Dyslexia in Children

Helmer R. Myklebust & Doris Johnson

n recent years perhaps no part of the public school program has received more attention or more criticism than reading. To many it has become synonymous with education. In appraising the adequacy of an educational program, whether at the elementary, high school, or college level, reading often is used as the criterion. In some respects this emphasis has been rewarding and beneficial because it has stimulated an awareness that reading plays a critical role in the educative process. On the other hand the concern has been with reading as a skill rather than as an integral facet of that significant, if not unique, characteristic of human behavior, language. This has detracted from the importance of reading as a type of verbal functioning and has led to an essentially exclusive concern with factors pertaining to speed and the use of the eyes. Only recently has the process of learning to read and its relationship to other aspects of verbal behavior been emphasized. Reading is more than a skill. It is a symbol system, a means whereby man internalizes, integrates and organizes experience. It is related to the other principal verbal system which he uses, the spoken word. These two verbal systems, the read and the spoken, constitute man's language and each can be understood only in relation to the other. When studying the process of learning to read, it is revealing to include phylogenetic and

ontogenetic considerations. Phylogenetically, when man acquired verbal facility, he did not first learn to read. His first acquired verbal symbol system was auditory language, the spoken word. When he acquired this facility is not known because it occurred many millenia ago. In comparison, man acquired the ability to read only about 5000 years ago (Friederick, 1957). We find a similar circumstance ontogenetically. The infant does not first learn to read; he too first learns to use the spoken word. By two years of age he has achieved considerable fluency in the use of this symbol system. Only after four or five years of additional "evolution" is he ready to learn to read. This discloses the well known relationship between reading and mental and physical development. What is less obvious and less well known is that this hierarchy also reveals a fundamental inter-relationship between man's verbal symbol systems, between the spoken and the read word. It is this knowledge which is providing new insights into the process, into the psychoneurological dynamics of learning to read.

Reading and Language Development Learning to read is an integral part of total language development, and, therefore, study of this process must include study of all the other aspects. Much has been learned concerning the

14

SEPTEMBER 1962

requisites and means whereby a child acquires language; thus the developmental sequence is becoming clarified (McCarthy, 1946). Functionally, there are five types of verbal behavior and all are developmentally inter-related. First the child learns the meaning of words which he hears; he learns to associate the symbol "dog" with the unit of experience "dog." This acquiring of meanings is referred to as the development of inner language. When the symbol "dog" and the experience "dog" have been associated, comprehension begins and initiates the second stage of language development, the use of auditory receptive language. About three months later, at approximately twelve months of age, the child speaks his first word which initiates the third type of verbal function, auditory expressive language, or speech. Because of this developmental hierarchy, no child speaks until he has learned the meaning of words or until he comprehends. Input precedes output. Many children who do not speak at the usual age do not have defects in ability to use words expressively. Their limitations in expression derive from their inabilities receptively. Speaking is the expressive side of auditory comprehension (Myklebust, 1954). The same type of relationship exists between reading and writing. As the child does not speak until he comprehends the spoken word, he does not write until he comprehends the written word; he does not write until he first learns to read. Therefore, the five types of verbal functioning in order developmentally, are: (1) Acquisition of meaning, (2) Comprehension of spoken word, (3) Expression of spoken word (speech), (4) Comprehension of printed word (reading), (5) Expression of printed word (writing). This hierarchy of language development has been discussed in greater detail elsewhere (Myklebust, 1960). Our emphasis here is that learning to read is a part of total language development. It is a step in a developmental sequence which is not fully matured until well after the age of entering school. While studies are limited, written language, which develops last, seems not to be fully matured until about thirteen years of age (Myklebust, 1960). From this developmental point of view we now consider more closely the inter-relationship between man's two basic verbal symbol systems. Such a consideration is of critical im-

