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The triumvirate in the adjustment of the child with a ‘cerebral dysfunction’: Psychologist, teacher and physician
~SYCHOLOGIST IN ACTION ".s the school psychologist with , n children referred for diagnostic ~l efforts at programming or re~ us should be on the process of rts may, in narrative style, surer mendations, method of consult~ follow-up services. IIN I1"11:: P~UJU:)IMI:INI U l " THE It : ADJUSTMENT OF CHIt A 'CEREBRAL DYSFUNCTION': PSYCHOLOGIST, TEACHER AND PHYSICIAN PHY.( Ronald H. Lingren One of the most difficult educational problems facing 1 ,chologist and classroom teacher is the child labeled as "hyp, trauss syndrome", "minimal brain injury" or "cerc "cerebral dys The latter term is preferred by the author beca because man h behavioral and educational difficulties frequentl3 uently demor~ "soft" neurological signs (e.g., unestablished laterallty, lat, c tor incoordination, etc.). Generally, there is equi~ tuivocal ph~ tee of "brain damage" but a host of symptoms a ppear to afing and behavioral difficulties (perceptual and motor ~eractivity, distractability, etc.). Despite an increased incre: awareness of [dren with these problems, no thoroughly effective remediation program m has been devised to accomodate them educa' ucationally. Clements and! Peters (1962), Cruickshank, Ratzeburg and Tannhauser Ta ( 1961 ), Strauss ~uss and Lehtinen (1947), and Shields (1965) have ha offered fruitful sugigestions for their educational and behavioral management. mal The case described herein is an example of an eclectic approach devi;Jsed by the school psychologist, teacher, and ph) ~sician to manage andI educate a child with a "cerebral dysfunction." A seven-year, year, three-month-old boyy (J. (l. B.) was referred to the school psychologist for learnin arning and behavioral problems in the classroom. J. B. was nearing completion of the first grade and manifested the following problems: (a) a) "inability to complete a given task without constant reminders"; (b) "immature~difficult to motivate"; (c) "poor peer relations . . . aggressive"; ve"; (d) "poor achievement in reading, humbers and writing"; and (e) e) "poor attention, always too active to settle at reading or numbers for: any period of time." 11:
IKIUMYIKAIC
R. H. kingren is currentl,tly Director, Psycho-Educatlonal Clinic and Chairman, School Psychology Area Commifl~ imiflee at the University of Wisconsln-Milwaukee. Prior to obtalnlng a PhD in Education tiona[ Psychology at the University of Iowa, the author served as a School Psycholo! gist in Jefferson County, Iowa.
319
duation
proved
J. B. to be d
'
aent at the readiness level O n 1 R A T ) , J. B. could read only fo )rimer words on the Gray Oral was nonexistent on the W R words could be spelled. His per ditatively and quantitatively very m problems. zeption Test stories showed as~ stortion. The addition of many rt parts gave a "rambling"' effect to the stories. " Psychodyl 1 iking, his stories further indicated displacement of aggressive a a other children; they did not contain reprimands, or punist aggression (which seemed in accord with a lack of cont~ ressive behavior at school and home). In general, his react :er controlled and organized in the structured testing ISC) than in the relatively unstructured situation ( T A T ) . In the interview, J. B. was seemingly unafraid of the ¢ the the contrary, he made continued attempts to dominate dotal: h his egocentric remarks and tales. Generally, J. B. d, blems and projected the blame for behavioral difficulties dif a his peers. Time orientation appeared tenuous. Subsequent to the psycho-educational evaluation, j. B. was referred The physician t local physician for a neurological and physical exam. ex~ reported arted "active" hut not "hyperactive" reflexes. No neurological signs "so: signs" : borderwere•e present except those typically referred to as "soft laterality, hyperactivity, line hopping and balance control, unestablished latera and short attention span. approach for A conference designed to plan a total educational educatic ~hysician, principal, J . B~. . was arranged. It included the psychologist, ph and the retea a s[pecial education teacher, his regular classroom teacher, 4~1 ro,~A~n~ r P e ~ r o m P n d ~ t { n n ~ rresulting ~IG • e recommendations from this conmedial reading t,~,~,-,hov teacher. 