Clinical decision making in treatment of learning disabled children.

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PRACTICE WATCH: THINGS TO THINK ABOUT

Clinical Decision Making in Treatment of

Learning Disabled Children W. Michael Magnm, MS, OTRfL

SUMMARY.This aper describes current theories and intervention strategies employe$in the treatment of learning disabilities. Type, duration and effectiveness of approaches are considered. Criteria for choosing different q e s of treatment and the responsibility of therapists to provide specificity in treatment are explored. The future of public school based therapy is challenged directly by outcomes of treatment, its documentation and linkages to educational performance. T h e challenge for therapist clinicians is the selection and application o f treatment techniques for given disability populations. TheraW. Michael Magrun is currently in pediatric private practice in Little Rock, AR and may be contacted at 9201 Kanis Road, 12G, Little Rock, AR 72205. n i s article appears jointly in The Occupational Therapy Mamger's Survival Handbook (The Haworth Press, Inc., 1988) and in Occupational Therapy in Health Care. Volume 5. Number 1 (1988). '

0 1988 by The

Haworth Press, Inc. All rights resewed.

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peutic interventions must be specific to the unique disability characteristics of individual patients even when within identical classified diagnostic groups. In no area is this challenge more evident than in the treatment of children with learning disabilities. The diverse characteristics of children with specific and related learning problems require therapists to surmise causal relationships in a disorder that cannot be medically diagnosed on hard neurological data. The commonly used diagnostic label of learning disability, therefore, relates to behavioral and educational findings collected primarily through observation and to the interpretation of wide ranging developmental and other performance norms. Due to the levels of observational and interpretive skills required of therapists in this treatment area, as well as the necessity for understanding and applying diverse intervention techniques, it is critical for therapists to develop effective decision making strategies. Choice of treatment type, duration of treatment, expected results and documentation of effectiveness is becoming increasingly important, not only to establish appropriateness of intervention, but to insure and guide the quality of care. Unless therapists can offer stronger evidence of the relationship between therapy given and the child's academic achievement, it is not valid to assume that therapeutic intervention has any advantages over efforts by special education alone. With the shrinking financial resources in education for related services, the lack of conclusive data on therapy effectiveness may well result in public schools insisting that therapeutic intervention no longer be an educational responsibility. This paper will explore the major theories and intervention styles currently in use for the treatment of children with learning disabilities as they relate to occupational therapy. The approaches will be contrasted and discussed in the spirit of application to various learning problems or underlying syrnptomology. A process of decision making for evaluation and treatment will be developed to assist the therapist in choosing specific, eclectic and effective intervention strategies.

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GENERAL BACKGROUND Sensory integration theory and practice is currently one of the approaches most widely applied by occupational therapists to the treatment of children with learning disability. Because of this broad acceptance it deserves special attention in any discourse about strategies employed for addressing the problems of the learning disabled. Although it is not the purpose of this paper to provide an exhaustive literature review or critique of sensory integration treatment, certain questions and issues will be raised about this as well as other approaches. The reader is advised to investigate more fully literature pertaining to the many specific treatment approaches that will be included and draw their own conclusions about their individual efficacy. Sensory integration theory has achieved unprecedented interest and application in occupational therapy over the past several years. Articles published in the American Joumal of Occupational Ther~py'.~.'.>ertaining to this subject have outnumbered those in any other category or area of practice. Throughout the occupatioiral therapy literature, sensory integration principles, based on the work of Ayresjd have been applied by therapists in treating those with learning disabilities, the developmentally disabled, adults with physical disabilities or psychosocial dysfunction as well as those from geriatric populations. ~ e s ~ iat proliferation e of general information and reports of research, the effectiveness of sensory integration therapy has been challenged. 7.8.9 IU.11.1Z With such widespread use of sensory integration strategies within the field of occupational therapy and the continual controversy outside of the field surrounding the application and effectiveness of this treatment approach with almost all disability groups, Ottenbacher" has suggested that occupational therapists exercise caution and strive for specificity in the delivery of sensory integration therapy. In defense of sensory integration, Ayres has cited several relevant studies supporting its effectiveness." Jenkins and Sells" have recently reported improvement of motor skills in learning disabled children from a combined approach of neurodevelopmental therapy

