Standing Committee On Social Issues
Issues Paper 4, March 2002
Foundations For Learning:
Rosemary Boon, Psychologist & Teacher
M.A.(Psych), Grad. Dip. Ed. Studies (Sch.Counsel), Grad. Dip. Ed., B.Sc., MAPS, AACNEM
Special Education & Science Teacher
Member of Australian Psychological Association
Member of Specific Learning Difficulties of NSW
Member of The Learning Difficulties Coalition of NSW
Affiliate of EEG Spectrum International, Encino, CA, USA
Member of SAMONAS Sound Therapist Association of Australasia
President-Elect International Society for Neuronal Regulation (Australian Chapter)
Affiliate Member of Australasian College of Nutritional & Environmental Medicine (Melbourne)
Member of the Interdisciplinary Council on Developmental and Learning Disabilities, Maryland, USA.
Learning Discoveries Psychological Services
P.O. Box 7120, Bass Hill NSW 2197
Telephone: (02) 9727 5794
This Inquiry into the early intervention of learning difficulties is really only the tip of the iceberg. In order to effectively address the issues raised, it is necessary to acknowledge and embrace the fact that we are in need of a paradigm shift, not only in the way we think, but in our whole societal structure.
The Berne Convention (1906), Ottawa Charter (1986) and The Convention on the Rights of A Child (1989) clearly state that the rights of a child pertain to access to the resources necessary not only for good health but general well being and optimal function. Australia signed the Convention on the Rights of a Child on the 7th December 1990. The rights of a child at risk of learning disabilities has yet to be recognised in NSW..
Children with learning disabilities develop these disabilities within the framework of social, cultural, demographic, health and educational domains. Therefore, it is impossible to delegate the many intrinsic and environmental factors that lead to the development of learning difficulties to the auspices of a single government department. The well being and needs of children with learning disabilities are not the sole responsibility of health, education or other government portfolios. A unifying multidisciplinary approach and a paradigm shift by all sectors of the community are vital with education, communication and the dissemination of information as the key ingredients.
While these challenges are formidable, "dealing with them is necessary to creating an individualised interdisciplinary approach that tailors the programme to the child rather than fits the child to the programme" (Stanley I. Greenspan, M.D., Clinical Professor of Psychiatry, Behavioural Sciences and Paediatrics, George Washington University Medical School and Chairman Interdisciplinary Council on Developmental and Learning Disorders (ICDL- See Appendix A for a list of Advisory members).
Collaborative discussion across disciplines offers the opportunities to develop new ways to identify, prevent and treat developmental and learning problems. Those who work with children with developmental and learning disorders find that each of the disciplines actually overlaps with other fields. In fact, with collaborative interdisciplinary effort, it is possible to ameliorate the conditions much faster than one discipline working in isolation. This occurs daily in the practices of those considered by this committee as "non-conventional".
Current research and clinical experience indicate "the importance of working with all the functional developmental capacities, rather than only with surface behaviours or isolated cognitive skills".(Stanley I. Greenspan, M.D., Clinical Professor of Psychiatry, Behavioural Sciences and Pediatrics, George Washington University Medical School and Chairman Interdisciplinary Council on Developmental and Learning Disorders-www.icdl.com).
Therefore, placing children into programmes without addressing the full range of developmental capacities the child should be achieving does not take into account how individual differences affect the child’s learning and functioning. The result is that children are often put into programmes rather than programmes being designed for the individual needs of children. There is no single "one-size-fits-all" programme and hence no quick and easy fix.
Children with learning disabilities need intervention strategies explicitly designed to:-
A comprehensive approach recommended by the ICDL includes work with processing capacities such as auditory processing and language, visual-spatial processing, motor planning and sequencing, sensory modulation and "new technologies designed to improve processing abilities" (Educational Guidelines for Preschool Children with Disorders in Relating and Communicating by Serena Wieder, Ph.D., and Barbara Kalmanson, Ph.D in the "Interdisciplinary Council on Developmental and Learning Disorders"- Clinical Practice Guidelines). "Non-conventional" therapies such as SAMONAS Sound Therapy and neurofeedback are examples of these new technologies designed to improve brain functioning and therefore cannot afford to be dismissed by this committee or anyone who is considered to be a real advocate of children’s rights. It is hoped that the opening address by Dr John Yu, at the launch of the Issues Paper, will not be brushed aside and continue to be ignored by the powers that be. Organisations purporting to deliver services for children with learning disabilities need to meet the guidelines in Appendix C before further funding is allocated.
Question 1Do General Practitioners have adequate skills and/or training to identify and assist children with potential or actual learning difficulties?
The unequivocal answer to this question is a resounding NO. The content of medical training and the conditions of training to paraphrase Leo Galland M.D. in the "Four Pillars of Healing" is "designed to make doctors good medical mechanics, not healers. They are taught to analyse data, but nothing about patients". Doctors fail to recognise that their "patients are not just the bearers of disease, but individuals who become sick within a social, cultural and demographic context and many doctors fail to meet "essential core competence in clinical nutrition" (Galland, L (1997): "The Four Pillars of Healing" p 38-39).
It has been my experience that the majority of those in mainstream medicine are quick to show their bitter opposition to any form of "alternative" or "complementary" medicine dismissing or refusing to read the published literature in peer reviewed journals and research studies on natural therapies. However, they fail to recognise that most of what they practice is not based on solid scientific evidence. There is not one medication without side effects yet "medications that profoundly alter the availability of neurotransmitters and affect a hypothesised pathophysiology are routinely prescribed by practitioners and little or no attempt is made in most cases, even in the treatment-resistant patient, to use biological assessment methods to select a treatment, to evaluate its physiological effect and to demonstrate its efficacy objectively" (Hughes & John, 1999 Conventional and Quantitative Electroencephalography in Psychiatry).
