Controversial Practices: The Need for a Reacculturation of Early Intervention Fields
R. A. McWilliam
As if families didn’t have enough to contend with, the fields designed to help them now include more and more practices that have little research basis, provoke intense debate among professionals, and usually require a disruption of the family’s life. This article explores what makes controversial practices controversial, what some of them are, what makes people adopt them, and what the early intervention field should do now. The purposes of this article are to raise awareness about controversies in the field, to give a few examples, and to present some issues for further debate. I do not claim to provide a comprehensive evaluation of specific treatments or even a comprehensive review of their advantages and disadvantages. The very act of labeling practices as controversial is controversial, because supporters of those practices do not like to have aspersions cast on them. Even the criteria for what makes a practice controversial could spur debate.
WHAT MAKES PRACTICES CONTROVERSIAL?
What makes a practice controversial in any field is worthy of an article itself. In discussing treatment approaches for children with learning disabilities, Silver (1995) considered them controversial if (a) the approach was presented before any studies were available or when pilot studies had not been replicated, (b) the presented treatment went further than the data, or (c) the treatment was used in an isolated way when a multimodal assessment and treatment approach was needed. In this article, I propose five similar criteria for what constitutes a controversy: claims that the practice produces a cure, requirement of practitioner specialization, questionable research, high intensity requirement, and legal action.
Cure Claims
If a practice is claimed to cure a disability that theoretically cannot be cured, it is controversial. Thus, claims that the Lovaas (1987) treatment results in children with autism no longer needing special education and claims that Upledger’s (1978) craniosacral therapy cures cerebral palsy render these practices dubious.
Practitioner Specialization
If a practice requires people who are already specialists to undergo even more specialized training, it is probably controversial. The stipulation that only certain disciples can practice the treatment ensures that the market will be stable and increases the mystique of the practice. Thus, special training for neurodevelopmental therapy, sensory integration, and Lovaas therapy make those treatments abstruse (and their practitioners valuable). Some practices appear to belong to certain disciplines, which hinders the adoption of transdisciplinary approaches to service delivery (see McWilliam & Bailey, 1994). If occupational therapists are the people to call for sensory integration techniques, physical therapists for craniosacral therapy, and speech-language pathologists for Fast ForWord, it is in those practitioners’ interests to vaunt the practices.
Questionable Research
An important link between research and practice is the development of clinical treatment approaches based on theoretical frameworks and scientifically validated findings. This link has historically been tenuous in physical therapy and occupational therapy, according to Darrah and Bartlett (1995). No longer can these fields continue to rely on personal sources of authority rather than scientific knowledge.
When there are no published true experimental studies demonstrating the effectiveness of one treatment (e.g., craniosacral therapy) over other treatments, nothing adequately separates the treatment in question from a placebo effect. Upledger’s (1978) study, showing how craniosacral motion examinations could be used to help diagnose a variety of disorders, was criticized, in a letter to the journal in which his study was published, on the basis of unreliable disorder definitions and unreliable cranial rhythmic measures (Steiner, 1979). One of the arguments for labeling practices as controversial, therefore, concerns the validity of the research to prove effectiveness (Rogers & Witt, 1997).
It should be noted, however, that most studies could be criticized on methodological grounds. If readers or reviewers really do not like the findings, they can always question the quality of a study. Similarly, if they like the findings (i.e., they agree with the theory, or they have been acculturated to accept the practice), they may overlook methodological flaws.
Matthews (1988) noted that many of the treatments for the management of cerebral palsy were developed first from clinical observation; later, a theoretical framework was forged to account for the feasible neurological and physiological principles. Rogers and Witt (1997) suggested that qualitative research could provide an understanding of how and why craniosacral therapy might help a child, but we still need controlled single-subject studies and randomized clinical trials to provide outcome support for the practice. It is imperative that readers, researchers, and reviewers become well versed in yardsticks of good qualitative research so as not to confuse unanalyzed opinions and anecdotes with qualitative investigation.
Intensity
Intense treatment appeals to parents and professionals, if not to administrators. The more-is-better phenomenon has been identified as a theme in studies about service utilization (McWilliam, Tocci, & Harbin, 1995) and service integration (McWilliam, Young, & Harville, 1996). This apparently explains the appeal of therapy services as a whole, with early intervention teams planning for therapy on the basis of the child’s diagnosis rather than as a support to meeting functional goals (McWilliam et al., 1996). Thus, any therapeutic practices can become controversial when they are described as needing to occur for a certain amount of time per week. Families are likely to think that doubling that amount of time, whatever its duration, would increase the likelihood of the therapy being effective with their child. This is particularly likely if the therapy has also promised a cure.