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(NDT) and sensory integration. They did not, however, specify how these two approaches were combined or delivered. There is other literature both supporting and challenging sensory integration therapy. The interested reader is advised to pursue a comprehensive literature review. For purposes of this article, let it suffice to establish that sensory integration theory, the most popular current treatment approach in occupational therapy for such conditions, has its advocates and adversaries. Such a position, however, is not unique to sensoty integration theory. Most major approaches used in the profession's practice have ridden the crest of popularity and felt the sting of criticism. Historically Frostig, Kephart, Bobath, Rood and others have experienced clinical acceptance and scientific criticism. Furthermore, it is not science that is in question, but rather the application of a working hypothesis of intervention that must be considered. Outcomes can only be evaluated in behaviors. Individuals with the same classification or diagnosis have nothing in common with homogenous control or treatment groups. The issue of treatment effectiveness cannot be determined solely on the basis of a controlled variable. The diverse human nervous system refuses to comply. Although sensory integration theory has received considerable recent attention by clinicians, other approaches also continue to be applied by therapists to the problems of the learning disabled. St~ckrneyer'~ and Heil" have applied Rood techniques with reported success. Randolph and Henigerl"havecombined Kephart, Rood and Ayres in their approach to the problem. Knickerbocker describes an holistic approach which appears to incorporate some of the concepts of Ayres, de Quiros and Kephart.19 Nortonmsuggested the application of NDT and more recently Nelson and Benabib2' and Mag r ~ nhave ~ . documented ~ postural changes in the learning disabled after short-term intensive NDT treatment for small samples of children using case and single subject designs. Where does this leave the clinician? Squarely in the center of controversy. What works? Why? How? The problems of how to assess, choose treatment and evaluate its effectiveness remain the greater challenge than supporting one avenue of thought. In fact, the greatest caution should be not to be more of an advocate for a treatment approach than for the therapeutic change in the patient.

Practice Watch: ntings to Think Abouf


DECISION MAKlNG STRATEGIES In working with the learning disabled, in order for a therapist to provide comprehensive treatment, a child's particular learning problem(s) must first be identified. Such is usually first established by the record of the child's consistent academic or behavioral difficulty. Most often such difficult is then documented through educational and psychological testing. Therapists are usually not directly involved in these initial steps in recognition or diagnosis of learning disability. More often therapists are called upon to analyze the child's learning process or to interpret sensory-motor characteristics which may be contributory to difficulties in the behaviors seen. This aspect of therapeutic evaluation is critical, as the findings often directly guide the choice of the specific treatment approach for intervention. If, for example, a therapist relies solely on a certain set of tests in evaluation, treatment decisions will be based on results of these tests. In other words, a predetermined notion of underlying cause could bias both test choice and then, the interpretation and application of findings. For instance, the results of the Frostig test" may indicate a child has a perceptual deficit. Based on "the Frostig school of thought," the child would likely receive treatment inte~ventionbased upon Frostig's approach of visual perception worksheets and movement exploration activities to enhance sensory-motor fundamentals. If the child was given the Southern California Sensory Integration Tests (SCSIT)=he would be described as having a sensory integrative dysfunction of a particular domain, for instance, vestibularbilateral integration. Based on these test results the child would receive sensory integrative therapy utilizing suspended equipment to attempt to normalize processing of vestibular sensory input. If, on the other hand, the child was given the Purdue Perceptual Motor SurveyBhe would be described as having a problem in monitoring and matching the monitor and perceptual systems. Treatment following Kephart would include balance training, visual tracking exercises and chalkboard activiries to enhance bilaterality and rhythmic coordination. A Rood approach would concentrate on the developmental sequence of extension against gravity and isolate light workheavy work activities to enhance stability/mobility fac-


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tors necessary for coordinated function. Finally, Bobath oriented clinicians would evaluate proximal/distal relationships in stability and movement, the distribution of weight as it effects postural tone and treat the resultant incoordination of sensory and motor organization with facilitation and inhibition techniques requiring direct physical manipulation of responses. Obviously these examples are not all-inclusive of possible occupational therapy strategies and represent only general aspects of the treatment approaches described. The degree to which any approach is followed however, requires clinician judgement. Many clinicians, in designing treatment programs, are eclectic in nature, using a variety of techniques. Some readers may consider being eclectic as having no definite approach and liken one to a "jack of all trades, master of none." Such could not be further from the truth. Eclectic means choosing what appears to be the best for the purpose from diverse sources. To be truly eclectic one must be master of all those approaches in order to be able to determine a best combination. The lack of true eclecticism is at the root of the therapeutic dilemma. The degree to which a clinician relies on one particular approach, its testing tools and interpretation, will likely result in use of the same treatment applications over and over again. It is much like what Abraham Maslow described . "If the only tool you have is a hammer, you tend to see every problem as a nail." The question arises then, why do some therapists choose parts of some approaches and none of others?

