Tuesday, July 28, 2009

Mind Myth 9: Primitive reflexes, a new old fad

If you studied in any field related to child development, you would have learned about primitive reflexes. These reflexes are present in early childhood, but are inhibited and disappear in normal children. They may be retained in conditions such as cerebral palsy and may re-appear after serious brain injury, especially of the frontal lobes. Where significant primitive reflexes are retained or re-appear in later life they are invariably signs of significant brain injury. Persons with athetoid cerebral palsy sometimes learn to utilize some of their retained primitive reflexes to induce more reliable and predictable movements, i.e. the asymmetric tonic neck reflex to induce arm movement.

A new (old) fad has developed around the phenomenon of primitive reflexes. It is based on the old idea that ontogeny recapitulates phylogeny (or the development of the individual organism repeats the evolution of the species), the basic idea behind one of the classic 20th century quackeries, Doman and Delacato's patterning. One of Doman and Delacato's aims were to inhibit primitive reflexes in severely brain injured children through long term, intensive therapy.

Now in the 21st century, some modern, controversial therapies claim that physically normal individuals typically still have retained primitive reflexes that hinder achievement and that their particular brand of therapy can correct that unfortunate state of affairs in short order. Predictably, with many gullible educational officials and teachers always on the lookout for a magical silver bullet, therapies that claim to integrate putative primitive reflexes have taken a foothold in education.

This is from an interview in The Herald (Edinburgh) with Professor Sergio Della Sala, Professor of Human Cognitive Neuroscience at the University of Edinburgh, on the issue of the newfound popularity of primitive reflexes in quack therapies:

Professor Della Sala adds: "A primitive reflex is a very serious thing - people with cerebral palsy have it. Did they win a Nobel Prize for this? Because someone who could treat a primitive reflex would be in line for one." ...

The professor adds that he is "greatly sceptical" about the science behind it. "Why not report proper studies and proper trials?" he asks.
In fairness to the therapy under discussion, the Institute of Neuro-Physiological Psychology, it seems to have done some research. As Professor Della Sala pointed out, however, where is the evidence?

A range of other therapies have joined the primitive reflexes bandwagon, despite the lack of evidence. These are typically what I would call shotgun therapies, therapies that are so eclectic that they incorporate just about any nonsense ideas into their therapeutic approaches. Those that I have seen include Brain Gym, Mind Moves and HANDLE. In my opinion, all of these are long on claims and short on evidence.

HANDLE is particularly 'comprehensive' and claims to encompass aspects of INPP, Montessori‘s educational concepts, Kephart‘s visual-perceptual-motor programs, Ayres‘ sensory integration and praxis therapies, Bobath neurodevelopmental therapy, developmental optometry, Tomatis and Berard auditory therapies, Irlen‘s scotopic sensitivity screening, Piaget‘s cognitive psychology, Lindamood‘s approach to language learning, the effects of nutrition on neurodevelopment, homeopathy, reflexology, myofascial release, cranio-sacral therapy and energy therapy. With such a hodgepodge of ideas, how can you miss? The therapist should be able to fit any sign (normal or abnormal) the patient/client presents with somewhere in the framework. I wonder whether insurance and medical aid companies will fall for this?

5 comments:

  1. This author denigrates numerous therapies without providing any evidence at all, while complaining that there is inadequate research on the part of the proponents. At least the proponents provide some research and lots of anecdotal evidence. Personally, I am as skeptical of "alternative therapies" as I am of people who refuse to believe in anything not proven by expensive double-blind studies. Many alternative therapies work for some people but not for others, which may merely mean that we have not yet isolated the variable which determines success or failure. It does not mean that anecdotal evidence is useless or that lack of formal study condemns the approach. Of course, there is also the financial reality: the economic structure of formal studies supports certain approaches and is very threatened by other approaches. There just is no neutral, unbiased source of funding to address approaches which threaten the status quo.
    Should we be cautious about alternative treatments? Absolutely. We should be cautious about conventional treatments as well, especially when the revered studies have been funded by, for example, the pharmaceutical companies, which is often the case. We should be cautious about respected professionals who say things like, "What he needs is a good beating," (from a neurologist) or "Why would you ever want your son to be independent from prescription drugs?" (from a psychiatrist). Both of these, and many other unhelpful comments have been made to me by conventionally trained doctors to whom I was referred by other respectable, conventional doctors, all covered by insurance. If you're using insurance coverage as a yardstick for reasonableness of treatment, you may want to re-think your approach.
    So should families coping with challenging children trust no one and do nothing? Obviously that is not a good option, either.
    A vitriolic commentary such as Mr. Stander's does nothing to advance the discussion, to increase accountability of either conventional or alternative approaches, or to help families advocate for their children.

