(
Received May 30; revision accepted for publication October 1, 1969.)The research reported is supported in part by the National Institutes of Health, National Institute of Child Health and Human Development (HD 00719); the Association for the Aid of Crippled
Children; the National Association for Retarded Children; the United Cerebral Palsy Research and
Education Foundation (CF-75-66C and CF-75-67C); and by the Children’s Bureau, Department of
Health, Education and Welfare (12:HS, No. 241).
ADDRESS FOR REPRINTS:
(
H.J.C.)
Department of Pediatrics, Albert Einstein College of Medicine, Eastchester Road and Morris Park Avenue, Bronx, New York 10461.PnrnAmics, Vol. 45, No. 2, February 1970
SPECIAL ARTICLE
SOME
CONSIDERATIONS
FOR
EVALUATING
THE
DOMAN-DELACATO
“PATTERNING”
METHOD
Herbert J. Cohen, M.D., Herbert G. Birch, M.D., and Lawrence T. Taft, M.D.
From the Department of Pediatrics and Departmen* of Rehabilitation Medicine,
Albert Einstein College of Medicine, Bronx, New York
I
N the present paper we plan to evaluatethe objective evidence available for an
estimation of the worth of the patterning
method advanced by Doman, Delacato, and their colleagues for the treatment of chil-dren with neuromuscular disorders, behav-ioral abnormalities, learning disabilities, and apparent mental subnormality. The method of treatment and habilitation
de-scribed by Doman and Delacato and called “patterning” has purportedly been useful
for
(
1)
achieving greater “mobility” inpa-tients with brain damage than has been achieved by classical therapy; (2) treating communicative disorders, including visual, speech, and reading disabilities; (3) en-hancing intelligence and elevating I.Q.
levels;
(
4)
preventing communicativedis-orders, altering aberrant behavior, and
im-proving coordination in normal infants, to-gether with;
(
5)
having other universal applications.’4More recently, proponents of the method have claimed that it is useful not only for
the handicapped child, but that it also may
have important consequences for the
pro-motion of normal physical and behavioral
development. Moreover, in one publication, they have inferred that the appropriate ap-plication of the method may enable parents to improve normal development
signifi-cantly.5
Any method capable of producing such
important consequences must be of serious
interest to all who are concerned with
chil-dren and their development. If, in fact, the method does have the consequences attrib-uted to it by its advocates and if it does not
do unintended harm, there can be no rea-son to restrict or to limit its universal
appli-cation. Consequently, the method must be
studied carefully and the data upon which
its claims are based must be subjected to
the most careful scrutiny. It is especially necessary to engage in such consideration
of the present state of evidence, since there is no universally accepted or successful set of procedures currently available for the effec-live habilitation of children with neuromus-cular disorders, brain damage, mental sub-normality, and serious educational handicap.
In the absence of a universally accepted set of procedures and in the presence of pressures for service to children exhibiting
the difficulties enumerated, it is inevitable that judgments of the value of any specific
procedure may tend more to reflect pas-sions and degrees of adherence to
view-points
than facts. Given thesecircum-stances, it is especially important to analyze the available data and to assess their direct or indirect pertinence to the issues of habil-itation, rehabilitation, and education for which they have been claimed to be rele-vant. In the present paper, therefore, we
shall review the available evidence and seek to relate it to more general knowledge. Such an effort, it is to be hoped, can both
point
to potential values and relate thea way as to permit us to assess its specific worth.
A NOTE OF CAUTION
In the course of our efforts to evaluate the patterning method, it is essential that
an objective and dispassionate attitude
be
maintained. One must not be provoked by
inaccuracies and extravagances which,
some-times in the heat of controversy and as a re-suit of zeal, may have been made by both the advocates and adversaries of the method.
In our effort to evaluate the worth of the
patterning method, we shall try to insulate ourselves from emotional reactions that may be stimulated by verbal extravagances.
Our emphasis and focus will be upon the facts with respect to the method and the degree to which reasonable conclusions
may be drawn from these facts.
THE PATTERNING
METHOD
The patterning method used by Doman and Delacato derives from a phylogenetic interpretation of development which seeks to correlate progressive changes in the
em-bryogenesis of the human nervous system, and in the ontogenesis of behavior with the
corresponding levels of representation of
motor functioning in the central nervous
system of lower vertebrates. This
concep-lion represents an extension of Haeckel’s#{176}
biogenetical principal derived by him from
the work of Fritz Muller7 on the develop-ment of crayfish. Briefly stated, this view implies that the ontogeny not only of man, but also of every living creature is a recapit-ulation of its phylogeny, and that “the de velopment of the embryo is an abstract of the history of the genus.” This recapitula-tive view of ontogenesis was most fully ap-plied to problems of nervous system
disor-ders in children by Temple Fay8 with whom Doman had been associated. The
present theories of “patterning” represent an extension and application of these reca-pitulationist principles and may briefly be
summarized.
