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Child Neuropsychology

A blog by Dr Jonathan Reed

  • Neuropsychologists have studied memory for a long time.   We have a clear system of memory classification involving declarative memory which includes episodic memory (memory for events) and semantic memory (memory for facts) and non declarative memory which includes more implicit systems such as procedural memory, classical conditioning and priming.  The neurological substrates of this system are understood.  Numerous case studies of individuals with brain injury and memory disturbance have been reported.   The whole enterprise is best summarised by one of the leading researchers Larry Squire in this excellent paper Memory and brain systems 1969-2009 .

    Yet despite all this knowledge I struggle to see the relevance for the many children I see with memory and learning difficulties.  I was therefore fascinated to read a new book Moonwalking with Einstein: The Art and Science of Remembering Everything by Joshua Foer.  Foer’s book is based around a strange group of people who compete in memory championships around the world.  He explains how these competitors memorise the orders of multiple packs of cards, very long strings of digits and long unpublished poems.  The amount of information they can remember is quite remarkable.  Yet Foer shows that these feats are based on some simple memory techniques.  The premise is that human memory evolved to aid survival (finding food and avoiding danger) and therefore is primarily visual and spatial (location based).  He also highlights the way the brain learns and remembers through associations.  The techniques he describes are based on creating an imaginary spatial location (a memory palace) and imagining different visual images which can be associated with what you want to remember in this location.  So for example if you wanted to remember a shopping list you may imagine your home and visualise the first item, which could be milk by imaging someone bathing in milk.  The next item may be fish and you could imagine a singing fish in the kitchen.  The more bizarre the image the better you will recall, hence the title of the book.  By recalling the location and image you can then easily recall the information.   Individuals can create huge memory palaces and remember large amounts of information this way.  Foer believed that these techniques were so powerful that anyone could become a memory champion and he sets out in the book to prove this by entering the US memory championship.  I won’t give away the ending but it is a fascinating read.

    I think that these ideas could have important implications for neuropsychological rehabilitation and teaching.  How many teachers and psychologists know about these techniques and use them?   The techniques would need some adaptation (learning packs of cards, shopping lists and strings of numbers is not that useful) but used properly it could be very helpful for children learning facts about the world or number facts or just developing more effective ways to pass exams.  Is anyone out there using these techniques to help children with learning problems? If so I would love to hear about it.

  • The founding father of psychology Sigmund Freud was fascinated by the unconscious mind and made this the centre of his study and practice.  The role of the unconscious in psychology quickly fell out of fashion.  This was because it could not be measured or easily understood.  Initially behaviourism became dominant, based on the objective analysis of observable behaviour.  Later the focus in psychology shifted to studying cognition – the study of thought processes.  Both areas resulted to different psychological therapies for example,  Cognitive Behavioural Therapy (CBT), and different ways of understanding learning.  Over the last decade or so neuropsychology has started to emerge.  Neuropsychology focuses on the relationship between the brain and behaviour (including cognition).  And guess what – as we begin to understand the role of the brain in psychology there is an increasing interest in the role of  unconscious processes (brain actions that we are not aware of consciously) .  Back to the start again- maybe Freud was right all along!

    I wrote about the importance if understanding the relationship between sub cortical structures and the cortex in a previous post. I have also just read a fascinating and very readable book by David Eagleman Incognito: The Secret Lives of The Brain.  This book looks at the dominant role that the unconscious brain plays in everyday human life.  Eagleman argues that most of what we do happens automatically and without our conscious brains being aware.  He gives numerous examples of how unconscious processes control our psychology including our attraction to others, our prejudices, our perception of the world, as well as the more obvious examples of motor control- I would really recommending reading the book to understand the richness of his argument.  He argues that conscious thought processes play a very small role in our lives,  perhaps just to allowing us to think flexibly and set goals (clearly this has big consequences as the achievements and dominance of the human species shows).  Intriguingly he also suggests that maybe our conscious self is not in control at all, but we (it) just think we are.  This was a central point in Chris’s Frith’s excellent although more academic book Making Up the Mind: How the Brain Creates Our Mental World.  Both authors report studies  showing that when you ask someone to tell when they have the urge to lift their finger and scan their brain, the part of the brain responsible for planning the action lights up before they report the urge to lift their finger.  Therefore the unconscious brain is making the decision before they are are consciously aware of it.

    Understanding the role of unconscious processes has important implications for psychology.  David Eagleman discusses in detail the implications for the criminal justice system.  Are criminals to blame for acts committed by unconscious processes (and especially when you add in abusive childhoods, brain injury, learning problems, genetics, which are all out of conscious control)?  I think there are also significant implications for child neuropsychology.  Understanding how our brains work and basing treatment and intervention on this understanding will lead to more effective intervention.  In my practice I work a lot with children with significant learning disabilities and brain injury.  Often they are unable to learn or control emotions and behaviour consciously.  I  look at ways to influence implicit processes  i.e changing the environment rather than expecting individual to change.  Also with my games company Neurogames I integrate implicit learning processes into the games, which I think is what makes them effective.  However we are only just starting to understand these processes and as our understanding increases I expect there to much more focus on sub cortical and unconscious processes in psychology.  This is not entirely easy as we create and develop psychological theories using the conscious parts of our mind, thus we are already biased.  We need to suspend our own perceptions and experience, based on our conscious view of the world and look at the data instead (a bit like theoretical physics).  Understanding how the brain actually works holds promise for major changes in psychological treatment, teaching and social policy.  Maybe we are also on the verge of a revolution in how we see ourselves?   I’ll keep you posted on ideas that emerge.

