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I read with interest "Is sensory integration dysfunction for real?" (Behavior: Ask the experts, May). As a mental health clinician working with emotionally and behaviorally challenged children, I have often noted symptoms that appear to be consistent with the concept of sensory integration dysfunction. Information I've found during literature reviews tends to be clustered into two broad descriptive categories: sensory integration dysfunction and nonverbal learning disorders. These behavioral constellations generally describe problems that are attributed to deficits in the ability to effectively make use of sensory information.
In "Prenatal Cocaine: What's known about outcomes?" (May), the guide for caregivers notes that "some infants who have been exposed to cocaine before birth have difficulty organizing the sensory information they receive." This appears to be evidence in support of sensory integration dysfunction as a working concept.
Kenneth H. Little, MABarre, Vermont
The author replies: I would like to reiterate that I have not stated that sensory integration therapy would not be indicated for some children with signs and symptoms that might go along with some difficulties in the general area supposedly subtended by this "disorder." I also recognize that nonverbal learning disorders have come to the fore recently, and perhaps children who fit into this loosely described category might benefit from some of the therapeutic efforts directed toward these children.
The most important statement that I would like to stand by, however, is that there are really no data proving the validity of either the diagnostic procedures or the remedial programs for children with these types of problems. The diagnostic criteria and tests that have been developed have not shown a substantial statistical significance in differentiating a group of children with this particular disorder. Thus, any therapeutic interventions must certainly be based on imperfect assessments and nonvalid types of testing. This is the main concern that I have in terms of validating a particular therapy for a particular disorder, which really does not exist except in the writings of one particular author published in the past.
I realize this is a very sensitive issue, but since we do not really have a true disorder or syndrome that has been proven by any validity studies, I certainly will hesitate to submit children to therapies based upon a nonvalid diagnostic category. An excellent review of this particular situation was published in the Journal of Learning Disabilities (Cummins RA: Sensory integration and learning disabilities: Ayres' factor analyses reappraised. 1991 Mar;24:160).
In "Preschoolers on Ritalin: An Alarming Increase" (Journal Club, May), Dr. Burke asks what a 3-year-old is learning in preschool that demands enough attention to justify treatment for attention deficit hyperactivity disorder (ADHD) and states that we can almost always hold off on prescribing Ritalin until the child enters first or second grade. I am utterly shocked that Dr. Burke could make such an inappropriate comment. The decision to treat children who have ADHD depends on the degree of impairment in one of three arenas. The first is school or job, the second is home environment, and the third is socially outside the home. Behavior modification should certainly be tried first. However, there are many children for whom behavior modification is not enough.
How could anyone make such a comment without analyzing each case individually? Perhaps Dr. Burke has lost faith in the other pediatricians in the country. The fact is that preschoolers may need stimulant medicine if behavior therapy fails; it may be necessary to protect their own safety, to enable the family to function in social situations, and, in some cases, to actually hold the family together.
Jack F. Trotter, MDTwin Falls, ID
The author replies: Dr. Trotter should rest assured that I continue to have great faith in pediatricians. And I agree with him that evaluation for ADHD requires individual attention to each child, family, home, and school. However, the point of the JAMA article by Zito and her colleagues is that, at least in the three large groups of patients they considered, use of stimulants to treat 2- to 4-year-olds increased two- to threefold between 1991 and 1995 (JAMA 2000;283:1025). Granted, times change, but I am not sure that the increased use is warranted. Did all of these children fail behavior modification? We need to continue to look at our own practices to assure that we don't rush to stimulant use before fully assessing the child, his or her environment, and other options.
Dr. Anderson's article "Co-sleeping: Can we ever put the issue to rest?" (June) only briefly addresses the potential difficulty in terminating the co-sleeping arrangement. Ideally, the parents and child will stop sleeping together by mutual agreement. More often, in my experience, the parents want the child out of the bed before the child chooses to leave. They then employ various methods to encourage the child to sleep on his own, often ending up utilizing the methods of Dr. Ferber that they disdained originally.
I counsel parents that sleep is a learned behavior. Once a child learns to co-sleep it can be difficult and traumatic to change the sleeping arrangements. Proponents of co-sleeping should address this "weaning" process and the family disruptions that can occur.
Bob Wiskind, MDAtlanta, Georgia
Another issue to consider in regard to co-sleeping is a child with or at risk for allergies. After convincing a parent to cover their child's bed mattress and pillowcase with a dust mite barrier cover, the child is then allowed to sleep with the parent, whose bed is usually not covered, thus defeating an important treatment plan. In addition, if the parent has been gardening, for instance, and does not shower before going to bed, the child may be exposed to even more potential allergens. Parents of allergic children who wish to co-sleep should be made aware of these issues.
Lawrence E. Kurlandsky, MDGrand Rapids, MI
Your cover story on co-sleeping was a breath of fresh air. How wonderful to have a major pediatric publication defend families against the intrusions of so-called experts. As a pediatrician, I would be the first to counsel parents against any unsafe practice. But to ignore millions of years of evolution and the example of every mammal and most humans throughout history on the basis of such slender evidence as that presented by the Consumer Product Safety Commission "investigators" is truly shocking.
Thank you for the article. I look forward to the day when we also stop preaching that babies be left to cry in separate rooms so that mothers can be better wage-slaves in the morning.
Omar Ali, MDDhahran, Saudi Arabia
The author replies: I appreciate the comments of Drs. Wiskind, Kurlandsky, and Ali. My intention was to present medical information that could be used by pediatricians and parents to help infants sleep safely, and so I did not address other sleep issues that might arise when co-sleeping is terminated. Parents do often choose to change the family's sleeping arrangements, so I agree with Dr. Wiskind that this should be a part of the conversation with parents. In the article I state that sleep patterns are usually set by 6 months of age, and so families should be encouraged to think through how long they desire to co-sleep prior to this time. Many families find the child normally "weans" from co-sleeping when there is another sibling to share a bedroom. For families experiencing difficulty with the "weaning" process, a "gradual withdrawal" is often a helpful method. The child can be moved to a futon or mattress next to the parents' bed, and then gradually moved farther away until the child is sleeping where the parents desire.
Dr. Kurlandsky raises a very thoughtful concern regarding children's exposures to allergens while in the parental bed. I would agree that parents should pay specific attention to their sleeping environment if allergies are present.
As pediatricians, we do need to assure that the sleeping environment is a safe one for infants and children, while incorporating the family's culture and values.
Jane E. Anderson, MDSan Francisco, CA
Julia McMillan. Letters. Contemporary Pediatrics 2000;11:21.