Thoughts on Brenda and Michael

My next task was to examine my findings on Brenda and Michael and try to make sense of them. After some delay I was able to submit a paper for publication (Miles, 1961), and, after suitable refereeing, the editor accepted it (note 3.1).

I entitled the paper 'Two cases of developmental aphasia'. The term 'developmental aphasia' was one which had been used by Macmeeken (1939), and although it has now been superseded I still believe it to be of theoretical interest; this is because it provides a link with acquired aphasia. This link is important not least because one can now be confident that the behaviour which I was describing has a constitutional basis - that some sort of deficiency in the physiological mechanisms for language is at work and that this was the main causal factor in creating Brenda's and Michael's literacy problems.

To illustrate my thinking at the time I shall now quote extracts from the theoretical parts of my paper (Miles, 1961). I have done some editing and left out some parts of the paper which do not now seem relevant. In essentials, however, I believe that the approach which I adopted at the time is a useful one. At the end of the chapter I have included some comments written in the light of my subsequent experiences. Where the letters (A), (B) etc. appear in brackets these refer to the comments which appear at the end of this chapter in the section 'Comments in retrospect'.

INTRODUCTION

Although the terminology is in some confusion there is little doubt that a concept is needed for referring to a certain specific syndrome (that is cluster of symptoms) displayed by an appreciable number of children whose reading and spelling ability falls short of their intelligence. Among educationalists in general the problem deserves more attention, in my opinion, than it has so far received.

In the present paper I wish the term 'aphasia' to be understood in a wide sense. By derivation it means simply 'not speaking', but it is nowadays used to indicate a whole range of disorders of speech and language. In speaking of 'developmental' aphasia I am contrasting it, as did Macmeeken (1939), with 'acquired' aphasia. The appropriate powers of recognition and spatial orientation (A) which occur in normal children in the course of development have in these cases temporarily failed to mature; and while aphasic symptoms in the adult can usually be attributed beyond reasonable doubt to some specific injury, e.g. brain-damage resulting from a bullet wound, in the case of children suffering from 'developmental' aphasia this is not so, and there is no record of any acquired injury.

It would have been possible, of course, to refer to the syndrome by some purely neutral term, e.g. 'the omega syndrome', and in so doing one would be making the minimum possible commitment on the theoretical side. In taking over the phrase 'developmental aphasia' I have deliberately chosen to go further than this. I wish to imply that our understanding of these disabilities in children can be helped by an examination of the whole group of aphasic disabilities in adults. Although there may be no history of actual brain damage, in the sense of injury, in the case of these children, their performance is sufficiently similar to that of brain-damaged adults to make us suspect an analogous failure of cortical function. By convention all terms such as 'aphasia', 'apraxia', 'dyslexia' etc. are assumed to carry the theoretical implication that they are caused by some neurological failure of function, and I have deliberately chosen a term with this implication. Thus to say that a child suffers from developmental aphasia is not, as some have supposed, simply a highfalutin way of saying that he is weak at reading; it is to postulate an identifiable syndrome and link its manifestations with those displayed by brain-damaged adults.

To avoid all possible misunderstanding I should make clear that in labelling a child a 'developmental aphasic' I am very far indeed from implying that he cannot be helped. What I have in mind is a behavioural label with physiological implications; this is perfectly compatible with the view that the practising teacher can learn more from behavioural descriptions than from physiological ones. My objection to the use of a behavioural label simpliciter is that in using it we are overlooking the analogies with adult aphasia, and thereby gratuitously depriving ourselves of the chance of increased theoretical understanding. To refuse to classify phenomena at all on the grounds of their diversity is surely to give up the scientific ghost altogether. In general I would say that the main difference between those who assert and those who deny the existence of developmental aphasia lies in the degree to which they are prepared to commit themselves theoretically. It seems to me an obvious requirement for scientific progress that our concepts should be as theory-laden as possible; it is better to say something and be proved wrong - and I would stress that my conclusions in this paper are tentative and exploratory - than not to say anything at all.

SOME THEORETICAL IMPLICATIONS

One of the main points which seems to me to be established by the cases of Brenda and Michael and similar ones is that there is a specific disability sui generis, as opposed to an ordinary manifestation of dullness or stupidity. Macmeeken (1939) has shown that developmental aphasia can occur in children of high intelligence, and this finding receives further confirmation from the cases of both Brenda (IQ 116+) and Michael (IQ 116-128) (B). Indeed it is more likely to be noticeable in children of high intelligence, since the discrepancy between their performance on the majority of tasks and their performance on tasks involving their specific disability is all the more marked.