'T'h,~ The ference were as follows: ethylphenidate (Ritalin). This cerebral stimu1. Drug therapy: methyl t ~xical calming effect upon children with signs lant often shows a parodoxical ." Other types of medication which have been of a "cerebral dysfunction." tccessful have been described by Clements and reported to be partially succe 962), and Whitsell (1965). Peters (1962), Doyle (1962), J. B. was to be seenLbiweekly by the physician for an evaluation of the medication effects. It was expected that the dosage would have les before optimal effects could be reached, if to be adjusted several times rye any effect at all. The teachers and parents indeed the drug would have were asked to report any aapparent medication e f f e c t s . . , the parents to ~v
o~
320
zd teachers at the commencement in a classroom containing few •e individual assistance could be this case an educable mentally Fhe teacher demonstrated a kee~ hildren in class who manifested jlties. The teacher was to work 1 writing readiness skills. Also, st ~wed an interest in a particular er [o reomm an interest m1 reading. reacung. Additional ~uoauonal work w in v itory discriminiation was recommended. The speci: ;pecific proce bed by Strauss and Lehtinen (1947) for use wit: with "brain dren were recommended. 3. Remedial reading - - three hours per week. wee The :her was to implement the techniques recomme commended by 43). Her method of reading instruction may be b sun'ln'l • ws: The child selects his own vocabulary, and in the f :ing is an important element in his learning. A new ne' word! the child in plain blackboard size script or in pl~rint if m ring is used. The child traces the word with the middle a :er saying each part of the word as he traces it. He repeats r th il he can write the whole word without looking at the tl copy. word once on scratch paper and then in his story. After the stor,y is written, it is typed for him and he reads it in i~ print. After the pl letters in his story is finished, the child files his words under the proper alphabeticaU aabetically arranged word file. The child automatically automatic drops tracing oncee he has learned to read and in later stages relies relJ more on oral, the auditory audit ~tory, and visual cues. Because the WISC indicated indic~ ~rocedures similar to those and • visual sequencing skills to be weak, procedures described :ribed by Shield (1965) were recommended. Remedial Rein reading was :ontinue throughout the entire year. to continue 4. A limited school day consisting of morning attendance until improvement in behavior could be observed. The school day was to be gradually expanded to a full till day attendance. 5. Behavioral limits set were to be consistently adhered to. For example, if J. B. became physically aggressive or demonstrated tantrum 'lost" a school privilege (e.g., carrying the behavior in school, he "lost" teacher's attendance report ,rt to the office; missed an art period or a portion of recess). However ever, specific attention was to be paid to ~ehavior rewarding the positive behaviol vior be it ever so small initially. The to ignore minor misbehaviors in order to teacher was encouraged avoid giving them reward status. eened corner for his "private desk" to be used 6. Provision of a screened J
A
1-
,.
1
1
1
1
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•
321
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•
the need for it. This was not pero private work area to be utiliz he became increasingly active into the regular first grade c ved in the "recreational" activit ]ually expanded to e n c o m p a s s rere adhered to and the foUov ss on a reduced time basis. Tt :noiogast cortterreu wxtn me= school scnool staff stau biweekly. mweeKly. A weekly 9rt was sent to the physician describing J. B.'s classroom cL s report assisted the physician in monitoring the rmedicafio ." boy and his parents were seen every two weeks for poss tification. After each visit, the psychologist and pl~hysician ut the progress of the case. Approximately seven weeks subsequent to the beginnin nificant impl school term, J. B.'s behavior began to show signific this time the physician had adjusted the medication medicatiol level t~ ~re an optimal level was attained. To the school staff, sta J. B. fistractable. :e attentive and motivated and less active and distl !aggressive behavior had been significantly reduced. reduc By :k, J. B. began part-time attendance with his regtular class week, he was "recreational" activities and, beginning the fourteenth fourtee and writing. arithl inte:grated into the regular classroom activities in arithmetic classes had rea At the eighteenth week, assimilation into the reading continued the guidelines beenn completed. The regular classroom teacher contin for behavior set up by the special teacher. Also, the private screened arose. corner aer in the regular class continued to be used as the need 1 At the completion of the first semester, J. B. was wa seen for a brief Test the cational evalaution. On the Wide Range Achievement Achk educational followin! 