Furthermore, the number of preschoolers on stimulant medication is rising in Australia and since there have been no double-blind placebo studies done on this group of children with stimulant and antidepressant medications every child is in essence "an uncontrolled experiment---but we never learn anything" (Steven Hyman, director of the National Institute of Mental Health (NIMH) Rockville, USA). This double standard is putting our children’s lives at risk.
Some doctors are becoming more aware of the shortfalls of their training and current practices. "All doctors are not the same and the sad fact is medical school does not well prepare people to serve as doctors beyond immediate life saving measures as the system is distorted by a strong bias toward drugs and surgery - both of which have their place of course, but not to the virtual exclusion of all other approaches. Most real medical education happens in practice and there the professionals are separated from the amateurs". (Kennedy, The Doctor's Medical Library Newsletter, April 30th 2002, http://www.medical-library.net).
Having worked with many members of the medical profession over the past twenty years the most common lament I have heard about their training is that the rote memorisation of facts out of context does not allow time for critical thinking and questioning, let alone time for the exploration of any alternatives- alternatives, which, in many cases are proving more valid than the disease model of allopathic medicine.
In a recent intensive post graduate course on nutrition presented by the Australasian College of Nutritional and Environmental Medicine, the views of general practitioners attending the course was summed up by one physician’s introductory statement: " I’m here because I realise that the medicine I practice and was taught at university is not healthy for me, my family or my patients" (ACNEM, Melbourne, March 2002).
In the largest survey conducted by the Victorian Parliamentary Enquiry into Alternative Medicine, 1984-1986 as many as 69% of respondents complained of no results from orthodox medicine (43%) or were dissatisfied with their own doctor (26%). Other reasons for abandoning orthodox medicine included preferring safer natural methods (21%), last resort for health problems (12%) and preferring preventative approach/treating causes rather than symptoms (16%) [Social Development Commission of the Victorian Parliament Report 1984-6, Table 8, p 42.].
The medical profession is unable to cope with the increasing number of children with learning disabilities and seem to have abandoned the most important part of the Hippocratic Oath- "do no harm" in favour of monetary gain and power. It is a well known fact that medicine as it is conducted today is big business and ultimately "the central issue above all others, is power" (Ministry of Women’s Affairs, New Zealand in Bad Medicine by John Archer 1995).).
Question 2Do General Practitioners fulfil a role in identifying children with learning difficulties and regularly refer them to the appropriate services? If not,why not?
While general practitioners should play an important role in identifying children with learning disabilities, they fail to do so.General practitioners who refer children with learning difficulties do so because of their own personal experience and because they want to avoid the system of which they are a part, knowing that it is incapable of meeting the needs of these children and unwilling to change its paradigm. Factors such as a lack of understanding, clinging to an outdated medical paradigm, pressure from drug companies to prescribe the latest and newest "wonder drug", and protecting their incomes have resulted in complementary therapies/appropriate services being ridiculed, its proponents persecuted and research dismissed in the name of the "scientific method". However, "only about 15 percent of medical interventions are supported by solid scientific evidence and only one percent of the articles in medical journals are scientifically sound" (Coleman , V. (1994): "Betrayal of Trust". British Medical Journal, p. 42).
General Practitioners do not have the time to read their own literature and once in the field, rely heavily on drug companies for their continuing education. The American Medical Association is attempting to define through case studies the ethical boundaries of drug company gift-giving to physicians. This is the second phase of a campaign launched last August to teach doctors about the AMA's ethical guidelines on accepting gifts from drug firms. "Accepting gifts that can influence patient care is a clear conflict of interest; practicing ethical medicine requires a physician to seek out objective sources of information, rather than making decisions based on advertising and promotion," said Jaya Agrawal, president of the American Medical Student Association and a student at Brown Medical School, in reaction to the industry's recent announcement. "Unfortunately, neither medical schools nor professional societies have demonstrated effective leadership on this issue." (New York, Reuters Health, April 26, 2002).
The alternative therapies that were submitted to the committee are not in line with the disease model and therefore are dismissed by the mainstream. Furthermore, most general practitioners view learning and behavioural disabilities as an educational or parental issue and fail to appreciate that there are natural alternatives just as powerful and considerably safer than the pharmacotherapy they have been taught at university.
Question 7Should nurses who primarily work with children and families be required to hold relevant specialist qualifications?
Without adequate training nurses cannot be expected to detect learning difficulties in the crucial stages of development. Their training however needs to encompass all of the factors (social, cultural, educational, psychological, nutritional) involved in identifying learning difficulties and not just the medical ones. It is doubtful that instructors in current teaching institutions are familiar with these factors or even acknowledge them as they cling to the old paradigms of the disease model which is clearly an ineffective paradigm for learning disabilities. Learning disabilities is not a disease entity. Therefore in order for effective training to occur in nursing it is vital that nurses are taught by experienced and practising practitioners in the field of learning disabilities and not merely by academics. Having conducted many in-service courses for professionals, I find it alarming that professionals in the "trenches" have little or no knowledge about these issues. Accurate and current information is crucial to stem the tide of increasing unemployment, substance abuse, mental health problems (depression, anxiety etc.), criminality and other health and social problems which result when the range of learning disabilities remain undetected, misdiagnosed and mismanaged. It is pointless saving dollars in this crucial stage only to build prisons later and support these children as adults on a pension or disability scheme or through Medicare which drains the economy.
Question 17Is reduction of staff/child ratios in NSW childcare centres and pre-schools a priority initiative? What would be the impact of a reduction in ratios on the quality of service provided and on children at risk of learning difficulties? Should there be a system of differential staffing for target areas where there are children with or at risk of learning difficulties?
