Child Neuropsychology

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.

This is not child neuropsychology but five cultural experiences that have had a impact on me so far this year.  Just thought I would share them.

History of the world in 100 objects.  A wonderful collaboration between the British Museum and the BBC telling the story of the world through a selection of 100 objects at the musuem.

The new Vampire Weekend album  Contra.  Clever music to make you feel happy.

The Stieg Larsson millennium trilogy The Girl with the Dragon Tattoo The Girl Who Played with Fire and The Girl Who Kicked the Hornets’ Nest Compelling psychologically driven page turning reading.

Cormac McCarthy  The Road – One of the most emotionally powerful books I have read for a while.

Channel 4 India season The people and particularly children living in the slums of Mumbai have so much to teach us about how we live in the west.

The news (posted here) that 2 boys aged 11 and 10 have been convicted of sadistically attacking and torturing other young boys has lead the media to question why they did it. Most newspapers have focused on the neglect and abuse the boys suffered at the hands of their parents and particularly their violent father. As I wrote in my last blog post this early history of abuse and neglect often leads to damaged brain development. However, this explanation doesn’t go far enough. Despite many children being abused and neglected very few go on to sadistically torture other children- see paper here reviewing the evidence. Therefore there has to been an additional explanation for such unusual behaviour. The key lies in understanding the development of empathy and distinguishing this from theory of mind (ToM). ToM relates to understanding other peoples mental states. Empathy is the ability to understand other peoples emotional states and to respond with appropriate emotion -as Simon Baron Cohen describes – experiencing an emotion triggered by other peoples emotion. People without empathy as considered psychopaths. They understand what other people are thinking or feeling (ToM) but do not feel the emotion themselves. They may feel a discordant feeling such as pleasure in response to other peoples pain or distress. Can this develop in children? Empathy normally develops at a very young age (about 14 months) and in my opinion is driven by genes- see some recent research here on this. I think therefore that this must develop in early childhood. There is likely to be a genetic predisposition that is triggered or made worst by an abusive childhood. Remember that in this case the children shared in part their violent father’s genes. The parent’s genes and experience will in turn shape the environment that the children are brought up in, thus leading to a toxic feedback cycle. Whilst it is difficult to think of children being psychopaths I fear that this is possible, although rare. I have probably seen about 10 children in my carer (out of 1000′s) with this presentation. It is difficult to know what you do about it other than try and minimize the resultant risks (which hasn’t happened in this case) or perhaps to intervene very early – although I am not aware of research showing that you can change this. To read more about the development of empathy see chapter 14 Social Neuroscience by Simon Baron Cohen and Bhismadev Chakrabati in our book Child Neuropsychology: Concepts, Theory, and Practice
.

I have written a previous post explaining why stem cells could be an important treatment for people with brain injury and disease. In summary the brain cannot repair itself. Stem cells are naturally occurring cells that turn into neurons but are only present in the embryo. The Bush government vetoed research in this area on religious and ethical grounds but Obama has overturned this.

Recently there have been two interesting studies that show the potential of stem cells for neurology and neuropsychology. They both use human stem cells transported to rats. If these results can be replicated in humans it will transform our world.

In first study published in PNAS Munjal Acharya and others from the University of California implanted human stem cells into rats that had damaged hippocampus due to radiation. Not only did the stem cells repair the damage they also resulted in restored learning and memory (functions associated with the hippocampus). If this could be replicated in humans we could have a treatment for neuropsychological impairment, which would benefit thousands of children and young people.

In the second study published in Stem Cell, Jason Sharpe and colleagues from the University of California transplanted human stem cells into rats that were paralysed by a spinal cord lesion. The stem cells repaired the lesion and resulted in improved recovery of forelimb function. Again if stem cells can repair spinal cord injury in humans the benefits would be huge.

Also although this is not neurological I was also fascinated to see researchers grow part of a human jaw bone using stem cells.

There is a huge amount of research being undertaken in this area at present (thanks to Obama). The NIH site on stem cells in the US is a good website for following what happens. There are a few human studies- see this on MS, but so far the majority of studies are animals although they are starting to use human stem cells with animals. If these results could be replicated in humans we may be able to repair bones, spinal cords, brains and restore neuropsychological function. Very exciting times!

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.

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.

