Child Neuropsychology

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!

Living in the 21st century can be stressful.  If you listen to the media there is potentially a lot to worry about now; economic meltdown, ecological catastrophe, medical pandemics to name but a few.  Also there are the constant distractions of 24 hour news, TV, email, twitter and blogs! In general there is information overload.  So how do you cope with this?  I am becoming increasing interested in the potential of mindful meditation.   Whilst this may seem a bit New Age, at its core it is in fact a very simple idea.  The key is to focus on the present moment.  Not to worry about the future or the past.  To try and focus on something simple like your breathing and to not be distracted by intrusive thoughts.  Humans have used meditation to cope with life in different cultures for 1000’s of years, be it though Buddhism, Christianity or Taoist teaching.  More recently it has been shown to be very effective in dealing with mental health problems.  Combined with Cognitive therapy it certainly seems helpful for depression see Ma and Teasdale 2004 and anxiety see Evans et al 2007 .

As a child neuropsychologist there are two areas of mindfulness that particularly interests me. Firstly it is becoming clear that meditation is associated with changes to brain function.  This includes increased thickness in prefrontal brain areas and increased grey matter in brain stem.  In his very impressive book The Mindful Brain in Human Development: Reflection and Attunement in the Cultivation of Well-being Dan Siegel discusses in detail the neuroscience and development of mindful meditation.  In my opinion mindfulness is closely related to working memory (see post for details of working memory) and meditating on a regular basis by focusing on a set stimuli (voice, breathing, light) may be similar to working memory training.  It requires holding a focus in mind.  As I have discussed in the past working memory can be improved with practice.  There is some research showing that meditation training brings cognitive benefits.  A recent paper in  Consciousness and Cognition by Zeiden and colleagues suggests that brief mindfulness training significantly improved visuo-spatial processing, working memory, and executive functioning.

Secondly can mindful meditation be used to help children?  A recent special issue in the Journal of Child and Family studies shows a number of potential applications including for children with ADHD and also to help parents cope with managing difficult children.  At present I think the evidence that it works with children with neurodevelopmental problems is not quite there although there are promising indications. Certainly working memory training works with children and so meditation should in principal.  I also think that in this increasingly distracted, stressful age, preparing children with skills to deal with life such as mindful meditation may prove to be very useful.

If you want to try it yourself there is a good resource site from UCLA with MP3 files with meditations etc here.  There is also a good paper with advice from Karen Hooker and Iris Fodor on how to help children in Gestalt Review here.

I attended the Games Based Learning conference this week to present research on Neurogames.  I also managed to hear some inspiring talks and people.  Here were the highlights for me:

Learning about the Channel 4 games.  High quality games to encourage learning.  Examples included the 1066 game.

Hearing Matt Mason talk on The Pirate’s Dilemma.  A great talk about the way culture has evolved with the help of copying and piracy and how business (and particularly the games business) could learn from this.  You can buy his book  The Pirate’s Dilemma: How Hackers, Punk Capitalists, Graffiti Millionaires and Other Youth Movements are Remixing Our Culture and Changing Our World or download it here

Jesse Schell’s talk on the ‘Future is Beautiful’ in relation to education.    As always inspirational.   The slides are here

Tom Chatfield Author of Fun Inc.: Why Games are the 21st Century’s Most Serious Business on the evolution of games.  In particular the point I appreciated was the way that games are starting to encourage co-operation, for example how players can help each out on the New Super Mario Brothers (Wii)

Margaret Robertson’s talk on casual games and what they can teach us about educational games. Casual games are quick, funny, social, topical, simple  cheap female friendly and competitive and also none of these – can educational games emulate this?  Margaret’s blog is here .  She also introduced me to drop7 an addictive game for the iphone

Overall I felt the that these exciting times for games based learning but that it is a very diverse field with a lot of uncertainty.  For example how do you fund this? How much education and how much entertainment? The role of learning experts in games.  Also there is a general uncertainty over where games are going – i.e cheap social gaming such as Farmville or high production games such as Call of Duty or both.  The uncertainty however may be just how it is and will always be and out of this messy uncertainty will arise failure and success and creativity.  It is a Darwinian world!

My talk in the research strand was on developing a theory and evidence based game to help children learn reading and maths.  We presented research from my colleague Misbah Khan showing that Neurogames significantly improve reading and maths in children.  The slides from the presentation are here.

