Socio-emotional processing in children, adolescents and young adults with traumatic brain injury

Objective: The significance of socio-emotional deficits in children, adolescents and young adults with traumatic brain injury (TBI) has been identified by a number of studies. However, the literature is poorly integrated. This literature review aimed to integrate the evidence base using Ochsner’s (2008) socio-emotional processing stream. Method: The online databases, PsychInfo and Web of Knowledge, were used to search for relevant available papers written in English during available years of publication until 2014. A number of youth, TBI, socio-emotional processing and offender search strings were used. Results: Twenty one studies were identified, mapping onto three of the five constructs of Ochsner’s (2008) model. Children, adolescents and young adults with TBI demonstrated impairments in recognition and response to social affective stimuli, high-level mental state inference and context sensitive regulation (constructs 2, 4 and 5). Conclusions: This review has highlighted that children, adolescents, and young adults who had a TBI experience a range of socio-emotional processing difficulties. Only some of the identified difficulties can be mapped onto Ochsner’s (2008) model and therefore, it may not be a suitable model for socio-emotional processing in this TBI population. Further research is required to increase the understanding of socio-emotional processing for this population and to explore suitable models. LITERATURE REVIEW: THE SOCIO-EMOTIONAL PROCESSING STREAM IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS WITH TRAUMATIC BRAIN INJURY 3 Introduction Childhood, adolescence and young adulthood have a high prevalence of traumatic brain injury (TBI), making TBI a leading cause of disability (Langlois et al., 2006; Yates, Williams, Harris, Round, & Jenkins, 2006). TBI prevalence rates, of all severities, in the general population have been reported at 5%-24% (McGuire, Burright, Williams, & Donovick, 1998), with a peak risk in adolescences (Yates et al., 2006). Brain injury is typically associated with neuropsychological, psychosocial and behavioural difficulties (Croker & McDonald, 2005). Recent studies suggest that socio-emotional deficits are prominent when TBI has occurred during childhood and remains persistent throughout development (Eslinger, Flaherty-Craig, & Benton, 2004; Tonks et al., 2009; Turkstra, McDonald, & Depompei, 2001). Evidence indicates that there are many brain structures and considerable overlap involved in socio-emotional processing (Johnson et al., 2005). For example, the prefrontal cortex, anterior cingulate, amygdala, insular, hippocampus, orbitofrontal, temporal, parietal and occipital cortices of the brain have all been associated with verbal and/or visual socio-emotional processes (Beason-Held, Goldski, Kraut, Esposito, & Resnick, 2005; Ochsner, 2008; Haxby, et al., 1991; Tonks et al., 2008). Consequently, socio-emotional processing is particularly susceptible to the crowding effect caused by neuro-plasticity (Anderson Catroppa, Morse, Haritou, & Rosenfeld, 2005). Following early childhood brain injury, neuroplasticity and recovery may allow a child to make good physical recovery, 1 Age bands were based on the World Health Organization (1999) categories: under 10 years of age: children; 10-19 years of age: adolescents; 20-25 years of age: young adults. 2 The preferential neural reorganisation and regeneration following brain injury of certain brain functions (e.g. language) at the expense of other functions (e.g. visuo-spatial) leading to potential developmental limitations (Stiles et al., 2000). 3 Functional recovery as a result of neural reorganisation and regeneration following brain injury. LITERATURE REVIEW: THE SOCIO-EMOTIONAL PROCESSING STREAM IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS WITH TRAUMATIC BRAIN INJURY 4 receive swift discharge from paediatric follow-up and even return to mainstream school (Tonks et al., 2009). However, deficits involving executive synthesis may remain hidden until later childhood or adolescence (Tonks et al., 2009). An individual who has suffered a childhood brain injury may not have developed the necessary skills to deal with demanding social situations (Tonks et al., 2009). As a result, social problems, such as inappropriate social responses, may begin to emerge. Such actions could be detrimental to social functioning and put an individual at greater risk of socially unacceptable behaviour. This has important clinical implications when considering rehabilitation following childhood, adolescent or young adulthood TBI. A number of socio-emotional processing models have been developed. For example, based on the child social information and adjustment literature, Crick and Dodge (1994) developed the social information processing (SIP) model involving five distinct cognitive stages that occur in response to a social situation (encoding, representation, response searching, selecting a response, acting). However, social interaction is not just a cognitive process (Ochsner, 2008) and subsequently, Lemerise and Arsenio (2000) revised the SIP model (Crick & Dodge, 1994) to include emotion processing. Tonks et al. (2009) proposed a three stage developmental model of emotion recognition for children and described the potential detrimental effects of childhood TBI within the model. The first stage of Tonks et al’s (2009) model is a fast unconscious recognition response that relies on subcortical brain structures (developed from birth). The second is a conscious process of emotion recognition involving more sophisticated cortical subsystems (developed at approximately 18 months old) and the third requires the synthesis of emotion and cognition to guide thought and response (developed throughout childhood). Although LITERATURE REVIEW: THE SOCIO-EMOTIONAL PROCESSING STREAM IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS WITH TRAUMATIC BRAIN INJURY 5 the models described above share common themes, none of them combine cognitive, emotional and neurological processes. Lemerise and Arsenio’s (2000) model does not consider cortical structures. Tonks et al.’s (2009) model describes the critical phases in childhood social emotional and neurological development, but does not break down and categorise these processes. Synthesising concepts described in Crick and Dodge’s (1994), Lemerise and Arsenio’s (2000) and Tonks et al’s (2009) studies, Ochsner’s (2008) socio-emotional processing model incorporates both affective/unconscious and cognitive/conscious processes and considers the cortical structures involved. Ochsner (2008) used the emerging neural, social and emotional research base to construct a framework. The five constructs of the socio-emotional processing stream are distinct in cognitive process and neural systems (figure 1; Ochsner 2008). According to Ochsner’s (2008) model, the constructs lie along a hierarchy of processes in which we: learn the value of a stimulus (construct 1); re-encounter it and recognise its value (construct 2); understand the beliefs and feelings of a stimulus (including oneself) in a bottom-up, experiential (construct 3) or top-down, attributional manner (construct 4); attempt to regulate responses to a stimulus in a context appropriate manner (construct 5). Although the evidence base is limited, Ochsner’s (2008) socioemotional processing stream appears to create a platform to consider cognitive, emotional and neurological processes together. These are important to consider following brain injury and make it a potentially appropriate model for TBI. The model provides the opportunity to identify and isolate specific socio-emotional processes and it could therefore, facilitate the LITERATURE REVIEW: THE SOCIO-EMOTIONAL PROCESSING STREAM IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS WITH TRAUMATIC BRAIN INJURY 6 targeting of specific behaviours and emotional processes that may require intervention. Furthermore, the model’s synthesis of the cognitive, emotional and neurological processes may allow the formulation of a heuristic that could enable the identification of gaps in the literature and develop testable hypotheses. Social functioning (Rosema, Crowe, Anderson, 2012) and emotional development (Tonks et al., 2009) following childhood and adolescent brain injury has been reviewed. However, to the author’s knowledge there appears to be no literature review assimilating all the experimental research into a socio-emotional model following childhood, adolescent or young adulthood TBI. This review aimed to identify the TBI socio-emotional literature, integrate the results into Ochsner’s (2008) model and test the suitability of the model for the childhood, adolescent and young adult TBI research base. LITERATURE REVIEW: THE SOCIO-EMOTIONAL PROCESSING STREAM IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS WITH TRAUMATIC BRAIN INJURY 7