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Exercise/fish oil intervention for dyslexia

The document discusses various approaches to treating reading disabilities, particularly dyslexia, highlighting traditional phonological interventions and alternative methods like the Dore method and fish oil supplementation. It raises critical questions regarding the scientific plausibility of these methods, their claimed benefits, and the validity of their supporting evidence, ultimately questioning the efficacy of motor training and alternative treatments without robust control groups. It concludes that while some treatments may seem promising, the actual improvements in literacy may not be significantly attributable to the interventions based on available data.

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1 Treating reading disability without reading: evaluating alternative intervention approaches Dorothy Bishop University of Oxford http://www.psy.ox.ac.uk/oscci/ TALK AT BRITISH DYSLEXIA ASSOCIATION, MARCH 2008
2 Conventional approaches to dyslexia • Most children have problems with “phonological awareness” • Interventions focus on training children to identify sounds in words and relate these to letters
3 Problems with conventional approach • Nicolson et al 2003 summarising previous work on phonological interventions: – Intensive and prolonged phonological intervention can be effective in improving reading accuracy – Reading fluency remains a problem – Methods that are effective for most children, don’t work for all: A hard core of children remain very hard to treat
4 Neuroscience studies of developmental disorders The Holy Grail Develop a theory of the disorder that not only explains why it occurs, but also motivates effective intervention
5 Goals of this talk • Identify some questions for parents considering a new treatments • Illustrate with Dore method and fish oil
6 Questions to ask of a new treatment 1. Is the theory scientifically plausible? 2. What does the intervention claim to improve? 3. Are costs reasonable relative to benefits? 4. Does evidence for efficacy goes beyond testimonials? – have studies been done with groups for whom treatment is recommended? 5. Is there evidence that gains are due to treatment rather than maturation, practice, placebo, etc.?
7 Dore method: what is it? • Method for curing cerebellar problems developed by Wynford Dore to help his dyslexic daughter • Individualised program of exercises, done for around 10 mins, 2 x per day, assessed every 6 weeks
8 Dore method: the exercises • Hundreds of exercises, e.g.: – standing on a cushion on one leg and throwing a beanbag from one hand to another for one minute – hopping on one leg in large circle, clockwise then anticlockwise – sitting upright in a chair, turning head from side to side, pausing to focus on chosen point – balancing on a wobble board (Examples only: full details confidential because commercially sensitive)
9 Dore method: the theory •Dyslexia and other learning difficulties arise when the cerebellum fails to develop normally •Cerebellar impairments differ from person to person but can be diagnosed by specific tests of mental and physical co-ordination
10 Cerebellar theory of dyslexia • Not proven, but some evidence for it • Brain imaging and neuroanatomical studies offer some support • Theory that dyslexia involves failure to automatise skills is plausible • Associated deficits in motor co-ordination in a subset of people with dyslexia
11 Previous research on effectiveness of motor training • Training can improve performance on motor tasks, e.g. juggling • In rats, exercise can reverse cerebellar deficits caused by prenatal alcohol or zero gravity • But no evidence that motor training enhances development of non-motor skills
12 The Theory: evaluation • Notion that training motor skills will have effect on other skills: • “This hypothesis required something of a leap of faith, in that it is generally believed that the cerebellum comprises a very large number of independent ‘cerebro-cortical microzones’, and so it is not clear why training on one sort of task should generalize to unrelated tasks” (Reynolds et al, 2003, p 53) Reynolds, D., Nicolson, R. I., & Hambly, H. (2003). Evaluation of an exercise-based treatment for children with reading difficulties. Dyslexia, 9(1), 48–71. https://doi.org/10.1002/dys.235
13 The Theory: evaluation • If training focusing on one region of cerebellum had general effects on all cerebellar functions, then – activities like juggling and skateboarding should benefit everyone – sportsmen and women should have low risk of dyslexia Paul Nixon Kenny Logan Duncan Goodhew
14 Questions 1. Is the theory scientifically plausible? • Notion that cerebellum may be implicated in dyslexia is plausible though not proven • Notion that motor exercises will have beneficial effect on regions of cerebellum concerned with learning is considerably less plausible
15 Q2: What does the intervention claim to improve? Dore intervention recommended for: • Dyslexia • Dyspraxia • Attention Deficit Hyperactivity Disorder • Asperger syndrome
16 Dore (2006): Symptoms which respond dramatically to treatment – poor handwriting – low self-esteem – poor spelling – poor short-term memory – poor organisational skills – sporting skills – poor concentration – clumsiness – frustration and anger – phobias – faddiness with food – oversensitivity to touch – poor social skills – lack of empathy – lack of eye contact – poor posture – travel sickness – poor sleep patterns Dore (2006), chapter 7
17 Costs in relation to benefits Cost of treatment is around £1700-£2000: “ Surely it is a price worth paying in the attempt to transform the life of your child so that they are able to enjoy school, to develop social skills, to develop good sporting skills, to have good prospects in life?” Dore (2006) p. 171 “Money-back guarantee” But only if “no physiological change” – i.e. child who improves on balance/eye tracking won’t get refund, even if dyslexia/ADHD etc unchanged
