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Child Neuropsychology

A blog by Dr Jonathan Reed

  • In the past few weeks there have been a number of stories in the UK media about violent behaviour by young people such as Ben Kinsella being stabbed, the robbery, torture and murder of the two French students. In the Times last week there was a story about record numbers of children being excluded from school at a young age for aggressive behaviour. It is difficult to make sense of these stories and they obviously cause concern. I tend to think about the neuropsychological reasons why such behaviour occurs. Obviously there can be a number of explanations for violent behaviour but I thought I would mention three important developmental factors to consider.

    1. Development of Self Regulation. Through development children learn to self regulate their behaviour and emotions. There seems to be a neurological correlate to this. Primitive emotions and behaviours are driven by the brain stem, the hypothalamus and the limbic system, which is present at birth. Over time the cerebral cortex develops to regulate this primitive system. Initially this involves the ventral prefrontal cortex (VPC) and the anterior cingulate cortex (ACC). This process seems to happen in early childhood and is associated with reactive control. This is a more sub conscious control involving inhibiting impulsive emotional responses which would include aggressive outbursts. This normally develops through the experience of being parented, whereby the parent provides external regulation which becomes internalized over time by the child. Later (age 4 to 6) the Dorsal-lateral pre frontal cortex develops allowing self control. This results in more effortful conscious control over emotions and behaviour. Children learn to use internalized strategies to regulate themselves. This development process can go wrong for a variety of reasons including brain injury, developmental ADHD and also lack of adequate parenting. The result is individuals who have poor control over emotional impulses including aggressive impulses. These processes can also be temporarily affected by drugs and alcohol. To read more about this developmental process see chapter 13 self regulation and the developing brain by Rebecca Todd and Marc Lewis in our book Child Neuropsychology: Concepts, Theory, and Practice

    2. Development of Empathy- this is the drive to identify another persons emotions and thoughts and to respond to these with appropriate emotion (Davis 1994 Empathy: A Social Psychological Approach (Social Psychology)
    This seems to develop very early in most children’s lives (at about 14 months). It is different to Theory of Mind which seems to be about understanding other peoples thought’s. The classic disorder of empathy is a person described as a psychopath. They understand other peoples thoughts but feel no emotion in relation to this and as a result have nothing to stop them hurting others. Empathy seems to be related to gender in that males are more likely to show less empathy. A few children in my experience seem to lack empathy as a developmental disorder. Sometimes this seems to occur for children with traumatic childhoods with experience of early violence, but in my experience it is rare. It seems to be associated with the inferior frontal gyrus (IFG), which in turn is associated with a discrete network of brain processes involving face processing (fusiform gyrus, inferior occipital gyrus), emotion (amygdala, insula, ventral stratum and other structures) and with action perception (mirror system). To read more about this see chapter 14 social neuroscience by Simon Baron-Cohen and Bhismadev Chakrabarti in our book Child Neuropsychology: Concepts, Theory, and Practice

    3. The third important factor is social processes. Classic social psychology from H.Tajfel has shown how social identity influences group behaviour. Individual placed in a group would quickly begin to favour and maximise the benefits to their group at the detriment of other groups even when they didn’t know the other members of their group. Group identity is very powerful and may explain some of the gang behaviour in inner cities i.e. why gang members hate members of other gangs. Also there are the studies on social influence by Stanley Milgram. In this study volunteers delivered what they thought where powerful electric shocks to others when told to do so by someone in authority. This authority effect may explain the way that leaders in a group will influence other lower members . This is particularly pertinent in gangs with children- the younger children being influenced by older members. These social influences may also explain state controlled violence where leaders get subordinates to carry out violence on their behalf. It seems to me that social influences can override individual brain processes. This is an important factor in gang related violence – much of which is a problem in London UK at the moment. Children will do what older gang members want through the influence of authority and also start to hate other groups/gangs through social identity processes. There are likely to be wider social influences in society but I will leave that to the sociologists to explain.

    These factors don’t explain all the reasons for violent behaviour but they are important and may be helpful in thinking how to prevent violent behaviour developing. Certainly help with early parenting skills for parents with young children at risk would help with development of self regulation. Early identification and treatment for disorders of regulation such as ADHD and brain injury is important. Early screening for signs of empathy disorder is an option to be explored (treatment options for this are at a very early stage). Finally realizing the negative social influences of groups or gangs is important. The social influences surrounding the gang will be more powerful than the individual within the gang (and perhaps by a certain age their parents) can control. To try and prevent violence in inner cities it is necessary to disrupt the gang itself and find other ways for children to meet their social needs. In the meantime unless these issues are addressed in childhood we will continue to have news headlines about young people being killed and others being jailed for life- not a good option for either or for us.

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  • I have been working clinically with children with head injury now for over 12 years and this has allowed me to see the longitudinal effects of childhood head injury for myself. What I have noticed is that some children with what appeared to initially be mild head injury (i.e. no prolonged loss of consciousness) continued to have problems over time. I have looked at these cases in some detail and their developmental problem can’t be explained by pre morbid functioning (i.e. any difficulties before the head injury). This experience is not what the textbooks say is supposed to happen. Mild head injury is thought to be associated with better prognosis and is very rarely followed up by medical services. However, three new studies this year suggest that Mild Head Injury may result in more problems than previously though.

    A new study reported in the Journal of Head Trauma and Rehabilitation looked over time at preschool children (before the age of 5) who suffered a minor head injury. They reaseessed these children at age 14 to 16 years and found that the group who had been hospitalised with MHI were significantly more likely to show symptoms of ADHD, conduct/oppositional disorder, substance abuse and mood disorder than a control group or a non hospitalized group.

    This research group also reported in a separate journal with similar findings and the results are summarised in the excellent child psychology research blog. As Nestor Lopez-Duran the blog’s author reports ‘ the data strongly links TBI history to the presence of ADHD and conduct disorder symptoms years after the injury, and regardless of the underlying mechanism”

    These studies are also on the back of another study by Keith Yeates and his research group published in Pediatrics . They found persistent problems more than 12 months after mild head injury.

    So what are the implications of this. Firstly I think we need to look at categorisation of head injury in children. At present the main categorization tool is the Glasgow Coma Scale (GCS). This basically looks at levels of consciousness. Another important measure is Post Traumatic Amnesia -PTA (which looks at length of time where the person is confused or amnesic following the HI), however PTA in my experience is rarely assessed clinically. I think that both categorization tools are very blunt instrument. I have seen many children, for example with skull fractures who have not lost consciousness but seem to have poor outcome. The New Zealand studies above found that hospitalization was an important indicator. The Yeates study found that children with ‘mild traumatic brain injuries whose acute clinical presentation reflected more severe injury’ had a worst outcome. Therefore it seems clear that GCS is not sufficient in predicting neuropsychological outcome. All clinicians and researchers should be looking in more detail at the wider clinical picture.

    The other implication is that many of these children are discharged from hospital back to their families and schools with no follow up and no information that there may be ongoing problems. About 1 in 30 children suffer a traumatic brain injury so the problem is potentially very big and will affect all schools. It may that teachers could be the best people to identify these children providing that they have the knowledge to do so. There is a great need to educate teachers and other educational professionals about this. Most children with problems after a head injury will show a deterioration in behaviour and academic functioning in school often over time. For the teachers out there if you notice a child struggling or notice a deterioration in behaviour and performance it is worth enquiring whether the child has suffered a head injury. If this is the case it would be important to alert child health services. Also for mental health professionals it is important to always check for a history of head injury including mild head injury especially for children with ADHD or behaviour problems. I am certain that there are many children and adults out there who are not being indentified and suffering as a result.

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