The Lovaas (1987) program, although very popular with parents, has not been embraced as enthusiastically by all professionals in the field. The Lovaas treatment features the systematic application of contingencies to reinforce desired behaviors; this is known as applied behavior analysis. The analysis refers to the careful collection and graphing of data, which is an important aspect of the intervention. The reason for professional skepticism might be twofold. First, it is an educational rather than a therapeutic practice (therefore having less mystique). Professionals, especially special educators, can examine the treatment and determine for themselves whether 40 hours a week is unnecessary. This is the second reason for skepticism: The time required is excessive. Professionals might advocate greater intensity for other treatments in early intervention–but that would be for fewer than 5 hours a week. Thus, familiarity and excess might explain why professionals are not as enthusiastic about the intensity of the Lovaas program. Lest this seem like professionals are entirely justified in their disaffection, it is remarkable how seldom behavior analysis–at any intensity–appears to be implemented. Professionals’ skepticism would be more credible if they used more systematic instruction, at whatever rate (see Strain et al., 1992).
The problem with intensive treatments for many early intervention programs (and for states) is the associated costs. As soon as parents, sometimes in collusion with professionals, want a costly service, a dispute (i.e., a controversy} is likely to arise about its necessity and effectiveness. When parents sense that administrators or state officials are balking at providing a service because of its cost, they don’t know whether to trust what they hear about that treatment. This has been at the root of many lawsuits in early childhood special education. Groups that deliberately encourage families to sue school systems and states are capitalizing on this distrust.
Legal Action
The Lovaas controversy continues to be instructive about what makes a practice controversial with regard to legal action. Almost by definition, as soon as the merits of a practice are debated in court, it is controversial.
If a practice meets one of these five criteria–cure claims, practitioner specialization, questionable research, intensity, or legal action–it is likely to be controversial in early intervention. If it meets more than one criterion, which often happens (each criterion tends to lead to others), it almost certainly qualifies as a controversy. Ultimately, however, controversy begins when someone casts aspersions on a practice that others are promoting. It is not simply a question of whether the practice is good or bad. Controversy arises when people react to practices. Hence, I have considered evaluative reviews of research as well as the primary sources themselves.
SOME CONTROVERSIAL TREATMENTS
The decision about what to include in the list of controversial treatments might itself be controversial. Advocates for treatments mentioned in this article may argue that their treatments are effective and, therefore, should not be controversial. Others might argue that treatments they dislike should have been included. The treatments I include here do not constitute an exhaustive list; they merely represent some that generate arguments in state-level corridors, Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP) meetings, or professional conferences.
Controversial treatments in early intervention can be grouped into the following three broad areas: medical, educational, and therapeutic. I hesitate to separate the last two, because I don’t want to exacerbate the already insidious problem of discipline overspecialization (McWilliam, 1996; McWilliam et al., 1996; McWilliam & Sekerak, 1995). Nevertheless, the roots of the treatments I discuss are in the specific disciplines, and, therefore, anything we do about the controversies needs to be addressed accordingly. Medical controversies are addressed relatively superficially, because most readers of this journal will have more to do with educational and therapeutic treatments.
Medical
Alternative therapies are becoming of great interest in the medical field. National surveys confirm that there has been a statistically significant increase in the percentage of the population using alternative medicine between 1990 and 1997 (Eisenberg et al., 1998). The therapies with the most increased usage were herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. Using my proposed criteria for controversial treatments, these approaches are controversial primarily because of cure claims and questionable research. The medical profession’s penchant for seeking a cure is reflected in medical early intervention practices. Although medical research is often guided by methodological rigor (e.g., double-blind clinical trials), the theoretical rationale or causal implications are not always convincing. For example, we sometimes learn that group differences are found but cannot infer that the treatment accounted for these differences. Medical practices that have been considered controversial in early intervention include diets, surgical procedures, and drug treatments.
Diet. Vitamin supplementation has been proposed for numerous behavioral and cognitive disorders in children with mental retardation. A review of the literature has shown that vitamin [B.sub.6] was ineffective in treating children with Down syndrome, folic acid treatment had very limited effects on some children with fragile X syndrome, megadose multivitamin supplements have not been effective with cognitive disorders or attention-deficit disorders, and multivitamins and minerals have not been effective with Down syndrome or other forms of mental retardation (Kozlowski, 1992). To judge the efficacy of diets requires an examination of the primary sources (i.e., the original studies), but the controversy has arisen because of people’s interpretations of the pros and cons of a practice. Therefore, this article relies on both primary and secondary sources.
Much of the controversy with early intervention treatments is based on the belief that, if a little is good, more must be better (Haslam, 1992; McWilliam et al., 1996). Megavitamin therapy has been defined as “treatment with quantities of one or more times the recommended dietary allowance” (Haslam, p. 303). Haslam conducted a clinical trial comparing 41 children diagnosed with attention-deficit/hyperactivity disorder with a control group of 75 children. The two groups did not differ in teacher, mother, and father behavioral ratings of the child. Other dietary treatments generating controversy have included sugar reduction to control behavior and macrobiotics for overall (including developmental) well-being. The dietary practices mentioned here are only a sampling of the treatments suggested in early intervention. They are controversial, according to the criteria proposed in this article, because the research is questionable. The link between the diet and the conditions that the diet is designed to cure or ameliorate is often tenuous. It could also be argued that dietary approaches are controversial because practitioners have to be specialized (i.e., nutritionists).
