ADD / ADHD Treatment, Digital Fitness, Dore Achievement Centres, Dyslexia Treatment, Nintendo Wii, Wii Fit

With the financial collapse of Dore in Australia, it is inevitable that questions will be because its ask about the long-term future of cerebellum training. The financial problems are Dore will cast a shadow over this approach to dyslexia and ADHD but I don’t believe it will kill it. Why? Partly because it works for some people but mostly because Dore is irrelevant to the future.

One of Dore’s key selling points was a personalised program based on the six weekly check-ups using their hi-tech balance machine. However that advantage has gone or will be gone in the next few months. The worldwide release of the Wii Fit Balance Board put a hi-tect balance machine in people’s living rooms for £69.99.

The balance board is not any use without some software and the Wii Fit software that comes with it, whilst good for general balance training, is nowhere near a replacement for Dore. Unfortunately developing software for a console like the Wii is expensive because of licensing issues and the special tools need to write the software. So its unlikely any company involved in cerebellum training will have enough money to pull it off.

However, the Wii Fit balance board can also be made work with PC’s and Macs. At the moment the software is a hack, a quick & dirty solution, but over the next few months these will stabilize and become easier to work with. Now, any one with a bit of programming skills and a good knowledge of cerebellum training could create a great dyslexia / ADHD orientated training program. One that personalises the training plan every time it is used, not once every six weeks.

Of course, the any training program would need to be tested and validated. Once again, technology can allow the little guy to do this on a budget. Anyone using the training system can sign-up to be part of the trial. Via the internet they can automatically log their usage and fill out regular questionnaires on symptoms or take online reading tests. All this data can then be anonymised and placed online so that anyone, pro or anti cerebellum, can analyse that data. Such a study would have many problems, not least the self-reporting aspect of it, but if the training works there should be a strong signal in the data to warrant more detailed studies.

ADD / ADHD, ADD / ADHD Medication, ADD / ADHD Treatment, Medication

What is Intuniv?

Intuniv is the latest ADHD drug from Shire PLC, the makers of Adderall XR, for tackling ADHD and it marks a big change in potential treatment options. It is not a stimulant like Ritalin or Adderall but instead its a selective alpha-2A receptor agonist. More simply, the active part of the drug helps specific parts of the brain to function more effectively. The key to making it an effective ADD medication is that it targets the area of the brain relating to the central nervous system. This, in theory has a calming effect, suppresses the fight / flight response and allows the normal functioning of the brain.

Secret Ingredient

Intuniv is based on the drug Guanfacine (also known as Tenex) that is used for treating hypertension and blood pressure. In 2006 the makers applied to FDA to allow its approval as a treatment for ADHD and this was granted in June 2007. However Guanfacine is only effective for a few hours before the patient has to take more pills. In the ADHD market, parents want to be able to give their child a tablet in the morning before school and have it working all day. This makes life easier for the school who no longer have to give out medicines at lunch time.

Adderall XR has been very successful for Shire PLC because it proved to be an effective, time release version of the standard stimulant used in Ritalin. Intuniv is very much in the same mold. Taking the existing drug Guanfacine and repackaging it in a time delayed formula. It is not clear exactly how it works but most likely it will use the same system as Adderall XR. The pill effectively consists of two tablets, one of which dissolves quickly in the stomach providing an immediate dose, and the second tablet, protected by a special coating, dissolves a lot slower, delivering its medicine some hours later and at a slower rate. The effect is that the patient receives a continuous level of medication through-out the day.

Intuniv Trial Success

Intuniv has not yet been given full approval by the FDA. In a recent press release, Shire stated that a 25% reduction in ADHD symptoms were seen in children compared with a placebo. This sounds good but remember this against children receiving no treatment. How effective it is versus Adderall XR or non-medical interventions has not been measured. It is also worth remembering that Shire PLC are selling Intuniv and will therefore be putting the best possible spin on their results. Independent researchers often find that real-world results do not match up to the drug company’s trial results.

Side Effects and Other Health Worries

Unlike most other ADHD medications, Intuniv is not stimulant based and is not a controlled substance. This means it has no potential for abuse in the way that Ritalin etc have. This should mean the drug is safer to take for long-periods of time but there has been no research in this area.

