THE APHASIC CHILD* DIANA M . WHITING B.A. LOG (RAND) L . C . S . T . Speech Therapist, Groote Schuur Hospital, Cape Town Aphasia in children is of two main types, acquired aphasia and congenital or developmental aphasia. I n acquired aphasia, in a child whose language function has developed normally for his age, the disturbance may result from acute illnesses such as cerebral infections of encephalitis or meningitis; from cerebral tumour or cerebral abscess, or it may be due to a head injury. T h e result- ing language disturbance may be transitory and recovery is often good, residual deficit depending on the extent of the cerebral damage and the age of the child. It is this type of aphasia which we meet more frequently in our clinical experience at Groote Schuur Hospital. My clinical experience with the child with congenital or developmental aphasia is far more limited. Looking back I feel certain that misdiagnosis and failure to recognise the syndrome has played its part. For the purpose of this paper, I use the term congenital aphasia to imply a specific language disability of probable organic origin, a failure to develop symbolic language due to minimal diffuse neurological deficit, or at least some neurophysiological immaturity or a "developmental lag" as some writers prefer to think of it (de Hirsch, Bender, Ingram, Morley et al.). Most writers seem to agree that this special entity of the impairment of the acquisition of language function does exist. Aphasia is the term, controversial though it may be, most generally used to denote it. Some writers, however, restrict the term aphasia to refer to linguistic impairment of oral and aural .communications, whereas others extend it to embrace the continuum of the more complex language functions of reading, writing, spelling and composition (Arnold, de Hirsch et al.). Some feel the symptoms of aphasia in children are limited to language as expressed orally and perceived aurally whereas others feel elements of the syndrome are to be found outside of the behaviour of speaking and listening. T h i s seems reasonable to me as perception gives meaning to sensation and evidence of deficits of neurophysiological ^phenomena underlying linguistic behaviour should aid diagnosis and guide therapy planning. T h e child's ability to form concepts of size, shape, form, colour, number, time, space and so on is an integral part of learning to use func- tional language. Some writers feel that the diagnosis of aphasia is onlv plausible when the linguistic disturbance stems from a definite demonstrable organic * This paper was read on 14 October 1965 at the Cape Education Department's Conference for Teachers of Speech Defective and Hard of Hearing Children. Journal of the South African Logopedic Society, Vol. 13, No. 1: May 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) The Aphasic Child 37 o r i g i n , w h e r e a s o t h e r s feel t h a t t h e r e is a g r o u p i n w h i c h a l a r g e familial c o n s t i t u t i o n a l factor is i m p o r t a n t , a n d yet o t h e r s feel t h a t t h e l a n g u a g e s y m p t o m s t h e m s e l v e s a r e sufficient t o classify t h e d i s o r d e r as a p h a s i a . T h e s e d i v e r s i t i e s of o p i n i o n are, of c o u r s e , a n i n d i c a t i o n of t h e c o m - p l e x i t y of t h i s specific l a n g u a g e d i s a b i l i t y . D E F I N I T I O N S Eisenson defines aphasia in children as "an impairment of the ability to express and comprehend verbal symbols." West defines it as "an impairment of language function, receptive or expressive, resulting from maldevelopment or injury to the central nervous system pre-, para- or post-natally." Mycklebust defines is as "a language disorder which derives from organic impairment, i.e. a symbolic disorder due to neurological involvement." McGinnis and Kleffner define it as "an inability to express a n d / o r understand language symbols as a result of a deficit in the central nervous system rather than as the result of a deficit in the peripheral speech mechanism, ear or auditory nerve, a defect of intelligence or severe emotional disturbance." Language Development in Children F u n c t i o n a l l a n g u a g e d e v e l o p m e n t m a y b e d i v i d e d i n t o 3 t y p e s : 1. Inner Language: the language we use for inner life and thought. 2. Receptive Language: the language we use to understand others. 