Brain Activation While Thinking About the Self From Another Person’s
Perspective After Traumatic Brain Injury in Adolescents
Mary R. Newsome, Randall S. Scheibel,
and Gerri Hanten
Baylor College of Medicine
Baylor College of Medicine and Texas Children’s Hospital
Joel L. Steinberg
The University of Texas Health Science Center at Houston
Jill V. Hunter
Baylor College of Medicine and Texas Children’s Hospital
The University of Texas Southwestern Medical Center at Dallas
Ana C. Vasquez, Xiaoqi Li, and Xiaodi Lin
Baylor College of Medicine
The University of Texas at Dallas Center for BrainHealth
Harvey S. Levin
Baylor College of Medicine
Deficits in self awareness and taking the perspective of others are often observed following traumatic brain
injury (TBI). Nine adolescents (ages 12–19 years) who had sustained moderate to severe TBI after an average
interval of 2.6 years and nine typically developing (TD) adolescents underwent functional MRI (fMRI) while
performing a perspective taking task (D’Argembeau et al., 2007). Participants made trait attributions either
from their own perspective or from that of the significant other. The groups did not differ in reaction time or
on a consistency criterion. When thinking of the self from a third-person perspective, adolescents with TBI
demonstrated greater activation in posterior brain regions implicated in social cognition, the left lingual gyrus
(BA 18) and posterior cingulate (BA 31), extending into neighboring regions not generally associated with
social cognition, that is, cuneus (BA 31) and parahippocampal gyrus, relative to TD adolescents. We postulate
that adolescents with moderate to severe TBI recruited alternative neural pathways during perspective-taking
because traumatic axonal injury disrupted their fronto-parietal networks mediating social cognition.
Keywords: traumatic brain injury, fMRI, social cognition, adolescents
Hospitalizations and deaths due to traumatic brain injury (TBI) are
more common in late adolescence than during any other time in
childhood (Langlois, Rutland-Brown, & Thomas, 2006). Despite at
least partial recovery of many cognitive abilities following moderate
to severe TBI in adolescents, a limited number of studies have shown
deficits in social–cognitive skills and psychosocial adjustment that
can persist or worsen over time (Muscara, Catroppa, Eren, & Ander-
son, 2008; Yeates et al., 2004). In comparison to typically developing
remains impaired in adolescents during the first year following mod-
erate to severe TBI (Hanten et al., 2008) with similar findings at four
years postinjury (Janusz, Kirkwood, Yeates, & Taylor, 2002; Yeates
et al., 2004). In uninjured adolescents, diminished friendships, in-
creased loneliness, and reduced quality of life are associated with
reduced social skills (Bohnert & Garber, 2007; Parker, Rubin, Erath,
Wojslawowicz, & Buskirk, 2006) and are problematic because peer
interactions and support are especially salient during adolescence.
Difficulty in processing the intentions and emotions (Dennis & Bar-
nes, 1990; Dennis, Barnes, Wilkinson, & Humphreys, 1998; Henry,
Phillips, Crawford, Ietswaart, & Summers, 2006) and taking the
perspectives (Turkstra, Dixon, & Baker, 2004) of others may contrib-
ute to the observed deficits in social problem solving and poor
psychosocial adjustment that persist after moderate to severe TBI in
adolescents (Max et al., 2006).
The abilities to reflect on knowledge about the self as distinct
from knowledge of other people and to adopt others’ perspectives
are key for effective understanding of others’ intentions, beliefs,
and feelings necessary for guiding communication and social
actions. The ability to take another person’s perspective enhances
social interaction when one mentally places oneself in another
person’s position and makes a response based from that vantage
Editor’s Note. Keith O. Yeates served as the action editor for this
Mary R. Newsome, Randall S. Scheibel, Gerri Hanten, Ana C. Vasquez,
Xiaoqi Li, Xiaodi Lin, and Harvey S. Levin, Department of Physical Medicine
and Rehabilitation, Baylor College of Medicine; Z. Chu and Jill V. Hunter,
Department of Radiology, Baylor College of Medicine and E. B. Singleton
Department of Diagnostic Imaging, Texas Children’s Hospital; Joel L. Stein-
berg, Department of Psychiatry and Behavioral Sciences, The University of
Texas Health Science Center at Houston; Hanzhang Lu, Advanced Imaging
Research Center, The University of Texas Southwestern Medical Center at
Dallas; Lori Cook, The University of Texas at Dallas Center for BrainHealth.