Everyone is a psychologist.  By that I mean that everyone tries to work out why people behave the way they do.  This is an inbuilt social drive that helps us to interact normally.  It is based on theory of mind which is about understanding other people’s mental states and intentions.  Lack of theory of mind is the key disability in Autism.   In my work I find that most people have a strong belief about why someone is behaving the way that they do (although in my work I think that it is often a wrong belief).

I think we base our understanding on why others behave  the way that they do on what we think about ourselves and our cultural norms.  This is essential to group cohesion.  No one can truly know how another person is thinking but we automatically make an educated guess.  The difficulty comes when normal behaviour breaks down.   We know that in some individuals behaviour and personality changes dramatically with acquired frontal brain injury- see the case of Phineas Gage.   I see similar difficulties in my work with children with head injury, neurodevelopmental disorders and sometimes those with a history of abuse and neglect.  With these children I see very challenging behaviour that doesn’t respond to normal parenting or behaviour modification.  I will write about why this is in more detail at a later date (to with difficulties in development of frontal brain areas). In general though behavioural control is more complicated than it seems.

I was particularly struck by this difficulty in understanding why some people behave the way they do when reading a research paper looking at the most extreme of behaviours, murder.  Why does someone comit murder?  The paper looks at 77 inmates or defendants charged with murder in the US and referred for neuropsychological assessment.  The sample is self selected because they were referred for clinical assessment rather than randomly chosen for research.  However, the sample characteristics are striking.  Some of the key facts are:

• 49.4% had a developmental disorder in childhood.  (36.4% had ADHD)
• 87% had a brain injury (self reported and 10% had documented evidence)
• 85% had a history of substance abuse.
• 45% had a psychiatric history
• 35% had a history of abuse in childhood.

From the neuropsychological assessment the mean IQ was 84 , which is a standard deviation below the norm.  Mean working memory was 87 which is low average.  The mean logical memory score was 68 which is very low indicating significant memory problems.  The sample also had a high rate of assessed executive function difficulty (executive function is the cognitive ability associated with the front area of the brain).

You will need to read the paper to find all the details because there are so many interesting factors in the sample.   However, taken together the majority of the sample had some form of brain damage/ disorder or abuse stemming from childhood (which as I have discussed here often leads to developmental brain damage).   Exactly what is going on in their heads can never be know and the neuropsychological factors don’t explain the trigger or situation in which the murder took place.  However, it is clear that there are neurological and neurodevelopmental factors going on here, and given what we know about these in childhood and from case studies, it is unclear how much control such individuals have in a given situation.  I don’t offer this as an excuse to let people off and certainly I think many of these people are extremely dangerous.  But the results may shake our assumptions  (based on our own theory of mind) as to why people behave the way that they do.  Consider this next time you hear about a murder in the News.  Also the results may point to the importance of prevention in terms of early identification and treatment of childhood neurological problems and childhood abuse.  So many of these people’s problems seem to stem from experiences and events in their childhoods.

There is increasing evidence that playing video games improves neuropsychological function.  I have just been reading another excellent paper from the people at the University of Rochester called Increasing Speed of Processing with Action Video Games.  The paper written by Mathew Dye, Shawn Green and Daphne Bavelier looks at a range of previous studies on reaction time and video game playing.  The introduction to the paper states:

Playing action video games-contemporary examples include God of War, Unreal Tournament, GTA, and call of Duty – requires rapid processing of sensory information and prompt action, forcing players to make decisions and execute responses at a far greater pace than is typical in everyday life.

Looking at lots of different studies they conclude that:

• Video Game Players (VGP) have faster reaction times (RT).
• RT can be trained by action game play (thus showing causation)
• Improved RT is not at the cost of more impulsivity.  Increased RT do not result in more errors (as measured by the TOVA)

This paper adds to a body of research showing improved neuropsychological function; for example in working memory, increased literacy and numeracy and improved attention.

I don’t find this surprising.  Games provide reinforced repetitive mental activity.  Anyone who plays them knows that they are challenging yet very motivating (even in those with generally poor motivation).    Games designers are experts in terms of human motivation. I have written before about the benefits of computer game based learning here.

