Three Case Studies in the Diagnostic Education of Children with Speech Defects
- Author:
Richards
Formerly Clinic Teacher, Psychological Clinic, University of Pennsylvania
Introduction
One of the common reasons for bringing children to the speech clinic is a lack of speech, or an extremely slow development of the speech process. The diagnosis of these defects in speech must necessarily be based on an understanding of the several causes which may be responsible for the existing condition. The speech clinic at the University of Pennsylvania, under the direction of Dr Edwin B. Twitmyer, has suggested that there are at least five specific reasons why a child does not learn to talk. These are (1) deafness, (2) negativism, (3) amentia, (4) anatomical defect of the mechanism required to produce speech, and (5) defect due to brain injury. It will be seen at once that the differential diagnosis demands a varied clinical approach. A complete medical examination is implied in the diagnosis of anatomical defect and brain injury, partially in the case of deafness, and as providing valuable supplementary and explanatory data in the diagnoses of amentia and negativism. The psychological examination and, in many cases, continued observation must determine the degree of amentia, and follow-up study must indicate the modifiability of each factor. During the academic year, 1930-31, three cases were referred to the department of clinic teaching by the speech clinic for follow-up observation.
I Raymond was brought by his parents in November at the age of seven years and one month. The parents were born in Armenia; the father was employed as a weaver. Raymond was their first child. According to the information given by the parents, conditions at his birth were normal; he was breast fed; at five months he sat up; at nine months he walked and talked and at ten months he developed satisfactory sphincter control. At about eleven months the boy fell from his chair and became unconscious; he was taken to the hospital where he recovered shortly and was returned to his home.
About a week after this first attack, Raymond suffered another, while walking about the house. He was taken to the hospital again where he had three convulsions within six hours. One of the physicians, who saw the case at this time, suggested cranial pressure as a cause for the convulsions but predicted that within a few hours the child would fully recover. In despair, however, the parents took the boy home, still unconscious, and three consultants were called in. The parents told us that the physicians attending the case thought the boy as good as dead. After twenty-four hours of constant attention he moved, opened his eyes and his mouth. It was found, according to his mother, that he had cut five teeth. His condition subsequently was very serious, however, for he was blind, deaf, and partially paralyzed. Constipation developed and it became very difficult to nourish him properly. For three months Raymond was paralyzed, and it was not until fifteen months had elapsed that he could stand and walk. He seemed then to have recovered from the paralysis, except that his right hand was still weak. Until he was five years of age he was unable to hold objects with this hand, and even at present it does not function well. The spasms continued, the condition seeming to be intensified by teething. Until he was five years of age he had seizures at least monthly; often they occurred as frequently as twelve times per day. The constipation still presented trouble. When six years old, Raymond had one convulsion. He rarely or never had them at the time of examination.
A number of physicians saw the child at different times. From what we could deduce from the reports of the parents, one specialist felt that the teething was the cause of the trouble which would continue until this process was complete, though after that the boy should be normal. Another physicain, who examined the child a few months prior to his examination in the speech clinic, was quite positive in his opinion that the boy would be normal when teething was completed. Still another physician who saw the boy later believed that he had suffered from epilepsy due to cerebral injury, and that this injury accounted for his other abnormalities as well.
When he was examined in the speech clinic by Dr Yale S. Nathanson, Raymond demonstrated symptoms strongly suggesting amentia. Deafness was counted out as a factor, though it was CHILDREN WITH SPEECH DEFECTS 211 suggested by the extreme distractibility present. The right hand and arm showed an abnormal contraction. Throughout the examination he tired easily and little could be done with him after a few minutes’ application to a specific task. His behavior was marked by hyperdistractibility and inattention. He was able to execute a few simple commands, such as to stand, to sit, to move from one place to another. From a number of toy animals he chose at command a dog and a cat. He performed both the threedisc and the three-figure Seguin formboards but the Witmer formboard was too difficult for him. Lapses in attention made this work extremely difficult, but it was felt that under proper discipline and with more time devoted to specific training the boy’s ability to learn?at least to be trained?might be displayed to better advantage. The diagnosis of amentia might thus be modified to some extent. Raymond was, therefore, referred for clinic teaching, in order that the diagnosis of amentia might be modified if it was deemed necessary.