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PROBLEMS IN TEST TOOLS AND TREATMENT: QUESTIONS W I T H NO CLEAR ANSWERS How does a therapist choose testing tools? In what combination or isolation are they used? How do they relate to each other and to the treatment problem? Let's take a hypothetical example. Approaching a problem of learning disability with the most widely used intervention strategy, let us assume we evaluate a child from the point of view of the SCSIT. Since these tests have not yet proven reliable on a test-retest basis, let us also assume other testing would be valuable, from a standardized retest possibility, to determine therapeutic effectiveness. (It can be argued that the SCSIT,


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has retest reliability for some of its subtests; however since the test was standardized as a battery for diagnosis interpretation in a specific sequence of administrahon, it i s appropriate to seek alternate verification of therapeutic change.) If the Frostig or other tests are administered along with the SCSIT, how do they influence decisions on SI treatment? Are they used as retest tools because of the retest problems with the SCSIT? If the SCSIT cannot be used as a retest tool how can improved sensory integration be documented? If SI improvement needs documentation through other tests such as the Illinois Test of Psycholinguistics (ITPA),l7Bender Gestalt," Frostig, Beery Visual Motor Integration Test" or academic performance testing, is it necessary to administer the lengthy SCSIT? Is there diagnostic value to the SCSIT which cannot be ascertained through clinical observation and other standardized testing? If so, how is this unique information which is provided retested to get clinical documentation of change? How do the Ayes clinical observations of neck cocontraction or residual reflex activity influence choice of testing tools, treatment provided or the interpretation of test data from other sources? Do these clinical observations alter the types or amounts of sensory integration activities used or contribute only to the identification of a type or classification of sensory integrative dysfunction? Since SI treatment is primarily child directed and is not a direct therapeutic handling approach, do the clinical observations of primitive reflex activity or weak neck cocontraction influence the types of activities the therapist allows the child to choose? Does the choice of specific SI activities alter the child's sensory integration or postural organization? Do some activities result in greater improvements than others? Can therapists study the effectiveness of sensory integration intervention as a child directed approach without evaluation, as specific treatment interventions, of the exact types of activities within the treatment approach? Can any approach suggest effectiveness without specificity of particular techniques and their sequential order even within a theoretical framework unique to that approach? The Southern California Postrotary Nystagmus Test is another widely used evaluative tool." If a child has demonstrated low postural tone and weak neck cocontraction on clinical observation, can a therapist be sure he is evaluating vestibular function or, rather, the


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joint and muscle proprioceptors responsible for the orientation of the head to the trunk, essential to isolate vestibular response to discrete testing? How each therapist answers these and other questions depends on individual education, experience, expertise and his clinical judgement. This is the art of therapy and has its own unique value. However, therapists can develop a more systematic problem solving strategy of criteria-based questions to assist in achieving specificity of their treatment and in documentation of results. For example, a child scores below normal on a test for visual-motor or eye-hand coordination. A motor free test reveals better results but scores are still below normal. The therapist observes a hypelvestibular response to rotation, the presence of residual reflex activity, inadequate prone extension and tactile discrimination problems. What conclusions can the clinician make? Criteria-based questions can assist in interpreting these raw test results. Is there evidence of poor postural shoulder stability which might influence eye-hand coordination? Do residual reflex reactions inhibit the smooth use of head, neck, eyes, shoulders? Can the eyes track better when reflex activity is manually inhibited? Is the hyperactive vestibular response related to poor postural tone and primitive reflex activity interfering with stable alignment of head to trunk? Is eye-hand incoordination due to a visual motor matching problem or is it influenced by postural disorganization? Following this line of reasoning the therapist has the opportunity to identify possible causal relationships in a way that attempts to eliminate some of the contributory characteristics of the identified learning and behavioral problem. For instance, a direct physical approach might be used to determine and treat shoulder instability on a musculoskeletal level. Following such an approach, eye-hand coordination could be reevaluated to determine any relationship. Physical handling, to integrate the postural mechanism, could eliminate causal relationship with vestibular function, and occular-motor tracking based on retest results after direct inhibition and facilitation of postural movement to establish somatic integrity with gravity. This pre-condition for vestibular testing reliability is essen-


