus an added process
(Donders, 1969; Sternberg, 1969). This task was selected
2366 D. T. Stuss et al.

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Fig. 1 Schematics of lesion location. The lesion location for the available scans for each patient in each
of the de®ned patient groups is illustrated. In some cases, lesion location had been documented and the
scan subsequently lost. As described in the text, the SM group is labelled superior medial, even though
several of the group had extension into IM regions, to distinguish them from the group with IM lesions only.

because it had been used effectively to study RT and dominant hand as quickly as possible, making as few errors as
variability in traumatic brain-injured individuals (Stuss et al., possible. In some of the tasks, a non-target stimulus was
1989, 1994b). In each task, the subject had to detect a target presented, requiring a response using a second response
stimulus and press a hand-held response button with the button mechanism held in the non-dominant hand.
 Individual variability in reaction time 2367

Table 2 Sample sizes and mean demographic statistics for the two subject assessments
Sample Age Sex Education National Digit Boston Beck Lesion Time since
size (years) (proportion (years) adult reading span naming test depression size1 injury2
female) test forward inventory (months)

Single Assessment
LDL 6 53 0.67 12 100 4.5 37 4.7 1.6 62
RDL 7 57 0.29 10 102 5.3 52 1.2 2.8 10
SM 6 58 0.33 12 99 6.4 46 6.3 4.3 34
IM 6 46 0.17 11 100 6.0 47 4.2 1.4 20
NF 11 43 0.73 13 106 6.2 48 3.2 1.4 70

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CTL 12 67 0.67 12 108 7.2 52 NA NA NA
Three repeated assessments
DL 6 61 0.40 10 101 5.3 48 3.8 2.2 56
SM 3 55 0.33 11 91 6.0 48 4.0 3.3 7.4
IM 4 55 0.25 9.3 99 6.3 50 3.5 1.6 20
NF 9 44 0.78 13 105 6.2 47 3.4 1.3 74
CTL 10 66 0.70 12 108 7.2 52 NA NA NA

Groups with frontal lesions are LDL, RDL, SM, IM and combined DL. Brackets indicate sample size where missing values occur. As
noted in the text, analyses were completed for the ®rst day of assessment (ONE), and for three separate test sessions approximately one
week apart (THREE). Because of attrition over the 3 weeks of testing, the patients with right or left lateral lesions were combined into
one group labelled DL. The sample sizes for the various groups are given in the ®rst column of the table. 1Size of lesion and TSI are
summarized from Table 1 to allow comparison of the groups in the single assessment and three repeated assessments. There are missing
values for some clinical variables. The size represents the percentage of lesion in relation to the total brain volume. 2TSI indicates the
chronicity of the lesion when the patient was entered into the study. NA = not applicable.

There were several hypotheses derived from the previous
literature:
(i) Patients with frontal lesions will show greater dispersion
and inconsistency relative to control (CTL) group of partici-
pants and to patients with non-frontal (NF) lesions.
(ii) Based on previously demonstrated impairments in
maintenance of sustained attention, patients with lesions of
the right frontal lobe will have impaired consistency of
performance; there is insuf®cient information in the literature
to predict speci®c effects of other frontal lesion sites.
(iii) More complex RT tasks require more executive
control and, thus, in patients with lesions of the frontal lobes,
such tasks will elicit greater IIV than simpler RT tasks.
(iv) We presume that the effects of errors on dispersion will
differ in the groups, but unique effects of different frontal
lesions are not speci®able.
Methods
Subjects
Thirty-six patients with focal lesions documented by CT or
MRI evidence were assessed. Inclusion criteria were as
follows:
(i) The aetiology was an acquired acute disorder such as
infarction, haemorrhage, trauma or resection of a benign
tumour;
(ii) There had been suf®cient time post-onset to allow for
stability of the medical condition (range 1.3±291 months
post-onset, mean = 42.4; all but one past 2.5 months);
(iii) Absence of severe aphasia or clinically detectable
neglect;
(iv) There was a CT or MRI scan demonstrating unequivo-
cal frontal or NF damage.
The exclusion criteria for patient subject selection were the
following: untreated hydrocephalus on CT or MRI scan;
presence of any systemic illness; history of alcoholism,
hospitalization for a psychiatric disorder, or prior neuro-
logical illness. The varied aetiologies allowed for the
assessment of potential localization differences within the
frontal lobes (Stuss et al., 1995). In addition, the localization
of the lesion has been reported as more relevant than the
aetiology (Elsass and Hartelius, 1985; Stuss et al., 1994a;
Burgess and Shallice, 1996;).
The patients were divided into ®ve groups based on the
location of their primary lesion. Eleven patients had path-
ology located in NF regions (seven left, four right). They were
combined into one group for two reasons: posterior hemi-
spheric differences were not a focus of this study; and
preliminary analyses indicated no consistent differences on
the tasks used between the left and right posterior lesioned
patients. The 25 patients with focal frontal lesions were
divided into four groups based on the location of their
primary lesions: (i) left dorsolateral (LDL) frontal (n = 6); (ii)
right dorsolateral (RDL) frontal (n = 7); (iii) inferior medial
(IM) (n = 6); and superior medial (SM) (n = 6). This
classi®cation derived from a history of 10 years of uncovering
increasing anatomical/behavioural speci®city within the
frontal lobes (for reviews see Stuss et al., 2002a; Stuss and
Levine, 2002). The patients classi®ed as SM tended to have
both IM and SM pathology. They were designated as SM to
differentiate them from the patients who had IM pathology
only. The ®ve patient groups were compared with 12 control
2368 D. T. Stuss et al.