3. Expressive Language: the language we use to express thoughts and ideas to others. INNER LANGUAGE D u r i n g t h e first m o n t h s of life t h e infant r e c e i v e s m u l t i p l e s e n s a t i o n s of m a n y t y p e s . T h r o u g h g r a d u a l i n t e g r a t i o n h e d e v e l o p s a b a s i c i n n e r a n d f u n d a m e n t a l l a n g u a g e , i.e. a n a w a r e n e s s of s e n s a t i o n a n d r e c o g n i t i o n . A t 8 - 9 m o n t h s h e b e g i n s t o c o m p r e h e n d s p o k e n l a n g u a g e a n d at + 1 y e a r h e b e g i n s t o u s e e x p r e s s i v e l a n g u a g e . A c c o r d i n g t o K a r l i n , t h e d e v e l o p m e n t of r e c e p t i v e a n d e x p r e s s i v e l a n - g u a g e f u n c t i o n s follow a n o r d e r of i n c r e a s e d c o r t i c a l c o m p l e x i t y . R E C E P T I V E L E V E L S First Level: T h e awareness of sensation, or the arrival platform as Orton calls it. Second Level: Recognition, i.e. the ability to recognize objects and symbols and build u p memory constellations capable of recall. Third Level: Symbolic formulation where concepts are formed and language is elaborated. M O T O R L E V E L S First Level: Ability to contract striated muscles voluntarily. Second Level: Ability to prform purposeful movements. Third Level: Ability to express meaningful language. A disturbance and disorder of function at any of these levels will result in : Receptive Motor 1. Cortical blindness/deafness Dysarthria 2. Visual/auditory agnosia Dyspraxia 3. Receptive Aphasia Expressive Aphasia. Tydskrif van die Suid-Afrikaanse Logopediese Veren'ging, Vol. 13, Nr. 1: Mei 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 38 Diana Μ. Whiting Assessment In the absence of valid and reliable assessment techniques the diagnosis of developmental aphasia becomes one of elimination as is implied by McGinnis and K l e i n e r ' s definition. T h e aphasic child must be differentiated from the deaf child, the men- tally retarded child, the autistic child and the severely emotionally dis- turbed child for failure to acquire language and respond to speech is common to all these groups. Diagnosis should therefore be a multi-disciplinary process and should include: (a) A detailed developmental, medical and social history. (b) Neurological examination. (c) Psychiatric evaluation. (d) Psychometric testing. (e) Audiological investigation. (f) An assessment of inner, receptive and expressive language functions. (g) Observations of behaviour and neuro-physiological phenomna underlying linguistic behaviour. History. A careful developmental, medical and social history of the child must be taken. T h i s should include a family history of speech, reading, writing, laterality and neurological deficits. It is important to note the presence or absence of vocal play in infancy, and responses to sounds and speech. Such comments as "he doesn't listen," "he's disobedient," "sometimes he seems to hear sounds," "he keeps on saying ' w h a t ' " may prove to be significant, as may be reports of clumsiness, hyperactivity, falling, etc. Goldstein, Landau and Kleffner believe that the etiological background contributes to differentiation. They believe t h a t : (a) Meningitis, infantile infections and family history of deafness support the classification of deafness. (b) Jaundice from Rh incompatibility, anoxia at birth, convulsive disorders, congenital brain abnormalities and a family history of speech and neurological disorders support the classification of aphasia. Many asphasic children respond normally to social training in a broad sense and are then capable of fairly normal behaviour, whereas the autistic child and the severely emotionally disturbed child will present a different picture and is more likely not to respond to social training. Extreme "aloneness," failure to make contact and persistant bizarre behaviour may hallmark the autistic child. Neurological Investigation. Many aphasic children show/no obvious neurological deficit. Sub-clinical diffuse organic involvement may only be picked up when the child fails to acquire the complex activities of speaking and reading. Some show no deviations on classical neurological examination and electroencephalography. Yet performance on more subtle neurological tests may infer minimal neurological deficit. Focal abnormalities on electroencephalography are more common among aphasic than deaf children as is "obst'ruseness" during neurological test- Journal of the South African Logopedic Society, Vol. 13, No. 1: May 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) The Aphasic Child 39 ing as evidenced by an inability to grasp a perceptual non-language task (Goldstein, Landau and Kleffner). Psychiatric Evaluation. Receptive and expressive language functions are frequently disturbed in severely emotionally disturbed and autistic children. T h e bizarre behaviour and failure to make contact exhibited by the autistic child may be readily distinguishable to those familiar with the disorder. But the partially autistic child and the emotionally disturbed child may not be so readily recognized without the help of a child psychiatrist. Psychometric Testing. Testing the intelligence of the non-communi- cating child presents the psychologist with many problems. Testing pro- cedures which require no language in their administration and response may be required. T h e performance and verbal scales of the Wechsler