4. DEFINITIONS OF DISORDERS An example of the first type of definition was presented by Clements (1966): The term "minimal brain dysfunction syndrome" refers to children near average, average, or above average general intelligence with certain learning or behavioral disabilities ranging from mild to severe, which are associated with deviations of function of the central nervous system. These deviations may manifest themselves by various combinations of impairments in perception, conceptualization, language, memory, and control of attention, impulse, or motor function (p. 9-10). Another definition that gives reference to the central nervous system was proposed by Mykelbust (1963): We use the term "psychoneurological learning disorders" to include deficits in learning, at any age, which are caused by deviations in the central nervous system and which are not due to mental deficiency, sensory impairment, or psychogenicity. The etiology might be disease and accident, or it might be developmental (p. 27). In the second category of definitions, behavioral characteristics without reference to brain dysfunction or etiology are stressed. The authors of such definitions feel that since all normal and abnormal behavior is related to brain function, it is of no benefit educationally to infer brain dysfunction from behavior. For pragmatic purposes, the educator's task is to isolate within a child the basic behavior disability or disabilities, and to organize a remedial program for the correction of the disability. Chalfant and Scheffelin (1969), reviewed a number of definitions and reported a variety of descriptive characteristics: Characteristics which are often mentioned include disorders in one or more of the processes of thinking, conceptualization, learning, memory, speech, language, attention, perception, emotional behavior, neuromuscular or motor coordination, reading, writing, arithmetic, discrepancies between intellectual achievement potential and achievement level, and developmental disparity in the psychological processes related to education (p. 1). Because of national interest in the problem and because states and the Federal Government were engaged in passing legislation, the National Advisory Committee on Handicapped Children of the U.S. Office of Education proposed a definition (1968) which was used in the Congressional bill entitled "The Learning Disabilities Act of 1969." This definition stated: Children with special (specific) learning disabilities exhibit a disorder in one or more of the basic psychological processes involved in understanding or in using spoken or written language. These may be manifested in disorders of listening, thinking, talking, reading, writing, spelling, or arithmetic. They include conditions which have been referred to as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, developmental aphasia, etc. They do not include learning problems that are due primarily to visual, hearing, or motor handicaps, to mental retardation, emotional disturbance, or to environmental disadvantages (p. 14). All of the definitions contain a common core even though their emphasis on the central nervous system may be different. The common areas of agreement are: 1. The learning problem should be specific and not a correlate of such other primary handicapping conditions as general mental retardation, sensory handicaps, emotional disturbance, and environmental disadvantage. 2. The children must have discrepancies in their own growth (intraindividual differences) with abilities as well as disabilities. 3. The deficits found in a child must be of a behavioral nature such as thinking, conceptualization, memory, speech, language, perception, reading, writing, spelling, arithmetic, and related abilities. 4. The primary focus of identification should be psychoeducational (Kirk, 1972, p. 44). The prevalence of learning disabilities is difficult to estimate. The best guess is that from one to three percent at the least and possibly seven percent at the most of the school population require special remedial education (Kirk, 1972, p. 45). It would be simple if there were only one kind of specific learning disability. In this case the task would be to identify it, determine the extent of the disability, and apply one effective remedial program. This is not the case. There are diverse problems, correlates and remedial methods. One remedial procedure may be appropriate for one type of disability and completely inappropriate for another type. Over the centuries, neurologists investigated the relationship between brain function and communication in an attempt to determine what caused learning disabilities. Hughling Jackson (Taylor, 1932) related the problem to cerebral dominance and other behavioral disorders. In 1868, Jackson pointed out that there are various degrees of aphasia (loss of ability to speak), and that aphasia, agraphia (loss of the ability to write), and alexia (loss of the ability to read), are defects in utilizing symbols, i.e., thinking. He alleged that writing was affected not