JOURNAL
OF COMMUNICATION
TRAUMATIC
DISORDERS
9 (1976), 281-288
APHASIA IN CHILDREN:
A CASE STUDY
MARY LEE OELSCHLAEGER AND JOHN SCARBOROUGH ofSpeech Communication and Drama, North Texas State Universiry Denton, Texas
Department
76203
Traumatic aphasia in children has been recognized as adistinct clinical pathology, differing from adult aphasia in symptomatology and course of recovery. The upper limit for complete recovery has been identified as age 10. However, there is a paucity of literature documenting recovery of children with traumatic aphasia. It is apparent that definitive statements of the upper age limit for complete recovery from traumatic aphasia in children cannot be made at this time. This article reviews the literature concerning traumatic aphasia and presents case information of a lo-year-old traumatic aphasic girl seen at the North Texas State University Speech and Hearing Center. The design, execution, and assessment of therapeutic interaction and the observed language abilities of the client are reported.
Introduction Acquired aphasia in children refers generally to the language disorganization resulting from focal cerebral lesions that occurs during childhood. Although acquired aphasia in children has been identified as a distinct pathology for a long time, little attention has been devoted to it. It was once thought to be a rare disorder but, as Guttman (1942) pointed out, acquired aphasia occurs in children with the same reularity as it does in adults. Acquired aphasia in children has been proposed as a clinical entity differing from adult aphasia in course of recovery (Guttmann, 1942; Perlstein and Sugar, 1954; Basser, 1962; Alajouanine and Lhetmitte, 1965; Lenneberg, 1967). It is a commonly held belief that acquired aphasia in children is transitory and that sequelae are very few or absent. Lenneberg (1967) most clearly relates the differential course of recovery from traumatic aphasia in children and adults. He states that “although the symptoms of aphasic children who experience unilateral aphasia-producing lesions between 4 and 10 years of age are similar to adult symptomatology, the overwhelming majority recover fully and have no aphasic residue later in life.” In a communication with Dr. J. M. Neilsen, Sugar (Perlstein and Sugar, 1954) stated “that if the speech center is damaged before the age of 10, the child will recover his speech.” Ten years of age has been proposed as the upper limit for complete recovery based on the premise that cerebral plasticity is lost by this age as a result of the development of cerebral dominance or lateralized specialization of language function. However, there are few documented reports of recovery of children up to this age. Evidence supporting this age demarcation for recovery is gained from ’ American Elsevier Publishing Company,
Inc.,
1976
281
282
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
reports that have indicated permanent residual defects in children above the age of 10 who incurred traumatic aphasia (Guttmann, 1942; Lenneberg, 1967). However, evidence that would not support this age limit is seen in the reports by Basser (1962) and Lenneberg (1967) of children of 9 and 8 years of age, respectively, who did not recover completely. The establishment of an age limit for complete recovery is further complicated by Basser’s ( 1962) detailing of case information of a 16year-old who did recover completely. It is apparent that it is not presently possible to state definitively where childhood aphasia ends and adult aphasia begins. In other words, it is not possible to state when complete recovery will occur or residual defects will persist. Certainly, there is little question that age plays a role in consideration of prognosis in traumatic aphasia, but additional information is needed before definitive statements can be made concerning the upper age limit for complete recovery. The question of recovery became very important when a lo-year-old traumatic aphasic girl was brought to the North Texas State University Speech and Hearing Center. As the literature is unclear concerning this question, an attempt was made to gain information by following her course of recovery through 6 months of therapeutic involvement. Therapeutic sessions were conducted 4 days a week, with each session extending for 2% to 3 hours. The following is an account of therapeutic interaction with this girl, including a description of the formulation and application of a therapeutic regimen and assessment of her language abilities. Case History In May, 1974, D. G. fell from a horse onto the pavement. She was immediately unconscious and bled from her left ear. She was brought to the hospital and underwent surgery 3 hours later. A left hemicraniectomy was performed. The postoperative diagnosis was “left subdural hematoma, epidural hematoma and brain laceration.” At the time of her discharge from the hospital, she exhibited right hemiplegia and severe traumatic aphasia. There was no indication of any involvement of the right cerebral hemisphere. Prior to the occurrence of this accident and consequent surgical procedure, D. G. was in the fourth grade. She was a healthy, “normal” active lo-year-old. She had performed well in school, receiving all A’s in the past academic year. She was also a cheerleader. Speech, Hearing, and Language Assessment D. G. was brought to the Speech and Hearing Center in August, 1974. She was nonambulatory, requiring the use of a wheelchair. Both formal and informal testing procedures were performed to assess speech and language ability. The following is a summary of the diagnostic findings.