In its broadest sense the viewpoint has been stated by Delacato as follows : “Man has evolved phylogenetically in a known
pattern. The ontogenetic development of
normal humans in general recapitulates
that phylogenetic process. We have been able to take children who deviate from
nor-ma! development
(
severe brain injured) and through the extrinsic imposition of nor-ma! patterns of movement and behavior have been able to neurologically organizethem sufficiently so that they can be placed within a human developmental pattern of crawling, creeping and walking. Finally, with man’s unique lateral neurological function added to this structure, talking, reading and writing developed.”3 In
an-other place Delacato1 states: “man’s final and unique developmental progression takes place at the level of the cortex, and it
is lateral (from left to right or from right to left). This progression is an interdependent
continuum . . . if a lower level is incom-plete, all succeeding higher levels are af-fected both in relation to their height in the
central nervous system and in the relation to the chronology of their development.”
In a concrete sense these general con-cepts have been elaborated in the following way:
1. Truncal movements of the newborn infant are comparable to the swimming movements of the fish and correspond to a
medullary level of brain function.
2. “Homolateral crawling”
(
i.e., crawling in such a manner that the arm and leg on the side toward which the head is turned are flexed, while the opposite arm and legare extended) is analogized to crawling in amphibia and believed to reflect a pontine level of brain organization.
3. “Cross-pattern creeping”
(
i.e., creep-ing with a flexed arm and extended leg on the side toward which the head is turned, while the opposite side has the armextended and the leg flexed) is related to
reptilian creeping and viewed as a mid-brain level of function.
with-out a cross-pattern
)
is a primate movement and is believed to represent an earlymani-festation of a cortical functioning.
5. “Cross-pattern walking” is considered
to be a distinctly human form of locomotion
and is identified with mature cerebral
func-lion and with the establishment of
hemi-spheric dominance.
Basing themselves upon this set of
con-cepts, the proponents of patterning have argued that each of the levels is stage
de-pendent and that adequate organization at
any subsequent level is dependent upon
mastery of the coordination requisite for the
antecedent stages.3 In this sense, each ear-her stage represents a critical step in
devel-opment for adequate organization of func-tioning at succeeding stages. Thus, it is suggested that, if cross-pattern creeping were not successfully practiced and mas-tered, crude and cross-pattern walking would be abnormally organized. From these assumptions it has been inferred that abnor-mal organization of function reflects failure
to achieve mastery at antecedent levels, and that rehabilitation requires the development of adequate organization at these levels. A progressive advance to higher levels of
or-ganization may, they suggest, occur only
after appropriate patterning at the earlier
level has been established.
The therapeutic program has reflected these views and has been based upon an at-tempt to recapitulate the physiologic stages of motor development through exercises. This has been done either by the external
involuntary imposition of patterns of
activ-ity, or by having the child voluntarily prac-tice presumably missed earlier stages of
mastery. When applied, the program has been tailored to the presumed needs for such experience in the individual patient.
With individual variation, the following two general types of program have been proposed.23
Treatment Program 1
This program is recommended for all nonwalking children and requires that the patient spend most of the day
(
except forspecial treatment periods and for
satisfac-tion of physical and emotional needs
)
on the floor in the prone position, where crawl-ing and creeping are encouraged.Treatment Program 2
When the patients with damage are un-able actively to engage in specific patterns
of activity, such patterns are passively fin-posed by manipulation of the limbs by the therapists, parents, and other teams of
cooperating individuals. It is argued that such passive manipulation will impose
“pat-terns” on the central nervous system.
The actual “patterning” procedures are executed by three to five adults, who ma-nipulate the right arm and right leg, the left arm and leg, and the head. The “pat-tenting” is performed smoothly and
rhythmically and in a meticulously ordered sequence. Each child is “patterned” for pe-nods of at least 5 minutes four times a day, 7 days a week, without exception. At first the procedures may be carried out by ther-apists, but subsequently the administration of the entire program can become the re-sponsibility of the family and friends.
The patterning procedures are supple-mented by a program of sensory stimula-tion, breathing exercises, and a plan of re-striction and facilitation which is claimed to
foster the establishment of hemispheric dominance.2’3
ASSESSMENT OF THE METHOD
There are at least two levels at which to consider the therapeutic method-theoreti-cal and empirical. The theoretical involves a consideration of the degree to which the
concepts underlying the method are in ac-cordance with current knowledge
of
thede-velopment
and organization of the centralnervous system both in
phylogenesis
andontogenesis.
