SCHOOL
PROBLEMS
Marcel
Kinsbourne, M.D., Ph.D.From the Departments of Pediatrics and Neurology, Duke University Medical Center, Durham, North Carolina
(Received and accepted for publication July 9, 1973.)
ADDRESS FOR REPRINTS: (M.K.) Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710.
Pxnwriucs, VoL 52, No.5, November 1973
DIAGNOSIS
AND
TREATMENT
EDIToR’s No’it: Half an hour after Professor Kinshourne finished this address to the Annual
Meeting of the American Academy of Pedi-atrics, October 18, 1972, his audience was still
surrounding him to ask questions. The hall
could onlq be cleared by a promise to record
what he had said for future reference-a prom-ise here happily fulfilled.
Tim EDITOR
DEFINITIONS AND DOCUMENTATION
School problems result from factors of three types : environmental, emotional, and developmental. The great bulk of illiteracy
in this country derives from socioeconomic adversity and cultural alienation that
pre-sents a primarily political rather than a medical challenge. But some children, even when offered adequate schooling under tolerable conditions, fail to achieve at a
level to be expected from normally
intelli-gent children at that age. Such children often also appear to be emotionally dis-turbed, and it may be difficult to decide what is the primary cause of the school fail-ure. There are some cases in which the emo-tional disorder was clearly antecedent. These I will not discuss. I will talk about children who underachieve for no obvi-ous reason.
Learning disorder is very much a matter
of unexpected school failure, of the child
doing less well than his parents or teachers expected. Before he does anything else, the clinician needs to satisfy himself that the child is really underachieving. There are
two parts to this investigation:
achieve-ment tests and intelligence tests. It is not
necessarily true that the child is doing badly because the teacher says so nor be-cause the parents say so. You cannot know
whether the child in fact is falling well short of national norms without a reading
achievement test such as the California,
Metropolitan, or Wide Range. An
advan-tage of these tests is that they do not only
give information about the child’s ability in reading and writing, which for some reason are almost the only subjects ever complained of (and on which I will, there-fore, concentrate
),
but they also measurehis ability in arithmetic. So the clinician
can form an impression as to whether the
deficit is specific to reading and writing or
is more general.
FIG. 1. Levels of investigation of learning difficulty.
life of its own and the child is categorized. So, close your eyes to that information and request an individually administered, stan-dard intelligence test. You need a relation-ship with a clinical psychologist which ex-tends beyond the transaction over the pa-tient to an understanding of what the psychologist is talking about. You should
have a telephone-conversation relationship
with the psychologist. You send him the
child and questions, he tests the child, he sends you back the answers which are completely unintelligible, and you call him
back and ask, “What in the world are you
talking about?” At the end of all this, he
will come up with the information that the child either is or is not functioning within
the normal range of intelligence. If
inteffi-gence is really normal and achievement is
depressed below the level to be expected
of a normal child at that age, then the child is an underachiever. Even then, there are
a variety of causes of underachievement
which are outside the range of the
clini-cian. The child may be culturally alienated,
and this is an enormous problem and a
common one but not one that the clinician
can handle. Or, the child may be
inade-quately taught in a class in which the
pri-mary concern. Or, he may not go to school
regularly, if for instance he is the child of a military family. As you know, the military
seems to feel it is essential for the security of this nation to move its families once
every three months. It is impossible to learn in such a situation.
So only when you have excluded factors of this type can you entertain the possi-bility of selective reading difficulty, or what
I would like to call a “selective reading
un-readiness.” The investigation of selective
reading readiness should be of a very prac-tical kind. A child in the first or second grade is sent to you with this complaint. What is worth doing? It is not helpful to
explore the antecedents of selective
read-ing unreadiness in any detail. That is
for-tunate, because we don’t know what they are. Nor will I talk about predicting it,
because we don’t know how to do that. I
will talk about what to do when the prob-lem comes your way.
THE EXAMINATION
When in doubt, the pediatrician takes a
history. When he remains in doubt, he does
an examination. The first slide
(
Fig. 1)shows things you can do in this situation.
I say “things you can do” rather than
“things that are helpful.” Just as with
new-born infants, you can elicit 73 reflexes-more for something to do than because they tell you anything-so with these children you can go through a lot of busywork
which makes you feel you have done some-thing when you haven’t. I have organized the schema according to Dante’s Inferno,
in concentric circles. It gets hotter as you get further inside. You start with routine
questions above the family history. Yes, of
course, some families have histories of learning difficulty, and this may confirm
your suspicions. But if there is no history, so what? And if there were prenatal, peri-natal, or postnatal catastrophes, you can look wise and say, “Ah, of course.” But if
no such thing happened, you can just quietly pass on to your next question. Just make a note on the chart.
There follows the physical examination. Here you are interested in those parts of the nervous system that are relevant to
be-ginning reading. These obviously are cere-bral, and they are not the sensorimotor but
the association areas. The part of the
neu-rologic examination which is relevant to reading is the physical examination of the
association areas of the cerebral cortex. So you look back on your notes from medical
school about the physical examination of the association areas. These are lacking.
