An Intensive Therapeutic Program for Learning Disabled Prepubertal Children
Malcolm West, PhD, Myrna Carlin, MSc, Beverly Baserman, BA, and Maxine Milstein, BSc
This article contends that intervention in learning problems should be twofold. First, the child's attitudes toward both himself and learning need to be reworked. Second, remediation to ameliorate specific learning deficits is required. Traditionally, these two aspects have been carried out by two different professionals, the psychologist and the teacher. The present article describes a program that has attempted to synthesize these functions into one composite helping role. A case example is offered to illustrate the approach.
hrough our contact with a large number of children referred to our clinic for a variety of learning and adjustment problems, we are often impressed by the following polarity. Quantitative changes in objective performance (for example, in visual perceptual, auditory perceptual, and memory functions or in language and motor areas) can be contrasted with qualitative changes of the child's psychic life (lowered self-
esteem, subjective experience of tenseness and discouragement). In short, and to construct an artificial dichotomy that is only rarely encountered in its pure form, in the one instance there is altered capacity for performance in an intact personality as distinguished from changes in personality where the performance is intact. In the former case we are dealing with children who present with a primary learning defect, wherein whatever emotional problems that may exist are a reflection of the learning disability. In the latter, the child's personality has been modified so that his use of the tools for learning is either inefficient or deteriorates all together. The point of the preceding discussion is to highlight the necessity of paying attention to each component in planning a treatment program. For example, for those children in whom the learning disability is primary, the treatment of choice is remediation via special education techniques. However, the frustrations and failures attendant upon being disabled often create such severe feelings of inferiority as to Journal of Learning Disabilities
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render the child relatively unresponsive to a strictly remedial approach. Thus the child needs concurrent help with his feelings resulting from the learning deficiency in addition to the appropriate tutoring program. The personality is the force that puts the learning tools to work. If it is unavailable or unresponsive, remediation of the target learning symptoms is difficult. To take the reverse situation, that is, where the capacity for performance is intact but is hampered in its effectiveness by primary emotional problems, special educational techniques often need to be combined with psychotherapy. Tutoring changes the performance, which in many instances is a precondition, or at least a very valuable aid, which makes changes in the personality possible. For example, while it is possible to rework the child's lowered self-image through therapy, an actual improvement in his performance can be the tangible basis on which feelings of mastery may be built. Here we describe a program with the aid of a case example, which is based on the premise that there is a close connection between learning capacity and personality; therefore, the reciprocal influence of one on the other is the expected and reinforced process of the program.
DESCRIPTION OF THE PROGRAM The program consisted of five boys and three girls, ranging in age from 11 to 13 years. The children's intellectual abilities varied between borderline — dull normal to high average — with reading levels ranging from grades 2 to 6. All had either attended special classes or were recent school referrals. Learning problems were the major complaint; however, each child also experienced social and emotional difficulties. Because the children's learning disabilities not only hampered their effectiveness in school but also resulted in loss of self-esteem and •difficulties in peer relationships, it seemed important to provide both remedial tutoring and
therapy. Further, it was decided that an intensive experience wherein each child attended the program four days a week for one month would have maximal impact. Finally, a very conscious effort was made to group the children according to their specific learning problems and their emotional needs. For example, children who had language problems were grouped together; children who were anxious about their performance were placed in groups where they could feel comfortable. When a child needed individual help, he worked on a one-to-one basis. The children were assembled at the beginning of each day for a group discussion on selected topics, such as feelings about family life and future goals. The nature of the group's interactions and the children's perceptions of one another and the staff members were highlighted. To encourage prosocial behavior, each child as well as each staff member was asked to think of a behavior that he or she would like to improve, or one was suggested by the group. Behaviors to be modified included nagging, whining, bossing, fighting, smoking, and working independently. One point was awarded per period for good behavior. At the end of each week, the points were added and the results reviewed. Following the discussion were periods of reading instruction (including word attack skills, oral and silent reading, and comprehension), written expression (including typing for some with poor eye-hand coordination), visual training, language development activities, arithmetic, and specific classroom skills such as summarizing, outlining, and dictionary use. Each day closed with a period of either arts and crafts or role playing, designed to alleviate some of the tensions of the tutoring sessions and to help prepare the children for certain situations at home and at school.
