J. Paediatr. Child Health (1992) 28, 343-346
Annotation The effectiveness of early intervention: A critical review T. S.PARRY State Child Development Centre, Health Department of Western Australia, West Perfh, Western Australia, Australia
Along with improved early identification of children with developmental delay has emerged the concept of early intervention. As in all areas of medicine this has produced its strong proponents and ardent critics. Ferry somewhat caricatured the present dilemma when she addressed the effectiveness of early intervention programmes:’ In recent years, there has been an exponential proliferation of developmental stimulation programmes for environmentally deprived and neurologically handicapped children. Premature infants in neonatal intensive care units are being cuddled, patted, stroked with vibrators, and rocked in water beds and motorised hammocks. They are exposed to flashing lights, dangling birds and toys, and piped-in heartbeat sounds and music. Infants and preschoolers with neurologic disorders roll on beach balls in special ‘infant classrooms’ or ‘therapeutic playgrounds’ and in ’creative play centres’. We have home-based orientated programmes; home-based child-orientated programmes; centrebased, parent-child orientated ones. Older children with learning disabilities practice walking on balance beams to improve their gross motor skills and learning abilities . . . Infant ‘stim’ and developmental therapy programmes now represent a major industry in our country, employing thousands of personnel (infant therapists, child developmental specialists, movement therapists, physical and occupational therapists, early child educators, parent trainers, home teachers and aides). There are three broad categories of children for whom early intervention services are offered: (1) Infants and children at environmental risk. (2) Infants and children at increased biological risk. (3) Infants and children with established developmental delays, deviations or di~abilitiesz-~ The bulk of research on the value of early intervention is related to those who are environmentally at risk - for this group, given certain criteria, intervention is highly effective. The principles have tended to be extrapolated to biologically impaired children but with less clear proven effectiveness. The aims of early intervention have been summarized recently by Moore4 (1) To promote the social, emotional, intellectual and physical growth of young children with developmental problems and to take maximum advantage of their potential for learning.
Correspondence: T. S. Parry, State Child Development Centre, Health Department of Western Australia. PO Box 510, West Perth, WA 6872, Australia. T. S. Parry, FRACP, DPH, DCH, FRACMA. Senior Paediatrician. Accepted for publication 18 November 1991.
(2) To prevent the development of secondary disabilities in young children with developmental problems. (3) To support the families of young developmentally disabled children so as to enable them to meet the needs of the children as effectively as possible. Nevertheless, within these broad aims it must be recognized that there is no one concept of early intervention. As Guralnick and Bennett point out? Early intervention is not a singular construct, but rather is a term that refers to a collection of different ‘early interventions’,each varying widely in its goals, nature and scope. For any group of handicapped children the different forms these early interventions can take can range considerably. Variations in focus,. . . type of developmental or educational model,. ..timing of intervention... . duration,. . . intensity, location...and the object of the intervention are only some of the important dimensions across which early interventions can differ. Any statements relating to the effectiveness of early intervention must consider these variations. Current research evidence can be summarized as pointing to intervention programmes that show: (i) known benefits; (ii) known non-benefits; and (iii) unproven or unknown.