Table 3 Means and SDs of average reaction times (ii) Easy Choice RT (100 trials). Four different shapes were
LDL RDL IM SM NF Control presentedÐone designated as target (25% chance occur-
rence) and the other three as non-targets (75%).
Simple Mean 300 391 240 433 283 258 (iii) Complex RT (100 trials). The discrimination was
SD 61 220 15 145 55 45 based on three characteristics of the stimuliÐshape, colour,
Easy Mean 644 609 449 795 533 449
SD 230 193 45 193 124 63 and internal texture. The shapes appeared in one of four
Complex Mean 712 823 544 894 737 610 colours (yellow, green, blue and red) and contained internal
SD 143 210 62 131 182 135 texture in the form of lines that were oriented horizontally,
Redundant Mean 628 700 474 887 563 511 oriented vertically, slanting forward or slanting backward.
SD 149 341 68 251 165 116 The target, representing ~25% of the trials, was de®ned as a

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subjects. The subjects were primarily right-handed. The
presence of left-handed individuals were allowed in the
different patient groups for the following reasons: (i) the left
hander in the left brain damaged group was aphasic; (ii) the
left hander in the right brain damaged group was not aphasic
and had a typical right hemisphere syndrome; and (iii) the
third left hander was in the IM non-impaired group, where
laterality is not relevant. The lesion aetiology, location, lesion
size, time since injury (TSI) (chronicity of lesion) and subject
handedness are presented in Table 1. The individual lesions
divided by group are illustrated in Fig. 1.
The National Adult Reading Test, Digit Span forward,
Boston Naming Test, and Beck Depression Inventory were
administered to all participants with a few exceptions. All
subjects had normal colour vision. Demographic and clinical
data are summarized for each of the groups in Table 2. The
project was approved by the University of Toronto/Baycrest
Centre Human Subjects' Research Ethics Committee and
consent for participation in the project was obtained for each
participant according to the Declaration of Helsinki.
particular combination of the three features (e.g. a red circle
with horizontal lines). The non-targets could be any other
combination of features.
(iv) Redundant RT (100 trials). In this task, the target was
characterized by a combination of three separate features, but
subjects were informed about the fact that none of the non-
targets would contain any of the features in the target. That is,
if the target were a yellow square with backward slanting
lines, no other stimulus would be square, be coloured yellow,
or have backward slanting lines. The Simple task was
repeated after the Redundant task, but is not analysed here.
These tasks were presented in a ®xed order.
Measures of IIV/analyses of factors
Mean RT and errors for the ®rst assessment have been
presented elsewhere (Stuss et al., 2002b); the means and SDs
for the RT results of this study are presented in Table 3 as
background information. In this paper, the focus is on
variation within an individual. There were two potential
categories of IIV studiedÐdispersion and consistency of
performance.

Tasks and procedures
Stimuli measuring ~3 cm high and 3 cm wide were presented
centrally on a 35 3 35 cm square colour monitor, located
~1 m from the subject's head position, at a variable inter-
stimulus interval lasting 4±6 s. Stimuli remained on the
screen until a response was made or for a default duration of
2 s. Subjects responded to a designated target stimulus by
pressing the button on a hand-held response mechanism with
their dominant hand. Non-target stimuli, when presented,
required a non-dominant hand response. Stimuli were always
one of four shapes (circle, square, triangle or cross). Subjects
were instructed to respond as quickly and as accurately as
possible.
There were four different RT tasks requiring different
levels of feature discrimination and identi®cation; for more
detailed explanations of the procedures, see Stuss et al.
1994b, 2002b).
(i) Simple RT (50 trials). A single shape, in light grey
against the dark grey background of the computer screen, was
presented;
Measures of dispersion
Dispersion refers to IIV within the continuous time period of
a single test. In our study, this was evaluated in the ®rst test
session. Each of the following scores was calculated for each
individual for each of the ®ve RT tasks.
Intra-individual standard deviation (ISD)
Within a task, we calculated the SD of each subject's RTs for
correct target trials. The ISD provided a general index of each
subject's performance spread about his or her mean RT.
Intra-individual coef®cient of variation (ICV)
To investigate the possibility that longer RTs could also be
more variable for the sole reason that they are farther away
from the ¯oor, we calculated coef®cients of variation (ISD/
mean) for each subject. The ICV measures performance
controlled to some degree for speed of response. To validate
the use of the ICV, we also investigated the relationship
between speed and variability within each group using a
linear model of subject's SD in the Complex task as a

