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Child Neuropsychology

A blog by Dr Jonathan Reed

  • I have just created a new game that involves working memory as part of the play.  The game is called Memorise and is available free on iTunes .  Memorise allows you to test your visual spatial working memory and to see if you can improve it over time.

    Working memory is the ability to hold information in mind in the short term and manipulate it.

    The reason I chose to develop a game involving working memory is the increasing body of research that shows that working memory can be improved with training and that improving working memory can have a wealth of other benefits.

    Examples in the research include:

    Working memory training can change brain function – see Olesen, Westerberg and Klingberg 2004

    Improve Fluid Intelligence (IQ) see Jaeggi et al 2008

    Reduce some symptoms in ADHD  see Klingberg et al 2005

    Help improve academic achievement see Holmes and Gathercole 2009

    and help individuals with brain injury see Johansson and Tornmalm 2012

    Developing visual spatial working memory seems to be particularly important and is associated with increased brain activity in Frontal and Parietal areas in childhood and similar brain network in adults

    Working memory training basically involves repeated practice at holding information in mind.  This can be boring but with Memorise I have tried to create a fun and motivating game that also produces benefits.  Memorise has some built in rewards to encourage your brain to carry on playing.  Memorise also adjusts according to your level, which reduces the sort of frustration seen in many similar games.   You can download the training report to monitor your performance over time and to see if you can improve your working memory ability.

    Memorise is a fun way to test your working memory and try and improve.  It is not a medical treatment.  If you have a medical condition and want a more detailed and clinically focused approach I would recommend trying the Cogmed program.

    Have fun and let me know how you get on.

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  • 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.

  • 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.

  • Our rehabilitation company Recolo is now offering the Cogmed working memory training program. Working memory is the ability to hold information in mind for a short period of time and to be able to use this information in your thinking. Problems with working memory are associated with a number of childhood conditions including ADHD, brain injury and poor academic achievement.

    We decided to provide the Cogmed working memory training in the UK because the research literature on it is impressive. It is effective in improving working memory in 80% of cases. The improvements have been demonstrated in neuropsychological tests, fMRI changes and rating scales. It can also be demonstrated at the neurotransmitter level- see previous post for details. It has been shown to be effective in improving working memory difficulties in children with ADHD and in adults with strokes. Klingberg is the main researcher in this area and his lab website contains copies of all the most important research papers. In particular the 2002 and 2005 papers are important Working memory training has also recently been shown to improved academic functioning in children with low working memory (Holmes et al 2009).

    The program we offer includes computer training using a game format. The game adjusts itself depending on the level of ability of the person training i.e. if the child finds a task difficult it will lower the demand- if child is doing well demands increases. We monitor performance centrally so we can see how the training is progressing. We also provide weekly coaching to ensure motivation The program lasts for 5 weeks (25 sessions). All these features and the research make this training in my opinion unique and different from other brain training programs.

    We can provide working memory training for children from the age of 4 to young adults up to age 25. If you are in the UK and would like to find out more please contact us on 020 7617 7180 or email or visit our website.

  • There is a lot of debate particularly in the media about the pros and cons about computer use with children. I believe that there are some fantastic potential benefits in developing computer games to teach children. Here are 5 of them:

    1. Dissemination of information- Our knowledge about child neuropsychological development is increasing all the time. But there is a problem communicating this to teachers and parents and applying this knowledge. Computer game based learning allows this knowledge to be disseminated to a large number of children. An example is dyslexia (by this I mean difficulties in learning to read). As neuropsychologists we know how reading develops, what part of the brain is involved, how to intervene to improve reading and how this changes the brain areas involved. And yet there are thousands of children who leave school every year unable to read. Developing computer games to address dyslexia using up to date knowledge is possible. Simple computer based learning can spread best practice to everyone (national and international).
    2. Motivation-One of the problems in teaching is in motivating children who find learning difficult or unrewarding. Computer games designers are the experts in motivation especially for kids. I rarely see kids even with severe ADHD who can’t sustain motivation for computer games. Computer game based learning allows educators to combine these motivating factors with learning.
    3. Effectiveness-It is possible to test the effectiveness of computer games based learning programmes in easier ways than it is to assess human taught programmes. Computer games are a standardised procedure that can be easily tested. In this way we combine scientific method with education to determine which programmes are most effective. This in turn will drive development resulting in more effective games over time. This fits with government priorities in producing evidence based learning interventions.
    4. Addressing reasons for learning difficulties. As well as targeting a direct area such as reading it is possible to address indirect reasons for learning difficulties using computer games. A prime candidate is working memory. Whilst it is possible to target and improve working memory directly (see post), it is also possible to use computer games to minimize the demand on working memory with learning programmes by using techniques such as error free learning. It is possible to reduce the need for verbal instructions for children who find listening difficult. It is also possible to reduce attention demands by using visually stimulating action based games.
    5. Computer are patient. As a teacher or parent it can be very frustrating teaching the same thing to a child who just ‘doesn’t get it’. The child also picks up on this and is often anxious about failure. Computers can be very patient. They will repeat the same procedure in the same tone time and time again. Some clever games can lower or raise the demands on the child automatically depending on how the child is doing. The child can work at their own pace and level.

    Therefore in my opinion for all these reasons it makes a lot of sense to develop computer game based learning on a widespread basis. At the moment I think the field is in it’s infancy. To produce good computer game based learning requires a combination of great games design, cleaver programming to build in some of the important factors discussed above and expertise in teaching/ child neuropsychological development. There are thousands of learning games out there but very few based on knowledge of neuropsychological development, with good game play and research to show their effectiveness. I hope that this will change- it could change a lot of children’s lives.

    For an example of a computer game based learning using neuropsychological knowledge visit my games site- Neurogames.

  • There is more evidence of the neuropsychological benefits of playing action video games in a new paper to be published in July by Matt Dye and colleagues in Neuropsychologia. This paper shows that playing action video games resulted in improvmenets in attention allocation in children and young people. The authors used the Attention Network Test (ANT) which measure “how well attention is allocated to targets as a function of alerting and orientating cues, and to what extent observers are able to filter out the influence of task irrelevant information flanking those tasks”. The subjects were children and young people between the ages of 7 and 22 who had played action games (such as Halo, Metal Gear, Quake, Grand Theft Auto, Medal of Honor etc) and non action games (Age of Empires, Mario, Solitaire etc) for any length of time in the preceding 12 months (note see the paper for a full list of games categorized). The action video game players performed better on the ANT compared to non action game players. The authors interpret the results as the action players having better attention allocation. In my interpretation they seemed to be able to attend to more data simultaneously rather than focus on certain information. The action games players seemed to have faster speed of processing and picked up visual cues quicker.

    This paper adds to a body of work carried out by the University of Rochester showing how computer games change brain function (see examples in web pages by Daphne Bavelier and Matt Dye ). This also fits with other posts on this site. The reason I think that this happens is that computer games involve continued stimulation, seem to act on implicit learning, are structured, follow repeated patterns and are very rewarding ensuring that players practice them repeatedly. All of these factors show the potential of computer games for neuropsychological rehabilitation and for education. It is clear however that not all computer games work in the same way. For computer games to be harnesses in the most effective way it is important to know which parts of the brain are more plastic (i.e. more likely to change) and which elements of the computer games most produce this change. Candidates for areas of plasticity that I have come across include working memory, visual contract sensitivity, attention allocation, speed of processing, visual motor co-ordination and literacy and numeracy development (see Neurogames). There may be other areas. In terms of the type of games, certainty action based games seem to produce changes in attention and visual function. Games requiring remembering short term information are also important. Again there will be others. For any computer game development company out there there are potentially massive benefits (commercially and for social benefit) by getting these elements right. I would be keen to hear of other people’s experience and any ideas about how this can be taken forward.

