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Developmental Aphasia Observed in a Department of Child Psychiatry

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Developmental Aphasia Observed in a Department of Child Psychiatry Arch Dis Child: first published as 10.1136/adc.31.157.161 on 1 June 1956. Downloaded from DEVELOPMENTAL APHASIA OBSERVED IN A DEPARTMENT OF CHILD PSYCHIATRY BY T. T. S. INGRAM and J. F. REID From the Department ofPsychological Medicine, Royal Hospitalfor Sick Children, Edinburgh, and the Department of Child Life and Health, University ofEdinbrgh (RECEVw FOR PUBLICATION DECEMBER 7, 1955) Recent experience in the Department of Psycho- retained in this paper for want of another more logical Medicine, Royal Hospital for Sick Children, suitable. Edinburgh, has shown that educational difficulties To designate the reading and writing difficulties due to developmental aphasia were contributory the terms dyslexia and dysgraphia are employed. aetiological factors in a wide variety of behaviour By dyslexia is meant specific difficulty in learning to disorders. In the majority of patients the nature of read. This is evidenced quantitatively by retarda- the educational difficulties had not been recognized tion in reading attainment relative to the best avail- in time for them to obtain the maximum benefit from able estimate of intelligence and qualitatively by remedial teaching. In spite of increasing interest in resistance to normal methods of teaching and the the condition there still appears to be considerable recurrence of certain characteristic forms of error. delay in its diagnosis (Brain, 1955; Methven, 1955; The term dysgraphia applies similarly to the opera- Pearce, 1953; Morley, Court, Miller and Garside, tion of writing. The quantitative assessment of copyright. 1955). As a result many children suffer from dysgraphia is by a test of spelling, but the qualitative unnecessarily severe educational retardation and assessment covers all aspects of the writing opera- emotional stress. Yet we believe that the histories tion, of which motor function is only a part. and findings on examination of the majority of patients constitute a very characteristic clinical syndrome which should be recognized at an early Selecto of Patients in stage. In the present paper we review the findings Eight hundred and four patients were referred to http://adc.bmj.com/ 78 children of average intelligence who showed no the Department from January, 1954, to July, 1955, evidence of cerebral damage. for a wide variety of symptoms, which are shown in Table 1. Among them were 250 in whom educa- Tamenogy tional maladjustment was thought to be important, Specific difficulties in reading and writing have though only a minority were referred with the long been recognized as occurring in a proportion complaint of being backward at school. In most of the children educational maladjustment was of children of average intelligence who show no on September 27, 2021 by guest. Protected evidence of cerebral damage. The difficulties were attributed to intellctual or personality defects or attributed to 'word blindness' by Morgan (1896) and to neurological, visual or auditory abnormalities. Kerr (1897). Wben it became realized that many of There were, however, 78 children who proved the children with difficulties in reading and writing to be of average inteUigence on test and who were also had difficulties in comprehending and using the diagnosed as suffering from developmental aphasia. spoken word the terms 'developmental aphasia' and None of them showed evidence of neural, auditory 'developmental dysphasia' were coined to describe or cerebral abnormalities to which their symptoms this syndrome (Hinshelwood, 1917; Orton, 1937). could be attributed. Both terms are unfortunate and liable to lead to confusion, for though the majority of patients with developmental aphasia do show expressive or Sex and Age Ditbutio receptive aphasia the difficulties in reading and Sixty-five of the patients were boys, and 13 were writing are more consistently present manifestations. girls. The ages varied from 6 to 15, but more than The term developmental aphasia has, however, been half were between the ages of 6 and 9 years. 161 Arch Dis Child: first published as 10.1136/adc.31.157.161 on 1 June 1956. Downloaded from 162 ARCHIVES OF DISEASE IN CHILDHOOD Reasons for Referral History Taking. Psychiatric social workers in The reasons given for the referral of the patients the Department took detailed histories of the child's suffering from developmental aphasia, and those of physical, mental and social development, and noted other children sent to the clinic, are shown in Table 1. any family history suggesting psychiatric distur- bances or hereditary physical disorders. Teachers TABLE 1 were asked to supplement these histories with details CAUSES OF REFERRAL of the child's educational progress. The handed- ness of the patient's siblings, parents and parents' Primary Causes Secondary Causes siblings was determined, usually of necessity by of Referral of Referral 1- questionnaire. On the basis of their histories the Approxi- Appro:)xi- Approxi- Approxi- mate % mate mate % mate % psychiatric social workers attempted to define some Series of 726 OtI:her Series of 726 Other of the aetiological factors which might be important 78 Cliniic 78 Clinic Patients Patien,its Patients Patients in the patient's educational or general behaviour Educational difficul- symptoms. ties with or with- out other symp- was toms 33 20 39 4 Physical Examination. Every patient sub- Speech defects or jected to physical examination, including detailed retarded speech 5 6 9 2 Withdrawal, e.g., neurological examination. Audiometry, detailed day-dreaming, solitariness, fail- ophthalmic investigation and electroencephalo- ure to make graphy were performed when they seemed indicated friends, immature behaviour.. 