  • I want to discuss an important new book for understanding how the brain works, which I have just read and is called Subcortical Structures and Cognition: Implications for Neuropsychological Assessment by Leonard Koziol and Deborah Budding.  Our current understanding of how the brain works using Neuropsychology has traditionally focused on the cortex part of the brain – frontal, temporal, parietal and occipital lobes and has looked at what happens psychologically when there is damage to these particular areas.  From this we understand perception, memory, language etc pretty well.  However we have tended to ignore subcortical brain areas such as the basal ganglia and cerebellum and have considered these areas as being responsible mainly for motor co-ordination.   This new book by Koziol and Budding challenges this view and presents a view of sub cortical structures being central to the way the brain works.  It is a detailed book with many arguments (a summary can be seen on the website here) and needs to be read carefully, but some of the important points for me were:

    1.  The brain responds to the environment in two key ways.  Firstly most of the time it responds in an automatic way (subconscious way using procedural memory) which requires little thought, is fast and is adaptive.  You don’t need to work out how to respond to most everyday occurrences you just do it.  However, when a new situation arises, maybe a threat, maybe something you need to learn, the front part of the brain takes control and thinks about how to respond (i.e. executive function).  Both systems operate in tandem and are connected by the basal ganglia.  The default setting for the brain, however, is to make unfamiliar familiar.  This is more efficient.  Hence there is a drive to turn new information into automatic memory.

    2. Koziol and Budding argue that the basal ganglia is key in determining this process i.e. linking controlled and automatic responses.   It does this by being part of a feedback loop connecting the cortex to the limbic system (thalamus) and acting as a gate between the two. Basically the cortex is stimulated by sensory input and the sub cortex inhibits responses by deciding what information is returned to the cortex.

    3. The other main sub cortical area the cerebellum works to further fine tune responses using a mix of excitation and inhibition.

    4. The book details how and why such a system would have evolved.  This is often missing in neuropsychology accounts.  The book offers a plausible explanation of what any organism needs to function and how brains have evolved to meet these needs.  The key purpose of an organism is to survive.  In order to survive an organism needs to recognise objects, locate objects and detect movement (all cortex functions) and then to know what to do, how to do it and when to act (all mediated by the subcortex).  Koziol and Budding compare the subcortical structures in vertebrates, primates and humans to illustrate this point.

    5. The  basal ganglia acts as a gate to switch responses on and off, which is the key to regulation.  Knowing when to start a behaviour (initiation) and when to decease from a behaviour (inhibition) is key to how we function (and yet is rarely explored). The cerebellum further fine tunes this process.

    6.  Traditionally the sub cortical structures have been though of as mainly involved in motor responses.  However one of the many interesting ideas in the book is that  the same structures may have a similar  function for emotion, behaviour and cognition.  This would make sense from an evolution and developmental point of view.  Undertaking complicated motor sequences such as kicking a ball i.e. judging when to move and adjust can be similar to knowing how to control anger, social response or thoughts.

    7. Why this is important in my opinion is that it starts to offer explanations for disorders of regulation, which are so common in children, e.g. ADHD, TBI, OCD, emotional disorder, motor co-ordination and speech disorders.  Neuropsychology does not provide very good explanations for these disorders at present and yet they are the most common difficulties encountered especially with children.  The key issues in these disorders is regulating and adjusting responses to the environment.

    8.  Another reason the book is important is that it gets away from the view that we need to focus on a single brain area and it’s function and looks instead about how different brain areas act in circuits in relation to one another.  The circuits work by involving different brain areas in feedback loops using excitation and inhibition to regulate the system.   This makes sense biologically, developmentally and from an evolutionary point of view.

    Therefore I would highly recommend this book to anyone interested in neuropsychology and how the brain works.  It challenges existing thinking.  It is a specialist book but is well written and informative.   There are detailed sections on neuropsychological assessment for those interested, although these sections are in my opinion of more limited interest because most tests don’t assess subcortical functions that well.  The important thing the book does for me as well as explaining sub cortical anatomy and function is to start to provide a more coherent framework for understand brain regulation, which I think is fundamental for understanding child neuropsychology.   I think that ultimately this understanding will help us better assess and help children with brain dysfunction and particularly regulation difficulties.

  • 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.

  • I recently wrote that too many educational computer games look too educational and are not fun to play.  I have recently, however, come across a couple of causal games that although they don’t set out to be educational actually are, but are also addictive and fun.   Casual games are simple, cheap games that are easy, yet compelling to play.   The first game Drop 7  by area/code is a game involving numbers but also works a bit like Tetris.  To play 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.  I think that this game, without intending to, actually reinforces numerosities,  which is the ability to automatically recognise the number of objects in a set.  Understanding Numerosities is associated with the intraparietal sulcus in the brain and is the foundation for the development of mathematical thinking.  Individuals with dyscalculia (maths dyslexia) have difficulties with this concept.   I don’t think the designers knew this and just designed an addictive clever game.   But it would be interesting to research whether this does actually help children and especially those with developmental dyscalculia to develop in terms of maths.   In the meantime at the least it is a good fun way for children to reinforce automatic number understanding.

    The second game by one of my favourite casual gaming companies Popcap is called Bookworm.  In this game you have a grid of letter tiles and have to create words out of them.  You get points for the complexity of the word.  You also have to use up a burning tile before it reaches the bottom of the page (it goes down one step every time).  It is a fun, fast moving, compelling game but improves word knowledge and spelling at the same time.  Popcap are great at developing addictive simple games such as Bejeweled and Peggle.  It is great to see that they can use the same principles to create games that are educational.

    I should note that both games are also just fun for adults and children to play.  Me and my children enjoying playing them as well as other games just to relax.  They are great on the iphone.  I am sure that they are good at producing increased levels of dopamine (the reward neurotransmitter) in my brain!

  • 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.

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  • 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.