Controversial Therapies for Specific Learning Disorders: A review of the literature

Clinical Psychological practice is grounded in the principles of the Scientist-Practitioner model (Page & Stritzke, 2006). This paradigm provides a framework for training practitioners who  create a synergy between scientific research and practice (O'Gorman, 2001). The foundations of the Scientist-Practitioner model rest of three tenets, asserting that practitioners must be "consumers... evaluators... (and) producers" of research (Page & Stritzke, 2006, p. 2). An essential element of this assertion is that Clinical Psychologists should readily access and critically evaluate research in order to select, recommend and advise their clients regarding evidence-based best practice. This is a crucial reminder that treatment options should not be taken at face value and that availability alone of an intervention should not dictate the implementation of such treatments. Instead, treatment choice should be driven by methodologically sound and rigorously validated research findings. Childhood learning disorders is one area in particular where a number of therapies, with controversial research support, are readily available (Kurtz, 2008, p. 12). These children and their families are particularly vulnerable to unfounded promises of quick fixes, emphasising the role of the Clinical Psychologist in guiding treatment selection (Silver, 1995). Irlen Lenses, Psychomotor Patterning and Sensory Integration Therapy are three such examples of controversial therapies (Pennington, 2009, p. 264). The current paper will briefly review the literature available on these three therapies and will provide a critique.  

 

Irlen Lenses  

Irlen Lenses were developed by Helen Irlen as a treatment for a reading condition coined "Scotopic Sensitivity" or "Irlen Syndrome" (Irlen, 1983).While a thorough investigation of the validity of Irlen Syndrome as a diagnosis is beyond the scope of this paper it should be noted that many question the scientific rigour of the disorder itself and how it is measured (Jacobson, Foxx, & Mulick, 2005, p. 178; Pennington, 2009, p. 274). The condition is believed to be grounded in visual perception difficulties causing reading deficiencies (Kurtz, 2008, p. 58). It is hypothesised that the subgroup of children with reading difficulties affected by Irlen Syndrome can be assisted by utilising specially designed coloured lenses or overlays when reading. It is believed that the individually matched coloured lenses/overlays make reading individual words less arduous and tiresome by neutralising the perceptual difficulties associated with the condition, increasing fluency. It is then expected that an increase in fluency will come with the added benefit of improved comprehension (Kurtz, 2008, p. 58). This theoretical position is in stark contrast to the myriad of scientific knowledge available on the subject of reading disorders. The vast majority of cases place developmental dyslexia as primarily a deficit characterised by phonological weaknesses, not visual difficulties (Pennington, 2009, p. 59).

            Interestingly the popularity of Irlen Lenses quickly spread, after the theory was introduced at the 91st Annual Convention of the American Psychological Association, even though independent validity for the treatment had not been established (Irlen, 1983; Pennington, 2009, p. 274).  Further, Irlen's (1983) own tenet, that coloured lenses would only be effective with a subset of dyslexics, was largely ignored by the professional community and coloured lenses/overlays were promptly established as a broad-spectrum treatment for reading disorders (Irlen, 1983; Pennington, 2009, p. 274). Such conflict is also inherent in the published literature investigating the efficacy of lenses as a treatment (Jacobson, et al., 2005, p. 178).

            At a glance, early research investigating the effectiveness of coloured lenses as a treatment was promising (Cardinal, Griffin, & Christenson, 1993; Robinson, 1994; Robinson & Conway, 1990, 1994; Whiting, Robinson, & Parrot, 1994).  The various studies asserted findings such that participants experienced reductions in print distortion, increased reading rates and improved academic attitude/motivation.  However reading accuracy was not consistently improved (Robinson & Conway, 1990, 1994). While the results appeared quite hopeful the validity of the findings have since been questioned due to several ethical and methodological flaws (Bowd & O’Sullivan, 2004). Concerns have been raised regarding the heterogeneity of the samples used, ineffective masking/blinding, researcher bias/financial interests, selection bias, lack of controls and underestimation of placebo effects (Menacker, Breton, Breton, Radcliffe, & Gole, 1993 ). Studies with increased methodological integrity have supported this contention, contradicting the positive findings and indicating no change in rate, accuracy or comprehension when using coloured lenses (Gole et al., 1989). More recent studies continue this pattern of inconsistent findings. For instance Solan, Ficarra, Brannan and Rucker (1998) found increased reading rates while using coloured overlays while others researchers found now such evidence (Christenson, Griffin, & Taylor, 2001).