The
history of biology isre-plete with considerations of the weaknesses
of recapitulationist theory and no
substan-tial support for the general viewpoint can
be
drawn from current consideration of the nervous system and its development.treat-SPECIAL ARTICLE
ment method in basic science does not in
it-self justify the rejection of a practice. The
history of medicine contains many instances
of correct practice at first justified by
made-quate theory; and, quite independently of a
consideration of the rationale for
“pattern-ing,” one has the responsibility to consider its worth as an empirical procedure in
habil-itation and rehabilitation. It is with this
second question that we shall be centrally
concerned.
In considering the worth of patterning as
an empirical therapeutic method, several
questions must be answered. These may be
formulated as follows:
1. Does the evidence support the
conclu-sion that when applied the method results in improvement?
2. Is the improvement achieved equal to,
better than, or less substantial than that
achieved by the application of alternative therapies of equivalent human or monetary cost?
3. Are there negative consequences of the application of the method?
4. Are the results reported as deriving from the method directly dependent on it, or are they serendipitous consequences
de-riving inadvertently from the maturation of
the child, the amount of time and training devoted to his care, the structuring of
pat-terns of parental behavior, or the
placebo
effect of rearoused hopes for progress and improvement in functioning?Since the method is new and has been
systematically applied almost exclusively by
its advocates, any assessment of worth must
at present derive from their published data. These data are to be found in a number of
reports of both a professional and popular
variety
(
Life Magazine;9 Look Magazine;10Reader’s Digest; Saturday Evening Post;12 Doman and Delacato5 ). The two major sources for data are an article by Doman,
et
al.2 reporting, “the preliminary results . .
are encouraging” and promising “further
studies of these procedures will be
under-taken.” The second is a book by Delacato3 in which little new data on motor function-ing are advanced, but additional findings
on reading and changes in the intelligence
quotient are reported. Since the quantita-tive treatment of data is most clear in the 1960 paper by Doman, et ai.2 it will be con-sidered first.
The paper2 reports the results of a 2-year study of 76 children to whom the
pattern-ing was applied. The children were all out-patients and represented a most
heteroge-neous grouping of individuals with nervous
system pathology-ranging from dysgenesis
of major brain structures to hydrocephalous and subdural hematoma. Included in the group were children exhibiting a wide
range of physical findings usually asso-ciated with cerebral palsy such as spastic-ity, athetosis, ataxia, and rigidity.
Twenty-four of the children had clinically noted seizures. Four had been subjected to hemi spherectomy and 16 of the hydrocephalic
patients had shunts. The range of age of the children was wide and extended from 12 months to 9 years, with a median age of
26
months. Duration of treatment was also varied and ranged from 6 to 20 months, with a mean duration of 11 months. No control group was studied, nor was any reported effort made to compare the progress of matched clinical cases treated by other methods applied with equal conviction. Thereport therefore describes the changes noted
in a miscellaneous group
of
neurologicallydamaged children of wide age range treated for different lengths of time by the method
of “patterning.”
To assess these changes is not eaSy. For example, it is necessary to consider the
mi-tial status of the patient, the anticipated de-velopmental course independently of theapplication
of any defined
method oftreat-ment, the behaviors that have been changed, and the validity of the assessment. A recent editorial by Bax and MacKeith13
on the
results of treatment indicates theneed for all of these factors to be consid-ered if a treatment method is to be fairly assessed. The editors note:
The December 1966 issue of the Reader’s Digest
summarized a novel describing how a child,
306
EVALUATION OF “PATTERNING” METHODto have cerebral palsy of very poor prognosis as
re-gards motor function, had, after treatment
pre-scribed at a particular clinic, been able to go to an
ordinary school and was on the way to walking.
The treatment programme described was extremely
rigorous and demanding for all concerned but,
after all, worthwhile for the results were spectacu-lar. It is not emphasized that, however falsely gloomy earlier prognosis had been, the prognosis
given at Massachusetts General Hospital when she
was eighteen months old was that she was of aver-age intelligence, would be able to go to an ordi-naiy school and would eventually walk. In fact the
“special” treatment achieved much of what had
been indicated as likely to follow conventional management which would have been less demand-ing for the whole family.
The effects of treatment in the series of cases reported in 1960 was evaluated by Doman, Delacato, and their associates2 in
the following way: Prior to the initiation of treatment each child was evaluated on the therapist’s own “mobility scale” with re-spect to the locomotor stage and level he had achieved prior to “patterning” therapy. At the end of the treatment period, progress in motor organization was assessed in terms of the same scale. Other features of func-tion, such as the development of speech, were also noted.