There is no such examination. When you
do a physical examination, if you think you are examining a child for reading
disabil-ity, you are mistaken What you are doing is examining everything you know how to
examine. You are in fact examining the rest of his nervous system-his spinal cord and
brain stem-and your findings are relevant
to those parts of the neuraxis. This does not make them totally irrelevant, because any agent that damages one part of the nervous
system is quite likely also to damage
another part of it. So, by a logic of guilt by
association, if you find some hard and soft signs, that makes it somewhat more likely
that the cognitive problem was also organ-ically based. However, there are so many children without any physical abnormali-ties who have reading disability that is
developmentally (organically) based, and
so many children with nervous system
darn-age all the way up to the cerebral cortex who do not have reading disability, that in the individual case you haven’t gotten that
much further.
DEVELOPMENTAL LAG
The second thing to keep in mind is the
nature or type of deficit that occurs when
the developing nervous system is harmed. When the mature nervous system is dam-aged, the person loses those skills which
were subserved by the damaged areas. Not
FIG. 2. Forms for orientation testing.
happens. What happens ultimately is a
failure of the normal timing of develop-ment of the relevant function. The function
which is involved will develop later and more slowly. There will be a develop-mental lag with respect to the function to be subserved by the damaged area, irre-spective of the etiology of the damage. So what we see after perinatal trauma or other insult is that a particular skill comes in late.
With respect to that skill, the child behaves
like a normal younger child. I have never seen a case of learning disability that was essentially any different from a younger
child not yet ready to read. The kinds of
difficulties that learning disabled children have are the kinds of difficulties in master-ing the concepts that you would encounter if you were foolish enough to try to teach
a 3- or 4-year-old child to read. So, if you
want to understand what others than myself have called “dyslexia” (I never use that
term), try to teach your 3 year old to read,
and see what happens in terms of mental processes and attention. The concept of developmental lag has utility. As you know,
when in an adult you establish the status
quo, it stays quo. In a child, you are
work-ing against a changing base line. If a child at age 7 or 8 is inadequate in a function, that does not mean he will still be so at
age 10. The possibility of further maturation
always exists. The trick is not to change the maturation of the nervous system by some
dramatic intervention-we have no way of
doing that. It is rather to maintain the child
in a climate in which he can benefit from
further maturation, should it occur. This
mainly means helping him to control his emotional reactions and get people off his back. This, I think, is the most valuable
thing you can do.
Consider that, when the nervous system’s efficiency to perform mental tasks is dam-aged, this may manifest in one of two ways. The mental processes may be immature, like those of a younger child. If that is so, there is no way to accelerate their develop-ment. There are ways to spend money and
time trying to do it, but that’s a different
matter. The idea that techniques like
visuo-motor training and patterning enhance the
physical growth of the brain is irrational.
mental processes are adequately devel-oped, the child is not deploying them in the appropriate fashion. He is not using the right strategy. In fact, the very ability to deploy appropriate strategies is acquired
on a developmental basis. There are many things that normal children spontaneously find out how to do which children with
in-jured nervous systems do not. However, if you tell the injured children how, then in
many cases they can do it. So, you need not
look for ways to strengthen mental
pro-cesses but rather for ways to help children deploy the mental processes they possess.
Children with limited potential regularly underachieve, even with respect to that limited potential. They do this for a very
simple reason. If a child who should be
taught at a certain level is put in a class where teaching is at a higher level, he does not benefit from that instruction-it’s be-yond him-and he does not even learn at his own level. While potentially he could learn
at his own gentle rate, in a normal class-room he is not even learning at that rate. Failure to detect and cater to a learning difficulty depresses a child’s achievement below his potential, so that an element of underachievement complicates his intel-lectual limitation. I think that all successes in managing difficulties are compounded
of two factors. One is the spontaneous,
ir-regular maturation of the nervous system, which we as pediatricians uniquely benefit from. Our patients are on our side, which is not at all true for our colleagues the in-ternists. Second, these children improve when the superadded element of under-achievement is disposed of.
Now let us say a word about the
ex-amination of the nervous system from the developmental viewpoint. You are familiar
with the conventional distinction between hard signs and soft signs. A hard sign is
easy for the physician to elicit, and a soft sign is hard to elicit. That is not a very helpful definition. If these terms are to have any use, this is how they should be
understood: a hard sign is, to quote a
well-known personality, unsafe at any speed. At
no age is it normal, If a limb is paralyzed, that’s a hard sign. Nowhere in the develop-mental sequence is this to be expected. A soft sign is a sign whose normality or ab-normality you can only judge if you know the child’s age. A soft sign is a finding that is normal in a young child but that, in
the normal course of maturation, should
go away. If it persists unduly long, then it qualifies as an abnormality. It represents a developmental delay or lag in the differ-entiation of a sensory or motor system. Soft signs have two aspects. On the one hand, a soft sign represents a persistence of a primitive form of response. On the other hand, it represents a failure in a certain performance. The child fails to do some-thing which, at his age, he ought to be able
to do. A very simple test that I use will help
to illustrate what I mean. The child
ex-tends both his hands, and wooden sticks
are placed between the fingers of each
hand. Ballpoint pens will do just as well. The child is then asked to drop each stick singly in turn. A 3 or 4 year old is apt to drop not only the stick pointed to but others as well. He will be most likely to drop an adjacent stick in the same hand and the mirror-image one in the other hand. The easiest one to drop singly is the
one between the index and middle finger,
and the hardest is between the middle and ring finger. A 6 year old should not drop more than five extra sticks in the course
of six trials.