function of average RT, group membership, and the inter-
action between RT and group.
Autocorrelation
For each subject's ®ve tests, correlation between consecutive
observations was calculated. This measure denoted how
much linear association there was between one trial and the
next.
Factors possibly affecting dispersion
Task complexity
The effect of task complexity, as de®ned in these feature
integration tasks, on dispersion was analysed by comparing
the effect of increasing complexity of choice offered by the
Simple, Easy and Complex RT tasks.
Speed of RT
Since speed of RT has been related to increased variability
(Salthouse, 1993), we examined the relation of average RT to
ISD.
Trends
Steadily changing RT would increase IIV. To see if there was
any linear drift in an individual's RT across the duration of a
task, we calculated the linear slope estimate for each subject's
®ve tests.
Errors
The presence of errors could be related to increased
dispersion. We ®rst determined whether there was a general
relationship between the number of errors and IIV. We then
examined the effect of errors on RT by calculating the
following:
(i) The pre-error effect on RT, measured as the difference
between RT for the trial immediately preceding an error and
RT for the erroneous trial and calculated the average of these
differences for each subject;
(ii) The post-error effect on RT, measured as the difference
between the RT for an erroneous trial and the RT for the
subsequent trial and averaged these differences for each
subject.
Consistency
Consistency of performance is de®ned as the ability of an
individual to perform comparably across different testing
sessions. Inconsistency indicates impairment in this ability. In
this study, to assess IIV across non-continuous time periods,
the same tests were repeated on two additional occasionsÐall
three testing sessions occurring ~1 week apart. For each test,
Individual variability in reaction time 2369
the performance across the three sessions was compared for
the following measures: mean RTs; number of errors; ISD;
ICV; autocorrelations; effects of errors; and trends.
Results
Demographic data
In patient studies where the emphasis is on lesion localiza-
tion, a variety of different abilities may occur in the different
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patient subgroups for which it is dif®cult to ®nd controls. Our
major focus in selecting the CTL group was to control for
education and intelligence. There were no signi®cant differ-
ences between any of the patient groups and the CTL group in
this regard. Other signi®cant demographic differences were
observed. The age of the CTL group was signi®cantly older
than the NF group [F(1,42) = 23, P < 0.0001], the IM group
[F(1,42) = 13, P = 0.001] and the LDL group [F(1,42) = 5.2,
P = 0.03]. Forward digit span was signi®cantly shorter in the
RDL [F(1,33) = 8.4, P = 0.007] and LDL [F(1,33) = 7.7,
P = 0.009] groups relative to the CTL group. There were no
differences among the patient groups on the Beck Depression
Inventory measureÐthe group means ranging from 1.2 to 6.3,
with no subject over 11. Among the patient groups, there was
a signi®cant difference in lesion size between the groups
[F(4,27) = 3.8, P = 0.01], with the SM group having the
largest lesions.
For the comparison across the 3 days of testing, there
remained six dorsolateral frontal (DL) patients (two LDL,
four RDL), four IM patients, three SM patients, nine NF
patients and 10 CTL participants. The DL group had a
signi®cantly shorter forward digit span [F(1,26) = 7.4,
P = 0.01] and the SM group had a signi®cantly lower
National Adult Reading Test score [F(1,25) = 8.7, P = 0.007].
Demographic and neuropsychological variables showed
similar statistical differences for the IM and NF groups on
this reduced sample as in the full sampleÐexcept that the IM
group was no longer different on age [F(1,27) = 2.4, P = 0.13].
On this reduced sample, we found no effect of group on either
lesion size or time since injury. Table 2 summarizes the
demographic, neuropsychological and clinical characteristics
for the sample of subjects who participated in the three test
sessions.
Dispersion: ®rst test session
ISD
ISD was calculated for each subject within each of the four
tasks (Simple, Easy, Complex and Redundant) and group
differences were investigated using simple contrasts between
each lesion group and the CTL group. As presented
graphically in Fig. 2, ISD was signi®cantly higher on the
Easy task for the SM [F(1,42) = 10, P = 0.003], RDL
[F(1,42) = 7.4, P = 0.009) and LDL [F(1,42) = 7.1, P = 0.01]
groups relative to the CTL. ISD was signi®cantly higher on
the Complex task for the RDL [F(1,42) = 16, P = 0.0002], SM
2370 D. T. Stuss et al.
Fig. 2 Average ISD for the Simple, Easy, Complex and Redundant RT tasks.
[F(1,42) = 12, P = 0.001], LDL [F(1,42) = 5.9, P = 0.02] and
NF [F(1,42) = 6.1, P = 0.02] groups relative to the CTL. ISD
was signi®cantly higher on the Redundant task for the SM
[F(1,42) = 15, P = 0.0004] and LDL [F(1,42) = 8.0, P = 0.007]
groups relative to the CTL. The IM group did not show
signi®cantly elevated ISD on any of these tasks. Thus, using
the ISD measure of dispersion, all frontal groups except the
IM group revealed greater ISD than the CTL. The NF group
had signi®cantly greater ISD than the CTL only on the
Complex task.
ICV
The ICV was calculated for each subject within each task and
group differences were investigated using contrasts to the
CTLs. The mean ICV for each group on each task is presented
in Fig. 3. ICV was signi®cantly higher on the Easy task for the
RDL [F(1,42) = 7.6, P = 0.009] and LDL [F(1,42) = 4.3,
P = 0.045] groups relative to the CTL. ICV was signi®cantly
higher on the Complex task for the RDL [F(1,42) = 11,
p=.002], SM [F(1,42) = 5.3, P = 0.03] and LDL [F(1,42) = 5.1,
P = 0.03] groups relative to the CTL. ICV was signi®cantly
higher on the Redundant task for the LDL [F(1,42) = 6.6,
P = 0.01] group relative to the CTL. There were no signi®cant
ICV differences for the IM and NF groups.
Autocorrelation
The correlation between RTs for adjacent trials was calcu-
lated for each subject and for each task performed on the ®rst
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day. ANOVA (analysis of variance) did not detect differences
between patient groups and CTL group in their lag-1 auto-
correlation (P < 0.18).
Factors affecting dispersion
Task complexity. Because of the reported relationship of IIV
to task complexity, repeated measures ANOVA was evalu-
ated for the ISD across the Simple, Easy, Complex and
Redundant tasks. As can be seen in Fig. 2, the pro®le across
the four tasks for the control group was different from the
pro®les for the LDL [F(3, 123) = 3.5, P = 0.02] and NF
[F(3, 123) = 3.2, P = 0.03] groups. Dispersion in the control
group decreased from the Simple to the Easy task, whereas it
increased in the LDL group. The NF group interaction was
due to this group's large reduction in dispersion from
Complex to Redundant tasks. When this same complexity
evaluation was completed for ICV (see Fig. 3), no signi®cant
differences between pro®les were observed.
Average RT. We investigated the relationship between an
individual's average RT time and their SD deviation to see
how RT affected IIV. ISD was modelled as a function of
group, average RT, and the interaction between group and
RT. Fig. 4 shows the slope estimates for each group's
regression of ISD on average RT for the Complex task across
the range of individual average RT in each group and passing
through the group's grand average RT (the centre symbol on
each regression line). There was little evidence for a
relationship between average RT and the ISD in most groups.
For example, the two medial (SM and IM) groups, the former
 Individual variability in reaction time 2371

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Fig. 3 Average ICV for the Simple, Easy, Complex, and Redundant RT tasks.

