Seminar 4 –
Intervention
David Sugden:
University of Leeds
Theory, Empiricism and Experience in Intervention Research
The field of motor impairment including DCD field has attracted researchers and clinicians from a variety of professional and academic backgrounds, such as health, psychology and education, and it is not surprising that different approaches to intervention have grown up. The aim of this presentation is to examine some of these methods and provide a framework for debate. However, this is not a full evaluation of the various approaches to intervention; the proposal is to mirror the aim espoused by John Morton (2004) in his book ‘Understanding Developmental Disorders’ when he says he is providing a tool to think about developmental disorders. Here the aim is very similar to Morton’s: that of providing a way for examining approaches to intervention; of making comparisons across studies and clinical settings; and allowing decisions to be made according to individual situations. The manner in which this is being proposed is to examine approaches from theoretical, empirical and experiential perspectives. It is recognised that the approaches examined here do not represent the full range of methods of intervention; it is also recognised that the approaches very often do not have sufficient information across all three criteria. However, indicative examples have been chosen to illustrate how analysis of approaches can be undertaken and these can be tailored to other method and to individual situations. The words ‘theory’, ‘empiricism’ and ‘experience’ are first elaborated and although these are set out as discrete distinct entities, it is clear that overlaps do occur but this does not detract from the overall point that the framework provides a method of thinking about intervention.
Development and Learning
Many disorders (including DCD) are developmental in nature with possible
faulty learning processes. If the disorder is a breakdown in learning and
it follows in some way a developmental progression, the logic is that we
utilise these two in our approach to intervention. Both developmental and
learning theories are examined as they apply to motor behaviour with a
preference in both instances from a theoretical standpoint for a dynamic
systems approach while recognising that empiricism and experience while
supportive will require more data across more varied situations.
Specific Intervention Cases
Coupling in children with Cerebral Palsy (CP)
If a theoretical approach is taken to reaching and grasping in children with
CP, a dynamics systems theory has much to offer. For example, both intrinsic
and extrinsic constraints affect action with the intrinsic ones including
the neural properties of CP and the integrity of the neural system, with
external constraints being the context in which the action took place and
the demands of the task such as the speed of the movement, the properties
of the objects to be grasped, the visual array of the field of action and
the instructions for the action. Intrinsic constraints also include how
the movements of one side of the body (namely the affected side) are influenced
by movements of the side that is less affected. Studies employing unimanual
and bimanual tasks have shown that in many cases of reaching and grasping
some form of bimanual coupling take place. The most common form of coupling
occurs in timing; usually the hemiplegic limb being slower than the less
affected limb in the unimanual conditions and often in the bimanmual condition
the hemiplegic limb moves faster towards the speed of the less affected
limb.
This is not always the case; in some instances one limb slows down and the other speeds up to form a coupling and in one or two cases the less affected limb slows down completely to the speed of the hemiplegic limb (Sugden & Utley, 1995; Utley & Sugden 1998; Utley, Steenbergen & Sugden, 2004). However, the theoretical principle of how limbs are controlled remained, with one affecting the other through what has come to be called coordinative structures. Here both theory and empiricism would have some support but experiential reports are not yet as forthcoming.
Constraint induced therapy (CIT)
In a totally different vein yet working with the same group of children again
on upper limb functioning there has been strong support for the use of
constraint induced therapy (CIT). Simply put CIT is based on learned non
use of the affected hand in hemiplegic individuals and constraining the
non affected limb through a splint or glove or other methods encourages
the use of the affected limb. This is followed by mass practice of the
affected limb and the use of intensive techniques to train the limb.
When examining the evidence from our three standpoints of theory, empiricism and experience, it is here difficult to sort out the theory from empirical evidence. Certainly we have fundamental evidence originally from animals but more recently from humans that prolonged practice does induce plastic dynamic changes in the central nervous system. This would be classed as empirical support for the methods as it does not really address the issue of how we control movements and how CIT affects this type of control. What it certainly does do is produce behavioural changes in the child’s functioning and this has been noted both empirically and experientially with experimental groups using CIT showing advantages over control groups (See Eliasson et al 2005 for review and references). The empirical support for CIT looks promising and it is spilling over into practice and thus the experiential part could soon be supportive. There is the gap as to where the theoretical base lies as to why it works; whether this is some new and progressive explanation as to how movements are controlled or whether the theory is abiding by the principle that the amount of appropriate practice is overwhelmingly the most important training variable.
