Anda di halaman 1dari 170

Part Six:

Innovative Models that Work with Especially Challenging Functional Developmental Capacities


ICDL Clinical Practice Guidelines

Chapter 19. The Miller Method: A Cognitive-Developmental Systems Approach for Children with Body Organization, Social, and Communication Issues



Arnold Miller, Ph.D., and Eileen Eller-Miller, M.A., C.C.C.-S.L.P.

WHAT IS THE MILLER METHOD? The Miller Method is an integrated approach that addresses problems of body organization, social interaction, and communication in school, clinic, and home settings as presented by children on the autistic spectrum as well as those with significant challenges in learning or communication. Integrated means that, in this approach, each person working with the childwhile focusing on one aspect of the childs functioningalso addresses other areas of concern. It is also a coordinated program in that each person working with the child is in close touch with and contributes to others working with that child. It is an action-oriented program, which assumes that children learn best when they move and make direct physical contact with things and people. It also assumes that children learn best when they are taught or treated by those who understand that they require a combination of both support and demand. Greenspan and Wieder (2000) refer to the present approach as semistructured, in that the people working with a child are guided both by the initiatives of the child and by certain

developmentally organized interventions introduced by teachers and therapists. The Miller Method is guided by a cognitive-developmental systems theory with links to the work of Piaget (1948, 1954, 1962), von Bertallanfy (1968), Vygotsky (1962), Werner (1948), and Werner and Kaplan (1963) and is adapted to the needs of children with severe developmental challenges. It was developed by the authors during the last 40 years (Miller, 1963, 1968, 1991; Miller & EllerMiller, 1989; and Miller & Miller, 1968, 1971, 1973). Current outcome research includes studies by Cook (1998), Messier (1971), Miller and Miller (1973), and WarrLeeper, Henry, and Lomas (1999). The approach is cognitive because it deals with the manner in which children organize their behavior, develop concepts of time and space, problem solve, and form
The Miller Method is currently in practice at schools and clinics within six States as well as in Canada and other countries, under videoconferencing consultation arrangements with the Language and Cognitive Development Center in Boston, Massachusetts. For additional information, contact the Language and Cognitive Development Center at (800) 218-5232 or through its website:


ICDL Clinical Practice Guidelines

relationships with people. It is developmental because it deals with the ability of children to shift from action stages of functioning to communication and representation of reality through various symbolic forms. It also is a systems approach because it views the formation and use of systems as indispensable to the entire array of human performance. The goals of the Miller Method are to: Assess the childs capacity to interact with people and objects, adapt to change, and learn from experience. Build the childs awareness of her own body as it relates to objects and people. Guide children from closed, disconnected, or scattered ways of being into functional, social, and communicative exchanges. Provide the necessary transitions from concrete to more abstract symbolic functioning. Unique Aspects of the Miller Method Among the novel features of the Miller Method are its pragmatic use of two major strategies. The first is the exploitation for developmental gains of the aberrant systems, or part systems, the children bring. The assumption behind this strategy is that all organized behaviorseven those that are aberranthave within them the potential for developmental gain. For example, atypical behavior systems of children with disorders (e.g., lining up things, flicking light switches, or flushing toilets) can often be transformed into functional, interactive behaviors. The second major strategy is the systematic introduction of developmentally relevant spheres (repetitive activities concerned with objects and people) to repair developmental lags and restore developmental progressions. For example, children who have never experienced picking up and dropping objects or who have not learned that they can push over

an object with their hands or with a stick can be taught to do so in a way that helps fill in a developmental gap by establishing, often for the first time, their ability to act on and influence objects and events in their surroundings. Another important strategy is having the therapist narrate, with signs and spoken words, what the children are doing while they are doing it. We find that such narration helps the children relate the words and signs to their own actions. As this happens, they seem to become more aware of themselves and to begin to develop the inner speech so important in communicating both with themselves and with others. This process is facilitated by elevating the children 21/2 feet above the ground on an Elevated Square or similar structure. Elevating the children seems to enhance not only word-sign guidance of behavior but also to induce an awareness of body/self and others, more focused and organized planning of behavior sequences, and better social-emotional contact. It also provides a framework in which the children can more readily be taught to transition without distress from one engaging object or event to another. In addition to work on the Elevated Square and other such structures, special programs are introduced during the day to help children develop both spoken and written language. These programs are described later in this chapter. DEFINING CENTRAL CONCEPTS Before discussing assessment and intervention, it is desirable to define and discuss the concept of systems and the various roles that systems play in the economy of both typical children and those with disorders. Systems Systems are organized, coherent chunks of behavior that are, initially, quite repetitive.



They involve the child acting with the body on or with some object, event, or person in a predictable manner. A 10-month-old baby repetitively involved in picking up and dropping everything on the food tray is involved in a system, as is the 15-month-old toddler repeatedly filling and emptying a sand bucket. There are also interactive systems, such as when the12-month-old plays peek-a-boo with her mother, an 18-month-old child realizes that after the ball is rolled to her she is to roll it back, or when the small child holds up his arms to communicate a desire to be picked up. Systems also are involved in symbolic play, such as when children begin to feed their dolls in the manner in which they themselves are fed. When children are able to indicate objects by pointing, gestures, or words, these gesture/word relations to various objects, events, or people are systems that may be regularly reactivated by the sight of particular referents. Systems vary in their complexity from the simplest one-component systems such as pick up/drop, which are referred to as minisystems, to more complex, multistep systems leading to a particular goal. The latter are referred to as integrative systems as, for example, when a child learns to climb up steps to go down a slide or to open a cupboard door to get something inside. Children who are able to address previously developed (internalized) systems in new ways (spontaneous expansions) have a basis for problem solving and creative thought and play. The hallmark of all systems is the investment the child has in maintaining or continuing them. This investment becomes apparent when a particular system is interrupted. For example, a 15-month-old child involved in a system of putting on and taking off a series of bracelets on her arm became very distressed when a bracelet was takencrying, pointing at the desired bracelet and even trying to say the wordin an effort to have it replaced on

her arm to restore the interrupted system. As discussed later, the careful interruption of systems is an important technique for helping children initiate actions or words to help repair their broken systems. Interrupting systems is also used to motivate a child. For example, one child who at first refused to use a rake to get a disc that was out of reach did so when the therapist proceeded as follows. First, the therapist helped the child establish a disc-in-bottle system by having the child repeatedly put discs in the slit on top of a bottle until the child did this completely on his own. Then, the therapist interrupted this system by placing the disc out of the childs reach while placing the rake between the child and the disc. At this point, the child immediately used the rake to bring the disk closer so that he could restore the interrupted system by continuing to place the disks in the slit on top of the bottle. Unlike typical children, those on the autistic spectrum as well as those with other developmental issues show system aberrations that interfere with their performance and development: They may, for example, tend to become so overinvolved with things and events that they are unable to detach from them, as does the child who perseveratively flicks on and off light switches or television sets. Alternatively, these children may be so uninvolved or disconnected from things and people around them, that there is little basis for building or sustaining relations with either things or people. This means that before such children can progress, careful attention must be given to their system problems. Steps in the Early Formation, Maintenance, and Expansion of Systems For children with disorders to develop, it is important that many different kinds of


ICDL Clinical Practice Guidelines

systems form, expand, and, increasingly, come under their control. There is a progression in the manner in which systems are formed. At first, system formation is driven by the external properties of objects, events, and people, with the child reactive to the process. Later, the formation, expansion, and combination of systems come increasingly under the childs active control as the child uses previously developed systems in the service of various ends. The following sections outline the progressive steps of forming, maintaining, and expanding systems. Orienting Systems begin to form as a salient sound, motion, or a particular property of an object, event, or person induces the child to turn toward, or orient, toward the source of the stimuli (Goldstein, 1940; Pavlov, 1927; Sokolov, 1963). Orienting has been shown to make the stimulus that the child is turning toward more salient for the reacting child. However, even at this initial phase of system formation, aberrations are evident among many developmentally challenged children. For example, some children with disorders are so driven that they orient to any stimuli that they see, hear, or feel in a way that keeps them helplessly reacting to so many stimuli that they have difficulty with the next step in system formationengagement. Engagement Once a child orients toward a salient stimulus, the next step in system formation entails the child moving toward and becoming physically and emotionally involved or engaged with the stimulus properties of the object, event, or person in his immediate surroundings. In cognitive-developmental systems theory, orienting plus engagement provides the precondition for the formation of systems which, in turn, provides the

framework for not only making functional and emotional contact with things and people but for maintaining and expanding that contact. However, engagement by itself does not ensure the development of a system. From Engagement to System Formation Engagement is to system formation as a casual encounter between one person asking another for the current time is to a life-long friendship between the two people. The initial brief encounter (engagement) is a necessary prerequisite for a relationship (system) to develop between people or objects, but such a relationship may or may not develop from the initial encounter. The system develops only through a more prolonged and repetitive engagement with an object, event, or person. For example, a 16-month-old girl who stumbles over a bucket half filled with sand is momentarily engaged with that bucket. However, she has not formed a system with that bucket until she repetitively addresses it in any of a variety of ways: Having stumbled over it, she may form a system by repeatedly kicking the bucket across the sand or by repeatedly filling and emptying the bucket, and so forth. Once her behavior with the bucket follows a predictable pattern she has transformed her initial engagement with the bucket into a system. At that point, her behavior is internalized as a way of being with that object. The decisive indication that an internalized system has developed occurs when, following interruption of the childs system by removing her bucket or preventing her from acting on or with it, the child becomes compensatorily driven to maintain or restore action with that object by reaching for the bucket, yelling, pointing, and otherwise indicating her urgent need to continue that system. When interruption of an activity does



not induce a child to continue or restore that activity, a system has not yet developed. However, if systems are to move beyond mere rituals, there must be both a means of recalling or reactivating them when they have not been used for a time and a means of extending their influence to other aspects of a childs surroundings. Two principlesinclusion and extensionsuggest how this occurs. The Inclusion Principle This principle states, Whenever the child, engaged by a stimulating object or event, is concurrently stimulated by a background aspect of the situation, that background aspect soon becomes part of the total, engaging system which emerges. Subsequently, when only the background aspect appears (partial interruption), the child compensatorily behaves as he/she had toward the originally engaging object (Miller & Eller-Miller, 1989). For example, if while an infant is nursing at the breast (nursing system), the mother simultaneously croons and strokes the infants cheek, then subsequently, in the absence of the breast, the mothers crooning or cheek-stroking, by itself, will elicit vigorous sucking by the infant. In a similar fashion, a small child who has not previously responded to the term Push! or to a pushing gesture will do so if, while the child is pushing a wagon (pushing-wagon system), the child repeatedly hears the therapist saying, Push ... push ... push! accompanied by pushing gestures. As this occurs, both word and gesture soon become included within the childs pushing-wagon system so that when the therapist later introduces either word or push-gesture in the presence of the wagon (partial interruption), the child feels compelled to push the wagon to complete the system.

The following outline summarizes the steps involved in system formation and expansion via the inclusion principle: 1. Orienting Child orients (turns toward) the introduction of a large object (a wagon) within her visual field. 2. Engagement to system forming Child approaches and pushes the wagon, which moves and then stops in a way that induces him to push it again and again until a pushing-wagon system forms. 3. Inclusion process a. Introducing new parts to the system. Therapist uses words and gestures to introduce the word push while the child is repeatedly pushing the wagon. At first, the child orients toward the sounds and gestures (indicating that she still experiences them as separate from her pushing-wagon system). b. Assimilating new parts to the system. As the spoken word and gesture continue to accompany the pushingwagon system, the child no longer orients toward them as if they were separate entities but experiences them as part of the pushing-wagon system. In other words, the child now experienced it as a pushing-wagon + push (word) + (gesture) system. 4. Partial interruption Later, when only the spoken word or gesture part of the system is introduced (partially interrupted system), the child compensatorily searches for a wagon or other moveable objects to push.


ICDL Clinical Practice Guidelines

The Extension Principle The extension principle comes into play when the child has already developed some gestures, utterances (natural signs), or spoken words that are closely related to a particular referent located in the childs immediate surroundings. This principle explains how the familiar meanings attached to these expressive systems become extended to an initially neutral entity, which then becomes part of the childs expressive system. This occurs by the childs expressive system acting upon the neutral property. The principle states, Whenever a system with which the child is engaged acts upon a new property of an object or event, that property becomes an extended part of the original system. The child then maintains the integrity of the newly extended system when it is interrupted just as with the original system (Miller & Eller-Miller, 1989). Two examples illustrate the operation of the extension principle. In one, the child has established the natural sign ch ch to refer to his small train. Subsequently, the parent introduces the term train. The child responds by saying, ch ch train, clearly extending the rhythmic ch ch cadence to include the new term. In the second example, a 2-year-old child sees a bird land on the fork of a branch and begin pecking on it. The child points and exclaims, Bird! (word bird plus bird-pecking-on-forked-branch system). Abruptly, the bird disappears (interruption) behind the fork in the branch. Nevertheless, the child continues to point at the forked branch (where the bird had been pecking) and to exclaim, Bird! On subsequent occasions when the child passes that forked branch, the child points at the branch and says Bird! even though no bird is present. Because the bird had acted upon the forked branch, it had assumed bird significance for the child. In other words, the bird

system had been extended for this child to include not only the bird but the forked branch on which the bird had been pecking. However, the bird valence of the forked branch only became evident when the bird disappeared behind it (interruption) and left only the forked branch part of the system, which the child continued to designate as bird. This extension principle, as illustrated later in this chapter, plays an important role in the transfer of meaning from spoken words to the arbitrary forms of printed words in the Symbol Accentuation Reading Program (Miller & Eller-Miller, 1989). Executive Function The system expansions discussed so far have largely depended on external events driving the system. Early in a childs life, such externally driven expansions are the primary mode by which systems are expanded. They entail minimal intention or initiative on the part of the child. Gradually, however, this reactive mode of expanding systems is accompanied by a new mode whereby the child deliberately forms systems as well as new combinations of systems based on an inner plan. This emerging capacity is referred to as the development of executive function. Early examples of executive function may be noted as a child decides that he no longer wishes to go down the slide in the sitting position but prefers, instead, to slide down on side, back, stomach, etc. These spontaneous expansions of the slide system are possible because of the newly emerging executive function. It appears that executive function is only possible when children have developed sufficient awareness of their bodies to self consciously direct them in different ways. When this occurs, they find that they have the ability to choose one system over another, to alter systems, or to combine previously developed systems in new ways. Perhaps the best known



indication that executive function is well established occurs when the typical 2-yearold responds to her mothers request to do something with a defiant No!a statement that marks both awareness of self and other as well as the notion of choice. The failure of this shift to fully occur among developmentally challenged children accounts for many of the dramatic differences in behavior between typical and compromised development. The following examples of childrens activities with blocks during an unstructured period contrasts the functioning of a 3-year-old who has developed executive function with the functioning of two children on the autistic spectrum who demonstrate little or none of this capacity. Children With and Without the Capacity for Executive Functioning Jack, a typical 3-year-old with capacity for executive function. As soon as Jack received the pile of assorted blocks, he began to build a connected structure of ramps and towers. He picked up each block, examined it, selected a place for it in the block structure, and inserted it carefully. Needing a block of a particular size, he scanned the blocks and spotted an appropriate one near the foot of the observing adult about 6 feet away. He looked at the adult, pointed at the block, and exclaimed, Block, please! After receiving the block, he smiled at the adult, added the block to his structure, and took another block. Next, while making rmm car sounds, he drove his block up the ramp and around the block towers. Finished with car-block play, he got up and set off for something else to do. Damon, a 3-year-old boy on the autistic spectrum with minimal capacity for executive function. Damon, seeing the pile of

blocks, immediately began to build a connected structure. But, unlike Jacks construction, his structure consisted only of a row of rectangular blocks carefully placed so that each block abutted the previous one. Curved or triangular blocks were not attended, and he did not make the sounds that other children made as they played. Damon worked with rapid intensity, regularly scrambling from the end of the row of blocks to get another block so that he could continue extending the structure. At no time did Damon acknowledge the existence of the adult seated nearby. When the adult tried to hand him a block, Damon rapidly turned his body so that his back was between the adult and the blocks. When the adult removed one block from the row, Damon screamed, then frantically sought another block to close the gap in the structure. Damon continued to extend the row of blocks until it reached the wall. Confronted by the wall, he made a right angle with the next block and continued placing blocks along the wall until there were no more blocks. Then he began rocking back and forth while twiddling his fingers in front of his eyes. Except for his scream when the adult altered his block structure, he uttered no sound. Brian, a 3-year-old boy on the autistic spectrum who demonstrates little or no executive function. Presented the blocks, Brian was momentarily drawn to the clattering sound they made when they were placed in front of him. What Brian saw and heard, however, seemed quite disconnected from what his hands were doing. Even though he picked up a block, it soon slid from his hands, forgotten, as he was caught by the movement and sound the


ICDL Clinical Practice Guidelines

adult made as she seated herself in a nearby chair. When the adult offered him another block, he seemed not to notice it because he was now turned toward the sound of a bus starting up outside the building. At no time did Brian spontaneously explore his surroundings or examine the manner in which blocks stacked or things worked. Instead, time and again, he turned toward or began to move toward a stimulating object or event only to be diverted by another new stimulus, which drove his behavior. An Analysis of the Childrens Executive Functioning and System-Forming Ability Although both Jack and Damon produced systems, their systems differed dramatically. Jack, the typical child, had a complex, integrative system composed of towers, ramps, and cars. As Jack played with the blocks, it became evident that he experienced himself as the executive or master-builder with an inner plan to which both the blocks and the adult contributed. This allowed him to form a complex, integrative system with the blocks (towers and ramps) that he could exploit in different ways. He could, for example, turn a block into a car and move it, car-like, up and down the ramps. He could also turn from the main block structure to request a block from an adult and turn back to his structure without losing touch with his goal. In carrying through his plan, Jack demonstrated that he could integrate several smaller systems into a larger one. In sharp contrast, Damon, the autistic child with a closed-system disorder, had a single, minisystem composed of lining up blocks. Damons system was not driven by any inner plan but by the way each block abutted the next one. He changed the structure only when the physical barrier of the wall

required such a change. This change, however, came about not through any executive decision on Damons part, but because the wall required the change. Finally, there was no decision to stop connecting blocks; Damon stopped when he ran out of blocks. When this occurred, he had no means of directing himself to a new activity. Apparently, the only means he had of filling the void left by the end of the block-connecting system was rocking and hand twiddling. For Brian, the observing adult seemed to exist only momentarily as the adult moved and made sounds. Brians constant tendency to be driven by transient stimuli (sudden sound or motion) interfered with the prospect of a deeper relationship with either people or objects. Brian oriented but seemed unable to become physically engaged with the stimuli. Because of his drivenness, Brian formed only fleeting contact with objects and events as he was driven from one source of stimulation to anothernever lighting long enough to physically engage the stimulating source. The unfortunate outcome is that he failed to develop either coherent systems or the executive capacity required to explore their properties. In short, like Damon, Brian lacked the executive functioning to guide his own behavior, but unlike Damon, he also lacked coherent, compelling systems. The different ways the children related to the observing adult illuminates the extent to which they dominated or were dominated by their systems. Jack, needing a block to complete his block structure and seeing a block near the adult, was able to turn toward the adult and ask her for the block. In doing this, Jack creatively brought together the world of relationships with people with his world of objects. The situation was very different for Damon: for him, the observing adult did not exist except as a momentary threat (when removing a block from his lined-up blocks) to



the integrity of the structure being built. Clearly, he lacked the executive function required to draw upon relationships with people. Stated differently, his closed-system tendency precluded people from being part of his system. After children make the shift to executive function, their relation to the systems they have formed changes radically. Systems previously triggered only by properties of the environment are now at the disposal of the executive capacity of the child. The distinction between systems that dominate the behavior of children and those which children dominate is evident in the comparison of Jack, who has made the shift to executive function, with Damon and Brian, who have not. Closed-System and System-Forming Disorders There are two broad system dispositions among children having autistic spectrum as well as those with other developmental disorders: closed-system disorders (Miller, 1991; Miller & Eller-Miller, 1989) and systemforming disorders. Both kinds of system disorders are divided into Type A and B forms to indicate the nature and limitations of their systems and the extent to which executive function plays a role. Type A of the closed-system disorders refers to those children, like Damon, who become so involved with one or two actionobject systems that they are unable to notice or respond to any stimuli unrelated to the system with which they are engaged. These are the children who are so unresponsive to being called that parents often have the childrens hearing checked. They are also unable to scan their environment, tending to live quite close to their bodies. Not surprisingly, these children have great difficulty shifting from one object or event to another. Equally

important, children with Type A closed-system disorders tend to prohibit parents or others from entering and participating within their object or event systems. In other words, having only minimal executive function, these children are quite dominated by their few systems. Clearly, children with such closed systems are restricted in their social interactions and ability to communicate with others about things and events in the immediate environment. Children with Type B closed-system disorders share some but not all dispositions with Type A closed-system children. Similarly, they resist having people enter their systems. However, unlike Type A children, Type B children are able to demonstrate executive functioning in a circumscribed domain composed of action-object systems. In contrast to Type A children who tend to remain engaged with one or two objects from which they cannot extricate themselves, Type B children have sufficient executive function to scan their surroundings and to move without difficulty from one object or event system to another. However, their executive functioning does not yet permit them to allow people to participate in their systems. In other words, they have child-object systems but not child-object-person systems. Should a person attempt to enter one of their systems, the children show the same kind of resistant behavior (although to a lesser degree) found with Type A children with closed-system disorders. Children with system-forming disorders are very different from those with closed-system disorders. Children with system-forming disorders have great difficulty forming any systems. Brian (described earlier), with his tendency to be driven by every salient stimulus, falls into a Type B system-forming disorder. Children such as Brian are repeatedly driven to orient toward stimuli from objects and events but fail to engage them physically.


ICDL Clinical Practice Guidelines

However, there is another group of children, designated Type A system-forming disorder, whose difficulty forming systems stems largely from their poor sensory-motor coordination. Such a child may orient toward a particular salient object or event but have difficulty relating his body to that object or event in a way that forms either mini- or multistep integrative systems. It is interesting to note that children with Type A system-forming disorders can, with proper intervention, learn to form integrative systems, such as climbing up steps to slide down a slide. The problem is that the childs sensory-motor coordination is often so sluggish that by the time the child has climbed the stairs and slid down, she has completely lost contact with the location of the stairs and so, having slid down, continues straight ahead. Failing to return to the stairs, the child at first cannot repeat and own that system without continuing physical support. However, with many repetitions and rapid pacing, the child will begin to anticipate the various parts of the step-slide system. Nevertheless, the rigid, circumscribed quality of the integrative

systems, which these children achieve through repetition, is very different from the creative and complex integrative systems achieved by the typical child, such as Jack. Because Jack had achieved executive functioning, he could creatively combine systems following his inner plan. In contrast, children with Type A system-forming disorders, who lack executive function, can form integrative systems only in a rigid, unvarying manner by virtue of having been repeatedly led by a therapist through the system until it takes. While children with both Type A and Type B system-forming disorders have difficulty forming coherent systems with objects and events in their surroundings, their challenges come from different sources. Type B children are too sensorily driven by various stimuli to readily form systems, whereas Type A children have physical coordination problems that interfere with the sequencing and motor planning they need to form their systems. (See Table 1). Finally, there is a developmental sequence in the formation of systems. Least developed are children such as Brian, whose drivenness

Table 1. Contrasting Children with Closed-System and System-Forming Disorders Disorder Type A Closed system Minimal executive functioning and few systems. Poor shifting/scanning. People excluded from systems. Minimal executive functioning. Poor sensory-motor coordination limits system forming. Children Type B Executive functioning with many object systems. Ability to shift from one to another system. People excluded from systems. Little executive functioning. Salient properties of many sources induce repeated orienting, but not engagement.




results in aborted system formation and an almost total lack of executive function. More developed, but still compromised, are those closed-system, Type B children whose modest executive function enables them to shift from one closed system to another but who still exclude people from their systems. Most developed are children such as Jack, who have the executive capacity to creatively assemble a variety of minisystems into an integrative system (involving people) that they can modify as they choose in accord with their inner plans. Table 1 captures the major distinctions between the two types of disorder and their subcategories. ASSESSMENT Before therapists can intervene effectively, they need to assess the nature of each childs system functioning. The following sections explore different assessment strategies. Assessing the Children One of the goals of the Miller Method is to assess each childs capacity to interact with people and objects, adapt to change, and learn from experience. An Umwelt assessment was developed to determine how best to intervene with children on the autistic spectrum (Miller & Eller-Miller, 1989). An

Umwelt (Uexkll, 1934) refers to the world around one. Consequently, in performing an Umwelt assessment for a particular child, we try to determine the nature of the systems the child brings to a new situation by first examining his behavior in unstructured situations where he has access to both people and a variety of objects, but where the adults are passive. We also examine the childs ability to become engaged in new systems that the examiner introduces. Recently, influenced by the work of Greenspan and Wieder (1998), we have been paying more attention to affectively driven systems between the child and others. Now, just as we examine the childs resourcefulness in coping with objects via detours or by using tools, we seek to determine the childs emotional resourcefulness in initiating and maintaining ongoing interactive systems supported by the adult. This means that we now examine three kinds of interaction with a particular child: (1) the childs response to unstructured situations (adults passive); (2) the childs ability to maintain an interactive system with the examiner when the examiner actively builds on the childs initiatives, and so forth; and (3) the childs ability to accept and participate in examiner-initiated systems. Table 2 captures the three different ways of examining the child. Each of the adult stances is important in determining how well a child can cope with

Table 2. General Strategies Used During the Umwelt Assessment Assessment Strategies Unstructured Child-initiated Adult Stance Passive Interactive Childs Task Child to initiate without support. Child initiates and cyclically builds on adults response to his or her initiatives. Child to accept adult-initiated interaction and expansions.




ICDL Clinical Practice Guidelines

people and things in her immediate surroundings. The child who, during the unstructured period, canwithout supportinitiate actions toward people and things in unfamiliar surroundings demonstrates a repertoire of organized behaviors (systems) that enable her to engage with people or objects. In this condition, the relative emphasis on people or objects, and the quality of interaction or exploration (if it exists at all) tells much about the coping resources available to that child. On the other hand, child-driven interactions tell more about the emotional capacity of the child to initiate and to sustain more prolonged interactive systems with the examiner (Greenspan & Wieder, 1998). How well the child can sustain shared attention and involvement with the adult is an important indication of the relationship potential of the child. However, since many circumstances, such as school, entail teaching the child from the adults and not the childs agenda, it is also important to determine how well the child can accept adult-driven interactions. How the child responds to an adult setting up, expanding, and directing shifts from one system to another provides important clues about how well the child will learn in schoolrelated or similar situations. Further, the importance of therapist- or teacher-initiated systems (called spheres) lies in their potential for remedying serious developmental lags. Different tasks from the Umwelt assessment help clarify the unique way in which

each child with disorders experiences reality as well as her adaptive potential. The following example indicates how one of the Umwelt tasks throws light on a childs ability to interact with both a person and an object in a simple game. Assessing the Capacity to Interact with a Person and an Object: The Swinging Ball Task Figure 1 illustrates the manner in which the examiner assesses the childs ability to form an interactive system involving an object and another person. Figure 1a represents a child enjoying a repetitive pushing-game (a child-object-adult system) in which adult and child push a swinging ball back and forth. The dotted lines to both ball and adult indicate that the childs system includes awareness of both the ball and the adult. Figure 1b, reflects a more limited childobject system that includes the ball, (which the child pushes whenever it arrives) but does not include the adult. Figure 1c shows an even more circumscribed system. Here, the child fails to react even when the ball bumps into him, which infers that the child lacks that object system. Typical children as young as 2 years of age will behave interactively with ball and person as illustrated in Figure 1a. Children with closed-system disorders will interact with the ball but not with the person, as shown in Figure 1b. Children with system-

Figure 1a, b, c. Assessing a Childs Ability to Form an Interactive System: a. Child-object-adult b. Child-object c. No object system



forming disorders may respond as shown in Figure 1c because they have difficulty coordinating with the balls trajectory. Assessing the Capacity to Adapt to Change: Stacking Cups and Bowls Successfully coping with surroundings requires the child to adjust her approach to changing circumstances. To get at this capacity during the Umwelt assessment, the child is required to stack cups and bowls in different ways. The task is graduated from simple stacking of cups (then bowls) with their openings facing upwards to those involving progressively more complex adjustments. At the most complex stacking level, the child is required to alternately stack cups and bowls, with the cup presented upside-down over the bowl and the bowl presented right-side-up over the right-side-up cups (Figure 2).

Figure 3 with additional cues to determine how close a child is to making the shift from one kind of organization (vertical stacking) to another (lateral). Problem Solving and Learning from Experience: The Elevated Swiss Cheese Board The next two tasks examine, although in different ways, the childs ability not only to adjust to changing circumstances but to learn from the experience. One task examines the childs response to the elevated Swiss Cheese Board (Figure 4); another, called Croupier (Figure 5), examines the childs manner of coping with progressively more demanding tasks involving the use of rakes and obstacles to gain a desired object.

The final sequence tests the childs ability to shift from a stacking mindset to one in which he is required to place a cup in each of six bowls spread out in front of the him (Figure 3). Closed-system Type A children typically show such a strong perseverative tendency that they persist in stacking the cups given theminstead of placing a cup in each bowleven after the examiner has modeled placing one or two cups in the bowls in front of them. Often, we will repeat the set-up in


ICDL Clinical Practice Guidelines

The ability to learn from experience comes into play when the child on the Swiss Cheese Board inadvertently steps in a hole (care being taken that the child does not fall). Then, as the child continues to cross the board, we are able to determine whether or not the child now avoids the holes by stepping over them. In the rake-obstacle task, we seek to determine if the childshown pulling a desired object toward himselfcan learn to push it away from himself through the gap and then toward himself. Often we will test the limits by placing the desired object closer and closer to the gap to determine at what point the child will understand the need to first push the object away before it can be brought closer. Once the child pushes the object away, we return the next object to the center of the horseshoe ring to determine if the child has generalized this understanding to the new object given or will revert to the original, unsuccessful effort to bring the object toward himself. INTERVENTIONS Before a child can achieve executive control of his own systems, he must first achieve a certain awareness of his body and the distinction between his body and that of others, as well as the object or event system with which his body is engaged at a particular

moment. If there is little or no awareness of the body or body-self as a separate entity independent of what the body is engaged with, then the child becomes so captured by the ongoing body-object system in play at that time that he cannot spontaneously detach from the ongoing system. Only as the child develops the notion that his body and its parts have an existence independent of the object or event system with which he is engaged can the executive function emerge (which makes possible a childs spontaneous expansion of his systems). In other words, body-world polarity is a prerequisite for executive function. Among typical children, this capacity emerges gradually in the course of the first 2 years of development. For example, by 6 months of age, the child has achieved sufficient differentiation between her body and others to demonstrate a clear preference for her mother over others. Between 6 and 9 months of age, the child is able to relate to (establish systems with) either a person or an object. By 9 or 10 months of age, the child can relate to another around an object (childobject-person system) as evident in the ability to give an object to a caregiver on request (Trevarthen & Hubley, 1979). And, of course, by 24 months of age, the child becomes selfconsciously aware of her ability to accept or refuse requests. Children whose development has been compromised often fail to achieve these basic body-object-other capacities. For example, they may not differentiate between one person and another, and they may not be able to give an object on request. They remain fixed in a single track involvement with a particular property of an object or event and show striking difficulties in relating their bodies to people and objects in their surroundings. The following section details some ways in which these difficulties become apparent.



Body-world problems may become apparent with child-object systems, child-person systems, and child-object-person systems. For example, picking up and dropping an object or flicking a light switch on and off are child-object systems, while peek-a-boo and chase games are childperson systems. On the other hand, rolling a ball back and forth with mom or dad is a child-object-person system that combines both object and people worlds. The problem for developmentally challenged children stems from the unusual way they form or fail to form systems in the world of objects and the world of people and their difficulty in forming systems that combine the two worlds. Strategies for Developing Body-World Awareness Strategies for developing body-world awareness include rough and tumble activity, mutual face-touching, estabilization, deep pressure, swinging, elevation, and introducing causal systems. One goal of these strategies is to guide children from closed, disconnected, or scattered ways of being into functional, social, and communicative exchanges. An Intervention Case Example: Damon Damon, the 3-year-old described earlier, is a child on the autistic spectrum with a closed-system disorder, Type A. His various problem areas are: 1. Poor human contact (wont look at people) or include them in his systems. 2. Perseverative tendencyhas great difficulty shifting from one action-object system to another. 3. Does not seem to hear or follow directions (word deaf ). 4. Does not communicate his needs except by pulling the adult toward the desired object. 5. Does not participate in make-believe play.

The following illustrates the treatment approach Damon received at the Language and Cognitive Development Center (LCDC), in Boston, MA. Although children at LCDC participate in both school classes (limited to six children with three teachers), as well as individual therapies guided by the Centers orientation (cognitive-developmental systems therapy, speech/language therapy, movement and occupational therapies as well as manual arts), for clarity, this discussion relates only to the childs work in cognitive-developmental systems therapy. (A chapter appendix outlines a typical daily curriculum for nonverbal or limited verbal children.) The word we refers to all the therapists at the Center who worked with Damon. Improving Damons Human Contact We begin each 45-minute therapy session with about 5 to 10 minutes of big-body work. This entails a combination of pleasurable rough and tumble activity, guided bouncing on a trampoline, and swinging him in a sheet. We follow this activity by gentle, mutual face touching coupled with subtle destabilizing (i.e., tugging him front and back and left to right in a way which makes it necessary for him to constantly right himself). Our experience with these procedures is thatwhen introduced carefullythey result in the child smiling or laughing and in improved eye contact. Then, when certain big body systems (jumping, swinging, rough and tumble) are abruptly interrupted, the child often indicates by natural signs a wish to continue the activity. Working with Damons Perseverative Tendency and Difficulty Following Directions Following the big body work just described, we introduce Damon to the Elevated Square. Before describing work on


ICDL Clinical Practice Guidelines

the Square, it is important to understand why we used it. The Elevated Square The Elevated Square we have designed (see Figure 6) is about 5 feet by 8 feet, with boards about 14 inches wide. The structure is 21/2 feet high, which places most 3- to 6-yearold children at or near eye level with most adults. The short side pieces of the square are removable, making it possible for the therapist to stand in the middle in easy reach of the child. Removing the side pieces also creates the conditions in which the child must make a detour in order to get to a person on the opposite side. The steps used with the Elevated Square are attached to each other with Velcro andbecause they are designed to fit snugly in the channels of the Elevated Squareare readily used as obstacles or small platforms placed around the square so that the child can respond to Up!, Down!, and Around!, as well as Get up! and Sit down! Finally, there are stations at each corner of the square, which can be adjusted to the childs height to provide the best possible conditions for effective eye-hand coordination with the various tasks placed on these stations. The last piece of equipment is the slide, which connects to the Square but can be readily removed.

Placing the child on the Elevated Square effectively limits the childs options for movement because of the constraints the Square places on movement. The Square serves different purposes for different kinds of children. For easily scattered children with system-forming disorders, the Square provides the external organization the children desperately require in order to function. However, for children with closed-system disorders, such as Damon, the Square provides the framework in which they can be taught to expand their systems, learn to move from one system to another, and to include people within these systems. Contributing to these changes is the enhanced awareness of body and other that the elevation seems to induce. This changed state is evident not only in the improved eye contact almost immediately evident but in the finding that many children who toe-walk on the ground walk with their feet firmly grounded when elevated. Working the Short and the Long Sides Once Damon climbs the steps that places him on top of the Square, we begin a systematic process of both expanding his systems and including people within them. First, a parent is placed at one end of the short side of the Square and a therapist on the other side. The parent is instructed to say Come! while using the manual sign (beckoning). The vector of the board, coupled with the parent calling and with the therapists support, quickly allows Damon to move to his mother. She then briefly hugs him, does mutual face-touching with him, turns him around and directs him toward the therapist, who also says and signs Come! Once Damon is responding to Come! appropriately, the same procedure is used on the long side of the Square. This continues until Damon can respond to Come from mother and therapist from both the short and long distances on the Square.



