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There is a PowerPoint file available to accompany this presentation. The BDA Conference 2001 CD-ROM contains 61 PowerPoint files. For details of how to obtain the CD-ROM, please contact the BDA.
Saturday stream 1 Session 09.00 - 11.10 Length 25 minutes
Wynford Dore and Roy Rutherford
The Old School, Holly Walk, Leamington Spa CV32 4GL WynfordDore@goalplc.co.uk
Abstract
The work of most researchers in the field of dyslexia and related disorders concentrate on helping sufferers develop ways of coping and / or developing compensatory techniques for the symptoms. However a small number of researchers have for some time been suggesting that removal of many of the symptoms may be achievable. Finding sufficient evidence to persuade others in the field that these results are meaningful has been difficult despite the claims by not insignificant numbers of patients that their progress using these controversial interventions is very real indeed. At the Old School Clinic we cater for children (and adults) where a 'gap' between their apparent intellectual potential (albeit only occasionally noticeable!) and their academic ability / achievement has been identified. The work of The Old School Clinic has been split into 3 phases. First we evaluated the research from several sources that were indicating the results described above to find any common denominators. It quickly became clear that cerebellar / balance issues figured prominently in several of these theories and we chose to focus our work accordingly. Among the various studies conducted we commissioned an independent evaluation of a small (17) sample of patients studied closely for educational changes during a 6 month period of treatment. This was completed earlier this year and to our surprise showed that the various pieces of research being evaluated fitted into a reasonably complete jigsaw puzzle! Our next phase, also now complete, was to put together a program of diagnosis and interventions utilising the theories collated to start treatments that achieved similar (and if possible better / faster) results. Our aim was to carry out remediation in a way that enabled the collection of objective physiological and educational data to further the research exercise. This phase saw the treatment of a number of patients each of whom demonstrated physiological improvements and reported a number of clearly demonstrated important practical improvements. In turn these were in many cases supported by teacher claims of unexpected and significant changes in class attitude and exam performance. The third phase, just started (July 2000) is to conduct treatment on a much larger sample whose progress will be monitored closely. This will enable the fine tuning of prescribed interventions according to symptoms displayed and physiological measurements taken. By March 2001 an interim report of significant size will be available.
Introduction
This brief report introduces some of the motivations, scientific principles, practices and research activities of the DDAT Centre in Kenilworth.
Its existence was motivated by the suffering of Wynford Dore's daughter, who at the age of 26 was still unable to read a book or write a sentence coherently. Along with many others who suffer from severe dyslexia her self-esteem was badly affected despite her having received many of the available help systems designed to aid those with her condition. The authors of this paper met to discuss the prospects of finding a way of reducing or eliminating the symptoms and decided to embark on a study of research papers which could have a bearing. As a deliberate policy they refused to be constrained by any one discipline, preferring to open-mindedly assess the whole spectrum of research taking place.
Research being conducted by Nicolson and Fawcett seem to make particularly good common sense when the implications of their research was discussed with parents of dyslexic children and the children themselves. Support for the possibility of finding an effective solution to the cerebellar cause was also indicated from the work of Dr Harold Levinson who prescribes various drugs to stimulate the cerebellum. A study commissioned by one of the authors on Levinson's work confirmed that the results were encouraging enough to pursue this line of investigation. Other work studied included that of Peter and Sally Blythe (showing the implications of developmental issues on dyslexic and other related symptoms). However, we have looked extensively at all the most up to date literature, including work on the visual magnocellular theories (J Stein et al) and phonological theories (P Tallal et al). Please refer to Bibliography at the end of this report.
By late 1999 Dr Rutherford and Rachel Smith became convinced that there were various pieces of the research jigsaw which, when placed together, gave great hope that effective remediations could be developed without the use of drugs and we embarked on finding the equipment necessary to help evaluate and prescribed effective interventions. By early 2000 we were ready to open our first research clinic and commence work with patients.