This research was supported by Grant NS021889. We thank the adoles-
cents and their families for their participation. The General Clinical Re-
search Center at Texas Children’s Hospital and Ben Taub General Hospital
in Houston, Children’s Medical Center, and Our Children’s House at
Baylor Medical Center in Dallas facilitated this study, and the South
Central Mental Illness Research, Education, and Clinical Center
(MIRECC) and The Michael E. DeBakey Veteran’s Affairs Medical Center
provided access to laboratory facilities used for the analysis of the image
data. We thank Keith Yeates and three anonymous reviewers for helpful
comments. Stacey Martin aided in the preparation of this article.
Correspondence concerning this article should be addressed to Mary R. New-
some, Baylor College of Medicine, Cognitive Neuroscience Laboratory, 1709
Dryden Road, Suite 725, Houston, TX 77030. E-mail: email@example.com
2010, Vol. 24, No. 2, 139–147
© 2010 American Psychological Association
point. By approximately age eight years, typically developing chil-
dren realize that their feelings or thoughts may differ from those of
others, with self-awareness continuing to develop throughout adoles-
cence (Damon & Hart, 1982). By approximately 9 years, children
appreciate that their own traits can be stable over time, as opposed
to being based on one instance of behavior (Damon & Hart, 1988).
In uninjured populations, Choudhury, Blakemore, and Charman
(2006) reported less efficient perspective taking in preadolescents
than young adolescents, with both groups being less efficient
than adults. As traumatically brain injured populations com-
monly show deficits in reflecting on their own postinjury abil-
ities and changes in behavior (e.g., Bach & David, 2006),
self-awareness during perspective taking may be particularly
affected in adolescents after TBI.
The neural underpinnings of making judgments about the self
and adopting the perspectives of others involve several brain
regions, based on results from previous fMRI studies. In an fMRI
task, Pfeifer, Lieberman, and Dapretto (2007) reported activation
in medial prefrontal cortex (MPFC) in both healthy children and
adults when retrieving knowledge about the self, including traits of
the self such as “I am popular” and “I am a good speller,”
compared to when retrieving knowledge about others, with greater
activation in children than adults, suggesting that the neural net-
works for differentiating the self from others are in place by
approximately 11 years and become more focal with age. Posterior
brain regions, precuneus and posterior cingulate, were activated
during retrieval of knowledge about another person. In healthy
adults, D’Argembeau et al. (2007) reported activation in different
locations in the MPFC when uninjured adults judged from a first or
third person perspective whether they or a significant other dis-
played various personality traits, consistent with Schmitz and
Johnson’s (2007) review of dorsal-ventral MPFC regions involve-
ment in self-appraisal. Trait judgment additionally activated pre-
cuneus, while perspective-taking also activated temporal pole,
inferior parietal lobe, and precuneus. MPFC was again implicated
when participants had to think about themselves from another
Frontal and temporal regions are the most frequently injured
regions following TBI (Graham, Ford, Adams, et al., 2002; Levin,
Mendelsohn, Lilly et al., 1997). The vulnerability of prefrontal and
anterior temporal cortex to focal lesions and disruption of the
circuitry for neural networks mediating social cognition have been
implicated in reduced awareness of one’s own mental state, im-
paired processing of the mental states of others, and inability to
make social inferences (Cicerone, Levin, Malec, Stuss, & Whyte,
2006). We were interested in brain activation in adolescents with
moderate to severe TBI when they had to evaluate themselves
from another person’s perspective, given the difficulty in self
awareness and in processing the mental states of others following
TBI (Henry et al., 2006). We chose to measure brain activation
while thinking of the self from another’s perspective with a task
that has shown reliable activation in prefrontal regions during
perspective taking. As the task used by D’Argembeau et al. (2007)
replicated areas of activation reported in several previous studies
of trait attribution (e.g., D’Argembeau et al., 2005) and perspective
taking (e.g., Ruby & Decety, 2001, 2004), suggesting reliability,
we employed a similar design in the present study, which adapted
the stimuli for TBI patients. Traumatically brain injured and typ-
ically developing (TD) participants were asked to think about
themselves or a significant other either from their own perspective
or from that of the significant other, with the trait attribution
condition included solely to provide content for the perspective
taking. This design allowed us to measure the brain activation
associated with thinking of the self from another’s perspective. We
hypothesized that disruption of circuitry involving MPFC, medial
parietal cortex, and temporal regions would result in more exten-
sive activation in adolescents with moderate to severe TBI to
compensate for reduced neural resources (Newsome et al., 2008).