Once Damon develops the appropriate response to a command while on the Square, the next step is for his parents to help him expand his response to their settings. The goal is to get Damon to generalize Come! to first short and then longer distances on the ground at both the LCDC and at home until he responds from various distances to everyone in his family. Turning the Corners Turning the corners may be difficult for Damon because it requires a sudden shift of direction. However, turning corners to get to a person just around the corner of the Square is an important part of understanding how the body must adjust to changing circumstances. When turning the corner is mastered at one location on the Square, Damon generalizes the skill by performing it at other locations. Successfully coping with corners as well as short and long sides of the Square enables Damon to become quite comfortable working on the Square. Understanding Detours Next, Damon is shown how detours work. This is taught by placing Damon on the short side of the Square and removing the short piece. His mother stands on the opposite side and calls and beckons as before. Eventually, Damon, seeing the gap, looks around the Square and then navigates around it until he gets to his mother. In doing so, he demonstrates a beginning understanding of how detours work. He then has to perform detours with others calling him across the gap from both directions and using both short and long sides of the Square. Using Multispheres to Cope with Damons Perseverative Tendency One of Damons most serious difficulties is his tendency to perseverate with a task, such

as lining up blocks, to the exclusion of all else. Once he becomes comfortable with the Elevated Square, we address this issue by setting up a multisphere arrangement designed to reduce Damons perseverative tendency and to make it possible for him to transition without distress from one system to another. A sphere is any activity that we introduce repetitively with the expectation that the child will take it over and transform it into an internalized system. Therefore, a multisphere setup is one in which the child learns to cope with two, three, or four different spheres. The rationale for the multisphere procedure is that the child perseverates because (a) he lacks knowledge of how to detach from the action-object system, and (b) because the child has no sense of the systems continuing existence once it is left (the out of sight/out of mind phenomenon). Based on this rationale, our procedures are designed to teach the child that he can detach from a compelling system and still return to it. The assumption is that by demonstrating this to the child, then the childs perseverative impulse will be attenuated. We do this by first engaging the child in a particular actionobject system and then interrupting it by leading the child to a second, then a third, and then a fourth system and repeating the process as follows. After the child becomes engaged with Athe first sphere (for example, pouring water over a water wheel) we interrupt this sphere at the point of maximal tension (the point at which the child most needs to continue the activity). When this is done, the child experiencesin Lewinian (1935) termsa tension state related to the need to continue that activity. By maintaining that tension state while having the child become engaged with Ba second, entirely different sphere (sending marbles down a zigzag ramp) the first sphere continues to remain


ICDL Clinical Practice Guidelines

alive for the child even while the child becomes engaged by the second sphere. (It is this duality of experience that begins to make it possible for the child to relate and soon easily shift from one sphere or station to another.) After a number of cycles involving two (AB), then three (ABC, hanging up cups), and four (ABCD, cutting clay) spheres, the child begins to demonstrate by glancing at the different spheres a sense of possible relations between them. After a few sessions, he is no longer distressed when one sphere is interrupted because he understands that he will soon return to it. But merely being able to shift clockwise from A to B to C to D spheresalthough importantis not sufficient for Damon to cope flexibly with his surroundings. At this point, we begin to vary the stations. In other words, after A, Damon expects to move from A to B. Instead, Damonclearly unhappy is guided past Station B to Station C. This process is continued over a number of sessions until Damon can tolerate shifts from one station to another in all possible combinationsACBD, DBAC, and so on. Once Damon can cope with shifting in all possible combinations on the Elevated Square, stations are shifted to the ground. Here, without the support of the Square, Damon generalizes his new ability to shift to various stations set up on the ground. After Damon masters this sequence, he is placed in a position where he can scan all the stations. He is then asked to choose which one he wishes to go to. When he can express a preference for one system over another by pointing, sign, or word, we have evidence of the emergence of new executive functioning. Developing Damons Language Receptive Language Damon, as described earlier, is word deaf, which means that it is not possible to

guide his behavior solely by using words. He will do better when spoken words are paired with signs, as do most nonverbal children on the autistic spectrum (Konstantareas, 1984; Konstantareas, Oxman, & Webster, 1977; Miller & Miller, 1973). To increase Damons capacity to respond to spoken words, we follow the principle of inclusion described earlier under Defining Central Concepts. By repeating the appropriate word while Damon is performing the relevant action, he soon includes both word and manual sign as part of his action system. We use this technique with the words Up!, Down!, Push!, Pull!, and Around!, followed by Pick up!, Drop!, Pour! and many others. For example, as Damon steps up on the block in his path, we say Up! while pointing upward. We continue in similar fashion with Damons pushing and pulling actions. Each time that Damon performs the action we also narrate what he is doing by saying, Damon is pushing (going up, down, etc.). We support Damons behavior by using a vocal tone that expresses the delight we feel at the childs performance. We find this affective narration to be far more relevant to the development of the childs receptive language than using the term Good job!, with its doubtful meaning to the child. In developing receptive language, we find it important to gain a clear sense of the extent to which the child is guided by just the spoken word in contrast to the word in context. In doing so, we: Determine if the child can give an object to us when it is right in front of us and we tap an extended hand while saying, Give! Determine if the child can retrieve a designated object in plain sight some 8 to 10 feet away. Determine if the child can bring a familiar object (out of sight) from an adjacent room after we designate that object.



Determine if the child can bring a familiar object (out of sight) from an unusual location in another room (e.g., Bring shoe on kitchen table!). Place two familiar objects, one in front of the other, directly in front of the child. We then ask the child for the object farthest from him. The child who is word-guided will succeed; the child who is still guided more by context will incorrectly select the closest object to the examiner (Vygotsky, 1962).

Developing Expressive Language from Systems Before expressive language can develop to any extent, a child such as Damon must first solve the problem of including people within his systems. This is because communication requires the ability to relate to another around a third entity, such as an object, event or person that becomes the conversation piece. Often, we see children able to relate to their parents or to objects but not to both at the same time The capacity for communication is developing when reciprocal games (such as the swinging ball) become possible or at the earliest level, when the small child at 9 or10 months of age finds it possible to give an object on request (Trevarthen & Hubley, 1979). A second important precursor of communication is the childs understanding that her actions are influential. In other words, that she can cause things to happen first with hands, then with tools that extend the reach of hands, then by gestures that simulate actions, and finally by spoken words. All the action systems developed on the Elevated Square and on the ground provide a basis for eliciting expressive signs and words from Damon and others like him. However, before the action system can be used in this way it is desirable to expand all the systems so that

they are not limited to one context. To do this we make certain that Damon performs an activity with different people, in different locations, with different objects, presented in different positions.2 It is also desirable to expand from simple minisystems to more complex integrative systems. Once this is accomplished, we can systematically begin to interrupt the system at different points to elicit the signs and words that previously have been introduced with the system. For example, suppose Damon has to pick up a box to get a marble to send down a ramp. We stop the marble midway down the ramp, inducing Damon to say or sign, Go! After such integrative setups are repeated several times, we can then selectively stall (interrupt) at key places to elicit the signs or words the child needs to produce to have the system continue. For example, by preventing the child from lifting the box, the child must sign or say, Pick up! Or, after repeatedly opening a box with the word and sign for open, we interrupt the system by holding the box closed and, in doing so, elicit from the child the word or sign Open! Another important strategy used when the child is responding very well to the sign and word Come! entails having the child sit on a box in the middle of the short end of the Square with a therapist behind him, while the mother stands at the other end of the Square (opened to accommodate her). Then, we help the child make the come sign, beckoning the mother to move toward him. Mother is instructed to take one step each time her child makes the come sign. Often, suddenly, the child becomes aware of the influential nature
We are indebted to Dr. Louise Ross for the acronym PLOP to remind staff to perform Position, Location, Object, and Person expansions with each developing system.


ICDL Clinical Practice Guidelines

of his come sign and will repeat it rapidly to bring mother swiftly toward him. The contagious excitement that goes with this often elicits the vocalized word, Come! Supplementing the work on the Elevated Square is work with the Sign and Spoken Language Program (SSLP), which presents real-life situations of children running, jumping, and performing other activities interspersed with signs that closely resemble these activities. Children sitting around the television monitor are guided in the use of signs in the context of the videos. They then have the opportunity to use the signs with teachers, parents, and the other children. An example of one such sign from the SSLP may be seen in Figure 7. Teaching Order for Developing Communication Using the Miller Method The following outline summarizes the manner in which we work to help the children learn to communicate: 1. Teaching action words related to self and others. (a) Begin receptively by having the child learn to respond to certain imperative signed and

spoken directions: Come!, Stop!, Get up!, and Sit down! The childs capacity to respond immediately to Come! and Stop! can be a matter of survival. (b) Transform receptive sign-words to expressive. After the child understands two or three action sign-words, we help the child use them expressively with others. It is desirable to do this early on so that the child learns that not only do these sign-words compel her to respond, they also can be used to compel a response in others. If a child is having trouble using signs expressively (and it does not seem to be a motor-based problem), it may be because the child does not yet understand the influential power of signs. Introducing more causal experiences can be helpful. Parents should be encouraged to find dramatic cause-and-effect toys and to work with their child in using them. Providing the child with many opportunities to experience the self as agent can prepare the way for the child to use sign-words to effect a desired response in others. 2. Teaching objects and the sign-words that designate them. The child must learn to designate objects both close to his body and at a distance. To achieve the latter, the child must learn how to scan; that is, to distinguish the desired object from an array of competitive objects and stimuli. (a) Begin by using engaging objects close to the childs body. Engage the child with objects that lead to actionobject systems and use sounds and intonation both to draw the childs attention to the object and to enrich

Figure 7. Videotape sequencing of a child jumping and the signs for jump.



the action-object system (e.g., Rrrmcar or Car-rrrm). Narrate the sequence while and just after the child performs the activity; fo example, Damon sends car down! We teach the child to differentiate sequences: Car-down-ramp vs. ball in bucket vs. ring on pole, and so forth. Having differentiated one sign-word-action sequence from another, the child can follow spoken and signed directions appropriately. Have the child use sign-words to designate different people. Each person working with the child should have their own unique sign paired with their name. The child should also have access to a full-face, 8-by-11 inch picture of each person to assist the child with recall in the persons absence and to help with syntax development. (b) Teach objects, and the sign/words that designate them, away from the childs body. The strategy is aimed at getting the child to differentiate a distant object from its surrounding field by pointing at it, touching it with a long stick, snaring it, or by squirting water at it with a squirt bottle. The use of sticks or squirting may be thought of as preliminary steps toward perceptually holding the object by pointing and, eventually, by designating it via sign-word or picture. In teaching objects at a distance, we use objects that already have been part of minisystems. By removing an object from a well-established system, we induce an interrupted system that can only be completed by the child acquiring the object part of that system. For example, if the child has been pumping water into a cup, then the cup should be one of the distant objects.

(c) At home, parents or caregivers should use the same principle of narration and interrupted systems to develop object awareness and designation. For example, the spoon required to eat dessert may be located on the wall, a missing shoe can be located on top of a bureau and so forth. We have parents do scavenger hunts with their child. The parents should help their child find various objects (a rusty bolt, a hairpin, a washer, or empty candy box), point at and name them, put them in a sack or other container, and bring them home. At home, they should pour out the contents on a table, examine them together, talk about them, and mount them on boards for future reference. (d) The parents should perform adjunct procedures for building vocabulary. The parents can videotape their child in action. For example, as he loads a wagon or wheelbarrow, pulls/pushes it to another site, and dumps out the cargo; climbs monkey bars or swings on a swing; pushes a cart in the grocery store; or rides a tricycle. They can narrate what the child is doing, interrupting periodically to see if the child contributes a sign or word. If possible, they should encourage the child to simulate the videotaped activity with miniature toys. 3. Moving the child toward the naming insight (Miller & Eller-Miller, 1989). Although we cannot guarantee that a child will achieve the notion that each thing has its name and that the name is actually a category for all things that have those particular properties, we can facilitate the likelihood of the child gaining this insight. One way of doing this is to teach


ICDL Clinical Practice Guidelines

the critical properties of certain objects on the Elevated Square. For example, to teach the properties of cup, at one station we have the child place cups on hooks (accenting the handle of the cup); at a second station, we have the child stack cups (accenting their contours); and at a third station, we have the child pour water in and then out of a series of cups (accenting their water-holding property). In a similar fashion, we can teach that a ball is an object that can be thrown, caught, bounced, rolled, placed in a container, and so forth. Each varied use of the object is, of course, accompanied by its sign and name. As children learn the multiple properties of each object subsumed under a unique name, they internalize the criteria for that object to be generalized. In other words, even if a cup or ball has unusual characteristics, if the essential properties are present they may be able to identify it as belonging to the cup or ball category. When children can do this with a number of common objects, they often achieve the generalization that each thing has its own name. 4. Developing syntax. It is often a challenge to help children who have single signs or spoken words move toward functional syntax. Recently, we have developed effective procedures for achieving this with the help of sign-morphs and pictures. The sign-morphs are cards that, when held at a certain angle, produce an action sign in motion. By tilting the card, the child sees the manual sign for push in action, the sign for jump seems to jump, the break sign makes a breaking motion, and so forth. Since the children are already familiar with these signs from the SSLP and from daily use in class and in therapy sessions, it is not difficult for

them to correctly identify the signs. Then, to teach subject plus verb sequences, we pair a full-face picture of the child with the sign-morph and require the child to perform the appropriate action. (a) For example, a picture of Damon plus sign-morph for jump requires Damon to jump. Then pictures of mother, teacher, or therapist are substituted and placed next to the signmorph so that Damon expects others to perform the action. We followed this procedure with a range of signmorphs until the notion is well established that changing the picture next to the sign-morph induces that person to perform the action. (b) Once the child fully understands subject plus verb sequences (step one), we shift the emphasis to sign-morph plus noun (step two). For example, we follow the sign-morph for pour with either a picture of water or rice. The child demonstrates her understanding of the verb plus noun relation by selecting and pouring the correct material from the bottle. (c) The final step in this process is when the child understands subject plus verb plus noun sentences. We teach this by combining strategies from steps one and two. Once the children have internalized this assisted procedure for developing syntax, we find that many can eventually use it spontaneously without picture or signmorph support. Providing the Necessary Transitions from Concrete to Symbolic Functioning Many children with developmental issuesbut particularly children on the autistic spectrumrequire assistance to achieve



symbolic functioning. Often, for example, there is little evidence of symbolic play, as was the case with Damon. However, we can encourage such play by providing a careful transition from a real-life experience a child has just had to a comparable play experience that relates directly to the real-life situation. We find that we can often induce symbolic play by first having a child perform certain acts on the Elevated Square and then introducing the child to a miniature Elevated Square with dolls. Observing the miniature Square, a number of children have spontaneously moved a doll figure in the same way they have just moved on the large Elevated Square. Similar transitions may be made for those children who have learned to speak in two- to three-word sentences but who seem stymied when they first confront the arbitrary forms of printed words and are asked by teachers and parents to attribute specific object meanings to these forms. Just as some children have difficulty with the shift from object to picture, so others have difficulty with the shift from picture to printed word. Assisting children with this transition requires another set of strategies. We derived these strategies from the observation that, unlike the iconic relation between picture and object, the forms of printed words do not resemble their referents. Therefore, before many children can understand that a printed word may convey the meaning of an object to which it bears no resemblance, they require an interim means of investing printed words with object meaning. In a series of experiments, we demonstrated that children previously unable to find meaning in printed words could do so when provided a transition from picture to printed word (Miller & Miller, 1968, 1971). This was first accomplished by having pictures of objects fused with the printed word on one side of a flash card that could be flipped to

the other side, revealing the word in its conventional form (Figure 8). Subsequently, even very delayed children could recognize the meaning of the printed word.

These procedures have been developed further in the Symbol Accentuation Reading Program (Miller, 1968/1996) so that, with the help of animation to make the transition from picture to printed words and from mouth movements to letters (Figure 9), many children with disorders who were previously unable to read and write have learned to do so.

SUMMARY This chapter described the Miller Method in detail, including its basic concepts and its principles of assessment and intervention. It also presented a case study of a 3-year-old boy on the autistic spectrum to illustrate how this method can be used to improve poor human contact, decrease perseverative tendencies, develop receptive and expressive language, and engage a child in symbolic functioning (or


ICDL Clinical Practice Guidelines

pretend play). Our experience suggests that there are five general factors that play a role in determining how successful the Miller Method will be for a child. These are: 1. The childs age (younger children tend to do better than older); 2. Neurological status (those without cortical insult or seizure disorders do better); 3. The childs relationship with his parents (those with a bond with at least one parent do better than those who have no such bond); 4. System characteristics (those with closed-system disorders progress more

rapidly than those with system-forming disorders); and 5. Support demand stance (parents with a high support/high demand stance have children who progress more rapidly than those who have high support/low demand stance). Beyond these general impressions, we find that highly motivated families who live the program by implementing it in their homes and who form a close alliance with the therapeutic staff frequently have children who make unexpectedly strong gains. s



REFERENCES Cook, C. (1998). The Miller Method: A case study illustrating use of the approach with children with autism in an interdisciplinary setting. Journal of Developmental and Learning Disorders, 2, 231-264. Goldstein, K. (1939). The organism: A holistic approach to biology. New York: American Book. Greenspan, S. I. (1998). Personal Communication. Greenspan, S. I., & Wieder, S. (1998). The child with special needs: Encouraging intellectual and emotional growth. Reading, MA: Addison Wesley Longman. Greenspan, S. I., & Wieder, S. (2000). Developmentally appropriate interactions and practices. In S. I. Greenspan (Ed.) The Interdisciplinary Council on Developmental and Learning Disorders clinical practice guidelines (Chap. 12). Bethesda, MD: Interdisciplinary Council on Developmental and Learning Disorders. Konstantareas, M. M., Oxman, J., & Webster, C. D. (1977). Simultaneous communication with autistic and other severely dysfunctional nonverbal children. Journal of Communication Disorders, 10, 267-282 Konstantareas, M. M. (1984). Sign language as a communication prosthesis with languageimpaired children. Journal of Autism and Developmental Disorders, 17(1), 115-131. Lewin, K. (1935). Dynamic theory of personality. New York: McGraw-Hill. Messier, L. P. (1970). Effects of reading instruction by symbol accentuation on disadvantaged children. Unpublished doctoral dissertation, Boston University, Boston. Miller, A. (1963). Verbal satiation and the role of concurrent activity. Journal of Abnormal and Social Psychology, 3, 206-212. Miller, A. (1968). Symbol Accentuation: Outgrowth of theory and experiment (symposium paper). In the Proceedings of the First International Congress for the Scientific Study of Mental Deficiency, Montpellier, France (pp. 766-772). Surrey, England: Michael Jackson Publishers. Miller, A. (1991). Cognitive-developmental systems theory in pervasive developmental disorders. In J. Beitchman & M. Konsstantareas (Eds.), Psychiatric clinics of North America (Vol. 14): Pervasive developmental disorders (pp. 141-161). Saunders Press. Miller, A., & Miller, E. E. (1968). Symbol accentuation: The perceptual transfer of meaning from spoken to written words. American Journal of Mental Deficiency, 73, 200-208. Miller, A., & Miller, E. E. (1971). Symbol accentuation: Single-track functioning and early reading. American Journal of Mental Deficiency, 110-117. Miller, A., & Miller, E. E. (1973). Cognitivedevelopmental training with elevated boards and sign language. Journal of Autism and Childhood Schizophrenia, 3, 65-85. Miller, A., & Eller-Miller, E., (1989). From ritual to repertoire: A cognitive-developmental systems approach with behavior-disordered children. New York: Wiley & Sons. Pavlov, I. P. (1927). Conditional reflexes: An investigation of the psychological activity of the cerebral cortex. Oxford: Oxford University Press. Piaget, J. (1948). Language and thought of the child. London: Routledge and Kegan Paul. Piaget, J. (1954). The construction of reality in the child. New York: Basic Books. Piaget, J. (1962). Play, dreams and imitation in childhood. New York: Norton. Sokolov, Y. N. (1963). Perception and the conditioned reflex. New York: MacMillan.


ICDL Clinical Practice Guidelines

Trevarthen, C., & Hubley, P. (1979). Secondary intersubjectivity: Confidence, confiding, and acts of meaning in the first year of life. In A. Locke (Ed.), Action, gesture, and symbol (pp. 83-229). London: Academic Press. Uexkull, J. von (1934, 1957). A stroll through the worlds of animals and men. In Claire Schiller (Ed.), Instinctive behavior. New York: International Universities Press. von Bertalanffy, L. (1968). Organismic psychology and systems theory. Clark University Press with Barre Publishers. Vygotsky, L. S. (1962). Thought and language. Cambridge, MA: The MIT Press.

Warr-Leeper, G. A., Henry, S. L., & Lomas, T. C. (in press). The effects of Miller Method intervention on functional communication: Multiple case studies for children with severe communication disorders and hearing impairments. Submitted for publication in the Journal of Developmental and Learning Disorders. Werner, H. (1948). Comparative psychology of mental development. Chicago: Follett. Werner, H., & Kaplan, B. (1963). Symbol formation: An organismic developmental approach to language and the expression of thought. New York: Wiley & Sons.




Time 8:30 am

Activity Orienting: Handing over the child Massage/compression with voice modulation Rough-and-tumble and selective tickling Narrating and predicting imminent events Reciprocal touching, exploration and part naming Tableau calendar for structured transitions From One-on-One to Group: Circle spheres- contagious activity with teachers and children. (This is the way we pat our head [rub nose, run, walk, jump, fall, stamp feet], etc.) Sign and Spoken Language Program: Training Film I (action signs/words: walk, run, jump, fall, come, go, stop, etcreceptive and expressive). Generalizing action concepts to other settings. Toileting/washing Snack Time: Child uses signs/words give, pour, eat, cookie, drink, spoon, fork, etc., for desired objects/events Elevated Board Spheres: Using Bridge or Template Tunnel and combined board structures including Grand Central sphere. Using multiple orienting to revitalize an inert system. Reciprocal Spheres: Using Traveler with terms push, open, pick up, close Reciprocal ball pushing sphere Lunch Rest Period Cooperative Building Spheres: Boards to build large and small Velcro house Cooperative repair of Broken Table and Chair C-D Art Program: Repetitive circles, lines and dots as minispheres and integrative spheres Symbolic Play Spheres: Using Elevated board replicas (small) with dolls

Areas Developed Interaction Body awareness Body awareness Communication Interaction Interaction Interaction Body awareness Communication Communication Interaction

9:00 am

9:30 am

10:00 am 10:20 am

Coping Coping Communication Body efficacy/awareness Interaction Coping Interact/communication Interaction Coping Coping Interaction Representation

10:40 am

11:15 am 11:45 am 12:00 12:30 pm 1:00 pm

1:30 pm

2:00 pm


All children in this category will spend at least 30 minutes each day working on elevated board structures as part of a class of five or six children with three teachers. In addition, each child in the non- or limited-verbal category is scheduled for 45 minutes each week with a therapist and a parent in cognitive-developmental systems therapy, which typically involves work on the Elevated Square. Children also have access to speech and language therapy, occupational therapy, movement therapy, adaptive physical education, and manual arts during the course of the week.


ICDL Clinical Practice Guidelines

Chapter 20. Visual-Spatial Thinking



Visual-Spatial Thinking
Harry Wachs, O.D.

THE THEORETICAL BASIS OF VISUAL-COGNITIVE INTELLIGENCE Jean Piaget and Hans Furth subdivided intelligence into three categories: (1) biological intelligence (Furths term), (2) sensorimotor intelligence, and (3) operational intelligence (Furth, 1986).1 Biological intelligence is prewired in utero and is manifest after birth in the form of developmental reflexes. Sensorimotor intelligence can be referred to as action knowing, and continues throughout adult life. When Piaget discovered object permanence (which occurs developmentally in a child around 2 years of age and involves the ability to do things at a mental levelin the childs headrather than solely to know them through physical action), he became more fascinated and involved with what he termed operational intelligence. Although Piaget delved very little into sensorimotor intelligence beyond object permanence, he did not imply that sensorimotor intelligence stopped at object permanence. Operational intelligence can be described as reasoning or thinking by a child, which usually starts around age 2 and matures around ages 5 to 7, but continues to be embellished throughout life. To these three categories, Furth and I added a fourthbody and sense thinkingto describe sensorimotor development in a child

between the ages of approximately 2 and 7 years of age (Furth & Wachs, 1974). Extending Piagets theory from object permanence through concrete operationsthe period when a person can use reasoning to tap sensorimotor intelligencethe term describes the childs ability to apply reasoning to sensorimotor experiences once the child can mentally manipulate his or her visual-spatial world. During this period, the childs action knowing can be enhanced by reasoning or operatory thought. Piagets theory can be applied to all individuals, impaired or nonimpaired. Its application includes the autistic spectrum, from pervasive developmental disorder (PDD) to severe autism, as well as attention deficit disorder (ADD) and the more common learning disabilities (LD) and dyslexia (Wachs, 1980, Vol. 2, pp. 51-78). In my research on the application of Piagetian theory, I have worked with children from Europe, Asia, and North and South America, as well as with many indigenous groupsAfricans, South American Indians, Bedouins, Aborigines, Eskimos, Native Americans, mestizos, and hill tribes in Thailandwith similar results on sensorimotor and body and sense thinking tasks.
The term operational describes intelligence, whereas the act of doing something operational is described as operatory.


ICDL Clinical Practice Guidelines

The word intelligence is often misused in common speech, as in statements like Scott is intelligent or Cathy is not very intelligent. In fact, intelligent should not be used to describe a person, but rather what a person does or is involved in. Scott is doing this intelligently would be a better use of the word. This chapter deals with visual and spatial intelligence and spans the childs development from birth to approximately age 7. All the developmental visual-cognitive hallmarks are stages of growth and should not be misconstrued as age-related norms (Wachs & Vaughn, 1977). Some children with special needs have difficulty developing intellectually, even up to the level of an average 7-yearold. A negative outcome, however, should not be assumed, as I have seen many children develop far beyond their prognoses. A distorted body does not necessarily imply a distorted mind.2 Furth and I have coordinated our work to follow the general principles of Piagets constructivist theory in both diagnosis and intervention. For all children, especially those with special needs, we assign tasks chosen from a repertoire of probes and interventions designed to diagnose, elicit, and foster cognitive understanding. All our probes and interventions are hierarchically based. They are not designed solely to achieve the right answer from the child, but rather to lead the child to construct cognitive understanding by developmentally raising or lowering the demands of the tasks. The following brief outline lays out our developmental approach for developing the visual-spatial aspects of body and sense intelligence: I. General Movement Reflexes (e.g., obligatory arm movements when head or feet move)

Mental map of body (e.g., awareness of joints and body dimensions) Integration of body sections (e.g., creeping-crawling, angels in the snow) Integration of body axes (e.g., rolling, bimanual circles on chalkboard) Rhythm (e.g., moving or tapping body parts to the accompaniment of a metronome) Coordinated actions (e.g., skipping, hopping, jumping rope) II. Discriminative Movement Fingers (e.g., crumpling or tearing paper) Eyes (e.g., focusing, tracking, fixating on an object) Lip, tongue, and vocal chords (e.g., tongue motility, making funny faces, gargling) III. Visual Thinking A. Matching (e.g., household items, blocks, pegs) Coincident (reconstructing a given model with some part of each block touching other blocks) Separated (matching items spread apart) Negative space (placing items in spaces purposely not filled in) Recalling (reconstructing a given model in a distant part of the room) B. Transposition (coordinated with body axes) Horizontal (toward and away) Vertical (right and left) Transverse (rotations)
In this context, see Furth, H. (1991). Lifes essential: The story of mind over body. Human Development, for a discussion of the 1989 memoirs of Ruth Sienkiewicz-Mercer.

Chapter 20. Visual-Spatial Thinking


Analysis (determining how a given design was transposed) Positions (constructing from a different viewpoint; that is, north, south, northeast, etc.) Vision is another misused word. A parent who says, My childs vision is 20/20, really should be saying, My childs sight is 20/20. The difference is tremendous. We look with our eyes (looking); we see with our brains (sight); and we understand with our minds (vision). Here is where Piagetian theory is so valuable. Piagets theory of constructivism holds that knowledge is not neurally constructed; instead, neural connections are built through mental constructs. In other words, the retina and the brain are used to construct, not evoke, new knowledge. Piagets theory of sensorimotor intelligence lays the foundation for visual intelligence. The determining factor for visual intelligence is not what passes through the eye but rather what a person can understand from a particular visual experience and eventually coordinate with other aspects of body and sense thinking. Thus, a partially sighted child may have well-developed visual intelligence and a child with acute 20/20 sight may have poorly developed visual intelligence. The foundation for visual intelligence is developed through sensorimotor intelligence in the first few years of a childs life, even during the neonatal period when the child is nonmobile. This does not imply that visual intelligence cannot be developed in the movement-impaired child, but rather that the more developed the childs movement (or sensorimotor) intelligence, the better the opportunity for the child to develop visual intelligence. In addition, even in the nonmotorically impaired child, a lack of movement intelligence development could confuse and inhibit the development of visual intelligence. My experience has shown that most children with cerebral palsy have inadequate

visual intelligence, and also that many children with inadequate visual intelligence have inadequate movement intelligence, despite being neurologically intact (Fraiberg, 1977). DEVELOPMENTAL REFLEXES For biological intelligence, Furth uses the phrase biological knowledge to describe the intelligence the child is born with. Modern neuroscientists refer to this knowledge as pre-wiring, observable in the many developmental reflexes in a healthy, intact newborn (Goddard, 1996). Clinical experience has shown that the existence of these primitive reflexes can inhibit sensorimotor function and that removal of the reflex obligatory responses actually can aid the efficiency of such sensorimotor functions as ocular motility and general body motility. British neuropsychologist Peter Blythe has made an exhaustive study on the diagnosis and treatment of such reflexes sustained beyond their useful years (Blythe, 1990; personal communications with H. Wachs, 19951999). His work shows that children who retain primitive reflexes often show the following dysfunctional traits (this list is not allinclusive and does not imply that primitive reflexes are the sole factors involved): Rigidity of movement Poor handwriting Gaps in athletic performance, especially in throwing or catching Clumsiness Bumping into things Dis-coordination Poor ocular tracking Poor rhythm Difficulty in showing usual expected response to intervention procedures Though I have not been trained in Blythes methods, I have incorporated three


ICDL Clinical Practice Guidelines

Tables 1A. Primitive Reflexes Adopted into Vision and Conceptual Development Theory
Table 1A. Feet Observed Reflex
FEET (exact origin still undetermined, possibly caused by the amphibian, labyrinthine, or Moro reflex)

Diagnostic Procedure
Stand erect, hands hanging by side. Turn feet inward in pigeon-toed position, then outward in Charley Chaplin position.

Clinical Picture, if Sustained

With feet pointing inward, the child thrusts elbows and arms backward in scarecrow position, hands rotated with palms facing away from body. With feet pointing outward, the child moves elbows toward body and rotates hands so that palms face forward. Thus any movement of feet triggers an obligatory movement of arms. This could be very confusing and disturbing, especially to an already confused child.

Clinical Picture, if Reabsorded

The child does not move arms in either feet position, even when marching in place.

NOTE: Some individuals have such severe gaps in sensorimotor development that they are unable to rotate their feet in either one direction or both directions. These individuals require specific therapy procedures (see treatment section for more information). Other individuals show no reflexive arm movement until asked to turn their feet in or out while marching in place and swinging their arms accordingly. The sustained reflex inhibits and sometimes actually stops the arm movements. I am presently treating a young Mennonite child in rural Maryland who is so reflex-bound that every time she attempts to turn her feet inward, even when seated, her left arm shoots straight up in the air. How can she possibly participate successfully in daily activities at home and in school?

Chapter 20. Visual-Spatial Thinking


Table 1B. Asymmetric and Symmetric Tonic Neck Reflexes Observed Reflex
Asymmetric Tonic Neck Reflex (ATNR)*

Diagnostic Procedure
With hands and knees on the floor in a creeping position and head hanging downward, rotate head right and left.

Clinical Picture, if Sustained

Elbow on opposite body side of head rotation bends; i.e., rotate head to right and left elbow bends, etc. Occasionally only one side is affected.

Clinical Picture, if Reabsorded

Neither elbow bends.

Symmetric Tonic Neck Reflex (STNR)**

Ask child to get down on hands and knees (or place child in creeping position), and to drop head downward. Repeat, alternately raising and lowering head. This could cause poor posture, with all its visceral and skeletal problems, or dysfunctional results when working at a desk or reading in a chair.

Sitting back on heels indicates retention of STNR. Collapse (flex) of elbows and/or humping of back when head is lowered (and collapse of back when head is raised) indicate existence of STNR. Elbows collapse

Back stays straight; elbows do not bend.

Back sags

Back arches

Sitting on heels

* An occupational therapist (OT) told me that she felt the ATNR was responsible for some auto accidents. The drivers head turned to the right caused flexion of the left arm and the resultant swerving of the car. ** Imagine trying to learn to swim, ski, or play a sport if your symmetric tonic neck reflex is severe and inhibitory.


ICDL Clinical Practice Guidelines

of the primitive reflexes identified by him and some of his teachings in my therapy procedures. Tables 1A and 1B list the identifying features (diagnostic procedure) of each reflex and its clinical picture if sustained or reabsorbed as a result of therapy. Treatment for Children Who Retain Primitive Reflexes My approach to therapy for children who retain the reflexes just described is twofold. I have the child (1) work through sensorimotor experiences that in normal development precede cessation of the reflex and (2) participate in sensorimotor experiences that contradict the obligatory movements of the reflex in question. For step 1, my therapists and I use such early sensorimotor experiences as rolling, crawling and starfish. Starfish is a simulated in utero procedure borrowed from Peter Blythe in which the child, in a sitting position, first crosses the right leg over the left leg and the right arm over the left arm, with body and head leaning forward. The child maintains this position for a count of ten. The child then thrusts both arms and legs apart and leans body and head backward, again for a count of ten. The child repeats this two-step procedure several times, alternating right over left and left over right (Blythe, 1990). For step 2, we use animal walks (e.g., bear walk, crab walk, duck walk, inchworm, crawling on the belly) to contradict the FEET and ATNR reflexes. In each of these actions, the hands and feet must coordinate, though they each play an independent but supportive role in the activity. The wall walk and feet-in-andout have also proved helpful in eliminating the FEET reflex. In the wall walk, the child stands more than an arms length from a wall, the distance forcing a stretch to reach the wall. With feet stationary, the child walks both hands up

and down the wall, as high and as low as possible. The wall-walking procedures can be made more complex by having the child place hands alternately on either side of a vertical line, move hands rhythmically to a metronome, turn hands and feet outward and inward opposite to the assumed position of the feet reflex, and turn the head right and left opposite to the ATNR. For treatment to eliminate the symmetric tonic neck reflex, I use two procedures adopted from yoga practice. In the turtle, the child sits erect on heels with toes bent under, hands resting on thighs, and back straight. After staying in this position for a count of five, the child leans forward and, supported by the arms, straightens toes (toenails toward the floor) and again sits back on heels with arms resting in the lap for a count of five. The child then grasps the back of the neck with both hands and tucks the head downward between knees, again for a count of five. This is repeated several times. In the yoga technique of cat and cow, the child on hands and kneestucks head down and between arms while arching the back upward, and then bends head backward and arches back downward. This, too, is repeated several times. Eventually, the child performs this procedure rapidly and vigorously. Readers can add to these examples of treatment activities or use them to build procedures of their own. After the child is free from obligatory reflex movement, the therapist can employ procedures to construct sensorimotor knowledge that will eventually lead to the childs spatial knowledge of the construction of his own body. This is known as endogenous spatial constructs, and is analogous to the knowledge of a cars construction

Chapter 20. Visual-Spatial Thinking


that is required by a person to parallel park the car (Furth & Wachs, 1974, pp. 71-110). SENSORIMOTOR My format for addressing sensorimotor growth and endogenous spatial constructs leading to exogenous spatial constructs follows a proven hierarchical developmental plan: 1. Developmental absorption of primitive reflexes 2. Mental map of the body 3. Integration of body sections 4. Rhythm 5. Coordination of body axes 6. Coordination of body actions Occupational therapy procedures are a valuable adjunct to movement development prior to the body and sense activities just listed. Occupational therapy should be used for children with vestibular (balance) needs and lack of motility or muscle joint adequacy (Furth & Wachs, 1974, pp. 94-107). Perceptual-motor procedures are also a valuable adjunct at the level of coordinated actions. Ocular, digital, and oral discriminative movements also play important roles in spatial constructs in that each has a component of right-left, up-down, and forwards-backwards. This discussion, however, relates only to ocular discriminative movement. Before discussing interventions for sensorimotor growth, it is necessary to clarify the major difference between development and externally imposed learning. Development implies new mental constructs leading to Piagets object concepts (mental awareness of an item in the absence of that item) (Ginsberg & Opper, 1979). Externally imposed learning could be conceptual if it were based on solid mental constructs, or solely content learned if the child did not have the prior mental constructs to understand that which was being

taught. Children with special needs are particularly prone to such memorized or rote learning. Excessive content learning can actually thwart development and make intervention more difficult because such rote learning encourages the child to memorize and not search for understanding. The following traits can be observed in children with gaps in sensorimotor development: Clumsiness Bumping into things Inability to ride a bicycle Inability to skip Poor performance in sports Inability to catch or throw, or awkwardness or poor institution of these actions Poor handwriting Tendency to lose place when reading or when switching fixation from far to near Carsickness, especially in the back of a car Preference for verbal or manual activities Difficulty using scissors Difficulty staying within borderscoloring or walking Difficulty drawing geometric forms Moving of head rather than eyes Inability to maintain personal space The next section briefly discusses probes and interventions for gaps in body and sense thinking, which could well be the cause of the preceding traits. GENERAL MOVEMENT Mental Map of Body The body is a physical construction in which the person resides. The person, or the self, is that unique property that characterizes one as an individual. At death, the person leaves; but the body, as a construction, remains. The person has to develop an understanding of the width, height, and breadth of


ICDL Clinical Practice Guidelines

the body, as well as its hinges and rotary components. Mobility through space requires knowledge of the extensions and limitations of the spatial components of the body, just as parallel parking requires knowledge of the extensions and limitations of the spatial components of a vehicle. Any dysfunctional movement warrants suspicion of an inadequate mental map of the body. A therapist can determine if a child has an adequate mental map of the body through the following probes (Furth & Wachs, 1974, pp. 77-83). Mental Map of Body Probes Body lifts. The child lies prone (face down) on the floor, feet extended and arms at sides on the floor. The therapist touches each of the childs limb individually; then two limbs of the same side of the body; then two limbs on opposite sides of the body; then three; then in sequence; then in sequence asking for a response in reverse order; then touching specific parts such as shoulder or elbows; and so on. If the child does not respond while in a prone position, the therapist starts with the child in a supine position (face up), but switches the child to a prone position as soon as possible. Observations: Does the child move only the limb that is touched? When the lower leg is touched, does the child lift the whole leg? When the elbow is touched, does the child raise the whole arm? When the head is touched, does the torso remain stationary? Does the child move several parts before deciding on the proper part to move? Dimensions. The child stands facing the therapist, who is about 6 feet away. The therapist holds a pole (or thick dowel) horizontally and perpendicular to the vertical axis of

the child, and asks the child to indicate, either verbally or through gestures, whether the pole should be raised or lowered until it is the same height from the floor as the specified body parts of the child (e.g., eyes, knees, shoulders). This procedure is performed sidewaysright and leftas well as frontward. In another task, the therapist asks the child to estimate how far to walk forward or sideways to be at arms length or foots length from a wall. At that point the child, with eyes shut, extends a limb to check body judgment. The therapist uses similar techniques to elicit a response for torso dimensions, height, and movements required to get under a stick. Various other tasks can be assigned to encourage body spatial judgment. Observations: Is the child unable to make a judgment? (If so, the therapist works closer to the child, or moves rather than asking the child to move.) Does the child seem to be confused, guessing rather than making judgments? (If so, the therapist has the child walk under the stick, try to touch the stick while seated, or walk between two chairs while varying the spatial requirements.) Joints. The therapist moves a pole or stick toward various parts of the childs body, and the child stands glued to one spot and bends the body at the joints to avoid being touched by the stick. Another adult can first demonstrate (but not teach!) how to avoid the stick. Observations: Does the child bend only at the waist? Does the child have to move feet from the glued spot? Are there any joints that seem confusing to the child?