The data as presented are extremely diffi-cult to assess because, given the
heteroge-neity of the sample studied, no reported
effort was made to treat the data in an age-specific or entity-specific manner. The only
concession to age heterogeneity is the global division of mean progress by three gross age categories. For the rest, the group
is considered as a unit.
The data on motor progress indicate gen-era! improvement in the group. However,
of the 56 children who were
nonambula-tory
at the beginning of the study, 45 were still not walking at the end of the treatmentperiod.
Of the 11 children who achievedin-dependent walking, 9 (or 82%) were under the age of 2 years at the start of treatment. Other general progress in motor coordina-lion
(
such as improved arm and legmove-ment, crawling and creeping
)
is also re-ported for the group as a whole.In the absence of a control group, it is
not possible to assess the degree to which the reported progress was the result of the treatment applied. Clearly, maturational factors independent of the treatment regi-men could have resulted in similar changes,
especially in the very young patients. Such
an interpretation is supported by our own
experience
on locomotor development inpatients seen at the Developmental
Evalua-tion Clinic of the Albert Einstein College of Medicine.
Of the first 345 patients seen in this
clinic, 119 retarded and handicapped
chil-dren
were unable to walk by 18 months of age. Of these children, 70 (or 58.8%)achieved independent walking by 24 months of age. These children received no special therapeutic programs but still
at-tained ambulation, though often with sig-nificant delay. These findings are in agree-ment with those of Levinson, et al.14 who, in their studies of motor development in mongoloid children, noted that 60% walked
by 2 years of age and over 80% did so by 3 years of age without any special training.
On the basis of these clinical experiences with essentially untreated children exhibit-ing delays in motor development, the
re-suits reported by the advocates of pattern-ing appear to be singularly unimpressive
and lead to the possible inference that the reported changes were at least as much a function of maturation over time as they were improvement induced by treatment.
In a more recent report of data,3 the find-ings of the first paper are repeated and a further point is made that, of the group of
retarded children seen, 59% began to talk at some time during the treatment period.
Once
again
a comparison with our ownclinical data is of interest. In our own
clinic, of the first 239 cases for whom
accu-rate data were available, only 48 children were speaking intelligible words by 24 months of age. Of the remaining 191
pa-tients, 112 (or 58.6%) were using words by
group of 2 year olds who received no spe-cial therapy.
The comparative figures on locomotor
development and on speech progress should
not be taken literally. The cases in our
clinic and those to whom patterning was
applied may of course have been different
from one another. They are presented less
in a spirit of refutation than as an illustra-tion of the need to have comparable data
on an appropriately selected control group,
if the changes attributed to therapy in
chil-dren exhibiting delays in development are to be meaningfully assessed.
Other publications describing the use of
“patterning” regimens present no additional
supportive data but rather use vague case histories as testimonials of effectiveness.
Two brief examples may be cited.
1. An 83-year-old, nonreading boy3
“for-merly diagnosed as brain-injured, mentally
retarded
(
IQ 85) [sic], and emotionally dis-turbed . . . disorganized neurologically at both cortical and sub-cortical levels. His at-tention span was extremely short and hewas very resistant to guidance.” No
addi-tional medical history is given. The patient
is “patterned” and strenuously programmed to “establish hemispheric dominance.” The
results are described as one of the author’s
“most dramatic successes,” when after 1%
years of therapy the patient received a
post-treatment I.Q. score of 133, accompa-nied by the disappearance of his emotional problems.
2. Age not stated. “At the time of the original testing, this student evidenced neu-rologic disorganization, lack of laterality, and walked with a slightly rigid gait. This
condition could indicate abnormal neuro-motor activity. After 6 weeks of therapy ex-cellent progress was made in neurological
organization, laterality was established, and
there was some success in maintaining a
correct sleep pattern
(
tonic neck posture). Coordination improved and the walk be-came less rigid.”3 The patient showed anI.Q. gain of 9 points.
The case history just considered
repre-sented one of a group of 14 children in a
“12 week therapy program in neurologic or-ganization and dominant laterality.”3 This group of children was reported to achieve an average I.Q. gain of 9.2 points over a 9-month period subsequent to the initiation
of treatment.
Besides the vagueness of the case
histo-ries, notable for their lack of objective neu.. rologic data, idiosyncratic definitions of mental subnormality, and presumptions of
neuroanatomic localization of lesion, the
re-ported studies also manifest a number of other significant shortcomings in the light of existing knowledge. These must be briefly considered.
Since the advocates of patterning have emphasized changes in intelligence quo-tient as being due to “patterning” therapy,
it is of value to view these data against the background of accumulated knowledge on
stability and instability in I.Q. Bayley15 has demonstrated that a 20-point swing in I.Q.
score over a year of time is not uncommon
for the young average child. Honzikl6 has noted that I.Q. retest scores vary widely as a function of altered environmental condi-tions. Other studies, too, have illustrated
the favorable effects of diverse educational programs on I.Q. scores.