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tial to negate confusion between primary vestibular proprioceptive disorganization and somatic proprioceptive disorganization." Further, such a direct approach to the somatosensory process assists in the determination of tactile defensiveness as a discriminative response or a reaction to initial tactile assault such as with light touch. True tactile defensiveness can only be a light touch phenomenon. Avoidance of tactile input in movement or discrimination is a deep pressure response and therefore cannot be viewed discreetly from somatic pr&prioception. Interpretation of pivot prone extension suffers from the same lack of differentiation in the evaluation process. Prone extension is governed by somatic proprioceptors as well as vestibular proprioceptors, and further initiation of the response evokes a different process than the static maintenance response. Causal relationships of occular righting; fmation and focus distance, as well as deep somatic receptors must be eliminated before vestibular system dysfunction can be attributed to failure of prone extension. This example serves only to illustrate some aspects of clinical questioning necessary to provide a specific and progressive treatment and to avoid the pitfalls of one isolated approach to evaluation, interpretation and treatment application. In good conscience therapy cannot continue throughout the entire school year routinely without constant modification based on ongoing documented improvements. This cannot be accomplished unless possible causal effects are identified, remediated and eliminated.

DEVELOPING AN ECLECTIC FRAMEWORK FOR TREATMENT Before an eclectic framework for treatment can be developed it is essential for the therapist to be well versed in the relative treatment approaches. It is not enough to be "familiar" with these approaches. One must be a skilled practitioner of each approach to apply eclectic judgement. Several major approaches will be reviewed here, for the purpose of providing identification only, and thus do not serve as an adequate basis for necessary understanding of each approach. Readers are advised to investigate more fully areas pertinent to their own needs. Four of the major theorists who


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have shaped the treatment of children with learning disabilities over the last two decades are Kephart, de Quiros, Ayres and Bobath. Determining their major contributions and analyzing similarities and differences will provide a backdrop for discussion of organized strategies of intervention. Kephart3>placed emphasis on the motor stage of development. - He saw the child's reflexive movements as the means for the child to be exposed to the perceptual world. Raw sensation, in Kephart's view, during this stage, contributed to and initiated random motor behavior but held little direct functional meaning. As the child developed a motor base he was able to begin to pair motoric ability to his perceptual world through exploration. Later the child was able to switch the process using perception to direct motoric behavior. The emphasis on perceptual motor behavior for Kephart was a result, therefore, of a motor/sensory/motor perceptual process. Much of today's emphasis is on the sensoryhotor concept; however, without the motoric base, sensation would have no organized meaning. Certainly there is no motor behavior without sensation. No treatment one is able to offer can deal with motoric function in the absence of sensation. Yet, there can be a big difference between providing sensory stimulation for an arousal of sensory pathways and providing controlled and graded sensory input to reinforce or establish an organized motor base through direct physical handling. Kephan also offered the concept of kinesthetic figure-ground. He saw this concept as providing the child with the postural control to support directed movement. It affords the maintenance of posture automatically so that functional movement can occur with intention on a stable base of support. Kinesthetic figure-ground in essence is what allows the child to progress from motor/perceptual behavior to perceptuaVmotor behavior. Ayres' brought the importance of the vestibular system and the underlying sensory integration nature of the nervous system to the awareness of therapists. She challenged therapists to reevaluate training activities and pursue a more causal relationship between senori-motor process and learning skills. She expected the postural system to respond to improved sensory integration primarily