Process and product approaches in children with Developmental Coordination
Disorder
Recently there have been good reviews of intervention in children with DCD
and the approaches have been divided up into different categories (Pless & Carlsson,
2000; Wilson, 2005). Here a simple approach is taken which places the approaches
into two categories those of process oriented and those of task oriented
while recognising that within these broad categories substantial differences
will be found between the methods.
Most process approaches do not directly address the functional deficits
in the child’s everyday skills but concentrate on the underlying causes
or processes that appear to delay or inhibit the acquisition of the daily
skills. The advantages of this type of approach usually revolve around the
transfer of skill; it is not possible to teach every motor skill required
to be functional and thus by teaching the underlying processes, there may
be produced a positive effect across a wide variety of tasks. The downside
is the often tenuous relationship between the underlying processes and the
functional tasks. Both Sensori Integration Therapy (Ayres, 1972) and Kinaesthetic
Training (Laszlo & Bairstow, 1985) would be included here and over the
years have had strong experiential support, particularly SIT.
Overall the approaches have some theoretical support but not sufficient to
include more modern theories of development and learning and a full range
of motor skills and the recent empirical support is thin outside of the original
pioneering studies.
At first glance task oriented approaches seem relatively straightforward,
with the approach being aimed at remediating the actual functional tasks
on which the child is failing. They have strong theoretical face validity
when for example a child is poor in manual dexterity skills, the approach
would be to directly intervene in these skills. The emphasis here is on cognitive
approaches that teach responses to novel situations.
A recent cognitive approach is the Cognitive Orientation to daily Occupational
Performance (CO-OP) devised by Polatajko and Mandich and colleagues in Canada
(Polatajko et al 2001). The approach has four objectives of skill acquisition
which is the primary aim, cognitive strategy use, generalisation and transfer.
A number of fundamental principles underpin the methods which collectively
provide the theoretical base for the approach and these would appear to be
very much in line with those espoused by cognitive psychology. Earlier versions
of cognitive approach were pioneered by Henderson & Sugden in their manual
for the Movement Assessment Battery for Children (1992) that have provided
the basis for a number of empirical investigations. Task oriented approaches
using more cognitive methods derived from cognitive psychology and child
development incorporating ecological and dynamical perspectives would appear
to have sound theoretical bases. Empirically the cognitive approaches have
support from the proponents of the approach but we are waiting for more independent
studies of their efficacy. Experientially its usage is spreading slowly through
the professions.
Analysing intervention approaches through theoretical, empirical and experiential evidence may accomplish two related and relevant goals: first it can aid in explaining differences of opinion between various professional bodies and secondly it can help in directing the profession to the most appropriate stance according to particular circumstances.
References
1. Ayres, A.J. (1972) Sensory integration and learning disorders. Los Angeles: Western Psychological Services
2. Eliasson, A.E., Krumlinde-Sundholm, L., Shaw, S. & Wang, C. (2005) Effects of constraint-induced therapy in young children with hemiplegic cerebral palsy: an adapted model. Developmental Medicine and Child Neurology, 47, 266-275.
3. Henderson, S.E. & Sugden, D.A (1992) Movement Assessment Battery for Children. London: Psychological Corporation.
4. Laszlo, J.I. & Bairstow, P.J. (1985) Perceptual-motor behaviour: development assessment and therapy. London: Holt, Rinehart and Winston.
5. Morton, J. (2004) Understanding developmental disorders. London: Blackwell.
6. Pless, M. & Carlsson, M. (2000) Effects of motor skill intervention on DCD: a meta analysis. Adapted Physical Activity Quarterly, 17, 381-401.
7. Polatajko, H., Mandich, A.D. & Miller, L. (2001) Cognitive orientation to daily occupational therapy: part II the evidence. Physical and Occupational Therapy in Paediatrics, 20, 83-106.
8. Sugden, D.A. & Utley, A. (1995) Interlimb coupling in children with hemiplegic cerebral palsy. Developmental Medicine and Child Neurology, 37, 293-309.
9. Utley, A. & Sugden, D.A. (1998) Interlimb coupling in children with hemiplegic cerebral palsy during reaching and grasping at speed. Developmental Medicine and Child Neurology, 40, 396-408.
10. Wilson, P.H. (2005) Approaches to assessment and treatment of children with DCD: an evaluative review. Journal of Child Psychology and Psychiatry, 46,806-823.