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Developmental aphasia revisited
Journal ofcommunication Disorders 3 (1970) 181-197.0
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Department of CommunicativeDisorders, WisconsinState Universityat StevensPoint
The article describes a variety of patterns of auditory behavior as well as speech and language behavior expectant of children with developmental aphasia as reported through review of the literature and/or noted by personal observation. 7’he article offers a diagnostic and prognostic key for differential diagnosis.
troduction
To the concern of diagnosticians and habilitators throughout the country there exists a behavioral entity that continues to poke its handicapping head out of the clinic windows and its descriptive features out of the pages of the literature. Mullins (1969) surveyed public residential schools for the deaf in the U.S.A. to note the presence of some aphasic children in two-thirds of the schools. The language learning disability of concern will be referred to in this article as developmental receptive-expressive aphasia. The performance characteristics that mark this condition have been so delineated that they can be described. The above term of choice has familiar synonyms such as “Idiopathic language retardation”, “Congenital auditory imperception with idioglossia”, “‘Word deafness with verbal apraxia”, and “Childhood aphasia”. of concern seemingly challenge what is usually considered a somewhat undeniable propensity for language development. However, in that they still retain the option of responding to a treatment program that usually fosters their language development, the adjective “developmental” is considered an important inclusion in the title in agreement with the rationale of Eisenson (1968). Myklebust (1954) stressed that the adequacy of the expressive language is highly dependent upon the integrity of the receptive language. Thus the presence of output deficits in their mirroring of input disabilities necessitates a descriptive attention to both language functions in the terminology. Whereas expressive aphasics may have several faces (e.g., word finding difficulties, verbal apraxia, syntax building problems, etc.; Johnson
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and Myktebust, 1967) while their comprehension is essential& intact, the receptive aphasics may also have several faces, but have them because .:heir compsehension is not intact. By labeling our case of concern as receptiveexpressive, the implication is that we may see output problems arising from the input disability and/or additive output deficits. The presence of the receptive drsability does seriously influence expressive output unfavorably. A diligent seeker can now select from the often misleading literature those reported observations which frequently reappear anci which show compatible trends in performance. The reported trends strongly indicate the features to be expected of children with developmental receptiveexpressive aphasia. The reports of authorities who have seen a number of these children are usuahy directed toward descriptions of total perfl3rmance. As CarrelI and Bangs (1957) wisely remarked, “.... it seems quite obvious that any language deficit will result in a significant alteration of the child’s total behavior”. However,- two areas of behavior have received sufficient documentation to warrant singling out for individual consideration: namely, (1) auditory behavior, and (2) speech and language behavior in children with developmental receptive-expressive aphasia. Furthermore, the descriptions are clear enough to ahow for the delineation of relatively “pure” performance features for the case of developmental receptiveexpressive aphasia although such purity USWNY yields to modification because of the influence of the multiple handicap of such children who may possess additional complicating features such as the Strauss Syndrome and hearing loss.
Auditw behavior The following symptomatology highlights the auditory behavior of children with developmental receptiveexpressive aphasia. Some of the features are compatrble and appear together. Others are not compatible and seldolm unite to characterize the same clients. In other words, not all features appear in all cases and the particular clumping of features tends to mark the nature of the client and his prognosis. Consistent respotzseto environmental noise Ssme children clinically identified as experiencing developmental recept-
iveexpressive aphasia respond consistenly to environmental sounds as they demonstrate excellent recognition of the sources of familiar noises in their s~~ou~d~~~ Morley et al. (193, Landau et al. (1960), Rappaport (1965), E&%son (1968) represent authorities who have supported the existence of auditory integrity for general sound through statements or case reports. St& chiJdren establish an auditory recognition o:Shousehold sounds like the WrbeQ,the hum of an electric shaver, the toaSter’s6Cpop-up”,the whine of
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the vacuum cleaner, etc.; outr’oor noises as those made by horns, airplanes, whistles, lawn mowers, etc.; and animal vocalizations as those of the dog, cat, pig, horse, etc. Consistent response Popure tone stimuli Some children with developmental receptive-expressive aphasia respond well to traditional pure torte audiometry and play, audiometry and display normal or near normal hearing sensitivity. Morley et al. (1955), Landau et al. (1960), Goldstein et al. (1958), and Karlin et al. (3965) typify those who have observed such behavior. These children experience little difilculty conditioning to the audiometric tasks and they use their hearing projectively to scan their surroundings and to maintain auditory contact. McGinnis (1963) described such a subgroup of aphasic childrcq who respond well to audiometric conditioning offering consistent and fairly reliable responses but who have slightly defective hearing. The audiologist finds that these children pose few problems during the hearing evaluation. Inconsistent suprathreshold response to pure tone stimuli A mofe typical performance during pure tone audiometry is characterized by inconsistent suprathreshold response patterns. More than likely there is an actual mild to moderate reduction in hearing sensitivity in such cases. However, because exact threshold determinations are difficult, suprathreshold responses are often obtai;ned. Froeschels (1949), Myklebust (1954, 1957), Morley et al. (1955), Carrel1 and Bangs (1957), Goldstein (1965), Goldstein et al. (l958), Landau et al. (1960), Monsees (1961), Taylor (1964), Rappaport (1965), De Hirsch (1967), Stein and Curry (1968), and Thomas (1969) have reported the unreliability of pure tone audiometry with these children due to erratic, inconsistent thresh01 responses and/or some reduction in hearing sensitivity. Eisenson (1968) remarked that whether or not the child responds with an actual reduction in hearing acuity, he does evidence a perceptual impiirment in audition - a difficulty in the physical reception of sound. Some authorities such as Rappaport (1965) report the test-retest fluctuations in threshold as ranging from normal acuity to profound hearing loss. McGinnis (1963) states that most sensory aphasic children have some deficit in hearing and poor response to hearing test situations often negates the determination of hearing levels. Thresholds are rarely considered valid with confidence because of inconsistencies in test responses. “Tuning in” to the abstract pure tone stimulus in the soft intensity zone of from 0 dB to 30 dB seems especially difficult for such children even when they understand the task and are cooperating. They may show difficulty of similar nature in receiving familiar speech stimulus for the determination of the SRT. The fact that they can hear softer stimulus than the audiometric results indicates is possible is evidenced by response to at least a few meaningful environmental nOiSeS.
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Van Arnold (1959) and Johnson and Myklebust (1967) emphasize the phenomenon in which there is a frequent time lag between auditory sthullation and patient response in such children as they stress the necessity of repeating the same SthdiJs several times and/or for longer presentation bursts. Listening itself taxes their patience and seem very demanding and they fatigue e&y. A. conditioning program that extends over a number of short sessions is requisite for threshold determination. Talylor (1964) remarked that in the severely affect;&* young cases it is possible to obtain responses by distracting techniques L-Yiy, never by performance tests of hearing (audiometric). Johnson and Myklebust (1967) offer an explanation for the failure of such children to respond to pure tones in their discussion of the concept of auditory agnosia. For such children all but the loudest of pure tone stimulation remains too abstract to elicit meaningful associations between the audiometer and its noises and their resultant auditory-motor responses. The same child who does poorly in “tuning in” to ongoing pure tone presentations for the establishment of thresholds. will probably also display the following characteristic. Inatten tiun to environmental sounds The child with auditory agnosia experiences an auditory inefficiency Over
and above what may be expected from audiometrically determined !heakg 10s. He responds inconsistently to environmental sound and has marked restrictions on his projective use of hearing. The implication for these children is that they can hear but are unable to interpret that which is heard. The child is seemingly unable to structure his auditory world and to sort out and associate sound with particular objects and experiences. His attention to common environmental sounds, such as animal vocalizations - the noises of household appliances - and the auditory experiences of familiar outdoor noises, is highly inconsistent. The associative link between noise sources ad their products seemingly is never established. Taylor (1964) comments that these children show distinct difficulty in responding to auditory signals if their vision or hand manipulation is engaged. Myklebust (1954) seems to be describing children with developmental receptive.expressive aphasia with general auditory agnosia when he states that awditc
emphasizesthe feature of
to loud backgswnd noise ‘md ‘bunawakednessYp. Not absent from the case history report nor the observations made in the clinic setting is the notation that the ental receptiveexpressive aphasic earl hear and may res e sound of soft intensity (or one suprathreshold to a mild to moderate hea:-ing loss if they have one) out of curiosity when ignoring loud highly familiar sounds. Such childrenmay also have made a few auditory associations like recognition of their name and respond to it when it is used in verbal manding. Or they nlay show consistent response to a plane roar or train whistle that is so far in the distance as to be a stimulus of soft int.:nsity. Such behavior natur,llly perplexes the parents but also gives them the feeling that thei:. child possesses somewhat normal hearing sensitivity. A “voice and noisemaker” approach tends to demonstrat,.: their inattentiveness to voice that is directed toward them as well as their lack of integrative perception (auditory imperception?) of a variety of object produced so1mds. Johnson and MyMebust (1967) have described such children as looking ciazed at times even to stimulus such as their names. Their lack of i
iattentiveness
eech. VOW Arnold (1959) called their inattentiveness
response to many ongoing dynamic sound experiences certainly is .the behavior trait that often leads to the false labeling of deafness. Their lack of response to an examiner’s auditory stimulation may be viewed as a purposeful “ignoring” of the sound after it is established that near normal acuity is
available for use. In 1959 Hardy and Pauls posited the following explanation fluctuating hearing behavior of children with aphasia:
for the