12 17 9 8 to exclude the possibility of sensory or cerebral Night terrors 6 5 12 2 Aggression 3 2 6 8 abnormalities. Thumb-sucking and clothes chewing, etc. 3 8 5 Tests of 'Handedness'. Handedness was tested Blinking, twitching, rather unscientifically by noting the hand which the habit spasms 5 3 5 5 Temper tantrums 4 5 8 7 used in each of four tests carried child performance copyright. Aches and pains 4 4 8 6 Enuresis 6 1 1 10 10 out three times. Each patient was asked to turn Encopresis 4 4 4 6 a door handle, dig with a trowel and catch a ball. Asthma 5 2 1 2 Truanting 4 3 6 1 Patients using each hand six times or one hand Stealing-pilfering.. 6 10 3 7 in total of 12 Other 0 7 0 4 seven times and the other five the sub-tests were arbitrarily classified as ambidextrous Total 100 100 one hand or nine times ,~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ L (A). Patients using eight and the other three or four times were classified as It will be observed that educational difficulties being ambidextrous with lateralizing preference http://adc.bmj.com/ (sometimes specified further as poor progress in (A/L or A/R). If the child used one hand, 10, 11 learning to read and write) were the premier cause or 12 times, as the majority of other clinic children in 33 % of the cases. They were the only symptom did, they were classified as showing definite hand in 190%, and associated with others in 140%. In a preference (R or L). 'Footedness' was tested by further 39 % they were a secondary cause, but in as standing the child at the bottom of a flight of stairs many as 280% learning difficulties were not men- without a banister, and making him climb them and him to kick a ball three tioned at the time the initial history was taken. three times, asking on September 27, 2021 by guest. Protected Apart from a higher proportion of patients referred times. 'Eyedness' was tested by asking the patient on account of learning difficulties, the causes of to look through a punch hole in a card attached to referral of the group studied were remarkably the desk three times, and to sight a gun or a telescope similar to those of other clinic patients who did not three times. The eye and foot used for each test suffer from developmental aphasia. was noted. If the patient used each foot or eye for three sub-tests he was classified as showing no preference (A). If he used one eye or foot for The Method of Study four sub-tests he was classified as showing slight The patients suffering from developmental aphasia preference (A/R or A/L) and if he used the same were studied in more detail with the aim of defining side in five or six sub-tests he was considered to show more accurately the difficulties from which they marked preference (R or L). suffered, and the extent to which hereditary, social and educational circumstances seemed important in Speech. In as many cases as possible, interviews producing them. with patients were recorded on tape, in order that Arch Dis Child: first published as 10.1136/adc.31.157.161 on 1 June 1956. Downloaded from DEVELOPMENTAL APHASIA IN A DEPARTMENT OF CHILD PSYCHIATRY 163 detailed study of their speech could subsequently be ception and visualizing power enter into this. made in collaboration with phoneticians. In a few (2) Picture arrangement, in which a series of pictures cases it was found impossible to make recordings has to be arranged in correct order to tell a story. and speech studies were necessarily incomplete. (3) Block design, a version of Kohs' Blocks, where Apart from the recording of conversation, geometrical designs have to be reproduced to receptive and expressive aphasia was also tested by correspond with a given model. (4) Object assembly, means of a short series of selected questions and a test where cut-up silhouettes of objects bearing commands. some single line drawing have to be put together. Both outline and line drawing are used as clues, and Psychiatric Assessment Psychiatric interviews all the joins are straight line cuts. (5) Coding test, a with the patients were as frequent as possible and an series of geometrical shapes have to be inserted attempt was made to find out what environmental underneath their appropriate numbers (1-9) accor- factors the child felt to be important in causing his ding to a code given at the top of the page.
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