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Child Neuropsychology

A blog by Dr Jonathan Reed

  • 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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  • 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.

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

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

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

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

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

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

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

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

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

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

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

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  • 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

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