Understanding Attention, Learning, and Memory Challenges: Insights from CALM and Beyond
Introduction
Difficulties in attention, learning, and memory can significantly impact individuals, especially children, affecting their academic performance, social interactions, and overall well-being. The Centre for Attention, Learning and Memory (CALM) was established to address these challenges through a transdiagnostic approach, identifying the underlying cognitive, behavioral, neural, and genetic factors. This article delves into the complexities of these difficulties, exploring the work of CALM, the impact of anxiety on memory, and potential strategies for support.
The Centre for Attention, Learning and Memory (CALM)
Established in 2014, The Centre for Attention Learning and Memory (CALM) was created to study children experiencing difficulties in attention, learning, and/ or memory. The mission was to take a transdiagnostic approach to identifying the cognitive, behavioural, neural and genetic dimensions that underpin a broad range of cognitive difficulties faced in childhood. The CALM cohort has been essential for much of the work of the 4D research group, with multiple team members using the data in their projects.
Transdiagnostic Approach
CALM's approach contrasts with traditional methods that focus on specific diagnoses like ADHD or dyslexia. Our understanding of learning difficulties largely comes from children with specific diagnoses or individuals selected from community/clinical samples according to strict inclusion criteria. Applying strict exclusionary criteria overemphasizes within group homogeneity and between group differences, and fails to capture comorbidity. Instead, CALM adopts a broader perspective, acknowledging the high rates of comorbidity among developmental disorders and learning-related difficulties. This approach aims to identify continuous dimensions that distinguish individuals, which can be used as potential targets for intervention.
Data-Driven Group Identification
In a study using unsupervised machine learning, specifically Self-Organizing Maps (SOMs), cognitive profiles were identified in a large heterogeneous sample of struggling learners. Children were referred to the Centre for Attention Learning and Memory (CALM) by health and education professionals, irrespective of diagnosis or comorbidity, for problems in attention, memory, language, or poor school progress (n = 530). Children completed a battery of cognitive and learning assessments, underwent a structural MRI scan, and their parents completed behavior questionnaires. Within the network we could identify four groups of children: (a) children with broad cognitive difficulties, and severe reading, spelling and maths problems; (b) children with age-typical cognitive abilities and learning profiles; (c) children with working memory problems; and (d) children with phonological difficulties. Despite their contrasting cognitive profiles, the learning profiles for the latter two groups did not differ: both were around 1 SD below age-expected levels on all learning measures. Importantly a child’s cognitive profile was not predicted by diagnosis or referral reason. We also constructed whole-brain structural connectomes for children from these four groupings (n = 184), alongside an additional group of typically developing children (n = 36), and identified distinct patterns of brain organization for each group. This allowed for the clustering of children based on shared profiles derived from empirical data, informing classification systems and treatment approaches.
Cognitive and Learning Assessments
The children attending the clinic completed assessments of the cognitive skills known to be impaired in children with learning-related problems including measures of phonological processing, short-term and working memory, attention and fluid reasoning (nonverbal IQ). Children with deficits in reading or language, or associated diagnoses of dyslexia or SLI often have phonological processing problems. In contrast, those with specific problems in maths or diagnosed dyscalculia are typically characterized by more severe deficits in spatial short-term and working memory and broader executive functions.
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Prevalence and Comorbidity of Learning Difficulties
Prevalence rates of developmental disorders linked with learning difficulties, including attention deficit hyperactivity disorder (ADHD), dyslexia, dyscalculia, and specific language impairment (SLI), range from 3% to 8%. However, the number of children who struggle at school is far higher. In the UK for example, around 30% of the school population fail to meet expected targets in reading or maths at age 11.
Challenges of Traditional Diagnostic Approaches
Our understanding of the causes of learning difficulties comes largely from studying children with a specific diagnosis (e.g., ADHD or SLI) or those selected from community or clinical samples on the basis of strict inclusion criteria (e.g., children with poor reading skills, but age-typical IQ and maths abilities). Most studies recruit children with “pure” problems (e.g., children with ADHD without comorbid dyslexia, or children with maths problems in the absence of reading problems or low IQ). However, this approach can fail to accommodate the high rates of comorbidity within developmental disorders and learning-related difficulties. Over 80% of children with ADHD meet criteria for at least one additional diagnosis and 15%-45% have co-occurring reading difficulties. Using strict exclusionary criteria also overemphasizes similarities within groups, and the distinctiveness between groups. It is widely documented that symptoms vary between children with the same diagnosis. For example, performance on cognitive tasks within ADHD groups is notoriously variable. Symptoms also co-occur across groups.
