JOURNAL OF THE SOUTH AFRICAN LOGOPEDIC SOCIETY WORD DEAFNESS KATRINA DE HIRSCH, L.C.S.T. and The term "word deafness" has been used in the literature with reference to both children and adults; the present discussion is confined to word deafness in children. The word-deaf child is entirely or partially unable to comprehend spoken language. In some of the milder cases all that can be observed is a time lag between reception and interpretation of the verbal, stimulus. There may or may not be difficulty in attaching meaning to sounds other than language such as the ring of the telephone or the bark of a dog. Occasionally there is trouble with localiza- tion of sounds. However, the disturbance is essen- tially on the verbal symbolic level and these children are often good at interpreting the inflection of the speaker's voice or his facial and bodily expression. The degree of expressive language impairment varies. Language may be non-existent, limited in quantity or poor in quality; jargon may be substi- tuted for meaningful speech. The diagnosis of word-deafness is appropriate only when significant peripheral auditory loss, mental retardation and psychopathology are ruled out as major contributory factors. Differential diagnosis is by no means always easy (particularly in the case of young children) and can be arrived at only by a process of elimination. It was Kussmaul(8) in 1877 who first coined the term "word-deafness" when referring to patients who had difficulty with comprehension of speech. Allen( 1 ) in 1951 divided the historical development of the concept into four phases. During the first phase from 1828 to 1868 the tendency was (with only a few exceptions) to regard word-deaf children as idiots. During phase two (from about 1868 to 1900) the expressive aspects of the disorder were emphasised, and Hale-White, Golding-Bird, Bastian and others described children who had a language all their own. During phase three, lasting through World War I, there; was a shift back to the receptive field. During the fourth phase the study of traumatic aphasias resulting from the first world war gave new impetus! to these investigations. Wallin in 1927 first suggested that the disorder might be more widespread than was generally recognized. Worster-Drought's(13) description of the syn- drome is basic to present understanding of the dis- order. He said that these children's speech, once it develops, is monotonous, indistinct and often complicated by what he calls verbal aphasia. He feels that the disturbance is probably the result of a biological variation in the nature of an agenesis. Froeschels(5) focusses interest mainly on the audi- JEANETTE JEFFERSON JANSKY tory inattention of word-deaf children and recom- mends therapy directed towards this aspect of the syndrome. In 1937 Orton ( 1 1 ) drew attention to the hyperactivity of word-deaf children, also to their delay in developing a master hand. He was parti- cularly interested in what he calls "developmental" word deafness — cases which did not show a reli- able history of brain-injury but in whose family background there was ample evidence of various forms of language disability. Ewing's(4) study in 1940 showed that of 10 children who had been diag- nosed as word-deaf six had high frequency losses, thus pointing up the necessity for careful hearing evaluation. Nance ( 1 0 ) , in 1946, described intelli- gence evaluation of word-deaf children by means of tests not requiring comprehension and use of language. In a report in 1950 Goldenberg((1) (stimulated by Bangs' study done in 1948) did an exploratory investigation on 14 children said to be word-deaf, by comparing their performance with that of 10 "normal" youngsters and found that in- tellectual retardation, brain injury and regional hearing loss accounted for "numerous" cases diag- nosed as being word-deaf. Carrell and Bangs( 2 ) in 1951 asserted that trouble with language compre- hension was but one aspect of a more widespread syndrome and suggested that disturbed visuo-motor function, poor abstract performance, inferior figure- background discrimination are worth while investi- gating. In a paper in 1952 de Hirsch( 3 ) took up some problems in differential diagnosis and drew attention to the fact that profound auditory inatten- tion, tendency to echolalia and paucity of language are features found both in word-deaf and in autis- tic children and that only prolonged clinical obser- vation of the child's total behaviour enables the clinician to discriminate between the two. She emphasized the fact that while not all word-deaf children show a positive electro-encephalogram or gross neurological signs, observation of their per- formance reveals perseveration, stimulus-bound behaviour, severe hyperkinesis and difficulty with control. In a later publication(3) she stresses these children's basic Gestalt difficulties. Myklebust(9) in- his book published in 1954, throws light on behavioural symptoms of word-deaf children. He feels that their disturbance on the cortical level makes for difficulty with integration in most areas of functioning. Strauss(12) in his very important contribution to the problem views word-deaf child- ren as brain-damaged. Brain injury, he says, results in poor development of basic sensory-motor schemata and thus leads to difficulty with language reception and expression. 