Yet despite these increasing positive findings I don’t see research being translated into great educational application.   Many educational/brain training games are actually quite dull- a point well made on the educational games research blog.  Partly to me there still seems to be a mindset that educational games and brain training games need to look educational. It would be good to produce educational and brain training games that look and play like real games.   Also games based on research are often devised by academics, teachers and clinicians (like me) who don’t have the budget and expertise to produce games in the way that commercial games developers do. Whilst there is research showing that existing commercial games can improve neuropsychological benefits, imagine what specifically designed games could do.

To move the situation forward there is a need to put serious attention and resources into educational/neuropsychological games that combine the latest research with the latest exciting, engrossing game play.  I think that this does require a new mindset and a good degree of creativity.  Also it is uncertain where the market is for this is-; Schools? Concerned parents?  Governments?  It may not be profitable at first.  Existing brain training tends to target adults looking for self improvement and adults are always willing to pay for this.  Trying to improve child education/development is different.  However if someone/ some company was prepared to invest they could produce something fantastic, with great benefit.   I think video games can change education and development but I think it will take something special to realize this potential.

This is not child neuropsychology but five cultural experiences that have had a impact on me so far this year.  Just thought I would share them.

History of the world in 100 objects.  A wonderful collaboration between the British Museum and the BBC telling the story of the world through a selection of 100 objects at the musuem.

The new Vampire Weekend album  Contra.  Clever music to make you feel happy.

The Stieg Larsson millennium trilogy The Girl with the Dragon Tattoo The Girl Who Played with Fire and The Girl Who Kicked the Hornets’ Nest Compelling psychologically driven page turning reading.

Cormac McCarthy  The Road – One of the most emotionally powerful books I have read for a while.

Channel 4 India season The people and particularly children living in the slums of Mumbai have so much to teach us about how we live in the west.

The news (posted here) that 2 boys aged 11 and 10 have been convicted of sadistically attacking and torturing other young boys has lead the media to question why they did it. Most newspapers have focused on the neglect and abuse the boys suffered at the hands of their parents and particularly their violent father. As I wrote in my last blog post this early history of abuse and neglect often leads to damaged brain development. However, this explanation doesn’t go far enough. Despite many children being abused and neglected very few go on to sadistically torture other children- see paper here reviewing the evidence. Therefore there has to been an additional explanation for such unusual behaviour. The key lies in understanding the development of empathy and distinguishing this from theory of mind (ToM). ToM relates to understanding other peoples mental states. Empathy is the ability to understand other peoples emotional states and to respond with appropriate emotion -as Simon Baron Cohen describes – experiencing an emotion triggered by other peoples emotion. People without empathy as considered psychopaths. They understand what other people are thinking or feeling (ToM) but do not feel the emotion themselves. They may feel a discordant feeling such as pleasure in response to other peoples pain or distress. Can this develop in children? Empathy normally develops at a very young age (about 14 months) and in my opinion is driven by genes- see some recent research here on this. I think therefore that this must develop in early childhood. There is likely to be a genetic predisposition that is triggered or made worst by an abusive childhood. Remember that in this case the children shared in part their violent father’s genes. The parent’s genes and experience will in turn shape the environment that the children are brought up in, thus leading to a toxic feedback cycle. Whilst it is difficult to think of children being psychopaths I fear that this is possible, although rare. I have probably seen about 10 children in my carer (out of 1000’s) with this presentation. It is difficult to know what you do about it other than try and minimize the resultant risks (which hasn’t happened in this case) or perhaps to intervene very early – although I am not aware of research showing that you can change this. To read more about the development of empathy see chapter 14 Social Neuroscience by Simon Baron Cohen and Bhismadev Chakrabati in our book Child Neuropsychology: Concepts, Theory, and Practice
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Children’s welfare and development entered UK politics yesterday with David Cameron the Conservative leader talking about the warmth of parenting being more important than poverty in outcomes with poor children. Polly Tonybee in the Guardian wrote a stinging reply. This prompted me to think about my experience as a child psychologist with children from neglected backgrounds. For the past 13 years some of my work has involved assessing children in care, both residential and foster care. This has shown me how damaging early experience of abuse and neglect is for children, how it is reinforced and not addressed. It is a big problem. There are approximately 60000 children in care in the UK . The number of children with a child protection plan is increasing every year. The vast majority of children that I see in this context have cognitive, social and emotional difficulties. It is rare to see a good outcome. In the UK 12% of children in care get 5 GCSE passes compared to 59% in the general population. 23% of adult prison population were in care as children, 42% of prostitutes had been in care and 45% have mental health problems.