Chapter 20. Visual-Spatial Thinking


Vertical axis (X axis)

Diagrammatic representation of retina quadrants of eye

Horizontal axis (Y axis)

Transverse axis Z axis)

Figure 1. Schematic Representation of Body Axes Integration of Body Sections and Axes The body, which is the container and vehicle of the person in all of us, is divided into a right and left half and an upper and lower half. These sections rotate around three axesvertical, horizontal, and transverse. The axes remain constant in all body positions. The person inside must manipulate the body (the container) for effective, efficient movement. The midline of the body, which lies along the vertical axis, is the longitudinal center of the container and the spatial reference center for the inside persons orientation in space and self (see Figure 1). The ear is thus further from the person than the nose. The eye can focus more easily on an object held temporally than on an object held nasally under binocular exposure because the object held nasally is closer to the persons center of reference. The three axes interact to develop endogenous spatial coordinates and are our internal reference for three-dimensional space. Thus an object moving from right to left moves toward us until it reaches our bodys midline, where it begins to move away from us. As evidence, try


ICDL Clinical Practice Guidelines

this simple exercise. Keep both your eyes shut. Hold your right hand level with your face but off to your right. Slowly move your right hand toward the left. As you cross your bodys center line, you will feel that your arm and hand have shifted direction and are moving away from your bodyeven though they are still moving in the same direction, leftward. The construction of this internal directional focus depends on physiological readiness and psychological awareness and motivation. To properly establish an internal directional focus, the child must develop integration and coordination of all sections of the body and coordinate all this mentally through vision, hearing, smell, and touch. Once this is established, the child is ready to develop efficient exogenous spatial coordinates, or a knowledge of the three-dimensional space of the childs external world. A child who has difficulty imitating simple body positions that involve right and left arm, or a child who is unable to walk cross-legged backward along a line on the floor, has not yet developed adequate endogenous spatial coordinates. These are usually developed around 6 years of age prior to school entry in the United States and are the foundation of the right-left concept important to academics. Most children with reversal difficulties fall into the nondeveloped endogenous and exogenous visual-spatial category (Fraiberg, 1977, pp. 5, 78, 157-159, 197; Furth & Wachs, 1974, pp. 86). (Endogenous is internal; exogenous can be described as a babys ability to project an internal model of space through visual, auditory, and manual appreciation of spatial relationships in its external world) A therapist can determine adequate integration of body sections through the following probes.

Integration of Body Section Probes Static imitative movement. The child and the therapist (or parent) stand facing each other about 10 feet apart. The therapist raises his own right hand and instructs the child to imagine standing alongside the therapist and to raise the same hand as the therapist has raised. Keeping that hand raised, the child moves alongside the therapist and observes whether they both have the same arms raised. If not, the child is told to fix it. The child then returns to the original positionfacing the therapist from 10 feet away. The therapist again asks the child if the raised arm is the same arm as the therapist has raised. Observations: Does the child then mirror the therapist (e.g., uses the left arm to imitate the therapists right arm)? If so, no further probe is necessarythe child has not developed adequate visual-spatial knowledge. If the child successfully imitates the therapist, the therapist models several right-left positions but does not cross hands over the midline. The therapists final modeling is to put the right hand on nose and left hand on right ear. This position requires a crossover of the central body locus. Observations: Can the child imitate the positions modeled by the therapist? The childs successful imitation of this position indicates basic development of endogenousexogenous, visual-spatial knowledge. An inability to imitate the position indicates that the child has not yet developed this visual-spatial knowledge. Cross-legged walk-on-line. The therapist places a strip of tape approximately ten feet long on the floor, and demonstrates walking forward cross-legged (right foot forward over left foot, then left foot forward over right), until the entire tape is traversed. Then the

Chapter 20. Visual-Spatial Thinking


therapist instructs the child to do the same walk backward (placing the left foot backward and behind the right foot, etc.) Observations: Does the child have an inability to perform the action backward? This indicates inadequate endogenous spatial development. Does the child have an inability to perform the action forward? This indicates a severe lack of endogenous spatial development. Skipping. The therapist asks for and/or demonstrates skipping, having the child skip at least 20 feet (in a circle, if space is limited). Observations: The child may not skip at all. (My research with Orinoco children of the Waika tribe in Venezuela revealed that skipping is not part of their culture, nor are hopping or jumping up and landing on both feet simultaneously. On the other hand, Zulu children in South Africa skip well at age three. Children in the Western world usually skip by approximately six years of age.) Skipping cannot, and should not be taught. Step-hop is not skipping. A sighted child who has the necessary motoric constructs will skip by observing others. Angels in the snow, crawling on the belly, creeping on hands and knees, human ball roll, and rolling (Furth & Wachs, 1974, pp. 84-107) all involve sensorimotor knowledge of how body halves can work together for purposeful movement. Any physical challenge that requires basic understanding of how to coordinate right and left as well as top and bottom of body sections can be used. The key is not to teach. Tasks can be demonstrated but not taught. If the child is unable to perform the task, the demands and complexity of the task should be simplified, but not taught.

RHYTHM Rhythm adds a temporal component to body and sense thinking. Though often categorized as an auditory function, rhythm is really internal timing with an auditory, visual, and tactile component. In half a century of clinical experience, I have seen very few children in need who have adequate, if any, rhythm constructs. The following three probes can be used to test rhythm constructs. Rhythm Probes Accompanying tapping (observed). The therapist taps rhythmically in steady beats on a table in front of the child. The child accompanies the therapists tapping. Both child and therapist are observing. Accompanying tapping (hidden). The child accompanies the therapists tapping while the tapping instrument is hidden from the child. Recall tapping. The therapist taps rhythmically and stops. The child recalls the rhythm and taps accordingly. Observations: A well-developed 3-year-old can accompany rhythmic tapshidden or visible. A well-developed 4-year-old can recall a simple rhythm pattern. By age 6, a well-developed child can maintain rhythm under various conditions with hands and feet, stopping one limb and reversing the cycle in time to the beat of a metronome. Rhythm Interventions Body support. The therapist stands behind the child and taps on the childs shoulder to the beat of a metronome set at about 100 beats per minute. The child taps on a table to the accompanying


ICDL Clinical Practice Guidelines

sound of the metronome and the therapists tapping. The therapist gradually ceases tapping on the childs shoulder as the childs tapping on the table becomes more efficient. Rhythm light. The child observes as the therapist flashes a light rhythmically to the beat of a metronome. This adds an additional signal to the child to reinforce the childs rhythmic response. Puppet. The child sits in a chair with hands on the table and feet flat on the floor. To the beat of a metronome (started slowly at 100 beats per minute) the child taps, in a circular pattern, right hand, right foot, left foot, left hand, right hand and maintains this pattern. The therapist decides when the circle should be reversed clockwise and counterclockwise. An advanced step is to ask the child to stop one limb and maintain the beat. Thus, the right hand stops but the child maintains the beat as though the right hand were moving. Eventually, two limbs can be stopped. The therapist can also ask the child to reverse the circular patternclockwise and counterclockwise. Another advanced procedure is simultaneous same (right hand, right foot, then left hand, left foot) and not same (right hand, left foot, then left hand, right foot). Again, stopping of limbs adds complexity. As the child improves, the speed of the metronome can be varied. Sitting spider. This activity is similar to the Puppet, but the child sits on the floor with hands on the floor, hips and feet flat on the floor, and knees bent and raised. The same procedure is used as in the Puppet, that is, circular, same/not same, stopping of limbs, and reversing circular motion clockwise and counterclockwise. Creeping. (Furth & Wachs, 1974, pp. 90-91). On hands and knees, the child creeps simultaneous same and not same on the therapists

command to various rhythmic beats of the metronome. Complexity can be added by placing signs printed with an R (for right hand) and L (for left hand) on the floor in varying sequences. If the child has no knowledge of the symbols, the therapist can just put blank cards on the floor or designate the hand that is to touch that card with a pattern (e.g., a red dot) and draw the same symbol on the childs hand. Coordination of Body Actions Coordination of body actions is a very high phase of sensorimotor intelligence. At this point, the childs sensorimotor development is fairly well established. Too early involvement in coordinated action activities can mask, or even thwart, development of the basic sensorimotor foundation for well-developed sensorimotor intelligence. Jumping rope, sports, gymnastics, rope and monkey bar activities, and walking rails and balance boards are all physical skill activities that require total body coordination. OCULAR SENSORIMOTOR DISCRIMINATIVE MOVEMENT The four basic movements of ocular sensorimotor intelligence are: Tracking Fixation Focus Convergence Tracking is the ability to sustain fixation on a moving object. An intact, well-developed 4year-old child should have adequate tracking. A 3-year-old can fixate, or move the eyes to point to a specific exogenous spatial object. Focusing is the ability to see an exogenous object clearly, and is not well developed until a child is 4 or 5 years old. Convergence is the ability to bifixate (point each eye at) an object as that object moves toward the eyes. A well-developed 3-year-old

Chapter 20. Visual-Spatial Thinking


should be able to converge on a target held 2 inches from the eyes. An intellectually healthy, well-developed 5-year-old can perform adequately in all these areas (Furth & Wachs, 1974, pp. 71-110). The following probes can be used to test the basic movements of ocular-sensorimotor intelligence. Tracking Probes The therapist asks the child to fixate (look at, point their eyes at) a penlight or other attention-getting object while the therapist moves the object horizontally, right to left and back to the right. Observing the ocular movement and, if possible, reflection of the object in the center of the childs eyes, the therapist then moves the target up and down vertically, with the child fixating the target. The therapist follows this with irregular, reverse motion movement of the target while the child tries to fixate and follow the target. Observations: Is the child able to fixate on even a stationary target? Does the child move the head rather than the eyes? Does the child lose fixation? Do the childs eyes cross in the attempt to follow the target? Does the child track horizontally but not vertically? Does one eye stop while the other continues tracking? Does the child track if the therapist uses slow, steady motion, but lose fixation when the tracking pattern is irregular? Tracking Interventions Pen stab. The child holds the top cover of a felt tip pen. The therapist holds the pen itself and moves it in various directions at various heights while the child tries to put the cover on it.3

Paper stab. The therapist draws a bulls-eye target on a piece of paper and ascribes various scores to the rings on the bulls eye (the center area has the highest score and the area outside the bulls eye has a minus score). The paper is moved on the table with the bulls eye in view, and the child uses a felt tip pen to stab at the bulls eye as in a game of darts. After a specified number of stabs, the therapist adds up the score . The child tries to better the recorded score during the next session. Washer or ball stab. The therapist suspends a metal or wooden washer (or other device with a hole in the center) from a rope. The child tries to stab the hole in the washer with a pencil or stick as the washer swings to and fro (Furth & Wachs, 1974, pp. 111-128). Fixation Tracking is dynamic fixation. Since a person who has difficulty tracking has difficulty fixing, the probes for tracking will also indicate the adequacy of fixation. Focus Focusing requires optometric evaluation. Asking a child whether she sees something clearly is far too subjective to indicate adequate focusing. However, looking far to near and back to far, and having to identify the target used, is the treatment of choice. Convergence Convergence is the ability to turn each eye inward to bifixate a near vision target. A well-developed 3-year-old should be able to converge on a target held 1 inch from the
Dr. Arnold Sherman, O.D., of New York, first invented this simple procedure.


ICDL Clinical Practice Guidelines

eyes. Two basic probes can determine the adequacy of convergence. Convergence Probes First, the therapist brings a fixation object forward from over the childs head to approximately 1 inch in front of the bridge of the childs nose while the child bifixates the target. Second, the therapist holds the fixation object from above about 8 inches from, and aligned with, the bridge of the childs nose, and then moves the object toward the child while the child tries to bifixate on the target. Observations: Do the childs eyes remain looking straight aheadno convergence? Does one eye fixate the target while the other remains looking straight ahead, turns in, or turns out? Does the child try to fixate by thrusting the head forward rather than converging the eyes? Convergence Intervention Convergence is a complex function and often requires professional intervention. If not, the simple procedure called push-ups can be used. The therapist has the child bifixate a target while moving the target toward and away from the child. If this does not help, the parents should enlist the aid of a visualcognitive or developmental optometrist. VISUAL THINKING Visual thinking is making sense out of the sense of sight. As described earlier, the eyes role is to change photic energy into neural energy. When this energy is transmitted to the brain, a child with the requisite mental construct will either understand the photic event or develop a new scheme to enhance knowledge of that photic event. Visual thinking is involved in all performance testing as well as

academic and intelligence testing. Visual thinking also is involved in mathematical thinking, especially in geometry. Visual thinking is involved in viewing and understanding molecular structures in organic chemistry. In short, visual thinking is visual intelligence. To explore visual thinking, the therapist can best do probes using parquetry blocks, pegs, form boards, and sticks (Furth & Wachs, 1974). Most children in need start by matching patterns of blocks placed before them. Some can only stack blocks. The following outline illustrates a hierarchy of actions using parquetry blocks. At any step, time can be introduced as a factor (e.g., speed, time limits, tachistoscope). A minimal clue also can be introduced, such as blurring the childs vision, camouflaging the model with overlays, and partially hiding or partially forming the model. The therapist should avoid developmentally inappropriate strategies. A Hierarchy for Demonstrating Visual Thinking This hierarchy (Furth & Wachs, 1974, pp. 286-287; Wachs & Vaughan, 1977, pp. 8-10) is not sacrosanct. The progression does apply generally but not totally universally. Some individuals (both child and adult) may be able to use strategies and appear to achieve a higher function but still not be conceptually solid on a lower function (Wachs & Vaughan, 1974). A. Same/not same A tenet basic to both learning and development is recognition of the conflict between known and unknown elements (Furth & Wachs, 1974; Wachs & Vaughan, 1977). This conflict provides the impetus for inquiry and eventual understanding. To probe a childs ability to distinguish between what is known and not known, the therapist asks the child to

Chapter 20. Visual-Spatial Thinking


differentiate one color, size, or shape of block from another. B. Stack blocks The child is asked to duplicate the therapists model by placing one block upon another in a balanced position, matching either the broad side or the narrow side of the blocks. (See Figure 2.) C. Build a bridge The therapist makes a model by placing blocks at least one pencil width apart and spanning them with another block, and then asks the child to duplicate the model. (See Figure 2).

Figure 3. Three Arrangements of Blocks Around a Parallel Square other). The ultimate number of blocks is fivepreferably two squares, one triangle, and two diamonds. The following procedures are designed to build same/not same awareness: take away add on substitute b. Off-center The blocks are placed so that the edge of any block only meets half the edge of the central block.

Figure 2. Illustration of Stacking Blocks and Building a Block Bridge D. Actual match (blocks to blocks) The therapist asks the child to reproduce a model arrangement of blocks. The reproduction should be such that the model, when placed on top of the reproduction, fits exactly. Various configurations of blocks can be made. 1. Parallel square - the central block (square) placed so that the sides of the square are parallel to the sides of the table. (Figure 3 illustrates the following variations on the parallel square.) a. Juxtaposition - The sides of all blocks are coincident (the whole side of one touches the whole side of the

c. Hole The blocks are placed so that their edges only partially meet the edges of the central block, thus creating holes (or spaces) between blocks. 2. Tilted square - The central square is tilted so that the corners, rather than the sides, point to the sides of the table. The substeps are the same as those for the Parallel Square. 3. Separation - This activity can either be simple (i.e., blocks edges are parallel, but the blocks do not touch) or advanced (i.e., blocks edges are not parallel nor do the blocks touch). (See Figure 4.) Separation involves the following elements: add-on take away substitute


ICDL Clinical Practice Guidelines

Figure 5 illustrates transposition according to the following hierarchy of axes. 1. Hierarchy of axes a. Horizontal b. Vertical c. Transverse side-to-side corner-to-corner corner-to-side side-to-corner 2. Hierarchy of block assembly - Using three blocks, the therapist can instruct the child to assemble the blocks according to the following hierarchy of increasing complexity. Figure 6 illustrates the final two levels of this hierarchy. 1. Parallel basic - center square parallel to the sides of the table and the sides of the other two blocks coincident with the sides of the square. 2. Parallel advanced - center square parallel, and only one of the other two blocks coincident with the square. 3. Tilted basic - center square tilted and the other two blocks sides coincident with a side of the square. 4. Tilted advanced - only one of the other two blocks coincident with the square. 5. Individual placement the therapist presents the child with the blocks one

Figure 4. Simple and Advanced Separation of Blocks 4. Recall - The therapist presents a model, either in another room or apart and unseen in the same room. The child assembles a reconstruction of the model from memory. The therapist encourages repeat viewing until the child completes the replica, and then the therapist places the model on top of the replica to give the child visual feedback. E. Transposition This is the introduction to exogenous visual-spatial concepts. Flipping and rotation of blocks are simulations of the rotation around the three body axes: vertical (through the head down), horizontal (through the hips side to side), and transverse (through the navel and out the back). Knowledge of how to manipulate the body around these various axes provides our endogenous spatial concepts.

Figure 5. Transposition of One Block Along a Hierarchy of Axes

Chapter 20. Visual-Spatial Thinking


toward and away, rotate from corner to side or side to corner of sheet) required to transpose the model into the replica (that is, how the model was flipped or rotated to create the replica). H. Pictures Around the Room The therapist places a drawing of a three-, four-, or five-piece block design in various positions around the room, and then a blank card before the child. The child is asked to duplicate the designs. I. Outline The therapist traces the outline of a threeor four-block design (with blocks placed either horizontally or vertically) onto a card and asks the child to visualize the component parts of the outline and construct the design alongside (not on) the card. Basic to this is placing the blocks on the card within the outline. J. Positional Hierarchy (from basic to complex) 1. Coincidence 2. Off-center 3. Hole K. Hierarchy of Media Complexity Within each of the following elements, there is a hierarchy; that is, chips are juxtaposed, then overlap; pegs are in sequence, then in random order lying flat and diagonal. Any medium lends itself to both matching and transposition tasks. 1. Cuisenaire rods 2. Cubes or chips 3. Parquetry blocks 4. Pegs 5. Dot patterns (4 or 5 missing dots) 6. Geometric designs

Figure 6. Illustration of a Double Flip and Flip Rotation of Blocks at time, with the central block last. The above hierarchy is maintained, and the child or person is not to reposition the blocks until the final one is placed on the table. 6. Double flip the therapist asks the child to flip the blocks in two directions simultaneously. 7. Flip rotation - transverse axis rotation combined with a horizontal or vertical flip. The hierarchy of block assembly, as well as the transverse axis complexity, is maintained for both the Double Flip and the Flip Rotation. F. Positions The therapists blocks remain stationary in the center of the table. The child replicates the design as it would be viewed from any of the four cardinal positions of the table (north, east, south, west), as well as from the corners of the table. In previous actions, the blocks were moved and the child was stationary; here, the child moves and the blocks remain static. G. Analysis The model and the transposed replica are both presented to the child who must determine the type of transposition (e.g., horizontal flip, double flip, flip side-to-side or


ICDL Clinical Practice Guidelines

7. KOHS blocks or other multicolored cubes (the position of color or block adds another dimension) CONCLUSION I have made no attempt to be all-inclusive in this chapter, as a full explanation of visual-cognitive development would require many pages of text. Instead, I have tried to introduce optometric, visual-cognitive therapy in the hopes of encouraging parents of children in need to seek the help of a visualcognitive optometrist. The consequences of well-developed visual thinking are manifold. Academic subjects such as geometry (a visual mathematics), biology (with its visually presented experiments), geography (requiring the visualization of graphically presented symbols), and organic chemistry (demanding visual organization of molecular structures) are some of the visually dependent tasks students are required to perform. Such vocations as architectural design, engineering, surgery, dentistry, sculpture, and painting are visually dependent. The congenitally totally blind person can learn to do many things that sighted people can do, but are restricted when the activity is solely visually demanding, as in dentistry or restoration of a painting. My research has shown that mathematical thinking is very visually dependent. A small study I conducted at West York School District in Pennsylvania demonstrated that second-grade pupils who scored high in state-level math competency tests had welldeveloped visual thinking, visual-logic, and numerical literacy, whereas children who scored poorly were inadequate in these functions. Because mathematics is a visual-related child, the use of manipulatives to teach math in normal and remedial settings has long been the method of choice.

In essence, visual-spatial knowledge plays a major role in our intellectual growth and everyday existence. Children have a right to every opportunity to develop this knowledge to their fullest capacity. This tenet guides the work of visual-cognitive optometry, which is a necessary link in the chain of total development. CASE STUDIES Case One M. was 11 years old when I met him. His father was a teacher in rural Maryland, and his mother a college-educated homemaker. M. had received occupational therapy and countless hours of remedial reading. He had also been seen by several outstanding opthamologists. He was a large boy, affable and cooperative. His verbal ability was superior, and all previous mentors and testers had assured his parents that he was of superior intellect. Nevertheless, M. still could not read. He had trouble even with the words the and and. The boys most serious problem was his lack of development in ocular sensorimotor schemes. He measured slight hyperopia (far-sightedness) and had severe esophoria (overfocus) bordering on intermittent esotropia (crossed eyes). M. could not see near objects clearly, and glasses alone could not solve his problem. He was so uncomfortable trying to perform near vision tasks that he had simply stopped trying by the time I met him. One helpful eye doctor had actually suggested that M. learn Braille. M. also had developmental gaps in general movement as well as operatory thought. I worked with M. in my home office for about one hour weekly for nearly a year. Since M.s most serious problem concerned his poor ocular sensorimotor schemes, I first concentrated on developing his skills in tracking, fixation, focus, and convergence. We then

Chapter 20. Visual-Spatial Thinking


worked on general movement to improve his mental map of his body and on visual thinking to help him make sense out of what he could now see. M. did not complete as much of the visual-cognitive therapy as I would have liked, but he did complete enough of the sensorimotor (ocular and body as well as visual thinking) therapy to begin reading. His reading proficiency was sufficient to enable him to finish high school in the upper part of his class and attend college. The last I heard, M. had moved up in the corporate world to a position as assistant director of a major museum in Washington, D.C. From an illiterate, pseudo-blind school failure, this boy became a literate, successful person. Case Two Y. first came to my office when she was almost 8 years of age. Her early developmental milestones were severely delayed. She had received speech therapy and special education in her native Middle Eastern country, but she spoke very few words and was extremely withdrawn. All testing had resulted in a clinical developmental age of 3 to 4 years. When I first met her, Y. did not respond to anything. She would not, or could not, interact in any way. Her social and societal dysfunction, together with her major cognitive deficits, had resulted in a guarded and unfavorable prognosis. Upon testing, I found her visual acuity to be 20/20 at distance and near, but she had considerable sensorimotor confusion when attempting near vision fixation. She was under such stress and visual confusion at near that she actually crossed her eyes from the distress of near vision binocular fixation. I prescribed glasses with special lenses to relieve her near vision distress. When I

offered to work with Y., her parents moved to Washington, D.C., and were totally cooperative and consistent, both with her therapy in our office and with other therapies in the Washington area. Treatment continued for a 3-year period. I worked with Y. on an optometric, visual-cognitive regime consisting of general body and ocular sensorimotor development as well as very basic body and sense thinking. I paid special attention to Y.s receptive-expressive language, having her stay focused on a task, and improving her ability to follow verbal and gestural instructions. For example, I had Y. place inch cubes (or other objects) on designated locations, as well as walk to specific locations or mark specific locations on a chalk board or table top. To do this, I had to ascertain her level of development in each task on each day as it varied quite often. I then presented each task at a slightly more challenging complexity, being certain that the new task was not too high for Y. to comprehend. As Y. grew cognitively and new tasks became more complex in minute steps, I introduced new aspects of intelligence. Other therapists addressed her speech, her neuro-physiology, and her special education needs. The family lived in Washington, D. C. from September to June every year and returned home for the summers, during which they maintained a home therapy program. The results of these efforts have been outstanding. Y. is now a gregarious and talkative girl, attends a local public school, and reads adequately. Her eyes are straight and her parents are delighted. At 11 years old, Y. functions at about age 8. She may never perform at an age-appropriate level, but her prognosis for a normal, intellectually competent adult s life is now excellent.


ICDL Clinical Practice Guidelines


Blythe, P. (1990). A physical basis for panic disorder. Paper presented at the 4th International Conference on Neurological Dysfunction in Children and Adults, Guernsey, Channel Islands, UK (September). Fraiberg, S. (1977). Insights from the blind. Boston: Basic Books. Furth, H. (1991). Lifes essential: The story of mind over body. Human Development. Basel, Switzerland: S. Karger AG. Furth, H. (1986). Piaget for teachers. Washington, D.C.: C.A.E. (Originally published by Englewood Cliffs, NJ: Prentice Hall, 1970). Furth, H. & Wachs, H. (1974). Thinking goes to school; Piagets theory in practice. New York: Oxford University Press.

Ginsberg, H. & Opper, S. (1979). Piagets theory of intellectual development. Englewood Cliffs, NJ: Prentice-Hall. Goddard, S. (1996). A teachers window into the childs mind. Eugene, OR: Fern Ridge Press. Wachs, H. (1980). Piagets theory in special education. In B. Keogh (Ed.), Advances in Special Education, Vol. II (pp. 51-78). Columbus, OH: JAI Press. Wachs, H. & Vaughn, L. J. (1984). The Wachs analysis of cognitive structures. Huntingtown, MD: Huntingf ields. (Originally published by Los Angeles: Western Psychological Services, 1977).

Chapter 21. Sensory-Motor Integration: A Perceptual-Motor Approach for Enhancing Motor Planning in Children with Special Needs



Parviz Youssefi, Ed.D, and Arousha Youssefi Sensory-Motor Integration (SMI) is a multifaceted approach developed by the authors to enhance the quality of movement and motor planning for children with special needs. This chapter describes the SMI approach as well as its methods of assessment and intervention. This material is intended to serve as a guide for parents and professionals who seek new methodology for instructing movement in children with special needs. SMI can be best described as a multisensory approach to addressing learning needs of children who have been diagnosed primarily with developmental delays, autistic spectrum disorders, hypotonia/motor delays, and apraxia, among other diverse clinical diagnoses related to early childhood development. By incorporating visual- and audio-motor perception, kinesthetic awareness, laterality, directionality, haptic perception, and vestibular stimulation, SMI enables children with special needs to sequentially and successfully acquire motor capabilities and motor planning. The goals of the SMI approach are to: Enhance the childs quality of movement and motor planning. Expose the child to a multisensory milieu that will strengthens his relationship with the world around him. Incorporate perceptual-motor activities to improve visual-motor, audio-motor, and spatial awareness.

To achieve these goals, SMI builds upon two basic concepts: a child (1) learns to move, and (2) learns through movement. The fundamental difference between these two concepts is very important. Learning to move involves continuous development in a childs ability to use the body effectively and joyfully, with increasing evidence of control and quality in movement. It involves the growing ability to move in a variety of ways, in expected and unexpected situations, and in increasingly complex tasks. Learning through movement implies using movement as a means to an end, but the end is not necessarily the end of improvement in the ability of the child to move effectively. It is a means through which a child may learn more about herself and about her environment. It is not enough to assume that movement control and skill development will automatically occur for all children simply by virtue of having experienced a movement task: the challenge is far greater than this. To imply that a child may not improve and extend the range of quality in her movement as she tries to express feeling through movement is not to


ICDL Clinical Practice Guidelines

say that she will not. The learning environment must make it possible. Consequently, it is essential for therapists to know what they hope to accomplish both in and through movement as they plan for this learning environment. In other words, to know what is possible, therapists must know the child and know movement. MOVEMENT: THE BASICS A number of clinicians have observed the importance of movement to the larger goal of integrating different mental processes. For example, it has been observed that, through movement, individuals have greater access to thoughts and emotions and can better translate them into a language of action. It is this expression that creates intelligence and individuality. Hannaford (1995) hypothesized that Every time we move in an organized manner, full brain activation and integration occurs, and the door to learning naturally opens. Recent research has suggested that two areas of the brainthe basal ganglia and the cerebellumwhich are associated solely with control of muscle movement, are also critical to coordinating thought. These areas are connected to the frontal lobe, where subsequent motor planning and reaction time occur (Humphries, 1990). Neuropsychological functions relate to movement and are extremely important in how the child will feel about himself emotionally, as well as interact with, and learn from, his social world. For example, problems in motor planning and sequencing (stringing together a set of motor responses) not only lead to frustration and lowered self esteem in a child, but may also impair a childs further brain and social-emotional development, including: Play with parents and peers. When a child cannot maintain reciprocal motor responses with others in a play game, the

result is dysynchrony, or the child being out of sync. Exploration of the environment, which leads to a sense of ones body and a sense of self, and the ability to distinguish reality from ones imagination. Mastery of separation anxiety, and control over his body environment.

Furthermore, these children frequently have temperaments that are immature, demanding, needy, oppositional, and defiant. These qualities, in addition to the childs movement difficulties, will further strain the childs relationship with her parents, who may already have their own stresses, such as marital problems or financial difficulties. Parents may then respond negatively, leading to a vicious cycle of constant tension and negative interactions between child and parent. The consequences of this negativity may be seen in temper tantrums, emotional outbursts, control and power struggles, and other adversarial behaviors. By the age of 2 or 3, children can begin to manifest the beginning of certain developmental pathways, placing them at risk for specific problems later in development. An awareness of these patterns allows a therapist to intercede with early identification of at-risk children, early treatment interventions, andvery importantly prevention. There is conclusive evidence that school programs for preschoolers with learning disabilities are working by preventing future learning failures. The SMI approach stresses the importance of a multisensory approach that stimulates two or more sensory apparatus each time a child attends a therapeutic session. The typical SMI candidate ordinarily exhibits several of the following characteristics: low muscle tone, delayed speech, poor motor planning, poor body awareness, and a fear of heights.

Chapter 21. Sensory-Motor Integration: A Perceptua-Motor Approach for Enhancing Motor Planning in Children with Special Needs


SMI attempts, in each therapeutic session, to encourage the child to perform activities that she has not been able to accomplish elsewhere. We allow her to engage in activities that demand rapid and frequent left brainright brain communication, and make certain the child is exposed to situations where she is able to express herself freely and creatively, stimulating many new avenues of the nervous system. Activities that involve height, speed, excitement, courage, and revolution activate many different parts of the cerebral cortex, causing never-before-stimulated parts of the brain to wake up! (Youssefi, 1987). The critical link between brain activity and movement has been a curiosity to scientists for many years. Scientists have long recognized that children who skip the critically important crawling stage may exhibit learning difficulties in the future school years. The motor act of crawling activates development of the corpus callosum. Performing cross lateral movements, like crawling, stimulates both sides of the body to function in unison. With equal stimulation of the two hemispheres, the senses actively access the neural pathways, which allow both sides of the body to move together in an integrated fashion for more efficient movement (Hannaford, 1995). THE IMPORTANCE OF THE INDIVIDUALISTIC SENSORY-MOTOR INTEGRATION APPROACH In addressing the childrens mental health needs as well as their physical and emotional well being, SMI creates an environment for learning that addresses the specific learning deficiencies of each individual child. SMI, in conjunction with other essential developmental therapies, aids in sensory-motor processes such as reading, writing, language development, cognition, social awareness, kinesthetic awareness, and self-concept. The difference

between the SMI approach and other distinct therapeutic approaches lies primarily in the implementation and lesson planning procedures. It is based on the belief that children surmount insurmountable tasks through the knowledge of and exposure to multisensory activities that are designed specifically to meet individual needs. It is imperative for children to be exposed to and explore each and every aspect of the sensory milieu in order to be proficient in their learning processes. Thirty years of experience with children with special needs and with movement has led to the formation of a few basic principles for SMI, which are: Children perform more efficient motor planning when given the opportunity to explore diverse movement settings. Children with special needs need to engage in integrated activities in order to improve multifaceted learning deficiencies. Affect-driven responses can be attributed to a childs interest and sensory-motor needs. Therapists involved in the childs treatment program play a critical role in motivation and encouragement. FORGOTTEN PERCEPTUAL-MOTOR AND SENSORY EFFICIENCY THEORIES Motor therapy specialists and perceptualmotor pioneers discovered many links between movement and learning. Unfortunately, their contributions and hypotheses have long been overlooked and unappreciated. The lack of demand for perceptual-motor theory and a lack of educational curriculum for the field has buried many important concepts and methodologies. Research by many theorists supports the principles behind the integrated SMI approach. Raymond Barsch (1967) explored the educational needs of children whose


ICDL Clinical Practice Guidelines

problems in learning did not lend themselves to precise and neat categorization. Barschs theory of movigenics depicted the origin of development of patterns and movement in man and the relationship of those movements to his learning efficiency. Barschs primary concern was the developing child and his problems in achieving a mature adult status. The backbone of Barschs movigenics was the concept that physical and cognitive movements are inseparable. Barsch based his theory on the concept that Man moves. Man learns. He learns to move. He moves to learn. This concept helps to describe problems confronted by children in static classroom and learning environments. Barsch, therefore, linked the necessity of developing mature movement patterns to proper cognitive processes, which would lead to success in learning environments. Newell Kephart further advanced the theory of perceptual-motor development and its impact on academic potential. In his now classic book, The Slow Learner in the Classroom, Kephart (1960) stated that in order for learning to take place effectively, perception and movement had to be coordinateda process that occurred through a wide variety of sensory experiences and movement opportunities. As a result, movement and perception had to be integrated and function simultaneously (Arnheim & Sinclair, 1975). Getman, an optometrist who believes visual perception could be developed through motor training, analyzed perceptual-motor development and its component parts. According to Getman, perception is a process through which an individuals sensory skills translate reaction to the environment into physical movement. An individuals perception of her environment serves as a blueprint for her subsequent motor tasks. Perception includes the integration of visual, auditory, and tactile functions.

