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Improving Accountability of ASHA Approved Continuing Education Providers

Image result for accountabilitySeveral days ago I had a conversation with the Associate Director of Continuing Education at ASHA regarding my significant concerns about the content and quality of some of ASHA approved continuing education courses. For many months before that, numerous discussions took place in a variety of major SLP related Facebook groups, pertaining to the non-EBP content of some of ASHA approved provider coursework, many of which was blatantly pseudoscientific in nature.

The fact is while there is a rigorous process involved in becoming an ASHA approved continuing education provider, once that approval is granted, ASHA is not privy to course content. In other words, no staff member at ASHA is available to screen course documents (pdfs, pptx, handouts, etc.) to ensure that it is scientifically supported and is free of pseudoscientific and questionable information.

Furthermore, in order to account for the lack of review of course content, ASHA has an explicit disclaimer, which is placed on all the accredited promotional CEU material. It states that: “ASHA CE Provider Approval does not imply endorsement of course content, specific products, or clinical procedures.”

However, this creates a significant disconnect between what is being ‘preached’ and what is being ‘practiced’. This is especially important because many SLPs are spending their hard-earned money on ASHA approved courses, which they leave not only feeling significantly disappointed and disillusioned but also feeling like they had completely wasted their money.

As a result, it is very important for ASHA to know when the SLPs has taken a particularly disappointing and pseudoscientific slanted course. For a review of what constitutes pseudoscientific practices, I highly recommend becoming familiar with the body of work of Dr. Gregory Lof as well as reading a serious of block posts on this topic by Mary Huston.

 So if you are unhappy with an ASHA approved continuing education course (PRESENT or PAST) because its content him is/was heavily biased and unscientific in nature, it is important that ASHA knows about it! Be as vocal as you can in order to raise the alarm about pseudoscientific CEUs from ASHA approved providers.  Below are some ways members can complain to ASHA (these complaints can be copied and pasted to save time).

Provider Complaint Submission Form:https://www.asha.org/Form/CE-Provider-Complaint-Submission/

SLP Advisory Council: https://www.asha.org/About/governance/Speech-Language-Pathology-Advisory-Council-Members/

Audiology Advisory Council: https://www.asha.org/About/governance/Audiology-Advisory-Council-Members/

Provide Feedback to the Board of Directors:http://www.asha.org/Form/Board-of-Directors-Feedback/

SLPs can also access a letter template in the files section of the SLPs for Evidence-Based Practice group on Facebook, to voice their dissatisfaction when encountering questionable coursework presented by ASHA  approved providers.

Remember that you are not obligated by any means to take ASHA Approved CEU Courses in order to maintain your certification!  As such, you do NOT have to spend your hard earned money on low-quality coursework! Continuing education is a significant revenue stream for ASHA. Refusing to participate, unless a meaningful change is implemented, will go a long way in delivering a serious message to the association that things cannot remain as they are now.

So go ahead and make your voice heard! ASHA relies on member feedback in order to implement meaningful and constructive change. Don’t depend on others to complain, get involved yourself first, and make sure that ASHA hears you loud and clear. The first step on the long road to making a difference needs to be taken by you!  Please take it!

 

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Making Our Interventions Count or What’s Research Got To Do With It?

Two years ago I wrote a blog post entitled: “What’s Memes Got To Do With It?” which summarized key points of Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“. It delved into answering the following question: “Why do some terms, labels, ideas, and constructs [in our field] prevail whereas others fail to gain acceptance?”.

Today I would like to reference another article by Dr. Kamhi written in 2014, entitled “Improving Clinical Practices for Children With Language and Learning Disorders“.

This article was written to address the gaps between research and clinical practice with respect to the implementation of EBP for intervention purposes.

Dr. Kamhi begins the article by posing 10 True or False questions for his readers:

  1. Learning is easier than generalization.
  2. Instruction that is constant and predictable is more effective than instruction that varies the conditions of learning and practice.
  3. Focused stimulation (massed practice) is a more effective teaching strategy than varied stimulation (distributed practice).
  4. The more feedback, the better.
  5. Repeated reading of passages is the best way to learn text information.
  6. More therapy is always better.
  7. The most effective language and literacy interventions target processing limitations rather than knowledge deficits.
  8. Telegraphic utterances (e.g., push ball, mommy sock) should not be provided as input for children with limited language.
  9. Appropriate language goals include increasing levels of mean length of utterance (MLU) and targeting Brown’s (1973) 14 grammatical morphemes.
  10. Sequencing is an important skill for narrative competence.

Guess what? Only statement 8 of the above quiz is True! Every other statement from the above is FALSE!

Now, let’s talk about why that is!

First up is the concept of learning vs. generalization. Here Dr. Kamhi discusses that some clinicians still possess an “outdated behavioral view of learning” in our field, which is not theoretically and clinically useful. He explains that when we are talking about generalization – what children truly have a difficulty with is “transferring narrow limited rules to new situations“. “Children with language and learning problems will have difficulty acquiring broad-based rules and modifying these rules once acquired, and they also will be more vulnerable to performance demands on speech production and comprehension (Kamhi, 1988)” (93). After all, it is not “reasonable to expect children to use language targets consistently after a brief period of intervention” and while we hope that “language intervention [is] designed to lead children with language disorders to acquire broad-based language rules” it is a hugely difficult task to undertake and execute.

Next, Dr. Kamhi addresses the issue of instructional factors, specifically the importance of “varying conditions of instruction and practice“.  Here, he addresses the fact that while contextualized instruction is highly beneficial to learners unless we inject variability and modify various aspects of instruction including context, composition, duration, etc., we ran the risk of limiting our students’ long-term outcomes.

After that, Dr. Kamhi addresses the concept of distributed practice (spacing of intervention) and how important it is for teaching children with language disorders. He points out that a number of recent studies have found that “spacing and distribution of teaching episodes have more of an impact on treatment outcomes than treatment intensity” (94).

He also advocates reducing evaluative feedback to learners to “enhance long-term retention and generalization of motor skills“. While he cites research from studies pertaining to speech production, he adds that language learning could also benefit from this practice as it would reduce conversational disruptions and tunning out on the part of the student.

From there he addresses the limitations of repetition for specific tasks (e.g., text rereading). He emphasizes how important it is for students to recall and retrieve text rather than repeatedly reread it (even without correction), as the latter results in a lack of comprehension/retention of read information.

After that, he discusses treatment intensity. Here he emphasizes the fact that higher dose of instruction will not necessarily result in better therapy outcomes due to the research on the effects of “learning plateaus and threshold effects in language and literacy” (95). We have seen research on this with respect to joint book reading, vocabulary words exposure, etc. As such, at a certain point in time increased intensity may actually result in decreased treatment benefits.

His next point against processing interventions is very near and dear to my heart. Those of you familiar with my blog know that I have devoted a substantial number of posts pertaining to the lack of validity of CAPD diagnosis (as a standalone entity) and urged clinicians to provide language based vs. specific auditory interventions which lack treatment utility. Here, Dr. Kamhi makes a great point that: “Interventions that target processing skills are particularly appealing because they offer the promise of improving language and learning deficits without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (95) The problem is that we have numerous studies on the topic of improvement of isolated skills (e.g., auditory skills, working memory, slow processing, etc.) which clearly indicate lack of effectiveness of these interventions.  As such, “practitioners should be highly skeptical of interventions that promise quick fixes for language and learning disabilities” (96).

Now let us move on to language and particularly the models we provide to our clients to encourage greater verbal output. Research indicates that when clinicians are attempting to expand children’s utterances, they need to provide well-formed language models. Studies show that children select strong input when its surrounded by weaker input (the surrounding weaker syllables make stronger syllables stand out).  As such, clinicians should expand upon/comment on what clients are saying with grammatically complete models vs. telegraphic productions.

From there lets us take a look at Dr. Kamhi’s recommendations for grammar and syntax. Grammatical development goes much further than addressing Brown’s morphemes in therapy and calling it a day. As such, it is important to understand that children with developmental language disorders (DLD) (#DevLang) do not have difficulty acquiring all morphemes. Rather studies have shown that they have difficulty learning grammatical morphemes that reflect tense and agreement  (e.g., third-person singular, past tense, auxiliaries, copulas, etc.). As such, use of measures developed by (e.g., Tense Marker Total & Productivity Score) can yield helpful information regarding which grammatical structures to target in therapy.

With respect to syntax, Dr. Kamhi notes that many clinicians erroneously believe that complex syntax should be targeted when children are much older. The Common Core State Standards do not help this cause further, since according to the CCSS complex syntax should be targeted 2-3 grades, which is far too late. Typically developing children begin developing complex syntax around 2 years of age and begin readily producing it around 3 years of age. As such, clinicians should begin targeting complex syntax in preschool years and not wait until the children have mastered all morphemes and clauses (97)

Finally, Dr. Kamhi wraps up his article by offering suggestions regarding prioritizing intervention goals. Here, he explains that goal prioritization is affected by

  • clinician experience and competencies
  • the degree of collaboration with other professionals
  • type of service delivery model
  • client/student factors

He provides a hypothetical case scenario in which the teaching responsibilities are divvied up between three professionals, with SLP in charge of targeting narrative discourse. Here, he explains that targeting narratives does not involve targeting sequencing abilities. “The ability to understand and recall events in a story or script depends on conceptual understanding of the topic and attentional/memory abilities, not sequencing ability.”  He emphasizes that sequencing is not a distinct cognitive process that requires isolated treatment. Yet many SLPs “continue to believe that  sequencing is a distinct processing skill that needs to be assessed and treated.” (99)

Dr. Kamhi supports the above point by providing an example of two passages. One, which describes a random order of events, and another which follows a logical order of events. He then points out that the randomly ordered story relies exclusively on attention and memory in terms of “sequencing”, while the second story reduces demands on memory due to its logical flow of events. As such, he points out that retelling deficits seemingly related to sequencing, tend to be actually due to “limitations in attention, working memory, and/or conceptual knowledge“. Hence, instead of targeting sequencing abilities in therapy, SLPs should instead use contextualized language intervention to target aspects of narrative development (macro and microstructural elements).

