RECOGNeyes is a computer game that you play using your eyes as the game controller. It has been developed at the University of Nottingham in collaboration with people with ADHD. The game is designed to train people to have better control over their attention.  As you advance in the game, you learn to control different aspects of your visual attention system.

Here is a video providing an overview.

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We organised a PPI group with four members. The goal was to discuss our research plans. By involving patients and members of the public we had the opportunity to get a common sense opinion of what we’re doing from the perspective of those with lived experience. The panel had an opportunity to get to know one another a little before we started. The general consensus was that as a condition ADHD is neglected and often those with the condition are discriminated against. There are few supports available and little understanding of the condition. It was felt that children with ADHD are often labelled as naughty.

Recruitment

To optimise recruitment it was suggested that the research team attempt to identify the potential frustrations and reservations potential participants might have around involvement in the research. Then use this information to inform our recruitment strategy.

It could be useful to get schools interested in participating in the research by saying that we are trying to give something to an under services group, a group that is discriminated against. Also, it might be helpful to highlight that the intervention is something that may help to get children who have been excluded from getting back involved with the mainstream.

It was suggested that ultimately an effective route for the delivery of the intervention would be to have a child’s paediatrician recommend to the child’s school that the pupil receives the training intervention in the school environment. Also, more emphasis could be given to this approach to our recruitment.

There is the danger that by recruiting pupils in schools who might benefit from receiving the training we are also putting a target on them. Some schools may find these same students to be difficult and their involvement in our study could be used to support arguments that would exclude these children from the main stream. Schools that already have special “units” for children with special needs would not have this problem to the same extent. These units are mostly in secondary schools.

It was suggested that we inquire of the parents of potential participants what supports are currently in place at their child’s school.

Completing the training

It was suggested that teachers might find it easier if we stated that pupils should complete 9 school training sessions with 3 per week occurring at the same time of day each time. This approach would fit well with teaching schedules.

It was felt that for younger children completing home training would likely need to be encouraged with parental support. For older children, it was suggested that parental supervision of adherence to a training schedule could be counter-productive. It was felt this supervision could undermine the potential enjoyment of playing the game.

Generally, it was felt that a training schedule and reminder texts would be useful and welcome for home users.

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Changes were made to the RECOGNeyes attention training game based on feedback from a local ADHD support group. We then arranged to provide five local schools with the RECOGNeyes game along with laptops and eye-trackers. These schools are currently providing access for their pupils to RECOGNeyes.

Teachers have been very enthusiastic about using RECOGNeye.  They feel the use of technology in this way has great potential in supporting pupil engagement and learning. Some commented that this was just the kind of thing that was needed and helps to make school fun for children. Teachers felt that the RECOGNeyes game in particular could be a really useful resource in the class room. They felt the novelty of the eye-tracking element would be of great interest to the children.

Teachers were shown how to set up the equipment and start the game. All found this straight forward and within a short period had learnt to set up the equipment, calibrate the eye-tracker and run the training game. Calibration is the process of ensuring the eye-tracker correctly knows where you are looking. Some teachers found it a little frustrating when they performed poorly on the game but it was noted that this was typically due to the system being poorly calibrated. We are currently working on simplifying the calibration process.  Some found the game more difficult than others. We are currently refining the manner in which the difficulty of the game changes in response to the player’s performance and deciding on a reasonable starting difficulty. On the whole the teachers seemed to have had a lot of fun playing the game.

We are now looking forward to feedback from the pupils. Once the pupils have had an opportunity to play the game we will be interested in their feedback about the acceptability, enjoyability, and challenge of the game. For the game to successfully improve attention it is critical that players find it engaging and challenging but not excessively difficult and frustrating. The difficulty of the game should closely match the player’s ability as they improve.  This approach to training is called “scaffolding” as the idea is to the support the trainee as they grow in skill. The feedback the game provides should be informative and help them to understand better how to control their attention system.

When we collect the systems teachers will provide further feedback about the game based on their own experience of using the system. They will let us know how useful they think it might be for their work. We are also interested in how easy they found the technology to use and whether they feel a resource such as this could be readily integrated into their teaching duties.

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Following on from earlier input we were eager to continue to include individuals with ADHD in the collaborative development of the game. Individuals with ADHD have lived experience of the condition and their input is therefore of critical importance for its success as an effective intervention. An overview of the RECOGNeyes game was presented to the Nottingham Adult ADHD Group at their monthly meeting.