Surgery. Because of their invasiveness, surgical procedures tend to generate controversy. One neurosurgical treatment is dorsal rhizotomy for spasticity. Peacock, Arens, and Berman (1987) developed a method of stimulating rootlets to produce sustained muscle contraction or spread, resulting in reduced spasticity and significant gains in some children. The major concern is that more effectiveness evidence, acceptable protections, and selection parameters are needed before the technique is widely used (Matthews, 1988). Another fairly common surgical procedure that is not totally accepted is cutting the tight heel cords.
Perhaps the most controversial surgical procedure is plastic surgery for children with Down syndrome. This is controversial because elimination of one of the defining characteristics of the syndrome, facial features, can be construed as denial and lack of acceptance. Cochlear implants have generated a similar controversy; some members of the Deaf culture have declared the surgical implant to be a repudiation of the person’s innate culture. They maintain that professionals with hearing are convincing parents of deaf children to agree to the implants. The examples of cosmetic surgery and cochlear implants introduce the element of cultural values to the controversy of a practice. Surgery is therefore controversial because procedures involve cure claims and, in some cases (e.g., rootlet stimulation), because the research is questionable (see Note).
Drugs. Few medications elicit such strong reactions as Ritalin, because many people feel that it is over-prescribed and overdemanded. Ritalin is a stimulant that helps children with attention-deficit disorder with or without hyperactivity to focus, thus causing hyperactive children to calm down. Some suggested alternatives, such as craniosacral therapy, biofeedback, traditional Chinese medicine, homeopathy, the Feingold diet, and minerals (see “Alternatives,” 1998), are no less controversial. The main controversy about Ritalin is that it might be prescribed too quickly, before less invasive (i.e., nonmedical) practices, such as behavior modification, have been adequately tried. Parents and teachers have been criticized for jumping on the Ritalin bandwagon. The effectiveness of Ritalin with many children is well documented, which is one reason for its popularity. Documentation alone does not, however, make a practice popular. Adding to the controversy about Ritalin is the fact that the manufacturer has subsidized the largest parent support group for children with attention-deficit disorder.
Another drug practice that is becoming increasingly controversial is the prescription of Prozac for children with autism. One controversial aspect of these drug treatments is that they are largely prescribed for disabilities for which many cures are sought and submitted: attention-deficit disorder, hyperactivity, learning disabilities, and autism. Wherever these disabilities are found, so are all kinds of practices. Drugs are controversial, according to the criteria used in this article, because of cure claims and questionable research.
Educational
Educational practices tend to be controversial because of all the criteria listed earlier: cure claims, practitioner specialization, questionable research, intensity, or legal action. In special education, two practices have generated enormous controversy in the United States: intensive applied behavior analysis and facilitated communication. In early intervention and early childhood special education in the United States, there has been some debate about developmentally appropriate practice. We also need to be aware, however, of conductive education, a Hungarian program sure to generate argument once it becomes better known in this country.
Lovaas Approach to Autism Treatment. Nothing approaches the controversy of intensive behavioral therapy for the treatment of autism, and Lovaas therapy is the most controversial of all. The program calls for 40 hours a week of one-on-one therapy provided by specially trained personnel and by the parents. It is, therefore, very costly, which partly explains the enormous debate it has generated. Estimates of the cost have ranged from $12,000 to $22,000 a year (“Requests,” 1995). Because of the costs, litigation has ensued, with some cases (e.g., Delaware County Intermediate Unit v. Martin and Melinda K., 1995) ruling in favor of parents demanding Lovaas therapy and others (e.g., Fair[ax County Public Schools, 1995) ruling in favor of schools’ alternatives to Lovaas therapy. This program has been substantiated by studies examining the short- and long-term outcomes for children with autism (Lovaas, 1987; McEachin, Smith, & Lovaas, 1993). By 7 years of age, 19 children who had received a very intensive behavioral intervention as preschoolers achieved less restrictive school placements and higher IQs than did a control group of 19 similar children who had received less intensive intervention (McEachin et al., 1993). At age 13 for the experimental group and age 10 for the control group, the gains of the experimental group had been maintained. The 9 children in the experimental group who had achieved the best outcomes received intensive evaluations that showed them to be indistinguishable in intelligence and adaptive behavior from typically developing children. Schopler and his colleagues (Campbell, Schopler, Cueva, & Hallin, 1996) have criticized Lovaas’s research methods for using placement in a mainstream program as an outcome, which says more about the school’s philosophy than about the treatment’s efficacy. An important consideration, however, is that the autism controversy often pits Lovaas therapy against the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) program, which is Schopler’s creation. Ironically, the TEACCH program is also extremely structured.
Wolery (1997) has thrown common sense into the autism debate with four notions about children with autism. First, children with autism are children, and there are few, if any, autism-specific educational practices. Second, children with autism grow up, and we ought to maintain a longitudinal perspective, because the reversibility of human behavior is a well-established fact. Third, children with autism have families who must be intimately involved in making decisions about what to teach their children and about their involvement in instructional activities. Fourth, children with autism live in communities, and the curriculum–even at the preschool level–should be community referenced. Wolery’s points are related to education placement and services; these four points demonstrate that children need vital learning environments with many supports. They also demonstrate the tragedy of the current autism controversy, which assumes that there are autism-specific practices, that certain practices absolutely must be employed in the preschool years, that parents need to become teachers as well as parents, and that special settings are necessary. The Lovaas approach is, therefore, controversial because claims of recovering from autism have been made (e.g., Maurice, 1993), specially trained practitioners are needed, an extremely intensive regimen is required, and parents and states have gone to court to demand or repudiate–respectively–this particular treatment. It should be noted that, although practitioners of the Lovaas approach need specialized training, the requirements are not as demanding as the requirements for some other controversial practices. Most special education teachers, for example, can be trained to administer the Lovaas approach.