Fig. 4 Regression of ISD on mean RT. The symbol for each group locates average mean RT and average
ISD on that group's regression line. The slope of the regression line across the group's range indicates the
magnitude of the association between mean RT and ISD. The LDL group, with the third shortest average
mean RT showed a signi®cantly larger association between mean RT and ISD than the control group (CTL).

with notable IIV and the latter not, were most similar to the
CTL group with respect to their relationship between
variability and average RT. The LDL group, with the third
fastest mean RT, showed the largest association between ISD
and average RT (b = 0.60)Ða signi®cantly larger association
than the CTLs [F(1,36) = 5.7, P = 0.02].
Trends. Slopes were calculated within each patient's con-
tinuous stream of RTs for each task in an effort to detect any
consistent speeding up (negative slope) or slowing down
(positive slope) throughout the period that might affect any
dispersion measure. Only the two lateral groups revealed
signi®cant slope differences compared with CTLs: the RDL
2372 D. T. Stuss et al.

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Fig. 5 Regression of ISD on sensitivity. Propensity for making errors of any type (sensitivity) is measured
by d¢. The symbol for each group locates average d¢ and average ISD on that group's regression line. The
slope of the regression line across the group's range indicates the magnitude of the association between
sensitivity and ISD. Despite the differences in sensitivity between the RDL and LDL groups, both groups
show similar associations between ISD and sensitivity.

group on the Simple task, with a negative average slope
signi®cantly different than the CTL group's average slope
[F(1,41) = 4.6, P = 0.04]; the LDL group on the Easy task,
with a positive average slope signi®cantly different than the
CTL group [F(1,42) = 6.1, P = 0.02], and on the Complex
task, with an average negative slope signi®cantly different
than the CTL group [F(1,42) = 5.3, P = 0.03].
General effect of error rates. We examined whether com-
mitting errors in the Complex task was related to increased
variability. As already described, the LDL, RDL, SM and NF
groups each had higher ISD than the CTL. In a previous paper
describing the basic RT data for this experiment (Stuss et al.,
2002b), the RDL group alone had a signi®cantly lower
sensitivity measure (d¢) than the CTL group; i.e. they were
impaired in discriminating targets from non-targets. In Fig. 5,
average ISD and average d¢ scores on the Complex task are
plotted with the symbols for each group, and the slope of the
effect of d¢ on ISD for each group is illustrated with a
regression line across the groups' ranges. The two medial
(SM, IM) and NF groups were not signi®cantly different from
the CTL. The RDL group showed a negative association
between d¢ and ISD, which was signi®cantly different from
the CTL group [F(1,36) = 4.3, P = 0.045]. The next largest
association was in the LDL group.
Local effect of errors. Two RT differences were calculated in
the Complex task, where the most errors occurred: the
average change in RT before and the average change in RT
after an error. Fig. 6 shows the average RT on trials with an
incorrect response for subjects within each group who made
at least one error. The average RT change from the correct
antecedent response to the erroneous response and the
average RT change from the erroneous response to the
correct subsequent response are depicted with lines to the left
and right of the symbol identifying each group (acceleration
with a negative slope and deceleration with a positive slope).
The normal pro®le is shorter RT on the error trials and longer
RT on the trial after an error (Rabbitt and Vyas, 1970), as if
recalibrating response speed. The IM group showed the
expected pro®le before and after an error. Before an error, the
SM group revealed slowing (although not signi®cant,
P = 0.13) on the erroneous trial. Three groups (IM, NF and
control) showed the expected slowing after an error. The RDL
group was somewhat ¯at before and after an error. The LDL
group on average was 174 ms faster on trials after an error,
which was signi®cantly different from the control group
[F(1,35) = 5.0, P = 0.03].
Summary
Dispersion was assessed for the ®rst test session allowing the
full sample of participants to be included. All groups of
frontal patients (except the IM group) had greater dispersion
than the CTL. The NF group was signi®cantly different from
the CTL only on the Complex task, and only for ISD.
 Individual variability in reaction time 2373

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Fig. 6 Relationship in RT speed for trials antecedent and subsequent to an error. The symbol for each
group locates average RT for trials with an erroneous response. Direction and magnitude of changes in
RT antecedent and subsequent to an error are identi®ed by the slope of the lines to the left and right of
each group's symbol. A positively sloped line indicates slowing while a negatively sloped line indicates
acceleration. The control group followed the normal pattern (Rabbit and Vyas, 1970) of speeding up into
an error and slowing after. Note the slowing from the antecedent to the error trial in the SM group and
the acceleration after error trials in the LDL group. The RDL group revealed little ¯uctuation before or
after an error.

