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Child Neuropsychology

A blog by Dr Jonathan Reed

  • Our ability to control our impulses is a key executive skill that marks us out as human.  Rather than just reacting to the environment we can choose what responses to make in any given situation. However anyone temped by chocolates or distracted by Facebook or Twitter will know that self control can be hard.  It requires some mental effort.   This ability to control impulses develops throughout childhood and individuals differ in their ability.  There are also a number of developmental conditions where individuals have difficulty in self control including ADHD and brain injury.   The ability to self control requires attention and response inhibition (i.e stopping responding automatically).  These abilities are associated with the Prefrontal and parietal areas of the brain.  There has been some research showing it is possible to improve these abilities but these tend to be experiment based and not freely available- see Yang and Posner for example.  I therefore decided to develop another Neurogame based on attention and self control.  It is called Impulse Control and is available in iTunes for iPhone and iPad.  It is my attempt to find a fun way of testing and improving attention and self control.  It is based on the neuropsychological theory behind these functions.  The game is designed for all ages and becomes progressively harder the more you play.  The idea is that by practice you will become better in terms of attention and self control. The game is free and can be found on iTunes.   You can monitor your training using the training report in app feature.  Try it and give your brain a workout and let me know how you get on.

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  • Dyscalculia is a type of specific learning difficulty where individuals have difficulty in understanding basic concepts in maths. It is surprisingly common affecting 6-7% of the population.  However it is not so recognised in the same way that dyslexia (problems with reading) is.  The key problem in dyscalculia seems to be difficulty in understanding numersiories, which is the ability to automatically recognize the number of objects in a set. Understanding Numerosities seems to be neurologically based and is associated with the intraparietal sulcus in the brain.  Treatment for dyscalculia is not readily available.  I was interested therefore to be sent an app called Babakus by a Swedish psychologist Björn Adler.  You can purchase on the iTunes store here.    The app is designed to help people with dyscalculia.  It works on the same principal as an abacus but with real numbers.  Therefore the learner can associate numbers with quantity when performing calculation.  Thus it helps the learner bridge the gap from objects or fingers to numbers when undertaking maths.   The app is well made and worked well in the trials I gave it.  It is a bit fiddly at first and requires reading the guide to work out how it works.  However once you are used to it it works well.  Using it on the iPad gives it a multi sensory element.  The app contains a video teaching guide, instructions and also contains an eBook about dyscalculia by Björn Adler.  The app is relatively expensive at £20.99 in the UK app store, but is I guess good value compared to other interventions for dyscalculia.  Whilst the app is based on the science of dyscalculia, there is no research as yet looking at outcome.  I understand that research is planned, however some caution about the efficacy of the app is needed until then.   I would recommend trying this app if you have a child or young person struggling with understanding basic maths concepts.   It is a welcome tool in an area where there are few good interventions.  (Note: I have no financial interest in this app and have not been paid to review it.)

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  • I have recently been reading a very interesting book on the impact of technology on children.  The Curiosity Cycle by Jonathan Mugan is particularly interesting because Jonathan has a degree in psychology and is a researcher in machine learning.  His area of research is about how robots can learn about the world in the same way that human children do.  He is in a good position to tell us about what is happening with robot development and what we should do about it.

    The book is divided into three parts.  Firstly there is a section on how children construct a view of the world and how this can used to stimulate curiosity .  This section is packed with ideas for parents and teachers about how to encourage curiosity in children.  Jonathan is particularly good at tips for stimulating curiosity in Math, normally a hard subject to be interested in.

    The second section is about how children’s curiosity is shaped by physical exploration (children are embodied creatures- a very current topic) and by interaction with others.  Again there are tips on how to encourage these areas of development.

    Finally and most interesting part for me is how technology is advancing and the impact of this on children’s development.  Jonathan explains in a very thought provoking way how robots and computers are developing and the ways this will shape our children’s lives.   The pace of change he highlights is quite astonishing.   There are going to be many opportunities but also there is some caution -  “Children shouldn’t spend too much time connected since their embodied selves were meant to be out in the sunshine”.  The key point is that while computers and robots are going to be able to do amazing things, where humans have the advantage is in their curiosity.  ”Curiosity will allow your child to go beyond answering questions to asking the right questions and to make inferences beyond the information explicitly given“.