18 Question 4 Have studies been done with groups for whom treatment is recommended?
19 Published study on Dore intervention • Two papers in Dyslexia reporting different phases
20 2003 study at Balsall Green school • 296 children from 3 school yrs • Selected 35 “at risk” on basis of Dyslexia Screening Test : strong risk in 34%, mild in 21% • Divided randomly into untreated and treated groups • Previous diagnoses: – treated: 4 dyslexic, 1 dyspraxic – control: 2 dyslexic, 1 dyspraxic, 1 ADHD • Mean ‘reading age’ at start: – -10.6 months in treated; -4.4 months in control
21 Q5. Is there evidence that gains are due to treatment?
22 How to measure reading etc. 0 10 20 30 40 50 60 70 5 6 7 8 9 10 11 12 13 14 15 age (yr) words read A 9-year-old reads 20 words Reading Age is 8 years: Sounds bad: 12 months behind age level
23 Reading age misleading: does not take into account spread of scores at a given age; non-linear relation with chronological age A 9-year-old reads 20 words. Error bars show middle 50% of children Within normal range for children of this age 0 10 20 30 40 50 60 70 80 5 6 7 8 9 10 11 12 13 14 15 age (yr) words read
24 Better to measure reading in terms of statistical abnormality at that age 0 10 20 30 40 50 60 70 80 5 6 7 8 9 10 11 12 13 14 15 age (yr) words read Percentile: % of children of this age obtaining this score or lower; Also z-score or standard score: different way of expressing same idea
25 Uninteresting reasons why scores may improve - 1 • Maturation –Children change with age –Shoe size may go up after treatment, but does not mean that treatment made feet bigger • A particular problem if “reading age” used, but should not be an issue if age-adjusted scores used
26 Uninteresting reasons why scores may improve - 2 • Practice effects • Child does test better 2nd time around because they have done it before • Numerous examples in research literature: e.g. Oxford-Durham fish-oil study: motor skills improved significantly in untreated as well as treated children on retest
27 Uninteresting reasons why scores may improve - 3 • Regression to the mean –Statistical artefact whereby someone selected for extreme score at time 1 will on average have less extreme score at time 2
28 Regression to the mean -8 -6 -4 -2 0 2 4 6 8 1 2 test occasion score -4 -3 -2 -1 0 1 2 3 1 2 test occasion average score Correlation between time 1 and time 2 = .11
29 Regression to the mean Correlation between time 1 and time 2 = .99 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 1 2 test occasion score -4 -3 -2 -1 0 1 2 3 1 2 test occasion average score
30 Regression to the mean Correlation between time 1 and time 2 = .76 -3 -2 -1 0 1 2 3 4 1 2 test occasion score -4 -3 -2 -1 0 1 2 3 1 2 test occasion average score
31 Uninteresting reasons why scores may improve - 4 • Other intervention/placebo effect –Child may be having other help or may respond to increased attention
32 These unwanted sources of change can be identified if we have a CONTROL GROUP • Untreated matched group given same pre- and post-test will control for: – Maturation – Practice effects – Regression to the mean – Effects of other intervention
33 Alternative treatment control group • Crucial to see if improvement due to: • Placebo/expectation effects –Child, parent, teachers all expect and want to see gains –Child gets more attention, boosted confidence, etc.
