Child Neuropsychology

Motor co-ordination is a key factor in development and also seems to be important for general brain regulation and development – see previous post.

The i-phone and i-pad devices are unique in that they allow you to interact with games and programmes using movement and touch.  They have the potential in my opinion to develop and reinforce motor-co-ordination.  I have chosen 5 apps that I think particularly focus on key aspects of motor  co-ordination.  Games in particular are a fun way of developing skills- they are designed to engage and encourage repetitive play (practice) and all the ones I have chosen start off easy and build in difficulty over time.    Also the apps I have chosen are beautifully designed, often with a good soundtrack and most appeal to adults and children alike.

My top 5 are:

1.  For fine motor control –  Doodle Jump This requires fine hand control by tilting the device to allow the character to jump.  It is very intrinsically rewarding resulting in continued practice.

2 For motor inhibition and regulation – Whale Trail .  This game requires tapping the screen to make Willow the whale fly and eat bubbles. The key to success on this game is to inhibit the urge to tap the screen too much or too little and thereby avoid the hazards (thunder clouds) and  follow the rewards (swallowing bubbles).  It is fast moving and you need to anticipate what is going to happen adding an element of motor planning.   Again it is great fun, with a great sound track and very rewarding encouraging you to keep trying (and getting better).

3  For motor planning- Bumpy Road .  This requires trying to move a car along a bumpy road by lifting the road beneath.  The game requires anticipating ahead by moving the car not too fast, jumping and avoiding hazards (rivers).   This is a beautiful app that is just fun to play for the graphics and music alone.

4 For developing visual motor co-ordination –  Dexteria - This is a more formal teaching app focusing on tapping, letter formation and pinching objects (fine motor control).  This is definitely aimed at children but is the best example I have come across of a comprehensive  motor co-ordination teaching app.  There are timed elements which are challenging.  The app allows you to monitor progress over each session showing improvement over time.

5 For visual motor planning – Flight control – With this game you have to guide airplanes into land by tracing their flight path into the airport.  It requires anticipating future events and altering plans when you see that two planes may crash.  It gets hard when lots of planes are coming into land together .

So if you want to improve your or your child’s motor co-ordination playing with these apps may well help.  Although I am not aware of research in this area from a clinical point of view these apps all tap abilities that are important for development of visual motor-co-ordination (and perhaps wider brain regulation).  They are also brilliantly designed, addictive and fun.

Imagine being able to remember everything you have ever learnt or experienced.   Well I have just read a fascinating book Total Recall by Graham Bell of Microsoft labs which suggests that we may soon be able to do this using digital technology.  He set up a project to see whether he could digitally record everything that happened to him, in essence to create a virtual memory.

In order to learn and remember there is the need to encode information, store and retrieve it.  We now have the technology to do all three of these cheaply and efficiently.  We presently have lots of digital recording devices including, cameras, voice recorders, word processors, emails, answering machines, scanners, PDA’s etc, that can encode information into a virtual memory.   We have very large storage capacity in the case of hard drives (you can now store vast amounts of information even on mobile devices quite cheaply) that can act as a memory store.  In terms of memory retrieval we have sophisticated search engines either on the web or built into computers to find what we need to remember.  This is the first time in history that all three components of digital memory- encoding, storage and retrieval are available in such a cheap and easy to use way.

The implications for this are potentially huge.  In terms of personal enhancement it should be possible to have digital devices that store and retrieve everything that happens to you. No more forgetting what you have done, where you have been, facts about the world etc.   Your whole life experience could be stored on a device for future reference.  Maybe in the future when you are no longer around people will be able to review your life through such a device.  Bell documents how he records every telephone call, uses Sensecam to record all he sees, stores all his photos, scans every document and bill he receives, stores every email, stores all his medical records  and every web page he has ever seen.  Using a program he has devised he can search for any specific piece of information (memory) and retrieve it easily.  In the future it will be possible to record personal health data such as blood pressure, diet and alcohol intake and even how many steps you take on the same device and integrate it into your memory, which will make healthcare appointments much more efficient.  The book is a fascinating read and Bell believes that this is one of the key trends for the future and that we will all be able to access such technology within the next 10 years.

