DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY

REVIEW

The development of emotion and empathy skills after childhood

brain injury
JAMES TONKS
PHIL YATES

PHD

DCLIN

| ALAN SLATER PHD 1 | IAN FRAMPTON DCLIN 2 | SARAH E WALL PHD 1 |

| W HUW WILLIAMS DCLIN PHD 1

1 School of Psychology, University of Exeter, Exeter, UK. 2 Cornwall Partnership NHS Trust, Cornwall, UK. 3 Royal Devon and Exeter Hospital, Exeter, UK.
Correspondence to James Tonks, University of Exeter, School of Psychology, Washington Singer Laboratories, Perry Road, Exeter EX4 4QG, UK.
E-mail: j.tonks@exeter.ac.uk

PUBLICATION DATA

Accepted for publication 4th June 2008.

ACKNOWLEDGEMENT

Huw Williams' contribution to this paper was

funded by a grant from the Economic and
Social Research Council (RES-062-23-0135).

Lasting socio-emotional behaviour difficulties are common among children

who have suffered brain injuries. A proportion of difficulties may be attributed to
impaired cognitive and or executive skills after injury. A recent and rapidly
accruing body of literature indicates that deficits in recognizing and responding
to the emotions of others are also common. Little is known about the development of these skills after brain injury. In this paper we summarize emotionprocessing systems, and review the development of these systems across the
span of childhood and adolescence. We describe critical phases in the development of emotion recognition skills and the potential for delayed effects after
brain injury in earlier childhood. We argue that it is important to identify
the specific nature of deficits in reading and responding to emotions after brain
injury, so that assessments and early intervention strategies can be devised.

Epidemiological studies of children admitted to emergency

departments with head injuries have recently drawn attention to the increased risk for both male and female children
across all levels of injury severity. This has been found in
the USA1,2 where 40% of all attendees for traumatic brain
injury (TBI) are under the age of 14 years. In the UK, rates
have been found to remain relatively high up to the age of
20 years, but with moderate to severe head injuries in
urban males and females under 5 years being highly represented.3
Emotional and social behaviour difficulties are very
common among children who have suffered an acquired
brain injury (ABI). Anderson4 suggests that children with
ABI typically display emotional distress, poor conduct, or
problematic peer relationships. Anderson et al.5 report disruptive behaviour, poor empathy, and lack of moral reasoning in a sample of older children as a result of TBI
sustained under the age of 5 years. Behavioural change of
this kind is often more problematic and concerning for
parents than cognitive deficits.6
These symptoms may persist as long-term difficulties,
and can endure into adulthood with lasting and disturbing
consequences.7,8 Research carried out with prison popula8

The Authors. Journal compilation Mac Keith Press 2008

DOI: 10.1111/j.1469-8749.2008.03219.x

tions indicates that untreated childhood brain injury is a

factor in predisposing an individual to violent crime in
adulthood.7 Adults who have suffered brain injury in childhood are twice as likely to develop mental health disorders.8 Despite such enduring difficulties, the relationship
between brain injury in childhood and lasting socioemotional disturbance has received little attention, or scientific scrutiny, and is relatively unexplored in comparison
to adult brain injury.
A proportion of children who display emotional and
social difficulties post-injury may have at least some of
their difficulties accounted for in terms of secondary effects
(e.g. family dysfunction, depression, or adjustment problems brought on by the realization of ABI and its limitations), but other research suggests that the injury itself is
the direct cause.4
Injuries can result in impaired visual or verbal processing speed, poor attention and concentration, visuoperceptual spatial processing problems, poor memory, and
impaired language or executive skills.9 Some of these skills
are reported to be necessary for synchronicity in social
situations. For example, Anderson et al.5 and Ylvisaker
and Feeney10 attribute socio-emotional difficulties to