34 Need for controls Parallels in physical medicine suggest dangerous to assume you know answer in advance – e.g. congestive heart failure treatment
35 Results: total on dyslexia screening • High score indicates more risk • NB score include bead-threading/posture • Treated: mean fell from 0.74 to 0.34 – “strong risk” fell from 33% to 11% • Control: mean fell from 0.72 to 0.44 – “strong risk” fell from 35% to 24% Everyone gets better, even if not treated
36 DST results Treated Group 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 2 time 1 usual cutoff for dyslexia * * * * *
37 Significant group differences in gain on reading, bead threading, semantic fluency Control group 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 2 time 1 Treated Group 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 2 time 1
38 Control group subsequently given the treatment • Results published in Dyslexia journal in November 2006 • Control group now known as group D (delayed intervention) Reynolds, D., & Nicolson, R. I. (2007). Follow-up of an exercise-based treatment for children with reading difficulties. Dyslexia, 13(2), 78–96. https://doi.org/10.1002/dys.331
39 Group I 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 1 time 4 GroupD 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 1 time 4 Note: lack of “stunning” progress on literacy tests Results on dyslexia screening test, time 1 and time 4
40 Interim conclusion • Dyslexia screening test data – Little evidence of improvement on literacy tests associated with intervention • How, then can Dore (2006) conclude that the results were “stunning” and that: – comprehension age: increased almost 5 x – reading age, increased 3 x – writing, increased by “an extraordinary 17 x”
41 Data from school-administered tests, treated group only NFER reading test 84 96 108 120 132 144 -15 -3 9 21 time relative to grp I start mean reading age (mo) DDAT groups mean national average % improvement calculated by dividing pink line by orange line Conclude “reading age increased 3 times” Meaningless without control data!!!
42 Data from school-administered tests, treated group only NFER reading test 84 96 108 120 132 144 -15 -3 9 21 time relative to grp I start mean reading age (mo) DDAT groups mean national average % improvement calculated by dividing pink line by orange line Conclude “reading age increased 3 times” Meaningless without control data!!! Goes on to do similar calculations on SATS scores, which are based on teacher ratings
43 Q5. Is there evidence that gains are due to treatment? • Improvement looks dramatic only on measures where there is no control data • On reading measures where control group available, no evidence of sustained gains in the treated group
44 Fish oil
45 The theory • Certain highly unsaturated fatty acids (HUFAs) important in brain development and neuronal signal transduction • Could be problematic if: – Dietary insufficiency – Genetic abnormality in phospholipid metabolism • Administration of HUFAs may improve synaptic transmission
46 Evidence of abnormal fatty acid levels in dyslexia • Clinical signs of fatty acid deficiency found in adults with dyslexia (Taylor et al, 2000) • Clinical signs of FAD correlate with severity of dyslexia in children (Richardson et al, 2000) • Taylor, K. E., Higgins, C. J., Calvin, C. M., Hall, J. A., Easton, T., McDaid, A. M., & Richardson, A. J. (2000). Dyslexia in adults is associated with clinical signs of fatty acid deficiency. Prostaglandins, Leukotrienes and Essential Fatty Acids (PLEFA), 63(1), 75–78. https://doi.org/10.1054/plef.2000.0195 • Richardson, A. J., Calvin, C. M., Clisby, C., Schoenheimer, D. R., Montgomery, P., Hall, J. A., Hebb, G., Westwood, E., Talcott, J. B., & Stein, J. F. (2000). Fatty acid deficiency signs predict the severity of reading and related difficulties in dyslexic children. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 63(1–2), 69–74. https://doi.org/10.1054/plef.2000.0194
47 Evidence from treatment trials • Significant reduction in ADHD symptoms in children with comorbid dyslexia/ADHD cf. placebo (Richardson & Puri, 2002) – reading not assessed (!!??) • Cf. no improvement of ADHD symptoms vs. placebo in 2 studies of ADHD, though studies vary in fatty acid, sample, etc – Hirayama et al. 2004; Voigt et al., 2001 • Richardson, A. J., & Puri, B. K. (2002). Progress in Neuro-Psychopharmacology & Biological Psychiatry, 26(2), 233–239. https://doi.org/10.1016/s0278- 5846(01)00254-8 • Hirayama, S., Hamazaki, T., & Terasawa, K. (2004).. European Journal of Clinical Nutrition, 58(3), Article 3. https://doi.org/10.1038/sj.ejcn.1601830 • Voigt, R. G., Llorente, A. M., Jensen, C. L., Fraley, J. K., Berretta, M. C., & Heird, W. C. (2001) The Journal of Pediatrics, 139(2), 189–196. https://doi.org/10.1067/mpd.2001.116050