The Evaluation and Treatment Process
In an attempt to reduce the incidence of building up false hopes, a positive attempt is made to eliminate, prior to the first visit, all enquirers whose symptoms appear to be anything other than classical dyslexic/dyspraxic/ attention deficient disorders. In practice approximately between 5-10% are eliminated at the time of the first telephone enquiry. When the patient first arrives at the clinic a full medical history is taken with particular attention given to birth traumas and developmental issues. The patient then undergoes a series of tests, including the following:
Dynamic Posturography Test: The patient is subjected to posturography tests to evaluate the balance strategy adopted by the cerebellar. This enables us to evaluate the degree of influence the three main sensory inputs provide in the development of the strategy, ie somatosensory (feelings through feet, legs etc), visual (data taken in through the eyes in the balance process) and vestibular (information from the inner ear). Almost without exception children suffering from a learning difficulty have a poorly developed vestibular input and frequently have a reduced level of visual input. At the same time it is common to find somatosensory operating at a higher than normal level compensating for the deficiencies in the other areas. Children in late teenage and adults frequently show signs of having compensated in an unconventional way for the lack of data input from vestibular/visual areas and have developed what they find to be an acceptable balance strategy. Where this is the case diagnosis and the monitoring of progress is less reliable using posturography alone. In the majority of cases however the balance strategy displayed in the way described enables us to prescribe remediation exercises and monitor the progress of the patient and guide on the prescription of further balance remediations to fine tune the intervention.
Electronystagmograph (ENG): This device enables the plotting the movements of the eyes when watching a moving target. It, in effect, demonstrates any weaknesses in visual-motor controls and, therefore, assesses some of the kind of problems experienced by children suffering from a learning difficulty when they attempt to read.
Doctor's Examination: During this examination conventional subjective neurological tests are carried out to establish whether or not there could be other causes for the learning difficulty and, to confirm any evidence of cerebellar signs and retained primitive reflexes.
Dyslexia Screening Test: This test uses the one developed by Nicolson and Fawcett and the University of Sheffield. The results produced give a degree of "at risk" and can be used to measure objectively any progress achieved following a six month programme of interventions.
Attention/Hyperactivity Questionnaire (DSM4) Classification: This tests is to asses the risk level for ADD and ADHD and is used by the doctor in the medical diagnosis.
Educational Measures: Children are given English and Maths assessments using the GOAL on line system. This multi-choice question approach on computers appears to be particularly friendly to children with learning difficulties and seems less threatening to them due to the absence of the requirement to provide written answers. This test is also capable of being applied every 4-6 weeks so that the speed of progress educationally can be monitored objectively and frequently.
Potential/Attitude Assessment:
IQ Tests: Both verbal and non-verbal skills tests are performed on line at the start and termination of the programme in order to assess progress.
Attitude Assessments: This test measures a range of attitudes of the patient to self, parents, peers and school. Again the test is performed on line and assessed before and after the programme.
The Treatment Begins!
When all the physiological and medical tests point to the existence of a developmental disorder the patient is prescribed the BRET System of exercises. These are determined by a therapist who looks at the combination of the physiological data and symptoms described by parents/patient. These exercises take, typically, 10 minutes per day and can be conducted at home using simple equipment. BRET exercises incorporate the use of bean bags, large rubber balls and wobble boards. The child returns in, typically, six weeks and the posturography and ENG tests are conducted again. From these results and evidence of how the response to exercises is proceeding the trained therapist will prescribe the next stage of exercises appropriate to the patient. This process is continued usually for up to 24 weeks although the speed of progress varies significantly from patient to patient.
The Results
The results of an in-depth study of the impact of the BRET System on patients will start to emerge later this summer (2001). Meanwhile reported here is some of the earlier evidence that has been collated to support substantial amounts of anecdotal and other evidence provided by parents, teachers and individual patients.
Physiological Tests
Some 97% of patients treated for more than three months up to December 2000 experienced significant improvements in both posturography and ENG tests.
These physiological improvements reflect the anecdotal evidence provided by parents, teachers and patients. With the wide variety of symptoms evidenced in children with learning difficulties it would be impossible to summarise in a meaningful way this anecdotal evidence. It is appropriate to point out that in addition to the more obvious improvements that come as a result of corrections to visual motor disorders (reading speed, accuracy, writing neatness, etc.) there are a larger number of less expected improvements, eg short-term memory, self-esteem, tidiness and body to eye co-ordination exercises like catching balls. Significant quantities of somewhat more objective data is coming from teachers who report surprising increases in (for instance) GCSE predicted grades during the time that the intervention is taking place and a marked reduction in the incidence of disruptive behaviour. All this and more will be structured into the fuller objective report being worked on currently.