There are two advantages to doing this test. One is that the objects fall to the ground so that you can show off your catching, and the child may smile in the middle of a rather solemn procedure. It really cheers the children up to see you groveling on the floor. Secondly, you are studying associated movements in a way
that goes beyond clinical impressions. You
can’t say, “It is my clinical impression that two sticks dropped.” You say, “Two sticks
dropped,” and cut the rest of that phrase
SCHOOL PROBLEMS
while leaving the rest in place. He still has a mass response of general abduction, In
the course of motor maturation, selective
finger abduction differentiates out. The same applies to contralateral associated
movements. Motor overflow to the opposite
side gradually comes under inhibitory
con-trol. In this way, movements become more precise, clearcut, and skillful.
Some have promoted the presence of soft signs into a “diagnosis”-minimal brain dys-function
(
MBD).
This has confusing impli-cations. It has a sound of finality and yet isno guide to any remedial effort that might be undertaken. It implies the presence of
some reasonably coherent and character-istic constellation of symptoms and signs,
when in fact it is a blanket term describing
soft signs at any neural level, from the tri-vially important presence of associated movements
(
as elicited by the finger stick test) to serious problems like hyperactivityand defective visual memory (which may
or may not coincide in the same child
).
The term blurs essential distinctions. If we bracket lack of dexterity and hyperactivity together as signs of MBD, we will soon be treating clumsiness with stimulant drugs. In this way, an effective therapy becomesdiscredited because of misuse. Use of the term MBD is not only unhelpful but actu-ally harmful.
When the nervous system is considered
in relation to reading, the matter of
left-handedness and ambidexterity keeps
rear-ing its head. Too much has been said about
left-handedness, and I am tempted not to say anything more about it. But I need to
say this. It turns out that left-handed
people
are not much good. You find anunduly high proportion of left-handers
among the mentally retarded, the brain-damaged, psychopaths, alcoholics, the
criminally insane, and in each succes-sive class of entering medical students at
Duke. But look at it from a different per-spective. There are more right handed mental retardates than left-handed, and there are more right-handed brain-dam-aged, psychopaths, alcoholics, politicians,
and entering medical students. Yes, there
are some statistical differences. They are of
some research interest, and indeed
some-times left-handedness does represent an immaturity of brain development which is also related to delayed acquistion of read-ing skills. But in the case of one individual child, his handedness is really of no diag-nostic help. As for compelling him to
change his handedness or eyedness, that is
absolutely absurd. Such peripheral
manip-ulations do not change the brain. Nor does
strabismus cause, or its correction cure, a reading disability. Optometry has no
legiti-mate role in learning problems.
INTELLIGENCE AND PSYCHOMETRY
As we proceed further up the neuraxis,
we come to the areas that subserve intel-lectual function, and there we can look for what one might term as “intellectual soft signs.” You can look for those in three ways: in psychometric test results, in the
pattern of errors in reading and writing,
and, ideally, through measurement of the specific processes involved in beginning
reading and writing. First, the
psycho-metric test profile. You are interested not only in the overall IQ but also in what factors conspired to generate that
figure-were there signfficant unevennesses in the
various aspects of intelligence that are tested by the different subtests of the
psy-chometric test battery? A selective
imma-turity in intellectual development may not
be apparent before school entry because
social demands may not be made on the child in these respects before that time. School presents the child with new chal-lenges, which he may unexpectedly prove unready to meet. That this can happen
should not be surprising. On the contrary,
the notion that intelligence is unitary is
baffling. There is verbal intelligence, spa-tial intelligence, numerical intelligence,
abstract reasoning, and so forth. Look
in-side your heads, and decide whether you are equally good at all of these. I, for one, should keep the right side of my head
skills do not bear inspection. These varia-tions in patterns of intelligence have more serious implications during than after school age. Once we have left school, we
can choose what to do and do what we are best at; but in school, we have to do what
we are told. So, in the psychometric data, we
will look at disparities between various aspects of intelligence and see whether the
discrepancies have any bearing upon the type of difficulty the child is experiencing while trying to learn to read.
Some children have substantially lower verbal than performance ability
(
in terms of Wechsler intelligence testing). A verbal-performance discrepancy in this direction often is found in a child who is male, hasa positive family history for learning diffi-culty
(
but few or no soft signs),
and wasrather slow to acquire language. He is much worse at reading and writing than arithmetic, and in reading and spelling
introduces many extraneous speech sounds
which do not at all sound anything like words to normal people. In contrast to this “language” type of reading difficulty is the child, as often female as male, who has a relative deficit on the Wechsler perform-ance tests. He often has soft signs, is poor also at arithmetic, but showed no early
language delay. Such a child often shows disordered finger sense which I will define later, has trouble differentiating right from left, and in misreading and misspelling con-fuses the sequence of the letters. Yet dther children are handicapped by poor visual memory which is brought out by standard visual retention tests, such as Benton’s.
