Child Neuropsychology

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.

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.

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.

I have been reading an excellent book on personality research called Personality: What makes you the way you are by Daniel Nettle. It is written for the non expert and is easy to read and full of interesting observations. In the UK the psychology of personality has not been very influential on clinical practice. Most Clinical Psychologists do not assess personality, particularly in children and young people. In addition the study of personality has not featured on many university courses and certainly was not part of my undergraduate degree. However, recently I have began to take an interest in this area of psychology because it makes a lot of sense clinically. The children and young people I see have clear personality traits which fit with the current research. Having read Daniel Nettles’ book I believe that there will be a renaissance in personality assessment and understanding over the coming years. There are three key facts driving this, which are:

1. Researchers studying personality using factor analysis have come to a consensus that there are five main personality factors, which are:

Extraversion

Agreeableness

Conscientiousness

Openness

Neuroticism (emotional stability)

2. The behavioural genetics work fits with the five factor model and also suggests that these traits have a large genetic component.

3. There is increasing interest in the neuroscience of personality. The five factors are associated with different neural pathways e.g. Neuroticism (amygdala, hippocampus and R dorsolateral prefrontal cortex); Conscientiousness (dorsolateral prefrontal cortex); Extraversion (mid brain dopamine reward systems).

Given the genetic and neuroscientific evidence it would make sense to consider personality when looking at development, emotional and social difficulties in childhood.

There are lots of thought provoking issues raised in the book but I will highlight three that I think have major implications:

Firstly behavioural genetics studies have shown consistently that shared family environment i.e. parents, have little to no effect on development of adult personality (not sure what the Freudians make of this!).

Secondly that multivariate analysis shows that children’s personality seems to affect the way parent’s treat them rather than the other way round.

Thirdly : Personality seems to predict quite strongly, certain life experiences. For example high scores on Neuroticism predicts higher likelihood of divorce and low scores on conscientiousness predicts early death. Nettle argues that personality assessment together with IQ are two of the strongest predictors for how you will do in life. It is important to note that the genetics of IQ and personality account for about 50% of variance and environment is also important. There are ways of course that you can alter your environment to influence your life course. However, I think that it is likely that without intervention the genetic biases we all have will lead us in certain directions.

If you want to find out what your personality is there is a online test at the personality project website where you can take an anonymous personality test as part of an online research study. More information on personality can be found at the main personality project website.

In the past few weeks there have been a number of stories in the UK media about violent behaviour by young people such as Ben Kinsella being stabbed, the robbery, torture and murder of the two French students. In the Times last week there was a story about record numbers of children being excluded from school at a young age for aggressive behaviour. It is difficult to make sense of these stories and they obviously cause concern. I tend to think about the neuropsychological reasons why such behaviour occurs. Obviously there can be a number of explanations for violent behaviour but I thought I would mention three important developmental factors to consider.

1. Development of Self Regulation. Through development children learn to self regulate their behaviour and emotions. There seems to be a neurological correlate to this. Primitive emotions and behaviours are driven by the brain stem, the hypothalamus and the limbic system, which is present at birth. Over time the cerebral cortex develops to regulate this primitive system. Initially this involves the ventral prefrontal cortex (VPC) and the anterior cingulate cortex (ACC). This process seems to happen in early childhood and is associated with reactive control. This is a more sub conscious control involving inhibiting impulsive emotional responses which would include aggressive outbursts. This normally develops through the experience of being parented, whereby the parent provides external regulation which becomes internalized over time by the child. Later (age 4 to 6) the Dorsal-lateral pre frontal cortex develops allowing self control. This results in more effortful conscious control over emotions and behaviour. Children learn to use internalized strategies to regulate themselves. This development process can go wrong for a variety of reasons including brain injury, developmental ADHD and also lack of adequate parenting. The result is individuals who have poor control over emotional impulses including aggressive impulses. These processes can also be temporarily affected by drugs and alcohol. To read more about this developmental process see chapter 13 self regulation and the developing brain by Rebecca Todd and Marc Lewis in our book Child Neuropsychology: Concepts, Theory, and Practice