The emotional welfare of children should be our prime responsibility and therefore a priority for our society.Anyone who has had a child with learning difficulties knows that they require extra time and effort to accomplish even the most basic of skills- skills which normal children acquire with ease. Learning disabled children themselves know they have to work harder than their peers to reach their potential. The enormous effort required of them has to be experienced to be appreciated. "If it takes around 100 hours for a normal child to master a skill, it takes a LD child 1000 hours to reach the same level" (Fawcett, A.J. (1995): "Case studies and some recent research". In Dyslexia and Stress T.R. Miles & V.P. Varma (Eds- p 26).). It gets even worse as the number of hours for a normal child to learn a skill increases! Therefore reducing the staff/child ratio in child care centres will allow for more time to be spent on those who need it. Somewhere along the line children with learning disabilities need to be given the time to learn and there is no substitute for trained teachers and quality teaching. This cannot occur if the staff/child ratio in preschools remains at its current level. Failure to achieve the basic readiness skills necessary for school entry means that a gap already exists upon school entry between those who are ready and those who are not. Sadly, this gap only widens as they progress through each successive school year and it impossible for these children to grasp basic numeracy and literacy skills without many hours of individualised interventions.
"Unless basic skills are taught before the child reaches secondary school, the gap between his level of ability and that of his peers will have widened to the extent that catching up will be an almost impossibly long and demoralising process" (Thompson, P. (1995): "Stress factors in early education". In Dyslexia and Stress T.R. Miles & V.P. Varma (Eds- p 46). Smaller staff/child ratio in a pre-school setting would therefore be considered a priority and staff need to be equipped with the skills to identify, know where to refer and are guided/supervised in carrying out effective intervention programs. Since some demographic areas have more children at risk of learning disabilities, a system of differential staffing for target areas is essential.
Question 18What can be done to ensure that childcare and pre-school workers have the necessary skills to identify and assist children with or at risk of learning difficulties?
Adequate training of childcare workers and pre-school staff is essential and the response to Question 7 is valid for this group as well as nurses.
Question 19What can be done to address the current shortage of trained early childhood teachers in childcare and pre-school services?
Although teaching is second only to parenting in importance, teachers in Australia are grossly underpaid. It is little wonder that top graduates (especially men) look elsewhere for lucrative career pathways. Since the future of thousands of Australian children lie in the hands of their earliest teachers, these are the ones who need to be the best qualified (personally and professionally) and the best paid.
Question 20What other ways are there to improve the capacity of childcare and pre-school services to identify and assist children with or at risk of learning difficulties?
A child's healthy development in all areas, particularly those of social/emotional, communication, and behaviour, needs to be closely monitored by parents and care-givers continually, and by childcare workers and teachers through screenings at regular intervals. Education of all concerned in the care of children as to the early warning signs and the potential triggers of the developmental disorders, as well as knowledge of both the available interventions and current research should be a priority of all governments. Initial teacher training is essential as is continuing in-service education in order for teachers to keep abreast of new developments in the field. Once again, this training needs to be conducted by practising clinicians who have experience in this field and who can assist in the initial screening of children at risk. So many parents complain about the lack of awareness, support and understanding from childcare and preschool staff. When a problem arises in preschool the usual course of action is to either suspend the child from the centre or ask them to leave.
Question 21What are the advantages and disadvantages of a curriculum for early childhood services for children with or at risk of learning difficulties?
This really depends on who (experience, knowledge of recent research, personal qualities) sets the curriculum, the basis of that curriculum and the flexibility allowed to cater for individual differences otherwise it is in danger of becoming yet another area in which these children fail, only this time at a much younger age. There are no simple band-aids or "perfect programmes" that can be applied to this area. Clinical experience and research has repeatedly demonstrated that children with learning difficulties manifest them in a multitude of different ways and that a "one-size-fits-all" approach currently employed in education is futile. If the curriculum is simply a "watered-down" or revised version of what currently exists in Kindergarten, then it is pointless to expect different results.
Research has repeatedly shown that "Students who participate in a high calibre early childhood education program make a better transition from school to community and ultimately gain lasting benefits as socially responsible adults. High quality early childhood programs are more effective in helping children to learn. They are more beneficial than remedial programs in later school life. Experiences in the early years of life are more influential on the development of the brain than experiences at any other time in life. Early brain development has a profound effect on a person's learning, behaviour and health throughout life. Children's well-being, emotional maturity, language development, thinking skills, creative skills and social and physical skills are all established and strengthened. Children develop initiative and responsibility and the ability to analyse, to question, to make decisions and to solve problems. They learn how to be friendly, share, and cooperate with others. They develop the ability to act with confidence and they gain independence" (Department of Education Western Australia http://www.eddept.wa.edu.au). Children at risk of learning disabilities in NSW do not have the same opportunities as their counterparts in other states or countries. Appendix B contains a checklist of relevant criteria compiled by the ICDL that are critical to the success of early intervention programmes.
Question 22What is the best way to support home-based carers in the care and education of children with or at risk of learning difficulties?
The selection of suitable home-based carers is of prime importance. At present the screening system for this is inadequate. Little or no support is available from agencies offering these services since they are ignorant about the area of learning difficulties. Therefore stricter guidelines are necessary as is more frequent home inspections. Education is the key to better support for home based carers. Most of my clients have searched for years to get effective help and all say these problems were evident since their children were a year old and in care. Furthermore, all of them were shunted from "pillar-to-post" over the years as the underlying difficulties were never recognised and many of them vent their anger at a system that does not seem to care and is unwilling to open its eyes. There was little comfort for these families and children in the dismissive words "don’t worry, he’ll grow out of it" Sadly, these children did not, and now they face the daunting task of catching up on years of education that they missed. Since children are the future of this planet- ignorance about the area of learning disabilities is no longer acceptable and the costs of human suffering to our society far outweigh the money spent on prevention. For every dollar spent on early intervention, seven dollars is saved. This expenditure is necessary in order to reduce the enormous cost to the community for Medicare, unemployment and sickness benefits.
Question 28Should schools be encouraged to place greater emphasis on formal transition to school programs? Should they be required to provide formal transition programs for children who have not attended prior-to-school services?