TRAUMATIC
APHASIA
IN CHILDREN:
A CASE STUDY
283
Auditory D. G. did not respond appropriately to any simple or complex auditory stimuli. Simple questions or commands to identify pictures, objects, or body parts yielded essentially no response. She did not score a single correct response with a formal administration of the Peabody Picture Vocabulary Test (1959). The desired pointing response for this testing procedure could not be obtained with verbal instruction but was elicited with gestural stimulation. However, she pointed randomly to one, or in some instances, all of the pictured items. Auditory testing with pure tones was unsuccessful as D. G. did not condition to the task. However, she did display orienting responses to free-field pure-tone presentations at 15 dB (ANSI, 1969). It was also observed that she attended to environmental stimuli such as the sound of a door being opened or the voice of a speaker. Apparently, she was able to perceive auditory stimuli at a level considered normal but was completely unable to comprehend auditorily any speech stimuli. Verbal Spontaneous use of language was essentially nil. The only verbal response she made was iteration of the syllable “na.” This iterative response was without linguistic meaning. Attempts to elicit imitative verbalization were unsuccessful. She was able to protrude, lateralize, and elevate her tongue in imitation of the examiner. Visual The only task that D. G. performed accurately was visual matching of geometric objects, numbers, pictures, and pictures with objects. She could not match written words either to pictures or objects. Graphic No spontaneous writing was emitted. However, using her left nondominant hand, she successfully copied written words of four or five letters. Writing was restricted to copying and could not be elicited with any other stimulus presentation. It was apparent that D. G. displayed a severe language deficit affecting all language modalities to an apparently equally debilitating extent. If these symptoms had been displayed by an adult, prognosis for recovery of functional language would have been poor (Schuell, 1964, Sarno et al., 1970). However, as she was only 10 years old and as the literature is unclear about course of recovery in children of this age, an intensive therapeutic program was designed for her.
284
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
Therapy Design Therapy was designed according to the principles stated by Schuell(l964). This design was dependent on (1) intensive auditory stimulation, (2) requirement of a response to each stimulus presentation, (3) use of meaningful language units, (4) controlled stimulus presentations, and (5) use of all language modalities to reinforce one another. Initially, several language categories were selected for presentation to D. G. However, it was almost immediately apparent that a large number of categories was not conducive to fulfilling the objective of repeated response trials. Therefore, the number of categories was reduced. The following represents the categories with expanded concepts that were presented in therapy: food: bread, milk, fruit, egg, coke; clothing: coat, shoes, pants, socks, shirt; place setting: knife, fork, spoon, plate, cup, glass; grooming articles: brush, comb, mirror, toothbrush. Activities
and Sequence
of Activities
Therapeutic activities were designed to stimulate all language modalities. An attempt was made to design a sequential introduction of the activities on the basis of their presumed difficulty. Each activity and the sequence of presentation of the activity during the therapy session is presented in Table 1. Description
of Therapeutic
Activities
Prior to initiation of each session, stimulus items of a language category with expanded concepts were selected for presentation. Each therapy session began with the first three activities, i.e., matching like pictures or objects, graphic
Therapeutic Activity
Activities
and Sequence
TABLE 1 of Activities -.~~
in Treatment
Matching like pictures or objects Graphic imitation of printed word Matching graphic imitation with printed word Matching printed word to picture or object Matching picture or object to printed word Matching auditory stimulus to word or picture or object Spontaneous verbal production* Spontaneous graphic production* *The term spontaneous a task.