During the months of March and April Raymond received six hours of observation and teaching under Miss Margaret Shank. The work was confined almost solely to the use of the Witmer formboard in an attempt further to determine the child’s trainability and mental level. He was able to do the Seguin boards as before but on the first trial of the Witmer board the boy was “totally unsuccessful.” For two hours the teacher showed Raymond how to replace the blocks; at the end of this period he iwas able to put them in their respective recesses without much help, though he was extremely slow. At the end of the third hour, with a great amount of persuasion, he completed the task of replacing the blocks in four minutes, but at the end of the fourth hour with but one suggestion from his teacher he could complete the board in no less than six minutes. In her reports his teacher states that “all of Raymond’s performances were by trial and error.” He never tried to find the block for the recess or the recess for the block by observation and analysis; rather he tried to force each block as he came to it into every recess, whether or not it was vacant. His discrimination was very poor, and his teacher never felt that he fully comprehended the problem. Hyperdistractibility as characterized by attention to every sound was always evident. Sometimes “he would look as if he were in a trance with a very blank expression and a remote look in his eyes. I would motion for him to proceed with his perform212 THE PSYCHOLOGICAL CLINIC ance and he would imitate my movement.’’ His teacher found this tendency so common as definitely to suggest echopraxia.
Although his mother had reported to the examiner originally and to Raymond’s teacher that he could “say many short sentences,” “mama” and “papa,” he was only once heard to speak while he was in clinic. This was on the occasion of his first visit, when he shouted a loud “good-bye” as he left the room. His teacher tried throughout her contact with the boy to elicit a speech response, occasionally soliciting the assistance of the mother but with no success.
As the result of clinic teaching in the case of Raymond it was clear that the boy was feebleminded. Deafness had been ruled out, and the degree of negativism was not at all abnormal. Medical examination had indicated no anatomical defect which might account for the lack of speech, although if we view the possible epileptic condition and the defective nervous system as basic to a deficiency in the neural coordination necessary for the speech function we might well consider such a factor as causal in a primary way. In view of the indication of normal development up to eleven months of age followed by retardation in almost every aspect of behavior with the onset of convulsions, the physical condition was no doubt basic to the mental status. Yet the recovery of use of limbs, the gradual return to normal motor function would suggest that there should be a rehabilitation of the speech function, provided that other factors were conducive to it. The fact that it had not developed suggested amentia to be basic. II In the case of Sam we find a picture different in many respects from that of Raymond. His particular defect was not a lack of speech but a slow development of speech function in addition to an evident general mental retardation. Sam was born of Russian parentage, the fourth child in a group of five. The father was employed as a tailor. Conditions at birth were normal, and the medical history showed the child to have suffered no diseases during childhood except frequent colds. At two years of age Sam walked; at three years he talked “a little.” When brought to the Clinic in January, at the age of five years and seven months, he had not yet become entirely clean.
The medical history of Sam’s siblings shows that each of the older children had suffered diphtheria, and the eldest, a boy of nineteen, had had scarlet fever. A girl of seventeen had stopped school but was not working, while another girl of fifteen was in the tenth grade in the public school. The only child younger than Sam, a boy of two and a half years, showed many of the behavior symptoms demonstrated by Sam, which we shall describe later. Observations made at the time of Sam’s examination in the Clinic indicate that he presented an abnormal picture generally. Definitely low motor competency was manifest in his shuffling, ambling gait, in his manner in playing with toys on the table, in the way he stood before the examiner. He drooled during the examination. He did not know how to hold a toy gun nor how to cock it. Presented with the Witmer formboard, he simply removed the blocks carelessly and placed them on a toy chair which rested on the table before him. He was very distractible, proceeding from one toy to another, asking for each only to discard it as he became, after a moment, interested in another. His speech was incessant though unintelligible. We learned from his sister who accompanied the boy to the Clinic that occasionally he dressed himself, but that he could not button his clothes. He was able, however, to put on and lace his shoes. When asked if he were a boy or girl he immediately said, “a girl,” demonstrating here an echolalia which the examiner felt to be evident also in the audito-vocal memory span of four and five. In attempting to sit upon the small toy “kiddie-car” he demonstrated the same lack of discrimination and sense of proportion which was shown in his manner of handling the forms in the formboard test.