When a child presents with a reading difficulty at this clinic, it is the last issue to be addressed. The antecedents, triggers and mediators must be identified and addressed first. It is because these have been missed, that the reading problem persists. Transition programmes such as "Reception" in South Australia or Pre-Primary in Western Australia are good models to follow. Having worked with Pre-Primary teachers in Western Australia over the past two years, it is evident to me that the training, knowledge and personal qualities of the teacher are crucial to whether a child with learning disabilities is identified and how he is managed at the school level. Lack of leadership and vision on the part of principals and administrators can defeat the best intentions of any programme or teacher.
Early screening, referral and intervention by appropriately qualified and experienced professionals is essential to ensure that each child is ready to learn. The intrinsic and environmental factors which contribute to the development of learning difficulties can be ameliorated provided there is cooperation between professionals. If transition education is to become a reality in NSW then it needs to be based upon research based functional developmental models as research has repeatedly shown that "high quality early childhood programs are more effective in helping children to learn. They are more beneficial than remedial programs in later school life". (http://www.eddept.wa.edu.au). For transition programs to be effective they need to emphasis early recognition and appropriate synergistic interventions and any problem perceived by a parent or teacher should warrant attention. Yet for many children, the early warning signals of underlying problems go unnoticed until preschool when the demands of disciplined structure and academic learning increase.
Question 36Do K-Y2 teachers need specific training in the developmental domains of early childhood? If so,what is the best way to ensure they receive this training?
Teacher training as it is presently delivered is inadequate in the area of child development because it fails to acknowledge the sound research showing that intelligence can be enhanced. The policy and practice in the NSW education community continues to be based on and guided by traditional beliefs which support a mechanistic model of teaching and learning- a model which ensures that many children with learning disabilities continue to fall through the cracks.
Models for working differently with learning disabled children to promote the full expression and extension of their talents and intelligence have been shunned by the conservative NSW academic community for political, economic, and bureaucratic reasons. Therefore, education as practiced in NSW ignores the role of development, and teaching amounts roughly to pouring information down the heads of children and those children who are able to test well on the material they are given are thought to be the most intelligent; to have the best brains.
A thorough revision of the model, more in keeping with the current research is urgently needed as is the re-education of all teachers to accommodate the diverse learning styles of the learning disabled population. Teaching a child with learning disabilities is the responsibility of all teachers- infants, primary, secondary and tertiary and therefore all need to be aware of these difficulties and use effective strategies to help these children show their knowledge and reach their inherent potential, whatever that potential may be. So many children are emotionally scarred by their experiences at the hands of insensitive and ignorant teachers in a system that refuses to acknowledge their difficulties or the right to equal opportunity in the classroom simply because in most cases their difficulties are subtle. This would have to be the worst form of discrimination.
Furthermore, feedback from recently trained teachers indicates that they are not taught how to explicitly teach children how to read. For the learning disabled child, much of the activity in K-2 classrooms is a waste of time because it is inappropriate for their developmental needs. Alarmingly, many teachers have mild literacy problems themselves (a legacy of their own education) and I can recall spending a lot of time as a school counsellor correcting grammar and spelling in teachers’ reports before handing them in to Review Committee Meetings with my own.
The early identification of learning disabilities is urgently needed and all teachers in K-2 need this specialist training. However, much of this is pointless if, when in practice, the department simply fills the vacancy with a teacher who is not qualified in this area.
My teacher training and experiences within the Department of Education as a teacher and school counsellor, led me to focus on a more wholistic approach to the interaction between home and school that either promoted or limited growth along all the developmental pathways - physical, social interactive, psycho-emotional, ethical, linguistic, intellectual and cognitive. While schools still focus primarily on the linguistic, intellectual cognitive dimensions, the social interactive, psycho-emotional, are just as important in promoting the kind of interaction between child, family and school that can lead to school success and lifelong learning.
Question 41Should Reading Recovery be modified so that it is better able to support children with specific reading difficulties?
Reading Recovery can never meet the needs of children with central auditory processing disorders (CAPD) because it fails to take into account that these children do not have the necessary neurological maturation to develop phonemic awareness skills necessary for successful reading. A plethora of research here in Australia and overseas indicates that phonemic awareness is the best predictor of reading success or failure; better than any other indicators including intelligence and verbal skills (Perfetti 1985, Adams 1990, Stanovih 1986, Andrews 1992). "No one aspect of research into reading has been so extensively examined or supported as being essential to superior reading skills as phonemic awareness. It is the "linchpin" to developing and understanding "the alphabetic principle and as such needs to be incorporated into any beginning reading program" (S. Dallas, NSW Dept of Education in "Prevention of Reading Failure" p 130-131, Ashton Scholastic 1992). Auditory processing skills which lead to phonemic awareness are underdeveloped in one third of the general population (Lindamood 1986) and Reading Recovery does not specifically address this deficit. This fact should have been researched thoroughly before it was adopted.
Reading Recovery was used extensively by the Ohio State University and in one of its statistical analysis reports that "two thirds of the group were discontinued from the project because of the gains they made…within the average level for their classes and continued to do so for the next two years" (Truch, "The Missing Parts of Whole Language, 1991, p106). This begs the question about the third that were not discontinued. Did they also manage to keep up? Furthermore, the report did not include this 30% in the presentation of their statistical analysis. Could it be that these 30% are the CAPD children who fail to progress with Reading Recovery and end up spending years in remediation without satisfactory progress and hence end up looking outside the education system for help? Are these the very same 30% in Australia who fail to reach minimum literacy scores?
Since the Department of Education does not assess or cater for children with CAPD, it must enlist the help of experienced professionals to increase teacher and school counsellor awareness of the disorder so that referrals for appropriate intervention occurs. School counsellors who are familiar with the disorder and its intervention strategies are forbidden to refer students to professionals outside government departments. These children therefore waste precious years in useless programmes/tutoring etc. because the underlying neurological deficits are never addressed even in conventional speech therapy. As a result, parents despair as they see their children’s self esteem being eroded. Without addressing the underlying neurological (auditory) processes necessary for the development of phonemic awareness and without explicit training in this area, 30% of the population will continue to fail to learn to read adequately and Australia will continue to foot the bill for unemployment and the sequela which inevitably follows. The educational system can no longer afford to bury its head in the sand since research information is readily available.
