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Child Neuropsychology: A Journal on

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Planning and Problem Solving Skills

Following Focal Frontal Brain Lesions
in Childhood: Analysis Using the Tower
of London
Rani Jacobs & Vicki Anderson
Published online: 09 Aug 2010.

To cite this article: Rani Jacobs & Vicki Anderson (2002) Planning and Problem Solving Skills
Following Focal Frontal Brain Lesions in Childhood: Analysis Using the Tower of London, Child
Neuropsychology: A Journal on Normal and Abnormal Development in Childhood and Adolescence,
8:2, 93-106, DOI: 10.1076/chin.8.2.93.8726

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2002, Vol. 8, No. 2, pp. 93–106 # Swets & Zeitlinger

Planning and Problem Solving Skills Following

Focal Frontal Brain Lesions in Childhood:
Analysis Using the Tower of London
Rani Jacobs1,2,3 and Vicki Anderson2,3
1
Royal Children’s Hospital, Melbourne, Australia, 2Murdoch Childrens Research Institute, Melbourne, Australia,
and 3University of Melbourne, Australia
Downloaded by [New York University] at 19:26 10 January 2015

ABSTRACT

Problem solving skills were investigated in children with focal lesions using the Tower of London test (TOL;
Shallice, 1982). The scoring procedure was elaborated from previous studies to delineate separate processes
contributing to overall performance in children. Thirty-one children with focal frontal pathology, 18 children
with focal pathology in other brain regions (extra-frontal), 17 children with generalized pathology and 38
healthy children participated in the study. Results suggest a distributed network for problem solving skills,
particularly cognitive flexibility and goal setting skills. Within the frontal group, children with lesions
involving the right pre-frontal cortex had greatest problems with self-regulation, with rule breaks most
common among this group. As these skills develop relatively early in comparison to other aspects of
executive function, right pre-frontal regions may play a particularly important role in the development
of executive skills in childhood, with damage to these regions rendering children vulnerable to a range of
cognitive and social deficits.

Adult lesion studies have shown that specific pre-
frontal regions play a greater role in mediating
particular aspects of executive function. For
example, right pre-frontal regions are implicated
in attention, planning, spatial working memory,
self-regulation and monitoring, while left pre-
frontal regions are associated with verbal proces-
sing and verbal fluency, initiation of task activities
and verbal working memory (Alexander & Stuss,
2000; Eslinger & Biddle, 2000; Eslinger, Biddle
& Grattan, 1997; Grattan, Bloomer, Archambault,
& Eslinger, 1994; Grattan & Eslinger, 1992; Stuss
et al., 1998, 1999). In contrast, relatively little is
known about the localization and lateralization of
executive skills in children, due to the difficulty in
obtaining a large sample of children with focal
frontal lobe damage, and the relative immaturity
of these skills in childhood.
Executive Function
Executive skills are generally considered to be
mediated by the pre-frontal cortex, as damage to
this region often leads to impairments in self-
regulation, attentional capacity, reasoning and
emotional control (Luria, 1980; Stuss & Benson,
1986; Walsh, 1978). These problems have
significant functional implications impacting on
a child’s quality of life, impeding academic
progress, limiting their capacity to acquire and
sustain meaningful employment or to develop and
maintain appropriate social relationships. In
severe cases, sociopathic behavior may also be