Since Sam was referred by a community center having a supervised nursery school group which he had attended we had some report of his social behavior. He did not get along at all well with other children. He seemed to this institution “very individualistic.” His delight was to take toys from other children, to knock the children down if they resisted, to maltreat his younger brother (who reciprocated in much the same manner).
The results of the psychological examination as well as the history of the case, particularly those aspects which had to do with the development of behavior patterns such as walking, talking, and becoming clean, at once suggested amentia. A high degree of excitability and aggressiveness coupled with lack of emotional control normal in a child of five indicated that the prognosis for normal behavior development was not good. Dr Twitmyer felt that the mechanism for normal behavior as well as for speech had somehow been damaged, and that Sam was “a very decided ament.” Clinic teaching for the purpose of continued observation was recommended. Sam was, therefore, placed for teaching with Mr. Bernard Gekoski, a student teacher, and received during the spring term eight hours of teaching.
Sam’s teacher reports that the outstanding characteristic of the case was extreme distractibility. The boy paid no attention to commands, and the same shift of interest which had marked the psychological examination was manifest in the first hours of teaching. His speech defect seemed much less serious than his mental deficiency. The “shuh” for shoe which was given in the psychological examination soon became 11 shoe’’; the ‘’ bur’’ for four was corrected. “Bife” continued for jive, as did “bish” for fish. His teacher thought the boy’s speech was not unintelligible, although it was very defective.
Regular work with performance material, including the Seguin and Witmer boards, proved to some extent effective, but the boy’s performance was constantly hampered by his distractibility. Although he never managed throughout the whole period of teaching to perform successfully the Witmer cylinder test he did show marked improvement under coaching. “His failures,” writes the teacher, “can be attributed only to lack of persistent attention and desire to proceed.”
On the Stanford Revision of the Binet-Simon test Sam was given an intelligence quotient of 56. Young’s Maze A proved too difficult: “He simply slid the shoe back and forth in the groove. The command to ‘take the shoe to the boy’ he did not understand, as was evidenced by his attempt to pick out the shoe and place it down again by the boy. He had no ability at all to look ahead and avoid the blind alleys; it was evident that he had not even any conception of what was required of him.”
Sam was able to recognize all the numbers through nineteen except four, which he called a bridge. His ability to name the figures on the blackboard seemed to vary from day to day, but on the last day he named them successfully, even including his bugbear, the four. Disciplinary measures became increasingly necessary as the teaching proceeded. Excitability and obstinacy increased, as did resistance to authority. It was evident that coupled with the problem of low mentality was one of emotional instability, or deCHILDREN WITH SPEECH DEFECTS 215 ficiency in emotional control. Further observation of the family, particularly of the mother and sister who accompanied the child to the clinic, led to the belief that each of these factors had its share of hereditary predisposition. The extreme lack of control which characterized his behavior was infantile, far inferior to that normal in children of five and six. His teacher believed, however, that the boy had never demonstrated all of which he was capable. The evidence of trainability could not be denied and the prognosis, particularly for speech development, seemed not at all poor though much more teaching was necessary; at worst a middle grade imbecile the boy needed training in manual work and in social behavior. Whether or not the emotional twist can be modified to the extent that the boy will develop a useful place in the world cannot be determined as yet.