Furthermore, here it is also important to note that the “sequencing fallacy” affects more than just narratives. It is very prevalent in the intervention process in the form of the ubiquitous “following directions” goal/s. Many clinicians readily create this goal for their clients due to their belief that it will result in functional therapeutic language gains. However, when one really begins to deconstruct this goal, one will realize that it involves a number of discrete abilities including: memory, attention, concept knowledge, inferencing, etc.  Consequently, targeting the above goal will not result in any functional gains for the students (their memory abilities will not magically improve as a result of it). Instead, targeting specific language and conceptual goals  (e.g., answering questions, producing complex sentences, etc.) and increasing the students’ overall listening comprehension and verbal expression will result in improvements in the areas of attention, memory, and processing, including their ability to follow complex directions.

There you have it! Ten practical suggestions from Dr. Kamhi ready for immediate implementation! And for more information, I highly recommend reading the other articles in the same clinical forum, all of which possess highly practical and relevant ideas for therapeutic implementation. They include:

References:

Kamhi, A. (2014). Improving clinical practices for children with language and learning disorders.  Language, Speech, and Hearing Services in Schools, 45(2), 92-103

Helpful Social Media Resources:

SLPs for Evidence-Based Practice

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Early Intervention Evaluations PART II: Assessing Suspected Motor Speech Disorders in Children Under 3

In my previous post on this topic, I brought up concerns regarding the paucity of useful information in EI SLP reports for children under 3 years of age and made some constructive suggestions of how that could be rectified. In 2013, I had written about another significant concern, which involved neurodevelopmental pediatricians (rather than SLPs), diagnosing Childhood Apraxia of Speech (CAS), without the adequate level of training and knowledge regarding motor speech disorders. Today, I wanted to combine both topics and delve deeper into another area of EI SLP evaluations, namely, assessments of toddlers with suspected motor speech disorders.

Firstly, it is important to note that CAS is disturbingly overdiagnosed. A cursory review of both parent and professional social media forums quickly reveals that this diagnosis is doled out like candy by both SLPs and medical professionals alike, often without much training and knowledge regarding the disorder in question.   The child is under 3, has a limited verbal output coupled with a number of phonological processes,  and the next thing you know,  s/he is labeled as having Childhood Apraxia of Speech (CAS).  But is this diagnosis truly that straightforward?

Let us begin with the fact that all reputable organizations involved in the dissemination of information on the topic of CAS (e.g., ASHA, CASANA, etc.), strongly discourage the diagnosis of CAS in children under three years of age with limited verbal output,  and limited time spent in EBP therapy specifically targeting the remediation of motor speech disorders.

Assessment of motor speech disorders in young children requires solid knowledge and expertise. That is because CAS has a number of overlapping symptoms with other speech sound disorders (e.g., severe phonological disorder, dysarthria, etc). Furthermore, symptoms which may initially appear as CAS may change during the course of intervention by the time the child is older (e.g., 3 years of age) which is why diagnosing toddlers under 3 years of age is very problematic and the use of  “suspected” or “working” diagnosis is recommended (Davis & Velleman, 2000) in order to avoid misdiagnosis. Finally, the diagnosis of CAS is also problematic due to the fact that there are still to this day no valid or reliable standardized assessments sensitive to CAS detection (McCauley & Strand, 2008).

In March 2017, Dr. Edythe Strand wrote an excellent article for the ASHA Leader entitled: “Appraising Apraxia“, in which she used a case study of a 3-year-old boy to describe how a differential diagnosis for CAS can be performed. She reviewed CAS characteristics, informal assessment protocols, aspects of diagnosis and treatment, and even included ‘Examples of Diagnostic Statements for CAS’ (which illustrate how clinicians can formulate their impressions regarding the child’s strengths and needs without explicitly labeling the child’s diagnosis as CAS).

Today, I’d like to share what information I tend to include in speech-language reports geared towards the assessing motor speech disorders in children under 3 years of age. I have a specific former client in mind for whom a differential diagnosis was particularly needed. Here’s why.

This particular 30-month client, TQ, (I did mention that I get quite a few clients for assessment around that age), was brought in due to parental concerns over her significantly reduced speech and expressive language abilities characterized by unintelligible “babbling-like” utterances and lack of expressive language.  All of TQ’s developmental milestones with the exception of speech and language had been achieved grossly at age expectancy. She began limitedly producing word approximations at ~16 months of age but at 30 months of age, her verbal output was still very restricted. She mainly communicated via gestures, pointing, word approximations, and a handful of signs.

Interestingly, as an infant, she had a restricted lingual frenulum.  However, since it did not affect her ability to feed, no surgical intervention was needed. Indeed, TQ presented with an adequate lingual movement for both feeding and speech sound production, so her ankyloglossia (or anterior tongue tie) was definitely not the culprit which caused her to have limited speech production.

Prior to being reevaluated by me, TQ underwent an early intervention assessment at ~26 months of age. She was diagnosed with CAS by an evaluating SLP and was found to be eligible for speech-language services, which she began receiving shortly thereafter. However, Mrs. Q noted that TQ was making very few gains in therapy and her treating SLP was uncertain regarding why her progress in therapy was so limited. Mrs. Q was also rather uncertain that TQ’s diagnosis of CAS was indeed a correct one, which was another reason why she sought a second opinion.

Assessment of TQ’s social-emotional functioning, play skills, and receptive language  (via a combination of Revised Westby Play Scale (Westby, 2000), REEL-3, & PLS-5) quickly revealed that she was a very bright little girl who was developing on target in all of the tested areas. Assessment of TQ’s expressive language (via REEL-3, PLS-5 & LUI*), revealed profoundly impaired, expressive language abilities.  But due to which cause?

Despite lacking verbal speech, TQ’s communicative frequency (how often she attempted to spontaneously and appropriately initiate interactions with others), as well as her communicative intent (e.g., gaining attention, making requests, indicating protests, etc), were judged to be appropriate for her age. She was highly receptive to language stimulation given tangible reinforcements and as the assessment progressed she was observed to significantly increase the number and variety of vocalizations and word approximations including delayed imitation of words and sounds containing bilabial and alveolar nasal phonemes.  

For the purpose of TQ’s speech assessment, I was interested in gaining knowledge regarding the following:

  • Automatic vs. volitional control
  • Simple vs. complex speech production
  • Consistency of productions on repetitions of the same words/word approximations
  • Vowel Productions
  • Imitation abilities
  • Prosody
  • Phonetic inventory
  • Phonotactic Constraints
  • Stimulability

TQ’s oral peripheral examination yielded no difficulties with oral movements during non-speaking as well as speaking tasks. She was able to blow bubbles, stick out tongue, smile, etc as well as spontaneously vocalize without any difficulties. Her voice quality, pitch, loudness, and resonance during vocalizations and approximated utterances were judged to be appropriate for age and gender.  Her prosody and fluency could not be determined due to lack of spontaneously produced continuous verbal output.

  1. Phonetic inventory of all the sounds TQ produced during the assessment is as follows:
    • Consonants:  plosive nasals (/m/) and alveolars (/t/, /d/, n), as well as a glide (/w/)
    • Vowels: (/a/, /e/, /i/, /o/)
  2. TQ’s phonotactic repertoire was primarily comprised of word approximations restricted to specific sounds and consisted of CV (e.g., ne), VCV (e.g., ada), CVC (e.g., nyam), CVCV (e.g., nada), VCVC (e.g., adat), CVCVCV (nadadi), VCVCV(e.g., adada) syllable shapes
  3. TQ’s speech intelligibility in known and unknown contexts was profoundly reduced to unfamiliar listeners. However, her word approximations were consistent across all productions.
  4. Due to the above I could not perform an in-depth phonological processes analysis

However, by this time I had already formulated a working hypothesis regarding TQ’s speech production difficulties. Based on her speech sound assessment TQ presented with severe phonological disorder characterized by restricted sound inventory, simplification of sound sequences, as well as patterns of sound use errors (e.g., predominance of alveolar /d/ and nasal /n/ sounds when attempting to produce most word approximations) in speech (Stoel-Gammon, 1987).