Intelligence Scale for Children seem to be the most commonly used here in assessing child- ren with brain damage or suspected neurological deficit. In this test it appears that there are also certain items which enable the tester to distinguish the neurologically involved child with a language deficit. Memory for temporal and spacial patterning appears to be markedly weak in aphasic children, and therefore memory test items may be diag- nostically significant. However, it must be remembered that ultimately it is the information derived from the analysis of the test results rather than the score that is of importance and significance in planning treatment and education. Visuo-motor Organization. In this sphere the Bender Gestalt T e s t is useful. Responses in the aphasic child seem to be developmental^ immature or to show poor spacial organization (de Hirsch). Goodenough Draw-a-Man Test, de Hirsch finds the responses of a child with a specific language disability may be two years behind his mental and chronological age, indicating disturbances of body schema. Figure Ground Organization.. Differentiation between figure and ground is essential for both speech and reading, i.e. in both auditory and spacial areas. Spacial Organization. T h i s must be observed within the age limits of the child. Ambilaterality is related to difficulties with temporal and spacial sequences. T h e child who says "ricecrispsy" for "rice crispy," "hostipal" for "hospital" and the one who reads " w o n " for " n o w " and " t a p " for " p a t " has the same difficulty but in different modalities. Confusion of temporal and spacial organization, according to de Hirsch, may be related to familial factors but is also indicative of central nervous system immaturity or deficit. Audiological Investigation. Children who do not respond to sound or speech are not necessarily deaf, nor can they all be educated by methods conventionally used with the deaf. One of the most striking features of the aphasic child's behaviour is his inconsistency of response. This inconsistency of response to all types Tydskrif van die Suid-Afrikaanse Logopediese Verening, Vol. 13, Nr. 1: Mei 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 4 0 Diana Μ. Whiting of hearing tests makes assessment of his hearing-potential extremely, diffi- cult. It may be some time before a reliable audiogram is obtained, for at times the child seems to be hard of hearing, and at other times not. Attention span is generally poor, so it is wise to test for quiet sounds first. He may alert to faint sounds such as the rustling of tissue paper or a quiet " s h " and fail to respond at all to loud sounds and speech. He may show a normal response to one or two sounds only. He may alert to everyday sounds or unusual sounds, but fail to alert to speech. If no startle response is elicited it may be necessary to use psycho- galvanic or electroencephalographic audiometry to establish the presence or absence of hearing. Gordon and Taylor have reported some interesting .work with electroencephalographic audiometry in Manchester with child- ren with severe communication disorders. T h e y have recorded responses at 30 db in children who have failed to respond at all to conventional pure tone and speech audiometry. Such results are significant diagnostically in that peripheral hearing is intact, and so cortical deafness and auditory agnosia are implied. Goldstein, Landau and Kleffner reported half the aphasic group at the Central Institute for the Deaf to have some degree of peripheral hear- ing loss but this was not considered to be the major factor contributing to their failure to use language. T h e y n o t e d : (a) Normal hearing or moderate loss on all frequencies was characteristic of the aphasic group. (b) Sloping audiograms with severe loss was characteristic of the deaf group. (c) Sloping audiograms with moderate to severe loss were found in both groups. (d) Normal vestibular responses were characteristic of the deaf group, except in meningitis when there was no response. (e) Depressed vestibular responses were characteristic of the aphasic group. Assessment of Language Function: (a) Inner Language. This may be observed by presenting the child with toy objects and family figures related to his environment and watching his play for association of objects, con- creteness and abstractness. It is likely that the aphasic child's play is less imaginative than the deaf child's. (b) Receptive Language. Observations must include auditory memory and auditory discrimination as well as auditory recognition and compre- hension of language of increasing complexity. Predominantly Receptive Aphasia. T h e basic characteristics a r e : i. An inability to understand and use language. ii. A poor memory for learning it. Other clinical manifestations are variable. T h e following are typical: i. Intelligence within normal limits. / ii. Normal or slightly impaired