Undoubtedly, a good part of the I.Q. gains that have been reported were the
re-suit of test familiarization. However, that this is by no means the whole story is sug-gested by other studies such as that of Wellman and Pegram,17 who analyzed the beneficial effect of preschool nursery atten-dance on I.Q. score. In this study, a group
of orphanage children regularly attending nursery school had an average I.Q. jump of
6.8 points over a 20-month period. In
con-trast, a matched control group of children
without nursery school experience had lower scores on retesting. Under similar conditions, children with initially average levels of intelligence experienced an 18.2
hospitalized children within 1 week of
re-turning to their homes.
While advocates of “patterning” note an
improvement in intelligence after the thera-peutic program, a recent report by
Kershnerbo indicates that, when the pattern-ing regimen was applied to moderately re-tarded children, the resultant I.Q. gains were not in excess of that noted by other authors who have reported spontaneous
I.Q. gains in both normal and subnormal individuals. Clarke, et al.20 reported that children with I.Q.’s of 50 to 70 were not subject to reliable predictions of later func-tion, particularly if they suffered from the
destructive effects of adverse environmental conditions. Many children exhibited
sponta-neous increments in I.Q. as they grew
older. Helm and Wallace,21 however,
sug-gest that repetitive I.Q. testing was
suffi-cient, in itseff, to produce a consistent rise
in I.Q. scores and state that learning can
occur during intelligence testing.
Social and environmental conditions, too, are motivating factors which affect both
general performance and I.Q. test results.
Newman, et al.22 in their study of twins, in-dicated that environmental differences af-fect ultimate intelligence. Haggard23 achieved remarkable I.Q. improvements in
groups of children prepared for I.Q. tests
with 50-minute practice sessions on each of the 3 days immediately preceding retest-ing. These sessions enabled children to
be-come acquainted with methods and situa-lions similar to the mode of presentation used for actual testing. Preparatory mate-rials were presented under conditions and in a form more familiar to the children. In addition, a mere change of attitude and at-mosphere has affected significant improve-ment in overall function. Tizard24 studied the influence of different types of supervi-sion on the behavior of mental defectives.
With strict supervision, the majority of the patients performed better than with a more relaxed atmosphere. In another study,
Tizard25 illustrated that the psychological
development of handicapped children is
profoundly modified by a change in
envi-ronment. This change was accomplished by the transfer of children from an institu-tional setting to a cottage nursery in which an extensive program of physical exercise was integrated into the usual educational activities. The specifically treated group
demonstrated a marked improvement in adaptive behavior, in self-care skills, and in language usage as compared to a control group.
Most dramatically, Skeelsl6 recently
re-ported a 30-year follow-up of children
ini-tially diagnosed as mentally subnormal.
Most of these children achieved normality when given affectionate care by mildly sub-normal adolescent girls in an institution.
The original gains were sustained into adult life.
Since close supervision, repeated testing,
structured environment, and a favorable at-mosphere all may produce substantial
bene-fits in I.Q. and social functioning, there is ample reason to question the claim that the
types of improvement reported by Doman
and Delacato are the direct result of
“pat-terning” treatments.
The same type of analysis can be applied to other claims advanced by the advocates of “patterning,” e.g., improvements in motor function, perception, speech, language, and reading. Considerations of space limit such explicit evaluation. However, the
in-terested reader may view the papers by Freeman,27 and for reading progress in par-ticular, by Robbins.28’29
Having viewed the evidence in relation
to the worth of “patterning” as an empirical procedure for the correction of certain
functions and found it inadequate, we can
now turn
to
a consideration of thetheoreti-cal basis of the method. Such consideration
is of value because, even if a given empiri-cal application may be unconvincing, the concepts that have been suggested as to mechanisms underlying handicap may be of importance.
THE RATIONALE FOR “PATTERNING”
Following
Temple
Fay,8’30’31
Delacato’organiza-lion and development ontogenetically
re-capitulates the phylogenetic development
of the nervous system.” He states, “this
whole phylogenetic process is recapitulated
ontogenetically with each human being”l
and suggests that, in the event that there is
a disturbance in the phasing of such
onto-genetic recapitulation, adaptive functioning vill be impaired. He has further indicated
that deviation from the reported evolution-ary sequence of neurologic development
can create perceptual and motor difficulty as well as disturbance in language and com munication skills. The theory emphasized that hemispheric differentiation and, in par-ticular, dominance represent the highest level of neurologic organization. “Brain
in-juries
or inadequate
subcortical
organiza-tion both result in difficulty in the
establish-ment of hemispheric dominance”3 and much of the attending therapeutic recom-mendations are centered around “a program of establishing cortical hemispheric
domi-nance through the development of
unilat-eral handedness, footedness, and
‘eyed-ness .