48 Evidence from treatment trials • Oxford-Durham study on children with developmental coordination disorder; Treated show significantly more improvement in literacy and ADHD symptoms: (Richardson & Montgomery, 2005) • Requests to see data to identify children with dyslexia from this sample get no response Richardson, A. J., & Montgomery, P. (2005). The Oxford-Durham study: A randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics, 115(5), 1360–1366. https://doi.org/10.1542/peds.2004-2164
49 Controlled trial of fish oil in dyslexic adults • Cyhlarova et al, 2007 report baseline results - no differences in membrane fatty acid levels between dyslexic and control adults, though ratio of types of fatty acid differs • Requests for information on progress of this treatment trial get no response Cyhlarova, E., Bell, J. G., Dick, J. R., MacKinlay, E. E., Stein, J. F., & Richardson, A. J. (2007). Membrane fatty acids, reading and spelling in dyslexic and non- dyslexic adults. European Neuropsychopharmacology, 17(2), 116–121. https://doi.org/10.1016/j.euroneuro.2006.07.003
50 Q1. Is the theory scientifically plausible? • Membrane phospholipid deficiency: speculative theory developed to account for schizophrenia, extended to neurodevelopmental disorders • Most plausible when applied to children who show physical symptoms suggestive of essential fatty acid deficiency
51 Q2. What does the intervention claim to improve? • Very generally applied to neurodevelopmental disorders, including ADHD, dyslexia, dyspraxia and autism
52 Q3. Are costs reasonable? • MorEPA £19.50 for 60 capsules (1 per day) • Treatment may need to be ‘long term’ • £118 per year
53 Q4. Does evidence for efficacy goes beyond testimonials? – have studies been done with groups for whom treatment is recommended? • Several clinical trials but only one specifically on children with dyslexia (and ADHD) - did not look at reading outcomes • Study of developmental coordination disorder included measures of reading as part of outcome assessment
54 Q5. Is there evidence that gains are due to treatment? • Inclusion of control group makes it possible to take into account practice, maturation, etc. • However, some effects likely to be chance when many comparisons done; need for replication in new sample using better measures of reading outcomes
55 Barriers to objective evaluation • Failure to recognise important effects of : – expectations – practice – maturation – statistical artefact • Human tendency to be impressed by testimonials
56 Testimonials more compelling than statistics • E.g. quote from a parent, re. MMR vaccine and autism: “The only evidence which I’ve seen cited is epidemiological. Now to me that’s statistics. Now statistics either turn you on or they don’t. I don’t have time for statistics when I see a sick child in front of me.” • Response from “guardian badscience” blog: “You should be thankful that somebody has had time for statistics, or else you’d be treating that sick child by bleeding her.”
57 N.B. Testimonials problematic because (a) selective (b) often at odds with objective evaluation
58 Barriers to objective evaluation • Failure to recognise important effects of : – expectations – practice – maturation – statistical artefacts • Human tendency to be impressed by testimonials • Human tendency to think something that has taken time/effort/money was worthwhile
59 Trial of Sunflower therapy Bull (2007) • Both treated and control children improved their test scores over time to similar extent • Higher academic self-esteem in those undergoing treatment • 57% of parents thought Sunflower therapy was effective in treating learning difficulties Bull, L. (2007). Sunflower therapy for children with specific learning difficulties (dyslexia): A randomised, controlled trial. Complementary Therapies in Clinical Practice, 13(1), 15–24. https://doi.org/10.1016/j.ctcp.2006.07.003
60 Barriers to objective evaluation • Failure to recognise important effects of : – expectations – practice – maturation – statistical artefacts • Human tendency to be impressed by testimonials • Human tendency to think something that has taken time/effort/money was worthwhile • Human tendency to be impressed by neuroscientific explanations
61 “The seductive allure of neuroscience explanations” Weisberg et al. 2008. J. Cognitive Neuroscience 20: 470-7 mean rating of satisfaction with explanation

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Exercise/fish oil intervention for dyslexia

  • 1.
    1 Treating reading disability withoutreading: evaluating alternative intervention approaches Dorothy Bishop University of Oxford http://www.psy.ox.ac.uk/oscci/ TALK AT BRITISH DYSLEXIA ASSOCIATION, MARCH 2008
  • 2.
    2 Conventional approaches to dyslexia •Most children have problems with “phonological awareness” • Interventions focus on training children to identify sounds in words and relate these to letters
  • 3.