There is an interesting article in the Sunday Times this week entitled ‘how to make your child more intelligent’. It seems to be based in part on a new book by Richard Nisbett entitled ‘Intelligence and How to Get it: Why Schools and Cultures Count. Whilst the article makes a number of important points the overall tone feels a bit like the old nature/ nurture debate, which I thought was over years ago. The article starts by stating that ‘Over recent years most experts have concluded that intelligence is largely genetic in origin, and that nurture does relatively little to raise an individual’s potential’. I am not sure which experts they are referring to here as anyone who knows anything about the genes and IQ literature knows this not to be true. The relationship between IQ and genes has been researched very thoroughly. The consistent finding is that genes account for about 50% of variance, which leaves 50% due to environmental factors. The article seems to try and overemphasize the role of environment and diminish the role of genes. It states ‘demolishing the finding of twin studies is part of the argument against genes controlling intelligence.’ This is the argument that twins who are adopted and reared apart have similar IQ. The article argues that twins who are adopted and reared apart have a similar environment in that adopted parents are highly likely to give their children a good start in life. This seems a highly tenuous argument. Are all adoptive environments the same? Would this produce such consistent findings? Also would this argument hold for all the twin studies looking at heritability in schizophrenia, autism, ADHD etc. Dismissing twin studies is a familiar ploy of people who want to dismiss the genetic factors and one I thought had died years ago. It undermines what is otherwise a good argument. The results for the gene and IQ studies are very consistent and researched in some detail. It seems silly to me to claim that genes don’t have an effect on brain and psychological development. You don’t need to knock the gene studies to show that environment is important. The gene studies already do this.

Another factor that points to the importance of genes in IQ is that clinical experience and research suggests that IQ is remarkable stable through lifetime. Twins actually become more similar in IQ scores as they get older. Something must be driving this. IQ doesn’t change easily, although there are obvious environmental factors at work. Certainly it is clear from the Flynn effect that IQ has been steadily rising over the last 100 years (obviously genes are not evolving that fast). There is a lot of research on environmental factors influencing IQ. IQ is a complex concept that is not totally understood, but from the research there are some candidates for strong environmental factors that have an impact on IQ development. These include having a stimulating early environment, good early nutrition, an environment rich in language and literacy. There is also research showing how targeted computer games may raise IQ. There are other suggestions in the article although i am not sure about the research to back them up – I am certainly not aware of the value of meditation on IQ, encouraging self control or having bigger babies to name a few mentioned in the article.

So overall, yes I believe we can encourage children to be more intelligent (although as IQ as currently assessed is a comparison measure it will be difficult to measure this) and I applaud the article for highlighting this. I think we should try. But don’t dismiss the influence of genes. That influence is always there and if ignored can result in my opinion in insidious effects such as a lack of social mobility. Parent’s genes are important in part in determining early child environments (i.e. stimulating, language rich environments with high levels of nutrition) and therefore IQ development. This is a political question. I think that overall improved IQ and literacy should lead to a better society (although many other factors are important too). To achieve this early intervention by the State will be probably be needed. We will need to understand the whole picture if we are to move forward.

PS the article does contain a good section demolishing the race, genes and IQ argument and should be read for that alone.

There is some interesting new research showing how video games can improve visual skills. The research by Renjie Li and others from the University of Rochester and published in Nature Neuroscience showed how playing an action based vidoe game improved Contrast Sensitivity Function (CFS). This was a good study with controls and pre and post assessment showing clearly that it was the video game training that made the difference. The key factor was that only action games worked e.g. Call of Duty. Non action games such as the Sims didn’t result in improvements. Contrast Sensitivity is the visual ability to see objects that may not be outlined clearly or that do not stand out from their background. It is a visual perceptual function that is important for night vision, facial perception, reading and a host of other activities. Whilst physical properties in the eye are involved it is also a neurological function. The study was on adults but I don’t see why the same effects wouldn’t be seen in children. The study showed that training using the video games can improved contrast sensitivity and therefore neural function. This provides further evidence that video games may be a very important way to improve neurological function. However as I have reported in other posts it is a question of targeting the right areas with the right games. It is important to have a good research base. Not all games work and not all functions can be trained. For those of you interested the Center for Visual Science at University of Rochester has a number of papers looking at the use of video game training in visual, motor and attentional tasks.

There is more evidence of the effectiveness of computer based working memory training with the early publication of a new study in Developmental Science. In this paper Joni Holmes, Susan Gathercole and Darren Dunning took children with low working memory and provided training in the form of computer game designed to improve working memory- see Cogmed. They assessed IQ, working memory and academic attainment before and after training. The training which was only for about 6 weeks resulted in substantial gains in working memory. It also resulted in significant improvements in maths 6 months after the training. There weren’t any gains in IQ or in verbal abilities suggesting that the gains were quite specific. This study adds to the evidence that computer game based training can improve neuropsychological functioning. The target for the training however, need to be specific and based on areas that the research shows can improve. It also shows that training working memory can have an impact on educational development, in this case maths. As the authors point out there will typically be 4-5 children in a class of 30 with poor working memory. The study therefore has big implications for future education practice.