Materials and Methods
Patient and Comparison Groups
Nine adolescents (mean age at scanning ? 16.8 years, standard
deviation (SD) ? 2.4, range ? 12.8–19.1 year; 6 males) who had
sustained moderate to severe TBI as defined by a postresuscitation
score of 3–12 on the Glasgow Coma Scale (GCS; Teasdale &
Jennett, 1974) or a higher score associated with brain pathology on
computed tomography were selected from a cohort of pediatric
moderate to severe TBI patients (see Table 1). Selection criteria
included severity of injury, age, availability for participation, and
ability to provide valid responses (see below) and restrain move-
ment during scanning. Patients were recruited from hospitals in
Dallas and Houston, Texas, and were studied between 1.9 years
and 3.6 years (mean 2.6 years) postinjury. For comparison, nine
TD adolescents (mean age ? 16.8 years, SD ? 1.8, range ? 13.9–
19.3 years) served as controls (see Table 2). All participants were
right-handed (Oldfield, 1971). No child was taking psychoactive
medications and none had previous neurologic or psychiatric dis-
order. All TBI patients had focal frontal lobe lesions, and five
patients had temporal lesions on structural MRI. Child assent and
parental consent were obtained, and the study was approved by the
institutional review boards at Baylor College of Medicine and The
University of Texas Southwestern Medical School at Dallas.
To understand the performance of our social cognition task in
the context of general social and cognitive functioning, additional
measures were administered outside of the scanner (see Table 2).
The Functional Assessment of Verbal Reasoning and Executive
Strategies (FAVRES; MacDonald & Johnson, 2005) measured
social problem solving in a naturalistic setting, requiring the par-
ticipant to make inferences, view the situation from another’s
perspective, eliminate irrelevant facts, choose a correct answer
from a large number of options, and formulate a rationale to defend
the option chosen. The Virtual Interpersonal Negotiations Strategy
Interview (after Yeates, Schultz, & Selman, 1990), presented so-
cial dilemmas via live dialog between computer-animated charac-
ters to which the participant answered questions linked to four
steps of a social problem-solving model (defining problem, gen-
erating solutions, evaluating outcome selecting solution). The
Gray Oral Reading Test (GORT; Weiderholt & Bryant, 2001)
provided a developmental measure of oral reading. The Keep
Track Task (Friedman et al., 2006) measured working memory
updating. The vocabulary and block design subtests of the Wech-
sler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999)
measured verbal knowledge and spatial processing.
Trait Attribution Task
Procedures for presentation of the Trait Attribution Task were
modified from D’Argembeau et al. (2007) to be readily understood
NEWSOME ET AL.
by brain injured adolescents and to present two choices between
two response buttons rather than four. The participant was asked to
make judgments about whether an adjective described himself or
herself (Target ? Self) or described a significant other (Target ?
Other) whom the participant designated prior to beginning the task.
Orthogonal to the target condition, the perspective for making
judgments varied as the participant was asked to take either his or
her own (first-person) perspective, or the perspective of the other
person (third-person). This 2 ? 2 (Target ? Perspective) design
included four conditions: Self-First Person (S1P), Other-First Per-
son (O1P), Self-Third Person (S3P), and Other-Third Person
(O3P). Across the top of a computer screen, the participant viewed
one of four incomplete statements that respectively described each
of the four conditions: “You think you are . . . ,” “You think
(significant other) is . . . ,” “(Significant other) thinks you are . . . ,”
and “(Significant other) thinks she is . . . .” After 3 s, adjectives
were presented below each statement for 4.5 s, during which time
the participant pressed a response button held in the right hand if
the adjective described the target some or all of the time or a
response button held in the left hand if the adjective did not
describe the target or did so to a limited degree. These choices,
presented in child/adolescent vernacular (Kind of/Totally and No
way/Not really) were presented at the bottom right and left sides of
the screen, respectively, throughout the task as reminders. This
was an fMRI block design, in which each block consisted of a
condition that was presented for five trials of 22.5 s per block,
followed by an interblock interval in which a fixation cross was
presented for 9 to 15 s. After all four block conditions were
Features of Nine Traumatically Brain Injured Patients
of injuryGCS score Lesion sites
TBI1 18.3316.012.32 14F Fall 15 (?complications) R OrbG, B IFG, R MFG, R MedFG,
B SFG, R Temp Pole
L GyrRect, B OrbG, B IFG, L MFG,
B Temp Pole, L Thal
B OrbG, R IFG, R MFG, L Cblm
L OrbG, R IFG, R MFG, B SFG,
L MidCC, L Cblm, L OccLobe
R MFG, L MedFG, B SFG, B MTG,
B Temp Pole, L Operculum
L OrbG, B ITG
L MFG, L SFG
L IFG, B MFG, R SFG, B SPC, R Thal,
B OrbG, L MFG, B SFG, L STG, R MTG,
R ITG, R Temp Pole, B Ant Temp Pole,
Midline Ant CC
TBI2 16.03 13.072.96 12MFall3
TBI5 18.66 16.671.99 16MMVA 10
TBI914.62 12.711.92 16F Fall7
Note. Ant ? Anterior; B ? Bilateral; L ? Left; Mid ? Middle; R ? Right; Cblm ? Cerebellum; GyrRect ? Gyrus Rectus; IFG ? Inferior Frontal Gyrus;
ITG ? Inferior Temporal Gyrus; MedFG ? Medial Frontal Gyrus; CC ? Corpus Callosum; MFG ? Middle Frontal Gyrus; OccLobe ? Occipital Lobe;
OrbG ? Orbital Gyrus; SFG ? Superior Frontal Gyrus; Thal ? Thalamus. ATV ? All-Terrain Vehicle accident; MVA ? Motor Vehicle Accident.