impaired executive function in childhood. Eslinger and

Biddle11 suggest attention difficulties and impulsivity are
causal factors. In non-injured children and adolescents
the emergence of more skilful social responses has traditionally been associated with greater conscious control
over intrinsic emotional arousal and improved cognitive
functioning (working memory, attention, executive functions), which is facilitated by growth of the prefrontal cortex.12 Given this view, cognitive functioning may be
regarded as essential in guiding the appropriate adjustment
of behaviour according to the rich complexities of social
rules and demands.13
However, social functioning requires the rapid processing of emotionally valenced stimuli, in ascertaining the
intentions, motivations, and emotional reactions of others.
Essential emotional signalling information is conveyed by
facial expression, vocal prosody, and expression in the eyes.
In discussing child brain injury and recent adult brain
injury research, the present authors suggest that while cognitive abilities are important in guiding appropriate socioemotional behaviour, other skills, utilized in recognizing
the emotional state of others, are also essential.14 Few studies have explored the development of emotional expression
recognition abilities, how these may be related to increased
social competence in children, and how brain injury may
impair the expression and or development of these skills.
In this paper we outline the three distinct levels of processing involved in recognizing and responding to emotion
in others, and review the current literature on the development of emotion processing across the span of childhood.
We also discuss the complex issues that arise when considering emotion recognition impairments in children with
brain injuries.
Within this framework we note the importance of a temporal (early vs late) evaluation of the effects of insult. This
explicates the effect of brain growth, subsequent to ABI,
during various stages of childhood. Thus, consideration of
the effects of age, possible critical periods in development, and potential for delayed developmental effects, is
most important.15 It is our view that, in working with children after brain injury, an understanding of how deficits
may arise in the context of development is essential.

IMPAIRMENTS IN EMOTION AND INCREASED RISK

OF OFFENDING BEHAVIOUR IN LATER LIFE
Brain injury sustained in childhood can have severe psychosocial consequences if the effects of such an injury are not
recognized, treated, and planned for.7,8 There is emerging
evidence of links between brain injury and crime. However,
it must be acknowledged that the risk factors for crime and
for TBI may overlap and therefore the relationship may, to
a degree, and in parts, be coincidental and not causal.16

Studies of TBI prevalence rates in prison populations

reveal that prevalence estimates of brain injury within a
forensic context vary considerably, with 25 to 87% of
inmates reportedly experiencing a head injury.1719 In
investigating associations between head-injury and crime
in the general population Timonen et al.8 undertook population-cohort based research in Finland (involving more
than 12 000 participants). The authors identified head
injury frequencies of a type and severity that closely
matched UK prevalence rates.3 Children and adolescents
who had sustained injuries were found to be four times
more susceptible to later life mental health disorders.
Coexisting offending behaviour was commonly reported in
adult males who had sustained a TBI during childhood.
Children who had sustained their injuries before 12 years
old were found to have committed crimes significantly earlier than those who had a head injury after this age. The
earlier onset of offending in those injured earlier suggested
a degree of causality between injury and crime.
After childhood brain injury, impaired socio-emotional
communicative skills increase the risk of offending. Children and adolescents with TBI typically experience difficulty in understanding the social situations in which they
find themselves. They make poor social judgements and
lack communication skills essential in negotiating in conflict situations.16 Such difficulties may be associated with
problems in regulating emotions ) typically related to
executive disorders. Interestingly, in this context, there is
evidence that criminals noted as psychopathic may have
inefficiencies in activation patterns between neurological
systems for social-emotional processing. Birbaumer et al.20
present fMRI evidence indicating that frontal and limbic
systems (amygdala, hippocampus, and insula) are involved
in responses to situations that require empathy and fear
responses, and that psychopathic criminals lack activation
in limbic structures compared to controls. Mobbs et al.21
suggest that inappropriate emotion recognition (e.g. being
unable to recognize fear in another) is associated with
behavioural dyscontrol in violent encounters. The development and function of these structures is the focus of this
review.