Moving Towards Empirically Based Systems
For these reasons a number of researchers have advocated empirically based quantitative classification systems, although few studies have done this. The aim of this approach is to move away from identifying highly selective discrete groups and instead focus on identifying continuous dimensions that distinguish individuals and can be used as potential targets for intervention. Dimensions are derived through data-driven explorations of the data, with no a priori assumptions about group membership. For example, factor analysis, a statistical method that groups variables based on shared variance, is used most commonly to derive underlying dimensions from sets of symptoms or measures. This technique has been used to identify dimensions of phonological and nonphonological skills in children with diagnosed SLI and dyslexia and separate latent constructs for inattention and hyperactivity in children with ADHD.
Machine Learning Approach
In this study, we use a different data-driven approach-machine learning. Machine learning methods have rarely been applied to understanding developmental disorders. Typical applications use supervised machine learning in which the algorithm attempts to learn about predefined categories of children. Here, we use an unsupervised learning approach whereby the algorithm attempts to learn about the structure of the data itself rather than which data correspond to predefined groups. Specifically, we used Self Organising Maps (SOMs; Kohonen, 1989), a type of artificial neural network. Due to their efficacy in visualizing multidimensional data, SOMs have been successfully applied to a variety of tasks including textual information retrieval, the interpretation of gene expression data, and ecological community modeling. SOMs use an algorithm that projects the original data from a multidimensional input space onto a two-dimensional grid of nodes called a “map”, while preserving topographical information. This produces an intervariable representational space, wherein the geometric distance between nodes corresponds to the degree of similarity in the input data. Within the current context, input data are individual children from our sample. The map will represent the cognitive profiles of the children; the closer the children are represented within the map, the more similar their cognitive profiles. We applied this technique to a large heterogeneous sample of struggling learners. Children were referred to a research clinic, the Centre for Attention Learning and Memory (CALM), by health and education professionals for ongoing problems in attention, memory, language, or poor school progress in reading and/or maths. Recruitment was deliberately broad to capture the wide range of poor learners in the school population. Children were accepted into the study irrespective of diagnosis or comorbidity: only non-native English speakers and those with uncorrected sight or hearing problems were excluded.
The Impact of Anxiety on Memory
Anxiety can significantly affect cognitive functions, including memory. There are issues related to anxiety that can lead to short-term memory loss and a general inability to remember things, and unfortunately as long as you live with anxiety you put yourself at risk for this forgetfulness to get worse. But there is good news - memory issues caused by anxiety are not permanent. Like most anxiety symptoms, your memory will probably return to normal levels of functioning as your anxiety levels are reduced. Your memory is actually very fragile. Your ability to create and recall memories is related to a variety of different factors, including things like nutrition and sleep. Did you know that when we sleep, our brains use this opportunity to sort and encode many of the memories that we have made during the day? Therefore, if you're not sleeping as result of anxiety, it's possible that you’re forgetful because your brain isn’t able to properly process what’s happening to you during the day. However, there are many other potential causes of forgetfulness as well.
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Physiological and Psychological Mechanisms
Cortisol, the hormone released during stress, can interfere with memory formation and recall. When you have anxiety, your body and mind are frequently in a state of stress, thereby increasing the amount of cortisol in your system throughout the day. A person who is anxious is more likely to be distractible. When we're easily distracted, we struggle to focus our attention. When we're not attending to the information that we're receiving, our brain is unable to take-in that information as a memory. Similarly, a lack of focus can make it harder to even pay attention to the world around you. People with anxiety are often "in their own head." When they hold a conversation with someone else, it's much harder for them to find that their heart is in the conversation. Sleep deprivation, often linked to anxiety, further impairs concentration and memory consolidation.
