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- 1. 1 Dyslexia, Dyspraxia, Autism Spectrum Disorders, ADHD: Assessment and Intervention Dr Madeleine Portwood Dubai Feb 2015 ‘Movement is a child’s first language – it is the first medium of expansion of the physical and emotional conditions of an individual. Self control begins with the control of movement’. Kiphard and Schilling 1994. Dyslexia, Dyspraxia ADHD and ASD Dyslexia specific problems with written language skills (reading / spelling) Dyspraxia problems in planning / execution, poor motor coordination, attention, perception ADHD hyperactivity / impulsivity attentional problems impaired social & communication skillsAutism Spectrum Disorders -
- 2. 2 Dyslexia, Dyspraxia, ADHD and the Autism Spectrum – the Overlap Dyspraxia Autistic SpectrumDyslexia ADHD Studies of the effects of nutrition on brain development Information based on a multi-centre study from Cambridge and East Anglia carried out by Professor Alan Lucas 1990 Pre-term vs term formula. Period of nutritional intervention. 4 weeks showed significant developmental advantages at 18 months 1992 Lucas reported 8.3 IQ advantage in 7 ½ - 8 year old children born pre-term when fed mothers’ milk by tube vs donor breastmilk and formula. Hypothesis : Since human milk is lower in most nutrients compared with formula milk it must contain something more specific which helps the development of the C.N.S. 1994 Donor breastmilk vs pre-term formula reports no difference In developmental outcome at 18 months. 1996 Maureen Hack, Nancy Klein and Gerry Taylor (Semin Neonatal 1996:1:277- 288) studies of school-age outcomes In children of low birthweight and gestational age. M Makrides and R Gibson (Recent developments in Infant Nutrition 202-211) defining the LCPUFA (long chain polyunsaturated fatty acids) requirement of term infants. Suggested that LCPUFAs are the probable explanation for the substance in breastmilk responsible for the results observed by Lucas. Linoleic acid (LA) ▼ Gamma-linolenic acid (GLA) ▼ Dihomogammalinolenic acid (DGLA) ▼ Arachidonic acid (AA) ▼ Adrenic acid (AdrA) ▼ Docosapentaenoic acid (ω6-DPA) Alpha-linolenic acid (ALA) ▼ Stearidonic acid (SA) ▼ Eicosatetraenoic acid (ETA) ▼ Eicosapentaenoic acid (EPA) ▼ Docosapentaenoic acid (ω3-DPA) ▼ Docosahexaenoic acid (DHA) Synthesis of HUFA from EFA The omega-6 EFA’s The omega-3 EFA’s
- 3. 3 Formula Vs Breastmilk 0 2 4 6 8 10 12 14 16 LA AA ALA DHA Formula Breastmilk ‘Maternal Malnutrition Is the Most Significant Factor for Adverse Outcomes in Pregnancy’ Symptoms of EFA Deficiency n Dry itchy skin n Coarse bumpy patches particularly at the back of the arms n Soft broken nails n Frequent urination n Excessive thirst n Dull dry hair n Allergies
- 4. 4 LA to ALA Ratios of Foods OILS LA ALA LA/ALA Rapeseed 13.02 6.50 Soybean 51.50 7.30 Olive 7.50 0.70 Corn 50.40 0.90 Sesame 43.10 0.30 Sunflower 63.20 0.10 2 7 11 56 144 632 LA to ALA Ratios of Foods FATS LA ALA LA/ALA Butter 0.95 0.46 2 Cream 1.95 0.65 3 Chocolate 7.34 0.67 11 Ice Cream 14.70 0.98 15 Fat Spread (70% fat, polyunsaturated) 33.26 0.09 370 Study Design n This was a randomised, double-blind placebo-controlled trial, with a total duration of 6 months. On recruitment, children were allocated at random to either the active treatment (the HUFA supplement, ‘eye-q’) or an identical-looking placebo (1). At the three-month point there was a one-way treatment crossover (placebo to active treatment) and all children were then followed up for a further 3 months. Assessments at: baseline 3 months 6 months. Group 1 (N=50) active active |. Group 2 (N=50) placebo active |. (1) Randomisation and blinding of treatments were organised by the suppliers, Equazen ltd, who kept the register of treatment codes. Allocation of subjects to treatments was pre- randomised with the constraint that the numbers of active and placebo-treated subjects were balanced within males and females.