hearing. iii. Inability to associate names with objects. iv. Inability to name objects. v. Inability to imitate names of objects. vi. Poor recall of names he has repeated. vii. Inability to interpret and use environmental language. According to McGinnis the speech behaviour of these children mani- fests itself in 4 different ways: i. Silence or rare vocalization. ii. T h e use of jargon with inflections indicative of adequate hearing. Journal of the South African Logopedic Society, Vol. 13, No. 1: May 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) The Aphasic Child 41 iii. Jargon speech interspersed with intelligible words or phrases. iv. Echolalia, where the child can repeat words and phrases without any associa- tion of meaning. R e c e p t i v e a p h a s i a is f r e q u e n t l y a c c o m p a n i e d b y o t h e r c o n d i t i o n s a n d it m a y b e difficult t o d e c i d e w h i c h is t h e p r e d o m i n a n t factor i n t h e failure t o l e a r n s p e e c h a n d l a n g u a g e . (c) Expressive Language. A s s e s s m e n t of e x p r e s s i v e l a n g u a g e a b i l i t y m u s t b e g u i d e d b y t h e stage of l a n g u a g e d e v e l o p m e n t , if a n y , t h a t ' t h e c h i l d h a s r e a c h e d . I t is i m p o r t a n t t o n o t e h i s a b i l i t y t o u s e vocal p l a y a n d h i s a b i l i t y t o n a m e o b j e c t s , r e p e a t n a m e s or s o u n d s , u s e o n e w o r d s e n t e n c e s , p h r a s e s , e t c . Predominantly Expressive Aphasia. T h e b a s i c c h a r a c t e r i s t i c s a r e : i. Intelligence within normal limits. ii. Adequate hearing and understanding of speech. iii. I n general behaviour symptoms of perseveration, disinhibition, hyperactivity and distractibility are in evidence. iv. Echolalia, where the child can repeat words and phrases without any associa- wardness, poor balance, a tendency to fall and confused laterality. S p e e c h b e h a v i o u r m a n i f e s t s itself i n t h e following m a n n e r : i. Vocalization may be limited to staccato vowels and occasional consonants. ii. T h e r e is usually some evidence of a constant chatter of perseverative patterns in no way resembling words these children attempt to say. iii. A limited ability to imitate words. iv. A limited ability to initiate speech sounds. v. A delay in onset of speech until the age of four years or later. vi. A pronounced difficulty in memory for sequences of sounds. W h e n a s s e s s i n g older" c h i l d r e n w i t h s p e e c h a n d / o r r e a d i n g d i s a b i l i t i e s w h o h a v e h i s t o r i e s of late a c q u i s i t i o n of s p e e c h , t h e following c h a r a c t e r - istics m a y b e i n d i c a t i v e of r e s i d u a l specific l a n g u a g e d i s a b i l i t y a n d s h o u l d t h u s b e fully i n v e s t i g a t e d : i. Poor memory for word sequences in sentences, e.g. question and negation forms such as " H e r come here?" " M e no can do." ii. Difficulty in discriminating like sounds. iii. Confusion of the beginnings and ends of words. iv. Word-finding difficulties. v. Many sound substitutions and the omission of final consonants. vi. Pronounced developmental lag in the language area. vii. Grammatical confusions, e.g.: Omission of prepositions and articles. Omission of forms of the verb "to be," e.g. "Billy going school." Objective use of pronouns, e.g. " M e do it," "her want it." Infinitive form of verbs for every person. Exclusive use of the present tense. viii. Striking monotony with distortions of rhythm and rate. ix. Motor immaturity such as turning the head when flexing the tongue. x. Difficulties with conceptualization related to time and space. xi. At about twelve years or m o r e : Trouble with formulating ideas. Poor ability to put a story together. Difficulty in functioning on a high abstract verbal level. Difficulty with literal and figurative meanings of words. Difficulty with metaphors. A marked concreteness, e.g. an ability to do better with pictorial rather than verbal absurdities. E a r l y d i a g n o s i s a n d t r e a t m e n t for t h e a p h a s i c c h i l d is a d v o c a t e d b y all w r i t e r s . P r o g n o s i s is infinitely b e t t e r , p a r t i c u l a r l y for s e v e r e cases w h e n Tydskrif van die Suid-Afrikaanse Logopediese Verening, Vol. 13, Nr. 1: Mei 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 4 2 Diana Μ. Whiting the problem is recognized early and adequate treatment is provided in the pre-school years. Treatment There appear to be two main approaches to the treatment of young aphasic children: 1. The Association Method. T h i s was devised and used at the C e n t r j l Institute for the Deaf by McGinnis. It is an elemental approach in which the child is taught t o : (a) Articulate a number of speech sounds correctly. (b) Produce several individual sounds in a set sequence. (c) Read and write these sounds. T h i s is all taught before the sequence is identified as a word and associated with an object or picture representing it. · A multi-sensory approach is emphasized to reinforce the auditory channel and when a number of words have been acquired, sentence building is begun. Cursive writing, never printing, is used from the start. 