Conductive Education. Conductive education has not yet caught on in the United States, but it has become very popular in parts of Europe. It is an approach for people with motor disabilities caused by damage to the central nervous system, and it involves active learning. It was developed by Andras Peto in Hungary in the 1940s (see Kozma & Balogh, 1995), who believed that a child could learn even if challenged by his or her disability (usually what we would call cerebral palsy). The key to conductive education is the conductor–that is, the interventionist. Kozma and Balogh–who are the director general and associate director general of the Pet/5 Andras Institute for Conductive Education of the Motor Disabled and Conductors’ College–described conductive education as the development of personality, not a therapy. Supposedly, the treatment is integrated into family routines and prevents disruptions in families’ lives. Children are taught to perform the following age-appropriate skills, regardless of their “motor dysfunctions”: changing position, task series, speech, self-help skills, successful actions, and preparation for kindergarten.
The treatment itself revolves around the two basic meanings of conductive education: (a) orchestration by the conductor who has had special education training and combines the skills of occupational, physical, and speech-language therapists; and (b) an emphasis on the child’s completing an action once it has been initiated (see Spivack, 1995). Conductive education has been described as a classroom-based approach, in which rhythmic intention (children being taught sing-song rhymes to accompany their intended actions–the actions the conductor wants them to intend) is a primary teaching principle. Other characteristics of the approach are that the conductor deliberately plans to motivate the children and that the children learn in groups. Research on conductive education has been scant, with very few children but with data subjected to statistical analyses (Bairstow, Cochrane, & Hur, 1993; Russell, 1994; Weber & Rochel, 1992). An evaluation of German and British studies concluded that neither the most hopeful expectations nor the worst apprehensions about conductive education were confirmed. Notably, Spivack reported that efficacy studies have been tried in his own conductive education center in the United States (in Brooklyn, NY), “but the most dramatic are the personal reports from parents and children after leaving the program” (p. 84). One of the claimed advantages of the model is that the conductor takes the majority of the work away from highly paid physical and occupational therapists, who are used mostly as evaluators. One problem for the New York center is that state agencies do not endorse conductors as a separate professional program; conductors must have masters’ degrees in special education.
Conductive education has been embraced by some factions in the United Kingdom, as a result of British families who had been to Hungary and returned with success stories. It is well known in Britain that parents have played an important role in pushing for the method’s use (Taylor & Emery, 1995). Using the proposed criteria, conductive education qualifies for controversy because specially trained practitioners (not to mention special schools) are required, the research is questionable, and the treatment is very intensive. It is also controversial because it breaches American values about remediation of children with cerebral palsy (it doesn’t even acknowledge that diagnostic label because of its finality), it pits conductors against allied health practitioners, and it violates American values about child initiation in interactions.
Facilitated Communication. One of the most controversial treatments for children with disabilities has been facilitated communication. It has been tried with children with autism and other significant communication and behavior disorders. The approach consists of a child’s typing answers to questions while receiving hand-over-hand assistance from an adult. Witnesses have been amazed to see users pressing keys without even looking at the keyboard or having their hands anchored on the keyboard (e.g., beginning with index fingers on the F and J keys). Meanwhile, however, the facilitator is watching the keyboard. The evidence in support of facilitated communication has been equivocal. As with many controversial practices, much of the research has been conducted by the developer of the practice. In the case of facilitated communication, that person has been Biklen (1990, 1992, 1993; Biklen & Schubert, 1991). In a study by others, several participants were able to complete simple set work and related responses to requests and questions when the facilitators knew the answers (Simpson & Myles, 1995). On the other hand, when the facilitators did not know the answers, the students were unable to respond correctly. The controversy of facilitated communication first arose because of wild statements that the users supposedly made, including accusations of abuse by their parents. Using the proposed criteria for controversy, however, this practice is controversial because of questionable research.
Developmentally Appropriate Practice. The effectiveness of developmentally appropriate practice (DAP; Bredekamp, 1987) has been deliberated in numerous articles in Topics in Early Childhood Special Education (e.g., Carta, Schwartz, Atwater, & McConnell, 1991; Johnson & Johnson, 1992; Mahoney, Robinson, & Powell, 1992; Mallory, 1992), including the last time controversies were deliberately addressed in this journal. Because these articles are easily available, I will not dwell on the arguments here. Suffice it to say that the original concept of the practice as defined by the National Association for the Education of Young Children (see Bredekamp) appeared to offer too little structure for actual instruction to occur. Some early childhood special educators thought that specific instruction was necessary especially for children with disabilities. Over time, and in collaboration with early interventionists (Wolery, Strain, & Bailey, 1996), the National Association for the Education of Young Children has clarified or actually modified its position on instruction to allow for the possibility of systematic instruction within the framework of developmentally appropriate practice. The controversy of DAP arose first because it was presented as an alternative to the status quo–as the approach that would be most consistent with the values of normalization and inclusion. It was presented as a replacement for behavioral practices, which were deemed too unnatural. Unfortunately for the proponents of DAP, however, they were trying to replace a well-researched approach with a poorly researched one. DAP is controversial because of the questionable research criterion.