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through vestibular processing and thus establish a postural background for the support of coordinated praxis and perceptual constancv. ,de Quiros)' offered a more comprehensive view of vestibularproprioceptive function. He reminded therapists that vestibular receptors are also proprioceptors and cannot be separated from joint and muscle proprioception. He identified vestibular-proprioceptive disassociation with dominance of either system, resulting in an interruption of normal equilibrium and righting reactions. In addition de Quiros emphasized the cervical spine as the dependent variable for normal vestibular reception and intcgration. His notions of "wrporal potentiality" and "kinetic input and output" are essentially similar to Kephart's kinesthetic figure-ground and Ayres' postural background, although each theorist subscribes to a different process of its establishment. The neuro-postural approach modeled after Bobath principles primarily organizes somatic proprioception for the enhancement of sensory integration through postural integrity with gravity. As with Kephart the neuro-postural approach places significant importance on a motor or postural base. As with de Quiros it also considers the vestibular and proprioceptive systems as inseparable. The primary philosophy of Bobath treatment approach is that normal movement cannot take place unless there is normal postural tone, and sensory reception cannot be integrative without normal postural alignment in relation to gravity. In addition, the interplay between stability and mobility requires reciprocal innewation and normal equilibrium and righting reactions, what Bobath has described as the postural reflex mechanism." ZNTEGRATZNG APPROACHES

Most important in the process of integrating approaches to treatment, is the notion that use of any test battery or theoretical construct is only an indication of direction one might take. Much like a road map they can only direct one to a city and perhaps a street, but not a specific address. The individual "address" should be the challenge, responsibility to be determined by each therapist for each individual patient.


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Eclectic means choosing the best among approaches. Choosing the best requires expert knowledge in a variety of approaches. Further, the application of expertise demands an in-depth awareness of the characteristics of diagnostics and, more importantly, of normal learning and performance processes. Any theorist or therapist, advocating an approach, who is invested in the theory and style of that approach, or the research of only one variable of an approach such as vestibular function, does little to assist therapists at large in developing their own problem solving strategies for therapeutic change on an individual patient basis. As unpopular as this notion might be to some, it is at the heart of the current dilemma in the treatment of learning disability: loyalty to technique or patient change, to theory or practice? The question remains. How does one develop a problem solving strategy in treatment planning independent from conventional wisdom of individual approaches? How does one know his ~atientis benefitting from treatment eiven? A primary factor in determining the cYhoice of assessme% strategy and treatment technisue becomes the answer to two fundamental questions. How is the problem seen? Why is a specific treatment applied? It is simply not enough to associate the learning disabled as "SI kids" and apply sensory integration techniques, any more than labels of perceptual dysfunction or postural disorganization should automatically lead to Frostig, Kephart or NDT approach. Indeed this kind of label association with intervention is a root cause of much misdiagnosis and treatment, and lack of effective results. What is a problem solving strategy? Clearly stated it is a method of investigation which leads to decisions to use, and consequent application of, appropriate intervention tools regardless of their theoretical alliance. CASE EXAMPLE It is not the purpose of this paper to establish a definitive problem solving sequence for treatment of learning disability. An example of such a sequence will be presented, however, to assist the reader in conceptualizing the process. Once a therapist is called upon to intervene with a child said to have learning disability he should think first not of the label or of


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possible approaches or specific testing tools. Rather, he should begin to investigate possible layers of underlying dysfunction. The primary starting place is, in this example, on musculoskeletal integrity. One should investigate the postural musculature for boney alignment or malignments through position palpation of structure. Then, observe the distribution of weight and postural tone in various positions of rest and movement. Next, identify possible transitional movements which increase incoordination or inhibit smooth grading between postural adjustments. Finally, determine the status of proximal stability and distal movement in skilled performance. choose testing tools, be they observational or standardized instruments, based on what somatic functional information is desired. Ask questions pertaining to the relationship of these factors and the symptoms the child presents which first drew attention to the stated problem. It is critical to evaluate for and establish presence of a controlled, integrated and adaptive somatic integrity, with gravity. The soma is the structure of reception for sensory input and its reaction determines the difference between a somatosensory dysfunction or a sensory integrative dysfunction. Following such an investigation one should proceed to the evaluation of specific sensory responses to visual, tactile, auditory and vestibular stimulation. These responses can more fully be determined after neuromuscular and musculoskeletal problems have been eliminated. Treat these process problems as they appear and then go on to investigating perceptual constancy and learning performance. From there shape and train skilled responses, through activities, to enhance experience in specific learning areas. The entire intervention demands the use of a variety of approaches and techniques. As the process unfolds, many of the superficial symptoms such as problems of sensory discrimination or reception, praxis, attentional deficits and the like spontaneously reduce since the foundation for their function or dysfunction has been altered. The rule of thumb is to start at the beginning. The rule never to break is do not view symptom as cause and do not apply "a recipe." In this light the following association of problem, investigation and remediation for learning disability is offered.