....an aphasic child in early infancy may have shown clear auditory orienting rn and remember verbal symbols, reflexes, but later, not being able naturally to may have inhibited the reception of SW commonly enough ali sound, environmental as well as verbal. . ...The problem ,..... is not that they do not hear. The problem lies at a higher organizational level, an inadequacy in memory for the symbols of sound and a resultant failure in ordinary reflexive responses to sound of any kind. It may well be that these children learn “not hearing’ 3s 3 kind of defense . ... ..to a confusing world. If the developmental aphasic’s experience with sound has been unsuccessful he may begin to ignore sound and reject it as a worthwhile stimulus. The case reported by Stein and Curry (1968) was followed longitudinally through
childhood into youth. An early history of normal audition reportedly yie.lded to a hearing loss due to brain damage at age 3. Surprisingly, after a number of years of being reportedly “deaf” a “return of hearing” was noted at 10 years of age. The authors felt that the “deaf period” was a defensive period of sound rejection which relieved the child of the need to handle the cacophony of au&tory stimuli around her which had resulted from her experienciq of au&tory agnosia. Over the time involved the need for such a defense
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apparently dissipated. The auditory agnosia con~tinu?d at the age of 22 and was typified by inability to recognize many nor speech sounds such as noisemakers and animal sounds. Eisenson (1968) acknowledges the possibility of a psychological barrier to learning in such children in the form of perceptual defenses. The child may generalize his perceptual defenses against speech signals, which are beyond his coping ability at a given stage of development, to all environmental sound. A child who has developed such defenses needs to be and can be enticed back to sound. Summary on auditory behavior ln man!,!of the chikiren of concern there thus appears to be an auditory receptive deficit that is far more encompassing and is of far greater magnitude
as a disabling effect than the inability to comprehend words. The auditory agnosia, when present, is an auditory irnperception for sound in general. When a child experiences a failure to establish a receptive and interpretive structure or internal organization for handling the bombardment of his complex auditory world he may defensively reject the meaningless sensorium which he views as unmanageable. Interestingly, most of these children respond to the structured auditory training of a clinic program and gradually establish luditory associations and recognitions toward the elimination of much of the auditory agnosia. The fact that most of the children can learn to respond to environmental sound under therapeutic guidance attests to the psychoper ceptual nature of their disability. Apparently, behaviorally as well as theoretically, receptive aphasia can stand alo re as a specific agnosia for heard verbal symbols in a child who is free of tfre general auditory agnosia. He functions normally by projectively using his auditory environment and he can respond well to the audiometric experience. More expectant, however, is the more general psychoperceptual disability of general auditory agnosia which more seriously disables the receptive aphasic in that ,here seems to he little internal organization available for coping with any kind of sound. Many of the developmental receptive-expressive aphasics are characterized by the learning barriers mherent in auditory agnosia.
Speech-language hr Lavior Ewing (1930), McGinnis (1963), Taylor (1964), Hardy (1965), Rappaport (1965), De Hirsch (1967), Johnson and Myklebust (1967), and Eisenson (1968) are among the leading authorities who consider the heart of the problem of children with reqtiveexpressive developmental aphasia as being a severe disability in the comprehension and usage of the language system.
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Thus the communicative disorders inherent in the psychoperceptual problems of mastering symbolization arid speech motor patterns also eserve attefitioj~.
ceptive language Limited comprehension of verbal symbols The preschool aphasic demonstrates little understanding of verbal symbols.
He does not associate words with their referent objects, actions, or quAties and thus does not respond to the basic noun names of common items, the verb names of familiar actions, nor the adjectival and adverbial modifiers when they are referred to directly before him. In turn the functional u.tility of common prepositions eludes him. His lack of response in the play or evaluative situation to the examiner’s naming behavior suggests that he does not hear the names or is not aware of the fact that the intent of the verbal activity is to elicit identification behavior on his part. He doesn’t move to point out the named item to acknowledge that he knows the name in this condition of “word deafness”. Myklebust (1954) attributed the condition to marked difficulty in integrating and interpreting the auditory impressions of words. De Hirsch (1967) considers the lack of understanding due to a poorly structured percejptual field in which words do not stand out from the mass of unorganized stimuli impinging on the hearer. The configuration of the word, as well as its meaning, appears to be so unstable as to never become familiar. Eisenson (1968) suggests that the inability to process speech signals results from inability to deal with linguistic signals because of storage, discrimination, rate, or sequencing problems. Regardless of the cause, the preschool a sic demonstrates a unique ghly familiar and frequently inability to recognize most of what should b heard words as they are directed toward him relative to a select group of such items before him. Verbal comprehension, if there is any rece at all, is so limited as to be non-functional for even primitive communicative interaction. Limited comprehension of verbal directives
Directives might as well not be spoken for the preschool aphasics are not cognizant of the intent nor the message. Even when their interactive attention is captured and they are seemingly listening to the clinician’s simple verbal commands, such as “Stand up”, “Sit down”, or “Open the door”, they fail to respond. Even after they have registered some receptive and possibly expressive vocabulary of nouns and verbs they evidence difficulty in meaningfully linking the syntactical significance of the two parts of speech and responding to the intended directives. The longer the linguistic unit directed
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toward them, the greater their difficulty for they do not seem able to differentiate the mea&g units involved nor sense their SyntaCtiCd functions. The difficulty in processing speech signals in linguistic events that are temporal and spatial increases as the length of the linguistic units increases (De Hirsch 1967; Eisenson ( 1968). Bangs (1968) states that the young child may learn to perform well regarding hi: understanding of single words, yet he performs below age level when the examiner uses these known words with function words to present a task. If the child is asked to put the spoon in the cup, he will probably not be able to comply, for although he knows the meaning of “cup” and “spoon” he is unable to comprehend the total directive and its message. A further characteristic feature of these children is their blank stares indicative of having not understood the directive or their nodding for ‘yes” as if they had been asked a question rather than given a directive. The case reported by Landau et al. (1960) failed to learn to comprehend any but the most familiar expressions when spoken at a normal rate. He comprehended ora! language best when it was spoken slowly, with a definite pause after each word. A case described by Morley et al. (1955) reportedly failed to learn to understand speech beyond a few words as his receptive vocabulary was very restricted in his fifth year. Johnson and Myklebust (1967) report on the subtle difficulties of even the less severe cases who struggle with the receptive mastery of adjectives and related descriptive words as used in context, Unless they are taught in context, words representative of qualities as characteristically related to objects - feelings - and experiences, such as “big”, ‘“hard”, “soft”, “sharp”, etc., are received as if renamings of the “knife”, “pillow”, “rock”, etc., tha; are involved. The meanings of a word such as “cover” that represents an object ti one context and an action in another are most difficult to master receptively. Some aE,ililyto learn to comprehend
In spite of apparent restrictions in learning that are inherent in the condition of developmental receptiveexpressive aphasia and the subtle if not great symbolization problems that may be insurmountable, these children evidence some ability to learn to comprehend linguistic units. The files of the Aphasia Division of the Central Institute of the Deaf, The Northwestern Institute of Language Pathology, and The Pathw.4~ House, among other clinics that see such children in sizeable number, attest to this fact. Although learning to comprehend may be slow and tedious, some progress is relatively certain for the mjority of the cases. Jo-n and Myklebust (1967) sygest that as these children grow older and have been exposed to and respond to a training programthey may grasp simple words such as noun referents to key concrete high& familiar objects
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but evidence greater diffict&y acquiring words that represent actions, qualities, feelings, or ideas. ‘n a training program the instiUment of the concepts of verb action, modifiers, or prepositional concepts of direction, location, time, etc. may be most difficult. When (1965) reminds of the inability of these children to respond spontaneously in their reception of verbal requests due to their difficulty in retention and recall and conceptual difficulty in transferring what has been practiced and supposedly learned in one situation to another. Early receptive responses to sentenced directives have to be very structured and have to be guided from one structure to others to establish transfer abilities. any one viewing the film demonstration of the McGinnis Association of all struck with the need for a repeated exposure of these simple directives like “Come, Joe”, “Sit down, Jerry”, “Bill, Stand on the line”, etc. The clinician often notes in the training process that involves a number of directives and language units that the developmental receptiveexpressive aphasic may be trained to respond to a high level of consistency within one structuxd receptive language situation with directives specific thereto. But the same child breaks down in his ability to comply when the same directives arc transferred by the clinician to another language unit. That is, the child seemingly learns to manipulate the “eating utensils” by certain commands with accuracy in the structure of that set of materials but when the same commands are then presented for the unit on “Vehicles” it is like starting all over. After considerable training the child may be viewed as functioning commendably in certain structured situations as he receives and responds from session to session with high consistency. Yet approach him in the waiting room where the situational cues of the materials of the language units are not before him and he may fail to comprehend the simplest directive or question. Possibly this phenomenon is be explained as due to the child’s an a few alternate linguistic inability to cope receptively with more structures at a time. Seemingly his comprehension problems and speech processing inadequacies are so great as to negate reception of all but a restricted set of directives in all but the most structured verbal situations where he senses that the command can and will be one of a select and limited number of verbal alternatives. The receptive comprehension of the child who does SO well in the structured situation - perhaps with the aid of reading the structural pattern of the directives of concern - often seemingly regresses to little more than a noun or “noun-plus-verb” comprehension when away from the structured session. Taylor (1964), Ewing (1930), Johnson and Myklebust (1967), Stein and curry (1968), and Eisenson (1968) have alluded to the possible superiwity in reading ability (visual response to the written directive) over their response to au&tory symbols and syntax although there is no assurance that the cmd will be free of dyslexic handicap.