Therapeutic
The allied health fields are particularly prone to controversial practices. What they do is less familiar to everyday parents and professionals, so some practices become widely adopted with little questioning. I describe a number of treatments, ranging from prevalent ones such as sensory integration therapy to little known ones such as Fast ForWord. The list at the end of this section indicates the huge number of practices potentially bewildering to early intervention teams.
Sensory Integration. Perhaps the most pervasive controversial practice in early intervention is sensory integration. The fact that many professionals and parents will wonder what is controversial about it indicates how well accepted it has become in the field, particularly among occupational therapists. Yet, the claim that sensory integration is effective has not been substantiated by empirical studies (e.g., Matthews, 1988).
Sensory integration (SI) is both a theory and a practice. It is based on the work of Ayres (1972a), who theorized that sensory input from motor movement and touch provides feedback to the integration process occurring at different levels of the nervous system. The treatment emphasizes tactile and vestibular stimulation of motor and sensory input. Ayres claimed that improvement in sensorimotor integration would result in improvement in motor skills, academic achievements, language abilities, and emotional tone. Most studies with reasonable guards against threats to internal validity have borne out the first claim–to a degree (e.g., Montgomery & Richter, 1977; Ottenbacher, 1982). Some research has supported the claim of improved motor and academic functioning of children with learning disabilities (e.g., Ottenbacher’s meta-analysis). Serious methodological problems exist with most SI studies, however. None of them included an examination of the effectiveness of SI in relation to other therapies; they did not control for the heterogeneity of the participant groups; the studies conducted by Ayres (e.g., 1972b, 1978) and many of the studies reviewed by Ottenbacher employed inadequate sampling and matching procedures and failed to control for a placebo effect.
In a review of seven studies involving children with both a learning disability and a diagnosed “sensory integration dysfunction” and at least one comparison group with random assignment to groups, each study was reported to show improvement on both academic and motor variables over time regardless of the treatment. One study showed that academic tutoring seemed to influence the motor skills of children with learning disabilities (Wilson, Kaplan, Fellowes, Gruchy, & Faris, 1992). Other authors (e.g., Kavale & Mattson, 1983) have speculated that much of the improvement seen in SI treatment research and in research involving other forms of therapy might be the result of the extra attention that these children received. Unfortunately, this potential variable has not been isolated and studied. In general, the many studies purporting to show the effectiveness of SI are highly unconvincing when held under reasonable scrutiny (see Arendt, MacLean, & Baumeister, 1988). This is especially worrisome given the popularity of SI with families who have a child with Fragile X syndrome. Although the effectiveness of the practice with these particular children has not yet been documented, research showing positive outcomes in people with mental retardation (some of whom we can assume had Fragile X syndrome) could easily be explained by alternative theories. The conceptual foundation of sensory integration therapy has been seriously discredited (see Arendt et al.). For example, one popular aspect of sensory integration is the diagnosis of tactile or sensory defensiveness, which is typically treated with brushing programs, oral-motor stimulation, and a “sensory diet” (Wilbarger & Wilbarger, 1991). In a randomized study, no group differences could be detected on any measure between children with learning disabilities who received sensory integration therapy and those who received perceptual-motor therapy (Polatajko, Law, Miller, Schaffer, & Macnab, 1991). A subsequent study did find that children receiving perceptual-motor therapy showed more gains, especially in gross motor performance, than groups receiving either sensory integration therapy or no therapy (Humphries, Wright, Snider, & McDougall, 1992). The SI group did show more gains in motor planning. Despite the widespread adoption of sensory integration practices, the theory supporting SI is poorly defined, and efficacy research is practically nonexistent. Sensory integration and its associated techniques are controversial because the claims exceed what they logically or empirically can treat, because specialized practitioners are needed, and because the research in support of SI is highly questionable.
Patterning. Perhaps the most controversial treatment in early intervention has been the Doman-Delacato patterning approach for children with cerebral palsy (American Academy of Pediatrics, 1982), in which a set of exercises mimicking locomotion states of animals was repeated throughout the day. The idea was to establish cerebral dominance and normalization of function by unlocking reflexes and by positioning. The research base for this approach was sketchy at best, but the controversy was primarily provoked by the intensity of the treatment. The developers of patterning claimed that it only worked with many hours of application every day. Families therefore had to recruit a small army of volunteers to help them with this intensive treatment. The cost to families, and their feelings of guilt about what their child had to endure, eventually caught up with many of them. The approach also stressed the resources of agencies serving children with cerebral palsy. At the same time, many parents developed a strong belief that this was the right and the only treatment for their child. These characteristics are disturbingly similar to the situation today with the Lovaas approach to treating children with autism. Yet we appear to have learned little from history. Patterning, according to the criteria used in this article, is controversial because of cure claims, questionable research, and intensity.