KNOWN BENEFITS Early intervention increases the intellectual functioning of children in lower socio-economic circumstances, particularly where the mother is of limited intelligence. ‘Head Start’ programmes and the Milwaukee project6 are examples of this, and Bronfenbrenner summarized 12 research studies in 1974.’ The most sustained results were obtained when cognitively structured curricula were used rather than play orientated programmes, if home visiting was included and continued, when parents were also involved in the programmes, and where children entered into the programme in the first or second years of life. The Perry Pre-School Project reported substantial effects of early intervention on variables such as high school graduation rates, employment and teenage pregnancy rates.*,’ The cost benefit of the High Scope project indicated ‘for every $1000 that was invested in the preschool programme, at least $4130 (after inflation) has been or will be returned to society’.’’ For the environmentally at risk, programmes do not primarily enhance early intellectual development to an above average range, but rather aim to prevent or slow a decline away from the average. Many earlier studies considered outcome only in terms of intel-
T. S. Parry
344
lectual progress or academic achievement. Investigators who have focused primarily on cognitive function have ignored other outcomes such as social competence, family functioning and adaptability which are closely related to the goals of most intervention programmes. There is a need for what Guralnick calls second generation approaches. One such second generation approach in preterm infants indicated marked improvement in sensitive transactions between parents and child following 11 one h sessions in the week prior to discharge.” There was associated increase of cognitive development over a 4 year period compared with a decline in the control group. A related study of what is called parental ‘empowerment’ showed similar result^.'^ The Portage Scheme has been shown to benefit intellectually handicapped children14 while progress in developmentally delayed preschool children using a similar home training scheme has been reported.15 However, in line with earlier research, those who benefited most were the environmentally deprived group, particularly in personal and social development. There has been controversy concerning the benefits of early intervention for Down syndrome children. Piper and Pless reported no demonstrable improvements in infants with Down syndrome receiving a 6 months stimulation programme.16 Similarly, no difference was shown in motor or mental performance in those receiving a neurodevelopmental programme compared to those who did not, though some studies did show improvement.”-19 Progress in personal/social development of Down syndrome children involved in a Portage style based programme has been r e p ~ r t e d . It ’ ~would seem that early intervention programmes for Down syndrome children have the effect of preventing typical decline in intellectual function.20s21 Another home intervention programme involved parents of severely intellectually handicapped preschool children. There were two experimental groups, one visited individually at 2 week intervals and one at 8 week intervals over a 3 year period; a third group received no intervention. Results indicated measurable improvement in intellectual ability in the two experimental groups irrespective of social class. Again the importance of parental involvement was s t r e ~ s e d . ’ ~ In children with cerebral palsy there is no doubt that early intervention improves socio-emotional status and enriches the parent/child relationship, particularly when parents are included in the programme; however, there is controversy about the role of physiotherapy. Children with spastic diplegia walked earlier and more steadily if placed in an early treatment group (before 9 months of age) compared with those for whom treatment was initiated after 9 months.22The effects on children with spastic diplegia who received 12 months of neurodevelopmental therapy (Bobath), compared to 6 months of comprehensive infant stimulation followed by 6 months of neurodevelopmental therapy, indicated a significant advantage on both motor and cognitive measures for the group receiving infant s t i m u l a t i ~ nThis . ~ ~ study indicated that a systematic and comprehensive programme of parent mediated infant stimulation benefited both motor and cognitive development. Of eight studies reviewed recently in the area of cerebal palsy, five were found to support the effects of early intervention on improving children’s motor progress and encouraging parental acceptance. Nevertheless, the variety of type and severity of cerebal palsy emphasizes the need for careful study definition as well as highlighting the complexity of evaluation. Language intervention programmes have also been found to produce sustained benefits if commenced early in preschool
years, if they follow a developmental approach and if parents are used as teachers in partnership with t h e r a p i s t ~ z ~ - ~ ~ For specific language disorders in particular, centre-based programmes may be better than home-based programmes alone, but those where parents reinforce centre-based work at home have good results for generalizing the skills learned beyond the therapy session. Language delay may have links with maternal depression, behaviour problems and subsequent learning difficulties, highlighting the importance of early language intervention programmes coupled with family ~ u p p o r t z ~ ~ ~ * For children with primary autism, intellectual, academic and social improvement has been demonstrated, with the following being important components of such programmes:z9~30 (i)structured behavioural treatment; (ii) parent involvement; (iii) treatment at an early age with intensive treatment (several hours a day, 5 days a week); (iv) generalization of skills. For children who are visually impaired, research is meagre, with small numbers and variable conditions. Early intervention is likely to produce near normal functioning in blind children on the assumption that there is a carryover between centre and home. Similarly, for hearing impaired children, good outcomes are related to early parental counselling, adequate staff training, the early inclusion of some signing language and the use of deaf persons in the programmes.