They misread and misspell by using letters that “sound right.” So disparities between
test results can give a clue to the kind of
difficulty that is holding the child back.
REVERSALS
One type of error that has achieved con-siderable notoriety is the sin of reversal.
This is the deadly sin for reading teachers. When they see a reversal, they go com-pletely out of their minds. That is very
peculiar, as of all kinds of mistakes the
reversal is the least specific as an indicator of the type of difficulty the child is
experi-encing. The kinds of reversals that children with reading difficulty make are exactly the same as those that all normal children make when they try to learn to read at a
younger age (in preschool). A 3, 4, or 5
year old will reverse in copying, he will remember things the wrong way around, and this is totally normal. But if you are
one of those Creative Plaything nuts or one
of those people who would prefer children to be adults and teaching reading too soon, then you will come across these reversals and will rush the child to the doctor; and if you are lucky, he will say, “Cool it, your child is only this large.” Why do normal children make these reversals, and why do they persist unduly in some children?
Children who make copious reversals in
their written work do not make reversals
using the simple materials shown on the
next slide
(
Fig. 2). We have the child copythese shapes individually, pick out a test
shape from among a group of them, or,
when shown a model, take one of these shapes and hold it up the same way around. The very young child often will even copy them reversed and do so in a specific pattern. The reason he does this is not because he sees it in some different
way than you do, because then he would
also see his copy in a different way, and
there would be no difference between his
copy and the model. Rather, he doesn’t
know you care which way around the form
is. Does it matter? He is completely be-wildered by the fact that whatever adult designed our script was so short of shapes that he had to use orientation to distinguish
between letters. He was so short of forms that he had to use the same form four times
for lower-case “b’s, p’s, d’s, and q’s.” How absurd! As for those other letters that have
unique shapes, the child is surprised that
adults pretend that they cannot read an
“e” because it happens to be written the
other way around. Of course, it is the wrong way around, but it is still perfectly
communi-cate, or what are you trying to do? This is
adult compulsiveness. They insist that you write a letter a certain way around, even though the function of communication is served anyway, because it is clear which letter it is, however it is oriented.
The notion that a thing’s identity depends
on which way around it is is something children unlearned when quite young. Whichever way around mother is, it’s still mother. Whichever way they see their bottle, it’s a bottle. Then suddenly, that is
not true of letters. Now, for some reason,
the older child is less surprised, and correct
copying of our simple shapes without re-versals is normal. But when you ask older children to remember a letter shape and
which way it is pointing, then you realize
that remembering a shape and remember-ing its orientation are separate items of mental accomplishment. You can remem-ber one and forget the other. Not only with children but also with rats and other ani-mals, form has precedence over orientation. When mental energies are engaged in re-membering, the big push is to remember
form and orientation tends to get lost. The
incidence of reversal errors increases with the difficulty of the word the child is trying to remember. The child may correctly
on-ent a letter in isolation, but when he is trying to come up with this letter in spelling a hard word, he may get its orien-tation wrong. He is trying to remember, “What were those letters?” not “Which way around were they?” Basically, reversals within a word are a sign that the child is finding it hard to remember or to write
the word, which is where you came in.
The pattern of reversals is invariant. Our
data from children aged 4 through 8 years
show that by far the most common errors are mirror-image reversals, next are inver-sions, then inverted reversals, and least
common are rotations. There is something
very basic about this hierarchy of errors. It
characterizes rats learning to choose be-tween shapes for reward, and it
character-izes normal adults when they are briefly
presented with more of these shapes at
once than they can handle. When we try to remember which way a form is pointing,
we make a series of binary decisions. First,
is it upright or sideways? Next, if upright,
is the knob at the top or the bottom; if
sideways, is the knob at the right or the
left? Third, if upright with knob at the
top, then is the knob to the right or left;
if sideways and knob at the left, is the knob up or down?, and so forth. These are three
successive decisions, of wh!ch the latter
ones are the most apt to get lost under pressure. This is why simple reversal (failure of the third decision) is the most common.
Children who make reversals can be
taught not to in a very simple way, which
illustrates how children should be taught
anyway. In fact, the way that people should be taught from kindergarten to
medical school is the same. It is not in the
traditional way: “If he doesn’t understand, say it again, and if he still doesn’t
under-stand, then shout.” There is a viable
alternative, which is to work out the corn-ponents of what you are saying, say them separately, and discover which one was not
understood. Don’t start by saying, “Oh, by
the way, kids, this is a ‘b,’ this is a ‘p,’ this is a ‘d,’ and this is a ‘q.’ If you do that, you are telling them the shapes, the sounds that go with the shapes, and the associations between the two, all at once. Do these one at a time. Show the shapes, by themselves.
