Long-term psychological consequences of childhood frontal lobe lesion in patient DT

The Implications of Moral Neuroscience for Brain Disease: Review and Update

The last 2 decades have seen an explosion of neuroscience research on morality, with significant implications for brain disease. Many studies have proposed a neuromorality based on intuitive sentiments or emotions aimed at maintaining collaborative social groups. These moral emotions are normative, deontological, and action based, with a rapid evaluation of intentionality. The neuromoral circuitry interacts with the basic mechanisms of socioemotional cognition, including social perception, behavioral control, theory of mind, and social emotions such as empathy. Moral transgressions may result from primary disorders of moral intuitions, or they may be secondary moral impairments from disturbances in these other socioemotional cognitive mechanisms. The proposed neuromoral system for moral intuitions has its major hub in the ventromedial prefrontal cortex and engages other frontal regions as well as the anterior insulae, anterior temporal lobe structures, and right temporoparietal junction and adjacent posterior superior temporal sulcus. Brain diseases that affect these regions, such as behavioral variant frontotemporal dementia, may result in primary disturbances of moral behavior, including criminal behavior. Individuals with focal brain tumors and other lesions in the right temporal and medial frontal regions have committed moral violations. These transgressions can have social and legal consequences for the individuals and require increased awareness of neuromoral disturbances among such individuals with brain diseases.

Culpability for offenses in frontotemporal dementia and other brain disorders

The responsibility of persons with brain disorders who commit offenses may depend on how their disorders alter brain mechanisms for culpability. Criminal behavior can result from brain disorders that alter social cognition including a neuromoral system of intuitive moral emotions that are absolute (deontological) normative codes and that includes an emotion-mediated evaluation of intentionality. This neuromoral system has its hub in the ventromedial prefrontal cortex (VMPFC) with other frontal, anterior temporal-amygdalar, insular, and right temporoparietal connections. Among brain disorders, investigators report offenses in persons with brain tumors, epilepsy, and traumatic brain injury, but it is those with a form of dementia with VMPFC pathology, behavioral variant frontotemporal dementia (bvFTD), who are most prone to criminal behavior. This review presents four new patients with bvFTD who were interviewed after committing offenses. These patients knew the nature of their acts and the wrongness of the type of action but lacked substantial capacity to experience the criminality of their conduct at the intuitive, deontological, moral emotional level. Disease in VMPFC and its amygdalar connections may impair moral emotions in these patients. These findings recommend evaluation for the experience of moral emotions and VMPFC-amygdala dysfunction among persons with antisocial behavior, with or without brain disease.

Life-long deficits in social adaptation and the frontal lobes: New evidence, seventy-five years after Ackerly and Benton's landmark case report of JP

The case of JP, reported by Ackerly and Benton in 1948 with a detailed follow-up by Ackerly in 1964, stands as the index case of developmental prefrontal damage and its impact on social adaptation. Although the 1948 case report included findings from a 1933 pneumoencephalogram and exploratory craniotomy, a definitive cause was never established for JP's prefrontal damage. Etiologies were never determined for the left-sided seizures that occurred when JP was age four, nor for the progressive anterograde amnesia that JP developed in middle age. Given Ackerly's thoroughness and long-term follow-up of his patient, it was hoped that a brain cutting would have been done, though no report of a post-mortem examination was published. The lead author of this paper (SB) set out to discover what had happened to JP after Ackerly's 1964 report and whether a brain cutting had in fact occurred. Using a variety of investigative approaches, it was discovered that a post-mortem brain examination had taken place. Those present at the brain cutting were identified, and the still-living witnesses to the brain cutting were interviewed. Previously unpublished, relevant materials were uncovered from archival sources. A film of the brain cutting, as well as photos, were located. A film of Ackerly interviewing JP prior to JP's death at age sixty-four also was found. The authors studied autopsy findings in the newly discovered video and still images. These findings were judged consistent with massive perinatal hemorrhagic damage to both frontal lobes. JP's left-sided seizures were likely due to activation of a focus from his congenital brain damage. The anterograde amnesia that was documented when JP was twenty-five and that was noted to worsen when he was forty-nine remains unexplained but may have been related to slowly progressive hydrocephalus. This paper expands what is known about the case of JP, making it the only report of a person with congenital frontal injury followed for their entire life including post-mortem brain examination.

Social Functioning and Autistic Behaviors in Youth Following Acquired Brain Injury

Children and adolescents who survive the pediatric intensive care unit (PICU) with an acquired brain injury (ABI) often demonstrate a variety of physical, cognitive, emotional/behavioral, and social sequelae termed post-intensive care syndrome (PICS). Social communication and interaction challenges have also been observed clinically, and there is growing literature documenting these occurrences in youth following ABI. The extent of these social changes varies among patients, and a subset of patients go on to exhibit social and behavioral profiles closely resembling those of autistic youth. We reviewed empirical research regarding social functioning in youth following ABI, as well as the overlap between individuals with ABI and autistic youth, published from January 2009 to August 2022 on PubMed and Scopus databases. Clinical case examples from a well-established post-PICU follow-up program are also provided to exemplify the complexity of this phenomenon.