Address correspondence to: Rani Jacobs, Department of Psychology, Royal Children’s Hospital, Parkville, Vic.
3052, Australia. Tel.: þ61 3 9345 5511. Fax: þ61 3 9345 6002. E-mail: jacobsr@cryptic.rch.unimelb.edu.au
Accepted for publication: September 20, 2002.
 94 RANI JACOBS & VICKI ANDERSON
observed (Anderson, Bechara, Damasio, Tranel,
& Damasio, 1999; Blair & Cipolotti, 2000).
Attention and self-regulation skills underpin
efficient executive function with impairments in
these abilities resulting in impulsive responses,
poor self-control, difficulty completing tasks and
multiple errors. As these skills appear to be
mediated by right pre-frontal regions, at least in
adults, right pre-frontal damage in childhood may
render children vulnerable to impairment in abil-
ities requiring these processes. Such problems
incorporate cognitive, emotional and behavioral
domains, limiting a child’s capacity to acquire
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knowledge, successfully solve problems, learn
from previous mistakes and to respond appropri-
ately in social situations, therefore impeding for-
mation of lasting friendships (Eslinger, Biddle,
Pennington, & Page, 1999; Marlowe, 1992).
Thus, children with damage to right pre-frontal
brain regions may be particularly vulnerable to
cognitive, learning and social difficulties. Despite
their importance in childhood, to our knowledge,
no controlled group studies have attempted to
investigate the role of the right pre-frontal brain
regions in mediating attention and regulation
skills in childhood.
Executive deficits are not specific to frontal
pathology, but can also occur secondary to a
disruption to connections that feed into these
cerebral regions (Eslinger & Grattan, 1993).
This observation may be particularly relevant to
children sustaining early brain insults due to the
immaturity of the central nervous system at the
time of insult, and the reliance of the frontal lobes
on efficient transmission of information from
posterior and subcortical brain regions for ade-
quate development. Whether the nature and sever-
ity of executive impairments following damage to
these ‘‘extra-frontal’’ brain regions is similar to
that seen following frontal lobe damage, has not
been systematically studied in childhood popula-
tions, possibly due to the difficulty in recruiting
large samples of children with focal cerebral
pathology.
Neuroanatomical and neurophysiological stu-
dies have demonstrated multiple bi-directional
connections between the pre-frontal cortex and
all other cortical and subcortical structures
(Denckla & Reiss, 1997; Luria, 1980; Stuss &
Benson, 1984). Together, these results imply that
executive skills are subsumed by cerebral systems
rather than discrete unitary processes, with the
pre-frontal regions acting as a ‘supervisory sys-
tem’, integrating and coordinating information
from posterior and subcortical cerebral regions
(Alexander & Stuss, 2000; Stuss & Alexander,
2000; Welsh & Pennington, 1988).
The systemic basis of executive function may
be best illustrated in the developing brain. The
frontal lobes are the last cerebral structures to
reach maturity, with elaboration and myelination
of pre-frontal cerebral circuitry as well as changes
in metabolic activity occurring throughout child-
hood and adolescence (Hudspeth & Pribram,
1990; Huttenlocher & Dabholkar, 1997; Klinberg,
Viadya, Gabrieli, Moseley, & Hedehus, 1999;
Thatcher, 1997). These changes are consistent
with a protracted development of executive func-
tion, which commences in infancy but is not
complete until around mid-adolescence (Ander-
son, this edition; Anderson, Anderson, Northam,
Jacobs, & Catroppa, 2001; Diamond & Doar,
1989; Diamond & Taylor, 1996; Espy, Kaufman,
& Glisky, 2001; Kelly, 2000; Klenberg, Korkman,
& Lahti-Nuutila, 2001; Levin, Culhane, Hartman,
Evankovich, & Mattson, 1991; Stuss, 1992). This
development does not appear to be a uniform
process for all components of executive function.
Rather, there appears to be different developmen-
tal trajectories for specific aspects of executive
function, with some aspects not reaching maturity
until mid-adolescence. For example, attention,
self-regulation and inhibitory responses appear
to mature earlier than skills such as speed of
processing, planning, goal setting and cognitive
flexibility (see Anderson, this edition for sum-
mary; Anderson, Anderson, Northam, & Jacobs,
et al., 2001; Diamond & Doar, 1989; Diamond &
Taylor, 1996; Espy, 1997; Espy, Kaufman,
McDiarmid, & Glisky, 1999; Kelly 2000; Levin
et al., 1991; Luciana & Nelson, 1998; Welsh &
Pennington, 1988; Welsh, Pennington, &
Grossier, 1991).
The protracted development of these skills and
the ‘supervisory’ role of the frontal lobes in
coordinating many daily activities suggests that
children may be particularly vulnerable to impair-
ment following frontal lobe damage, with the
 PROBLEM SOLVING AND FOCAL FRONTAL LESIONS
nature and severity of problems dependent on the
age at which the damage occurs, and the devel-
opmental stage of cognitive skills subsumed by
these damaged regions (Anderson & Moore,
1995; Dennis, 1989; Pentland, Anderson, &
Wrennall, 2000; Taylor, Albo, Phelps, Sachs, &
Bierl, 1987). These deficits may not be restricted
to the domain of executive function, but impact
more broadly on cognitive and social develop-
ment, leading to behavioral regulation problems,
emotional dysfunction, reduced intellectual skills
and learning difficulties (Eslinger et al., 1997;
Marlowe, 1992).
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Given the critical role of the frontal lobes in
learning, skill acquisition and social development,
it is important to be able to assess these skills in
children. Historically, executive function mea-
sures were developed for use with adults, when
these skills are considered mature, and so im-
paired performance can be assumed to reflect
executive dysfunction. In children, however, this
association may be less clear, due to both the
relative immaturity of executive skills at the time
of insult and the lack of maturity of these skills at
the time of assessment. These developmental
issues also need to be taken into account, as
poor performance may reflect impairment or
developmental delay. Alternatively, a child’s per-
formance may appear to be impaired when com-
pared with adult data, but may actually be within
developmental expectations when compared with
other children of the same age. Mapping the
development of executive function has received
much focus in recent years and led to the val-
idation of executive function measures that are
appropriate for use with children, and an increased
understanding of the way these skills develop in
healthy children (Anderson et al., 1996;
Anderson, Anderson, & Garth, 2001; Anderson,
Anderson, Northam, & Jacobs, 2001; Anderson,
Anderson, Northam, & Taylor, 2001; Espy, 1997;
Jacobs, Anderson, & Harvey, 2000; Klenberg
et al., 2000).
In addition to identifying more appropriate
executive function measures for children, there
has also been a move to design scoring systems
that allow for quantification of specific processes
that contribute to overall performance on execu-
tive measures (Anderson, Anderson, & Garth,
95
2001; Anderson, Anderson, & Lajoie, 1996;
Anderson, Anderson, Northam, et al., 2001;
Anderson, Anderson, Northam, Jacobs, et al.,
2001; Espy, 1997; Espy et al., 2001; Gioia,
Isquith, Guy, & Kenworthy, 2000; Jacobs et al.,
2000; Taylor et al., 1987). Such scoring ap-
proaches appear to be more informative than
traditional summary scores, which give an indi-
cation as to whether executive skills are impaired,
but are not useful in identifying the specific
reasons for this impaired performance. For
example, self-regulation deficits may underpin
problem solving deficits following frontal pathol-
ogy, while memory or perceptual problems may
interfere with problem solving capacity following
damage to posterior brain regions. This ‘micro-
analysis’ of task performance is also able to
account for different developmental trajectories
for specific aspects of executive function per-
formance.
Microanalysis of task performance may also
be a useful means of investigating the contribu-
tion of frontal and extra-frontal brain regions to
executive function performance, providing the
opportunity to separate out lower order functions
(e.g., visuo-spatial skills, memory, etc), from
more strategic aspects of performance such as
planning and cognitive flexibility. Specifically,
one might expect primary deficits in executive
skills, such as regulation and attentional control,
following pre-frontal damage. In contrast, impair-
ments in planning, organization and problem
solving may occur either as a direct consequence
of pre-frontal injury or secondary to an interrup-
tion to areas that feed into frontal lobes and
associated deficits in skills such as information
processing, memory, visuo-spatial and visuo-
motor skills.
The Tower of London (TOL)
The Tower of London Test (TOL; Shallice, 1982)
is commonly employed as a measure of executive
function, with a particular focus on planning,
strategic decision-making and problem solving
(Anderson et al., 1996; Levin & Kraus, 1994;
Levin et al., 1994; Morris, Ahmed, Syed, &
Toone, 1993; Owen, Downes, Sahakian, Poleky, &
Robbins, 1990). This test was initially devised for
use with adults, but is frequently utilized in
 96 RANI JACOBS & VICKI ANDERSON
pediatric settings due to the recent availability of
normative information for children (Anderson
et al.,1996; Krikorian, Bartok, & Gay, 1994).
Impaired performance on the TOL has been
reported in a range of pediatric disorders such as
closed head injury, hydrocephalus, meningitis
and early-treated phenylketonuria (Dimitrov,
Grafman, & Hollnagel, 1996; Fletcher,
Brookshire, Landry, & Bohan, 1996; Levin &
Kraus, 1994; Levin et al., 1997; Welsh,
Pennington, Ozonoff, Rouse, & McCabe, 1990).
However, in these conditions damage has incor-
porated, but has not necessarily been confined to,
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pre-frontal cortex (Dimitrov et al., 1996; Fletcher
et al., 1996; Levin & Kraus, 1994; Levin et al.,
1997; Welsh et al.,1990), suggesting that while
the TOL may be sensitive in detecting brain
impairment its utility in specifically tapping
frontal lobe damage in childhood, remains
unclear.
TOL scoring systems such as that outlined by
Anderson et al. (1996) may assist in delineating
executive aspects of performance from lower
order skills. This version of the TOL uses three
balls on three posts of differing heights and
involves 12 trials of increasing difficulty, ranging
from two moves to five moves. The child is shown
a card with the final configuration and told to
match the configuration on the card in the speci-
fied number of moves. In addition to a measure of
overall performance, which incorporates time and
errors, Anderson et al. also provide developmen-
tal data for separate aspects of performance such
as failed attempts and the number of trials suc-
cessfully solved.
In the current study, the scoring procedure
developed by Garth, Anderson, and Wrennall
(1997) was further extended to include quantifi-
cation of a number of ‘strategic’ aspects to per-
formance. The task was administered to a group
of children with focal lesions involving the pre-
frontal cortex, and their performance compared
with children with focal lesions to other cerebral
regions (extra-frontal), those with generalized
pathology and healthy children. Using this proce-
dure, scores were derived for a number of separate
but integrated processes including, planning, effi-
ciency, regulation, goal setting and switching, as
well as overall task performance (problem
solving). It was expected that:
(i) All children with cerebral damage (frontal,
extra-frontal and generalized pathology
groups) would perform more poorly than
controls on all aspects of performance on
the TOL. However, children with damage to
the pre-frontal regions would have relatively
greater impairments than children with extra-
frontal and generalized damage on the more
strategic aspects of performance (e.g., self-
regulation, goal setting and switching), due to
the direct effects of damage to the pre-frontal
cortex;
(ii) Within the frontal group, self-regulation
skills would be more clearly lateralized due
to the relative maturity of these skills at the
time of assessment. Specifically, children
with damage to the right pre-frontal regions
would exhibit relatively greater problems
with self-regulation than those with left-
sided lesions. Children with bilateral lesions
would perform most poorly due to the extent
of damage to pre-frontal regions.
METHOD
Participants
The sample comprised 107 children, aged between 7
and 16 years. The clinical sample (n ¼ 69), was
ascertained via neurology and neuroradiology clinics
at the Royal Children’s Hospital, Melbourne, Australia.
Etiology and timing of lesion were diverse and included
a number of acquired (penetrating head injury, stroke,
hemorrhage, tumor, contusion following fall, cyst) and
developmental (focal dysplasia, tuberous sclerosis,
schizencephaly) lesions.
(i) Frontal lesion group: comprised 31 children with a
focal lesion to pre-frontal cortex (n ¼ 12 left, n ¼ 9
right and n ¼ 10 bilateral lesions) evident on mag-
netic resonance imaging (MRI). Children with
frontal lesions that involved extensive posterior
cortical regions (more than 10% of another lobe
affected) were not included in the frontal sample.
(ii) Extra-frontal lesion group: consisted of 18 children
with a focal lesion to cortical regions excluding
the frontal lobes (parietal, temporal or occipital
lobe), evident on MRI. As with the frontal sample,
etiology of lesion was diverse and timing of
lesion included both acquired and developmental
disorders.
 PROBLEM SOLVING AND FOCAL FRONTAL LESIONS 97

