728 t.SHALLICE AND P W BURGESS is strongly prompted by the examiner and what constitutes successful trial completion is clearly characterized.Rarely are patients required to organize or plan their behaviour over longer time periods,or to set priorities in the face of two or more competing tasks. Yet it is these sorts of'executive'abilities which are a large component of many everyday activities. For instance,consider a situation which gave problems for a patient who had had a right frontal glioma removed and who was Wilder Penfield's sister.In Penfield and Evans(1935)he writes:'She had planned to get a simple supper for one guest(Penfield) and four members of her family.She looked forward to it with pleasure and had the whole day for preparation.When the appointed hour arrived she was in the kitchen, the food was all there,one or two things were on the stove,but the salad was not ready. the meat had not been started and she was distressed and confused by her long continued effort alone.'If in addition to the actual preparation of the meal one also has to decide the menu,then an everyday task such as this will require certain capacities,none of which are clearly captured in the standard neuropsychological test.Planning will have to be carried out and preparatory purchases made.Different considerations- osts,tastes. available time,etc. may have to be weighed against each other.Many minor decisions mereoenmy ee over the time available. Before this second explanation can even be seriously considered,however,it is necessary to develop quantifiable analogues of the op en-ended multiple subgoal situations where this subset of frontal patients would theoretically have problems.Only then can this possibility be realistically considered.In this paper we describe 3 patients with severe problems in the organization of everyday life activities arising from head injuries primarily affecting the frontal lobes.Their performance on a large set of standard neuropsychological tests ranged from generally good with patchiness on some'frontal'tests in the worst of the 3 patients,through to almost consistently bright average to superior performance in the b-st of the 3.However,all 3 patients performed especially poorly on two tests designea w assess performance in more open-ended multiple subgoal situations.Various alternative explanations for their poor performance are then assessed. CASE HISTORIES n April 8,2016 Case I 0f23 ossa fracture.req ltipl His condition grac ally improved not able to ear later he asa a patient to Hospita for rehabilitation.He was wel and keen but uld not carry ou even the simplest activity be use of an inability to keep his mind or outside the thera mto fetch s letel was that tobe doing.Hewas unable to shop for himself because othe as methodsd ity to organ728 T. SHALLICE AND P. W. BURGESS is strongly prompted by the examiner and what constitutes successful trial completion is clearly characterized. Rarely are patients required to organize or plan their behaviour over longer time periods, or to set priorities in the face of two or more competing tasks. Yet it is these sorts of 'executive' abilities which are a large component of many everyday activities. For instance, consider a situation which gave problems for a patient who had had a right frontal glioma removed and who was Wilder Penfield's sister. In Penfield and Evans (1935) he writes: 'She had planned to get a simple supper for one guest (Penfield) and four members of her family. She looked forward to it with pleasure and had the whole day for preparation. When the appointed hour arrived she was in the kitchen, the food was all there, one or two things were on the stove, but the salad was not ready, the meat had not been started and she was distressed and confused by her long continued effort alone.' If in addition to the actual preparation of the meal one also has to decide the menu, then an everyday task such as this will require certain capacities, none of which are clearly captured in the standard neuropsychological test. Planning will have to be carried out and preparatory purchases made. Different considerations—costs, tastes, available time, etc.—may have to be weighed against each other. Many minor decisions will need to be made and typically they are undertaken in parallel with other activities. There is no clearly correct solution and many different activities may have to be scheduled over the time available. Before this second explanation can even be seriously considered, however, it is necessary to develop quantifiable analogues of the open-ended multiple subgoal situations where this subset of frontal patients would theoretically have problems. Only then can this possibility be realistically considered. In this paper we describe 3 patients with severe problems in the organization of everyday life activities arising from head injuries primarily affecting the frontal lobes. Their performance on a large set of standard neuropsychological tests ranged from generally good with patchiness on some 'frontal' tests in the worst of the 3 patients, through to almost consistently bright average to superior performance in the b"*5t of the 3. However, all 3 patients performed especially poorly on two tests designed io assess performance in more open-ended multiple subgoal situations. Various alternative explanations for their poor performance are then assessed. CASE HISTORIES Case 1 A.P., a right-handed man was involved in a road traffic accident at the age of 23 yrs, approximately 4.5 yrs before the present investigation. He sustained a serious open head injury involving an anterior fossa fracture, requiring multiple operations. His condition gradually improved, but he was not able to return successfully to his job. A CT scan that year showed evidence of extensive bifrontal damage. A year later he was admitted as a day patient to St Andrew's Hospital for rehabilitation. He was well-motivated and keen but could not carry out even the simplest activity because of an inability to keep his mind on the task in hand. For example, on one occasion he was discovered on the local golf course having originally stepped outside the therapy room to fetch some coffee. At these times he maintained that he 'completely forgot' whatever it was that he was supposed to be doing. He was unable to shop for himself because he would buy one item at a time returning to his car after his every purchase. Rehabilitation as a day patient had limited success, and after 3 months A.P. was transferred to another rehabilitation centre as an inpatient. There he was treated with behavioural methods described by Wood and Burgess (1988) with a slow but progressive improvement in his ability to organize his activities of by guest on April 8, 2016 http://brain.oxfordjournals.org/ Downloaded from