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.

We decided to provide the Cogmed working memory training in the UK because the research literature on it is impressive. It is effective in improving working memory in 80% of cases. The improvements have been demonstrated in neuropsychological tests, fMRI changes and rating scales. It can also be demonstrated at the neurotransmitter level- see previous post for details. It has been shown to be effective in improving working memory difficulties in children with ADHD and in adults with strokes. Klingberg is the main researcher in this area and his lab website contains copies of all the most important research papers. In particular the 2002 and 2005 papers are important Working memory training has also recently been shown to improved academic functioning in children with low working memory (Holmes et al 2009).

The program we offer includes computer training using a game format. The game adjusts itself depending on the level of ability of the person training i.e. if the child finds a task difficult it will lower the demand- if child is doing well demands increases. We monitor performance centrally so we can see how the training is progressing. We also provide weekly coaching to ensure motivation The program lasts for 5 weeks (25 sessions). All these features and the research make this training in my opinion unique and different from other brain training programs.

We can provide working memory training for children from the age of 4 to young adults up to age 25. If you are in the UK and would like to find out more please contact us on 020 7617 7180 or email care@recolo.co.uk or visit our website.

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.

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.