(iii) Generalized group: comprised 17 children with Procedure

diffuse cerebral pathology detected on MRI. Etiol-
ogy included closed head injury, neurofibromato-
sis and developmental disorders (e.g., subcortical
band heterotopia, polymicrogyria) incorporating
multiple brain regions.
Inclusion criteria for all participants in lesion groups
were: (i) attendance at mainstream school; (ii) cerebral
MRI; (iii) no history of psychiatric disturbance or
attention deficit disorder prior to lesion onset; (iv)
minimum of 3 months post lesion onset at time of
assessment.
A control group was recruited from mainstream
schools for comparison purposes. Children were
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Children in the frontal and extra-frontal groups were
recruited prospectively over a 7-year period, and
identified on the basis of MRI evidence of a focal
cortical lesion. A neuroradiologist and pediatric
neurologist rated the scans according to site and nature
of cerebral pathology. Children in the generalized
group were identified either on the basis of CT or MRI
evidence of a diffuse injury (e.g., diffuse axonal
shearing), multi-focal pathology (e.g., tuberous sclero-
sis involving all lobes) or global developmental brain
anomaly (e.g., subcortical band heterotopia). Once
identified, permission was sought from the primary
consultant to approach families about the study.
Following consent from the consultant, a letter was

identified via their school, and parents contacted for
consent. The group comprised 38 children between 7
and 16 years, with no previous history of learning
disability, attentional problems, and psychiatric or
emotional disturbance.
All children were required to have English as a
primary language and a Full-Scale IQ  70 (WISC-III,
Wechsler, 1991). Demographic data for the sample are
presented in Table 1, and demographic data and lesion
characteristics for the frontal group are presented in
Table 2.
sent to families describing the study and inviting them
to participate. Children in the control group did not
undergo MRI. Consent to approach schools for the
purpose of recruiting healthy control children was first
obtained via the Education Department for Government
schools and via the appropriate board for Non-
Government schools. Following consent, letters were
sent to the principals of primary and secondary schools
in the Melbourne metropolitan region, incorporating a
range of socio-demographic regions. Schools that
consented to participate were then asked to randomly

Table 1. Demographic Characteristics of Each Group.

Frontal Extra-frontal Generalized Control Partial

n ¼ 31 n ¼ 18 n ¼ 17 n ¼ 38
2

Males n (%) 19 (61.3) 11 (61.1) 12 (70.6) 19 (50) n/a

Age: M(SD) 11.3 (2.8) 10.7 (3.0) 10.6 (2.6) 10.8 (2.7) .011
SESa: M(SD) 4.7 (1.4) 4.0 (0.8) 3.9 (0.9) 4.1 (1.2) .076
Full-Scale IQ: M(SD) 90.2 (10.1) 92.4 (10.4) 88.9 (10.6) 105.2 (13.6) .283
a
SES: Socio-economic status (Daniel, 1983) – low scores reflect high SES.

p < .01 (all clinical groups significantly lower Full-Scale IQ than controls).

Table 2. Demographic and Lesion Characteristics of Frontal Group.

