By: Nancy Roosa, Psy.D.
Pediatric Neuropsychologist, NESCA
Melanie is a sweet, hard-working 11-year-old girl whose parents brought her to NESCA for an evaluation to try to understand why she was struggling in school. Melanie was a cheerful, vivacious girl who seemed intelligent, curious and articulate. But she was barely getting by in fifth grade, putting in hours on homework every night on assignments her teachers thought should take 30 minutes. Her parents were concerned about how she was going to manage middle school next year.
During the evaluation, Melanie did quite well on most tests. Her intelligence measured in the “Above Average” range, and her academic skills were solid. She worked hard and even did well on a test of sustained attention. So, it was clear she did not have a classic case of attentional dysregulation.
Upon further analysis, a few striking results emerged. Melanie had a good ability to remember information or work on structured tasks, but got confused on multistep tasks. One important result: she was able to remember and repeat back long strings of digits when repeating them verbatim, but she really struggled when she had to repeat them in reverse. The mental manipulations involved flummoxed her.
This is working memory: the ability to hold multiple bits of information in memory banks while there is another, distracting bit of information processing going on. Working memory is the “working” part of memory, as it holds information long enough for us to use it or store it away in longer-term memory banks. Analogies can be made to computer storage, where current information is held while processing occurs; or a mental chalkboard, where we jot down our ideas while working out a problem. For some children, like Melanie, that computer storage or chalkboard space is quite limited, causing difficulty with many aspects of learning. As a first grader, Melanie easily learned the sounds of letters, but it was harder for her to remember and apply that knowledge while reading words. Similarly, she easily learned math facts, but got stymied on multistep math problems. Finally, she had trouble with multistep directions. When her parents or teachers told her three things to do, her response was typically, “Wait, what?”.
Melanie’s parents were right to be concerned about middle school, since this is when students are presented with more complex assignments, such as lengthy reading and writing assignments, PowerPoint presentations and many other multistep projects, which were going to be hard for her.
Working memory deficits are related to other cognitive processes. Children with attentional regulation deficits or learning disabilities often – but not always – have working memory deficits. However, every child is unique, with an individual set of strengths and weaknesses. Therefore, a comprehensive and well-done evaluation is essential to clarify a child’s specific profile – a vital first step in crafting an appropriate plan for support and treatment.
Now that we identified Melanie’s difficulties as primarily due to working memory deficits, how do we help her?
My recommendations centered first on the types of accommodations Melanie would need in school to manage an uptick in demands.
- Any complex or multistep assignment needed to be presented in writing so Melanie can refer back to the directions. She should be shown completed models and provided with scoring rubrics.
- Melanie might need support from a learning specialist to manage complex tasks, by dividing them into component parts, then completing each part and integrating the whole.
- Melanie should not be expected to take notes while simultaneously listening to a teacher’s instruction. She should be provided with notes or given an outline of the teacher’s talk that she could fill in.
- Melanie’s pace of work was slow, given the need to frequently check back and remind herself what she was doing. Therefore, teachers should consider giving her shorter homework assignments that focus on quality not quantity, and extra time to complete tests and assignments.
We also discussed the strategies that Melanie would need to learn to compensate for working memory deficits. She was already using some important strategies, likely based on coaching from some talented teachers in her past. She knew she needed to write things down to remember them, so she had become good at creating outlines before she started writing and drawing pictures of math problems. However, as assignments got longer, Melanie was going to need additional strategies. For example, for lengthy reading assignments, Melanie might need to jot down sticky notes on pages or develop an ongoing “story board” to keep track of main character descriptions or plot points.
Once the family brought this information to Melanie’s educational team, they were able to meet and establish important accommodations, including time to work with a learning specialist several times weekly. The team also agreed to continue to monitor her ability to manage future challenges.
Beyond accommodating working memory deficits, there is ongoing research into programs that could actually improve an individual’s working memory. The hope is that by targeted practice, one could strengthen one’s working memory the way we strengthen muscles by working out at the gym. Despite a great deal of research, the preponderance of evidence does not indicate that these kinds of training programs are effective in improving working memory, except on the specific tasks used in the training program itself. At NESCA, we remain optimistic that further research and refinements will eventually yield more promising treatments.
Finally, one of the most important outcomes of the evaluation was a feedback session with Melanie herself, where I explained her learning profile to her in age-appropriate terms. My goal was to help her appreciate her many strengths and understand that her learning challenge was relatively small and specific. She might have to work harder in certain ways, but would be able to be successful in school and life.
At NESCA, we find that when a child is old enough to process this information about their profile, it is vital to provide it. We find that many children, even teenagers and young adults, tend to be black-and-white thinkers. When they struggle in school in any way, they conclude they are “stupid.” It is obviously vital to prevent this kind of global, negative self-concept from developing. Rather, we hope to give the child the self-awareness and confidence to develop and use compensatory strategies, no matter the area of weakness. We need Melanie and children like her to be confident enough to ask a teacher, college professor or even a job supervisor to provide written instructions to a task or go over directions more than once. Our goal is to arm her with enough self-awareness and confidence that she can go into any new situation, as a student or adult, and be successful while not letting her challenges define or limit her.
About the Author:
Dr. Roosa has been engaged in providing neuropsychological evaluations for children since 1997. She enjoys working with a range of children, particularly those with autism spectrum disorders, as well as children with attentional issues, executive function deficits, anxiety disorders, learning disabilities, or other social, emotional or behavioral problems. Her evaluations are particularly appropriate for children with complex profiles and those whose presentations do not fit neatly into any one diagnostic box. As part of this process, Dr. Roosa is frequently engaged in school visits, IEP Team Meetings, home observations and phone consultations with collateral providers. Dr. Roosa has also consulted with several area schools, either about individual children or about programmatic concerns. She speaks to parent or school groups, upon request.
Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email email@example.com or call 617-658-9800.