The Treatment of Neurologically Impaired Children Using Patterning

POLICY STATEMENT

PEDIATRICS Vol. 104 No. 5 November 1999, pp. 1149-1151

AMERICAN ACADEMY OF PEDIATRICS:

The Treatment of Neurologically Impaired Children Using Patterning

Committee on Children With Disabilities

ABSTRACT

This statement reviews patterning as a treatment for children with neurologic impairments. This treatment is based on an outmoded and oversimplified theory of brain development. Current information does not support the claims of proponents that this treatment is efficacious, and its use continues to be unwarranted.

Patterning has been advocated for more than 40 years for treating children with brain damage and other disorders, such as learning disabilities, Down syndrome, cerebral palsy, and autism.1-5 A number of organizations have issued cautionary statements about claims for efficacy of this therapy,6-10 including the American Academy of Pediatrics (AAP) in 1968 and 1982.3,11 Media coverage,12 inquiries from parents and public officials, the use of alternative forms of treatment by parents for their children,13 and the existence of a new generation of pediatricians who may be unaware of the programs that involve patterning have prompted the AAP to review the current status of this controversial treatment.

Patterning is a series of exercises designed to improve the "neurologic organization" of a child's neurologic impairments. It requires that these exercises be performed over many hours during the day by several persons who manipulate a child's head and extremities in patterns purporting to simulate prenatal and postnatal movements of nonimpaired children.14 Concern about patterning has been raised because promotional methods have made it difficult for parents to refuse treatment for their children without questioning their motivation and adequacy as parents.3 Moreover, dire health consequences for children are implied if parents do not make arrangements to have their child begin patterning.

Several treatment options are offered, ranging from a home program to an intensive treatment program, which states that each succeeding option "offers greater chance of success." Participation in the intensive treatment program requires completion of 3 of the 5 preceding programs, is by invitation only for the "most capable families," and potentially could deplete substantially a family's financial resources. The regimens prescribed can be so demanding, time-consuming, and inflexible that they may place considerable stress on parents and lead them to neglect other family members.15,16(pp251-252)

Patterning programs use a developmental profile designed by the Institute for the Achievement of Human Potential both to assess a child's neurologic functioning and to document change over time.16(p40)17 However, the validity of using this profile for these domains has not been demonstrated, nor has it been compared with currently accepted methods of measuring a child's development. In addition to making claims that a number of conditions may be improved or cured by patterning, proponents of the program assert that patterning can make healthy children superior in physical and cognitive skills.18-22

The aims of treatment programs include attainment of normality of physical, intellectual, and social growth in children with brain injuries. According to providers of patterning therapy,1 the majority of children treated are claimed to achieve at least 1 of those goals. To our knowledge, however, no new data have been presented to support the use of patterning since the AAP reissued its policy statement in 1982. The lack of supporting evidence for the use of this therapy brings into question once again its effectiveness in neurologically impaired children.

THE THEORY

Neurologic organization, the principle central to the patterning theory of brain functioning, is an oversimplified concept of hemispheric dominance and the relationship of individual sequential phylogenetic development.1623-25 This theory also states that failure to complete properly any stage of neurologic organization adversely affects all subsequent stages and that the best way to treat a damaged nervous system is "to regress to more primitive modes of function and to practice them."17 According to this theory, the majority of cases of mental retardation, learning problems, and behavior disorders are caused by brain damage or improper neurologic organization, and these problems lie on a single continuum of brain damage, for which the most effective treatments are those advocated by patterning.3,16
Current information does not support these contentions. In particular, the lack of dominance or sidedness probably is not an important factor in the cause of, or the therapy for, these conditions.3,16,17 Several careful reviews of the theory have concluded that it is unsupported, contradicted, or without merit based on scientific study.16,17,23,25 Others have described the hypothesis of neurologic organization to be without merit23 and concluded that the theoretical rationale for the treatment is inconsistent with accepted views of neurologic development.24,27(pp207-235)28(pp207-247)