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Expressive speech and language behavior When the receptive integrity for speech-language comprehension is disturbed developmentally, there seems to be agreement that there will be a mirroring of the receptive deficits on the expressive side of language behavior. Certainly there are expressive {deficits,however, such as verbal apraxia, that may exist above and beyond those resulting from the receptive problems to further complicate the learning of expressive language skills. The literature suggests that the following resultant subgroups of speech-language patterns can be expected in children with developmental receptive-expressive aphasia. Speech as used in this article will refer to articulatory performance and the general intelligibility of the oral language. Muteness
McGinnis (1963) discusses, this small subgroup that offer infrequent vocalizations. The silent type, they seldom vocalize. The educational prognosis is not gocd for this group who seemingly have never sensed the utility of a ianguage system or have found it impossible to cope with and master to any extent. They have even rejected vowel-like vocalizations for projective use to draw attention and make their desires known. They may never attain the goal of speech if there is too great a time lag in receiving the teaching suited to their needs. From a psychoperceptual viewpoint they may choose to withdraw from verbal interaction because of the frustration resulting from inability to cope satisfactorily with the language system. Their social interaction may ‘be superficial as it is limited to head nodding and quietly standing back and watching what’s going on. Urge oj’jmgon or scribble speech
McGinnis (19153), in her description of the nature of the jargon in this group of children, stated that although perseverative patterns predominate there is other vocal activity. The rapid and abundant vocalizations resemble a recording that is run at too high a speed. Expectant patterns of voice quality and inflection te:nd to be imitated. McGinnis refers to these children as the group with motor aphasia with the vocalizations being limited to staccato vowels, occasional consonants, or to syllables consisting of lingual dental or lingual palatal c:onsonants combined with vowels, Some children use the speech patterns freely and keep up a constant chatter of perseverative patterns in attempted conversation; others limit their use of speech patterns to requests for something they want. In that they appear to be using their speech projectively and thus purposefully, interest shown by the listener will encourage continuation of tlhe vocalizations, while indifference will discourage further attempts to communicate. Some of these children cannot imitate in isolation the sounds they use in then random vocalizations. The Patterns used my in no way resemble the words they are trying to say.
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Carrel1 and Bangs (1957) ark? Taylor (1964) report c;,ses whose speech was jargon in nature. Eisenson (196’8) suggests that the child who produces jargon may well hear jargon. He may transpose speech sounds because he is unable to keep the order of sounds in mind. A child who cannot sequence sounds is impaired for learning to understand language and so to speak. Johnson and Myklebust (1967) view the expressive verbal apraxic deficit as an inability to coordinate the auditory-motor patterns for speaking. Such children have not learned and will experience difficulty in learning to coordinate the acoustic products or effects with the respective articulatory gestures. The association between oral acoustic output and the acts of speech articulation that lead thereto is not established. Pronunciation remains distorted - with a slow tedious progression with training from great distortion to subtle distortion - until the speech motor pattern is fully established. Willful appropriately directed and controlled movements of the articulators for the articulatory gestures seemingly are not known or alre very poorly remembered. The child’s attempt to repeat words is marked by struggle a. Id articulatory inaccuracy, substitution, and general lack of distinctiveness. Pattern non-retention yields speech distortion that is further complicated by sound transpositions and sequencing difficulty. The auditory memory span problems and difficulties for judging word succession and order are slowly being indentified by research effort (Monsees 1961, Lowe and Campbell 1964, and Stark 1967). Morley et al. (1955) found that 7 of 15 aphasic children experienced articulatory apraxia. The child described as possessing “scribble speech” by Landau et al. (1960) was usually devoid of actual words. He could imitate short words but it was evident that he did not know their meanings. His attempts to imitate phrases and sentences resembled the original only in rhythm and inflection. Carrel1 and Bangs (1957) comment that frequently the speechless child uses grunts, noises, cries, and o er undifferentiated vocalizations, sometimes to attract attention or make his desires known, but often for ~10observable reason. While communicating via scribble speech such children emphasize what they are trying to say b), gestures and facial expressions which seem to be appropriate to their message and which are sometimes surprisingly complex. Usage uf jargorzinterspersed with inteiligible words or phrases McGinnis (1963) suggests that this expressive condition is either a milder form of the problem or the children are beginning to use the words they have learned via repeated auditory exposure. As vocabulary increases there is less and less jargon. Rappaport (1965) reports cases whereby meaningful speech was utilized by the aphasic child in the therapy setting after therapeutic training. However, spontaneous usage was not achieved outside of the therapy setting. De Hirsch (1967) comments that even the speech of these children
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may be severely hmited in quantity, crude, and undifferentiated in quality. Lennenberg (1964) comments on the primitiveness of their utterances. They simplily blends, telescope words, and their verbalizations are only crude approximations of the correct model. Worster-Drought (1943) stated that even when speech is developed in such children the quality is monotonous, toneless, and indistinct. Johnson and Tavalla (1945) as cited in CarreB and Bangs (1957) observations included rnon.,tonous inflections, Some elements of perseveration in sounds at the beginning and ends of words, reversals of sounds and lack of syllable division or accentuation which added to the impression of monotony in the speech. McGinnis (1963) suggests that the problems in memory for sequencing sounds to compose and articulate words (even after articulation of individual sounds is mastered) hampers expressive word mastery. Later in the training program such children experience similar difficulty in the word order sequencing necessary for using sentences. Structuring is necessary to surmount these organizationu hurdles. Some of the cases possess or acquire normal speech inflectional patterns - others lack normal cadence. Johnson and Myklebusi (1967) suggest that it is characteristic of these children to forget how to produce a sound or a word that their teacher would think they had well registered. Relative to words for which the motor pattern is nearly established but not totally automatic, they sometimes forget how to start the word and there seems to be an inconsistency in the availability of the pattern for use. A verbal, visual, or auditory preparatory set or prompting may be all that is necessary to refresh their memory. Relative toi the difficulty in learning, Taylor (1964) states that a S-year-old aphasic seen by him needed to relearn phrases and words that she had appeared to kraow at an earlier date. The 3-year-old aphasic may not have more than several reappearing and meaningful words that are linked with their referents, By age 6 his expressive vocabulary may remain very restrictive with the words unintelligible to anyone outside the immediate family. He may have or may not have responded to the inflectional patterns of voice and the prosodic features of sentence utterances. Even when a verbal apraxic factor is absent, a semantic aphasia or syntactical aphasia may be further complicating aspects of the expressi1.e meffciency of the developmental receptiveexpressive aphasia. The case described by J-andau et al. (1960) learned a vocabulary of 175 words in one Year, correct simple sentences in two years plus reading and writing, and some functional language in three years of chnical therapy. The child described by orleY et al. (195% developed phrases in the 5th year. His speech consisted of a small number of words, and phrases which were often noun equivallents, e.g., “sit on” = chair, -cut it off’ = scissors, and “goes up in air” = airplane. Eisen~n 1(19a) sees the acquired language as characterized by an absence
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Of conventional grammar - a deviation from developmental norms. When finding difficulties sf a semantic or dysnomjc a ect of language disabW are involved, perhaps in the ;hewe of the apraxja, the mental search&i for cmmon names of actions, objects, qualities,, etc., i.e., the substantive words, is characteristic. ‘The retreival problem may show it self in the child’s response to such st i as the picture cards of the articulation test and the hesitations marl, e searching behavior. A use of demonstrative and personzd pronouns *b “that”, “there”, “‘those”, “he”, “she”, “it”, and “they” in termingled me function words of jargon may allow for an indirect reference that is often deceiving. In class responses can be expected such as “knife” for “fork ’ and “toe” for ‘( ger”. hey may display over a period of time the inconsistent availability of common words having them one week but not the nt . However, by and large, once registered, words are available to them. heir articulatory accuracy may fluctuate considerably and much practice in speech motor patterning is necessary o keep the words acceptably int:lligible. It is possibly characteristic of the developmental rece aphasic to be so involved expressively as to negate the identification of the extent to which underlying aspects of syntactical aphasia will hinder the learning of complete linguistic utterances of even 2 or 3 words later on.?hat is, the child has not advanced beyond the naming level and has such a restricted vocabulary that he has not reached Ypoint in development where the syntactical errors have had a chance to show their faces. A most outstanding characteristic of many of these children is an inability to acquire functional expressions of even phrase length or noun-verb combinations probably for the reason of inadequate retention integrities for the word ordering and sequencing concerns of the longer linguistic units. The same problems that prohibit learning to corn rehend directives undoubtedly function to interrupt the learning of even the simplest expressive verbal utterances. Even in the children who imitate single words well the generative inadequacies are vividly demonstrated by their inability to repeat 3 and 4 word expressions with a clarity of articulation and a cadence that suggests that they are saying meaningful sentences. Their own retention (for later spontaneous usage) of sentence structures that have been repeatedly practiced in therapy seems lacking. Some cases who can orally read from the blackboard do so with great effort and articulatory distortion as visual stimuli seemingly facilitates recall of the rrecessary articulatory gestures for producing words and longer linguistic units. However, at moments away from the therapy session in which the same utterances would have great utility for them, they experience such frustration in unintelh@ble pronunciation and in improper word inclusion and ordering as to withdraw from the attempts. Their psychoperceptual awareness of their communicative inadequacies may markedly restrict their spontaneous offermg of verbal utterances outside of the clinic therapy setting.