    3 Problems with conventional approach •Nicolson et al 2003 summarising previous work on phonological interventions: – Intensive and prolonged phonological intervention can be effective in improving reading accuracy – Reading fluency remains a problem – Methods that are effective for most children, don’t work for all: A hard core of children remain very hard to treat
  • 4.
    4 Neuroscience studies of developmentaldisorders The Holy Grail Develop a theory of the disorder that not only explains why it occurs, but also motivates effective intervention
  • 5.
    5 Goals of thistalk • Identify some questions for parents considering a new treatments • Illustrate with Dore method and fish oil
  • 6.
    6 Questions to askof a new treatment 1. Is the theory scientifically plausible? 2. What does the intervention claim to improve? 3. Are costs reasonable relative to benefits? 4. Does evidence for efficacy goes beyond testimonials? – have studies been done with groups for whom treatment is recommended? 5. Is there evidence that gains are due to treatment rather than maturation, practice, placebo, etc.?
  • 7.
    7 Dore method: whatis it? • Method for curing cerebellar problems developed by Wynford Dore to help his dyslexic daughter • Individualised program of exercises, done for around 10 mins, 2 x per day, assessed every 6 weeks
  • 8.
    8 Dore method: theexercises • Hundreds of exercises, e.g.: – standing on a cushion on one leg and throwing a beanbag from one hand to another for one minute – hopping on one leg in large circle, clockwise then anticlockwise – sitting upright in a chair, turning head from side to side, pausing to focus on chosen point – balancing on a wobble board (Examples only: full details confidential because commercially sensitive)
  • 9.
    9 Dore method: thetheory •Dyslexia and other learning difficulties arise when the cerebellum fails to develop normally •Cerebellar impairments differ from person to person but can be diagnosed by specific tests of mental and physical co-ordination
  • 10.
    10 Cerebellar theory ofdyslexia • Not proven, but some evidence for it • Brain imaging and neuroanatomical studies offer some support • Theory that dyslexia involves failure to automatise skills is plausible • Associated deficits in motor co-ordination in a subset of people with dyslexia
  • 11.
    11 Previous research on effectivenessof motor training • Training can improve performance on motor tasks, e.g. juggling • In rats, exercise can reverse cerebellar deficits caused by prenatal alcohol or zero gravity • But no evidence that motor training enhances development of non-motor skills
  • 12.
    12 The Theory: evaluation •Notion that training motor skills will have effect on other skills: • “This hypothesis required something of a leap of faith, in that it is generally believed that the cerebellum comprises a very large number of independent ‘cerebro-cortical microzones’, and so it is not clear why training on one sort of task should generalize to unrelated tasks” (Reynolds et al, 2003, p 53) Reynolds, D., Nicolson, R. I., & Hambly, H. (2003). Evaluation of an exercise-based treatment for children with reading difficulties. Dyslexia, 9(1), 48–71. https://doi.org/10.1002/dys.235
  • 13.
    13 The Theory: evaluation •If training focusing on one region of cerebellum had general effects on all cerebellar functions, then – activities like juggling and skateboarding should benefit everyone – sportsmen and women should have low risk of dyslexia Paul Nixon Kenny Logan Duncan Goodhew
  • 14.
    14 Questions 1. Is thetheory scientifically plausible? • Notion that cerebellum may be implicated in dyslexia is plausible though not proven • Notion that motor exercises will have beneficial effect on regions of cerebellum concerned with learning is considerably less plausible
  • 15.
    15 Q2: What doesthe intervention claim to improve? Dore intervention recommended for: • Dyslexia • Dyspraxia • Attention Deficit Hyperactivity Disorder • Asperger syndrome
  • 16.
    16 Dore (2006): Symptomswhich respond dramatically to treatment – poor handwriting – low self-esteem – poor spelling – poor short-term memory – poor organisational skills – sporting skills – poor concentration – clumsiness – frustration and anger – phobias – faddiness with food – oversensitivity to touch – poor social skills – lack of empathy – lack of eye contact – poor posture – travel sickness – poor sleep patterns Dore (2006), chapter 7
  • 17.
    17 Costs in relationto benefits Cost of treatment is around £1700-£2000: “ Surely it is a price worth paying in the attempt to transform the life of your child so that they are able to enjoy school, to develop social skills, to develop good sporting skills, to have good prospects in life?” Dore (2006) p. 171 “Money-back guarantee” But only if “no physiological change” – i.e. child who improves on balance/eye tracking won’t get refund, even if dyslexia/ADHD etc unchanged
  • 18.