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) JOURNAL OF THE SOUTH AFRICAN LOGOPEDIC SOCIETY November The latest (as yet unpublished) study in the field by Jansky(7), who with de Hirsch investigated in detail 12 word-deaf children, points in the same direction. Diagnosis of word-deafness in this investigation was arrived at after other possible etiology had been ruled out. The audiograms of some of the children studied showed some incon- sistency.. However, careful testing (including the psycho-galvanic skin resistance test) proved absence of a significant peripheral hearing loss in every single case, though some patients manifested marked delay in response to verbal stimuli. All of the 12 children were carefully evaluated as to intel- lectual potential. In addition to a quantitative analysis (the children's I.Q. ranged from dull normal to superior), they were analysed qualita- tively- so as to assess functioning in areas other than language. All 12 cases were studied by signs of withdrawal or other psychopathology and only if it was possible to really reach the child was the diagnosis of autism ruled out. Jansky closely inves- tigated the receptive aspect of language by testing the children's interpretation of both words and sentences. Inability to attend to verbal material, need for frequent repetition of linguistic stimuli, excessively short auditory memory span were all found to be of interest. The categories articulation, intelligibility, quantity of verbal out- put, pitch and rate were evaluated so as to assess the children's competence in terms of the expres- sive aspect of language. The children's body image, their perpetual, their motor and their visuo-motor performance were studied, as well as figure-ground discrimination. In addition, other "soft" neuro- logical signs: evidence of disorganization, impul- siveness, distractibility, rigidity and perseveration, were noted. Laterality was evaluated in the frame- work of the child's ability to deal with spatial rela- tionships. The results of Jansky's study showed that in word-deaf children language deviations are accompanied by disturbances in other areas of functioning and suggest that their performance is similar to that found in youngsters with verifiable brain-injury. Severe word-deafness is not a frequent syndrome. When it occurs there is often a history of anoxia, birth injury, haemorrhage, convulsions, or erhyro- blastosis fetalis due to the RH factor. In cases where neurological and encephalographic tests are negative it has been usually inferred that one deals with what is generally called "developmental" word- deafness. However, Strauss' findings indicate that diffuse organicity can be inferred from severe motor area as well as from behavioural and lan- guage symptoms in the absence of a positive electro- encephalogram and gross (as opposed to soft) deviations in the percepetual-motor and visuo- neurological signs. One therefore feels inclined to assume that many of the cases diagnosed as "developmental" actually do present diffuse, non- focal and probably mild organic signs on a central level. The writers agree with Strauss that word-deaf children have trouble with fundamental sensory- motor-schemata. They feel that these youngsters' inability to respond to the highly complex patterns as they are presented in spoken speech is but one aspect of their difficulty with perceptual-motor and visuo-motor configurations. They have trouble structuring the perceptual field and experience speech in a diffuse, undifferentiated manner. The figure — be it the spoken word or the sentence — does not stand out from the vast number of unorganised stimuli constantly impinging on the organism. Thus, words fail to have meaning. The word-deaf child's attempts at speech—monotonous, indistinct, formless and slurred, reflect equal diffi- culty in organization and differentiation. From these theoretical assumptions certain con- clusions can be drawn for therapy: 1. While word-deafness in severe form is a rare occurrence, it is probably insufficiently recog- nized that a relatively large number of children referred for dyslalia suffer from mild, receptive language disturbances — even where there is no significant peripheral hearing loss. Failure to recognize that the resulting paucity of lan- guage, the paragrammatism and the poor motor speech patterns have a receptive basis, results in wasteful and ineffective therapeutic efforts. 2. Inconsistent audiograms are fairly typical for word-deaf children. 3. A time lag in response to auditory stimuli is not always due to a hearing deficit, nor is it necessarily an indication of mental retardation. It might occur as part of the word-deaf syn- drome and represent difficulty with differentia- tion and integration of the essential feature" of an auditory experience. 4. Since the latest studies have shown that hyper- kinesis and distractibility are important feat- ures of the syndrome (many of these children are explosive and disorganized) it would follow that they need help with structuralization of their environment. The number of stimuli has to be reduced, and a relatively simple frame of reference has to be set up before language train- ing can be undertaken. 5. Since it is assumed that these children's diffi- culty is primarily one of organization of complex auditory configurations, the cutting down of these configurations into shorter units is thus a prerequisite of treatment. Speech must also be slowed up, dramatized in actual life situations. Constant repetition of verbal stimuli is needed to facilitate the integration of the material of experience with the linguistic symbols representing' them. 