-Therapy involves “utilization of patterns
of activity administered passively to a child, which reproduce the mobility functions for which the injured brain levels are responsi-ble.”2 The rationale for this method was first elaborated by Fay,8 who wrote,
“de-spite loss of higher voluntary levels, crude
patterns of movement remain in the human
being, and these can be trained
to
obtainthe least spasticity, coordinated movements and useful activity. . . . Properly timed, coordinated, and conditioned use of these reflexes, in conjunction with the tonic neck reflex sequence makes semi-automatic
crawling and walking possible.”
In addition to Fay’s earlier emphasis on motor functioning, Doman and Delacato have added a regime of sensory stimulation,
since they indicate that “sensory reception
is a prerequisite to motor expression.”2 In one place they have stated: “At the root of
all learning are stimulation of the senses
and organization of the nervous system,
be-cause the brain learns how to be brainy by
building its experience on a foundation
of
early sensations and certain very basic body movements.”5 By applying these principles,
Delacato has claimed to have taken “chil-dren who deviated from normal develop-ment
(
severely brain-injured)
and through the imposition of normal patterns of move-ment and behavior, have been able to neu-rologically organize them sufficiently so that they could be placed within the humandevelopmental patterns of crawling, creep-ing and walking.”3 He adds, “if we can ac-complish this with the severely brain in-jured, we should be able to organize those
children who are not brain injured but only
neurologically disorganized, with much
greater results and much less effort.”3
These general notions clearly lead to the possibility of formulating a set of questions,
the
answers to which are pertinent for a consideration of the theoretical rationale“patterning”
method.
We shall limit ourconsiderations to the following:
What are the effects of practice, sensory stimulation, and repetitive actions on neu-rological organization?
What is the significance of lateral
domi-nance to communicative or motor
dysfunc-tions and in particular what effect does “patterning” have on the acquisition of
reading abilities and the alteration of I.Q. scores?
THE EFFECTS OF SENSORY STIMULATION
AND PRACTICE ON DEVELOPMENT
There is little doubt that sensory stimula-tion has important effects on neurological growth and organization. Studies of animals
reared in darkness by Goodman,32 Riesen,33 Brattgard,34 and, more recently, by Altman35 of rats reared in an “enriched” versus a stricted” environment have clearly demon-strated that gross sensory deprivation has important neuropathological and functional
consequences. However, little evidence is available to indicate that less severe degrees of deprivation have identifiable
rectification of the neurological defects once they have occurred.
“Patterning,” or the repetitive simulation
of normally occurring movement sequences,
employs passive motor activity as its prime
therapeutic technique. Its proponents claim that such movements, performed in the
proper sequence, are not only reparative but when spontaneously performed in nor-ma! children are also essential for the de-velopment of normal function. However, numerous studies of the development both
of animals in experimental circumstances and of human children, reared under
spe-cial conditions, suggest that adequate orga-nization of neurological function is
achieved despite specific deprivations re-sulting from motor restriction.
The studies of Carmichael3#{176} are funda-mental for clarifying the role of sensory
feedback in the continuity of neurologic or-ganization. Carmichael studied frog and
salamander embryos that were stripped of
their protective jelly coating and immersed in a chlorotone anesthetic solution. Both
anesthetized and controlled embryos expe-rienced normal growth, but the anesthe-tized embryos were never allowed to make
body movements. After removal from the
chlorotone, the anesthetized group
immedi-ately, after the anesthetic had worn off,
displayed swimming movements
indistin-guishable from those made by the non-anesthetized controls. Carmichael’s subse-quent studies37’3 demonstrated that the
lapse of time prior to the onset of
move-ments in anesthetized embryos did not
rep-resent a period of rapid learning or
acceler-ated functional development but, in fact, was the time required by the organism to
escape from the effects of anesthesia. These studies support the view that the embryo’s neuromuscular apparatus, which had never before functioned as a response mechanism, was capable of participating appropriately in organized motor behavior the first time it
was permitted to do so.
These experiments of Carmichael suggest that, in a typical lower vertebrate, the de-velopment of structures on which behavior
depends can and does take place during a
period in which there is no motor response and thus no feedback from action.