Academic institutions prefer to ignore/dismiss it and infants teachers are still not taught how to explicitly develop this skill in their students nor are they taught how to identify central auditory processing disorders (CAPD). Most paediatricians are unaware of the precise nature of CAPD and organisations purporting to deliver services for learning disabled children are also unaware of this, let alone how to remediate it.
My clinical practice is full of children and adults who in the words of one mother "have been everywhere in search of an answer" and who were not told by professionals that any sort of help existed. Parents are becoming more frustrated with the educational system and the lack of assistance provided by government departments and as a consequence, litigation against the Department of Education for failure to teach basic literacy skills or inform parents where they can get appropriate help, will become a reality. A lack of knowledge will not be an acceptable defence since the research in reading has existed for the past 20 years. At present, such a case is occurring in England, and multimedia devices will ensure that news travels fast.
Question 42Should the number of Support Teachers Learning Difficulties be increased or are there any other ways to increase the coverage of Support Teachers Learning Difficulties across the State?
Increasing the numbers of Support Teachers is of little value if they are untrained or continue to be trained in the existing archaic paradigm and if logistics place an unrealistic demand on their time.
Question 43Are there any other issues or concerns regarding the Support Teachers Learning Difficulties program?
The common practice of hiring untrained teachers aides to "hear children read"together with allocating 30 minutes of STLD time per week to children with specific learning difficulties is of little value to the children with CAPD and other learning difficulties. Schools on tight budgets opt for the cheapest possible labour and unfortunately there is no substitute for quality teaching. Communication between home and the STLD is vital since what is taught at school needs to be reinforced at home. Therefore, itis crucial that parents be involved in and understand the importance of all interventions because the skills learned in intervention sessions need to be practiced throughout the child’s waking hours. Expecting children to perform appropriately only during sessions will not be sufficient. They will not learn to generalise these new skills and much of this new learning will be maladaptive.
Question 44What are the barriers to the early identification of children with learning difficulties in the first three years at school and what should be done to overcome these barriers?
There are many barriers to the early identification of children with learning difficulties in the first three years at school. These include:
(1) the lack of an underlying multidisciplinary framework and understanding of the factors involved in learning disabilities;
(2) the unilateral acceptance of the medical model of disease and the dark art of pharmacotherapy;
(3) lack of awareness/education on the part of childcare workers to identify these children coupled with a lack of knowledge as to where to refer apart from conventional avenues;
(4) schools and organisations that deliver learning programmes working with outdated models and that fail to take into account individual differences or ignore the latest research and offer instead a "one-size-fits-all"/cookbook approach;
(5) the blind partnership between education, government and medicine which obscures issues of accountability and places participants in these systems beyond reproach;
(6) the Department of Community Services who do not appear to be able to save the lives of children at risk and have therefore closed its doors to public accountability offering instead platitudes for their failure to carry out their duties;
(7) lack of communication between government departments and the amount of bureaucracy that parents have to deal with to get any help or useful information;
(8) competition, lack of cooperation and poor communication between professionals;
(9) the dismissal and/or violent opposition of complementary interventions as "unconventional" by the academic and scientific community because they challenge the current status quo;
(10) community attitudes which seem to want a cheap "quick-fix" and therefore opt for the path of least resistance (medication);
(11) socio-cultural factors, particularly in minority populations which deny the existence of any problems and who refuse to accept help because of the stigma attached to admitting that their child is different;
(12) a society that appears intolerant and insensitive to the needs of children with learning disabilities and does notsupport these children or their parents, at any level;
(13) failure on the part of the government to adhere to "The Convention on the Rights of A Child (1989) which clearly state that "the rights of a child pertain to access to the resources necessary not only for good health but general well being and optimal function" and therefore
(14) lack of government funding to provide assistance to families for appropriate research based programmes.
Addressing these issues will require more than a band-aid approach from the government as these barriers are systemic. Simply creating one department or funding organisations which tenaciously cling to archaic models of child development and education to provide services which are inappropriate will not meet the needs of the learning disabled population (See Appendix B and the Learning Pyramid in the original submission).Overcoming these barriers will require organising the vast amount of clinical knowledge required to work with all the functional developmental capacities at the level of each child’s and family’s unique profile, and therefore must, by necessity, be an ongoing, dynamic process. By its nature, such a process needs to involve all those who work with children and their families in sharing their observations and insights to build upon the growing body of clinical knowledge that can guide what to assess, how to intervene, and where to direct research.
A paradigm shift is required to include the concept of "learning disability" which needs to be adequately and operationally defined and based on the current research. This operational definition needs therefore to include children with ADHD/ADD and associated disorders. This concept needs to be incorporated into funding criteria across many different portfolios. Cutting corners in relation to the training of health care and educational professionals will only ensure that that these problems persist. Simplistic solutions such as employing speech therapists in schools will not be enough since in order for language and cognition to develop, the brain has to integrate and process information effectively and quickly and new technologies are available for just that purpose even though the detractors may consider them "unconventional".
The Committee is once again directed to the 900 page document produced byStanley I. Greenspan, M.D., Clinical Professor of Psychiatry and Chairman of the Interdisciplinary Council on Developmental and Learning Disorders. If one reads the document carefully it will be noted that the ICDL have actually incorporated some of the "unconventional" therapies dismissed by detractors and this committee. Furthermore, they are open to accepting the value of other "unconventional therapies" as researchers and clinicians report on the efficacy of these new technologically-based interventions in ameliorating autism, mental retardation, attentional and learning difficulties.
Question 46 Is there any reliable evidence about the efficacy of non conventional treatments to help overcome the intrinsic factors that result in learning difficulties? If so, how should this knowledge be reflected in practice?
