Child Neuropsychology

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.

Does brain training work? There are a number of conflicting studies in the literature see Guardian games blog for example. There has recently been a lot of interest in the Ninetendo DS brain training game although I am not aware of any published work on it’s effectiveness (but see this BBC site article for some anecdotal evidence.) I have just come across a good study in the British Journal of Educational Technology by Miller and Robertson 2009 showing improvements in self esteem, and accuracy and speed of mental maths using the DS brain training games (Also see comment from Derek Robinson below). I note that in this study only the specific task of mental maths improved, which is partly what the DS program trains.  I don’t think there is evidence that the DS BT works across different areas to train the brain as a whole.  Nintendo brain training does not train specific brain areas or functions and does not fit with contemporary neuropsychological theory.  It is a more broad brush approach.   In reality the brain has numerous functions linked to different anatomical areas and trying to train the whole thing at once is, I think nonsensical. Brain training will have to become a lot more targeted if it is to work.

There is some evidence that targeting specific areas can be effective. The key candidate at the moment is working memory. Working memory is the ability to hold information in mind i.e mental arithmetic , remembering lists of instructions etc. Working memory is associated with the dorsal-lateral pre- frontal cortex in the brain. There is an interesting paper in PNAS that shows that training working memory resulted in increased IQ levels. You can access the training site and try it for yourself here for free. Also there is some interesting new research on improving working memory using a computer game, which is due to be published soon and which I will report on here.

The key to brain training is to know how the brain works and how it develops and then to target set areas. My own company Neurogames produces brain training games based on the science of brain and psychological development. The games are targeted on areas where I think we should be able to produce change and where I think brain plasticity exists. It is important to understand how the brain and it’s functions develop as this holds the key to what can potentially change. I am carrying out research on this at the moment. If we can show through good science and based on solid neuropsychological theory that change can occur and how it occurs, then there is the possibility to revolutionize how we learn.

Note: Update 20.4.10 a new large scale study published in Nature suggests that Nintendo brain training is not effective in producing transferable cognitive benefits.  Initial nature study is published here

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.

I have just developed a new concept combining my knowledge of neuropsychology with computer games. It is called Neurogames and the games are available for purchase on my new website neurogames.co.uk. At present I have developed four games helping children to develop maths and numeracy. The games are based on the science of the development of reading and numeracy drawing on some of the work from the contributors writing in our book Child Neuropsychology as well as some of the research studies highlighted in this blog. The games take a developmental course mirroring the normal developmental sequence of reading and maths acquisition. The games also draw on my clinical expertise in terms of what helps children with neurodevelopmental difficulties. This includes errorless learning, frequent extrinsic rewards, visual based learning with bright attractive graphics and short game sequences with clear indicators to help children with short attention span. Computer games are also not critical and therefore the social pressure on learning is eliminated. Finally games are fun and Neurogames provides a new fun way of learning. I hope that the games will be helpful for children who find learning difficult whether it be because of a specific difficulty such as dyslexia or dyscalculia or because of a general difficulty such as ADHD, learning disability or brain injury. The games are easily to download and can be purchsed direct from the site. I also hope over the next year to develop more games to help with language and memory development. Let me know what you think.

Technology is developing very fast and I think there are increasing applications for children and young people with neurological or neurodevelopmental difficulties. Recently I have recommended the Apple system for several of my clients. I am fairly new to Apple but I am very impressed by its applicability in rehabilitation. Theses are some of the areas where it can benefit:

Executive function- Individuals with executive difficulties have difficulties with planning and organisation, working memory, self monitoring, flexibility etc. This typically occurs after a brain injury but is also seen in ADHD and other neurodevelopmental disorders. What I like about the Apple imac and Apple iphone is that it doesn’t rely on planning. It is very visual and intuitive. The menus open out across the page so you can see where you are and where to go rather than as in Windows having to work out where to find what you are looking for and remembering where it is. It is very visually icon based. The calendar feature allows parents, support worker and young people to produce colour coded structured timetables which help with planning, initiation, flexibility issues etc. It is also possible to set reminders of tasks to do.

Memory difficulties- As well as the calendar which can be on both the imac and the iphone ,the mobile me feature allows you automatically synch timetables, diaries and to do lists. If the iphone is lost there is an automatic back up. You don’t need to remember to back up. The reminders feature gives prompts regarding what to do next. I also like the photo albums on the iphone. These can be used as a memory prompts when set up right. The Google maps feature is useful when lost!

Social difficulties- I have found the photo albums very helpful for individuals who are unsure what to say in social situations (either because of social difficulties or memory difficulties). Showing someone what you have been doing (through photos) is a good way to start a conversation. There is also the possibility of using social network sights such as Facebook and Bebo which is great for individuals with disability. The photos can also be used for children with communication problems and children who rely on visual based learning and organisation.

Finally there are an increasing number of applications for learning and fun which can be downloaded quickly. I think that the potential benefits of these systems and technology in general for rehabilitation are great and I will be reviewing this over time.

Children with brain injury often have memory problems which means that they find learning new material difficult. One particular problem seems to be with trial and error learning. Children (and adults) with memory problems find it hard to eliminate the errors. The original work was done on amnesic patients in a study by Alan Baddeley and Barbara Wilson . They introduced the concept of errorless learning as a way of helping the individuals with amnesia learn. Errorless learning means intervening before the person makes the errors. It may seem counter intuitive but I have seen it work repeatedly in children in clinical practice. Over time it is best to withdraw support gradually whilst still trying to avoid errors. One of the best people talking and writing about child neuropsychological rehabilitation is Mark Ylvisaker from New York and he has a good way of explaining how this concept can be used to teach children. He is a great speaker and we met when he came over to London to talk at a conference I arranged. I would recommend trying to get to see him speak but if you can’t he has a great website with videos of him talking about different topics. The video on errorless learning is particularly good http://www.bianys.org/learnet/tutorials/errorless_learning.html. The video didn’t work well for me on his website (lots of stops and starts) so I would recommend downloading it first.