Left Right Bilateral Partial

n ¼ 12 n¼9 n ¼ 10
2

Males: N (% of sample) 9 (75) 4 (44.4) 6 (60) n/a

Age: M(SD) 11.9 (2.4) 10.8 (3.4) 11.4 (2.9) .016
SES: M(SD) 4.7 (1.4) 4.8 (1.1) 4.5 (1.8) .015
Full-Scale IQ: M(SD) 92.0 (8.6) 89.3 (13.0) 88.8 (9.6) .022
Lesion Characteristics
Developmental lesion: N (% sample) 4 (33.3%) 3 (33.3%) 3 (30%) n/a
Epilepsy: N (% sample) 8 (66.7%) 4 (44.4%) 6 (60%) n/a
Age at seizure onset: M(SD) 7.3 (4.3) 5.0 (4.5) 9.0 (5.0) .108
Note. No significant differences.
 98 RANI JACOBS & VICKI ANDERSON
identify a male and a female whose birth date fell in the
first and second half of the year, for each birth year
specified. Letters were then sent to these families via
the school principal (to ensure anonymity for families
who did not wish to be involved), outlining the study
and inviting them to participate. Where families did not
wish to be involved, the principal was asked to send a
letter to another family that matched the gender and
birth date criteria of the child who declined to be
involved.
Children of families who provided written consent
as per hospital ethics procedure, then participated in a
neuropsychological assessment incorporating a stan-
dardised measure of general intellectual ability and a
range of traditional and more experimental executive
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function measures. Children in the lesion groups were
seen either at the hospital or at home in a single session
with a break. Children in the control group were seen at
school, in a single session with breaks in accordance
with timetabled recess and lunch breaks.
Measures
(i) Intellectual capacity: This was obtained using the
Wechsler Intelligence Scale for Children, III
(WISC-III). Verbal, Performance and Full-Scale
intellectual quotients were calculated.
(ii) The Tower of London (Anderson et al., 1996;
Shallice, 1982): Comprises 12 items of increasing
complexity. Children are required to rearrange
three coloured balls on three posts of differing
heights to match a specified configuration, in a
specified number of moves. In manoeuvring the
balls, children are told that they may only move
one ball at a time, must place each ball on a post
and not on the desk, and may only place two balls
at a time on the middle post and only one at a time
on the last post. The task is timed and children must
Table 3. Summary of Tower of London Variables, the Aspect of Executive Function Tapped and the Regions Shown
to Mediate These Skills in Adults.
Variable Aspect of executive function
tapped
Mastery
No. items correct Problem solving
Total score Problem solving
Rate
Planning time (s) Planning
Total time taken Efficiency
Strategy
No. rule breaks Self-regulation
No. failed attempts Goal setting
Perseverative errors Switching
complete each problem within 1 min. Timing com-
mences once the card containing the configuration
is exposed, and ceases following successful com-
pletion of the problem. Following an unsuccessful
attempt, the balls are placed back in their original
position and the child may attempt the problem
again. This procedure may be repeated as many
times as required within the 1 min time limit.
The score for each trial is based on speed and
accuracy with a maximum score of 9 given for each
problem. Children are penalized for each failed attempt
or for any rule breaks they make while completing each
problem. In addition to the overall score, which is
calculated by summing the time score for each
individual trial, the total time taken to complete all
trials, and the total number of failed attempts were also
calculated independently (Anderson et al., 1996). An
estimate of planning time was derived by recording
time taken between the child seeing the problem and
moving the first ball from the post and placing it on a
new post (Garth et al., 1997). This was then averaged
across the 12 trials. To investigate regulation skills, the
total number of rule violations (rule breaks) was also
recorded. These violations included a child picking up
more than one ball at a time, placing two balls on the
smallest post or placing balls on the desk. When a rule
break occurred, the child was reminded of the rule, the
balls were placed back to the original position, a failed
attempt recorded, and the child was instructed to try
again. Perseverative errors were recorded as errors
where after making a failed attempt, the same sequence
of moves was repeated on the subsequent attempt.
These errors were considered to be a measure of
cognitive inflexibility, reflecting impaired working
memory and/or the inability to modify behavior
following feedback. These scores are summarized in
Table 3.
Frontal region involved
Left
Left
Right
Right
Right
Right (spatial tasks)
Right, left, superior medial
 PROBLEM SOLVING AND FOCAL FRONTAL LESIONS
Statistical Analyses
(i) Demographic characteristics: Differences between
the groups on demographic characteristics of age,
socio-economic status (SES) and Full-Scale IQ
were investigated using analysis of variance
(ANOVA). Where significant differences were
observed, post-hoc analysis was conducted using
Tukey’s Honestly Significant difference. Chi-
square analyses were employed to investigate dif-
ferences between the groups with respect to gender
distribution as well as lesion characteristics for the
frontal group (% children with epilepsy, % children
with developmental lesions).
(ii) TOL variables: Raw scores for variables of the
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TOL were used in the analysis as age standardized
scores were not available for all variables. As the
groups were not matched for age, differences
between lesion and control groups, and between
laterality groups within the frontal lobe group,
were investigated using analysis of covariance co-
varying for age (ANCOVA). Post-hoc analyses
were performed by investigating the 95% confi-
dence intervals for each group.
RESULTS
Demographic Characteristics
There were no differences between the four
groups with respect to gender, age and socio-
economic status (SES), although a significant
between group difference was found for Full-
Scale IQ, F(3, 100) ¼ 13.8, p < .01,
2 ¼ .29. As
expected, post hoc analysis revealed that the
frontal (p < .01), extra-frontal (p < .01) and gen-
eralised (p < .01) groups all obtained significantly
lower scores than controls.
Within the frontal group, there were no differ-
ences between the left, right and bilateral groups
with respect to gender, age, SES and Full-Scale
IQ.
Between Group Comparisons
on the TOL
(a) Mastery: As outlined in Table 4, all groups
performed similarly with respect to total
number of trials correct and the overall score.
(b) Rate: There were also no differences between
the groups with respect to the total solution
time and average planning time.
99
(c) Strategy: Differences were identified across
all three strategy variables. There was a sig-
nificant group effect for failed attempts F(3,
100) ¼ 3.4, p < .05,
2 ¼ .09, and rule breaks,
F(3, 100) ¼ 5.0, p < .01,
2 ¼ .13, with the
95% confidence intervals showing that the
frontal group made more failed attempts and
more rule breaks than the control group. Of
note, for control children, only those
younger than 9 years at the time of the assess-
ment made rule breaks. Children who made
five or more rule breaks had either frontal
(n ¼ 4) or generalized (n ¼ 1) pathology.
There was also a significant group effect for
perseverative errors, F(3, 100) ¼ 4.3, p < .01,