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  • There is an interesting article in the Sunday Times this week entitled ‘how to make your child more intelligent’. It seems to be based in part on a new book by Richard Nisbett entitled ‘Intelligence and How to Get it: Why Schools and Cultures Count. Whilst the article makes a number of important points the overall tone feels a bit like the old nature/ nurture debate, which I thought was over years ago. The article starts by stating that ‘Over recent years most experts have concluded that intelligence is largely genetic in origin, and that nurture does relatively little to raise an individual’s potential’. I am not sure which experts they are referring to here as anyone who knows anything about the genes and IQ literature knows this not to be true. The relationship between IQ and genes has been researched very thoroughly. The consistent finding is that genes account for about 50% of variance, which leaves 50% due to environmental factors. The article seems to try and overemphasize the role of environment and diminish the role of genes. It states ‘demolishing the finding of twin studies is part of the argument against genes controlling intelligence.’ This is the argument that twins who are adopted and reared apart have similar IQ. The article argues that twins who are adopted and reared apart have a similar environment in that adopted parents are highly likely to give their children a good start in life. This seems a highly tenuous argument. Are all adoptive environments the same? Would this produce such consistent findings? Also would this argument hold for all the twin studies looking at heritability in schizophrenia, autism, ADHD etc. Dismissing twin studies is a familiar ploy of people who want to dismiss the genetic factors and one I thought had died years ago. It undermines what is otherwise a good argument. The results for the gene and IQ studies are very consistent and researched in some detail. It seems silly to me to claim that genes don’t have an effect on brain and psychological development. You don’t need to knock the gene studies to show that environment is important. The gene studies already do this.

    Another factor that points to the importance of genes in IQ is that clinical experience and research suggests that IQ is remarkable stable through lifetime. Twins actually become more similar in IQ scores as they get older. Something must be driving this. IQ doesn’t change easily, although there are obvious environmental factors at work. Certainly it is clear from the Flynn effect that IQ has been steadily rising over the last 100 years (obviously genes are not evolving that fast). There is a lot of research on environmental factors influencing IQ. IQ is a complex concept that is not totally understood, but from the research there are some candidates for strong environmental factors that have an impact on IQ development. These include having a stimulating early environment, good early nutrition, an environment rich in language and literacy. There is also research showing how targeted computer games may raise IQ. There are other suggestions in the article although i am not sure about the research to back them up – I am certainly not aware of the value of meditation on IQ, encouraging self control or having bigger babies to name a few mentioned in the article.

    So overall, yes I believe we can encourage children to be more intelligent (although as IQ as currently assessed is a comparison measure it will be difficult to measure this) and I applaud the article for highlighting this. I think we should try. But don’t dismiss the influence of genes. That influence is always there and if ignored can result in my opinion in insidious effects such as a lack of social mobility. Parent’s genes are important in part in determining early child environments (i.e. stimulating, language rich environments with high levels of nutrition) and therefore IQ development. This is a political question. I think that overall improved IQ and literacy should lead to a better society (although many other factors are important too). To achieve this early intervention by the State will be probably be needed. We will need to understand the whole picture if we are to move forward.

    PS the article does contain a good section demolishing the race, genes and IQ argument and should be read for that alone.

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  • One of the most distressing symptoms for many of the children and young people I see clinically after a traumatic brain injury or stroke is the physical disability caused by the neurological injury. Most parents, children and young people hold out most hope for a physical recovery. The physical disability is the most visible symptom to the patient, their families and to other people. At present the main therapy to help with this is physiotherapy. Physiotherapy requires repeated exercise to try and improve physical function. Recent research has shown that physiotherapy is more effective in treating adult stoke patients than no therapy, although the type of physiotherapy used didn’t seem to make a difference. However, even with a disorder as physically treatable as stroke about 50-60% of individuals do not make a full physical recovery. I think the numbers for TBI based injury who don’t make a recovery would probably be higher. The other problem with a behavioural based phsyiotherapy is that it is difficult to maintain particularly for children and young people with neurological based injury. The exercises tend to be repetitive, lack meaning and often require the individual to remember and practice the therapy on a daily basis. This is a particular problem when children are discharged from hospital and may only see the physiotherapist on a weekly basis. An additional problem maintaining therapy occurs for children and adults with other neurological symptoms such as executive function difficulties (i.e difficulties with initiation, self monitoring, motivation etc) and memory difficulties. Therefore there is a need to develop other treatment approaches. A special edition of the Journal of NeuroEngineering and Rehabilitation out last month is devoted to innovative ways to treat neurologically based physical disability. These are mainly based on non invasive brain stimulation. One approach is Transcranial Magnetic Stimulation. This is based on stimulating the brain using powerful magnets. The neuroscience behind this is explained in detail here. It is believed to enhance the process of plasticity. In terms of outcome this article concludes that ‘There has been some modest functional improvement reported after some NBS interventions, however the longer-term clinical benefits remain unproven’.