word
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Echoldic repetition The last group demonstrate repetitions of words without association of maaflbg_ They repeat words and phrases while attaching no meaning and are
viewed as echolalic or using parrot speech. Some of them ShOWthis ability at an early :kgeand o&n vocalize infrequently before teaching for articulation is begun. They then show an ability to imitate words, phrases, and even sentences commensurate with their memory spans. Johnson and Myklebust (1967) report case types that are echolalk W;lO merely repeat what they hear without understanding. ‘The implication is that they do not comprehend the words but acknowledge some reward for their participation in tb.e parrot act. Rappaport (1965), McGinnis (1963), and Karlin et al. (1965) state that the child demonstrates the limited ability to associate names with objects or to interpret or use environmental language. Wilson (1965) attributes the inability to difficulty in retention and recall of symbols and, conceptually, a difficulty in transferring what has been learned in one situation to another. She states that the sensory aphasic often echoes words, phrases, or even sentences and that prognosis fior such children is poor for it is harder to get through to them. Eiseqson (1968) remarks that the articulatory inaccuracy of many of their repetitioqs results from the fact that they may be able to imitate speech signals only if there is no delay period for imitation. They may have difficulty identifying the auditory speech signals and keeping their order in mind. The accuracy of their immediate auditory-motor recall which is on an automatic rather than conceptual and thus symbolic and representational level is often deceiving, for it suggests ease of learning when that is not the case. The ease of repetition does indicate freedom from verbal apraxic difficulties bu.t word registry in any form of language memory bank apparently does not occur. The echoic repetitions do not seem to foster skills for an auditory recognition of the words next time they are heard nor does the act of repeating equip them with appropriate speech motor patterns for naming at a later date. Summaly of speech-languagebehavior
Thus when initially contacting the preschool child with the behavioral entity considered in this article, the developmental receptive-expressive aphasia, the diagnostician will be faced with a stark but not necessarily foreboding picture of an essentially non-verbal child. The examiner’s attempt to measure the child’s receptive integrity for word recognition at even the naming level of language behavior will be met with a paucity of meaningful responses. The examiner’s naming of most common items will fail to evoke all but occasional identification behavior from the child. The addressing of directives relative to test materials or to the manipulation of doll people and miniature furniture in even an informal play setting will quickly demonstrate an absence of specified responses that challenges the differential diagnostician.
The training task is a mar tlmental and tedious one because of the apparent lack of a natural propensity for the learning of language. Resistances inherent in the condition make learning difficult and the prognosis guarded for establishing a completely. functional communication skill. ecause receptive language skilh as gained are viewed a reflection of the internalization of a language system, expressive language skills seldom excell over receptive skills. USUdY, but notalways, if a child fails to comprehend a word or a directive it is unlikely that he will turn around and use it spontaneously. The establishment of an associative linkage between words as heard and differentiated events and the combined speech motor patterns that produce them seems to be the foremost task of the training program for words do not easily take on a synesthetic sensory-motor image for these children. hether auditory imperception or speech signal processing deficits are the ba problems or are coupled with further complicafing image retention and/or sensory-motor apraxic components, the heard words as dinstinctive acoustic events must be somehow linked in the training process with the movements of the speech mechanism as combined articulatory gestures and that association must be long term and readily available. By fighting that inherent weakness these children can learn an expressive vocabulary and patterned utterances of combined words, but the articulatory proficiency - prosody - and grammatical accuracy and completeness of their vocalizations are difficuh to bring to a functional smoothness. Depending upon how well they learn to comprehend all the semantic and syntactic subtleties of connected discourse as well as their freedom from underlying and further complicating expressive deficits such as verbal apraxic and syntactic sentence building problems or mastery thereof, they may or may not become effective members of a verbal community. The case presented by Stein an Curry (1968) demonstrates the unfavorable alternative, i.e., joining a deaf society or equivalent course of action, that may be chosen by many of these children later in life unless their educational assistance begins early and is continued in a concentrated and extensive program of habilitation. Thomas (1969) nicely sums up the prognosis for the severe condition of language disability considered in this article: “After more than ‘25years of de&g with th.is condition I know that sheer plodding, flexibility of ideas for daily treatment, and belief in success are essential and, much as one might wi& it, there is unlikely to be a magic wand method for obtaining fluency and communication at a rapid rate.”
eferences Allen, I., 1952, The history of congenital auditory imperception. /vev Zealand Medical J. 51,239-247.
_. a
50n, J., 1968, Developmental aphasia: a ~~~~t~~ tien\. .f. Speech Hearing5is. 33 p 3 - 13. A.w.C., 1930, A$IQS~U in children. New I’m
v
FI-Q~~~&s,E.. 1949, Pure word-deafness in a child. 22S-240. G&&t&n, R., 1965, Discussion of aphasia. In: &_@e?eatialdkgnoris. Volume II, edited by S. Gddstein.. R., WM. Landau and F.R. Kleffner. 1958, %eu deaf and aphanc children. The Annals of Otdofl. fZhin 468-4179. HZ&~, W.G., 1965, On language disorders in young cbildrw; a thinking. 1. Speech Hearing5is. 30,3- 16. Hardy, W.G. and M.D. Pauls, 1959, Atypical children with c~~~ tier diwrders. Children 6,13- 16. Jansky, J., 1960, Congenitally word deaf children. Masters Thesis, C New Yark. Johnson, D.J. and H.R. Myklebust, 1967, Leaming disohidiries.New Y Stratton. Johnson,‘M.L. and N.M. Tavella, 1945, lmperception audlrtiva coq&ta asor congenital) con illustration de un case complicado con sor&zra Argentine s/de Pediatria,23-25. Karlin, I.W., 1951, Congenital verb&auditor)l agnosia (word deafrzssll. 60-68. Karlin, I.W., D.B. Karlin and L. Gurren, 1965, Development and ch in of childhood. Springfield, Ill., Charlcc C. Thomas Publisher. Landau, W.M., R. Goldstein and F.R. Kleffner. 1960, Congeniid sph 915-921. Lowe, d. and R. Campbell, 1964, Temporal discrimination in aphas&d and normd children. J. Speech HearingDis. 8.313-315. hlc(;infiS, M.A., 1963, Aphasic children, Washiyton, AlesiPnder crah;un B&I Awiation for the deaf, Inc, MoDsees, E., 196 1, Aphasia in childtcn. J. Speec/t ffeaeng nis, 26.8 Moth’, M., D. Court, H. Miller and R.F. Carside, 1955, &?hw and P mental aphasia. l-WishMedicalJottrttuj2, 463-467. Mullins. J.B., 1969, Provisions for aphasic children in public m&au wh&s for the deafinthe United States. Amer. Amals oftjle 5eaf 114,64._7~. MyklebW Ii% 1954, Auditory &so&x Bt clri&qr, hew Yo&, Gmnc and Stratton. Myuebust, H.R.5 19% Langul~c training: u comparison kwm chfthn 0~5thaphasia and those with deafness. Arrrcri~+~rr Anrl& o~q 101, 24g-244.
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Myklebust, H.R., 1957, Aphacr; in children - diagnosis and training. In: Handbook uf speech pathology, edited b? L. Travis. New York, Appleton, Century, Crofts, Inc. Grton. ST., 1937, Reading, wiring, and speech problems in cltkkn. New York, W.W. Norton&Company, Inc. Rappaport, S.R., 1965, Childhood aphasia and bruia damage: differential diagnosis, Volume 11. Narbeth, Pa., Livingston Pubhshing Company. Stark, J., 1967, A comparison of the performance of aphasic children on three sequencing tests. J. Communication Dis. 1, 3 I- 34. Stein, L.K. and K.W. Curry. 1968, Childhood auditory agnosia. J. Speech ond Hearing Dis. 33, 361-370.