As well as personal enhancement this technology has huge implications for neuropsychological rehabilitation.  One of the most devastating consequences of child brain injury is impairment of memory.  There are some techniques that we can use to help with memory retrieval (see previous post ) but these are slow and take a lot of effort to work.  It would be far easier and more efficient to use technology to compensate. It should be possible to equip children (and adults) with memory impairment with a handheld device that will enable them to recall what they have experienced and compensate for their learning and memory problems.  This would revolutionise care for individuals with amnesia and dementia.

I would love to use this type of technology myself.  I am one of those people who wants to learn and experience everything.  I read avidly, try to keep up with the rapidly expanding neuropsychology literature and try to experience as much as possible while I can.   However the ratio of knowledge that I retain and can retrieve I think is pretty small relative to the amount of input.   At present looking at Bell’s book and the technology available, the issue is about integrating existing technology in order to create a device or program that automatically records, stores and retrieves information.  It can’t be that hard to do as much of the technology is already available.  The challenge will be creating a user friendly program or device that works seamlessly.  Ideally there would be psychology input to match the technology with human experience.   I am not aware of any company undertaking this work at present but please let me know if anyone knows whether anything like this is being created.  Maybe one day we will all be able to achieve total memory recall of everything we have ever experienced.  It could change the world as we know it.

Children and adults learn and develop through play.  I am a great believer that playing computer games as well as being fun can be good for your brain.  I have therefore created a list of 10 great games that I think require very specific areas of neuropsychological function to play.  Some even have research to show that they can change brain and neuropsychological function. These games are for a range of different ages and come in different formats.  Let me know of others that could be included in the list.

1 Portal 2 (PC/Mac) Probably one of my favourite games.  Portal 2 requires good executive function (associated with frontal areas of brain).  In particular you need to be able to problems solve and plan ahead in this game.  Also it is a beautifully designed game, showing what computer games can achieve in terms of entertainment.

2 Call of Duty 4 (X box)- An exciting fast paced game that requires good speed of processing and visual attention.   There are a number of academic papers such as this one by Bjorn Hubert-Wallender, C. Shawn Green and Daphne Bavelier Stretching the limits of visual attention: the case of action video games that show games like these can actually improve visual attention and speed of processing.  It seems that this only applies to really fast paced games such as Call of Duty. (note Call of Duty is for age 16 and above).

3. Tetris (ipad) A classic arcade style game that keeps you focused.  There is research by Haier et al from University of California to suggest that playing this game results in increased cortical thickness. There is also research by Emily Holmes from the University of Oxford to suggest that playing Tetris can help with symptoms of PTSD.

4 Drop 7 (iphone).  To play this game you have to drop different balls with numerals inside into rows or columns and try and ensure that the numerals and the number of balls match i.e. every time you line five balls up the ones with the numeral 5 in them disappears.  This reinforces the neuropsychological concept of Numerosities, which is the ability to automatically recognise the number in a set.   Difficulties with this concept seem to be the underlying disability in dyscalculia ( specific deficit in maths).

5 New Super Mario Brothers (Wii) The Wii version allows two people to play together and work in collaboration to progress through levels and therefore involves social co operation.  This would be an ideal game to play with a child with Autistic Spectrum Disorder ASD.  Playing alongside side children with ASD on a shared task  can be better than trying to directly interact with them. It is also fun to play with children and adults of all ages.

6. Where’s Wally (ipad).  This game requires a very specific form of attention called selective attention.  This is the ability to spot a stimulus within an array of other information. This game may be helpful for children with attention difficulties.  The ipad version is particularly good with changing goals and rewards.