3wing grade level scores were obtained: Reading - - 1.4; Arithmetic - - 1.5; S p e l l i n g - 1.4. The teacher reported that he was progressing adequately through the primer imer in the reading series. At the end of the school chool year J. B. was again evaluated by the school psychologist. W R AkT T scores were: Reading - - 2.2; Arithmetic - - 1.7; S p e l l i n g - 1.9. On the oral reading subtest of the Durrell :ulty he scored at the 2.0 grade level. Reading Analysis of Reading Difficult had progressed to the comapletion of Book I of the series and he ranked lass of 26 children in the reading skills. 18th by the teacher in a class Placement in second1 grade was recommended. A conference to discuss future guidelines for the behavioral management of J. B. and his educational needs wass attended by the psychologist, all the school tucational tional planning for first grade, and his personnel ,involved in educatior 322
aer. Drug therapy was continued :tended to bimonthly intervals. grade, J. B. was described by th •k", "getting along well with pe of tantrum or aggressive beha~ ome and neighborhood confinuec Discussion >sychologist approach a mutual c~ Consequently, the gap of know ~nsibilities is perpetuated or t ened. Although the disposition and outcome of this tl partic ~ ideal, the successful cooperation among the sc school psy sician, and teachers in the experimental therapeuti~ Lpeutic prograI rebral dysfunctioning" child was evident. To enhance enham such p elationships as these, in-service training of psychol, ~sychologist and ooperation with local physicians is strongly suggeste ested. Many physicians and psychologists are unaware unawar~ of the adoxical effects of the cerebral stimulant drugs, although altt th~ ct on "brain-injured children" is certainly not universal. uni P :hologists and teachers may have to monitor the drug effi longed period of time with continued adjustment b [mal level can be determined. However, the dramatic dramatic behavio previously deLsometime occur with a drug regimen, as in the case c bed, should suggest its trial in selected cases. In this case, the medication, the remedial and individual indi instruction, combinz that brought and •the structured environment was the correct combination ut its successful conclusion. It is unlikely that an'y one regimen by about itselfLf could have facilitated the attained level of succes Success. The improved professional relationship between the tl school psycholteacher is ;t and local physician in cooperation with the classroom cla child with a "cerebral paramount amount in planning the total program for the chik dysfunction." References Clements, S. D. & Peters, J. E.~,. Minimal brain dysfunctions in the school-age child. Arch. o~ gen. Psychiat., 196~ 962, 6, 185-197. Cruickshank, W. M., Bentzen , F. A., Ratzeburg, F. H. & Tannhamer, M. T. A u-injured and hyperactive children. Syracuse; Syracuse teaching method for brain-in Univ. Press, 1961. ~perkinetic syndrome. ]. ot Sch. Health, 1962, 32, Doyle, P. J. The organic hyp 299-306. Fernald, G. M. Remedial techni~ niques in basic school subjects. New York: McGrawHill, 1943. Shields, O. L. Remediafion of learning disabilities in a public school system. Mental Retardation, 1965, 3, 27-28. Strauss, A. A. & Lehfinen, L. E. Psychopathology and education of the brain-injured child. New York: Grune &: Stratton, 1947. Whitsell, L. J. Neurological aspects of reading disorders. In Flower, Gofman & Lawson (Eds.), Reading disorders. Philadelphia, Pa.: F. A. Davis Co., 1965.
323
IKIUMYIKAIC
R. H. kingren is currentl,tly Director, Psycho-Educatlonal Clinic and Chairman, School Psychology Area Commifl~ imiflee at the University of Wisconsln-Milwaukee. Prior to obtalnlng a PhD in Education tiona[ Psychology at the University of Iowa, the author served as a School Psycholo! gist in Jefferson County, Iowa.