Briefly, the rationale behind the training game is that individuals with ADHD have an underdeveloped attention control system. This attention control system is underdeveloped not because they lack capacity but because this ability has not been sufficiently developed. This may be because of differences in how individuals with ADHD learn. RECOGNeyes isolates the underdeveloped attention control system and provides an opportunity to train this system.

Those in attendance at the Nottingham Adult ADHD meeting had an opportunity to play the game. The game is played on a laptop with a small eye-tracker attached below the screen. Players provided us with feedback with respect to acceptability, enjoyability, and challenge.

One of the main themes highlighted by the group was the wide variation in starting ability. The game employs tracking algorithms that change the game difficulty based on performance. However, the group highlighted the need to ensure that the difficulty settings are initially set low to avoid frustration when people first play the game.

Players generally liked the game theme and graphics but highlighted the need to introduce more variability to improve the replay value. Players also made suggested modifications to the game instructions. While the game does contain feedback players wanted a more obvious scoring system. Players additionally helped to identify a number of programming bugs.

The best news, however, was that players did feel that they had to concentrate specific aspects of their attention system in order to succeed at the game. While some players found the game frustrating the majority found it challenging and enjoyable.

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RECOGNeyes is a computer game that you play using your eyes as the game controller. It has been developed at the University of Nottingham in collaboration with people with ADHD. The game is designed to train people to have better control over their attention.  As you advance in the game, you learn to control different aspects of your visual attention system.

The game has been developed as an intervention for training attention in ADHD. However, it may also have wider applications. For instance, it may help people with dyslexia, autism and other conditions in which learning greater control over your direction of gaze could help. Apart from improving attention, it is also a fun challenging game to play. It can be a strange sensation for players at first to have the game play on screen wholly determined by how they move their eyes. The game isolates specific aspects of attention in a unique manner, and it is immediately evident to players that they must carefully control their attention if they wish to succeed.

Two critical aspects of the game that support learning are that:

• Players receive continuous immediate feedback while playing the game
• The difficulty of the game continually changes to match the players current level of performance

We continue to develop the game. We have recently presented the game at a local ADHD group meeting. We have also provided equipment and the game to individuals we ADHD so they can play it in their homes. Currently, local schools are making the game available to pupils. The information we gather in this way will allow us to

• Further develop the game
• Understand the best environment for people to play the game

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The annual conference for the Centre for ADHD and Neurodevelopmental Disorders across the Lifespan was held Friday 5^th of February 2016 at the Institute of Mental Health, University of Nottingham.  The theme of this year’s conference was enhancing understand of ADHD. Due to the kind support of Shire the audience were introduced to their ‘in my shoes’ campaign. The in my shoes campaign is a virtually reality experience and was developed with the help of Professor David Daley from CANDAL.  In the experience participants wear Oculus rift glasses and enter a virtual reality world of three different individuals with ADHD, a young boy during a PE lesson at School, An adolescent girl who is taking an exam at school, and an adult having a challenging day at work.   The experience allows participants to see the world through the eyes of three different patients with ADHD.   This innovative experience aims to help clinicians fully understand what it is like to have ADHD so that they can see the individual behind the disorder.  The experience was a big hit with clinicians, patients and service users and sparked a very useful debate among participants about the contribution the experience could make to enhancing public understanding of ADHD.

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Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in children and adolescents. Young people with ADHD find it hard to sit still and concentrate and often do things without thinking them through; this can make it harder for them to do well at school and get on with friends and family, and they often get into trouble more than other young people.

Methylphenidate (commonly known as Ritalin) is the drug most commonly prescribed to treat ADHD and has been used for over 50 years. A recent review (November 2015) of methylphenidate by the respected Cochrane group provides valuable information about how much it can help, and if there are any problems with it.

The review looked at 185 studies in which young people with ADHD were randomly assigned to a treatment group, usually methylphenidate, or a placebo (something which looks and tastes like methylphenidate but has none of its active ingredients). They found methylphenidate did improve some of the symptoms of ADHD and helped young people to concentrate. The reviewers suggest it can help improve the behaviour and quality of life of young people with ADHD. They found no evidence to suggest methylphenidate increased the risk of serious harm when used for up to six months. However, there was an increased risk of what they describe as non-serious harms. These included sleeping problems or trouble sleeping and decreased appetite.

