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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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  • All children should be able to learn to read.  Our scientific understanding of how children learn to read is becoming very advanced.   I have reviewed some the research here.   Now a meta analysis (review of lots of studies) published this month in Psychological Bulletin by Monica Melby-Levag et al shows very strong evidence for the importance of phonological awareness in learning to read.  The blog post by psychologist Daniel Willingham explains in more detail the implications of this. The most notable points are that there is a causal relationship between phonological awareness and reading and phonological awareness seems to be the most important factor in reading development.

    Yet despite this knowledge there are still high levels of poor reading worldwide and in the UK.  A recent report by Department of Education shows that In the UK city of Nottingham 15% of boys (1 in 7) aged 7 had not reached the expected level in reading.

    Somehow the scientific information is not being applied.   Is there anything that can be done about this?

    I believe that technology may have a role to play.  It is possible to incorporate these latest scientific findings about reading into computer games, which help children learn.   I have attempted to do this in a small way in a new app for the iPad called phonics with Letter Lilies which can be downloaded here.  The game is free so available to anyone.  It is based on teaching phoneme awareness.  It is important to point out that whilst there are an number of games that claim to teach phonics most are actually just teaching ABC and letter sounds.  Phonemes are the actual units of sound used when reading.  I believe that there is great potential to teach phonological awareness using games.  I have undertaken some initial research which suggests that these games significantly improve reading, although more research is required to understand this fully.  More background on the games can be found on this website.

    One of the key issues is getting these games out to a wide audience.  I think games which help learning can be a very efficient and cost effective intervention.   Ideally schools should be investing in iPads because they are great ways to learn- see previous post .  One of the problems at present is that there are a large number of apps on the market, many of which have not been designed with much thought.   There is a need to sort and review the ones that are most effective and helpful.  I think that there is tremendous potential in developing iPad games based on science.  There may come a day when children are not leaving school unable to read.

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  • 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!

  • 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.

  • I am a avid user of Twitter and find all sorts of interesting information on there. As with the web, however it is difficult to sort out what is important. It also moves so fast that it is hard to keep track. This post highlights some important tweets I have seen regarding advances in neuroscience in the last two weeks.

    1. Repairing brain cells- Researchers at the Montreal NeurologicaI Institute and Hospital (The Neuro) and McGill University group at Montral University have developed a new technique to help repair damaged nerve cells. The study was in the October 7 issue of Journal of Neuroscience. They show that it is possible to use plastic beads coated with a substance that encourages adhesion to help cells grow and form new synapses. You can read about this study here

    2 Gene therapy. A study reported in Nature News investigated possible gene therapy for Parkinson’s disease. Parkinson’s disease is a neurological condition affecting motor control and is associated with a depleted neurotransmitter, dopamine. Stéphane Palfi, a neurosurgeon at the French Atomic Energy Commission’s Institute of Biomedical Imaging in Orsay, and his colleagues simulated Parkinson’s disease in monkeys and then injected the monkeys’ brains with three genes essential for synthesizing dopamine. They saw significant improvements in motor behaviour after just two weeks, without any visible adverse effects. “We don’t see any problems in these monkeys,” says Palfi. One animal even exhibited sustained recovery more than 3.5 years later. You can read about this study here.

    3. Understanding brain development. Researchers at the Stanford University School of Medicine have identified a key molecular player in guiding the formation of synapses. The paper, published online Oct. 8 in the journal Cell, looks at the interaction between neurons and astrocytes. The relationship is complicated but to quote from the report in science daily “It is commonly agreed that the precise placement and strength of each person’s trillions of synaptic connections closely maps with that person’s cognitive, emotional and behavioral makeup. But exactly why a particular synapse is formed in a certain place at a certain time has largely remained a mystery. In 2005, Barres took a big step toward explaining this process when he and his colleagues discovered that a protein astrocytes secrete, called thrombospondin, is essential to the formation of this complex brain circuitry.

    In this new study, Barres, lead author Cagla Eroglu, PhD, and their colleagues demonstrate how thrombospondin binds to a receptor found on neurons’ outer membranes. The role of this receptor, known as alpha2delta-1, had been obscure until now. But in an experiment with mice, the scientists found that neurons lacking alpha2delta-1 were unable to form synapses in response to thrombospondin stimulation.

    The researchers stimulated neurons with thrombospondin and found, those neurons produced twice as many synapses in response to stimulation than did their ummodified counterparts. Understanding this key mechanism could help explain children’s brains development and why this goes wrong for some children. Understanding the biochemistry holds out hope for future treatments. You can read the full report here.

    4. Computer games and rehabilitation. Every week there are reports on how computer games can help learning. As you will see from previous posts on this blog I am great believer in the potential of computer games for rehabilitation and learning. Just one interesting post this week shows an initiative to help individuals with strokes to regain movement using computer game technology. Read about it here.

    This is just a small selection of the information I am finding on Twitter. It shows some of the advances that are being made to understand and help individuals with neurological illness. You can follow me on Twitter here.

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  • I have just seen the preliminary findings of the first independent research study on Neurogames, the games I have developed to help reading and maths. The study was undertaken on 20 children aged 4 to 6. 10 children were given the computer games to play for 20 mins twice a week for 13 weeks at school. 10 children were not given the game and received normal teaching in a different class. Both groups were tested on standardized reading and maths tests (WIAT) before and after the intervention. The results show that the computer game group had an average maths score of 102 (average) before using the games which rose to 123 (above average) after playing the game for 13 weeks. The average group reading score before playing the games was 101.7, which increased to 114.9 after the game. In contrast the children not playing the game started with a reading score of 106.4 and this increased to 109.1 over time. Their maths score started at 103.6 and increased to 109.9. Therefore the study shows that exposure to the Neurogames for 13 weeks lead to substantial increases in maths and reading compared to the control group. These are preliminary findings and they need to be independently reviewed and published but they indicate what may be possible with computer based learning.

    I think that this also shows the importance of scientifically evaluating computer games based on learning. At present whilst there are many educational or brain training games on the market very few are being scientifically evaluated to see if they are effective. There are lots of games that look very good and claim to be brain training or educational but don’t seem to me to have any rationale let alone any evidence. For computer games based learning to develop in my opinion more research has to happen. Computer games lend themselves to scientific study given that they can be seen as a standardised intervention (i.e. they are the same each time they are given) and are easy and ethical to administer. Games can also be developed to incorporate the lasted scientific knowledge- see previous post for discussion on this. I intend to encourage other researchers (please contact me if interested) to independently evaluate the Neurogames with a larger number of children next and also with children with different neurodevelopmental disorders such as dyslexia and dyscalculia. I hope that over the next few years there will be an increasing body of research showing which games and which elements of games are effective in learning and neuropsychological development. This could lead to a revolution in education and rehabilitation.

  • 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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  • 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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