Craniosacral Therapy. Whereas sensory integration is the controversial therapy most closely associated with occupational therapy, craniosacral therapy and myofascial release represent the emerging controversies in physical therapy. There are others, but these are likely to generate the most heated debate. Because the two practices overlap, I will discuss only craniosacral therapy.
Craniosacral therapy shares with cranial osteopathy the theoretical belief in cranial bone motion. Craniosacral therapists propose that repeated oscillations in cerebrospinal fluid pressure cause rhythmic motion of the cranial bones and sacrum–the craniosacral rhythm. By putting careful pressure on the cranial bones, they manipulate this craniosacral rhythm to effect a therapeutic outcome in their patients. Although cranial bone motion has been embraced by a number of physical therapists, some are skeptical and consider the approach controversial (see Rogers & Witt, 1997). Conventional physiologists do not conceive of the cranial sutures as playing any significant role in this intervention, which is focused on a belief that unfused sutures can move throughout life. Efficacy studies have been reported to contain inadequate information and have often been conducted by colleagues of John Upledger, the founder of this approach (e.g., Retzlaff, Jones, Mitchell, Upledger, & Walsh, 1982; Retzlaff, Micheal, Roppel, & Mitchell, 1976; Retzlaff, Walsh, Mitchell, & Vredevoogd, 1984). Claims that palpation of the craniosacral rhythm can be reliably measured have been shown to be exaggerated when subjected to statistical analysis (Wirth-Pattullo & Hayes, 1994). Upledger’s (1978) study on the relationship of craniosacral examination findings in grade school children with developmental problems was criticized by a fellow osteopath (Steiner, 1979) as “combining figures derived from personal impressions of motion with uncoordinated personal opinions concerning behavior…. No justifiable conclusions can be drawn from the paper” (p. 386). Upledger (1979) replied, basing much of his defense on low p values associated with low correlations, which could be explained by his high (203) sample size. Questionable research, the fact that only specially trained practitioners can use the method, and cure claims all qualify craniosacral therapy as controversial.
Auditory Integration Training. Guy Berard, a French doctor, developed this approach to speech therapy. It is based on the theory that some people are extremely sensitive to certain sounds, hear distortions of sounds, or hear certain sounds in the normal range that make them uncomfortable. Treatment consists of playing compact disks through a device (which has been banned by the Food and Drug Administration) that amplifies certain sounds and filters others, according to individual needs. Silver (1995) reported that the literature sent by providers of the service was “full of claims of success. Parents are almost made to feel guilty if they do not avail their child (sic) of this treatment. No research supports the theory or claims” (p. S98). In fact, two studies have found reductions in hearing problems as well as improvements in behavior (Rimland & Edelson, 1992, 1994). Nevertheless, controversy about the approach is still widespread (see Berkell, Malgeri, & Streit, 1996). One area of concern is that many unlicensed practitioners are offering auditory integration training (AIT). Other concerns are that AIT’s efficacy for treating people with autism is unclear and that the devices might be unsafe. According to Berkell et al., “there are no published research reports which meet scientific standards to support or refute the validity of AIT as an effective treatment” (p. 70).
Gravel (1994) has expressed grave reservations about AIT, noting that within 4 years of its introduction to the United States it had been used with more than 10,000 children (citing Georgiana Organization, Inc., personal communication). Gravel takes issue with three premises on which AIT is founded. First, auditory distortions are claimed to underlie autism, but there is no scientific support for the idea that auditory distortions as described by Berard exist. Furthermore, no research supports the notion that peripheral distortions exist in people with autism. Second, the claim that AIT “straightens out” the peaks and valleys of the conventional audiogram cannot be substantiated, because variations of [+ or -] dB are normal in conventional audiograms and need not be eliminated. Third, the claim that AIT is a safe procedure does not convince many speech-language pathologists and audiologists, because there are no data to verify that threshold shifts could not occur, especially in young listeners. Using the criteria for controversy presented earlier, AIT qualifies as controversial because of questionable research.
Fast ForWord. Another treatment touted as helping children’s language skills is the Fast ForWord system, a program rooted in how infants hear and how they learn language. Paula Tallal hypothesized that some children might not be able to process fast elements of speech because of a deficit in the rate at which they process information (Tallal & Merzenich, 1997). Preliminary research indicated that these children could discriminate speech syllables that had been modified to emphasize the rapid acoustic elements. The Fast ForWord exercises thus consist of identifying and repeating computer-made speech sounds that are stretched and in which the important acoustic differences are emphasized. According to Tallal, the program can only be provided by a licensed and trained clinician or educator, and it only works when a child performs the exercises daily for 100 to 140 minutes, 5 days a week (information from Scientific Learning Corporation Web site, http://www, fastforword.com). According to the Web site, children make on average 1.5 years of language gains after 4 to 8 weeks of training. Fast ForWord is backed by a corporation with impressive marketing that includes a comprehensive Web site, many publications, and an elaborate conference display booth. This company, recognizing the need for validating a practice that was only introduced in 1997, emphasizes peer-reviewed articles demonstrating the effectiveness of Fast ForWord (e.g., Merzenich et al., 1996; Tallal et al., 1997), and the national field trial preceding its introduction (http://www.scientificlearning.com). This practice qualifies as controversial because specially trained practitioners are needed and because the practice requires intensive application. These two criteria alone may not make a practice controversial, so it is perhaps the newness of Fast ForWord, the remarkable efficacy claims, the polished marketing, and the strangeness of the intervention that qualify it for inclusion in this list.
