Questions and Answers

Question # 26

You appear to have coined the term, "false attribution of therapeutic
efficacy." What does this mean? Examples would help.

The term is meant to convey the following when applied to modes of intervention for persons with NLD:

A particular mode of intervention is viewed as the agent through which positive therapeutic change has been achieved; this is, however, not the case. Put in other words: Although it may appear that a particular mode of intervention was responsible for positive change, this judgment of the intervention's effectiveness is erroneous.

Usually, this attribution error is made because the person with NLD is seen to be demonstrably better following exposure to a particular mode of intervention. This may be the case. But, one must be aware of the "post hoc ergo propter hoc" fallacy (translation: After which, therefore because of which). In simple terms: Just because B follows A, this does not mean that A has caused B.

Example 1. A six-year-old child with NLD is assessed and judged to be at risk for failure to learn to read. All members of the treatment team are in agreement with the conclusions of the assessment, including the prognosis. Thereafter, a particular form of intervention is applied. About one year later, the child is seen to be making some progress in single-word reading.The therapy is continued. By the end of Grade 2, the child is reading at the Grade 3 level; one year later, at the Grade 5 level.

One can imagine the glee and mutual congratulations that the "early assessment team" experiences. This is so because it is clear to the members of the team that they did all of the right things: early assessment; early diagnosis; early, and quite obviously, appropriate intervention. And the results evident are absolutely wonderful!

Unfortunately for the team, the result was predictable, and would have happened almost regardless of what they had done. All the child really needed was sufficient exposure to print and quite ordinary reading instruction. This is so because the natural history of NLD (see NLD Content and Dynamics) involves the following: The child at the age of five or six years appears to be at risk for learning-to-read failure; he struggles with reading in Grade 1, but seems to make good progress in Grade 2; thereafter, he reads single words at the Grade 4 or 5 or 6 level at the end of Grade 3, and at the Grade 10 level when he is 10 years of age. That is, he exhibits "hyperlexia."

Bottom line: The natural history of NLD involves eventual single-word reading levels far above chronological age expectations. There is almost nothing that can prevent this from happening.
Prowess in spelling follows a similar course. To think that any therapeutic intervention should be viewed as crucial to this very apparent advancement in "language-based" academic learning skills is wrong. To repeat: Just because a child gets better after a programme of intervention, it is not reasonable to assume that the therapy was efficacious. One must consider the natural history of the disorder before entertaining and testing such an inference.

An explanation: Some children with NLD are precocious readers; most are not. Most come to school at the age of five years or so and, when examined closely, are found to exhibit delays or impairments in many so-called "pre-reading" skills. A closer examination of their precise deficiencies reveals that they have significant difficulties in visual-spatial feature analysis and related skills. That is, they exhibit one of the primary deficits of NLD. With the passing of time, some progress is made in these skills and--lo and behold!--they begin to read single words and go on to make rapid, even astounding, strides in this area. Of course, what has transpired in this situation is as follows: The child, initially deficient in the minimal visual-spatial analysis skills necessary for reading words, acquires these skills. Then, his very well-developed "verbal" skills are recruited to drive rapid advances in this skill. All of this will transpire without any specific intervention. In the best sense of the term, it is "natural," as in the natural history of NLD.

Example 2. Young (5- to 8-year old) children with NLD are often diagnosed with Attention Deficit/Hyperactivity Disorder. Frequently, they are subjected to various forms of intervention, including pharmacological and behavioural treatments, to deal with this. Almost without exception, the child eventually becomes "normoactive" and displays considerable capacity for focussing and maintaining attention to verbal discourse in the classroom and elsewhere. It is, thus, easy to see why the therapeutic programme applied is thought to have been enormously effective. However, this judgement of efficacy is rarely justified, principally because the natural history of NLD involves just such a transition from apparent and pervasive problems in attention and "associated" hyperactivity to normal attentional skills (especially in auditory-verbal interaction situations) and eventual hypoactivity. Once again, a full consideration of the natural history of NLD is necessary if one is to discern this particular example of the false attribution of therapeutic efficacy. (For a fuller explanation of this scenario, see Question #7.)

Apart from errors made in attributing effectiveness to various forms of treatment, there is this problem: Instead of wasting time with special interventions for children at risk for reading failure, the child with NLD could--indeed, in most cases, should-- be offered opportunities to enhance his psychosocial skills. We know that this should be given serious consideration because the natural history of NLD (see Questions # 18, 21, and 22) involves a very high probability of deficits in most facets of psychosocial skill development. In the case of the child misdiagnosed with ADD/HD, there is an added difficulty: The natural history involves eventual hypoactivity. Measures to quell activity level in the child with NLD are almost always counterproductive. Indeed, measures to maintain normal levels of activity are called for, and usually require considerable therapeutic effort and cooperation of caregivers.

General dimensions of treatment choice : Careful consideration of the natural history of NLD will lead to the following conclusions: Although the very young child with NLD may appear to be in need of therapy for his apparent risk for reading failure, his real needs (which can be expected to develop over time) are for interventions that target the various dimensions of psychosocial skill development. (An analogous state of affairs obtains in the case of the erroneous diagnosis of ADD/HD). Of course, this is a therapeutic tack that is difficult to "sell" because it involves treatment for problems that are not yet apparent, and actively avoiding treatment of problems that appear significant and important to treat now. Clinicians have a firm foundation for mounting and continuing an appropriate programme for children with NLD. This foundation consists of the relevant considerations that arise from the natural history of the syndrome of NLD.