Unfortunately the story with side effects is not so good. Over 80% of children using it ireported adverse events (medical problems) during the 20 day trial. Most are unconnected to the drug and represent the normal childhood health problems but only 71% of users on the placebo had adverse effects. This is a significant difference and clearly shows that Intuniv has health risks. Adverse events reported include somnolence (32 percent), headache (26 percent), fatigue (18 percent), upper abdominal pain (14 percent) and sedation (13 percent) plus constipation, dizziness, dry mouth, hypertension and sedation. Shire PLC describe these as non-serious problems and highlight that fractionally less children on the drug developed serious problems compared to the placebo.

ADD / ADHD, ADD / ADHD Medication, ADD / ADHD Treatment

We have looked at Caffeine as a treatment for ADHD before and the science indicated that it could have some benefits. As a footnote to this Wired has a report that regular small doses of caffeine are more effective than one single large dose.

Throughout the day, your noodle fills up with adenosine, a chemical thought to cause mental fatigue. Caffeine blocks the brain’s adenosine receptors, countering the chemical’s dulling effects. To maximize alertness and minimize jitters, keep those receptors covered with frequent small doses — like a mug of low-caf tea or half a cup of joe — rather than a onetime blast. Test subjects reported that periodic small shots made them feel clearheaded and calm, both of which enhance mental performance. Even better, add a lump of sugar or have a carbohydrate-rich snack at the same time for an extra cognitive kick. It seems that glucose and caffeine together do more to enhance cognition than either does alone.

Source: Caffeinate With Care: Small Shots Do a Brain Better Than Big Blasts. Note no reference to the research is given so please take this data with a large pinch of salt.

ADD / ADHD, ADD / ADHD Medication

I’ve not had time to check into this further but it suggests that children on medication like Ritalin, Adderall and other stimulants are at risk of sudden cardiac failure if they have a rare heart condition. The American Heart Association is therefore advising that children are given a ECG prior to being prescribed stimulents.

Children diagnosed with attention deficit and hyperactivity disorder should have a thorough heart work-up, including an electrocardiogram, before taking stimulants such as Ritalin to treat the condition, according to a new recommendation by the American Heart Association.

The advice marks the first time a medical-guidelines body in the U.S. has urged wide use of an electrocardiogram, which charts electrical activity in the heart, to screen a presumed healthy population for abnormalities.

From: New Guidelines Urge Heart Tests Before Kids Take ADHD Drugs

ADD / ADHD Treatment, Digital Fitness, Dore Achievement Centres, Dore Sport, Dyslexia Treatment, Nintendo Wii, Wii Fit

One of the short comings of the Dore program and all movement based treatments is the low level of feedback you get when doing the exercises. Without someone watching you and checking the instructions for an exercise, its very hard to tell if you are doing them correctly. This is a major problem for people who cannot tell left hand from right and could easy spend ten minutes doing an exercise without noticing they are doing it completely wrong. Of course having someone to help is ideal but for adults doing the course that isn’t always possible and for children, it demands a great deal of time from other members of the family.

Its partly because of this problem that I’m interested in how technology can help deliver training programs like Dore. Computers or games consoles are the perfect way to monitor the exercises and provide feedback so that the exercisers knows they are doing it correctly. This reduces wasted time, improves the rate of progress and most importantly, reduces the demand on the rest of the family. This all adds up to a more effective treatment with a lower drop-out rate.

One technological development that has a lot promise is the slowly emerging 3D cameras. These are not strictly speaking 3D cameras, instead they use a variety of methods to identify depth and distance. This information is then passed back to the computer which can use it to workout if objects are moving towards it or away from it. Something that is very hard to do with a traditional camera.

The best demonstration of this technology I can find is this Second Life demonstration. Second Life (SL) is a virtual reality world shared by many thousands of people. Using a mouse and keyboard the players moves their avatar through the world but in this demo, a 3D camera is used to track the players movements.

It is not hard to make the leap from this demonstration to a computer program that tracks how well the person does does an exercise. We are already seeing this sort of approach in Wii Fit. More demonstrations of the technology are available from the makers of the camera. Here, an on-screen avatar mimics the movement of a real person and in this one, the player is throwing and catching a virtual ball. More are available from 3DVSystems.

