Clinicians

Foundations of Learning: Creating the Ability to Learn
By Linda Narun, M.A., CCC-SLP

Dr. Tarnow discussed the concept of brain plasticity in the introduction of this newsletter. The increased understanding we have of the brain and the obvious correlates between behavior and pathways in the brain must assist us in providing interventions for many aspects of learning. It seems so obvious but also so easy not to remember that for every experience or action we do, something happens in the brain. We take it for granted that to be a good athlete your body has to be in good condition. No one would attempt to run a marathon before first undergoing fitness and training programs. The brain is no different from the rest of the body. It needs to be functioning in tiptop condition for it to complete the many marathons of learning that is required of each of us.

The brain of individuals with Learning or Attention Deficit Disorders can be working in a disorganized manner. The more assistance and condition we can provide this most important "muscle" the better off the student will be when he or she is actually required to achieve formal learning in the classroom. As knowledge increases, so will our ability to assist both children and adults to maintain and improve skills and learn new ones. I think it is helpful to understand the developing brain to better understand the non-medical interventions that depend on brain plasticity and neuroscientific principles.

The brain begins its work as soon as the infant is born. At birth, the infant brain has millions of pathways which all fire in a disorganized, asynchronous manner. These early pathways depend on use to remain operational.

If they are not used, the old saying applies, i.e. "use it or lose it." Without environmental stimulation the pathway ceases to exist. With stimulation, Dr. E. Goldberg stated, "use it and get more of it". Before the advent of fMRI, it was assumed that brain development occurred during optimal periods and if these periods were missed, little could be done to alter the structure of the brain. With our better understanding of the continuing development of the brain throughout life, we are able to create programs that address the underlying health of the brain. These programs help to develop pathways that may not have previously existed; therefore, improving the necessary skills required by the individual to be successful.

The brain is indeed "plastic" in that it can be molded by the stimulation it obtains. Think of the children who have been raised in overcrowded orphanages who, because of the lack of stimulation develop visual and auditory processing difficulties and consequent emotional problems. The deprivation suffered by these children and the consequent learning difficulties they suffer are dramatic examples, but help us to better see the relationship between the environment and the very basic structure of the brain.

For reasons that may not always be clear, many children experience processing difficulties in spite of having been raised in a good early learning environment. These difficulties may relate to genetic predisposition, early illness, birth trauma, etc. Depriving the brain of stimulation results in it developing weaker, slower pathways. There has been much controversy in the literature about the effects of mild, early hearing loss in children secondary to chronic middle ear infections.

A study recently completed by Han Xu, Vibhaker Kotak and Dan Sanes at NYU showed that changes occurred in projections to the auditory cortex following a brief period of hearing loss. This study demonstrates the importance of the environment to neural development. Efficient pathways to process incoming information may not become well established and the brain has difficulty "firing" in an organized temporal sequence. As Merzenich has stated, neurons that "fire together, wire together" resulting in a brain that is temporally organized. An inefficient brain while not related to intellectual potential, often prevents a student from realizing his potential. If pathways are not developed or work too slowly, difficulties in specific area of the brain result in poor skill development i.e. poor reading, writing, attention etc. Logically, improvement in the sequential firing of appropriate pathways in the brain must lead to improved performance and successful learning.

A better understanding of the brain has also provided insight into adult learning as well as the aging brain. Brain plasticity can, have negative consequences if we do not maintain the use and health of the brain. Returning to the developmental approach to brain plasticity, aging had previously been thought of as a period of decline and reduced memory, cognition and speed of processing. A number of studies, however, are demonstrating that a substantial improvement in function is possible using appropriately designed behavioral training paradigms. Plasticity can, therefore, be used to improve brain function or it can result in substantial loss of function.

How can this improvement in the brain and in skill learning be achieved? The neuroscientists have demonstrated that interventions which provide intensive stimulation to the brain over a specific amount of time while the student is a) actively involved in the process, b) where a response to the stimulation is required and c) when immediate feedback and reward are provided, new pathways can be established. Using these pathways and practicing the new skills result in permanent changes in the brain. The pathway must then be used in various settings (educational therapy, school, social settings) for the skills to generalize and become new "habits". As with any intervention it is important to ensure that the programs that depend on neuroplasticity and our new understanding of the brain and learning, follow scientific principles that have been well researched. At the Tarnow Center we have been careful to include only those programs that meet these criteria. The programs in use currently are Fast ForWord, Cogmed and Interactive Metronome. These programs, when used in a total therapeutic intervention program that includes education, language and/or psychotherapeutic intervention, are proving to be very effective. They provide the "brain foundation" that promotes success in much the same way as the foundation to a house must be constructed before the rest of the structure can be securely built.

