A learning difficulties programme that claims to re-train the cerebellum makes some impressive claims which don’t stand close scrutiny.
DORE is an organisation that claims to treat learning difficulties without drugs. Their programmes supposedly
“… tackle the root cause of learning difficulties by improving the efficiency of the cerebellum – the brain’s ‘skill development centre’ – and the part of the brain now understood to play a significant role in learning, coordination, emotional control and motor skills.”
Recently the company held a series of information sessions to coincide with the opening of a new Dore centre in Lower Hutt, to go with their existing centres in Auckland and Christchurch. I attended a session to see what it was all about.
As we entered the room, video testimonials were playing, showing parents and their children claiming dramatic results for a range of learning disabilities and conditions, such as Asperger’s syndrome. An information pack was handed out, which included newspaper clippings and another testimonial. It claimed that Dore gets to the “core of learning difficulties”, “actively improves ability to learn”, is drug-free, based on scientific principles, is personally tailored and is not a “quick fix” or “soft option”. A FAQ stated that people who successfully complete the programme did the exercises accurately and consistently and if improvements don’t occur this is mainly because people are not sticking to the routine.
A video introduced Wynford Dore, who stated his daughter had learning problems, for which he searched for a solution. Then a mother and her son related how the son had dyslexia and behavioural problems at school which the mother was only made aware of after a few years when a teacher spoke to her. The child was already on a three-year programme with SPELD when the family discovered Dore; they followed this programme for a year concurrently with SPELD. They claimed significant improvement about three months after starting Dore.
The presentation went on to claim that approximately 16 percent of the New Zealand population had learning difficulties, with only four percent diagnosed; these were said to affect one in six New Zealanders. It was difficult to locate comparative figures, but SPELD estimates that seven percent of children have a specific learning disability, which would equate to about 50,000 school children.
The Dore programme claimed to assist with dyslexia, ADD/ADHD, dyspraxia (motor skills) and Asperger’s syndrome, and is targeted at people aged seven and over. The presenter briefly went over the typical feelings of those struggling with learning difficulties, and described how they thought these conditions manifest – as a multitude of literacy, numeracy, memory, attention, coordination, social and emotional problems. This was all claimed to be due to an inefficient cerebellum. Dore, they said, addresses underlying causes rather than symptoms (where have I heard that before I wonder?).
The conditions treated all allegedly have a physiological basis and nothing to do with other factors. Figures were presented, said to be from the Otago University longitudinal study and purporting to show that dyslexics were significantly disadvantaged compared with peers (with the consequent implication that treatment would help prevent this disadvantage).
Dyslexic students were more likely to leave school with no qualifications, much less likely to have a Bachelors degree, and none achieved Masters/Doctorate levels. Average income was more than $10,000 less than their peers. However, there was no word on whether this lack of achievement could be generalised to all people suffering dyslexia, given the long time period of the study and the considerable changes in educational services over that time.
In a further video presentation a Dr Sara Chamberlain claimed the cerebellum governs the automatic performance of simple tasks, and that this facility can be enhanced through exercise. We then heard about Dore’s assessment process. Following an initial phone consultation, prospective clients fill out a questionnaire, and there are a variety of tests and a medical assessment. Posture and ocular-motor skills are tested, and then dyslexia is screened for, apparently using a standard tool. Other conditions such as ADD/ADHD are assessed using the DSM-IV manual; the whole initial appointment takes three to four hours. The programme, it appears, is not suitable for everyone. Clients then have 1.5-hour interviews at three-monthly intervals and on completion of the course.
It was claimed that many scientific papers link the cerebellum with learning, attention, etc; these can be found on their website. They say they have done research themselves and written papers, and will provide details on request. They mentioned ongoing studies into ADHD at Ohio State University and by another US office; the Ohio State University testing appears to be a pilot study, but I couldn’t find any references to the other. A testimonial was introduced from a Dr Edward Hallowell, presented as an expert in ADD and ADHD. When I checked on this later, he appears to be involved with the Dore programme and would hardly be an unbiased commenter.
We were presented with figures from self-evaluation claiming to show 86.5 percent of children and 88.5 percent of adults showed progress in literacy and numeracy after taking the Dore programme. For coordination the respective figures were 81 percent and 75.4 percent, and for social skills 78.1 percent and 72.6 percent. The exercise programme was claimed to be individualised, unlike other programmes like ‘Brain Gym’ that aren’t (for more information on Brain Gym see Ben Goldacre’s Bad Science blog(.
The regime
The exercises take 10 minutes twice daily, with a mandatory four-hour break between; they have 400 exercises and 16 levels that could be completed. These involve such things as using a wobble board, or an exercise ball, or throwing and catching mini bean bags. Again, the cerebellum was claimed to be receiving, processing and automating sensory information from somatosensory, visual and vestibular inputs. The cerebral cortex (the thinking part of the brain) is apparently supposed to integrate all of this but with the conditions Dore say they treat, it is claimed the cerebellum isn’t working with the cerebral cortex.
The idea that defects in the cerebellum cause learning difficulties would seem to be a classic case of correlation not necessarily equating with causation. As noted by Oxford University psychologist Dorothy Bishop in her 2007 paper “Curing dyslexia and ADHD by training motor co-ordination: Miracle or myth?”, cause and effect would seem to be not so simple as presented at the session.