TQ’s difficulties were not consistent with the diagnosis Childhood Apraxia of Speech (CAS) at that time due to the following:

  • Adequate and varied production of vowels
  • Lack of restricted use of syllables during verbalizations (TQ was observed to make verbalizations up to 3 syllables in length)
  • Lack of disruptions in rate, rhythm, and stress of speech
  • Frequent and spontaneous use of consistently produced verbalizations
  • Lack of verbal groping behaviors when producing word-approximations
  • Good control of pitch, loudness and vocal quality during vocalizations

I felt that the diagnosis of CAS was not applicable because TQ lacked a verbal lexicon and no specific phonological intervention techniques had been trialed with her during the course of her brief therapy (~4 months) to elicit word productions (Davis & Velleman, 2000; Strand, 2003). While her EI speech therapist documented that therapy has primarily focused on ‘oral motor activities to increase TQ’s awareness of her articulators and to increase imitation of oral motor movements’, I knew that until a variety of phonological/motor-speech specific interventions had been trialed over a period of time (at least ~6 months as per Davis & Velleman, 2000) the diagnosis of CAS could not be reliably made.

I still, however, wanted to be cautious as there were a few red flags I had noted which may have potentially indicative of a non-CAS motor speech involvement, due to which I wanted to include some recommendations pertaining to motor speech remediation.

Now it is possible that after 6 months of intensive application of EBP phonological and motor speech approaches TQ would have turned 3 and still presented with highly restricted speech sound inventory and profoundly impaired speech production, making her eligible for the diagnosis of CAS in earnest.  However,  at the time of my assessment,  making such diagnosis in view of all the available evidence would have been both clinically inappropriate and unethical.

So what were my recommendations you may ask? Well, I provisionally diagnosed TQ with a severe phonological disorder and recommended that among a variety of phonologically-based approaches to trial, an EBP approach to the treatment of motor speech disorders be also used with her for a period of 6 months to determine if it would expedite speech gains.

*For those of you who are interested in the latest EBP treatment for motor speech disorders, current evidence supports the use of the Rapid Syllable Transition Treatment (ReST). ReST is a free EBP treatment developed by the SLPs at the University of Sydney, which uses nonsense words, designed to help children coordinate movements across syllables in long words and phrases as well as helps them learn new speech movements. It is, however, important to note for young children with highly restricted sound inventories, characterized by a lack of syllable production, ReST will not be applicable. For them, the Integral Stimulation/Dynamic Temporal and Tactile Cueing (DTTC) approaches do have some limited empirical support.

I also made sure to make a note in my report regarding the inappropriate use of non-speech oral motor exercises (NSOMEs) in therapy, indicating that there is NO research to support the use of NSOMEs to stimulate speech production (Lof, 2010).

In addition to the trialing of phonological and motor based approaches I also emphasized the need to establish consistent lexicon via development of functional words needed in daily communication and listed a number of examples across several categories. I made recommendations regarding select approaches and treatment techniques to trial in therapy,  as well as suggestions for expansion of sounds and structures. Finally, I made suggestions for long and short term therapy goals for a period of 6 months to trial with TQ in therapy and provided relevant references to support the claims I’ve made in my report.

You may be interested in knowing that nowadays TQ is doing quite well, and at this juncture, she is still, ineligible for the diagnosis CAS (although she needs careful ongoing monitoring with respect to the development of reading difficulties when she is older).

Now I know that some clinicians will be quick to ask me: “What’s the harm in overdiagnosing CAS if the child’s speech production will still be treated via the application of motor speech production principles?” Well, aside from the fact that it’s obviously unethical and can result in terrifying the parents into obtaining all sorts of questionable and even downright harmful bunk treatments for their children,  the treatment may only be limitedly appropriate, and may not result in the best possible outcomes for a particular child. To illustrate, TQ never presented with CAS and as such, while she may have initially limitedly benefited from the application of motor speech principles to address her speech production, shortly thereafter, the application of the principles of the dynamic systems theory is what brought about significant changes in her phonological repertoire.

That is why the correct diagnosis is so important for young children under 3 years of age. But before it can be made, extensive (reputable and evidence supported) training and education are needed by evaluating SLPs on the assessment and treatment of motor speech disorders in young children.

References:

  1. Davis, B & Velleman, S (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers”. The Transdisciplinary Journal. 10 (3): 177 – 192.
  2. Lof, G., & Watson, M. (2010). Five reasons why nonspeech oral-motor exercises do not work. Perspectives on School-Based Issues, 11.109-117.
  3. McCauley RJ, Strand EA. (2008). A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of Speech-Language Pathology, 17,81-91.
  4. McCauley R.J., Strand E., Lof, G.L., Schooling T. & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech, American Journal of Speech-Language Pathology, 18, 343-360.
  5. Murray, E., McCabe, P. & Ballard, K.J. (2015). A Randomized Control Trial of Treatments for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research 58 (3) 669-686.
  6. Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
  7. Strand, E (2003). Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, L & Campbell, T (Eds) Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation.
  8. Strand, E, McCauley, R, Weigand, S, Stoeckel, R & Baas, B (2013) A Motor Speech Assessment for Children with Severe Speech Disorders: Reliability and Validity Evidence. Journal of Speech Language and Hearing Research, vol 56; 505-520.
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The End of See it, Zap it! Ankyloglossia (Tongue-Tie) Controversies in Research and Clinical Practice

Today it is my pleasure and privilege to interview 3 Australian lactation consultations: Lois Wattis, Renee Kam, and Pamela Douglas, the authors of a March 2017 article in the Breastfeeding Review: “Three experienced lactation consultants reflect upon the oral tie phenomenon” (which can be found HERE).

Tatyana Elleseff: Colleagues, as you very well know, the subject of ankyloglossia or tongue tie affecting breastfeeding and speech production has risen into significant prominence in the past several years. Numerous journal articles, blog posts, as well as social media forums have been discussing this phenomenon with rather conflicting recommendations.  Many health professionals and parents are convinced that “releasing the tie” or performing either a frenotomy or frenectomy will lead to significant improvements in speech and feeding.

Image result for evidence based practicePresently, systematic reviews1-3 demonstrate there is insufficient evidence for the above. However, when many professionals including myself, cite reputable research explaining the lack of support of surgical intervention for tongue tie, there has been a pushback on the part of a number of other health professionals including lactation consultants, nurses, dentists, as well as speech-language pathologists stating that in their clinical experience surgical intervention does resolve issues with tongue tie as related to speech and feeding.

So today, given your 33 combined years of practice as lactation consultants I would love to ask your some questions regarding the tongue tie phenomena.

I would like to begin our discussion with a description of normal breastfeeding and what can interfere with it from an anatomical and physiological standpoint for mothers and babies.

Now, many of this blog’s readers already know that a tongue tie occurs when the connective tissue under the tongue known as a lingual frenulum restricts tongue movement to some degree and adversely affects its function.  But many may not realize that children can present with a normal anatomical variant of “ties” which can be completely asymptomatic. Can you please address that?

Lois Wattis:  “Normal” breastfeeding takes time and skill to achieve. The breastfeeding dyad is multifactorial, influenced by maternal breast and nipple anatomy combined with the infant’s facial and oral structures, all of which are highly variable. Mothers who have successfully breastfed the first baby may encounter problems with subsequent babies due to size (e.g., smaller, larger, etc.), be compromised by birth interventions or drugs during labor, or incur birth injuries – all of which can affect the initiation of breastfeeding and progression to a happy and comfortable feeding relationship. Unfortunately, the overview of each dyad’s story can be lost when tunnel vision of either health provider or parents regarding the baby’s oral anatomy is believed to be the chief influencer of breastfeeding success or failure.

Tatyana Elleseff: Colleagues, what do we know regarding the true prevalence of various ‘tongue ties’? Are there any studies of good quality?

Image result for prevalencePamela Douglas:  In a literature review in 2005, Hall and Renfrew acknowledged that the true prevalence of ankyloglossia remained unknown, though they estimated 3-4% of newborns.4

After 2005, once the diagnosis of posterior tongue-tie (PTT) had been introduced,5, 6 attempts to quantify incidence of tongue-tie have remained of very poor quality, but estimates currently rest at between 4-10%.7

The problem is that there is a lack of definitional clarity concerning the diagnosis of PTT. Consequently, anterior or classic tongue tie CTT is now often conflated with PTT simply as ‘tongue-tie’ (TT).    

Tatyana Elleseff: Thank you for clarifying it.  In addition to the anterior and posterior tongue tie labels, many parents and professionals also frequently hear the terms lip tie and buccal ties. Is there’s reputable research behind these terms indicating that these ties can truly impact speech and feeding?

Pamela Douglas:  Current definitions of ankyloglossia tend to confuse oral and tongue function (which is affected by multiple variables, and in particular by a fit and hold in breastfeeding) with structure (which is highly anatomically variable for both the tongue length and appearance and lingual and maxillary frenula).

For my own purposes, I define CTT as Type 1 and 2 on the Coryllos-Genna-Watson scale.8 In clinical practice, I also find it useful to rate the anterior membrane by the percentage of the undersurface of the tongue into which the membrane connects, applying the first two categories of the Griffiths Classification System.9 

There is a wide spectrum of lingual frenula morphologies and elasticities, and deciding where to draw a line between a normal variant and CTT will depend on the clinical judgment concerning the infant’s capacity for pain-free efficient milk transfer. However, that means we need to have an approach to fit and hold that we are confident does optimize pain-free efficient milk transfer and at the moment, research shows that not only do the old ‘hands on’ approach to fit and hold not work, but that baby-led attachment is also not enough for many women. This is why at the Possums Clinic we’ve been working on developing an approach to fit and hold (gestalt breastfeeding) that builds on baby-led attachment but also integrates the findings of the latest ultrasound studies.