THE KNOWN NON-BENEFITS Those treatment programmes based on the theory that either new neurons can be grown or unused neurons can be activated have not been scientifically validated. Treatment procedures developed at the Institute for the Achievement of Human Potential, especially ‘patterning’, have been evaluated and found not to significantly improve outcome3’ It was concluded that ‘patterning treatment should not be recommended for seriously retarded children, particularly considering its cost and parental effort, money and manpower’. The conclusions of the American Medical Association, the National Health and Medical Research Council of Australia and the British Paediatric Association have all been similar. It is also clear that Sica cell therapy for children with Down syndrome has no proven benefit or scientific basis. There has been no proven benefit of the use of multivitamins for children with developmental and particularly reading problems, and caution should be exercised with respect to the possible harmful side effects of excessive Vitamins A or D32133 Similarly optometric training, following the belief that learning disabilities are related to opticovisual perceptual difficulties and programmes can improve visual tracking and strengthen the so-called ‘dominant’ eye, have not been found to be effective.34
THE UNPROVEN OR THE UNKNOWN Controversy exists about a number of therapies used with developmentally delayed children including Sensory Integration Therapy as designed by Jean A ~ r e s . 3Similarly, ~ a kinaesthetic sensitivity test has been recently designed as a diagnostic and treatment tool to help children with difficulties in kinaesthetic ability.36 However, doubts about the validity of the test have been raised and the results of a study of a group of clumsy
Effectiveness of early intervention
children found that the kinaesthetic sensitivity test failed to distinguish between the performances of clumsy children and those of an age-matched control g r o ~ pThe . ~test ~ failed ~ ~ ~to fulfil the claims of the authors either as a research or a clinical tool. This controversy will no doubt continue. Claims have been made that people with reading difficulties have a visual distortion especially related to a white background. Coloured lenses, especially yellow and blue, have been alleged to help. There is no evidence yet available to substantiate the claims and even if visual/perceptual clarity is improved and reading technique enhanced, reading comprehension (a linguistic skill) is not influenced. This is not to say that some of these therapies have no benefit at all, but rather that their benefits are at present unproven. Where they do not require unreasonable expense or the deflection of professional time away from more demonstrably effective areas of involvement, their contribution to self-esteem and family acceptance of the disabled can be useful. Welldesigned prospective research is still needed.
345
early management. Paediatricians have a social responsibility to encourage the development of early intervention and management programmes, particularly for environmentally deprived children and children showing language delay. This may assist in preventing the frequent problems of borderline intellectual delay and learning disability with associated behaviour problems and social disruption. Paediatricians also have responsibility for ongoing and thorough research as to the efficacies of programmes already operating and a clear responsibility to warn families about those programmes which are proven harmful or useless. Nevertheless, all this is not to say that predominant benefits to children with disabilities is from professional groups alone. As Norman Acton pointed out ‘the most important aspect for any programme for disability, prevention and rehabilitation is the family’. Adequate counselling, support, empowerment and skills transference to families is probably the best service we are able to offer to our communities.
REFERENCES SUMMARY The following principles are now clearly defined in the management of children with developmental delay: (1) Multidisciplinary teams are more effective than individual therapeutic approaches. (2) The whole development of the child needs to be considered rather than a single deficient area alone. (3)Home-based programmes are more effective in the young preschool child than centre-based programmes alone. (4) Parent involvement in partnership with professionals is essential for sustained progress. (5) Maximum effectiveness is achieved when parental skills are increased. (6)Programmes commencing earlier in preschool years are more effective than those that commence late. This concept has been recently challenged and evidence supports benefits for the disadvantaged rather than the d i ~ a b l e d . ~ White also contends that there is ‘simply not enough information to be confident about the long-term impact of early intervention with handicapped children and evidence in support of many of the commonly held positions about mediating variables (e.g. parental involvement, age at start) is either non-existent or contradictory’? Early intervention is clearly effective in offering parental support, fostering parent/child relationships and diminishing anxiety even for those programmes that have not at present been proven in altering the developmental disability. Programmes that involve high cost, disrupt total family functioning, deflect scarce resources away from more proven areas of effectiveness should be discouraged, and they should never cause guilt in either parent or professional when they seem ineffective. Future research should include investigation of outcomes other than cognitive and physical functioning alone. We should be warned from the somewhat crisp statement of Mark Twain: ‘There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment in fact’. Paediatricians and other health workers have an important role in early identification and the steering of affected children to appropriately trained teams that can offer full assessment and