2 ¼ .11, again with the frontal group making
more perseverative errors than controls.
Laterality
(a) Lesion characteristics: There were no differ-
ences between the left, right and bilateral
groups with respect to proportion of children
with developmental lesions or seizures and
the age at seizure onset.
(b) TOL performance: Lateralization of skills
within the frontal group was investigated for
strategic variables, as these parameters were
sensitive to frontal lobe damage. These
results are summarized in Table 5.
There was a significant group effect for failed
attempts, F(3, 64) ¼ 3.9, p < .05,
2 ¼ .15. Al-
though the right and bilateral groups made more
failed attempts than the left lesion and control
groups, the only statistically significant difference
was observed between the bilateral and control
groups at the 95% confidence interval. As shown
in Figure 1, rule breaks were most common in
children with right (44% sample) and bilateral
(70% sample) lesions, and these groups also
obtained higher mean scores on this variable in
comparison to the left lesion and control groups.
ANCOVA revealed a significant main effect
for rule breaks, F(3, 64) ¼ 6.2, p < .01,
2 ¼ .23,
with the bilateral group making significantly more
rule breaks than the control group. The difference
between the right and control groups also
approached significance at the 95% confidence
 100
Table 4. Results for TOL Performance for Each Group: Adjusted Means and Standard Error.

Frontal Extra-frontal Generalized Control Partial

n ¼ 31 n ¼ 18 n ¼ 17 n ¼ 38
2
Age Adj. Age Adj. Age Adj. Age Adj.
M (95% CI) M (95% CI) M (95% CI) M (95% CI)

Mastery
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Problem solving
No. of trials correct 10.5 (10.1–10.9) 10.6 (10.0–11.1) 10.7 (10.1–11.2) 10.9 (10.6–11.3) .012
Total score 68.8 (65.9–72.2) 67.6 (63.6–71.8) 66.6 (62.3–71.1) 69.7 (67.8–73.7) .014
Rate
Planning, efficiency
Time taken (s) 271.0 (237.2–302.1) 289.5 (246.8–330.8) 292.9 (247.9–336.8) 277.0 (240.6–300) .008

RANI JACOBS & VICKI ANDERSON

Average planning time (s) 4.5 (3.7–5.5) 4.7 (3.4–5.9) 4.9 (3.7–6.0) 3.8 (3.0–4.6) .029
Strategy
Self-regulation
No. rule breaks 2.0 (1.3–2.6) 1.1 (0.2–1.9) 1.6 (0.7–2.5) 0.3 (0.3–0.9) .142
Goal Setting
No. failed attempts 9.5 (8.4–10.7) 9.2 (7.7–10.7) 10.2 (8.6–11.8) 7.3 (6.2–8.4) .107
Shifting set/switching
No. perseverative errors 2.2 (1.6–2.7) 1.8 (1.1–2.5) 1.9 (1.1–2.6) 0.9 (0.4–1.4) .103
Note. Age adjusted means.

p < .05;  p < .01.
 PROBLEM SOLVING AND FOCAL FRONTAL LESIONS 101

Table 5. Performance on TOL According to Lesion Laterality for Children With Frontal Lobe Lesions.

Left Right Bilateral Control Partial

n ¼ 12 n¼9 n ¼ 10 n ¼ 38
2
Age Adj. Age Adj. Age Adj. Age Adj.
M (95% CI) M (95% CI) M (95% CI) M (95% CI)

Strategy
Self-regulation
No. rule breaks 1.1 (00–2.2) 1.9 (0.7–3.1) 2.7 (1.6–3.9) 0.2 (0.4–0.8) .227
Goal setting
No. failed attempts 7.9 (5.9–9.9) 10.1 (7.7–12.4) 11.3 (9.0–13.5) 7.2 (6.1–8.4) .171
Shifting set/switching
No. perseverative errors 1.7 (0.8–2.6) 1.9 (1.0–2.9) 2.9 (1.9–3.8) 0.8 (0.4–1.3) .215
Note. Age adjusted means.
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p < .05;  p < .001.