Demographic and Outcome Data (Means and Standard Deviations) for TBI and TD Groups?
Group AgeGenderEthnicitySCIMother’s education
TBI16.8 years (2.4) range ? 12.8–19.1 4 Female1 African
?0.49 (1.06)12.00 years (3.43)
TD16.8 years (1.8) range ? 13.9–19.34 Female 0.17 (0.68)12.56 years (2.35)
95.0 (12.9) range ? 79–113
109.3 (11.3) range ? 96–129
Note. GORT ? Gray Oral Reading Test; FAVRES ? Functional Assessment of Verbal Reasoning and Executive Strategies; INS ? Interpersonal
Negotiations Strategy Interview; SCI ? Socioeconomic Composite Index; WASI ? Wechsler Abbreviated Scale of Intelligence.
?Data were not available for one TBI participant for the WASI, two TBI and two TD participants for the Keep Track Task, one TBI and two TD participants
for the GORT, and two TD participants for the virtual INS task.
?p ? .05.
??p ? .01.
SPECIAL SECTION: PERSPECTIVE TAKING IN ADOLESCENTS FOLLOWING TBI
presented, they were repeated during each run for a total of eight
blocks, or 40 trials, per run. Each run duration was 5 minutes and
3 s. There were four runs with 1 minute of rest between runs. Order
of conditions was counterbalanced between runs and between
subjects. Forty adjectives were selected from age of acquisition
and familiarity normative data (Wilson, 1988) to be on a third
to fourth grade reading level and to be high in familiarity, with
a mean familiarity rating of 552 (normative data M ? 488,
range 100–700). E-Prime (www.pstnet.com/eprime) was used
to present stimuli and collect responses.
Prescan training with a practice version of the task that
utilized words different from those presented in the scanner was
provided. Before scanning, the participant was also asked to
define the words that were to be presented during scanning. Any
errors in definition were corrected to ensure that all participants
understood the meanings of the adjectives to be presented
during the task. To validate performance during the scan, par-
ticipants were asked after the fMRI session to identify adjec-
tives from the task that have opposite meanings by drawing
lines between adjectives presented in two columns. Consistency
scores were calculated for each participant by comparing the
opposite words judgments to how the same words were re-
sponded to during the scan. For example, if after a scan a
participant indicated that “interesting” and “boring” are oppo-
sites, then during the scan (within a condition), one of the words
should have received a left button press, and the other word
should have received a right button press if the participant was
consistent. Agreement of 60% or higher on all four conditions
for eight word pairs was taken to indicate meaningful perfor-
mance in the scanner, and all participants met this criterion.
MRI Scanning Procedures
Whole brain imaging data were acquired using a multichan-
nel SENSE headcoil on identical 3.0 T Philips Achieva scanners
in Houston and in Dallas. Blood oxygen level dependent
(BOLD) T2?weighted single-shot gradient-echo echoplanar
images (EPI) were acquired in 32 axial slices of 3.75 mm
thickness with an 1.0 mm gap, using a 240 mm ? 240 mm field
of view (FOV), 64 ? 64 matrix, and a TR of 1700 ms, TE 30
ms, and 73 degree flip angle, and SENSE factor 2.0. After the
functional scans, a set of high-resolution T1-weighted 3D-
Turbo Field Echo (TFE) anatomical images was acquired in 132
axial slices of 1.0 mm thickness (no gap) with 240 mm ? 240
mm FOV, 256 ? 256 matrix, TR of 9.9 ms, TE of 4.6 ms,
and 8.0 degree flip angle, and SENSE factor 1.2. These param-
eters produced 1 mm isotropic voxels for the anatomical data.
