The New York Times has announced the recent death of J.M. Tanner, an extraordinary figure in the field of child development. This was the man who established the scientific study of children’s physical growth and thus opened the door for further research and for practical applications of this information. It was Tanner’s work on rates of growth and development that made possible the study of changes in the age of puberty and that helped neonatologists discriminate between babies who were born prematurely and those who were simply very small for their stage of development. When I needed to evaluate the status of a poorly-nourished child a few weeks ago, I went straight to my well-used copy of Tanner’s book Foetus into man and looked at the appropriate growth chart, which showed proportions of children of a certain age at or below given weights. Indeed, almost every parent has seen his or her child’s height and weight marked on growth charts derived from Tanner’s work.
A part of Tanner’s contribution was simply a matter of meticulous measurement of large numbers of cases. He recorded heights, weights, and other details of growth for large numbers of children of known ages, and dealt with issues like the differences between measurement of height for infants (lying down) and for older children (standing up),with the problems these presented for accuracy. A particularly important question involved tracing the events of development before and during puberty; Tanner established a set of data based on photographs and measurements of changes in girls’ nipples and breasts, in pubic and axillary hair, and in boys’ penis and scrotum characteristics. This information allowed him to establish ways of predicting menarche and spermarche with some accuracy, an important step in deciding how to provide suitable sex education for older children as well as establishing standards for precocious puberty.
Of course, a set of data alone is not much help for understanding or decision-making. Tanner treated his collected data as the normal distribution they were, and was able to use related statistical concepts to help identify abnormal growth patterns that needed treatment. With a large set of data from children of various ages, Tanner could establish the statistical average heights and weights at specific ages by adding all the figures from an age group and dividing by the number of children. This helped to characterize particular children’s growth as being above or below average, of course, but it accomplished something still more important: a way to decide when growth was inside or outside a normal range, and thus whether a child did or did not need treatment. Most of the children in any group will have heights or weights that are above or below the statistical average, so that comparison is not a very useful one-- but knowing how far away from the average someone is can be extremely helpful when it comes to identifying problems.
Tanner did the statistical work that allows us to look at a growth chart and to decide how far a given child is from the average height or weight for his or her age. Like others making statistical comparisons, he usually considered a “normal range” within which children did not need help. To establish the normal range, he calculated the weight or height than which only 10% of an age group were smaller (the 10th percentile, the number below which 10% of the heights or weights fell), and the weight or height than which only 10% were larger (the 90th percentile, the number below which 90% of the heights or weights fell). Children whose measurements were in the top or bottom 10% groups were outside the normal range, and the other 80% of children were within the normal range. Children who were bigger or smaller than that normal range might be in need of treatment; for younger children, being unusually small was of greatest concern because the condition might be associated with other problems.
Establishing a normal range for children of different ages was especially important for care of premature babies. Tanner’s work included measurement of fetuses whose gestational age (time passed since conception) was known. Babies who were small at birth could then be classified as small, average, or large for their gestational ages, rather than all being considered simply premature even though some might be full-term births. This kind of classification made it possible to understand and treat the differing problems associated with different ages and relative sizes, rather than trying the same general treatment for all very small babies.
Tanner’s enormously useful and influential work seems to have been related to the maturationist descriptive research of Arnold Gesell, who in the 1930s provided detailed information about early changes in functions like grasping and handedness. The matters that Gesell studied were, of course, much less easy to measure and analyze statistically than height and weight were, and no one has been able to establish the same types of comparisons to a normal range that Tanner achieved with his studies of growth. However, Tanner’s work has set a standard for the study of development that may inspire investigation of more complex events, perhaps some day allowing for much earlier diagnosis of problems like autism.
Wednesday, August 25, 2010
Thursday, August 5, 2010
Book Reviews: Alternative Therapies for Children
Two books published by Jessica Kingsley Publishers will be of interest to students of complementary and alternative treatments for disorders of childhood mental health or educational progress. Dyslexia and alternative therapies, by Maria Chivers (London: Jessica Kingsley, 2006) focuses on treatments for reading problems, but includes a variety of CAM approaches covering a spectrum of methods from physical manipulation to stress reduction. Understanding controversial therapies for children with autism, Attention Deficit Disorder, and other learning disabilities, by Lisa A. Kurtz (London: Jessica Kingsley, 2008) reviews a much broader range of problems and treatments, as its title suggests.
