If I wanted to introduce a new treatment for children with cerebral palsy at my clinic, I would be asked a simple question first: what is the evidence? Not evidence that it works somewhere, for someone. Evidence that it works for these children, in this setting, measured against outcomes that matter to them.

That is the standard every researcher and clinician at a university accepts as the price of doing serious work. It is also a standard that universities almost never apply to the way they manage the people doing it.

Over the past decades, three management practices have become so common in academic departments that they are rarely questioned: open-plan offices, pay tied to performance scores, and 360-degree reviews in which colleagues, subordinates and supervisors rate one another. All three were imported from the corporate sector. I went looking for the evidence behind them, and for the evidence that they transfer to the work of academics and physicians. Here is what I found.

Open-plan offices: good for the budget, bad for the people in them

The pitch for open-plan offices is collaboration and cost. The research tells a different story.

A 2023 meta-analysis of five Scandinavian studies covering more than 13,000 employees found that people in open-plan offices were more likely to take sick leave than people in single offices (Mauss et al., Industrial Health). The effect was modest and the statistics borderline, so I would not call it proven. But the direction was consistent, and no study found the reverse.

The collaboration claim fares worse. When Harvard researchers fitted employees with sensors before and after their company moved to an open floor plan, face-to-face conversation dropped sharply and email went up (Bernstein and Turban, Philosophical Transactions B). People who could suddenly be seen by everyone responded by withdrawing. The design meant to increase contact reduced it.

Performance pay: it works, in the wrong places

Here the evidence is more interesting, because performance pay genuinely does work. In the right setting.

The classic study is from an American windshield-replacement company that switched its installers from hourly wages to piece rates. Output per worker rose by more than a third (Lazear, American Economic Review). But the economist who ran that study was careful about what it showed. Installing a windshield is easy to count, and if it leaks, everyone knows who fitted it. He wrote that managerial and professional jobs may not be suited to this kind of pay. Nobody seems to have read that paragraph.

When researchers pool the experiments, a pattern emerges. Financial incentives reliably increase the quantity of work. They do not reliably improve its quality (Jenkins et al., Journal of Applied Psychology). And for work that is interesting and complex, one major analysis found that bonuses slightly reduced performance (Weibel et al., Journal of Public Administration Research and Theory). A rival analysis disputes that figure, but even it agrees that the effect on quality in complex work is where incentives are weakest (Kim, Gerhart and Fang, Journal of Applied Psychology). Academic work is complex, interesting, and judged almost entirely on quality. We are applying the tool exactly where it is least likely to help.

We do not have to guess how it plays out. A pediatrics department in Ontario spent two years paying its 37 physicians bonuses worth about 10 per cent of their contract, allocated by a carefully built productivity score. Overall scores did not move at all (Filler et al., Academic Medicine). The only group that improved was the most junior; the scores of senior physicians went down.

Pay can remove a grievance. It can buy more of something that is easy to count. It does not reliably make skilled people do better work.

360-degree reviews: feedback without follow-through

The idea of collecting ratings from every direction sounds thorough. The largest review of the evidence, pooling 24 studies that tracked people over time, found that improvement after multisource feedback was “generally small” and warned managers not to expect much (Smither, London and Reilly, Personnel Psychology).

When Dutch researchers interviewed hospital consultants a year after their 360-degree assessments, about half had changed something. What made the difference was not the ratings. It was a trained facilitator who helped them reflect, a small number of concrete goals, and a follow-up conversation (Overeem et al., Medical Education). In other words, it worked when it stopped being an evaluation and became mentoring.

None of this is new

What struck me most is how old these questions are. In 1959, Frederick Herzberg interviewed 200 engineers and accountants and concluded that what made professionals feel good about their work was the work itself: achievement, recognition, responsibility. Pay and working conditions could make them miserable when poor, but improving them did not make anyone more motivated (Herzberg, Mausner and Snyderman, The Motivation to Work). His theory was challenged within a decade, and rightly so; it was too neat (House and Wigdor, Personnel Psychology). But the question he raised, whether you can manage professionals the way you manage a production line, has now been studied for more than sixty years. The answer has not changed much. We have simply stopped asking.

How the methods got here

Sociologists have a name for the belief that all organisations are basically alike, so that the same management techniques will optimise a hospital, a factory or a university: managerialism. In this view, knowing the core business is secondary to knowing management (du Plessis, BCES Conference Books 2023, citing Klikauer, Critical Sociology 2015). Rosemary Deem documented its arrival in British universities in the 1990s and noticed something telling: it arrived alongside budget cuts, and was offered as a substitute for the money that had gone (Deem, International Studies in Sociology of Education). Better management, the argument went, would replace the missing resources.

The consequences for research are now being measured. In one survey of scientists, 71 per cent feared their colleagues could game the metrics used to evaluate them. Researchers report spending about half their time on administration and compliance (Edwards and Roy, Environmental Engineering Science).

And then we treat the symptoms

When these practices produce stress, universities respond with a second layer of programmes to manage it. Mindfulness training is the current favourite. A 2025 meta-analysis of 99 randomised trials found a small benefit against doing nothing and no benefit at all against other active programmes, with very low confidence in the evidence overall (Vainre et al., Stress and Health). The authors noted that employers might do as well by improving workload and working conditions. That is Herzberg’s conclusion, reached independently, 66 years later.

What I am asking for

I am not asking universities to abandon management. I am asking them to hold it to the standard they hold us to.