I personally don’t find the diagnoses of posterior tongue tie PTT and upper lip tie ULT helpful, and don’t use them. Lois, Renee and myself find that a wide spectrum of normal anatomic lingual and maxillary frenula variants are currently being misdiagnosed as a PTT and ULT, which has worried us and led Lois to initiate the article with Renee.

Tatyana Elleseff: Segueing from the above question: is there an established criterion based upon which a decision is made by relevant professionals to “release” the tie and if so can you explain how it’s determined?

Image result for release tongue tieLois Wattis: When an anterior frenulum is attached at the tongue tip or nearby and is short enough to cause restriction of lift towards the palate, usually associated with extreme discomfort for the breastfeeding mother, I have no reservations about snipping it to release the tongue to enable optimal function for breastfeeding. If a simple frenotomy is going to assist the baby to breastfeed well it is worth doing, and as soon as possible. What I do encounter in my clinical practice are distressed and disempowered mothers whose baby has been labeled as having a posterior tongue tie and/or upper lip tie which is the cause of current and even future problems. Upon examination, the baby has completely normal oral anatomy and breastfeeding upskilling and confidence building of both mother and baby enables the dyad to go forward with strategies which address all elements of their unique story.

Although the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) is a pioneering contribution, bringing us our first systematized approach to examination of the infant’s tongue and oral connective tissues, it is unreliable as a tool for decision-making concerning frenotomy.10-12 In practice many of the item criteria are highly subjective. Although one study found moderate inter-rater reliability on the ATLFF’s structural items, the authors did not find inter-rater reliability on most of the functional items.13 In my clinical experience, there is no reliable correlation between what the tongue is observed to do during oral examinations and what occurs during breastfeeding, other than in the case of classic tongue-tie (excluding congenital craniofacial abnormalities from this discussion.

In my practice as a Lactation Consultant in an acute hospital setting I use a combination of the available assessment tools mainly for documentation purposes, however, the most important tools I use are my eyes and my ears. Observing the mother and baby physical combination and interactions, and suggesting adjustments where indicated to the positioning and attachment technique used (which  Pam calls fit and hold) can very often resolve difficulties immediately – even if the baby also has an obvious frenulum under his/her tongue. Listening to the mother’s feedback, and observing the baby’s responses are primary indicators of whether further intervention is needed, or not. Watching how the baby achieves and retains the latch is key, then the examination of baby’s mouth to assess tongue mobility and appearance provide final information about whether baby’s ability to breastfeed comfortably is or is not being hindered by a restrictive lingual frenulum.

Tatyana Elleseff: So frenotomy is an incision (cut) of lingual frenum while frenectomy (complete removal) is an excision of lingual frenum.  Both can be performed via various methods of “release”. What effects on breastfeeding have you seen with respect to healing?

Lois Wattis:  The significant difference between both procedures involves the degree of invasiveness and level of pain experienced during and after the procedures, and the differing time it takes for the resumption and/or improvement in breastfeeding comfort and efficacy.

It is commonplace for a baby who has had a simple incision to breastfeed immediately after the procedure and exhibit no further signs of discomfort or oral aversion. Conversely, the baby who has had laser division(s) may breastfeed soon after the procedure while topical anesthetics are still working. However, many infants demonstrate discomfort, extreme pain responses and reluctance to feed for days or weeks following a  laser treatment.  Parents are warned to expect delays resuming feeding and the baby is usually also subjected to wound “stretches” for weeks following the laser treatments. Unfortunately, in my clinical practice I see many parents and babies who are very traumatized by this whole process, and in many cases, breastfeeding can be derailed either temporarily or permanently.

Image result for research studiesTatyana Elleseff: Thank you! This is highly relevant information for both health professionals and parents alike. I truly appreciate your clinical expertise on this topic. While we are on the topic of restrictive lingual frenulums can we discuss several recent articles published on surgical interventions for the above? For example (Ghaheri, Cole, Fausel, Chuop & Mace, 2016), recently published the result of their study which concluded that: “Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes”.  Can you elucidate upon the study design and its findings?

Pamela Douglas:  Pre-post surveys, such as Ghaheri et al’s 2016 study, are notoriously methodologically weak and prone to interpretive bias.14 

Renee Kam:  Research about the efficacy of releasing ULTs to improve breastfeeding outcomes is seriously lacking. There is no reliable assessment tool for upper lip-tie and a lack of evidence to support the efficacy of a frenotomy of labial frenula in breastfed babies. The few studies which have included ULT release have either included very small numbers of babies having upper lip-tie releases or have included babies having a release upper lip ties and tongue ties at the same time, making it impossible to know if any improvements were due to the tongue-tie release, upper lip-tie release or both. Here, to answer your previous question, to date, no research has looked into the treatment of buccal ties for breastfeeding outcomes.

There are various classification scales for labial frenulums such as the Kotlow scale. The title of this scale is misleading as it contains the word ‘tie’. Hence it can give some people the incorrect assumption that a class III or IV labial frenulum is somehow a problem. What this scale actually shows is the normal range of insertion sites for a labial frenulum. And, in normal cases, the vast majority of babies’ labial frenulums insert low down on the upper gum (class III) or even wrap around it (class IV). It’s important to note that, for effective breastfeeding, the upper lip does not have to flange out in order to create a seal. It just has to rest in a neutral position — not flanged out, not tucked in.

Lois Wattis: I entirely agree with Renee’s view about the neutrality of the upper lip, including the labial frenulum, in relation to latch for breastfeeding. Even babies with asymmetrical facial features, cleft lips and other permanent and temporary anomalies only need to achieve a seal with the upper lip to breastfeed successfully.

Image resultTatyana Elleseff: Thank you for that. In addition to studies on tongue tie revisions and breastfeeding outcomes, there has been an increase in studies, specifically Kotlow (2016) and Siegel (2016), which claimed that surgical intervention improves outcomes for acid reflux and aerophagia in babies”.  Can you discuss these studies design and findings?

Renee Kam: The AIR hypothesis has led to reflux being used as another reason to diagnose the oral anatomic abnormalities in infants in the presence of breastfeeding problems. More research with objective indicators and less vested interest is needed in this area. A thorough understanding of normal infant behavior and feeding problems which aren’t tie related are also imperative before any conclusions about AIR can be reached.

Tatyana Elleseff: One final question, colleagues are you aware of any studies which describe long-term outcomes of surgical interventions for tongue ties?

Pamela Douglas:  The systematic reviews note that there is a lack of evidence demonstrating long-term outcomes of surgical interventions. 

Tatyana Elleseff: Thank you for such informative discussion, colleagues.

Related imageThere you have it, readers. Both research and clinical practice align to indicate that:

  • There’s significant normal variation when it comes to most anatomical structures including the frenulum
  • Just because a child presents with restricted frenulum does not automatically imply adverse feeding as well as speech outcomes and immediately necessitates a tongue tie release
  • When breastfeeding difficulties arise, in the presence of restricted frenulum, it is very important to involve an experienced lactation specialist who will perform a differential diagnosis in order to determine the source of the baby’s true breastfeeding difficulties

Now, I’d like to take a moment and address the myth of tongue ties affecting speech production,  which continues to persist among speech-language pathologists despite overwhelming evidence to the contrary.

For that purpose, I will use excerpts from an excellent ASHA Leader December 2005 article written by an esteemed Dr. Kummer who is certainly well qualified to discuss this issue. According to Dr. Kummer, “there is no empirical evidence in the literature that ankyloglossia typically causes speech defects. On the contrary, several authors, even from decades ago, have disputed the belief that there is a strong causal relationship (Wallace, 1963; Block, 1968; Catlin & De Haan, 1971; Wright, 1995; Agarwal & Raina, 2003).”

Related imageSince many children with restricted frenulum do not have any speech production difficulties, Dr Kummer explains why that is the case by discussing the effect of tongue tip positioning for speech production.

Lingual-alveolar sounds (t, d, n) are produced with the top of the tongue tip and therefore, they can be produced with very little tongue elevation or mobility.

The /s/ and /z/ sounds require the tongue tip to be elevated only slightly but can be produced with little distortion if the tip is down.

The most the tongue tip needs to elevate is to the alveolar ridge for the production of an /l/. However, this sound can actually be produced with the tongue tip down and the dorsum of the tongue up against the alveolar ridge. Even an /r/ sound can be produced with the tongue tip down as long as the back of the tongue is elevated on both sides.

The most the tongue needs to protrude is to the back of the maxillary incisors for the production of /th/. All of these sounds can usually be produced, even with significant tongue tip restriction. This can be tested by producing these sounds with the tongue tip pressed down or against the mandibular gingiva. This results in little, if any, distortion.” (Kummer, 2005, ASHA Leader)

In 2009, Dr. Sharynne McLeod, did research on electropalatography of speech sounds with adults. Her findings (below) which are coronal images of tongue positioning including bracing, lateral contact and groove formation for consonants support the above information provided by Dr. Kummer.

Once again research and clinical practice align to indicate that there’s insufficient evidence to indicate the effect of restricted frenulum on the production of speech sounds.