The interdependence between perceptual and motor skills is a priority for the SMI methodology and for childrens academic and social success (Youssefi, 1987). A child with special needs may inefficiently integrate these perceptual-motor skills. To address this need, Jean Ayres analyzed central nervous system processes and their impact on learning (Ayres, 1979). Her theories of sensory integration described how the child used the input of the eyes, ears, and body to acquire information from the outside environment to help make sense of it. According to Ayres, the brain must organize all sensations to learn in order to behave normally. Exposing children to tactile stimulation, vestibular stimulation, and motor activity stimulates and involves portions of the brain stem. With the information from the sensory system, a child can perceive and learn on a progressive level. Bryant Cratty (1969) developed his concept of adaptive physical education to address the needs of children who required special services. Cratty stressed the importance of the motivational levels of children when learning in academic and nonacademic settings. Cratty believed a childs inability to perform motor tasks could lower his selfesteem as well as his acceptance by peers, which could adversely affect motor and cognitive processes (Arnheim & Sinclair, 1975). The SMI methodology uses the frameworks established by these pioneers and others. It has, however, sought to systematize the work of various pioneers into a practical, individualized approach that can help children integrate the most critical motor and sensory processing capacities. With these concepts as background, the following section explores the SMI approach in detail.



MOTOR DEVELOPMENT The observable course of motor development in humans begins about 71/2 weeks after conception when, for example, the fetus flexes its head laterally away from stimulation in the lip region. By week 81/2, this isolated avoidance response has radiates into patterns of movements organized in space and time. Simple lip stimulation now elicits contra-lateral flexion of the neck and trunk, extension of the arms at the shoulders, and rotation of the pelvis away from the side of stimulation. The earliest patterns of motor behavior appear to be genetically coded in the species; that is, humans have some initial organization or template that guides the pattern of new formations. In addition, there are some operational rules that lead to patterns of behavior. Variable changes in these patterns are accounted for by the particular conditions of individual experience (learning). The study of motor development is concerned with the factors that influence motor behavior, the design of experiences that will result in desirable changes in behavior, and the influence of this learning on the capacity of the individual for future development (Thomas, 1984). As a child grows, expectation of more mature movements increases proportionally. Movement becomes symbolic of life and existence. Movement is the sole manner of the physical expression of intelligence. It is believed that movement as the important expressive aspect of the human personality has great potential for use in educational programs for the child with special needs. However, motor activity constitutes only a component of the human personality. Numerous distinct modalities accompanied by, or exclusive of, overt action are also brought into use as the human infant and adult deal with their worlds (Cratty, 1969).

Similar to building blocks, there are graduated levels of motor development and motor planning originating from fundamental sensory-motor development. Children should complete patterns at every stage of development before they can efficiently carry out a more complex pattern. If a child misses a critical developmental stage, if he lacks the link from one pattern to the next, he will show evidence of problematic motor performance. The following behaviors may be indicative of a disintegration of senses and of gaps in motor development: Poor coordination Poor awareness of time and space Poor visual judgement Clumsiness Poor rhythm Poor flexibility of movements Poor handwriting Difficulty maintaining balance Motion sickness Kinesthetic and tactile defensiveness Fear of velocity Fear of inversion Fear of heights Fortunately, delayed reflexive activity, which is indicative of poor sensory-motor development, can be detected at an early stage. Within the first few months, a parent should be able to identify certain motor patterns their infant has displayed or skipped. Table 1 describes the expected movement pattern of a growing child. To reach and enjoy full motor maturity, the infant must receive the constant stimulation that comes from experiencing a rich variety of stimuli. However, if the interactive environment has excessive visual or auditory stimuli, sensory overload will occur and hinders the natural course of development. Incorporating the sensory systems into learning has an enormous impact on delayed and


ICDL Clinical Practice Guidelines

Table 1. Expected Movement Patterns of Growing Children

Age Newborn-12 weeks Expected Movement Pattern Predominately reflexive Flexion of knee and hip when soles of feet are pricked Head flexes laterally towards source of stimulation Head is held erect and steady Rolls front side to back Reaches for hanging object Grasps hanging object Rolls from back to side Sits alone Transfers object from one hand to the other Crawls purposefully to get from one place to the next Homolateral pattern of crawling observed Creeps on hands and knees Cross-lateral pattern of creeping observed Pulls up to a standing position Follows simple commands Picks up food with hands and attempts to self-feed Copies simple movements Stands alone Grasps and releases object Walks alone Uses hands and fingers to explore space (under, over, beneath, across) Uses hands and fingers to push and pull objects Changes directions Awareness of force distribution increases (stroking vs. striking) Maneuvers efficiently about objects Proficient pincer grasp Crawls up stairs efficiently Plays peek-a-boo Runs Spins about central axis by taking small steps in a circular pattern Bounces, with both feet simultaneously lifting off the ground Slides sideward Walks backwards Runs and stops on verbal command Premature under arm throw Rolls down an incline Performs inverted somersault Jumps from a 12-inch elevation Balances on 8-inch walking board Proficient grasping and hanging Jumps from 18-inch elevation Performs somersault on flat surface Walks on balance beam with 12-inch elevation Bounces efficiently on trampoline, maintaining balance Throws object over arm Dodges oncoming objects efficiently

15 weeks 7 months-8 months

9 months

11 months 12 months

14 months

16 to 18 months 24 months 32 months

3 years



autistic spectrum children. Stimulation of the sensory system and motor performance is influenced both by physiological conditions and by the dynamics of the learning environment. Special education professionals suggest a variety of social and personal traits will be enhanced as a child interacts with his learning environment. Essential to cognitive, social, emotional, and physical development is the interrelatedness of perceptual-motor processes, motor delays, hypotonicity, sensory-motor integration disorder, and audio-visual perception difficulties. The SMI approach to integrating

higher neural functions maintains that certain elements of movement and perception are essential to establish a network of neural pathways that interrelate, and to enhance communication of the left and right brains. These elements improve limb articulation, dominance, depth perception, body and space awareness, balance, and general coordination (Arnheim & Sinclair, 1975). Locomotion, balance, non-locomotion, kinesthetic awareness, visual-motor perception, and audio-motor perception are areas of main intervention by a SMI therapist (see Table 2).

Table 2. Areas and Elements of Sensory-Motor Intervention

Area of Intervention Locomotion SMI Elements


Nonlocomotor movements

Kinesthetic awareness

Visual-motor perception

Audio-motor perception

Physical fitness

Rolling Crawling Creeping Walking Hopping Static balance Dynamic balance General balance Throwing Catching Batting Kicking Laterality Directionality Body and space awareness Haptic perception Tactile perception Airborne activities Velocity modulation Eye-hand coordination Eye-foot coordination Fine motor visual planning Fine motor coordination Following verbal commands Beat discrimination Coding and decoding auditory cues Move to cadence Static strength Dynamic strength


ICDL Clinical Practice Guidelines

CASE EXAMPLE: SMI IN PRACTICE The following example presents the preevaluation, evaluation, and remediation procedures conducted for Sam, a 51/2-year-old child diagnosed with autistic spectrum disorder. Pre-Evaluation Because SMI training is an educational, progressive intervention program, it is most beneficial to children who can at least minimally respond to an educational environment. Due to a childs natural tendency to enjoy movement, the child who does not make eye contact soon finds in SMI an avenue of interest through which the therapist can become a part of his world and engage him in reciprocity. In Sams case, he was told to walk next to the therapist and follow him to the other side of the room. Sam was hesitant at first, but then followed. When the therapist initiated a game of catch, Sam had no awareness of the object that was being thrown and was unable to continue the game. Next, Sam was instructed to stand on an box elevated 2 feet off the ground. Sam was extremely uncomfortable with the situation. As Sam kicked and screamed, the therapists removed him from the box and his mother comforted him. Sam refused to detach himself from his mother after that point. Throughout the entire pre-evaluation procedure, he demonstrated extreme fear of heights and would not allow his mother to leave the room. However, because Sam was able to follow simple directions and make minimal eye contact, he could benefit from SMI intervention. Evaluation and Assessment After the informative pre-evaluation, the child undergoes a full evaluation procedure,

which is videotaped and later reviewed for detailed analysis. In a full evaluation, the child is separated from his caregiver and asked to perform certain skills based on the specifications of his age and diagnosis. The following evaluation is a modified version of an SMI assessment, which was used with Sam. As with all children, Sams movement skills were tested in several important areas. Directions for conducting each test, as well as observation questions, are included. Locomotion Log roll. Tell the child to roll like a pencil, either on a mat or down an incline. Observations: Do the body parts move together in one line? Crawl. Let child crawl under an object, telling him to crawl like an alligator. Observations: Look for homolateral body movement. Does the elbow meet the knee on one side while the other side of the body is straight? Does the head tilt to the side of the body that is flexed? Bounce. Instruct the child to bounce, lifting both feet off the ground. Observations: Do both feet leave the ground simultaneously? Is balance kept throughout bounce? Are arms down by his side or do they jerk? Hop. Instruct the child to hop on designated spots, eight hops on each foot. Observations: Is balance maintained easily? Does the child tire easily? Can the child perform hopping task with both feet?



Slide. Demonstrate sliding. Instruct the child to follow. Observations: Is head at midline? Are arms swinging easily? Is there planning of distance and direction? Are arms, head, and trunk involved in coordination? Static and Dynamic Strength Grasping. Instruct the child to hold onto a bar for 10 seconds. Observations: Does the head stay in alignment? Does grasp appear weak? Is the child able to perform the task without assistance? Leg lift. Instruct the child to lay on back and lift both legs 10 inches off the ground. Have the child hold legs off the ground for 10 seconds. Observations: Are both feet easily held off the ground? Is contraction equally distributed? Flexibility. Instruct the child to sit in a straddle position. Ask him to touch his elbows to the floor and/or forehead to the floor. Observations: Does the child perform a straddle sit? Does the child perform task with straight legs? Do elbows reach the center? Hamstring. Instruct the child to sit in a straddle position. Ask him to touch his elbows and/or forehead to the floor. Observations: Does the child perform the task with straight legs? Do elbows reach the center? Lower back. Instruct the child to perform an L shaped sit. Ask the child to touch his toes.

Observations: Does child perform L sit comfortably? Does the child touch toes with ease? Are knees kept straight? Back. Instruct the child to lie down in a prone position and hold his ankles. Observations: Does the child perform task with ease? Does his back contract to achieve an arch up position? Balance Balance board. Instruct the child to stand on balance board and try not to shift back and forth. Observations: Does the child maintain balance? Is force distributed evenly from both feet? Does head remain at midline? Are both sides regulating weight shift? Walking on 4-inch surface. Instruct the child to walk on a 4-inch-wide balance beam. Observations: Does the child walk heel to toe? Do feet alternate? Does the child perform task with hesitation? Walking on incline. Instruct the child to walk uphill on an incline. Observations: Does the child utilize his whole foot? Is weight shift smooth? Is balance maintained easily? Do eyes follow path? Do legs provide adequate balance? Walking down declined elevation. Instruct the child to walk down a 3-foot elevation. Observations: Do legs provide adequate balance? Do eyes follow path?


ICDL Clinical Practice Guidelines

Is child running to avoid controlled posture? Is changing directions done with ease? Are feet alternating?

Non-Locomotion Catching. Instruct the child to toss and catch large, medium, and small balls. Observations: Do the eyes follow the object? Does the body move in space to receive the object? Does the body shift weight as needed? Throwing. Instruct the child to throw a small ball to a target that is placed 5 feet from eye level. Observations: Do the eyes follow the object? Are both sides involved in throwing? Which is the dominant arm? Are shoulder joints loose? Does the child step into the task? Batting suspended ball. Instruct the child to strike the suspended ball with a large bat. Observations: Do the eyes follow the object? Does the child strike the ball with at least 50% accuracy? Is balance maintained? Is there planning of distance and direction? Are arms, head, and trunk involved in coordination? Visual-Motor Perception GMS balancing tube. (This tube is similar to a builders level, which has a bubble that moves left or right from a midpoint depending on slope. When the level is balanced, the bubble centers at the midline.) Instruct the child to hold the tube with both hands and try to roll the marble to the middle, between the red lines.

Observations: Does the child distribute force evenly throughout? Do the eyes follow the marble? Is motor planning adequate? Balloon paddling. Instruct the child to keep the balloon from hitting the ground. Ask him to count how many times he can strike the balloon. Observations: Do eyes follow the object? Are arms, head, and trunk involved in coordination? Is balance maintained easily? Running through hoops. Instruct the child to walk through a series of hoops. If the child walks without difficulty, ask him to run. Observations: Is running performed at an even speed? Is one foot placed in each hoop? Is running done while alternating feet? Does the child start and stop on command? Tracing using a flashlight. Provide an elevated surface on which the child can stand. Instruct the child to trace the designated lines with a flashlight. Observations: Do the eyes follow the light? Are wrists coordinated with arms and fingers? Is there planning of distance and direction? Is task performed with 50% accuracy? Evaluation Results and Lesson Planning Upon completion of the evaluation procedure, the videotape was reviewed and a lesson plan for Phase I of Sams therapy was



devised. The results of the evaluation, by assessed area, follow. Locomotion Sam, at 51/2, had the motor proficiency expected of a child at age 2 years, 3 months. The test of locomotor skills revealed his ineptness in large and small muscle control, a lack of communication between left brain and right brain functions, and the inability to produce effective motor-planning sequences. Locomotion Intervention and Lead-Up Drills. The following activities were selected to enhance Sams ability to utilize his upper and lower extremities and improve locomotor skills. Log roll. The child lies on his back with his shoulders positioned on a line, body fully extended, feet together, arms flat to the ground above his head. One therapist takes the left arm over the right arm in a crisscross manner, while a second therapist takes the left leg over the right leg in the same crisscross fashion, and proceeds to roll the child. Each time the child makes a full revolution of the body, he must become reoriented to the horizontal plane. The head first turns in the direction of the roll, followed by the hips. The trunk is twisted, the shoulders lifted, and one thigh rotated inward and over the other thigh. In this manner all segments of the body are aligned and maintained in good control. When the child is able to roll effectively in one direction, then rolling in the other direction should be attempted. Crawl. Crawling is a natural extension of rolling. Like rolling, crawling provides the physically clumsy child with security because the body is fully in contact with a surface. The child moves along the floor in a prone position by various movements of the

arms and legs. Each crawling task must be executed in the proper form before the next higher-level skill is attempted. Crawling is attempted in an amphibian fashion by moving the arm and leg on one side of the body in unison and then moving the limbs on the opposite side. The head should be turned toward the side on which the limbs are flexed. One therapist bends the child left arm, and bends the childs left leg so the elbow meets the knee. A second therapist holds the right arm and right leg, creating a straight line from the right hand to the right foot. One therapist counts 1-2-3 and manually alternates extended and bent positions. Bouncing. The ability to propel the body upward from a supporting surface requires much strength, balance, and coordination. To efficiently produce the correct pattern of bouncing, the child must distribute force equally between the right and left sides of the body. Modification of bouncing can be performed on a trampoline or mini trampoline. If the child has no pattern of bouncing, a therapist must stand behind the child, hold his hips, and initiate the motor act of jumping. Hop. The motor act of hopping requires static and dynamic balance, dynamic strength, and motor planning. The child must be able to stand on one foot to perform the act of hopping. Once he has mastered balancing on one foot, he will be able to proceed to the next level, hopping with support. A therapist stands behind the child, holding the childs left leg behind him and his right arm forward to initiate hop direction. As the therapist proceeds to walk forward, the child will reflexively want to maneuver forward, hence initiating the hopping task. Once the child has mastered this task, he will be able to perform hopping on an adaptive surface (e.g., springboard or minitramp).


ICDL Clinical Practice Guidelines

Static and Dynamic Strength The awkwardness in motor activity of children with special needs can be attributed to below-average motor fitness because motor ability and fitness are mutually dependent. Sam exhibited below-average muscle tone and tested at a proficiency level of a child of 3 years, 5 months. He had trouble maintaining balance and posture throughout the evaluation. Sam was only minimally able to perform static and dynamic strength activities. Sam could not sit in a chair without tiring, was unable to maintain his posture while walking, had no concept of hanging, and was completely unable to utilize fingers and wrists to hold a pencil. The following remediation procedures were devised to treat Sams lack of static and dynamic strength. Static and Dynamic Strength Intervention and Lead-up Drills Arm hang. Arm hanging is used to determine the efficiency of grasping ability. An average 51/2-year-old boy should be able to hang for 10 seconds or longer. A proficient arm hang suggests adequate strength of the shoulders, wrists, and forearm. The ability to hang from a bar, being suspended in the air without any support, involves regulation of the vestibular and proprioceptive systems. The therapist starts with a stick, 4 inches in diameter, with two lines drawn where the child should place his hands. The therapist raises the stick up and down until the child begins to support his own weight. Once the child feels comfortable with the stick, the therapist leads him to a bar with a 4-foot elevation. He holds the childs feet until he is comfortable hanging without support, making certain that the childs grip is correct. The whole palm of the childs hand should be in contact with the bar. Arch up. A modified pushup is a significant method for examining arm and shoulder

strength and muscle endurance. The child assumes a prone position with fingers pointed laterally away from him; legs are extended and relaxed. The child should then straighten both arms simultaneously to produce a seallike position. Abdominal and trunk strength. To improve upper abdominal muscle strength and endurance, the child should perform abdominal curls. The child assumes a supine position with knees bent, feet flat on the mat and arms folded across chest. The child lifts his head up until his chin touches his chest, rolls both shoulders forward, and lifts his back from the mat so that he comes to a full sitting position. Since Sam was not interested in performing this drill, the therapists modified it to create a more interactive approach to boring sit-ups. The therapists laid 10 beanbag animals on the floor directly behind Sams head. Sam would reach back and pick up a beanbag with both hands, and then sit up and shoot it in into a target. This allowed him to practice projectile management (throwing) while developing abdominal and trunk strength. Flexibility Flexibility refers to the capacity to move a particular joint in the body through its range of motion. A full range of motion of the hip flexor allows the child to crawl effectively; a full range of motion of the shoulders and wrists allows the child to explore the world of creative shapes and its relationship to body awareness. Sam exhibited extremely poor flexibility. The simple act of tying shoes was a motor disaster. When he sat on the floor to remove his shoes, his hands barely reached his toes. The position was extremely tiresome for Sam. After 2 minutes of reaching and struggling, he gave up and asked his mother for help. Crawling was problematic because of lack of flexibility in the lower trunk



region. Consequently, activities to improve Sams hamstring and trunk flexibility were of high priority. Flexibility Intervention and Lead-Up Drills Hamstring. The child sits on the mat with legs extended away from each other and toes pointed. The child tries to touch both elbows to the space created by the v shape position. Balance Balance is defined as the ability to maintain equilibrium while engaging in various locomotor and nonlocomotor activities. There are three basic categories of balance: (1) static balancethe ability to maintain a specific position for a given amount of time, (2) dynamic balancethe ability to control the body in motion, and (3) object balance the ability to support some external objects without letting it fall. Sam suffered from severe vestibular dysfunction as well as an excessive fear of elevated surfaces. Sam was unable to perform the simplest of balance tasks. When asked to walk across a balance beam with a 4-inch width, he walked with one foot leading the other, a behavior below his expected age proficiency. In fact, for static and dynamic balance, Sam tested at a 23 months of age level. The top priority for his lesson planning was to help him get over the fear of elevated surfaces and familiarize him with revolution and velocity. Balance Intervention Implementation and Lead-Up Drills Balance board. The therapist instructs the child to stand on a balance board and maintain his balance. Level 1:The child may use the wall or a bar for support as the therapist stands behind the child and holds his knees. The child needs

to have an idea of what the correct manner of balancing feels like. Level 2: The child uses therapist as support. Level 3: Child stands alone. Level 4: Child stands on balance board while catching a medium-size ball. Walking across a 4-inch-wide balance beam. The therapist should be positioned in such a way that he can easily give verbal directions and can spot the child when it is necessary. The child should hold all balance postures for 10 seconds. While balancing on a 8-inch side of the balance beam, the therapist instructs the child to: stand heel to toe, right foot in front of left, hands placed on the waist, stand heel to toe, left foot in front of right, hands out to the side, stand on left foot with arms crossed, stand on right foot with arms crossed, walk along the balance beam heel to toe, and then walk backward heel to toe. Walking up an incline. For this exercise, an elevated square is placed on a mat-covered surface, with one side of an 8-inch beam placed on the elevated square to create an uphill slope. The slope should be no more than 30 degrees from the floor. Level 1: The child creeps up the beam to adapt to height of elevation. Level 2: The child walks up the beam with one foot leading with support. Level 3: The therapist places beanbag buddies at increasing higher levels to indicate how high child should go (e.g., Sam, go up and say hi to Mr. Alligator). Level 4: Two therapists hold the childs hands and briskly walk him up the beam. (This helps the child walk with alternating feet.) Level 5: The child goes up the incline by himself.


ICDL Clinical Practice Guidelines

Walking down an elevated surface. Walking down an elevated surface involves tremendous strength as well as balance. The child must be able to control his speed as he walks down the beam. (Running down the beam is a good indicator of lack of visual-motor perception and static balance.) For this exercise, the therapist places a beam on an elevated surface to raise it 30 degrees from the ground, with the 8-inch side up. The therapist places dominoes or beanbag buddies on the beam about 1 foot apart from one another and asks the child to either count the dots on the dominoes or talk about the beanbag buddies as he steps over each object. This task will allow the child time to balance while he counts the dots or names the animals. Nonlocomotor Skills It is developmentally and socially important for a child to succeed in performing skills that consist of propelling and retrieving various objects. The child tends to receive a tremendous amount of self-gratification and praise from peers. Conversely, the child with special needs may lack the eye-hand or eye-foot coordination necessary for effectively managing objects in play. Nonlocomotor skills are motor tasks involving force application, reaction time, and visual judgment. Sam had severe visual-motor impairment and subsequent focal failure. In addition to the lack of visual acuity, Sam had no concept of reciprocity and had no interest in engaging in any catching, throwing, or batting tasks. Towards the end of the evaluation, Sam began to engage in several bouts of catching and throwing. A main priority for lesson planning was to enhance his awareness of reciprocity and reaction time. Nonlocomotor Intervention and Lead-Up Drills Catching. Catching is a reflexive activity proficient in a child by the age of 3. It

involves awareness of time, space, and use of legs to aid in the catching task. When using the skill of catching to improve visual-motor planning, the therapist should stress the fact that the eyes must remain open and watching the ball at all times. The thought of catching induces fear in many children. To minimize the anxiety as much as possible, a light plastic or rubber ball approximately 9 inches in diameter should be used at first. Level 1: Place a hula hoop in front of the child. Ask him to toss the ball around eye level and let it drop into the hoop. The task is to toss the ball and have a designated area for it to drop in. Level 2: Move the hula hoop 8 inches from the childs feet, and ask him to toss a medium-size ball, about 6 inches in diameter, and let it drop to the ground. Level 3: Instruct the child to toss the medium-size ball and catch it. Level 4: Instruct the child to toss a small ball, about 4 inches in diameter, and catch it. Throwing. Throwing is a skill that involves the release of an object with one or both hands in one of three basic patterns: (1) underarm pattern, (2) side arm pattern, and (3) overarm pattern. It also is a motor act that demonstrates the physics principle of a summation of forces as the total force of all the muscles and levers in the body move in a sequential pattern. Since the object is controlled by the speed and direction of the hand doing the throwing, improving a childs throwing ability requires the therapist to consider methods for developing speed and controlling the direction of the hand movement. It is imperative that each child be afforded ample opportunity to handle a variety of projectiles. In Sams case, the therapists used small balls that were projected toward a target. Level 1: A child who has no throwing pattern should start with a large rubber ball, 9 inches in diameter. The therapist should



start with underhand rolling. When object rolling is being taught, the child should lower his body by bending his knees with the back straight and head lifted. Level 2: The childs hands are placed on opposite sides of the ball with palms facing each other and fingers apart and pointing down. The ball is held in front of the body. As his arms swing forward, the child should flex his knees and release the ball onto the ground by extending his elbows and wrists. Level 3: The child uses two hands to throw the ball underhand. Level 4: The child performs a two-hand chest pass. Level 5: The therapist places the childs feet in a stride position, opposite to the dominant throwing hand. The therapist should hold the childs dominant hand behind the corresponding ear and then guide the childs arm forward to perform a throw into a target. Visual-Motor Perception One of the most important factors that links vision to movement is postural fitness. Posture is the primary pattern of movement on which all other patterns are based. Problematic visual perception may cause the child to exhibit poor and unstable posture. It is invariably found that children with movement problems are unable to integrate movement with vision. They also are unable to make accurate movements with their upper and lower extremities with adequate control. Sam tested extremely below age level in the area of visual-motor perception. He constantly tripped over objects and bumped into obstacles that were in his way. His poor posture resulted in an extremely limited span of visual stimuli. He could only interact with the area immediately around him. Sam was able to make minimal eye contact; however, the therapist had to stand right in front of him and hold his chin for 10 seconds

before any eye contact was achieved. Sam had no scope of vision above that of his eye level. His lesson plan would surely include maximum visual-motor perception at a very basic level. Visual-Motor Perception Intervention and Lead-Up Drills Balloon paddling. Level 1: The therapist allows the child to play with a balloon. The therapist instructs the child to try to keep the balloon off the ground as long as possible, counting each time the child hits the balloon. If the child cannot follow the balloon, the therapist must bat the balloon back and forth to the child until he can perform the task without help. The therapist instructs the child to keep his eyes on the balloon. This drill for increasing visual-motor perception allows the child to expand his visual field: for children who have difficulty looking up, balloon paddling exposes them to the wonderful world of up! Level 2: The therapist uses two paddles one red and one yellowand instructs the child to alternately hit the balloon once with the red and once with the yellow, while correctly saying red, yellow, red, yellow in time to the hits. This activity promotes verbal feedback and allows verbal processing to occur at the same speed as the action is proceeding. This task involves significant visual-motor planning. Level 3: The therapist uses two paddles and two balloons and asks the child to keep the two balloons within reach. Running through obstacles. If the child hits the hoops as he runs through them, the therapist uses the following lead-up drills: Level 1: The therapist places colored dots on the ground and asks the child to walk across the river by way of the stones. Telling the child to keep his feet dry and out


ICDL Clinical Practice Guidelines

of the water will help the child understand the concept of taking big steps. Level 2: The therapist places the hoops around the colored dots and asks the child to walk across the river and not touch his foot to anything other than the dots. Level 3: The therapist lays 10 hula hoops on a matted or carpeted surface and instructs the child to walk through the hoops without hitting the edges. If the child is placing two feet into each hoop, the therapist asks him to try to place only one foot in each hoop. Level 4: If the child can walk through without touching the edges of the hoops, the therapist asks the child to run through. (By age 51/2, the normally developed child runs through with 90% accuracy.) Flashlight tracing. Tracing shapes and lines with a flashlight improve handwriting and visual motor accuracy. Therapists try the following lead-up drills if the child is not proficient in tracing with a flashlight. Level 1: The therapist draws a figure on a dark surface so that the child can stand on a elevated surface and be directly above the drawn figure. The child flashes the light at the start position and travels in between the drawn lines until he reaches the finishing line. Level 2: The therapist draws a figure that incorporates the shapes of the alphabet, circles, half circles, straight lines, slanted lines, and zigzags. She traces the line and instructs the child to superimpose his light over the therapists light. The two lights travel together until their lights reach the finish line. Level 3: The therapist draws the same figures as in Level 2, but the child alone uses a light to trace the figure to the best of his ability. (A typical 51/2-year-old boy should be able to stay on the line for 90% of the figure.)

Audio-Motor Perception Children with special needs usually have difficulty processing auditory information as a result of a dysfunctional vestibular apparatus or structural deformities, which occur in the ear. The SMI technique of integrating auditory and motor perception provides the child an opportunity to connect auditory organization to movement that he already knows. Thus, pattern recognition, force application, and reaction time improve tremendously. Sam was a relatively average listener. He followed simple verbal commands; however, he could not react to them in an organized fashion. Audio-Motor Perception Intervention and Lead-Up Drills Drum activities. The therapist sits directly in front of the child and holds a buffalo drum, making sure the child imitates the position. The child tries to copy the therapists rhythm. Level 1: The child says how many beats the therapist is making (the therapist should not exceed 2 beats initially). Level 2: The child copies the number of beats the therapist played. Level 3: The child plays soft like a mouse, then loud like an elephant. Level 4: The child plays two loud beats, followed immediately by two soft beats, creating a pattern of BAM-BAM-bum-bum. Sound localization. This is the ability to determine the direction of sound. The following activities are lead-up drills to improve a childs sound localization. Level 1: The therapist stands behind the child and rings a bell, twice on the right and then to the left. The child points to the direction from which the sound originates. Level 2: The therapist blindfolds the child and asks him to follow the sound of the therapists voice and try to catch him. Where am I, Sam? Catch me! Although the child



should be challenged, the therapist should not allow the child to fail, but allow the child to catch him. Agility, Speed, and Body Awareness The child with special needs, whose problems include poor body perception, often has difficulty moving effectively in space. Bumping into obstacles and dropping things are indicative of poor body and space perception. Sam had marked trouble with body awareness. During the evaluation, Sam exhibited a lack of mental imagery and acquisition of body boundaries. He was unaware of his body in space, he did not want to be airborne. Sam was uncomfortable with velocity and heighthe would tremble at the very thought of swinging or hanging. Agility, Speed, and Body Awareness Intervention and Lead-Up Drills Running through poles. This is a drill used to increase body and space awareness. Ten poles, each about 5 feet high, are placed on a carpeted area in a straight line. The child runs through the poles in a zigzag fashion (similar to how a slalom skier races). A drawn path gives the child a visual cue of where to go. There is always a start and a finish line. Swinging in octagon. A suspended octagon should be placed 5 feet above a matted area. The child sits in the donut, holding the handles, legs straight in front of him (see Figure 1 for a picture of an octagon). Level 1: The therapist swings the octagon back and forth. Level 2: The therapist swings the octagon left and right. Level 3: The therapist swings the octagon in a circular manner, first slowly, then gradually increasing the speed.

Figure 1. Child in an Octogon Rolling in Octagon. Place the octagon on a matted area. The child lays on his back inside the octagon and holds onto the handles. Level 1: The therapist holds the child inside the octagon as he rolls the octagon back and forth. Level 2: The child lays on top of the octagon in a prone position. The therapist holds him by the legs and rock him back and forth, then left and right Level 3: The child gets inside the octagon and hold his legs straight onto the walls of the octagon. The therapist rolls the child all the way around, holding one hand on his legs to push them to the walls of the octagon, and having one hand free to roll the octagon. Laterality Laterality is defined as internalizing the awareness of the difference between right and left. Sam had no awareness of right and left. His therapists started with very simple tasks to teach the concept of the right side of the body by utilizing many techniques, including the following one.


ICDL Clinical Practice Guidelines

Laterality Lead-Up Drill Visual awareness of left and right via balloon paddling. Using a soft paddle stick with protusions at each end, the therapist marks an L and an R to represent right and left protrusions. The therapist instructs the child to strike the balloon with the left and then with the right protrusions. Multistepped Motor Planning Since Sam exhibited poor balance and coordination, as well as poor visual-motor perception, multistepped motor-planning skills were not a part of his initial lesson planning. However, the following lead-up drills were introduced 6 months after his therapy began. Multistepped Motor-Planning Intervention and Lead-Up Drills Jumping Jacks. Level 1: The child makes angels in the snow, performing X and I positions. Level 2: The therapist draws a picture of an X and a picture of an I on a wall where the child can stand directly in front of it. The child copies the pictures on the wall with his body position, first by making an X, then by making an I position. Level 3: The child performs jumping jacks to a cadence of X 2,3,4, I, 2,3,4. Making knots. Using two pieces of rope (one 3 feet long and the other 2 feet long), the therapist wraps about 3 inches of each end with a different color of tape (e.g., red and gray). Level 1: The child ties a knot with the 3foot rope. The therapist observes the knotting pattern. Level 2: Following a U-shape drawn on the floor with chalk, the child superimposes the U-shape with the 3-foot rope, keeping track of the red-taped end. The red end should represent the childs left hand. Next, the therapist draws two crossing lines in the

middle of the U-shape. The child superimposes the rope over the crossing lines, keeping the red-taped end on the top. Level 3: Using a 2-foot piece of rope that is thinner in diameter than the 3-foot rope, the child performs the same task as described in Level 2, again placing the red-taped end over the gray. The child reaches and pulls the red-taped end to form a knot. This procedure is repeated eight times. Finger-to-thumb taps a good morning ritual. Level 1: The therapist places a sticker on the thumb of the child. The child touches every finger individually to the sticker: the thumb is saying good morning to all the fingers. Level 2: With the sticker removed, the child taps his thumb to each of his fingers. Advanced Multisensory Intervention Drill The following activity requires proficient balance, coordination, audio-motor perception, projectile management, and visualmotor perception. Rhythm response. The child stands on a balance board, holding a 9-inch diameter ball. The therapist stands directly behind the child, holding a drum. The child listens to the number of drum beats and tosses the ball according to the number of beats heard, while maintaining his balance. If the therapist hits the drum twice, the child will perform two tosses of the ball. The task requires the child to integrate the eyes, ears, and vestibular system with gross motor coordination and projectile management. Sams Progress with SMI In the 2 years since Sam started his SMI training, he has made tremendous improvement in every aspect of his therapy. Sam now runs,



jumps, flips, swings, and climbs up a 40-foot spider net! He completely integrates visualmotor and audio-motor perception while performing motor tasks and absolutely loves swingingfast. Sam was selected as the case example for this chapter because he has made significant progress and provides readers a perfect opportunity to understand why. Sam speaks and asks questions, and greets his peers and the staff members with a warm smile every day. More important, he now enjoys the wonderful world of movement. CONCLUSION This chapter presents parents and professionals with a motor therapy program that uses the techniques of the SMI approach. The model presented is to be used in accordance with the concepts previously discussed, including: Academic tasks normally require skill in forming perception, symbol recognition, visual language development, and other motor-perceptual abilities. Practice and training aimed at helping children develop these skills can prevent or alleviate a certain proportion of learning problems. Children with learning disabilities often demonstrate inadequate development of perceptual-motor skills. Preparation for these tasks requires development of general coordination, physical balance, spatial relationships, eye-foot and eye-hand coordination, eye movement control, and sensory perception.

Just as children learn to walk and talk, they must learn to utilize their senses to fulfil motor and cognitive needs. They demand opportunities to examine things in their environment by looking, feeling, smelling, and sometimes tasting them. Through the manipulation of objects and gaining control of their body movements, children are using the sensory-motor process to learn and perform skills that require problem solving. They need to take things apart, discover how they work, and put them back together. They need to identify and relate to the various colors, shapes, sizes, textures, and noises around them. Thus, children learn to make a sensory impression and produce an appropriate motor response. Information applicable to the development of motor skills, sensory processing, and perceptual proficiency comes from a variety of sources including psychology, neurology, anatomy, physiology, physical therapy, occupational therapy, and human development. The goal of the SMI approach is to identify those movement priorities in both objective and expressive functioning that will further abilities best allocated to the motor and perceptual framework, in the psychological, social, intellectual, and physical development of the child. Finally, the concept of SMI factors that make up the intricate system of motor planning should be interwoven with the acquisition of new skills and extended through movement with different environs mental stimuli.