Unravelling moral cognition in acquired brain injury: a scoping review

Background:

Acquired brain injury (ABI) is accompanied by impairments in social, emotional, cognitive and behavioural skills and highly prevalent in the population. Social and emotional skills are crucial for moral cognition, but the extent to which moral cognition contributes to social competence deficits in people with ABI is largely unclear.

Method:

To provide more insight on this topic, we conducted a scoping review according to the PRISMA guidelines. After screening 1269 articles that we obtained via PubMed and Scopus, we found 27 articles on moral cognition in ABI.

Results:

We encountered four important topics across these studies which include traumatic brain injury (TBI) versus non-TBI, the influence of the different approaches used to measure moral cognition in ABI, the role of age of onset and the role of location of the injury. Overall, evidence suggests that the earlier the brain damage occurred, the more this leads to impairments in moral cognitive functioning. The location of the injury furthermore seems to differentially affect the way impairments are manifested. Finally, we found that the use of different measurement approaches can heavily influence the interpretation of the impairment.

Conclusion:

We conclude that impairments in moral cognition in people with ABI are derived from a complex interplay between the age of onset, the location and the approach used to index moral cognition.

Exploring the link between character, personality disorder, and neuropsychological function

Personality deviations and deficits in cognitive executive function are common among forensic populations. The present study on incarcerated offenders explored whether there are links between the two domains. Personality was assessed using the Temperament and Character Inventory (TCI). Neuropsychological performance, including visual working memory, attentional set-shifting and planning, were tested with the Cambridge Neuropsychological Test Automated Battery (CANTAB). Subjects with personality disorders scored high on harm avoidance, and low on self-directedness and cooperativeness. Personality disordered offenders did not differ from the comparison groups (offenders without personality disorder, and non-criminal controls) with regard to CANTAB measures of visual working memory (delayed matching to sample, spatial working memory) and planning (Stockings of Cambridge), but they made a larger number of errors on the attentional set-shifting task. Dimensional analysis of the personality and neuropsychological variables revealed significant associations between self-directedness and cooperativeness on the one hand, and attentional set-shifting on the other. Intellectually disabled, non-criminal individuals (marginal mental retardation) who performed poorly on attentional set-shifting also scored low on self-directedness and cooperativeness. The results indicate that poor development of certain personality traits may be associated with deficits in neuropsychological functioning.

Ventromedial Prefrontal Cortex Is Critical for Helping Others Who Are Suffering

Neurological patients with damage to the ventromedial prefrontal cortex (vmPFC) are reported to display reduced empathy toward others in their daily lives in clinical case studies. However, the empathic behavior of patients with damage to the vmPFC has not been measured experimentally in response to an empathy-eliciting event. This is important because characterizing the degree to which patients with damage to the vmPFC have lower empathic behavior will allow for the development of targeted interventions to improve patients’ social skills and in turn will help family members to better understand their impairments so they can provide appropriate supports. For the first time, we induced empathy using an ecologically-valid empathy induction in neurological patients with damage to the vmPFC and measured their empathic emotional responses and behavior in real time. Eight neurological patients with focal damage to the vmPFC were compared to demographically-matched brain-damaged and healthy comparison participants. Patients with damage to the vmPFC gave less money in the empathy condition to a person who was suffering (a confederate) than comparison participants. This provides the first direct experimental evidence that the vmPFC is critical for empathic behavior toward individuals who are suffering.

Moral Reasoning in Children with Focal Brain Insults to Frontotemporal Regions

Neuroscientific evidence indicates that human social functioning is supported by a distributed network of frontal and temporal brain regions that undergoes significant development during childhood and adolescence. Clinical studies of individuals with early brain insults (EBI) to frontotemporal regions suggest that such lesions may interfere with the maturation of sociocognitive skills and lead to increased sociobehavioural problems. However, little attention has focussed on the direct assessment of sociocognitive skills, such as moral reasoning, following focal EBI. In the present study, the performance of 15 patients with focal EBI (8–16 years) was compared to that of 15 demographically matched controls on basic neuropsychological measures (IQ and executive functions), sociocognitive tasks (moral reasoning, moral decision-making and empathy) and parent reports of sociobehavioural problems and social adaptive skills. Patients with focal EBI had significantly lower levels of moral reasoning maturity, moral decision-making, and empathy than their matched controls, but did not differ on more general measures of cognition. Their parents also reported increased sociobehavioural problems. These findings suggest that focal EBI to frontotemporal regions can result in reduced sociocognitive capacities, more specifically moral reasoning, and increased vulnerability to sociobehavioural problems.

Neuroimaging and Violence

Violence is a serious public health issue across the world. This article assists clinicians in understanding the most up-to-date literature regarding structural and functional brain theories related to risk of violence. In this article, we review anatomic regions of the brain that have been implicated in violence and associated personality constructs associated with violence. We discuss different imaging techniques that have been used to uncover abnormal brain volume, associations, and functions throughout the brain in samples with violence history or risk. Finally, we discuss implications of these findings both for treatment considerations and future research directions.