Say, “See how this is different from that.” Separately train on the differences among the sounds or names of the letters, and then teach the association between the sound and the shape. Always make sure that each item of information is fully understood be-fore introducing another. In organizing
remedial teaching, you look for the same
systematic teaching, which will ascertain the level the child is at and, one by one, teach him the things he doesn’t know from that point upwards. You need to find out,
at each point, whether the child under-stands. There is nothing very special about
this remediation. It is good individual teaching. Unless you can attend
are not going to meet them; if you do at-tend to them, you don’t need to have many diplomas.
SERIAL ORDERING
Another way to examine the nervous system for a cognitive “soft sign” is to elicit “finger agnosia,” or what I like to call “disordered finger sense.” One of the abilities usually acquired at about age 6 or 7 years is the ability to differentiate cer-tam sequences. These sequences are the relative positions of the fingers on the hand and the relative positions of right and left. Immaturities in development of this ability often are accompanied by immaturities in learning both to spell and to calculate. These two skills are affected by the same type of mistake. The child cannot identify the fingers in terms of their relative posi-tions. As this is what distinguishes them from one another, he fails to recognize them. He cannot identify right and left in terms of their relative positions. Front and back are different because you cannot see in back. Up and down are different be-cause you fall down, not up. But right and left look alike and are relative concepts rather than immediate percepts. The same children make order errors in their spelling, and in arithmetic they mix up the place value of the digits (56, 65) and have trouble carrying from column to column. The tests that I use for finger agnosia are very simple, in that they use a minimal number of words. For example, the finger differentiation test. I touch the child in two places at the same time, either on the same finger or on two different fingers. Can he tell the difference? Another is the “in-between test,” in which I touch the child
on two different fingers and ask him how many fingers are in between the ones I am touching. Only if he has the concept of
sequential position of the fingers can he
tell me how many there are in the middle. Another test, shown in the figure, ap-proaches the same problem from an osten-sibly different perspective. A child holds a block in his hand, behind his back with
his fingers stationary, and he is asked, “Which of these four blocks in front of you is the same as the one you are holding?”
He can only tell this if he knows which
fingers are next to which, because in each case he holds the block with two fingers more flexed than the others. The difference is determined by the pair of fingers it hap-pens to be. There is a paper in a sym-posium, the Pediatric Clinics of North
America,
1968,
which tells you more exactly how to do the tests.COGNITIVE PROCESSES IN READING
We now enter the central circle on the
slide I showed you
(
Fig. 1)
For practicalpurposes, that circle is empty. We need to identify the operations involved in be-ginning reading itself. These are
discrimi-nating forms, discriminating their
orienta-tion and the sequence in which they are presented, and, naturally, remembering
these three things. That’s already six func-tions. Each can be damaged separately, and they should be measured separately. These are just the visual prereading skills. Acoustically, you have to be able to break
up a word into its speech-sound elements
or phonemes and put it together again from
its phonemes. Prior to this, there are neces-sary prereading skills such as appropriate listening. Some children listen and look inappropriately. They finish looking before they have seen all the items. They finish listening before they have heard all of each word. This is because in everyday
perceiv-ing, one makes use of context and only pays attention to an extent sufficient to understand what is being viewed and heard. Perceiving analytically and ex-haustively, which are requirements for earning to read, is a novel skill for chil-dren. When children look, they will base
their judgements on the first few letters of
the word, and when they listen, they will
ignore the word endings. If children make
these errors, it is no good
trying
to teachword. This is the “whole-word” method of
learning to read. They have to associate
individual shapes with phonemes when
they are learning by the “phonics” method.
Each of these operations can theoretically be tested separately, and we have tests for each and are trying them out. The tests are
not yet ready for use. But for now I just wanted to point out to you that if we could
measure the processes involved in reading itself, who would care about hard signs and soft signs and all that stuff? If you could do that, then you would find out that there is no “dyslexia”; there is no one syn-drome in which children do this and that. Each child has his own pattern of
difficul-ties in learning to read. There are so many mental processes involved, each of which
can be impaired to a varying degree that you cannot expect the next child with
read-ing difficulty to be like the last one. So the same management also will not do for both. You have to identify the configura-tions of the mental abilities of each child
from the beginning. The finding that he
has an unexpected disproportionate read-ing difficulty, otherwise often called
dys-lexia, is not a solution. It is the very
prob-tern he came with. Calling it dyslexia
achieves nothing, and if you think it does,
you are doing harm.
We have tested several hundred children on entry into first grade and some of them
again at six-month intervals. Among this
relatively underprivileged group, there were widespread deficiencies in preread-ing skills-not in discriminating individual shapes or sounds as some perceptual
train-ing programs would have us believe, but
rather in fully attending to and noticing all elements of a visual or auditory display.