319
duation
proved
J. B. to be d
'
aent at the readiness level O n 1 R A T ) , J. B. could read only fo )rimer words on the Gray Oral was nonexistent on the W R words could be spelled. His per ditatively and quantitatively very m problems. zeption Test stories showed as~ stortion. The addition of many rt parts gave a "rambling"' effect to the stories. " Psychodyl 1 iking, his stories further indicated displacement of aggressive a a other children; they did not contain reprimands, or punist aggression (which seemed in accord with a lack of cont~ ressive behavior at school and home). In general, his react :er controlled and organized in the structured testing ISC) than in the relatively unstructured situation ( T A T ) . In the interview, J. B. was seemingly unafraid of the ¢ the the contrary, he made continued attempts to dominate dotal: h his egocentric remarks and tales. Generally, J. B. d, blems and projected the blame for behavioral difficulties dif a his peers. Time orientation appeared tenuous. Subsequent to the psycho-educational evaluation, j. B. was referred The physician t local physician for a neurological and physical exam. ex~ reported arted "active" hut not "hyperactive" reflexes. No neurological signs "so: signs" : borderwere•e present except those typically referred to as "soft laterality, hyperactivity, line hopping and balance control, unestablished latera and short attention span. approach for A conference designed to plan a total educational educatic ~hysician, principal, J . B~. . was arranged. It included the psychologist, ph and the retea a s[pecial education teacher, his regular classroom teacher, 4~1 ro,~A~n~ r P e ~ r o m P n d ~ t { n n ~ rresulting ~IG • e recommendations from this conmedial reading t,~,~,-,hov teacher. 'T'h,~ The ference were as follows: ethylphenidate (Ritalin). This cerebral stimu1. Drug therapy: methyl t ~xical calming effect upon children with signs lant often shows a parodoxical ." Other types of medication which have been of a "cerebral dysfunction." tccessful have been described by Clements and reported to be partially succe 962), and Whitsell (1965). Peters (1962), Doyle (1962), J. B. was to be seenLbiweekly by the physician for an evaluation of the medication effects. It was expected that the dosage would have les before optimal effects could be reached, if to be adjusted several times rye any effect at all. The teachers and parents indeed the drug would have were asked to report any aapparent medication e f f e c t s . . , the parents to ~v
o~
320
zd teachers at the commencement in a classroom containing few •e individual assistance could be this case an educable mentally Fhe teacher demonstrated a kee~ hildren in class who manifested jlties. The teacher was to work 1 writing readiness skills. Also, st ~wed an interest in a particular er [o reomm an interest m1 reading. reacung. Additional ~uoauonal work w in v itory discriminiation was recommended. The speci: ;pecific proce bed by Strauss and Lehtinen (1947) for use wit: with "brain dren were recommended. 3. Remedial reading - - three hours per week. wee The :her was to implement the techniques recomme commended by 43). Her method of reading instruction may be b sun'ln'l • ws: The child selects his own vocabulary, and in the f :ing is an important element in his learning. A new ne' word! the child in plain blackboard size script or in pl~rint if m ring is used. The child traces the word with the middle a :er saying each part of the word as he traces it. He repeats r th il he can write the whole word without looking at the tl copy. word once on scratch paper and then in his story. After the stor,y is written, it is typed for him and he reads it in i~ print. After the pl letters in his story is finished, the child files his words under the proper alphabeticaU aabetically arranged word file. The child automatically automatic drops tracing oncee he has learned to read and in later stages relies relJ more on oral, the auditory audit ~tory, and visual cues. Because the WISC indicated indic~ ~rocedures similar to those and • visual sequencing skills to be weak, procedures described :ribed by Shield (1965) were recommended. Remedial Rein reading was :ontinue throughout the entire year. to continue 4. A limited school day consisting of morning attendance until improvement in behavior could be observed. The school day was to be gradually expanded to a full till day attendance. 5. Behavioral limits set were to be consistently adhered to. For example, if J. B. became physically aggressive or demonstrated tantrum 'lost" a school privilege (e.g., carrying the behavior in school, he "lost" teacher's attendance report ,rt to the office; missed an art period or a portion of recess). However ever, specific attention was to be paid to ~ehavior rewarding the positive behaviol vior be it ever so small initially. The to ignore minor misbehaviors in order to teacher was encouraged avoid giving them reward status. eened corner for his "private desk" to be used 6. Provision of a screened J
A
1-
,.