Although the frontal group performed most

Fig. 1. Proportion of children in the frontal group
making rule breaks according to lesion
laterality.
interval. There was also a significant main effect
for group on the number of perseverative errors,
F(3, 64) ¼ 5.7, p < .01,
2 ¼ .21, with the bilateral
group once again making more of these errors
than the controls.
DISCUSSION
There were no differences between the frontal,
extra-frontal, generalized and control groups on
mastery and rate scores despite differences on
more strategic aspects of performance, suggesting
that at least in children, rate and mastery
parameters are not particularly sensitive in
distinguishing site specific problems associated
with executive dysfunction. Differences were
evident on all strategy scores, with the frontal
group consistently performing more poorly,
suggesting that strategy scores may be more
sensitive for detecting frontal pathology.
poorly on strategy variables, the performance
of the extra-frontal and generalised groups was
also reduced in comparison to controls, suggest-
ing that while executive dysfunction may be more
severe following frontal pathology, it is also a
feature of childhood cerebral pathology, irrespec-
tive of the site of damage.
There were no differences between the groups
with respect to the time taken to plan an approach
to each problem. One explanation for this may be
that the measure of planning used in this study
was not a reliable indicator of planning ability. A
recent adult study using a computerized version
of the TOL would support such a notion. Owen
et al. (1990) used a procedure where the number
of moves to solve a problem was not specified and
found similar mean latencies between the frontal
pathology group and controls for the time taken
between the problem being exposed and partici-
pants making an initial move. However, the fron-
tal lobe pathology group took longer than controls
to implement their second move, suggesting less
efficient planning in the frontal pathology group,
which may be masked when only looking at the
initial latency between seeing the problem and
making the first move. This study also showed
less efficient problem solving skills in the frontal
pathology group who required more moves to
solve problems than controls. Similarly, tasks
such as the Tower of Hanoi, which is purported
to also assess planning and problem solving skills,
requires children to solve each problem in the
 102 RANI JACOBS & VICKI ANDERSON
smallest number of moves, rather than giving this
information to the child, as was done in this study.
Thus, it is important to note that the nature of the
task may vary according to the procedure
adopted. For example, protocols requiring chil-
dren to solve a problem in the fewest number of
moves, may impose a greater demand on plan-
ning, working memory and cognitive flexibility
skills as children need to think about a number of
alternatives and choose the most efficient strategy
prior to commencing the task.
The total time taken to complete the 12 trials
was not sensitive in detecting group differences in
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performance. As this measure reflects global
performance, it is not helpful in detecting intra-
individual variation in performance on each trial.
For example, some children were quick to com-
plete some trials, approaching problems impul-
sively but obtaining the correct solution, thereby
obtaining a high score, while on other trials, such
an impulsive approach was associated with many
errors and a longer solution time. In contrast,
other children methodically planned their ap-
proach to each trial, made fewer errors but took
longer to solve each problem.
Although the greatest deficits on strategy vari-
ables were observed following focal frontal
pathology, reduced performance was also found
for the other lesion groups. These findings support
a systemic rather than localized basis for execu-
tive skills, with deficits occurring either as a direct
consequence of damage to the pre-frontal cortex
or secondary to a disconnection between frontal
and other brain regions. These results are consis-
tent with functional imaging and animal studies,
which have demonstrated rich connections
between the pre-frontal cortex and posterior and
subcortical regions, with particularly strong links
between posterior association areas and dorsolat-
eral pre-frontal cortex, a region associated with
problem solving skills (Alexander & Stuss, 2000).
Although children with extra-frontal and gen-
eralized pathology were also prone to making rule
breaks and perseverative errors on the TOL rela-
tive to controls, these problems were more severe
following frontal lobe lesions. Thus, while the
integrity of the frontal lobes is critical for self-
regulation and adaptive behaviour, input from
posterior and subcortical regions is also required
for efficient function in these domains. There may
be different reasons for impaired executive func-
tion performance depending on the site of patho-
logy. For example, goal setting deficits in the
frontal pathology group may in part be accounted
for by impairments in self-regulation, with this
group making the greatest number of rule breaks,
which were also recorded as a failed attempt.
While the extra-frontal group performed similarly
poorly in the domain of goal setting, the severe
self-regulation deficits observed in the frontal
group were not as apparent, raising the possibility
for different reasons for impaired goal setting
skills in these two groups.
Although the reasons for goal setting deficits
may vary according to the site of pathology, these
difficulties in devising and carrying out goals have
similar functional implications for children in
everyday life, impacting on learning, social inter-
action and cognitive development. As a result of
their impairment, children may struggle to know
how to start open-ended tasks, to set realistic study
goals, to organise incoming information in an
efficient manner for later recall, and to generate
appropriate solutions to problems at school, in the
workplace and in personal relationships. In addi-
tion, children with frontal pathology may also be
impulsive, failing to consider the consequences of
their actions, and may act inappropriately in social
situations despite being aware of social rules,
which may further isolate them from their peers.
Lateralization of Executive Skills
Overall, children with bilateral lesions performed
most poorly on the TOL in comparison to those
with unilateral lesions, possibly reflecting the
greater volume of frontal lobe pathology. Chil-
dren with right-sided lesions also experienced
relatively greater problems with self-regulation,
goal setting and shifting set than those with left-
sided lesions and controls. Based on the scoring
procedure used in this study, deficits in self-
regulation and goal setting lead to a lower overall
score on the TOL, reflecting less efficient problem
solving skills. These findings, in conjunction with
normative data showing that regulation skills
develop relatively early, suggest that although
many brain regions may be involved in successful
performance on the TOL, the right pre-frontal
 PROBLEM SOLVING AND FOCAL FRONTAL LESIONS
cortex may play a particularly important role in
early development of non-verbal problem solving
skills, via it’s role in regulating behavior. Some
caution must be applied to this statement, as the
study focussed on non-verbal problem solving. It
is possible that children with left pre-frontal
lesions may demonstrate similar problems to the
right lesion group on verbally based problem
solving measures.