Different factors increased IIV in different lesion groups
relative to CTL group. Increasing task complexity by adding
a choice component to the reaction time affected ISD in the
LDL and NF groups. An overall slow response time was
associated with increased ISD in the LDL group. The LDL
group was markedly faster on the trial after an error. An
increase in error rate was associated with markedly increased
IIV in the RDL group.
Consistency across test sessions
Inconsistency of mean RT
The ®rst analysis compared the changes in mean RT over the
3 days. The DL group was more inconsistent in mean
performance than the CTL group on the Simple [F(1,26) = 4.5,
P = 0.04), Easy [F(1,26) = 7.0, P = 0.01), and Redundant
[F(1,27) = 8.2, P = 0.008) tasks. The SM group was
signi®cantly more inconsistent than the CTL on the
Redundant task [F(1,27) = 5.1, P = 0.03]. Inconsistency for
the IM and NF groups did not differ from the CTL.
Inconsistency of ISD and ICV
These are described together since the results are almost
identical for the two measures. The DL group was more
inconsistent on at least one measure of dispersion (ISD or
ICV) than the CTL group on the Easy [ISD, F(1,26) = 7.6,
P = 0.01; ICV, F(1,26) = 2.0, P = 0.17], Complex [ISD,
F(1,27) = 5.9, P = 0.02; ICV, F(1,27) = 11, P = 0.003] and
Redundant [ISD, F(1,27) = 5.6, P = 0.03; ICV, F(1,27) = 4.4,
P = 0.046] tasks. The SM group was more inconsistent
in dispersion (ISD and ICV) than the CTL on the
Redundant task only [ISD, F(1,27) = 24, P < 0.0001; ICV,
F(1,31) = 5.4, P = 0.03]. The NF group was more inconsistent
in dispersion relative to the CTL on the Complex task [ISD,
F(1,27) = 3.8, P = 0.06; ICV, F(1,27) = 6.5, P = 0.02]. Again,
inconsistency in the IM group was not signi®cantly different
from the CTL.
The redundancy effect
The Easy and Redundant tasks do not differ in actual
dif®culty even though the presence of three features in the
Redundant task stimuli suggests an apparently greater
complexity. Comparison of the Easy and Redundant tasks
provides an index of the effect of irrelevant information in a
stimulus. The difference between a subject's speed on the
Redundant and Easy tasks was more variable over the three
assessment sessions for patients in the DL group relative to
the CTL group [F(1,31) = 13, P = 0.001].
2374 D. T. Stuss et al.
Errors
In a previous paper examining the RT and errors of the same
patients on these tasks (Stuss et al., 2002b), we reported that
the LDL group had decreased response bias (c)Ðtended to
make primarily false positive errorsÐpresumably a criterion
setting problem. The RDL group, on the other hand, had
decreased response sensitivity (d¢)Ðmade more errors of all
typesÐpresumably a problem differentiating targets and non-
targets. The SM group exhibited an error pattern, in terms of
bias and sensitivity, which fell in between the LDL and RDL
groups. In this paper, we analysed whether bias and
sensitivity changed over the three testing days. With the
groups as de®ned, there were no signi®cant differences from
CTL subjects on any task on either d¢ or bias (NF, d¢,
complex, P > 0.06). Because of the potential importance of
the regional differences within the frontal lobes (which by
grouping both DL groups may have obscured any ®ndings),
we also analysed the original groups, even though the sample
size was reduced. No group had signi®cantly different
inconsistency of sensitivity or bias compared with the CTL
group. That is, the group impairment in bias (LDL) or
sensitivity (RDL) was consistent from test session to test
session.
Summary
Consistency of performance was assessed by comparison of
measures over three assessment days. The consistency
®ndings were interpreted compared with consistency in the
CTL group. Normal consistency means that performance on
one testing session on a given measure will as closely re¯ect
performance on another testing session as the same compari-
son in the CTL group. There could be (and was) abnormal
dispersion within a test session, but the dispersion could be
(and often was) consistent between different test sessions.
Dispersion and inconsistency are different measures of IIV.
The IM group did not show any inconsistency in perform-
ance. All other patient groups were inconsistent on many
measures. The lateral (LDL, RDL) and SM frontal groups
were inconsistent on considerably more measures than the NF
group.
Discussion
There are four main conclusions from our study:
(i) Increased IIV may be caused by damage to speci®c
brain regions. Lesions in the frontal lobes (with the exception
of the ventral medial/orbitofrontal region) in particular impair
stability of behaviour and led to increased IIV on the tests
used here.
(ii) These ¯uctuations of performance in an individual are
not simply error variance or statistical noise (Kelly et al.,
2001). Individual differences, inter-trial ¯uctuations and
inconsistency over repeated assessments are important
measures of impairment.
(iii) There are different kinds of IIV. Not all types are
elevated as a consequence of brain damage and different
types of IIV are affected by damage in different brain regions.
If disorders of stability of performance re¯ect impairment in
top±down control, multiple mechanisms of control are
disturbed.
(iv) Task factors have important effects on demonstration
of variability.
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Lesion site effects
IIV on RT tasks is signi®cantly increased in most patients
with frontal injury, but the effects are not uniform across all
frontal regions.
Dispersion was highly associated with frontal injury (with
the exception of the IM group) and was abnormal in the NF
patients on the tests used here only for the Complex task ISD
measurement. Thus, increased dispersion on RT tasks,
measured by both ISD and ICV, is clearly more affected by
SM and DL frontal lesions, even at a level of simple feature
discrimination and choice. Dispersion is not a general effect
of any brain damage, although task context may play a role
(see below).
Analysis of lesion site effects on inconsistency could not be
examined in such detail because of sample attrition secondary
to the demands of three consecutive weeks of testing (see
below). All of the patient groups, except the IM group, had
some degree of inconsistency.
Task demands are likely to have an effect on whether IIV is
observed or not after lesions in different regions. For
example, the IM group revealed no IIV in the RT tasks
used. Yet, in a study on the Wisconsin Card Sorting Test, this
same group had dif®culty staying on task (and thus were
variable in a certain manner) under certain task conditions
and not others (Stuss et al., 2000). The NF patients were
variable when the task required three feature integration, such
integration having been related to posterior brain regions
(Bernstein and Robertson, 1998). There has been reported IIV
after right and left brain injury related to neglect and lexical
decision tasks, respectively (Anderson et al., 2000; Milberg
et al., 2003). In future research, the potential impact of any
frontal involvement in the patients examined, the differential
impact of speci®c task demands (e.g. feature integration,
visual spatial attention, language), general task complexity
and the possible interactions of these factors should be
investigated.
Lesion and test factors affecting variability
The effects of frontal lesions on IIV are complicated by
interactions between lesion site and task factors, and the
results of this study illuminate some of the reasons for
con¯icting results in past reports.