as a separate "faculty" but as a part of the failure to express oneself in words. He formulated his theories on studies of brain-damaged adults and epileptics (p. 47). A good example of the inferences from adult brain damage to that of children can be found in the work of Hinshelwood (1917). From his work with children and adults in his practice as an ophthalmologist, he discovered that children who had difficulty in learning to read must have had an injury or underdevelopment of the left angular gyrus which produces what he called "word blindness." Hinshelwood differentiated between adults who lost the ability to read as "acquired word blindness" (alexia) and children who were unable to or had difficulty in learning to read as "congenital word blindness," sometimes referred to as "dyslexia." In the United States, Samuel T. Orton (1928) questioned Hinshelwood's concept of congenital word blindness and its localization in the left angular gyrus. He proposed the theory of cerebral dominance which could account for a child's stuttering or inability to read. He postulated that when neither of the two cerebral hemispheres was dominant over the other, the child began twisting symbols and seeing "no" as "on", or "saw" as "was." He called it the theory of "strephosymbolia" (twisted symbols). Orton's associates, Marion Monroe (1932), and Gillingham (1936), followed his theories by developing diagnostic procedures and phonic remedial methods for children diagnosed as dyslexic or as having strephosymbolia. During the post-World War II period, Strauss and Lehtinen (1947) generated wide-spread interest in the problem of specific learning disabilities by focusing attention on brain-injured children. Strauss's main thesis was that children with brain injuries incurred before, during, or after birth are subject to major disorders in (1) perception, (2) thinking and (3) behavior, and that these disorders affect the child's ability to learn to read, write, spell, or calculated using arithmetic symbols. Although Strauss's concept of brain-damaged children and the procedures and assessment that led to such a diagnosis have been challenged, the educational procedures for remediation of the behavioral symptoms have not been seriously questioned. Many subsequent developments in learning disabilities were stimulated by these two and included Cruickshank (1961), Kephart (1964), Barsch (1967), and Getman (1968). The thread of similarity among all the approaches proposed by these men involved the use of perceptual-motor diagnosis and subsequent remediation through sensory-motor activities. Kirk (1972) noted that a century and a quarter ago Edward Sequin (1846) emphasized sensory-motor training for the mentally retarded. His aim, like that of Strauss and Kephart and partly like that of Barsch and Getman, was from motor or muscular training to sensory-motor training, and from sensory-motor training to abstract thought. Sequin's use of the trampoline to develop balance, or the game of "statue" to develop attention, or perceptual motor training to develop cognition are similar to aim and practice to those of the current perceptual-motor emphasis. Another approach to modifying certain kinds of learning disabilities was developed by Marianne Frostig at the Frostig Center of Educational Therapy in Los Angeles. Frostig's Developmental Test of Visual Perception (1964) measures the child's developmental level of ability in various tasks involving visual perception. Recognizing that evaluating a single facet of visual perception does not give a true picture, Frostig developed tests in five different areas of perception skill. These five areas are: 1. Eye-hand coordination (the child draws between increasingly narrower boundaries); 2. Figure-ground discrimination (the child traces figures on increasingly complex backgrounds); 3. Constancy of shape (the child recognizes geometric figures presented in different sizes, contexts, or positions); 4. Position in space (the child discriminates reversals and rotations of figures); 5. Spatial relations (the child perceives space relations between simple forms and parts of a pattern and their relationship to himself) (p. 53). Kirk (1972) noted that the description of the tests and the remedial procedures of Frostig did not imply that she excluded other approaches. She used an eclectic approach in both diagnosis and remediation. The Myklebust (1960) approach to remediation of learning disabilities was eclectic rather than a unique diagnostic remedial system. It emphasized neurological relationships as explanations, but in practice it was a behavioral approach with an emphasis on psychoeducational diagnosis of specific disabilities followed by remediation of the disabled behavioral responses. The emphasis was on auditory-vocal disabilities as basic to other disabilities in school-age children. Myklebust presented a hierarchical scheme by which language develops. He stated that a child first gains experience, then develops by stages through (1) development of inner language or meaning, (2) comprehending