The Chivers book is notable for its completely uncritical consideration of an extensive list of dyslexia treatments. The author concedes that “tried and tested teaching methods should not be replaced, and… alternative approaches should be treated as complementary”. She asks readers to judge for themselves but notes that “it will pay dividends to keep an open mind”. She applies this approach even to “distant healing” methods, about which she remarks that “some people are skeptical about therapists who state they can cure them without touching or even seeing the clients themselves. But as with many therapies in this book they may be worth trying.” About one method, Chivers says, “This definitely works for me.” She advises that “it is healthy to maintain a critical faculty and to question what you are told, but equally make sure this does not prevent you from being open to some of the valuable treatments that are out there.” Clearly, Chivers is not one to concern herself with the evidence basis for a practice.
Chivers provides no discussion whatever of issues concerning research design or the concept of evidence-based practice, but simply presents a list of CAM treatments and summarizes the claims made by their proponents. She includes a bibliography with a small number of articles from peer-reviewed journals, a very few of which report randomized controlled trials; most of the resources listed are non-technical or even speculative in nature. The book also features a list of organizations whose websites offer either general information or advocacy for specific methods such as chiropractic treatment.
Chivers’ book is not a resource for those who are interested in evidence-based practice, but it does provide a lengthy and sometimes surprising list of CAM methods that have been put forward as potential treatments for reading disabilities. These include acupuncture, hypnotherapy, and nutritional supplements as well as “visual” treatments like the use of colored overlays. The suggested treatments resemble each other, not only in the absence of empirical support for their usefulness, but in their complete lack of plausibility. Curiously, the one highly plausible, although little-supported, method of treating dyslexia, FastForWord, is omitted from the list.
The Kurtz book makes a somewhat better effort to deal with the issue of evidentiary foundations for CAM therapies. One reason for this may be the fact that Kurtz is looking at treatments for psychiatrically-diagnosed conditions as well as for educational problems. The higher cost and insurance-related decisions of the former suggest the need to focus on efficacy, whereas the effectiveness of educational methods is less frequently subjected to serious evaluation. Kurtz presents reference lists for treatments, including outcome research in some cases, but providing only occasional and cursory guidance about conclusions to be drawn; much more space is devoted to methods for training practitioners than to the evidence bases of these treatments. As was the case for the Chivers title, plausibility is not mentioned as a concern, and the completely implausible “Bach flower remedies” receive the same attention as the quite plausible but weakly supported FastForWord.
Kurtz’s discussion of several methods involves notable omissions. The reference list for the Doman-Delacato “patterning” technique includes a reference to the 1999 policy statement of the American Academy of Pediatrics on this method, but the text does not note that this statement was the second of two by this group, both rejecting the use of “patterning”. The discussion of Facilitated Communication refers in passing to the possible influence of the practitioner on this method, but does not discuss some of the serious accusations families have suffered as a result of the assumption that the technique yields accurate information about a child’s intention.
Kurtz’s discussion of Holding Therapy is problematic in that it describes only one of the several approaches that would be categorized under that label. In addition, the description fails to explain the length or frequency of sessions, a point that would do much to communicate the intense experiences characteristic of the specific treatment described (the Welch method). Kurtz does not mention that Holding Therapy has been classed as a potentially harmful treatment.
It was a surprise to this reader to see DIR/Floortime listed as a CAM treatment by Kurtz. DIR (Developmental, Individual-difference, Relationship-based therapy ) is indeed lacking in an established evidentiary foundation, and it uses some of the problematic methods associated with Sensory Integration. However, DIR has a highly plausible theoretical basis and there is ongoing work aimed at outcome evaluation, so DIR would seem to stand in considerable contrast to other methods discussed by Kurtz.
Like some other Jessica Kingsley publications, the Chivers and Kurtz books give the reader a certain sense of incompleteness, as if no reviewer or copy editor had acted to jog the authors’ memories and remind them to include or elaborate on various points. As simple lists of treatments, or as compilations of resources for further study, however, they provide well-organized though unevaluated information for the interested researcher.