Before extending a practice, test it. Measure outcomes that matter, not outputs that are easy to count. When the evidence says a method works for assembly lines and not for complex professional work, believe the evidence. And put the effort where the research has pointed for six decades: protected time for concentrated work, real autonomy, and mentoring that helps people grow.

A research institution that would never accept an untested treatment for its patients should not accept untested management for its people.

Use of AI. This document was prepared with the assistance of Claude Sonnet 5.5 and Claude Fable 5.1 (Anthropic), used on 2 October 2026 for retrieval and reading of references, verification of additional sources, drafting of all sections (Sonnet 5.5) and a second review of the claims against the sources and production of this version (Fable 5.1).

Dynamic Movement Intervention, usually shortened to DMI, is now offered in a growing number of Canadian clinics. Along with it has come something I am seeing more and more often: families running fundraising campaigns so that a child can attend an intensive week, or so that other children can. A week of intensive therapy typically costs in the region of $2,500 to $5,000 USD, before travel, accommodation and time away from work, and it is generally not covered by insurance.

I want to explain why I think those campaigns should come with a clear statement about the state of the evidence, and to introduce a term that I have found useful for describing what is going on: neurowashing.

Let me start with what the families running these campaigns are right about, because it is a lot. Children’s treatment centres in Ontario are losing therapists. Waitlists are long. Families of children with complex physical needs often feel that the public system has quietly moved its attention elsewhere, towards conditions that are more common and towards behavioural approaches. That frustration is not a misunderstanding of the system. It is an accurate reading of it, and I share it.

The disagreement is about one word. Evidence.

1. What I am saying, and what I am not

I am not saying that children receiving these therapies make no progress. I am not saying that the therapists delivering them are dishonest, or that the families who describe benefit are imagining things. I have no reason to believe any of that, and it would be both unkind and unscientific to suggest it.

What I am saying is narrower, and I think it is the right place to draw the line: it is not fair to ask people for money — or to ask a family to spend their own — without telling them plainly that the method being funded has not been shown to work. That is not an attack on a therapy. It is a statement about consent.

When we ask parents to consent to a medical or rehabilitative intervention, we are supposed to tell them three things: what is known, what is not known, and what it will cost them in money, time and opportunity. A fundraising campaign is a request for consent too, just spread across a wider group of people. If the second of those three things is left out, the consent is not informed.

2. Two different kinds of knowing

Here is where these conversations usually get stuck, and I do not think either side is being unreasonable.

A parent watches their child over months. They see new strength, better balance, a skill that was not there before. They are not making this up, and they are usually the most careful observers of their own child that anyone will ever meet. So when a researcher says “there is no evidence,” it sounds like a denial of something they have seen with their own eyes. It sounds insulting.

But the two statements are answering different questions.

The parent is answering: did my child improve while receiving this therapy? Often the honest answer is yes.

The researcher is answering: did my child improve because of this therapy, more than they would have with something else, or with nothing extra at all? That question cannot be answered by watching one child, or a hundred children, without a comparison.

The reason is not stubbornness. It is that several things reliably produce the appearance of improvement even when a treatment does nothing:

Children develop. This is the big one, and in childhood-onset disability we actually have good data on it. Twenty years ago, Peter Rosenbaum and colleagues at CanChild followed 657 children with cerebral palsy in Ontario and produced motor development curves showing the expected trajectory of gross motor function by severity level. Children continue to gain motor skills over years, at rates that differ by level and vary considerably between individual children. Any therapy delivered during that period will appear to be accompanied by progress, because progress was going to happen.

We start therapies at the worst moments. Families typically seek out something new when things feel stuck or have just deteriorated. Things that are unusually bad tend to drift back towards a person’s average afterwards, whatever is done. Statisticians call this regression to the mean. It looks exactly like a treatment effect.

Several things are usually happening at once. The one published case description of DMI I am aware of is a conference poster describing two infants with spinal muscular atrophy who received gene replacement therapy and, in one case, a further disease-modifying drug, alongside the DMI. They gained motor milestones. Attributing that to the DMI would be a considerable leap.

Expectation is powerful, in both directions. A therapist who believes deeply in a method is warmer, more attentive, more encouraging. Parents who have invested money and hope look harder for change and find it. None of this is dishonesty. It is how human perception works, which is precisely why we invented controlled studies.

We hear from the families who stayed. Those who tried something and saw nothing, and those who quietly stopped, are not posting about it. The testimonials we see are a filtered sample.

This is not an argument for ignoring what parents observe. Parent observation is how most good research questions begin. It is an argument for treating it as the beginning of an investigation rather than the end of one. That is why colleagues at CanChild created the Family Engagement in Research Program.

3. Four things people say back to me

When I make this argument, four responses come up almost every time. They are all reasonable-sounding, and I think all four are worth answering directly rather than brushing past.

”The researchers never actually spoke to the families or the therapists who use it.” This is usually offered as the decisive objection, and it rests on a misunderstanding of what a review is for. A literature review does not ask practitioners whether they believe their method works — of course they do, and asking them would reintroduce precisely the bias the review exists to remove. It asks a narrower question: has anyone published a study? In this case the authors did go further than that. They wrote to the founder of the older method for his research, and they contacted the team conducting a scoping review to check whether anything newer had surfaced. What they found was case reports, not studies.