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PROBLEM LEVELS ADDRESSING FOR LEARNING DISABILITY


PROBLEM LEVEL I MusculoskeletallNeuromuscular boney alignment and integrity joint freedom or restriction distribution of postural tone dissociation of body parts stabilitylmobility factors postural reflex reactions myofacialtsoft tissue restrictions transitional movement components flexion/extension/rotation imbalances

PROBLEM LEVEL 2 AfferentEfferent Sensory Process visual orientationladaptability auditorylorientation vestibular adaptation tactile irritability

PROBLEM LEVEL 3 Functional Integrative Factors occulo-motor organization visual-motor coordination eye-hand hand-eye ear-eye-hand eye-hand-mouth auditory-motor sequence language enactment directional tactile manipulative


PROBLEM LEVEL 4


Skilled Behavior speedldexterity handwriting reading cognitive creativity speecManguage specialty academics ZNVESTIGATION/REMEDU TION POSSIBILITIES

Level 1:

Level 2:

Level 3:

Level 4:

palpation; manipulation; muscle energy (osteopathic) mobilization; tissue release; (manual therapy) inhibition/facilitation (Bobath) lightlheavy work resistive (Rood) repetitive movement patterns (PNF) visual field manipulation (optometric) dichotic listening (audiometry) vestibular responsive (SCPIW, ENG, neurological) tactile sensitivity (neurological, SCSIT) visual tracking (Kephart, motor free perceptual tests) perceptual constancy (Frostig, SCSIT, ITPA) fine motor manipulation academic/psychological

Asking criteria-based questions for each level can assist the therapist in the investigation and remediation process. For example, one might begin a line of questioning regarding the musculoskeletal level. Has the child a history of any falls or trauma that may have affected boney articulatory efficiency? Does the child favor certain movement patterns more than others? Does the child tend to fur proximally when engaged in balance activities? Is smooth rotation available during transitional movement? Are there any restricted or tight joint capsules? How might these factors affect higher levels? It is not rational to assess all problems and levels during the initial evaluation. There is little or no assurance that test results have


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any validity in reference to cause. The fact that a child cannot score normally on visual-motor tests does little to identify the true nature of the problem. Is there free dissociation of eyes to neckhead relationships? Does the child have an assymetrical shift in tone in sitting such that proximal shoulder stability is compromised during the writing process? These questions cannot be answered through batteries of tests. As each layer or problem level is assessed and treated the next level can more appropriately be addressed with a more logical chance to identify causal relationships to the child's dysfunction. The above example and level delineation is offered as a sample only. It is not meant to be a completed format for developing decision making strategies. As a guide it has purpose, but the variable nature of disability characteristics makes it imperative that decision making and criteria-based investigation be more philosophical than standardized. Such an approach requires judgement, not simply allegiance to a theory or technical skill in a modality. In normal children it is well recognized that the tactile and vestibular systems are active before birth. This sensory influence no doubt contributes heavily to the child's development of postural and proprioceptive control against gravity. However, in the presence of low postural tone and delayed development, so characteristic of children with learning disabilities, these same sensory influences may result in disorganization of the central nervous system. Therapists are familiar with children who often show low postural tone and poor joint cocontraction, whose developmental histories indicate they spend little or no time prone and who perhaps skipped crawling altogether. These children often have hyposensitive or hypersensitive vestibular responses, as tested by those who use the SCPNT. In both extremes of vestibular dysfunction there may be an over reliance on either the somatic proprioceptors or the vestibular proprioceptors. As de Quiros has shown," children can be dominated by either form of proprioception. In cases of somatic dominance the child relies mostly on joint and muscle feedback, thus often clutching himself in balance challenging situations. The vestibular system does not have the opportunity to experience free