    18 Question 4 Have studiesbeen done with groups for whom treatment is recommended?
  • 19.
    19 Published study onDore intervention • Two papers in Dyslexia reporting different phases
  • 20.
    20 2003 study atBalsall Green school • 296 children from 3 school yrs • Selected 35 “at risk” on basis of Dyslexia Screening Test : strong risk in 34%, mild in 21% • Divided randomly into untreated and treated groups • Previous diagnoses: – treated: 4 dyslexic, 1 dyspraxic – control: 2 dyslexic, 1 dyspraxic, 1 ADHD • Mean ‘reading age’ at start: – -10.6 months in treated; -4.4 months in control
  • 21.
    21 Q5. Is thereevidence that gains are due to treatment?
  • 22.
    22 How to measurereading etc. 0 10 20 30 40 50 60 70 5 6 7 8 9 10 11 12 13 14 15 age (yr) words read A 9-year-old reads 20 words Reading Age is 8 years: Sounds bad: 12 months behind age level
  • 23.
    23 Reading age misleading:does not take into account spread of scores at a given age; non-linear relation with chronological age A 9-year-old reads 20 words. Error bars show middle 50% of children Within normal range for children of this age 0 10 20 30 40 50 60 70 80 5 6 7 8 9 10 11 12 13 14 15 age (yr) words read
  • 24.
    24 Better to measurereading in terms of statistical abnormality at that age 0 10 20 30 40 50 60 70 80 5 6 7 8 9 10 11 12 13 14 15 age (yr) words read Percentile: % of children of this age obtaining this score or lower; Also z-score or standard score: different way of expressing same idea
  • 25.
    25 Uninteresting reasons why scoresmay improve - 1 • Maturation –Children change with age –Shoe size may go up after treatment, but does not mean that treatment made feet bigger • A particular problem if “reading age” used, but should not be an issue if age-adjusted scores used
  • 26.
    26 Uninteresting reasons why scoresmay improve - 2 • Practice effects • Child does test better 2nd time around because they have done it before • Numerous examples in research literature: e.g. Oxford-Durham fish-oil study: motor skills improved significantly in untreated as well as treated children on retest
  • 27.
    27 Uninteresting reasons why scoresmay improve - 3 • Regression to the mean –Statistical artefact whereby someone selected for extreme score at time 1 will on average have less extreme score at time 2
  • 28.
    28 Regression to themean -8 -6 -4 -2 0 2 4 6 8 1 2 test occasion score -4 -3 -2 -1 0 1 2 3 1 2 test occasion average score Correlation between time 1 and time 2 = .11
  • 29.
    29 Regression to themean Correlation between time 1 and time 2 = .99 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 1 2 test occasion score -4 -3 -2 -1 0 1 2 3 1 2 test occasion average score
  • 30.
    30 Regression to themean Correlation between time 1 and time 2 = .76 -3 -2 -1 0 1 2 3 4 1 2 test occasion score -4 -3 -2 -1 0 1 2 3 1 2 test occasion average score
  • 31.
    31 Uninteresting reasons why scoresmay improve - 4 • Other intervention/placebo effect –Child may be having other help or may respond to increased attention
  • 32.
    32 These unwanted sourcesof change can be identified if we have a CONTROL GROUP • Untreated matched group given same pre- and post-test will control for: – Maturation – Practice effects – Regression to the mean – Effects of other intervention
  • 33.
    33 Alternative treatment control group •Crucial to see if improvement due to: • Placebo/expectation effects –Child, parent, teachers all expect and want to see gains –Child gets more attention, boosted confidence, etc.
  • 34.
    34 Need for controls Parallelsin physical medicine suggest dangerous to assume you know answer in advance – e.g. congestive heart failure treatment
  • 35.
    35 Results: total ondyslexia screening • High score indicates more risk • NB score include bead-threading/posture • Treated: mean fell from 0.74 to 0.34 – “strong risk” fell from 33% to 11% • Control: mean fell from 0.72 to 0.44 – “strong risk” fell from 35% to 24% Everyone gets better, even if not treated
  • 36.
    36 DST results Treated Group 02 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 2 time 1 usual cutoff for dyslexia * * * * *
  • 37.
