Volume 1 AN EXPLORATORY STUDY OF DEVELOPMENTAL CONFABULATION IN CHILDREN By Jane Hood University College London Continuing Professional Development Doctorate in Educational Psychology UMI Number: U593B29 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U593329 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Abstract Background: This study was undertaken to investigate the phenomenon of confabulation in children following the presentation of several children with this condition to a neurodevelopmental clinic. Aims: The study was conducted in order to investigate developmental and acquired confabulation in children from a neuropsychological and behavioural perspective. The study was also used to investigate options for managing confabulation in the home and school context. The literature relating to confabulation and the development and management of lying in children was reviewed. Samples: Three children with developmental confabulation and one with acquired confabulation were investigated. Their ages ranged from 8:1 to 10:9 and only one child was female. They were matched with four non-confabulating clinic control children within the same age range. Methods: A full neuropsychological assessment of each child was conducted and a log of their confabulations was kept over a four-week period by their parents to monitor the type of confabulation exhibited and its approximate frequency. Results: The confabulating children showed specific difficulties with impulse control and self-monitoring that were not seen on neuropsychological testing of the control group. Children from both groups showed some executive difficulties. The logs of 1 the confabulator’s behaviour showed that they exhibited spontaneous and forced confabulation. Conclusions: Confabulation can exist as a persistent difficulty in children and appears to be particularly associated with an impulsive response style (a common feature of ADHD), although few children with ADHD confabulate. The confabulators also showed a specific difficulty with memory in that they remembered their false beliefs as real. A model showing a process for evaluating and managing confabulation is presented. Suggested strategies for the management of confabulation at home and at school and proposals for further study are made. Table of Contents Page number Section 1: Abstract 1 Tables and figures 7 Acknowledgements 8 Section 2: Literature Review 10 2:1) Abstract 10 2:2) Introduction 11 2:3) The normal development of lying 14 a) Summary of lies children tell 21 2:4) Children’s memory and suggestibility 21 2:5) Confabulation and neurodevelopmental disorders 24 a) Types of confabulation 27 2:6) The neurocognitive skill of lying 29 2:7) The neuropsychology of confabulation 30 a) Do confabulators believe their stories? 36 2:8) The neural basis of confabulation - case studies 38 a) Imaging studies 42 b) Confabulation and alcoholism 44 c) Confabulation in Alzheimer syndrome and dementia 45 d) Delusional beliefs - schizophrenia 46 2:9) Summary of the neuropsychological profile of confabulators 49 a) Table 1: Summary of the process of confabulation 51 2:10) Managing confabulation 52 a) Figure A - Different circumstances under which 3 children lie 61 2:11) Suggestions for further research 62 2:12) Summary 66 Section 3: Empirical Paper 67 3:1) Introduction 68 a) Confabulation and the development of lying 68 b) Studies of confabulation 70 c) Source-monitoring tasks 74 d) Summary of neuropsychological profile of confabulators 75 e) Research question 76 3:2) Method 77 a) Research design 77 b) Participants 78 c) Experimental group 78 d) Table 2: Experimental group 80 e) Control group 80 f) Table 3: Control group 81 g) Measures 82 3:3) Results 87 a) Case studies and information from logs 89 b) DC - case 1 89 c) AJ - case 2 94 d) BC - case 3 99 e) S T -c ase 4 105 4 f) Neuropsychological assessment results 110 g) Intellectual ability measures 110 h) Attention/Executive functioning measures 111 i) Memory measures 115 j) Behavioural questionnaires 119 3:4) Discussion 120 a) Research question 120 b) Table 16: Summary of the process of confabulation 125 in children c) Do the neuropsychological assessment results and case studies inform intervention at home and at school? 