- 5. 5 Study Design Treatments. n Eye Q is on open sale in the UK as a food supplement, and contains premium quality fish oil and evening primrose oil. Study dosage will be fixed at the recommended initial intake of 6 small capsules / day, supplying omega-3 HUFA (EPA , DHA), and the omega-6 HUFA GLA and AA plus vitamin E (alpha-tocopherol). n The placebo treatment was an identical-looking capsules of an oil containing medium-chain triglycerides (MCT) – derived from tropical oils such as coconut, pal etc). These fatty acids contain neither omega-3 nor omega-6 HUFA, but are often used in food supplements designed as an energy source, e.g. For athletes. Exclusion criteria. n Significant neurological psychiatric, or other medical problems,current medication (unless this is judged irrelevant by the GP). n NB: GP consent was required for all participants, but we excluded a priori children receiving treatment for major health problems e.G. Cerebral palsy, epilepsy, MS. ME or any other major physical condition. Gains in Reading and Spelling -2 -1 0 1 2 3 4 5 6 7 Agegain(inmonths) Reading Spelling Reading age and Spelling age gains beyond expectation after 3 months Active placebo 0 1 2 3 4 5 6 7 8 9 10 Agegain(inmonths) Reading Spelling Reading and Spelling gains after 0-3 months' supplementation Active placebo Effect size of Active and Placebo treatments on ADHD Global Scales (CTRS-R:L) -0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Emotional Lability DSM Hyperactive -Impulsive DSM Global Total Global Total DSM Inattention Restless-Impulsive ADHD Index placebo LC-PUFA
- 6. 6 The Durham Trial We need to remember that this is not about chemistry. This is about children. What’s the issue? n we try to help before we know what the issue is. n importance of effective, timely screening and simple interventions What we discovered n less excitability n greater memory and concentration n improved reading and spelling
- 7. 7 Eston Park School n 40% made better than expected gains in reading (in some cases 2yrs 3 mths over 3 months). n 62% showed improvements in auditory memory. n At the beginning of the trial, 35% of children reported having mild-moderate emotional difficulties. After the trial only one pupil reported mild-moderate problems in this area. n The results the Head Teacher and senior management noted for themselves on individual pupils was enough for the sceptical Head Teacher to subsidise continuing the supplements. He is not known for parting with school money easily. Ian Hoy, Inclusions Officer, Eston Park School Changing how we do things n longer sequence of instructions can be remembered n more able to stay ‘on task’ and less likely to be disruptive n more able to access texts (so less adult input needed) n writing less physically exhausting n more energy for creative processes n self esteem raised Clinical Features in Infancy Hyperactive Hypoactive Sleep Problems Feeding Difficulties Undemanding ‘Colic’ High Levels of Motor Activity Repetitive Behaviour Slow to achieve independent sitting Usually do NOT go through crawling stage Late to walk Delayed Acquisition of Language
- 8. 8 Pre-School (3 – 5 Years) n Very High levels of motor activity u Feet swinging and tapping when seated u Hands clapping or twisting u Unable to stay in place longer than 5 minutes n Poor figure ground awareness u No sense of danger u Jump from inappropriate heights n Very Excitable u Voice Loud and Shrill u Easily distressed, temper Tantrums n Continue to be messy eaters u Often spill liquid from drinking cups u Prefer to use fingers to feed n Move Awkwardly u Constantly bumping into objects and falling u Associated Mirror movements, hands flap when running or jumping n Avoid Constructional Toys u Jigsaws u Building Blocks (Lego) n Difficulty pedalling tricycle or similar toy Pre-school (3 – 5 years) continued n Poor Fine Motor Skills u Pencil grip u Use of scissors u Immature drawings n Language difficulties persist u Children often referred to speech therapist n Lack of imaginative play u Does not enjoy ‘dressing up’ or playing in home corner/ Wendy House n Sensitive