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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.

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  • I work a lot with children and young people who have suffered a brain injury.  It is one of the most devastating conditions.  Brain injury often results in changes to personality, to memory, to social ability and sometime to physical disability.  It often occurs to normally developing individuals.  Because brain cells do not repair themselves there is no cure and it is a case of living with and adapting to the condition.  I have noticed however that there is one area of functioning that seems to be preserved and often actually enhanced following a brain injury and that is creativity.  Although the brain can not repair itself new neural pathways can develop which I believe can allow new talents to emerge or create a different way of seeing the world.  I have worked with several young people who have gone on to A level and university to do photography or Art despite their disability.   One person I know, Spencer Aston is working as a freelance photographer. He takes photos from a unique perspective in my opinion.  I have come across other individuals who have become artists following a brain injury- see this site for examples.   Also in terms of music there it the amazing Melody Gardot who makes beautiful music  despite or perhaps as a result of suffering a severe brain injury as a teenager.  Other singers I really like and who have suffered severe brain injury and recovered to do some great work include Marc Almond (details of injury here) and Edwin Collins (details of recovery here).   All these people are inspiring.  The message is that while having a severe brain injury can be devastating there is hope and possibly new futures.  I would encourage young people with brain injury or their parents to explore different potential creative opportunities.  I would also love to hear of other stories of people with a brain injury who have developed creatively following their injury.

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  • 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 care@recolo.co.uk or visit our website.

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  • 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.

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  • 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.

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  • I have just been reading a very good new book on neuropsychological rehabilitation by Barbara Wilson and colleagues Neuropsychological Rehabilitation: Theory, Models, Therapy and Outcome
    I also heard her give an interesting talk this week on memory rehabilitation. In the book and the talk she discuses proven techniques to help with memory. These are designed for individual with memory problems but they also work really well for anyone wanting to learn and remember information. The methods are backed with experimental evidence. They will work for adults as well as children.

    1. Encourage associations or links when learning- the best way is to use visual or spatial images and associate these with what you are trying to learn. Some of the best learners use an internal picture of a house or journey and imagine what they have to remember placed in different places in the house. This helps with retrieval of information from memory.

    2. Spaced retrieval i.e. gradually extend the recall time. With this you need to initially recall what you have learnt straight away and then over time extend the time gap between learning and retrieval. For example look at a fact to remember, cover and recall immediately, then look again and wait for 15 seconds and try and recall, then 30 seconds and then 1 min etc. This leads to information stored more deeply in memory.

    3. Pace your learning and reduce the amount you are trying to learn at any one time. Learn a few bits of information, have a break and learn a few more. Trying to do too much at once doesn’t work.

    4. Organize the information e.g. if learning a list, group the items together according to meaning. For example for a shopping list put the items of fruit together, drink together etc. If learning facts group together for meaning. The brain likes to store information semantically i.e. according to categories.

    5. Error free learning- this is used to teach others. If the person doesn’t know the answer to the question immediately provide the answer and ask them to repeat. Continue to support until the answer is recalled automatically without any errors. This works for adults with memory problems including those with Alzheimer’s and also for children with learning difficulties. See previous post for more details

    It does take a bit more effort to store information more efficiently in memory when learning but these methods are proven to work. There are other techniques and also the research behind them in the book.

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  • I have been working clinically with children with head injury now for over 12 years and this has allowed me to see the longitudinal effects of childhood head injury for myself. What I have noticed is that some children with what appeared to initially be mild head injury (i.e. no prolonged loss of consciousness) continued to have problems over time. I have looked at these cases in some detail and their developmental problem can’t be explained by pre morbid functioning (i.e. any difficulties before the head injury). This experience is not what the textbooks say is supposed to happen. Mild head injury is thought to be associated with better prognosis and is very rarely followed up by medical services. However, three new studies this year suggest that Mild Head Injury may result in more problems than previously though.

    A new study reported in the Journal of Head Trauma and Rehabilitation looked over time at preschool children (before the age of 5) who suffered a minor head injury. They reaseessed these children at age 14 to 16 years and found that the group who had been hospitalised with MHI were significantly more likely to show symptoms of ADHD, conduct/oppositional disorder, substance abuse and mood disorder than a control group or a non hospitalized group.

    This research group also reported in a separate journal with similar findings and the results are summarised in the excellent child psychology research blog. As Nestor Lopez-Duran the blog’s author reports ‘ the data strongly links TBI history to the presence of ADHD and conduct disorder symptoms years after the injury, and regardless of the underlying mechanism”

    These studies are also on the back of another study by Keith Yeates and his research group published in Pediatrics . They found persistent problems more than 12 months after mild head injury.

    So what are the implications of this. Firstly I think we need to look at categorisation of head injury in children. At present the main categorization tool is the Glasgow Coma Scale (GCS). This basically looks at levels of consciousness. Another important measure is Post Traumatic Amnesia -PTA (which looks at length of time where the person is confused or amnesic following the HI), however PTA in my experience is rarely assessed clinically. I think that both categorization tools are very blunt instrument. I have seen many children, for example with skull fractures who have not lost consciousness but seem to have poor outcome. The New Zealand studies above found that hospitalization was an important indicator. The Yeates study found that children with ‘mild traumatic brain injuries whose acute clinical presentation reflected more severe injury’ had a worst outcome. Therefore it seems clear that GCS is not sufficient in predicting neuropsychological outcome. All clinicians and researchers should be looking in more detail at the wider clinical picture.

    The other implication is that many of these children are discharged from hospital back to their families and schools with no follow up and no information that there may be ongoing problems. About 1 in 30 children suffer a traumatic brain injury so the problem is potentially very big and will affect all schools. It may that teachers could be the best people to identify these children providing that they have the knowledge to do so. There is a great need to educate teachers and other educational professionals about this. Most children with problems after a head injury will show a deterioration in behaviour and academic functioning in school often over time. For the teachers out there if you notice a child struggling or notice a deterioration in behaviour and performance it is worth enquiring whether the child has suffered a head injury. If this is the case it would be important to alert child health services. Also for mental health professionals it is important to always check for a history of head injury including mild head injury especially for children with ADHD or behaviour problems. I am certain that there are many children and adults out there who are not being indentified and suffering as a result.

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  • 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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