CASE EXAMPLE Robert is a plump, unkempt boy, very verbal but physically passive, demanding, and whining. He
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is the youngest of three boys and has been overprotected by his mother. He has never done well at school or at establishing peer relations. Psychologicarassessment indicated high average intelligence but deficits in memory, sequencing, and motor coordination, a three-year lag in reading and four-year lag in spelling. Projective testing revealed a passive personality with identification difficulties and a high level of anxiety. Robert's style of doing was characterized by a pretense of helplessness through which he attempted to control others and have them do for him. He nagged everybody, staff and students, but was especially controlling toward the other children. A further impediment to successful interpersonal relations was Robert's problem of personal appearance and physical hygiene. Finally, a rather blatant passive resistance was evidenced in strategies such as follow: "I need a chair, get me a chair." "My pencil dropped, where's my pencil?" "I lost my exercise book, find me another one." All of these ploys, which displayed an inability to proceed independently and to persevere in the face of even slight difficulty, were systematically ignored and then countered by a restatement of work orders. Other techniques used included careful behavioral monitoring and charting coupled with a reward system for each task completed and for time periods free of demanding, nagging, or bossing behaviors. A behavior modification program called "Operation Skunk" was aimed at cleaning up physical appearance. Robert was inspected each morning with respect to fingernails, hair grooming, and body odor. He earned points for compliance, which were subsequently changed for tangible rewards. Group discussions and roleplaying situations around such carefully selected topics as "Sharing," "How to Apologize," "Getting up in the Morning," and "How to Look Your Best" were also used to provide him with alternate responses. When work attitudes and habits improved, parallel progress in basic skills also became 58
apparent in such areas as word attack skills (decoding), spelling, and fine motor skills.
DISCUSSION As outlined, the objectives of therapeutic tutoring encompass both remediation of specific learning deficits and help with the attendant feelings of inferiority and discouragement about these deficiencies in skills. Remedial work helped the children to improve their proficiency in reading, spelling, and mathematics, thereby giving them less reason to feel inferior. (In attempting to set up a study of pretesting and posttesting in reading and spelling, we discovered that methodological problems loomed large. A major setback was the lack of availability of appropriate tests — ones with alternate, equivalent forms or ones that permitted a split-half format. We are at present developing appropriate material.) Additionally, elevated self-esteem may also be attributed to the ego support the children derived from an adult who cared for and accepted them. The staff consciously used the strength of their relationships with the children to encourage them to try new ways of dealing with old problems. The availability, openness, and positive contact of teachers became a corrective emotional experience for these children who were more accustomed to critical and rejecting behavior from adults. This was impressed upon us, often in a heartbreaking way, by the children's comparison between our behavior and the angry, rejecting behavior of regular classroom teachers toward them. Perhaps avoidance of learning is more understandable in view of repeated experience with failure and with adults who are not sensitive to the students' needs and feelings. Motivation becomes negative in focus, directed toward avoiding potential failure situations instead of seeking success. In addition to fostering a nonanxious learning atmosphere by praising effort and by planning learning activities that would Journal of Learning Disdbilities
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guarantee success, we also used group discussions, behavioral techniques, and role playing to deal with feelings and attitudes that interfered with learning. For example, the behavior chart for staff and students alike encouraged the students' awareness of self and others and their efforts to succeed, knowing that the staff members freely admitted their own imperfections and participated fully in the undertaking. The children's unexpected reaction to role playing was especially gratifying. We had originally anticipated difficulty, thinking that the children, many of whom were passive and concrete, would not enjoy the activity nor be able to understand the method or purpose. To our great surprise, "acting" (as they called it) became a favorite period into which the children threw their full energy. Apparently unhampered by the need to read or memorize a script, they vied for roles and happily performed on the basis of their own experiences or imaginations, revealing a wealth of material about family attitudes and patterns, personal attitudes and styles, and gaps in social experience. The group discussion period that followed focused on the themes and feelings that emerged during role playing so that further ventilation, clarification, and working through of feelings could occur. Follow-up with teachers the next year indicated that, while learning deficits were still present, a major change in attitudes and self-
concept had occurred. The children were described as much more self-confident, eager to learn, and persistent. Thus it seems that the intensive help of the summer program changed these children from chronic "losers" to achievers who w ere closing the gap between achievement and their potential. In summary, this program has emphasized the importance of taking into account the personality variables in learning and suggests to us the value of including changes in self-concept and attitudes toward learning in outcome studies of remedial programs. The lack of attention to these personality variables may derive from the traditional dichotomization of the child whereby he has been seen for remediation of learning deficits by teachers and for attitudes by psychologists. Therapeutic tutoring is for the total child, as it combines both aspects into one helping person or setting.
Malcolm West is a staff psychologist in the Child and Adolescent Unit of the Department of Psychiatry of the Queen Elizabeth Hospital of Montreal and assistant professor of psychology at Concordia University. Myrna Carlin is a staff psychologist in the Child and Adolescent Unit and also director of the learning Clinic of the Queen Elizabeth Hospital of Montreal. Beverly Baserman and Maxine Milstein are clinical teachers in the learning Clinic of the hospital and in priixtte practice. Requests for reprints should be sent to Dr. West at the Department of Psychiatry, Queen Elizabeth Hospital of Montreal, 2100 Marlowe Ave., Montreal, Quebec H4A 3Ui.
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