It will be seen at once that the problem in the case of Sam is one of low grade mentality coupled with emotional instability. The factors which provide for the retardation in development of speech rest in this general incompetence, but the ways in which the deficiency makes itself manifest are not confined to the sphere of speech defect. Curiously, the prognosis for the development of speech is better than is that for normal behavior development, yet it was because of “speech defect” that the case was brought to us. Although the case of Sam differs in many ways from that of Raymond, they have in common a general retardation as explanatory of the speech retardation. In this respect both of these cases differ from the third one, Albert, whose general deficiency was believed, finally, to rest on a specific sensory defect.
Ill Albert came to us at the age of five years and seven months, brought by an agency for family work because of a problem in regard to placement in school, and for advice as to speech training. A medical examination preceding the general mental examination in the clinic revealed a condition of otitis media, purulent and bilateral. The physician stated that both drums were practically destroyed, and that the prognosis for hearing was extremely poor. We were able to learn but little of the history of the case. Albert was the child of parents who had separated. The father was a Roumanian by birth and the mother was American born. The mother brought Albert up with his younger brother and an infant daughter who died, until Albert was five years old, when she deserted the family entirely. Nothing was learned in regard to her whereabouts at the time Albert was examined. From scraps of information gathered from the family organization we were told that the children originally had not been wanted, and that the environmental conditions which surrounded them until the mother left were poor.
Conditions at the birth of Albert were reported normal. At nine months he had suffered severely from double pneumonia, from which the running ears developed. At eleven months he walked, however; at sixteen months he “jabbered,” or first used speech of any kind. At two years he was clean. When he was about three and a half, tonsils and adenoids were removed, and at some later time, the boy had three abscessed teeth removed; perhaps this operation was connected in some way with the fact that in one of his tussles with the younger brother he had two of his incisors “knocked out.”
On the disappearance of the mother, a grandmother of the children took the younger boy into her home, but Albert she refused to provide for because he was “different.” He was accordingly placed with a child helping agency, and subsequently, in a foster home of good standing. Here he “caused much trouble?showed terrific fear, was stubborn, whined, cried, spit at visitors, broke all toys, etc. He was afraid of the dark, afraid to go to bed, to bathe, or to go to the toilet. When he was thus terrified he masturbated (but) this condition cleared up. He showed no affection for anyone, spit at anyone who tried to kiss him. He ran into the street deliberately, annoyed children by pushing sticks into their velocipedes.” He threw toys at visitors (including one from the social agency), threw objects at a lamp until he broke it, scratched furniture with his finger nails, and destroyed pictures on the wall. All this was reported by the social worker who placed the child. We had reason later to believe that although Albert misbehaved frequently while in his first foster home, he was particularly bad when this individual was near him. Perhaps the vivid account of his misdeeds was penned by her originally. An attempt at placing Albert in a second foster home was for a time unsuccessful but in a short time in this home his behavior underwent a complete transformation. He “showed no fear of anything in the house, played normally with other children, exhibited nothing but an extremely amiable disposition, was much embarrassed if he broke anything by accident, and learned to talk.” Up to the time when he left the first foster home he had 110 speech. All the above observations on the child were made by the new foster mother, who brought Albert to the Clinic. She stated as evidence of improvement that he could be sent to the store and would bring home an order. In her opinion the problem was one of deafness more than anything else.
Albert was first examined in the Psychological Clinic by Dr. Arthur Phillips, as a mental case. The speech defect quite naturally hindered a maximum performance on material such as the Binet-Simon, but he received an intelligence quotient of 62. He gave a forward memory span of three, but he could give neither a reverse nor a visual span. He was unable to name the primary colors, but matched them and handed the properly colored block to the examiner when asked for it. On the Witmer formboard he was inferior on first trial to only twenty per cent of first grade children, though he dropped to inferior to seventy per cent on the second. He failed the Witmer cylinders. Albert had had, of course, no schooling, but he counted readily to four. Physical measurements indicated nothing abnormal.
The recorder writes in regard to the child’s appearance and personality: ‘’ The little boy though not at first exceptionally prepossessing, was not hard to like. When we tried to take him away from (his foster mother) he refused to go and began to cry and resist. He finally was taken into the office, and there the sobs increased in frequency and volume. One of the female examiners was then put in charge of bringing order out of chaos, and after a final expenditure of energy Albert was taken on her lap, and the sobs gradually diminished… . From then on be became quite willing to work and very cheerful, … a very likeable boy.”
