Physiotherapists are knowledgeable and responsible health professionals, trained to work with children with neurological disorders, developmental problems, orthopaedic conditions and res-piratory illnesses. We are obligated to ensure the correct information is provided to the public while protecting our profession and guiding our patients. Please see the position statement (press release) drawn up by The South African Society of Physiotherapy (SASP®) Paediatrics Physiotherapy Group’s General Executive Committee regarding the Doman Delacato Patterning Therapy (DDPT).

POSITION STATEMENT: PRESS RELEASE 
31 January 2017

The South African Society of Physiotherapy (SASP®) is a professional member organisation and Non-Profit Organisation (NPO) that represents the majority of physiotherapists in South Africa. Our aim is to protect,
enhance and promote our profession, while ensuring the accurate education and
empowerment of the public. One of the Special Interest Groups within the SASP®
is the Paediatrics Physiotherapy Group, which represents physiotherapists
working with infants and children in both the private and public sectors.

Many South African children with neurological disabilities are currently treated by members of the Paediatrics Physiotherapy Group of the SASP®. Paediatric physiotherapists work with infants and children in both the private and public sectors. As qualified and registered medical health care professionals working with these children on a daily basis, we wish to make you aware of the Doman Delacato Patterning Therapy (DDPT), and the current scientific evidence for and against it.
We understand that a child with a neurological disability is a huge challenge to parents, as it means many years of sacrifice to seek and manage the best treatment for their child. So it’s little wonder that any news of a possible ‘miracle cure’ without a therapeutic ceiling effect for complete recovery is greeted with ripples of excitement, as happened after the Brain Child Fund published information regarding the Family Hope Centre from the United States of Ameri-ca, bringing DDPT to South African families in February 2017.

The Doman Delacato Patterning Therapy (DDPT)

The Institute for the Achievement of Human Potential (IAHP) in Philadelphia, United States of America (USA) was founded in 1955 by Glenn Doman, Dr Robert Doman, Dr Temple Fey and Carl Delacato. They developed pattern-therapy, now known as the Doman Delacato Patterning Therapy (DDPT) or the Doman’s Method, based on fundamental neurophysiology work and the recapitulationist theory of ontogeny and phylogeny by Dr Temple Fay, stating infant develop-ment happens in evolutionary and phylogenetic stages towards maturity. Its core assumption is that brain damage causes obstructions in the normal pattern of brain development and DDPT can eliminate these obstructions through “rewiring” of the brain. The Institute promotes DDPT as healing the brain and being the pathway to full recovery, no matter what neuronal disability or diagnosis an infant or child may have. A second facility has been established, namely the Na-tional Academy of Child Development (NACD), in Utah, USA. There are also many other centres associated with the IAHP and the NACD offering DDPT.

Medical and scientific health interventions are evaluated on both a theoretical basis and on empirical value. DDPT has been widely criticised by the Western world and the scientific com-munity since the 1960s, and the recapitulation theory of Dr Fay has been largely discredited by current biological and neuro-pathophysiological research advances. Many discredit DDPT due to its misinterpretation of the basics of neuroanatomy and localisation of function, as well as the problematic claim that the same intervention will be effective for and cure a variety of dis-eases with diverse aetiologies. Every study published by the IAHP has been criticised for the flawed methodology (study design) and the lack of any control or comparative ‘gold standard’ intervention/s with which to ascertain effectiveness. It has been documented and published that the IAHP has also refused to participate in objective well-designed studies by external re-searchers/agencies and they request parents of children participating in the DDPT programme not to take part in any external research projects. They also often promote their DDPT pro-gramme as being able to “multiply a child’s intelligence” as “each child has the potential to be a genius”.

Considering the flawed and oversimplified theoretical foundation of DDPT, we have concerns about two (2) specific techniques used in DDPT that may lead to complications and side-effects, namely masking and patterning. We will not be commenting on the other sensory, learning and language techniques used in DDPT as they are not within our scope and field of expertise.

1. Masking
Masking is described by the IAHP as breathing into a sealed mask to increase ex-haled carbon dioxide (an acid by-product from breathing) which is re-inhaled, which is purported to increase blood flow to the brain’s cerebral hemispheres. The mask is not connected to an additional oxygen source and is sealed around the face with a very small hole at the bottom to allow minimal room-air oxygen to enter. This prac-tice is continued for 30-60 seconds (or more) and repeated multiple times a day.