Before answering this question it is necessary to ask some questions about the detractors themselves. For instance, do they themselves have children with learning disabilities and have they had any personal experience with these "non-conventional treatments?" Why do they continue to support a status quo which continues to fail our children and contaminate their bodies and brains with neurotoxic chemicals and medications? Are they affiliated with drug companies and other powerful political lobbies? Are they even familiar with the evidence presented? Are they not concerned for instance, about the increasing number of recent studies reporting on the negative side effects of stimulant, antidepressant, and anticonvulsant medications?
The MIMS (a doctor’s desk top reference manual) clearly states that for most of the medications listed, "the mode of action is not understood", and then goes on to list various "known" side effects. In a recent discussion with a pharmacist colleague, he stated that "doctors are required to study interactions of many drugs released ‘as approved’ each year. When these drugs are first released upon the public, two to three ‘adverse’ side effects are noted. By the time the drug has been on the market for one to two years, the list of side effects has increased to over one hundred, including death. Yet they are still marketed". This serious concern over drug toxicities was reported in the Journal of the American Medical Association, (JAMA Jan 2002, Vol 287, 2215-2220, 2273-2275). Additionally, there is no way of knowing how an individual will react to a given drug – it is like playing Russian Roulette -- and unfortunately I see the effects of such mismanagement daily in private practice.
There is overwhelming evidence for the need for proper nutrition in a range of medical disorders and for the efficacy of essential fatty acids in many of the disorders of the Western World. However, the issue of nutrition has been ignored by this committee, dismissed by mainstream medicine and not considered worthy of attention by administrators as is evidenced by the plethora of junk food on sale at most school and hospital canteens. The "Textbook of Nutritional Medicine" and "Nutritional Influences on Mental Illness" cites all published studies in this area.
Furthermore, are the detractors even aware of current research which is being conducted at Sydney University which is employing the technique of functional imaging of the brain, and that these results are concordant with consistent findings in the QEEG? "Given the present lack of objective measures to make a differential diagnosis of ADHD, it appears time to integrate this powerful tool (QEEG) into standard clinical practice…..The QEEG abnormalities seen in ADHD are common, appear in most identified patients, and are not subtle when the proper technology is used to observe them". (Nash, J. Clinical Electroencaphalography, 2000, Vol 31, No.1 p 32 "Treatment of ADHD with Neurotherapy"). "QEEG studies are particularly well suited to identifying subtle changes in the topographic distribution of background activity and can aid in difficult differential diagnoses such as assessing cognitive, attentional or developmental disorders" (Hughes & John, 1999 Conventional and Quantitative Electroencephalography in Psychiatry).
The following information taken from the EEG Biofeedback Institute in the Czech Republic investigated the efficacy of neurofeedback in a variety of disorders using meta-analysis. (http://www.eegbiofeedback.cz/English/bioEFF.htm).
EEG Biofeedback in Medicine
Up to 1980
Number of Studies
These studies have been published in diverse peer review journals and have been found effective for a range of disorders including the following:- ADHD, Learning Difficulties, Epilepsy, Depression, Alcoholism, Anxiety and Stress, Migraines & Headaches, Sleep Disorders, Chronic Fatigue Syndrome, Tourette’s Syndrome, Stroke, Autism, Traumatic Brain Injury, Multiple Sclerosis and Schizophrenia.
Given the fact that none of these studies were sponsored by drug companies, and were funded by either practising clinicians or are the result of research in universities around the world, it is time that the detractors retracted their statements about the lack of evidence for neurofeedback and instead started to ask how this learning strategy could help children in NSW keeping in mind "The Best Practices" guidelines and recommendations of the Interdisciplinary Council on Developmental and Learning Disorders in Bethesda, Maryland, USA.
As far as the therapeutic value of sound therapy is concerned, the first published article appeared in the American Medical Association’s professional journal in 1914 and was written by Dr Evan O’Neil Kane. Since then many hospitals and teaching institutions have incorporated sound therapy into their environments. The committee was supplied results from SAMONAS Sound therapists here in Sydney and need to remember that clinicians do not have the time or the money to fund large scale studies. Active opposition by the medical establishment and multinational drug companies has resulted in a scarcity of research dollars to support the study of treatments/interventions that cannot be patented, making the personal price too high for most researchers wishing to conduct research into non-conventional treatments. Clinicians can only report on the results we obtain for the conditions which are presented.
Detractors who are so concerned about the lack of double blind, placebo-controlled studies which are considered the "gold standard" for evaluating medical therapies, need to be reminded of the fact that most accepted treatments in current use were validated by the "silver standard" of clinical trial. In other words, they worked. Once a method is shown to work, it becomes very difficult, if not frankly unethical, to do a placebo-controlled study. Furthermore, placebo double blind studies are only suitable for drug testing and inappropriate for "non-conventional therapies" simply because these therapies are drug-free. This does not mean that these methods cannot be scientifically evaluated, since there are many other valid means of testing.
Since the evidence presented to the committee and its detractors is unacceptable, it is proposed that the detractors and the committee find the keys to support the considerable research funding necessary to validate the effectiveness of all the "non-conventional" therapies submitted to them. It seems pointless to submit any more evidence since the establishment is unwilling to acknowledge the possibilities and embrace the shift in paradigm that is required to incorporate these models into practice.
The committee is redirected to the evidence it was originally presented and reminded of an old adage which states that the "truth always goes through three stages- first it is ridiculed, then it is violently opposed and finally accepted as self evident"(Polonious). How much longer must children with learning difficulties suffer before the "detractors" finally admit that current conventional practice is not best practice for these children? It is glaringly obvious that conventional methods are failing to serve the needs of the learning disabled population and is precisely why a small group of professionals around Australia have eagerly pursued and incorporated the latest and most effective research-based methods into their practices. The Committee is therefore directed to the 900 page document produced by Stanley I. Greenspan, M.D., Clinical Professor of Psychiatry and Chairman of the Interdisciplinary Council on Developmental and Learning Disorders. It is interesting to note that the ICDL have actually incorporated some of the "unconventional" therapies dismissed by this committee.