”Families keep coming back, because it works.” Retention feels like proof, and it is easy to see why. But people return to things for many reasons: hope, relationship with a therapist, the fear of losing ground if they stop, and the ordinary human difficulty of walking away from something you have already spent thousands of dollars on. Retention measures how a service feels to the people still using it. It cannot tell you what would have happened had they done something else.

”It is highly specialised physiotherapy and occupational therapy — it is not snake oil.” Agreed that it is not snake oil, and I would not use that phrase. But the legitimacy of a profession does not transfer automatically to every technique practised within it. Regulated therapists are licensed to practise, not to guarantee that any given method has been tested. This matters especially where elements of an unproven approach are folded into otherwise ordinary sessions — it makes the method look established without anything having been established.

”You sound very certain. Try to stay curious.” I take this one seriously, because certainty is a real failure mode in my profession. But I would put it the other way round. Curiosity is what makes you run the study. Certainty is what makes you decide the study is unnecessary because you can already see that it works. Saying “we do not yet know” is the curious position, not the closed one.

4. “Neurowashing”

Which brings me to the term that prompted me to write this.

My colleague Álvaro Hidalgo-Robles and his team have coined the word “neurowashing”, built on the model of “greenwashing.” Greenwashing is when a company drapes itself in environmental language without changing what it does. Neurowashing is when an intervention drapes itself in neuroscience language without having the evidence that would justify the claim.

The vocabulary is by now familiar to any parent who has spent an evening reading therapy websites: neuroplasticity, neural pathways, brain connectivity, synaptic pruning, reflex integration, task specificity. These are real concepts. Neuroplasticity in particular is real, well established, and genuinely central to modern rehabilitation.

That is exactly what makes the borrowing effective. The words carry the authority of laboratory science, and they are difficult to argue with unless you happen to know the underlying literature. As Álvaro put it in a recent podcast conversation, the terms have become so ubiquitous that they no longer distinguish anything — when every programme claims to harness neuroplasticity, the claim stops carrying information, and the interventions that genuinely apply those principles become harder for families to pick out.

There is a further problem. Some of these terms are used to mean close to the opposite of what the science says. Take task specificity. In motor learning research it means practising the actual activities of a child’s life, in the settings where those activities happen: drinking from a cup, climbing at the park, getting into the car. Contemporary approaches with strong evidence share a recognisable set of ingredients — the child initiates the movement, the tasks are real and meaningful to them, practice is frequent, and the child is motivated and engaged. Reflex-based, therapist-led handling, in which the child’s cooperation is explicitly described as not always necessary, is not a variation on those ingredients. It is a different theory of how children learn, one largely set aside decades ago.

5. What the evidence on DMI and CME actually shows

In 2025, a group of clinicians and researchers — Ginny Paleg, Dayna Pool, Álvaro Hidalgo-Robles, David Frumberg, Roslyn Livingstone and Diane Damiano — published an open-access review in Pediatric Physical Therapy examining DMI and the older method it grew out of, Cuevas Medek Exercises (CME). The paper is free to read and I would encourage any interested parent to read it rather than take my summary on trust.

Their findings, in brief. CME, after five decades of use, is supported by a handful of case reports and two small comparative studies with serious methodological problems. DMI, introduced in 2021, has no published empirical evidence beyond a single conference abstract, and the authors found no prospectively registered trials in the major clinical trial registries. Both methods therefore sit at the lowest level of the evidence hierarchy (here is a response of authors where they reiterate this issue to the founders of DMI): level 5, meaning descriptive reports only, no controlled studies. Meanwhile, more than 3,300 therapists in over 61 countries had been trained in DMI as of 2024.

The founders have not disputed the absence of research. In a 2022 interview, one co-founder acknowledged that the method was new and the research had not yet been done. I take that at face value. My response is simply: then say so, clearly, to every family and every donor, until it has been done.

What does have evidence is a subject for a separate post, and a longer one. For now it is enough to say that alternatives exist and are well documented: the 2021 international clinical practice guideline (Paywall) for children aged 0 to 2, and the French national guidelines (Paywall) covering ages 2 and up, both set out plainly what is recommended and what is recommended against.

6. “No evidence” does not mean “proven useless”

This deserves saying plainly, because it is where I think critics of these methods sometimes overreach.

“No evidence” is a statement about the state of the literature, not a verdict on the therapy. It means nobody has done the study or the studies that exist were not able to show superiority to treatment as usual or even no treatment. It leaves open the possibility that the method works, and equally the possibility that it does not, and it tells us nothing about harm because adverse events have not been systematically collected either.

It is also worth remembering that it takes on average around 17 years for research findings to reach everyday practice, so a genuine lag between innovation and evidence is normal and expected. But DMI’s theoretical lineage runs back through CME to 1972. That is a long time to be waiting for the first controlled study.

So my position is not “this cannot work.” It is: nobody currently knows, the people best placed to find out are the people offering it, and until they do, families deserve to be told that they are the ones carrying the risk.

7. Four questions worth asking: the HYPE framework

Álvaro and his colleagues are developing a simple tool to help families and clinicians appraise claims like these. It is called HYPE, and it is deliberately a set of conversation-starters rather than a scoring system. Validation studies are still under way, so treat it as a work in progress rather than a finished instrument — but the four questions are useful today:

H — Honesty. Is the provider open about what is known and what is not? Do they volunteer the limits, or do you have to dig for them? A provider who tells you unprompted “this has not been studied properly yet” has earned some trust.