Finally, I would like to conclude this post with a list of links from recent systematic reviews summarizing the latest research on this topic.

Ankyloglossia/Tongue Tie Systematic Review Summaries to Date (2017):

  1. A small body of evidence suggests that frenotomy may be associated with mother reported improvements in breastfeeding, and potentially in nipple pain, but with small, short-term studies with inconsistent methodology, the strength of the evidence is low to insufficient.
  2. In an infant with tongue-tie and feeding difficulties, surgical release of the tongue-tie does not consistently improve infant feeding but is likely to improve maternal nipple pain. Further research is needed to clarify and confirm this effect.
  3. Data are currently insufficient for assessing the effects of frenotomy on nonbreastfeeding outcomes that may be associated with ankyloglossia
  4. Given the lack of good-quality studies and limitations in the measurement of outcomes, we considered the strength of the evidence for the effect of surgical interventions to improve speech and articulation to be insufficient.
  5. Large temporal increases and substantial spatial variations in ankyloglossia and frenotomy rates were observed that may indicate a diagnostic suspicion bias and increasing use of a potentially unnecessary surgical procedure among infants.

References

  1. Power R, Murphy J. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Archives of Disease in Childhood 2015;100:489-494.
  2. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135(6):e1467-e1474.
  3. O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, et al. Frenotomy for tongue-tie in newborn infants (Review). Cochrane Database of Systematic Reviews. 2017 (3):Art. No.:CD011065.
  4. Hall D, Renfrew M. Tongue tie. Archives of Disease in Childhood. 2005;90:1211-1215.
  5. Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby, American Academy of Pediatrics. 2004 Summer:1-6.
  6. Coryllos EV, Watson Genna C, LeVan Fram J. Minimally Invasive Treatment for Posterior Tongue-Tie (The Hidden Tongue-Tie). In: Watson Genna C, editor. Supporting Sucking Skills. Burlington, MA: Jones and Bartlett Learning; 2013. p. 243-251.
  7. National Health and Medical Research Council. Infant feeding guidelines: information for health workers. In: Government A, editor. 2012. p. https://www.nhmrc.gov.au/guidelines-publications/n56.
  8. Watson Genna C, editor. Supporting sucking skills in breastfeeding infants. Burlington, MA: Jones and Bartlett Learning; 2016.
  9. Griffiths DM. Do tongue ties affect breastfeeding? . Journal of Human Lactation. 2004;20:411.
  10. Ricke L, Baker N, Madlon-Kay D. Newborn tongue-tie: prevalence and effect on breastfeeding. Journal of American Board of Family Practice. 2005;8:1-8.
  11. Madlon-Kay D, Ricke L, Baker N, DeFor TA. Case series of 148 tongue-tied newborn babies evaluated with the assessment tool for lingual function. Midwifery. 2008;24:353-357.
  12. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110:e63.
  13. Amir L, James JP, Donath SM. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function. International Breastfeeding Journal. 2006;1:3.
  14. Douglas PS. Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improve breastfeeding are not substantiated. Breastfeeding Medicine. 2017;12(3):DOI: 10.1089/bfm.2017.0008.

Author Bios (in alphabetical order):

Dr. Pamela Douglas  is the founder of a charitable organization, the Possums Clinic, a general practitioner since 1987, an IBCLC (1994-2004; 2012-Present) and researcher. She is an Associate Professor (Adjunct) with the Centre for Health Practice Innovation, Griffith University, and a Senior Lecturer with the Discipline of General Practice, The University of Queensland. Pam enjoys working clinically with families across the spectrum of challenges in early life, many complex (including breastfeeding difficulty) unsettled infant behaviors, reflux, allergies, tongue-tie/oral connective tissue problems, and gut problems. She is author of The discontented little baby book: all you need to know about feeds, sleep and crying (UQP) www.possumsonline.com; www.pameladouglas.com.au

Renee Kam qualified with a Bachelor of Physiotherapy from the University of Melbourne in 2000. She then worked as a physiotherapist for 6 years, predominantly in the areas of women’s health, pediatric and musculoskeletal physiotherapy. She became an Australian Breastfeeding Association Breastfeeding (ABA) counselor in 2010 and obtained the credential of International Board Certified Lactation Consultant (IBCLC) in 2012. In 2013, Renee’s book, The Newborn Baby Manual, was published which covers the topics that Renee is passionate about; breastfeeding, baby sleep and baby behavior. These days, Renee spends most of her time being a mother to her two young daughters, writing breastfeeding content for BellyBelly.com.au, fulfilling her role as national breastfeeding information manager with ABA and working as an IBCLC in private practice and at a private hospital in Melbourne, Australia.

Lois Wattis is a Registered Nurse/Midwife, International Board Certified Lactation Consultant and Fellow of the Australian College of Midwives. Working in both hospital and community settings, Lois has enhanced her midwifery skills and expertise by providing women-centred care to thousands of mothers and babies, including more than 50 women who chose to give birth at home. Lois’ qualifications include Bachelor of Nursing Degree (Edith Cowan University, Perth WA), Post Graduate Diploma in Clinical Nursing, Midwifery (Curtin University, Perth WA), accreditation as Independent Practising Midwife by the Australian College of Midwives in 2002 and International Board Certified Lactation Consultant in 2004. Lois was inducted as a Fellow of the Australian College of Midwives (FACM) in 2005 in recognition of her services to women and midwifery in Australia. Lois has authored numerous articles which have been published internationally in parenting and midwifery journals, and shares her broad experience via her creations “New Baby 101” book, smartphone App, on-line videos and Facebook page. www.newbaby101.com.au Lois has worked for the past 10 years in Qld, Australia in a dedicated Lactation Consultant role as well as in private practice www.birthjourney.com

 

 

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C/APD Update: New Developments on an Old Controversy

In the past two years, I wrote a series of research-based posts (HERE and HERE) regarding the validity of (Central) Auditory Processing Disorder (C/APD) as a standalone diagnosis as well as questioned the utility of it for classification purposes in the school setting.

Once again I want to reiterate that I was in no way disputing the legitimate symptoms (e.g., difficulty processing language, difficulty organizing narratives, difficulty decoding text, etc.), which the students diagnosed with “CAPD” were presenting with.

Rather, I was citing research to indicate that these symptoms were indicative of broader linguistic-based deficits, which required targeted linguistic/literacy-based interventions rather than recommendations for specific prescriptive programs (e.g., CAPDOTS, Fast ForWord, etc.),  or mere accommodations.

I was also significantly concerned that overfocus on the diagnosis of (C)APD tended to obscure REAL, language-based deficits in children and forced SLPs to address erroneous therapeutic targets based on AuD recommendations or restricted them to a receipt of mere accommodations rather than rightful therapeutic remediation.

Today I wanted to update you regarding new developments, which took place since my last blog post was written 1.5 years ago, regarding the validity of “C/APD” diagnosis.

In April 2016, de Wit and colleagues published a systematic review in the Journal of Speech, Language, and Hearing Research. Their purpose was to review research studies describing the characteristics of APD in children and determine whether these characteristics merited a label of a distinct clinical disorder vs. being representative of other disorders.  After they searched 6 databases they chose 48 studies which satisfied appropriate inclusion criteria. Unfortunately, only 1 study had strong methodological quality and what’s even more disappointing, the children in their studies were very dissimilar and presented with incredibly diverse symptomology. The authors concluded that: “the listening difficulties of children with APD may be a consequence of cognitive, language, and attention issues rather than bottom-up auditory processing.”

In other words, because APD is not a distinct clinical disorder, a diagnosis of APD would not contribute anything to the child’s functioning beyond showing that the child is experiencing linguistically based deficits, which bear further investigation.

To continue, you may remember that in my first CAPD post I extensively cited a tutorial written by Dr. David DeBonis, who is an AuD. In his article, he pointed out numerous inconsistencies involved in CAPD testing and concluded that “routine use of CAPD test protocols cannot be supported” and that [CAPD] “intervention needs to be contextualized and functional.”

In July 2016, Iliadou, Sirimanna, & Bamiou published an article: “CAPD Is Classified in ICD-10 as H93.25 and Hearing Evaluation—Not Screening—Should Be Implemented in Children With Verified Communication and/or Listening Deficits” protesting DeBonis’s claim that CAPD is not a unique clinical entity and as such should not be included in any disease classification system.  They stated that DeBonis omitted the fact that “CAPD is included in the U.S. version of the International Statistical Classification of Diseases and Related Health Problems–10th Revision (ICD-10) under the code H93.25” (p. 368). They also listed what they believed to be a number of article omissions, which they claimed biased DeBonis’s tutorial’s conclusions.

The authors claimed that DeBonis provided a limited definition of CAPD based only on ASHA’s Technical report vs. other sources such as American Academy of Audiology (2010), British Society of Audiology Position Statement (2011), and Canadian Guidelines on Auditory Processing Disorder in Children and Adults: Assessment Intervention (2012).  (p. 368)

The also authors claimed that DeBonis did not adequately define the term “traditional testing” and failed to provide several key references for select claims.  They disagreed with DeBonis’s linkage of certain digit tests, as well as his “lumping” of studies which included children with suspected and diagnosed APD into the same category. (p. 368-9)  They also objected to the fact that he “oversimplified” results of positive gains of select computer-based interventions for APD, and that in his summary section he listed only selected studies pertinent to the topic of intelligence and auditory processing skills. (p. 369).