While children with unilateral left and unilat-
eral right pre-frontal damage were prone to mak-
ing perseverative errors on the TOL, greatest
deficits in the ability to shift set were seen in
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children with bilateral damage. The ability to shift
set requires a number of skills including memory,
in particular working memory, self-monitoring
and an ability to inhibit or relinquish a previous
response in order to develop an alternative
approach. A deficit in any of these skills may
contribute to perseverative errors, with the rela-
tive combination of these problems varying
according to the site of pathology, and resulting
in reduced performance irrespective of laterality
of damage.
Rate scores were not particularly useful in
delineating laterality groups. This is not surpris-
ing given that these scores tend to reflect informa-
tion processing and speed of response, skills
believed to be linked to the integrity of white
matter structures in the brain, and are therefore
less likely to be localized to any specific cerebral
region.
Overall, the pattern of results suggests that
while the frontal lobes play a particularly impor-
tant role in mediating executive skills in child-
hood, other brain regions are also important for
efficient function. The frontal lobes have been
suggested to be important in coordinating and
integrating information from other brain regions
and have rich connections to posterior and sub-
cortical cerebral structures (Alexander & Stuss,
2000; Eslinger & Grattan, 1993; Stuss &
Alexander, 2000; Welsh & Pennington, 1988).
Thus, damage to ‘extra-frontal’ brain regions is
likely to disrupt the transmission between poster-
ior regions and the frontal lobes, resulting in
functional problems as evidenced by difficulty
planning one’s approach to problems and identi-
fying sub-goals to achieve an overall goal. The
103
systemic nature of executive skills has also
been described in adult studies showing the
involvement of posterior cerebral regions on
some executive function tasks (Stuss et al.,
1998, 1999). This has significant implications
for children who may be vulnerable to a range
of executive impairments either as a direct con-
sequence of frontal lobe damage or secondary
to damage to regions that feed into the frontal
lobes.
The pattern of lateralization described in the
adult literature was not as clearly delineated in
children. Self-regulation, an aspect of executive
function which is relatively mature by mid-child-
hood, did show a pattern similar to that demon-
strated in adults, with the right pre-frontal region
appearing to be more important in mediating
these skills. The early development of regulation
skills is likely to reflect their importance in the
subsequent development of other aspects of
executive function, thus suggesting that the nature
and severity of executive impairments may be
greatest in children with right pre-frontal pathol-
ogy, at least when tasks do not have a significant
verbal component. Self-regulation problems are
likely to have broad implications for learning and
social interaction, interfering with a child’s capa-
city to persist with problems in order to achieve
an appropriate solution, to think about many
possible solutions to a problem before attempting
to solve the problem, or respond appropriately in
social situations.
The high rate of regulation problems in chil-
dren with bilateral pre-frontal damage suggests
that as with adults, the medial regions of the pre-
frontal cortex may also be important in mediating
these skills as bilateral damage frequently in-
volves these areas. However, as the bilateral
group also have a greater loss of frontal volume,
large group studies that incorporate children with
focal medial damage are required to investigate
this relationship between specific site of da-
mage (e.g., dorsolateral vs. medial) and the
development of executive skills in childhood.
Studies utilizing tasks that tap both verbal and
non-verbal problem solving skills will also
assist in differentiating the contribution of the
left and right pre-frontal regions in problem sol-
ving skills.
 104 RANI JACOBS & VICKI ANDERSON
ACKNOWLEDGEMENTS
This research was funded by grants from the National
Health and Medical Research Council, Australia, and
the Murdoch Childrens Research Institute, Melbourne,
Australia. We are deeply indebted to the families who
agreed to be involved in this research.
REFERENCES
Alexander, M., & Stuss, D. (2000). Disorders of
frontal lobe functioning. Seminars in Neurology,
20, 427–437.
Downloaded by [New York University] at 19:26 10 January 2015
Anderson, P. (2002). Assessment and development of
executive function (EF) during childhood. Child
Neuropsychology.
Anderson, P., Anderson, V., & Garth, J. (2001).
Assessment and development of organizational
ability: The Rey Complex Figure Organizational
Strategy Score (RCF-OSS). The Clinical Neuro-
psychologist, 5, 81–94.
Anderson, P., Anderson, V., & Lajoie, G. (1996). The
Tower of London Test: Validation and standardiza-
tion for pediatric populations. The Clinical Neu-
ropsychologist, 10, 54–65.
Anderson, P., Anderson, V., Northam, E., & Taylor,
H.G. (2001). Standardization of the Contingency
Naming Test (CNT) for school-aged children: A
measure of reactive flexibility. Clinical Neuropsy-
chological Assessment, 1, 247–273.
Anderson, S., Bechara, A., Damasio, H., Tranel, D., &
Damasio, A. (1999). Impairment of social and moral
behavior related to early damage in human pre-
frontal cortex. Nature Neuroscience, 2, 1032–1037.
Anderson, V., Anderson, P., Northam, E., Jacobs, R., &
Catroppa, C. (2001). Development of executive
functions through late childhood and adolescence in
an Australian sample. Developmental Neuropsy-
chology, 20, 385–406.
Anderson, V., & Moore, C. (1995). Age at injury as a
predictor of outcome following pediatric head
injury. Child Neuropsychology, 1, 187–202.
Blair, R.J.R., & Cipolotti, L. (2000). Impaired social
response reversal: A case of ‘‘acquired sociopathy’’.
Brain, 123, 1122–1141.
Daniel, A. (1983). Power, privilege and prestige:
Occupations in Australia. Melbourne: Longman-
Cheshire.
Denckla, M.B., & Reiss, A.L. (1997). Pre-frontal-
subcortical circuits in developmental disorders. In
N.A. Krasnegor, G.R. Lyon, & P.S. Goldman-Rakic
(Eds.), Development of the pre-frontal cortex.
Evolution, neurobiology and behavior (pp. 283–
293). Baltimore, USA: Paul H. Brookes Publishing.
Dennis, M. (1989). Language and the young damaged
brain. In T. Boll & B. Bryant (Eds.), Clinical
Neuropsychology and brain function: Research,
measurement and practice. (pp. 85–123).
Washington: American Psychological Association.
Diamond, A. (1985). Development of the ability to use
recall to guide action, as indicated by infants’
performance on AB. Child Development, 56,
868–883.
Diamond, A., & Doar, B. (1989). The performance of
human infants on a measure of frontal cortex
function, the delayed response task. Developmental
Psychobiology, 22, 271–294.
Diamond, A., & Taylor, C. (1996). Development of an
aspect of executive control: Development of the
abilities to remember what I said and to ‘‘do as I say,
not as I do’’. Developmental Psychobiology, 29,
315–334.
Dimitrov, M., Grafman, J., & Hollnagel, C. (1996). The
effects of frontal lobe damage on everyday problem
solving. Cortex, 32, 357–366.
Eslinger, P.J., & Biddle, K.R. (2000). Adolescent
neuropsychological development after early right
pre-frontal cortex damage. Developmental Neuro-
psychology, 18, 297–329.
Eslinger, P.J., Biddle, K.R., & Grattan, L.M. (1997).
Cognitive and social development in children with
pre-frontal cortex lesions. In N.A. Krasnegor, G.R.