is used to refer to a response performed
of Acquired Aphasia ~.__ Sequence
1 2 3 4 5 6 I 8 .__ under the defined stimulus control of
TRAUMATIC
APHASIA IN CHILDREN:
A CASE STUDY
285
imitation of printed word, and matching of the graphic imitation with printed word. These activities were not for training purposes per se as D. G. was able to respond correctly in these tasks from the onset of therapy. Rather, they provided opportunities to pair auditory stimuli or graphic stimuli simultaneously and thus were considered pretraining for activities to follow. In addition, they provided opportunities to reinforce correct responding for maintenance of D. G.‘s response rate. As D. G.‘s performance improved in consequent tasks, these initial activities were omitted. Matching word to picture or object and matching picture or object to word were redundant in actuality and one or the other was then introduced in the therapy session. Correct responding was believed to be predominantly dependent on visual ability, yet these activities were presumed to be more difficult than the initial tasks as they used linguistic stimuli. The next activity in the sequence was matching auditory stimuli to printed word, picture, or object. This activity was of critical importance as correct performance was believed to be dependent on auditory comprehension alone. The difficulty of this activity was thought to be increased as a function of the decrease in the amount and type of information available for correct responding. Successful auditory comprehension was followed by an activity directed toward eliciting spontaneous verbal production. Based on data suggesting that auditory comprehension abilities precede verbal expression abilities (Schuell et al., 1964)) this appeared to be the most logical sequence of activities. Attempts were made to elicit the desired response through the presentation of stimuli, i.e., printed word, object, or picture, that were presented in previous activities. The last activity in the sequence of therapy was a spontaneous writing task. This activity, again, involved presentation of stimuli used in the preceeding tasks. In summary, activities were designed and presented in an order presumed to be of increasing difficulty. Purely visually mediated activities were followed by others requiring imitation, comprehension, and finally, verbal and graphic production. Although auditory processing was not necessary to perform correctly in many of these activities, auditory stimuli were consistently presented during presentation and execution of these tasks. For example, each letter was spelled out to D. G. as she copied words, each word was read to her, and each stimulus item was identified for her during matching tasks. Results A daily record was kept of the language category and specific concepts presented, the number of presentations of each concept, and the time spent on each activity. This information aided in determination of content and conduct of subsequent therapy sessions. It also permitted assessment of the control of stimulus presentations.
286
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
All responses were recorded. Absolute scores were converted into percentage scores relative to the recorded number of trials for each activity. Such a treatment of data was not possible for recording responses in spontaneous writing activities. Rather, to assess this ability, a written statement describing performance on this task was made daily. Data accumulated at the end of this therapeutic involvement are presented in Table 2. In viewing this table, it can be seen that the activities involving the matching of pictures and objects and graphic imitations were consistently associated with correct responding. This, of course, was an expected finding as D. G. was able to perform these tasks at the onset of therapy. Therapeutic progress was definitely noted in activities requiring matching of words with pictures or objects or matching pictures or objects with words. D. G. was able to perform these tasks with an average of 90% and 95% accuracy, respectively. These scores were regarded as indicative of therapeutic progress, since D. G. was completely unable to perform these tasks at the onset of therapy. In addition, this high level of correct responding was interpreted as indicative of the appropriateness of the adopted sequence of tasks and basic principles from which they were derived. Reading is regarded as a language function dependent on audio-visual abilities. Apparently, D. G.‘s audio-visual abilities were less impaired, since the matching of words to pictures or objects reflected the greatest amount of improvement. It might have been assumed that successful performance of this activity would be dependent on successful performance of visual activities and auditory comprehension activities. This reading task would have been regarded as more difficult and placed later in the sequence of tasks. However, as the data suggest, this was apparently not the case. Data from the auditory comprehension activity show a mean of 61.24% accuracy at the end of this therapeutic period. Almost two-thirds of the time, D. G. identified stimuli, a picture, word, or object, when given the auditory stimulus
Mean Percentage
TABLE 2 of Correct Responses for Language Categories Responses for Each Activity
