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Functional Learning Disorders
Symposium on Learning Disorders
Functional Learning Disorders
Frank T. Rafferty, M.D. *
The physician's role in the treatment of functional disorders of learning is neither secure nor precisely defined. Only rarely will the usual medical illnesses contribute directly to poor cognitive performance. It is not at all unusual for the physically ill or the psychosomatically disabled child to be more than adequate in school performance. Some conditions may contribute to difficulties in learning by limiting school attendance, but children with such illnesses can do extraordinarily well in home or hospital teaching situations. The most outstanding exceptions occur in the areas of unrecognized vision and hearing defects, the latter frequently being part of an upper respiratory infectious process. Even these defects are more likely to be present in the child whose medical problem is embedded in socioeconomic or family problems. Enuresis also presents in children with other developmental and behavioral problems. Overall though, the physician with average adroitness in choosing patients, some competence in selective inattention to intellectual performance, and a careful wariness about asking stray questions of school adjustment can avoid the embarrassment of impotent involvement in probably the most pervasive problem of children, a problem limited in distribution only by our methods of inquiry and level of expectation. Concern for and evaluation of an individual's capacity and efficiency in processing information has only surfaced as an issue of national and international concern in the second half of the twentieth century. It is easy and perhaps accurate to associate this development with growth of societies increasingly dependent on industrial and science-oriented technologies, and the change of attitude toward education where economic and social status is, in part, identified with scholastic achievement. Not infrequently the association is also made with the historical development of the secularization and humanization of man's position in the cosmos. If man's position is determined in some absolute sense by omnipotent, omniscient, and omnipresent external forces, then intelligence in man is an interesting but hardly crucial attribute and quality. If, on the other hand, man really does participate in his own creation, then intelligence as *Director, Institute for Juvenile Research, and Professor of Psychiatry, Abraham Lincoln School of Medicine, University of Illinois, Chicago, Illinois
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a major instrument of this creative act must be a source of intense concern. Some preliminary considerations are required of the differences between a disease in the specific Virchow sense and individual variations in the actualization of a human potential. In the classical concept of a disease one postulates clearly a differentiated etiology, the expressive symptoms and signs, the characteristic pathology, the treatment, and finally a prognosis. In actual operation this disease model was not so precise, in that various parts such as determination of cause or treatment might be missing for a prolonged period. Furthermore, factors such as social class, and environment were frequently contributory, as so well demonstrated in tuberculosis. Nevertheless, even with such uncertainties, one did not doubt the existence of the disease - nor did one have to take a vote on the effect on human life. The potential of death or physical suffering negates any doubt of the value of this concept of a disease process. Recently, in that part of psychiatric practice more closely related to the social than the biological sciences, considerable energy has been expended in attacking the disease or medical model as applied to a wide array of variations in human behavior. Considerations of intelligence have not been as virulent as those related to homosexual behavior, for example, even though considerations of intelligence are at least as, or even more, appropriate. Essentially, the argument holds that many elements of human behavior are in nature quite varied, including intelligence, language usage, sexual behavior, gender differentiation, parenting, level of activity, and a variety of cultural styles such as a work ethic. The definition of that which is normal and that which is deviant becomes a question of preference or value judgment or, at times, a matter of numerical strength setting up a majority-minority problem. The life or death issue is not present to arbitrate a clearly defined good or bad. Every individual behavioral event is simultaneously a social event in some multi-individual system such as a family, classroom, school, neighborhood, ethnic group, or social class. The behavior is scrutinized as a social event and a value placed on it, but a value relative to the social system doing the evaluation. Quite probably that value would be different in a different social system. This type of situation leaves the normalcy or deviancy of a behavior to be determined by a political process and opens the way for the oppression of people by other people who have the political power, however derived, to specify deviancy and its treatment. Those accustomed to the more biologically structured aspect of medicine quickly lose patience with this argument and desert the arena where such confrontations are necessary. Psychiatry is probably only a forerunner in this problem, which will become part of other specialty practices as the concepts of comprehensive health and maintenance of health become more pervasive. For now the problem presents here because I cannot offer to you a clear definition of intelligence, define the syndromes of its deficits, or outline the causes of deviance, much less instruct you in the procedures of correction. Instead I must develop a series of contingency consider-
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ations around the definition of intelligence, and its determinants, specifying some of the evaluating social systems and quite unsatisfactorily indicating some procedures for intervention, management, or control. Until approximately 1960, intelligence was more clearly understood. There was presumed a general intellectual factor that could be operationally measured or even defined by an intelligence test that reliably and validly distributed the population along a normal curve. Obviously, one end of the curve was more desirable than the other; basic hereditability was assumed and measured; and there was a clearly defined unfolding of intellectual power from birth through adolescence. In short, there was a neat and tidily defined issue that unfortunately rested on conceptual quicksand. I do not intend to deal in depth with the resolution of these issues or aspects more adequately dealt with elsewhere in this symposium. But some relatively brief attention to these theoretical issues is required to make sense of the problem for the practicing physician. The modern history of concern about intellectual achievement usually begins with the account of the government of Paris in 1904, requesting the psychologist Alfred Binet and the physician Theodore Simon to help with the problem of children failing in school. They responded with the development of the intelligence test and the intelligence quotient-the ratio of intellectual age to chronological age - which served for many years to orient a child of a particular age to a classroom of a specific degree of difficulty. The intelligence quotient.and intelligence test come to us today essentially unchanged, providing beautifully circular but satisfying answers to the questions: What is intelligence? How do you measure it? And, what is its relationship to school achievement? The score on the test was the answer to all three questions, since the intelligence quotient correlated highly with achievement in school. Today, the same problem is presented to the physician by the parent or sometimes by the school, but the easy answer has been removed from the reach of the conscientious physician, since he will not be treating a statistic, but will be confronted with an individual child. Since Binet, the population of children in school has been changed by a number of factors: (1) all children now go to school, by law if necessary; (2) school achievement is considered equivalent to success in later life; (3) the material to be learned has increased many times in amount and complexity; (4) large populations of children previously unschooled and from different cultures have migrated into the urban areas; (5) the schools and school districts are qualitatively different because of the increase in population of all categories; (6) the expectations of achievements are applied nearly universally despite much rhetoric about individualization even in circumstances that would be material for stage comedy, if they were not so destructive of individual children (e.g., instructing a class in a language not understood by the children); (7) previously oppressed people now demand their equal rights and equal opportunity, which not only changes the school situation for them but alters the whole social climate of going to school for every one. The physician searching the above for some clue to manage the child expected in his office tomorrow will be properly frustrated, since the big