2. Development of Empathy- this is the drive to identify another persons emotions and thoughts and to respond to these with appropriate emotion (Davis 1994 Empathy: A Social Psychological Approach (Social Psychology)
This seems to develop very early in most children’s lives (at about 14 months). It is different to Theory of Mind which seems to be about understanding other peoples thought’s. The classic disorder of empathy is a person described as a psychopath. They understand other peoples thoughts but feel no emotion in relation to this and as a result have nothing to stop them hurting others. Empathy seems to be related to gender in that males are more likely to show less empathy. A few children in my experience seem to lack empathy as a developmental disorder. Sometimes this seems to occur for children with traumatic childhoods with experience of early violence, but in my experience it is rare. It seems to be associated with the inferior frontal gyrus (IFG), which in turn is associated with a discrete network of brain processes involving face processing (fusiform gyrus, inferior occipital gyrus), emotion (amygdala, insula, ventral stratum and other structures) and with action perception (mirror system). To read more about this see chapter 14 social neuroscience by Simon Baron-Cohen and Bhismadev Chakrabarti in our book Child Neuropsychology: Concepts, Theory, and Practice

3. The third important factor is social processes. Classic social psychology from H.Tajfel has shown how social identity influences group behaviour. Individual placed in a group would quickly begin to favour and maximise the benefits to their group at the detriment of other groups even when they didn’t know the other members of their group. Group identity is very powerful and may explain some of the gang behaviour in inner cities i.e. why gang members hate members of other gangs. Also there are the studies on social influence by Stanley Milgram. In this study volunteers delivered what they thought where powerful electric shocks to others when told to do so by someone in authority. This authority effect may explain the way that leaders in a group will influence other lower members . This is particularly pertinent in gangs with children- the younger children being influenced by older members. These social influences may also explain state controlled violence where leaders get subordinates to carry out violence on their behalf. It seems to me that social influences can override individual brain processes. This is an important factor in gang related violence – much of which is a problem in London UK at the moment. Children will do what older gang members want through the influence of authority and also start to hate other groups/gangs through social identity processes. There are likely to be wider social influences in society but I will leave that to the sociologists to explain.

These factors don’t explain all the reasons for violent behaviour but they are important and may be helpful in thinking how to prevent violent behaviour developing. Certainly help with early parenting skills for parents with young children at risk would help with development of self regulation. Early identification and treatment for disorders of regulation such as ADHD and brain injury is important. Early screening for signs of empathy disorder is an option to be explored (treatment options for this are at a very early stage). Finally realizing the negative social influences of groups or gangs is important. The social influences surrounding the gang will be more powerful than the individual within the gang (and perhaps by a certain age their parents) can control. To try and prevent violence in inner cities it is necessary to disrupt the gang itself and find other ways for children to meet their social needs. In the meantime unless these issues are addressed in childhood we will continue to have news headlines about young people being killed and others being jailed for life- not a good option for either or for us.

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.

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.

The world of genetics is moving so fast it is hard to keep up. Luckily one of my favorite writers on the subject Robert Plomin (together with Oliver Davies) has written an update on the genetics of child psychology and psychiatry in the Journal of Child Psychology and Psychiatry. There is a lot of information in the article regarding the latest genetic findings but the issue that stuck me most was about how our understanding about how genes work is changing. My understanding of genes was the classic model described succinctly by Plomin and Oliver as “a gene is a sequence of DNA that is transcibed into messenger RNA which is then translated into amino acid sequences, the building block of protein”. The proteins then build to form brain structure, neurotransmitters etc.

The hunt has been on to find the genes that affect behavior and illness using this classic DNA process. There have been successes with a number of single gene neurological disorders identified such as Huntington’s Chorea and PKU. For these conditions the gene has been located and the sequence from gene to protein to behavior is well documented. Unfortunately this process has not worked in discovering the genes for most other psychological/ psychiatric disorders or for behavior in general. Although it is clear that there is a substantial genetic component in behaviors such as IQ, reading and language and disorders such as ADHD and Autism, as shown by twin studies, the actual genes responsible have not been found. Recent arguments have focused on the idea that many genes may be involved in combination to influence such behaviors. Plomin’s article however also raises another difficult issue. There may also be a problem with the standard DNA model as an explanation for gene- behavior effects. There are a number of puzzles regarding the standard coding DNA model. Firstly there are far fewer of these traditional genes than expected (about 24,000 in humans). Also they only make up about 2% of DNA, the other 98% were said to be junk, a byproduct of evolution. Another factor is how little these traditional genes vary between individuals and species for example simple worm like creatures called called nematodes have 19000 genes compared to the 24000 in humans. Are we not that much different to nematodes? Chimpanzees share 99.4% of DNA coding genes with humans.