1 Ferry P. C. On growing new neurons: Are early intervention programmes effective? J. Paediatr. 1987; 67: 38-41.
2 Tjossem D. T. lntervention Strategies for High Risk lnfants and
Young Children. University Park Press, Baltimore. 1987. 3 Browder J. A. The Paediatricians’ orientation to infant stimulation programmes. J. Paediatr. 1981; 67: 42-4. 4 Moore T. J. Helping young children with developmental problems: An overview of current early interventionaims and practices. Aust. J, Early Child. 1990; 15: 3-8. 5 Guralnick M. J., Bennett F. C. The Effectiveness of Early lntervention for At-risk and Handicapped Children. Academic Press, Orlando. 1987. 6 Heber R., Garber H. The Milwaukee project: A study of the use of family intervention to prevent cultural familial mental retardation. In Friedlander B. Z.,Sheriff G. M., Kirk G. E. eds. Exceptional Infant, Vol. 3, Assessment and Intervention. Brunner & Mazel, New York. 1975; 399-433. 7 Bronfenbrenner U. Is early intervention effective? In Friedlander 8. Z.,Sheriff G. M.,Kirk G. E. eds. ExceptionalInfant, Vol. 3, Assessment and Intervention. Brunner & Mazel, New York. 1975; 449-57. 8 Berrueta-Clement J. R., Schweinhart L. J., Barnetl W. S.,Epstein A. S., Weikart D. P. Changedlives: The effects of the ferry Preschool Programme on youths through age 19. The High/Scope Press, Ypsilanti, MI. 1984. 9 White K. R. Efficacy of early intervention. J. Spec. Ed. 1985-6; 19: 410-15. 10 Lazar I.,Darlington R. eds. Lasting effects of early education: A report from the Consortium for Longitudinal Studies. Monogr. SOC. Res. Child Dev. 1982; 47: 2-3. 11 Greenspan S. I.,White K. R. The efficacy of preventive intervention:A glass half full? In Provence S.ed. Zero to Three. Bull Natl. Center Clin. lnfant Prog. 1985; 5(4): 1-5. 12 Rauh V. A., Achenbach T. M., Nurcombe B., Howell C. T.. Teti D. M. Minimizing adverse effects of low birth weight: Four-year results of an early intervention programme. Child Dev. 1988; 59: 544-53. 13 Resnick M. B., Armstrong S., Carter R. L. Developmentalintervention program for high-risk premature infants: Effects on development and parent-infant reactions. J. Dev. Behav. Paediatr. 1988; 9: 73-8. 14 Bluma 6.S.,Shearer M., Frohman A., Hillard J. Portage Guide to Early Education. Co-operative Educational Service Agency, no. 12, Portage, WI. 1976. 15 Barna S., Bidder R. T., Gray 0. P., Clements J.. Gardner S. The progress of developmentally delayed preschool children in a home training scheme. Child Care Health Dev. 1980; 6: 157-64. 16 Piper M. C., Pless I. B. Early intervention for Down’s syndrome: A controlled trial. J. Paediatr. 1980 65: 463-8.