Y — Yielding to evidence. When they say “there is research,” ask to see it. Is it a published, peer-reviewed study, or a testimonial page, a course manual, or a conference poster? Is it about this method, or about a general principle the method claims to embody? Ask what the study compared the treatment against.

P — Precision and plausibility. Do the mechanisms described actually match what is being done? If a claim involves changing brain connectivity or reducing tone, ask how that was measured. Watch for language that is either vague enough to mean anything or technical enough to end the conversation.

E — Ethics. What is the cost, in money and in the child’s time? What is the child giving up to attend? Is distress during sessions framed as effort or exertion? Children cannot consent, which places a heavier duty on the adults around them.

8. What I would ask of everyone involved

Of therapists and providers: say plainly where the evidence stands. You can offer something and still be honest that it is unproven. If you are confident enough in a method to build a career on it, be confident enough to study it, and to report adverse events as your regulatory college requires.

Of professional bodies: accreditation and continuing-education credits are endorsements. They should not be granted to training programmes that have no evidence behind them.

Of families: you should ask hard questions, and a good provider will welcome them. If your instinct is that a method is helping your child, that instinct is worth taking seriously — take it to a clinician who has no financial interest in the answer and talk it through. And a practical thought: decide with your therapist, before you start, what would count as success and how you will measure it. That single step protects you more than almost anything else. I wrote more about this in How can parents make good therapy choices?

Of researchers, including myself: we do not always study what families most need us to study, and in cerebral palsy this has been counted. An analysis of National Institutes of Health grants (Paywall) from 2014 to 2023 found an average of about $22.7 million a year. Roughly half of it went to treatments and early interventions, around eight per cent to services and implementation research, and 2.3 per cent to anything concerning adults and the lifespan — never more than $0.91 million in a single year — at a time when there are now more adults living with cerebral palsy in the United States than children. The same authors note, for comparison, that autism research exceeds $300 million a year, and that multiple sclerosis, stroke and Parkinson disease receive $110 million, $443 million and $253 million. Meanwhile the community has said plainly what it wants examined: a patient-centred research agenda (Paywall) generated by people living with cerebral palsy and those who care for them was published in 2018, and a scoping review last year (OpenAccess) found only five such priority-setting exercises worldwide, all of them from North America and Australia. So when a parent tells me that research is not asking their questions, I do not think they are being unfair.

But notice what those numbers do not excuse. Treatments and early interventions are the single best-funded category in the portfolio. A method whose lineage runs back to 1972 cannot claim there was no money to study it. If we want families to trust the evidence, we have to produce evidence about the questions they are actually living with — and we have to be as vocal about the failures of the public system as we are about the failures of private alternatives.

9. Where this leaves us

None of this changes the fact that the families running these campaigns are trying to get their children something they need in a system that is not providing it. That impulse deserves respect, not correction. And is a reminder to all of us to advocate for changes in our systems.

But I keep returning to the same place. If a therapy works, evidence will show it, and the evidence will make the case for public funding far more powerfully than any campaign. If it does not work, families will have spent money they did not have and hours their children could have spent at school, at the park, or with friends — the things that, in the end, actually make a childhood.

The honest position is not “this is snake oil,” and it is not “this is evidence-based.” It is: we do not know yet, and you deserve to be told that before you decide.

Views expressed here are my own and not those of my employer.

With thanks to Alvaro Hidalgo-Robles for his helpful feedback on an earlier version. This post was prepared with the assistance of Claude (Anthropic, model Claude opus 5).

Vaccines, Tylenol, and Circumcision — any of these purported potential “causes” for autism, besides being unscientific claims, are based on an outdated paradigm of thinking. It is a simplistic understanding that every disease has a specific cause. Once that is known, it can be prevented or cured. This type of thinking is based on the concept known as the “medical model.” It is not entirely wrong, but it is incomplete. Health is more than the absence of disease. Recognizing this, in 2001, the World Health Organisation launched an international classification system of health:
The full name is “International Classification of Functioning, Disability and Health — ICF”(World Health Organization, 2001). While people might be familiar with the term “Health”, the terms “Functioning” and “Disability” often need some elaboration.

“Disability” was traditionally (in the medical model) used to describe a specific type of diagnosis. Conditions that have no cure and cannot be fixed. Typical examples are Autism, Cerebral Palsy, or Down Syndrome. The modern understanding of disability is more complex.

Disability is what a person with a health condition experiences.

The degree of disability depends not on the specific diagnosis, its severity, or its prognosis. It is defined by what the person wants to do in life and how their environment facilitates or hinders such participation.

The “environment” encompasses not only the physical and natural environment, but also other people, medications, devices, services, laws, attitudes, and the social environment.

In this modern definition of the WHO, “Functioning” and “Disability” are two extremes of a spectrum. To promote functioning and reduce disability, health professionals, educators, employers, and families need to have a detailed understanding of the individual’s characteristics, life goals, and the environmental factors surrounding them. Knowing their diagnosis is not enough.

The ICF calls these contributing elements “Body Functions and Structures”, “Activities and Participation”, “Personal and Environmental factors”. This structure provides a framework and a starting point for discussing potential investigations, therapies, supports, and interventions to be considered.

In 2012, scientists Peter Rosenbaum & Jan Willem Gorter from the CanChild Centre for Childhood-onset Disability Research in Canada proposed a simplified way to convey the ideas of the WHO ICF framework to children and families (Rosenbaum & Gorter, 2012). That concept is now known as “The F-words for Child Development.” They are a witty way to translate the language of the ICF into meaningful concepts applicable to any child and family, enabling them to have a conversation with professionals about what is essential to the child, help professionals understand the child’s environment better, and support children and families in achieving optimal participation in life.