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movement in space, thus resulting in vestibular hypersensitivity. In cases of vestibular dominance, the child is often in continual, albeit clumsy, motion thus not allowing an opportunity for somatic receptors to experience graded and controlled input though the joints in a stable relationship with gravity. Hyposensitivity to vestibular stimulation may result due to excessive stimulation and a high sensory threshold for vestibular input. At the same time, the child may have a hypersensitivity to sustained weight through the joints or during graded transitional movement, causing some symptoms consistent with hyperactivity. Choosing a course of treatment requires a decision about causal relationship to symptomatology. In the case of hypersensitivity it is possible that sensory stimulation, and particularly vestibular stimulation, would cause more proximal or somatic fmtion for stability. In the case of hyposensitivity the somatic proprioceptors have no opportunity to adapt to movement. They are unable to maintain the alignment of head and neck. In this situation, more sensory stimulation, particularly vestibular, would not necessarily be more integrating since it might continue to disorganize the body propricoeptors. In relation to the previously presented problem levels in learning disability, it is consistent first to deal manually through direct physical handling to provide a better gravity relationship for sensoIy integration. The rapid improvements within weeks of treatment reported after intensive physical handling2'-a.2.'is in marked contrast with the improvements predicted utilizing sensory integration therapy. Mailloux" has previously suggested treatment results from sensory integration therapy are usually not seen prior to six months and children are often in therapy for several years. It is possible that some postural musculoskeletal changes are obtained prior to six months, however, such results have not been suggested or reported.

In order for the therapeutic services to remain a necessary part of the leaning disabled child's educational program, it is imperative that the effectivenessof therapy be firmly established. If one cannot


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demonstrate and document adequate proof of improvement in a period shorter than one year, one cannot answer the critics who point to maturation as the major agent of change in the child's performance. It could be argued that comparing expected chronological development to therapy gains might rebut the critics. This is unfortunately s notion that has no rational value. If a child's therapeutic gains outpace expected chronological gains, such improvement should be demonsacabk much sooner than in one year. Pm order 80 establish the aeiatiowshi~between movement.. oosture and sensory integpatio~lto academic performance, improvement in the underlying sensory integrative processes and postural mechanisms must be established. Once this is done, changes seen can be waaePated with academic achievement. Without such correlation here is no basis for re~mrnendingtherapist intervention over reguPar special education routines. To be successful in documenting change, therapists must base reports on more specific therapeutic approaches. "Impr~vingsensory integration" is a goal which is far too general; further, achievement of it cannot be measured. Improving specific aspects of sensory integrative functions such as balance reactions, smoothness of movement patterns, graphesthesia, duration of attention span, speed anad accuracy of performance in reading, writing or eye-hand adi in at ion can be more appropriately measured and related POtreatment particularjy if treatment is based on fundamental levels and does not specifically train splinter skills. Type, duration and intenasiiy of therapy should be clearly prescribed in records. Therapeutic procedures which do not yield measurable changes, within a period of time less than six months, cannot be expected to impress either the scientific or the educational communities. Therapists are encouraged to look more closely at the types of evaluation tools they use, the usefulness of data gained from them and the specificity of their resulting treatment choices. Therapists should have a clear understanding of why they are using given intervention procedures, what they want to change in patient behavior and how that change will be evident, if treatment is successful. Otherwise there can be no responsible or dynamic treatment.

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REFERENCES 1. Viseltear E (ed): Index, Am J Occup Ther 39:12,833-841. 1985 2. Ibid 38:12.837-844, 1984 3. Ibid 37:12.86&878, 1983 4. bid 36:12, 848-860, 1982 5. Ayres AJ: Sensory Integration and Learning Disabilities. Los Angeles CaliE Western Psychological Sewicis, 1972 6. Ayres AJ: Sensory Integration and the Child. Western Psychological Services, Los Angeles, Calif: 1979 7. Lerer RI: An open letter to an occupational therapist. J Learn Disabil 14:3-

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4. 1981 -

8. Sieben RL: Controversial treatments for learning dibrders, Acad Ther 13:2. 138-145, 1977 9. Sieben E U Dr. Seiben responds, Acad Ther 13:2,217,1977 10. Batshaw ML, Perret YM: Children with Handicaps-A Medical Primer. Baltimore Md: H. Bmkes Pub Co., 1981 11. Hightower-Vandamm MD: Nationally Speaking-The perils of occupational therapy in several special arenas of practice. Am I Occup Ther 34:307-309, 1980 12. Bocher S: Ayres, sensory integration and learning disorders: A question of theory and practice, Austr J Ment Retard 5:41-45. 1978 13. ~ttehbacherK: Sensory Integration therapy: Affect or effed, Am J Occup Ther 36:9. 571-578. 1982 14. Ayres Al: A response to defensive medicine. Acad 'her 13:2. 149-152, 1977 .