Inability to empathize: brain lesions that disrupt sharing and understanding another's emotions

Emotional empathy--the ability to recognize, share in, and make inferences about another person's emotional state--is critical for all social interactions. The neural mechanisms underlying emotional empathy have been widely studied with functional imaging of healthy participants. However, functional imaging studies reveal correlations between areas of activation and performance of a task, so that they can only reveal areas engaged in a task, rather than areas of the brain that are critical for the task. Lesion studies complement functional imaging, to identify areas necessary for a task. Impairments in emotional empathy have been mostly studied in neurological diseases with fairly diffuse injury, such as traumatic brain injury, autism and dementia. The classic 'focal lesion' is stroke. There have been scattered studies of patients with impaired empathy after stroke and other focal injury, but these studies have included small numbers of patients. This review will bring together data from these studies, to complement evidence from functional imaging. Here I review how focal lesions affect emotional empathy. I will show how lesion studies contribute to the understanding of the cognitive and neural mechanisms underlying emotional empathy, and how they contribute to the management of patients with impaired emotional empathy.

A preliminary investigation of moral reasoning and empathy after traumatic brain injury in adolescents

PRIMARY OBJECTIVE

Traumatic brain injury (TBI) sustained during childhood can affect a number of socio-cognitive skills; however, little attention has focused on the integrity of moral reasoning in the assessment of post-TBI social sequelae and the role of empathy and intelligence on moral maturity.

RESEARCH DESIGN

In a quasi-experimental, cross-sectional research design, moral reasoning maturity and empathy in adolescents with mild-to-severe TBI (n = 25) were compared to typically-developing peers (n = 66).

METHODS AND PROCEDURES

Participants were administered the So-Moral and So-Mature, tasks of socio-moral reasoning and maturity, the Index of Empathy for Children and Adolescents, the Wechsler Abbreviated Scale of Intelligence and a demographic questionnaire.

MAIN OUTCOMES AND RESULTS

Participants with TBI had significantly lower levels of moral reasoning maturity. Further, adolescents with moderate-to-severe TBI had lower levels of empathy. Empathy correlated positively with moral reasoning abilities and, together with intellectual function, predicted a small, but significant proportion of moral reasoning outcome.

CONCLUSIONS

Youth who sustained TBI during childhood have poorer moral reasoning abilities than their non-injured peers, potentially placing them at risk for poor social decision-making and socially maladaptive behaviour. This can have a significant impact on long-term social functioning.

Prefrontal damage in childhood and changes in the development of personality: a case report

Frontal lobe lesions are associated with behavioral abnormalities and executive dysfunction. When these lesions occur early in life, the symptoms are even more severe as the anatomical and functional substrates underlying personality and behavior are damaged, distorting normal modulation by interaction with the psychosocial environment. We present a case of a 40-year-old man who suffered a frontal lobe lesion at the age of nine years and developed impulsivity, disinhibition and inappropriate behaviors while showing some preservation of insight. Brain MRI revealed lesions to bilateral orbitofrontal cortex, ventromedial prefrontal cortex, anterior cingulate gyri and genu of the corpus callosum, which were more extensive on the right side. The right prefrontal dorsolateral cortex was severely damaged, whereas the right ventrolateral prefrontal cortex was spared. We will discuss the correlation of the damaged pre frontal regions with the symptoms presented by the patient.

Social function in children and adolescents after traumatic brain injury: a systematic review 1989-2011

Clinical reports and case studies suggest that traumatic brain injury (TBI) can have significant social consequences, with social dysfunction reported to be the most debilitating problem for child and adolescent survivors. From a social neuroscience perspective, evidence suggests that social skills are not localized to a specific brain region, but are mediated by an integrated neural network. Many components of this network are susceptible to disruption in the context of TBI. In early development, a brain injury can disrupt this neural network while it is in the process of being established, resulting in social dysfunction. In order to clarify the prevalence and nature of social dysfunction after child TBI, studies of social outcomes in children and adolescents after TBI over the last 23 years have been reviewed. Despite casting a wide net initially, only 28 articles met review criteria. These studies were characterized by methodological weaknesses, including variations in definitions of TBI, limited assessment tools, reliance on parent reports, small sample sizes, and absent control groups. Despite these limitations, the weight of evidence confirmed an elevated risk of social impairment in the context of moderate and severe injury. While rarely examined, younger age at insult, pathology to frontal regions and the corpus callosum, and social disadvantage and family dysfunction may also increase the likelihood of social difficulties. More research is needed to obtain an accurate picture of social outcomes post-brain injury.

Adaptive Behaviour and Moral Reasoning in Children with Frontal Lobe Lesions

Children with frontal lobe damage often appear to demonstrate remarkable recovery with few apparent signs of impairment immediately after injury. Over time, however, many develop increasing deficits in self-regulation, attention, and executive function, as well as in otherhigher functions. Current literature suggests that, in particular, these children seem to experience worsening socio-behavioural problems. Some case studies (Grattan & Eslinger, 1992; Anderson et al., 1999) describe individuals with childhood frontal lesions who developed severe social problems, deficits in executive functions and who also had lower than expected levels of moral reasoning. In the present study, social-adaptive behaviour and maturity of moral reasoning were measured in 16 children with focal frontal lesions and in 12 age-matched controls. Children with frontal lobe lesions had poorer adaptive behaviour ratings and lower levels of moral maturity than controls. These results support previous research suggesting that children with frontal lobe lesions have reduced social understanding and typically experience ongoing sociobehavioural problems.