portance in understanding the process of learning to read, as well as the problem of dyslexia. Contrary to an assumption held by many, there is a relationship between the spoken and read word. As indicated above, spoken language precedes read language; this was true phylogenetically and it is true ontogenetically. The relationship developmentally between the spoken word and the read word evidently is much more intimate, as well as intricate, than has been generally assumed (Brown, 1958). Initially the process of learning to read entails superimposing the read symbol onto the auditory; the child first converts the visual word into an auditory one. Only much later is he able to "read silently," and it appears that no one achieves complete success in reading by visual means alone. We all "regress" and sound out words when they are difficult and unfamiliar. Such a comment is not mere speculation. Evidence is accumulating from diverse sources; experience in teaching foreign languages, study of language development in normal children, and from the area of language pathology. A definitive source of information is the deaf child. It is well known that children who have deafness from the preverbal age do not acquire auditory language and are seriously deficient in learning to read. They do not hear the spoken word and therefore do not acquire auditory language. But why are they so deficient in learning to read? Presumably, because there is no auditory symbol system on which to superimpose the visual; learning to read by visual means alone, that is, without audition, is extremely difficult. The relationship between the auditory and the read word is being manifested also through the study of children who have dyslexia. Such study is disclosing that certain types of auditory disorders other than deafness preclude normal acquisition of ability to read. Childhood Dyslexia Despite the pioneering work of Morgan (1896), Thomas (1905), Hinshelwood (1900), Orton (1937), Hallgren (1950), and Hermann (1959), only minor attention has been given to the problem of dyslexia in children. Reading specialists to a great extent have ignored this condition as a causative factor in children's reading disabilities. Nevertheless, gradually there is a growing awareness of its importance, not only in terms

liXCEPTIONAL CHILDREN

15

of the need for appropriate diagnosis and specialized training, but because of the opportunities for expanding our knowledge of the processes whereby all children learn to read. As in the case of the aphasias, dyslexia was first described in adults. Because of some type of brain disease an otherwise normal adult lost his ability to read. Gerstmann (1940) helped establish the relationship between behavioral deviations and brain dysfunction. More recently the work of Neilsen (1946), Critchley (1953), Penfield and Roberts (1959), and Brain (1955) has been especially revealing in regard to adults. That dyslexia occurs in children has been less generally recognized. Dyslexia by definition is an inability to read normally as a result of a dysfunction in the brain. It is a type of visual agnosia and in the past commonly was referred to as word-blindness. Although the individual is of normal mental capacity, has no deficiency in ability to see and is not emotionally disturbed, he cannot associate the printed word with the appropriate unit of experience. He has established the unit of experience "dog," he can see the printed word "dog," but he cannot relate the two. It is a language disorder, an inability to normally symbolize experience verbally. That dyslexia occurs in children cannot be questioned. It occurs on at least three primary bases; as a result of disease, from accidents, and on the basis of heredity. Various types of accidents might result in injury to the brain (Frantzen, Jacobsen, & Therkelsen, 1961). Diseases which are frequently associated with psychoneurological learning disorders are erythroblastosis, encephalitis, anoxemia, and rubella; damage from disease might occur prenatally, at the time of delivery, or postnatally (Lamm, 1959; Clemmens, 1961). In the past workers such as Orton (1937) stressed the hereditary factor in dyslexia and more recently Hallgren (1950) has shown the pronounced effect of endogeny. A child might inherit a defect in the eighth nerve and thus be unable to hear, or he might inherit a defect in the optic nerve and be unable to see. Likewise, he might inherit a specific type of deficit in the brain which precludes his being able to learn to read normally (Auerbach, 1961). To date only very little information is available on the incidence of dyslexia in children. Hallgren (1950) states that ten percent of

school children have a reading disability of this type. Myklebust and Boshes (1960) have reported that at least five percent of school children have some type of psychoneurological learning disorder. Although extensive knowledge in regard to incidence is lacking, it is evident that dyslexia is substantially more widespread than has been assumed by most educators. Moreover, there is agreement that it is much more common in males than in females, suggesting the prevalence of a sex-linked genetic factor; it occurs at least five times more frequently in males. While dyslexia can occur in association with other conditions such as mental retardation, children having this type of reading disorder are not generally inferior in intelligence; some are gifted intellectually. On the other hand, as indicated by the illustrative cases below, dyslexia rarely occurs in isolation. As stressed by Bender (1958), this type of reading disability often is found together with other learning disorders. Gerstmann (1940) first described a syndrome in adults which included dyslexia and much of this syndrome is found also in children. Furthermore, other aspects of the "dyslexia syndrome" in children now can be described. In a recent analysis of approximately 200 such children we found the following to be characteristic. A Dyslexia Syndrome in Children Disturbance of Orientation This is an inability to properly orient oneself in space and to learn to distinguish right from left; Benton (1959) has made extensive study of this ability and its maturation in children. Usually the child cannot indicate right or left, and cannot associate meaning with directions such as north, south, east, and west. He is at a loss in giving the direction a flag would fioat if the wind is from the north, or in determining the direction to his right if he is facing south (Goody & Reinhold, 1952). Disturbances in orientation cause him to be confused in many daily life situations. Topographic Disorder A disturbance of the ability to read maps, globes, graphs, floor plans and blue prints is referred to as a topographic disorder (Paterson, 1945). The child cannot normally learn to as-