the spoken word, or auditory receptive language, (3) speaking, or auditory expressive language, (4) reading, or visual receptive language, and (5) writing, or visual expressive language. Johnson and Mykelbust (1967) emphasized the diagnosis of learning disabilities by first asking, "what disability?" The analysis of the problem in a child required neurological, psychological, and educational assessment. When the specific disability was isolated, remediation could be organized to correct the deficit (p. 54). Friedus (1964) was influenced by Strauss and Lehtinen in developing her remedial procedures, but she recognized that no one method applied to all types of learning disabilities. She likened the child to a computer in which the child must (a) attend to and (b) receive information through the senses, then (c) integrate this information with other information, (d) organize the perceptual with the motor activities, and (e) produce an adequate response. She emphasized materials and methods that give feedback and that will allow the child to monitor his own response. In teaching arithmetic, the child is given instructions to check his own work through concrete aids. Her teaching approach was applied to special disabilities as well as to the teaching of academic subjects such as arithmetic. Many learning disabilities are not detected until the child begins to fail academically in school. Failure in reading is the most common point of detection and one of the most frequent kinds of learning disabilities with which the school is concerned. All children are exposed to reading programs, sometimes these begin at home, sometimes in kindergarten, but most commonly when they are admitted to the first grade. Reading instruction may proceed on any one of three different levels: (1) developmental reading, (2) corrective reading, and (3) remedial reading. Developmental reading refers to the various systems of teaching reading in the classroom and provides a sequential development of the skills of reading. Corrective reading refers to the methods used to change minor incorrect habits or gaps in knowledge acquired in the course of a developmental reading program. Remedial reading refers to the procedures used with children whose reading skills are still not developed after exposure to developmental reading and corrective reading. The most well known of all remedial reading methods is the Kinesthetic Method developed by Grace Fernald (1943), a psychologist who became interested in children who had difficulty in learning to read or spell. Her method involved four developmental stages: (1) In stage one the child traces the form of a known word while saying it, then writes it from memory, comparing each trial with the original model. (2) In stage two he just looks at the word or phrase while saying it, then tries to write it from memory, comparing his result with the model until he is successful. (3) In stage three he writes the word without vocalizing it until he is successful. (4) In stage four he begins to generalize and reads new words on the basis of his experience previously learned words. Other remedial methods which seem to produce effective results are the phonic-grapho-vocal method of Hegge, Kirk, and Kirk (1936), the VAK (Visual-Auditory-Kinesthetic Method) of Gillingham and Stillman (1965), and the Spaulding Method (1957), a phonic system presented in The Writing Road to Reading. Kirk and Kirk (1971) proposed a psychoeducational diagnostic procedure for assessing learning disabilities which comprised the following five stages: (1) determining whether the child's learning problem is specific, general, or spurious; (2) analyzing the behavior manifestations which are descriptive of the specific problem; (3) discovering the physical, environmental, and psychological correlates of the disability; (4) evolving a diagnostic inference (hypothesis) on the basis of the behavior manifestations and the correlates; and (5) organizing a systematic remedial program based on the diagnostic inference (p. 72). Speech involves more than the ability to articulate sound. It calls for the assimilation of sounds into words, then the combination of these words into units that convey meaningful utterances. It may be defined as the vocal, as opposed to written, representation of the symbols of a formalized language, and its aim is to achieve the mutual exchange of ideas (Kirk, 1972, p. 73). In the development of speech and language in humans, organic factors such as sensory impairment, structural abnormalities, or problems of muscular incoordination may produce a speech defect. Often defective speech and language are correlates of a developmental lag or of nonorganic factors such as psychological, cultural, or environmental problems. Defective speech is any speech which draws unfavorable attention to itself, whether through unpleasant sound, inappropriateness to the age level, or interference with communication. To be normal, speech should permit the undistracted interchange of verbal language, free from grimaces, phonemic misarticulations, unnatural and unusual voice qualities, speaking rates, and rhythms (Kirk, 1972, p. 74). Most frequently, articulation difficulties are encountered in the cerebral-palsied, in the deaf and hard of hearing, and in the mentally retarded. But a direct relationship between speech defects and a lack of educational achievement has not been clearly established. Weaver, Furbee, and Everhart (1960) believed that there is a causal relationship between poor speech and poor reading and it could be accounted for in one of the following ways: 1. Poor speech habits may result in silent reading. 