ADD / ADHD, ADD / ADHD Treatment, Digital Fitness, Dore Achievement Centres, Dyslexia, Nintendo Wii, Wii Fit

The Wii is showing great potential for physical and mental skills training. The nature of the Wii’s controls plus the add-ons like Wii Fit‘s balance board mean its can be used to track and sense all sorts of movements and actions. Just to show the potential of the Wii, a grad student called Johnny Chung Lee has come up with a way to track your head movements. He’s used this create a prototype virtual reality system which you can see in the video below (skip to 2:45 if you are not interested in the technical stuff).

Virtual reality may be great for games but from neurological training point of view its not that interesting. Its the other potential uses for the head tracker that interests me. A Wii head tracking combine with the balance board allows the Wii to track many of the movements used in the Dore system and other movement based approaches to dyslexia and ADHD. A computerised system will have an advantage over the traditional approaches as it can give feedback on how well the exercise is being done and control its difficulty to reflect the skills of the user.

ADD / ADHD

From the BBC

The University of Southern California found a lack of zinc, iron, vitamin B and protein in the first three years caused bad behaviour later on. At eight years old, children fed poorly were more likely to be irritable and pick fights than those fed healthily. Aged 11, they swore, cheated and got into fights, and at 17, they stole, bullied others and took drugs. The researchers analysed the development of more than 1,000 children on Mauritius, an island in the Indian Ocean off the coast of Africa, over 14 years. They found the more malnurished the children were, the greater the anti-social behaviour later on.

Poor diet linked to bad behaviour

ADD / ADHD, ADD / ADHD Treatment, Digital Fitness, Nintendo Wii, Rhythm Games, Wii Fit

A couple of days ago I posted about a theoretical iLearn device based on iPhone technology. The main point being that cheap, powerful technology can be used to teach small children basic skills such as rhythm. Today a firm called Emotiv Systems have announced a cheap ($300 is cheap for this technology) headset that monitors brain activity for controlling games.

Biofeedback using devices that monitor brain activity has been tried to treat a number of neurological problems including ADHD. Play Attention are the market leaders in this area with their $1700 dollar system. Good scientific research in this area is thin on the ground (see this for more detail) but the idea is sound in principal. If you can learn to clam your mind, the problems of impulsiveness and hyperactivity should be reduced.

If there is some way combine Emotiv’s headset with the electronic balance board in Wii Fit then you have the basis of a very effective brain and body training system. With well designed games and a gradual progression from easy to hard, such a system should be able teach children to calm their minds and control their bodies at the same time. This would bring the same improvement in control as, say, learning a martial art to a high level but in a form that is easier to learn, with better feedback and generally more convenient. For the company that gets this right, there is a multi-billion dollar market to be taken from the drug firms.

Source: Brain control headset for gamers

ADD / ADHD, Dore Achievement Centres, Dyslexia, Science

Mind Hacks points to a good article on the current state of research into the effectiveness of biofeedback on ADHD. Its conclusion that biofeedback is a promising but unproven treatment is fair one.

What is interesting about the article is that it talks about what makes a good research study and delves into the problems of having a control group. In medication trials the control group takes a placebo pill, an inert sugar pill, whilst the study group takes the real medication. Both pills look the same and none of the medical staff handing out the pills know who is getting what. This minimises the confounding variables in the experiment.

In biofeedback studies, the problem is what to do you do with the control group. The treatment typically consists of 30 minutes a day using a computer and a biofeedback device. The control group needs to have a dummy treatment that is identical so that no one knows who is getting the real treatment but yet is guaranteed to have no effect. By its nature, biofeedback is an interactive process so the control group must have some sort of interactive experience. A device that just randomly responses to the the biofeedback would be quickly spotted.

This problem, when applied to a treatment such as the Dore program, becomes even more significant. Dore is series of exercises forming a 12 month program of twenty minutes a day. What activity could be used as a placebo that isn’t immediately recognised as the placebo? The only possibility would be to give one group the proper Dore exercises whilst the control group gets a random selection of exercises. But, the random exercises are too much like the real thing and there is a chance they help develop the cerebellum. Though they certainly would not be as effective it would introduce an unknown variable into an experimental set-up designed to remove unknowns.