16

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1962

sociate meaning with such representational materials; he cannot spatialize symbolically, which might cause a serious deficiency in school subjects, especially geography. Dyschronojnetria A dyschronometric disturbance means that the child cannot normally learn the significance of sequence and time (Goody, 1958). He cannot learn to tell time from a clock and usually he has great difficulty in learning to name the days of the week, the months and seasons of the year. Often highly intelligent dyslexic children have not learned to give simple sequences in order even by fifteen years of age. Inability to Write Most dyslexic children are referred for study with the complaint, "he is unable to read or write." Actually, except for a few who are dysgraphic, the limitation in writing is a direct manifestation of the inability to read. As indicated above, writing is possible only after ability to read has been achieved. Hence, written language is the last verbal symbol system to be acquired; written language is the highest level of verbal behavior achieved by man. As the dyslexic child learns to read he can write. In general, dyslexic children can copy but those having dysgraphia cannot (Orton, 1937; Critchley, 1953). Spelling Pisability Ability to write and ability to spell are not synonymous. Many dyslexic children, although able to write sentences, are seriously deficient in spelling. An inability to spell can be viewed as an excellent indication of a reading disorder such as dyslexia. Apparently spelling in the written form requires simultaneous ability to visualize and to auditorize letters. If either of these is deficient it will result in limitations in both reading and spelling (Monroe, 1932; Thurston, 1954). Dyscalculia A deficiency in learning the symbolic significance of numbers because of a dysfunction in the brain is referred to as dyscalculia (Cohn, 1961; Gertsmann, 1940). In school children this condition often is manifested by an obvious disability in arithmetic although intelligence and other aspects of behavior are well within the normal range. Some are deficient in arithmetical

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concepts, some cannot read numbers and hence, cannot write them. Others cannot associate meaning with the symbols which indicate the arithmetical process to be employed, such as =, X and -h. Hermann (1959), too, found that dyslexic children often were dyscalculic. Foreign Language Disability A number of our subjects from high schools and colleges have attempted to learn a foreign language. Almost without exception this has resulted in failure. As a part of our counseling of such students we advise that they do not include a foreign language in their studies. Memory Disorders A/Iemory disorders are extremely common in dyslexic children, some having deficits in both auditory and visual recall. However, one of these usually is substantially more affected than the other. There are several types of memory disturbances, each with its own significance in terms of learning and adjustment. Some children cannot remember the sequence to be followed from a given set of instructions; they are confused and make errors when told to "first close the door, then get your book, and bring your chair over here and sit next to Johnny." Some cannot recall what they have read; others cannot remember a series of numbers or repeat a sentence. These memory deficiences are of utmost importance diagnostically and therapeutically. biability to Auditorize or Inability to Visualize Extensive psychometric appraisal reveals that the dyslexic child usually is characterized by a learning disorder which is primarily auditory or visual in nature. This is the basis for the generalization that some children cannot read because of an inability to learn what letters sound like, while others cannot read because of a deficit in learning what the letters look like. Although an obvious over-simplification, with many children showing limitations in both, the sensory channel which is most effective for 1 earning must be ascertained through diagnosis and stressed in remedial instruction (Gates, 1947). As might be anticipated from the above discussion, those having primary deficits in ability to aud.rorize are the most affected psychologically; they show more debilitation psychoneu-