Abilities of preschoolers: comparing different tools

Background

There is a strong need for studies evaluating tests in terms both of psychometric properties (i.e. their efficacy or ability to be helpful in reaching a diagnosis) and of their cost-effectiveness (i.e. their efficiency). These data are essential for planning a correct evaluation to identify children's needs (both educational and abilitative).

Methods

We evaluated 58 children attending for the first time the last year of the Scuola dell'Infanzia. Parental view was obtained with Child Behaviour Check-List and Conners' Rating Scales - Revised, and family socio-economic status was evaluated using Hollingshead's Four Factor Index; teacher compiled the IPDA questionnaire; children were administered Raven's Progressive Matrices, Modified Bell Cancellation Test, BVN 5-11 (a neuropsychological battery).

Results

A correlational analysis was conducted using Spearman's Rho (since variables were not normally distributed). These asymptomatic children show a good global cognitive functioning, but also a deficit of attention and of Executive Functions. Some of the tests used seem more cost-effective than others and there are some redundancies in information obtained.

Conclusions

Our data show that there are significant correlations between different neuropsychological and behavioural measures. It is therefore possible to rationalize diagnostic protocols without a significant information reduction. A deeper analysis will require a preliminary definition of the psychometric properties of used tools.

The development of a new measure of social-emotional functioning for young adolescents

Social and emotional impairments are frequently reported following acquired brain injury, including an inability to adopt another's perspective, empathize, and display guilt, and inappropriate social conduct. Case studies suggest that these problems are particularly apparent when the injury is sustained in childhood, with deficits increasing with age and persisting throughout adulthood. In addition to these deficits, individuals may have limited insight into their cognitive or social-emotional deficits, which in turn may also affect social functioning and have implications for the success of rehabilitation. Despite the frequency of these problems, there is a dearth of suitable measures for detecting them in children or adolescents. The purpose of the current study was to develop one such measure from a measure initially intended for adults. Normative data were collected from 109 typically-developing 11- to 14-year-olds and their parent/guardian on the Social-Emotional Questionnaire for Children (SEQ-C). Factor and reliability analyses were conducted and the subscales were then explored in association with key demographic information. Social-emotional development showed a fluctuating course across early adolescence, alongside some gender differences. This measure, with its normative data, will be of value to neuropsychologists wishing to explore such functioning in their clinical practice.

Thalamic T-type Ca²+ channels mediate frontal lobe dysfunctions caused by a hypoxia-like damage in the prefrontal cortex

Hypoxic damage to the prefrontal cortex (PFC) has been implicated in the frontal lobe dysfunction found in various neuropsychiatric disorders. The underlying subcortical mechanisms, however, have not been well explored. In this study, we induced a PFC-specific hypoxia-like damage by cobalt-wire implantation to demonstrate that the role of the mediodorsal thalamus (MD) is critical for the development of frontal lobe dysfunction, including frontal lobe-specific seizures and abnormal hyperactivity. Before the onset of these abnormalities, the cross talk between the MD and PFC nuclei at theta frequencies was enhanced. During the theta frequency interactions, burst spikes, known to depend on T-type Ca(2+) channels, were increased in MD neurons. In vivo knockout or knockdown of the T-type Ca(2+) channel gene (Ca(V)3.1) in the MD substantially reduced the theta frequency MD-PFC cross talk, frontal lobe-specific seizures, and locomotor hyperactivity in this model. These results suggest a two-step model of prefrontal dysfunction in which the response to a hypoxic lesion in the PFC results in abnormal thalamocortical feedback driven by thalamic T-type Ca(2+) channels, which, in turn, leads to the onset of neurological and behavioral abnormalities. This study provides valuable insights into preventing the development of neuropsychiatric disorders arising from irreversible PFC damage.

Early bifrontal brain injury: disturbances in cognitive function development

We describe six psychomotor, language, and neuropsychological sequential developmental evaluations in a boy who sustained a severe bifrontal traumatic brain injury (TBI) at 19 months of age. Visuospatial, drawing, and writing skills failed to develop normally. Gradually increasing difficulties were noted in language leading to reading and spontaneous speech difficulties. The last two evaluations showed executive deficits in inhibition, flexibility, and working memory. Those executive abnormalities seemed to be involved in the other impairments. In conclusion, early frontal brain injury disorganizes the development of cognitive functions, and interactions exist between executive function and other cognitive functions during development.

Social competence intervention for youth with Asperger Syndrome and high-functioning autism: an initial investigation

Individuals with high functioning autism (HFA) or Asperger Syndrome (AS) exhibit difficulties in the knowledge or correct performance of social skills. This subgroup's social difficulties appear to be associated with deficits in three social cognition processes: theory of mind, emotion recognition and executive functioning. The current study outlines the development and initial administration of the group-based Social Competence Intervention (SCI), which targeted these deficits using cognitive behavioral principles. Across 27 students age 11-14 with a HFA/AS diagnosis, results indicated significant improvement on parent reports of social skills and executive functioning. Participants evidenced significant growth on direct assessments measuring facial expression recognition, theory of mind and problem solving. SCI appears promising, however, larger samples and application in naturalistic settings are warranted.