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17 Harris S. Effects of neurodevelopmental therapy on motor performance of infants with Down’s syndrome. Dev. Med. Child Neurol. 1981; 23: 477-83. 18 Bricker D., Dow M. Early interventionwith the young severely handicapped child. J. Assoc. Sev. Handicap. 1980; 5: 130-42. 19 Sandow S. A,, Clarke A. D. B., Cox M. V., Stewart F. L. Home interaction with parents of severely subnormal preschool children: A final report. Child Care Health Dev. 1981; 7: 135-44. 20 Reed R. B., Pueschel S. M., Schnell R. R.. Gonk C. E. Interrelationships of biological, environmental and competency variables in young children with Down Syndrome. Appl. Res. Ment. Refard. 1980; 1: 161-74. 21 Berry P.. Gunn P., Andrews R. J. The behaviour of Down’s syndrome children using the ‘Lock Box’. A research note. J. Child Psychol. Psychiatry 1984; 25: 125-31. 22 Kanda T., Yuge M., Ymori Y., Suzuki J., Fukaseh. Early physiotherapy in the treatment of spastic diplegia. Dev. Med. Child Neurol. 1984; 26: 438-44. 23 Palmer F. B., Shapiro E. K.. Wachtel R. C. et a/. The effects of physical therapy on cerebral palsy. N. Engl. J. Med. 1988; 318: 803-8. 24 Cooper J.. Moodley M.. Reynell J. Helping Language Development. Edward Arnold, London. 1978. 25 Fowler W. A,, Ramey C., Bricker W. Papers presented at Early Language Intervention Conference, Sturbridge, MA. May 1979. 26 Miller J. F. Early language intervention.When and how. In Lewis M.. Taft L. L. eds. Developmental Disabilities, Theory, Assessmenf and lntervention. MTP Press, New York. 1982. 27 Rickman N., Stevenson J., Graham P. J. Preschool to School. A Behavioural Study. Academic Press, London. 1982.
T. S. Parry
28 Carmichael A,, Williams H. E.,Picot S., Yen L., Huntley M. Family and social correlates of health, growth and development in four year old children from a birth cohort. Aust. Paediatr. J. 1984; 20: 251. 29 Lovaas 0. I. Behavioural treatment and normal education and intellectual functioning in young autistic children. J. Consult. Clin. Psychol. 1987; 55: 3-9. 30 Strain P. S.,Hoyson M. H.. Jamieson 6.J. Normally developing preschoolers as interventionagents for autistic-like children. Effects on class department and social interactions. J. Div. Early Child. 1985; 9: 105-15. 31 Sparrow S., Zigler E.Evaluation of a patterningtreatment for retarded children. J. Paediatr. 1978; 62: 137-50. 32 Storm G. Alternative therapies. In Levine M. D., Carey M. B., Crocker A. C.. Cross R. T. eds. Developmental/Behavioural Paediatrics. W. 6. Saunders. Philadelphia. 1983. 33 Golden G. S. Controversial therapies. In Symposium on Learning Disorders. Pediatr. Clin. North Am. 1984; 31: 459-69. 34 Benton C. The eye and learning disabilities. J. LearningDisab. 1973; 6: 334. 35 Ayres A. J. Sensory lntegrafion and Learning Disorders. Western Psychological Services. Los Angeles. 1972. 36 Laszlow J. I., Bairstow P. J. Perceptual-Motor Eehaviour. DevelopmentalAssessment and Therapy. Holt, Rinehart and Winston, London. 1985. 37 Doyle A. J. R., ElliottJ. M., Connolly K. J. Measurement of kinaesthetic sensitivity. Dev. Med. Child Neurol. 1986; 28: 188-93. 38 Lord R., Hulme C. Kinaesthetic sensitivity of normal and clumsy children. Dev. Med. Child Neurof. 1987; 29: 720-5.