Strauss, A.A., 1954, Aphasia in children. Amcr, .I. Physical Med. 33. 93 - 99. Taylor, I.G., 1964, The neurological mechanism of hearing and speech in children. Washington, The Volta Bureau. Thomas, M.E., 1969, Assessment and treatment of receptive and cxupressive aphasia in identical twin boys. British 3. Dis. Communiration 4. 5 7 -63. Von Arnold, G., 1959, Llber Zusamrnenhange von zerebralen Ilijrstijrungen und Horstummhcit. Folia Phoniutrico 2, 12.-22. Wilson, L.F., 1965, Assessment of congenital aphasia. In: Childhood aphasia and brain damage: differential diagnosis. Volume II, edited by S.R. Rappaport. Narbeth, Pa.. Livingston Publishing Company. Worster-Drought, C., 1943, Congenital auditory imperception (congenital word deafness) and its relationship to idioglossia and allied speech defects. Medicul Press & Circular 210,411-417.
hl&
~fojlvld
Department of CommunicativeDisorders, WisconsinState Universityat StevensPoint
The article describes a variety of patterns of auditory behavior as well as speech and language behavior expectant of children with developmental aphasia as reported through review of the literature and/or noted by personal observation. 7’he article offers a diagnostic and prognostic key for differential diagnosis.
troduction
To the concern of diagnosticians and habilitators throughout the country there exists a behavioral entity that continues to poke its handicapping head out of the clinic windows and its descriptive features out of the pages of the literature. Mullins (1969) surveyed public residential schools for the deaf in the U.S.A. to note the presence of some aphasic children in two-thirds of the schools. The language learning disability of concern will be referred to in this article as developmental receptive-expressive aphasia. The performance characteristics that mark this condition have been so delineated that they can be described. The above term of choice has familiar synonyms such as “Idiopathic language retardation”, “Congenital auditory imperception with idioglossia”, “‘Word deafness with verbal apraxia”, and “Childhood aphasia”. of concern seemingly challenge what is usually considered a somewhat undeniable propensity for language development. However, in that they still retain the option of responding to a treatment program that usually fosters their language development, the adjective “developmental” is considered an important inclusion in the title in agreement with the rationale of Eisenson (1968). Myklebust (1954) stressed that the adequacy of the expressive language is highly dependent upon the integrity of the receptive language. Thus the presence of output deficits in their mirroring of input disabilities necessitates a descriptive attention to both language functions in the terminology. Whereas expressive aphasics may have several faces (e.g., word finding difficulties, verbal apraxia, syntax building problems, etc.; Johnson
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and Myktebust, 1967) while their comprehension is essential& intact, the receptive aphasics may also have several faces, but have them because .:heir compsehension is not intact. By labeling our case of concern as receptiveexpressive, the implication is that we may see output problems arising from the input disability and/or additive output deficits. The presence of the receptive drsability does seriously influence expressive output unfavorably. A diligent seeker can now select from the often misleading literature those reported observations which frequently reappear anci which show compatible trends in performance. The reported trends strongly indicate the features to be expected of children with developmental receptiveexpressive aphasia. The reports of authorities who have seen a number of these children are usuahy directed toward descriptions of total perfl3rmance. As CarrelI and Bangs (1957) wisely remarked, “.... it seems quite obvious that any language deficit will result in a significant alteration of the child’s total behavior”. However,- two areas of behavior have received sufficient documentation to warrant singling out for individual consideration: namely, (1) auditory behavior, and (2) speech and language behavior in children with developmental receptive-expressive aphasia. Furthermore, the descriptions are clear enough to ahow for the delineation of relatively “pure” performance features for the case of developmental receptiveexpressive aphasia although such purity USWNY yields to modification because of the influence of the multiple handicap of such children who may possess additional complicating features such as the Strauss Syndrome and hearing loss.
Auditw behavior The following symptomatology highlights the auditory behavior of children with developmental receptiveexpressive aphasia. Some of the features are compatrble and appear together. Others are not compatible and seldolm unite to characterize the same clients. In other words, not all features appear in all cases and the particular clumping of features tends to mark the nature of the client and his prognosis. Consistent respotzseto environmental noise Ssme children clinically identified as experiencing developmental recept-
iveexpressive aphasia respond consistenly to environmental sounds as they demonstrate excellent recognition of the sources of familiar noises in their s~~ou~d~~~ Morley et al. (193, Landau et al. (1960), Rappaport (1965), E&%son (1968) represent authorities who have supported the existence of auditory integrity for general sound through statements or case reports. St& chiJdren establish an auditory recognition o:Shousehold sounds like the WrbeQ,the hum of an electric shaver, the toaSter’s6Cpop-up”,the whine of
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the vacuum cleaner, etc.; outr’oor noises as those made by horns, airplanes, whistles, lawn mowers, etc.; and animal vocalizations as those of the dog, cat, pig, horse, etc. Consistent response Popure tone stimuli Some children with developmental receptive-expressive aphasia respond well to traditional pure torte audiometry and play, audiometry and display normal or near normal hearing sensitivity. Morley et al. (1955), Landau et al. (1960), Goldstein et al. (1958), and Karlin et al. (3965) typify those who have observed such behavior. These children experience little difilculty conditioning to the audiometric tasks and they use their hearing projectively to scan their surroundings and to maintain auditory contact. McGinnis (1963) described such a subgroup of aphasic childrcq who respond well to audiometric conditioning offering consistent and fairly reliable responses but who have slightly defective hearing. The audiologist finds that these children pose few problems during the hearing evaluation. Inconsistent suprathreshold response to pure tone stimuli A mofe typical performance during pure tone audiometry is characterized by inconsistent suprathreshold response patterns. More than likely there is an actual mild to moderate reduction in hearing sensitivity in such cases. However, because exact threshold determinations are difficult, suprathreshold responses are often obtai;ned. Froeschels (1949), Myklebust (1954, 1957), Morley et al. (1955), Carrel1 and Bangs (1957), Goldstein (1965), Goldstein et al. (l958), Landau et al. (1960), Monsees (1961), Taylor (1964), Rappaport (1965), De Hirsch (1967), Stein and Curry (1968), and Thomas (1969) have reported the unreliability of pure tone audiometry with these children due to erratic, inconsistent thresh01 responses and/or some reduction in hearing sensitivity. Eisenson (1968) remarked that whether or not the child responds with an actual reduction in hearing acuity, he does evidence a perceptual impiirment in audition - a difficulty in the physical reception of sound. Some authorities such as Rappaport (1965) report the test-retest fluctuations in threshold as ranging from normal acuity to profound hearing loss. McGinnis (1963) states that most sensory aphasic children have some deficit in hearing and poor response to hearing test situations often negates the determination of hearing levels. Thresholds are rarely considered valid with confidence because of inconsistencies in test responses. “Tuning in” to the abstract pure tone stimulus in the soft intensity zone of from 0 dB to 30 dB seems especially difficult for such children even when they understand the task and are cooperating. They may show difficulty of similar nature in receiving familiar speech stimulus for the determination of the SRT. The fact that they can hear softer stimulus than the audiometric results indicates is possible is evidenced by response to at least a few meaningful environmental nOiSeS.
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Van Arnold (1959) and Johnson and Myklebust (1967) emphasize the phenomenon in which there is a frequent time lag between auditory sthullation and patient response in such children as they stress the necessity of repeating the same SthdiJs several times and/or for longer presentation bursts. Listening itself taxes their patience and seem very demanding and they fatigue e&y. A. conditioning program that extends over a number of short sessions is requisite for threshold determination. Talylor (1964) remarked that in the severely affect;&* young cases it is possible to obtain responses by distracting techniques L-Yiy, never by performance tests of hearing (audiometric). Johnson and Myklebust (1967) offer an explanation for the failure of such children to respond to pure tones in their discussion of the concept of auditory agnosia. For such children all but the loudest of pure tone stimulation remains too abstract to elicit meaningful associations between the audiometer and its noises and their resultant auditory-motor responses. The same child who does poorly in “tuning in” to ongoing pure tone presentations for the establishment of thresholds. will probably also display the following characteristic. Inatten tiun to environmental sounds The child with auditory agnosia experiences an auditory inefficiency Over
and above what may be expected from audiometrically determined !heakg 10s. He responds inconsistently to environmental sound and has marked restrictions on his projective use of hearing. The implication for these children is that they can hear but are unable to interpret that which is heard. The child is seemingly unable to structure his auditory world and to sort out and associate sound with particular objects and experiences. His attention to common environmental sounds, such as animal vocalizations - the noises of household appliances - and the auditory experiences of familiar outdoor noises, is highly inconsistent. The associative link between noise sources ad their products seemingly is never established. Taylor (1964) comments that these children show distinct difficulty in responding to auditory signals if their vision or hand manipulation is engaged. Myklebust (1954) seems to be describing children with developmental receptive.expressive aphasia with general auditory agnosia when he states that awditc
emphasizesthe feature of
to loud backgswnd noise ‘md ‘bunawakednessYp. Not absent from the case history report nor the observations made in the clinic setting is the notation that the ental receptiveexpressive aphasic earl hear and may res e sound of soft intensity (or one suprathreshold to a mild to moderate hea:-ing loss if they have one) out of curiosity when ignoring loud highly familiar sounds. Such childrenmay also have made a few auditory associations like recognition of their name and respond to it when it is used in verbal manding. Or they nlay show consistent response to a plane roar or train whistle that is so far in the distance as to be a stimulus of soft int.:nsity. Such behavior natur,llly perplexes the parents but also gives them the feeling that thei:. child possesses somewhat normal hearing sensitivity. A “voice and noisemaker” approach tends to demonstrat,.: their inattentiveness to voice that is directed toward them as well as their lack of integrative perception (auditory imperception?) of a variety of object produced so1mds. Johnson and MyMebust (1967) have described such children as looking ciazed at times even to stimulus such as their names. Their lack of i
iattentiveness
eech. VOW Arnold (1959) called their inattentiveness
response to many ongoing dynamic sound experiences certainly is .the behavior trait that often leads to the false labeling of deafness. Their lack of response to an examiner’s auditory stimulation may be viewed as a purposeful “ignoring” of the sound after it is established that near normal acuity is
available for use. In 1959 Hardy and Pauls posited the following explanation fluctuating hearing behavior of children with aphasia:
for the
....an aphasic child in early infancy may have shown clear auditory orienting rn and remember verbal symbols, reflexes, but later, not being able naturally to may have inhibited the reception of SW commonly enough ali sound, environmental as well as verbal. . ...The problem ,..... is not that they do not hear. The problem lies at a higher organizational level, an inadequacy in memory for the symbols of sound and a resultant failure in ordinary reflexive responses to sound of any kind. It may well be that these children learn “not hearing’ 3s 3 kind of defense . ... ..to a confusing world. If the developmental aphasic’s experience with sound has been unsuccessful he may begin to ignore sound and reject it as a worthwhile stimulus. The case reported by Stein and Curry (1968) was followed longitudinally through
childhood into youth. An early history of normal audition reportedly yie.lded to a hearing loss due to brain damage at age 3. Surprisingly, after a number of years of being reportedly “deaf” a “return of hearing” was noted at 10 years of age. The authors felt that the “deaf period” was a defensive period of sound rejection which relieved the child of the need to handle the cacophony of au&tory stimuli around her which had resulted from her experienciq of au&tory agnosia. Over the time involved the need for such a defense
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apparently dissipated. The auditory agnosia con~tinu?d at the age of 22 and was typified by inability to recognize many nor speech sounds such as noisemakers and animal sounds. Eisenson (1968) acknowledges the possibility of a psychological barrier to learning in such children in the form of perceptual defenses. The child may generalize his perceptual defenses against speech signals, which are beyond his coping ability at a given stage of development, to all environmental sound. A child who has developed such defenses needs to be and can be enticed back to sound. Summary on auditory behavior ln man!,!of the chikiren of concern there thus appears to be an auditory receptive deficit that is far more encompassing and is of far greater magnitude
as a disabling effect than the inability to comprehend words. The auditory agnosia, when present, is an auditory irnperception for sound in general. When a child experiences a failure to establish a receptive and interpretive structure or internal organization for handling the bombardment of his complex auditory world he may defensively reject the meaningless sensorium which he views as unmanageable. Interestingly, most of these children respond to the structured auditory training of a clinic program and gradually establish luditory associations and recognitions toward the elimination of much of the auditory agnosia. The fact that most of the children can learn to respond to environmental sound under therapeutic guidance attests to the psychoper ceptual nature of their disability. Apparently, behaviorally as well as theoretically, receptive aphasia can stand alo re as a specific agnosia for heard verbal symbols in a child who is free of tfre general auditory agnosia. He functions normally by projectively using his auditory environment and he can respond well to the audiometric experience. More expectant, however, is the more general psychoperceptual disability of general auditory agnosia which more seriously disables the receptive aphasic in that ,here seems to he little internal organization available for coping with any kind of sound. Many of the developmental receptive-expressive aphasics are characterized by the learning barriers mherent in auditory agnosia.
Speech-language hr Lavior Ewing (1930), McGinnis (1963), Taylor (1964), Hardy (1965), Rappaport (1965), De Hirsch (1967), Johnson and Myklebust (1967), and Eisenson (1968) are among the leading authorities who consider the heart of the problem of children with reqtiveexpressive developmental aphasia as being a severe disability in the comprehension and usage of the language system.
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Thus the communicative disorders inherent in the psychoperceptual problems of mastering symbolization arid speech motor patterns also eserve attefitioj~.
ceptive language Limited comprehension of verbal symbols The preschool aphasic demonstrates little understanding of verbal symbols.
He does not associate words with their referent objects, actions, or quAties and thus does not respond to the basic noun names of common items, the verb names of familiar actions, nor the adjectival and adverbial modifiers when they are referred to directly before him. In turn the functional u.tility of common prepositions eludes him. His lack of response in the play or evaluative situation to the examiner’s naming behavior suggests that he does not hear the names or is not aware of the fact that the intent of the verbal activity is to elicit identification behavior on his part. He doesn’t move to point out the named item to acknowledge that he knows the name in this condition of “word deafness”. Myklebust (1954) attributed the condition to marked difficulty in integrating and interpreting the auditory impressions of words. De Hirsch (1967) considers the lack of understanding due to a poorly structured percejptual field in which words do not stand out from the mass of unorganized stimuli impinging on the hearer. The configuration of the word, as well as its meaning, appears to be so unstable as to never become familiar. Eisenson (1968) suggests that the inability to process speech signals results from inability to deal with linguistic signals because of storage, discrimination, rate, or sequencing problems. Regardless of the cause, the preschool a sic demonstrates a unique ghly familiar and frequently inability to recognize most of what should b heard words as they are directed toward him relative to a select group of such items before him. Verbal comprehension, if there is any rece at all, is so limited as to be non-functional for even primitive communicative interaction. Limited comprehension of verbal directives
Directives might as well not be spoken for the preschool aphasics are not cognizant of the intent nor the message. Even when their interactive attention is captured and they are seemingly listening to the clinician’s simple verbal commands, such as “Stand up”, “Sit down”, or “Open the door”, they fail to respond. Even after they have registered some receptive and possibly expressive vocabulary of nouns and verbs they evidence difficulty in meaningfully linking the syntactical significance of the two parts of speech and responding to the intended directives. The longer the linguistic unit directed
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toward them, the greater their difficulty for they do not seem able to differentiate the mea&g units involved nor sense their SyntaCtiCd functions. The difficulty in processing speech signals in linguistic events that are temporal and spatial increases as the length of the linguistic units increases (De Hirsch 1967; Eisenson ( 1968). Bangs (1968) states that the young child may learn to perform well regarding hi: understanding of single words, yet he performs below age level when the examiner uses these known words with function words to present a task. If the child is asked to put the spoon in the cup, he will probably not be able to comply, for although he knows the meaning of “cup” and “spoon” he is unable to comprehend the total directive and its message. A further characteristic feature of these children is their blank stares indicative of having not understood the directive or their nodding for ‘yes” as if they had been asked a question rather than given a directive. The case reported by Landau et al. (1960) failed to learn to comprehend any but the most familiar expressions when spoken at a normal rate. He comprehended ora! language best when it was spoken slowly, with a definite pause after each word. A case described by Morley et al. (1955) reportedly failed to learn to understand speech beyond a few words as his receptive vocabulary was very restricted in his fifth year. Johnson and Myklebust (1967) report on the subtle difficulties of even the less severe cases who struggle with the receptive mastery of adjectives and related descriptive words as used in context, Unless they are taught in context, words representative of qualities as characteristically related to objects - feelings - and experiences, such as “big”, ‘“hard”, “soft”, “sharp”, etc., are received as if renamings of the “knife”, “pillow”, “rock”, etc., tha; are involved. The meanings of a word such as “cover” that represents an object ti one context and an action in another are most difficult to master receptively. Some aE,ililyto learn to comprehend
In spite of apparent restrictions in learning that are inherent in the condition of developmental receptiveexpressive aphasia and the subtle if not great symbolization problems that may be insurmountable, these children evidence some ability to learn to comprehend linguistic units. The files of the Aphasia Division of the Central Institute of the Deaf, The Northwestern Institute of Language Pathology, and The Pathw.4~ House, among other clinics that see such children in sizeable number, attest to this fact. Although learning to comprehend may be slow and tedious, some progress is relatively certain for the mjority of the cases. Jo-n and Myklebust (1967) sygest that as these children grow older and have been exposed to and respond to a training programthey may grasp simple words such as noun referents to key concrete high& familiar objects
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but evidence greater diffict&y acquiring words that represent actions, qualities, feelings, or ideas. ‘n a training program the instiUment of the concepts of verb action, modifiers, or prepositional concepts of direction, location, time, etc. may be most difficult. When (1965) reminds of the inability of these children to respond spontaneously in their reception of verbal requests due to their difficulty in retention and recall and conceptual difficulty in transferring what has been practiced and supposedly learned in one situation to another. Early receptive responses to sentenced directives have to be very structured and have to be guided from one structure to others to establish transfer abilities. any one viewing the film demonstration of the McGinnis Association of all struck with the need for a repeated exposure of these simple directives like “Come, Joe”, “Sit down, Jerry”, “Bill, Stand on the line”, etc. The clinician often notes in the training process that involves a number of directives and language units that the developmental receptiveexpressive aphasic may be trained to respond to a high level of consistency within one structuxd receptive language situation with directives specific thereto. But the same child breaks down in his ability to comply when the same directives arc transferred by the clinician to another language unit. That is, the child seemingly learns to manipulate the “eating utensils” by certain commands with accuracy in the structure of that set of materials but when the same commands are then presented for the unit on “Vehicles” it is like starting all over. After considerable training the child may be viewed as functioning commendably in certain structured situations as he receives and responds from session to session with high consistency. Yet approach him in the waiting room where the situational cues of the materials of the language units are not before him and he may fail to comprehend the simplest directive or question. Possibly this phenomenon is be explained as due to the child’s an a few alternate linguistic inability to cope receptively with more structures at a time. Seemingly his comprehension problems and speech processing inadequacies are so great as to negate reception of all but a restricted set of directives in all but the most structured verbal situations where he senses that the command can and will be one of a select and limited number of verbal alternatives. The receptive comprehension of the child who does SO well in the structured situation - perhaps with the aid of reading the structural pattern of the directives of concern - often seemingly regresses to little more than a noun or “noun-plus-verb” comprehension when away from the structured session. Taylor (1964), Ewing (1930), Johnson and Myklebust (1967), Stein and curry (1968), and Eisenson (1968) have alluded to the possible superiwity in reading ability (visual response to the written directive) over their response to au&tory symbols and syntax although there is no assurance that the cmd will be free of dyslexic handicap.