A secondary problem is that children are assessed every six weeks under Dore using sensitive balance and eye-tracking devices. The child gets regular empirical evidence that the treatment is having an effect long before any improvements are seen in academic work. Obviously the users of the placebo should not see any improvement and this could have a significant effect on the child’s general confidence.

There is a way to conduct trials in these situation. You have two treatment groups, A and B plus a control, Group C. Group A gets the treatment whilst Group B gets a different activity, for example one-to-one help for 20 minutes a day. Group C gets no treatment. After Group A has received the treatment, the groups switch so Group B get the treatment and Group A gets the other activity. Once Group B has completed the treatment the experiment ends.

Both Groups A and B should of made more academic progress than the control Group C because of the one-to-one help they received and confounding variables such as the Placebo and Hawthorne effects. If the treatment worked better than the one-to-one help, then Group A would be expected to show academic improvements during the first period greater than Group B. This progress would slow down in the second period after the two groups switched roles and Group B would catch-up. If the treatment did not work, Group B would be ahead after the first period thanks to the one-to-one help and Group A would catch-up in during the second period.

There are some obviously difficulties in using this experimental design with Dore. Firstly it is a year long treatment. That means the whole experiment will last two years. To allow for people to move schools or drop out without having a major impact on the statistics, each group needs to be quiet large. Given that for the two treatment groups, there is a lot of investment of time in doing the exercises or taking children to the one-to-one sessions, the drop-out rate is likely to very high. Each group would probably need to start with about 50 people.

The cost of all this is significant. One-to-one teaching everyday for 50 people for year, twice, won’t be cheap. Nor will provision of the Dore treatment. Overheads in managing the experiment, tracking the academic performance of the children all add up. A gold standard experiment like this costs tens of thousands of pounds. Of course if Wynford Dore pays for the experiment then it won’t be an independent study but no one else will fund the experiment. The only dyslexia research body with that sort of funding is the department at York University. It is run by Professor Snowling who is rabidly opposed to Dore so its unlikely that any funding will come from there.

Another problem with an experiment on Dore is an ethical one. Asking a child to take part in a drug trial for four weeks is OK because if the treatment has no benefit then the child isn’t effected in anyway. For a Dore trial, the child has to spend twenty minutes a day for a year. If the treatment doesn’t work then the child has lost a huge amount of time and effort that could of been spent on more established therapies and the child would of fallen even further behind academically. This is major problem as the basis of any ethical experiment is that in no way, regardless of the experiment’s outcome, should the subjects experience any detrimental effects.

There are good reasons to criticise Dore’s scientific research and similar research by other alternative treatment but it has to be seen in context. The practicalities of an effective study that proves in one go the treatment works are both difficult and expensive. Dore and others are stuck in a catch-22 situation where if they pay for research there will be immediate accusation of bias but if they don’t pay for it, no one else will. Finally the ethical issues make the whole feasibility of an experiment doubtful.

Source: How Strong is the Research Support for Neurofeedback in Attention Deficits?

ADD / ADHD, Current Affairs, Dyslexia

All over the UK’s news today is a report into our primary school (age 4 – 7) education. One of the areas being discussed is what age children should start school. In the UK it is normally aged four and mandatory by age five. Some other countries don’t require it until aged seven.

School starting age may impact on educational problems such as dyslexia and ADHD if these are caused by a neurological underdevelopment. The early start to school may exaggerate the difference between those children who’s development is equal or greater than average and those who are below average. With the under-developed children immediately falling behind, their better developed peers and once behind they may never catch up. The argument for a later school starting age is that by seven there is a lot less variation in neurological development (at least relating to basic skills such speaking, listening and movement),

The report by the National Foundation for Education Research looked at a variety of research that should children in the UK who are summer born (April to August) do worse than those that are winter born. The obvious answer was that the summer born children got less schooling because they tend to started schooling later. However more detail research found that this wasn’t the issue. The report offers no easy answer why summer-born children do worse.

One interesting nugget the report throws out is that when our starting age was first set, part of the motivation was financial. The sooner the children entered school, the earlier the school leaving age would be, allowing the children to enter the workforce sooner. May be its time we embraced a schooling system more like that of our european neighbors and discard our system that dates back to the time we had children working up chimneys.