Their main objection, however, had to do with the section of DeBonis’s article that contained “recommended assessment and intervention process for children with listening and communication difficulties in the classroom”.  They expressed concerns with his recommendations on the grounds that he failed to provide published research to support that this was the optimal way to provide intervention. The authors concluded their article by stating that due to the above-mentioned omissions they felt that DeBonis’s tutorial “show(ed) unacceptable bias” (p. 370).

In response to the Iliadou, Sirimanna, & Bamiou, 2016 concerns, DeBonis issued his own response article shortly thereafter (DeBonis, 2016). Firstly, he pointed out that when his tutorial was released in June 2015 the ICD-10 was not yet in effect (it was enacted Oct 1, 2015). As such his statement was factually accurate.

Secondly, he also made a very important point regarding the C/APD construct validity, namely that it fails to satisfy the Sydenham–Guttentag criteria as a distinct clinical entity (Vermiglio, 2014). Namely, despite attempts at diagnostic uniformity, CAPD remains ambiguously defined, with testing failing to “represent a homogenous patient group.” (p. 906).

For those who are unfamiliar with this terminology (as per direct quote from Dr. Vermiglio’s presentation): “The Sydenham-Guttentag Criteria for the Clinical Entity Proposed by Vermiglio (accepted 2014, JAAA) is as follows:

  1. The clinical entity must possess an unambiguous definition (Sydenham, 1676; FDA, 2000)
  2. It must represent a homogeneous patient group (Sydenham, 1676; Guttentag, 1949, 1950; FDA, 2000)
  3. It must represent a perceived limitation (Guttentag, 1949)
  4. It must facilitate diagnosis and intervention (Sydenham, 1676; Guttentag, 1949; FDA, 2000)

Thirdly, DeBonis addressed Iliadou, Sirimanna, & Bamiou, 2016 concerns that he did not use the most recent definition of APD by pointing out that he was most qualified to discuss the US system and its definitions of CAPD, as well as that “the U.S. guidelines, despite their limitations and age, continue to have a major impact on the approach to auditory processing disorders worldwide” (p.372). He also elucidated that: the AAA’s (2010) definition of CAPD is “not so much built on previous definitions but rather has continued to rely on them” and as such does not constitute a “more recent” source of CAPD definitions. (p.372)

DeBonis next addressed the claim that he did not adequately define the term “traditional testing”. He stated that he defined it on pg. 125 of his tutorial and that information on it was taken directly from the AAA (2010) document. He then explained how it is “aligned with bottom-up aspects of the auditory system” by citing numerous references (see p. 372 for further details).  After that, he addressed Iliadou, Sirimanna, & Bamiou, 2016 claim that he failed to provide references by pointing out the relevant citation in his article, which they failed to see.

Next, he proceeded to address their concerns “regarding the interaction between cognition and auditory processing” by reiterating that auditory processing testing is “not so pure” and is affected by constructs such as memory, executive function skills, etc. He also referenced the findings of  Beck, Clarke and Moore (2016)  that “most currently used tests of APD are tests of language and attention…lack sensitivity and specificity” (p. 27).

The next point addressed by DeBonis was the use of studies which included children with suspected vs. confirmed APD. He agreed that “one cannot make inferences about one population from another” but added that the data from the article in question “provided insight into the important role of attention and memory in children who are poor listeners” and that “such listeners represent the population [which] should be [AuD’s] focus.” (p.373)

From there on, DeBonis moved on to address Iliadou, Sirimanna, & Bamiou, 2016 claims that he “oversimplified” the results of one CBAT study dealing with effects of computer-based interventions for APD. He responded that the authors of that review themselves stated that: “the evidence for improving phonological awareness is “initial”.

Consequently, “improvements in auditory processing—without subsequent changes in the very critical tasks of reading and language—certainly do not represent an endorsement for the auditory training techniques that were studied.” (p.373)

Here, DeBonis also raised concerns regarding the overall concept of treatment effectiveness, stating that it should not be based on “improved performance on behavioral tests of auditory processing or electrophysiological measures” but ratheron improvements on complex listening and academic tasks“. (p.373) As such,

  1. “This limited definition of effectiveness leads to statements about the impact of certain interventions that can be misinterpreted at best and possibly misleading.”
  2. “Such a definition of effectiveness is unlikely to be satisfying to working clinicians or parents of children with communication difficulties who hope to see changes in day-to-day communication and academic abilities.” (p.373)

Then, DeBonis addressed Iliadou, Sirimanna, & Bamiou, 2016 concerns regarding the omission of an article supporting CAPD and intelligence as separate entities. He reiterated that the aim of his tutorial was to note that “performance on commonly used tests of auditory processing is highly influenced by a number of cognitive and linguistic factors” rather than to “do an overview of research in support of and in opposition to the construct”. (p.373)

Subsequently, DeBonis addressed the Iliadou, Sirimanna, & Bamiou, 2016 claim that he did not provide research to support his proposed testing protocol, as well as that he made a figure error. He conceded that the authors were correct with respect to the figure error (the information provided in the figure was not sufficient). However, he pointed out that the purpose of his tutorial was to “to review the literature related to ongoing concerns about the use of the CAPD construct in school-aged children and to propose an alternative assessment/intervention procedure that moves away from testing “auditory processing” and moves toward identifying and supporting students who have listening challenges”. As such, while the effectiveness of his model is being tested, it makes sense to “use of questionnaires and speech-in-noise tests with very strong psychometric characteristics” and thoroughly assess these children’s “language and cognitive skills to reduce the chance of misdiagnosis”  in order to provide functional interventions (p.373).

Finally, Debonis addressed the Iliadou, Sirimanna, & Bamiou, 2016 accusation that his tutorial contained “unacceptable bias”. He pointed out that “the reviewers of this [his 2015 article article] did not agree” and that since the time of that article’s publication “readers and other colleagues have viewed it as a vehicle for important thought about how best to help children who have listening difficulties.” (p. 374)

Having read the above information, many of you by now must be wondering: “Why is the research on APD as a valid stand alone diagnosis continues to be published at regular intervals?”

To explain the above phenomenon, I will use several excerpts from an excellent presentation by Kamhi, A, Vermiglio, A, & Wallach, G (2016), which I attended during the 2016 ASHA Convention in Philadephia, PA.

It has been suggested that the above has to do with: “The bias of the CAPD Convention Committee that reviews submissions.” Namely, “The committee only accepts submissions consistent with the traditional view of (C)APD espoused by Bellis, Chermak and others who wrote the ASHA (2005) position statement on CAPD.”

Kamhi Vermiglio, and Wallach (2016) supported this claim by pointing out that when Dr. Vermiglio attempted to submit his findings on the nature of “C/APD” for the 2015 ASHA Convention, “the committee did not accept Vermiglio’s submission” but instead accepted the following seminar: “APD – It Exists! Differential Diagnosis & Remediation” and allocated for it “a prominent location in the program planner.”

Indeed, during the 2016 ASHA convention alone, there was a host of 1 and 2-hour pro-APD sessions such as: “Yes, You CANS! Adding Therapy for Specific CAPDs to an IEP“, “Perspectives on the Assessment & Treatment of Individuals With Central Auditory Processing Disorder (CAPD)“, as well asThe Buffalo Model for CAPD: Looking Back & Forward, in addition to a host of posters and technical reports attempting to validate this diagnosis despite mounting evidence refuting that very fact. Yet only one session, “Never-Ending Controversies With CAPD: What Thinking SLPs & Audiologists Know” presented by Kamhi, Vermiglio, & Wallach (two SLPs and one AuD) and accepted by a non-AuD committee, discussed the current controversies raging in the fields of speech pathology and audiology pertaining to “C/APD”. 

In 2016, Diane Paul, the Director of Clinical Issues in Speech-Language Pathology at ASHA  had asked Kamhi, Vermiglio, and Wallach “to offer comments on the outline of audiology and SLP roles in assessing and treating CAPD”.  According to Kamhi, et al, 2016, the outline did not mention any of controversies in assessment and diagnosis documented by numerous authors dating as far as 2009. It also did not “mention the lack of evidence on the efficacy of auditory interventions documented in the systematic review by Fey et al. (2011) and DeBonis (2015).”

At this juncture, it’s important to start thinking regarding possible incentives a professional might have to continue performing APD testing and making prescriptive program recommendations despite all the existing evidence refuting the validity and utility of APD diagnosis for children presenting with listening difficulties.

