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Q Over the last one or two years I have beenreceiving many requests from families, and especially occupational therapists,for evaluation and treatment for sensory integration dysfunction. Generally,the patients in question are having problems with learning disabilities,ADD/ADHD, or autism. I have done literature searches and asked pediatricneurologists and developmental pediatricians about this problem, but I amunable to find much besides what's in the occupational therapy literature.Is sensory integration dysfunction a real entity and, if so, how does ageneral pediatrician make the diagnosis? I'd also appreciate your thoughtson therapy for sensory integration, how long it takes to treat, and whatimprovements can be expected.
Sheldon T. Berkowitz, MDMinneapolis, MN
A Between 1965 and 1987, Jean Ayers, an occupationaltherapist, published several papers about her conception of sensory integrationdifficulties. Since that time, most occupational therapists throughout thecountry have seized on these purported scientific studies to develop methodologiesfor dealing with children with all types of behavioral and developmentalproblems, including learning disabilities, ADHD, and autism.
During the past 10 to 15 years, appraisals of the Ayers studies and thetherapeutic implications of this work have appeared in the literature. Thesearticles all come to the same conclusion: Ayers's research does not supporta neurophysiologic or neuropsychologic disorder such as sensory integrativedysfunction. Further, a summary of reviews of therapeutic interventionsbased on Ayers's work found no support for either the diagnostic proceduresor the remedial programs associated with these therapies for children withlearning disabilities or other neurodevelopmental difficulties. The summaryconcluded that sensory integrative therapy was unproven and ineffectiveand could not be considered a remedial treatment for specific learning disabilities,attention disorders, and other childhood problems for which it was used.In spite of these findings (and no new ones that I am aware of), the therapyfor sensory integration dysfunction has flourished. Huge numbers of childrenare referred for this diagnosis and interventions, and many school districtshave taken up sensory integration programs.
Yet numerous occupational and physical therapists do an extremely finejob dealing with children with motor disorders, oral speech difficulties,and other dysfunctions of the central nervous system that have to do withsensory as well as motor difficulties. These therapists can help many childrenwith severe developmental delays, cerebral palsy, and other neurodevelopmentaldifficulties. The problem, as I see it, arises when this therapeutic approachis applied to disorders that have nothing to do with so-called sensory integration.
Thus, in my practice, I support using occupational and physical therapyto deal with some of the pragmatic problems of children with neurodevelopmentaldifficulties. This type of therapy is especially valuable for children whohave writing problems secondary to motor difficulties. I do not supportusing a scientifically invalid form of testing leading to a nondiagnosticcategory to set up interventions for such disorders as learning disabilitiesand ADHD.
Martin Baren, MDOrange, CA
DR. BAREN practices educational, behavioral, and developmental pediatrics.
Q The parents of a 9-year-old are disturbedthat their son's public school says the boy should repeat third grade becausehis reading skills are poor. The parents asked me if they should allow thisor request that the child be advanced to fourth grade but be put in a resourceroom. They worry that their child will be labeled learning impaired. Howshould I advise these parents?
Kim Burlingham, MDWinnsboro, TX
A Parents of this boy are right to be concernedabout the possible consequences of having their child labeled learning disabled.Not only would repeating a grade fail to close the gap between him and childrenof normal achievement, it would likely have serious negative developmentaland psychologic consequences. Before being consigned to repeat a grade,the child needs an educational diagnosis. The parents should request testingto determine the precise cause(s) of the child's reading difficulties. Howthese difficulties are addressed will depend on whether the child has aproblem with word recognition, a deficit in reading comprehension, or alanguage disorder or other developmental aberration. The parents may alsofind it useful to consult with an advocacy organization for the learningdisabled or the National Center for Learning Disability.
Federal regulations are very specific about how school districts mustconduct special education eligibility evaluations. If the child does notmeet the criteria for a reading disabilitydetermined by the size ofthe discrepancy between the child's IQ and achievement scoresthe youngstercan be directed to the school's reading specialist instead of their learningdisability specialist. Other possibilities are resource room help (as theparents suggest), tutoring, and use of high-interest reading materials.Having the child make a practice of explaining to his parents what he hasjust read also can be productive.
Morris Green, MDIndianapolis, IN
DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana UniversitySchool of Medicine, Indianapolis, and a member of the Contemporary PediatricsEditorial Board.
Morris Green. Behavior: Ask the experts.