The interventions utilize the computer to provide the carefully controlled stimuli, with the predetermined frequency required to establish new pathways to support skill building. A brief description of the programs will be provided.

Fast ForWord

Language impaired children (oral and written) do not progress in the development of hearing fast, successive sounds. Fast ForWord has been shown on fMRI studies to develop pathways to allow this rapid processing to occur, which in turn results in a more organized efficient brain. Dr. Merzenich, Dr. Jenkins and Dr. Tallal designed computer "games" which hold the child's attention and assist him in paying attention to the small details of speech components (phonemes). The games also provide many rewards to motivate continued listening. The child hears thousands of practice sounds daily over a successive series of days. The training is progressive and adaptive, going from easy to more difficult so that success is obtained nearly all the time.

For children who have frequently experienced much failure in their attempts to learn, Fast ForWord affords them the opportunity to be successful and develop a more positive attitude to learning and frequently improve reading and understanding without the old dread of reading. As their comprehension and listening improve, we also see the concommitent increase in attention and compliance.

A recent study from Boston's Children's Hospital Laboratory of Cognitive Neuroscience has demonstrated improved reading and changed fMRI's in a group of Dyslexic children following completion of Fast ForWord. (gab, 2007). More importantly, scores on language and reading tests show significant improvement.

Cogmed

Working memory is the ability to keep information "online" for a brief period of time, typically a few seconds. In daily life, we use working memory to remember plans or instructions of what to do next, in problem solving, and for controlling attention, "remembering what to attend to".

When people have deficits in working memory, it is often experienced as "inattention problems", e.g. to have problems focusing on reading a text, or "memory problems". In children the problem is often remembering what to do next, which makes them unable to finish an activity according to plan.

Attention Deficit Hyperactivity Disorder (ADHD) is associated with disturbances of both the frontal lobe and the dopaminergic system, and is consequently also associated with working memory deficits. Deficits in working memory are thought to be of central importance in explaining many cognitive and behavioral problems in ADHD.

Multiple clinical studies have supported the efficacy of Cogmed's working memory training. Additionally, fMRI studies have demonstrated change in brain activity. Because working memory is a major factor in ADHD improvements in this skill have also demonstrated improvement in a student's ability to manage the behaviors associated with this disorder. In fact, the changes observed in the brain are permanent because working memory is a skill that is used in many everyday situations.

The training consists of a specific set of working memory tasks that are performed on a computer, where the difficulty level is adjusted according to a specific algorithm. The children complete a fixed number of trials every day, taking about 30 minutes daily. This is done for five days a week over five weeks. The "games" are challenging, but highly motivating.

Interactive Metronome

The Interactive Metronome program is an advanced brain-based assessment & treatment program developed to directly improve the processing abilities that affect motor planning and sequencing. Motor planning and sequencing are central to human activity—from the coordinated movements needed to walk or climb stairs, to the order of words in a sentence to provide meaning.

A recently published study by Taub, McGrew and Keith (2007), demonstrated that students who underwent IM training obtained significantly higher reading scores than their peers in a control group who did not receive the treatment.

Other studies have shown improvement in motor planning and processing speed. Processing speed is very important as it is one of the signs of an organized brain and therefore necessary to complete academic tasks efficiently. The human brain's efficiency and performance depend on the seamless transition of neuronetwork signals from one area of the brain to another. Recent findings suggest that IM works by augmenting internal processing speed within the neuroaxis. The key regions affected appear to include the cerebellum, prefrontal cortex, cingulated gyrus and basal ganglia. The IM program provides a structured, goal-oriented process that challenges the patient to synchronize a range of hand and foot exercises to precise computer generated reference tone heard through headphones. The patient attempts to match the rhythmic beat with repetitive motor actions. The training is intense - 1 hour, 3 times per week for 5 weeks.

Over the course of the treatment, patients learn to:

  • Focus and attend for longer periods of time 
  • Increase physical endurance and stamina 
  • Filter out internal and external distractions 
  • Improve ability to monitor mental and physical actions as they are occurring 
  • Progressively improve performance

While these novel, non-academic interventions create the foundations of learning they do not take the place of the structure of conventional academic programs. The results of the combined effects of new and conventional treatments are providing encouraging results and hope for the future as our knowledge of the brain increases.

The Tarnow Center has obtained excellent results using these programs because of our ability to integrate their use into a complete therapeutic program of intervention. The integration of computer based programs with medical and therapeutic intervention is proving to be more beneficial than any one aspect of intervention on its own.