“The notion that the cerebellum might be implicated in some children’s learning difficulties is not unreasonable: both post-mortem and imaging studies have reported cerebellar abnormalities. Furthermore, some studies have reported behavioural deficits involving balance and automatisation of motor skills in a subset of people with dyslexia, consistent with a cerebellar deficit hypothesis. However, it is premature to conclude that abnormal cerebellar development is the cause of dyslexia, rather than an associated feature. Many people with dyslexia do not show any evidence of motor or balance problems. Furthermore, the cerebellum is a plastic structure which can be modified by training, raising the possibility that cerebellar abnormalities might be a consequence of limited experience in hand-writing in those with poor literacy.”
The programme used to use a book, but is now web-based. Exercises are carried out and then “marked” according to their criteria. They stressed that compliance was key, along with parental support. Times for completion vary, but are usually 12-14 months, with a weaning process at the end of the programme where the exercises are gradually wound down. The course is expensive, costing almost $5,400 or a little less for a one-off payment. They did say that they gave three “sponsored” places per month, but didn’t describe what exactly this entailed, outside of mentioning that it was for low income families and that children with a medical diagnosis could apply for a disability allowance through WINZ which could be used to access their programme.
A few questions
During question time, they were asked how they could be sure the child in the video testimonial had improved because of Dore and not the other programme he was on. The answer was fudged: they said they didn’t diagnose but looked for “sensory processing problems” and it was those they treated, which then enabled the person to learn. In other words, if there was improvement, it was Dore, not any other intervention specifically targeted at helping the person learn to overcome their disability and learn to read.
Another questioner asked why it was so costly given that the programme is mostly self-directed. They equivocated, talking about staffing costs, the website, and having support available. They said that braces cost much more and that that is basically cosmetic, when their programme “benefited a person for life” so was worth the investment. Yet another question was about the doctors – why wouldn’t they use paediatricians and other suitably qualified professionals? They stated that for their purposes, the level of medical expertise was sufficient.
Dore has obviously learned from experience following actions taken by overseas advertising standards authorities, and no longer make claims of “100 percent cure” and “miracle cure” for the conditions they claim to treat. In fact they seemed to be reasonably realistic in introducing caveats such as “it doesn’t work for everyone”. Despite this, they still claim to be proven to help overcome learning difficulties even though the evidence base is weak to non-existent. Although they make many claims to be “scientific” and have an extensive list of papers on their website, when the UK Advertising Standards Authority considered a complaint against Dynevor, Dore’s parent company, they assessed the studies submitted in support as poor, lacking control groups, and not supporting the treatment claims made:
“The ASA noted Dynevor’s interpretation of the ad. We considered, however, in the absence of any qualifying text to the contrary, that consumers were likely to understand the claim “Need help with Dyslexia, ADHD, Dyspraxia or Asperger’s?” to mean that the DORE programme could help treat the named conditions. We also considered that we would need to see robust, scientific evidence to support the claim. We noted that the two studies provided by Dynevor assessed the effect of the exercise-based DORE programme on children with reading difficulties and children and adults with ADHD respectively…
“… As neither the first nor second study referred to Asperger’s syndrome and only two participants in the first study had dyspraxia, we considered that the evidence was inadequate to support claims to treat those conditions. With regards to dyslexia and ADHD, we did not consider that the studies were sufficiently robust to support the treatment claims for those conditions, and we therefore concluded that the claim was misleading…”
The average person would have trouble verifying claims about the role of the cerebellum and the ability of an exercise programme to improve function. If it really was that easy everyone would be using Dore’s exercises. Their claim that dyslexia, dyspraxia, ADD/ADHD and Asperger’s syndrome have one cause, one cure, is insufficient. The conditions they claim to treat are disparate and cause and effect is not established. There was little discussion of how cerebellar function or dysfunction is assessed, or of the relevance of their testing of such things as eye tracking, and no discussion at all of how the exercises impact on the cerebellum or how outcomes are measured. Bishop says:
“The gaping hole in the rationale for the Dore Programme is a lack of evidence that training on motor-coordination can have any influence on higher-level skills mediated by the cerebellum. If training eye-hand co-ordination, motor skill and balance caused generalized cerebellar development, then one should find a low rate of dyslexia and ADHD in children who are good at skateboarding, gymnastics or juggling. Yet several of the celebrity endorsements of the Dore programme come from professional sportspeople.”
There is little real involvement from the company once the programme has commenced, with only a few appointments to follow up after the initial assessment. Many who join the programme don’t apparently have a formal diagnosis of the conditions Dore claims to treat, and they won’t get that from the company, as they state they don’t diagnose anything other than the alleged cerebellar problems.
It’s not surprising that some would see benefits though – the commitment and parental support required to do the programme would alone benefit some children. Then there is regression to the mean, the Hawthorne effect (subjects modify an aspect of their behaviour being experimentally measured simply in response to being studied) and natural improvements with growing maturity. On retesting later, there may appear to be improvements due to the client having done the test before and being aware of what is required. Many would concurrently use other services such as reading recovery, and Dore themselves recommend that if the child has spare time, that it is spent practising reading and writing. That extra practice reading could be extremely beneficial.
The high cost of the programme is concerning, especially when they acknowledge that not everyone will benefit. Despite this, they had parents travelling from the Wellington region to undertake assessments in Auckland – hence the opening of an office in the region. There may also be a financial risk to participants; Dore UK and Australia have both failed, leaving clients out of pocket. In New Zealand Dore was placed in liquidation in 2009 and the Companies Office states: “This Company currently has Liquidators, Receivers or Voluntary Administrators appointed” with the liquidators due to report again in May 2011.