What is of particular interest and difficulty is to indicate just what it is (or what is the main thing) which the developmental aphasic cannot do. There are, of course, the reversals (C) of letters and words and the tendency to become 'tied up' in saying long words (both very pronounced in Michael), and there is the constructional apraxia (D), which was very pronounced in Brenda (C). The main difficulty, however, which they both shared, was a special sort of failure in word recognition. This failure resulted not only in poor reading ability but also in extreme difficulty in spelling, together with a complete failure to recognise if their effort was right or wrong. I shall attempt in what follows to throw further light on the question of what this failure involves.

THE CONCEPT OF WORD-BLINDNESS

Hinshelwood (1917) writes of 'word-blindness'. This must presumably be taken as a metaphor, since the children are certainly not blind in the normal sense, as Hinshelwood himself agrees (1917, p. 2). Any child who cannot recognise a word is to that extent 'blind' in a sense, but this tells us nothing. Indeed the term 'word-blindness' has been criticised (like the term 'dyslexia') for being an unnecessary and even misleading way of saying that the child cannot read - unnecessary because it adds nothing, and misleading because the word 'blindness' suggests a permanent and perhaps incurable state. Yet it is surely significant that Hinshelwood wanted to use the metaphor, and we may well ask if there is not something which the child cannot 'see' in some sense. What exactly is the connection between this disability and vision?

THREE SUGGESTED ANALOGIES

A possible analogy would be the following experiment. Suppose that the subject places his hand downwards on a table and that the observer writes words on the back of it with a pencil (E). The subject is then asked to 'read' by tactile-kinaesthetic cues what is written there. The result of this experiment is what might be expected. The subject can feel something on his hand (just as the developmental aphasic can see something on the paper) but cannot without practice organise what he feels into a meaningful whole. Now to speak of numbness or insensitivity here seems to be wrong in much the same way as it is wrong to describe the developmental aphasic as 'word-blind'; it is rather that the subject in this experiment cannot operate symbolically with tactile data, just as the developmental aphasic cannot operate symbolically with visual data.

Another possible analogy would be with our failure to grasp sentences as meaningful wholes if the letters are simply read out in succession. Thus, without practice, it would not be easy to grasp the significance of the auditory stimuli which for purposes of this paper may be visually represented as: 'tee' 'aitch' 'ee' 'see' 'ay' 'tee' 'ess' 'ay' 'tee' 'oh' 'en' 'tee' 'aitch' 'ee' 'em' 'ay' 'tee'.

It should be noted that in both these two analogies the different parts of the stimulus are presented successively; there is therefore to that extent a difference from the visual word where the different parts of the stimulus are present simultaneously. If these two analogies are valid, we must say that the act of integration which most people find difficult in the case of successive stimuli is difficult for the developmental aphasic even in the case of vision.

The most satisfactory analogy, however, is, I think, that of the word which loses its meaning if we repeat it sufficiently often. This phenomenon is so familiar, and, to my mind, so important, that it is surprising that such scant attention has been paid to it by psychologists (F). I have not so far attempted any systematic experimentation; but we can, I think, take it as a matter of common experience that if we repeat a word, say, 10 or 20 times in immediate succession that word ceases to have any meaning for us. What happens here appears to be the converse of what happens in certain patients with acquired aphasia (Head, 1926). Unable to produce, say, the word 'key' when presented with a key, they revert to circumlocutions, e.g. 'You unlock doors with it'; their problem is finding the right name for a visually presented object.

It seems, then, for the developmental aphasic that the visual symbol fails to carry any meaning; it is as meaningless as the word 'key' when one has repeated it 20 times.