The Research Study
This is being carried out by Professor David Reynolds of the University of Exeter - he summarises his plans as follows:
RESEARCH AT THE DDAT CLINIC - Prof David Reynolds
A major research programme is being mounted to measure the possible effectiveness of the novel treatment for Dyslexia being utilised at the Clinic. This is in four Phases, as follows:
Analysis will look at possible change over time in the group as a whole, with distinct analyses for any possible sub groups of children identified subsequent to the whole sample analysis. This Phase should be completed by end May 2001, and reported before the 'summer shutdown', in end-July 2001.
Analysis will be of the whole group, and of any possible sub groups shown to be important from the First Phase and in this Phase. This Phase should be analysed for a sample of several score of children by the end of July 2001.
The same 'process' information as before will be collected and utilised. These children will also be generating scores on the Dyslexia screening test in the same way as those in Phase Two, with re-testing taking place after six months.
Comparison will be made with expected changes on the Dyslexia test scores and with change on the test results of the GOAL on-line system shown by the large samples of children nationally using the system. Analysis will also focus on any change over time in the data generated by the standard questionnaire on pupils' lives.
This Phase should be analysed for several score of children by September/October 2001.
Both groups will be furnishing the same data through utilising the GOAL on-line system as children in Phase Three above, and will be administered the standard questionnaire on their lives as above also. They will also of course possess scores from the Dyslexia screening tests. All children will additionally be given a test of reading ability. Process data will be collected as before, for the experimental group only obviously. Additional information will also be obtained from the children's teachers on their academic progress, their attitudes and the like (the teachers are of course 'blind' to the screening results for all children and will be unaware of which children are in which group).
A Steering Committee of experienced researchers in this field is currently being established, and will meet in May 2001 to consider these research plans, look at instrumentation and consider any needed changes in research strategy.
Professor David Reynolds, School of Education, University of Exeter,
Heavitree Road, Exeter. EX1 2LU
Telephone: 01392 264990
Fax: 01392
264998
E-mail: David.Reynolds@exeter.ac.uk
Early Findings from Retrospective Valuation
Plans for the Rolling Out of the Treatment
To satisfy the existing demand for treatment a number of clinics will need to be opened both in the UK and overseas. Alongside that the authors have the commitment to develop hardware, software and training to enable low cost availability of this system to as many as possible. Interest has been received from a number of local education authorities and other school groupings who wish to purchase the system as a complementary way of helping with their special needs cases.
The software is being designed so that all data from each patient will be collated in a central file server. This will facilitate both vital research information logging progress and also data that will help enhance and refine the interventions.
Next Phases of Research and Development
Shortly we will begin to seek appropriate partners to conduct research into the following:
For further details contact -
The DDAT Centre
6 The Square
Kenilworth
Warwickshire
CV8 1EB
Tel: 01926 855277
Email: wynford@compuserve.com
REFERENCES
Cerebellum
Nicolson R I, Fawcett A J Developmental Dyslexia: The Role of the Cerebellum Submitted to Dyslexia: International Journal of Research and Practice April 1999
Fawcett A J, Nicolson R I 1999 Performance of Dyslexic Children on Cerebellar and Cognitive Tests Journal of Motor Behaviour Vol 31 No.1 68-78
Fawcett A J, Nicolson R I 1992 Automatisation Deficits in Balance for Dyslexic Children Perceptual and Motor Skills 75, 507-529
Nicolson R I, Fawcett A J, Berry E L, Jenkins I H, Dean P, Brooks D J. 1999 Association of abnormal cerebellar activation with motor learning difficulties in dyslexic adults Lancet 353: 1662-67
Nicolson R I, Fawcett A J, Dean P 1994 Time estimation deficits in developmental dyslexia: evidence of cerebella involvement.