Neurodevelopmental Therapy. Neurodevelopmental therapy (NDT) has been described as the most widely used method for treating children with cerebral palsy (see Matthews, 1988). This method is based on the premise that cerebral palsy is a disorder of the postural mechanism and that treatment should emphasize normal movement, decrease or increase in muscle tone, and the reduction of abnormal postures. The approach has gone out of fashion as motor learning and dynamic systems theory have replaced it (see Darrah & Bartlett, 1995). At one time, it was de rigueur for early intervention physical therapists and others to be specially trained in NDT. This practice is derived from a neuromaturational perspective of motor development–along with sensory integration (Adams & Snyder, 1998). This perspective holds that, as the nervous system matures, adaptive behavior emerges; therefore, more elaborate behaviors represent higher levels of organization within the central nervous system. Whereas sensory integration is well entrenched in the field, however, NDT is now controversial because many physical therapists have moved away from it. The motor field, especially occupational therapy, presents a confusing message: Although neuromaturational approaches are being criticized, occupational therapists continue to be trained in sensory integration. Practitioners’ gradual rejection of NDT is related to the controversy criterion of practitioner specialization: The very people who were trained in the approach are now eschewing it. Furthermore, the well-conducted research examining NDT has not supported it strongly.
This concludes the discussion of certain, somewhat arbitrarily selected, controversial practices. Even though many practices were discussed, these are not the only ones. Parents and practitioners are faced with even more options rife with controversy. To illustrate the extent of these controversial treatments, I am listing some others, although it is beyond the scope of this article to discuss them. It might be useful for readers to be aware that, if someone suggests applying one of these treatments, it is worth investigating whether cures are claimed, whether practitioners have to be specially trained, whether the research is solid, whether the treatment is very intense, or whether legal action has ensued (the five controversy criteria). In no particular order, other controversial practices are relaxation and biofeedback for children with cerebral palsy, functional electrical stimulation and epidural electrical stimulation over the dorsal column (Matthews, 1988), optometric visual training (eye exercises) for children with learning disabilities, cerebellar-vestibular dysfunction (antimotion sickness medication to treat dyslexia), applied kinesiology (manipulation of the sphenoid and temporal bones in the cranium), tinted lenses (also known as Irlen lenses, claiming to help people with reading problems who have scotopic sensitivity syndrome; Silver, 1995), the Snoezelen experience (using intensive sensory experiences to diagnose and treat children with severe learning disabilities; Whitaker, 1994), myofascial release (similar to craniosacral therapy but involving release of cerebrospinal fluid), articulation therapy (controversial because it is exceedingly common and unquestioned in application with children who are not yet developmentally able to articulate well), auditory enhancement (increasing volume through amplification to improve concentration), acupressure (for motor improvement, based on Chinese acupuncture theory), oral-motor strategies (noncontingent stimulation similar in theory to sensory integration techniques–and almost equally unquestioned by practitioners), and chiropractic treatment (historically controversial as an alternative to orthopedic medicine or physical therapy). Adams and Snyder (1998) provided a thoughtful discussion of options for the treatment of cerebral palsy. When considering how to help a child, why do professionals and parents sometimes choose these controversial practices over more parsimonious and usually better proven ones?
REASONS FOR ADOPTING UNPROVEN PRACTICES
An area ripe for and desperately warranting research is the cause of professionals’ and parents’ adopting unproven practices. From research on service utilization and integrated therapy (McWilliam & Bailey, 1994; McWilliam et al., 1995, 1996), I speculate as follows:
Proven Practices Are Not Necessarily the Easiest to Implement. For example, techniques for integrating therapeutic elements into a generalist model of service delivery exist, but home visitors and classroom teachers might not be using them because it is easier to stick to educational activities and leave therapy to the specialists.
Some Unproven Practices Reinforce the Specialization of the Professional. To preserve their identity as a valuable service provider, professionals often have a vested interest in letting everyone know that the child needs the particular treatment that only they can provide. For example, if a therapist trained in sensory integration can make the case that the child has “sensory problems,” then that therapist will become invaluable. It is hardly surprising that such therapists might find sensory problems in most children they see.
Professionals Do Not Read the Literature. The bridge from research to practice is weak (Shavelson, 1988), and many proponents of controversial therapies spout sound bite findings that cannot be substantiated by either the actual findings or the quality of the research quoted. For example, sensory integration advocates appear to be unaware of the methodological and conceptual problems with Ayres’s research.
People Only Believe the Research That Supports Their Values. As mentioned earlier, acceptance of research findings depends to a considerable extent on the consumer’s willingness to be influenced.