1
1
1
1
•
•
321
e
•
the need for it. This was not pero private work area to be utiliz he became increasingly active into the regular first grade c ved in the "recreational" activit ]ually expanded to e n c o m p a s s rere adhered to and the foUov ss on a reduced time basis. Tt :noiogast cortterreu wxtn me= school scnool staff stau biweekly. mweeKly. A weekly 9rt was sent to the physician describing J. B.'s classroom cL s report assisted the physician in monitoring the rmedicafio ." boy and his parents were seen every two weeks for poss tification. After each visit, the psychologist and pl~hysician ut the progress of the case. Approximately seven weeks subsequent to the beginnin nificant impl school term, J. B.'s behavior began to show signific this time the physician had adjusted the medication medicatiol level t~ ~re an optimal level was attained. To the school staff, sta J. B. fistractable. :e attentive and motivated and less active and distl !aggressive behavior had been significantly reduced. reduc By :k, J. B. began part-time attendance with his regtular class week, he was "recreational" activities and, beginning the fourteenth fourtee and writing. arithl inte:grated into the regular classroom activities in arithmetic classes had rea At the eighteenth week, assimilation into the reading continued the guidelines beenn completed. The regular classroom teacher contin for behavior set up by the special teacher. Also, the private screened arose. corner aer in the regular class continued to be used as the need 1 At the completion of the first semester, J. B. was wa seen for a brief Test the cational evalaution. On the Wide Range Achievement Achk educational followin! 3wing grade level scores were obtained: Reading - - 1.4; Arithmetic - - 1.5; S p e l l i n g - 1.4. The teacher reported that he was progressing adequately through the primer imer in the reading series. At the end of the school chool year J. B. was again evaluated by the school psychologist. W R AkT T scores were: Reading - - 2.2; Arithmetic - - 1.7; S p e l l i n g - 1.9. On the oral reading subtest of the Durrell :ulty he scored at the 2.0 grade level. Reading Analysis of Reading Difficult had progressed to the comapletion of Book I of the series and he ranked lass of 26 children in the reading skills. 18th by the teacher in a class Placement in second1 grade was recommended. A conference to discuss future guidelines for the behavioral management of J. B. and his educational needs wass attended by the psychologist, all the school tucational tional planning for first grade, and his personnel ,involved in educatior 322
aer. Drug therapy was continued :tended to bimonthly intervals. grade, J. B. was described by th •k", "getting along well with pe of tantrum or aggressive beha~ ome and neighborhood confinuec Discussion >sychologist approach a mutual c~ Consequently, the gap of know ~nsibilities is perpetuated or t ened. Although the disposition and outcome of this tl partic ~ ideal, the successful cooperation among the sc school psy sician, and teachers in the experimental therapeuti~ Lpeutic prograI rebral dysfunctioning" child was evident. To enhance enham such p elationships as these, in-service training of psychol, ~sychologist and ooperation with local physicians is strongly suggeste ested. Many physicians and psychologists are unaware unawar~ of the adoxical effects of the cerebral stimulant drugs, although altt th~ ct on "brain-injured children" is certainly not universal. uni P :hologists and teachers may have to monitor the drug effi longed period of time with continued adjustment b [mal level can be determined. However, the dramatic dramatic behavio previously deLsometime occur with a drug regimen, as in the case c bed, should suggest its trial in selected cases. In this case, the medication, the remedial and individual indi instruction, combinz that brought and •the structured environment was the correct combination ut its successful conclusion. It is unlikely that an'y one regimen by about itselfLf could have facilitated the attained level of succes Success. The improved professional relationship between the tl school psycholteacher is ;t and local physician in cooperation with the classroom cla child with a "cerebral paramount amount in planning the total program for the chik dysfunction." References Clements, S. D. & Peters, J. E.~,. Minimal brain dysfunctions in the school-age child. Arch. o~ gen. Psychiat., 196~ 962, 6, 185-197. Cruickshank, W. M., Bentzen , F. A., Ratzeburg, F. H. & Tannhamer, M. T. A u-injured and hyperactive children. Syracuse; Syracuse teaching method for brain-in Univ. Press, 1961. ~perkinetic syndrome. ]. ot Sch. Health, 1962, 32, Doyle, P. J. The organic hyp 299-306. Fernald, G. M. Remedial techni~ niques in basic school subjects. New York: McGrawHill, 1943. Shields, O. L. Remediafion of learning disabilities in a public school system. Mental Retardation, 1965, 3, 27-28. Strauss, A. A. & Lehfinen, L. E. Psychopathology and education of the brain-injured child. New York: Grune &: Stratton, 1947. Whitsell, L. J. Neurological aspects of reading disorders. In Flower, Gofman & Lawson (Eds.), Reading disorders. Philadelphia, Pa.: F. A. Davis Co., 1965.
323