Annotation The effectiveness of early intervention: A critical review T. S.PARRY State Child Development Centre, Health Department of Western Australia, West Perfh, Western Australia, Australia
Along with improved early identification of children with developmental delay has emerged the concept of early intervention. As in all areas of medicine this has produced its strong proponents and ardent critics. Ferry somewhat caricatured the present dilemma when she addressed the effectiveness of early intervention programmes:’ In recent years, there has been an exponential proliferation of developmental stimulation programmes for environmentally deprived and neurologically handicapped children. Premature infants in neonatal intensive care units are being cuddled, patted, stroked with vibrators, and rocked in water beds and motorised hammocks. They are exposed to flashing lights, dangling birds and toys, and piped-in heartbeat sounds and music. Infants and preschoolers with neurologic disorders roll on beach balls in special ‘infant classrooms’ or ‘therapeutic playgrounds’ and in ’creative play centres’. We have home-based orientated programmes; home-based child-orientated programmes; centrebased, parent-child orientated ones. Older children with learning disabilities practice walking on balance beams to improve their gross motor skills and learning abilities . . . Infant ‘stim’ and developmental therapy programmes now represent a major industry in our country, employing thousands of personnel (infant therapists, child developmental specialists, movement therapists, physical and occupational therapists, early child educators, parent trainers, home teachers and aides). There are three broad categories of children for whom early intervention services are offered: (1) Infants and children at environmental risk. (2) Infants and children at increased biological risk. (3) Infants and children with established developmental delays, deviations or di~abilitiesz-~ The bulk of research on the value of early intervention is related to those who are environmentally at risk - for this group, given certain criteria, intervention is highly effective. The principles have tended to be extrapolated to biologically impaired children but with less clear proven effectiveness. The aims of early intervention have been summarized recently by Moore4 (1) To promote the social, emotional, intellectual and physical growth of young children with developmental problems and to take maximum advantage of their potential for learning.
Correspondence: T. S. Parry, State Child Development Centre, Health Department of Western Australia. PO Box 510, West Perth, WA 6872, Australia. T. S. Parry, FRACP, DPH, DCH, FRACMA. Senior Paediatrician. Accepted for publication 18 November 1991.
(2) To prevent the development of secondary disabilities in young children with developmental problems. (3) To support the families of young developmentally disabled children so as to enable them to meet the needs of the children as effectively as possible. Nevertheless, within these broad aims it must be recognized that there is no one concept of early intervention. As Guralnick and Bennett point out? Early intervention is not a singular construct, but rather is a term that refers to a collection of different ‘early interventions’,each varying widely in its goals, nature and scope. For any group of handicapped children the different forms these early interventions can take can range considerably. Variations in focus,. . . type of developmental or educational model,. ..timing of intervention... . duration,. . . intensity, location...and the object of the intervention are only some of the important dimensions across which early interventions can differ. Any statements relating to the effectiveness of early intervention must consider these variations. Current research evidence can be summarized as pointing to intervention programmes that show: (i) known benefits; (ii) known non-benefits; and (iii) unproven or unknown.
KNOWN BENEFITS Early intervention increases the intellectual functioning of children in lower socio-economic circumstances, particularly where the mother is of limited intelligence. ‘Head Start’ programmes and the Milwaukee project6 are examples of this, and Bronfenbrenner summarized 12 research studies in 1974.’ The most sustained results were obtained when cognitively structured curricula were used rather than play orientated programmes, if home visiting was included and continued, when parents were also involved in the programmes, and where children entered into the programme in the first or second years of life. The Perry Pre-School Project reported substantial effects of early intervention on variables such as high school graduation rates, employment and teenage pregnancy rates.*,’ The cost benefit of the High Scope project indicated ‘for every $1000 that was invested in the preschool programme, at least $4130 (after inflation) has been or will be returned to society’.’’ For the environmentally at risk, programmes do not primarily enhance early intellectual development to an above average range, but rather aim to prevent or slow a decline away from the average. Many earlier studies considered outcome only in terms of intel-