of Correct
Mean percentage activity
Mean percentage category
Activity
Matching pictures and objects Graphic imitation to printed word Matching graphic imitation with word Matching printed word to object or picture Matching object or picture to word Auditory comprehension Spontaneous verbal production
and Mean Percentage
Food
Clothing
Place setting
Grooming articles
100 100 99 87 92.75 63.16 8
90 100 92 90 93.66 66.66 40.66
96 100 99 96 98 54.12 33.50
89 100 100 88.25 97 61 No data
93.75 100.00 97.50 90.31 95.35 61.23 27.66
TRAUMATIC
APHASIA
IN CHILDREN:
A CASE STUDY
287
alone. This socre reflects great gains in auditory comprehension ability. To be sure, auditory comprehension remained impaired, but was significantly improved. As she initially did not use verbal language spontaneously, the mean of 20.5% correct responding from activities designed to elicit this response reflects therapeutic progress. It is interesting to note that correct verbal production was markedly less than auditory comprehension. Whether or not this reflects the need for comprehension of language units prior to expression of them and that D. G.‘s course of recovery parallels the manner in which children acquire language is not known. Yet such a theoretical notion would be supported by these data. In addition to the data presented in Table 2, a daily description of spontaneous writing was made. Responses obtained varied in success from total inability to total spontaneity and self-initiation. For example, on two separate occasions, the stimulus word “egg” was printed following auditory cues alone. During one of the final sessions, D. G. wrote the words “spoon,” “comb,” and “brush” without assistance. In other instances, an object was shown to her and she would print the first three of four letters of the word but was unable to complete it. In such instances, attempts were made to elicit the final letter by supplying an auditory cue of the letter. This frequently met with success, yet was also followed by failure to complete the writing tasks. Discussion It is apparent that many changes in D. G.‘s language abilities were observed during this period of therapeutic interaction. It should be realized that this report details only the information that was systematically obtained during the programmed therapeutic sequence of activities and thus does not relate other instances in which D. G. spontaneously emitted verbal responses or responded appropriately to auditory stimulation. As this report is being written, D. G. is still in therapy. Additional language changes have been noticed. Presently, her language use could best be described as agrammatic. She frequently responds appropriately to questions about her activities. She also speaks spontaneously in attempts to relate experiences. Still, langauge abilities are significantly impaired. At this point in time, 1 year after her accident, this lo-year-old girl cannot be regarded as having completely recovered and the question of prognosis remains. It is interesting to note that in all but one of the reported cases of recovery from traumatic aphasia in children reviewed by Lenneberg ( 1967)) restoration of language occurred within 1 year from the time of insult. However, the limited number of case reports precludes determination of expected length of recovery. The value of this case report then is thought to be more heuristic than definitive. The age limit of complete recovery from traumatic aphasia is still unknown and it is hoped that interest will be generated and will lead to documentation of other children who have incurred aphasia-producing lesions.
288
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
Although it is not possible to resolve presently the issue of age limits of expected complete recovery, review of the therapeutic program and data derived from it does permit several conclusions to be drawn. First, the program appeared to be viable and productive in its approach to treatment of this lo-year-old aphasic girl. A great deal of language change cocurred during this therapeutic involvement. Second, the therapeutic design permitted a systematic approach to the problem and was conducive to ongoing assessment of progress. Third, the therapeutic activities represented a hierarchical presentation of tasks in terms of their difficulty. References Alajouanine, T., Lhermitte, F. Acquired aphasia in children. Brain, 1965, 88, 653-662. American National Standards Institute. American National Standard specijcations for audiometers. ANSI 53.6-1969. New York, 1969. Basser, L. S. Hemiplegia of early onset and the faculty of speech with special reference to the effect of hemispherectomy. Brain, 1962, 85, 427460. Guttmann, E. Aphasia in children. Brain, 1942, 65, 205219. Lenneberg, E. H. The biologicalfoundations of language. New York: John Wiley&Sons, Inc., 1967. Peabody Word Recognition Test: Manual for the Peabody Picture Vocabulary Test. L. M. Dunn, Minnesota: American Guidance Service, Inc., 1959. Perlstein, M. A., Sugar, 0. Hemispherectomy in infantile hemiplegia. Arch. Neural. Psychiatry, 1954,72, 256-257. Same, M. T., Silverman, M. G., Sands, E. S. Speech therapy and language recovery in severe aphasia. J. Speech Hearing Res., 1970, 13, 607-623. Schuell, H., Jenkins, J., Jimenez-Pabon, E. Aphasia in adults. New York: Harper and Row, 1964.