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) JOURNAL OF THE SOUTH AFRICAN LOGOPEDIC SOCIETY BIBLIOGRAPHY (11 Allen I. " T h e History of Congenital Auditory Imper- ( ception:·' The New Zealand Medical Journal, 51: 239- 274; June 1952. m Carrel James and Bangs, Jack. " D i s o r d e r s of Speech U ) comprehension Associated with Idiopathic Language R e t a r d a t i o n . " T h e Nervous Child, 9: 64-76, 1957. (3) De Hirsch, Katrina. "Developmental W o r d Deafness and SDeech T h e r a p y . " Bulletin of the Orton Society, 3 11-20- April 1953 " G e s t a l t Psychology As Applied to Language Disturbances." Journal of Nervous and Mental Diseases, Vol. 120, Nos. 3: 4, 1954. (4) Ewing, Alex. Differential Diagnosis of Aphasia in Children, London Oxford University Pifess, 1940. (5) Froeschels, Emil. " P u r e W o r d Deafness in a Child (Auditory Verbal Agnosia Nielsen) " T h e Quarterly Journal of Child Behaviour, 1: 228-240; April 1949. (6) Goldenberg, Samuel. " A n Exploratory Study of some Aspects of Idiopathic Language Retardation. ' The Journal of Speech and Hearing Disorders, 15: 221 - M i , September 19t>0. (7) Jansky, Jeanette. " W o r d Deafness Viewed as One Aspect of An Inclusive S y n d r o m e . " Paper written for City College, N e w York, M a y 1955. (8 Kussmaul. " D i e Sterungen der Sprache," Ziemssen's Handbuch der Speziellen Pathologie und Therapie 1877. (9) Myklebust, Helmer. Auditory Disorders in Children, N e w Y o r k : Grune and Stratton, 1954, 380p. (10) Nance Lorna. "Differential Diagnosis of Aphasia in Children." The Journal of Speech Disorders, 2: 219- 223: September 1946. (11) Orton, Samuel. Reading, W r i t i n g and Speech P r o b - lems in Children. N e w Y o r k : W . W . Norton and C o m - pany, Incorporated, 1957 , 215p. (12) Strauss, Alfred. " A p h a s i a in Children." American Journal of Physical Medicine, 32, 93-99, 1954. Strauss, Alfred and Kephast, Newell. Psychopathology and Education of the Brain-Injured Child. (Volume I I ) N e w Y o r k : Grune and Stratton, 1955, 267p. Strauss, Alfred and Lehtinen, Laura. Psychopatholosy and Education of the Brain-Injured Child... N e w Y o r k : Grune and Stratton, 1950, 220p. (13) Worster-Drought, C. "Congenital Auditory I m p e r - ception (Congenital W o r d Deafness) and its Relation to Idioglossia and Allied Speech Defects." T h e Medical Press and Circular, 210, 411-417. BOOK REVIEWS THE RIDDLE OF STUTTERING, C. S. Bluemel, M.D., Danville, Illinois: The Interstate Publish- ing Company, pp. 142, $3.50. Dr. Bluemel has added significantly to the litera- ture on stuttering by his latest book The Riddle of Stuttering. After many years of thinking and writing on the subject, (Dr. Bluemel's first book. Stammering and Cognate Defects of Speech, was published in 1913), he approaches the subject in a mature, yet new and stimulating' manner. He seeks the answer to the riddle in the field of psychiatry. Unlike many of the writers in the field he says that stuttering results from a combination of many, at least three, different causes. This means that the riddle is not a simple speech dis- order, but a complex disturbance which must be studied in its many aspects of both speech and personality. The three factors or causes which, according to the author, produce stammering are: the person- ality of the stammerer, the non-organization of the original speech, and dis-organization of the speech by stress before it becomes securely established. He says stammerers have a predisposition to their speech difficulty, as they are poorly organized in their neuromuscular reactions, and their inco-ordinatio'ns include the function of speech. Under stress the poorly organized speech readily becomes dis-organized. This latter is non- organized speech, or speech in the un-making, and occurs when the psycho-physiological pattern has not been safely and securely organised. The chapter on "The Organization of Speech" is excellent and is particularly good for the non- medical person. The chapter on the "Disorgani- zation of Speech" is equally good and, as far as this reviewer knows, is an entirely new approach in the speech pathology literature. Dr. Bluemel's therapy is directed toward reorganizing the basic speech of the stammerer. While ear training is one of the most popular and valuable techniques in working with an articulation speech problem, his concept of sensory stimulation, i.e. ear training, as a therapeutic device to use with stammerers is new and thought provoking. He says: Ear training is employed to establish a good mental pattern of speech. Attention is then directed to the thinking process in speech, which is more important in the therapy than the talk- ing process. In this concept of therapy, talking is thinking out loud. The mind broadcasts to the mouth; the words say themselves. The importance of mental hygiene in the pro- gramme of stammerers is not overlooked. For the personality re-education it is suggested that psychotherapy be used. The book ends on an optimistic note with the feeling that the riddle will soon be solved. There are many new and scientific ideas in the book, and it should be read and absorbed by everyone interested in speech problems. RUTII M. CLARK, Ph.D., Professor Speech Pathology, University of Denver, Denver 10, Colorado. "THE VOICE AND ITS DISORDERS," by Margaret C. L. Greene, L.C.S.T. London, Pitman, 1957, pp. 224. In the Preface of this book there are a few items worth discussing: 1. The author says, p.V, "no comprehensive (sic!) study of normal and disordered voice existed to serve as a single source of reference for those interested in vocal rehabilitation." She 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)