126 d) Recommendations for managing confabulation, 130 including case study examples e) Figure B: Managing confabulation and lying 136 f) Review of the effect of recommendations for case studies 137 g) Methodological issues 139 h) Future Studies 142 Section 4: Critical Appraisal 144 4:1) Introduction 145 4:2) Discussion 146 a) Reasons for conducting a small-scale study 146 b) Strengths and limitations of single and small-scale studies 148 c) Issues in the interpretation of small-scale study data 150 d) Is confabulation really that rare? 153 e) Difficulties with acquiring normal controls 155 5 f) The inclusion of a control group with neurodevelopmental 156 disorders g) The pilot study 157 h) Limitations of neuropsychological assessments for children 160 i) Reliability of data collection methods 162 j) Establishing a confabulation battery for children 164 k) Potential difficulties in working with confabulators 166 1) Developing evidence-based interventions 167 m) Relevance of the study to the field of educational 170 psychology and other professional groups n) Issues of confidentiality related to small sample size 173 o) Limitations of ethics permission 175 p) Personal reflection on research process 176 4:3) Summary 177 Section 5: Appendices 179 A) References 178 B) Ethical approval 203 C) Sample letter, information sheet and consent form 210 D) Source Monitoring 1 Protocol 215 E) Source Monitoring 2 Protocol 219 F) Sunderland Everyday Memory Questionnaire Results Table 224 G) Parental log sheet 230 6 Tables and Figures Page Table 1: Summary of the process of confabulation 51 Figure A: Different circumstances under which children lie 61 Table 2: Experimental Group 80 Table 3: Control Group 81 Table 4: Intellectual ability measures 110 Table 5: Test of Everyday Attention for Children 111 Table 6: Delis-Kaplan Executive Function System Trail-Making 111 Table 7: Delis-Kaplan Executive Function System Colour/Word 112 Interference Table 8: Delis-Kaplan Executive Function System Verbal Fluency 112 Table 9: Delis-Kaplan Executive Function System Design Fluency 113 Table 10: Delis-Kaplan Executive Function System Tower 113 Table 11: Behavioural Rating Inventory of Executive Function 114 Table 12: Children’s Memory Scale 115 Table 13: Sunderland Everyday Memory Questionnaire 116 Table 14: Source Monitoring Measures 117 Table 15: Strengths and Difficulties Questionnaire 119 Table 16: Summary of the process of confabulation in children 125 Figure B: Managing confabulation and lying 136 7 ACKNOWLEDGEMENTS First and foremost I would like to thank all the children and families that contributed to this study. I also owe a debt of gratitude to my tutors, Professor Tony Cline (and originally) Dr Sandra Dunsmuir, for their expertise, humour, patience and flexibility because without these qualities the process of completing the doctorate would not have been an enjoyable one. Naturally Dr Sean Cameron, Helen Hosier, Stephanie Douglas, Mary Turner and Cassandra Wood also need acknowledgement for their extensive support and friendliness. My supervisor, Dr Elizabeth Isaacs, has provided the neuropsychological expertise for this study and has also been a great role model and source of inspiration throughout my clinical work. I would like to thank Professor Baird for encouraging me to study this area and providing so much guidance and enthusiasm for my work throughout my career. This project would probably not have been possible without the financial support of the Guy’s and St Thomas’ Charity, the Charles Hawkins Fund and my grandmother, Molly. I’d like to thank my husband, Dr Peter Rankin, for his endless support throughout this endeavour and for training me to complete the majority of the thesis in 15- minute slots between baby-care duties. I’d also like to thank my family, especially my parents, for continuously forcing me along the path of education and instilling in me an unerring belief that education should not be a privilege but a right and that all opportunities need to be fully appreciated. I’d also like to thank my young son, Stevie, for occasionally managing to sleep at the right times to allow me do some 8 work. Without the support of these people, this milestone would never have been reached. GUY’S &/ St T h o m a s ’ C h a r it y 9 Section 2: Literature Review Abstract Background: This review provides an introduction to the neuropsychology of confabulation in both children and adults. The review of the literature pertaining to confabulation in children includes an examination of relevant aspects of the process of the development of lying in typically developing children, so that the phenomenon of confabulation can be set within a developmental context. Strategies for maximising accurate recall in children