Additional anatomical series to assess neuropathology included
T2-weighted gradient echo imaging, T2-weighted FLAIR, and
T2-weighted GRASE. Similar ranges of values for Weisskoff
stability measurements (Weisskoff, 1996; minimum 1/SNR in-
dex, peak-to-peak and RMS stability) taken on the day of scan
indicated stability of both scanners over time.
Functional MRI data were processed and analyzed using
Statistical Parametric Mapping software (Friston et al., 1995;
SPM2, Wellcome Department of Cognitive Neurology, London,
U.K.) implemented in Matlab (Mathworks Inc., Sherborn, MA,
U.S.A.). Spikes greater than 2.5 standard deviations above the
mean voxel intensity across time series were replaced with the
median voxel intensity for that time series using Analysis of
Functional Neuroimages software (AFNI; Cox, 1996). There-
after, all processing and analyses were completed in SPM2.
After slice-timing correction, the fMRI time series was re-
aligned and corrected for head motion and susceptibility-by-
movement interactions. Series with head motion component on
any axis greater than 2.0 mm translational or 2.0 degrees
rotational were eliminated from analysis. The high-resolution
anatomical scan was coregistered to the fMRI images and was
transformed to the stereotactic coordinates of the Montreal
Neurologic Institute using the SPM2 Normalize procedure. The
same transformation was applied to the functional images,
which were then resliced to 2 mm isotropic voxels and spatially
smoothed with a 6 mm isotropic full width at half maximum
Gaussian filter. The cluster-defining (height) threshold was
voxel-level p ? .05, uncorrected. All reported clusters were
statistically significant (p ? .05) at the cluster level of infer-
ence, using Random Field Theory correction for multiple com-
parisons over the whole brain volume. When cluster sizes
exceeded 2000 voxels, a more stringent voxel-level (height)
threshold was used to reduce cluster sizes to 2000 voxels or
less. Significant coordinates were converted to the coordinates of
the Talairach Atlas (Talairach & Tournoux, 1988), using the
mni2tal script (Brett, 1999). The Talairach Daemon (Lancaster et
al., 2000) and the Talairach Atlas were then used to determine the
anatomical locations and approximate Brodmann’s Areas (BA;
when available) of the Talairach coordinates.
Trait Attribution Performance
Table 3 reports mean reaction time (ms) by group for each
condition. Because there are no correct or incorrect answers for the
trait attribution task, accuracy analyses are not reported. Average
consistency scores were similar between groups (TD M ? 0.80,
SD ? 0.10; TBI M ? 0.78, SD ? 0.15), t(16) ? ?0.36, p ? .72,
Cohen’s d ? 0.174. Significant main effects of response time (RT)
for Target, F(1, 16) ? 8.14, p ? .01, Cohen’s f ? 0.71, and
Perspective, F(1, 16) ? 5.79, p ? .03, Cohen’s f ? 0.60, indicate
that judgments about the Self were made more quickly than
judgments about the Other (1360 msec vs. 1434 msec) and that
judgments from the First Person perspective were made more
quickly than those from a Third Person perspective (1373 msec vs.
1431 msec), replicating D’Argembeau et al. (2007). There were no
significant interactions of group with Target, F(1, 16) ? 2.02, p ?
.17, Cohen’s f ? 0.36; Perspective, F(1, 16) ? 0.01, p ? .93,
Cohen’s f ? 0.025; or Target and Perspective, F(1, 16) ? 0.07,
p ? .80, Cohen’s f ? 0.07.
Trait Attribution Related Brain Activation
Table 4 presents the coordinates, cluster sizes, and probability
levels of significant clusters of activation observed for between-
Main effect of target (Self vs. Other).
icant between groups differences for the main effect of target.
There were no signif-
NEWSOME ET AL.
Main effect of perspective (First-Person vs. Third-Person).
There were no significant between groups differences for the main
effect of perspective.