Dennis’ studies39 of Hopi Indian infants
cause one to question the proposition that all infants require an unbroken, uninhibited
chain of phylogenetically primitive stages of development as a prerequisite for normal adult function. These infants, who are by
custom strapped to a “tote” board almost continuously through the first year of life, displayed no retardation of walking or other organized motor integrations when compared with a control group of uninhib-ited Hopi infants. In another study, Dennis4#{176} reported that an infant who was restrained and forced to remain flat in bed later manifested only slight retardation of walking, sitting, and standing. These stud-ies suggest that, in the absence of emotional
deprivation, physical restraint sufficiently severe to limit practice, training, and feed-back may delay the elaboration and im-provement of certain motor skills but not necessarily prevent their eventual
emer-gence.
McGraw’s” extensive study of a set of
twins further explored the effects of
prac-lice on motor development. One twin was exposed to earlier and more extensive prac-tice to motor and adaptive functions. The other twin was permitted to develop ad
ii-bitum. They demonstrated no significant
difference in the chronology of the appear-ance of motor landmarks, nor in the quality of these basic performances. Subsequent 1.9. tests showed little difference between the twins. Though basic motor patterns were not improved or benefitted by repeti-live exercises, certain of the more adaptive motor activities were more quickly per-fected by the practicing twin.
A further important finding in the McGraw study was that development,
a!-though
capable
of being viewed as aex-311
taught through both forced restriction of
hibit overlap in the stages of motor
devel-opment but also can show reversals of usual
developmental sequences, e.g., walk before
cross-pattern crawling. These children may be normal or superior in motor, intellectual,
perceptual, and language skills. Thus, fail-ure to perform a motor pattern at a specific
stage in development or to exhibit a
stereo-typed sequence of skills does not
necessar-ily have adverse effects on current or subse-quent learning and behavior.
CORTICAL
ORGANIZATION
AND
INTELLECTUAL COMPETENCE
The relationship of laterality to commu-nicative and intellectual competence is a complex and rather confused issue. There is
little doubt, as shown in many studies, that disordered lateral dominance appears as one of the symptoms in a wide variety of functionally handicapping conditions in
children. Orton42 proposed that certain of
these handicaps may in fact, in themselves,
derive from the incomplete establishment
of dominance. Delacato3 has expanded on the importance of dominance and has argued that imperfect laterality
signifi-cantly affects all areas of communicative
function. However, the recent studies of Benton and Kemble3 and Belmont and
Birch4 have produced data that challenges certain of these conclusions. These studies
have reported that:
(
1)
individuals withmarkedly disordered lateral dominance may
in fact be excellent readers and have
nor-ma! language function; (2
)
when adistur-bance in dominance is associated with
func-tional handicaps, the association may derive from a common underlying cause for both types of dysfunction in a damaged central
nervous system.
Delacato3 emphasizes that
communica-tive disorders of all types are helped by a
program of neurologic organization
stress-ing achievement of mature dominance.
Achievement of dominance is stressed as the primary aim of a program for the treat-ment of communication disorders. The
regi-men is fully described.3 Hand dominance is
the nondominant hand and active exercises and training of the “dominant” hand. Eye dominance is promoted by occlusion of one eye and forcing the use of the other eye to train and “to strengthen the dominant eye.” Additional procedures used in dominance
training include the imposition of simulated tonic-neck sleep patterns and the deletion
of nonverbal musical influences which it is claimed stimulate the subdominant hemi-sphere.
Needless to say, there are many who dis-agree with Delacato’s views with respect to
dominance as well as with the therapeutic techniques that are recommended. Exten-sive factual evidence has evolved to contest the diagnostic significance and therapeutic implications of dominance.
Zangwill45 in his monograph on cerebral dominance illustrates that handedness is a
graded phenomenon. Left handedness ap-pears less clearly established than right handedness. Zangwill presents detailed in-formation about 54 patients with left-sided cerebral lesions and resultant aphasia.
Twenty-four of the fifty-four (or 44%) were
left handed. Zangwill concludes that left
cerebral dominance appears to be present either partially or completely in some left-handed individuals.
In another report Zangwill46 observed that many dyslexic patients with poor gen-eral coordination, clumsiness and motor dif-ficulties exhibited faulty laterality. However, some dyslexic patients had well established lateral dominance and no associated motor
difficulties. These patients appeared to have
a “purer form of dyslexia.” This report con-cludes that patients need not necessarily have defective lateral dominance to be dys-lexic. However, when dyslexia and faulty dominance occurred coincidentally in the same patient, the patient seemed to be the
victim of a more generalized disorder.
Zangwill observed that only a small per-centage of ambidextrous people have com-municative disorders, and this “cerebral
ambilaterality does not in itself imply any
field impairment in patients with a history of intracranial gunshot wounds, determined that visual systems seemed to react in a uniform pattern to dissimilar central ner-vous system lesions. Furthermore, local
le-sions often produced diffuse visual
impair-ment. The overall functional results from
any specific lesion were often
unpredict-able. These findings inferred that the visual
system does not react in a uniform fashion
and cannot always be accurately related to concepts of hemispheric dominance.