The basic theory behind this is that an increase of carbon dioxide in the blood (as in-haled from the lungs) causes the brain to increase blood flow to itself. The IAHP claims this will heal the brain and increase brain function. But the true pathophysio-logical theory is that the increase in blood flow to the brain is a reflex autonomic re-sponse to asphyxia (being smothered/suffocated). If the carbon dioxide continues to build up, one develops hypercapnia, which in turn, due to lowered oxygen levels (hy-poxia), causes respiratory acidosis, which is a medical emergency. The effects of re-duced oxygen levels in cerebral blood could exacerbate brain damage. Furthermore, this could lead to respiratory failure, coma, organ failure and death. It is also not advisable to exert an infant or child during exercises or in therapy with a pre-existing suboptimal respiratory state. It is important to note that the infant or child’s arterial blood gases, blood oxygenation and carbon dioxide levels are not monitored during masking therapy, nor is this performed or supervised by health care profes-sionals.

The South African Children’s Act 35 of 2005 (promulgated in 2010), which forms part of the South African Constitution, resonates with the United Nations Convention and African Union Charter on the protection of children’s rights. It explicitly addresses child abuse, and defines it as “any form of harm or ill-treatment deliberately inflict-ed on a child”. Suffocation and/or asphyxia practices inflicted on infants and children are forms of physical child abuse. Health care professionals are obligated by law to report any suspected child abuse to the South African Police Service (SAPS) and their local Social Services Department. In a 2013 book, looking at controversial issues in special education, Hornby et al refer to this technique of DDPT as “gagging” and concluded that it is ineffective and potentially damaging. These sentiments are shared by the American Academy of Paediatrics (AAP) in their statements on DDPT in 1964, 1982, 1999 and re-affirmed in 2010.

2. Patterning and cross-patterning
DDPT states that creeping ability affects the development of reading ability. Using the phylogenetic development theory they use psychomotor patterning, a homo-lateral crawling pattern (passive head rotation with flexion of arm and leg on the same side and extension of the arm and leg on the opposite side) to impose the proper pattern onto the brain. This passive movement is carried out by adults for in-fants and young children who cannot do this on their own. This movement is repeat-ed in a fast rhythmic fashion for five (5) minutes, at least four (4) times per day and requires three to four (3-4) adults to perform. This is combined with movement re-striction and facilitation intended to promote hemispheric dominance.
These coordinated passive movements have no scientific backing to improve motor function and learning. Furthermore, many infants and children with neuronal disabil-ities present with low bone density due to being non-ambulatory and not being weight-bearing through long bones. They may also present with spasticity (tight muscles and reactive nervous systems) or low muscle tone/joint hypermobility (neu-ral muscle weakness and lax connective tissues and joints). Doing these passive movements against resisted spasticity can cause severe pain, discomfort, joint dislo-cations and pathological fractures (due to low bone density causing weak bones). In addition these passive movements can over-mobilise the joints, especially the neck of infants and children with low muscle tone or joint hypermobility. This may lead to less stable joints and predispose the spine and joints to injuries during normal activi-ties.

We are also concerned about the fluid restrictions imposed on children following the DDPT programme. The IAHP claims that for brain-injured children, one should attempt to prevent the possible over-accumulation of cerebrospinal fluid by restricting normal fluid intake. There is no scientific proof or pathophysiological foundation to this ‘theory’ as the theory actually refers to active or forced excessive fluid intake above the norm, causing water toxicity. Therefore this practice borders on volitional dehydration. An example of this is when an active 5-year-old par-ticipating in DDPT during summer months is placed on a 500-600ml fluid intake restriction per day, which is comparative to the normal recommended intake for a 5-6kg infant, typically a 4-5 month old. It must be mentioned that the gold standard for fluid intake prescription used by qualified and registered Dietitians is the evidence-based ‘Holiday-Segar Method’. Thus the fluid restrictions imposed by IAHP are not in line with the current evidence-based fluid requirements for infants and children, and we urge parents to consult with qualified and registered Dietitians and Paediatricians regarding the individualised nutritional and fluid requirements of their chil-dren. It is very important to remember that children should not participate in active therapy or exercises in a dehydrated state, as research has shown that children dehydrate faster than adults, due to brain receptors not being sensitive to initial changes in electrolyte and metabolic concentrations – even less so in children with Cerebral Palsy.