The words used for this conversation all start with the letter F and relate directly to the ICF framework: “Fitness” is used to talk about body functions and structures (physical and mental fitness), “Functioning” to describe what the child can do (Activities in the ICF), “Friends” to focus on the aspect of participation, “Family” to describe the most critical environmental factor for a child and “Fun” as this allows to understand the child’s personal preferences and priorities. Rosenbaum and Gorter added a sixth “F-word” called “Future” because that is the reason to have such conversations in the first place: to support the child’s development for their own future.

Since 2012, these ideas have been adopted globally. The original paper was downloaded over 100,000 times and cited more than 875 times at the time of writing. F-words posters hang in clinics from Denmark to Australia and have been translated into over 35 languages. The CanChild website features an F-words hub that provides free tools for applying them in goal setting, determining needs, and communicating with other professionals or at school (F-Words Knowledge Hub, 2021). Those tools were co-created with families from around the world, with ideas being shared from Brazil to New Zealand.

This fantastic uptake demonstrates the desire of families to be heard, to share what is important to them and their child, and to embark on a journey of hope that allows their children to thrive.
They are a contribution to change the debate from a simplistic reasoning of finding “causes” and “cures” to a differentiated perspective of how society supports diversity and inclusion. It is time that health administrations recognize this paradigm shift and invest more in what matters to the children and their families. In a publication from 2021, the authors state:

“We found that the largest portion of federal funding during 2017–2019 was awarded to research on the biology of autism (32.59%) and treatments and interventions for autism (22.87%). Less funds were awarded to research areas that are high funding priorities by the Interagency Autism Coordinating Committee budget recommendation, including services (5.02%) and lifespan issues (2.51%)” (Cervantes et al., 2021).

We need investments that help children build friendships, have stable and supportive families, stay physically and mentally fit, and give them hope for their future.

References

Cervantes, P. E., Matheis, M., Estabillo, J., Seag, D. E. M., Nelson, K. L., Peth-Pierce, R., Hoagwood, K. E., & Horwitz, S. M. (2021). Trends Over a Decade in NIH Funding for Autism Spectrum Disorder Services Research. J Autism Dev Disord, 51(8), 2751–2763. https://doi.org/10.1007/s10803-020-04746-3
F-Words Knowledge Hub. (2021). CanChild — Centre for Childhood Disability Research. Retrieved June 30 from https://canchild.ca/en/research-in-practice/f-words-in-childhood-disability
Rosenbaum, P., & Gorter, J. W. (2012). The ‘F-words’ in childhood disability: I swear this is how we should think! Child Care Health Dev, 38(4), 457–463. https://doi.org/10.1111/j.1365-2214.2011.01338.x
World Health Organization. (2001). International Classification of Functioning, Disability and Health (Vol. 13.9). World Health Organization.

I consider the invited commentary by Gunnoe et al. “An update on the scientific evidence for and against the legal banning of disciplinary spanking” (1) a weaponization of science and explain why: it conflates scientific inquiry with moral deliberation.

The issue of whether parents should use physical force as a disciplinary tool is not only a question of evidence but, more critically, a question of ethics and societal values. While empirical research can inform such debates, it cannot, and should not, be the sole basis for resolving moral questions.

The Limits of Evidence in Addressing Moral Dilemmas

The authors of the paper make the implicit assumption that if spanking can be proven to have neutral or positive outcomes, its use is justifiable. This assumption, however, disregards the broader ethical implications of physical discipline. A useful analogy is the debate on capital punishment: even if scientific evidence demonstrated that the death penalty reduces crime, many would still oppose its use on ethical grounds. Similarly, the acceptability of spanking as a disciplinary practice must be considered within the framework of children’s rights, the inherent power dynamics in parent-child relationships, and the broader societal norms we wish to promote.

Inadequate Consideration of Developmental and Contextual Factors

While the authors praise Canada’s age-specific approach to spanking (permissible between the ages of 2 and 12), this framework fails to account for the high variability in developmental maturity among children. A child’s cognitive, emotional, and social capacities are not strictly tied to chronological age. Moreover, the paper does not consider the unique challenges faced by parents of children with disabilities, whose needs and responses to discipline often differ significantly from those of neurotypical children. Effective and ethical parenting in such contexts requires an individualized approach that prioritizes understanding and accommodation over punitive measures.

Methodological Critiques and Evidence Bias

The authors critique studies opposing spanking for methodological weaknesses, such as the conflation of spanking with abusive practices or the reliance on correlational and longitudinal methods. Yet, they themselves rely heavily on outdated randomized controlled trials (RCTs) from the 1980s, which fail to capture the nuanced, long-term impacts of spanking on children’s development. Additionally, their selective emphasis on studies that align with their conclusions raises questions about the objectivity of their review.

The Ethical and Social Costs of Endorsing Spanking

By framing spanking as a potentially “neutral” or “effective” corrective action, the authors risk legitimizing a practice that is increasingly viewed as inconsistent with contemporary understandings of children’s rights and dignity. Their argument that restrictions on spanking may undermine parental authority is both speculative and ethically troubling. Such reasoning shifts responsibility for abuse onto external factors, rather than addressing the broader societal need to support parents in adopting non-violent and constructive discipline strategies.