Elsewhere, Teuber48 described the effects of cerebral damage on sensation. He ob-served that left hemispheric lesions
pro-duced sensory changes on both hands. Right-sided lesions occasionally had bilat-era! effects. In addition, unilateral lesions often had contralateral perceptual and
vi-sual effects. Bilateral lesions could produce paradoxical effects, which were not the sim-pie summation of unilateral effects. Because of these findings Teuber objected to the use of the term “dominance” to describe the difference in the role of the two
hemi-spheres.
More recently Belmont and Birch44 stud-ied hand preference in a large population
of school children. This study provided sig-nificant data, clarifying the relationship
be-tween disturbances in lateralization and reading difficulties. In this study, lateral
preference for hand and eye awareness
was studied in an age homogeneous
sam-pie of 200 boys selected from a total
popu-lation of 9 and 10-year-old boys attending
school in Aberdeen, Scotland. One hundred
and fifty boys were among the poorest
readers, and 50 boys served as controls. No
difference was noted in lateralization of
preferential hand and eye usage between
the two groups. Significant differences were found in the level of right-left orientation. Confusion in right-left identification of own body parts in retarded readers was as-sociated with the lowest test scores on tests of sequential reading. Analysis of intellec-tual performance in the retarded readers
in-dicated that a disturbance in lateralization
was more strongly associated with perfor-mance than with verbal I.Q.
Delacato has stressed that, if you correct the dominance factor and convert a patient into a consistent unihemispheric dominant
individual, you will ipso facto improve all associated communicative, visual, and motor disturbances.
Since Belmont and Birch’s study44 plus
that of Zangwill46 indicate that faulty domi-nance may be but a symptom of an under-lying disorder and not the cause of reading
and communicative disorder, there seems
little justification for training in dominance unless it results in “learning to learn” a consequence quite distinct from the
objec-tive of the trainer.
THE EFFECT OF PATTERNING ON THE
ALTERATION OF .0. SCORES
AND THE ACQUISITION
OF READING ABILITIES
Delacato states, “any seeming improve-ment in intelligence on the part of children with whom this rationale is used
consis-tently, must be related to increased
commu-nicative and expressive facility.” He then
indicates that communicative disorders have “the same cause and need the same treatment-the only variable being one of degree.” The cause which he refers to is defective “neurologic organization,” and the treatment consists of “patterning” or
“externally imposing the bodily patterns of
activity which were the responsibility of damaged brain levels”2 plus dominance training.
“Patterning” and dominance training are
purported to be useful in themselves in treating reading disabilities and in raising
I.Q. scores. Most recently, Robbins29 stud-ied the specffic effects of patterning on read-ing and the relationship of reading to the
organization of neurological function. He concluded that:
(
1)
there was no evidence to support the postulated relationshipbe-tween neurological organization and
develop-ment. In addition, as noted earlier,
equiva-lent or even more substantial I.Q. and
read-ing gains than those claimed by the
advo-cates of patterning were achieved via nursery
school and special educational programs. Tizard2 reported similar levels of I.Q. change merely by shifting children from an
institution to a cottage-nursery school set-ting. Clarke, et al.2#{176}and Bayley15 noted the
variability of I.Q. scores and noted that
sig-nificant 1.9. improvement can occur in the
absence of any planned interventions.
When the results of other studies on I.Q. change are compared with the data pre-sented by Delacato,”3 it is clear that
“pat-terning” provides no panacea for mental
subnormality.
SUMMARY
A method of rehabilitation therapy and development training named “patterning”
has been considered. The theories upon
which the method is based and the findings which have stemmed from its application
have both been analyzed.
It has been concluded that the data thus far advanced are insufficient to justify
affir-mative conclusions about the system of treatment. Consideration of the statistics of individual case reports suggest that the
changes obtained may reflect normal growth
and development occurring independently of the method applied, or the inadvertent
consequence of social stimulation and
en-vironmenta! change inherent in, or result-ing from, the application of almost any
method. We have also noted evidence that
is available that justifies questioning the theoretical premises of the method.
The problem of selecting optimal
ther-apy for patients with brain damage and ce-rebral dysfunction is complicated by the finding that sensory and motor function are not affected in a uniform and consistent manner by damage to the central nervous
system. Lack of understanding of the
fun-damental mechanisms which integrate
sen-sory and motor activities continues to make the selection of a therapy most difficult.
Until we gain a greater understanding of
sensory and motor integrative mechanisms, scientific
(
statistically corroborated)
proofis needed before “patterning” or any other
method
may
claim sufficient universalap-plicability to serve as the sole therapeutic approach to one or more disturbances of
in-tellectual and motor function.
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