15. Jenkins JR. Sells U:Physical and occupational therapy: Effects, J Learn Disabil 17:89-95. 1984 16. Stockmeyer S: Open Discussion in Body Senses and Perceptual Deficit, Henderson A. Coryell J, (eds), Proceedings of the Occupational Therapy S y m p sium on Somatosensory Aspects of Perceptual Deficit, Boston U., 1972 17. Heil CL: Open Discussion of the Body Senses and Perceptual Deficit. Henderson A. Coryell J. (eds). Proceedings of the Occupational Therapy Symposium on Somatosensory Aspects of Perceptual Deficit, Boston U.. 1972 18. Randolph S, Heiniger M: The Learning Tree Workshop. Little Rock, AR.. 1981 19. Knickerbocker BM: A Holistic Approach to Learning Disorders. Charles B. Slack. 1980 20. Notion Y: Minimal cerebral dysfunction. Part 11, Modified treatment and evaluation of movement, Am J Occup Ther 26, 186-189, 1972 21. Nelson C, Benabib R: Righting and Equilibrium Reactions as an Integrating Influence on Motor Organization. Problems de Aprendizaje Memorias del Sominario. Garcia LJ, editor, Seminario International Sobre Aprendizaje, Gaudalajara, 1978


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22. Magrun WM: Somatic adaptation in developmentally disabled children through neurodevelopmental therapy, Somatin, 5:3,58-62, 1985 23. Magrun WM: In press, Normalizing equilibrium and righting reactions in learning disabled children, Somatin 24. Frostig M: Marianne Frostig Developmental Test of Visual Perception, Palo Alto Calif: Consulting Psychologists Press, 1961 25. Ayres N : Southern California Sensory Integration Tests, Los Angeles Calif: Western Psychological Services, 1972 26. Roach EG, Kephart NC: The Purdue Perceptual-Motor Survey, Columbus Ohio: Charles Merrill Wks. 1966 27. Kirk SA. McCarthy JJ. Kirk V4D: The Illinois Test of Psycholinguistic Abilities, University of Illinois Press, 2968 28. Bender L: Visual Motor Gestalt Test and its Clinical Use, New York: American Othopsychatric Association, 1938 29. Beery KR, Buktenica NA: Developmental Test of Visual-Motor Integration. Modem Curriculum Press, 1967 30. Ayres AJ: Southern California Postrotary Nystagmus Test: Manual, Los Angeles Calif: Western Psychological Services, 1975 31. de Quiros JB: Neuropsychological Fundamentals in Learning Disabilities, Academic Therapy Publications, 1978 32. Kephart NC: The Slow Learner in the Classroom, Charles Merrill Books, 1960

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Brainstem evoked potentials in learning disabled children.

Laterality preference patterns of learning disabled children.

Clinical decision making in the treatment of mixed states.

Clinical decision-making in the evaluation and treatment of insomnia.

Paradigmatic language training for learning disabled children.

Caregiver Perceptions of Clinical Decision-Making for the Treatment of Children.

[Clinical decision making algorithms].

Clinical Decision Making.

Linguistic decision making for robot route learning.

Sociometric status of learning disabled children in an integrative program.

Perspective on parental involvement in the diagnosis and treatment of learning disabled children.

Body movement and inattention in learning-disabled and normal children.

Development and evaluation of learning module on clinical decision-making in Prosthodontics.

Attention and the EEG alpha rhythm in learning disabled children.

Letter: Soft neurological signs in learning-disabled children and controls.

An empirical subgrouping of Finnish learning-disabled children.

Written narratives of normal and learning disabled children.

Constructive memory of normal and learning disabled children.

Intellectual characteristics of school labeled learning disabled children.

Human and machine learning in non-Markovian decision making.

From Learning to Decision-Making: A Cross-Sectional Survey of a Clinical Pharmacist-Steered Journal Club.

Decision making. Stability of clinical decisions.

Shared mechanisms of perceptual learning and decision making.

An intensive therapeutic program for learning disabled prepubertal children.