Dichgans J, Diener H C 1983 Postural Ataxia in Late Atrophy of the Cerebellar Anterior Lobe and Its Differential Diagnosis In Igarashi M, Black FO, eds. Vestibular and Visual Control of Posture and Locomotor Equilibrium. Basel S Karger, :282-289
Diener H C, Dichgans J, Scholz E, Ackermann H 1983 Long Loop Reflexes in a Standing Subject and Their Use for Clinical Diagnosis In Igarashi M, Black FO, eds. Vestibular and Visual Control of Posture and Locomotor Equilibrium. Basel S Karger, : 290-294
Fukuda T 1983 Postures of Momentary Arrest of Motion In Igarashi M, Black FO, eds. Vestibular and Visual Control of Posture and Locomotor Equilibrium. Basel S Karger, : 43-53
Neurological
De Quiros JB 1979 Neurophysiological Fundimentals in Learning disabilities Academic Therapy Publications USA
Kubo T, Sakata Y, Shiraishi T, Matsunaga T, Nogawa T 1992 Neurological findings in cases of cerebellar infarction. In Arenberg (ed) Surgery of the Inner Ear New York: Kugler Publications : 453-460
Vestibular System Applications (Balance Testing)
Black FO, Nashner LM 1985 "Postural control in four classes of vestibular abnormalities" In Igarashi M, Black FO, eds. Vestibular and Visual Control of Posture and Locomotor Equilibrium. Basel S Karger, : 271-281
Black FO, Wall III C, Nashner LM 1983 Effect of Visual and Support Surface References upon postural control in vestibular deficit subjects. Acta Otolaryngol Scand 95 : 199-210
Casselbrant ML, Furman JM, Rubenstein E, Mandel EM 1995 Effect of otitis media on the vestibular system in children Ann. Otol, Rhinol, Laryngol 104 : 620-624
Forssberg H, Nashner LM 1982 Ontogenetic development of postural control in man: adaption to altered support and visual conditions during stance. J. Neursci 2: 545-52
Kiem RJ 1993 Clinical comparisons of posturography and electronystagmography Laryngoscope 103 : 713-716
Mizukoshi K, Asai M, Watanabe Y, Ohashi N 1992 "Comparison between dynamic posturography and ENG recordings in patients with peripheral vestibular disorders" In Arenberg (ed) Surgery of the Inner Ear New York: Kugler Publications : 467-470
Kohen-Raz, Reuven 1996 Learning Difficulties and Postural Control London:Freund Publinshing House isbn 965-294-017-8
Motor Contol Tests and the cerebellum
Voorhees RL 1990 Dynamic posturography findings in central nervous system disorders. Otolaryngol. Head Neck Surg. 103 : 96-101
Rehabilitation Applications
Evans MK, Krebs DE 1999 Posturograpy does not test vestibulospinal function. Otolaryngology Head/Neck Surgury, 120:164-173
Horak FB 1992 Motor control models underlying neurologic rehabilitation of posture in children. In Forssberg H, Hirshfield H, (eds): Movement Disorders in Children. Med. Sport Sci. Basel, Karger, :1-10
Paediatric/Neurodevelopmental
Hirabayashi S, Iwasake Y 1995 Developmental perspective of sensory organisation on postural control Brain & Development 17 : 111-113
Horak FB, Shumway-Cook A, Crowe TK, Black FO 1988 Vestibular function and motor proficiency of children with impaired hearing, or with learning disability and motor impairment. Dev. Med. Child Neurol. 30 :64-79
Rine RM, Rubish K, Feeney C 1998 Measurement of sensory system effectiveness and maturational changes in postural control in young children. Pediatric Physical Therapy 10: 16-22
Shimizu K, Asai M, Takata S, Watanabe Y 1994 The development of equilibrium function in childhood. In Taguchi K, Igarashi M, Moru S (eds) Vestibular and Neural Front New York: Elsevier Science BV : 183-186
Shumway-Cook A, Horak F, Black FO 1987 A critical examination of vestibular function in motor-impaired learning disabled children. International J. Pediatric Otorhinolaryngol. 14: 21-30