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issues are beyond his power of intervention. This individual clinical problem requires the phenomena to be differentiated into three clusters of variability: (1) the absolutely fantastic individual variation in cognitive competencies and styles; (2) the extraordinarily complex adaptive task presented to a child by the requirement that he or she go to a particular school and classroom; (3) the mix of support, expectation, and interfering problems presented by the three major social systems in which the child is attempting to participate-family, school, and peer group. Understanding of the pervasive individual variations in cognitive performance is at present in its own primitive stage of development, and is roughly analogous to the understanding of viruses in the early 1950's. The bulk of educational psychological research has assessed the status of a child's educational endeavors by comparing his performance with that of other individuals of the same age. Underlying this practice was a focus on curricular content or what there was to teach. Implicitly, the child was an empty vessel of various age-determined shapes, into which information could be poured at will. To ridicule a naive model is, however, easier than providing an adequate replacement. Much confusion is present and can only be reflected here by pointing out that we may be talking about different things when we discuss perception, learning, memory, cognitive development, concept development, problem-solving, intelligence, or creativity. It would be foolhardy to attempt an exposition of anyone of these, much less make an attempt to reconcile their diversity or to try to relate them systematically to the subject areas, e.g., reading, language, mathematics, history, science, or to determine an appropriate instructional sequence. Most research has been performed on either college students or preschool children and the patient presenting to the physician will most often be in the elementary or secondary school grades. Research in these areas has yet to make a substantial contribution to the field of everyday education and to the physician concerned with the diagnosis and treatment of an individual patient. Ideally, one would like a detailed map of cognitive capacities with information about the pervasive individual differences; the relationship of each of these capacities to age; the effect of previous experience; prerequisite capacities; tests to locate an individual on the range of any skill with respect to criteria of performance rather than comparison to peers; precise knowledge of the cognitive capacities required by any given curriculum; and teaching techniques catalogued according to the cognitive capacities utilized. Failing in this, it is worthwhile to take a hasty look at some of the partial answers, not so much to give the physician usable tools as to inculcate a respect for the extraordinary range of individual differences. In one sense, the most ambitious and complete view of intellectual structure is that provided by Guilford, which, since it has not derived from the child development tradition, has been little used in education. Starting with adults, working from aptitude scale-type tests and utilizing
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factor analysis, this system describes a potential total of 120 different kinds of intelligence. A matrix of five operations - memory, cognition, divergent thinking, convergent thinking, and evaluation-act on four content categories - behavioral, figural, symbolic and semantic transformations, and implications. Perhaps 80 kinds of intelligence have been supported by actual test results. 4 The tests most widely used in schools are still those identified as IQ tests-the Stanford-Binet Test and the Wechsler Intelligence Scale for Children (WISC). These share the problem that they were developed with the underlying theory of a general intelligence factor. However, the WISC does consist of 10 different tests in two major categories - the verbal, consisting of information, comprehension, arithmetic, digits forward and backward; and the performance, consisting of picture completion, picture arrangement, object assembly, block design, digit symbol; and a special vocabulary sub-scale. Although it is invalid to project the score of any individual subtest to arrive at an IQ score, a practice has grown up of analyzing the subtest scores as well as the two major components, verbal and performance. An individual may demonstrate considerable scatter among the tests. Although the tests were chosen for their correlation with the total score rather than their ability to sharply differentiate different kinds of intelligence, the skilled, experienced psychologist can provide remarkable descriptions of -individual differences that often will be the best available to the physician. Certain cautions are in order, beginning with the repetition that this was not the purpose of the test and following with the precaution against either of two inclinations -assuming that scatter or an individual test is tantamount to a diagnosis of pathology or to assume that the highest score amidst a scatter represents a potentially "normal" IQ.! A widely used test in elementary schools is the Primary Mental Ability Test developed by Thurston on a factor analytic basis. This provides six subtests of performance in verbal, numbers, reasoning, word fluency, memory, and spatial. Illustrative of the general problem under discussion is the fact that if memory, as reported in the PMA, is further analyzed, it can be discovered that there can be differences between auditory and visual memory, or between remembering a series of items and remembering paired items. Brief mention of the more complex theories of cognition can add an appreciation for their complexity. Piaget has been systematically exploring how a child acquires knowledge for half a century. In this system, internal cognitive structures called schemes are in continuous adaptive interaction with the environmental structures, and through processes of assimilation and accommodation, progress from relatively simple structures based on sensory-motor action of infancy through specific concrete cognitive operations of the older child to the highly elaborate formal logic possible in adolescence and maturity. New intellectual structures are continuously and actively built on previous foundations. The moving force for intellectual development is within the cognitive apparatus and is not derived from any other set of body tensions or motives. 3 , 5 Piaget's theory is the antithesis of the empty jar view of intelligence: " ... passive interpretation of the act of knowledge is, in fact, contradicted
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at all levels of development and particularly at the sensory-motor and prelinguistic levels of cognitive adaptation and intelligence. Actually, in order to know objects, the subject must act upon them, and therefore transform them; he must displace, connect, combine, take apart, and reassemble them. From the most elementary sensory-motor action, such as pushing and pulling, to the most sophisticated and intellectual operations, which are internalized actions carried out mentally, e.g., joining together, putting in order, putting into one-to-one correspondence, knowledge is constantly linked with actions or operations, that is, with transformations."5 The effort to utilize Piaget's theories in education is only in its infancy, as are the efforts to use his system to build psychometric instruments, and to come to any understanding of individual differences. Bruner and his associates2 have devoted sustained effort to exploring school learning problems, to observing children performing in the classroom, and to altering the manner in which children are taught the strategies of problem-solving. In essence, these are intimately related to the style of classifying environmental stimuli, how an individual moves from defining certain attributes of an object or situation to classifying or identifying the object or situation. There is a fundamental process of development applicable to developmental stages in children, but also maintained in all cognitions in modes of representation. These are described as: enactive -a representational process dependent upon sensory-motor activity; ikonic-representing the world in imagery; and finally, symbolic-which frees the concepts from a dependence on perceptual cues and permits the internal manipulation of symbols in abstract and logical thought. These modes of representation are vital in consideration of the instructional process and Bruner has demonstrated remarkable achievements in teaching young children complex concepts. 2 With this background discussion of the complex, confused, and incomplete field of intelligence, it should be apparent that the apparently simple, if urgent, complaint of a parent that a child is not doing well in school is really an iceberg with behavioral, motivational and cognitive facets. We shall deal here with the large category of children who are, in their language "doing their thing," i.e., they are doing the best they can quantitatively and qualitatively in school with the given instructional process. Parents and school personnel may be unhappy with their academic performance for a host of reasons, but they have in common the desire for a different level or style of performance. Behaviorally the strong child may adapt well to the mismatching of expectations and cognitive ability or style, but most often, particularly if adverse conditions have gone on for months or years, the child is also demonstrating anxiety and depression, e.g., somatization, hyperactivity, withdrawal, hostility, lying, stealing, resentment of school. The difficulty in school can in itself be a major source of emotional distress. In fact, many school districts especially those in the inner-city are the source of much emotional distress and chronic school failure because of an inability to be flexible and responsive to the individual in curriculum and instructional style.