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Expressive speech and language behavior When the receptive integrity for speech-language comprehension is disturbed developmentally, there seems to be agreement that there will be a mirroring of the receptive deficits on the expressive side of language behavior. Certainly there are expressive {deficits,however, such as verbal apraxia, that may exist above and beyond those resulting from the receptive problems to further complicate the learning of expressive language skills. The literature suggests that the following resultant subgroups of speech-language patterns can be expected in children with developmental receptive-expressive aphasia. Speech as used in this article will refer to articulatory performance and the general intelligibility of the oral language. Muteness
McGinnis (1963) discusses, this small subgroup that offer infrequent vocalizations. The silent type, they seldom vocalize. The educational prognosis is not gocd for this group who seemingly have never sensed the utility of a ianguage system or have found it impossible to cope with and master to any extent. They have even rejected vowel-like vocalizations for projective use to draw attention and make their desires known. They may never attain the goal of speech if there is too great a time lag in receiving the teaching suited to their needs. From a psychoperceptual viewpoint they may choose to withdraw from verbal interaction because of the frustration resulting from inability to cope satisfactorily with the language system. Their social interaction may ‘be superficial as it is limited to head nodding and quietly standing back and watching what’s going on. Urge oj’jmgon or scribble speech
McGinnis (19153), in her description of the nature of the jargon in this group of children, stated that although perseverative patterns predominate there is other vocal activity. The rapid and abundant vocalizations resemble a recording that is run at too high a speed. Expectant patterns of voice quality and inflection te:nd to be imitated. McGinnis refers to these children as the group with motor aphasia with the vocalizations being limited to staccato vowels, occasional consonants, or to syllables consisting of lingual dental or lingual palatal c:onsonants combined with vowels, Some children use the speech patterns freely and keep up a constant chatter of perseverative patterns in attempted conversation; others limit their use of speech patterns to requests for something they want. In that they appear to be using their speech projectively and thus purposefully, interest shown by the listener will encourage continuation of tlhe vocalizations, while indifference will discourage further attempts to communicate. Some of these children cannot imitate in isolation the sounds they use in then random vocalizations. The Patterns used my in no way resemble the words they are trying to say.
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Carrel1 and Bangs (1957) ark? Taylor (1964) report c;,ses whose speech was jargon in nature. Eisenson (196’8) suggests that the child who produces jargon may well hear jargon. He may transpose speech sounds because he is unable to keep the order of sounds in mind. A child who cannot sequence sounds is impaired for learning to understand language and so to speak. Johnson and Myklebust (1967) view the expressive verbal apraxic deficit as an inability to coordinate the auditory-motor patterns for speaking. Such children have not learned and will experience difficulty in learning to coordinate the acoustic products or effects with the respective articulatory gestures. The association between oral acoustic output and the acts of speech articulation that lead thereto is not established. Pronunciation remains distorted - with a slow tedious progression with training from great distortion to subtle distortion - until the speech motor pattern is fully established. Willful appropriately directed and controlled movements of the articulators for the articulatory gestures seemingly are not known or alre very poorly remembered. The child’s attempt to repeat words is marked by struggle a. Id articulatory inaccuracy, substitution, and general lack of distinctiveness. Pattern non-retention yields speech distortion that is further complicated by sound transpositions and sequencing difficulty. The auditory memory span problems and difficulties for judging word succession and order are slowly being indentified by research effort (Monsees 1961, Lowe and Campbell 1964, and Stark 1967). Morley et al. (1955) found that 7 of 15 aphasic children experienced articulatory apraxia. The child described as possessing “scribble speech” by Landau et al. (1960) was usually devoid of actual words. He could imitate short words but it was evident that he did not know their meanings. His attempts to imitate phrases and sentences resembled the original only in rhythm and inflection. Carrel1 and Bangs (1957) comment that frequently the speechless child uses grunts, noises, cries, and o er undifferentiated vocalizations, sometimes to attract attention or make his desires known, but often for ~10observable reason. While communicating via scribble speech such children emphasize what they are trying to say b), gestures and facial expressions which seem to be appropriate to their message and which are sometimes surprisingly complex. Usage uf jargorzinterspersed with inteiligible words or phrases McGinnis (1963) suggests that this expressive condition is either a milder form of the problem or the children are beginning to use the words they have learned via repeated auditory exposure. As vocabulary increases there is less and less jargon. Rappaport (1965) reports cases whereby meaningful speech was utilized by the aphasic child in the therapy setting after therapeutic training. However, spontaneous usage was not achieved outside of the therapy setting. De Hirsch (1967) comments that even the speech of these children
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may be severely hmited in quantity, crude, and undifferentiated in quality. Lennenberg (1964) comments on the primitiveness of their utterances. They simplily blends, telescope words, and their verbalizations are only crude approximations of the correct model. Worster-Drought (1943) stated that even when speech is developed in such children the quality is monotonous, toneless, and indistinct. Johnson and Tavalla (1945) as cited in CarreB and Bangs (1957) observations included rnon.,tonous inflections, Some elements of perseveration in sounds at the beginning and ends of words, reversals of sounds and lack of syllable division or accentuation which added to the impression of monotony in the speech. McGinnis (1963) suggests that the problems in memory for sequencing sounds to compose and articulate words (even after articulation of individual sounds is mastered) hampers expressive word mastery. Later in the training program such children experience similar difficulty in the word order sequencing necessary for using sentences. Structuring is necessary to surmount these organizationu hurdles. Some of the cases possess or acquire normal speech inflectional patterns - others lack normal cadence. Johnson and Myklebusi (1967) suggest that it is characteristic of these children to forget how to produce a sound or a word that their teacher would think they had well registered. Relative to words for which the motor pattern is nearly established but not totally automatic, they sometimes forget how to start the word and there seems to be an inconsistency in the availability of the pattern for use. A verbal, visual, or auditory preparatory set or prompting may be all that is necessary to refresh their memory. Relative toi the difficulty in learning, Taylor (1964) states that a S-year-old aphasic seen by him needed to relearn phrases and words that she had appeared to kraow at an earlier date. The 3-year-old aphasic may not have more than several reappearing and meaningful words that are linked with their referents, By age 6 his expressive vocabulary may remain very restrictive with the words unintelligible to anyone outside the immediate family. He may have or may not have responded to the inflectional patterns of voice and the prosodic features of sentence utterances. Even when a verbal apraxic factor is absent, a semantic aphasia or syntactical aphasia may be further complicating aspects of the expressi1.e meffciency of the developmental receptiveexpressive aphasia. The case described by J-andau et al. (1960) learned a vocabulary of 175 words in one Year, correct simple sentences in two years plus reading and writing, and some functional language in three years of chnical therapy. The child described by orleY et al. (195% developed phrases in the 5th year. His speech consisted of a small number of words, and phrases which were often noun equivallents, e.g., “sit on” = chair, -cut it off’ = scissors, and “goes up in air” = airplane. Eisen~n 1(19a) sees the acquired language as characterized by an absence
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Of conventional grammar - a deviation from developmental norms. When finding difficulties sf a semantic or dysnomjc a ect of language disabW are involved, perhaps in the ;hewe of the apraxja, the mental search&i for cmmon names of actions, objects, qualities,, etc., i.e., the substantive words, is characteristic. ‘The retreival problem may show it self in the child’s response to such st i as the picture cards of the articulation test and the hesitations marl, e searching behavior. A use of demonstrative and personzd pronouns *b “that”, “there”, “‘those”, “he”, “she”, “it”, and “they” in termingled me function words of jargon may allow for an indirect reference that is often deceiving. In class responses can be expected such as “knife” for “fork ’ and “toe” for ‘( ger”. hey may display over a period of time the inconsistent availability of common words having them one week but not the nt . However, by and large, once registered, words are available to them. heir articulatory accuracy may fluctuate considerably and much practice in speech motor patterning is necessary o keep the words acceptably int:lligible. It is possibly characteristic of the developmental rece aphasic to be so involved expressively as to negate the identification of the extent to which underlying aspects of syntactical aphasia will hinder the learning of complete linguistic utterances of even 2 or 3 words later on.?hat is, the child has not advanced beyond the naming level and has such a restricted vocabulary that he has not reached Ypoint in development where the syntactical errors have had a chance to show their faces. A most outstanding characteristic of many of these children is an inability to acquire functional expressions of even phrase length or noun-verb combinations probably for the reason of inadequate retention integrities for the word ordering and sequencing concerns of the longer linguistic units. The same problems that prohibit learning to corn rehend directives undoubtedly function to interrupt the learning of even the simplest expressive verbal utterances. Even in the children who imitate single words well the generative inadequacies are vividly demonstrated by their inability to repeat 3 and 4 word expressions with a clarity of articulation and a cadence that suggests that they are saying meaningful sentences. Their own retention (for later spontaneous usage) of sentence structures that have been repeatedly practiced in therapy seems lacking. Some cases who can orally read from the blackboard do so with great effort and articulatory distortion as visual stimuli seemingly facilitates recall of the rrecessary articulatory gestures for producing words and longer linguistic units. However, at moments away from the therapy session in which the same utterances would have great utility for them, they experience such frustration in unintelh@ble pronunciation and in improper word inclusion and ordering as to withdraw from the attempts. Their psychoperceptual awareness of their communicative inadequacies may markedly restrict their spontaneous offermg of verbal utterances outside of the clinic therapy setting.