2. The reader, intent on his speech, may ignore the meaning. 3. Speech defects may interfere with rate and phrasing. 4. Articulatory disorders may result in misunderstanding of words. 5. Speech defects may cause reading to be unpleasant and result in less practice. Eisenson (1963) stated: "(1) the two disabilities have a common cause; (2) speech disability may cause reading disability, especially when reading is taught by the oral method; and (3) reading disability may cause speech deficiency" (p. 200). The maturational cycle for the development of verbal behavior was described by Berry (1969) as follows: 1. Prelinguistic vocalization. An infant cries, utters sounds of various kinds. 2. Babbling. Babbling follows early vocalization, but may not be clearly differentiated from early vocalization and may not relate to later speech. 3. Imitation. At this stage, usually between the fourth and sixth month, the child "oohs" and "ahs," imitating his own speech production and responding in some vocal fashion to the speech of others. 4. First words. It is difficult to establish an age level for first intelligible and meaningful words. By 18 to 20 months most children may be saying "mama" or "daddy" and a few other words. 5. Two-word sentences. At about 2 years of age most children are using two-word sentences like "more milk," "shoe off," and so forth. 6. Development of syntax. After age 2 to 3 the child begins to develop his own grammatic system, explores his own use of grammar, noun-phrases, subject-predicate sentences and so forth. Somewhere between birth and the first years of school, a minimum of five percent of the future school population do not reach the efficiency in speech which is considered normal or adequate for the age level. In many school systems, the procedure in establishing a speech correction program follows three stages: 1. Screening children in the grades to identify those requiring further diagnosis; 2. Diagnosing those selected from the initial tests; 3. Choosing those children who require and can benefit from speech correction. In screening, most speech correctionists use a picture type of test, such as the Deep Test of Articulation (McDonald, 1964), and the Goldman-Friscoe Test of Articulation (1969). The Templin-Darley Tests of Articulation (1960) provide a total of 176 items, 50 of which may be used for screening purposes. Previous research by Templin (1952) on the development of articulation in children provides test items and norms. Children referred by teachers or parents for speech correction and those who have been identified through the screening procedure require a diagnosis of their specific speech problems before correction can be started. Kirk (1972) described the following diagnostic steps that are often used: 1. Intellectual assessment. 2. Assessment of the specific defect. 3. Determining Causal Factors and Correlated Defects (p. 78). In most research on speech disorders, the grouping of speech defects has been narrowed for practical rather than logical reasons to include: 1. Disorders of articulation, 2. Disorders of voice, 3. Stuttering, 4. Retarded speech development, 5. Cleft palate, 6. Cerebral palsy, 7. Impaired hearing, 8. Aphasia and related disorders (Kirk, 1972, p. 79). Articulatory disorders are those deviations which involve substitutions, omissions, distortions, and additions of phonemes. These difficulties may occur as the articulators (tongue, cheek, lips, palates, jaws) modify the flow of air-sound from the larynx by changing their positions and contacts. Learning to direct the air flow and to make rapid shifts in the position of the articulators in order to emit intelligible sounds and sound sequences is largely imitative and associative, utilizing visual perception, kinesthetic awareness, memory, touch, and auditory discrimination. The articulatory mechanism is part of an intricate speaking system, any part of which may show abnormalities of structure or function. It includes (1) a breathing apparati to assist in the production, formation, and direction of sound through the various resonating cavities; (2) two vocal cords housed in the larynx to vibrate for the phonation of sound; (3) an auditory mechanism for discrimination between sounds; (4) an intact brain and nervous system; (5) swallowing musculature, involving tongue and pharynx; and (6) oral mechanism, including tongue, lips, teeth, hard and soft palates, and jaws, which can be