    Overall the book is very clear and readable.  It is thought provoking but also practical.  Jonathan provides a number of media resources.   I would thoroughly recommend to anyone with or working with kids now.  The world is changing and we and our children need to be prepared.

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  • Motor co-ordination is a key factor in development and also seems to be important for general brain regulation and development – see previous post.

    The i-phone and i-pad devices are unique in that they allow you to interact with games and programmes using movement and touch.  They have the potential in my opinion to develop and reinforce motor-co-ordination.  I have chosen 5 apps that I think particularly focus on key aspects of motor  co-ordination.  Games in particular are a fun way of developing skills- they are designed to engage and encourage repetitive play (practice) and all the ones I have chosen start off easy and build in difficulty over time.    Also the apps I have chosen are beautifully designed, often with a good soundtrack and most appeal to adults and children alike.

    My top 5 are:

    1.  For fine motor control –  Doodle Jump This requires fine hand control by tilting the device to allow the character to jump.  It is very intrinsically rewarding resulting in continued practice.

    2 For motor inhibition and regulationWhale Trail .  This game requires tapping the screen to make Willow the whale fly and eat bubbles. The key to success on this game is to inhibit the urge to tap the screen too much or too little and thereby avoid the hazards (thunder clouds) and  follow the rewards (swallowing bubbles).  It is fast moving and you need to anticipate what is going to happen adding an element of motor planning.   Again it is great fun, with a great sound track and very rewarding encouraging you to keep trying (and getting better).

    3  For motor planning- Bumpy Road .  This requires trying to move a car along a bumpy road by lifting the road beneath.  The game requires anticipating ahead by moving the car not too fast, jumping and avoiding hazards (rivers).   This is a beautiful app that is just fun to play for the graphics and music alone.

    4 For developing visual motor co-ordination –  Dexteria - This is a more formal teaching app focusing on tapping, letter formation and pinching objects (fine motor control).  This is definitely aimed at children but is the best example I have come across of a comprehensive  motor co-ordination teaching app.  There are timed elements which are challenging.  The app allows you to monitor progress over each session showing improvement over time.

    5 For visual motor planningFlight control – With this game you have to guide airplanes into land by tracing their flight path into the airport.  It requires anticipating future events and altering plans when you see that two planes may crash.  It gets hard when lots of planes are coming into land together .

    So if you want to improve your or your child’s motor co-ordination playing with these apps may well help.  Although I am not aware of research in this area from a clinical point of view these apps all tap abilities that are important for development of visual motor-co-ordination (and perhaps wider brain regulation).  They are also brilliantly designed, addictive and fun.

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  • Imagine being able to remember everything you have ever learnt or experienced.   Well I have just read a fascinating book Total Recall by Graham Bell of Microsoft labs which suggests that we may soon be able to do this using digital technology.  He set up a project to see whether he could digitally record everything that happened to him, in essence to create a virtual memory.

    In order to learn and remember there is the need to encode information, store and retrieve it.  We now have the technology to do all three of these cheaply and efficiently.  We presently have lots of digital recording devices including, cameras, voice recorders, word processors, emails, answering machines, scanners, PDA’s etc, that can encode information into a virtual memory.   We have very large storage capacity in the case of hard drives (you can now store vast amounts of information even on mobile devices quite cheaply) that can act as a memory store.  In terms of memory retrieval we have sophisticated search engines either on the web or built into computers to find what we need to remember.  This is the first time in history that all three components of digital memory- encoding, storage and retrieval are available in such a cheap and easy to use way.