Children have become accustomed to look-ing and listening in an integrative fashion,
using all possible sources of evidence, con-text and expectancies included, to make
their decision, and ignoring all detailed features that are not relevant to the overall
meaning of the message. In sheer
per-ceptual terms, they can handle and retain
shapes and sound sequences far more corn-plex than those involved in beginning read-ing when these occur in the natural
en-vironment. The difficulty rests in perceiv-ing analytically; this is artificial and has to
be taught. This is particularly true for
spoken words, as the phonemes in words
run together more closely than do written
letters grouped to represent a word. We find that in the course of the first grade,
chil-dren mature greatly in both visual and
auditory prereading skills. But it is the children who make the greatest relative
gains auditorily who are found to be the
best readers at the end of the year.
In the course of training in systematic selective looking and listening, children are taught to refrain from impulsively coming to decisions as to the identity of a word or
phrase on the basis merely of a few
begin-ning letters. This impulsivity may be
merely a transitory and manageable
man-ifestation of immaturity, or it may be in-tegral to a seriously handicapping disability next to be discussed-developmental hyper-activity.
HYPERACTIVITY
We now turn to the controversial ques-tion of hyperactivity. This is an uncommon but important cause of school problems. There are three reasons why a child might be fidgety and restless in the classroom. First, he may not be smart enough to un-derstand what the teacher is saying (or the teacher may not be saying anything that
can be understood). As all of you have
observed in lectures, people who don’t
understand what the speaker is saying are restless and fidgety. This is as true of children as it is of pediatricians. Many children who are overactive in the class-room shouldn’t really be there, because
their mental abilities are not adequate to the task they are faced with. The second cause of restlessness is anxiety. Children who are preoccupied with emotional con-cerns cannot concentrate. The real
hyperactive-differ from these others in that they sometimes can be immcasurably helped by appropriate medication.
How to spot them? First of all, the
not-so-bright children and the children who are very active because they are upset are only restless and fidgety in those situations which stress them. The less bright children
are only overactive in the classroom. The
anxious children are overactive in the class-room and elsewhere where they are stressed. But the organically hyperactive children are always overactive. It’s not situational with them. Also, the mentally slow children and the emotionally dis-turbed ones are not happy. The young
organically hyperactive child is a happy hyperactive. He doesn’t start out sad, though as his behavior is such as to alienate both adults and peers, this, as he grows older, begins to show up in his increasingly less happy feelings about himself. So, the presence of emotional problems does not exclude organic hyperactivity in the older child. In a typical case, the parents will tell you that their child was exceptionally mobile even as an infant, that his develop-mental milestones were, if anything, fast, and that he was colicky and fretful and never slept very much. When he would wake up at night, it wasn’t because he was frightened or wanted to be hugged. He wanted to get up and get busy. Mother comes into his room at two o’clock in the morning and starts to rock him, but he doesn’t want to be rocked. He’s jet pro-pelled out of her arms. He wants to go down the corridor and out. And often, he wants
to jump off a precipice. These children are quite unusually subject to a variety of hazards. They are fearless, or at any rate oblivious of danger. They frequently ingest a variety of poisons because they love to explore. They are just supercharged. They need less sleep, and they have more energy. These children present either at age 2 or
3 if they come from middle-class homes, or at age 6 or 7 if they come from poor homes.
The reason is that, in the middle-class
homes, the sound of breaking glass gets to be too tedious, and mother will not put up with it. In the poor homes the children are turned out into the street early in the
morn-ing, where they can work off their energy
however they please all day before they
come home in the evening for their few minutes of sleep. But when they reach the classroom, that’s where the trouble begins.
The essential ingredient of
develop-mental hyperactivity is an impulsive
ap-proach to any new situation or event and
poor impulse control. The ability to control one’s attention and focus it is only gradu-ally acquired by normal children as they mature. Hyperactive children lag behind in acquiring this control, presumably be-cause their cerebral control systems are for some reason slow to mature. The child is
not totally unable to attend consistently,
but the cost in effort is disproportionately
great, so that only in unusually terrifying
surroundings, like the doctor’s office, will some such children exhibit appreciable self-control. Threats and punishments are
surprisingly ineffective, and they usually only drive the child into a spiraling frenzy of disobedience. For this reason, behavior modification is relatively ineffective. This is not to say that the environment is totally ineffective, or that structure is undesirable. Hyperactivity is rare in the Orient. This may reflect genetic differences. Or rigidly traditional societies may make these
chil-dren so anxious that they somehow manage to control themselves (perhaps at the cost
of becoming depressed
)
- However, weknow that hyperactivity can be helped by medication. Medication sometimes makes
other therapies unnecessary and at other times makes psychotherapy possible by enabling the child to focus his attention on
the therapy. Stimulants, notably
am-phetamine and methylphenidate, help the child control his behavior as he wishes; without them he is at the mercy of every passing stimulus.
ex-pensive. The two agents have similar ef-fects, but if one fails it is worth trying the other. There is no reason to impose a lower age limit on use of these drugs. I have treated 2 year olds with good results. The
FDA does not approve use of
methylpheni-date below age 6. It is curious, but not really surprising, that the FDA makes us use the more hazardous drug for the younger child. If both stimulants fail, the pediatrician should hesitate before he passes on to magical remedies like mega-vitamins, or tranquilizers which I think are the business of the child psychologist.