utilized in modifying sounds coming from the larynx. Malfunctioning of any of these parts may cause speech difficulty (Kirk, 1972, p. 82). Vocal disorders, not as common as articulatory disorders, appear mainly in connection with (1) vocal quality, (2) vocal pitch, and (3) vocal loudness. Instead of speaking of the formation of sounds, one is concerned with the production of sound in the larynx, with the selective transmission of that sound in the various resonating cavities, with the pitch level and intonation pattern of sound sequences, and with the loudness or softness of vocal production. The more common defects in vocal quality are found in (1) phonation, or production of sounds, and (2) resonance, or the direction of the sound in voice placement. Stuttering is a pattern of speaking in which rhythms of speech are disrupted or broken by excessive or inappropriate prolongations and/or repetitions of sounds, syllables, words, or parts of sentences, usually accompanied by struggle and avoidance behavior. Van Riper (1963) defines stuttering in the following terms: "When the breaks in speech occur too frequently or are accompanied by other peculiar behaviors which call attention to themselves and interfere with communication and are received as abnormal by the listener, we call it stuttering (p. 312). West (1958) summarized some factors related to stuttering. Those agreed upon include (1) stuttering is a phenomenon of childhood, (2) there are three to eight times as many males as females who stutter, and (3) stuttering runs in families. Although there is some evidence that stuttering is associated with left-handedness, this evidence is not conclusive. Nor is there conclusive evidence that stutterers are more susceptible to allergies, blood-sugar ratings, and so forth. Theories which explain the stuttering phenomenon are numerous but can be categorized into two major groups: (1) organic theories and (2) behavioral (psychological or sociological) theories. Organic Theories. The theory of cerebral dominance, proposed by Lee Edward Travis (1931) purported that stuttering is the result of lack of cerebral dominance. In most individuals one cerebral hemisphere of the brain controls the flow of speech, while the other hemisphere remains subordinate. Lacking cerebral dominance, so that neither hemisphere takes the lead role or there is an alternation of roles, the individual stutters. In reviewing physiological studies on stutters, Perkins (1970) questioned the conclusions that stuttering is organic origin. He stated: When the difference among stutters and nonstutterers are viewed collectively--in terms of sex ratio, audition, twinning, familial incidence, diabetes, epilepsy, laterality, motor coordination, perseveration, allergy, developmental history, psychosis, and CNS (central nervous system) functions--we must recognize the possibility of a constitutional predispositions to stuttering. To take this conclusion, seriously, however, would be risky on several counts. For one thing, no factor or combination of factors has been reported as consistently present in all or most instances of stuttering. If organic variants are operative, they would presumably be effective continuously, at least from moment to moment (p. 190). Psychological Theories. The psychological theories tend either to ascribe stuttering to emotional factors or to the process of learning during development. Johnson's (1956) "diagnosogenic" theory stated that parents, failing to realize that the very young child is passing through a normal stage of language learning, diagnose the child's normal repetitions and hesitations as stuttering, a label which becomes a stigma, adding fear to anxiety. Then when the parental responses show concern or are not understanding, the child hastens to get the words out before he is reproved, thus continuing the cycle of fear-anxiety-nonfluency. The stuttering of the child, then, is something in the mind of the parent. Eventually, the child will experience "anticipatory, apprehensive, hypertonic, avoidance reactions" in speech situations, which is another way of saying the child anticipates stuttering, dreads it, becomes tense in trying to avoid it, and so stutters. Sheehan (1970) conceived of stuttering not as a speech disorder, but as a conflict about self and role, actually an identity problem or a "special instance of self-role conflict." He blended the role theory with advances in learning theory and clinical psychology. Van Riper (1970a) first believed stuttering had multiple origins, a constitutional predisposition, emotional conflict, or low frustration tolerance, but eventually pointed out that stuttering was a learned behavior, susceptible to unlearning. Van Riper (1970b) wrote that speech pathologists had accepted and incorporated behavior modification techniques to correct stuttering, but it has been a major difficulty for speech clinicians. They have been using these principles for years in speech correction practice. Historically, there have been many theories and approaches to the treatment