OF COMMUNICATION
TRAUMATIC
DISORDERS
9 (1976), 281-288
APHASIA IN CHILDREN:
A CASE STUDY
MARY LEE OELSCHLAEGER AND JOHN SCARBOROUGH ofSpeech Communication and Drama, North Texas State Universiry Denton, Texas
Department
76203
Traumatic aphasia in children has been recognized as adistinct clinical pathology, differing from adult aphasia in symptomatology and course of recovery. The upper limit for complete recovery has been identified as age 10. However, there is a paucity of literature documenting recovery of children with traumatic aphasia. It is apparent that definitive statements of the upper age limit for complete recovery from traumatic aphasia in children cannot be made at this time. This article reviews the literature concerning traumatic aphasia and presents case information of a lo-year-old traumatic aphasic girl seen at the North Texas State University Speech and Hearing Center. The design, execution, and assessment of therapeutic interaction and the observed language abilities of the client are reported.
Introduction Acquired aphasia in children refers generally to the language disorganization resulting from focal cerebral lesions that occurs during childhood. Although acquired aphasia in children has been identified as a distinct pathology for a long time, little attention has been devoted to it. It was once thought to be a rare disorder but, as Guttman (1942) pointed out, acquired aphasia occurs in children with the same reularity as it does in adults. Acquired aphasia in children has been proposed as a clinical entity differing from adult aphasia in course of recovery (Guttmann, 1942; Perlstein and Sugar, 1954; Basser, 1962; Alajouanine and Lhetmitte, 1965; Lenneberg, 1967). It is a commonly held belief that acquired aphasia in children is transitory and that sequelae are very few or absent. Lenneberg (1967) most clearly relates the differential course of recovery from traumatic aphasia in children and adults. He states that “although the symptoms of aphasic children who experience unilateral aphasia-producing lesions between 4 and 10 years of age are similar to adult symptomatology, the overwhelming majority recover fully and have no aphasic residue later in life.” In a communication with Dr. J. M. Neilsen, Sugar (Perlstein and Sugar, 1954) stated “that if the speech center is damaged before the age of 10, the child will recover his speech.” Ten years of age has been proposed as the upper limit for complete recovery based on the premise that cerebral plasticity is lost by this age as a result of the development of cerebral dominance or lateralized specialization of language function. However, there are few documented reports of recovery of children up to this age. Evidence supporting this age demarcation for recovery is gained from ’ American Elsevier Publishing Company,
Inc.,
1976
281
282
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
reports that have indicated permanent residual defects in children above the age of 10 who incurred traumatic aphasia (Guttmann, 1942; Lenneberg, 1967). However, evidence that would not support this age limit is seen in the reports by Basser (1962) and Lenneberg (1967) of children of 9 and 8 years of age, respectively, who did not recover completely. The establishment of an age limit for complete recovery is further complicated by Basser’s ( 1962) detailing of case information of a 16year-old who did recover completely. It is apparent that it is not presently possible to state definitively where childhood aphasia ends and adult aphasia begins. In other words, it is not possible to state when complete recovery will occur or residual defects will persist. Certainly, there is little question that age plays a role in consideration of prognosis in traumatic aphasia, but additional information is needed before definitive statements can be made concerning the upper age limit for complete recovery. The question of recovery became very important when a lo-year-old traumatic aphasic girl was brought to the North Texas State University Speech and Hearing Center. As the literature is unclear concerning this question, an attempt was made to gain information by following her course of recovery through 6 months of therapeutic involvement. Therapeutic sessions were conducted 4 days a week, with each session extending for 2% to 3 hours. The following is an account of therapeutic interaction with this girl, including a description of the formulation and application of a therapeutic regimen and assessment of her language abilities. Case History In May, 1974, D. G. fell from a horse onto the pavement. She was immediately unconscious and bled from her left ear. She was brought to the hospital and underwent surgery 3 hours later. A left hemicraniectomy was performed. The postoperative diagnosis was “left subdural hematoma, epidural hematoma and brain laceration.” At the time of her discharge from the hospital, she exhibited right hemiplegia and severe traumatic aphasia. There was no indication of any involvement of the right cerebral hemisphere. Prior to the occurrence of this accident and consequent surgical procedure, D. G. was in the fourth grade. She was a healthy, “normal” active lo-year-old. She had performed well in school, receiving all A’s in the past academic year. She was also a cheerleader. Speech, Hearing, and Language Assessment D. G. was brought to the Speech and Hearing Center in August, 1974. She was nonambulatory, requiring the use of a wheelchair. Both formal and informal testing procedures were performed to assess speech and language ability. The following is a summary of the diagnostic findings.