    Another approach discussed in this article is the use of robotics e.g using a robotic arm/ exoskeleton to deliver the physical therapy. This takes the effort away from the person and could deliver very precise exercises. It also seems to rely on implicit (rather than explicit) learning which is the way that individuals with brain injury seem to learn best – see this post. The authors describe the outcome research as follows “In a systematic review of eight robotic neurorehabilitation trials, Prange and colleagues concluded that robotic therapies led to long-term improvement in motor control by increasing speed, muscle activation patterns and movement selection, although no consistent benefit was found with ADL (Activities of Daily Living) measures (note the authors explain why this may be the case). There could also be the possibility of combining the robotics with virtual reality and computer games to make physical rehabilitation motivating, fun and engaging. This would make it much more likely for children and young people to benefit from the therapy.

    In all it is still very early in terms of this research to recommend new types of treatment now, but it does show that there are a number of new techniques on the horizon. These techniques would be especially relevant for children and young people with a neurologically based physical disability.

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  • You can now try Neurogames for free with the demos online for the basic maths game Nutty Numbers and the reading game Letter Lilies. The games are specially formulated to help children who find learning difficult including children with dyslexia, dyscalculia, ADHD and Learning difficulties. However, they are based on normal child development and so can be used by anyone learning to read or learning maths. I use them clinically in my practice and I have had great feedback from children of different abilities who have played the games. I believe that using games to help children learn holds great promise for the future. So try the games for free here and let me know what you think.

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  • Scientific and technological knowledge is developing very fast. This post is about some of the ways in which we could use this knowledge to help children develop in ways that will help them and change society in the long term. These are just a few examples of what we know and what we could do.

    1. Eliminate dyslexia- not being able to read as well as being difficult for the individual involved also is associated with significant social problems for example approximately 50 % of adult in prison in the UK have difficulty reading and 80% have difficulty with writing. We know how to treat dyslexia (see this post) Eliminating dyslexia has been attempted in one school district in Scotland with great success. Why can’t we do this everywhere?

    2. Teach children how to be happy- There is a large literature on the science of happiness. For example see Paul Martin’s book Making Happy People: The Nature of Happiness and Its Origins in Childhood. We could use this science to teach children how to live happy lives. Helping children develop in this way early on could set up life long patterns. Imagine the effect on society.

    3. Introduce safe internet based social networking for all children. The potential power of computer based social networks is immense. With twitter, facebook and email we can now talk, communicate and work with people from all walks of life and from all over the world. These have the power to expand social networks and work against isolation and xenophobia. School children could from an early age learn to communicate and work with other children all over the world. There are risks for children in terms of social networking which are often highlighted in the media i.e. abuse online- but the key is to develop safe social networks, for example see Moshi Monsters. Developing safe social networks for children at school could have massive benefits for how they see the world from a social perspective.

    4. Improve children’s working memory (short term memory) – see post. Working memory involves holding information in mind and manipulating it. It is involved in listening to instructions, formulating thoughts, planning etc. It is linked with academic and intellectual development. It is a key skill to have as an adult. Difficulties with working memory are also associated with children with neurodevelopmental problems such as ADHD. We have the tools to help improve working memory in children. This is brain training at it’s best. Could this be part of regular school exercises in the same way as PE is?

    5. Develop Computer based learning- so many children become disillusioned with learning and give up. Computer based learning has the power to engage children and deliver learning in new specialized ways. Games designers have worked out with great success how to motivate children. Neuroscientists know how children learn. If we combine knowledge in these two areas we could revolutionize learning. I have started on this process in with Neurogames. Also see the Consularium blog for examples of how this has been tried in innovative ways in schools in Scotland.

    These are just some ideas, but imagine if we could produce a generation of children who were happy, with optimal brain development, with a broad social network, whose brains are primed to learn and think. What would this do for the next generation and for society in the future. We have the knowledge to do this. Could we make it happen? Let me know what you think?

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