word
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Echoldic repetition The last group demonstrate repetitions of words without association of maaflbg_ They repeat words and phrases while attaching no meaning and are
viewed as echolalic or using parrot speech. Some of them ShOWthis ability at an early :kgeand o&n vocalize infrequently before teaching for articulation is begun. They then show an ability to imitate words, phrases, and even sentences commensurate with their memory spans. Johnson and Myklebust (1967) report case types that are echolalk W;lO merely repeat what they hear without understanding. ‘The implication is that they do not comprehend the words but acknowledge some reward for their participation in tb.e parrot act. Rappaport (1965), McGinnis (1963), and Karlin et al. (1965) state that the child demonstrates the limited ability to associate names with objects or to interpret or use environmental language. Wilson (1965) attributes the inability to difficulty in retention and recall of symbols and, conceptually, a difficulty in transferring what has been learned in one situation to another. She states that the sensory aphasic often echoes words, phrases, or even sentences and that prognosis fior such children is poor for it is harder to get through to them. Eiseqson (1968) remarks that the articulatory inaccuracy of many of their repetitioqs results from the fact that they may be able to imitate speech signals only if there is no delay period for imitation. They may have difficulty identifying the auditory speech signals and keeping their order in mind. The accuracy of their immediate auditory-motor recall which is on an automatic rather than conceptual and thus symbolic and representational level is often deceiving, for it suggests ease of learning when that is not the case. The ease of repetition does indicate freedom from verbal apraxic difficulties bu.t word registry in any form of language memory bank apparently does not occur. The echoic repetitions do not seem to foster skills for an auditory recognition of the words next time they are heard nor does the act of repeating equip them with appropriate speech motor patterns for naming at a later date. Summaly of speech-languagebehavior
Thus when initially contacting the preschool child with the behavioral entity considered in this article, the developmental receptive-expressive aphasia, the diagnostician will be faced with a stark but not necessarily foreboding picture of an essentially non-verbal child. The examiner’s attempt to measure the child’s receptive integrity for word recognition at even the naming level of language behavior will be met with a paucity of meaningful responses. The examiner’s naming of most common items will fail to evoke all but occasional identification behavior from the child. The addressing of directives relative to test materials or to the manipulation of doll people and miniature furniture in even an informal play setting will quickly demonstrate an absence of specified responses that challenges the differential diagnostician.
The training task is a mar tlmental and tedious one because of the apparent lack of a natural propensity for the learning of language. Resistances inherent in the condition make learning difficult and the prognosis guarded for establishing a completely. functional communication skill. ecause receptive language skilh as gained are viewed a reflection of the internalization of a language system, expressive language skills seldom excell over receptive skills. USUdY, but notalways, if a child fails to comprehend a word or a directive it is unlikely that he will turn around and use it spontaneously. The establishment of an associative linkage between words as heard and differentiated events and the combined speech motor patterns that produce them seems to be the foremost task of the training program for words do not easily take on a synesthetic sensory-motor image for these children. hether auditory imperception or speech signal processing deficits are the ba problems or are coupled with further complicafing image retention and/or sensory-motor apraxic components, the heard words as dinstinctive acoustic events must be somehow linked in the training process with the movements of the speech mechanism as combined articulatory gestures and that association must be long term and readily available. By fighting that inherent weakness these children can learn an expressive vocabulary and patterned utterances of combined words, but the articulatory proficiency - prosody - and grammatical accuracy and completeness of their vocalizations are difficuh to bring to a functional smoothness. Depending upon how well they learn to comprehend all the semantic and syntactic subtleties of connected discourse as well as their freedom from underlying and further complicating expressive deficits such as verbal apraxic and syntactic sentence building problems or mastery thereof, they may or may not become effective members of a verbal community. The case presented by Stein an Curry (1968) demonstrates the unfavorable alternative, i.e., joining a deaf society or equivalent course of action, that may be chosen by many of these children later in life unless their educational assistance begins early and is continued in a concentrated and extensive program of habilitation. Thomas (1969) nicely sums up the prognosis for the severe condition of language disability considered in this article: “After more than ‘25years of de&g with th.is condition I know that sheer plodding, flexibility of ideas for daily treatment, and belief in success are essential and, much as one might wi& it, there is unlikely to be a magic wand method for obtaining fluency and communication at a rapid rate.”
eferences Allen, I., 1952, The history of congenital auditory imperception. /vev Zealand Medical J. 51,239-247.
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50n, J., 1968, Developmental aphasia: a ~~~~t~~ tien\. .f. Speech Hearing5is. 33 p 3 - 13. A.w.C., 1930, A$IQS~U in children. New I’m
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FI-Q~~~&s,E.. 1949, Pure word-deafness in a child. 22S-240. G&&t&n, R., 1965, Discussion of aphasia. In: &_@e?eatialdkgnoris. Volume II, edited by S. Gddstein.. R., WM. Landau and F.R. Kleffner. 1958, %eu deaf and aphanc children. The Annals of Otdofl. fZhin 468-4179. HZ&~, W.G., 1965, On language disorders in young cbildrw; a thinking. 1. Speech Hearing5is. 30,3- 16. Hardy, W.G. and M.D. Pauls, 1959, Atypical children with c~~~ tier diwrders. Children 6,13- 16. Jansky, J., 1960, Congenitally word deaf children. Masters Thesis, C New Yark. Johnson, D.J. and H.R. Myklebust, 1967, Leaming disohidiries.New Y Stratton. Johnson,‘M.L. and N.M. Tavella, 1945, lmperception audlrtiva coq&ta asor congenital) con illustration de un case complicado con sor&zra Argentine s/de Pediatria,23-25. Karlin, I.W., 1951, Congenital verb&auditor)l agnosia (word deafrzssll. 60-68. Karlin, I.W., D.B. Karlin and L. Gurren, 1965, Development and ch in of childhood. Springfield, Ill., Charlcc C. Thomas Publisher. Landau, W.M., R. Goldstein and F.R. Kleffner. 1960, Congeniid sph 915-921. Lowe, d. and R. Campbell, 1964, Temporal discrimination in aphas&d and normd children. J. Speech HearingDis. 8.313-315. hlc(;infiS, M.A., 1963, Aphasic children, Washiyton, AlesiPnder crah;un B&I Awiation for the deaf, Inc, MoDsees, E., 196 1, Aphasia in childtcn. J. Speec/t ffeaeng nis, 26.8 Moth’, M., D. Court, H. Miller and R.F. Carside, 1955, &?hw and P mental aphasia. l-WishMedicalJottrttuj2, 463-467. Mullins. J.B., 1969, Provisions for aphasic children in public m&au wh&s for the deafinthe United States. Amer. Amals oftjle 5eaf 114,64._7~. MyklebW Ii% 1954, Auditory &so&x Bt clri&qr, hew Yo&, Gmnc and Stratton. Myuebust, H.R.5 19% Langul~c training: u comparison kwm chfthn 0~5thaphasia and those with deafness. Arrrcri~+~rr Anrl& o~q 101, 24g-244.
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Myklebust, H.R., 1957, Aphacr; in children - diagnosis and training. In: Handbook uf speech pathology, edited b? L. Travis. New York, Appleton, Century, Crofts, Inc. Grton. ST., 1937, Reading, wiring, and speech problems in cltkkn. New York, W.W. Norton&Company, Inc. Rappaport, S.R., 1965, Childhood aphasia and bruia damage: differential diagnosis, Volume 11. Narbeth, Pa., Livingston Pubhshing Company. Stark, J., 1967, A comparison of the performance of aphasic children on three sequencing tests. J. Communication Dis. 1, 3 I- 34. Stein, L.K. and K.W. Curry. 1968, Childhood auditory agnosia. J. Speech ond Hearing Dis. 33, 361-370.
Strauss, A.A., 1954, Aphasia in children. Amcr, .I. Physical Med. 33. 93 - 99. Taylor, I.G., 1964, The neurological mechanism of hearing and speech in children. Washington, The Volta Bureau. Thomas, M.E., 1969, Assessment and treatment of receptive and cxupressive aphasia in identical twin boys. British 3. Dis. Communiration 4. 5 7 -63. Von Arnold, G., 1959, Llber Zusamrnenhange von zerebralen Ilijrstijrungen und Horstummhcit. Folia Phoniutrico 2, 12.-22. Wilson, L.F., 1965, Assessment of congenital aphasia. In: Childhood aphasia and brain damage: differential diagnosis. Volume II, edited by S.R. Rappaport. Narbeth, Pa.. Livingston Publishing Company. Worster-Drought, C., 1943, Congenital auditory imperception (congenital word deafness) and its relationship to idioglossia and allied speech defects. Medicul Press & Circular 210,411-417.