TRAUMATIC
APHASIA
IN CHILDREN:
A CASE STUDY
283
Auditory D. G. did not respond appropriately to any simple or complex auditory stimuli. Simple questions or commands to identify pictures, objects, or body parts yielded essentially no response. She did not score a single correct response with a formal administration of the Peabody Picture Vocabulary Test (1959). The desired pointing response for this testing procedure could not be obtained with verbal instruction but was elicited with gestural stimulation. However, she pointed randomly to one, or in some instances, all of the pictured items. Auditory testing with pure tones was unsuccessful as D. G. did not condition to the task. However, she did display orienting responses to free-field pure-tone presentations at 15 dB (ANSI, 1969). It was also observed that she attended to environmental stimuli such as the sound of a door being opened or the voice of a speaker. Apparently, she was able to perceive auditory stimuli at a level considered normal but was completely unable to comprehend auditorily any speech stimuli. Verbal Spontaneous use of language was essentially nil. The only verbal response she made was iteration of the syllable “na.” This iterative response was without linguistic meaning. Attempts to elicit imitative verbalization were unsuccessful. She was able to protrude, lateralize, and elevate her tongue in imitation of the examiner. Visual The only task that D. G. performed accurately was visual matching of geometric objects, numbers, pictures, and pictures with objects. She could not match written words either to pictures or objects. Graphic No spontaneous writing was emitted. However, using her left nondominant hand, she successfully copied written words of four or five letters. Writing was restricted to copying and could not be elicited with any other stimulus presentation. It was apparent that D. G. displayed a severe language deficit affecting all language modalities to an apparently equally debilitating extent. If these symptoms had been displayed by an adult, prognosis for recovery of functional language would have been poor (Schuell, 1964, Sarno et al., 1970). However, as she was only 10 years old and as the literature is unclear about course of recovery in children of this age, an intensive therapeutic program was designed for her.
284
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
Therapy Design Therapy was designed according to the principles stated by Schuell(l964). This design was dependent on (1) intensive auditory stimulation, (2) requirement of a response to each stimulus presentation, (3) use of meaningful language units, (4) controlled stimulus presentations, and (5) use of all language modalities to reinforce one another. Initially, several language categories were selected for presentation to D. G. However, it was almost immediately apparent that a large number of categories was not conducive to fulfilling the objective of repeated response trials. Therefore, the number of categories was reduced. The following represents the categories with expanded concepts that were presented in therapy: food: bread, milk, fruit, egg, coke; clothing: coat, shoes, pants, socks, shirt; place setting: knife, fork, spoon, plate, cup, glass; grooming articles: brush, comb, mirror, toothbrush. Activities
and Sequence
of Activities
Therapeutic activities were designed to stimulate all language modalities. An attempt was made to design a sequential introduction of the activities on the basis of their presumed difficulty. Each activity and the sequence of presentation of the activity during the therapy session is presented in Table 1. Description
of Therapeutic
Activities
Prior to initiation of each session, stimulus items of a language category with expanded concepts were selected for presentation. Each therapy session began with the first three activities, i.e., matching like pictures or objects, graphic
Therapeutic Activity
Activities
and Sequence
TABLE 1 of Activities -.~~
in Treatment
Matching like pictures or objects Graphic imitation of printed word Matching graphic imitation with printed word Matching printed word to picture or object Matching picture or object to printed word Matching auditory stimulus to word or picture or object Spontaneous verbal production* Spontaneous graphic production* *The term spontaneous a task.
