M.A.(Psych), Grad. Dip. Ed. Studies (Sch.Counsel), Grad. Dip. Ed., B.Sc., MAPS, AACNEM

Registered Psychologist
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.

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 7^th 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".

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:-

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 30^th 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).).

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.

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.

"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.

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.

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.

(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;

(14) lack of government funding to provide assistance to families for appropriate research based programmes.

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 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).

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 "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.

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.

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.

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?

4938 Hampden Lane, Suite 800 Bethesda, MD 20814 301-656-2667 www.icdl.com

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

(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;

• provision of ongoing interactive learning opportunities geared to the child’s individual differences and current functional developmental capacities throughout most of the child’s waking hours (at an appropriate intensity); and
• a balance between one-on-one caregiver-to-child interactions and peer-to-peer interactions appropriate to the child’s individual differences and functional developmental capacities.

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.