Relationship between average performance and
variability
To investigate the impact of average performance on IIV, the
ICV was used as one way of adjusting for the mean
performance of the individual, and then comparing ISD and
ICV results. A comparison of the ISD and ICV results across
all tasks illustrated that dispersion measured as ISD was no
longer signi®cant when measured as ICV in the following
cases: Easy RT: SM group; Complex RT: NF group;
Redundant RT: SM group. Note that the SM group had the
slowest RT and the LDL group among the faster.
A direct method of analysing the relationship between IIV
and average performance is to compare the slope of ISD with
respect to average performance within each group compared
with the CTL. Only the LDL group was signi®cantly different
from the CTL in its association between individual variability
and average RT. The SM group, with the slowest RT, showed
the ¯attest relationship between ISD and performance, second
only to the CTL.
There have been con¯icting reports about the relationship
between variability and mean performance, particularly in RT
tasks. Some claim a direct relationship between mean RT and
both diversity and dispersion (Hale et al., 1988; Salthouse,
1993); others demonstrate the relative independence of IIV
from RT latency (Schwartz et al., 1989; Whyte et al., 1995;
West et al., 2002b). Our results using the RT tasks in this
study do not support a necessary relationship between an
individual's lengthening of RT and individual variability.
Specifying complexity
This is not transparent. In our study, the signi®cant effects of
complexity were seen in the comparison of Simple to Easy
tasks in the LDL group only, with no additional effect into the
Complex task. The step from constant stimulus±response
mapping to any level of variable response appeared suf®cient
to elicit greater IIV in this susceptible patient group. In
patients with left frontal injury, if the executive control
system is already stressed, little complexity is required to
produce failure of top±down control. In normal individuals,
for a task to be complex enough to stress the executive control
system, it must be much more dif®cult (West, 1999a).
Trends
Only the lateral groups showed signi®cant differences in
trendsÐthe tendency to speed up or slow down over time.
Drift will affect ISD and ICV. The fact that the SM group did
not show signi®cantly different slope suggests that several
different factors may affect ISD and ICV in different groups.
Errors
There are effects of both the overall rate of errors and of the
immediate neighbourhood presence of an error on dispersion.
Individual variability in reaction time 2375
For the right lateral frontal group, an increase in the error rate
was associated with increased dispersion (ISD). Analysis of
RT pre- and post-errors as an index of executive control
reveals a complex pattern: the RDL group was not abnor-
mally affected by an error; the LDL group was faster after an
error; and the SM group was much slower on trials with an
error than the preceding trial. Different frontal regions
contribute different mechanisms of control to the RT target
behaviour.
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Consistency versus dispersion
We tested a subset of the patients on three separate occasions
over 3 weeks. All of the patient groups (excepting IM) had
greater inconsistency, but the DL frontal patients were
particularly inconsistent. The DL patients showed greater
inconsistency than the CTL, had more instances of inconsist-
ency than the NF group, and only patients with DL frontal
pathology were inconsistent dealing with extraneous infor-
mation on the Redundant RT task. Three assessments may not
have been suf®cient (especially with small groups) to uncover
details about inconsistency, although Spikman et al. (1996),
who reported increased IIV after TBI, noted that IIV actually
diminished by the fourth block of testing. Consistency
appears more robust than dispersion, in that it was not as
affected by lesions as dispersion, but the investigation of
consistency of performance is just beginning.
Unaffected aspects of variability
Not all indices of IIV are affected by brain damage. We did
not ®nd signi®cant group differences in consecutive trial
¯uctuations, as assessed by autocorrelations. This measure
denoted how much linear association there was between one
trial and the next. We used autocorrelations to investigate trial
to trial patterns rather than autocovariance because the former
adjusts for inter-trial variability (Wei, 1990). That is, while
the actual RTs among the groups may have differed, the
¯uctuations from trial-to-trial of individuals regardless of
group were as stable as the CTL group.
Regional brain lesions and variability
Our ®rst hypothesis was supported. Patients with frontal
lesions do have greater IIV on these RT tasks than CTL
subjects or patients with NF lesions, but the increased IIV is
not seen uniformly. Patients with IM lesions have absolutely
normal levels of IIV on the tasks used. The abnormal
dispersion on ISD, which is not present with ICV, and only
the occasional appearance of inconsistency in the posterior
lesion group, who were comparable statistically with the CTL
in most measures, indicates that increased IIV is not simply
due to brain damage. To the best of our knowledge, our
results (®rst presented in Stuss et al., 1999) are the ®rst
demonstration of a focal CNS cause of abnormal intra-
individual variation. IIV is modulated by stimulus±response
2376 D. T. Stuss et al.
control mechanisms (Rabbitt and Rodgers, 1977); and those
control mechanisms for the execution of behaviours/
responses are largely located in the frontal lobes. Whether
this level of control is unique to the frontal lobes remains to
be fully determined. However, in those studies that have
demonstrated IIV after right or left hemisphere lesions, there
is a need to dissociate the differential impact of frontal versus