The relation of cognitive control to social outcome after paediatric TBI: Implications for intervention

HYPOTHESIS

This study postulated cognitive control is related to social outcome in children with traumatic brain injury (TBI) and orthopaedic injury (OI). PROCEDURE AND DESIGN: This study analysed 12-month, post-injury, cross-sectional data from 52 children (7-17 years) with moderate-to-severe TBI and 41 children with OI. Cognitive control was measured with the Sternberg Task (memory) and the Flanker Task (resistance to interference). Relations to social outcome (Vineland Adaptive Behavioural Scales-Socialization and Communications domains) were measured.

RESULTS

Reaction time (RT) on the Sternberg task was related to social outcome, with stronger relations in children of lower SES. Flanker baseline and interference RTs were related to social outcome, with the relation for interference RT more robust in children with lower SES.

CONCLUSIONS

Cognitive control is related to social outcome. Further, it is suggested that cognitive training may have positive effects on social function through improved efficiency of social information processing.

Prefrontal structural and functional brain imaging findings in antisocial, violent, and psychopathic individuals: a meta-analysis

Brain-imaging studies suggest that antisocial and violent behavior is associated with structural and functional deficits in the prefrontal cortex, but there is heterogeneity in findings and it is unclear whether findings apply to psychopaths, non-violent offenders, community-based samples, and studies employing psychiatric controls. A meta-analysis was conducted on 43 structural and functional imaging studies, and the results show significantly reduced prefrontal structure and function in antisocial individuals. Effect sizes were significant for both structural and functional studies. With minor exceptions, no statistically significant moderating effects of sample characteristics and methodological variables were observed. Findings were localized to the right orbitofrontal cortex, right anterior cingulate cortex, and left dorsolateral prefrontal cortex. Findings confirm the replicability of prefrontal structural and functional impairments in antisocial populations and highlight the involvement of orbitofrontal, dorsolateral frontal, and anterior cingulate cortex in antisocial behavior.

Theory of mind in children with traumatic brain injury

OBJECTIVE

This study was designed to examine the existence of deficits in mentalizing or theory of mind (ToM) in children with traumatic brain injury (TBI).

RESEARCH DESIGN

ToM functioning was assessed in 12 children aged 6-12 years with TBI and documented frontal lobe damage and compared to 12 controls matched for age, sex and verbal ability. Brief measures of attention and memory were also included.

MAIN OUTCOME AND RESULTS

The TBI group was significantly impaired relative to controls on the advanced ToM measure and a measure of basic emotion recognition. No difference was found in a basic measure of ToM.

CONCLUSION

Traumatic brain damage in childhood may disrupt the developmental acquisition of emotion recognition and advanced ToM skills. The clinical and theoretical importance of these findings is discussed and the implications for the assessment and treatment of children who have experienced TBI are outlined.

Psychopathology of early frontal lobe damage: Dependence on cycles of development

A new theory of frontal lobe development is presented in which the role of the human frontal lobes during normal development and the psychopathological consequences of early frontal lobe injury are explored. Analyses of the development of human electroencephalograph (EEG) coherence indicate that there are oscillations and cyclic growth processes along the mediolateral and anterior-posterior planes of the brain. The cycles of EEG coherence are interpreted as repetitive sequences of increasing and decreasing synaptic effectiveness that reflects a convergence process that narrows the disparity between structure and function by slowly sculpting and reshaping the brain's microanatomy. This process is modeled as a developmental spiral staircase in which brain structures are periodically revisited resulting in stepwise increases in differentiation and integration. The frontal lobes play a crucial role because they are largely responsible for the selection and pruning of synaptic contacts throughout the postnatal period. A mathematical model of cycles of synaptic effectiveness is presented in which the frontal lobes behave as gentle synaptic “predators” whereas posterior cortical regions behave as synaptic “prey” in a periodic reorganization process. The psychopathological consequences of early frontal lobe damage are discussed in the context of this model.

Gender differences in empathy: the role of the right hemisphere

The relationship between activation of the right cerebral hemisphere (RH) and empathy was investigated. Twenty-two men and 73 women participated by completing a chimeric face task and empathy questionnaire. For the face task, participants were asked to pick which of the two chimeric faces looked happier. Both men and women were significantly more likely to say the chimera with the smile to their left was happier, suggesting activation of the RH. As expected, men scored significantly lower than women on the empathy questionnaire, p=.003. A correlation was found between RH activation on the face task and empathy for women only, p=.037, suggesting a possible neural basis for gender differences in empathy.

Caught in the act: The impact of audience on the neural response to morally and socially inappropriate behavior

We examined the impact of witnesses on the neural response to moral and social transgressions using fMRI. In this study, participants (N=16) read short vignettes describing moral and social transgressions in the presence or absence of an audience. In line with our hypothesis, ventrolateral (BA 47) and dorsomedial (BA 8) frontal cortex showed increased BOLD responses to moral transgressions regardless of audience and to social transgressions in the presence of an audience relative to neutral situations. These findings are consistent with the suggestion that these regions of prefrontal cortex modify behavioral responses in response to social cues. Greater activity was observed in left temporal-parietal junction, medial prefrontal cortex and temporal poles to moral and to a lesser extent social transgressions relative to neutral stories, regardless of audience. These regions have been implicated in the representation of the mental states of others (Theory of Mind). The presence of an audience was associated with increased left amygdala activity across all conditions.