Connolly K J, Fossberg H 1997 Neurophysiology and Neuropsychology of Motor Development London: Mackeith Press (ISBN 1898683 10 7) Fossberg H, Hursefield H 1992 Movement Disorders in Children Switzerland (ISBN 3 8055 5556 3)
Visual
Doman R J 1984 The importance of visual pursuits and convergence Journal of the National Academy for Child Development Vol 4 No. 4
Araie M, Ozawa T, Away Y. A case of congenital ocular motor apraxia with cerebellospinal degeneration. Jpn J Ophthalmol 1977; 21 355-65
Aslin RN Development of smooth pursuit in human infants. In Fisher DF, Monty RA, Senders JW, eds. Eye movements: cognition and visual Perception. Hillsdale, New Jersey: Earlbaum, 1981:31-51
Aslin R, Salapatek P Saccadic localisation of visual targets by the very young human infant. Percept Physchophys 1975;17 293-302
Atkinson J Development of optokinetic nystagmus in the human infant and monkey infant. An analogue to development in kittens. In: Freeman RD, ed Developmental Neurobiology of vision. New York press, 1979: 227-87
Baloh RW, Honubria V, Yee RD, Hess K Changes in the human vestibulo-ocular reflex after loss of peripheral sensitivity. Ann Neurol 1984; 16 222-8
Baloh RW, Konrad HR, Dirks D et al: Cerebellar-pontine angle tumors: Results of quantative vestibulo-ocular testing. Arch Neurol 33-507 1976
Baloh RW, Yee RD, Kimm J, Honubria V Vestibulo-ocular reflex in patients with lesions involving the vestibulo-cerebellum.Exp Neurol 1981;72:141-52
Barnes GR Visual-vestibular interaction in the control of head and eye movement: the role of visual feedback and predictive mechanisms. Prog Neurol 1993; 41: 435-72
Becker W, Klein HM Accuracy of saccadic eye movements and maintenance of eccentric eye positions in the dark. Vision Res 1973; 13 1021-34
Brandt T, Dieterich M How do vestibular disorders affect spatial orientation and motion perception? In Bahol RW, Halmagyi GM (eds): Disorders of the vestibular system, Oxford University press, New York, 1996: 126
Bruininks V. and Bruininks G Motor proficiency of learning disabled and non-learning disabled students. Perc. & Motor Skills,1977, 44,1131-1137
Stein J. Walsh V 1997 To see but not to read; the magnocellular theory of dyslexia. Trends in neurosciences 20:147-52
Stein J F, Glickstein M 1992 Role of the cerebellum in visual guidance of movement. Physiological Reviews 72: 972-1017
Other physical treatments
"Dyslexia Syndrome" Dyslexia, Dyspraxia, ADD
Frank, J. Levinson, H "Dysmetric Dyslexia and Dyspraxia - Synopsis of a continuing research project" ACADEMIC THERAPY PUBLICATIONS Vol. Xi no. 2, winter 1975-76
Pumfrey P D, Reason R Specific Learning Difficulties
Attwood T 1998 Asperger's syndrome: a guide for parents and professionals London: Jessica Kingsley Publishers Ltd (ISBN 1 85 302 557 1)
Sensory Integration
Jean Ayres 1998 Sensory Integration and the child LA: Western Psychological Services
Anderson, R 1999 First Steps to a physical basis of concentration Wales: Crown House Publishing Limited
Newspaper Articles
Daily Mail Tuesday June 6 2000: 44 "Could a travel sickness pill beat dyslexia?"
Web Pages
17/7/ 2000
"Eye exercises to Increase Attention and Reduce Impulsivity" by Moore D
T,
Http://www.familyclinic.simplenet.com/adhd/vision.html
"Issue Briefs: Vision Therapy"
Http://www.eyenet.org/member/comm/issue_briefs/vision.html
"children with special needs, vision, learning and nutrition."
Http://www.children-special-needs.org/vision_therapy/esophoria_reading.html
24/4/01
For information about what ADD is, we would suggest looking at
www.sciam.com/1998/0998issue/0998barkley.html
For some helpful teacher advice on ADD look at
www.nhmrc.health.gov.au/publicat/adhd/app.htm
For some helpful teacher advice on dyslexia look at
www.bda-dyslexia.org.uk/
Dyspraxia Foundation
www.emmbrook.demon.co.uk/dysprax/homepage.htm
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