rologically. In one of our studies comparing the "auditory" with the "visual" we found that the "visuals" were superior in social maturity, ability to unscramble scrambled sentences, articulation, writing numbers from dictation, and ability to draw a man; the differences were statistically significant. Moreover, from experience in language therapy it is apparent that unless the remedial instruction is pursued according to the primary type of deficit, progress in learning to read is impeded (Pimsleur & Bonkowski, 1952). Deviate Motor Pattern Dyslexic children do not have obvious motor disorders, nor are they significantly retarded in sitting or walking age. However, when motor tests are administered they fall below average as a group; we have found them to be inferior on tests of locomotor coordination. Furthermore, they manifest a higher incidence of disturbances of laterality as compared to the normal (Orton, 1937; McFie, 1952). Neurological Disturbances While some authorities have indicated that neurological studies do not reveal characteristic dysfunctioning in dyslexic children (Hermann, 1959), our results are to the contrary. In 100 consecutive cases, 75 percent showed positive neurological findings. This was true of the electroencephalographic findings as well as the results from the neurological examination; each revealed brain dysfunction in approximately 75 percent of the children. When the findings of the two procedures, the EEG and the neurological examination, were combined, the evidence of neurological disturbance was even higher. It should not be construed that all facets of this syndrome of childhood dyslexia necessarily will be present in a given child. Rather, when taken as a group, these symptoms characterize children having this type of reading disorder. Illustrative Cases
Case One: A Primary Deficiency in Ability to Visualize

Jack was referred for study when lie was six years, ten months of age because he was making poor progress in school learning. He seemed to memorize whole stories from hearing others read them, but could not recognize any words from seeing them. Before entering school he seemed normal in every

18

SEP I EM HER 1962

way; sitting, walking, learning to care for himself all were achieved at the usual age. Diagnostic study at this time revealed: Mental Ability M.A. Binet Vocabulary 6 Manikin S Picture Completion 6 Picture Absurdities 7 Story Recall Digit Span Kohs Block Goodcnough M.A. 8 4 5 7

Orientatio?! No concept of right and left. Chronometria No ability to judge time, could not tell whether such obvious events as breakfast came in the morning or afternoon. Reading Readiness At thirty-ninth percentile for his age, with visual abilities falling much below the auditory. Neurological Findings Persistent larval Babinski on botb sides and an abnormal electroencephalogram. The EEG was unstable with paroxysmal activity in drowsiness. Also, in sleep there were spike and wave patterns with dissimilarities in the occipital areas. Conclusions Dyslexia, with need for specialized language therapy. Jack was begun on language training for dyslexia, two periods per week, each of one hour in duration. Special emphasis was placed on visual reading readiness skills. He confused letters that looked alike and had difficulty in learning to look from left to right on the page. He also_showed limited ability to describe people and his daily surroundings, indicating that his deficiency in visualizing was not restricted to the printed word. Many aids were used to help him overcome these special deficits. After the training program had been in progress for approximately six months he was reappraised with the following results: (C.A. 7-4) Mental Ability WISC: Performance IQ 89 Sub-test scaled scores Picture Completion 9 Coding 8 Picture Arrangement 7 Mazes 7 Block Design 7 Digit Span 10 Object Assembly 12 Kent Oral EmergencyMA 6-6 Binet Vocabulary MA 8-8 Language and Speech Rating Comprehension of spoken word Average Discrimination of speech sounds " Articulation " Sentence formulation (from given word) "

Story recall (when read to him) " Sentence repetition " Dysnomia None Ability to writecould copy but could not write spontaneously Reading Gates Reading Diagnostic Test Results: Age Oral reading 6-9 Phrase perception 6-8 Syllabication 6-8 Letter sounds 7-2 Blending letter sounds 8-3 Initial sounds 7-8 Final sounds 6-6 Laterality Right handedRight footed DynamometerLeft hand stronger than right Hearing and Vision Normal Social Maturity Vineland Social Maturity ScaleSQ 109 Orientation Deficient in right-left orientation Chronometria Deficient in ability to tell time Neurological Findings Neurological disturbance, chiefly right cerebral lesion; left Babinski; external rotation of lower left extremity; increased deep tendon reflexes; no abdominal reflex in left lower quadrant. Moderately abnormal EEG with scattered slow waves, more prominent on right, occasionally becoming paroxysmal of a 4 per second nature. Conclusions A psychoneurological learning disorder, mainly dyslexia with primary deficiency in ability to visualize. Psychometric variations but learning potential estimated to be average.

Jack was continued on a program of language therapy; training sessions of one and one-half

Figure 1. Errors in Reading Readiness When Training Was Begun.