Decision-making after traumatic brain injury in children: a preliminary study

Decision-making under conditions of uncertainty was studied in 11 children with moderate to severe post-acute traumatic brain injury (TBI) using a modification of the Iowa Gambling Task (Bechara et al., 1994). We hypothesized that decision-making would be compromised in children with TBI. The results revealed that when divided into subgroups by lesion location, children with lesions in the amygdala (AM) were impaired on modified gambling task performance, but children with ventromedial (VM) lesions did not appear to be impaired on the task. These results are in contrast to studies of decision-making in adults with focal lesions of vascular etiology.

Social cognition: a multi level analysis

This paper investigates the construct of social cognition from an interdisciplinary perspective blending social psychology and cognitive neuroscience. This perspective argues for the inclusion of processes used to decode and encode the self, other people and interpersonal knowledge in the definition of social cognition. The neural modularity of social cognition is considered. The paper concludes by considering a number of challenges for social cognition research including questions of accuracy and the influence of motivation and bias in social cognitive processing.

Psychological and adjustment problems due to acquired brain lesions in childhood: a comparison between post-traumatic patients and brain tumour survivors

OBJECTIVE

To define and differentiate psychological and adjustment problems due to brain injury or brain tumour in children and adolescents.

METHODS

Two groups of patients with acquired brain lesions (24 post-traumatic patients and 22 brain tumour survivors), ranging in age between 8-15 years, received a psychological evaluation, including the Child Behaviour Checklist for Ages 4-18 (CBCL) and the Vineland Behaviour Adaptive Scales (VABS).

RESULTS

Both groups showed psychological and social adjustment problems. Post-traumatic patients were more impaired than brain tumour survivors. Social adjustment problems were associated to externalizing problems in post-traumatic patients and internalizing problems in brain tumour surviving patients.

CONCLUSIONS

These differences in psychological and behavioural disorders between the two groups must necessarily be considered when developing psychological treatment, rehabilitation plan and social re-entry.

Neural mechanism for judging the appropriateness of facial affect

Questions regarding the appropriateness of facial expressions in particular situations arise ubiquitously in everyday social interactions. To determine the appropriateness of facial affect, first of all, we should represent our own or the other's emotional state as induced by the social situation. Then, based on these representations, we should infer the possible affective response of the other person. In this study, we identified the brain mechanism mediating special types of social evaluative judgments of facial affect in which the internal reference is related to theory of mind (ToM) processing. Many previous ToM studies have used non-emotional stimuli, but, because so much valuable social information is conveyed through nonverbal emotional channels, this investigation used emotionally salient visual materials to tap ToM. Fourteen right-handed healthy subjects volunteered for our study. We used functional magnetic resonance imaging to examine brain activation during the judgmental task for the appropriateness of facial affects as opposed to gender matching tasks. We identified activation of a brain network, which includes both medial frontal cortex, left temporal pole, left inferior frontal gyrus, and left thalamus during the judgmental task for appropriateness of facial affect compared to the gender matching task. The results of this study suggest that the brain system involved in ToM plays a key role in judging the appropriateness of facial affect in an emotionally laden situation. In addition, our result supports that common neural substrates are involved in performing diverse kinds of ToM tasks irrespective of perceptual modalities and the emotional salience of test materials.

Opinion: the neural basis of human moral cognition

Moral cognitive neuroscience is an emerging field of research that focuses on the neural basis of uniquely human forms of social cognition and behaviour. Recent functional imaging and clinical evidence indicates that a remarkably consistent network of brain regions is involved in moral cognition. These findings are fostering new interpretations of social behavioural impairments in patients with brain dysfunction, and require new approaches to enable us to understand the complex links between individuals and society. Here, we propose a cognitive neuroscience view of how cultural and context-dependent knowledge, semantic social knowledge and motivational states can be integrated to explain complex aspects of human moral cognition.

Executive functions after traumatic brain injury in children

There is growing recognition that executive function, the superordinate, managerial capacity for directing more modular abilities, is frequently impaired by traumatic brain injury in children and mediates the neurobehavioral sequelae exhibited by these patients. This review encompasses the definition of specific executive functions, age-related changes in executive functions in typically developing children, and the effects of traumatic brain injury on executive functions. The neural substrate for executive functions is described, including relevant functional brain imaging studies that have implicated mediation by prefrontal and parietal cortex and their circuitry. The vulnerability of the neural substrate for executive function to the pathophysiology of traumatic brain injury is discussed, including focal lesions and diffuse axonal injury. Domains of executive functions covered in this review include the basic processes of working memory and inhibition and more complex processes such as decision making. Other domains of executive function, including motivation, self-regulation, and social cognition are discussed in terms of research methodology, clinical assessment, and findings in children with traumatic brain injury. Proposed approaches to the rehabilitation of executive functions are presented.