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The variety and shades of this problem are almost infinite but, for example, consider that each cognitive concept is actively constructed on the base of a previous cognitive activity, which in turn is dependent on the experience of the learner. Experience prior to school and out of school differ widely according to culture, ethnic group, race, social class, and family subculture. With a moment's reflection, this would appear to be obvious. But all of us must bear the shame of shared responsibility that allows "empty vessel" model of intelligence and the corresponding curriculum to be dominant. Instead of altering curriculum and style of instruction, the child or his race, culture, or class has been indicted as being deficient. The evidence is that these children are intellectually capable. Furthermore, the idea of a critical learning period should be severely examined. The so-called cumulative deficit is an artifact of the educational system. A quantity of curricular material is offered to the unprepared child. He fails, but the educational process moves on inexorably and another quantity of material is presented. So-called compensatory education misses the point by gratuitously offering to enrich the child's life rather than alter the instructional approach, sequences, and pace of the total educational experience. Results are also confounded by inability to deal with the higher prevalence of organic problems, the time range of individual variation within the cultural group, and the literally silly practice of insisting on instruction in a language not yet understood. A second category of youngsters subjected to the same educational process for entirely different reasons is found in almost every kindergarten, first, or second grade in the country. Even in culturally homogenous groupings the range of cognitive, sensory-motor, and behavioral control developed at the time of starting school varies enormously. In some of the early classes the most significant variable in altering the rank order of children in a classroom will be a few months of chronologic age. Perhaps, from 10 to 20 per cent of a given first grade class will be mismatched with the curriculum. 6 This group of youngsters shades inperceptibly into that group which may be diagnosed as having minimum brain damage or specific learning disabilities. The frequent description is that of a child of normal intelligence but behaviorally immature, in that his behavior is too motor-oriented and is lacking in either external verbal or internal controls. At first the child may be relatively impervious and oblivious to disapproval by the teacher and seems to maintain his good humor. However, this can last only so long, and resentment, hostility, and defensive lying or escape behaviors become part of the picture. Referrals of boys in this category will outnumber girls about three to one. There is suspicion that the cognitive disjunction with the curriculum may be equally prevalent in girls, but behavioral response to the frustration will be less motoric and aggressive and thereby incur less counteraggressive exclusion by teachers. The physician is often not consulted until relatively late in the process - even as late as adolescence, when again the secondary emotional problems attendant to the internalized self-image of failure becomes obvious and are too often well fixed. Further variation on this theme occurs when parents with perhaps
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considerable social and intellectual success of their own fail to appreciate that their children may not be equally gifted. Professionally trained parents are especially susceptible to this lack of sensitivity, and are particularly vulnerable if intellectual success has been a keynote of their personality structure, perhaps representing overcompensation for less well-developed artistic, cultural, athletic, or social skills. The intellectual aspirations of the parents may result in the misplacement of children into narrowly aimed private college preparatory schools or the advanced placement track of the neighborhood high school. In a credentialoriented society the completion of a particular segment of education does seem to open doors to future success, but level of academic achievement within that segment of education correlates much less with the broader definitions of success in later life. The management of these situations rests on: (1) the determination of the individual intellectual competence; (2) support of the child or adolescent in his efforts to establish his individual effort; (3) counseling of the parents in their efforts to understand and to find appropriate educational placement; and finally (4) consultation to the school as requested and, perhaps most important, action as an influential citizen in the community to obtain effective schools and teachers capable of responding to the variety of children enrolled. The physician needs to be alerted to another large category of children, though they are frequently not considered symptomatic. Scholastic achievement can be overvalued, but perhaps equally frequently the intellectual potential of a child is not valued or even considered by himself, his family, his physician, his peers, or his school. Cognition is but one of the adaptive systems for the human individual and social group, and it is a resultant of the environmental forces eliciting, selecting, and strengthening various potential cognitive skills. In many segments of society cognition is not identified as an active powerful tool of individual achievement. This is particularly true during infancy and preschool years. Many families are preoccupied with the more demanding necessities oflife - problems such as housing, nutrition, employment, transportation, health, money, physical energy, number of family members, family conflict, or physical and economic safety. Frequently neglected are activities of the infant and toddler in manipulating and exploring his physical environment and in being introduced through play to auditory, visual, and tactile stimuli that are the progenitors of symbols. Playing, talking, and reading with a child sometimes appear to be unnecessary, wasteful luxuries of time and energy in the hectic daily life of many parents. The pediatrician in the hurried well baby visits has focused on nutrition, physical growth and episodic illness. As a major carrier of culture, he must find means and opportunity to express as much concern for the intellectual development of the children under his care as he does for their physical growth. This extends to all considerations of pediatric education and hospital practice, as well as other aspects of child care in which the pediatrician may become involved such as day care centers and foster and adoptive homes. The preschool years have been emphasized because of their crucial influence on development and the way in which an individual's interac-
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tion with his environment is carried into the later years of childhood and adolescence through the mediation of the child's self-image and family and peer models. The school age child is acutely aware of which behaviors carry status and rewards within his family and peer systems. Positional or territorial power as a resident of a particular neighborhood, a member of a specific family or a street gang, or more simply the positional role of the child may be overriding determinants, as may physical strength, size, athletic skills, money, sexual attractiveness, and street cunning. The point is that cognitive skills are but a fragile and sometimes seemingly powerless tool in managing one's environment. The physician can only be alert to the different worlds in which his patients live. Finally, it is important to identify those situations in which emotional and mental illness interfere with the development and utilization of intelligence. Unfortunately, for those whose tolerance for ambiguity is low, there is no clear separation of the major syndromes under discussion. Any child may be considered in anyone or all, and the opening discussion of the confusion of disease and individual variation should be reconsidered. The life of any individual, from gestation on, can be considered to be a minute to minute, hour by hour, or year by year continuous process of solving the problems of transaction between the organism and the environment. The organic structures and physiologic processes in adaptation are the basic sciences of organic medicine. But the environment also consists