THREE LEVELS OF EMOTION PROCESSING

Marked qualitative differences exist in terms of the underlying emotion processing impairments that children with
ABI have. This is essentially because a variety of brain areas
are involved in guiding socio-emotional behaviour.14,22
Frith and Frith23 suggest that the ability to make inferences
about the emotional intentions of others is a product of a
number of subsystems in the human brain. Adolphs24 also
views emotion recognition ability as a product of multiple
information systems operating in parallel. In discussing the
Review

External stimuli
Thalama
amygdala pathway.

Functional at birth enables

association learning

Intrinsic emotional arousal/control system

Amygdala.
Emotion recognition.
Eye gaze detection/reading

Hippocampus
external context
information

Emotional response

Develops rapidly during the 18

months following birth, with an
identifiable further significiant
stage of improvement at
around 11 years old

Sensory/spatial analysis system.

Face expression
analysis

Vocal analysis

Eye configuration
analysis

Executive system synthesis.

Develops throughout
childhood and adolescence,
assuming increasing executive
control over emotions.

Affect perception

Executive functioning
Emotion regulation control

Figure 1: A model of the development and emergence of the emotion recognition processing system (adapted from Tonks et al.).14

psychological and neurological mechanisms that underlie

facial expression recognition, Adolphs24 distinguishes
between recognition and perception of facial expression.
He notes that multiple brain structures are integral in recognizing facial expression.
The present authors have indicated that emotion processing can be seen to occur at three levels.14 These are
presented in Figure 1. We summarize these levels here.
For a more detailed discussion of the components of the
emotion processing system see our groups previous
work.14
The first level of processing is a fast recognition
response system, which can be called the intrinsic emotional
arousal and control system. The structures of intrinsic emotional arousal control are largely subcortical. Adolphs24
and Rolls25 identify the amygdala and hippocampus as
essential components of emotional arousal and control.
At the second level of processing, more sophisticated
cortical subsystems become involved in emotion recognition. These serve to moderate or confirm initial
non-conscious recognition through more detailed analysis.
Both the amygdala and orbitofrontal cortex have response
neurons that become active when presented with emotionally valenced stimuli. These enable reward-based associative learning of visual or auditory emotional displays.25,26 A
variety of sensory and spatial information processing path10 Developmental Medicine & Child Neurology 2008, 51: 816

ways converge on the amygdala, which serves the purpose

of triggering an appropriate non-conscious emotional reaction. Hence this level of processing may be termed sensory spatial analysis.
The third level of processing involves the synthesis of
emotion and cognition in guiding thought and action.
Research on executive functioning,27 and somatosensory
representation28,29 suggests subtle interplay of higher cortical processing is involved in adjusting responses to emotional displays in synchronized interaction. Executive
functioning exerts conscious and purposeful control over
emotional reaction. This is based largely on contextual
knowledge and the ability to empathize with others emotional states of mind.24,29 In this way, emotional responses
can be modulated to enable goal-orientated interaction,
although it must also be said that this conscious control
relationship is non-consciously reciprocal; emotions and
cognition are integrated so that emotion largely predetermines conscious thought.30 This level of processing can be
referred to as executive system synthesis.

THE DEVELOPMENT OF EMOTION RECOGNITION

SKILLS IN CHILDREN AND ADOLESCENTS
Intrinsic emotional arousal and control and eye gaze
Studies indicate that intrinsic emotional arousal is functional from birth. Schaffer,31 for example, reports that some

non-cognitive primary emotions are present from birth,

while others emerge in subsequent phases of development
(when possessing them will provide adaptive and communicative benefit). Schaffer31 attaches communicative significance to two bipolar emotions that are easily identifiable
from birth: distress and pleasure. Other primary emotions
present within the first 6 months from birth are: surprise,
interest, anger, sadness, and fear.32 The expression of these
emotions in early infancy appears to be primarily reflexive,
and does not rely on higher order cortical processing, while
providing the physiological basis for an adequate stimulus
learning mechanism in the absence of higher order systems.
These early and primary emotions are manifest in distinctive facial expressions that include smiling and crying,
together with other behavioural indices that serve to communicate affective state and function as social signalling.
With innate stimulus learning mechanisms in place, and
equipped with the capacity to communicate basic emotions, the prerequisites of sophisticated patterns of communicative value quickly emerge in young infants. Schaffer31
and Lewis32 suggest that enhancing such skills into a complex repertoire of social signalling requires the emergence
of the type of cognition related to self that is known as consciousness (from around 8)9mo), and subsequent cognitive
development and social experience.