As the result of his examination Dr Phillips placed the boy intellectually in the lowest decile of children of his age, and marked the special disabilities in hearing and in speech. Recommendation was made for examination in the speech clinic, and for training if examination should indicate its advisability.
It was not until six weeks after the mental examination that Albert was brought to the Clinic for speech examination. In this instance he was examined by Dr Twitmyer. As the result of this examination, it was evident that Albert has sufficient hearing to warrant speech training. He ‘’ responded exceptionally well to commands given with the mouth of the speaker hidden from his view. The intonation of the boy’s voice certainly did not suggest total deafness. In clinic he seemed very well oriented socially, played normally with the toys by putting the shoe on the doll and on the right foot and buttoning it. He reacted well to the personnel in the examination room.”
As the result of the speech examination it was recommended that the child receive “clinic teaching for a few weeks to determine whether of not to recommend the special class for the hard of hearing in the public schools.’’
Albert received about five hours of teaching under Miss Margaret Shank, the student teacher who taught Raymond, our first case. A re-examination in May with the use of only the BinetSimon examination indicated the boy’s intelligence quotient to be 67, but slight improvement over that given in January. In regard to this examination the teacher reports, “I think he has a mental capacity higher than that indicated by an intelligence quotient of 67.” She attempted during the hours of her contact with Albert to teach him to say a few words correctly. A meagre apperceptive background in language, exceedingly poor familiarity with words, due in some measure, no doubt, to deficient hearing, contributed toward a general inability to understand language even when he could hear it. When told that A-L-B-E-R-T spelled his name, he learned to make the letters himself on stimulus, but he did not know what name meant. His comprehension seemed poor, yet already he had developed some proficiency in lip-reading, using his visual discrimination in place of the auditory, which quite naturally was defective. The teacher concluded in regard to the child’s speech that the bi-lingual situation in the home of his early years contributed in some measure to the language handicap.
The notes made by Albert’s teacher in respect to his behavior during her contact with him are interesting. She felt him to be efficient, to some slight degree intelligent, well motivated and unexpectedly cooperative and persistent. “In clinic his behavior is quite normal. He is curious, and proud of his notebook and pencil, and he tries hard to learn. When I give him a new word to learn he sticks to it; later when I ask him for it he does not always understand put persists until he gets it or I give him a hint. He is not in the least apathetic or negativistic toward his work. From what I have seen of Albert he is more trainable than educable.” It seemed after even this short contact with Albert that he was in no way feebleminded, and that placement in a class for the hard of hearing was the logical course to pursue.
Our plan was to continue observation with Albert, until we might achieve some definite data on his ability to learn words in speech, and thereby recommend the best course in education for him. Our findings at the end of the term suggested that deafness was the outstanding problem in this case and that the antisocial behavior in response to the first home situation, as well as the general behavior retardation manifest in his response to test situations of various types might be explained on the basis of this deficiency. Certainly he was intellectually deficient, but it was believed that he was capable of sufficient schooling (of an expert sort, of course) to remedy this situation in large measure.
The purpose in presenting these three cases is not in any sense to give a complete picture of the child who is brought to the speech clinic and referred for continued observation in clinic teaching. We have taken three clinical pictures and sought to trace out the differential aspects of each. The first, Raymond, was a child obviously retarded because of infection or cerebral injury, for whom the prognosis was poor. The second case, Sam, was born into a family handicapped mentally and emotionally, whose retardation was complicated, and for whom prognosis was uncertain. The third case, Albert, came to us because of a general retardation and because his educational future was complicated by extremely deficient hearing. We did not feel at the end of the term that we could properly recommend a course for Albert at that time, unless it was for further teaching in the clinic. The prognosis for his case was, therefore, uncertain, though we felt it to be better than for either of the other cases presented here.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.