            Overall there has been a large amount of literature published on the subject of the effectiveness of Irlen Lenses however the majority of these studies are case study or self-report data, which are not subject to peer-reviewed rigour (Jacobson, et al., 2005, p. 178). Increasing focus has been placed on addressing the above mentioned methodological weaknesses, decreasing the subjectivity of the findings by utilising controlled studies and submitting to the peer-review process for empirical validation (Noblea, Ortonb, Irlenc, & Robinsond, 2004). While such approaches are improvements on early studies they are not without their flaws. One recent study found that immediate increases in reading abilities were gained by utilising coloured overlays however these improvements met a plateau after 3 months of use (Noblea, et al., 2004). Again at a glance these improvements appear noteworthy, as the study utilised a waitlist control for comparison, yet there are weaknesses inherent in the study's design. For instance, the waitlist was not an active control group so treatment improvements cannot be ruled out as a placebo, increasing motivation and engagement of participants using overlays due to an expectancy bias. More importantly this particular study excluded participants with weaknesses in phonological decoding skills, noting that such weaknesses need to be addressed primarily before coloured interventions can be of assistance. In essence the study  removed a large proportion of children likely to have a reading disorder (i.e. those with phonological deficits) and may have merely provided a placebo to a group of weaker readers. The resulting increased engagement in reading may account for the increase in skills observed.

            One major weakness of studies investigating Irlen Lenses has been pre-selection of participants who have shown a response to treatment and a lack of masking knowledge of their prescription colour (Ritchie, Sala, & McIntosh, 2011). This weaknesses was addressed in a recent investigation by utilising a blinded within and between subjects design (Ritchie, et al., 2011). Children were not informed if diagnosed or what their prescribed colour was if they had one. Each participant was administered reading tasks with various overlays and without. No differences were identified between or within subjects across the various conditions, indicating that when expectancy is controlled for, through masking, the effects of coloured therapies are negligible. This supports the notion that Irlen Lenses are a placebo and there is increasing evidence in support of this assertion (Bowd & O’Sullivan, 2004).   

 

Psychomotor Patterning

The "Doman-Delacato" method or "Psychomotor Patterning" is a treatment for neurological and intellectual conditions developed by Educational Psychologist Carl Delacato and Physical Therapist Glenn Doman in the 1960's (Kurtz, 2008). The theoretical underpinnings of Patterning are based on the belief that intellectual disability and learning difficulties are a result of neurological disorganisation caused by a failure to progress through the normal developmental stages of movement (Pennington, 2009, p. 276). It is asserted that revisiting earlier stages (e.g. crawling) and practicing them repeatedly  over long periods assists with neurological reorganisation and  the progression of developmental milestones (Jacobson, et al., 2005, p. 67). It is at the basis of these theoretical foundations that the paradigm begins to come unstuck. In essence, the treatment claims to alter the structure and functioning of the brain through repetitive body movements however these principles are noted to be unfounded and inconsistent with contemporary views of neurological development (American Academy of Pediatrics, 1999; Silver, 1995).

            Further difficulties arise when the nature of the treatment program is examined.  Treatment is rather time-consuming and requires repetition over long periods of time, often upward of months or even years (Novella, 2008). As a result developmental progression will continue in most intellectually disabled children during this time, albeit at a delayed rate (Novella, 2008). Proponents of Patterning use this progress as evidence of the program's success and do not acknowledge the normal nature of this progression (Novella, 2008). Also, the extended structure of the programs, combined with the pseudoscientific nature of the theorem, raises several ethical concerns surrounding the delivery of Patterning as a treatment.  That is, by engaging in this therapy families are less likely to engage in evidence-based scientifically proven practices and are unlikely to come into contact with professionals who are familiar with critical literature (Jacobson, et al., 2005, p. 67).    

            Since its creation, and assertions of effectiveness by its developers, Patterning has been scrutinised empirically (American Academy of Pediatrics, 1999). While a small amount of studies have made claims of improvements in the areas of visual perceptual skills and mobility through Patterning, these findings are clouded with doubt due to methodological weaknesses (Neman, Roos, McCann, Menolascino, & Heal, 1975). For instance, critics of these positive findings suggest flaws in participant selection, procedural abnormalities, poor statistical analyses and inadequately interpreted results (Ziegler & Victoria, 1975). Even these studies in which visual-motor improvements are suggested, the findings do not present evidence of intellectual improvements (Neman, et al., 1975). This is in clear contrast to the treatment's theoretical claims. Other studies have noted short-term developmental improvements in children treated however researchers are quick to acknowledge that such results are linked to a relative increase in familial attention towards the child (Bridgman, Cushen, Cooper, & Williams, 1985).