Developmental outcomes after early prefrontal cortex damage

The neuropsychological bases of cognitive, social, and moral development are minimally understood, with a seemingly wide chasm between developmental theories and brain maturation models. As one approach to bridging ideas in these areas, we review 10 cases of early prefrontal cortex damage from the clinical literature, highlighting overall clinical profiles and real life developmental outcomes. Based on these cases, there is preliminary evidence to support distinctive developmental differences after: (1) dorsolateral, (2) mesial, and (3) orbital-polar prefrontal lesions, for more profound impairments after bilateral damage, and possibly for recovery differences after very early vs. later childhood lesion onset. Further case and group studies are needed to confirm reliable effects of specific lesion locations, the influence of age of lesion onset, and related experiential and treatment variables in determining adult outcomes. Rather than a single underlying deficit associated with early prefrontal cortex damage, we interpret the findings to suggest that it is the altered integration and interplay of cognitive, emotional, self-regulatory, and executive/metacognitive deficits that contribute to diverse developmental frontal lobe syndromes. The findings support the fundamental importance of prefrontal cortex maturation in protracted cognitive, social-emotional, and moral development.

Attention, memory, and behavioral adjustment in children with frontal lobe epilepsy

To explore whether attention, memory, and behavior would be more affected in children with frontal lobe epilepsy than in children with other types of epilepsy, we compared 16 children with frontal lobe epilepsy (FLE), 8 with temporal lobe epilepsy (TLE), and 8 with generalized absence (GEA) seizures on the Performance Speed (PS) and Freedom of Distraction (FD) indices of the WISC-III, the Continuous Performance Test (CPT), the California Verbal Learning Test (CVLT), and Rey-Osterrieth Complex Figure (ROCF). Parents completed Achenbach's Child Behavior Check List. Children with FLE scored significantly lower than the other two groups on the PS and CPT. On the CVLT they made more intrusion errors and were more prone to interference. Furthermore, they had more difficulties copying and recalling the ROCF. Behavior profiles revealed greater attention problems in this group. This may put children with FLE at greater risk of developing school problems than children with TLE and GEA.

Executive skills in Klinefelter's syndrome

Executive skills are those involved in concept formation, problem solving, switching tasks, inhibiting inappropriate responses, initiating rapid and fluent responses, planning and sustained attention. Different patterns of disorder amongst these skills have been found in several developmental abnormalities including autism, attention deficit hyperactivity disorder (ADHD) and Turner's syndrome (TS). This study explored, for the first time, executive skills in children with Klinefelter's syndrome (KS), a sex chromosome abnormality in which there is one or more additional X-chromosomes. Intelligence in KS is normal but there is academic underachievement. A battery of executive tasks was administered, in a series of case studies, to three 10-year-old boys with KS and to controls matched for age, sex and intelligence. The results demonstrate that children with KS have impairments in executive skills. However, the pattern of impairment is task-specific. There is evidence from multiple tasks of impairment in inhibitory skills, for each case of KS. In contrast, concept formation, problem solving, task switching and speeded responding are normal. These results support theories that argue for distinct sub-components of executive skills within development that may develop relatively independently. The results have relevance for modelling both child and adult executive systems. They also confirm that an additional X-chromosome has highly selective effects upon the consequent cognitive phenotype seen in development.

Common and distinct neural responses during direct and incidental processing of multiple facial emotions

Whether common or distinct neural systems underpin perception of different emotions and the degree to which these systems are automatically engaged during emotional perception are unresolved. We performed an event-related fMRI experiment in which subjects viewed morphed emotional faces displaying low or high intensities of disgust, fear, happiness, or sadness under two task conditions. The amygdala and fusiform cortex responded to high-intensity expressions of all emotions, independent of task. Right superior temporal sulcus showed an additive effect of the emotion-directed task and high-intensity emotion. Ventromedial prefrontal and somatosensory cortices, regions implicated in providing representations of somatic states, showed enhanced activity during explicit emotional judgments. We failed to find predicted differences between emotions. The results suggest that amygdala contributes to task-independent perceptual processing of a range of emotions. We interpret ventromedial prefrontal and somatosensory cortex activations as evidence that these regions contribute to explicit emotion processing through linking emotion perception with representations of somatic states previously engendered by emotions.

How (and where) does moral judgment work?

Moral psychology has long focused on reasoning, but recent evidence suggests that moral judgment is more a matter of emotion and affective intuition than deliberate reasoning. Here we discuss recent findings in psychology and cognitive neuroscience, including several studies that specifically investigate moral judgment. These findings indicate the importance of affect, although they allow that reasoning can play a restricted but significant role in moral judgment. They also point towards a preliminary account of the functional neuroanatomy of moral judgment, according to which many brain areas make important contributions to moral judgment although none is devoted specifically to it.

The relationship between executive function abilities, adaptive behaviour, and academic achievement in children with externalising behaviour problems

BACKGROUND

Specific domains of adaptive behaviours and academic achievement may, in part, depend on executive function capacities. Executive function deficits have been found to be associated with Attention Deficit Hyperactivity Disorder (ADHD), not Oppositional Defiant Disorder/Conduct Disorder (ODD/CD).

METHOD

Using a sample of 110 adolescents, comprising four groups, ADHD only, co-morbid ADHD and ODD/CD, ODD/CD only, and a normal community control group, we assessed socialisation and communication skills with the Vineland Adaptive Behaviour Scales, along with reading ability, and executive functioning.

