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Child Neuropsychology

A blog by Dr Jonathan Reed

  • I want to discuss an important new book for understanding how the brain works, which I have just read and is called Subcortical Structures and Cognition: Implications for Neuropsychological Assessment by Leonard Koziol and Deborah Budding.  Our current understanding of how the brain works using Neuropsychology has traditionally focused on the cortex part of the brain – frontal, temporal, parietal and occipital lobes and has looked at what happens psychologically when there is damage to these particular areas.  From this we understand perception, memory, language etc pretty well.  However we have tended to ignore subcortical brain areas such as the basal ganglia and cerebellum and have considered these areas as being responsible mainly for motor co-ordination.   This new book by Koziol and Budding challenges this view and presents a view of sub cortical structures being central to the way the brain works.  It is a detailed book with many arguments (a summary can be seen on the website here) and needs to be read carefully, but some of the important points for me were:

    1.  The brain responds to the environment in two key ways.  Firstly most of the time it responds in an automatic way (subconscious way using procedural memory) which requires little thought, is fast and is adaptive.  You don’t need to work out how to respond to most everyday occurrences you just do it.  However, when a new situation arises, maybe a threat, maybe something you need to learn, the front part of the brain takes control and thinks about how to respond (i.e. executive function).  Both systems operate in tandem and are connected by the basal ganglia.  The default setting for the brain, however, is to make unfamiliar familiar.  This is more efficient.  Hence there is a drive to turn new information into automatic memory.

    2. Koziol and Budding argue that the basal ganglia is key in determining this process i.e. linking controlled and automatic responses.   It does this by being part of a feedback loop connecting the cortex to the limbic system (thalamus) and acting as a gate between the two. Basically the cortex is stimulated by sensory input and the sub cortex inhibits responses by deciding what information is returned to the cortex.

    3. The other main sub cortical area the cerebellum works to further fine tune responses using a mix of excitation and inhibition.

    4. The book details how and why such a system would have evolved.  This is often missing in neuropsychology accounts.  The book offers a plausible explanation of what any organism needs to function and how brains have evolved to meet these needs.  The key purpose of an organism is to survive.  In order to survive an organism needs to recognise objects, locate objects and detect movement (all cortex functions) and then to know what to do, how to do it and when to act (all mediated by the subcortex).  Koziol and Budding compare the subcortical structures in vertebrates, primates and humans to illustrate this point.

    5. The  basal ganglia acts as a gate to switch responses on and off, which is the key to regulation.  Knowing when to start a behaviour (initiation) and when to decease from a behaviour (inhibition) is key to how we function (and yet is rarely explored). The cerebellum further fine tunes this process.

    6.  Traditionally the sub cortical structures have been though of as mainly involved in motor responses.  However one of the many interesting ideas in the book is that  the same structures may have a similar  function for emotion, behaviour and cognition.  This would make sense from an evolution and developmental point of view.  Undertaking complicated motor sequences such as kicking a ball i.e. judging when to move and adjust can be similar to knowing how to control anger, social response or thoughts.

    7. Why this is important in my opinion is that it starts to offer explanations for disorders of regulation, which are so common in children, e.g. ADHD, TBI, OCD, emotional disorder, motor co-ordination and speech disorders.  Neuropsychology does not provide very good explanations for these disorders at present and yet they are the most common difficulties encountered especially with children.  The key issues in these disorders is regulating and adjusting responses to the environment.

    8.  Another reason the book is important is that it gets away from the view that we need to focus on a single brain area and it’s function and looks instead about how different brain areas act in circuits in relation to one another.  The circuits work by involving different brain areas in feedback loops using excitation and inhibition to regulate the system.   This makes sense biologically, developmentally and from an evolutionary point of view.

    Therefore I would highly recommend this book to anyone interested in neuropsychology and how the brain works.  It challenges existing thinking.  It is a specialist book but is well written and informative.   There are detailed sections on neuropsychological assessment for those interested, although these sections are in my opinion of more limited interest because most tests don’t assess subcortical functions that well.  The important thing the book does for me as well as explaining sub cortical anatomy and function is to start to provide a more coherent framework for understand brain regulation, which I think is fundamental for understanding child neuropsychology.   I think that ultimately this understanding will help us better assess and help children with brain dysfunction and particularly regulation difficulties.

  • I work a lot with children and young people who have suffered a brain injury.  It is one of the most devastating conditions.  Brain injury often results in changes to personality, to memory, to social ability and sometime to physical disability.  It often occurs to normally developing individuals.  Because brain cells do not repair themselves there is no cure and it is a case of living with and adapting to the condition.  I have noticed however that there is one area of functioning that seems to be preserved and often actually enhanced following a brain injury and that is creativity.  Although the brain can not repair itself new neural pathways can develop which I believe can allow new talents to emerge or create a different way of seeing the world.  I have worked with several young people who have gone on to A level and university to do photography or Art despite their disability.   One person I know, Spencer Aston is working as a freelance photographer. He takes photos from a unique perspective in my opinion.  I have come across other individuals who have become artists following a brain injury- see this site for examples.   Also in terms of music there it the amazing Melody Gardot who makes beautiful music  despite or perhaps as a result of suffering a severe brain injury as a teenager.  Other singers I really like and who have suffered severe brain injury and recovered to do some great work include Marc Almond (details of injury here) and Edwin Collins (details of recovery here).   All these people are inspiring.  The message is that while having a severe brain injury can be devastating there is hope and possibly new futures.  I would encourage young people with brain injury or their parents to explore different potential creative opportunities.  I would also love to hear of other stories of people with a brain injury who have developed creatively following their injury.