Furthermore the IAHP often recommends stopping prescription medications such as anti-epileptics as they claim that “epilepsy is a myth” and medications are only treating symptoms while masking the root cause.

The American Academy of Paediatrics (AAP)

The AAP has condemned DDPT since 1964. They published a second statement in 1982. Their 1999 statement on DDPT, which was re-affirmed in 2010, clearly states:

“Treatment programs that offer patterning remain unfounded; ie, they are based on oversim-plified theories, are claimed to be effective for a variety of unrelated conditions, and are sup-ported by case reports or anecdotal data and not by carefully designed research studies. In most cases, improvements observed in patients undergoing this method of treatment can be accounted for based on growth and development, the intensive practice of certain isolated skills, or the nonspecific effects of intensive stimulation.

“Physicians and therapists need to remain aware of the issues in the controversy over this spe-cific treatment and the available evidence. On the basis of past and current analysis, studies, and reports, the AAP concludes that patterning treatment continues to offer no special merit, that the claims of its advocates remain unproved, and that the demands and expectations placed on families are so great that in some cases their financial resources may be depleted substantially and parental and sibling relationships could be stressed.”

In addition, the following committees, associations and societies have publically and formally stated they support the AAP regarding not endorsing or accepting DDPT: the Executive Commit-tee of the American Academy of Cerebral Palsy, the United Cerebral Palsy Association of Texas, the Canadian Association for Disabled Children, National Down Syndrome Congress (USA), and the Executive Board of the American Academy of Physical Medicine and Rehabilitation.

A cost-analysis review (2012), looking at DDPT from 2003 to 2011, concluded that non-proven intensive training programmes for patients with brain damage are costly, and as long as their effectiveness has not been properly researched and documented, health care professionals should not spend resources on these programmes outside of clinical trials.

Public Health and Safety

With public safety as a priority, and through our compulsory registration with the Health Pro-fessions Council of South Africa (HPCSA) under the Health Professions Act of 1976 (Act no 56 of 1974), we as physiotherapists are required by law to ensure that our treatment approaches are evidence-based and we also apply the principle, “First, do no harm”. The use of non-evidence-based techniques that could have potential complications and side effects, by persons who are possibly not registered with the HPCSA in South Africa, is of great concern to us.

In addition, we have requested The Brain Child Fund, as organisers of the upcoming DDPT pa-rental seminar/workshop presented by Family Hope Centre from USA (associated with the IAHP) in February 2017, to provide proof of registration and approval from the Health Profes-sions Council of South Africa (HPCSA) for the instructors, as legally they are required as foreign health care professionals to be registered and have this approval to be able to physically evalu-ate and treat children as patients in South Africa.

Conclusion

To conclude, due to the impact of the techniques of DDPT on the respiratory system, hydration and joint mobility, it could impact on the safety and therapeutic outcomes of a child participat-ing in conventional therapies as well, implicating qualified and registered health care profes-sionals involved with children undergoing both DDPT and their conventional therapies such as physiotherapy and occupational therapy.

As research has shown, the only reason for possible benefits reported in case reports for DDPT comes down to possibly the increased activity and attention the programme offers, and not the therapy in itself.

According to the Constitution of South Africa and The Children’s Act, every decision concerning a child has to be made in the best interest of the child. In addition, the HPCSA is concerned with protection of vulnerable patient groups. Children with neuronal disabilities and their parents are especially vulnerable. These children are generally unable to provide assent for interven-tions, and the parents, although usually acting in what they feel to be in the child’s best inter-ests, are desperate for a ‘cure’, and therefore are open to coercion.

In the interests of public and patient safety, it is vital that the public, and particularly the par-ents of children with neuronal disabilities, are provided with the correct and complete infor-mation and background to foreign alternative therapeutic approaches, especially concerning a controversial approach not endorsed or accepted by the AAP and other affiliated associations and organisations. Interventions like these may lead to unreasonable expectations for curing brain damage and complete healing of neuronal disabilities. It may further cause undue stress and anxiety to parents of children with neuronal disabilities, who may now doubt their current therapist/s approach and consider going to extremes to get these expensive alternative prac-tices and therapies for their children.

 
References

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