is used to refer to a response performed
of Acquired Aphasia ~.__ Sequence
1 2 3 4 5 6 I 8 .__ under the defined stimulus control of
TRAUMATIC
APHASIA IN CHILDREN:
A CASE STUDY
285
imitation of printed word, and matching of the graphic imitation with printed word. These activities were not for training purposes per se as D. G. was able to respond correctly in these tasks from the onset of therapy. Rather, they provided opportunities to pair auditory stimuli or graphic stimuli simultaneously and thus were considered pretraining for activities to follow. In addition, they provided opportunities to reinforce correct responding for maintenance of D. G.‘s response rate. As D. G.‘s performance improved in consequent tasks, these initial activities were omitted. Matching word to picture or object and matching picture or object to word were redundant in actuality and one or the other was then introduced in the therapy session. Correct responding was believed to be predominantly dependent on visual ability, yet these activities were presumed to be more difficult than the initial tasks as they used linguistic stimuli. The next activity in the sequence was matching auditory stimuli to printed word, picture, or object. This activity was of critical importance as correct performance was believed to be dependent on auditory comprehension alone. The difficulty of this activity was thought to be increased as a function of the decrease in the amount and type of information available for correct responding. Successful auditory comprehension was followed by an activity directed toward eliciting spontaneous verbal production. Based on data suggesting that auditory comprehension abilities precede verbal expression abilities (Schuell et al., 1964)) this appeared to be the most logical sequence of activities. Attempts were made to elicit the desired response through the presentation of stimuli, i.e., printed word, object, or picture, that were presented in previous activities. The last activity in the sequence of therapy was a spontaneous writing task. This activity, again, involved presentation of stimuli used in the preceeding tasks. In summary, activities were designed and presented in an order presumed to be of increasing difficulty. Purely visually mediated activities were followed by others requiring imitation, comprehension, and finally, verbal and graphic production. Although auditory processing was not necessary to perform correctly in many of these activities, auditory stimuli were consistently presented during presentation and execution of these tasks. For example, each letter was spelled out to D. G. as she copied words, each word was read to her, and each stimulus item was identified for her during matching tasks. Results A daily record was kept of the language category and specific concepts presented, the number of presentations of each concept, and the time spent on each activity. This information aided in determination of content and conduct of subsequent therapy sessions. It also permitted assessment of the control of stimulus presentations.
286
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
All responses were recorded. Absolute scores were converted into percentage scores relative to the recorded number of trials for each activity. Such a treatment of data was not possible for recording responses in spontaneous writing activities. Rather, to assess this ability, a written statement describing performance on this task was made daily. Data accumulated at the end of this therapeutic involvement are presented in Table 2. In viewing this table, it can be seen that the activities involving the matching of pictures and objects and graphic imitations were consistently associated with correct responding. This, of course, was an expected finding as D. G. was able to perform these tasks at the onset of therapy. Therapeutic progress was definitely noted in activities requiring matching of words with pictures or objects or matching pictures or objects with words. D. G. was able to perform these tasks with an average of 90% and 95% accuracy, respectively. These scores were regarded as indicative of therapeutic progress, since D. G. was completely unable to perform these tasks at the onset of therapy. In addition, this high level of correct responding was interpreted as indicative of the appropriateness of the adopted sequence of tasks and basic principles from which they were derived. Reading is regarded as a language function dependent on audio-visual abilities. Apparently, D. G.‘s audio-visual abilities were less impaired, since the matching of words to pictures or objects reflected the greatest amount of improvement. It might have been assumed that successful performance of this activity would be dependent on successful performance of visual activities and auditory comprehension activities. This reading task would have been regarded as more difficult and placed later in the sequence of tasks. However, as the data suggest, this was apparently not the case. Data from the auditory comprehension activity show a mean of 61.24% accuracy at the end of this therapeutic period. Almost two-thirds of the time, D. G. identified stimuli, a picture, word, or object, when given the auditory stimulus
Mean Percentage
TABLE 2 of Correct Responses for Language Categories Responses for Each Activity