non-frontal involvement, and the relationship of the task
demands (e.g. language) to the location of the lesion. It is
possible that content-related variability may be more domain-
speci®c and related to NF regions, with the frontal lobes
contributing a more generic top±down control.
The second hypothesis was partly supported. Patients with
right frontal lesions do have increased inconsistency, but so
do the LDL and SM groups. The patients with lateral frontal
regions may have a particular propensity to be affected by
inconsistency of performance. The potential laterality and
mechanisms of these effects need to be studied with a larger
number of patients. The third hypothesis, that increased
complexity would increase IIV in patients with frontal
lesions, was supported and in an intriguing, not altogether
expected, manner. No signi®cant differences were found for
either ISD or ICV in the Simple RT task, but signi®cant
differences were observed for the Easy task for all except the
IM and NF groups. The critical step was introducing any
complexity, i.e. going from Simple to Easy choice. When the
effect of complexity was examined directly, the increased
dispersion from the Simple to Easy tasks was observed in the
LDL group. The fourth hypothesis was under-speci®ed: a
general presumption that errors would have a different effect
on IIV in patients with frontal lesions than in CTLs. Although
weak, the hypothesis was supported. Error feedback is one
index of the control mechanism. If error analysis can be
considered an indirect re¯ection of control mechanisms, this
study demonstrates different disorders of control related to
lesion location within the frontal lobes. Normal subjects
maintain fast and accurate responses by dynamic response
programming: error responses tend to be faster than correct
responses, but after error detection responses slow as if re-
calibrating speed-accuracy limitations (Rabbitt and Vyas,
1970). To a greater or lesser degree, the CTL, IM frontal and
NF groups exhibited this normal pro®le of response tracking
with faster responses preceding errors, followed by slowing.
The RT of the RDL group was least affected by or after an
error. This is compatible with our previous report (Stuss et al.,
2002b) that this group showed the greatest impairment in
sensitivityÐde®ned as the ability to differentiate ef®ciently
between targets and non-targets. Patients with RDL lesions
have dif®culty distinguishing what is important, and their
lack of differential reaction to errors indicates low sensitivity
to target. Low sensitivity and absence of change in response
time after errors may underlie monitoring de®cits after right
frontal injury. In contrast to the CTL group, the LDL group
had faster reaction times after the error. This suggests a de®cit
not in error detection (which would be re¯ected in minimal or
no difference in RT as in the RDL group), but in error
utilization (Konow and Pribram, 1970), as if attention were
captured by the error. A seemingly similar and selective LDL
frontal de®cit was reported in our earlier study (Stuss et al.,
1999) using an Inhibition of Return paradigm. The left frontal
group in that study showed facilitation rather than inhibition
of return.
The SM group was slower on trials with an error, but after
the error, there was no additional slowing. This result
suggests that the patients in the SM group were alerted by
committing an error. We have proposed that the fundamental
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impairment caused by damage to the SM areas is maintaining
response activation or energization. We have demonstrated
blunted activation in this group on numerous tasks: the Stroop
test (Stuss et al., 2001), verbal ¯uency (Stuss et al., 1998) and
Simple RT (Stuss et al., 2002b). The current error feedback
results strongly support this view. SM damage causes loss of
activation over time and RT becomes slower. Then, with an
external warning stimulus (the error), arousal or effort
necessary to maintain that level of activation is restoredÐat
least temporarily. In clinical reports. this behaviour has been
labelled `drifting attention' (Stuss and Benson, 1986).
A tentative model: effects of speci®c frontal
lesions on IIV
Lesions in the SM region disrupt maintenance of activation to
respond and of energization of various schemata in the
response set (see also Stuss et al., 1995). Thus, lesions in the
SM region cause signi®cant dispersion and inconsistency
compared with CTLs that is not simply due to errors or speed,
even though this group was the slowest of the patient groups.
Lesions in the RDL region impair sensitivityÐthe ability
to differentiate the correct stimulus. Thus, patients with RDL
lesions make multiple errors and, in this group, it is the
overall error rate that is associated with IIV. The effect of a
particular error on the surrounding trials is weak as the
patients are relatively insensitive to errors.
Lesions in the LDL region impair establishment of criteria
for functional response. Thus, dispersion is high, and
complexity and, probably to some degree errors and
inconsistent bias, all combine to increase IIV. This was the
one group in which the RT slowing was related to variability,
even though this group was among the faster patient groups.
The IM group had normal IIV. If variability is related to
executive control of the deployment of attentional resources,
of activation to respond and to maintenance of sharp criteria
(`if-then' operations) as in our earlier model (Stuss et al,
1995), then IM regions apparently do not contribute to this
deployment. On a much different task, the Wisconsin Card
Sorting Test (Stuss et al., 2001), when patients in the IM
lesion group were made explicitly aware of their on-going
performance, theyÐuniquely among frontal injured pa-
tientsÐappeared to lose track of what they were doing.
This may be a different type of variability of performance at
the level of simultaneous attention to accuracy and to
feedback.