    The implications for this are potentially huge.  In terms of personal enhancement it should be possible to have digital devices that store and retrieve everything that happens to you. No more forgetting what you have done, where you have been, facts about the world etc.   Your whole life experience could be stored on a device for future reference.  Maybe in the future when you are no longer around people will be able to review your life through such a device.  Bell documents how he records every telephone call, uses Sensecam to record all he sees, stores all his photos, scans every document and bill he receives, stores every email, stores all his medical records  and every web page he has ever seen.  Using a program he has devised he can search for any specific piece of information (memory) and retrieve it easily.  In the future it will be possible to record personal health data such as blood pressure, diet and alcohol intake and even how many steps you take on the same device and integrate it into your memory, which will make healthcare appointments much more efficient.  The book is a fascinating read and Bell believes that this is one of the key trends for the future and that we will all be able to access such technology within the next 10 years.

    As well as personal enhancement this technology has huge implications for neuropsychological rehabilitation.  One of the most devastating consequences of child brain injury is impairment of memory.  There are some techniques that we can use to help with memory retrieval (see previous post ) but these are slow and take a lot of effort to work.  It would be far easier and more efficient to use technology to compensate. It should be possible to equip children (and adults) with memory impairment with a handheld device that will enable them to recall what they have experienced and compensate for their learning and memory problems.  This would revolutionise care for individuals with amnesia and dementia.

    I would love to use this type of technology myself.  I am one of those people who wants to learn and experience everything.  I read avidly, try to keep up with the rapidly expanding neuropsychology literature and try to experience as much as possible while I can.   However the ratio of knowledge that I retain and can retrieve I think is pretty small relative to the amount of input.   At present looking at Bell’s book and the technology available, the issue is about integrating existing technology in order to create a device or program that automatically records, stores and retrieves information.  It can’t be that hard to do as much of the technology is already available.  The challenge will be creating a user friendly program or device that works seamlessly.  Ideally there would be psychology input to match the technology with human experience.   I am not aware of any company undertaking this work at present but please let me know if anyone knows whether anything like this is being created.  Maybe one day we will all be able to achieve total memory recall of everything we have ever experienced.  It could change the world as we know it.

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  • Children and adults learn and develop through play.  I am a great believer that playing computer games as well as being fun can be good for your brain.  I have therefore created a list of 10 great games that I think require very specific areas of neuropsychological function to play.  Some even have research to show that they can change brain and neuropsychological function. These games are for a range of different ages and come in different formats.  Let me know of others that could be included in the list.

    1 Portal 2 (PC/Mac) Probably one of my favourite games.  Portal 2 requires good executive function (associated with frontal areas of brain).  In particular you need to be able to problems solve and plan ahead in this game.  Also it is a beautifully designed game, showing what computer games can achieve in terms of entertainment.

    2 Call of Duty 4 (X box)- An exciting fast paced game that requires good speed of processing and visual attention.   There are a number of academic papers such as this one by Bjorn Hubert-Wallender, C. Shawn Green and Daphne Bavelier Stretching the limits of visual attention: the case of action video games that show games like these can actually improve visual attention and speed of processing.  It seems that this only applies to really fast paced games such as Call of Duty. (note Call of Duty is for age 16 and above).

    3. Tetris (ipad) A classic arcade style game that keeps you focused.  There is research by Haier et al from University of California to suggest that playing this game results in increased cortical thickness. There is also research by Emily Holmes from the University of Oxford to suggest that playing Tetris can help with symptoms of PTSD.

    4 Drop 7 (iphone).  To play this game you have to drop different balls with numerals inside into rows or columns and try and ensure that the numerals and the number of balls match i.e. every time you line five balls up the ones with the numeral 5 in them disappears.  This reinforces the neuropsychological concept of Numerosities, which is the ability to automatically recognise the number in a set.   Difficulties with this concept seem to be the underlying disability in dyscalculia ( specific deficit in maths).

    5 New Super Mario Brothers (Wii) The Wii version allows two people to play together and work in collaboration to progress through levels and therefore involves social co operation.  This would be an ideal game to play with a child with Autistic Spectrum Disorder ASD.  Playing alongside side children with ASD on a shared task  can be better than trying to directly interact with them. It is also fun to play with children and adults of all ages.