Professionals Believe What Other Professionals Tell Them. The mystique of controversial practices is related to arcane language, which only certain professionals–those who have received the relevant special training–have mastered. When a specialist, therefore, tells the team that a certain problem exists and that a certain treatment is warranted, the other professionals and parents have little reason to question the suggestion. This is an instance of specialist-to-generalist influence. An instance of specialist-to-specialist influence is the acculturation that exists within disciplines. For example, sensory integration is well established in occupational therapy, even among experts who promote an integrated approach (see Dunn, 1996).
A Parent’s Job Is to Have Hope, and These Practices Offer Hope. Families understandably think that they should accept and fight for any practice that claims to be beneficial for their children. By definition, controversial treatments have pros and cons, and families feel that they cannot afford to ignore the potential advantages. Often the battle is between values and data, and we cannot count on data to win. This point has been made in the context of inclusion (Bailey, McWilliam, Buysse, & Wesley, 1998), which could well have been listed among the educational controversies, particularly for children with sensory impairments and those with autism.
These speculative reasons for the adoption of controversial practices are clearly not exhaustive. To improve early childhood special education and its accompanying disciplines, we should study the factors that lead to the adoption of controversial practices.
WHAT SHOULD THE FIELD DO NOW?
This article has described numerous controversial practices that are currently popular and has alerted readers to others that might gain in popularity. Criteria that make certain treatments controversial have been proposed so that we can more clearly understand the nature of controversy in early intervention. Inherent in the problem is the eagerness of professionals and parents to adopt unproven practices. I have tried to make the case that we are at a point in the evolution of early intervention where we need do something about these practices. Five recommendations are provided.
Evaluate and Summarize the Research
The problems of studying controversial practices are multifaceted. Simply grasping and analyzing the existing research is a big enough endeavor considering the manydisciplines involved. This should probably be accompanied by reviews of research into the development of cultural models related to early intervention practices, to understand better the phenomenon of belief in unproven treatments, especially by professionals.
As mentioned earlier, evaluators of the existing research will need to make careful assessments of the anecdotal evidence that permeates these practices. My own fairly cursory reviews have convinced me that the evidence is typically no more than that–anecdotes. But the proliferation of qualitative research in early intervention necessitates clear demarcations between mere vignettes or simple quotations and true narrative data with sophisticated qualitative analysis. The best vehicle for handling the large task of summarizing and evaluating all this research would be an early childhood research institute funded by the Office of Special Education Programs. This competition has a rich history of funding research on important topics in early intervention.
Conduct Comparative Research
Although an institute to analyze the existing research is necessary to understand the state of the art, the future requires comparative research. On the principle that–despite proponents’ protestations to the contrary–there is no one right way to address a problem, two or more practices should be compared. Methods for conducting such research exist within the statistical, group-design paradigm (see Burchinal, Bailey, & Snyder, 1994) and within the single-subject, applied behavior analysis paradigm (see Wolery, Bailey, & Sugai, 1988).
Legislate Practice Guidelines
Practice guidelines exist to direct teams to appropriate types and levels of service delivery. For example, the State of New York is currently reviewing the appropriate intensity, locations, and personnel for working with children with autism. Although such guidelines have the appearance of removing the autonomy of the individual child’s team, they are designed to provide parameters. The development of such guidelines gives states the opportunity to stop and evaluate many of the practices listed here. Without such a step, teams have blundered ahead with little direction. Although the legal system has been used effectively for ensuring needed services, it has also been used as a tool to force states and communities to provide the practice du jour. Thus, practice guidelines would help decrease the inappropriate use of the courts in determining appropriate practices.
Prepare Expert Witnesses
Because litigation will continue at some level, we need to have experts prepared to speak clearly, concisely, and knowledgeably about the evidence and the costs of these different practices. Court testimony is an unfamiliar art to most researchers, so they will need to be prepared.
Reacculturate the Field About the Role of Specialists
The introduction of more and more controversial practices goes hand in hand with a pernicious slide toward the overspecialization of early intervention (see McWilliam et al., 1996). Currently, early intervention professionals from different disciplines are usually trained separately, both at the preservice and inservice levels, although efforts have been made to bring them together for some courses and activities. As long as specialists continue to think that their role is to provide direct, hands-on therapy, we can expect the advocacy of dubious treatments to continue. When specialists realize that nearly all the intervention occurs between specialists’ visits (i.e., primary caregivers are providing the real intervention in daily routines), we might see common sense prevail.
The two outcomes needed from this reacculturation are a demystification of the field and honesty by practitioners. The more controversial treatments we have, the more esoteric the field appears. This promotes the notion that only highly trained individuals can have positive effects on children. In fact, we need the highly trained individuals to fashion their knowledge to match the daily demands of primary caregivers. When those caregivers are empowered, services will be less expensive, and specialists will be able to have a wider influence. Practitioners need the assurance that their new role as consultants to primary caregivers will be just as valued as their old role as direct healers of children. Research, policy, management, and personnel preparation will need to play a part in this reacculturation.
NOTE
For a good example of discussion of this controversy, see www.deafworldweb.org/chat
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