of stuttering. West (1966) described seven approaches: (1) psychoanalysis, (2) mental imagery, (3) classical conditioning, (4) negative practice, (5) general semantics, (6) hemispheric dominance, and (7) somatic or physiological approaches to treatments. Delayed Speech. Some children do not develop speech as expected at their age level or they develop only a partial understanding of language or vocal expression. This lack in speech development has been classified as delayed speech. Some of the causes of delayed speech include hearing loss, mental retardation, emotional disturbances, environmental disturbances, environmental deprivation, cerebral dysfunction, glandular irregularities, and the intangible "congenital aphasia." Wood (1959) defined differences in delayed speech according to the disturbances of symbolic language formulation. Myklebust (1954) differentiated among the receptive aphasic, psychic deaf, mentally deficient, and peripherally deaf, according to patterns which he has established. McGinnis (1963), who developed a specific method of training children with delayed speech, preferred the term "aphasia." Eisenson (1963) emphasized the difference between delayed speech and congenital aphasia. He defined a child with this condition as "one whose language development is significantly below what we would have a right to expect on the basis of his age and an estimate of his intelligence" (p. 210). He viewed congenital aphasia as a "separate syndrome that must be considered among the organic causes of language retardation." He insisted on definite evidence for "atypical cerebral development" on a congenital basis. Speech Defects Associated with Hearing Loss. Hearing losses, mild or severe, have been associated with delay in speech development or with inadequate speech. Surveys of speech- handicapped children in schools revealed a greater frequency of children who have speech defects and hearing losses. Sullivan (1944), Fiedler (1949), and Mase (1946) in large sample surveys of school children found a higher percentage of hearing losses among speech defectives than among children who did not have speech defects. Speech Defects Associated with Cleft Palate. The speech disorder with cleft palate and lip is due not to cerebral dysfunction but to structural deficiencies caused by the failure of the bone and tissue of the palates to fuse during the first thirteen weeks of pregnancy. A number of studies indicated that cleft palate and lip may be hereditary but do not explain what factor or combination of factors in the germ plasm may be causing the difficulty. The classic study by Fogh-Anderson (1942) revealed that inheritance is more likely to be associated with either cleft lip alone, or lip and palate, than with the palate alone. Persons having unrepaired cleft palate and lip deformity usually exhibit a severely nasal voice or hoarse quality and a wide range of articulation disorders, depending on the nature and extent of the problem. In cleft palate conditions there usually is an insufficiency of tissue and an inability to move the soft palate toward the pharyngeal wall the required degree to achieve effective interruption and redirection of the air-sound stream. Either of these conditions may serve to render the child incapable of achieving complete velopharyngeal closure to correct the nasality and to produce correctly articulated phonemes. Denhoff and Robinault's (1960) thesis pointed out the chief departure in therapy for cerebral-palsied children by asserting, "The neuromotor disturbances may appear to be the most important component to overcome, but in the long run, the associated visual, hearing, speech, perceptual, behavioral, and emotional handicaps can affect the ultimate development more than does the motor status" (p. 27). Speech Correction for the Cerebral-Palsied Child. The correction of speech impairments in the cerebral-palsied child does not differ greatly from that for other children. There are six major areas requiring attention. 1. It is necessary to solicit the cooperation of the parents and to motivate speech through experience and exercise. 2. Sometimes the speech clinician must alleviate as soon as possible the stigmata generally associated with cerebral palsy such as drooling and the protruded tongue hanging out of the mouth. The child should be taught to swallow acceptably, to close the mouth and enclose the tongue in its habitat. 3. The use of mirrors in speech correction is sometimes thought to create greater muscular tension when the child sees his own reactions. 4. Language is aided by exploration, experience, and the need for verbal expression. 5. Children do not speak unless they are motivated to speak. One of the problems with cerebral-palsied children is how to create a need in them for improving their speech. 6. Finally, it will be necessary for a speech clinician to help the child manage his tongue movements, control the synergic movements of swallowing, control facial movements, and control breathing, inflection, and intonations of the voice (p. 99).