ICDL Clinical Practice Guidelines


Arnheim, D. D., & Sinclair, W. A. (1975). The clumsy child. St. Louis, MO: Mosby. Ayres, J. (1979). Sensory integration and the child. Los Angeles, CA: Western Psychological Services. Barsch, R. H. (1967). Achieving perceptual motor efficiency. Washington, D.C.: Special Child Publications. Braley W. T., Konicki G., & Leedy, C. (1968). Daily sensory-motor training activities. CA: Peek Publications. Cratty, B. (1969). Movement, perception and thought. CA: Peek Publications. Cratty, B., & Martin M. M. (1969). Perceptual motor efficiency in children. Philadelphia: Lea & Feibger. Eckert, H. M. (1987). Motor development. IN: Benchmark Press. Greenspan, S. I. (1995). The challenging child. Reading, MA: Addison Wesley Longman. Hannaford, C. (1995). Smart moves. Arlington, VA: Great Ocean.

Humphries T. (1990). The efficacy of sensory integration therapy for children with learning disability. The Journal of Developmental and Learning Disorders, 2(2), 171-192. Kephart, N. (1960). The slow learner in the classroom. Thomas, J. R. (1984). Motor development during childhood and adolescence. MN: Burgess. Tomatis, A. (1996). The ear and language. Canada: Moulin. Stallings, L. (1983). Motor skills. Wm. C. Brown. Youssefi, P. (1987). Preparation of human development resources for improving the physical education programs suitable to the needs of students with disabilities. Unpublished doctoral dissertation, George Washington University, Washington, D.C.

Chapter 22. Mediated Learning Experience, Instrumental Enrichment, and the Learning Propensity Assessment Device



Mediated Learning Experience, Instrumental Enrichment, and the Learning Propensity Assessment Device1
Reuven Feuerstein, Ph.D. (with an Introduction by Serena Wieder)

INTRODUCTION During the past 50 years, Reuven Feuerstein and his colleagues have pioneered a variety of approaches to enhance the cognitive abilities of children. Children with special needs have challenges to learning for many different reasons, but their learning difficulties have often been used to set limits on their potential, just as symptoms and other signs have often been used to limit expectations. As a result, many believe that little can be done to modify the course of life for children with autistic spectrum disorders or difficulties in relating and communicating, as well as those with Down, fragile X, and other syndromes. Feuerstein has long refuted this notion that signs, symptoms, and diagnostic labels lead to a condition of immutability. Instead, he believes that with appropriate mediation (i.e., interactive learning experiences) many children can learn to greater degrees than usually expected. Feuerstein has not only pioneered understanding of the basic conditions underlying learning disorders and defined the specific cognitive capacities necessary for learning, but also how to develop these

capacities to allow each child to move forward through mediated learning experience. The following chapter presents a brief overview of Feuersteins theory and practice of enhancing cognitive functioning. The main part of the chapter focuses on specific techniques developed to enhance abstract thinking and problem-solving skills in children with cognitive challenges, including children with the syndromes mentioned previously. Because so much has been written about Mediated Learning Experience, Feuersteins Instrumental Enrichment, and the Learning Propensity Assessment Device, this chapter willby necessitypresent the highlights in an outline and schematic fashion. More detailed descriptions, including a large number of research studies, are available on the website for The International Center for the Enhancement of Learning Potential at

With the exception of the Introduction and the Conclusions section, this chapter has been adapted, with permission, from information available from the website for The International Center for the Enhancement of Learning Potential at


ICDL Clinical Practice Guidelines

MEDIATED LEARING EXPERIENCE Mediated Learning Experience (MLE) describes a special type of interaction between a learner and a person, whom we shall call a mediator. A mediator is different from a teacher, as illustrated by Figures 1 and 2.

Figure 2. Schematic of Mediator-Learner Model

For the learners thinking process to be successful, at least three important features must characterize the interaction: intentionality and reciprocity, mediation of meaning, and transcendence. 1. Intentionality and Reciprocity Intentionality has been explained previously. The mediator concentrates on understanding and helping the learner understand how the learner is using his or her brain. Reciprocity refers to the need for the learner and the mediator to see each other at the same level. That is, the teacher does not pretend to know the answer as to how the learner should be thinking. 2. Mediation of Meaning The mediator interprets for the learner the significance of what the learner has accomplished. The mediator also mediates feelings of accomplishment. Now that you have figured that out, you can probably use the same method on this harder problem. Now Ill bet you see the advantage of having developed a strategy for solving the problem. Did you notice how you went faster when you decided you could be flexible in your approach? In various ways, the mediator causes the learner to reflect not just on the solution to the problem but also on how the solution was obtained and the generalizations that flow from it. 3. Transcendence Human beings differ from the other species in the way they can transfer lessons learned from one experience to rules and methods to use in another situation. Indeed, this is what learning should be about, for if a person does

Figure 1. Schematic of Teacher-Learner Model

In this model, the teacher provides a suitable stimulus (e.g., homework, test, or assignment) and then observes the response of the learner to the stimulus. Based on the response, the teacher interacts with the learner (e.g., praise, criticism, encouragement, grade, new assignment) and the process is continued until either the teacher or the learner is satisfied or time runs out. Teachers develop their own repertoire of methods depending upon the size of the class, the apparent ability of the learner(s), and the subject matter. In Feuersteins method, the above figure is replaced by one in which a warm human being, indicated by the H in the diagram, intervenes in the process by placing himself or herself between the learner and the stimulus and between the learner and the response. The intentionality of the mediator is different from that of a teacher. The mediator is not concerned with solving the problem at hand. Rather, the mediator is concerned with how the learner approaches solving the problem. The problem at hand is only an excuse to involve the mediator with the learners thinking process.



not generalize from experience that person does not gain 30 years of experience, that person simply repeats one year 30 times. Transcendence means bridging between the experience and lessons learned in the current situation and new situations. Where else in your life to you suppose it is important to have a strategy? How often has impulsivity gotten you into difficulty in your family life? Where else do you find that you are imposing structure on what would otherwise be a confusing set of input information? When and where do you find it useful to categorize information? The above three criteria are essential in defining MLE. However, the mediator also pays close attention to other aspects of learning from experience, and mediates for other (affective) components of learning, including: Regulation and control of behavior Feelings of competency Sharing behavior Individuation/psychological differentiation Goal seeking/setting/achieving/monitoring Challenge: The search for novelty and complexity Awareness of the potential for change The search of optimistic alternatives Feeling of belonging Cognitive Dysfunctions at the Three Problem-Solving Stages In examining the approach of the learner in a problem-solving situation, it is helpful to the mediator to develop a mental image of the steps learners take in successful problem solving and in what can go wrong. Feuerstein and his associates have developed the following examples of cognitive dysfunctions at the three stages of problem solving.

Stage 1: Difficulties of the Learner During the Input Stage of Problem Solving Blurred and sweeping perception. Unplanned, impulsive, and unsystematic exploratory behavior. Lack of or impaired receptive verbal tools that affect discrimination, (e.g., objects, events, and relationships are not appropriately labeled). Lack of or impaired spatial orientation and lack of stable system of reference by which to establish topological and Euclidian organization of space. Lack of or impaired temporal concepts. Lack of or impaired conservation of constancy. Lack of or a deficient need for precision and accuracy in data gathering. Lack of capacity for considering two or more sources of information at once. (This is reflected in dealing with data in a piecemeal fashion rather than as a unit of facts that are organized.) Stage 2: Difficulties of the Learner During the Elaboration Phase Inadequacy in the perception of the existence of a problem and its definition. Inability to select relevant as opposed to irrelevant cues in defining a problem. Lack of spontaneous comparative behavior or the limitation of its application by an inhibited need system. Narrowness of the mental field. Episodic grasp of reality. Lack of need for the establishment of relationships. Lack of need for and/or exercise of summative behavior. Lack of or impaired need for pursuing logical evidence. Lack of or impaired ability to use inferential or hypothetical (if) thinking.


ICDL Clinical Practice Guidelines

Lack of or impaired ability to use planning behavior. Non-elaboration of certain categories because the verbal concepts are not part of the individual verbal inventory on a receptive level, or because they are not mobilized at the expressive level.

Stage 3: Difficulties of the Learner During The Output Phase Egocentric communication modality. Blocking. Trial and error responses. Lack of or impaired verbal or other tools for adequately communicating elaborated responses. Lack of or impaired need for precision and accuracy in the communication of ones responses. Deficiency of visual transport. Impulsive, random, unplanned behavior. Although MLE may be used with any situation in which the learner is challenged by a problem, there are some situations which are much easier to deal with than others. For example, in Feuersteins Instrumental Enrichment, the problems have been designed to be attractive and fun to solve. They have also been designed to emphasize one or another of the potential dysfunctions listed earlier. Another example is in the Learning Propensity Assessment Device, in which the problems posed to the learner are aimed specifically at one or another of the above potential difficulties. FEUERSTEINS INSTRUMENTAL ENRICHMENT Feuersteins Instrumental Enrichment Program (FIE) is a cognitive education program that was begun in the 1950s. The program has been successfully used in 70 countries as a

tool for the enhancement of learning potential in specially challenged individuals and those in high-risk environments. FIE is a classroom curriculum designed to enhance the cognitive functions necessary for academic learning and achievement. The fundamental assumption of the program, based on the theory and research pioneered by the author is that intelligence is dynamic and modifiable, not static or fixed. Thus the program seeks to correct deficiencies in fundamental thinking skills: provide students with the concepts, skills, strategies, operations and techniques necessary to function as independent learners; to diagnose; and to help students learn how to learn. FIE materials are organized into instruments that comprise paper-and-pencil tasks aimed at such specific cognitive domains as analytic perception, orientation in space and time, comparative behavior, classification, and more. The FIE program is mediated by a certified FIE trainer and can be implemented in the classroom setting or as an individual tutoring and remedial teaching device. This program has received worldwide recognition and has been translated into 16 languages. Mastery of the tasks in FIE is never a matter of rote learning or mere reproduction of a learned skill. It always involves the application of rules, principles, or strategies in a variety of tasks. Thus, FIE systematically reinforces the cognitive functions that enable learners to define problems, make connections and see relationships, motivate themselves, and improve their work habits. FIE consists of fourteen instruments that focus on specific cognitive functions. Learning how to learn takes place through repetitionnot repetition of the FIE tasks themselves, but of the cognitive functions that enable individuals to think effectively. Tasks become increasingly complex and abstract, and the instruments reinforce cognitive functions



in a cyclical manner. Deliberately free of specific subject matter, the FIE tasks are intended to be more readily transferable to all life situations. Through FIE, students develop the ability to apply their cognitive functions to any problem or thinking situation. Samples from each of the 14 instruments in the FIE program follow. Each sample describes an instrument, provides a summary of the cognitive processes the instrument addresses, and presents a task from the instrument. The sample tasks have been chosen randomly from the sequence of tasks in each instrument and do not necessarily reflect the development of the program. Instruments of FIE Organization of Dots Organization of Dots provides practice in projecting virtual relationships through tasks that require an individual to identify and outline given figures within a cloud of dots. The projection of a potential relationship requires that the learner search for meaning among otherwise separate phenomena. Through repeated practice and successful completion of progressively more difficult exercises, the instrument encourages task-intrinsic motivation and activates a variety of cognitive functions. Cognitive Functions Developed Definition of the problem Selection of dots that are relevant to the figure that is sought Planning behavior Hypothetical thinking and use of logical evidence Summative behavior Mediation of Sample Task Mediation of challenge is indicated in the sample task shown in Figure 3, in which there are no given cues and the dots are numerous

and close together. Mediation of a feeling of competence is important as the students compare strategies of solution. As in all tasks in Organization of Dots, there must be regulation and control of behavior. Sample Task Spontaneous comparison of projected figure to the model. Instructions: Connect the dots so that the geometric figures in the first frame appear in each of the following frames. The orientations of the figures may be different from the first frame. Some of the figures overlap.

Figure 3. Sample Task in the Organization of Dots Instrument

Comparisons The Comparisons instrument increases an individuals ability to differentiate between parameters of comparison and to develop the cognitive functions involved in comparative behavior. The instrument provides concepts, labels, and operations with which to describe similarities and differences. From Comparisons individuals learn to organize and integrate separate and distinct bits of information into coordinated and meaningful systems. The instrument helps build learners feelings of competence and independence by enriching the repertoire of attributes by which they compare objects and events.


ICDL Clinical Practice Guidelines

Cognitive Functions Developed Ability to keep in mind a great number of parameters during the process of elaboration. Making a plan that will take into account the complexity of the tasks. Use of hypothetical thinking and hypothesis testing to evaluate the alternative response. Selection of relevant cues and reference points. Mediation of Sample Task An opportunity for mediated regulation and control of impulsive behavior is provided in the sample tasks shown in Figure 4, in which an individual must discriminate among a number of given parameters. A feeling of competence is mediated to the students as strategies for the solution of the tasks are discussed. Goal-setting and goal-achieving behavior must also be mediated. Sample Task Instructions: Circle the word or words that describe what is common between the sample picture on the left and each of the pictures in the same row.

detach oneself from ones own body position as a reference. It deals with a relative system of reference for localizing objects in space and in relation to one another. As a result of their experience with these tasks, learners discover why there are differing points of view in the perception of an object or an experience and how to give consideration to an opinion that is different from their own. Cognitive Functions Developed Definition of problem when no instructions are given or when tasks vary from frame to frame. Hypothetical thinking: If...then. Use of logic to solve tasks for which the information is not directly provided. Comparison as a strategy for checking ones work. Internalization of the relationship between the elements of the system of reference. Mediation of Sample Task Mediation of goal-seeking, goal-setting, goal-planning, and goal-achieving behavior is indicated in the sample task shown in Figure 5, which varies from frame to frame. Mediation of challenge is also indicated. Sample Task Instructions: Fill in what is missing so that each frame will contain an arrow, a dot, and an indication on which side of the arrow the dot is located.

Figure 4. A Sample Task in the Comparisons Instrument

Orientation in Space-I Orientation in Space-I addresses the poor articulation, differentiation, and representation of space that may result from an inability to

Figure 5. A Sample Task in Orientation in Space -I Instrument



Analytic Perception Analytic Perception enhances ones ability to differentiate (divide a whole into its parts) and integrate (join parts into a whole). Adaptation to the world depends upon the flexibility to alternate between these two perceptual processes. As a result of their experiences with the tasks in this instrument, learners begin to differentiate between inner and outer sources of reference. They are then able to form and discriminately use internal referents to process information and to structure and restructure their varied life experiences. Cognitive Functions Developed Spontaneous comparison to model. Establishment of relationship between parts, and between the parts and the model. Categorization of parts according to their shapes and colors. Visual transport of parts to the model. Mediation of Sample Task Mediation for intentionality, reciprocity, transcendence, and meaning are necessary in confronting the sample task in Figure 6. Sharing behavior is encouraged in comparing strategies and expression. Sample Task Instructions: In each of the exercises below you are given a model. Choose the box that

contains all the parts that make up the design, and write its number in the circle provided. Illustrations Illustrations presents a collection of situations in which a problem can be perceived and recognized. Learners attempt to offer an appropriate solution to the identified problem. This instrument mediates learners ability to perceive details, use several sources of information, and exercise comparative behavior. Illustrations lends itself to the development of vocabulary and oral and written language; it is also highly useful for generating taskintrinsic motivation. Cognitive Functions Developed Definition of the inferred problem. Use of relevant cues as a basis for inference. Use of comparative behavior. Use of summative behavior. Hypothetical thinking and use of logical evidence to support conclusions. Establishment of relationships between the individuals, objects, and events shown in the illustrations. Mediation of Sample Task Goal-seeking, goal-setting, goal-planning, and goal-achieving behavior must be mediated in the discussion of the plight of the piano movers in the sample task shown in Figure 7. Regulation and control of behavior should be mediated as playing a major role in ensuring time for planning and reflection. The meaning of the pictured event should be mediated and projected into various life situations. Sample Task Instructions: Examine the picture carefully. Is there a problem?

Figure 6. A Sample Task in the Analytic Perception Instrument


ICDL Clinical Practice Guidelines

Mediation of Sample Task Individuation and psychological differentiation, as well as sharing behavior, should be mediated in the sample tasks shown in Figure 8, which require taking a point of view other than ones own. Mediation of goal-planning and goal-achieving behavior is necessary in discussing the process by which the tasks are solved. Sample Task Instructions: Using the information in the genealogical map, answer the questions listed on the page.

Figure 7. Sample Task in the Illustrations Instrument

Use the information in the geneological map to complete the page.

Family Relations The Family Relations instrument uses a system of relationships to link separate beings and categories and emphasizes the necessary and sufficient conditions for inclusion in and exclusion from categories. The exercises in Family Relations demand precise use of language in encoding and decoding relationships and require inferential thinking, analytic thinking, and deductive reasoning to justify conclusions based on logical evidence. Cognitive Functions Developed Definition of problem in order to determine what one is being asked to do. Using only information that is relevant. Comparison between elements and relationships to determine similarities and differences. Enlarging the mental field by bearing in mind a number of discrete elements and the relationships among them. Hypothetical thinking and the use of logical evidence to justify ones conclusions. Overcoming an episodic grasp of reality by seeking the links and bonds that unite separate entities.


Who says: 1. B is my wife __________________ 2. D is my daughter but I am not her father_________ 3. E is my sister but I am not her sister ___________ 4. J is my granddaughter as well as As granddaughter _____ 5. H is my cousin. He is also Ks cousin ___________ 6. H,I,J,K, and L are my nephews and nieces _______ What are the relationships?
1. 2. 3. 4. 5. G F A H E F A H G I

Figure 8. A Sample Task in the Family Relations Instrument

Categorization Categorization is based on successful comparison, differentiation, and discrimination. This instrument helps individuals develop the flexibility and divergent thinking necessary for categorizing and recategorizing



the same objects into different sets as the principles and parameters of categorization change with new needs and objectives. In categorizing, an individual moves from establishing relationships among concrete items to projecting relationships among concepts. This ability is essential to and basic for logical and verbal operations. Cognitive Functions Developed Comparative behavior to ascertain similarities and differences Selection of relevant attributes Summative behavior Projection of relationships Determination of cognitive categories Mediation of Sample Task Mediation of goal-seeking, goal-planning, and goal-achieving behavior is indicated for the sample tasks shown in Figure 9. Mediation of challenge is elicited in the complex task at the bottom of Figure 9. Individuation is mediated in comparing two alternative solutions to the same task. Sample Task Instructions: Classify the cubes according to size and color. Fill in the headings and write the correct letter in each empty square. Numerical Progressions The Numerical Progressions instrument helps learners search for, deduce, and induce relationships between separate objects or events. Learners draw accurate conclusions regarding the cause of progressions as the instrument increases their ability to compare, infer, and reason deductively and inductively. This instrument mediates precision, discrimination, and a willingness to defer judgment until all of the elements have been worked out in determining a common rule for a progression.

Write the correct letter in each empty space.




Classify the cubes according to size and color. Fill in the headings and write the correct letter in each empty square. Subject of classification: ________________________ Principle of (1) _________________ classification: ____________ (2) _________________ (1) _________________ ____________ (2) _________________

Figure 9. A Sample Task for the Categorization Instrument

Cognitive Functions Developed Use of relevant tacit cues like index (the place of a number in the progression). Projection of relationships between the elements of the progression. Mediation of Sample Task Mediation of challenge is essential for the very difficult, very complex, and novel sample tasks shown in Figure 10 (see next page). Mediation of intentionality, transcendence, and meaning is indicated in fostering an understanding of higher-order relationships. Sample Task Instructions: Fill in the progressions, the relationships between the numbers, and the relationship between the relationships. Temporal Relations The Temporal Relations instrument develops learners ability to use temporal concepts to describe and order their experiences. An


ICDL Clinical Practice Guidelines

tasks that follow and the relevance of the given information to its solution. Projection and control of behavior is mediated in restraining impulsivity in gathering and processing information. Sample Task Riddles: 1. Lucy has been in the United States for 2 years. Steve has been in the United States for 1 year. Is it possible to know which of the two is older? Why? 2. Terry runs 117 yards (107 meters) per minute. Harry runs 223 yards (214 meters) per minute. Is it possible to know who will win if they have a race? Why? 3. Marias mother arrived in Canada 15 years ago. Marias grandmother arrived 6 years ago. Who is older? 4. Mark and Lisa are new immigrants. Mark is 18 years old. Lisa is 16 years old. Which one has been in the country for a longer period of time? Instructions The Instructions instrument focuses on encoding and decoding verbal and written information. The difficulty in the tasks is not in the meaning of the words themselves, although learners may occasionally have problems with unfamiliar terms; the difficulty is rather with the significance of the words and with what they imply in context. Through the insights gained into the reasons for their successes and failures, learners are transformed into generators of information, able and willing to interpret and transmit complex instructions. Cognitive Functions Developed Definition of the problem Comparison of completed drawing with verbal instructions Use of relevant cues to clarify ambiguities Hypothetical thinking and use of logical evidence to support hypotheses

Figure 10. Sample Task for the Numerical Progressions Instrument

adequate orientation to time is important to relational thinking and is acquired through mediated learning experiences. Without an awareness of the continuity of time, its ordered succession, and of the rhythm of events, individuals make no use of their past to predict, anticipate, plan, and prioritize future events. The Temporal Relations instrument helps mediate temporal relationships and appropriate and precise use of temporal concepts and relationships. Cognitive Functions Developed Comparison of the temporal characteristics of events Use of relevant cues Formulation of hypotheses Mediation of Sample Task Mediation of a feeling of competence is necessary in order to define the nature of the sample



Mediation of Sample Task Mediated regulation and control of behavior is indicated until the instructions and picture have been completed and errors identified. Sample Task Instructions: Matching/not matching: On the left side of the page there is a description. Beside the description there is a corresponding drawing. Look at the drawing and read the description. Check whether the description matches the drawing. If it does, circle the word MATCHING and go on to the next exercise. If it does not, circle the words NOT MATCHING, and write on the lines the correct description that will match the drawing. Figure 11 shows a sample task.
READ There are three circles on a diagonal that starts in the right bottom corner. They are arranged according to size order. The smallest circle is at the bottom. There is a yellow diagonal starting from the left bottom corner. On it there are three circles arranged according to size order. the yellow circle is the biggest and it is in the middle.

apply the relative (internal) system of reference and the absolute (external) system of reference to describe and understand spatial relationships. Cognitive Functions Developed Definition of the problem. Comparison of alternative solutions. Summing right and left turns and finding their equivalents in fractions of a circle. Projection and description of spatial relationships in terms of relative and absolute systems of reference. Hypothetical thinking in considering alternative solutions. Use of logic in the integration of two systems. Mediation of Sample Task An opportunity for the mediated regulation and control of behavior is provided in the sample tasks. The willingness to defer the response until the information has been decoded, gathered, and elaborated and the strategy planned is especially necessary in the last task. Figure 12 shows a sample task. Sample Task Instructions: Using the picture, fill in the blanks (see Figure 12 on following page). Syllogisms The Syllogisms instrument presents formal, propositional logic. In syllogistic reasoning, the integration of information from two premises about the relationship between terms yields the deduction of an unknown relationship. Through the tasks of Syllogisms, learners gain the ability to discriminate between valid and invalid conclusions and between possible and inevitable outcomes. The instrument fosters inferential and abstract thinking.





There is a horizontal line and 3. above it there is a hexagon, a circle, and a square arranged according to size order. The hexagon is smallest and is on the right side. The square is the biggest. There is a horizontal line and above it there are two yellow triangles and a black circle. The large shape is on the left side, and the small shape on the right side.



Figure 11. A Sample Task in the Instructions Instrument

Orientation in Space-II Orientation in Space-II introduces and provides practice in the use of external, stable, and absolute systems of reference. Geographical concepts such as compass points, coordinates, and graphs are used to describe relationships and an objects orientation in space. Learners have to simultaneously


ICDL Clinical Practice Guidelines




1 turn = circle 2 turns = circle 3 turns = ___ circle ___ turns = full circle



the confines of the concrete experiences through inferential thinking. Goal-seeking, goal-setting, goal-planning, and goal-achieving behavior is mediated along with the mediation of regulated behavior and a feeling of competence. (See Figure 13). Sample Task Instructions: Using the drawing, answer the questions by writing the appropriate letters for each set in the parenthesis and by filling in the blanks.


LOOK AT THE ILLUSTRATION ABOVE AND FILL IN THE BLANKS BELOW 1. You are facing east. A. Make ____ turns to the right so that you return to where you started. B. Make a ____ circle, so that you return to where you started. 2. You are facing north. A. Make 4 turns to the right and 1 turn to the left. Where do you face now? ___________ B. Make a full circle to the right and circle to the left. Where do you face now? _________ One turn = _____ circles. _____ turns = circle. 3. You are facing north. Make 3 turns to the right and 1 to the left. Where do you face now? _________ To face east, one can move ____ circle to the right or ____ circle to the left. 4. You are to turn south to east in two steps. (There is more than one solution.)
A Alternative 1 (turns) FIRST STEP SECOND STEP 2 left 1 right Alternative 2 (turns) 2 right _______ Alternative 3 (turns) circle right __ circle left

Figure 12. A Sample Task in the Orientation in Space-II Instrument

All the exercises on this page are based on the above drawing. Look at the drawing above and write the appropriate letters for each set in the parentheses; then fill in the blanks. 1. All predatory animals (A) are dangerous (B). Some birds (C ) are predatory (__). CONCLUSION: Some ________(C ) are ________(B). 2. All redheads (__) have freckles (__). Some redheads (__) have blue eyes (__). CONCLUSION: _________(__) ___________(__).

Cognitive Functions Developed Appropriate definition of problem. Spontaneous comparative behavior between attributes of a set and those of set members. Selection of relevant data for elaboration. Overcoming episodic grasp of reality by establishing relationships. Broadening of mental field to simultaneously elaborate information from several sources. Elaboration of cognitive categories on the basis of conceptual criteria. Use of summative behavior. Hypothetical thinking and search for logical evidence. Mediation of Sample Task Transcendence is reached through insight and generalization from the sample task into other areas of academic, vocational, and life experiences. Meaning is assigned to the logical processes that allow the mind to exceed

Figure 13. A Sample Task in the Syllogisms Instrument

Transitive Relations The Transitive Relations instrument deals with relationships that exist in ordered sets, in which the differences between set members are described by the terms greater than, less than, and equal to. This instrument helps learners recognize conditions that permit deductive and inductive reasoning. Through the tasks in Transitive Relations, learners demonstrate their ability to engage in inferential thinking based on logical implication and relational thinking. Cognitive Functions Developed Definition of problem Selection of relevant information Comparison and categorization



Hypothetical thinking Planned and systematic behavior

Mediation of Sample Task Transcendence is reached through insight and generalization from the sample task into other areas of academic, vocational, and life experiences. Meaning is assigned to the logical processes that allow the mind to exceed the confines of the concrete experiences through inferential thinking. Goal-seeking, goal-setting, goal-planning, and goal-achieving behavior is mediated along with the mediation of regulated behavior and a feeling of competence. A feeling of optimism is mediated as students learn to induce conclusions about unknown relationships. (See Figure 14.) Sample Task Instructions: Complete the following problem. Four construction workers are building a building. Arthur and David together can put up two walls in one workday. Charles and Harold together can also put up two walls in one workday. Arthur does more work in one day than Charles does.

Representational Stencil Design Representational Stencil Design consists of tasks in which the student must mentally construct a design. The completion of the tasks requires a complex series of steps. The identification of the whole through its superimposed parts requires an active, mental construction with the help of inferences, and an anticipation and representation of the outcome. Answers are sought by affirmation, negation, and elimination of what is logically impossible. Learners must extrapolate from the known to the unknown and rely on logic to identify the constructions. Cognitive Functions Developed Comparison Summative behavior Categorization Establishment of temporal and spatial relationships Mediation of Sample Task Challenge, competence, and optimism are mediated as students realize their ability and teachers expect them to perform this very difficult task. Regulation of impulsive behavior and representational goal-oriented cognitive behavior are key to the mediation offered by the teacher in the context of this instrument. (See Figure 15.) Sample Task Instructions: List the stencil numbers that make up the completed design in the right order.

Substitute letters for the names: Arthur ___________ Charles __________ David ___________ Harold ___________ Using the signs (>, <), signify the relationship between the work rates: Arthur _______ David Charles _______ Harold Arthur _______ Charles Charles _______ David David _______ Harold Arthur _______ Harold Figure 14. Sample Task in the Transitive Relations Instrument

Figure 15. A Sample Task in the Representational Stencil Design Instrument


ICDL Clinical Practice Guidelines

A DESCRIPTION OF THE LEARNING PROPENSITY ASSESSMENT DEVICE (LPAD)2 Process and Instruments The Learning Propensity Assessment Devise (LPAD) is a series of tests or activities that (1) evaluate the way an individual learns, and (2) identify the development of cognitive functions. That is, the LPAD enables us to observe and record how a person learns, what kinds of teaching are required to respond more successfully, and how much of the observed learning is retained as new and more challenging tasks are presented. Through this approach, we can gain a picture of the way a person thinks, learns, and the possibilities for the development of their thinking and learning potential. The LPAD differs from traditional educational and psychological evaluation in that we gain information not from scores or single responses, but from observations of repeated responses to the tasks, and from teaching the subject how to solve problems and respond correctly (mediation). Used in conjunction with standardized assessment, the LPAD adds a perspective on what kinds of interventions are needed and the individuals learning abilities and potential for growth. Another important feature of the LPAD instruments is their inclusion of all of the various important ways of processing and responding to informationverbal, pictorial, numerical, figural, symbolic, graphicand the ways in which the subject combines them to respond cognitively.

An LPAD assessment consists of a battery of several instruments, chosen to allow the evaluator to observe as many as possible ways in which the learner responds. As the subject responds, the assessor gathers information, develops ideas about the learners needs and functions, and uses these insights in choosing and analyzing performance in subsequent instruments. Therefore, the amount of time needed for the assessment and the number and range of instruments can vary a great deal. The following is a brief description of each of the LPAD instruments used in this assessment. Instruments Focusing on Perceptual-Motor Functions Organized by Cognitive Components Organization of Dots On this test, the subject looks at a model figure containing simple geometrical shapes, starting with squares and triangles, and increasing in complexity with subsequent task demands to include shapes composed of both regular and irregular curvilinear and rectilinear forms. The subject is then asked to find the model shapes in frames filled with unstructured, visually amorphous clouds of dots. The task is to draw lines to connect the dots to produce the shapes of the model, presented in many instances as overlapped, rotated, and superimposed in various ways. The subject must look for the relationships, plan and use information that must be internalized, and exercise eye-hand coordination to draw the connecting lines. As the subject completes the tasks the examiner observes and mediates the development and use of cognitive strategies such as planning, inferring, and regulating perceptual conflicts. The primary modality of the task is figural and graphomotor. Operations in this task include

This section on LPAD has been previously adapted from Feuerstein, Re., Falik, L. H., & Feuerstein, Ra. (1998). The Learning Propensity Assessment Device: An alternative approach to the assessment of learning potential. In R. J. Samuda, Re. Feuerstein, A. S. Kaufman, J. E. Lewis, & R. J. Sternberg (Eds.), Advances in cross cultural assessment. Thousand Oaks, CA: Sage.



differentiation, segregation of overlapping figures, conservation of the figure across changes in its position, articulation of the field, and representation (interiorization). This instrument is based upon the original contributions of Andre Rey. Complex Figure-Drawing Test The Complex Figure Drawing Test is adapted from Rey (1941) and Osterrieth (1945). The subject is asked to copy the Rey/Osterreith complex geometric design by looking at the model. The subject must use organizational principles to create an efficient production in the face of the complexity of the task. The great number of units of information become reduced by organization and awareness of the succession of steps needed to internalize the multitude of details. During the first reproduction phase, only minimal orienting mediation is offered. Following the first reproduction, and after a 3- to 5-minute latency period, the subject is asked to reproduce the design from memory (without looking at the model). Following the memory phase, and based on observations of the subjects performance, a mediation phase is conducted where the examiner reviews with the subject aspects of his or her performance, identifies errors and inefficiencies, and teaches organizational and design aspects. After mediation the subject is asked to copy the design again from the stimulus model, and again from memory. Assessment is directed toward the initial performance (e.g., organizational approach, accuracy of motor skills and structural details) in reproducing the design and changes in the second copy, and memory productions, following mediation. The task requires functioning in a figural and graphic modality and measures both short-term learning and the persistence of perceptual organization difficulties. The mental operations

involved in this test include discrimination, segregation of proximal elements, the articulation of a complex field, and reproduction, representation, differentiation, integration, and visual-motor coordination. An additional phase is also available for this test, the Representational Organization of Complex Figures, in which the subject is presented with a template containing 10 designs, constructed in such a way that a central geometric figure is embedded in a set of adjacent or juxtaposed figures. The subject is asked to scan the first figure and indicate which part of the figure he or she would prefer to draw first, and the order in which all of the remaining parts would be drawn. The examiner then proceeds through the rest of the figures. No figure is actually drawnthe subject merely indicates the parts and sequence in which they would be drawn. This phase is useful for those subjects who present persistent difficulties in organizational aspects of the CFD, and reveals the effects of mediation offered in earlier phases of the instrument. It removes from performance any difficulties the subject may have in the visual-motor modality. Reversal Test This instrument requires the subject to look at two figural designs contained in a frame and indicate whether they are the same or different. If different, the subject is asked to make a rapid mark, and move on to the next differentiation. There is no focused mediation on this instrument other than establishing a clear response expectation in the subject, which is done with several practice problems before the test is given. The subject responds rapidly, using visual tracking, without mediational intervention. The differentiations are based on reversals, partwhole relationships, and structural changes. The modality is figural with minimal motor


ICDL Clinical Practice Guidelines

performance required. While this instrument does not involve mediational intervention, it gives excellent cues regarding the development of lexic functions in the subject, and orients to mediational options in other instruments (as on Raven and Set Variations), and in the content areas of reading and mathematics (as regards the decoding aspects of numerical symbols). As this instrument has recently entered the LPAD battery, there is no corresponding section in the LPAD Examiners Manual (Feuerstein, 1995) detailing its use. This test is based on the work of Edfeldt (1954). Diffuse Attention Test (Lahy) This instrument was developed by Lahy from the work of Zazzo (1964). It is used in the LPAD procedure to assess the subjects adaptability and flexibility, manifested in rapidity and precision on a task that requires visual scanning. The subject must maintain attention and focus on a visual/motor and repetitive process, learning a perceptual set, and either maintaining it over time or being able to learn a new set without interference from the prior learning. Three of the eight figures are designated as model figures, and are isolated at the top of each section of the test page which the subject learns to differentiate. The subject must then scan lines of 40 figures, comprising the eight figures presented in a random order, and mark the three model figures when they are perceived and identified. The stimulus field is thus perceptually quite dense, and requires the subject to scan carefully and work to maintain visual tracking and cognitive attention. There are two forms of this test, one having only one such array, and 24 lines of stimuli to scan. A second form has three sections, with three different sets of three-dimensional model figures, thus enabling the assessment of retroactive inhibitionthe effect of learning one set

of differentiations on the subsequent performance on another set. Performance is observed in one-minute intervals, yielding scores of the proportion of correct and incorrect inclusions, and omissions, within the segments. No mediation is typically offered during the performance on the task, but the task can be practiced and mediated in a variety of ways after performance, and repeated after various practice experiences, to assess the changes with over learning. The modality of this test is visual-motor and graphic. The operations included are limited to the identification of differentiated cues (an encoding process) and the re-cognition of the model. Instruments Focusing on Memory, With a Learning Component Positional Learning Test (5 x 25) This test is adapted from the work of Andre Rey. The subject is shown a grid of 25 squares, organized in 5 rows and 5 columns, with 5 positions (corresponding to one for each row and column) designated and indicated by the examiner using an auditory verbal and motor modality (saying here and pointing). After a short (10-second) latency period, the subject is asked to reproduce the indicated positions by marking them on the same grid. The procedure is repeated, with minimal mediation, until the subject can reproduce the pattern correctly three times in succession. If the subject experiences difficulty, mediation is directed toward the apparent source of the errors, and to establishing strategies that the subject can use. After learning one pattern, the procedure is repeated similarly with different patterns, enabling the examiner to observe learning of new patterns in the presence of previously learned and potentially confounding patterns. The learning on this instrument reflects a visual-motor and graphic modality



and requires the subject to use the operations of encoding, sequencing, and the reproduction of a perceived set of positions. Plateaux Test This instrument is also adapted from the work of Andre Rey. On this test, the subject is presented with a set of four plates, superimposed upon one another in the subjects view. Each plate contains nine buttons or pegs, arranged in three parallel columns or rows (a 3 x 3 design). Each plate has one peg that cannot be removed. The fixed peg is in a different position on each of the four plates. On the exploratory phase, the subject is asked to search for the fixed peg on the first plate by taking out the pegs and replacing them until the fixed one is located, and to identify its position. The subject is asked to repeat the process for the remaining three plates successively, being encouraged to develop strategies leading to learning the positions on each plate and discovering a generalizationrule or principlerelating to the pattern of fixed positions. After the subject has learned the four positions (making three errorless repetitions), the orientation of the plate is rotated and the subject is asked to identify the position of the fixed pegs following the rotation(s). A second, representational phase is undertaken when the subject is asked to draw the pattern of fixed pegs on paper, reflecting a two-dimensional transition and interiorization. This phase assesses the transition from the concrete position to the use of a memorized or internalized representation from a three dimensional experience to a graphical two dimensional planea substitution of learned reality. A third phase is introduced in order to learn about the plasticity and flexibility of the memorized data. In this phase the well established positions and their successions are successively rotated by 90, 180, and 270 degrees, and the examinee is required to represent schemati-

cally (on paper) the fixed peg in the new positions produced by the respective rotations. This phase represents a higher ordered cognitive operation than the simple reproduction of the positions and their initial graphic representations, reflecting the outcome of rotations requiring shifting of learned positions. Associative Recall Associative Recall is assessed through two tests: The Functional Reduction and PartWhole and the 16-Word Memory Test. Descriptions of these tests follow. 1. Functional Reduction and Part-Whole This test consists of two versions, similar in organization and objective but differing in stimulus presentation. The subject is shown a page that contains a row of 20 simple line drawings along the top row, selected for their familiarity to the subject and the unambiguity of their figural presentations. In the first row the objects are presented in their entirety, and the subject is asked to name them (a labeling phase). In the second row, on the Functional Reduction (FR) page drawings of functional substitutes are shown. On the PartWhole (PW) page a salient feature of the object is presented. In the third and fourth rows, there is a further stimulus reduction and changes in order of presentation. The subject is asked to recall the original labeled object on the top row from a visual inspection of the reduced stimuli under the various conditions presented in the subsequent rows that are exposed, with the preceding rows concealed. The FR page is usually used with most subjects, and the PW page may be used when the examiner feels further mediation is needed for repetition or crystallization of the functions learned on the FR page, or when the subjects level of perceptual functioning suggests that restricting the task to a focus on structural details as the link to associate