of other individuals and a bewildering array of social events and problems. The individual's internal cognitive and emotional systems guide the adaptive process, but to a degree far beyond what occurs in the biological systems, individual cognitive and emotional systems are themselves simultaneously being shaped in the adaptive process. The problems of interpersonal relationships offer a variety of settings, exceeding by far the range of experience to whieh kidney or heart must respond. An incomplete, logically fluctuating, chronologie ordering of the pertinent problems of a child's growth, development, and interpersonal context may be helpful: the establishment of satisfactory biological rhythms of feeding, elimination, and sleep; the internalized expectation that biological tensions will not be overwhelming and annihilative; the development of the sense of early object constancy and trusting dependency on the care-taking person; the beginning foundations of the sense of self and differentiation of self from others; the appreciation of motor skills and integrity of body location in space; the playful and manipulative beginnings of language; achievement of independent locomotion and other motor controls such as self feeding and control of anal and urethral sphincters; the social problems of toilet training; the evolving gradient of biologic and psychologic dependency and autonomy, the establishment of a sense of primary trust and safety in the human environment; the self conscious discovery of power and social control; the awareness of gender; the stabilization of language and cognitive skills; the awareness of the family and differentiation of roles in the family on basis of age, sex, and size; the introduction to school; the peer group society; the accommodation to school, new subjects, new teachers; the new body accommodation of puberty; the acquisition of adult identity and vocational roles. At each point in time the individual is constructing internal cognitive
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schemes ofworId order, of reality and of the categories and content of significant object relationships. At each point in time the internalized patterns of previous experience are being applied to current stimuli guiding the response. At each point in time the emotional system is being calibrated to give signals of well being and danger, pleasure and pain, satisfaction and fear, happiness and sadness, love and hate. Most of this cognitive and emotional functioning and structuring takes place without awareness and responses are automatic, particularly through the first 6 or 7 years. Maturation of cognitive processes, as Piaget had demonstrated, takes place steadily through adolescence, with major stage differences occurring at 7 and again around 11 years. To a surprising degree, the functional integrity of the cognitive and emotional systems are independent, leading to the delineation of the major clinical categories of mental retardation and emotional disturbance. The mentally retarded child can be quite normal emotionally with satisfactory emotional valences on interpersonal object relationships. Obviously though, the mentally retarded child with limited cognitive skills is at a competitive disadvantage in many physical and social situations and will experience the emotional signals of threat, danger, fear, and loss, the same as any other child. Clinical management requires that the child's vulnerability be accurately assessed and adequate protective measures taken. Conversely, the emotionally disturbed child-except for the most severely disturbed-is usually free of structured cognitive defects, though obviously not spared the full range of individual cognitive variation. Emotions can influence the functions of the cognitive system in interfering with the problem-solving processes of sustained attention, memory, and generation of hypotheses. If a child, for example, is preoccupied with the death of a parent, sexual guilt, impending divorce of parents, anxiety over loss of body integrity, etc., he will not direct the problem-solving processes into the more emotionally neutral task of the school curriculum. Perhaps more destructive of school achievement is the involvement of the social environment of school or the peer group at school in the emotional conflict. The cognitive competence of the child is not impaired. Characteristically the child may get involved in a dominance conflict with one or more teachers, and the resentment of authority, aggressive behavior, and escape behavior preclude the application of effort to intellectual exercises. Similarly, the child who gets involved with dominance struggles in the peer group or is for some reason rejected by the peer group will not be attending to the academic problems. At times, these interpersonal conflicts with teachers or other children represent a displacement of conflicts generated in the family. Emotional disturbance is more severe when the disorder occurs earlier in the development of the individual. When the process of forming the basic sense of trust in parents, in acquiring sense of safety from external or internal sources of annihilation, or the essential development of a sense of autonomy is interfered with, disorders of psychotic proportions take place. Failure of development of communicative language and of primary identification with parents can lead to interruption of intellec-
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tual and emotional processes so severe that the child is identified between 2 and 4 years of age and requires intensive, prolonged, and specialized treatment. There is also a group of children who, while developing a major flaw in their concept of self, and are unable to move into autonomous psychological functioning, nevertheless are able, usually with tremendous overindulgence and over-protection of parents, to make it into adolescence before seeking assistance. Often they are of superior intellectual ability and despite major defects in motivation are able to keep up with their less well endowed peers. Eventually, high school or college becomes more demanding than their marginal effort can meet and parents can no longer protect them. They can display a variety of symptoms, from severe psychophysiological problems, through anorexia nervosa, to serious acting out or blatantly bizarre psychotic behavior. This has been a terse summary of the position of the pediatric physician confronted with a patient presenting with a functional disorder in learning. The philosophical problem, the state of our knowledge about intelligence, the concern about the child's position in an evaluating, demanding, educational storm, and those conditions under which emotional development interferes with cognitive functioning have been mentioned. Management of these children requires an interest and commitment of effort and time that most often appears impossible in the busy clinic or practitioner's office. Yet the problem will be an increasingly pressing one as pediatrics move into the maintenance of health and quality of medical care. Technically the pediatrician must learn ways of utilizing the doctor-patient relationship to alter the disturbed transactions of patient-parent-peer-teacher. The first step is an attitudinal move into unfamiliar space-a large step, since it requires a change in self-image, the value judgments of the academic pediatrician, an appreciation that the doctor-patient relationship can be a sharp scalpel or potent medicine, and a painful politicalization of pediatric practice. The most practical method of intervention in the immediate present is fairly prompt referral to child psychiatrists or other qualified child therapists. Personnel such as child psychiatrists, psychologists, social workers, educators, and trained paraprofessionals should be added to the pediatric group or to the pediatric clinic.
REFERENCES 1. Bayley, N.: Development of mental abilities, In Mussen, P., ed.: Carmichael's Manual of Child Psychology. New York, John Wiley and Sons, pp. 1163-1210. 2. Bruner, J.: A Study of Thinking, New York, John Wiley and Sons, 1960. 3. Flavell, J. H.: The Developmental Psychology of Jean Piaget. New York, D. Van Nostrand Co., 1963. 4. Guilford, J. P.: The Nature of Human Intelligence. New York, McGraw-Hill, 1967, p. 537. 5. Piaget, J.: Piaget's theory. In Mussen, P., ed.: Carmichael's Manual of Child Psychology. New York, John Wiley and Sons, pp. 703-732. 6. Snyder, R. and Pope, P.: Auditory and visual inadequacies in maturation at the first grade level. J. Learning Disabilities, 5:40-45 (Dec.) 1972.