Conclusions:

  • There is still no compelling evidence that APD is a stand-alone diagnosis with clear diagnostic criteria
  • There is still no compelling evidence that auditory deficits are a “significant risk factor for  language or academic performance”
  • There is still no compelling evidence that “auditory interventions provide any unique benefit to auditory, language, or academic outcomes” (Hazan, Messaoud-Galusi, Rosan, Nouwens, & Shakespeare, 2009; Watson & Kidd, 2009)
  • APD deficits are linguistically based deficits which accompany a host of developmental conditions ranging from developmental language disorders to learning disabilities, etc.
  • SLPs should continue comprehensively assessing children diagnosed with “C/APD” to determine the scope of their linguistic deficits
  • SLPs should continue formulating language goals to  determine linguistic areas of weaknesses
  • SLPS should be wary of any goals or recommendations which focus on remediation of isolated skills such as: “auditory discrimination, auditory sequencing, phonological memory, working memory, or rapid serial naming” since studies have definitively confirmed their lack of effectiveness (Fey, et al, 2011)
  • SLPs should be wary of any prescriptive programs offering C/APD “interventions”
  • SLPs should focus on improving children’s abilities for functional communication including listening, speaking, reading, and writing
    • Please see excellent article written by Dr. Wallach in 2014 entitled: Improving Clinical Practice: A School-Age and School-Based Perspective. It “presents a conceptual framework for intervention at school-age levels” and discusses “advanced levels of language that move beyond preschool and early elementary grade goals and objectives with a focus on comprehension and meta-abilities.”

So there you have it, sadly, despite research and logic, the controversy is very much alive! Except I am seeing some new developments!

I see SLPs, newly-minted and seasoned alike, steadily voicing their concerns regarding the symptomology they are documenting in children diagnosed with so-called “CAPD” as being purely auditory in nature.

I see more and more SLPs supporting research evidence and science by voicing their concerns regarding the numerous diagnostic markers of ‘CAPD’ which do not make sense to them by stating “Wait a second – that can’t be right!”.

I see more and more SLPs documenting the lack of progress children make after being prescribed isolated FM systems or computer programs which claim to treat “APD symptomology” (without provision of therapy services).  I see more and more SLPs beginning to understand the lack of usefulness of this diagnosis, who switch to using language-based interventions to teach children to listen, speak, read and write and to generalize these abilities to both social and academic settings.

I see more and more SLPs beginning to understand the lack of usefulness of this diagnosis, who switch to using language-based interventions to teach children to listen, speak, read and write and to generalize these abilities to both social and academic settings.

So I definitely do see hope on the horizon!

References:

(arranged in chronological order of citation in the blog post):

Related Posts:

 

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What’s Memes Got To Do With It?

Today, after a long hiatus, I am continuing my series of blog posts on “Scholars Who do Not Receive Enough Mainstream Exposure” by summarizing select key points from Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“.

Alan Kamhi

Some of you may be wondering: “Why is she reviewing an article that is more than a decade old? The answer is simple.  It is just as relevant, if not more so today, as it was 12 years ago, when it first came out.

In this article, Dr. Kamhi, asks a provocative question: “Why do some terms, labels, ideas, and constructs [in the field of speech pathology] prevail whereas others fail to gain acceptance?

He attempts to answer this question by explaining the vital role the concept of memes play in the evolution and spread of ideas.

—A meme (shortened from the Greek mimeme to imitate) is an idea, behavior, or style that spreads from person to person within a culture”. The term was originally coined by British evolutionary biologist Richard Dawkins in The Selfish Gene (1976) to explain the spread of ideas and cultural phenomena such as tunes, ideas, catchphrases, customs, etc.

‘Selfish’ in this case means that memes “care only about their own self-replication“.  Consequently, “successful memes are those that get copied accurately (fidelity), have many copies (fecundity), and last a long time (longevity).” Therefore, “memes that are easy to understand, remember, and communicate to others” have the highest risk of survival and replication (pp. 105-106).

So what were some of the more successful memes which Dr. Kamhi identified in his article, which still persist more than a decade later?

  • Learning Disability
  • Auditory Processing Disorder
  • Sensory Integration Disorder
  • Dyslexia
  • Articulation disorder
  • Speech Therapist/ Pathologist

Interestingly the losers of the “contest” were memes that contained the word language in it:

  • Language disorder
  • Language learning disability
  • Speech-language pathologist (albeit this term has gained far more acceptance in the past decade)

Dr. Kamhi further asserts that ‘language-based disorders have failed to become a recognizable learning problem in the community at large‘ (p.106).

So why are labels with the words ‘language’ NOT successful memes?

According to Dr. Kamhi that is because “language-based disorders must be difficult to understand, remember, and communicate to others“. Professional (SLP) explanations of what constitutes language are lengthy and complex (e.g., ASHA’s comprehensive definition) and as a result are not frequently applied in clinical practice, even when its aspects are familiar to SLPs.

Some scholars have suggested that the common practice of evaluating language with standardized language tools, restricts full understanding of the interactions of all of its domains (“within larger sociocultural context“) because they only examine isolated aspects of language. (Apel, 1999)

Dr. Kamhi, in turn explains this within the construct of the memetic theory: namely “simple constructs are more likely to replicate than complex ones.” In other words: “even professionals who understand language may have difficulty communicating its meaning to others and applying this meaning to clinical practice” (p. 107).

Let’s talk about the parents who are interested in learning the root-cause of their child’s difficulty learning and using language.  Based on specific child’s genetic and developmental background as well as presenting difficulties, an educated clinician can explain to the parent the multifactorial nature of their child’s deficits.

However, these informed but frequently complex explanations are certainly in no way simplistic. As a result, many parents will still attempt to seek other professionals who can readily provide them with a “straightforward explanation” of their child’s difficulty.  Since parents are “ultimately interested in finding the most effective and efficient treatment for their children” it makes sense to believe/hope that “the professional who knows the cause of the problem will also know the most effective way to treat it“(p. 107).

This brings us back to the concept of successful memes such as Auditory Processing Disorder (C/APD) as well as Sensory Processing Disorder (SPD) as isolated diagnoses.

Here are just some of the reasons behind their success:

  • They provide a simple solution (which is not necessarily a correct one) that “the learning problem is the result of difficulty processing auditory information or difficulty integrating sensory information“.
  • The assumption is “improving auditory processing and sensory integration abilities” will improve learning difficulties
  • Both, “APD and SID each have only one cause“, so “finding an appropriate treatment …seems more feasible because there is only one problem to eliminate
  • Gives parents “a sense of relief” that they finally have an “understandable explanation for what is wrong with their child
  • Gives parents  hope that the “diagnosis will lead to successful remediation of the learning problem

For more information on why APD and SPD are not valid stand-alone diagnoses please see HERE and HERE respectively.

A note on the lack of success of “phonological” memes:

  • They are difficult to understand and explain (especially due to a lack of consensus of what constitutes a phonological disorder)
  • Lack of familiarity with the term ‘phonological’ results in poor comprehension of “phonological bases of reading problems since its “much easier to associate reading with visual processing abilities, good instruction, and a literacy rich environment” (p. 108).

Let’s talk about MEMEPLEXES (Blackmore, 1999)  or what occurs whennonprofessionals think they know how children learn language and the factors that affect language learning (Kamhi, 2004, p.108).

A memplex is a group of memes, which become much more memorable to individuals (can replicate more efficiently) as a team vs. in isolation.

Why is APD Memeplex So Appealing? 

According to Dr. Kamhi, if one believes that ‘a) sounds are the building blocks of speech and language and (b) children learn to talk by stringing together sounds and constructing meanings out of strings of sounds’ (both wrong assumptions) then its quite a simple leap to make with respect to the following fallacies:

  • Auditory processing are not influenced by language knowledge
  • You can reliably discriminate between APD and language deficits
  • You can validly and reliably assess “uncontaminated” auditory processing abilities and thus diagnose stand-alone APD
  • You can target auditory abilities in isolation without targeting language
  • Improvements in discrimination and identification of ‘speech sounds will lead to improvements in speech and language abilities

For more detailed information, why the above is incorrect, click: HERE

On the success of the Dyslexia Meme:

  • Most nonprofessionals view dyslexia as visually based “reading problem characterized by letter reversals and word transpositions that affects bright children and adults
  • Its highly appealing due to the simple nature of its diagnosis (high intelligence and poor reading skills)
  • The diagnosis of dyslexia has historically been made by physicians and psychologists rather than educators‘, which makes memetic replication highly successful
  • The ‘dyslexic’ label is far more appealing and desirable than calling self ‘reading disabled’

For more detailed information, why the above is far too simplistic of an explanation, click: HERE and HERE

Final Thoughts:

As humans we engage in transmission of  ideas (good and bad) on constant basis. The popularity of powerful social media tools such as Facebook and Twitter ensure their instantaneous and far reaching delivery and impact.  However, “our processing limitations, cultural biases, personal preferences, and human nature make us more susceptible to certain ideas than to others (p. 110).”

As professionals it is important that we use evidence based practices and the latest research to evaluate all claims pertaining to assessment and treatment of language based disorders. However, as Dr. Kamhi points out (p.110):

  • “Competing theories may be supported by different bodies of evidence, and the same evidence may be used to support competing theories.”
  • “Reaching a scientific consensus also takes time.”

While these delays may play a negligible role when it comes to scientific research, they pose a significant problem for parents, teachers and health professionals who are seeking to effectively assist these youngsters on daily basis. Furthermore, even when select memes such as APD are beneficial because they allow for a delivery of services to a student who may otherwise be ineligible to receive them, erroneous intervention recommendations (e.g., working on isolated auditory discrimination skills) may further delay the delivery of appropriate and targeted intervention services.

So what are SLPs to do in the presence of persistent erroneous memes?

Spread our language-based memes to all who will listen” (Kamhi, 2004, 110) of course! Since we are the professionals whose job is to treat any difficulties involving words. Consequently, our scope of practice certainly includes assessment, diagnosis and treatment of children and adults with speaking, listening, reading, writing, and spelling difficulties.