The model that we propose requires several caveats. To
insure that the basic RT task could be performed at a high
level, we excluded patients with signi®cant aphasia or
neglect. When a task has high verbal demands, there may
be high IIV introduced by aphasia. When a task has high
perceptual demands, visual neglect may inject IIV. Increased
IIV on domain-speci®c tasks is likely with lesions that disrupt
performance within those domains and has been demon-
strated for spatial neglect. Our results cannot be reduced to
differences in demographic variables, although these may
have some effect. For example, simple attentional problems
cannot explain the patterns of group differences. The LDL
and the RDL groups had lower forward digit span, but not the
SM group. Since these are the three groups which displayed
the most variability, it is unlikely that digit span scores were a
primary contributor to IIV. Age differences from the CTL
group were observed for NF, IM and LDL groups, of which
the former two were not variable. Differences in education or
intelligence are not likely to have a major impact, as there
were no signi®cant differences between the CTL group and
any of the patient groups for the dispersion measures.
Secondly, we are also aware and have published on the
possible effect of time of day on variability (West et al.,
2002a). Our subjects were studied at different times of the
day, depending on their availability but there was no
systematic bias across groups. However, for the repeated
testings, time of day was kept constant for the individual
subjectÐthus controlling for that factor within each partici-
pant for the consistency measures.
A third caveat concerns the distinction between frontal
lobe lesions and frontal system lesions. This report focused on
patients with focal frontal lobe lesions, but there are extensive
cortico-cortical and frontal-subcortical connections (e.g.
Nauta, 1971, 1973; Wiesendanger and Wise, 1992; Petrides
and Pandya, 1994, 1999) that may support performance
capacities. Damage to focal frontal regions or to NF regions
such as basal ganglia (Cummings, 1993) or cerebellum
(Holmes, 1939; Bastian et al., 1996) may produce similar
de®cits in executive function. A similar proposal of `frontal
lobe' dysfunction has been made for the increased IIV
reported in normal elderly people (West, 1999b; West et al.,
2002b). Frontal lobe dysfunction has also been proposed to
account for the increased IIV noted in TBI (thought to affect
the integrity of the frontal lobes) individuals (Stuss et al.,
1989, 1994b).
A fourth caveat is the fundamental claim that there are
properties of top±down regulation of attention that are
instantiated in frontal structures (and their connections).
There is a litany of impairments associated with frontal injury
that might be recruited to account for our ®ndings: reduced
sustained attention; poor working memory; perseveration;
failure to inhibit responses; and poor action planning or
strategy formulation. It is likely that some of these putative
de®cits do play a role in overall performance, but none seems
adequate to account for the general results on RT or to the
speci®c ®ndings for IIV. With regard to sustained attention,
Individual variability in reaction time 2377
we demonstrated that there were no consistent changes in the
slope of performance over time. It may be that the ¯uctuating
`top±down' attention that we have reported is a partial
explanation for impaired sustained attention in some groups
rather than the opposite. With regard to working memory, the
tasks have low demands on working memory as they are
blocked, require no response shift demands during blocks, and
show no consistent relationship between potential complexity
that might increase `keeping in mind' burdens. With regard to
perseveration and failure to inhibit responses, these terms are
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surface descriptions of error types more than basic processes.
Our patients made errors of these types, but there was no
consistent relationship between errors and IIV except in the
RDL group. There may be multiple routes to perseveration
and failure to inhibit depending on task, and we have
demonstrated this in other studies (Stuss et al., 1999, 2000).
With regard to strategy formation, patients with left DL and
right DL lesions surely do have impairments in strategy
formulation. In this and other reports (Stuss et al., 1994a,
2002b; Alexander et al., 2003), we have demonstrated that
patients with left DL lesions adopt a strategy of shifted bias
and that patients with right DL lesions adopt a strategy of
reduced sensitivity. Those strategies account for the nature of
their errors, but not the variability in their correct responses.
In this experiment, only the redundant task offers the
possibility of creating a strategy during the stimulus presen-
tations, that is, once the redundancy is detected. There may
have been an interaction between strategy and variability in
that task.
Rather than account for `micro-behaviours' such as
¯uctuating attention with `macro-behaviours' such as perse-
veration or inhibition failure, we prefer to demonstrate a
range of micro-behaviours that, depending upon varied and
distinctive patterns of recruitment, add up to the various
macro-behaviours. In the original outline (Stuss et al., 1995)
of this modi®ed form of the Norman and Shallice (1986)
theory, we proposed a number of forms of attention, all under
the control of frontal structures, which are differentially
recruited under different cognitive contexts to produce the
coarser behaviours that are commonly considered `frontal
lobe functions'.
Clinical implications
There is a very signi®cant implication of these data. A
patient's mean performance at one time may not re¯ect wide
irregularities over time and thus a single clinical assessment
of a patient with a frontal lesion may not capture dispersion or
inconsistency. Success in real-life tasks may depend as much
on predictability and consistency as on average performance.
Can dispersion and inconsistency be reduced? Bleiberg
et al. (1993) administered dextroamphetamine in a single
subject placebo crossover design to an individual with TBI.
On treatment only, variability decreased, but only the SDs
were reported, so the relationship to overall RT speed is
unknown. Verbal self-regulation (Luria, 1966) may be
2378 D. T. Stuss et al.
effective for tasks that unfold at a slower pace than RT tasks.
It was successful in reducing motor impersistenceÐa
disorder most commonly found after focal right frontal
pathology that has some similarity to IIV (Stuss et al., 1987).
The results of this study suggest a method to develop
behavioural interventions: specify a patient's lesion location
with appropriate imaging, then identify the systems involved
(i.e. SM or left dorsolateral, etc.), then assess the speci®c
form of IIV through appropriate assessment. Patients with
injury in SM regions and the pro®le of variability demon-
strated here might respond to alerting cues to maintain
appropriate activation. Patients with RDL lesions might
utilize explicit feedback to monitor their performance by
distinguishing better between targets and non-targets.
Clarifying the relationship between speci®c lesion sites and
speci®c basic processes of attention should lead to more
speci®c rehabilitation procedures and provide a base for
research efforts in rehabilitation.
Acknowledgements
We wish to thank the subjects for their participation and the
following people for testing as well as for ®gure and
manuscript preparation: S. Bisschop, A. Borowiec, L.
Buckle, R. Dempster, D. Derkzen, N. Fansabedian, D.
Floden, D. Franchi, S. Gillingham, L. Hamer and A. Savas.
R. West provided important feedback on earlier drafts.
Preliminary results of this study were ®rst presented at the
27th Conference of the International Neuropsychological
Society, Boston, MA, 1999, and published as an abstract
(Stuss et al., 1999). Funding for the research was provided by
the Canadian Institute for Health Research (MT-12853; and
CIHR-14974). D. Stuss is the Reva James Leeds Chair in
Neuroscience and Research Leadership, Baycrest Centre and
University of Toronto.
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Received August 15, 2002. Revised January 6, 2003.
Second revision May 16, 2003. Accepted May 19, 2003