Moving Beyond Empirical Justifications

The debate on disciplinary spanking must extend beyond empirical questions of harm or benefit. At its heart, it is a question of the values we hold as a society. Should physical force ever be an acceptable means of disciplining children? What messages does such an approach send about the use of power and authority in human relationships? These are the deeper, value-laden questions that cannot be resolved by data alone.

Conclusion

While the paper offers important insights into methodological considerations in spanking research, it is fundamentally flawed in its attempt to resolve a moral question through empirical evidence. The authors’ endorsement of Canada’s age-specific approach overlooks the variability in child development and the unique needs of children with disabilities. Addressing the issue of disciplinary spanking requires an ethical framework that prioritizes children’s rights, dignity, and well-being. Empirical evidence can inform this discussion, but it must not overshadow the moral principles at stake (2).

1. Gunnoe ML, Larzelere RE, Ferguson CJ, Ronald B. Cox J. An update on the scientific evidence for and against the legal banning of disciplinary spanking. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent. 2024;33(3).

2. Kraus de Camargo, O. (2025). The Need to Consider More Than Evidence When Justifying Physical Punishment. J Can Acad Child Adolesc Psychiatry, 32(2).

Published on behalf of PONDA

The way we understand and address “Disability,” “Health,” and “Rehabilitation” has undergone significant changes over the years. Previously, therapies for disabilities predominantly adhered to the biomedical model, focusing on the identification and restoration of impaired physical and mental functions. However, the current view is more holistic and person-centered.

In 2001, the World Health Organiza6on introduced the International Classification of Functioning, Disability, and Health (ICF) to complement the International Classification of Diseases (World Health Organization, 2001). This new classification incorporated the vital aspects of activities, participation, and contextual factors when assessing an individual’s health.

The ICF thus presents the concepts of “functioning” and “disability” as two ends of a health status continuum, drawing on ideas such as the biopsychosocial model by George Engel and the ecological model by Urie Bronfenbrenner (Engel, 1960, 1977), (Bronfenbrenner & Morris, 1998).

This perspective promotes a non-categorical and person-centered approach to therapy and care. In contrast to the more rigid protocols for specific diagnoses found in acute healthcare, most rehabilitation and developmental approaches are transdiagnostic, focusing on enabling individuals to participate in society by improving their functioning, like communication, mobility, or self-help skills, regardless of their underlying diagnosis (World Health Organization, 2023).

Additionally, enabling participation necessitates the removal of barriers and provision of facilitators to encourage participation. This approach involves broader participation from families, caregivers, schools, workplaces, etc., while focusing on the individual needs of each person according to their functioning profiles. This perspective has critical implications for how services for people with disabilities should be delivered:

1. Services should be needs-based: Considering the diverse needs of people with disabilities, a universal approach would not be sufficient, even if they share the same diagnostic label (Miller et al., 2013).

2. Funding should be public: All individuals, including those with disabilities, have a right to health. No state can excuse non-compliance with its obligations due to a lack of resources (Office of the United Nations High Commissioner for Human Rights/World Health Organization, 2008).

3. Coordination should be national: Considering disability as a multifaceted issue involving different public sectors, accessing funds and services from various channels of a fragmented system can result in repeated assessments, additional provider burdens, unnecessary delays, and inequalities (Leonardi et al., 2006) (McDowell & O’Keeffe, 2012). Therefore, a National Disability Strategy is needed to address these needs in a coordinated and equitable way (Kraus de Camargo, 2023)

These principles align with the goals of Every Canadian Counts, an initiative aimed at developing a national funding program to ensure essential disability supports are accessible to all Canadians with chronic, long-term disabilities. We, at PONDA, support the ask of Every Canadian Counts.

Full Reference List

Being disabled is a probable outcome for every citizen along their life. The more we are able to tackle acute health conditions, surviving threats from infections, cancers and accidents, the more we will be living longer lives, with a variety of chronic health conditions having diverse abilities and constraints of our functioning (Allotey et al., 2010). Being or becoming disabled is therefore a reality for a significant number of us. Indeed, recognizing this reality, people with longterm disabilities sometimes refer to the rest of us as the ‘temporarily able-bodied’!

Historically, supports for disabled people were delivered through charity, addressing the needs of war victims (Les Invalides = the “unworthy”). From those early times also stems the association that disabilities are bodily impairments (e.g. amputees) and visible.

Modern concepts of disability expand this vision by defining disability as a dynamic interaction between a person with a health condition and their contextual factors. It is important to see each person in their specific situation; often this means that there are many more elements to consider than simply the main physical, emotional or cognitive impairment defining their diagnosis. There is always more than a single story!

This expansion of perspective also changes how we identify the needs of disabled people. It requires a broad and holistic approach, combining relevant health, social and environmental information. The need cannot be determined simply by establishing a diagnosis and determining a “degree of disability” according to a standardized table with percentage values, depending on the organ that is damaged or has lost its function. The definition of needs goes beyond the diagnosis and requires a standardized and fair assessment by professionals with expertise in disability matters. Often, we see a cumulation of needs that require substantially more supports in individuals considered only “mildly” impaired as judged by an external assessor.

Currently, we have in Canada one national assessment for needs, which is the Disability Tax Credit Form.