Institute for Juvenile Research 907 South Wolcott Avenue Chicago, Illinois 60612
Functional Learning Disorders
Frank T. Rafferty, M.D. *
The physician's role in the treatment of functional disorders of learning is neither secure nor precisely defined. Only rarely will the usual medical illnesses contribute directly to poor cognitive performance. It is not at all unusual for the physically ill or the psychosomatically disabled child to be more than adequate in school performance. Some conditions may contribute to difficulties in learning by limiting school attendance, but children with such illnesses can do extraordinarily well in home or hospital teaching situations. The most outstanding exceptions occur in the areas of unrecognized vision and hearing defects, the latter frequently being part of an upper respiratory infectious process. Even these defects are more likely to be present in the child whose medical problem is embedded in socioeconomic or family problems. Enuresis also presents in children with other developmental and behavioral problems. Overall though, the physician with average adroitness in choosing patients, some competence in selective inattention to intellectual performance, and a careful wariness about asking stray questions of school adjustment can avoid the embarrassment of impotent involvement in probably the most pervasive problem of children, a problem limited in distribution only by our methods of inquiry and level of expectation. Concern for and evaluation of an individual's capacity and efficiency in processing information has only surfaced as an issue of national and international concern in the second half of the twentieth century. It is easy and perhaps accurate to associate this development with growth of societies increasingly dependent on industrial and science-oriented technologies, and the change of attitude toward education where economic and social status is, in part, identified with scholastic achievement. Not infrequently the association is also made with the historical development of the secularization and humanization of man's position in the cosmos. If man's position is determined in some absolute sense by omnipotent, omniscient, and omnipresent external forces, then intelligence in man is an interesting but hardly crucial attribute and quality. If, on the other hand, man really does participate in his own creation, then intelligence as *Director, Institute for Juvenile Research, and Professor of Psychiatry, Abraham Lincoln School of Medicine, University of Illinois, Chicago, Illinois
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a major instrument of this creative act must be a source of intense concern. Some preliminary considerations are required of the differences between a disease in the specific Virchow sense and individual variations in the actualization of a human potential. In the classical concept of a disease one postulates clearly a differentiated etiology, the expressive symptoms and signs, the characteristic pathology, the treatment, and finally a prognosis. In actual operation this disease model was not so precise, in that various parts such as determination of cause or treatment might be missing for a prolonged period. Furthermore, factors such as social class, and environment were frequently contributory, as so well demonstrated in tuberculosis. Nevertheless, even with such uncertainties, one did not doubt the existence of the disease - nor did one have to take a vote on the effect on human life. The potential of death or physical suffering negates any doubt of the value of this concept of a disease process. Recently, in that part of psychiatric practice more closely related to the social than the biological sciences, considerable energy has been expended in attacking the disease or medical model as applied to a wide array of variations in human behavior. Considerations of intelligence have not been as virulent as those related to homosexual behavior, for example, even though considerations of intelligence are at least as, or even more, appropriate. Essentially, the argument holds that many elements of human behavior are in nature quite varied, including intelligence, language usage, sexual behavior, gender differentiation, parenting, level of activity, and a variety of cultural styles such as a work ethic. The definition of that which is normal and that which is deviant becomes a question of preference or value judgment or, at times, a matter of numerical strength setting up a majority-minority problem. The life or death issue is not present to arbitrate a clearly defined good or bad. Every individual behavioral event is simultaneously a social event in some multi-individual system such as a family, classroom, school, neighborhood, ethnic group, or social class. The behavior is scrutinized as a social event and a value placed on it, but a value relative to the social system doing the evaluation. Quite probably that value would be different in a different social system. This type of situation leaves the normalcy or deviancy of a behavior to be determined by a political process and opens the way for the oppression of people by other people who have the political power, however derived, to specify deviancy and its treatment. Those accustomed to the more biologically structured aspect of medicine quickly lose patience with this argument and desert the arena where such confrontations are necessary. Psychiatry is probably only a forerunner in this problem, which will become part of other specialty practices as the concepts of comprehensive health and maintenance of health become more pervasive. For now the problem presents here because I cannot offer to you a clear definition of intelligence, define the syndromes of its deficits, or outline the causes of deviance, much less instruct you in the procedures of correction. Instead I must develop a series of contingency consider-
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ations around the definition of intelligence, and its determinants, specifying some of the evaluating social systems and quite unsatisfactorily indicating some procedures for intervention, management, or control. Until approximately 1960, intelligence was more clearly understood. There was presumed a general intellectual factor that could be operationally measured or even defined by an intelligence test that reliably and validly distributed the population along a normal curve. Obviously, one end of the curve was more desirable than the other; basic hereditability was assumed and measured; and there was a clearly defined unfolding of intellectual power from birth through adolescence. In short, there was a neat and tidily defined issue that unfortunately rested on conceptual quicksand. I do not intend to deal in depth with the resolution of these issues or aspects more adequately dealt with elsewhere in this symposium. But some relatively brief attention to these theoretical issues is required to make sense of the problem for the practicing physician. The modern history of concern about intellectual achievement usually begins with the account of the government of Paris in 1904, requesting the psychologist Alfred Binet and the physician Theodore Simon to help with the problem of children failing in school. They responded with the development of the intelligence test and the intelligence quotient-the ratio of intellectual age to chronological age - which served for many years to orient a child of a particular age to a classroom of a specific degree of difficulty. The intelligence quotient.and intelligence test come to us today essentially unchanged, providing beautifully circular but satisfying answers to the questions: What is intelligence? How do you measure it? And, what is its relationship to school achievement? The score on the test was the answer to all three questions, since the intelligence quotient correlated highly with achievement in school. Today, the same problem is presented to the physician by the parent or sometimes by the school, but the easy answer has been removed from the reach of the conscientious physician, since he will not be treating a statistic, but will be confronted with an individual child. Since Binet, the population of children in school has been changed by a number of factors: (1) all children now go to school, by law if necessary; (2) school achievement is considered equivalent to success in later life; (3) the material to be learned has increased many times in amount and complexity; (4) large populations of children previously unschooled and from different cultures have migrated into the urban areas; (5) the schools and school districts are qualitatively different because of the increase in population of all categories; (6) the expectations of achievements are applied nearly universally despite much rhetoric about individualization even in circumstances that would be material for stage comedy, if they were not so destructive of individual children (e.g., instructing a class in a language not understood by the children); (7) previously oppressed people now demand their equal rights and equal opportunity, which not only changes the school situation for them but alters the whole social climate of going to school for every one. The physician searching the above for some clue to manage the child expected in his office tomorrow will be properly frustrated, since the big