T. S. Parry
344
lectual progress or academic achievement. Investigators who have focused primarily on cognitive function have ignored other outcomes such as social competence, family functioning and adaptability which are closely related to the goals of most intervention programmes. There is a need for what Guralnick calls second generation approaches. One such second generation approach in preterm infants indicated marked improvement in sensitive transactions between parents and child following 11 one h sessions in the week prior to discharge.” There was associated increase of cognitive development over a 4 year period compared with a decline in the control group. A related study of what is called parental ‘empowerment’ showed similar result^.'^ The Portage Scheme has been shown to benefit intellectually handicapped children14 while progress in developmentally delayed preschool children using a similar home training scheme has been reported.15 However, in line with earlier research, those who benefited most were the environmentally deprived group, particularly in personal and social development. There has been controversy concerning the benefits of early intervention for Down syndrome children. Piper and Pless reported no demonstrable improvements in infants with Down syndrome receiving a 6 months stimulation programme.16 Similarly, no difference was shown in motor or mental performance in those receiving a neurodevelopmental programme compared to those who did not, though some studies did show improvement.”-19 Progress in personal/social development of Down syndrome children involved in a Portage style based programme has been r e p ~ r t e d . It ’ ~would seem that early intervention programmes for Down syndrome children have the effect of preventing typical decline in intellectual function.20s21 Another home intervention programme involved parents of severely intellectually handicapped preschool children. There were two experimental groups, one visited individually at 2 week intervals and one at 8 week intervals over a 3 year period; a third group received no intervention. Results indicated measurable improvement in intellectual ability in the two experimental groups irrespective of social class. Again the importance of parental involvement was s t r e ~ s e d . ’ ~ In children with cerebral palsy there is no doubt that early intervention improves socio-emotional status and enriches the parent/child relationship, particularly when parents are included in the programme; however, there is controversy about the role of physiotherapy. Children with spastic diplegia walked earlier and more steadily if placed in an early treatment group (before 9 months of age) compared with those for whom treatment was initiated after 9 months.22The effects on children with spastic diplegia who received 12 months of neurodevelopmental therapy (Bobath), compared to 6 months of comprehensive infant stimulation followed by 6 months of neurodevelopmental therapy, indicated a significant advantage on both motor and cognitive measures for the group receiving infant s t i m u l a t i ~ nThis . ~ ~ study indicated that a systematic and comprehensive programme of parent mediated infant stimulation benefited both motor and cognitive development. Of eight studies reviewed recently in the area of cerebal palsy, five were found to support the effects of early intervention on improving children’s motor progress and encouraging parental acceptance. Nevertheless, the variety of type and severity of cerebal palsy emphasizes the need for careful study definition as well as highlighting the complexity of evaluation. Language intervention programmes have also been found to produce sustained benefits if commenced early in preschool
years, if they follow a developmental approach and if parents are used as teachers in partnership with t h e r a p i s t ~ z ~ - ~ ~ For specific language disorders in particular, centre-based programmes may be better than home-based programmes alone, but those where parents reinforce centre-based work at home have good results for generalizing the skills learned beyond the therapy session. Language delay may have links with maternal depression, behaviour problems and subsequent learning difficulties, highlighting the importance of early language intervention programmes coupled with family ~ u p p o r t z ~ ~ ~ * For children with primary autism, intellectual, academic and social improvement has been demonstrated, with the following being important components of such programmes:z9~30 (i)structured behavioural treatment; (ii) parent involvement; (iii) treatment at an early age with intensive treatment (several hours a day, 5 days a week); (iv) generalization of skills. For children who are visually impaired, research is meagre, with small numbers and variable conditions. Early intervention is likely to produce near normal functioning in blind children on the assumption that there is a carryover between centre and home. Similarly, for hearing impaired children, good outcomes are related to early parental counselling, adequate staff training, the early inclusion of some signing language and the use of deaf persons in the programmes.