7. Ball frenzy (ipad)  A good simple but addictive game requiring good visual motor co-ordination.  Similar to marbles.

8 Bookworm (iphone).  A game requiring word finding and spelling.  This isn’t specifically designed as an educational game and is by Popcap who are great at designing addictive casual games.  It is fast moving and you are motivated by completion and reward rather than focusing on the educational side.

9. Connect Four (ipad).  Another simple game  but requiring good executive function.  You need to resist the impulse to act immediately and plan your response.  I and colleagues have long believed that playing this game with children is a better assessment of executive function than many formal tests.

10 Nutty Numbers (ipad)  I have including the game I have developed to help with numeracy for young children because there is research to show that it is effective in children’s development of numeracy.

I am really excited about the prospects of using the ipad to help children learn.  As I have previously discussed there are some important advantages in using the ipad, especially with younger children and children who find learning difficult.  I am developing games on the ipad to help learning and rehabilitation (see Nutty Numbers).   I am also clinically involved in rehabilitation and looking to find ways to help children with neurological conditions.   As a result I have looked in detail at what sort of apps are available.     My impression from studying the itunes educational app charts and trying out various games is that there is generally a lack of good quality educational apps that I could recommend.   Although I want to promote my own apps, I would also like to recommend apps to help particularly children who are finding learning hard or are in rehabilitation.  Whilst there are a lot of nice looking apps about there is mainly a lack of substance.  The sort of features I would like to see in apps and would recommend parents to look for include:

1.  Is the app based on learning theory?  There is increasing knowledge about how children learn.  Are the educational apps utilising this?

2. For younger children are there spoken instructions rather than written instructions?  Clearly young children can’t read and therefore will need a parent supervising them if the instructions require reading. The ipad will work best when children can explore and learn under their own initiative.

3. What happens if the child gets an answer wrong?  It can be very frustrating receiving a big cross or a sound effect indicating a mistake sound, especially if you don’t know the answer.   This is a particular problem for children who find learning difficult.  Several experiences of this will turn most children off.

4.  What are the reward structures?  Research has shown that positive affirmations (i.e. letting the child know that they are doing well) are very powerful by themselves in learning.  Any educational apps should have several layers of reward structure.

5.  Is there any research showing that the app improves learning?  For example Nutty numbers has been shown to significantly increase numeracy compared to a control group in a published experimental study.

6.  Is there a randomised presentation?  Just going through the same structure each time does not encourage learning.

These are some of the criteria that I consider important and have used to develop my apps.   I would like to see other educational apps with these features. I think this would help develop the field of games based learning and realise some of it’s potential.  Potentially many children could be using tablet devices such as the ipad to learn and develop.  I have written previously about the advantages of game based learning.  However, at present in my opinion it is still a field in it’s infancy.    I hope it does develop and that I can contribute to this.  I would be keen to hear of any other recommended educational apps fulfilling some of the criteria above.

One of the problems with Games Based Learning (i.e. educational computer games) is that many educational games look just too educational and are therefore dull and worthy.  Whilst many games are designed with education rather than play in mind, another major problem with GBL for me is that many educational games are desktop based and desktops are essentially boring.  Sitting at a desktop feels like work.  Using a keyboard and mouse is not easy particularly for young children.   Also according to most children I see, ICT is not a fun subject.   The iPad in contrast seems like fun.  The way it feels and the touch interface are intuitively satisfying.  You can pick it up, manipulate it, touch it and it responds- all fundamental aspects of play.   Children seem to particularly realise this -a point well made in this PC world article- Why iPad is children’s toy of the year. Give a child (and me) an iPad or iPhone and they will play with it.  Education works when children are engaged and motivated.  Children develop and learn through play.  An playful approach is in my opinion the best way to learn.   Because the iPad is a device to play with I think it could be the best device to move Games Based Learning on.

