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Child Neuropsychology

A blog by Dr Jonathan Reed

  • 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.

  • Children’s welfare and development entered UK politics yesterday with David Cameron the Conservative leader talking about the warmth of parenting being more important than poverty in outcomes with poor children. Polly Tonybee in the Guardian wrote a stinging reply. This prompted me to think about my experience as a child psychologist with children from neglected backgrounds. For the past 13 years some of my work has involved assessing children in care, both residential and foster care. This has shown me how damaging early experience of abuse and neglect is for children, how it is reinforced and not addressed. It is a big problem. There are approximately 60000 children in care in the UK . The number of children with a child protection plan is increasing every year. The vast majority of children that I see in this context have cognitive, social and emotional difficulties. It is rare to see a good outcome. In the UK 12% of children in care get 5 GCSE passes compared to 59% in the general population. 23% of adult prison population were in care as children, 42% of prostitutes had been in care and 45% have mental health problems.

    In my experience there is often a common pathway. There is a history of concern about abuse and neglect dating from birth. Often the parents themselves had a history of abuse which they cope with by taking drugs and alcohol. They have no experience of good parenting themselves. Women often end up with partners who perpetuate abuse in the form of domestic violence. Many children are placed on and off the Child Protection Register during early childhood. Eventually (normally from age 8-13) they are placed in foster care. The children in residential care seem to have had several foster placements break down first. By the time they are placed in residential care it is too late to change the situation. By this stage children start to become involved in drugs, gangs, criminal behaviour, start underachieving educationally and in the case of young women engage in abusive relationships. Obviously this doesn’t happen to everyone but I would estimate it does in 70% of the cases I see. The cost to society is massive and the cycle of problems continues.

    What is also often missing in the debate is the effect on the brain of abuse and neglect. The first five years of life are crucial in terms of brain development. A recent study by Evans and Schamberg looked at the effect of childhood poverty and stress on working memory and explains the mechanism by which this happens. For a review of the literature on neglect and brain development in general see this paper by Danya Glaser. My own data and experience shows a large proportion of children in care with learning problems, neuro-developmental difficulties, self regulation problems and difficulties with social relationships. Waiting until a child is a teenager and then putting them in prison, giving them counseling or criticizing them doesn’t work. Their brains are already damaged. Trying to blame their parents or fine them doesn’t work either. Often they can’t cope in life due to their own history of abuse, drug addiction or neurodevelopmental problems.

    In my opinion the state has to intervene at an early age to break this cycle. There was recently an interesting article by Camilla Batmangheldjh in The Times about the need for good child protection to break the cycle of violence. There may be a need to remove children much earlier from the damaging home environment and place them in care rather than wait for the damage to occur, reinforce it with several short term placements and then put them in residential care in their teens. It would be better for children to return back to parents without the early damage. It may be that providing very high levels of one to one support in the home situation would help. Leaving it to the parents to change by themselves or expecting them to change through nagging,criticism or simple intervention won’t work. Ignoring the problem won’t work. The fundamental point is the need to intervene early to change the inevitable brain damage that occurs. These children are often forgotten. Few people look out for them and I wish this would change. In my opinion it is not just about blaming poverty or blaming parents but seeing the cycle of abuse and neglect that occurs through generations, seeing how this affects brain development and then trying to intervene to stop that cycle perpetuating. Is this possible? Despite yesterday’s debate I don’t see any political party in the UK addressing this properly yet.