ICDL Clinical Practice Guidelines

memory will yield more efficient and elaborative responses. Both pages also enable the assessment of immediate free recall and delayed free recall of the original 20 objects. The modality of this test is visual, auditory, motor and graphic. It requires the subject to use the operations of encoding, symbolization, and the discovery of functional relationships. 2. 16-Word Memory Test This test consists to a group of 16 simple common words presented orally to the subject. The words are presented in a fixed but conceptually random order. The subject is asked to repeat as many as can be recalled following the presentation of the list and a latency period of approximately ten seconds. The subject is told that the process will be repeated several times. No mediation is offered for the first three or four repetitions. The examiner observes the subjects spontaneous recognition and inclusion in memory of the four categories into which the 16 words can be grouped. After approximately four repetitions, mediation is offered if needed to encourage the memory process, using a variety of cues, both mnemonic and cognitive, until the subject can recall all or a majority of the list using internalized memory functions and achieve accuracy and efficiency of response. The modalities of this test are auditory and verbal, and the mental operations require the reproduction of an auditory set of stimuli, internalized controls, organization, and both encoding and decoding (representationally) skills. Instruments Involving Higher-Order Cognitive Processes and Mental Operations Tri-Modal Analogies This instrument is used with younger children and low-functioning individuals to establish analogical thinking, using figural,

pictorial, symbolic, and verbal modalities. The stimuli require the subject to mentally manipulate and elaborate, thus moving the learner into abstract mental operations without needing to rely on concrete manipulatives. As such, the stimuli are useful as a preliminary to working on the more abstract and complex Ravens and Set Variations tasks. The instrument is administered in a format similar to the Set Variations described shortly. The subject is shown two stimuli, asked to consider the relationship between them, and then to look at a third stimulus. The subject is then asked to select from a number of alternatives a fourth choice that is consistent with the relationship existing in the first two. The learner is required to use concepts of size, shape, number, and positional orientation to establish relationships and complete the analogy. The mediational opportunities in this instrument enable the teaching of orienting and superordinate concepts, and the analysis of errors can indicate areas of deficiency or fragility in concept formation or acquisition. The general progression of tasks is at a lower level (as regards necessary mental operations), but assesses similar processes as in the Ravens and Set Variations instruments described shortly. This instrument has just entered the LPAD battery, but at the present time is not addressed in the Revised Examiners Manual (Feuerstein, 1995). However, the reader is advised to study the sections on the Ravens and Set Variations instruments to develop a deeper understanding of, for example, the mediational suggestions, general goals and objectives, because there is a close consonance. LPAD Matrices The instruments used in the LPAD procedures are those of the published Ravens Colored (CPM) and Standard Progressive



Matrices (SPM) (1956; 1958). Set Variations B-8 to B-12 are based on Ravens CPM items 8 to 12. Set Variations I is based on items from the CPM levels A, Ab, and B. Set Variations II is based principles similar to SPM levels C, D, and E, but the items present greater novelty in the modality of presentation. The LPAD objective in the presentation of these problems to the examinee is to assess to what extent a rule and set of prerequisites acquired to solve a particular problem are adaptively used in variations of the task, and to what extent the learned elements of the original task become the facilitating factor in adaptation to the new task. The Ravens instruments are administered according to LPAD procedures, using a testteach-retest approach. The Set Variations instruments are constructed and administered on principles similar to those of Ravens, with a sample problem for each set of variations which receives intensive mediation, and then independent performance is observed on a series of problems similar to but also becoming progressively more difficult than the mediational example. The tasks require the learner to look at a series of designs, and complete the series by selecting a correct alternative from a number of choices. To choose the correct alternative, the subject must understand the relationship among the variables. The tasks progressively add variables and change the dimensions used to establish the relationships. What is assessed on these tasks is the subjects ability to think using analogies presented as figural (visual/perceptual) information, and his or her response to the teaching of strategies to solve the problem. The operations involved are those of perceptual closure and discrimination; and the generation of new information through synthesis, permutations and seriation, inferential thinking, analogical thinking, deductive reasoning, and relational thinking.

Representational Stencil Design Test (RSDT) The RSDT is based on the Stencil Design Test of Grace Arthur (1930) but differs significantly in its structure and technique of application, primarily in its shift of the task away from the concrete, manipulative modality toward a representational, internalized modality. In the LPAD procedure, the design is constructed by the subject on a purely mental level. The instrument consists of 20 designs, which the subject must reconstruct representationally by referring to a page of model solid and cut-out stencils that must be mentally superimposed upon one another. The problems increase in level of difficulty (on dimensions of form, color, and structure) and are organized so that mastering simpler problems leads to the ability to successfully solve harder ones. The procedure of this test is to orient the subject to the Stencil page, offer a test page of problems, and then provide a training page to mediate various processes and strategies according to what is observed during performance on the test page. A parallel test is provided to be used following mediation. The instrument assesses the subjects ability to learn a complex task using internalized systems of organizing, and to use acquired learning to solve more complicated problems. Part of what is assessed in this instrument is how readily available the learners inner (representational) processes are, and how easily and adaptively they are used in subsequent problems of increased complexity and abstraction. The modalities involved are figural, numerical, and verbal. The operations involved in successful mastery of the tasks are segregation, differentiation, representation, anticipation of transformation, encoding and decoding, and generalization.


ICDL Clinical Practice Guidelines

Numerical Progressions This test assesses the subjects capacity to understand and deal with relationships, identify them as rules, and apply them to building new information, using numerical and graphic modalities. The task presents progressions of numbers related to one another according to rules which must be deduced from the available information. At the end of a sequence of numbers the subject is asked to supply the two missing numbers. A correct response infers that the subject has understood how the numbers are related to one another. The format is that of a pretest, a learning phase, and two forms of a post-test. In the learning phase, the subject is encouraged to formulate and state the rule by which the answers were achieved. The examiner teaches relationships that are not understood and establishes strategies according to an analysis of needs (errors and performance on the pretest). Following mediation, a post-test is given to determine how well the subject has learned strategies for solving the problems. The parallel form of the post-test makes possible the assessment of the permanence and stability of what has been learned over time. The operations involved in this instrument are those of basic mathematics (addition, subtraction, multiplication, and division) and the more generalized mental operations of differentiation, segregation, inferential thinking, and deductive reasoning. Organizer This instrument presents the subject with a series of verbal statements consisting of sets of items which must be organized according to closed, logical systems. The task involves the subject placing the items (e.g., colors, objects, people) in positions relative to one another according to the determined attributes or conditions presented in the statements. A series of statements or premises is

presented in each task. Each premise permits the extraction of only a part of the needed information required to determine a full and precise placement of the items. Thus, the subject must gather available information, develop and test hypotheses with succeeding information given, and generate information which is not immediately available in the given propositions. The tasks become more complex because of more units of information and the level of inference needed to solve them. What is assessed in this instrument is the subjects ability to gather new information through the use of inferential processes, formulate hypotheses and test them according to new information or assumptions generated, and apply strategies for discovering relationships. The instrument consists of pretest, learning, and test phases. The modality is verbal, with a numerical subcomponent. The operations involve decoding, encoding, representation, inferential thinking, transitive thinking, combinatorial skills, propositional reasoning, negation, with a heavy loading of mnemonic (memory) functions. CONCLUSION This chapter presented a brief overview of Mediated Learning Experience, Feuersteins Instrumental Enrichment, and the Learning Propensity Assessment Device. Work with these models has been done with many different groups of children and their families. The principles described in this chapter are consistent with the emphasis throughout The ICDL Clinical Practice Guidelines to use an understanding of a childs developmental profile as a basis for creating individualized learning interactions. It is these individualized learning interactions that create the opportunity for s growth.



REFERENCES Arthur, G. A. (1930) A point scale of performance tests: Clinical manual, Vol. I. New York: Commonwealth Fund. Feuerstein, R. (1995) Revised LPAD examiners manual. Jerusalem, Israel: International Center for the Enhancement of Learning Potential. Osterreith, P. A. (1945). Copie dune figure complexe. Archives de Psychologie, 205-353. Rey, A. (1959). Test de copie duse figure complexe. Manual. Paris: Centre de Psychologie Applique. Zazzo, R. (1964) Le test de deuz barrages. Neuchatel: Delachaux et Niestle.


ICDL Clinical Practice Guidelines

Chapter 23. Speech-Language Development: Oral and Written



Speech-Language Development: Oral and Written

Patricia Lindamood, M.S., C.C.C.-S.L.P., and Phyllis Lindamood

The human brain comes wired for language. Under normal development, the brain has a broad-based ability to acquire receptive and expressive oral language followed later by written language. Whatever the particular language a child is born into, the childs brain acquires those specific phonemes and the syllable patterns through which they combine to form words. These phonemes and syllable patterns are thus the foundation for acquiring the morphology, grammar, syntax, and semantics through which the words then form the structure of the language. Under normal development, acquisition occurs simply by having the brain immersed in the auditory input of that language. Considering that there are more than 5,000 languages in the world, this attests to the brains incredible flexibility and innate capacity for language. Immersion in language, however, does not result in normal oral language development for an estimated 10% or more of the population; problems in written language development are much higher. The National Adult Literacy Survey (1993) indicated that 48% of the adult population lack written language skills sufficient for the normal requirements of life. This is in spite of those individuals having had opportunities for schooling, with some of them even having college degrees. This chapter provides an

overview of what is known about normal oral and written language development, factors that can interfere with that development, current interventions that are proving effective in preventing or remediating speech-language and written language problems, and some questions in need of further investigation. HIERARCHIES IN ORAL LANGUAGE ACQUISITION Research and theory on language acquisition have largely dealt with English language learning. Contributions from crosslinguistic study of language acquisition and infant research are broadening our understandings. Although much is still unknown, infant research shows promise of helping to identify predictors of later problems, which could enable intervention to be mounted earlier for preventive action. David Lewkowicz and colleagues with the New York State Institute for Basic Research in Developmental Disabilities have been seeking better understanding of perceptual development in human infants in research spanning more than 20 years. Lewkowicz has particularly focused on how infants perceive the relationship between auditory and visual information within the general issue of intersensory integration. In his most recent work with faces and voices,


ICDL Clinical Practice Guidelines

Lewkowicz (1999, in press) found that complex relationships are involved in whether infants attend to auditory or visual information, and depend on the specific nature of the information presented. Overall, infants are sensitive to the synchrony of auditory and visual inputs. Lewkowicz (2000) has recently proposed a theoretical model related to responsiveness to the four basic features of multimodal temporal experience; that is, temporal synchrony, duration, temporal rate, and rhythm. Lewkowiczs model proposes that responsiveness emerges in a sequential, hierarchical fashion during the first year of life and that responsiveness to one temporal feature builds on the previously acquired intersensory temporal processing skills. According to Lewkowicz (personal communication), Much of the support for the model comes from our work showing that infants detect and respond to temporal synchrony relations very early in development, but that they do not begin to respond to intersensory temporal relations based on duration and rate until later in the first year of life. These findings suggest a probable benefit for speech-language development if we make it a point to hold our babies so they have the synchrony of visual input from our faces with the auditory input from our voices as we talk to them. Slobin (1997) has also been researching speech and language development for more than 20 years. He has led the way in identifying additional universals in language development through crosslinguistic studies. Slobins view of language acquisition has evolved. Initially skeptical regarding an innate structure for language, later he recognized strongly inbuilt tendencies to analyze speech into certain types of units, and to systematize and interrelate and cross-classify these units in highly specific ways (Slobin, 1985, p. 1244). His current view is that there are indications of accessibility hierarchies

and individual differences which are based on independent cognitive or processing variables rather than on linguistic features across languages (Slobin, 1997, p. 452, italics added). We at Lindamood-Bell Learning Processes strongly agree with Slobins current view. Our clinical and classroom experience and research definitely validate his position that it is not the linguistic features of languages that cause differences in how children access the hierarchies of developmental progression, but that the differences are due to individual variations in sensory or cognitive processing abilities. In approaching children with a wide range of special needs, including speech and language, Greenspan and Wieder (1997) have provided a Developmental, Individual Differences, Relationship-based (DIR) intervention model with this same basic philosophy: that individual differences in each childs functional developmental profile and the ability to interact with the sensory world, form emotional and interactive relationships with people, and cognitively connect to incoming sensory information are what should drive our intervention, not the childs chronological age (see Chapter 3 for further discussion of the DIR model). In their model, the ageappropriate interactions known as floor time set the tone for this philosophy of intervention. Floor time begins at the basis of communication; that is, emotional and interactive relationships between child, parents, and other caregivers. PROGRESSIONS IN NORMAL SPEECH-LANGUAGE DEVELOPMENT Vowels, Consonants, and Babbling Under normal patterns of acquisition, there is a normal range of individual differences in how early speech-language emerges.

Chapter 23. Speech-Language Development: Oral and Written


However, the development of spoken language follows a hierarchy of progression in its emergence, and that hierarchy is essentially the same across languages, regardless of the final form of the specific language. For example, in all languages, infants produce isolated vowel and consonant phonemes very early. The child, however, experiences several months of receptive language input before combining consonants and vowels together repetitively to produce simple syllables in the vocal play called babbling. Babbling, and the extension of this play with nonsense syllables into chants, rhymes, and songs by older children and adults, occurs in all known languages and tells us the human mind finds this play with syllables pleasurable. There is even a core of same-syllable configurations involving the same phonemes that occurs across many languages. Single Words Single words are the next step in the progression, and here the linguistic environment can have an effect. For example, nouns for names of people and things are stimulated and acquired first in English, but verbs are stimulated and acquired first in Japanese (Clancy, 1985) and in Mandarin Chinese (Tardif, 1996). Choi noted that verbs are acquired first in Korean, and reported a connection between language and cognition because her data indicated form-function relationships were attended to as early as first words (Slobin, 1997). The senior author of this chapter also observed this on the second morning of a car trip from New York to California. As her 9-month-old son awakened in a hotel room again, he looked around wonderingly and asked, Bye-Bye? His rising inflection clearly indicated he was asking whether he would be traveling again that day.

Interestingly, at 10 months of age, he began forcing the naming of things. When he saw something for which he didnt have a name, he would point and stare intently in its direction while making a radar-type blip sound. As we (his parents) named various things in the vicinity he was indicating, he would shake his head No and continue the sound until he was satisfied that he had a name for the object of his interest. Then the sound would stop. This naming demand may have been stimulated by our early efforts to introduce him to language. Starting when he was about 6 months of age, we had expressly given single words for things and actions so that he could experience the beginning and end of a word rather than having those features lost within the flow of a sentence. During his babbling period, we had also enjoyed an interaction with him that increased and varied his babbling. For example, after he said ba,ba,ba we repeated it, and then he said it again. When this interaction was set, we imitated the babbled pattern a second time but varied the final syllable as in ba,ba,ga or ba,ba,da to see if he would perceive and produce the change. He could and did, after a short transition period when he just accepted the second stimulation receptively for a period before he began to imitate the variation. The progression from isolated sounds to the syllable play of babbling to meaningful single words will, of course, occur normally without the interactive stimulation just described. However, many real words in our language are composed of only two sounds: a vowel/consonant (VC), that is, eat, in, out, up, on; or a consonant/vowel (CV), that is, go, bye, see, pie, no, and so on. When imitative interaction is established during babbling with these simple syllables, it facilitates the early acquisition of a vocabulary of similarly structured real words and


ICDL Clinical Practice Guidelines

empowers children to become early active communicators in their world. Jargon Just before or during the period when single words are first beginning to emerge, standard descriptions of language development cite a jargon period. This is when children express long strings of syllables inflected in the normal rhythm and prosody of sentences. The jargon period is referred to as a necessary and normal stage in speech and language development, but it can be a frustrating period for parent and child. The child appears to be communicating an idea or a request, but the parent cannot understand it because no single word is discernible. There is a possibility, however, that this frustrating jargon period could be avoided and does not have to be a step in normal development. For example, when my child forced the extensive singleword naming, he acquired sufficient words to go easily into phrases and sentences, thereby bypassing the jargon period. On the basis of that experience, the same babbling intervention and extensive single-word naming were provided to two more sons and a daughter, and the same phenomenon occurred. None of them experienced a jargon period. They bypassed it and went from intelligible single words to intelligible phrases and sentences. Although this is only anecdotal information, it would appear a pilot study is warranted with a formal experimental and control group design to explore whether the effect of such intervention can be replicated and jargon bypassed. Data from intervention research indicate that environmental variables can influence infant vocalization and later phonological development (McReynolds, 1978).

Milestones The following developmental milestones in speech-language acquisition were summarized by Berry (1969), although there can be wide individual variation. In general, the timing occurrence of Berrys milestones has not changed appreciably in the years since that initial analysis, judging by the work of Rescorla (1989). These milestones follow. With the single-word receptive and expressive vocabulary developing steadily in the period between 1 and 2 years, a child normally develops a minimum 50word vocabulary and combining of words into phrases between 18 and 24 months. A child will normally progress to short sentences before 30 months of age. By 36 months, a child can structure sentences as questions, and most sentences involve three or more words. Speech is fairly intelligible, although inconsistent substitutions, omissions, and distortions of consonants will be common. Between 3 and 4 years of age, a child makes important gains in phoneme production and accurate articulation of consonants in various positions in words. Omissions and substitutions are significantly reduced, and speech is 90% or more intelligible. By 5 years of age, some children will still have problems articulating the consonants /f/, /v/, /th/, /l/, /r/ or /s/. But, since these errors generally do not make speech unintelligible, speech pathologists in school settings tend to wait to see whether maturation will take care of these problems before scheduling these children for speech therapy. Between 6 and 8 years of age, a childs speech becomes virtually 100% intelligible. However, about 10% of children may need some assistance in mastering those final, more complex phonemes or in some

Chapter 23. Speech-Language Development: Oral and Written


aspect of language comprehension or expression. The average sentence involves about seven words, and any grammar irregularities are likely to be related to the childs cultural environment. In spite of this positive picture for oral language becoming adequate for the bulk of the population during the course of normal development, two major concerns remain. First, the picture for written language development is far different, as cited previously. Also, research has shown clearly that early problems in articulation are predictive of later problems in written language acquisition and that lack of phoneme awareness is a factor in both (Mann, 1993). This suggests that phoneme awareness should be routinely stimulated as a preventive early in speechlanguage development. Preventive action should also be planned to avoid written language problems by helping all children to develop and consciously connect phoneme awareness to the logic of our alphabet system for success in spelling and reading (Lindamood, Bell, & Lindamood, 1997a). Preventive action is not a waste for those with a genetic predisposition to acquire phoneme awareness; it simply accelerates their development of spoken and written language skill and the benefits and pleasures it provides (Lindamood, Bell, & Lindamood, 1997b). Second, when vocabulary and syntax are adequate, language comprehension and expression are often also assumed to be adequate. However, data from college and adult populations indicate that significant weakness in language comprehension can persist even into adulthood for significant numbers of individuals. For example, in a recent measure of performance of 60 freshmen Early Education majors on the Watson-Glaser Test of Critical Thinking, 50% of them ranked at the 20th percentile or below. In performance on the Watson-Glaser for 50 primary and

secondary classroom teachers, special education, resource, reading teachers, and speech pathologists, 28% ranked at the 25th percentile or below (Lindamood, Bell, & Lindamood, unpublished data). This should be of concern in these training programs because the weakness indicated can be identified and remediated. PREVENTING ORAL SPEECH-LANGUAGE PROBLEMS Vegetative Functions Speech is an overlaid function. The basic functions of the mouth are vegetative and involve sucking, valving, swallowing, and, later, chewing. Thus, the motor coordination of vegetative functions is a base for the motor coordinations of speech. Preventive and remedial intervention should first give attention to the vegetative acts to be certain this base is functional. The mouth at rest should be closed, with the tongue in light contact with the roof of the mouth. If the jaw is slack and the mouth open, the tongue follows the jaw and is pulled away from its normal rest position. We swallow twice a minute. If the tongue is resting down and forward instead of up and in, this encourages a tongue-thrust position in swallowing. The tongue sucks and valves forward rather than taking its normal position against the roof of the mouth, where it forms a peripheral seal while a peristaltic action moves liquids and solids to the back of the mouth for swallowing. When babies are nursed, the mothers nipple flattens between the tongue and the roof of the mouth and facilitates this normal swallowing action. When babies are bottle-fed, long firm nipples that dont flatten can interfere with this normal pattern. The MAWS Feeding Bottle with its VARIFLO nipple and the AVENT Naturally have nipples designed to facilitate


ICDL Clinical Practice Guidelines

this normal sucking and swallowing pattern and are wise choices. They are both European products, but are available widely in the United States in stores selling baby goods. It is well to avoid the extended use of pacifiers and thumb-sucking because they also interfere with the tongues normal rest position and action in sucking and swallowing and in speech. With well-coordinated vegetative functions, drooling is controlled, and the use of the tongue, lips, and mouth in articulatory action is facilitated. Vocal Play When sensory stimulation is begun by parents and other caregivers through early vocal play, an interactive relationship is established that can continue to develop and be enjoyed throughout the normal emergence and progression of language. The rationale is language emerges as a result of sensory stimuli. We see, hear, and feel and connect those experiences to form language. The procedure is to select and intensify the input of sensory stimuli basic to language. Given the brains innate tendency to imitate speech, vocal play with babies with individual consonants and vowels can be initiated very early. It is easy and fun to do and to observe their interest and response. For example, if babies are diapered on a counter or changing table, this is an ideal time for vocal play. The adults face and mouth are above the baby and close enough to give an excellent view of tongue and mouth actions. Another good time is when giving babies a bath, or anytime there can be close physical contact for a few minutes without other distractions. To make tongue actions visible, caregivers should keep their mouth as open as possible. All manner of nonspeech sounds and mouth

actions can also be included, such as tongue clucking, lip smacking, lip pursing and blowing, tongue grooving, tongue protrusion, or tongue trilling. Babies only a few months old can imitate tongue trilling. The first indication that they are registering the tongue action is when their tongue tip rises and holds on their upper gum ridge. Some time after that they will produce a trill, matching the trilling input. Because the processing of speech sounds and the human voice occur in different parts of the brain than are involved in the processing of other acoustic signals, it is important to include individual vowel and consonant sounds, too. High and low tonal contrasts should also be offered. For vocal play with vowels and consonants, the following categories and their labels are suggested from the Lindamood Phoneme Sequencing (LiPS) program (Lindamood & Lindamood, 1998), formerly the Auditory Discrimination in Depth (ADD) program. When the LiPS program is used to remediate oral and written language problems with children who can answer questions, its categories are not told; they are discovered through Socratic questioning and problem-solving experiences in analyzing the oral-motor actions that produce individual speech sounds. In preventive stimulation with infants, however, the individual sounds are simply produced in a play routine, twice with exaggerated articulation while the baby is watching, and again after approximately a 3second pause. No sound imitation occurs at first, but the babys mouth begins mirroring the stimulus mouth shape. The sensory input provided must be experienced receptively for some time before the brain begins to interact with it. With children between 1 and 3 years of age, the labels for the categories are verbalized during stimulation (i.e., Watch me make a lip popper - /p/!). This directs the childs attention to the motor production fea-

Chapter 23. Speech-Language Development: Oral and Written


tures that distinguish the sounds. The child can also feel the difference between plosive and continuant air streams by having the child feel the air stream on the back of his or her hand. Vowels There are four vowel categories, which are labeled for mouth shape. They should be stimulated in the order presented, with the easier ones to imitate given first. 1. Round sounds /OO/ (as in boot) /OO/ (as in foot) /OE/ (as in toe) 2. Open sounds /O/ (as in odd) /AW/ (as in paw) 3. Smile sounds /EE/ (as in eek) /I/ (as in it) /E/ (as in Ed) /AE/ (as in ape) /A/ (as in at) /U/ (as in up) As imitation occurs on some of these, add the Sliders, which involve sliding from one mouth shape to another. 4. Sliders /IE/ (as in ice) /UE/ (as in use) /OI/ (as in oil) /OW/ (as in owl) Consonants There are eleven categories of consonants. There are eight quiet/noisy pairs, in which each pair has the same mouth action but one sound is quiet (whispered) and the other is noisy (voiced). The whispered sound should be given first in each pair. There are also three other groups in this category for which some primary feature of the sounds is the same, and the label identifies that same-

ness. As with vowels, consonant sounds should be presented with exaggerated mouth actions. Quiet/Noisy Pairs: Lip poppers: /p, b/ Tip tappers: /t, d/ Scrapers: /k, g/ Lip coolers: /f, v/ Tongue coolers: /th, th/ Skinny air: /s, z/ Fat air: /sh, zh/ Fat pushed air: /ch, j/ Other Groups: Nose sounds: /m, n, ng/ Wind sounds: /w, h, wh/ Lifters: /l, r/ Babbling Babies babble spontaneously, producing repetitive CV syllables after enough play has occurred with isolated consonants and vowels. To increase the amount of babbling, feed back the syllables the baby has just produced. Pause to allow the baby to produce them again. To increase the variety of sounds used in babbling, feed back the sequence of syllables produced by the baby, but modify the last syllable. For example: Baby: /ba,ba,ba/ Adult: /ba,ba,ba/ Baby: /ba,ba,ba/ Adult: /ba,ba,da/ Baby: (May just listen for a while before imitating changes.) Some parents misinterpret participating in a babys babbling as encouraging baby talk. It is not. Baby talk is encouraging simplified mispronunciations of words (i.e., /boo/ for blue). Helping babies to extend and modify the babbling of syllables strengthens and enriches their experience with the building blocks of language. Even deaf babies babble initially, but the babbling extinguishes after a period because


ICDL Clinical Practice Guidelines

they do not experience the stimulation of the auditory feedback. However, when mirrors are hung over their beds so that they get visual feedback from their mouth movements, they continue to babble longer. Because of the crucial importance of early intervention for deaf and hearing-impaired babies, a coalition of 20 organizations capped a 9-year effort and attained passage of the Newborn and Infant Hearing Screening and Intervention Act by Congress in November 1999. This landmark legislation specifies that three federal agencies will work together to develop, expand, and link statewide screening programs and intervention services so that every newborn in America will be screened for hearing loss and will have access to intervention (Boswell, 2000). Single Words Naming As with the previous sensory input, babies need to experience naming input receptively for a period before they begin to name things in expressive output. Table 1 illustrates the differences between the receptive and expressive levels of naming. In naming, include single-word verbs and adjectives as well as nouns so children learn to name features and actions as well as things. For example, name the banana you are about to share, but also name what you do with it: peel, bite, chew. Use single words for what it is like: sweet, good. Also, use synonyms to

give exposure to more than one name for something. In this way, children are stimulated with single-word language that they soon use. This emphasis on providing stimulation with single words will not deprive children of exposure to the language they will use eventually because phrases and sentences are receptively stimulated whenever others are conversing around them. Exaggerate the final consonants in pronouncing words. Children perceive initial consonants earlier than final consonants unless the final consonants are given extra attention. When possible, hold objects being named next to your mouth to permit the child to synchronize the auditory and visual input. When saying words ending in the plosive sounds /p, b/, /t, d/, /k, g/, or /ch, j/, say the words against the childs hand so the exploded air can be felt, since it cannot be seen. Again, this permits a synchronized experience with the auditory and kinesthetic input and increases the sensory experience with the words. Phrases and Sentences In developing a childs phrases and sentences, use gesture to pantomime actions, size, shape, or movement when possible to provide visual images for the meaning of phrases and sentences. Synchronize these meaningful gestures with language. Verbalize about your activities: what you are doing, what you are noticing, what you are thinking. Table 2 illustrates the differences between the

Table 1. Receptive and Expressive Levels of Naming Receptive Level Hears own name, looks at self in mirror Touches body part named Points to people named Points to objects named Does actions named Expressive Level Names self Names body parts Names people Names objects Names actions to manipulate environment

Chapter 23. Speech-Language Development: Oral and Written


Table 2. Receptive and Expressive Levels in Phrase and Sentence Use Receptive Level Complies with noun/verb or noun phrase request Complies with sentence request receptive and expressive levels in phrase and sentence use. The suggested progression will assist the development of speech-language in three important ways. First, by starting at the sensory level to stimulate conscious awareness of the distinctive motor-kinesthetic, visual, and auditory features of phonemes, a child will develop phoneme awareness. Second, this progression also provides a strong support base for the later development of written language. Phoneme awareness has been documented in worldwide research as the best single predictor of success in acquiring written language skills (Shankweiler and Liberman, 1989). Third, stimulation of images for the meaning of words and the ideas expressed by language increases comprehension of oral and written language. Individuals with strong imagery for words have the benefit of dual coding of language (Paivio, 1996). REMEDIATING DELAYED LANGUAGE DEVELOPMENT Oral Language Delay What if oral speech-language development is obviously delayed? It is not uncommon for pediatricians to tell parents who are concerned because their 3-year-old does not have intelligible speech to relaxthat their child may just be a late bloomer. There are many reasons to take preventive action instead, primarily because speech-language delay also causes problems in several other Expressive Level Uses noun/verb or noun phrase to manipulate environment Communicates with sentences areas of development. Therefore, it would be highly desirable for pediatricians to lead in preventive action. Speech-language stimulation can be light and fun for both the person providing the stimulation and the one receiving it. Pediatricians could arrange with speech pathologists to teach parenting groups the art of enjoying vocal play with their babies, starting very early and then continuing through the progression of language development just described. From the field of behavioral psychology, the research of Hart and Risley (1996) strongly supports preventive action. In a 21/2-year longitudinal study, they observed 42 families for an hour each month to learn what typically went on in homes with 1- and 2-year-old children learning to talk. They report that the most important difference among the families was the amount of talking that went on within five categories of quality features: language diversity; proportional amounts of feedback tone providing encouragement and discouragement; emphasis on names, relations, and recall; an interactive style focused on asking rather than demanding; and responsiveness stressing the importance of the childs behavior during an interaction. In extrapolating from their observational data, Hart and Risley found significant differences in the amount of talking related to socioeconomic status (SES) differences. In a 100-hour week, the average child in the professional families was provided with 215,000 words of language experience, whereas the average child in a working-class family was provided with 125,000. The average child in a


ICDL Clinical Practice Guidelines

welfare family was provided with 62,000 words of language experience. A reverse pattern emerged for SES differences related to childrens hourly verbal encouragements versus discouragements from parents. In professional families, the average child accumulated 32 affirmatives and 5 prohibitions per hour, a ratio of 6 encouragements to 1 discouragement. In working-class families, the average child accumulated 12 affirmatives and 7 prohibitions per hour, a ratio of 2 encouragements to 1 discouragement. In welfare families, the average child received 5 affirmatives and 11 prohibitions per hour, a ratio of 1 encouragement to 2 discouragements (Hart & Risley, 1996, p. 199). Extrapolating these weekly and hourly differences to estimate differences in childrens cumulative verbal experiences makes it easy to understand why these differences were strongly linked to differences at age 3 in rates of vocabulary growth, vocabulary use, and general accomplishments, and strongly linked to differences in school performance at age 9 (Hart & Risley, 1996, p. 193). Hart and Risley point out that daycare providers and parents need specific training if they are to help close the gap for lower SES children. It is clear from these data that it is vital to have well-planned and funded intervention to help parents and other caregivers understand the critical effect on childrens speech-language development of the amount of time spent talking with them, the importance of an encouraging tone of voice, and why this input must begin in the infant years. However, the number of single words that a child recognizes and uses is not in itself a guarantee of language comprehension when those words occur in sequence to express ideas, requests, and questions. The ability to create visual images for the gestalts being expressed by language is an additional processing level that must not be taken for

granted. The problem is less likely to be recognized as a lack of imagery for language, and is often thought to be related to less intelligence or a problem in paying attention. Fortunately, in our experience we have found the ability to create visual imagery for language can be directly stimulated with special procedures, with life-enhancing effects. (See Bell, Chapter 25, this volume.) Written Language Delay What if written language development is delayed, not only in first and second grade when children are first learning to read, but through middle and secondary schools and into adulthood? Currently, the general guidelines that public schools work under require a childs reading skills to be 2 years or more below grade level before remedial services can be offered through Federal Title I funding. Compare this to a child having a physical illness. Would we require a child to be ill for 2 years before diagnosis and treatment could be provided? Research has shown that the lack of phoneme awareness is the primary cause of problems in learning to read, that it is a genetic tendency (DeFries, Fulkes, and Labuda, 1987), and that there is neurophysiological evidence that lack of phoneme awareness is related to brain structure and function differences. Given this information, is it reasonable then to require a child to endure this cause of an illness in learning to read for 2 years before treatment is officially considered appropriate? And, when medical treatment is offered to an ill child, would doctors offer the same treatment that did not work before? This is commonly the situation in educational settings when retention has been the solution to below-gradelevel reading. Fresh thinking and action in the educational field are required to address reading difficulties.