  • Everyone is a psychologist.  By that I mean that everyone tries to work out why people behave the way they do.  This is an inbuilt social drive that helps us to interact normally.  It is based on theory of mind which is about understanding other people’s mental states and intentions.  Lack of theory of mind is the key disability in Autism.   In my work I find that most people have a strong belief about why someone is behaving the way that they do (although in my work I think that it is often a wrong belief).

    I think we base our understanding on why others behave  the way that they do on what we think about ourselves and our cultural norms.  This is essential to group cohesion.  No one can truly know how another person is thinking but we automatically make an educated guess.  The difficulty comes when normal behaviour breaks down.   We know that in some individuals behaviour and personality changes dramatically with acquired frontal brain injury- see the case of Phineas Gage.   I see similar difficulties in my work with children with head injury, neurodevelopmental disorders and sometimes those with a history of abuse and neglect.  With these children I see very challenging behaviour that doesn’t respond to normal parenting or behaviour modification.  I will write about why this is in more detail at a later date (to with difficulties in development of frontal brain areas). In general though behavioural control is more complicated than it seems.

    I was particularly struck by this difficulty in understanding why some people behave the way they do when reading a research paper looking at the most extreme of behaviours, murder.  Why does someone comit murder?  The paper looks at 77 inmates or defendants charged with murder in the US and referred for neuropsychological assessment.  The sample is self selected because they were referred for clinical assessment rather than randomly chosen for research.  However, the sample characteristics are striking.  Some of the key facts are:

    • 49.4% had a developmental disorder in childhood.  (36.4% had ADHD)
    • 87% had a brain injury (self reported and 10% had documented evidence)
    • 85% had a history of substance abuse.
    • 45% had a psychiatric history
    • 35% had a history of abuse in childhood.

    From the neuropsychological assessment the mean IQ was 84 , which is a standard deviation below the norm.  Mean working memory was 87 which is low average.  The mean logical memory score was 68 which is very low indicating significant memory problems.  The sample also had a high rate of assessed executive function difficulty (executive function is the cognitive ability associated with the front area of the brain).

    You will need to read the paper to find all the details because there are so many interesting factors in the sample.   However, taken together the majority of the sample had some form of brain damage/ disorder or abuse stemming from childhood (which as I have discussed here often leads to developmental brain damage).   Exactly what is going on in their heads can never be know and the neuropsychological factors don’t explain the trigger or situation in which the murder took place.  However, it is clear that there are neurological and neurodevelopmental factors going on here, and given what we know about these in childhood and from case studies, it is unclear how much control such individuals have in a given situation.  I don’t offer this as an excuse to let people off and certainly I think many of these people are extremely dangerous.  But the results may shake our assumptions  (based on our own theory of mind) as to why people behave the way that they do.  Consider this next time you hear about a murder in the News.  Also the results may point to the importance of prevention in terms of early identification and treatment of childhood neurological problems and childhood abuse.  So many of these people’s problems seem to stem from experiences and events in their childhoods.

  • I have just been reading a very good new book on neuropsychological rehabilitation by Barbara Wilson and colleagues Neuropsychological Rehabilitation: Theory, Models, Therapy and Outcome
    I also heard her give an interesting talk this week on memory rehabilitation. In the book and the talk she discuses proven techniques to help with memory. These are designed for individual with memory problems but they also work really well for anyone wanting to learn and remember information. The methods are backed with experimental evidence. They will work for adults as well as children.

    1. Encourage associations or links when learning- the best way is to use visual or spatial images and associate these with what you are trying to learn. Some of the best learners use an internal picture of a house or journey and imagine what they have to remember placed in different places in the house. This helps with retrieval of information from memory.

    2. Spaced retrieval i.e. gradually extend the recall time. With this you need to initially recall what you have learnt straight away and then over time extend the time gap between learning and retrieval. For example look at a fact to remember, cover and recall immediately, then look again and wait for 15 seconds and try and recall, then 30 seconds and then 1 min etc. This leads to information stored more deeply in memory.

    3. Pace your learning and reduce the amount you are trying to learn at any one time. Learn a few bits of information, have a break and learn a few more. Trying to do too much at once doesn’t work.

    4. Organize the information e.g. if learning a list, group the items together according to meaning. For example for a shopping list put the items of fruit together, drink together etc. If learning facts group together for meaning. The brain likes to store information semantically i.e. according to categories.

    5. Error free learning- this is used to teach others. If the person doesn’t know the answer to the question immediately provide the answer and ask them to repeat. Continue to support until the answer is recalled automatically without any errors. This works for adults with memory problems including those with Alzheimer’s and also for children with learning difficulties. See previous post for more details

    It does take a bit more effort to store information more efficiently in memory when learning but these methods are proven to work. There are other techniques and also the research behind them in the book.

  • 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.