Although typical cases seem quite char-acteristic, the only firm way to diagnose is to discover whether they respond to stimulant therapy. Because I have had much trouble knowing which child will respond, I try it out on quite a few of them.
And that’s fine if one keeps them under
ob-servation. The presence or absence of other “minimal brain dysfunction” is quite irrele-vant. The beauty of using amphetamine or methylphenidate is that they act so quickly, and the effect stops so quickly, within a
few hours. Starting with as little as 2-5
mg dextroamphetamine sulfate (Dexedrine)
or 5 mg of methylphenidate
(
Ritalin)hy-drochloride twice a day, one can adjust the dose almost from day to day. I do it in two-day steps, keeping in touch by tele-phone with the parents and teacher, level-ing off at the appropriate level if there is an effect. If the drug does not work, one can stop at once and try something else.
It is not true that these children respond
paradoxically to stimulants and sedatives. Stimulants do not make them sleepy or subdued, but calm, effective, and better able to focus their attention. In fact, the main problem is not activity level but rather the focusing of attention. Indeed, it
is not even clear that hyperactives actually
move around more than normal children. It is the timing that attracts attention. They move when one would expect them not to. These children cannot maintain their
at-tention on any one thing for more than a few seconds. They are impulsive and
dis-tractable. Now, there are some things you
can learn that way, and indeed you are
trained to. If you think of it, Sesame
Street is hyperactivity training. Everything
changes from moment to moment. We tranquil adults can’t stand to watch it. So,
the world is changing in the direction of
the hyperactive life style. It hasn’t fully changed yet. It is with those tasks which require sustained attention that these
chil-dren have trouble. If you give them bar-biturates, their ability to focus attention becomes even less. This is something you may pick up when you treat a child for epilepsy. His fits may be fewer, but his
activity level goes wild. As far as we know,
any child who becomes disorganized on barbiturates is potentially in need of
stimu-lant therapy. The important point about
giving children amphetamines is that the
effect is always definite, either better or worse, if you give enougk If better, you have found an effective treatment, and as the alternatives are so arduous and unre-warding, it would have been a pity to miss
such an opportunity. On the other hand, no
pediatrician should give a prescription for
such drugs and lose sight of the child. If you are prepared to see the child again in a few days or a week, it is a good treatment.
What are the side effects? They include
loss of appetite and failure to sleep well, and possibly slower growth, but in
cor-rectly selected cases the benefits are so
great that this transaction is worthwhile.
Much more important is the effect of over-dosage. The overtreated hyperactive
be-comes irritable, withdrawn, tense, even
paranoid. He behaves in socially unaccept-able ways; for instance, he prefers his own company and a book to that of other
chil-dren. Massive overdosage causes gaze
avoidance, stereotypic movements, and
stimu-lants. If you use them, I think it is
important to use them continuously. Many excellent physicians only prescribe them during the school week and recommend that they be discontinued on weekends and during vacation time. The reason is a very healthy, natural aversion toward the use of drugs and a wish to minimize that use. Obviously, one cannot be uninfluenced by the epidemic of drug addiction in this country. So, it sounds like good practice.
But there are some cautionary notes I
would like to sound. First of all, if some-body has seen a hyperactive child become addicted to methylphenidate, he certainly has not reported it. Now, everything that never happens is sure to happen one day, and one day you will read about such a case in the New England Journal of
Medi-cine. But to the best of our present
knowl-edge, that complication is not a serious threat. You tell the child, “These pills will help you help yourself; when you want to pay attention, you will now be able to.”
The children do better on the drugs, they
achieve more, they get along better with people. Nevertheless, they hate to take those
pills, and you have to watch them like a
hawk to make sure they are really taking
them. Children hate to take medication because it means they are different, and the last thing a hyperactive child wants to do is take methylphenidate or dextroampheta-mine. If the agent seems to have failed, be very careful to make sure it has been administered.
School-age children who are hyperactive
don’t like themselves very much. They seem sullen, detached, alienated, they have
few friends, and their peers don’t like them.
They are socially maladjusted. There are plenty of cumulative social reasons for that, but curiously enough, we find that even on his very first pill ever, the child likes himself better. This is long before the en-vironment could have responded to any change in his behavior. If he has been on the medication for a year, and it is omitted for as little as one dose, his self-concept plummets down. We wonder if the agents
themselves don’t make the child feel better.
If that is so, we shouldn’t drop them during
vacations and at weekends. I don’t think that children should be helped to learn or to interact with others only in the class-room. Some children rebound from their noon dose to be hyperactive in the evening, and they should be given a further dose before dinner. It will not keep the child
awake but rather help him sleep. If
stimu-lants work, they should be given all the time, until some time in adolescence or later when it can be shown that they are
no longer needed. Perhaps because the
relevant brain areas fully mature, or perhaps because after leaving school people have more freedom in choosing what to do, hyperactivity becomes less obvious during adolescence and treatment usually is termi-nated some time around then. Actually, our criteria for discontinuing stimulant therapy are even less precise than those for be-ginning it. You can try the effect of omit-ting a dose or two any time. But the ab-sence of obvious motor exuberance tells us nothing about attention or feelings. These children often grow up into psychopathic or depressed adults. Were stimulants too soon withdrawn? Before discontinuing stimulants, I arrange for intelligence and personality testing on and off drugs and only discontinue if the two sessions yield essentially the same result.