Addressing Anxiety-Related Forgetfulness
Remember, if it’s your anxiety that’s making you forgetful, getting rid of your anxiety will often bring your memory back to the level at which it was initially. People who are forgetful may benefit by adopting compensatory strategies, which help them to cope despite their temporary memory lapses. For example, if you know you're forgetful, then when someone tells you something important, try to write it down (on paper or using your phone) immediately. Post-it notes can also be used to help you remember important bits of information. People tend to test their memories when they have anxiety or decide that they don't need to make changes because "this time" they won't forget. There's simply no reason to take that risk, and unfortunately, forgetfulness can actually contribute to further anxiety. Another strategy you may want to try is starting a blog or journal and using it to write down all of your thoughts. Your blog - like a journal - can be made private so only you can read it, but you can use it to take note of anything you want to remember. This could include what you did that day, the conversations you had, who you talked to, etc. It could also include any distressing or anxiety-related thoughts and feelings that came up for you during the day. Apart from helping you to remember important facts, this can also help to improve your mood, which in turn can reduce your anxiety and improve your memory.
CALM Clinic Services and Neurocognitive Assessments
CALM specializes in complete neurocognitive assessments. We believe strongly that a full and comprehensive evaluation yields the best results for treatment and moving forward.
Comprehensive Assessment Process
Our assessment process is a series of five separate appointments. The first appointment is a virtual telehealth intake with one of our providers. This appointment is a get-to-know-you session where the client can go over symptoms, specific concerns, and expectations for the assessment. From there, we perform three days of in-person testing. These sessions are held from 8:30-12:00 or 2:00-5:00 on Monday, or 8:30-12:00 or 1:30-5:00 on Wednesday, Thursday and Fridays. This extensive testing allows us to be incredibly comprehensive. CALM tests include IQ, Depression, Anxiety, Executive Function, Processing Speed, Learning Disorders, Social Interactions, Working Memory, and ADHD. This allows CALM to see the whole person and we believe this is the best way to do assessments. The fifth and final appointment, our follow-up, is a virtual telehealth appointment with the provider, where they will go over all testing results and help set up treatment plans for moving forward. We will also provide a written report with all of the testing results, as well as our specific recommendations. We emphasize treatments and how to move forward. Our full assessment time takes around 2- 2.5 months to complete once we have an intake appointment on the calendar.
Additional Testing Options
For those undergoing Neurocognitive assessment, we also offer what is called a QEEG. This is a non-invasive brain scan that allows us to measure a client's brain waves. The QEEG is a brain mapping procedure. We use this information to compare a client's brain waves against individuals diagnosed with ADHD, anxiety, depression. It can let us know the extent of previous head traumas and aid in recommendations for medical prescribers, if appropriate. The QEEG is not required, nor is it covered by any insurance companies at this time, so this is an optional procedure. For those undergoing Neurocognitive assessment, we also offer education testing is highly recommended for school-aged clients because it gives us an insight into their abilities, challenges, and learning style. This testing is not just for educational disabilities but can provide a meaningful picture of a cleint’s abilities compared to their peers. Knowing if a child is gifted or struggling is equally essential for the best treatment plans. Many kids can compensate for challenges with hard work and determination, or perhaps they are not having their full ability challenged in the classroom and could consider advanced classes. Educational testing can also be a good fit for some adults. If you are thinking about pursuing higher education or are having educational factors affect your work, knowing more about your strengths and challenges can be very helpful. Educational testing is optional and not covered by insurance.
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Cogmed Working Memory Training
Cogmed Working Memory Training is a solution for individuals who are held back by their working memory capacity. The Cogmed program can be used by children and adults with attention deficits or learning disorders, brain injury or stroke victims, and adults who are experiencing information overload or the natural effects of aging. Working memory is the ability to keep information in your mind for a short time, focus on a task, and remember what to do next. By training your working memory, you will be better able to stay focused, ignore distractions, plan next steps, remember instructions, and start and finish tasks.
Therapy Services
Our therapists offer the traditional form of therapy: being seen by the provider regularly for checkups and accountability checks and strategies for moving forward. These tend to be weekly appointments. At this time, all therapy is being done via Telehealth. Therapy is centered on your goals. Together, we’ll explore your stressors, changes you want, internalized messages, and actionable steps to get you where you want to be. We use multiple approaches to therapy. Techniques often used include solution-focused, narrative, and behavioral approaches. When you invest in your mental health, you will find that you ARE a good friend, a loving parent, a reliable employee, and a successful person.
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