involve: (1) reading emotions from eyes and understanding

of gaze; (2) vocal analysis; and (3) facial expression analysis.
Ability to process these emotional cues would seem to
develop in a distinct pre-verbal period of personal history,
without the aid of conscious memory systems that rely
largely on mature cortical processing.
Schaffer31 stresses that eye gaze has biologically-based
qualities, and that young infants, in the first few weeks of
life, smile reflexively at crude stimuli that may resemble
eyes. In discussing gaze cycles, Schaffer31 suggests infants
engage in rhythmic periods of gazing and looking away, in
order to moderate arousal levels and ensure control over
excitement gained from gazing at another person. Such
cycles double in frequency in the first 6 months of life, suggesting increased ability to control stimulation with cortical development.
Regarding vocal analysis, Schaffer31 states that affective
prosody and facial expressions convey messages about
emotional state and temperament. These are essential as
sources of interpersonal information, which infants can
combine in differentiating their mothers emotional states
by 5 months. Thus, infants can respond emotionally to
mothers relatively early on, while rapid cortical development enables and enhances more skilled recognition of
these social signalling cues.

The formation of sensory spatial analysis subsystems

Social interactions of ever-increasing complexity require
rapid improvements in the ability to recognize and understand emotions in others. Evidence indicates that relatively
sophisticated skills can be observed in young children.
Baron-Cohen33 demonstrates that females are skilled in
empathizing tasks, and this reflects in response to others distress from age 1, and using a theory of mind from age 3, while
males develop these skills slightly later. Indications that
children possess such empathetic skills are not entirely
recent. Developmental models of empathy, such as that of
Hoffman,34 indicate that primitive forms of empathizing
are evident in infancy. Although they are innate reactions,
the reactive responses of an infant are thought to be precursors to future developments in empathizing. Empathy
skills become increasingly more established throughout
childhood following the emerging sense of person permanence in the first year of life. Light,35 for example, demonstrated the capabilities of 3-year-old children in judging
emotions. Significantly, the children could recognize situations in which such emotional reactions would be appropriate. Thus, empathy with others was being demonstrated.
On the basis of these findings and those from other similar studies, there is a logical likelihood that the formation
of sensory spatial analysis systems takes place very early in
life. Three easily identifiable emotion recognition skills

Critical phases in the development of emotion recognition

skills
Bowers et al.36 suggest that emotion recognition skills
develop rapidly during early childhood and then remain
relatively stable throughout the rest of childhood and adult
life. Certainly, as we have described, by 3 years of age the
child possesses a complex and elaborate emotional system
which will continue to be enhanced and expanded. Indeed,
the 3-year-old child shows those emotions that Darwin
(cited in Lewis) characterized as unique to our species.32
Research indicates that these skills are subject to a further
critical phase of development before the transition period
between childhood and adolescence.
Kolb et al.37 initially demonstrated that improvement in
facial expression recognition arises in phases at around 10
and 14 years of age; periods that, they retrospectively suggest, appear to be close to periods of maturation associated
with brain growth spurts.38
Baron-Cohen et al.39 suggest that there may be similar
phases of improvement in relation to the ability to read emotion from eyes. Baron-Cohen et al. developed the Mind In
The Eyes Test to establish that a sample of 15 children with
Asperger syndrome could not determine emotional intent
from eye configuration. The comparative sample of 51
healthy children in the study demonstrated uniform
improvement in stages at around 8 and 10 years of age.
Review