The "unconventional" therapies submitted are complementary to conventional methods and the aim of these therapies is to individualise the approach to each child’s and family’s unique profile. This goes significantly beyond available research and requires a reliance on both research and clinical experience from each of the disciplines that work with children and families with special needs.
Questions 57 & 58. Should speech pathologists and other relevant therapists be employed by the department of Education and Training to work in schools? .Are there other ways to ensure that schools cater appropriately for children who have special therapy needs?
As mentioned above and in original submissions from sound therapists, central auditory processing disorders (CAPD) cannot be adequately treated by conventional speech therapy. This is the main reason why parents seek us out, because years of conventional speech therapy have failed their children. Unless the underlying neurological, (neuro-sensorial) deficits are addressed, speech therapy as it is practised in NSW and Australia will be of limited value to these children. This is especially evident with autistic, dyspraxic and dyslexic children.
For attention and behavioural disorders, self regulation training such as neurofeedback (over 500 peer review articles) is a safe, non-invasive drug free method to improve concentration, motivation, anxiety, depression etc. If the Department wants to take on the cost of establishing neurofeedback in the school system then the start up cost to each school will be around $50,000 for the unit and training of one technician. Experienced clinicians will still be necessary to screen, diagnose and set the protocols and consultant fees will need to be paid. Continual upgrading of the technician’s skills will also be necessary as neurofeedback is a clinically driven tool. (The Yonkers District in New York did establish neurofeedback in schools and it was very effective- however after the events of September 11, the program was put on hold). A more cost-effective way is to refer these children to appropriately experienced clinicians.
Other therapy such as neurodevelopmental therapy (inhibition of primitive reflexes etc.) is easy to implement in schools and has been done successfully in WA, Queensland and here in NSW once staff and parents have been trained. SAMONAS Sound therapy is also easy to implement in schools. Another important way in which schools could cater for these children is for school canteens to stop offering snack and junk foods which have virtually no nutritional value, are full of chemical additives, are low in protein and high in sugar, salt and trans fatty acids. A plethora of studies associate these factors to food allergies, yeast infections, hyperactivity and poor concentration in the medical literature. Yet this factor seems to have been ignored entirely by the committee and mainstream medicine.
Schools need to become more adaptable. Adaptability is a "state of management mind" resulting from a set of core values that include an emphasis on change. The school executive needs to ensure that staff members have a common set of core values which inspires passion in teachers. Ideally, these core values would include adaptability, flexibility, care and appreciation. Leaders need to ensure that the strategies change, adapt and transform into new activities uniquely suited to current needs and that core values and purpose remain stable and protected. The mechanical delivery of facts contained in a curriculum is an inappropriate way to teach children with learning disabilities. Timetables and staffing ratio need to be flexible, and the delivery of information needs to be tailored to cater for these children. Teachers need to be taught how to teach these children.
Within the realm of learning difficulties, including ADHD, dyspraxia, dyslexia, each child evinces his or her own unique profile.The goal of any early intervention programme is to help children acquire the highest possible level of independent functioning. It is therefore essential to employ a functional developmental approach that can tailor the assessment and intervention to a specific child and family, rather than fit the child into a standard assessment and treatment programme. Observation, assessment, and working with each area of functioning, both at home and at school, thus providing the infrastructure for a functional developmental approach is the key to success in amelioration of learning difficulties.
In protecting the prevailing paradigms, science, education and medicine, like all institutions move ever so slowly, so as purportedly 'not to make mistakes'. As a consequence, genuinely new and important ideas can tend to be subjected to intense and unprecedented scrutiny, or alternatively they are reviled, and rejected out of hand, until 'discovered' under more palatable circumstances. Detractors who tenaciously hold to dogmas of models that are proving to be inadequate, need to embrace the change of the times and work together toward solutions for the future of our children, our state and our nation. Unless the prevailing paradigms are radically modified, Australia will continue to foot the bill for unemployment and the sequela which inevitably follows undiagnosed and mismanaged learning difficulties.
With appropriate early interventions, a child can overcome or learn to compensate for a wide range of developmental problems. Intensive, well-designed, and timely intervention can improve the prospects—and the quality of life—for many children who are considered at risk for cognitive, social, or emotional impairment.There is much to be said for interdisciplinary discussion - solutions tend to be forthcoming in a shorter time. Development of a dynamic programme of health and education promotion which adapts to new knowledge and encourages interdisciplinary work with developmental delay and learning difficulties is a must, as is a change in the way we think.
The cornerstone of change, is education and attitudinal change. Learning disabled and ADHD children are precious resources for our society, with each one having intrinsic value in their own right. It is up to all of us concerned, professionals and lay people alike to open our minds, keep ourselves informed and advocate for best practice for these children.
Will this committee continue to entrust our future generations to the hands of conventional practice which obviously cannot meet the needs of learning disabled children, or will it embrace Dr John Yu’s suggestions and find the keys to "educate each child according to his ways" (Proverbs 22:6), thus ensuring best practice for children with learning disabilities?
The Interdisciplinary Council on Developmental and Learning Disorders
4938 Hampden Lane, Suite 800 Bethesda, MD 20814 301-656-2667 www.icdl.com
ICDL Advisory Board
Stanley Greenspan, M.D. Chair, Clinical Professor of Psychiatry, Behavioral Sciences and Pediatrics, George Washington University Medical School
Serena Wieder, Ph.D. Associate Chair, Clinical Psychologist
Frederick Almqvist, M.D., Professor of Child Psychiatry, University of Helsinki
Margaret Bauman, M.D., Associate Professor of Neurology, Harvard University
Lois Black, Ph.D, Director, Center for Psychological and Neuropsychological Services
Adele Brodkin, Ph.D., Clinical Associate Professor of Psychiatry, New Jersey Medical School
Cecilia Breinbauer, M.D., Child Psychiatrist, University of Chile
Harry Chugani, M.D., Professor of Pediatrics, Neurology and Radiology, Wayne State University School of Medicine
Susan Coates, Ph.D., Clinical Psychologist, Columbia University Center for Psychoanalytic Training and Research
Leon Cytryn, M.D., Clinical Professor of Psychiatry and Pediatrics, George Washington University Medical School
Georgia A. DeGangi, Ph.D., O.T.R, F.A.O.T.A,. Clinical Psychologist, ITS for Children and Families, Inc.