EXCEPTIONAL CHILDREN

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hours were held twice a week. Simultaneously he attended public school and the language therapist had frequent conferences with his teacher. Because Jack was a better auditorizer than a visualizer, the general therapy principle was to use an "auditory approach" to develop and strengthen the visual abilities. He could not learn by the look-say method as he could not visually retain a word in mind. However, phonovisual work was stressed and the principle of simultaneity was followed rigorously. This procedure of using the more intact channel as the basic avenue to the mind and si?nultaneously associating it with the more deficient channel seems to be of utmost importance in facilitating learning when this type of disorder is present. Many of the techniques which Gillingham (1940) suggested were helpful in working with Jack. He first learned single sound elements and progressed into word wholes. Devices for correcting reversal tendencies as described by Monroe (1932) also were helpful. Jack continued in this program for approximately three years. The progress he made is shown below by the reading test results and the work samples, Figures 1 and 2: }Vord Recognition Date
12-58 6-59 12-59 5-60 1-61 6-61 10-61 Grade 1.5 2.0 2.4 2.7 3.2 3.9 4.3 1.6 2.0 2.8 3.6 1.9 2.9 3.4 3.8 4.2 2.2 2.8 3.1 3.7 2.7 3.2 3.8 4.1 Age 6-10 7-4 7-8 7-11 8-5 9-1 9-6 6-11 7-2 8-0 8-9 7-11 8-1 8-7 9-0 9-4

In addition, Jack's progress, as well as his improvement in psychological functioning, is shown by the last diagnostic appraisal. This study was made precisely three years after he was seen for the first time. The results were as follows: (CA 9-10) Mental Ability WISCPerformance IQ 104 - Verbal IQ 91 Sub-test scaled scores Picture Completion 11 Information 10 Picture Arrangement 8 Arithmetic 5 10 8 Block Design Similarities 10 Object Assembly Vocabulary 10 9 Coding Digit Span 10 16 Mazes
Detroit Test of Learning AptitudeIQ 101 Sub-test scores (MA) Picture Absurdities 5-9 Free Associations 11-9 \'erbal Absurdities 8-6 Designs 9-9 Verbal Opposites 11-0 Auditory Span Attention Span Syllables 10-9 Words 9-3 Visual Span Oral Commissions 7-3 Syllables 12-9 Social Adjustment 9-6 Oral Directions 6-3

Visual Span Objects

Language

10-6

Likenesses and Differences Orientation

11-0 10-0

Peabody Picture VocabularyMA 10-2 Columbia Vocabulary (Read) 20th percentile for age

Figure 2. Progress Over an 18 Month Period in Writing From Dictation. Dec, 19)9

Sentence Meaning
12-58 12-59 5-60 1-61

Paragraph Meaning
6-59 5-60 1-61 6-61 10-61

on pay
(

for

no

for

day was big

Spelling
12-59 5-60 1-61 6-61 7-4 8-0 8-3 8-10 8-2 8-8 9-4 9-10

June, 1961

5" aw AI ^

for
for

for

person

Arithmetic
12-58 12-59 1-61 6-61

20

SEPTEMBER 1962

He learns single sounds 2 - 58

blends them into words 5 - 58

learns phonics and spelling rules 12 - 58

for h

wh and writes sentences S - 59

for tag

Figure i. Progress in Auditorizing atid Writing.

Gates Reading Diagnostic: Age Age Oral reading 8-6 Blending (perfect Phrase perception 8-5 score) 9-2 Syllabication 7-4 Letters for sounds 8-7 8-3 Letter sounds 8-8 Initial sounds Final sounds 6-11 Locomotor CoordinationMowr: age 10 years Social Maturity-SQ 109 OrientationTells time accurately, gives days of the week in sequence but fails months of the year. Jack has made his most rapid progress during the past eight months. He now says that he can "see words" in his mind. Formerly it seemed that each time he "saw" a word he was seeing it for the first time. Visual memory has improved considerably. As the test scores indicate, he still has residual dyslexia. However, he is in the fourth grade in public school and the outlook for him continues to be good. Case Two: A Primary Deficiency in Ability to Auditorize Sandy was referred for difficulties in learning to read when he was eight years, four months of age. The initial diagnostic study revealed an unusually brilliant boy (IQ at least 150) who in general scored substantially higher on tasks requiring visualization as compared to auditorization. Some of the test results were as follows:

Mental Ability Age Binet Vocabulary Adult Digit Span 9 Story recall 8 Verbal absurdities 7 Rhyme 7 Picture Absurdities 14 Language Comprehension of spoken word was excellent but he manifested auditory perceptual disturbance by confusing words such as cold and coal. Ability to read was limited, especially in view of his mental age, and he could not "sound-out" even the simplest words. He could neither spell nor write although he could copy. Chronometria Despite a brilliant mind he could not give the days of the week or the months of the year in sequence. He had great difficulty in learning to tell time. Orientation Sandy, like many other dyslexics, had difficulty with right-left orientation. He could remember which was his right hand but he became confused when instructed to put his name in the upper right hand corner or to draw a margin on tlic left side of the paper. Neurological Findings Neurological examination revealed positive evidence of neurological dysfunction. Likewise, the EEG was abnormal with paroxysmal slowing of 6-per-sec()nd frequency in the bitemporal and biparietal areas, becoming geiiL-ralized. Some decrease in voltage in the right

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temporal area was seen in the bipolar combination during sleep. Conclusion Sandy was diagnosed as having a psychoneurological learning disorder, mainly a dyslexia with a primary deficiency in ability to auditorize. A language therapy program was begun; the sessions were an hour and a half and held twice a week. Although some improvement was noted immediately, Sandy, being highly sensitive to failure experiences, wept whenever asked to perform auditorizing tasks. He manifested very limited ability in blending sounds into words and it was virtually impossible for him to identify words that rhymed. Intensive effort was given to helping him with auditory associations and integration. He also needed assistance with learning the sounds that letters make; the procedures suggested by Orton and Gillingham proved beneficial. As indicated by the test scores below, Sandy made rapid progress. However, spelling continued to be difficult for him. Typically, spelling is the last area to show improvement and frequently this ability remains below the level of competence in reading. His specialized language training continued for 25 months and his progress is shown below by the reading test scores and by the work samples. Figures 3, 4 and 5:
Date 12-57 Reading Skill Vocabulary Sentence meaning Paragraph meaning Comprehension Speed 3-58 Vocabulary Comprehension Speed 5-58 Vocabulary Comprehension Speed Spelling 10-58 Vocabulary Comprehension Speed 12-58 Paragraph meaning 6-59 Vocabulary Comprehension Speed Spelling Grade
3.3 3.9 3.5 3.4 2.3 4.4 3.7 3.8 6.5 4.2 5.8 2.8 6.4 6.5 6.1 6.8 7.2 8.9 7.1 3.2

READING SCORESDEC, 1957 READING SCORESMAY,

Grade Vocabulary 3.3 CompreheJtsion 3.4 Speed 2.3

Vocabulary Comprehension Speed

Grade 6.5 4.2 5.8

Figure 4. Drawings of the Human Figure Improve as Reading Scores Go Up.

1 u5 da ay
lu-

^ ^ < U 2 ^

Wn^da

Age
8-9 9-1 8-8 8-10 7-8 10-1 9-3 9-4 12-3 9-10 11-8 8-3 12-2 12-3 11-10 12-7 12-11 14-8 12-10 8-8

y
Figure 5. Progress Over a 4 Month Period in Writing Words Fro?n Dictation.

ing at a level commensurate with his mental capacity. He had been attending public school throughout the period that he received language therapy and when this remedial work was terminated he was placed in a class for the gifted.
Case Three: A Primary Deficiency in Ability to Visualize

These data reveal that at the termination of his training Sandy was advanced roughly three years in reading, which means that he was read-

While many children having psychoneurological learning disorders are identified when they enter the first, second or third grade, a large number are not identified until they enter high