    37 Significant group differencesin gain on reading, bead threading, semantic fluency Control group 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 2 time 1 Treated Group 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 2 time 1
  • 38.
    38 Control group subsequently giventhe treatment • Results published in Dyslexia journal in November 2006 • Control group now known as group D (delayed intervention) Reynolds, D., & Nicolson, R. I. (2007). Follow-up of an exercise-based treatment for children with reading difficulties. Dyslexia, 13(2), 78–96. https://doi.org/10.1002/dys.331
  • 39.
    39 Group I 0 24 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 1 time 4 GroupD 0 2 4 6 8 10 Read Spell Nons pass reading One min writing RAN Phon segment Backward digits Verbal Fl. Semantic Fl Bead thread Post Stability mean decile time 1 time 4 Note: lack of “stunning” progress on literacy tests Results on dyslexia screening test, time 1 and time 4
  • 40.
    40 Interim conclusion • Dyslexiascreening test data – Little evidence of improvement on literacy tests associated with intervention • How, then can Dore (2006) conclude that the results were “stunning” and that: – comprehension age: increased almost 5 x – reading age, increased 3 x – writing, increased by “an extraordinary 17 x”
  • 41.
    41 Data from school-administered tests,treated group only NFER reading test 84 96 108 120 132 144 -15 -3 9 21 time relative to grp I start mean reading age (mo) DDAT groups mean national average % improvement calculated by dividing pink line by orange line Conclude “reading age increased 3 times” Meaningless without control data!!!
  • 42.
    42 Data from school-administered tests,treated group only NFER reading test 84 96 108 120 132 144 -15 -3 9 21 time relative to grp I start mean reading age (mo) DDAT groups mean national average % improvement calculated by dividing pink line by orange line Conclude “reading age increased 3 times” Meaningless without control data!!! Goes on to do similar calculations on SATS scores, which are based on teacher ratings
  • 43.
    43 Q5. Is thereevidence that gains are due to treatment? • Improvement looks dramatic only on measures where there is no control data • On reading measures where control group available, no evidence of sustained gains in the treated group
  • 44.
  • 45.
    45 The theory • Certainhighly unsaturated fatty acids (HUFAs) important in brain development and neuronal signal transduction • Could be problematic if: – Dietary insufficiency – Genetic abnormality in phospholipid metabolism • Administration of HUFAs may improve synaptic transmission
  • 46.
    46 Evidence of abnormalfatty acid levels in dyslexia • Clinical signs of fatty acid deficiency found in adults with dyslexia (Taylor et al, 2000) • Clinical signs of FAD correlate with severity of dyslexia in children (Richardson et al, 2000) • Taylor, K. E., Higgins, C. J., Calvin, C. M., Hall, J. A., Easton, T., McDaid, A. M., & Richardson, A. J. (2000). Dyslexia in adults is associated with clinical signs of fatty acid deficiency. Prostaglandins, Leukotrienes and Essential Fatty Acids (PLEFA), 63(1), 75–78. https://doi.org/10.1054/plef.2000.0195 • Richardson, A. J., Calvin, C. M., Clisby, C., Schoenheimer, D. R., Montgomery, P., Hall, J. A., Hebb, G., Westwood, E., Talcott, J. B., & Stein, J. F. (2000). Fatty acid deficiency signs predict the severity of reading and related difficulties in dyslexic children. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 63(1–2), 69–74. https://doi.org/10.1054/plef.2000.0194
  • 47.
    47 Evidence from treatmenttrials • Significant reduction in ADHD symptoms in children with comorbid dyslexia/ADHD cf. placebo (Richardson & Puri, 2002) – reading not assessed (!!??) • Cf. no improvement of ADHD symptoms vs. placebo in 2 studies of ADHD, though studies vary in fatty acid, sample, etc – Hirayama et al. 2004; Voigt et al., 2001 • Richardson, A. J., & Puri, B. K. (2002). Progress in Neuro-Psychopharmacology & Biological Psychiatry, 26(2), 233–239. https://doi.org/10.1016/s0278- 5846(01)00254-8 • Hirayama, S., Hamazaki, T., & Terasawa, K. (2004).. European Journal of Clinical Nutrition, 58(3), Article 3. https://doi.org/10.1038/sj.ejcn.1601830 • Voigt, R. G., Llorente, A. M., Jensen, C. L., Fraley, J. K., Berretta, M. C., & Heird, W. C. (2001) The Journal of Pediatrics, 139(2), 189–196. https://doi.org/10.1067/mpd.2001.116050
  • 48.