MACMEEKEN'S DESCRIPTION

Macmeeken (1939, p.25) writes: 'The suggestion arises ... that for these children ... no word exists to be recognised until the child has rendered his written symbol in terms of the spoken word.' This seems to me a difficult but interesting statement of the problem. What is meant by saying that a word does or does not 'exist to be recognised' ? Perhaps the following points may clarify the position. When a normal person (G) recognises, say, the written word dog, we must suppose that this written word acts as a stimulus to 'touch off' one or more responses appropriate to dogs; these responses would be similar to those produced as a result of the auditory stimulus word dog and to those produced by the actual presence of a dog. In that case we could say that the word dog exists to be recognised; a feeling of familiarity attaches to it at sight. In the case of these children there is no such feeling of familiarity, or at any rate such a feeling of familiarity does not come easily. The appropriate responses are touched off only when the written symbol is converted into some other form, e.g. in terms of tongue and lip positions and movements or in terms of tactile-kinaesthetic memory ('tracing the word in the air'). As Macmeeken (1939) writes, 'Such effort is in many cases accompanied by exaggerated tongue and lip movements, movements of the head, facial grimaces, even by other body movements, say, of arm or leg' (H). It seems as though the visual letters will not fuse into a word, but that, at least in the case of intelligent children, they can be mouthed into forming a word. Similarly when a child is required to reproduce the word in writing, this creates particular difficulty since the feedback of combined visual letters does not convey meaning, as it does in the case of a normal reader, and the only way of obtaining feedback is to convert the individual letters into tongue and lip movements. In the case of Brenda this seems to have been precisely what was happening.

The objection may be raised that Brenda sometimes tried out the 'look' of words on rough paper; does not this suggest that after all she does have some visual memory for words? If my suggested view of the case is correct, it would seem to follow that the written word has no symbolic function for her; the letters d-o-g are a thing - a 'word-dog' one might say - which, when spoken together, indicate that one has mentioned the word dog. One recognises a word - in this case the word dog - by its general shape, and once one knows the shape one can compare one's written word with it. The difficulty is that the shape of words of more than three letters is very complex; we should expect failure on any but the shortest words, and this is precisely what we find. The fact that a person tries out the 'look' of words is thus quite compatible with saying that the visual word is not functioning as a symbol.

The child is not therefore 'rendering his written symbol in terms of the spoken word', as Macmeeken (1939, p. 25) says; he is converting a non-symbolic mark on paper letter by letter into some other form in such a way that the end product in its new form can function as a symbol. It is a laborious way of achieving what non-aphasic children can achieve much more easily.

If we take the essential features in the syndrome to be reversals (C) and failure at word recognition, the question arises as to how the two are related. This is a matter which seems to me very difficult, and what follows is put forward as speculation only. If it is correct that successive presentation of parts of a word (e.g. the auditory presentation of the noises 'see' 'ay' 'tee', see earlier) makes integration more difficult than if the parts of the word are given simultaneously as in vision, can it be that something analogous to successive presentation occurs in the case of developmental aphasics even when the visual word is involved? I am not of course suggesting that there is any failure of integration when things lie side by side, but only when symbols lie side by side. It seems to me not impossible that the visual perception of symbols should be disordered temporally as well as spatially, and this would create in the case of vision the same problems of integration as the rest of us have in the case of the 'successive' senses of hearing and touch. It is because of a failure of temporal integration that the visual word seems unfamiliar, and it is because vision is involved that one is tempted to speak of word-blindness. The connection with vision, however, is a de facto one, arising because visual symbols for normal people, unlike auditory or tactual ones, allow integration to be made with all the parts present simultaneously. The result of spatial and temporal disorientation is to affect vision rather than the other senses (I).

There are, in fact, many interesting analogies between spatial and temporal awareness; this was pointed out in particular in the eighteenth century by the philosopher Immanuel Kant (note 3.2), and it is therefore not unreasonable to suppose that the same cortical failure can affect both.

THE PSYCHOANALYTIC APPROACH

It is suggested by Blanchard (1946) that in a certain proportion of cases, perhaps 20 per cent, reading disability is a symptom of an underlying neurotic anxiety. She does not dispute that there may be many cases where there is emotional disturbance resulting from the failure at reading, but her special concern is with those cases where the neurotic anxiety is itself a causal factor. In such cases it would seem that improvement at reading is difficult or impossible without an adequate working through of the unconscious fantasies which underlie the neurosis.

In one of Blanchard's examples a boy is reported both as reversing letters and as combining them in odd ways. In explanation Blanchard calls attention to the view shared by most child analysts that words can be a means of displaying aggression. The behaviour in this particular case was indicative, according to Blanchard, of the boy's feelings towards his mother. The boy, we are told, was Jewish (on his father's side, presumably), whereas his mother was not. In the case of the reversals his purpose was aggressive, namely to attack her by writing in Hebrew; 'he tried to turn the English taught at school into Hebrew by writing it backwards' (Blanchard, 1946, p. 180). The other errors, in which he combined letters into what seemed nonsense, 'were symbolic of the love he still felt for his mother'. We are told, for instance, that he wrote: 'As ur mor' for Ask your mother. The boy also did what he called 'Chinese writing', which consisted of peculiar marks on paper. 'His "Chinese Writing" was a magic spell that would cause his mother to be tortured with sharp knives' (Blanchard, 1946, p. 181).