RESULTS

Poorer adaptive communication skills were specifically associated with ADHD when compared with either ODD/CD or the control group, and the social competence of adolescents with ADHD was as low as the levels associated with ODD/CD. Presence of ADHD was associated with lower word recognition scores, while the reading levels of adolescents with ODD/CD were equivalent to those without behaviour problems. Executive function test scores correlated with all adaptive behaviour outcomes. Multiple regression analyses indicated that verbal ability predicted communication and reading scores, with executive function abilities contributing significant variance to the prediction in the adaptive behaviour, communication, and socialisation domains.

CONCLUSIONS

Further research with other samples, both community and clinical groups, is needed to assess the generalisability of the findings. Small numbers of girls in the groups gave us insufficient power to adequately address potential gender differences.

Adolescent neuropsychological development after early right prefrontal cortex damage

Adolescent development and pattern of recovery are described for a 15-year-old boy who sustained extensive right dorsolateral prefrontal cortex damage at age 7 from rupture and surgical treatment of a deep arteriovenous malformation. Follow-up evaluations at 4 years and most recently 8 years after illness have shown clear improvement in social-behavioral and almost all cognitive areas initially assessed. He demonstrated resolution of left hemispatial neglect and other visuospatial impairments in working memory, design fluency, and planning and organization. However, at the 8-year follow-up interval, an acquired form of attention deficit disorder remains evident. We hypothesized that this is the likely cause of comparatively lower scores in general intelligence, verbal learning and memory, discourse, and processing speed, that at the 4-year follow-up interval. New measures of emotional face and voice recognition showed only minor difficulties, principally in identifying vocal disgust and fear. Social and psychological maturation has continued to improve, with no evidence of developmental arrest or pervasive social impairment, although the individual is confused at times by complexities and nuances of social interaction. The pattern of findings 8 years after early right dorsolateral prefrontal cortex damage suggests remarkable recovery of primary visuospatial and social impairments, but lingering and somewhat worsening performance deficits which may be due to attentional difficulties and impulsive responding. Treatment of the attentional difficulties is currently being investigated.

An intervention for children with disorders of executive functions

This article describes a cognitive-behavioral approach to teaching metacognitive executive thinking strategies to children with disorders of executive function. The intervention is based on the notion that some children with disorders of executive function have disorders of higher level language, which predispose them to the executive impairments. It is proposed that teaching and reinforcing metacognitive thinking strategies may help advance verbal mediation of complex tasks and self-regulation of behavior. Despite the growing literature on developmental executive disorders, little has been written about interventions that may enable the children to acquire some of the requisite adaptive skills. The ideas expressed herein should be considered an invitation for the initiation of empirical studies of intervention and outcome effects.

Investigating the functional anatomy of empathy and forgiveness

Previous functional brain imaging studies suggest that the ability to infer the intentions and mental states of others (social cognition) is mediated by medial prefrontal cortex. Little is known about the anatomy of empathy and forgiveness. We used functional MRI to detect brain regions engaged by judging others' emotional states and the forgivability of their crimes. Ten volunteers read and made judgements based on social scenarios and a high level baseline task (social reasoning). Both empathic and forgivability judgements activated left superior frontal gyrus, orbitofrontal gyrus and precuneus. Empathic judgements also activated left anterior middle temporal and left inferior frontal gyri, while forgivability judgements activated posterior cingulate gyrus. Empathic and forgivability judgements activate specific regions of the human brain, which we propose contribute to social cohesion.

Acquired mind-blindness following frontal lobe surgery? A single case study of impaired 'theory of mind' in a patient treated with stereotactic anterior capsulotomy

Social insight, specifically the ability to represent thoughts and feelings ('theory of mind'), may have a circumscribed and dedicated neurological substrate. Evidence of deficits in 'theory of mind' following acquired lesions would support this idea. Previous studies of lesions resulting from stroke or head injury have been hampered by lack of detailed lesion information and pre-lesion documentation. We report the case of a 76-year-old man who, following a standard surgical procedure to treat bipolar affective disorder, showed evidence of impaired 'theory of mind'. This case, which is the first of its type, may contribute to the search for the brain basis of social insight.

Management of attention and memory disorders following traumatic brain injury

Disorders of attention, memory, and executive function are common sequelae in children who have sustained traumatic brain injuries. Given the persistent nature of these deficits, there is a need for efficacious remedial approaches. Typically, remediation is approached, through one of three general intervention strategies: externally focused interventions aimed at changing the environment so that the effect of the dysfunction is minimized, internally focused interventions aimed at improving the underlying cognitive ability, and compensatory interventions aimed at teaching children to use alternate strategies that lessen the impact of the dysfunction. This article describes current research involving these approaches for the treatment of attention and memory disorders in children.

Executive functions and developmental psychopathology

In this paper, we consider the domain of executive functions (EFs) and their possible role in developmental psychopathologies. We first consider general theoretical and measurement issues involved in studying EFs and then review studies of EFs in four developmental psychopathologies: attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), autism, and Tourette syndrome (TS). Our review reveals that EF deficits are consistently found in both ADHD and autism but not in CD (without ADHD) or in TS. Moreover, both the severity and profile of EF deficits appears to differ across ADHD and autism. Molar EF deficits are more severe in the latter than the former. In the few studies of more specific EF tasks, there are impairments in motor inhibition in ADHD but not in autism, whereas there are impairments in verbal working memory in autism but not ADHD. We close with a discussion of implications for future research.