    6. Where’s Wally (ipad).  This game requires a very specific form of attention called selective attention.  This is the ability to spot a stimulus within an array of other information. This game may be helpful for children with attention difficulties.  The ipad version is particularly good with changing goals and rewards.

    7. Ball frenzy (ipad)  A good simple but addictive game requiring good visual motor co-ordination.  Similar to marbles.

    8 Bookworm (iphone).  A game requiring word finding and spelling.  This isn’t specifically designed as an educational game and is by Popcap who are great at designing addictive casual games.  It is fast moving and you are motivated by completion and reward rather than focusing on the educational side.

    9. Connect Four (ipad).  Another simple game  but requiring good executive function.  You need to resist the impulse to act immediately and plan your response.  I and colleagues have long believed that playing this game with children is a better assessment of executive function than many formal tests.

    10 Nutty Numbers (ipad)  I have including the game I have developed to help with numeracy for young children because there is research to show that it is effective in children’s development of numeracy.

  • Neuropsychologists have studied memory for a long time.   We have a clear system of memory classification involving declarative memory which includes episodic memory (memory for events) and semantic memory (memory for facts) and non declarative memory which includes more implicit systems such as procedural memory, classical conditioning and priming.  The neurological substrates of this system are understood.  Numerous case studies of individuals with brain injury and memory disturbance have been reported.   The whole enterprise is best summarised by one of the leading researchers Larry Squire in this excellent paper Memory and brain systems 1969-2009 .

    Yet despite all this knowledge I struggle to see the relevance for the many children I see with memory and learning difficulties.  I was therefore fascinated to read a new book Moonwalking with Einstein: The Art and Science of Remembering Everything by Joshua Foer.  Foer’s book is based around a strange group of people who compete in memory championships around the world.  He explains how these competitors memorise the orders of multiple packs of cards, very long strings of digits and long unpublished poems.  The amount of information they can remember is quite remarkable.  Yet Foer shows that these feats are based on some simple memory techniques.  The premise is that human memory evolved to aid survival (finding food and avoiding danger) and therefore is primarily visual and spatial (location based).  He also highlights the way the brain learns and remembers through associations.  The techniques he describes are based on creating an imaginary spatial location (a memory palace) and imagining different visual images which can be associated with what you want to remember in this location.  So for example if you wanted to remember a shopping list you may imagine your home and visualise the first item, which could be milk by imaging someone bathing in milk.  The next item may be fish and you could imagine a singing fish in the kitchen.  The more bizarre the image the better you will recall, hence the title of the book.  By recalling the location and image you can then easily recall the information.   Individuals can create huge memory palaces and remember large amounts of information this way.  Foer believed that these techniques were so powerful that anyone could become a memory champion and he sets out in the book to prove this by entering the US memory championship.  I won’t give away the ending but it is a fascinating read.

    I think that these ideas could have important implications for neuropsychological rehabilitation and teaching.  How many teachers and psychologists know about these techniques and use them?   The techniques would need some adaptation (learning packs of cards, shopping lists and strings of numbers is not that useful) but used properly it could be very helpful for children learning facts about the world or number facts or just developing more effective ways to pass exams.  Is anyone out there using these techniques to help children with learning problems? If so I would love to hear about it.

  • The founding father of psychology Sigmund Freud was fascinated by the unconscious mind and made this the centre of his study and practice.  The role of the unconscious in psychology quickly fell out of fashion.  This was because it could not be measured or easily understood.  Initially behaviourism became dominant, based on the objective analysis of observable behaviour.  Later the focus in psychology shifted to studying cognition – the study of thought processes.  Both areas resulted to different psychological therapies for example,  Cognitive Behavioural Therapy (CBT), and different ways of understanding learning.  Over the last decade or so neuropsychology has started to emerge.  Neuropsychology focuses on the relationship between the brain and behaviour (including cognition).  And guess what – as we begin to understand the role of the brain in psychology there is an increasing interest in the role of  unconscious processes (brain actions that we are not aware of consciously) .  Back to the start again- maybe Freud was right all along!