Stimulant therapy can be a cop-out by poor teachers and sloppy clinicians and a smoke screen to divert attention from so-cial injustices. The pediatrician will not become accessory to such misuse. By using these drugs with precision and care, he will protect his patients from misguided at-tempts to deprive them of irreplacable
help. While he remains in control of the
case, no one can misuse the drug.
SUGGESTED READING LIST
1. Bakker, D., and Satz, P. (eds.): Reading Re-tardation. Rotterdam: Rotterdam University Press, 1971.
2. Kavanagh, J. F., and Mattingly, I. C. (eds.):
Massachusetts: The Massachusetts Institute
of Technology Press, 1972.
3. Kinsbourne, M.: The developmental Gerstmann syndrome: A disorder of sequencing. Pediat. Clin. N. Amer., 15:771, 1968.
4. Kinsbourne, M.: Perceptual Learning
Deter-mines Beginning Reading. Washington, D.C.:
Society for Research in Child Development,
1973.
5. Money, J (ed.): The Disabled Reader. Balti-more: The Johns Hopkins Press, 1986.
6. Wender, P. H.: Minimal Brain Dysfunction in
Children. New York: Wiley-Interscience,
1971.
LYDIA MARIA CHILD ON THE MANAGEMENT OF GIRLS DURING THEIR TEENS
Lydia Child (1802-1880) , an American
author and reformer, was one of the most
prom-inent women of her day. Her advice to mothers
on the management of their teen-age daughters
would be exceedingly difficult for
contempor-ary mothers to follow. She wrote:
The period from twelve to sixteen years of age is extremely critical in the formation of character, particularly with regard to daughters. The imagi-nation is then all alive, and the affections are in
full vigor, while the judgment is unstrengthened
by observation, and enthusiasm has never learned
moderation of experience. During this important
period, a mother cannot be too watchful. As much
as possible, she should keep a daughter under her
own eye; and, above all things, she should
en-courage entire confidence towardr herself. This
can be done by a ready sympathy with youthful feelings, and by avoiding all unnecessary restraint
and harshness. I believe it is extremely natural to choose a mother in preference to all other friends
and confidants; but if a daughter, by harshness, indifference, or an unwillingness to make allow-ance for youthful feeling, is driven from the holy
resting place, which nature has provided for her security, the greatest danger is to be apprehended.
Nevertheless, I would not have mothers too
in-dulgent, for fear of warning the affections of chil-dren. This is not the way to gain the perfect love of young people; a judicious parent is always
bet-ter beloved, and more respected, than a foolishly
indulgent one. The real secret is, for a mother
never to sanction the slightest error, or impru-dence, but at the same time to keep her heart warm and fresh, ready to sympathize with all the
innocent gaiety and enthusiasm of youth.
Salutary restraint, but not unnecessary restraint, is desirable...
Nothing tends to produce a love of order so much as the very early habits of observations, and attention to trifles, which I have so particularly
urged . . . I would teach a daughter to observe
such trifling things as the best manner of opening a new piece of tape; and I would take every
pre-caution to conquer the spirit that leads young pee-plc to say “I don’t care,” “No matter how It is
done,” etc. .
With regard to the kind of books that are read, great precaution should be used. No doubt the
destiny of individuals have very often been decided
by volumes accidentally picked up and eagerly devoured at a period of life when every new
im-pression is powerful and abiding. For this reason,
parents, or some guardian friends, should care-fully examine every volume they put into the
hands of young people. In doing this, the
dispo-sition and character of the child should be
con-sidered. If a bold, ambitious boy is dazzled by the trappings of war, and you do not wish to indulge
his disposition to be a soldier, avoid placing in his way fascinating biographies of military heroes; for the same reason do not strengthen a restless, roy-ing tendency by accounts of remarkable voyages and adventures. I do not mean to speak disparag-ingly of Voyages and Travels; I consider them the
best and most attractive books in the world; I
merely suggest a caution against strengthening
any dangerous bias of character . .
Great caution should be used with regard to the
habits of talking in a family. Talk of things rather
than of persons, lest your children early imbibe a
love of gossipping (sic). Particularly avoid the habit of speaking ill of others. We acquire great quickness of perception in those things to which
we give attention in early life; and if we have been in the habit of dwelling on the defects of
others, we shall not only be ill-natured in our feelings, but we shall actually have the faculty of
perceiving blemishes much more readily than
vir-tues. This tendency always to look on the black side is a very unfortunate habit, and may often be
traced to the influences around us in childhood.’
No, BY T. E. C., JR., M.D.
REFERENCE
1. Child, L. M.: The Mother’s Book, ed. 6. New
York: C. S. Francis & Co., 1844, pp.