Chapter 23. Speech-Language Development: Oral and Written


Fortunately, more and more parents are becoming advocates for their children and are seeking out and demanding adequate intervention (Kantrowitz and Underwood, 1999). Unfortunately, when early intervention has not been provided or has not been successful, well-meaning but poorly informed educators, psychologists, and doctors may incorrectly advise parents that older students who are not reading well by middle-school age cannot be expected to overcome their problem. It is usually suggested that efforts must be directed instead toward making use of various compensatory strategies rather than pursuing intervention regarding the cause of the problem. Alternatively, individuals are often advised to pursue a livelihood that does not require reading. Is there such a thing today? On the basis of 30+ years of clinical and classroom experience, the author can say that age is not the issue in successful remediation of written language problems. The issue is that diagnosing and treating the cause(s) of the problem rather than the symptoms enables older as well as younger individuals to develop functional reading language skills. What if it is the encoding/decoding aspect of written language that is delayed? As discussed earlier, lack of phoneme awareness can be predicted if encoding (spelling) and decoding (word attack and word recognition) are the problem. What if decoding is accurate, but comprehension of what is read is the problem? Lack of, or partial and indistinct images for the ideas expresseda lack of concept imageryis revealed when the problem is comprehension of written language rather than decoding. And again, the need can be addressed both developmentally and remedially. Another way to describe these two problems is that they both involve difficulty with part/whole relationships, but from opposite

directions. In lack of phoneme awareness, for example, the person perceives a spoken word as a whole and cannot accurately identify and sequence the individual parts that comprise it. In lack of concept imagery, the person gets bits and parts, but doesnt comprehend the wholeness or gestalt of the message. It is encouraging to report, however, that success can be expected in addressing these problems in part/whole relationships with special procedures. INTERVENTION PROGRAMS The brain only receives information through the senses, and two levels of sensory processing are important. The first level is speed and magnitude of processing. How soon and with what vigor does the brain register incoming sensory information? Electrophysiology measures provide some objective information about this, and more access to this level of measurement would provide information that could assist improvement in treatment procedures. The second level involves incoming information from the three primary senses (auditory, visual, and motor-kinesthetic). How does the brain consciously process and integrate information so that these three senses support and augment each other? How are these senses additionally integrated with language for the cognitive benefit of dual coding (Paivio, 1986)? Performance measures can provide information about this to determine the effectiveness of intervention procedures and programs. Various interventions are effective in preventively and remedially developing this sensory processing and integration if they are used for the processing needs for which they were created. This is where the diagnostic evaluation makes its critical contribution. The battery of tests needs to be carefully chosen to


ICDL Clinical Practice Guidelines

provide a variety of performance information. When that information is appropriately interpreted, the diagnostic evaluation will indicate the areas of intervention that are needed. The next section describes the LindamoodBell intervention programs. Other technologies that facilitate language and motor function will be described in Chapter 24. Lindamood-Bell Sensory-Cognitive Programs Lindamood-Bell have developed intervention programs for five areas of learning need identified during the 30 years they have been engaged in diagnosis, clinical and classroom intervention, and research. The following sections describe these areas of learning need and the progression of small processing steps that must be developed through intervention. There is an important difference between most language intervention programs (including the technology-based programs described in Lindamood, Chapter 24, this volume) and the LindamoodBell programs described here. The difference is the degree to which sensory information is brought to a conscious level from the auditory, visual, and motor-kinesthetic modalities, made concrete, and integrated with language in a dual-coding support system. This approach enables both children and adults to own the sensory information and its relationship with language, and assists them in accessing both to crosscheck information. This process supports thinking and reasoning about relationships between parts and wholes involved in learning tasks. To understand the development, structure, and interrelationship of LindamoodBell sensory-cognitive programs, again we return to dual coding theory: Cognition is proportional to the degree to which images and language are integrated (Paivio, 1994).

Topping the array of research supporting this simple statement is a layer of our own experience as learners: for the things we know best, we have both sensory experience and rich and detailed mental imagery. This dual knowledge enables us to talk easily about our experiences, which enables us to think critically about them. That is how we know something and can reason about it even when the thing is not physically present: our images and language bring it into our central nervous system. For example, it is said that Native Americans in the far north have a very large number of words to describe snow. They have become aware of contrasts in the look, feel, sound, taste, and smell of snow that we more southern folks probably could not, at first, notice. They developed multisensory images of snow, they talked about and labeled their sensory awareness of differences in snow, and the labels captured and crystallized the sensory awareness. The sensory input/images triggered language, and the language strengthened the imagery. Noticing sensory contrast enables language, and language enables noticing. This reciprocal relationship between language and sensory-cognitive processing/imagery is the backbone of five sensory-cognitive programs developed at Lindamood-Bell Learning Processes. Their descriptions follow. Lindamood Phoneme Sequencing (LiPS) Program The discovery of the causal role of individual differences in phonemic awareness in producing differences in the development of reading skills is one of the most important findings in reading research during the last 20 years. As a result, however, educators must decipher the meaning of at least three now very familiar (but often misunderstood) phrases known as the PH terms: phonics,

Chapter 23. Speech-Language Development: Oral and Written


phonemic awareness, and phonetic or phonological processing. The differences among these concepts tend to confuse many who are trying to learn how best to help students. Does phonics develop phonemic awareness or phonetic processing? Or both? Or neither? Which is the cart and which is a horse? And what is the other one? It doesnt help that publishers have sprung into action adding PH words on their boxes and in their catalogs, sometimes without making any appreciable changes in program content. A simple understanding of these terms is of considerable help in understanding how various programs that address phonemes, phonics, and phonetic processing compare. Phonemic awareness is a sensory-cognitive ability to think about and manipulate sounds within words; it is an oral language processing function. Phonics is instruction about how letters represent sounds in our language; it is written language instruction. Phonetic processing is the ability to decode written words, and requires both phonemic awareness and phonics knowledge. Students can learn phonics information (the letter p says /p/, an e at the end of the word usually makes a vowel say its name) without phonemic awareness; but without phonemic awareness, they cannot do phonetic processing. They cannot apply their phonics knowledge about sounds and letters for fluent and accurate phonetic processing unless they can detect phonemes within words. Without phonemic awareness, students cannot detect decoding errors unless a disruption in meaning clues an error. In addition, without phonemic awareness, students cannot selfcorrect even when meaning does clue an error because they cannot determine the nature of their error. So, phonemic awareness is the horse and it pulls several carts: phonetic processing in reading and spelling, rhyming, and other phoneme-manipulation

tasks such as elision and substitution. (Another horse that pulls the phonetic processing cartsymbol imagerywill also be discussed later in this chapter and in Chapter 25.) The PH-word concepts provide background for categorizing the LiPS Program. It is truly a phonemic awareness program that also includes phonics instruction and application of phonemic awareness to phonetic processing in both reading and spelling. Before addressing letter symbols, the LiPS program engages students in discovering the articulatory gestures that differentiate phonemes so that they can use oral-motor feedback to concretize, track, and prove the identity, number, and order of phonemes in words. Second, LiPS engages students in a variety of phoneme tracking experiences that directly require application of the newly developed awareness of articulatory feedback. Then, as they learn the symbols that represent phonemes, students have only a half step to take into reading and spelling. Having already begun to sequence phonemes at a very concrete level, such as with mouth pictures, it is quite easy for students to grasp the logic of the alphabetic principle and the use of letters for sequencing phonemes. Also, all the instruction is delivered in a discovery format through the use of questioning techniques that connect students to sensory experiences in order to form concepts. In summary, LiPS stretches from a prereading level where phonemic awareness is developed, into single syllable, multisyllable, and contextual reading levels in which phonemic awareness and orthographic expectancies are applied. Steps in the LiPS Program The following steps comprise the key elements of the LiPS Program. 1. Setting the climate: Students are helped to understand what they will be doing and


ICDL Clinical Practice Guidelines

whylearning to feel as well as see and hear speech sounds in order to make reading and spelling easier. 2. Consonants: Students discover how each of the consonant sounds are articulated and use that sensory information to organize them into pairs and groups. Simple, high-imagery labels are attached to each category (e.g., lip poppers /p, b/, tongue lifters /l, r/) to enable teacher and students to communicate clearly about sounds within words in subsequent steps. For example, When you say /clap/, what do you feel last? 3. Vowels: Here, too, students discover how the sounds are articulated, and use that sensory information to organize the sounds into mouth shape categories such as Smile, Open, Round, and Sliders. 4. Tracking: As soon as students have awareness of the articulatory gestures for a few consonants and vowels, they need to begin using their oral-motor awareness to track the identity and order of phonemes in spoken words. They learn to use mouth pictures to show what they feel first in a word, and what comes right after that, and so on. Figures 1 and 2 are examples of mouth picture tracking.

colored blocks to show sounds in the tracking task (see Figures 3 and 4).
Figure 3. If that says/snip/... Figure 4. me/skip.

The labels (e.g., lip popper, tip tapper) are used as the teacher asks questions about what students feel and as students verbalize contrasts between words. Thus, phonemes are dual coded at each step with imagery and language. 5. Decoding and spelling: Tracking establishes a base for students to grasp the logic of coding speech sounds with letters. In decoding, Since I see an L right after the smile vowel, I will have to make my tongue do a lifter there. As phonetic processing emerges, orthographic expectancies are introduced so that students begin to integrate phonetic processing with an ability to predict how words will be spelled or read. Sight words also are stimulated so that students can progress simultaneously into fluent contextual reading and writing. Tracking, spelling, and reading are kept synchronized as work progresses through words with simple, complex, and multisyllable structures, in an age-appropriate format for the student. The intensive, concrete, dual-coded processing stimulated in the LiPS Program makes it quite different from others labeled as phonemic awareness programs. Although various studies show training in phonemic awareness to be effective in helping students understand the alphabetic principle and develop independent word reading skills, research points to a common problem in that phonemic awareness training procedures may

Fi Figure 1 1. Sh /if/ Show me.../if/.

Figure 2. That says/if/, now show me/it/.

Then, to move onward from this very concrete phoneme tracking, students use

Chapter 23. Speech-Language Development: Oral and Written


not be powerful enough to aid students who are most at-risk for the development of reading difficulties. For example, both Torgesen et al. (1992) and Lundberg (1988) found that a significant number (20%-30%) of the least able students were unable to profit from their phonemic awareness training procedures. These students are not missed if phonemic awareness stimulation is very concrete, with sensory experiences captured by language, as in the LiPS Program. For example, Alexander, Heilman, Voeller, and Torgesen (1991) used LiPS (then called the ADD Program) with a group of severely reading-disabled students with an average age of 10 years, 9 months. They had been unable to benefit from either regular classroom instruction in reading or resource help with several different remedial programs. After 65 hours of clinical intervention, this group of 10 students improved from an average standard score of 77 on a measure of alphabetic reading skills to an average of 98.4 (standard score mean=100). The poorest reader in the group improved his standard score in reading from 62 to 92, which placed him in the average range. This group of students had begun treatment with an average score on a measure of phonological awareness of 57.9 (minimum score recommended for their grade=86), and had improved to an average score of 99.9 following treatment. Although these students had been unable to progress in reading instruction previously, their situation changed after the development of their phonemic awareness and its application to decoding. Dr. Joseph Torgesen, one of the principal investigators in this study, states that a subsequent report after follow-up testing during the next 2 years indicated these students were continuing to gain in growth of sight word vocabulary and passage comprehension. To my knowledge, this is the first time we have observed a remedial study with older students

severely impaired in reading ability documenting continued growth after the instructional intervention is over. (Personal communication with permission to quote.) This significant effect for very at-risk students can also be seen in LindamoodBell clinical data on 76 students, randomly selected, who were seen individually for an average of 98 hours of LiPS combined with the Seeing Stars program (described later in this chapter). We routinely combine the two programs for students who have a severe lack of phoneme awareness because the Seeing Stars program develops students ability to make mental images for sequences of letters. We have found the ability to create symbol imagery interacts with phoneme awareness, and results in more fluent decoding as well as better gains in spelling. The group, composed of 36% females and 64% males, ranged in age from 6 to 18 years, with a mean age of 10 years, 3 months. The average pre- and posttest gains in percentile rankings shown on the various measures indicated in Graphs 1A and 1B that follow were all significant at the p<.05 level. Several preventive studies using LiPS to stimulate phonemic awareness and its application to reading and spelling in kindergarten and first grade have demonstrated strongly positive results. There are three primary reasons for its success. First, LiPS can stimulate phonemic awareness for all students in a classroom setting, with highly significant effects on word attack, word recognition, spelling, and reading comprehension. Second, stimulating a conscious processing base of phoneme awareness is productive for students who are not high-risk for reading difficulty as well as for those who are. And third, early phonemic awareness stimulation with LiPS produces advantages in written language skills that continue into high school (Lindamood, Bell, & Lindamood, 1997b). We


ICDL Clinical Practice Guidelines

Graphs 1A and B. Pre- and Post-Test Percentile Rankings on Various Measures for Students in a Combined Lips Seeing Stars Program Graph 1A.

75 50 25 0

75 63 50 19 21 47 21 42 18 32

Oral Directions

Word Attack

Word Recognition #1 Word Recognition #2




Graph 1B.

75 50 25 0 42

58 37 16 Problem Solving Reading Accuracy Pre-Test 37

63 37 16 Reading Comprehension Math-Word Problems Post-Test

are beginning to gather data on the effect on spelling and fluency in reading of combining the LiPS and Seeing Stars programs to focus on integrating stimulation of phoneme awareness and symbol imagery. Initial trends appear to indicate this is a productive approach, but more data are needed before we can publish findings. The concern is that significant gains in spelling and reading fluency have consistently been less predictable than decoding gains after development of phoneme awareness and sequencing. It will be a contribution to intervention if we are able to

document that there can be a better effect in those two areas if we directly stimulate symbol imagery along with phoneme awareness. Visualizing and Verbalizing for Language Comprehension and Thinking (V/V) In contrast to the LiPS Program, which stimulates accuracy and self-correction in decoding and spelling, the V/V Program stimulates concept imagery to develop language comprehension and higher-order

Chapter 23. Speech-Language Development: Oral and Written


thinking skills. Where LiPS develops students ability to process the smallest parts of language, V/V develops students ability to process gestalts of meaning, in which the whole is larger than the sum of the parts. The instructional procedures of the V/V Program are supported by dual coding theory; that is, visual imagery for language can produce powerful effects on the memorability and comprehensibility of sequentially presented material such as oral or written discourse. In the V/V Program, students are helped to discover that they can create visual images for single words, and can add more imagery to comprehend single sentences. They can then connect imagery for a first sentence to imagery for the next sentence and so on until a mental movie has captured an array of detail into a gestalt. The ability to create images is generally assumed in many comprehension programs, but the V/V Program actually helps students develop this ability where it is lacking (whether due to environmental or genetic influences, or both). Many of the same discovery and questioning techniques that are employed in the LiPS Program are utilized by the V/V Program. This is because teachers cannot create sensory experiences for students by telling them information; teachers must ask questions that cause students to check and notice sensory experiences. Similar to the LiPS Program, the V/V process first addresses the sensorycognitive function that underlies the skill students need to acquire. The horse in this case is concept imagery, which is the ability to create mental images for meaning of language, and the cart it pulls is language comprehension and expression. Vocabulary is also tightly related to imagery and comprehension, either as a second horse or second cart, depending on how it is conceptualized. Perhaps vocabulary should be pictured as the harness con-

necting the horse to the cart, connecting imagery to comprehension. (For further discussion of the V/V process, see Bell, Chapter 25, this volume.) Steps of V/V Program The following steps make up the key elements of the V/V program. 1. Setting the climate: Answers the questions of, What is the teachers job? What is the students job? 2. Picture to picture: Develops students ability to verbalize about given pictures before they verbalize their own mental images. 3. Word imaging: Develops detailed imagery for the meaning of single nouns. 4. Sentence-by-sentence imaging: Begins developing an imaged gestalt as detailed imagery is added and changed sentence by sentence through a paragraph. 5. Sentence-by sentence-imaging with HOTS (Higher-Order Thinking Skills): Begins stimulating students ability to use imagery for main idea, inference, conclusion, and prediction. 6. Multisentence imaging: In steps 5 through 8, students gain experience in capturing increasingly larger amounts of language in their imagery. 7. Paragraph imaging. 8. Paragraph-by-paragraph imaging. 9. Whole-page imaging. Graph 2 shows clinical data for 58 students, randomly selected, who were seen individually for an average of 96 hours of V/V. The group, composed of 53% females and 47% males, ranged in age from 6 to 47 years, with a mean age of 14 years, 7 months. Pre-and post-test average percentile gains on all measures indicated were significant at the p<.05 level of confidence.


ICDL Clinical Practice Guidelines

Graph 2. Pre- and Post-Test Average Percentile Gains on Various Measures by Students in a V/V Program

75 50 25 0 Problem Solving 9 42 25

75 63 50 25 50

Oral Directions Pre-Test

Reading Comprehension Math-Word Problems Post-Test

We have used V/V with many highfunctioning autistic/autistic spectrum students. Although autistic students are often thought to have strength in visual processing and visual-spatial imagery, it is our clinical experience that there tends to be a significant weakness in connecting images to language and language to images. In other words, dual coding tends not to occur for autistic students. However, tends not to occur does not mean will not occur for students. In applying V/V with students in our clinics, it has been our experience that dual coding can be stimulated even for students on the autistic spectrum, with measurable improvement in language comprehension and expression. Temple Grandin, a high-functioning autistic individual who is a professor of animal behavior and also a celebrated author, speaker, and researcher on autism, has analyzed her own problems with language. Her description of how she specifically has to assist herself to express her thoughts with language is remarkably similar to the imagery process Bell (2000) has developed, which has successfully assisted autistic as well as nonautistic individuals to improve their receptive and expressive language (see Bell, Chapter 25, this volume). Grandin

reports, In my brain, words act as a narrator for the visual images in my imagination When I am talking about something for the first time, I look at the visual images on the computer monitor in my imagination, then the language part of me describes those images (Grandin, 2000, p. 14). She describes this occurring as two separate steps for her, but believes they occur merged into one seamless consciousness for most people. Her assessment is striking because early in the V/V progression we see this two-step processing occur, but we also see the twostep process merging into one process as treatment is continued. The question in our minds is Would this merging of images and language occur and become seamless for Grandin if we took her through the small steps of processing in the V/V Program that enable the merged processing to develop? Grandin also verifies our clinical observation that autistic spectrum individuals tend to give more attention to details or to parts and miss the big picture, the whole or gestalt. Grandin states, I look at lots of little details and piece them together to make a concept. (Grandin, 2000, p. 18). She has figured out how to serve her comprehension needs by consciously making use of her inclination to

Chapter 23. Speech-Language Development: Oral and Written


give attention to details. However, autistic spectrum students in general need to be directly helped to discover they can do this to create an imaged gestalt for comprehension of spoken or written language. Seeing Stars: Symbol Imagery for Phonemic Awareness, Sight Words, and Spelling Seeing Stars is Lindamood-Bells other imagery program. Compared to Visualizing and Verbalizing, it addresses what we call the other side of the coin: not the ability to image the meaning of language but the ability to image the orthography of language, the letters and letter patterns of the written language. In her imagery chapter, Bell (Chapter 25, this volume) presents considerable evidence for the role of symbol imagery in phonemic awareness, spelling, word attack, word recognition, and fluency. She reports strong correlations between performance in these areas and imagery for letters in words. More important than the existence of symbol imagery as a sensorycognitive process and its relationship to written language processing is that symbol imagery can be stimulated. Even more important, stimulating symbol imagery produces significant gains in phoneme awareness, decoding, spelling, and reading in context. The steps of Seeing Stars stretch from imaging single letters, to imaging simple syllables (such as /if/, /fip/, and /cab/), to imaging complex syllables (such as /ask/ or /streak/), to imaging multisyllable words, to using imagery to learn specific sight words and spelling words, and on to applying symbol imagery to reading in context. Each step includes specific symbol imagery exercises such as naming requested letters (e.g., What letter do you picture after the r?), decoding the imaged word (e.g., The word youre picturing says ?),

and manipulating the image and decoding again (e.g., Take out the Twhat letters do you picture? So that says ?) Classroom findings indicate that these steps are very appropriate for students just beginning to learn about sounds and letters because symbol imagery instruction strengthens phoneme awareness and phonics instruction. For example, after observing early indications of a future phonemic awareness problem in her own daughter at 2 and 3 years of age, Phyllis Lindamood offered articulatory stimulation coupled with symbol imagery stimulation (LiPS and Seeing Stars) in a light and lively fashion. This could be quite manageable for many parents, and could prevent some early failure experiences for children, as it seems to have done for Phylliss child. Symbol imagery stimulation impacts far more than sound/symbol associations; we have shown its effects beyond phonics knowledge on phonemic awareness and phonetic processing. When teachers stimulate both articulatory feedback and symbol imagery for students, the students grasp of the alphabetic principle is strong, and their reading and spelling performance is significantly strengthened. Students and teachers then have a very concrete sensory reference for the elusive phonemes within words (articulatory feedback) as well as a rapid visualsensory reference (symbol imagery). Thus, when they need to, students can do slow and careful phonetic processing using articulatory feedback and, using symbol imagery, can shift to the faster processing that fluency requires. Even when teachers do not develop students use of articulatory feedback to concretize phonemes, symbol imagery can serve a concretizing function that supports phonemic awareness and phonetic processing. (See Bell, Chapter 25, this volume, for more detail on symbol imagery.)


ICDL Clinical Practice Guidelines

Steps of the Seeing Stars Program The following steps are key elements of the Seeing Stars Program. 1. Imaging letters: Stimulating sound/letter relationships and imagery for consonants and vowels. 2. Syllable cards: Stimulating the ability to image a word from a model (a card with a word on it) and decoding/encoding for single-syllable words using orthographic expectancies. 3. Syllable board: Generating symbol imagery from a spoken word (whole to parts) or spoken letters (parts to whole). Students also get motor-kinesthetic input at this step as they finger-write on a hard surface. 4. Imaging syllables with and without a chain: Stimulating symbol imagery and decoding/encoding for single syllable words. 5. Imaging sight words: Establishing visual memory and instant recognition. 6. Imaging spelling: Establishing visual memory for orthographic expectancies and real-word spelling. 7. Multisyllable reading, spelling, and imagery: Decoding/encoding imaging of affixes, use of multisyllable syllable cards, multisyllable syllable board, and multisyllable reading and spelling of real and nonword lists. 8. Contextual integration: Applying word attack and word recognition skills to contextual reading, with symbol imagery to print-comparing stimulated for rapid selfcorrection. Vanilla Vocabulary Vocabulary development is, appropriately, a major concern for those trying to help students with learning difficulties. A good vocabulary does not result in good compre-

hension and reasoning, but a weak vocabulary will limit comprehension, reasoning, and communicating. Teachers at every grade level see this issue in action: students who can decode words that have no meaning for them, or the difficulties of teaching new concepts when students have terrible gaps in basic vocabulary. Although teachers may be well aware of their students vocabulary needs, when asked how they help students develop vocabulary they typically talk about their frustrating search for tools and how little effect their efforts have. It is the premise of the Vanilla Vocabulary program (Bell & Lindamood, 1993, 1998), that studying wordsan unfamiliar word and more unfamiliar words to define itoften does not result in significant vocabulary growth because it does not result in dual coding. Unless words are tightly integrated with the sensory input of imagery, they tend not to become a part of ones functional vocabulary. Vocabulary drills often make individuals familiar with a word in terms of having heard it but do not stimulate enough imagery to enable use of the word in speaking or to gather complete meaning when listening and reading. Stimulating vocabulary with concept imagery (dual coding) is really quite straightforward with the structure that Vanilla Vocabulary provides. Beginning level (Book 1) and intermediate level (Book 2) words are defined by using high-imagery language to enable dual coding. For example, compare an American Heritage School Dictionary definition with a Vanilla Vocabulary definition: Dictionary: illusion an appearance or impression that has no real basis, i.e., creating the illusion of depth in a painting. Vanilla Vocabulary: illusion something that seems to be real, but is not. The castle towers appeared higher than the clouds but it was only an illusion.

Chapter 23. Speech-Language Development: Oral and Written


The Vanilla Vocabulary definition is created to provoke imagery. The high-imagery definition is followed by three simple, but high-imagery sentences for students to visualize using the new word. Many dictionaries do not provide sentences to further illustrate the meaning of words. It is not assumed that students will form an image just because Vanilla Vocabulary definitions and sentences are high imagery. Teachers are directed to question students about what they are picturing, using choice and contrast to develop vivid, personal imagery. Then, students visualize and verbalize to create their own sentence using the target word. As students master the new vocabulary by visualizing and verbalizing, there are companion books intended for reading aloud which use the target words again in humorous, high-imagery stories titled Ivan Sleeps Over and Ivan, King of the Neighborhood (Bell & Lindamood, 1997). On Cloud NineVisualizing and Verbalizing for Math While the sight words versus phonics versus whole language wars raged in the field of reading, the manipulatives versus memorization wars raged in math. Manipulatives have been used for years in teaching math (Stern & Stern, 1971), but many individuals who experienced success with this most concrete level failed in the shift to computation (Moore, 1990; National Council of Teachers of Mathematics, 1989; Papert, 1993). Some students could think logically in problem solving but couldnt seem to memorize the math facts that enable rapid processing. Others could memorize facts but couldnt seem to reason with those facts in word problems. At Lindamood-Bell, as we looked at students struggling with math, we saw the same critical sensory input/imagery/language link that had resulted in solutions for students with

decoding and comprehension problems. The missing link in the math wars seemed to be imagery: concept imagery and numeral imagery at a conscious level. Students who are not imaging do not leave behind the manipulatives and move on to mental imagery so that they are able to do mental manipulations with numbers. For individuals to grasp math concepts, reason with numbers, and compute accurately, concept imagery and numeral imagery are critical sensory-cognitive precursors. The On Cloud Nine math program moves through the following three basic steps to develop mathematical reasoning and computation: 1. Using manipulatives to experience the realness of math. 2. Using imagery and language with those manipulatives to concretize the realness in the sensory system. 3. Using numeral imagery and concept imagery to apply computation to word problems. The following specific steps illustrate how the program links sensory experience to language to concept imagery to numeral imagery. The goal is dual coding in math. Steps of the On Cloud Nine Program The steps of the On Cloud Nine Program begin with setting the climate, and proceed according to the increasing difficulty of number concepts, as follows: 1. Imaging numerals 2. Imaging the number line 3. Addition family facts 4. Subtraction family facts 5. Word problems 6. Place value 7. Jumping 8. Carrying and borrowing


ICDL Clinical Practice Guidelines

9. 10. 11. 12.

Multiplication Division Decimals Fractions and a step-ladder Drawing With Language

Because some individuals have adequate visual-motor processing, they easily think about and generate drawings. (By drawings, we mean anything where lines and space create a figure. A drawing is not just artistic pictures such as nudes and still lifes, but letters and numbers, maps, diagrams, geometric figures, and such.) But some individuals, especially young children, have difficulty processing visual-spatial relationshipsthe whole and the parts. These difficulties can persist beyond the developmental norm, causing individuals to have difficulty with print and handwriting, copying from the board, organizing work on the page, and interpreting graphically presented information. Based on the number of individuals referred to our clinics, those with weak visual-motor processing as the primary difficulty seem to comprise a smaller group than those with weak decoding or comprehension. Alternatively, perhaps educators and parents tend to view weak visual-motor processing as less of a problem and so are less concerned about it. The fact that fewer students are referred for difficulty in drawing than for difficulty in reading does not diminish the very real and negative effects for students. Although individuals certainly vary in the fine motor coordination needed to grip a pencil and generate a line, this variation does not account for the difficulties regularly seen as weak visualmotor processing. For example, Cody, a high school student, made many careless errors in math due to numeral misalignment and poor legibility, and often lost his way in unfamiliar physical environments. He could form

single lines in any direction, but had extreme difficulty recalling and drawing lines in relationships in even fairly simple figures, such as that shown in Figure 5, the Detroit Test of Learning Aptitude, Design Reproduction Subtest. The stimulus figure is shown for a specific number of seconds, then removed and the individual draws the figure.
Stimulus Response

Figure 5. Comparison of Stimulus and Student Response in a Design Reproduction Subtest

In our clinics, we have found that connecting language to sensory input/imagery is as effective with visual-motor development as with the other sensory-cognitive functions we address. We see significant improvement for students such as Cody through what we call our Drawing with Language Program. This program stimulates an individuals ability to: verbalize the units and relationships involved in drawings, and visualize those units and relationships as a mental model from which to compare and reproduce them. Steps of the Drawing with Language Program The following steps are key elements of the Drawing with Language Program. 1. Setting the climate 2. Collecting language for drawing 3. Learning three kinds of lines 4. Line-by-line production: verbalize-visualize-draw 5. Shapes 6. Designs and symbols 7. Drawings 8. Application

Chapter 23. Speech-Language Development: Oral and Written


In early steps, students learn to use language to create a mental image, compare what they drew to the model, and describe exactly how and where corrections need to be made. Although comparing a drawing and a model point by point can be a slow process, it is this ability to compare a stimulus and a response that results in self-correction. As verbalizing becomes more automatic and internalized, it becomes the inner language that the frontal cortex uses to direct the members of the orchestrathe visual and motor cortices. As visualizing becomes more automatic, imagery becomes the means of comparing drawing to model, a much more rapid process. As with other Lindamood-Bell programs, the goal is to address sensory-cognitive functions so that a person develops independent and, ultimately, rapid and automatic self-correction and accurate processing. Programs and Technology CD-ROMs are presently available for the LiPS and V/V programs, and the other programs are targeted for future CD-ROM support. Through careful planning, the technology contains interactions that border on artificial intelligence in providing feedback on error responses. This means technology can provide additional problem-solving practice that furthers the development of dual coding and rapid, automatic sensory-cognitive processing. CONCLUSION This chapter has presented issues in the prevention and remediation of problems in oral and written speech-language development. It also has included ways that can be used either preventively or remedially to approach problems in math and visual-spatial cognition because of the interactive roles of

sensory processing and language in these areas of learning as well. An over-arching theme in this chapter was the issue of parts/wholes relationships in sensory-cognitive processing. Our clinical experience at Lindamood-Bell makes us wonder if satisfying three conditions might enable us to teach virtually anyone virtually anything. These conditions are: 1. If we are able to identify, label, and experience the units involved concretely enough at the sensory level to bring them to consciousness. 2. If we use the labels, sensory information, and language to track and compare the relationships of the units. 3. If we think and reason together about how the units and relationships combine to create and form the whole that is greater than the sum of the parts. A secondary theme in this chapter was the evidence that there is sufficient research to drive practice in some of these areas of learning needs. Does this mean we shouldnt explore the use of emerging preventive and remedial practices until definitive research is available on their efficacy? The answer to that question is No. We can use emerging practices so long as they cannot harm children and there is a body of anecdotal support for their positive effect. Recent developments in technology are now making it possible for medical research and clinical practice to complement each other. Pilot findings from beginning efforts to look at brain functions pre- and postLindamood-Bell treatment indicate there may be information from fMRI and electrophysiology measures documenting that appropriate stimulation enables brain functions to become established or improved. These measures, analyzed in combination with performance measures, give hope of further progress


ICDL Clinical Practice Guidelines

in meeting the need for oral and written communication for more children and adults. We will soon conduct research aimed at answering the many questions that remain relative to management of intervention. It is our expectation that sorting by age groupings, severity of processing deficits, intensity of treatment (4 or more hours of daily intervention compared to the more common 1 hour), and single areas of processing need compared to two or more will generate information that will lead to better prognosis and treatment recommendations. Being (and feeling) competent in communicating through either oral or written language

is a base upon which a person can manage the rest of lifes demands. If we, as therapists, provide intervention in these areas we should never be satisfied with just our current efforts. Nor should we be isolated in our efforts. As discussed further in the next chapter, our goal should be to strive toward advances that we know may be possible through research on combining intervention programsrather than through research that compares intervention programs. Such research should be with programs in our own field as well as with programs of other discis plines in the team effort needed.

Chapter 23. Speech-Language Development: Oral and Written


REFERENCES Alexander, A., Anderson, H., Heilman, P. C., Voeller, K. S., & Torgesen, J. K. (1991). Phonological awareness training and remediation of analytic decoding deficits in a group of severe dyslexics. Annals of Dyslexia, 41, 193-206. American Heritage School Dictionary (1972). New York: American Heritage. Bell, N., & Lindamood, P. (1993). Vanilla vocabulary, level 2. San Luis Obispo, CA: Gander Educational. Bell, N., & Lindamood, P. (1998). Vanilla vocabulary, level 1. San Luis Obispo, CA: Gander Educational. Bell, N., & Lindamood, P. (1997). Ivan sleeps over & Ivan king of the Neighborhood. San Luis Obispo, CA: Gander Educational. Berry, M. (1969). Language disorders of children. Englewood Cliffs, NJ: Prentice Hall. Boswell, S. (2000). Congress funds newborn hearing screening. ASHA Leader, 5(1). Clancy, P. (1985). The acquisition of Japanese. In D. I. Slobin (Ed.), The crosslinguistic study of language acquisition: Vol. 1. The data (pp. 373-524). Hillsdale, NJ: Erlbaum. DeFries, J., Fulkes, D., & Labuda, M. (1998). Reading disability in twins: Evidence for a genetic etiology. Nature, 329, 537-539. Grandin, T. (2000). My mind is a web browser: How people with autism think. The Dana Forum on Brain Science, 2(1), 13. Greenspan, S. I., & Wieder, S. (1997). The child with special needs: Encouraging intellectual and emotional growth. New York: Perseus Books. Hart, B., & Risley, T. (1996). Meaningful differences in the everyday experience of young American children. Baltimore, MD: Paul H. Brookes. Kantrowitz, B., & Underwood, A. (1999). Dyslexia: New hope for kids who cannot read. Newsweek, November 22. Lewkowicz, D. (1999). Infants perception of the audible, visible, and bimodal attributes of talking and singing faces. In D. Massaro (Ed.), Proceedings of the auditory-visual speech processing international conference. Santa Cruz, CA. Lewkowicz, D. (in press). Infants perception of the audible, visible and bimodal attributes of multimodal syllables. Child Development. Lewkowicz, D. (2000). Development of intersensory temporal perception: An epigenetic systems/limitations view. Psychological Bulletin, 126, 281-308. Lindamood, P., & Lindamood, P. (1998). Lindamood phoneme sequencing (LiPS) program. Austin, TX: PRO-ED. Lindamood, P., Bell, N., & Lindamood, P. (1997a). Achieving competence in language and literacy by training in phonemic awareness, concept imagery, and comparator function. In C. Hulme & M. Snowling (Eds.), Dyslexia: Biology, cognition, and intervention. San Diego, CA: Singular. Lindamood, P., Bell, N., & Lindamood, P. (1997b). Sensory-cognitive factors in the controversy over reading instruction. The Journal of Developmental and Learning Disorders, 1, 143-182. Lundberg, I. (1998). Preschool prevention of reading failure: Does training in phonological awareness work? In R. L. Masland & M. W. Masland (Eds.), Prevention of Reading Failure (pp. 163-176). Parkton, MD: York Press. Mann, V. (1993). Phoneme awareness and future reading ability. Journal of Learning Disabilities, 26(4), 259-269.


ICDL Clinical Practice Guidelines

McReynolds, L. (1978). Behavioral and linguistic considerations in childrens speech production. In J. F. Kavanagh, & W. Strange (Eds.), Speech and language in the laboratory, school, and clinic. Cambridge, MA: MIT Press. Moore, D. (1990). Uncertainty. In L. Steen (Ed.), On the shoulders of giants: New approaches to numeracy. Washington, D.C.: National Academy Press. National Center for Education Statistics. (1993). National adult literacy survey. Washington, D.C.: Author. National Council of Teachers of Mathematics (NCTM) (1989). Curriculum and evaluation standards of school mathematics. Reston, VA. Paivio, A. (1986). Mental representations: A dual coding approach. New York: Oxford University Press. Paivio, A. (1994). Dual coding theory. Presentation at the National LindamoodBell Research and Training Conference, Sacramento, CA. Paivio, A. (1996). Dual coding: A factor in language processing. Presentation at the National Lindamood-Bell Research and Training Conference, San Francisco, CA. Papert, S. (1993). The childrens machine: Rethinking school in the age of the computer. New York: Basic Books.

Rescorla, L. (1989). The language development survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587-599. Shankweiler, D., & Lieberman, I. (1989). Phonology and reading disability. Ann Arbor, MI: University of Michigan Press. Slobin, D. (1985). Crosslinguistic evidence for the language-making capacity. In D. I. Slobin (Ed.), The crosslinguistic study of language acquisition: Vol. 2. Theoretical issue (p. 1244). Hillsdale, NJ: Erlbaum. Slobin, D. (1997). The crosslinguistic study of language acquisition: Vol. 5. Expanding the contexts (Beverly A. Goldfield, 1999). Applied Psycholinguistics. Book Review, 20(3). Stern, C., & Stern M. (1971). Children discover arithmetic. New York: Harper & Row. Tardif, T. (1996). Nouns are not always learned before verbs: Evidence from Mandarin speakers early vocabularies. Developmental Psychology, 32, 492-504. Torgesen, J., Morgen, S., & Davis, C. (1992). The effects of phonological awareness training on word learning in kindergarten children. Journal of Educational Psychology, 84, 364-370.