The authors of the study warn readers about the quality of the evidence which makes it hard to be certain about the extent of the positive benefits. They also raise concerns about the short follow-up period of the studies and the problems of ensuring that researchers do not know which treatment participants have received so results are not. These results are promising, although more research is needed with longer follow-up and high quality trials before we can be certain about the benefits of methylphenidate for the treatment of ADHD.

Find out more about the review here:-

http://www.cochrane.org/CD009885/BEHAV_benefits-and-harms-methylphenidate-children-and-adolescents-attention-deficit-hyperactivity-disorder

Dr Charlotte Beer, Assistant Professor in Behavioural Sciences, CANDAL member

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A few weeks ago, Steve Silberman’s Neurotribes became the first science book to win the prestigious Samuel Johnson prize. In his book, Silberman discusses the change in people’s attitudes towards autism over the years and urges us to refrain from making categorical assumptions about what distinguishes ‘normal’ from ‘abnormal’ behaviour. It is also refreshing to see how Silberman’s theoretical stance makes us realise that if we can understand better the differently-wired autistic brain we can make the world a better place for autism.

Reference:

The Guardian, Monday 2 November 2015; http://www.theguardian.com/books/2015/nov/02/steve-silbermans-neurotribes-is-the-book-families-affected-by-autism-have-long-deserved).

— Dr Elena Nixon, CANDAL Member

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Job opportunities and the employment prospects of young people with neurodevelopmental disorders are poorer than for their peers. This is the conclusion one is led to after reviewing research findings from both the UK and USA. For example Roux and colleagues (see study details below) found only just over half of young adults with an autistic spectrum disorder (ASD) had ever worked for pay outside the home, the lowest rate among disability groups in the USA.

A recent UK study exploring the relationship between Tourette syndrome (TS), tic severity and socioeconomic status found much higher rates of unemployment in a clinic sample of TS patients compared to an age- matched population: 29% compared to 7.5% (see study details below). Moreover, perhaps unsurprisingly, tic severity ratings were highest among unemployed participants compared to those from the highest socioeconomic group.

As a CANDAL team member I was therefore very excited when I stumbled on an item on the BBC website about a new programme they have commissioned. Given the working title “Employ Me” the three part series will follow the stories of unemployed people with what are described as neurological conditions from ASD and TS to Down’s Syndrome. The news item claims that working with Professor Baron-Cohen of the Autism Research Centre at Cambridge University they want to challenge existing conceptions and show people with neurodevelopmental disorders can have strengths as well as disabilities. See the BBC website details below to find out more, keep your eyes open for the programme and we will too!

Dr Charlotte Beer, Assistant Professor in Behavioural Sciences, CANDAL member

Find out more about Employ Me here

http://www.bbc.co.uk/mediacentre/latestnews/2015/employ-me

Roux, A. M., P. T. Shattuck, B. P. Cooper, K. A. Anderson, M. Wagner and S. C. Narendorf “Postsecondary Employment Experiences Among Young Adults With an Autism Spectrum Disorder.” Journal of the American Academy of Child & Adolescent Psychiatry 52(9): 931-939.

Mark, Aldred, Cavanna Andrea E. 2015. “Tourette syndrome and socioeconomic status.” Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology doi:10.1007/s10072-015-2223-0.

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One of the many remits of CANDAL is to train future leaders in Mental Health and Neurodevelopmental  Research. We were were very proud therefore at the recent Nottingham Graduation ceremony to graduate two CANDAL PhD students.

Dr Bethan Davies  PhD thesis was focused on the Development of an online intervention to increase mental health literacy and promote self-management of depression in university students. Dr Davies is now a Post-doctoral researcher within the MindTech Healthcare Technology Cooperative at the Institute of Mental Health, University of Nottingham.

Dr Joanne Tarver’s PhD was focused on exploring the Efficacy of a Self-help Parenting Intervention for Childhood Attention Deficit Hyperactivity Disorder (ADHD) as an adjunct to treatment as usual including Pharmacotherapy. Dr Tarver is now a Post-doctoral researcher at the Institute of Psychiatry, Psychology and Neuroscience, Kings College London.

Drs Davies and Tarver are pictured with their primary PhD supervisors Professor Cris Glazebrook and Professor David Daley

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