THE KNOWN NON-BENEFITS Those treatment programmes based on the theory that either new neurons can be grown or unused neurons can be activated have not been scientifically validated. Treatment procedures developed at the Institute for the Achievement of Human Potential, especially ‘patterning’, have been evaluated and found not to significantly improve outcome3’ It was concluded that ‘patterning treatment should not be recommended for seriously retarded children, particularly considering its cost and parental effort, money and manpower’. The conclusions of the American Medical Association, the National Health and Medical Research Council of Australia and the British Paediatric Association have all been similar. It is also clear that Sica cell therapy for children with Down syndrome has no proven benefit or scientific basis. There has been no proven benefit of the use of multivitamins for children with developmental and particularly reading problems, and caution should be exercised with respect to the possible harmful side effects of excessive Vitamins A or D32133 Similarly optometric training, following the belief that learning disabilities are related to opticovisual perceptual difficulties and programmes can improve visual tracking and strengthen the so-called ‘dominant’ eye, have not been found to be effective.34
THE UNPROVEN OR THE UNKNOWN Controversy exists about a number of therapies used with developmentally delayed children including Sensory Integration Therapy as designed by Jean A ~ r e s . 3Similarly, ~ a kinaesthetic sensitivity test has been recently designed as a diagnostic and treatment tool to help children with difficulties in kinaesthetic ability.36 However, doubts about the validity of the test have been raised and the results of a study of a group of clumsy
Effectiveness of early intervention
children found that the kinaesthetic sensitivity test failed to distinguish between the performances of clumsy children and those of an age-matched control g r o ~ pThe . ~test ~ failed ~ ~ ~to fulfil the claims of the authors either as a research or a clinical tool. This controversy will no doubt continue. Claims have been made that people with reading difficulties have a visual distortion especially related to a white background. Coloured lenses, especially yellow and blue, have been alleged to help. There is no evidence yet available to substantiate the claims and even if visual/perceptual clarity is improved and reading technique enhanced, reading comprehension (a linguistic skill) is not influenced. This is not to say that some of these therapies have no benefit at all, but rather that their benefits are at present unproven. Where they do not require unreasonable expense or the deflection of professional time away from more demonstrably effective areas of involvement, their contribution to self-esteem and family acceptance of the disabled can be useful. Welldesigned prospective research is still needed.
345
early management. Paediatricians have a social responsibility to encourage the development of early intervention and management programmes, particularly for environmentally deprived children and children showing language delay. This may assist in preventing the frequent problems of borderline intellectual delay and learning disability with associated behaviour problems and social disruption. Paediatricians also have responsibility for ongoing and thorough research as to the efficacies of programmes already operating and a clear responsibility to warn families about those programmes which are proven harmful or useless. Nevertheless, all this is not to say that predominant benefits to children with disabilities is from professional groups alone. As Norman Acton pointed out ‘the most important aspect for any programme for disability, prevention and rehabilitation is the family’. Adequate counselling, support, empowerment and skills transference to families is probably the best service we are able to offer to our communities.
REFERENCES SUMMARY The following principles are now clearly defined in the management of children with developmental delay: (1) Multidisciplinary teams are more effective than individual therapeutic approaches. (2) The whole development of the child needs to be considered rather than a single deficient area alone. (3)Home-based programmes are more effective in the young preschool child than centre-based programmes alone. (4) Parent involvement in partnership with professionals is essential for sustained progress. (5) Maximum effectiveness is achieved when parental skills are increased. (6)Programmes commencing earlier in preschool years are more effective than those that commence late. This concept has been recently challenged and evidence supports benefits for the disadvantaged rather than the d i ~ a b l e d . ~ White also contends that there is ‘simply not enough information to be confident about the long-term impact of early intervention with handicapped children and evidence in support of many of the commonly held positions about mediating variables (e.g. parental involvement, age at start) is either non-existent or contradictory’? Early intervention is clearly effective in offering parental support, fostering parent/child relationships and diminishing anxiety even for those programmes that have not at present been proven in altering the developmental disability. Programmes that involve high cost, disrupt total family functioning, deflect scarce resources away from more proven areas of effectiveness should be discouraged, and they should never cause guilt in either parent or professional when they seem ineffective. Future research should include investigation of outcomes other than cognitive and physical functioning alone. We should be warned from the somewhat crisp statement of Mark Twain: ‘There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment in fact’. Paediatricians and other health workers have an important role in early identification and the steering of affected children to appropriately trained teams that can offer full assessment and
1 Ferry P. C. On growing new neurons: Are early intervention programmes effective? J. Paediatr. 1987; 67: 38-41.
2 Tjossem D. T. lntervention Strategies for High Risk lnfants and
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