With regard to the 'Chinese writing', Blanchard unfortunately gives no examples. It would have been interesting to know if the 'peculiar marks' which she describes were ever actual letters, and whether they could have been genuine attempts to spell.

What is puzzling here is that both the reversals and the faulty spelling seem exactly comparable to those of Brenda and Michael as described in this paper. Unfortunately Blanchard does not give us details of whether and how the boy verbalised these alleged fantasies. If he did, one wonders if conceivably his remarks about writing in Hebrew could have arisen as an imaginative flight of fancy resulting from an already existing disability. In that case what happened was that the boy found himself, like other developmental aphasics, unable to spell, and then produced an imaginative story to explain it. We cannot tell on the evidence available.

What is crucial is this. The symptoms are so similar to those of Brenda and Michael that there are very strong prima facie grounds for looking for the same explanation in all three cases. If so, and if Blanchard's explanation is correct, it would follow that the weakness of both Brenda and Michael was due to some similar set of fantasies rather than primarily to any failure of cortical development. Unfortunately it is very difficult in practice to distinguish between the two hypotheses, since the improvement in Blanchard's boy could have been due to development, and the improvement in Brenda and Michael could have been due to the therapeutic effects of remedial teaching. It is worth noting that in Brenda's case she is reported as being in rather an excitable mood and as 'chaffing' her remedial teacher, and if the psychoanalytic approach to this type of disability is correct, it would follow that this incident, as part of a wider transference relationship, was of crucial importance.

However, there was no evidence in either case of any gross psychiatric disturbance, and I reached the conclusion that emotional maladjustment was not the main causal determinant (J).

SOME PRACTICAL IMPLICATIONS

If the main ideas expressed in this paper are correct, it follows that this type of disability is entirely beyond the child's control. This has important practical consequences for the handling of such cases. Both Brenda and Michael were able to appreciate and accept the fact that, for them personally, certain tasks were more difficult than for some of their contemporaries. For most of the time during the remedial teaching sessions they were prepared to make an effort; in special circumstances, e.g. when Brenda had a cold, making the effort was more difficult. A knowledge of these limitations enabled me to see how much could reasonably be expected of them at any particular time. There were times with Michael when I made clear that the required piece of reading or spelling was something within his power provided he was careful and followed the rules that I had given him. If he failed to be careful, I made clear that I expected him to do better, but where words were irregular or the rules which I had given him did not operate, there was no question of my finding fault with him or even expressing disappointment. What was necessary for me was to know when to say 'This is difficult - have a shot' and when to make clear that a particular task was within his power. If a child of this kind likes to be told whether he has done well or done badly, all that the teacher need do, to give an honest answer, is to adjust his standards of what constitutes doing well or doing badly in a special way on the basis of what a developmental aphasic can be expected to do.

A further point is this. On the assumption that developmental aphasia is a disability sui generis, it follows that figures obtained from many of the standard intelligence tests are liable to be under-estimations of the child's potential. The Terman-Merrill test, for instance, taps many abilities (this is one of the fascinating things about its use in practice), and includes items which the developmental aphasic is likely to find difficult (K).

In addition it should be remembered that among children of less ability the condition is more likely to pass unnoticed, since the discrepancy between reading ability and general brightness would be much less marked.

Finally, although I have suggested that the reason for developmental aphasia will ultimately be found to lie in a failure of function of the brain, it by no means follows that this failure of function will be permanent. The brain is in many ways altogether unlike a telephone system: if a telephone wire is broken, communication to a particular house is impossible, and there is no more to be said. The brain, on the other hand, is a very plastic organ, and even when there is definite damage to a particular area, as in acquired aphasia, another area can partially take over certain functions. In the case of developmental aphasia, where there is not so much damage as some failure of development, there is every prospect of fresh skills emerging. Individual attention is necessary for these children, and helping them to overcome their disability may be a lengthy and even painful process, but it seems from the data available that there is a good chance of successful progress.

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