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issues are beyond his power of intervention. This individual clinical problem requires the phenomena to be differentiated into three clusters of variability: (1) the absolutely fantastic individual variation in cognitive competencies and styles; (2) the extraordinarily complex adaptive task presented to a child by the requirement that he or she go to a particular school and classroom; (3) the mix of support, expectation, and interfering problems presented by the three major social systems in which the child is attempting to participate-family, school, and peer group. Understanding of the pervasive individual variations in cognitive performance is at present in its own primitive stage of development, and is roughly analogous to the understanding of viruses in the early 1950's. The bulk of educational psychological research has assessed the status of a child's educational endeavors by comparing his performance with that of other individuals of the same age. Underlying this practice was a focus on curricular content or what there was to teach. Implicitly, the child was an empty vessel of various age-determined shapes, into which information could be poured at will. To ridicule a naive model is, however, easier than providing an adequate replacement. Much confusion is present and can only be reflected here by pointing out that we may be talking about different things when we discuss perception, learning, memory, cognitive development, concept development, problem-solving, intelligence, or creativity. It would be foolhardy to attempt an exposition of anyone of these, much less make an attempt to reconcile their diversity or to try to relate them systematically to the subject areas, e.g., reading, language, mathematics, history, science, or to determine an appropriate instructional sequence. Most research has been performed on either college students or preschool children and the patient presenting to the physician will most often be in the elementary or secondary school grades. Research in these areas has yet to make a substantial contribution to the field of everyday education and to the physician concerned with the diagnosis and treatment of an individual patient. Ideally, one would like a detailed map of cognitive capacities with information about the pervasive individual differences; the relationship of each of these capacities to age; the effect of previous experience; prerequisite capacities; tests to locate an individual on the range of any skill with respect to criteria of performance rather than comparison to peers; precise knowledge of the cognitive capacities required by any given curriculum; and teaching techniques catalogued according to the cognitive capacities utilized. Failing in this, it is worthwhile to take a hasty look at some of the partial answers, not so much to give the physician usable tools as to inculcate a respect for the extraordinary range of individual differences. In one sense, the most ambitious and complete view of intellectual structure is that provided by Guilford, which, since it has not derived from the child development tradition, has been little used in education. Starting with adults, working from aptitude scale-type tests and utilizing
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factor analysis, this system describes a potential total of 120 different kinds of intelligence. A matrix of five operations - memory, cognition, divergent thinking, convergent thinking, and evaluation-act on four content categories - behavioral, figural, symbolic and semantic transformations, and implications. Perhaps 80 kinds of intelligence have been supported by actual test results. 4 The tests most widely used in schools are still those identified as IQ tests-the Stanford-Binet Test and the Wechsler Intelligence Scale for Children (WISC). These share the problem that they were developed with the underlying theory of a general intelligence factor. However, the WISC does consist of 10 different tests in two major categories - the verbal, consisting of information, comprehension, arithmetic, digits forward and backward; and the performance, consisting of picture completion, picture arrangement, object assembly, block design, digit symbol; and a special vocabulary sub-scale. Although it is invalid to project the score of any individual subtest to arrive at an IQ score, a practice has grown up of analyzing the subtest scores as well as the two major components, verbal and performance. An individual may demonstrate considerable scatter among the tests. Although the tests were chosen for their correlation with the total score rather than their ability to sharply differentiate different kinds of intelligence, the skilled, experienced psychologist can provide remarkable descriptions of -individual differences that often will be the best available to the physician. Certain cautions are in order, beginning with the repetition that this was not the purpose of the test and following with the precaution against either of two inclinations -assuming that scatter or an individual test is tantamount to a diagnosis of pathology or to assume that the highest score amidst a scatter represents a potentially "normal" IQ.! A widely used test in elementary schools is the Primary Mental Ability Test developed by Thurston on a factor analytic basis. This provides six subtests of performance in verbal, numbers, reasoning, word fluency, memory, and spatial. Illustrative of the general problem under discussion is the fact that if memory, as reported in the PMA, is further analyzed, it can be discovered that there can be differences between auditory and visual memory, or between remembering a series of items and remembering paired items. Brief mention of the more complex theories of cognition can add an appreciation for their complexity. Piaget has been systematically exploring how a child acquires knowledge for half a century. In this system, internal cognitive structures called schemes are in continuous adaptive interaction with the environmental structures, and through processes of assimilation and accommodation, progress from relatively simple structures based on sensory-motor action of infancy through specific concrete cognitive operations of the older child to the highly elaborate formal logic possible in adolescence and maturity. New intellectual structures are continuously and actively built on previous foundations. The moving force for intellectual development is within the cognitive apparatus and is not derived from any other set of body tensions or motives. 3 , 5 Piaget's theory is the antithesis of the empty jar view of intelligence: " ... passive interpretation of the act of knowledge is, in fact, contradicted
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at all levels of development and particularly at the sensory-motor and prelinguistic levels of cognitive adaptation and intelligence. Actually, in order to know objects, the subject must act upon them, and therefore transform them; he must displace, connect, combine, take apart, and reassemble them. From the most elementary sensory-motor action, such as pushing and pulling, to the most sophisticated and intellectual operations, which are internalized actions carried out mentally, e.g., joining together, putting in order, putting into one-to-one correspondence, knowledge is constantly linked with actions or operations, that is, with transformations."5 The effort to utilize Piaget's theories in education is only in its infancy, as are the efforts to use his system to build psychometric instruments, and to come to any understanding of individual differences. Bruner and his associates2 have devoted sustained effort to exploring school learning problems, to observing children performing in the classroom, and to altering the manner in which children are taught the strategies of problem-solving. In essence, these are intimately related to the style of classifying environmental stimuli, how an individual moves from defining certain attributes of an object or situation to classifying or identifying the object or situation. There is a fundamental process of development applicable to developmental stages in children, but also maintained in all cognitions in modes of representation. These are described as: enactive -a representational process dependent upon sensory-motor activity; ikonic-representing the world in imagery; and finally, symbolic-which frees the concepts from a dependence on perceptual cues and permits the internal manipulation of symbols in abstract and logical thought. These modes of representation are vital in consideration of the instructional process and Bruner has demonstrated remarkable achievements in teaching young children complex concepts. 2 With this background discussion of the complex, confused, and incomplete field of intelligence, it should be apparent that the apparently simple, if urgent, complaint of a parent that a child is not doing well in school is really an iceberg with behavioral, motivational and cognitive facets. We shall deal here with the large category of children who are, in their language "doing their thing," i.e., they are doing the best they can quantitatively and qualitatively in school with the given instructional process. Parents and school personnel may be unhappy with their academic performance for a host of reasons, but they have in common the desire for a different level or style of performance. Behaviorally the strong child may adapt well to the mismatching of expectations and cognitive ability or style, but most often, particularly if adverse conditions have gone on for months or years, the child is also demonstrating anxiety and depression, e.g., somatization, hyperactivity, withdrawal, hostility, lying, stealing, resentment of school. The difficulty in school can in itself be a major source of emotional distress. In fact, many school districts especially those in the inner-city are the source of much emotional distress and chronic school failure because of an inability to be flexible and responsive to the individual in curriculum and instructional style.