11

Tests of childrens abilities to infer emotion from speech

also indicate that such skills are subject to developmental
improvement. Morton and Trehub40 demonstrated that 4year-old children judge emotion from literal language content, whereas adults additionally rely on affective prosodic
tone. Children aged between 4 and 10 years show a gradual
transition towards (adult-like) reliance upon affective cues
in speech.
The extent to which these studies present trends that
can be viewed as representative of the larger population is
restricted by sample size. Importantly, however, they provide a possible indication that as the demands of the social
environment increase with development, emotion-recognition abilities undergo periods of development in response.
An identifiable phase of rapid socio-environmental change
occurs with the onset of adolescence, as children become
more adult-like in their social interactions.38,39
To explore this further, the present authors investigated
whether adolescence is a period during which skills in recognizing emotions improve.41 Measures of emotion processing were used in tasks that required sixty-seven 9- to
15-year olds to read emotion from voices, eyes, and faces.
A significant stage of improvement in facial expression recognition, and reading emotion from eyes, was found to
occur at around 11 years of age.
In considering the range and intensity of emotions
humans can display, and why improvements may take place
in reading expressions with development at around 11
years of age, it is plausible that increasingly complex social
interactions after the age of 11 may place greater demands
upon the brain systems responsible for sensitivity to emotional expression. Turkstra42 identifies eye contact gaze,
facial, and vocal expression as increasingly important in
adolescent interaction. It is possible to envisage that, after
childhood brain injury, a failure to attend to such cues
appropriately in interaction with peers or figures that are
formative (e.g. teachers or parents), will affect popularity,
self-esteem, and self-concept.43
Turkstra42 suggests that, at around 10 years of age,
interaction becomes more complex as a product of psychosocial development, greater personal and social awareness,
independence, self-image, moral consistency, etc. Given
the rudimentary nature of emotional expression monitoring skills in interaction, it is feasible that increasing external social demands in interactions would be a factor in the
enhancement of these skills across the transitional period
into adolescence.

Executive system synthesis

In children and adolescents, the emergence of more skilful
social responses has traditionally been associated with
greater conscious control over intrinsic emotional arousal
12 Developmental Medicine & Child Neurology 2008, 51: 816

and improved cognitive functioning (working memory,

attention, executive functions), which is facilitated by
growth of the prefrontal cortex. The highest stages of emotion processing (involving synthesis between intrinsic and
sensory spatial systems) rely on executive skills, and are
much more in step with cognitive development.
Conscious affect perception develops rapidly from the
middle of the first year of life (and in this sense it is usefully
viewed as a product of sensory spatial system development), but is also inextricably linked with social understanding. Baron-Cohen et al., for example, demonstrates
that affect perception, indicated by ability to detect social
faux pas, becomes more sophisticated with development.44
The ability to detect the presence of a faux pas is one of
the more advanced aspects of theory of mind.
However, less sophisticated components of theory of
mind are evident earlier in childhood. Over the first 3 to 4
years of life, a child develops increasing understanding of
the functions of the mind. Perner and Lang45 discussed
this developing ability, with 18-month-old infants, demonstrating the ability to infer anothers intentions to grasp an
object that they are observing. Gradually there are developments in understanding and engaging in pretence behaviours during the second year of life, described as a
primitive expression of theory of mind abilities.46
During the third year, children begin to comprehend
the possibility of individuals misconceiving situations. This
skill is established by around 4 years of age.45 More complex theory of mind, such as the ability to detect the presence of a faux pas, is not established until later in
childhood. Baron-Cohen et al.44 determined that females
are typically able to detect a faux pas between the ages of 7
and 9 years, while such ability is not typically consolidated
until later in males, between the ages of 9 and 11 years.
Hence, there is a continuing development of social understanding throughout the childhood years, as well as sex
differences in such developments, as evidenced in theory of
mind skills. Similar protracted developments in social
understanding are described in studies of empathic reasoning.34,47,48 This developmental dimension can only be
associated with growth of the prefrontal cortex, which in
turn influences perceptual understanding of the affective
states of others.