of Correct
Mean percentage activity
Mean percentage category
Activity
Matching pictures and objects Graphic imitation to printed word Matching graphic imitation with word Matching printed word to object or picture Matching object or picture to word Auditory comprehension Spontaneous verbal production
and Mean Percentage
Food
Clothing
Place setting
Grooming articles
100 100 99 87 92.75 63.16 8
90 100 92 90 93.66 66.66 40.66
96 100 99 96 98 54.12 33.50
89 100 100 88.25 97 61 No data
93.75 100.00 97.50 90.31 95.35 61.23 27.66
TRAUMATIC
APHASIA
IN CHILDREN:
A CASE STUDY
287
alone. This socre reflects great gains in auditory comprehension ability. To be sure, auditory comprehension remained impaired, but was significantly improved. As she initially did not use verbal language spontaneously, the mean of 20.5% correct responding from activities designed to elicit this response reflects therapeutic progress. It is interesting to note that correct verbal production was markedly less than auditory comprehension. Whether or not this reflects the need for comprehension of language units prior to expression of them and that D. G.‘s course of recovery parallels the manner in which children acquire language is not known. Yet such a theoretical notion would be supported by these data. In addition to the data presented in Table 2, a daily description of spontaneous writing was made. Responses obtained varied in success from total inability to total spontaneity and self-initiation. For example, on two separate occasions, the stimulus word “egg” was printed following auditory cues alone. During one of the final sessions, D. G. wrote the words “spoon,” “comb,” and “brush” without assistance. In other instances, an object was shown to her and she would print the first three of four letters of the word but was unable to complete it. In such instances, attempts were made to elicit the final letter by supplying an auditory cue of the letter. This frequently met with success, yet was also followed by failure to complete the writing tasks. Discussion It is apparent that many changes in D. G.‘s language abilities were observed during this period of therapeutic interaction. It should be realized that this report details only the information that was systematically obtained during the programmed therapeutic sequence of activities and thus does not relate other instances in which D. G. spontaneously emitted verbal responses or responded appropriately to auditory stimulation. As this report is being written, D. G. is still in therapy. Additional language changes have been noticed. Presently, her language use could best be described as agrammatic. She frequently responds appropriately to questions about her activities. She also speaks spontaneously in attempts to relate experiences. Still, langauge abilities are significantly impaired. At this point in time, 1 year after her accident, this lo-year-old girl cannot be regarded as having completely recovered and the question of prognosis remains. It is interesting to note that in all but one of the reported cases of recovery from traumatic aphasia in children reviewed by Lenneberg ( 1967)) restoration of language occurred within 1 year from the time of insult. However, the limited number of case reports precludes determination of expected length of recovery. The value of this case report then is thought to be more heuristic than definitive. The age limit of complete recovery from traumatic aphasia is still unknown and it is hoped that interest will be generated and will lead to documentation of other children who have incurred aphasia-producing lesions.
288
MARY
LEE OELSCHLAEGER
and JOHN
SCARBOROUGH
Although it is not possible to resolve presently the issue of age limits of expected complete recovery, review of the therapeutic program and data derived from it does permit several conclusions to be drawn. First, the program appeared to be viable and productive in its approach to treatment of this lo-year-old aphasic girl. A great deal of language change cocurred during this therapeutic involvement. Second, the therapeutic design permitted a systematic approach to the problem and was conducive to ongoing assessment of progress. Third, the therapeutic activities represented a hierarchical presentation of tasks in terms of their difficulty. References Alajouanine, T., Lhermitte, F. Acquired aphasia in children. Brain, 1965, 88, 653-662. American National Standards Institute. American National Standard specijcations for audiometers. ANSI 53.6-1969. New York, 1969. Basser, L. S. Hemiplegia of early onset and the faculty of speech with special reference to the effect of hemispherectomy. Brain, 1962, 85, 427460. Guttmann, E. Aphasia in children. Brain, 1942, 65, 205219. Lenneberg, E. H. The biologicalfoundations of language. New York: John Wiley&Sons, Inc., 1967. Peabody Word Recognition Test: Manual for the Peabody Picture Vocabulary Test. L. M. Dunn, Minnesota: American Guidance Service, Inc., 1959. Perlstein, M. A., Sugar, 0. Hemispherectomy in infantile hemiplegia. Arch. Neural. Psychiatry, 1954,72, 256-257. Same, M. T., Silverman, M. G., Sands, E. S. Speech therapy and language recovery in severe aphasia. J. Speech Hearing Res., 1970, 13, 607-623. Schuell, H., Jenkins, J., Jimenez-Pabon, E. Aphasia in adults. New York: Harper and Row, 1964.