STATUS OF CLAIMED THERAPEUTIC RESULTS

Results published on patterning have been inconclusive.29-31 Although reports of improvement in reading ability after treatment have been heralded as support for the theory,32,33 statistical analysis revealed few demonstrable benefits.34,35 Controlled studies of reading skills have shown little or no benefit from treatment.,16(pp333-352)36-38
Some disabled children who purportedly benefited from treatment had been given a misdiagnosis or an unduly pessimistic prognosis. The course of maturation in children with neurologic impairments varies, which leads to unwarranted claims that improvements in their conditions were the result of a specific form of treatment.17,39 Some of the cases publicized involved children with traumatic brain injury or encephalitis, who may make substantial health improvements without special treatment.
A well-controlled investigation40 compared 3 groups of children, all of whom were severely mentally disabled and institutionalized. One group received patterning, a second was treated by motivational techniques, and a third received routine care. Using a wide variety of behavioral measures, the investigators found no significant differences among the 3 groups. On the basis of this study, the investigators found nothing to recommend patterning treatment over routine care.40 They concluded that patterning cannot be considered superior to any other method of treatment for institutionalized mentally disabled children.
Other less well-designed studies41,42 also investigated the effect of patterning therapy on children with a heterogeneous range of disabilities. One showed a significant, but short-term, effect on developmental progress in comparison with that attained by children receiving traditional programs in New Zealand.41 The investigators disclosed that the relative success of the program was linked to the families' desire to take greater responsibility for their children's education. Another investigation demonstrated no significant progress in the development of mentally disabled children who had undergone patterning therapy.42 A review of the use of patterning to arouse children in a coma and for sensory stimulation in brain-injured children and adults also gave no scientific evidence or theoretical rationale for its use.43

CONCLUSION AND RECOMMENDATION

Pediatricians need to work closely with the families of their patients with neurologic disabilities and ensure that they have access to all standard services available in their communities. After the proper diagnosis is made, physicians should discuss controversial treatments as part of the child's initial management plan. Pediatricians, therefore, need to be acquainted with routine and controversial treatments, schedule ample time for their discussion, and explain to parents the placebo effect and the importance of basing treatment decisions on controlled research trials.
Treatment programs that offer patterning remain unfounded; ie, they are based on oversimplified theories, are claimed to be effective for a variety of unrelated conditions, and are supported by case reports or anecdotal data and not by carefully designed research studies. In most cases, improvement observed in patients undergoing this method of treatment can be accounted for based on growth and development, the intensive practice of certain isolated skills, or the nonspecific effects of intensive stimulation.
Physicians and therapists need to remain aware of the issues in the controversy over this specific treatment and the available evidence. On the basis of past and current analyses, studies, and reports, the AAP concludes that patterning treatment continues to offer no special merit, that the claims of its advocates remain unproved, and that the demands and expectations placed on families are so great that in some cases their financial resources may be depleted substantially and parental and sibling relationships could be stressed.

COMMITTEE ON CHILDREN WITH DISABILITIES, 1999-2000 Philip R. Ziring, MD, Chairperson Dana Brazdziunas, MD W. Carl Cooley, MD Theodore A. Kastner, MD Marian E. Kummer, MD Lilliam González de Pijem, MD Richard D. Quint, MD, MPH Elizabeth S. Ruppert, MD Adrian D. Sandler, MD
LIAISONS William C. Anderson Social Security Administration Polly Arango Family Voices Paul Burgan, MD, PhD Social Security Administration Connie Garner, RN, MSN, EdD US Department of Education Merle McPherson, MD Maternal and Child Health Bureau Linda Michaud, MD American Academy of Physical Medical/Rehabilitation Marshalyn Yeargin-Allsopp, MD Centers for Disease Control and Prevention
SECTION LIAISONS Chris P. Johnson, MEd, MD Section on Children With Disabilities Lani S. M. Wheeler, MD Section on School Health

FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.


ABBREVIATIONS
AAP, American Academy of Pediatrics.

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