Can brain injury selectively impair a child's ability to

read emotions?
Brain injuries that result in difficulties in recognizing
emotional expression would have profoundly negative consequences for children. Understanding of the communicative emotions of others and the capacity for mutual
influence would be lost.49 Such deficits would have devastating effects on social and intellectual development.

The present authors investigated potential differences in

emotion processing skills displayed by a cross-section of 18
children with brain injuries, compared with 67 matched,
non-injured controls.22 The sample of children with brain
injuries was found to be significantly less adept at reading
emotional expression as conveyed by faces, voices, and eyes
compared with non-injured controls. These effects were
not solely due to problems with cognition, rather they were
impairments in processing emotionally-laden stimuli.
The study indicated that the proportion of with ABI
children with emotion recognition difficulties may be more
prevalent than practitioners currently realize. Further, it
provided support for the view that brain injury in childhood can result in damage to any part of the emotion processing system we have described. Thus, injury may be to
the detriment of emotion-processing systems, or the particular systems associated with the cognitive skills that may
underlie the processing of emotions. Williams50 advocates
the need to distinguish between composite effects of injury
in socio-emotional disturbance, resulting from ineffective
executive functioning for example, and specific effects,
which may lead to more circumscribed forms of impaired
emotional processing, such as an inability to process
others emotional expression. Specific effects could remain
undetected by current cognitive-focused clinical neuropsychological assessment, and would significantly and
detrimentally disrupt social interaction as children mature.

Temporal (early vs late) effects of brain injury in

childhood
Unlike the fully formed adult brain, the childs brain is
subject to significant alterations in neural functioning during specific phases of childhood and adolescence.14 Rapid
development during the first 1 and a half years of life
occurs with a 30% brain growth spurt. Subsequent 5 to
10% growth spurts are identifiable at 2 to 4 years, 6 to 8
years, and 12 to 14 years.38 The prefrontal cortex, which is
intimately implicated in emotional development, develops
across the span of childhood and adolescence into early
adulthood.12
The delayed onset of social or emotional difficulties in
children with ABI is frequently related to compromised
prefrontal cortex development and impairment to executive cognitive control.51 Children who sustain brain
injuries in early childhood frequently experience socioemotional behavioural difficulties in later childhood, when
the proficient application of these skills in social situations
becomes more challenging.12 Hence, deficits involving
executive synthesis may remain hidden until later childhood or adolescence, when problems emerge to disadvantage sufferers in social relationships. Given the evidence of
phases in development of emotion recognition (presented

above) there is potential for delayed effects of deficits in

recognizing emotion too. These may also remain hidden
until early adolescence.
The potential for the effects of early childhood brain
damage to emerge at a later stage of adolescent development has important clinical implications. Children with
early ABI may make a good physical recovery, receive swift
discharge from paediatric follow-up, and, in most cases,
are returned to mainstream schools. Their future need for
psychological support may remain unmet or may be misattributed to other causes.

CLINICAL IMPLICATIONS
Assessment
Given the importance of emotion processing for human
psychological functioning it is not surprising that many
areas of the brain are implicated in such processing, and
that differential effects may result from damage to different
areas of the brain.52 The hidden deficits in recognizing
emotion that we have identified are pervasive, yet difficult
to detect. Clinicians working with children with brain injuries do not routinely assess emotion and empathy abilities
because of a lack of information about the emotional
sequelae of injury.53 The initial challenge for practitioners
working with children with brain injuries will be to identify
those who are in need of additional intervention to target
deficits in emotion. Preliminary measures have been developed by the authors,41 but it remains important to develop
sophisticated measures to assess emotion recognition skills
in children after injury.
Formulation and intervention
Awareness of the effects of brain injury during childhood,
and its long-term implications is currently limited. Neuroplasticity and natural recovery after childhood brain damage cannot be depended upon.53 Practitioners should be
mindful of the sleeping effects of brain injury when formulating the underlying causes of socio-emotional difficulties. Research indicates that an integrative approach to
formulation, utilizing a social contextual focus is most
effective.54 Thus work should be undertaken with the individual, but also with the wider systems (or social contexts)
in which difficulties arise.
While schools are in an ideal position to deliver interventions and work closely with students with post-injury
socio-emotional difficulties, for young people with a
history of brain injury there is a significant risk that their
schools will not have the mechanisms in place to provide
continuity, or to inform staff of the additional challenges
they face. Peer relationship problems and problematic
interactions with staff risk being misconstrued and mismanaged, contributing to further difficulties. Part of this
Review