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  2. Anonymous

    You are conveniently shifting the burden of evidence from the practitioners of scientifically questionable therapies to the critic. What exactly do you want me to provide - evidence that there is no evidence; or evidence that these therapies are ineffective? Many of the therapies that I comment on are large, or growing, franchises. The onus is on them to provide independent research evidence before starting to market themselves aggressively. As I've indicated before in posts about "evidence supported practice", I recognise that gold standard double-blind studies may not always be possible in this field.

    "... anecdotal evidence ..." is an oxymoron. Anecdotes are unverifiable and subject to confirmation bias, they are not evidence.

    I fail to see the relevance of out-of-context remarks made by individual doctors.

    I have no expection of "increasing accountability" of typical "alternative approaches", as many of them are so inherently nonsensical as to be beyond redemption. In the context in which I operate, education, I can only hope to raise the awareness of gullible educators and officials who have up to now given scientifically questionable approaches a free hand in schools. Blogs such as this one give parents a science based skeptical view to balance the quacking often found on specific approaches' websites or in promotional literature.

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  3. You are right. In a fit of frustration I shifted the burden of evidence to the critic. I apologize.

    Anecdotes may not be evidence, if you want to define evidence that way, and they may not be verifiable, but they should not be overlooked entirely. Might they be termed "data"? In any case, they should be used as the basis for hypotheses which might then be tested, and therefore are useful. How would you recommend securing funding for follow-up?

    If no study funding is or has been available, and a therapist believes that a particular approach could be helpful when nothing else has worked, is he or she supposed to keep silent because no double-blind study has been completed? I agree that a responsible practitioner should make it clear to parents or educators that no study to date confirms the benefits, but if the parents or educators choose to proceed anyway, might not the results contribute to the acceptance or rejection of the practice? Why withhold the option?

    The relevance of the out-of-context remarks by individual doctors is this: a) There is no context in which those comments from those professionals could possibly be appropriate. b) Insurance is not a reliable standard by which to measure the reliability, professionalism, or helpfulness of practices. (See your last line in the original piece.)

    I could give you a long list of useless testing and consultations we have undergone, all within the parameters of MD-approved, insurance-approved, conventional care. That framework is not a panacea. We wasted precious years on it, and a tremendous amount of money (because although other insurers covered each of these examples, our insurance coverage was minimal).

    Then there is the gray zone of approaches such as homeopathy and Chinese medicine, which are ignored or scoffed at by the American medical establishment but are held in high esteem elsewhere. Rejection by the local establishment does not determine the quality of results. Quality of results also does not guarantee acceptance by conventionally trained providers of care.

    I cannot afford the luxury of waiting until research catches up with the alternative or unconventional approaches. I have exhausted the standard routes. We need help now, so I turn to other routes. While some of them are pure drivel, some yield compelling anecdotal results and explain the full spectrum of my son's condition (unlike conventional medicine, which saw him through the fractured lens of a myriad of specialists). Can you offer a practical heuristic for immediately discerning the effectiveness of therapies which have not been properly studied? If not, then I, like many others, must use trial and error because there is nothing else left to do.

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  4. I am sorry that conventional approaches seem to have failed you. I have seen many scientifically questionable therapies come and go, usually leaving disillusioned parents in their wake, to even consider them. Despite your experiences, I believe that your best bet is to again review all possible conventional solutions, assisted by a trusted conventional practitioner, i.e. paediatrician, neurologist or psychiatrist. Unpalatable as it may be, maybe you should consider long term medication.

    I have no heuristic for choosing from scientifically questionable approaches. I would certainly no do just based on trial and error. Should you decide you have to go that route, I would suggest that you approach it "scientifically" by systematically reviewing different approaches and the claims they make. Full blown quacks and charlatans should be noticeable, even between others who practice questionable techniques.

    Good luck.

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  5. Thanks for posting this; I'm an occupational therapist, and I recently went to a course that discussed residual primitive reflexes. The kicker of course were the videos we saw of children (all of whom were referred to OT in the school system for various reasons) who were "poster children" for displaying these residual reflexes. I got all excited and wanted to test all my patients for these reflexes when I got back to the clinic.

    It wasn't until tonight while writing up a new patient evaluation that I got to doing some internet searching and got to wondering why we never learned about these methods in OT school. It was difficult to find any research on the methods for determining why a child has a "residual" reflex, who developed these clinical "signs" since they differed from tests performed on infants, or why certain "exercises" are supposed to "fix" these reflexes. It all felt like guesswork. Your post sadly confirmed what I thought might be going on.

    The questions I'm left with though, are what made some of the children show "positive" signs for the residual reflexes? Does it all just come down to poor coordination and praxis, which, to be honest, so many kids with learning disabilities and other developmental delays have? My thought was that all the "positive" reflex signs were simply examples of poor disassociation between left and right and upper limbs/lower limbs, as well as between the eyes and head---all of which are simply issues of praxis and coordination, seen through my OT eyes. Is it possible that since reflexes are supposed to help us develop voluntary movement, some people don't develop voluntary movement as well as others, so there is a *trace* of reflex left?

    I just feel like I have more questions than answers.

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