In order to prove my point I have just released one of my games Nutty Numbers on the iPad.  You can buy it in iTunes here.  Nutty Numbers is designed to teach basic numeracy concepts including addition, subtraction, multiplication and division.  The game is based on a motivating error free learning paradigm.  This cuts downs on frustration when learning and boosts motivation.  I think that this approach works and I have a research paper in press with International Journal of Virtual and Personal Learning Environments showing that it significantly improves levels of numeracy compared to controls. Children who have used it find it easy and fun to play and the iPad interface just feels a natural way to play this game.   I hope that some of you try it out and if so please let me have any feedback.  My goal is to use my knowledge of neuropsychology to produce games that are fun and engaging but are also effective.  I think that the iPad may be the best device to achieve this.   There are still too many children who struggle to learn to read and to attain basic numeracy and are turned off by education.  I think well designed motivating computer based learning games have the potential to change this. The iPad may just be the device to make this happen.

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.

Living in the 21st century can be stressful.  If you listen to the media there is potentially a lot to worry about now; economic meltdown, ecological catastrophe, medical pandemics to name but a few.  Also there are the constant distractions of 24 hour news, TV, email, twitter and blogs! In general there is information overload.  So how do you cope with this?  I am becoming increasing interested in the potential of mindful meditation.   Whilst this may seem a bit New Age, at its core it is in fact a very simple idea.  The key is to focus on the present moment.  Not to worry about the future or the past.  To try and focus on something simple like your breathing and to not be distracted by intrusive thoughts.  Humans have used meditation to cope with life in different cultures for 1000′s of years, be it though Buddhism, Christianity or Taoist teaching.  More recently it has been shown to be very effective in dealing with mental health problems.  Combined with Cognitive therapy it certainly seems helpful for depression see Ma and Teasdale 2004 and anxiety see Evans et al 2007 .

As a child neuropsychologist there are two areas of mindfulness that particularly interests me. Firstly it is becoming clear that meditation is associated with changes to brain function.  This includes increased thickness in prefrontal brain areas and increased grey matter in brain stem.  In his very impressive book The Mindful Brain in Human Development: Reflection and Attunement in the Cultivation of Well-being Dan Siegel discusses in detail the neuroscience and development of mindful meditation.  In my opinion mindfulness is closely related to working memory (see post for details of working memory) and meditating on a regular basis by focusing on a set stimuli (voice, breathing, light) may be similar to working memory training.  It requires holding a focus in mind.  As I have discussed in the past working memory can be improved with practice.  There is some research showing that meditation training brings cognitive benefits.  A recent paper in  Consciousness and Cognition by Zeiden and colleagues suggests that brief mindfulness training significantly improved visuo-spatial processing, working memory, and executive functioning.

Secondly can mindful meditation be used to help children?  A recent special issue in the Journal of Child and Family studies shows a number of potential applications including for children with ADHD and also to help parents cope with managing difficult children.  At present I think the evidence that it works with children with neurodevelopmental problems is not quite there although there are promising indications. Certainly working memory training works with children and so meditation should in principal.  I also think that in this increasingly distracted, stressful age, preparing children with skills to deal with life such as mindful meditation may prove to be very useful.

If you want to try it yourself there is a good resource site from UCLA with MP3 files with meditations etc here.  There is also a good paper with advice from Karen Hooker and Iris Fodor on how to help children in Gestalt Review here.

I attended the Games Based Learning conference this week to present research on Neurogames.  I also managed to hear some inspiring talks and people.  Here were the highlights for me:

Learning about the Channel 4 games.  High quality games to encourage learning.  Examples included the 1066 game.

Hearing Matt Mason talk on The Pirate’s Dilemma.  A great talk about the way culture has evolved with the help of copying and piracy and how business (and particularly the games business) could learn from this.  You can buy his book  The Pirate’s Dilemma: How Hackers, Punk Capitalists, Graffiti Millionaires and Other Youth Movements are Remixing Our Culture and Changing Our World or download it here

Jesse Schell’s talk on the ‘Future is Beautiful’ in relation to education.    As always inspirational.   The slides are here

Tom Chatfield Author of Fun Inc.: Why Games are the 21st Century’s Most Serious Business on the evolution of games.  In particular the point I appreciated was the way that games are starting to encourage co-operation, for example how players can help each out on the New Super Mario Brothers (Wii)