Interaction of target and perspective (S3P – S1P) – (O3P –
Figure 1 is an SPM activation map of between group
differences for the interaction of Target (Self vs. Other) and
Perspective (First-Person vs. Third-Person) when thinking about
the self from a third person perspective. There were no areas where
the interaction of target and perspective was significantly greater
in the TD group, relative to the TBI group. However, there was one
large cluster in which the interaction was significantly greater in
the TBI patients than in the TD adolescents (mean difference
across all voxels within the cluster ? 2.3% of whole brain BOLD
signal; 90% confidence interval ? 1.2–3.4), and this cluster in-
cluded the left posterior cingulate (Talairach x y z [mm] ? ?16
?52 6 BA 30; ?14 ?64 14 BA 31), cuneus (?8 ?60 8 BA 31),
lingual gyrus (?14 ?52 4 BA 18; ?12 ?52 0 BA 19), parahip-
pocampal gyrus (?16 ?48 4), inferior parietal lobule white matter
(?36 ?44 26), supramarginal gyrus white matter (?34 ?48 26),
posterior cingulate white matter (?14 ?48 18); bilateral thalamus
(?4 ?18 4; 6 ?20 4), brainstem (?8 ?24 ?26; 2 ?38 ?26), and
cerebellum (?10 ?52 ?42; 8 ?64 ?40).
To investigate the effects of moderate to severe TBI on neural
mechanisms mediating social cognition in youths, we performed
fMRI during a trait-attribution and perspective-taking task
(D’Argembeau et al., 2007) in adolescents an average of 2.6 years
postinjury and in TD adolescents. With traumatic axonal injury
(TAI) putatively disrupting interconnectivity of prefrontal subre-
gions involved in trait attribution and other social cognition tasks,
including medial prefrontal cortex (MPFC), anterior cingulate
cortex (ACC), and their connections to posterior cortical regions
(e.g., medial parietal and temporal cortex), we anticipated that
adolescents with TBI would exhibit more extensive activation to
compensate for fewer available resources.
We were interested in brain activation in adolescents with
moderate to severe TBI when they had to evaluate themselves
from another person’s perspective, given difficulty in self aware-
ness and processing mental states of others following TBI (Henry
et al., 2006). Measurement of how consistently the participants
defined adjectives during and after the task indicated good consis-
tency in both groups, suggesting that activation in the TBI group
reflected processes they were able to perform (Price & Friston,
1999). We did not find group differences in frontal regions. As
compared with TD adolescents, attribution of traits to the self
while taking a third-person perspective in adolescents with mod-
erate to severe TBI resulted in widespread brain activation in
posterior and subcortical regions. The greater activation found in
left lingual gyrus (BA 18), which is reported to be activated during
perspective-taking in adults (D’Argembeau et al., 2007), and in left
posterior cingulate (BA 31), which is reported to be activated in
Talairach Coordinates [X Y Z] mm, Cluster Sizes, and Probability Levels of Significant Clusters of Activation Observed for Between-
Groups Differences for the Target ? Perspective Interaction When Judgments About the Self Were Made From a Third Person
Perspective ((S3P – S1P) – (O3P – O1P)), Local Maxima Greater Than 16 mm Apart
Number of voxels
Number of voxels
TD ? TBITBI ? TD
L Cblm (Tonsil)
L S-L Extra-nuclear WM
R Cblm (Uvula)
L Cblm (Culmen)
L S-L Extra-nuclear WM
R Cblm (Inferior Semi-Lunar Lobule)
L Post Cing WM
(resels). NS ? Not statistically significant; L ? Left; R ? Right; S-L ? Sub-lobar; WM ? White matter; Cblm ? Cerebellum; Post Cing ? Posterior
Height threshold p ? .037 (T ? 1.90), smoothness FWHM ? 4.7 5.0 5.1 [voxels], search volume ? 164642 voxels ? 1262.1 resolution elements
Reaction Times (Msec) by Condition for the Typically Developing (TD) and Moderate to Severe
95% CI for group mean
Note. SD ? Standard Deviation; CI ? Confidence Interval.
SPECIAL SECTION: PERSPECTIVE TAKING IN ADOLESCENTS FOLLOWING TBI
children while attributing traits to other people (Pfeifer et al.,
2007), may indicate greater reliance on nonfrontal regions when
frontal areas and their connections have been disrupted (Price &
Friston, 1999). Neighboring regions not generally associated with
social cognition (i.e., parahippocampal gyrus and cuneus; BA 31)
were also recruited more by TBI adolescents, suggesting reorga-
nization. The cuneus has been suggested to provide compensatory
activation in aging and patient populations during different cogni-
tive tasks, such as category monitoring (Le ´onard, de Partz,
Grandin, & Pillon, 2009), recognition memory (Eliassen, Holland,
& Szaflarski, 2008; Scarmeas et al., 2003), and response inhibition
(Haldane, Cunningham, Androutsos, & Frangou, 2008). Addition-
ally, activation in the cuneus has been reported in several studies
of cognition when it had not been hypothesized, suggesting the
cuneus may have nonspecific effects. For example, in addition to
expected frontal and temporal areas, activation in the cuneus was
seen in a sentence completion task (Allen et al., 2008). Greater
activation in the parahippocampal gyrus may also be a result of
less efficient access to long term memory representations when
judging whether the other person has experienced a particular trait
in the subject. As TAI alters projections from the frontal lobes
(Wilde et al., 2006), increased thalamic activation in the TBI group
may indicate reliance on a more intact area in the fronto-thalamic
Given damage to frontal lobes following TBI, one might expect
reduced frontal activation in the TBI group to be evident in a group
difference. BOLD signal in damaged areas has frequently been
associated with increased activation (Turner & Levine, 2008),
possibly due to compensation from other frontal areas; in such
situations, any group effects where increased activation is nor-
mally expected in uninjured populations would be cancelled out.
