Child Neuropsychology

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 regulation – Whale 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 planning – Flight 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.

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.

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.

I am really excited about the prospects of using the ipad to help children learn.  As I have previously discussed there are some important advantages in using the ipad, especially with younger children and children who find learning difficult.  I am developing games on the ipad to help learning and rehabilitation (see Nutty Numbers).   I am also clinically involved in rehabilitation and looking to find ways to help children with neurological conditions.   As a result I have looked in detail at what sort of apps are available.     My impression from studying the itunes educational app charts and trying out various games is that there is generally a lack of good quality educational apps that I could recommend.   Although I want to promote my own apps, I would also like to recommend apps to help particularly children who are finding learning hard or are in rehabilitation.  Whilst there are a lot of nice looking apps about there is mainly a lack of substance.  The sort of features I would like to see in apps and would recommend parents to look for include:

1.  Is the app based on learning theory?  There is increasing knowledge about how children learn.  Are the educational apps utilising this?

2. For younger children are there spoken instructions rather than written instructions?  Clearly young children can’t read and therefore will need a parent supervising them if the instructions require reading. The ipad will work best when children can explore and learn under their own initiative.

3. What happens if the child gets an answer wrong?  It can be very frustrating receiving a big cross or a sound effect indicating a mistake sound, especially if you don’t know the answer.   This is a particular problem for children who find learning difficult.  Several experiences of this will turn most children off.

4.  What are the reward structures?  Research has shown that positive affirmations (i.e. letting the child know that they are doing well) are very powerful by themselves in learning.  Any educational apps should have several layers of reward structure.

5.  Is there any research showing that the app improves learning?  For example Nutty numbers has been shown to significantly increase numeracy compared to a control group in a published experimental study.

6.  Is there a randomised presentation?  Just going through the same structure each time does not encourage learning.

These are some of the criteria that I consider important and have used to develop my apps.   I would like to see other educational apps with these features. I think this would help develop the field of games based learning and realise some of it’s potential.  Potentially many children could be using tablet devices such as the ipad to learn and develop.  I have written previously about the advantages of game based learning.  However, at present in my opinion it is still a field in it’s infancy.    I hope it does develop and that I can contribute to this.  I would be keen to hear of any other recommended educational apps fulfilling some of the criteria above.

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.

One of the problems with Games Based Learning (i.e. educational computer games) is that many educational games look just too educational and are therefore dull and worthy.  Whilst many games are designed with education rather than play in mind, another major problem with GBL for me is that many educational games are desktop based and desktops are essentially boring.  Sitting at a desktop feels like work.  Using a keyboard and mouse is not easy particularly for young children.   Also according to most children I see, ICT is not a fun subject.   The iPad in contrast seems like fun.  The way it feels and the touch interface are intuitively satisfying.  You can pick it up, manipulate it, touch it and it responds- all fundamental aspects of play.   Children seem to particularly realise this -a point well made in this PC world article- Why iPad is children’s toy of the year. Give a child (and me) an iPad or iPhone and they will play with it.  Education works when children are engaged and motivated.  Children develop and learn through play.  An playful approach is in my opinion the best way to learn.   Because the iPad is a device to play with I think it could be the best device to move Games Based Learning on.

In order to prove my point I have just released one of my games Nutty Numbers on the iPad.  You can buy it in iTunes here.  Nutty Numbers is designed to teach basic numeracy concepts including addition, subtraction, multiplication and division.  The game is based on a motivating error free learning paradigm.  This cuts downs on frustration when learning and boosts motivation.  I think that this approach works and I have a research paper in press with International Journal of Virtual and Personal Learning Environments showing that it significantly improves levels of numeracy compared to controls. Children who have used it find it easy and fun to play and the iPad interface just feels a natural way to play this game.   I hope that some of you try it out and if so please let me have any feedback.  My goal is to use my knowledge of neuropsychology to produce games that are fun and engaging but are also effective.  I think that the iPad may be the best device to achieve this.   There are still too many children who struggle to learn to read and to attain basic numeracy and are turned off by education.  I think well designed motivating computer based learning games have the potential to change this. The iPad may just be the device to make this happen.

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.

I recently wrote that too many educational computer games look too educational and are not fun to play.  I have recently, however, come across a couple of causal games that although they don’t set out to be educational actually are, but are also addictive and fun.   Casual games are simple, cheap games that are easy, yet compelling to play.   The first game Drop 7  by area/code is a game involving numbers but also works a bit like Tetris.  To play 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.  I think that this game, without intending to, actually reinforces numerosities,  which is the ability to automatically recognise the number of objects in a set.  Understanding Numerosities is associated with the intraparietal sulcus in the brain and is the foundation for the development of mathematical thinking.  Individuals with dyscalculia (maths dyslexia) have difficulties with this concept.   I don’t think the designers knew this and just designed an addictive clever game.   But it would be interesting to research whether this does actually help children and especially those with developmental dyscalculia to develop in terms of maths.   In the meantime at the least it is a good fun way for children to reinforce automatic number understanding.

The second game by one of my favourite casual gaming companies Popcap is called Bookworm.  In this game you have a grid of letter tiles and have to create words out of them.  You get points for the complexity of the word.  You also have to use up a burning tile before it reaches the bottom of the page (it goes down one step every time).  It is a fun, fast moving, compelling game but improves word knowledge and spelling at the same time.  Popcap are great at developing addictive simple games such as Bejeweled and Peggle.  It is great to see that they can use the same principles to create games that are educational.

I should note that both games are also just fun for adults and children to play.  Me and my children enjoying playing them as well as other games just to relax.  They are great on the iphone.  I am sure that they are good at producing increased levels of dopamine (the reward neurotransmitter) in my brain!