    I wrote about the importance if understanding the relationship between sub cortical structures and the cortex in a previous post. I have also just read a fascinating and very readable book by David Eagleman Incognito: The Secret Lives of The Brain.  This book looks at the dominant role that the unconscious brain plays in everyday human life.  Eagleman argues that most of what we do happens automatically and without our conscious brains being aware.  He gives numerous examples of how unconscious processes control our psychology including our attraction to others, our prejudices, our perception of the world, as well as the more obvious examples of motor control- I would really recommending reading the book to understand the richness of his argument.  He argues that conscious thought processes play a very small role in our lives,  perhaps just to allowing us to think flexibly and set goals (clearly this has big consequences as the achievements and dominance of the human species shows).  Intriguingly he also suggests that maybe our conscious self is not in control at all, but we (it) just think we are.  This was a central point in Chris’s Frith’s excellent although more academic book Making Up the Mind: How the Brain Creates Our Mental World.  Both authors report studies  showing that when you ask someone to tell when they have the urge to lift their finger and scan their brain, the part of the brain responsible for planning the action lights up before they report the urge to lift their finger.  Therefore the unconscious brain is making the decision before they are are consciously aware of it.

    Understanding the role of unconscious processes has important implications for psychology.  David Eagleman discusses in detail the implications for the criminal justice system.  Are criminals to blame for acts committed by unconscious processes (and especially when you add in abusive childhoods, brain injury, learning problems, genetics, which are all out of conscious control)?  I think there are also significant implications for child neuropsychology.  Understanding how our brains work and basing treatment and intervention on this understanding will lead to more effective intervention.  In my practice I work a lot with children with significant learning disabilities and brain injury.  Often they are unable to learn or control emotions and behaviour consciously.  I  look at ways to influence implicit processes  i.e changing the environment rather than expecting individual to change.  Also with my games company Neurogames I integrate implicit learning processes into the games, which I think is what makes them effective.  However we are only just starting to understand these processes and as our understanding increases I expect there to much more focus on sub cortical and unconscious processes in psychology.  This is not entirely easy as we create and develop psychological theories using the conscious parts of our mind, thus we are already biased.  We need to suspend our own perceptions and experience, based on our conscious view of the world and look at the data instead (a bit like theoretical physics).  Understanding how the brain actually works holds promise for major changes in psychological treatment, teaching and social policy.  Maybe we are also on the verge of a revolution in how we see ourselves?   I’ll keep you posted on ideas that emerge.

  • I want to discuss an important new book for understanding how the brain works, which I have just read and is called Subcortical Structures and Cognition: Implications for Neuropsychological Assessment by Leonard Koziol and Deborah Budding.  Our current understanding of how the brain works using Neuropsychology has traditionally focused on the cortex part of the brain – frontal, temporal, parietal and occipital lobes and has looked at what happens psychologically when there is damage to these particular areas.  From this we understand perception, memory, language etc pretty well.  However we have tended to ignore subcortical brain areas such as the basal ganglia and cerebellum and have considered these areas as being responsible mainly for motor co-ordination.   This new book by Koziol and Budding challenges this view and presents a view of sub cortical structures being central to the way the brain works.  It is a detailed book with many arguments (a summary can be seen on the website here) and needs to be read carefully, but some of the important points for me were:

    1.  The brain responds to the environment in two key ways.  Firstly most of the time it responds in an automatic way (subconscious way using procedural memory) which requires little thought, is fast and is adaptive.  You don’t need to work out how to respond to most everyday occurrences you just do it.  However, when a new situation arises, maybe a threat, maybe something you need to learn, the front part of the brain takes control and thinks about how to respond (i.e. executive function).  Both systems operate in tandem and are connected by the basal ganglia.  The default setting for the brain, however, is to make unfamiliar familiar.  This is more efficient.  Hence there is a drive to turn new information into automatic memory.