The Chivers book is notable for its completely uncritical consideration of an extensive list of dyslexia treatments. The author concedes that “tried and tested teaching methods should not be replaced, and… alternative approaches should be treated as complementary”. She asks readers to judge for themselves but notes that “it will pay dividends to keep an open mind”. She applies this approach even to “distant healing” methods, about which she remarks that “some people are skeptical about therapists who state they can cure them without touching or even seeing the clients themselves. But as with many therapies in this book they may be worth trying.” About one method, Chivers says, “This definitely works for me.” She advises that “it is healthy to maintain a critical faculty and to question what you are told, but equally make sure this does not prevent you from being open to some of the valuable treatments that are out there.” Clearly, Chivers is not one to concern herself with the evidence basis for a practice.
Chivers provides no discussion whatever of issues concerning research design or the concept of evidence-based practice, but simply presents a list of CAM treatments and summarizes the claims made by their proponents. She includes a bibliography with a small number of articles from peer-reviewed journals, a very few of which report randomized controlled trials; most of the resources listed are non-technical or even speculative in nature. The book also features a list of organizations whose websites offer either general information or advocacy for specific methods such as chiropractic treatment.
Chivers’ book is not a resource for those who are interested in evidence-based practice, but it does provide a lengthy and sometimes surprising list of CAM methods that have been put forward as potential treatments for reading disabilities. These include acupuncture, hypnotherapy, and nutritional supplements as well as “visual” treatments like the use of colored overlays. The suggested treatments resemble each other, not only in the absence of empirical support for their usefulness, but in their complete lack of plausibility. Curiously, the one highly plausible, although little-supported, method of treating dyslexia, FastForWord, is omitted from the list.
The Kurtz book makes a somewhat better effort to deal with the issue of evidentiary foundations for CAM therapies. One reason for this may be the fact that Kurtz is looking at treatments for psychiatrically-diagnosed conditions as well as for educational problems. The higher cost and insurance-related decisions of the former suggest the need to focus on efficacy, whereas the effectiveness of educational methods is less frequently subjected to serious evaluation. Kurtz presents reference lists for treatments, including outcome research in some cases, but providing only occasional and cursory guidance about conclusions to be drawn; much more space is devoted to methods for training practitioners than to the evidence bases of these treatments. As was the case for the Chivers title, plausibility is not mentioned as a concern, and the completely implausible “Bach flower remedies” receive the same attention as the quite plausible but weakly supported FastForWord.
Kurtz’s discussion of several methods involves notable omissions. The reference list for the Doman-Delacato “patterning” technique includes a reference to the 1999 policy statement of the American Academy of Pediatrics on this method, but the text does not note that this statement was the second of two by this group, both rejecting the use of “patterning”. The discussion of Facilitated Communication refers in passing to the possible influence of the practitioner on this method, but does not discuss some of the serious accusations families have suffered as a result of the assumption that the technique yields accurate information about a child’s intention.
Kurtz’s discussion of Holding Therapy is problematic in that it describes only one of the several approaches that would be categorized under that label. In addition, the description fails to explain the length or frequency of sessions, a point that would do much to communicate the intense experiences characteristic of the specific treatment described (the Welch method). Kurtz does not mention that Holding Therapy has been classed as a potentially harmful treatment.
It was a surprise to this reader to see DIR/Floortime listed as a CAM treatment by Kurtz. DIR (Developmental, Individual-difference, Relationship-based therapy ) is indeed lacking in an established evidentiary foundation, and it uses some of the problematic methods associated with Sensory Integration. However, DIR has a highly plausible theoretical basis and there is ongoing work aimed at outcome evaluation, so DIR would seem to stand in considerable contrast to other methods discussed by Kurtz.
Like some other Jessica Kingsley publications, the Chivers and Kurtz books give the reader a certain sense of incompleteness, as if no reviewer or copy editor had acted to jog the authors’ memories and remind them to include or elaborate on various points. As simple lists of treatments, or as compilations of resources for further study, however, they provide well-organized though unevaluated information for the interested researcher.
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