In my experience there is often a common pathway. There is a history of concern about abuse and neglect dating from birth. Often the parents themselves had a history of abuse which they cope with by taking drugs and alcohol. They have no experience of good parenting themselves. Women often end up with partners who perpetuate abuse in the form of domestic violence. Many children are placed on and off the Child Protection Register during early childhood. Eventually (normally from age 8-13) they are placed in foster care. The children in residential care seem to have had several foster placements break down first. By the time they are placed in residential care it is too late to change the situation. By this stage children start to become involved in drugs, gangs, criminal behaviour, start underachieving educationally and in the case of young women engage in abusive relationships. Obviously this doesn’t happen to everyone but I would estimate it does in 70% of the cases I see. The cost to society is massive and the cycle of problems continues.

What is also often missing in the debate is the effect on the brain of abuse and neglect. The first five years of life are crucial in terms of brain development. A recent study by Evans and Schamberg looked at the effect of childhood poverty and stress on working memory and explains the mechanism by which this happens. For a review of the literature on neglect and brain development in general see this paper by Danya Glaser. My own data and experience shows a large proportion of children in care with learning problems, neuro-developmental difficulties, self regulation problems and difficulties with social relationships. Waiting until a child is a teenager and then putting them in prison, giving them counseling or criticizing them doesn’t work. Their brains are already damaged. Trying to blame their parents or fine them doesn’t work either. Often they can’t cope in life due to their own history of abuse, drug addiction or neurodevelopmental problems.

In my opinion the state has to intervene at an early age to break this cycle. There was recently an interesting article by Camilla Batmangheldjh in The Times about the need for good child protection to break the cycle of violence. There may be a need to remove children much earlier from the damaging home environment and place them in care rather than wait for the damage to occur, reinforce it with several short term placements and then put them in residential care in their teens. It would be better for children to return back to parents without the early damage. It may be that providing very high levels of one to one support in the home situation would help. Leaving it to the parents to change by themselves or expecting them to change through nagging,criticism or simple intervention won’t work. Ignoring the problem won’t work. The fundamental point is the need to intervene early to change the inevitable brain damage that occurs. These children are often forgotten. Few people look out for them and I wish this would change. In my opinion it is not just about blaming poverty or blaming parents but seeing the cycle of abuse and neglect that occurs through generations, seeing how this affects brain development and then trying to intervene to stop that cycle perpetuating. Is this possible? Despite yesterday’s debate I don’t see any political party in the UK addressing this properly yet.

I have written a previous post explaining why stem cells could be an important treatment for people with brain injury and disease. In summary the brain cannot repair itself. Stem cells are naturally occurring cells that turn into neurons but are only present in the embryo. The Bush government vetoed research in this area on religious and ethical grounds but Obama has overturned this.

Recently there have been two interesting studies that show the potential of stem cells for neurology and neuropsychology. They both use human stem cells transported to rats. If these results can be replicated in humans it will transform our world.

In first study published in PNAS Munjal Acharya and others from the University of California implanted human stem cells into rats that had damaged hippocampus due to radiation. Not only did the stem cells repair the damage they also resulted in restored learning and memory (functions associated with the hippocampus). If this could be replicated in humans we could have a treatment for neuropsychological impairment, which would benefit thousands of children and young people.

In the second study published in Stem Cell, Jason Sharpe and colleagues from the University of California transplanted human stem cells into rats that were paralysed by a spinal cord lesion. The stem cells repaired the lesion and resulted in improved recovery of forelimb function. Again if stem cells can repair spinal cord injury in humans the benefits would be huge.

Also although this is not neurological I was also fascinated to see researchers grow part of a human jaw bone using stem cells.

There is a huge amount of research being undertaken in this area at present (thanks to Obama). The NIH site on stem cells in the US is a good website for following what happens. There are a few human studies- see this on MS, but so far the majority of studies are animals although they are starting to use human stem cells with animals. If these results could be replicated in humans we may be able to repair bones, spinal cords, brains and restore neuropsychological function. Very exciting times!