As for myself, I intend to start that task right now by hitting the ‘publish’ button on this post!

I am a SLP

 References:

Kamhi, A. (2004). A meme’s eye view of speech-language pathology. [PDFLanguage, Speech, and Hearing Services in Schools35, 105-112.

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Alternative Therapies, Herbs, Pills, and Snake Oils or “What’s the Harm in That?”

I’ve been meaning to write this post for some time and have finally decided to do it now due to an increased prevalence of “non-traditional” treatment options available to parents of language impaired children.

More and more unscrupulous or misguided individuals are offering fantastical cures to children diagnosed with the wide variety of disorders including but not limited to: Autism (ASD), Childhood Apraxia of Speech (CAS), language disorders, “Auditory Processing Deficits (APD)“, Dyslexia, and much much more.

What are some examples of controversial products and therapies you may ask?

Below I cite several links (which are in no way exhaustive) for your convenience.

Controversial Autism Treatments: 

In 2013, Dr. Emily Willingham, guest writer for Forbes magazine wrote a post on the topic of “The 5 Scariest Autism ‘Treatments.  In it she described some pretty horrifying methods (e.g., chelation, chemical castration, hyperbaric oxygen therapy) which purportedly promised to “cure” autism. For more information on other controversial treatments in autism click to read this keynote address entitled Evidence-Based Practices for Children with Autism Spectrum Disorders by Dr. Tristram Smith for The Society for Clinical Child and Adolescent Psychology (SCCAP).

Controversial Speech Sound Disorder Treatments 

Dr. Caroline Bowen respected Speech Language Researcher from Australia has a delightfully edifying page on her website (http://speech-language-therapy.com/) entitled: “Controversial Practices in Children’s Speech Sound Disorders – Oral Motor Exercises, Dietary Supplements, Auditory Integration Training”.  On it she thoroughly reviews non-research supported practices to improve children’s sound production including the use of oral motor/mouth exercises, dietary supplements (Apraxia Diet, Nourish Life Speak, Nutri Veda, etc.), as well as Auditory Integration Training (AIT).

Parent‐Friendly Information about Nonspeech Oral Motor Exercises (HERE)

Controversial Treatments for Children with Developmental and Learning Disabilities 

Macquarie University Special Education Centre in Sydney Australia has even developed concise one-page briefings of a vast number of controversial treatments for children with developmental and learning disabilities (selected briefing links are below; the full list of briefings is available HERE):

How to Spot Controversial Practices? 

In her 2012 post entitled: “10 Questions To Distinguish Real From Fake Science“, Dr. Emily Willingham wrote that “science consumers need a cheat sheet … when considering a product, book, therapy, or remedy”. She advised consumers to consider some of the following criteria:

  • Consider the source
  • Determine their agenda
  • Do they use highly emotionally charged language or meaningless jargon?
  • Are they relying on testimonials vs. evidence?
  • Are they claiming to be exclusive?
  • Do they mention words like ‘conspiracy’?
  • Is their treatment promising to cure multiple unrelated disorders?
  • What does the money trail reveal?

The truth is that there’s a lot of pseudoscience out there and as such it is very important for both parents and professionals not to fall into its trap.  In 2012, Dr. Gregory Lof presented the following poster at the ASHA’s Atlanta Convention:  “Science vs. Pseudoscience in CSD: A Checklist for Skeptical Thinking” to “help clinicians evaluate claims made by promoters of products or services to help determine if they are based on scientific principles or on pseudoscience”. An interactive version of the checklist is available HERE, and for the summary based on the checklist,  written by Mary Huston,  fellow SLP and author of the Speech Adventures, click HERE

So what do pseudoscientific practices/claims look like?

  • People place heavy emphasis on beliefs and opinions vs. data, when it comes to therapeutic claims
    • SLPs: “You are wrong! I’ve seen ________ work with my clients!”
    • Parents: “Who cares about your research this _______worked for us so HOW DARE YOU question it?
  • The presented data is based on “expert opinions”, testimonials, and isolated case studies
    • “These ridiculously expensive ‘speech sticks’ at $120 a pop worked for us, Yay!”
  • Data is disseminated via self-published books, popular press, proprietary websites lacking research sections, as well as non-peer reviewed conferences.
    • You might want to review the list of predatory publishers HERE, review the guide of how to spot a bogus scientific publication HERE,  and if you ever find yourself reading anything on this website, I suggest you close your laptop as fast as you can and possibly put it into another room for a while (Read Why – HERE).
  • Treatment sounds like a magic potion since it works on a wide range of disabilities, appeals to fears and wishful thinking, preys on the desperate and uses hyperboles (“miracle cure”)
  • Use of disdainful comments against researchers because “only clinicians do real clinical work”coupled with over reliance on clinician’s experience and subjective judgment since it’s the “best way” to determine effectiveness
    • “I’ve found ___________ to be highly effective with gazillion clients”.
  • Lack of change in practices despite a veritable mountain of evidence to the contrary
    • “Your child NEEDS oral-motor exercises, NOW, for his speech to get better”
  • New terms are created to mask use of disproven pseudoscientific practices

Why do we keep believing when all the evidence points to the contrary?

Because our brains become emotionally attached to ideas. This is further supported by the construct of two biases.

Confirmation bias – our tendency to look for/interpret information in a way that confirms our beliefs by “cherry picking” the evidence that supports what we believe in and ignoring the evidence that argues against it.

Disconfirmation bias – when facing with evidence which directly contradicts our beliefs we will criticize and reject it because we do not want to be wrong.

So now let’s get back to talk about the title of this post: What’s the harm in that?” 

While I am accustomed to seeing the variation of this statement on parent forums, I was surprised when I learned that it’s popping up quite often in some unexpected places such as during IEP meetings or during doctor visits (as reported to me by some of my client’s parents).

So I wanted to take this opportunity to explicitly point out what the harm in these alternative practices could be, ranging from the obvious to the hidden.

For starters some of these ‘therapies’ could kill!

  • Over the years there has been a number of reports regarding deaths from controversial autism treatments including chelation and GcMAF injections.

Even if they don’t kill you they can cause some nasty side effects!

  • To illustrate, Nourish Life Speak Nutrientswhich were prescribed to children to “increase their language output or to make them speak better”, were so loaded with vitamin E (way above the legal amount), that a number of children who were taking them experienced significant seizure activity.

It’s going to cost you!

They create false hope!  

They can create a sense of  bitterness and hopelessness!

  • Ever spoken to parents who have tried every alternative treatment possible and have subsequently given up? If you haven’t, I assure you it’s not a pleasant or productive conversation.  At best you will hear a lot of vitriol and accusations and at worst they may actually start a forum thread or a website bashing effective treatments such as speech language therapy because of their negative experiences.  When you believe that you have tried everything and it’s still not helping, you feel defeated and lost and as a result tend to attack blindly anyone who attempts to assist you because you’ve stopped perceiving it as assistance but rather as just another scam.

They delay effective research-proven treatments! 

They affect self-esteem and self-efficacy! 

  • Now enough about parents and professionals. Let’s actually take a moment to talk about effect of these alternative practices on the most important people in question: the children who are on the receiving end of it! Let’s talk about all the negative effects that can be incurred by them by undergoing these useless treatments time after time.  And no I am not actually talking about the hugely dangerous treatments, which can cause physical harm or awful side effects.  I am talking about the relatively benign treatments of “vision therapy”, “memory training”, etc.
  • To illustrate, I work with are very bright 11-year-old boy with significant reading deficits and an extensive history of reading disabilities in the family.  This boy’s deficit is in the area of reading, there is no doubt about it! He knows it and it’s very acutely aware of it.  However, at the advice of well-meaning professionals he was taken to a behavioral optometrist, who told his mother that his issues with reading are due to visual processing deficits (despite the fact that his ophthalmologist ruled out any vision difficulties and declared his vision to be 20/20).    It was then recommended that he undergo a costly vision therapy program in order to improve his “visual processing”.  Guess, what his first words were, when I saw him in my office for reading intervention?  ‘I went to the doctor who told me that I have problems in my eyes and that I need to stop reading!  So I can’t do any more reading because of my eye problems.’   Imagine how he will feel when after several months of costly therapies there will be no functional improvement in his reading skills, since the only thing which can improve his reading abilities is the actual targeted reading instruction!
  • Our students are very acutely aware when something is not working. Just like us they get increasingly frustrated after being dragged from one professional to another, after ‘suffering’ through one controversial treatment after another with no respite in sight.  Imagine what havoc it begins to wreak on their self-esteem and their self-efficacy (belief in own abilities to complete tasks and reach goals), when they keep undergoing these treatments without any improvement? All the negative self-talk they will use? Here are just a few statements I’ve heard over the years: “I am so stupid”; “There’s something wrong with my brain”, “I am not good at this, etc.) Instead of building them up these alternative therapies and treatments will not just tear them back down but may potentially cause behavioral and psychiatric effects to boot.

There you have it: that’s what the harm is!  The toll of these quack practices can be very significant and can go far beyond the financial.  So the next time someone utters the statement: “What’s the Harm in That?” consider the above information in order to make the informed decisions regarding the treatment for the most vulnerable parties involved: the children in your care!