Further, it is possible that frontal activation might be reduced in
some subprocesses of thinking of the self from another person’s
perspective, but not in others, as seen in working memory with
TBI patients (Newsome et al., 2008). Future studies delineating
such subprocesses and associated activation with event-related
fMRI are needed to further characterize this possibility.
Our study did not reveal group differences in the activation main
effects of target type or perspective. The fact that the TBI group
showed more activation only for the interaction, that is, when they
considered themselves from another person’s perspective, may
reflect that this type of social thought is more demanding than the
other conditions examined in the study. Effects of TBI are often
observed during performance of more complex tasks (Gronwall &
Wrightson, 1981), and thinking of the self from another’s perspec-
tive may be more challenging than thinking of the self from one’s
own perspective (Dennis, Purvis, Barnes, Wilkinson, & Winner,
2001) or involve integration between more areas that had sustained
damage. The TBI group performed worse than the TD group on all
cognitive and social–cognitive measures, including reading
(GORT), working memory updating (Keep Track Task; Friedman
et al., 2006), everyday living executive function skills (FAVRES),
and judging social situations while holding information in working
memory (INS; Yeates et al., 1990). It is possible that the increased
activation observed when patients in the TBI group thought of
themselves from a third-person perspective is related to impaired
cognition. Impaired self-awareness and theory of mind have been
linked to deficits in executive functions in patients with TBI
(Bibby & McDonald, 2005; Bivona et al., 2008; Henry et al.,
2006). In severe TBI adult patients an average of seven years
postinjury, Bibby and McDonald (2005) reported that impairment
in thinking about what one fictional person thinks about another
person (second-order TOM task) could be accounted for by deficits
in inference making and executive function. However, deficits in a
task that involved thinking about one person only were attributed
to apparent deficits in TOM. Our task of thinking of the self from
another’s perspective is not the same as a first or second-order task
as it involves potentially overriding information that may be ac-
cessed about the self. However, it is similar, and because it may
potentially involve additional retrieval and inhibitory processing,
additional executive function may be implicated.
Relative to uninjured matched controls, TBI patients with poor
self-evaluative accuracy on sociocognitive functioning demon-
strated increased activation in some areas involved in social cog-
nition (anterior cingulate, precuneus, and temporal pole), when
judging personality traits about themselves (Schmitz, Rowley,
Karhara, & Johnson, 2006), suggesting increased activation in
areas potentially involved in the inaccurate self-assessment outside
of the scanner. Although similar to our task, this task did not
involve thinking from a third-person perspective. However, it is
interesting that greater activation in a frontal area was observed.
One potential explanation is that our sample size was smaller
(n ? 9 vs. n ? 20); however, there was no hint of a group
difference in frontal activation in our results. The patients of
Schmitz et al. were an average of 81 days postinjury, while ours
Perspective interaction when judgments about the self were made from a third person perspective, (S3P ?
S1P) ? (O3P ? O1P). TD ? TBI was nonsignificant. The right hemisphere of the brain is displayed on the right
side of the figure. Regions that showed significant t test results are displayed in black.
Maximum intensity projection map of the between group contrast, TBI ? TD, for the Target ?
NEWSOME ET AL.
were an average of 2.6 years, and, potentially, differences in
activation may in part be due to neural recruitment that may not yet
Milders et al. (2006) found impairment in a TBI group both one
month and one year after injury in two theory of mind (TOM)
tasks, the Faux Pas Task (Stone et al., 1998), in which subjects
identify inappropriate actions in social settings, and the Cartoon
Test (Happe ´ et al., 1999), which involved the comprehension of
jokes involving the false beliefs of others. When relating perfor-
mance on these tasks to external measures of social functioning
(Milders et al., 2008), they found no relationship, questioning
whether the link between TOM and behavior exists. Taking an-
other person’s perspective did not reveal a significant group dif-
ference in activation in the present study; behavior that neurally
distinguished groups involved relating another person’s perspec-
tive to themselves. Tasks in the Milders’ studies did not include a
condition in which subjects relate social mistakes or false beliefs to
themselves; possibly a TOM task which incorporates subjects into
settings personalized to them may find a relationship between
TOM and behavior.