22

SEPTEMBER 1962

school. Our language therapy program includes groups of high school age students. Statistical analysis of our records shows that the younger the child at the time of referral the more likely he is to have an "auditory" type of dyslexia, while the older he is when first seen the more likely he is to have a "visual" dyslexia. Joe, who was first identified when in the eighth grade, had a primary deficiency in ability to visualize. At the time of the initial diagnostic study he was fourteen years, two months of age. The conclusions from this study were: Mental Ability At least average Hearing and Vision Normal Language Good use of spoken language, receptively and expressively. Reading and spelling ranged from the third to the sixth grade. Orientation Confusion of right and left. Chronometria Limited ability to use time concepts and sequences involving time. Topographia Striking inability in spatializing; could not draw even simple maps, diagrams or floor plans from memory but could copy them. Conclusions Although the neurological studies were not done at this time (see neurological findings below) he was classified as having a psychoneurological learning disorder with a primary deficit in ability to visualize. The dyslexia syndrome was evident, including a disorientation, dyschronometria and dystopographia. A program of language therapy was inaugurated and continued for 29 months. Joe manifested severe problems in revisualization, being limited especially in ability to recall what letters looked like. In addition he had difficulty in "monitoring" visually, not being able to recognize spontaneously the difference when he wrote see as seee, or there as theere. Such errors were not made when he spelled orally. The techniques suggested by Fernald (1943), emphasizing tracing and tactual learning, were of help to him. He learned to rely on tactual cues and after writing a word often made comments such as "that didn't feel right; let me try it again." After he had been in therapy for 13 months a reappraisal was made with the following results: (CA 15-3)

Mental Ability W i s e Performance IQ 120 Verbal IQ 129 Sub-test scaled scores Picture Completion 14 Information 16 Picture Arrangement 12 Comprehension 17 Block Design 18 Arithmetic 13 Object Assembly 16 Similarities 16 Coding 9 Vocabulary 15 Mazes 8 Digit Span 11 Auditory Laiagnage Articulation Good Comprehension Excellent Discrimination " Alemory for sentences " Binet Vocabulary " Dysnomia None Reading Grade Oral reading 5.3 Phrase perception 4.0 Syllabication 3.7 Blending sounds 4.1 Grade Spelling 3.7 Letter sounds 3.2 Initial sounds perfect score Final sounds perfect score

Social Maturity SQ 108 Motor Ability and Laterality LateralityRight handed and right footed DynamometerStrongest on right hand; at age level on right hand but one year below age level on left hand. Orientation Gives days of weekconfuses months of year. Neurological Findings Bilateral involvement, but chiefiy on the right side of the brain; right cortical lesion, involving pyramidal tracts, going to part of the face and also to the left side of the body. Minimal left hemiparesis. EEG: Mildly abnormal, consisting of scattered high voltage slow waves in arousal phase of sleepseen also during hyperventilation. Conclusions A psychoneurological learning disorder affecting visualizing more than auditorizing. Mental capacity at an above average level with psychometric and neurological data both indicating major involvement in the right hemisphere. Further language training recommended. After this evaluation Joe continued to receive remedial instruction for a period of approximately 16 months. The reading test scores, given below, and the work samples (Figures 6 and 7) indicate his progress: Date 4-58 Reading skill Vocabulary Comprehension Grade
6.0 4.1

Age

11-0 9-10

EXCF.PTIONAT, CHII.nRF.N

23

Dec, 19)7

,^^<trxJ

Apr,,

Oct., 1958

May, 1919
^W^

Figttre 6, Progress in Written

Language.

12-58 5-59

Significance Details Directions Spelling Vocabulary Comprehension Comprehension Significance Details Directions Spelling

7.1 5.6 7.5 3.7 8.5 5.6 8.0 10.3 7.8 9.7 6.0

12-10 11-5 13-3 9-3 14-3 10-7 13-4 15-10 13-3 15-3 11-0

References Auerbach, C. The science of genetics. New York: Harpers, 1961. Bender, L. Problems in conceptualization and communication in children with developmental alexia. Psychopathology and Communications, Grune and Stratton, 1958, pp. 155-176. Benton, A. Right-left discrimination and finger localization. New York: Hoeber, 1959. Brain, R. Diseases of the central nervoits system. New York: Oxford Univer. Press, 1955. Brown, R. Words and things. Glencoe, 111: Free Press, 1958. Clemmens, R. Minimal brain damage in children. Children, 1961, 8, 179-183. Cohn, R. Dyscalulia. Archives of Neurology, 1961, 4, 301-307. Critchley, M. The parietal lobes. Baltimore: Williams and Wilkins, 1953. Fernald, G. Remedial techniques in basic school subjects. New York: McGraw-Hill, 1943. Frantzen, E., Jacobsen, H. & Therkelsen, J. Cerebral artery occlusions in children due to trauma to the head and neck. Nettrology, 1961, H, 695-699. Friederick, J. Extinct languages. New York: Philosophical Library, 1957. Gates, A. The iinprove?7tent of reading: a program of diagnostic and re?nedial methods, (3rd ed.) New York: Macmillan, 1947. Gerstmann, J. Syndrome of finger agnosia, disorientation for right and left agraphia nnd acalculia. Arch, Neitrol, Psychiat., 1940, 44, 398-408. Gillingham, A. & Stillman B. Remedial training for children with specific disability in reading,