    2. Koziol and Budding argue that the basal ganglia is key in determining this process i.e. linking controlled and automatic responses.   It does this by being part of a feedback loop connecting the cortex to the limbic system (thalamus) and acting as a gate between the two. Basically the cortex is stimulated by sensory input and the sub cortex inhibits responses by deciding what information is returned to the cortex.

    3. The other main sub cortical area the cerebellum works to further fine tune responses using a mix of excitation and inhibition.

    4. The book details how and why such a system would have evolved.  This is often missing in neuropsychology accounts.  The book offers a plausible explanation of what any organism needs to function and how brains have evolved to meet these needs.  The key purpose of an organism is to survive.  In order to survive an organism needs to recognise objects, locate objects and detect movement (all cortex functions) and then to know what to do, how to do it and when to act (all mediated by the subcortex).  Koziol and Budding compare the subcortical structures in vertebrates, primates and humans to illustrate this point.

    5. The  basal ganglia acts as a gate to switch responses on and off, which is the key to regulation.  Knowing when to start a behaviour (initiation) and when to decease from a behaviour (inhibition) is key to how we function (and yet is rarely explored). The cerebellum further fine tunes this process.

    6.  Traditionally the sub cortical structures have been though of as mainly involved in motor responses.  However one of the many interesting ideas in the book is that  the same structures may have a similar  function for emotion, behaviour and cognition.  This would make sense from an evolution and developmental point of view.  Undertaking complicated motor sequences such as kicking a ball i.e. judging when to move and adjust can be similar to knowing how to control anger, social response or thoughts.

    7. Why this is important in my opinion is that it starts to offer explanations for disorders of regulation, which are so common in children, e.g. ADHD, TBI, OCD, emotional disorder, motor co-ordination and speech disorders.  Neuropsychology does not provide very good explanations for these disorders at present and yet they are the most common difficulties encountered especially with children.  The key issues in these disorders is regulating and adjusting responses to the environment.

    8.  Another reason the book is important is that it gets away from the view that we need to focus on a single brain area and it’s function and looks instead about how different brain areas act in circuits in relation to one another.  The circuits work by involving different brain areas in feedback loops using excitation and inhibition to regulate the system.   This makes sense biologically, developmentally and from an evolutionary point of view.

    Therefore I would highly recommend this book to anyone interested in neuropsychology and how the brain works.  It challenges existing thinking.  It is a specialist book but is well written and informative.   There are detailed sections on neuropsychological assessment for those interested, although these sections are in my opinion of more limited interest because most tests don’t assess subcortical functions that well.  The important thing the book does for me as well as explaining sub cortical anatomy and function is to start to provide a more coherent framework for understand brain regulation, which I think is fundamental for understanding child neuropsychology.   I think that ultimately this understanding will help us better assess and help children with brain dysfunction and particularly regulation difficulties.

  • I work a lot with children and young people who have suffered a brain injury.  It is one of the most devastating conditions.  Brain injury often results in changes to personality, to memory, to social ability and sometime to physical disability.  It often occurs to normally developing individuals.  Because brain cells do not repair themselves there is no cure and it is a case of living with and adapting to the condition.  I have noticed however that there is one area of functioning that seems to be preserved and often actually enhanced following a brain injury and that is creativity.  Although the brain can not repair itself new neural pathways can develop which I believe can allow new talents to emerge or create a different way of seeing the world.  I have worked with several young people who have gone on to A level and university to do photography or Art despite their disability.   One person I know, Spencer Aston is working as a freelance photographer. He takes photos from a unique perspective in my opinion.  I have come across other individuals who have become artists following a brain injury- see this site for examples.   Also in terms of music there it the amazing Melody Gardot who makes beautiful music  despite or perhaps as a result of suffering a severe brain injury as a teenager.  Other singers I really like and who have suffered severe brain injury and recovered to do some great work include Marc Almond (details of injury here) and Edwin Collins (details of recovery here).   All these people are inspiring.  The message is that while having a severe brain injury can be devastating there is hope and possibly new futures.  I would encourage young people with brain injury or their parents to explore different potential creative opportunities.  I would also love to hear of other stories of people with a brain injury who have developed creatively following their injury.