to sensory stimulation u High levels of noise u Dislike being touched or wearing new clothes n Limited Creative Play n Isolated in Peer group u Rejected by peers – prefer adult company n Limited response to verbal instructions u Slower response time u Problems with comprehension n Laterality still not established u Problems crossing mid-line n Limited concentration u Tasks often left unfinished The differences between the processing styles of the left and right hemispheres represented both verbally and visually Left Hemisphere Right Hemisphere CAT Words Images 6 Numbers Patterns Parts Wholes Sequential Linear Simultaneous Patterns Connections
- 9. 9 The Effects of a Motor-Skills Programme Assessing Motor Skills Age 3+ Gross Motor Skills • Crawling through a tunnel (two metres length) coordinating arms and legs appropriately. • Walking backwards, forwards and sideways, arms alongside the body • Running a distance of 10 metres without tripping or falling over • Jumping from a low step, or on the spot with feet together • Climbing up and down stairs in an adult fashion, placing one foot on each step • Walking heel / toe along a measured distance of three metres • Balancing along a bench/ plank raised (10cm) from the floor
- 10. 10 Fine Motor Skills • Established hand preference • Building a tower of 6+ (2.5cm) bricks • Reassemble a screw toy or remove the top from a jar or bottle • Thread a determined sequence of large beads e.g. two red, one blue, two yellow • Complete a 6-piece inset puzzle / jigsaw • Copy simple shapes e.g. line, cross, circle, square
- 11. 11 Handedness RIGHT LEFT School-based Primary Programme
- 12. 12 Emotional Wellbeing Conners Rating Scales n Self Assessment n Parents’ n Teachers’ Completing Teacher Rating Scale
- 13. 13 Letter Parent Teacher A Oppositional Oppositional B Cognitive Problems/ Inattention Cognitive Problems/ Inattention C Hyperactivity Hyperactivity D Anxious – Shy Anxious – Shy E Perfectionism Perfectionism F Social Problems Social Problems G Psychosomatic H ADHD Index ADHD Index I Connors’ Global Index: Restless-Impulsive Connors’ Global Index: Restless-Impulsive J Connors’ Global Index: Emotional Lability Connors’ Global Index: Emotional Lability K Connors’ Global Index: Total Connors’ Global Index: Total L DSM-IV Symptoms: Inattentive DSM-IV Symptoms: Inattentive M DSM-IV Symptoms: Hyperactive- Impulsive DSM-IV Symptoms: Hyperactive- Impulsive N DSM-IV Symptoms: Total DSM-IV Symptoms: Total Long Form Scoring Grid Subscale Autism Spectrum Disorder Childhood Autism Rating Scales (CARS) Resources n Text Checker n Supporting the SENCO n Ideas to support children with ASD at home and in school n Developing Speech and Language n Building Self Esteem n Managing Behaviour
- 14. 14 References n Portwood et al (2014) The role of essential fatty acids in improving language skills in children with ASD Durham University International Conference n Portwood M: (2011) The Co-ordination Conundrum. SEN Magazine (September / October) n Portwood M: (2008) Movement Difficulties in the early years: a planned programme of support in The Dyslexia Handbook 2208/2009, British Dyslexia Association, Bracknall n Portwood M: (2006) Effect of Diet on children’s behaviour and learning. Br. Journal Nutrition & Health Vol. 18, pp. 219–232 n Portwood M: (2006) Essential Fatty Acids (EFAs) and their effect on children’s behaviour and learning. Journal of the Dyslexia Institute 14. (2) 4 - 7 n Portwood M: (2005) Dyspraxia in Special Teaching for Special Children: A Pedagogy for Inclusion? Eds Lewis & Norwich McGraw & Hill Open University Press n Portwood M: (2004) Children with movement difficulties – an epidemic Professional Journal of the Dyspraxia Foundation (Oct) n Portwood M. (2003) Dyslexia and P.E. BDA/ David Fulton, London n Portwood M. (2000) Understanding Developmental Dyspraxia – A Textbook for Students and Professionals, David Fulton London n Portwood M. (2000) Dyspraxia, British Journal of Teaching Physical Education 31(1), 22 - 25 n Portwood M. (1999) Developmental Dyspraxia: Identification and Intervention. David Fulton London