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Frontal lobe paradox and the Mental Capacity Act

Fri 04 May 2018

A new report from neuropsychologists aims to raise awareness of the 'frontal lobe paradox' in the context of mental capacity assessments.

The frontal lobe paradox, first coined in 1985, refers to patients with frontal lobe injury who have impairments in everyday life, such as problems with decision-making, multitasking and goal setting, yet continue to perform well in interview and test settings for a number of reasons, such as preserved language/communication skills or lack of insight. 

Assessors of such tests can therefore wrongly deem the frontal lobe injury survivor to be capable of a range of skills that do not otherwise transfer to everyday life, resulting in an inaccurate assessment with potentially serious consequences, especially where a survivor may have reduced or lack of capacity. 

In this newly published article, the authors discuss the frontal lobe paradox in the context of the Mental Capacity Act (2005), whereby capacity assessment interviews may fail to properly identify a survivor's capacity, potentially putting the survivor at risk. The authors point out the importance of addressing this area, as assessments are commonly conducted by professionals who, although experts in their own fields, do not have a psychology/brain injury background. 

The authors urge assessors to be cautious when interpreting mental capacity interview responses, and to seek information from relatives and significant others in the survivor's life about their actual behaviour in day-to-day life. Other recommendations include implementation of the Brain Injury Needs Indicator and collaborative working with and across social worker groups such as the British Association of Social Workers (BASW) and Brain Injury Social Work Group (BISWG).

Primary author of the article Dr Melanie George, Consultant Clinical Neuropsychologist at Kent Clinical Neuropsychology Service, says: "Dr Sam Gilbert (Institute of Cognitive Neuroscience) and I are very grateful to Headway for highlighting this issue. As Headway's article outlines, the 'frontal lobe paradox' and executive deficits in general are often misunderstood by others (including professionals) who do not have specialist expertise in brain injury. When this occurs in the context of a Mental Capacity Act (2005) interview, it can inadvertently place survivors at risk."

Read the full article on

A shorter version of the article is available on the online newspaper The Conversation's website.

Reference: George, M.S., & Gilbert, S. (2018). Mental Capacity Act (2005) assessments: why everyone needs to know about the frontal lobe paradox. The Neuropsychologist, 5, 59 - 66. 


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