It is possible that the IQ of the TBI group (M ? 95; 37th
percentile of the WASI) may be unexpectedly high, which could
account for the lack of group differences. Low IQ is associated
with severe TBI in very young children (mean age 5 years,
Anderson, Morse, Catroppa, Haritou, & Rosenfeld, 2004), al-
though children injured at older ages (8–12 years, Anderson,
Catroppa, Morse, Haritou, & Rosenfeld, 2000) show better intel-
lectual recovery. The TBI patients in our study sustained their
injuries during early adolescence (mean age 14.2 years) and had IQ
scores consistent with that of severe TBI patients reported in
Anderson et al., (2000).
There are several limitations in this study. Due to small sample
sizes, results should be considered tentative and pending confir-
mation. Although the groups were chosen to be similar in socio-
economic status, the TD group’s WASI score was higher than that
of the TBI group, which could have contributed to differences in
activation (Perfetti et al., 2009). Larger studies which manipulate
IQ would elucidate the role of intelligence in social perspective
taking. Potential confounds in this study include poor comprehen-
sion of the adjectives by adolescents with TBI. However, consis-
tency rates did not differ between the groups, suggesting that the
adolescents with TBI accurately processed the meaning of the
adjectives presented during the task. While our subjects appeared
to have been able to complete the task successfully, TBI patients
who have stronger impairments in thinking of the self from another
perspective may be less adept in recruiting additional brain re-
gions. Future studies in which patients receive training in perspec-
tive taking (Grizenko et al., 2000) and demonstrate improved
ability may also show increased activation in posterior brain re-
gions. In addition, while the TBI adolescents in our sample may
have been able to take another person’s perspective about them-
selves upon demand, an open question is how adeptly they do so
in naturalistic settings, which often have a strong visual component
not present in our task. In both types of real-life tasks administered
outside the scanner (FAVRES and the virtual INS), the children
with TBI performed less well than typically developing controls.
Although we might surmise the pattern of activation may show
differences in relation to performance on these tasks, sample size
prohibits meaningful correlational analyses. Future studies pre-
senting simulations of social interactions in a virtual reality envi-
ronment during fMRI would further elucidate behavioral and neu-
ral alterations during perspective taking in patients following TBI.
Patients with TBI frequently demonstrate impairments in self
awareness and in taking the perspectives of others. Because of the
roles of frontal, parietal, and temporal regions in perspective-
taking and trait attribution (D’Argembeau, et al., 2007; Pfeifer et
al., 2007), and given alterations in fronto-parietal and fronto-
temporal neural networks (Newsome et al., 2008; Wilde et al.,
2005), and given reduced social problem solving skills (Hanten et
al., 2008; Parker et al., 2006; Yeates et al., 2004) in adolescents
with moderate to severe TBI, we predicted that their brain activa-
tion would be altered during a social perspective task. Brain
activation when taking another person’s perspective to think about
the self was altered in adolescents after an average interval of 2.6
years post moderate to severe TBI. Relative to typically develop-
ing, uninjured peers, adolescents with TBI had greater activation in
left lingual gyrus (BA 18), a posterior brain region associated with
perspective-taking (D’Argembeau et al., 2007), and left posterior
cingulate (BA 31), a region associated with attribution of traits to
another person, (Pfeifer et al., 2007), as well as in subcortical
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Received October 10, 2008
Revision received June 19, 2009
Accepted June 22, 2009 ?
Correction to Van Braeckel et al. (2010)
On the first page of the article “Difference Rather Than Delay in Development of Elementary
Visuomotor Processes in Children Born Preterm Without Cerebral Palsy: A Quasi-Longitudinal
Study,” by Koenraad Van Braeckel, Phillipa R. Butcher, Reint H. Geuze, Marijtje A. J. van Duijn,
A. F. Bos, and Anke Bouma (Neuropsychology, 2010, Vol. 24, No. 1, pp. 90–100), the names of
authors Marijtje A. J. van Duijn and Anke Bouma were misspelled as Maritje A. J. van Dujin and
Anke Bourma, respectively. The online versions of this article have been corrected.
SPECIAL SECTION: PERSPECTIVE TAKING IN ADOLESCENTS FOLLOWING TBI