            Claims have been made by the founders of Patterning that reading improvements have been observed in children engaged in their treatment programs (Delacato, 1963, 1966). They state that improvements in reading results following treatment are support of these claims. Such claims have not been substantiated due to a lack of statistical significance in such improvements (American Academy of Pediatrics, 1999). Any improvements may also be the result of natural development over time as discussed earlier. Several studies have directly assessed the impact of Patterning on reading and improvements have been found to be negligible (American Academy of Pediatrics, 1999). All in all quite a number of well designed studies have assessed the efficacy of Patterning as a treatment, with the majority refuting its claims of success (American Academy of Pediatrics, 1999; Freeman, 1967; Jacobson, et al., 2005, p. 67; Sparrow & Zigler, 1978; Ziegler & Victoria, 1975). Within a decade of its launch Patterning was quickly established to lack its predicted effects (Jacobson, et al., 2005).

 

Sensory Integration Therapy

Sensory Integration Therapy (SIT) was developed by Dr Jean Ayres, Occupational Therapist and Psychologist, in the 1970's to assist individuals in organising their Central Nervous System's (CNS) response to sensory stimuli (Kurtz, 2008, p. 104). That is, some individuals with Intellectual and Developmental Disabilities are hypothesised to struggle to process sensory input resulting in hypo or hyper sensitivity (Kurtz, 2008, p. 105). While Sensory Integration Disorder (SID) cannot be validated as a recognised syndrome it is widely accepted that children with Autism Spectrum Disorders (ASD), Attention Deficit Hyperactivity Disorder (ADHD) and Anxiety Disorders regularly experience sensory sensitivity (American Academy of Pediatrics, 2012; Pennington, 2009, p. 275). However the principles of SIT are based on the theoretical underpinning of SID. This theory is noted to be erroneous and inconsistent with contemporary understandings of how the CNS operates and by extension SIT is likely to be ineffective (Pennington, 2009, p. 275). SIT utilises a number of techniques and tools such as tactile stimulation, weighted vests, brushing and purposeful movements to deliver a specifically tailored "sensory diet" (Jacobson, et al., 2005, p. 252).

            SIT is an extremely popular approach utilised widely by Occupational Therapists (Kurtz, 2008). It has been extensively studied and reviewed in relation to its efficacy and effectiveness (American Academy of Pediatrics, 2012; Hoehn & Baumeister, 1994; Vargas & Camilli, 1999 ). A number of studies report positive results in relation to meeting functional goals however the ability to generalise these results is limited due to them being based on case studies or being observational in nature (American Academy of Pediatrics, 2012). Such research is often biased by subjectivity. While a small number of controlled studies have reported positive results through the use of SIT these studies are restricted by considerable methodological flaws and thus their conclusions are tenuous (Baranek, 2002). It is interesting to note that its use is widespread in spite of their being minimal evidence of its effectiveness. In fact there is evidence from one small study that SIT may actually have a negative impact on the attainment of behavioural outcomes (Devlin, Healy, Leader, & Hughes, 2011). In this study it was observed that SIT had a constricting effect on behavioural improvements brought about through behavioural intervention. That is, the results suggest that the behavioural intervention alone was most effective in reducing self-injurious and challenging behaviours and the inclusion of SIT impeded progress.

                 A recent meta-analysis provides a  concise overview of the current state of the literature in the field of SIT (Vargas & Camilli, 1999 ). The findings of the review indicate many studies investigating the efficacy and effectiveness of SIT as a treatment display poor scientific rigor. As a result a large number of studies were excluded from the analysis. The meta-analysis concludes that the ability to detect a treatment effect for SIT is minimal, particularly in more recent studies where methodology has been enhanced. SIT appears to significantly lack the theoretical and empirical validation required of a widely employed treatment (American Academy of Pediatrics, 2012).   

 

Conclusion

Overall none of the three controversial treatments discussed in this current paper have demonstrated conclusive efficacy or effectiveness in the literature. Further, government and registration bodies caution  their use as treatments by professionals due to a lack of convincing evidence (American Academy of Pediatrics, 1999, 2009, 2012). Thus it is an ethical obligation of Clinical Psychologists to educate clients and other professionals regarding the current state of research for such treatments (Pennington, 2009). In the event that such questionable therapies are utilised anyway, clinicians should assist clients in monitoring the progress of such interventions. This should be done by setting specific and functional goals, assessing their level of effectiveness through simple pre and post test measures and setting time-limits on expectations for improvement (American Academy of Pediatrics, 1999, 2009, 2012; Pennington, 2009).    



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