Margaret Robertson’s talk on casual games and what they can teach us about educational games. Casual games are quick, funny, social, topical, simple  cheap female friendly and competitive and also none of these – can educational games emulate this?  Margaret’s blog is here .  She also introduced me to drop7 an addictive game for the iphone

Overall I felt the that these exciting times for games based learning but that it is a very diverse field with a lot of uncertainty.  For example how do you fund this? How much education and how much entertainment? The role of learning experts in games.  Also there is a general uncertainty over where games are going – i.e cheap social gaming such as Farmville or high production games such as Call of Duty or both.  The uncertainty however may be just how it is and will always be and out of this messy uncertainty will arise failure and success and creativity.  It is a Darwinian world!

My talk in the research strand was on developing a theory and evidence based game to help children learn reading and maths.  We presented research from my colleague Misbah Khan showing that Neurogames significantly improve reading and maths in children.  The slides from the presentation are here.

Everyone is a psychologist.  By that I mean that everyone tries to work out why people behave the way they do.  This is an inbuilt social drive that helps us to interact normally.  It is based on theory of mind which is about understanding other people’s mental states and intentions.  Lack of theory of mind is the key disability in Autism.   In my work I find that most people have a strong belief about why someone is behaving the way that they do (although in my work I think that it is often a wrong belief).

I think we base our understanding on why others behave  the way that they do on what we think about ourselves and our cultural norms.  This is essential to group cohesion.  No one can truly know how another person is thinking but we automatically make an educated guess.  The difficulty comes when normal behaviour breaks down.   We know that in some individuals behaviour and personality changes dramatically with acquired frontal brain injury- see the case of Phineas Gage.   I see similar difficulties in my work with children with head injury, neurodevelopmental disorders and sometimes those with a history of abuse and neglect.  With these children I see very challenging behaviour that doesn’t respond to normal parenting or behaviour modification.  I will write about why this is in more detail at a later date (to with difficulties in development of frontal brain areas). In general though behavioural control is more complicated than it seems.

I was particularly struck by this difficulty in understanding why some people behave the way they do when reading a research paper looking at the most extreme of behaviours, murder.  Why does someone comit murder?  The paper looks at 77 inmates or defendants charged with murder in the US and referred for neuropsychological assessment.  The sample is self selected because they were referred for clinical assessment rather than randomly chosen for research.  However, the sample characteristics are striking.  Some of the key facts are:

• 49.4% had a developmental disorder in childhood.  (36.4% had ADHD)
• 87% had a brain injury (self reported and 10% had documented evidence)
• 85% had a history of substance abuse.
• 45% had a psychiatric history
• 35% had a history of abuse in childhood.

From the neuropsychological assessment the mean IQ was 84 , which is a standard deviation below the norm.  Mean working memory was 87 which is low average.  The mean logical memory score was 68 which is very low indicating significant memory problems.  The sample also had a high rate of assessed executive function difficulty (executive function is the cognitive ability associated with the front area of the brain).

You will need to read the paper to find all the details because there are so many interesting factors in the sample.   However, taken together the majority of the sample had some form of brain damage/ disorder or abuse stemming from childhood (which as I have discussed here often leads to developmental brain damage).   Exactly what is going on in their heads can never be know and the neuropsychological factors don’t explain the trigger or situation in which the murder took place.  However, it is clear that there are neurological and neurodevelopmental factors going on here, and given what we know about these in childhood and from case studies, it is unclear how much control such individuals have in a given situation.  I don’t offer this as an excuse to let people off and certainly I think many of these people are extremely dangerous.  But the results may shake our assumptions  (based on our own theory of mind) as to why people behave the way that they do.  Consider this next time you hear about a murder in the News.  Also the results may point to the importance of prevention in terms of early identification and treatment of childhood neurological problems and childhood abuse.  So many of these people’s problems seem to stem from experiences and events in their childhoods.

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.