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The variety and shades of this problem are almost infinite but, for example, consider that each cognitive concept is actively constructed on the base of a previous cognitive activity, which in turn is dependent on the experience of the learner. Experience prior to school and out of school differ widely according to culture, ethnic group, race, social class, and family subculture. With a moment's reflection, this would appear to be obvious. But all of us must bear the shame of shared responsibility that allows "empty vessel" model of intelligence and the corresponding curriculum to be dominant. Instead of altering curriculum and style of instruction, the child or his race, culture, or class has been indicted as being deficient. The evidence is that these children are intellectually capable. Furthermore, the idea of a critical learning period should be severely examined. The so-called cumulative deficit is an artifact of the educational system. A quantity of curricular material is offered to the unprepared child. He fails, but the educational process moves on inexorably and another quantity of material is presented. So-called compensatory education misses the point by gratuitously offering to enrich the child's life rather than alter the instructional approach, sequences, and pace of the total educational experience. Results are also confounded by inability to deal with the higher prevalence of organic problems, the time range of individual variation within the cultural group, and the literally silly practice of insisting on instruction in a language not yet understood. A second category of youngsters subjected to the same educational process for entirely different reasons is found in almost every kindergarten, first, or second grade in the country. Even in culturally homogenous groupings the range of cognitive, sensory-motor, and behavioral control developed at the time of starting school varies enormously. In some of the early classes the most significant variable in altering the rank order of children in a classroom will be a few months of chronologic age. Perhaps, from 10 to 20 per cent of a given first grade class will be mismatched with the curriculum. 6 This group of youngsters shades inperceptibly into that group which may be diagnosed as having minimum brain damage or specific learning disabilities. The frequent description is that of a child of normal intelligence but behaviorally immature, in that his behavior is too motor-oriented and is lacking in either external verbal or internal controls. At first the child may be relatively impervious and oblivious to disapproval by the teacher and seems to maintain his good humor. However, this can last only so long, and resentment, hostility, and defensive lying or escape behaviors become part of the picture. Referrals of boys in this category will outnumber girls about three to one. There is suspicion that the cognitive disjunction with the curriculum may be equally prevalent in girls, but behavioral response to the frustration will be less motoric and aggressive and thereby incur less counteraggressive exclusion by teachers. The physician is often not consulted until relatively late in the process - even as late as adolescence, when again the secondary emotional problems attendant to the internalized self-image of failure becomes obvious and are too often well fixed. Further variation on this theme occurs when parents with perhaps
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considerable social and intellectual success of their own fail to appreciate that their children may not be equally gifted. Professionally trained parents are especially susceptible to this lack of sensitivity, and are particularly vulnerable if intellectual success has been a keynote of their personality structure, perhaps representing overcompensation for less well-developed artistic, cultural, athletic, or social skills. The intellectual aspirations of the parents may result in the misplacement of children into narrowly aimed private college preparatory schools or the advanced placement track of the neighborhood high school. In a credentialoriented society the completion of a particular segment of education does seem to open doors to future success, but level of academic achievement within that segment of education correlates much less with the broader definitions of success in later life. The management of these situations rests on: (1) the determination of the individual intellectual competence; (2) support of the child or adolescent in his efforts to establish his individual effort; (3) counseling of the parents in their efforts to understand and to find appropriate educational placement; and finally (4) consultation to the school as requested and, perhaps most important, action as an influential citizen in the community to obtain effective schools and teachers capable of responding to the variety of children enrolled. The physician needs to be alerted to another large category of children, though they are frequently not considered symptomatic. Scholastic achievement can be overvalued, but perhaps equally frequently the intellectual potential of a child is not valued or even considered by himself, his family, his physician, his peers, or his school. Cognition is but one of the adaptive systems for the human individual and social group, and it is a resultant of the environmental forces eliciting, selecting, and strengthening various potential cognitive skills. In many segments of society cognition is not identified as an active powerful tool of individual achievement. This is particularly true during infancy and preschool years. Many families are preoccupied with the more demanding necessities oflife - problems such as housing, nutrition, employment, transportation, health, money, physical energy, number of family members, family conflict, or physical and economic safety. Frequently neglected are activities of the infant and toddler in manipulating and exploring his physical environment and in being introduced through play to auditory, visual, and tactile stimuli that are the progenitors of symbols. Playing, talking, and reading with a child sometimes appear to be unnecessary, wasteful luxuries of time and energy in the hectic daily life of many parents. The pediatrician in the hurried well baby visits has focused on nutrition, physical growth and episodic illness. As a major carrier of culture, he must find means and opportunity to express as much concern for the intellectual development of the children under his care as he does for their physical growth. This extends to all considerations of pediatric education and hospital practice, as well as other aspects of child care in which the pediatrician may become involved such as day care centers and foster and adoptive homes. The preschool years have been emphasized because of their crucial influence on development and the way in which an individual's interac-
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tion with his environment is carried into the later years of childhood and adolescence through the mediation of the child's self-image and family and peer models. The school age child is acutely aware of which behaviors carry status and rewards within his family and peer systems. Positional or territorial power as a resident of a particular neighborhood, a member of a specific family or a street gang, or more simply the positional role of the child may be overriding determinants, as may physical strength, size, athletic skills, money, sexual attractiveness, and street cunning. The point is that cognitive skills are but a fragile and sometimes seemingly powerless tool in managing one's environment. The physician can only be alert to the different worlds in which his patients live. Finally, it is important to identify those situations in which emotional and mental illness interfere with the development and utilization of intelligence. Unfortunately, for those whose tolerance for ambiguity is low, there is no clear separation of the major syndromes under discussion. Any child may be considered in anyone or all, and the opening discussion of the confusion of disease and individual variation should be reconsidered. The life of any individual, from gestation on, can be considered to be a minute to minute, hour by hour, or year by year continuous process of solving the problems of transaction between the organism and the environment. The organic structures and physiologic processes in adaptation are the basic sciences of organic medicine. But the environment also consists of other individuals and