    48 Evidence from treatmenttrials • Oxford-Durham study on children with developmental coordination disorder; Treated show significantly more improvement in literacy and ADHD symptoms: (Richardson & Montgomery, 2005) • Requests to see data to identify children with dyslexia from this sample get no response Richardson, A. J., & Montgomery, P. (2005). The Oxford-Durham study: A randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics, 115(5), 1360–1366. https://doi.org/10.1542/peds.2004-2164
  • 49.
    49 Controlled trial offish oil in dyslexic adults • Cyhlarova et al, 2007 report baseline results - no differences in membrane fatty acid levels between dyslexic and control adults, though ratio of types of fatty acid differs • Requests for information on progress of this treatment trial get no response Cyhlarova, E., Bell, J. G., Dick, J. R., MacKinlay, E. E., Stein, J. F., & Richardson, A. J. (2007). Membrane fatty acids, reading and spelling in dyslexic and non- dyslexic adults. European Neuropsychopharmacology, 17(2), 116–121. https://doi.org/10.1016/j.euroneuro.2006.07.003
  • 50.
    50 Q1. Is thetheory scientifically plausible? • Membrane phospholipid deficiency: speculative theory developed to account for schizophrenia, extended to neurodevelopmental disorders • Most plausible when applied to children who show physical symptoms suggestive of essential fatty acid deficiency
  • 51.
    51 Q2. What doesthe intervention claim to improve? • Very generally applied to neurodevelopmental disorders, including ADHD, dyslexia, dyspraxia and autism
  • 52.
    52 Q3. Are costsreasonable? • MorEPA £19.50 for 60 capsules (1 per day) • Treatment may need to be ‘long term’ • £118 per year
  • 53.
    53 Q4. Does evidencefor efficacy goes beyond testimonials? – have studies been done with groups for whom treatment is recommended? • Several clinical trials but only one specifically on children with dyslexia (and ADHD) - did not look at reading outcomes • Study of developmental coordination disorder included measures of reading as part of outcome assessment
  • 54.
    54 Q5. Is thereevidence that gains are due to treatment? • Inclusion of control group makes it possible to take into account practice, maturation, etc. • However, some effects likely to be chance when many comparisons done; need for replication in new sample using better measures of reading outcomes
  • 55.
    55 Barriers to objectiveevaluation • Failure to recognise important effects of : – expectations – practice – maturation – statistical artefact • Human tendency to be impressed by testimonials
  • 56.
    56 Testimonials more compelling thanstatistics • E.g. quote from a parent, re. MMR vaccine and autism: “The only evidence which I’ve seen cited is epidemiological. Now to me that’s statistics. Now statistics either turn you on or they don’t. I don’t have time for statistics when I see a sick child in front of me.” • Response from “guardian badscience” blog: “You should be thankful that somebody has had time for statistics, or else you’d be treating that sick child by bleeding her.”
  • 57.
    57 N.B. Testimonials problematicbecause (a) selective (b) often at odds with objective evaluation
  • 58.
    58 Barriers to objectiveevaluation • Failure to recognise important effects of : – expectations – practice – maturation – statistical artefacts • Human tendency to be impressed by testimonials • Human tendency to think something that has taken time/effort/money was worthwhile
  • 59.
    59 Trial of Sunflowertherapy Bull (2007) • Both treated and control children improved their test scores over time to similar extent • Higher academic self-esteem in those undergoing treatment • 57% of parents thought Sunflower therapy was effective in treating learning difficulties Bull, L. (2007). Sunflower therapy for children with specific learning difficulties (dyslexia): A randomised, controlled trial. Complementary Therapies in Clinical Practice, 13(1), 15–24. https://doi.org/10.1016/j.ctcp.2006.07.003
  • 60.
    60 Barriers to objectiveevaluation • Failure to recognise important effects of : – expectations – practice – maturation – statistical artefacts • Human tendency to be impressed by testimonials • Human tendency to think something that has taken time/effort/money was worthwhile • Human tendency to be impressed by neuroscientific explanations
  • 61.
    61 “The seductive allureof neuroscience explanations” Weisberg et al. 2008. J. Cognitive Neuroscience 20: 470-7 mean rating of satisfaction with explanation