2. Synthetic Approach. T h i s approach starts with a word as a unit of language in order to let the child develop the concept of the word as a symbol. Eisenson advocates a uni-sensory approach initially until some basic symbolic communication is established, whether this be gesture, reading or speech, before reinforcement and further learning through a multi-sensory approach is begun. Both methods emphasize the need to speak slowly and clearly to the child at all times. According to authorities such as McGinnis, Eisenson and others; chil- dren with aphasia uncomplicated by other disorders, diagnosed correctly and treated from an early age may be ready to take their place in the ordinary classroom from the age of 9 or ι ο years. Those with less severe disturbances may be ready to take their place in the ordinary school system from the start, but may require special help with speech and the complex language functions of reading, writing, spelling and composition. T h e problem of childhood aphasia is a complex and- fascinating one requiring a multi-disciplinary approach. There is an increasing awareness in this country of the need for an expert team of specialists and educators to investigate this problem, develop reliable diagnostic techniques and to provide suitable treatment and education for this type of child. Opsomming 'n Kort opsomming van die algemene gedagte in verband met die verloop van aangebore of ontwikkelde afasie dien as 'n verwys van die ingewik- keldheid van hierdie spesifieke taalgebrek. Die identifisering van hierdie taalgebrek is afhanklik van 'n multi- disiplinere benadering tesame met neurologiese, psigiatriese, psigometriese en oudiologiese ondersoek en beraming van innerlike reseptiewe en ekspres- siewe taalvermoe. Journal of the South African Logopedic Society, Vol. 13, No. 1: May 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) The Aphasic Child 43 Die twee vernaamste behandelingsmetodes is reeds genoem en die belang- rikheid van vroee volledige diagnose en behandeling is benadruk. REFERENCES 1. Arnold, G. E. (1963): Language Disability. Speech Path. Therapy, 6, 15· 2. Clarke, R. (1962): Language Behaviour of Children with Unsuspected Brain Injury. Logos, 3, 22. 3. Critchley, M c D . (1963): The Problem of Congenital Dyslexia. Proc. Roy. Soc. Med., 56, 209. 4. de Hirsch, K. (1961): Diagnosis of Developmental Language Disorders. Logos, 4 . 3. 5. Eisenson, J. (1963): Disorders of Language in Children. J. Paed., 82, 20. 6. Goldstein, R., Landau, N. and Kleffner, F. R. (1958): Neurological Assess- ment of Some Deaf and Aphasic Children. Anal. Oto. Rhin. Laryng., 67, 468. 7. Gordon, N . and Taylor, I. (1964): Assessment of Children with Difficulties of Communication. Brain, 87, 121. 8. Gordon, N., Taylor, I. and Renfrew, C. (1964): The Concept of Central Deaf- ness; Differential Diagnosis of Hearing Disorders; Assessment of the Late and Poor Talker in The Child who Does not Talk: Report of an International Study Group, St. Mary's College, Durham, 1963. Ed. Renfrew, C. and M u r p h y , K. T h e Spastic Soc. Med. Educ. & Information Unit in association with William Heinemann Medical Books L t d . 9. Ingram, Τ . T . S. (1965): Specific Retardation of Speech Development. Speech Path. Therapy, 8, 3. 10. Ingram, Τ . T . S. (1963): The Association of Speech Retardation and Educa- tional Difficulties. Proc. Roy. Soc. Med., 56, 199. 11. Ingram, Τ . T . S. (1959): Specific Developmental Speech Disorders in Child- - hood. Brain, 82, 450. . 12. Ingram, Τ . T . S. and Reid, P. (1956): Developmental Aphasia Observed in a Department of Child Psychiatry. Arch. Dis. Child., 31, 161. 13. Karlin, I. W. (1954): Aphasia in Children. A.M.A. J. Dis. Child., 87, 752. 14. McGinnis, M . (1963): Aphasic Children. St. L o u i s : Graham Bell Assoc. for the Deaf Inc. 15. Morley, M., Court, D., Miller, H . and Garside, R. F . ( i 9 5 5 ) : Delayed Speech and Developmental Aphasia. B.M.J., 2, 463. 16. Mycklebust, H. (1957): Aphasia in Children in Handbook of Speech Patho- logy. New Y o r k : Appleton-Century-Crofts. 17. Nicolas, Mother M. (1962): The Aphasic Child. J. Irish Med. Assoc., 296, 42. 18. Reinhold, M . (1964): Congenital Dyslexia. Speech Path. Therapy, 7, 100. 19. Reinhold, M . (1963): Laterality and Reading and Writing. Proc. Roy. Soc. Med., 56, 203. 20. West. R. et al. (1962): Childhood Aphasia in Proceedings of the Institute on Childhood Aphasia, Stanford University School of- Medicine. California: Stan- ford Univ. Press. Tydskrif van die Suid-Afrikaanse Logopediese Verenging, Vol. 13, Nr. 1: Mei 1966 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)