This is filled out by a health professional and then reviewed by administrative staff at the CRA who decide in favor or decline the application. While it is still necessary to indicate the underlying health conditions, this form has been developed to meet modern definitions of disability and inquires about the needs of support in different life domains. As the disability tax credit only benefits those who have taxes to pay, often disabled people or their caregivers need to apply for additional supports at a provincial and/or municipal level and at different charity organizations (e.g. Easter Seals). Children who need supports at school need to apply to their school-boards and the resources available might vary not only from school-board to school-board but even between schools within the same school-board. The administrative burden to navigate all those applications is significant and families often require the assistance of a social worker for this process. While these supports are mostly financial and very helpful, the biggest challenge in my work with children experiencing neurodevelopmental disabilities is not being able to offer them adequate supports, services and therapies after identifying their needs. After a waitlist to be seen by a developmental pediatrician, children enter new waitlists for therapies, for assistive devices, for respite, for accessible housing, for educational assistants, for additional professional assessments. Years go by without any supports — years during which vital developmental processes should be happening, but may be delayed or missed entirely.

One group has been extremely effective in identifiying these gaps and voicing their concerns with advocates, lobbyists and policy makers (50K is not OK). Their pledge is not different from all the other conditions I see in my practice: they want “…to receive direct, timely and ongoing access to financial support, treatment and services.”

The federal government has recognized that “Whereas there is no coordinated national strategy that would expand the scope of support to ensure consistency and long-term solutions, especially for persons over the age of 18 years” such a strategy has been decided. This is great news! But only for those Canadians with a diagnosis of Autism Spectrum Disorder.

Nothing will change for people with Down syndrome, Fragile-X syndrome, Cerebral Palsy, Fetal Alcohol Spectrum Disorder or any other neurodevelopmental conditions. My hope is that this recent acknowledgment of a need for a national strategy will be expanded to address the needs of the largest diverse segment of the population. Ethical principles of justice, equity and fairness demand nothing less than a comprehensive inclusionary policy rather than one that privileges one ‘special’ population.

Developing such a strategy in the 21st century requires a reframing of how we value disability in our society. It requires moving away from a charitable mindset to a rights-based framework. It means moving away from a biomedical model of health to a modern biopsychosocial model. It means being inclusive of all diversity.

None of this is being achieved with the recent federal framework on Autism Spectrum Disorder. Focusing on one biomedical label, it ignores all the Canadians experiencing disability-related inequities. It is like developing a strategy to eliminate potholes — but only on the fast lane!

Autism Spectrum Disorder is by definition extremely variable in its presentation ranging from people requiring complete assistance in all activities of daily living to people living fully independently. It is not uncommon to identify similar needs among people with diverse neurodevelopmental conditions. If we continue to channel supports according to diagnostic labels (e.g. the Ontario Autism Program) it is very unlikely that their distribution will be equitable. The federal framework on Autism Spectrum Disorders is a roadmap to discrimination, inequity and exclusion. This policy requires a serious discussion and consideration about the ethical lenses by which we view disability. No citizen should be dreading the potential of having a child with an impairment or becoming incapacitated during their life course. Nor should parents be put in the surreal situation of “hoping” for a diagnosis of Autism to qualify for a service while others are disappointed if their child receives the “wrong” label as I have witnessed in my practice.

The way forward is a National Disability Strategy. Hopefully, the current framework for autism spectrum disorders will be the initial spark for such an all-encompassing nationwide conversation and effort towards a more inclusive society. An inspiration can be found in Europe: In 2021, the European commission presented a transnational strategy called “Union of Equality: Strategy for the Rights of Persons with Disabilities 2021–2030”.

WordDay is a worldwide initiative to raise awareness about rheumatic diseases in childhood. Today I had the opportunity to attend and speak at this fantastic event, for the first time in Brazil.
We listened to professionals, parents, and patients who addressed aspects of treatment, guideline developments, treatments, shared decision-making, personal stories, and the importance of support networks:

In my contribution to shared decision-making, I remembered the ethical aspects to guide us:

1. Do Good (Beneficence)
2. Do No Harm (Non-Maleficence)
3. Be fair (Equity)
4. Respect autonomy

I loved the Waze metaphor Dr. Sheila Knupp de Oliveira used to explain the therapeutic guidelines. With Waze, to reach a destination, there are often different routes with their advantages and disadvantages
(bumpy streets, more traffic, faster, more beautiful, etc.). In our relationship with patients, we are co-pilots and the patients are the pilots. In order to help them to take the best route for their life situation, we need to listen and inform. For example, many patients opt for complementary or alternative treatments. Without the openness of listening, we will never know the reasons, nor give them the support to be well-informed, before taking such decisions.
To facilitate a clinical conversation that addresses both physical, mental and social health aspects, I have shared “My favorite words” from our CanChild research center based on the World Health Organization International Classification of Functioning, Disability, and Health:

More materials and information are available on our website CanChild.
Finally, we talked about the importance of including patients in research activities as well. Dr. Claudio Len shared an interesting medical paper showing that the research goals of physicians and patients do not always align. Only by including patients in the research planning, we can understand what is relevant to their lives.
For those who want to know more about how to be engaged and involved (parents and children) in research, it is worth checking out our course on Family Engagement in Research.

O WordDay é uma iniciativa mundial para disseminar a palavra sobre as doenças reumáticas infantis. Hoje tive a oportunidade de assistir e participar deste evento fantástico, pela primeira vez no Brasil.