a bewildering array of social events and problems. The individual's internal cognitive and emotional systems guide the adaptive process, but to a degree far beyond what occurs in the biological systems, individual cognitive and emotional systems are themselves simultaneously being shaped in the adaptive process. The problems of interpersonal relationships offer a variety of settings, exceeding by far the range of experience to whieh kidney or heart must respond. An incomplete, logically fluctuating, chronologie ordering of the pertinent problems of a child's growth, development, and interpersonal context may be helpful: the establishment of satisfactory biological rhythms of feeding, elimination, and sleep; the internalized expectation that biological tensions will not be overwhelming and annihilative; the development of the sense of early object constancy and trusting dependency on the care-taking person; the beginning foundations of the sense of self and differentiation of self from others; the appreciation of motor skills and integrity of body location in space; the playful and manipulative beginnings of language; achievement of independent locomotion and other motor controls such as self feeding and control of anal and urethral sphincters; the social problems of toilet training; the evolving gradient of biologic and psychologic dependency and autonomy, the establishment of a sense of primary trust and safety in the human environment; the self conscious discovery of power and social control; the awareness of gender; the stabilization of language and cognitive skills; the awareness of the family and differentiation of roles in the family on basis of age, sex, and size; the introduction to school; the peer group society; the accommodation to school, new subjects, new teachers; the new body accommodation of puberty; the acquisition of adult identity and vocational roles. At each point in time the individual is constructing internal cognitive
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schemes ofworId order, of reality and of the categories and content of significant object relationships. At each point in time the internalized patterns of previous experience are being applied to current stimuli guiding the response. At each point in time the emotional system is being calibrated to give signals of well being and danger, pleasure and pain, satisfaction and fear, happiness and sadness, love and hate. Most of this cognitive and emotional functioning and structuring takes place without awareness and responses are automatic, particularly through the first 6 or 7 years. Maturation of cognitive processes, as Piaget had demonstrated, takes place steadily through adolescence, with major stage differences occurring at 7 and again around 11 years. To a surprising degree, the functional integrity of the cognitive and emotional systems are independent, leading to the delineation of the major clinical categories of mental retardation and emotional disturbance. The mentally retarded child can be quite normal emotionally with satisfactory emotional valences on interpersonal object relationships. Obviously though, the mentally retarded child with limited cognitive skills is at a competitive disadvantage in many physical and social situations and will experience the emotional signals of threat, danger, fear, and loss, the same as any other child. Clinical management requires that the child's vulnerability be accurately assessed and adequate protective measures taken. Conversely, the emotionally disturbed child-except for the most severely disturbed-is usually free of structured cognitive defects, though obviously not spared the full range of individual cognitive variation. Emotions can influence the functions of the cognitive system in interfering with the problem-solving processes of sustained attention, memory, and generation of hypotheses. If a child, for example, is preoccupied with the death of a parent, sexual guilt, impending divorce of parents, anxiety over loss of body integrity, etc., he will not direct the problem-solving processes into the more emotionally neutral task of the school curriculum. Perhaps more destructive of school achievement is the involvement of the social environment of school or the peer group at school in the emotional conflict. The cognitive competence of the child is not impaired. Characteristically the child may get involved in a dominance conflict with one or more teachers, and the resentment of authority, aggressive behavior, and escape behavior preclude the application of effort to intellectual exercises. Similarly, the child who gets involved with dominance struggles in the peer group or is for some reason rejected by the peer group will not be attending to the academic problems. At times, these interpersonal conflicts with teachers or other children represent a displacement of conflicts generated in the family. Emotional disturbance is more severe when the disorder occurs earlier in the development of the individual. When the process of forming the basic sense of trust in parents, in acquiring sense of safety from external or internal sources of annihilation, or the essential development of a sense of autonomy is interfered with, disorders of psychotic proportions take place. Failure of development of communicative language and of primary identification with parents can lead to interruption of intellec-
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tual and emotional processes so severe that the child is identified between 2 and 4 years of age and requires intensive, prolonged, and specialized treatment. There is also a group of children who, while developing a major flaw in their concept of self, and are unable to move into autonomous psychological functioning, nevertheless are able, usually with tremendous overindulgence and over-protection of parents, to make it into adolescence before seeking assistance. Often they are of superior intellectual ability and despite major defects in motivation are able to keep up with their less well endowed peers. Eventually, high school or college becomes more demanding than their marginal effort can meet and parents can no longer protect them. They can display a variety of symptoms, from severe psychophysiological problems, through anorexia nervosa, to serious acting out or blatantly bizarre psychotic behavior. This has been a terse summary of the position of the pediatric physician confronted with a patient presenting with a functional disorder in learning. The philosophical problem, the state of our knowledge about intelligence, the concern about the child's position in an evaluating, demanding, educational storm, and those conditions under which emotional development interferes with cognitive functioning have been mentioned. Management of these children requires an interest and commitment of effort and time that most often appears impossible in the busy clinic or practitioner's office. Yet the problem will be an increasingly pressing one as pediatrics move into the maintenance of health and quality of medical care. Technically the pediatrician must learn ways of utilizing the doctor-patient relationship to alter the disturbed transactions of patient-parent-peer-teacher. The first step is an attitudinal move into unfamiliar space-a large step, since it requires a change in self-image, the value judgments of the academic pediatrician, an appreciation that the doctor-patient relationship can be a sharp scalpel or potent medicine, and a painful politicalization of pediatric practice. The most practical method of intervention in the immediate present is fairly prompt referral to child psychiatrists or other qualified child therapists. Personnel such as child psychiatrists, psychologists, social workers, educators, and trained paraprofessionals should be added to the pediatric group or to the pediatric clinic.
REFERENCES 1. Bayley, N.: Development of mental abilities, In Mussen, P., ed.: Carmichael's Manual of Child Psychology. New York, John Wiley and Sons, pp. 1163-1210. 2. Bruner, J.: A Study of Thinking, New York, John Wiley and Sons, 1960. 3. Flavell, J. H.: The Developmental Psychology of Jean Piaget. New York, D. Van Nostrand Co., 1963. 4. Guilford, J. P.: The Nature of Human Intelligence. New York, McGraw-Hill, 1967, p. 537. 5. Piaget, J.: Piaget's theory. In Mussen, P., ed.: Carmichael's Manual of Child Psychology. New York, John Wiley and Sons, pp. 703-732. 6. Snyder, R. and Pope, P.: Auditory and visual inadequacies in maturation at the first grade level. J. Learning Disabilities, 5:40-45 (Dec.) 1972.
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