Lyon, & P.S. Godman-Rakic (Eds.), Development of
the pre-frontal cortex: Evolution, neurobiology and
behavior (pp. 295–335). Baltimore: Paul H.
Brookes Publishing.
Eslinger, P.J., Biddle, K., Pennington, B., & Page, R.
(1999). Cognitive and behavioral development up to
4 years after early right frontal lobe lesion.
Developmental Neuropsychology, 51, 517–191.
Eslinger, P., & Grattan, L. (1993). Frontal lobe and
frontal-striatal substrates for different forms of
human cognitive flexibility. Neuropsychologia, 3,
17–28.
Espy, K. (1997). The Shape School: Assessing execu-
tive functions in pre-school children. Developmen-
tal Neuropsychology, 13, 17–28.
Espy, K.A., Kaufman, P.M., & Glisky, M.L. (2001).
New procedures to assess executive function in pre-
school children. Clinical Neuropsychologist, 15,
46–58.
Espy, K., Kaufmann, P., McDiarmid, M., & Glisky, M.
(1999). Executive functioning in pre-school chil-
dren: Performance on A-not-B and other Delayed
Response Format tasks. Brain and Cognition, 41,
178–199.
Fletcher, J.M., Brookshire, B.L., Landry, S.H., &
Bohan, T.P. (1996). Attentional skills and executive
functions in children with early hydrocephalus.
Developmental Neuropsychology, 12, 53–76.
 PROBLEM SOLVING AND FOCAL FRONTAL LESIONS
Garth, J., Anderson, V.A., & Wrennall, J. (1997).
Executive functions following moderate to severe
frontal lobe injury: Impact of injury and age at
injury. Pediatric Rehabilitation, 1, 99–108.
Gioia, G., Isquith, P., Guy, S., & Kenworthy, L. (2000).
BRIEF – Behavior Rating Inventory of Executive
Function. Professional manual. Odessa, FL: Psy-
chological Assessment Resources.
Grattan, L.M., Bloomer, R.H., Archambault, F.X., &
Eslinger, P.J. (1994). Cognitive flexibility and
empathy after early frontal lobe lesion. Neuropsy-
chiatry, Neuropsychology and Behavioral Neurol-
ogy, 7, 251–259.
Grattan, L.M., & Eslinger, P.J. (1991). Frontal lobe
damage in children and adults: A comparative
Downloaded by [New York University] at 19:26 10 January 2015
review. Developmental Neuropsychology, 7(3),
283–326.
Grattan, L.M., & Eslinger, P.J. (1992). Long-term
psychological consequences of childhood frontal
lobe lesion in patient D.T. Brain and Cognition, 20,
185–195.
Hudspeth, W., & Pribram, K. (1990). Stages of brain
and cognitive maturation. Journal of Educational
Psychology, 82, 882–884.
Huttenlocher, P.R., & Dabholkar, A.S. (1997). Devel-
opmental anatomy of the pre-frontal cortex. In N.A.
Krasnegor, G.R. Lyon, & P.S. Goldman-Rakic
(Eds.), Development of the Pre-frontal Cortex:
Evolution, Neurobiology and Behavior (pp. 69–
83). Baltimore: Paul H. Brookes Publishing.
Jacobs, R., Anderson, V., & Harvey, A.S. (2000). The
Concept Generation Test as a measure of conceptual
reasoning skills in children: Examination of devel-
opmental trends. Clinical Neuropsychological
Assessment, 2, 101–117.
Kelly, T.P. (2000). The development of executive
function in school-aged children. Clinical Neuro-
psychological Assessment, 1, 38–55.
Klenberg, L., Korkman, M., & Lahti-Nuutila, P.
(2001). Differential development of attention and
executive functions in 3- to 12-year-old Finnish
children. Developmental Neuropsychology, 20,
407–428.
Klinberg, T., Viadya, C., Gabrieli, J., Moseley, M., &
Hedehus, M. (1999). Myelination and organisation
of the frontal white matter in children: A diffusion
tensor MRI study. NeuroReport, 10, 2817–2821.
Krikorian, R., Bartok, J., & Gay, N. (1994). Tower of
London procedure: A standard method and devel-
opmental data. Journal of Clinical and Experimen-
tal Neuropsychology, 16, 840–850.
Levin, H.S., Culhane, K.A., Hartmann, J., Evankovich,
K., & Mattson, A.J. (1991). Developmental changes
in performance on tests of purported frontal lobe
functioning. Developmental Neuropsychology, 7,
377–395.
105
Levin, H., & Kraus, M.F. (1994). The frontal lobes and
traumatic brain injury. Journal of Neuropsychiatry
and Clinical Neurosciences, 6, 443–454.
Levin, H.S., Mendelsohn, D., Lily, M., Fletcher, J.,
Culhane, K., Chapman, S., Howard, H., Kusnerik,
L., Bruce, D., & Eisenberg, H. (1994). Tower of
London performance in relation to magnetic
resonance imaging following closed head injury in
children. Neuropsychology, 8, 171–179.
Levin, H.S., Song, J., Scheibel, R.S., Fletcher, J.M.,
Harward, H., Lilly, M., & Goldstein, F. (1997).
Concept formation and problem-solving fol-
lowing closed head injury in children. Journal of
International Neuropsychological Society, 3,
598–607.
Luciana, M., & Nelson, C.A. (1998). The functional
emergence of pre-frontally-guided working memory
systems in four-to eight-year-old children. Neuro-
psychologia, 36, 273–293.
Luria, A.R. (1980). Higher Cortical Functions in Man
(2nd ed.). New York: Basic Books.
Marlowe, W.B. (1992). The impact of a right pre-
frontal lesion on the developing brain. Brain and
Cognition, 20, 205–213.
Morris, R.G., Ahmed, S., Syed, G.M., & Toone, B.K.
(1993). Neural correlates of planning ability:
Frontal lobe activation during the Tower of London
Test. Neuropsychologia, 31, 1367–1378.
Owen, A.M., Downes, J.J., Sahakian, B.J., Poleky, C.E.,
& Robbins, T.W. (1990). Planning and spatial
working memory following frontal lobe lesions in
man. Neuropsychologia, 28, 1021–1034.
Pentland, L.M., Anderson, V.A., & Wrennall, J. (2000).
The implications of childhood Bacterial Meningitis
for language development. Child Neuropsychology,
6, 87–101.
Shallice, T. (1982). Specific impairments in planning.
Philosophical Transcripts of the Royal Society of
London, 298, 199–209.
Stuss, D.T. (1992). Biological and psychological
development of executive functions. Brain and
Cognition, 20, 8–23.
Stuss, D., & Alexander, M. (2000). Executive functions
and the frontal lobes: A conceptual view. Psycho-
logical Research, 63, 289–298.
Stuss, D.T., Alexander, M.P., Hamer, L., Palumbo, C.,
Dempster, R., Binns, M., Levine, B., & Izukawa, D.
(1998). The effects of focal anterior and posterior
brain lesions on verbal fluency. Journal of
the International Neuropsychological Society, 4,
265–278.
Stuss, D., & Benson, D. (1984). Neuropsychological
studies of the frontal lobes. Psychological Bulletin,
95, 3–28.
Stuss, D., & Benson, D. (1986). The frontal lobes.
New York: Ravens Press.
 106 RANI JACOBS & VICKI ANDERSON
Stuss, D.T., Toth, J.P., Franchi, D., Alexander, M.P.,
Tipper, S., & Craik, F.I.M. (1999). Dissociation of
attentional processes in patients with focal
frontal and posterior lesions. Neuropsychologia,
37, 1005–1027.
Taylor, H.G., Albo, V., Phelps, C., Sachs, B., & Bierl, P.
(1987). Post-irradiation treatment outcome in chil-
dren with acute lymphoblastic leukemia: Clarifica-
tion of risks. Journal of Pediatric Psychology, 12,
395–411.
Thatcher, R. (1997). Maturation of the human frontal
lobes: Physiological evidence for staging. Develop-
mental Neuropsychology, 7, 397–419.
Walsh, K. (1978). Neuropsychology: A clinical
approach. New York: Churchill Livingston.
Downloaded by [New York University] at 19:26 10 January 2015
Wechsler, D. (1991). Manual for the Wechsler Intelli-
gence Scale for Children-III. San Antonio, TX:
Psychological Corporation.
Welsh, M.C., & Pennington, B.F. (1988). Assessing
frontal lobe functioning in children: Views from
developmental psychology. Developmental Neuro-
psychology, 4, 199–230.
Welsh, M.C., Pennington, B., & Grossier, D. (1991). A
normative-developmental study of executive func-
tion: A window on pre-frontal function in children.
Developmental Neuropsychology, 7, 131–149.
Welsh, M.C., Pennington, B.F., Ozonoff, S., Rouse, B., &
McCabe, E.R.B. (1990). Neuropsychology of early-
treated phenylketonuria: Specific executive function
deficits. Child Development, 61, 1697–1713.