During his junior and senior years at high school Joe was on the student council and president of his class. He is now enrolled in a small liberal arts college where he seems to be competing successfully.
Summary

The problem of childhood dyslexia has been discussed. A definition and frame of reference was given whereby this type of reading disability was viewed as a psychoneurological learning disorder. A syndrome associated with childhood dyslexia was presented, with case illustrations. While much remains to be done by way of developing remedial educational procedures, it is apparent that when a precise diagnosis is made of the major and minor learning disorders and when the language therapy is based on the results, the outlook is favorable for children having this condition.

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1962

Figure 7. Spontaneous Written Language After 20 Months of Training.

spelling and penmanship. New York: Sackett and Wilhelms, 1940. Goody, W . Time and the nervous system; the brain as a clock. Lancet, 1958, 1139-44. Goody, W . & Reinhold, M. Some aspects of human orientation in space. Brain., 1952, 75, 472. Hallgren, B. Specific dyslexia (congenital word blindness): clinical and genetic study. Acta Fsychiat. Neurol. (Supp. 65), 1950, 1-287. Hermann, K. Reading disability. Springfield, HI.: Thomas, 1959. Hinshelwood, J. Congenital word blindness. Lancet, 1900, 1, 1506-1508. Lamm, S. Pediatric Neurology. New York: Lansberger, 1959. McCarthy, D. Language development in children. In L. Carmichael (ed.). Manual of child psychology. New York: John Wiley, 1946. McFie, J. Cerebral dominance in cases of reading disability. / . Neurol. and Psychiat., 1952, 15, 194-99. Monroe, M. Children who cannot read. Chicago, 111: Univer. of Chicago Press, 1932. Morgan, W . P. A case of congenital word-blindness. Brit. Med. ]., 1896, 2, 1378-1379. Myklebust, H. R. Auditory disorders in children. New York: Grune and Stratton, 1954. Myklebust, H. R. Psychology of deafness. New York: Grune and Stratton, 1960. Myklebust, H. R. & Boshes, B. Psychoneurological learning disorders in children. Arch. Pediat., 1960, 77, 247-256. Neilsen, J. Ag?iosia, apraxia, asphasia: their value in cerebral localization. (2nd ed.) New York: Hoeber, 1946.

Orton, S. T . Reading, writing and speech problems in children. New York: W . W . Norton, 1937. Paterson, A. Topographical disorientation. Brain. 1945, 68, 188. Penfield, W . & Roberts, L. Speech and brain mechanisins. Princeton, N . J.: Princeton Univer. Press, 1959. Pimsleur, P. & Bonkowski, R. Transfer of verbal material across sense modalities. / . Ed. Psych., 1961, 52, 104-107. Thomas, C. J. Congenital word-blindness and its treatment. Ophthahnoscope, 1905, 3, 380. Thurston, J. R. An empirical investigation of the loss of spelling ability in dysphasics. / . Speech Hear. Dis., 1954, 19, 344-399.

R. MYKLEBUST is Professor of Language Pathology and Psychology, and Director of the Institute for Language Disorders, Northwestern University, Evanston, Illinois. DORIS JOHNSON is Supervisor of Therapy, Institute for Language Disorders, Northwestern University. The authors gratefully acknowledge the collaboration of Harold McGrady, Arthur Neyhus, and Katherine Poole, Language Pathologists and Research Assistants, Institute for Language Disorders, and of Benjaiiiiii Boshes (Chainnan), Joel Brumlik, Roland de la Torre, and D. AA. Vuckovich, Neurologists, Department of Neurology and Psychiatry, Northwestern University.

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