13

lack of awareness can also be a consequence of the delayed

onset of difficulties, reflecting the later failure in development of regions of the brain in adolescence that were compromised by brain injury during an earlier stage of
childhood.
The first stage in an intervention to support students
with brain injury in returning to school is simply to have in
place the mechanisms to identify students with a history of
brain injury and to provide advice and support for teachers
regarding the implications for subsequent social and educational development. In the UK, the Childrens Brain
Injury Trust (CBIT: http://www.cbituk.org) in conjunction with The Encephalitis Society has produced a psychoeducational resource in the form of a DVD titled Must
Try Harder for educational professionals to use. Teachers
are provided with a basic introduction, which encompasses
the implications of ABI during the school years, and makes
helpful recommendations for classroom practice.
Given that deficits in recognizing emotions in others
can be a discrete outcome of early brain injury, retraining
of impaired skills, using methods developed for young people with autistic spectrum disorders may prove to be successful. Golan and Baron-Cohen,55 for example, have
developed a Mind Reading programme, designed for
individuals with autism spectrum disorder as a systemizing
approach to empathizing. The programme aims to use
strong abilities (systemizing) to facilitate improvement in
areas of weakness (empathizing).33 The programme aims
to improve the recognition of a range of emotions across
different modalities. Despite limited generalization, the
authors observed improvement in emotion recognition
skills across a range of complex emotions and different
modalities, within a relatively short period of time. Such a
technique may therefore prove valuable with a braininjured population.
Cognitive rehabilitation resources are already in place
that can be used in working with individuals. In our clinical
practice with students aged between 11 and 14 we have
been testing a DVD version of the Cognitive Behaviour
Therapy programme Think Good: Feel Good56 for therapist-guided individual work with students with brain injuries. Developmental programmes designed specifically for
young people have the advantage over adult-oriented programmes of incorporating specific skills training around
the relationship between feelings and thoughts in learning
how to interpret somatic markers as clues to emotional
states.
For older students, individual programmes initially
developed to address impulsivity in students with attention-deficit)hyperactivity disorder can be helpful. We
have noted that Stop and Think programmes are useful in training students to take more time to process
14 Developmental Medicine & Child Neurology 2008, 51: 816

and understand their emotional state before making a

response. As with all such programmes, frequent sessions with opportunity to play back real world situations that have gone wrong are helpful to contextualize
learning.
While there is a clear rationale for trialling these
interventions, we do not have the evidence to recommend
one specific intervention programme above others. The
effectiveness of early intervention upon positive outcome is
also yet to be evaluated. This will be the subject of further
work.

CONCLUSION
We have seen in this review that emotion processing is carried out by a multifaceted system, which is dependent upon
unitary subsystems and systems that are generally associated with executive functioning in effective operation. We
have reviewed emotion-processing development in noninjured children and demonstrated that emotion-processing skills are subject to critical periods of rapid development as children develop. Evidence indicates that social
and emotional deficits can occur as a direct consequence of
injury to any system associated with emotion processing.
Age at which injury occurs and age when skills may be
assessed are therefore crucial considerations. Although
research offers some indication as to when separable processing systems emerge, knowledge of normal performance
levels in relation to age is essential if the full extent of the
effects of injury is to be recognized. If the long-term outcomes for children with ABI with lasting social and emotional deficits are to be improved upon, it is clearly
important to identify the specific nature of such deficits
and to develop and put in place interventions.
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