Ouvimos relatos de profissionais, pais e pacientes que abordaram aspectos de tratamento, desenvolvimento de diretrizes, tratamento, decisão compartilhada, relatos pessoais e a importância das redes de apoio:

Na minha contribuição sobre decisão compartilhada lembrei dos aspectos éticos para nos guiar:

1. Fazer o bem (Beneficência)
2. Não fazer mal (Não-Maleficência)
3. Ser justo (Equidade)
4. Respeitar a autonomia

Adorei a metáfora do Waze usada pela Dra. Sheila Knupp de Oliveira para explicar as diretrizes terapêuticas. E como no Waze, para se chegar num destino, muitas vezes há diferentes rotas com as suas vantagens e desvantagens (ruas esburacadas, mais transito, mais rápidas, mais bonitas, etc.) Na nossa relação com os pacientes, somos co-pilotos e os pacientes estão na direção. Para poderem tomar a melhor rota para a situação de vida em se encontram, precisamos ouvir e informar. Por exemplo, uma grande parte de pacientes opta por tratamentos complementares ou alternativos. Sem a abertura de ouvir, nunca saberemos os motivos, nem podemos apoiá-los para estarem bem informados, antes de tomarem tais decisões.

Para facilitar uma conversa clínica que aborda tanto os aspectos de saúde física, mental e social, compartilhei o trabalho sobre as “Minhas palavras favoritas do nosso centro de pesquisa CanChild baseado na Classificação Internacional da Funcionalidade, Incapacidade e Saúde da Organização Mundial de Saúde:

Mais materiais e informações estão disponíveis na parte de língua portuguesa do nosso site.

Por fim, refletimos sobre a importância de incluir pacientes também nas atividades de pesquisa. O Dr. Claudio Len compartilhou um artigo interessante mostrando que nem sempre os objetivos de pesquisa dos médicos e pacientes se alinham. Somente incluindo pacientes podemos gerar conhecimentos que têm relevância para as suas vidas.

Para quem quiser saber mais sobre envolvimento de parceiros (pais e crianças) em pesquisa, vale a pena verificar o nosso curso (por enquanto apenas em Inglês) de Engajamento de Familiares em Pesquisa.

This brief comment is reproduced with permission from ISSOP (International Society for Social Pediatrics and Child Health) and was first published in its 2020 November e-bulletin №48.

It is 2020 and most of our medical training and clinical services are still structured around organ systems and diagnoses, i.e. “biomedically”(1,2). In this context, Social Pediatrics is the odd specialty by explicitly expanding the focus of our work beyond the human body. This idea was already expressed by Stefan Engel about 100 years ago: “Every pediatrician that fully understands his/her task, in the first place, has to be a social doctor” (Stefan Engel, 1878–1968). From the “biomedical” side of medicine such social commitment has often been perceived as “less” — less medical, less precise, less exciting.

In the 1970s, George Engel (no relation) proposed to combine the medical with the social model of health (3). This “biopsychosocial” perspective would allow health care professionals to care for their patients more holistically. Recognizing that health is more than the absence of disease, the World Health Organization (WHO) developed the International Classification of Functioning, Disability and Health (ICF) as a framework and classification system (complementary to the International Classification of Diseases — ICD) based on the biopsychosocial model of health (4).

This classification not only allows but explicitly asks us to look beyond body structures and functions and to consider how the context of a person influences their “involvement in life situations” (participation). Their individual background such as culture, ethnicity, race and environmental factors such as social attitudes, policies, access to housing, food and drugs, the climate, environmental disasters and political disputes become an official part of their health status.

The ICF is the canvas for us to paint all those details we notice about a child and what is happening in their life (and that often worry us). A picture that moves us to think out of the box, be innovative, creative and drives our passion to reach out to partners outside of the health system such as education and social services. As a classification, the ICF also allows us to capture, codify, document and aggregate systematically the pulse of our society by caring for the most vulnerable among us.

Once the ICF becomes an integral part of health documentation, electronic health records and health statistics, we will be able to do more than count numbers of diagnoses, deaths and recoveries. We will be able to tell how people are managing, identify common barriers and discover ways to facilitate their full participation. Implementing the ICF will help us build a society that is more open, more inclusive, more diverse and values collaboration.

If you are curious to learn more about the ICF, go to www.icfeducation.org

References:

1. Ronen GM, Kraus de Camargo O, Rosenbaum PL. How Can We Create Osler’s “Great Physician”? Fundamentals for Physicians’ Competency in the Twenty-first Century. Med Sci Educ. 2020;30(3):1279–1284. https://doi.org/10.1007/s40670-020-01003-1

2. Kraus de Camargo O, Simon L, Ronen GM, Rosenbaum PL, eds. ICF: A Hands-on Approach for Clinicians and Families. First. London, UK: Mac Keith Press; 2019. http://www.mackeith.co.uk/shop/icf-a-hands-on-approach-for-clinicians-and-families-ebook/.

3. Engel GL. The need for a new medical model: a challenge for biomedicine. Science (80- ). 1977;196(4286):129–136. http://www.jstor.org/stable/1743658.

4. World Health Organization (WHO). International classification of functioning, disability and health : ICF. 2001. https://apps.who.int/iris/handle/10665/42407.

Ideas about how to implement the ICF into the curricula have been discussed for several years now. Here are some early examples:

Darrah et al., 2006

Gutenbrunner et al., 2010

More recently, it has become obvious that the ICF is an excellent tool for enabling interprofessional education and collaborative practice:

Moran et al., 2020

Scholten et al., 2020

A short overview of what the ICF is about can be found here:

CanChild