Barbara Dunbar, Ph.D., Developmental Psychologist, Adjunct Faculty, Psychology Department, Georgia State University
Sima Gerber, Ph.D., C.C.C.-S.L.P., Assistant Professor of Linguistics and Communication Disorders, Queens College, CUNY
Arnold Gold, M.D., Professor of Clinical Neurology and Clinical Pediatrics, College of Physicians and Surgeons, Columbia University
Lois Gold, O.T.R., Director of Occupational Therapy, Center for Pediatric Therapy
Myron Hofer, M.D., Professor of Psychiatry, College of Physicians and Surgeons, Columbia University
Barbara Kalmanson, Ph.D., Clinical Psychologist
Pnina Klein, Ed.D., Professor, Department of Education, Bar Ilan University
Karen Levine, Ph.D., Instructor, Harvard University Medical School
Pat Lindamood, M.S., C.C.C.-S.L.P., Director, Lindamood-Bell Learning Processes
Toby Long, Ph.D., P.T., Director, Division of Physical Therapy, Georgetown University Child Development Center & Associate Professor, Department of Pediatrics, Georgetown University
Darey Lowell, M.D., Assistant Clinical Professor, Yale University
Jane Madell, Ph.D., Director, Hearing and Learning Center, Beth Israel Medical Center, New York
Arnold Miller, Ph.D., Executive Director, Language and Cognitive Development Center, Boston
Nancy Minshew, M.D., Associate Professor of Psychiatry and Neurology, University of Pittsburgh School of Medicine
Robert Nardone, M.D., Clinical Instructor of Psychiatry, Harvard University Medical School
Stephen Porges, Ph.D., Professor, Department of Human Development, University of Maryland
Barry Prizant, Ph.D., C.C.C.-S.L.P., Director, Childhood Communications Services, Adjunct Professor, Brown University
Ricki Robinson, M.D., M.P.H., Clinical Professor of Pediatrics, University of Southern California
Molly Romer Whitten, Ph.D., Clinical Psychologist
Mark Rosenbloom, M.D., President, Unicorn Children’s Foundation, Assistant
Professor, Clinical Medicine, Northwestern University Medical School
Rebecca Shahmoon Shanok, M.S.W., Ph.D., Director, The Early Childhood Group Therapy Service and Training Program & Director, Institute for Clinical Studies of Infants, Toddlers and Parents, Jewish Board of Family and Children’s Services, New York
Stuart Shanker, Ph.D., Professor of Psychology and Philosophy, York University
Milton Shore, Ph.D., Adjunct Professor, Catholic University
Richard Solomon, M.D., Clinical Associate professor of Pediatrics, University of Michigan Medical School
Gerry Stephanatos, D. Phil., Associate Professor of Neuroscience, NJ Neuroscience Institute at JFK Medical Center
Amy Wetherby, Ph.D., Professor of Communication Disorders, Florida State University
Robert B. Wharton, M.D., Chief, Developmental and Behavioral Pediatrics, Massachusetts General Hospital and Spaulding Rehabilitation Hospital, Harvard Medical School
G. Gordon Williamson, Ph.D., Director, Project ERA, JFK Medical Center
Andrew Zimmerman, M.D., Associate Professor of Neurology and Psychiatry, Kennedy Kreiger Institute, Johns Hopkins University School of Medicine
The Developmental, Individual Differences, Relationship-Based (DIR) Approach
(Taken from the ICDL Clinical Practice Guidelines Overview and Recommendations pg 20)
The promising elements just identified can be conceptualized as part of a comprehensive developmental model (Greenspan, 1992; Greenspan & Wieder, 1998, 1999) by systematizing the elements into the three broad categories described in a previous section.
These broad categories are:
1. D – Developmental capacities that integrate the most essential cognitive and affective processes. These are the six functional functional developmental capacities described
previously on page 18 of this chapter.
2. I – Individual differences in motor, auditory, visual-spatial, and other sensory processing capacities.
3. R – Relationships that are part of child-caregiver and family interaction patterns and which provide:
– ongoing nurturing support;
– orchestration of the specific educational and therapeutic elements incorporated in 1 and 2 above;
In the Developmental, Individual Differences, Relationship-based (DIR) approach, functional developmental capacities, individual differences in processing capacities, and relationships embedded in the child-caregiver and family patterns are utilized together in clinical decision making to create an individualized program for a given child and family.
Moving from standardized, one-time assessments to observing functional impairments in the context of truly helpful interventions over time will certainly change how therapists diagnose problems. It may, at
times, change the ultimate diagnosis chosen for a child. These ongoing observations are especially relevant for autistic spectrum disorders, mental retardation, and many types of attentional and learning problems.
In conclusion, there is a wide range of research and clinical experience not just from the field of autism but from the field of early intervention and child development at large, which, when taken as a whole, provides considerable empirical support (far more than for more circumscribed approaches) for a comprehensive developmental model.
Restrictive frameworks that ignore a child’s relevant processing capacities, critical functional developmental abilities, the necessity for family support, and involvement of all relevant disciplines presents a special challenge. These restrictive frameworks also tend to promote adversarial interactions between educational or service system professionals and parents. Therefore before funding is allocated to organisations who provide learning programs, the following criteria compiled by the ICDL provides a baseline.
Checklist on Assessments and Interventions for Complex Developmental Problems, Including Autistic Spectrum Disorders
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