Plomin and Oliver show that part of the problem may be that we have not focused on the way that RNA works. Out of the 98% thought to be junk DNA about 1/2 does produce RNA but not the type of RNA that codes for amnio acids. Instead the non coding RNA ‘plays an important role in regulating the expression of the protein coding DNA‘. RNA is also much more complicated than once thought and many different types of RNA have now been identified, including microRNA, tRNA, snRNA, rasiRNA, snoRNA, etc. How RNA works is explained in detail in the article but that explanation is too detailed to describe here other than to say that there is much more variation between individuals and species in terms of their RNA profile and that it is the RNA that may hold the key to understanding more complex gene behavior effects. The implication of these findings according to Plomin and Oliver is that we should be analyzing the whole genomes of individuals rather than searching for individual genes. This is becoming cheaper and easier to do but so far the results are still very limited.

My take home message from the article was that genes and their effects are not as simple as most people believe and as much of the media describes. It is very unlikely that we will find the gene for Autism, for IQ or for being gay. Instead such behavior is likely to be the result of a complex interaction of many different genes, with different types of RNA dictating how the genes are expressed which in turn will probably be influenced by factors in the environment. Hugh discoveries are being made all the time but I think the more that is known the more complex it all seems.

A new study on the benefits of stem cell therapy in patients with multiple sclerosis is a very exciting one for all neuroscience. The study shows that by giving stem cells to MS patients, disability is halted or reversed. The study included measures of neuropsychological function as well as neurological rating scales and quality of life. Improvements in these areas were seen in 17 out of 21 patients and there was no deterioration in the other 4. The reason why it is so important lies in the use of stem cells. The problem with all neurological disability including childhood brain injury is that the brain can not repair itself. This is to do with the way the brain develops. The brain starts to develop at 40 days old with stem cells lining the neural tube. The stem cells turn into precursor cells, then blast cells and then specialized neurological cells. The whole process lasts until the fetus is approximately 6 months old. It is an amazing process with cells developing at the rapid rate of approximately 250,000 a minutes. However, by the end of six months the process stops and you are left with the brain that will last you the rest of your life. If you damage the cells in your brain they will not grow back in the same ways as skin and bone cells would. This is the reason why neurological injury is so hard to treat. If, however, we can replicate the natural development process by using stem cells the possibility is there to treat all neurological disability. It is still early days in terms of this research but these findings are very encouraging. A major problem has been that you basically need to use embryos to produce the stem cells. The recent Bush government in the US was against this on religious and moral grounds. There are however, some new discoveries now in using adult stem cells from different areas of the body. Also it is believed that Barak Obama will allow the stem cell research to start again. Just recently the FDA in the US approved use of stem cells in human medical trials for spinal chord injury. If the research does take off and if these early research findings are replicated there is the very exciting prospect of new treatments for neurological disability in the future.

A recently study from the University of California, Berkeley found differences in brain activation between children from low and high socioeconomic status (‘rich and poor kids’). The researchers used EEG to measure activation in the pre frontal cortex and found children from low socioeconomic backgrounds had a low EEG response which was similar to children with brain injury. The psychology group at Berkeley have a distinguished history of research looking at the development of pre frontal cortex. One of the key findings over the last 20 years is the role that the environment has in brain development. Originally work undertaken on rats showed that those in a drab environment had less well developed brains than those living in stimulating environments. It is likely that poor children have less stimulating environments which in turn affects their brain development. Some of my clinical work is with children who have been abused and neglected and a consistent finding is that they have lower than average intellectual functioning and low academic achievement. This latest study adds to the growing body of research highlighting the importance of early intervention for good brain development.