Chapter 24. Technologies to Facilitate Language, Sensory Processing, and Motor-Planning Capacities




Patricia Lindamood, M.S., C.C.C.-S.L.P. The rapid development and availability of technology is enabling many computer-assisted sensory, motor, and language training programs to be produced. There are hundreds of such programs available, and examples of the three types are included in this chapter. This chapter describes the contribution of technology to the area of augmentative and alternative communication, with some programs suitable for home as well as professional use. This chapter also briefly discusses the language therapies Fast ForWord and 4wd, Earobics, and The Sentence Master Program, as well as a motor-planning and timing program, the Interactive Metronome. In addition, auditory processing approaches using music are discussed. The programs described all have web sites that can be accessed for further information. AUGMENTATIVE AND ALTERNATIVE COMMUNICATION The field of augmentative and alternative communication (AAC) has found that it can combine assistance from technology with its basic efforts, and can make speech-language and the ability to communicate more widely available to populations with very special needs in this area. The AAC services, with the assistance of very creatively engineered technology products, are enabling many children and adults to interact with their world in spite of having little or no oral expressive language. Because humans have a universal need to communicate, AAC emerged as a service concept internationally, with the first efforts occurring during the 1960s in Canada, Sweden, the United Kingdom, and the United States. The International Society of Augmentative and Alternative Communication (ISAAC) has chapters in 11 countries and members in more than 50 countries. An international conference is held every 2 years in a different location. The organization recognizes the need to be research-oriented, and it follows each conference with a research symposium. There is also a journal, titled Augmentative and Alternative Communication, published by Decker. Much of this current information about AAC was graciously provided by Dr. Sarah Blackstone, past president of ISAAC. She is currently an AAC consultant, and has a web site that gives information about AAC as well as information regarding her widely read newsletter, Augmentative Communication News. AAC serves groups of individuals with varying degrees of need within three general categories: 1. Individuals whose poor ability to speak is secondary to a primary organic condition,


ICDL Clinical Practice Guidelines

such as cerebral palsy, aphasia, apraxia, multiple sclerosis, and traumatic brain injury, and who typically exhibit a big gap between their adequate receptive language and their lack of expressive language. 2. Individuals who are autistic or within the autistic spectrum. 3. Individuals who are physically able, but are, nonetheless, unable to engage in symbolic representation due to developmental delay or unknown cognitive disabilities. AAC goals are grounded in speech-language communication. It is an ongoing process for most clients, over a considerable period of time, and requires a team approach. It starts with an analysis of a clients most immediate needs at this time in regard to communication and an assessment of his or her future needs, with the ultimate goal being independence. The AAC process involves working step-by-step toward the highest degree of independence in communication that a person can achieve. A multidisciplinary provision of services is necessary in accomplishing this goal. Historically, the first AAC efforts involved Language Boards with pictures or, if the person was able to read, printed words and phrases to which the person pointed. Depending on the disability, a person in a wheelchair could find these boards physically difficult to handle. Manual signs were also used to augment the effort to communicate, and are still in use to some extent. The inclusion of technology started in England and Scotland in the 1970s, when electronic devices began to become available. There are more than 100 products available that use both synthesized and digitized speech. Some have become very sophisticated and somewhat difficult to use, which has led to a sense

within the AAC community that these devices need to be made more user friendly. This improvement is most likely to occur through the Rehabilitation Engineering Research Centers (RERC) authorized by the Rehabilitation Act of 1973. The mandate of a RERC is to enhance opportunities for meeting the needs and addressing the barriers confronted by individuals with disabilities in all aspects of their lives. The Secretary of Education may make grants to public or private agencies to conduct research, demonstrations, and training activities related to rehabilitation technology, but the RERC must be operated in, or in collaboration with, an institute of higher education or a nonprofit organization. By most recent count, there are now RERC in 14 different locations. For young children with cerebral palsy, Down syndrome, or autism, AAC serves as a bridge to speech-language communication. Its tools include manual gestures, signs, graphics, and print. These provide visible signs of communication that appear to stabilize beginning language input and enhance a childs ability to attend to it and acquire receptive language. Receptive language is the first level to be accomplished. Ultimately, however, AAC has a profound relationship with literacy. Until literacy is achieved, particularly the spelling aspect of literacy, the individuals are dependent on what someone else has put on their Language Board or in the technology device they are using. For individuals who lack oral speech-language, or for whom the speed and ability to articulate oral language is extremely slow and burdensome, true independence in communication hinges upon their success in generating what they want to say in written language. For this reason, it is very important for AAC professionals to understand the role of phonemic awareness in literacy development, presented in the discussion of written language in



Chapter 23 in this volume. It has been reported that many individuals receiving AAC services are not literate, which severely limits their ability to use many of the technology devices or even a Language Board if it uses print. If these individuals have received traditional instruction in reading and spelling but have not been able to benefit from it, a lack of phoneme awareness can be predicted. If this is a need, it can and must be addressed, as phoneme awareness is a primary factor in literacy development. Age and intelligence do not guarantee the availability of this genetic tendency of phoneme awareness, but it can be developed by special procedures. Practitioners in AAC have learned that the use of multiple systems is significantly more effective than the use of a single system. After a system for establishing or documenting some level of receptive language is successful, a current intervention of choice among AAC providers is The Picture Exchange Communication System (PECS). This system focuses on the initiation component of communication. In six phases of training, it integrates theoretical and fundamental teaching strategies from the fields of speech-language pathology and behavioral analysis. Its emphasis is on clarifying for family, residential-care providers, and educators the how of teaching initiation of communication rather than simply what to teach. The goal is the development of functional communication skills regardless of communication modality. PECS has been successful with individuals from preschool age to adults in a broad array of settings, and many preschoolers using PECS also begin developing speech. Training workshops for groups and programs are available both nationally and internationally, coordinated by Pyramid Educational Consultants. Present research in AAC involves a federally funded, 5-year longitudinal study of the

use of technology devices. Two groups in the study will receive AAC while using the devices, and one group will not use the devices. A pilot study found that devices help. Further research and sharing of experiences are needed to determine which individuals, with what types of abilities, benefit from what types of technology. The AAC goal is speech-language communication however it can best be accomplished, and the sense within the AAC community is that technology devices have their place as one of the many tools for individuals unable to speak. Telerehabilitation is a new element coming into play as the Internet is enabling expansion into distance access to AAC services. The issue of our aging population, the reality of strokes and other debilitating conditions that affect speech-language and the ability to communicate, and the fact that the Health Care Financing Administration (HCFA) is considering reimbursement through Medicare for AAC devices hold promise for impacting the expansion of AAC services and devices. What the future holds in full in respect to AAC and technology is yet to be seen. LANGUAGE AND MOTOR PROGRAMS There are a number of technologies that work on language functioning and a relatively new technology that works on motor-planning and sequencing capacities. The language technologies provide ways to exercise important language functions, especially receptive capacities. There are different theoretical rationales for the different approaches. Until there are comparative studies among the different technologies (and intensive speech-language therapy, employing the same number of hours as a particular technology) that can isolate the hypothesized mechanism of action, it will be difficult to know why a


ICDL Clinical Practice Guidelines

given technology may help. For example, improvement might be the result of a general practice effect or a specific process, such as initially slowing down auditory input. It is also vital to emphasize that the spontaneous, meaningful use of language is the cornerstone of progress. Computer-based technologies should not be allowed to detract from interactive play and conversation or peer play. In fact, during times of intensive computer-based work, it is important to increase dynamic interactive play and conversation to maintain the childs engagement, interactive capacity, flexibility, and creativity. Fast ForWord and 4wd These two computer programs work with the auditory and language processing abilities of individuals who have receptive language problems. Fast ForWord was developed for children whereas 4wd, which uses the same technology as Fast ForWord, was developed for adolescents and adults. The approach is based on research which shows that, at the rate phonemes occur in normal speech, language learning impaired (LLI) persons have difficulty accurately distinguishing short-duration consonants such as /b/, /d/, /p/, /t/ and even short-duration vowels such as /e/, /i/ when they occur in proximity to other short-duration consonants. When these phonemes are electronically slowed down, and emphasized by increasing the intensity of the sounds, or when the time between the phonemes is lengthened, LLI persons may be able to perceive them more effectively. The programs start with phoneme segments that are electronically stretched and/or emphasized to the point where they become distinguishable for each student using the program. The programs also separate speech elements in time. Next, the programs repetitively adjust these rate, emphasis, and spacing ele-

ments until the brains responses are trained and the ability to better process speech at the normal temporal rate is developed. A number of research studies in this approach (Merzenich et al., 1996; Tallal et al., 1996; Tallal, Merzenich, Miller, & Jenkins, 1998) have been conducted, with encouraging results. It would be highly desirable to have additional, more specific information so comparisons can be drawn. For example, within the total number in the representative populations, how many students did not move into the average range on the various measures? In addition, there need to be comparative studies that contrast this approach with other similar approaches or with an equal number of hours of speech-language therapy. Earobics Earobics is an auditory-processing and phonics program with two levels: Step 1, and Step 2. The content is chosen and organized to teach phonemic awareness and auditory-processing skills. Using an interactive game format, Step 1 provides 6 games with up to 114 levels of difficulty to be mastered within each game. This allows practice with each type of task presented. Acoustically modified speech, adaptive training, and careful control of learning variables are techniques given attention. The Earobics Clinician Version, Step 1, provides professional users with the ability to customize the program for students through the selection of games and starting levels, the ability to skip or repeat levels, and the ability to keep records on each student, generate reports, and cite learning objectives for each activity in the Individual Educational Program (IEP) format required by many schools. There is also a Home Version, Step1, which does not include the customizing features of the Clinician Version. The Earobics,



Step 2, program continues building the phonemic and phonological awareness skills addressed in Earobics, Step 1, and provides practice in phonics activities and various auditory-processing skills. A clinical study with third- to fifth-graders identified as having central auditory processing disorder (CAPD) and/or as learning disabled based on language impairment (LI), and a public school study comparing Earobics effectiveness with two other programs are reported as completed, but analyses of the data are still in progress. The Sentence Master The Sentence Master is a linguistically based reading program that integrates computer activities and print materials to focus on developing automaticity in the reading of more than 350 frequently occurring non-content and content words. This program, designed by psychologist Marion Blank, is for children and adults who are at risk for reading difficulty or who have already had problems in reading. The program links diagnosis and intervention with structured materials and motivating rewards to address and overcome language deficits known to exist for the majority of poor readers; that is, problems with naming, syntax, and comprehension. Phoneme awareness development is not included, but Dr. Blank recognizes its contribution to decoding and recommends including a phonemeawareness training program concurrently with her program for students who need it. Activities in the three areas of naming, syntax, and comprehension are included in each of the four levels of reading instruction. No formal research on this approach is available at present, and this is needed. Sites using The Sentence Master could make an important contribution by organizing to collect data on program effectiveness with the different populations it serves.

Interactive Metronome (IM) Motor Planning and Rhythmicity Program The IM intervention has findings from several studies indicating that it appears to work on underlying processes involved in motor planning, sequencing, timing, and rhythmicity that support motor, cognitive, and learning processes. In the IM program, the participants complete seven movements by keeping pace with the metronome beep. Through the computer program, they receive feedback that enables them to establish a close connection between the metronome beat and then their own motor patterns. The movements include patting knees with both hands, clapping hands together, patting knees with alternating hands, patting knee with preferred hand, patting knee with the non-preferred hand, and toe-tapping the floor pad with alternating feet. In many types of learning and developmental challenges, motor planning and sequencing are involved in problem solving and other adaptive actions as well as in executive functions, such as organizing information and planning. In the past, it has only been possible to work with these capacities clinically. In a recent study of the IM intervention, an attention deficit hyperactivity disorder (ADHD) population of 56 boys, ages 6 to 12, was randomly assigned to three groups and compared for findings on selected aspects of motor, attentional, and cognitive skills. The IM group received 15 hours of training, a placebo video group received an equal number of hours of training on selected nonviolent computer video games, and the other control group received no intervention. Each participant was pre- and post-tested with published tests in four areas of performance: attention and concentration; behavioral functioning; sensory and motor functioning; and academic and cognitive skills, including reading.


ICDL Clinical Practice Guidelines

The IM group showed statistically significant improvements over both of the control groups in attention, language processing, reading, and the regulation of aggression. This study will be published in the American Journal of Occupational Therapy (Burpee et al., in press; Shaffer et al., in press). Other studies have suggested that IM is helpful for children with special needs and show correlations between IM performance and academic performance (Kuhlman & Schweinhart, in press; Stemmer, 1996). Current studies include work with different developmental and learning challenges and studies of IM performance as a diagnostic tool for categorizing types of motor-planning, sequencing, and timing differences in children and adults with developmental and learning challenges. Additional research on larger populations that look at patterns of improvement in relationship to severity of challenge and other clinical characteristics is needed. AUDITORY PROCESSING THERAPIES USING MUSIC Evidence is accumulating that when there is delay in speech-language development, various interventions can be offered at the sensory level that may help the emergence of relating and communicating behaviors. Music therapies are one type of sensory therapy being offered. Stimulation with classical music in highly structured experiences is provided in three of these interventions: the Tomatis, the SAMONAS Sound Therapy, and the Berard Therapy. These therapies are theorized to generally have a balancing or integrating effect between the left and right hemispheres and to improve comfort in the world of sound. At present, there is a problem in predicting which individuals may benefit from them, and there is insufficient formal research on their effectiveness, with some

conflicting reports (American Academy of Audiology, 1993). However, there are many anecdotal reports of gains and a number of studies involving a small number of subjects that suggest improvements in aspects of auditory processing and social communication (Bettison, 1996; Edelson et al., 1999; Gravel, 1994; Highfill & Cimorelli, 1994; Madell, 1997; Madell & Rose, 1994; Porges & Barzhenova, 1997; Rimland & Edelson, 1991; Rimland & Edelson, 1994; Rimland & Edelson, 1995; Veale, 1994; Woodward, 1994). It appears to be a promising area, and is in the process of being researched. The Tomatis music therapy was developed in the l950s by Dr. Alfred Tomatis, a French physician. It filters classical music through an Electronic Ear, initially blocking some high and low frequencies and then including them later. Input is first given to just one ear, then to the other, and later to both. Amplitude modulation of the signal is also used. Therapy is given in daily segments, in periods spaced over 2 to 3 months. The program is currently administered in more than 200 Tomatis centers worldwide. Its effect on a variety of problems are described in Tomatis book, The Conscious Ear, and include voice and speech difficulties, developmental disturbances, and postural and social problems. Many parents are also reporting helpful clinical results, including improvement in reading, and efforts are being made to establish formal research. SAMONAS is an acronym for Spectral Activated Music of Optimal Natural Structure. Ingo Steinbach, a German physicist, sound engineer, and musician, developed the intervention after years of studying the work of Dr. Tomatis. He discovered that, although the human ear can only process frequencies up to 15,000 Hz, the brain can detect frequencies above that. He developed special recording and playback techniques that provide these



higher frequencies on his compact disks (CDs), which he believes challenge the brain to function at higher levels and enhance the therapeutic value of music by facilitating alertness and interest. The SAMONAS program uses classical music on all CDs, with the exception of one that uses the sounds of nature. Some of the CDs are only available to professional therapists, while most are available to parents or others along with extensive directions regarding their use. The Berard approach was developed in the 1960s, by Dr. Guy Berard, a French otolaryngologist/audiologist. This approach was introduced in the United States in 1991, and is also called Auditory Integrative Therapy (AIT). Berard worked with Tomatis and developed his own modifications. The first step of AIT involves a detailed audiogram: an individual is considered an appropriate program candidate if there are peaks of hypersensitivity or if there is hyposensitivity at certain frequencies. The individual takes another audiogram after 5 hours of listening to determine whether the auditory peaks are still present and whether new peaks have developed. A third audiogram is conducted after an individual completes the listening sessions. The listening sessions consist of two 30-minute sessions per day for 10 consecutive days, during which a person listens through headsets to ever-changing and unpredictable electronically altered music from an Audiokinetron device. Frick and Lawton-Shirley, occupational therapists, report on their web site that, in treating more than 300 children and adults, they have found persons with known vestibular dysfunctions to appear to make the greatest gains. There are also reports of some children increasing their sensitivities to sound rather than decreasing them. The American Academy of Pediatrics issued a policy statement in 1998 that, until further research information is available, AIT should be considered controversial, and pedi-

atricians should provide guidance and assistance in obtaining and reviewing information for families considering this treatment option. Clearly, more research is needed on technologies working with auditory processing. Until there is definitive research available, all aspects of a childs presenting symptoms and functioning should be weighed, and each family and the childs clinicians must make a careful decision whether to try one of these approaches. Nevertheless, this is an emerging area of intervention to watch and consider on an individual basis while it is under study. SUMMARY In addition to the programs described in this chapter, many other programs are available that use technology to assist the development of language, sensory processing, and motor-planning abilities. Most of them have web sites on the Internet, and many offer free demonstration CDs. A factor to be concerned about in evaluating their benefits for a given individual is whether, in assessing response errors, the programs assist the individual in analyzing the nature of their errors, rather than simply counting the number of right responses. The goal should be self-correcting behavior. Determining the nature of errors enables children as well as adults to consciously monitor and attend to what causes their errors so that, ultimately, they do not commit the same errors again and have to be corrected afterward. Another factor to keep in mind is that learning to learn is a complex process that is sensory-based. We must keep alert to the difference between activities that require application of a particular sensory or language processing capacity, and those that develop a capacity so that it is available to be applied. In this respect, it is evident that some technology-assisted programs are complementary.


ICDL Clinical Practice Guidelines

Rather than thinking of these programs as being competitive and researching their individual effects in comparison to each other, perhaps we should be researching how they could be sequenced, or whether they should be used concomitantly, for the best results. Many individuals have lives that are on hold because their sensory and/or language

processing needs have not been identified and/or addressed adequately. For their sake, we can not afford to approach program effectiveness research only from a competitive stance. Research on complementary use of certain programs might result in these individuals realizing their potential for communicating and learning sooner and more fully. s



REFERENCES American Academy of Audiology. (1993). Position statement: Auditory integration training. Audiology Today, 5(4), 21. Bettison, S. (1996). The long-term effects of auditory training on children with autism. Journal of Autism and Developmental Disorders, 26, 361-374. Burpee, J., DeJean, V ., Frick, S., Kawar, M., Koomar, J., & Murphy Fischer, D. (in press). Theoretical and Clinical Perspectives on the Interactive Metronome: A view from occupational therapy practice. American Journal of Occupational Therapy. Edelson, S., Arin, D., Bauman, M., Lukas, S., Rudy, J., Sholar, M., Rimland, B. (1999). Auditory Integration Training: A doubleblind study of behavioural and electrophysiological effects in people with autism. Focus on Autism and Other Developmental Disabilities, 14(2), 73-81. Gravel, J. S. (1994). Auditory integration training: Placing the burden of proof. American Journal of Speech-Language Pathology, 3(2), 25-29. Highfill, M., & Cimorelli, J. (1994). Positron emission tomography measure of modified auditory integration therapy: A case study. Poster presented at the Annual Convention of the American Speech-Language-Hearing Association, New Orleans, LA, November. Kuhlman, K. & Schweinhart, L.J. (in press). Timing in child development. Ypsilanti, MI: High/Scope Educational Research Foundation. Madell, J. R. (1997). New interventions to enhance auditory processing, language, reading, and learning. Paper presented at the Interdisciplinary Council on Developmental and Learning DisordersApproaches to Developmental and Learning Disorders in Infants and Children: Theory & Practice, McLean, VA, November 14-16. Madell, J., & Rose, D. E. (1994). Auditory integration training. American Journal of Audiology, March, 14-18. Merzenich M. M., Jenkins, W. M., Johnston, P., Schreiner C., Miller, S. L., & Tallal, P. (1996). Temporal processing deficits of language-learning impaired children ameliorated by training. Science, 271(5245), 77-81. Porges, S. W., & Bazhenova, O. V. (1997). Evolution and the autonomic nervous system: A neurological model of socio-emotional and communication disorders. Paper presented at the Interdisciplinary Council on Developmental and Learning Disorders conference, Approaches to Developmental and Learning Disorders in Infants and Children: Theory & Practice 1997, McLean, VA, November. Rimland, B., & Edelson, S. M. (1991). Improving the auditory functioning of autistic persons: A comparison of the Berard auditory training approach with the Tomatis audio-psychophonology approach. (Tech. Report No. 111). San Diego, CA: Autism Research Institute. Rimland, B., & Edelson, S. M. (1994). The effects of auditory integration training on autism. American Journal of SpeechLanguage Pathology, 3(2),16-24. Rimland, B., & Edelson, S. M. (1995). Brief report: a pilot study of auditory integration training in autism. Journal of Autism and Developmental Disorders 25(1), 61-70. Shaffer, R. J., Jacokes, L. E., Cassily, J. F., Greenspan, S. I., Tuchman, R. F., & Stemmer, P. J. (in press). Effect of Interactive Metronome (IM) training on children with ADHD. American Journal of Occupational Therapy.


ICDL Clinical Practice Guidelines

Stemmer, P. M. (1996). Improving student motor integration by use of an interactive metronome. Study paper presented at the 1996 Annual Meeting of the American Educational Association, Chicago, IL. Tallal, P., Miller. S. L., Bedi, G., Byma, G., Wang, X., Nagarajan, S. S., Schreiner, C., Jenkins, W. M., & Merzenich, M. M. (1996). Language comprehension in language-learning impaired children improved with acoustically modified speech. Science, 271(5245), 81-84.

Tallal, P., Merzenich, M. M., Miller, S., & Jenkins, W. (1998). Language learning impairments: Integrating basic science, technology, and remediation. Experimental Brain Research, 123(1-2): 201-209. Veale, T. K. (1994). Auditory integration training: The use of a new listening therapy within our profession. American Journal of Speech-Language Pathology, 3(2), 12-15. Woodward, D. (1994). Changes in unilateral and bilateral sound sensitivity as a result of AIT. Sound Connection, 2, 4.

Chapter 25. Imagery and the Language Processing Spectrum



Imagery and the Language Processing Spectrum

Nanci Bell, M.A. If I cant picture it, I cant understand it. - Albert Einstein Albert Einsteins achievements are milestones in the history of science and have become an integral part of the 20th century. No other modern physicist has altered and expanded our understanding of nature as significantly. Named man of the century by Time Magazine, Einsteins esteemed contributions were the result of his ability to think critically and creatively. He made his thinking concrete with a specific sensory system functionimagery. His statement, If I cant picture it, I cant understand it, not only illuminates his genius, but also embodies a truth about language processing that may unlock some answers for children and adults with weakness on the language processing spectrum. The language processing spectrum ranges from processing words (decoding and encoding print) to processing concepts (comprehending and expressing language). When there is weakness on the spectrum, labels such as dyslexia appear on the left and those such as hyperlexia appear on the right, extending into the label of autism. Figure 1 highlights the language processing spectrum. As causes and solutions have been sought for children and adults with weaknesses on the spectrum, important knowledge has been

Language Processing Processing Words (Symbol Imagery) Dyslexia Processing Concepts (Concept Imagery) HyperlexiaAutism

Figure 1. The Language Processing Spectrum

gained. Researchers know that the sensory system is the issuethe heart of good language processing or the root of the problem. People can process language across the spectrum because they can receive and process sensory information, generally in the form of imagery. Strength in imagery results in language processing strength; weakness in imagery results in language processing weaknesswords and concepts. On the left side of the spectrumthe processing of wordsa rather recent breakthrough has changed the lives of many dyslexics. We now know that in order to read and spell written language, the human sensory system needs to process sounds and letters


ICDL Clinical Practice Guidelines

within syllables, referred to as phoneme awareness and symbol imagery. However, during the years of searching for answers, the professional community was lost for awhile. Dyslexia was often viewed as an array of symptoms so disparate that, it was thought, they could not be related. Dyslexia was attributed to everything from misreading words to not being able to program a VCR. Rampant symptoms seemed unrelated. With the problem so extensive, uncovering a primary cause seemed both impossible and improbable. Statements such as not everything works for everybody and not everybody is the same worsened the problem. Too often, each dyslexic was viewed as unique rather than as sharing a simple, yet core, sensory weakness. After years of studying the problem, some organizations suggested that there was no cure for dyslexia. Compensation strategies were offered that didnt fix the problem. Learning to live with dyslexia was painful and gave little hope to the many that suffered. Fortunately, however, persistent research provided answers and solutions. Stimulation at the sensory levelphonological awareness and symbol imagerybrought significant improvement in reading and spelling skills. Gains, seemingly impossible before, were made even with adult dyslexics. As a core sensory deficit was specified, treatment became specific rather than random. In addition to the research, the shortcomings of the whole language movement provided additional information about the importance of developing phonological processing. By failing to stimulate phoneme awareness, the whole language approach increased the incidence of poor reading and dyslexia increased. This failure provided a contrast and an additional lesson about the underlying sensory processing necessary for reading and spelling words. Unfortunately, while the professional community searched and debated, children and adults often were not given appropriate sensory stimulation.

Research and insight about the sensory system has since contributed to solving some issues on the left side of the spectrum. Because of a better understanding of the sensory system, improvements are now being made that were previously considered impossible. But what about the right side of the language processing spectrum? Has the volume of symptoms and their seeming disparity caused scientists to think that there may not be primary sensory causes, or contributors, to the range of symptoms and labels on the right side? If Einstein used imagery for his genius of thought, is imagery a primary sensory system factor related to weak comprehension, hyperlexia, and possibly even autism? Is imagery just imagery, or is there more than one type of imagery? Is the imagery for letters the same as the imagery for concepts? Is imagery a two-sided coin? A TWO-SIDED SENSORY COIN: MARCUS AND HANNAH There are two primary language processing deficits that cause individuals to perform below their potential: weak decoding/encoding of words and weak comprehension/expression of concepts. These two deficits are the two sides of the sensory processing coin. Each side uses imagery in a specific manner, opposite in nature from the other side. One side images and processes parts, while the other images and processes wholes. The story of Marcus represents the side of the coin concerned with difficulty in processing concepts, the primary focus of this chapter. His symptoms stem from weakness in his sensory system, and are not disparate or disconnected. Hannah, Marcuss twin, represents the other side of the coin. The following case study, told in his mothers words, describes how Marcus functions.

Chapter 25. Imagery and the Language Processing Spectrum


Marcuss Story Our son, Marcus, is 9 years old now, and we have been everywhere for help. We dont know what to do. They are suggesting a special day school, but we are reluctant to make another change. Marcus has been in speech therapy since he was 4 years old. Weve tried special therapy, special classes, summer programs, and medication. We just dont know what to do. Marcus is a sweet boy, but no one seems to be able to help himor us. What? Oh, yes. Hes been tested, repeatedly, by a variety of professionals. I have accumulated everything in a file thats about 4 inches thick. It began when he was a toddler because he wasnt developing language as well as his twin sister, Hannah. Yes. They first diagnosed Marcus as having a delay in speech development and more recently he was diagnosed as hyperlexic. He can read words, but he cant understand what he reads. Actually, remembering back, it seems that he could read before he could talk! He learned to read long before he went to school, and in first and second grade, he got really good marks in reading. Its just that he cant comprehend or understand what he readsbut he can read it. No, he doesnt seem to understand what he hears either. For example, at the dinner table, or in any conversation, he doesnt appear to get what is going on around him but he is very easy to be with since he tends to entertain himself. What? Well, yes, he has a good oral vocabulary. He generally tests well in vocabulary. He seems to understand the meaning of individual words very well. His expressive language? Like how much does he talk? Well, no, he doesnt talk a lot, like his sister does, but he can talk. He has never had trouble saying words. He just doesnt talk a lot.

Sequence? No, his expression doesnt seem sequential. It comes out out of sequence. Sometimes he tells us things, but we have difficulty putting what he says together. He talks about the last thing first, or the middle thing last, and his language gets all messed up and he gets frustrated. And, sometimes it seems as if he is stuck on some detail, like a specific part in a movie he watched or a detail from a television show. What? No, he doesnt contribute much to conversation. Well, sometimes he does if it is about a very specific thing he is interested in. He has difficulty making friends and almost seems confused by social situations. It seems like he isnt getting what is going on around him. Sometimes we see him off by himself, just playing with a certain toy or a certain computer game. He is generally quiet. He does answer questions...though sometimes I have to repeat the questions to him quite a few times. No, he is not generally a behavior problem. His teachers say that he is pleasant, but sort of spacey. Do you know what I mean? Sometimes he just looks a little dazed when youre talking to him. I think he wants to have friends because I see him watching other children. I think he just doesnt know what to do or how to interact, and he ends up being alone. Yes, he has a lot of trouble following directions. He doesnt seem to pay attention to what you say to him, and he cant follow a stream of directions, especially with more than one or two things to do. It seems like what I say just goes in one ear and out the other. One physician thought he had attention deficit disorder, and we have been trying medication. He is a little better on medication, but it still hasnt fixed the problem. I keep thinking were missing something. No, he doesnt get jokes easily. In fact, he is pretty serious most of the time.


ICDL Clinical Practice Guidelines

What? No, he never had difficulty with spelling! He can spell anything! His sister cant, however. His sister, Hannah, has recently been labeled learning disabled and put in a special class one hour a day. She is having trouble reading and spelling words. They think she may be dyslexic. Hannah? No, she has never had trouble understanding conversation. Hannah is talkative, friendly, and very social. She has lots of friends and tells us all the things that happened to her during the day. Pretty much just the opposite of Marcus. Yes, I read to both children when they were little, but Marcus didnt like it. Sometimes he looked at the pictures, but then he got bored and left. Yes, his sister liked to listen to stories. Yes. She definitely gets what she reads; she just has trouble reading the actual words. They seem to have exactly the opposite problem! Marcus can read the words but cant comprehend. Hannah can comprehend, but she cant read the words. Hmmm. Now that you ask, a few years ago a physician did suggest that Marcus might be autistic. It seems that some of the best and most caring professionals have given attention to Marcus, but nothing seems to really be helping him. Weve tried everything. A few days ago, I took Marcus to a new professional who told me that if something didnt change by the time Marcus is 12 well, it is very likely it will never change. I came home, pulled the drapes, and spent the rest of the day crying on the couch for my son. Im calling you for one more try. Weak Concept Imagery: A Primary Deficit for Marcus Marcuss weakness in processing language had not been diagnosed or addressed, even by age 9, despite care and concern from many qualified professionals. The symptoms

he exhibited were on the right side of the language processing spectrum and matched those of hyperlexia and high-functioning autism, perhaps Aspergers syndrome. In response to his mothers concern, Marcus was given an extensive battery of diagnostic testing for language processing. During the testing, Marcus did not express himself easily, make eye contact well, relate to the tester, or appear to understand directions or conversation. Though his oral vocabulary was at the 75th percentile and he could read words at the tenth grade level, he performed at a 5-year-old mental age level in oral language comprehension and the 5th percentile in following oral directions. He scored above the 99th percentile in paragraph decoding, but below the 1st percentile in comprehension. When asked what his favorite thing in school was, he didnt answer at first, then finally said, What? He appeared not to hear the language. The question was repeated and again he said, What? This time he appeared confused. Finally, the question was stated as simply as possible, What do you like best in school? Recess. What is the hardest thing in school? After a delay, Marcus replied, Paying attention. Marcus had a primary weakness in his sensory systemweak concept imagery. As he took language in, he did not have adequate imagery activity to make language stop, make language connect, or make language relate. Language entered adequately through the auditory channel but then faltered for lack of sensory activity in imagery. Concept imagery is the ability to create imaged gestaltswholes. Marcuss sensory system could not easily create mental representations for the whole, but he could easily create mental representations for parts.

Chapter 25. Imagery and the Language Processing Spectrum


Words seemed to go in one ear and out the other without the sensory mechanism of concept imagery to anchor and relate them. The side of his sensory coin that imaged and processed parts was functioning well, but the side that imaged and processed wholes was not. Processing languagecognitionis a parts-whole issue. Some individuals, Einstein included, are able to rapidly and automatically create an imaged gestalt from what they read or hear. They can combine parts into a whole. Most important, with the imaged gestalt they can process language and think critically. From the gestalt, they can comprehend oral language, comprehend what they read, problem solve, think logically, think creatively, get the big picture, move from concrete to abstract thinking, express themselves relevantly, make their point, get humor, read social situations, make inferences, draw conclusions, and pay attention. Referring to imagerys contribution to thought and problem solving, Einstein said that imagination is more important than knowledge. Although the ability to create gestalt imagery is a basic and primary asset in the sensory system, there are many individuals who find concept imagery difficult, slow, partially accessible, situation-specific, or unavailable. These individuals, like Marcus, may process parts well. Many even appear to be stuck on partsdetailsbecause their sensory system is able to image them rapidly and automatically. They can create images for partsletters, isolated facts, names, and datesand they can often read and spell words well. Their sensory system easily and rapidly gives them information about bits and pieces by easily and rapidly creating mental representations for parts of language, parts of conversations, parts of oral language, parts of directions, parts of written language, parts of movies, and parts of social situations.

Sometimes the parts seem to be overwhelming and consuming. A part in a conversation or lecture is imaged and processed, then discussed, often irrelevantly. The point of a conversation is missed, but the parts are processed. The main idea is lost somewhere in an array of random parts. The critical thinking ability to draw a conclusion or make an inference is impaired because there is a limited gestalt, or whole, from which to process or think. Unrelated or unconnected imaged parts float around in a sensory-cognitive system, contributing to erroneous conclusions and inferences. The random and unconnected imaged parts often bounce back in the form of random and unconnected language expression. As parts are taken in, they come back out. Parts are expressed. Bits and pieces that are imaged and processed are expressed. Language expression may not be sequential. With no imaged gestalt, written or oral language expression is an array of parts with the first, middle, and last out of sequence. Social interaction and conclusions may suffer the same fate. Parts of social situations are processed. A part of a situation is misread and then reacted to, with limited understanding of cause and effect. Personal interaction may be difficult. Language swirls around, parts are processed and parts are expressed. Social interaction with a language-filled environment is difficult if the primary, incoming sensory information is in parts. Weakness in concept imagery may range from mild to severe, with some individuals experiencing moderate difficulty comprehending and expressing language. Those individuals might have to study a little harder or read chapters a few more times. However, as the weakness in imaging gestalts becomes more severe, so do the symptoms. Labels such as hyperlexia, Aspergers syndrome, and autism begin to surface. Weak concept


ICDL Clinical Practice Guidelines

imagery is a primary sensory deficit for hyperlexia, and while it is not the only weakness related to autism, poor concept imagery may be a primary contributing factor. The right side of the language processing spectrum requires concept imagery function. Marcus received 6 weeks of intensive concept imagery instruction (4 hours a day, 5 days a week) and improved from the 5th to the 75th percentile in following oral directions and from the 1st to the 50th percentile in reading comprehension. He also began to engage in conversation, interact socially, and understand humor. SYMPTOMS OF WEAK CONCEPT IMAGERY Understanding the range of weakness in concept imagery is important in order to understand the symptoms it presents. College students and educated adults may experience language processing weakness stemming from the same sensory system weakness as Marcus had. For example, Sam, a college graduate, experienced mild concept imagery weakness that had negative consequences for his chosen vocation. With good decoding and above average intelligence, Sam attempted to enter medical school; however, he was unable to pass the MCAT entrance test. His reading comprehension score was 4, but 8 was average. He waited a period of time and retook the test. Again he scored 4. Persistent and committed to becoming a physician, he sought help to improve his reading comprehension. During the diagnostic testing, in which he scored significantly below his potential in reading comprehension, Sam described his frustration throughout his schooling. He felt that he missed most of his academic course content, indicating that information seemed to go in but out again. He likened his comprehension disability to an incomplete cognitive tool kit.

I couldnt get [comprehend] things, but Id look around me and others seemed to get things easily. I couldnt understand how they did itand why I couldnt. It seemed like when I opened up my cognitive tool kit there was something missing. Another student had a more serious weakness in concept imagery, though still not severe. Peter had good oral vocabulary and good decoding, but was on academic probation in college, despite having saved the difficult classes for his last years in college. He said, There wasnt one thing I could do right in school. I couldnt easily get the lectures, and I didnt remember anything I read. It was very frustrating. I read each sentence three times and then went on to the next sentence and read it three times. It didnt make any sense put togetherIf I read the information enough times, I could remember it for maybe 30 seconds and then I had no clue. Peter dropped out of college. Sam, Peter, and Marcus are examples of individuals with mild to severe concept imagery weakness, but there are a host of others, some milder and some more severe. The weakness moves on a continuum, a spectrum. As the sensory weakness becomes more severe, so do the symptoms. The following behaviors are symptoms of weak concept imagery, based on a range of individuals, from young to old, with mild to severe weakness. The issue of a weak gestalt contributes to each symptom. At the time these symptoms were noted several years ago, the diagnosis of autism was not as prevalent. Symptoms of Weak Concept Imagery An individual with weak concept imagery has: A tendency to process parts more than, or rather than, wholes. Gets details rather than big pictures. Attends to facts more than concepts.

Chapter 25. Imagery and the Language Processing Spectrum


Difficulty with conceptual, critical, logical, and/or abstract thinking. Gets stuck on details and parts. Enjoys facts rather than concepts. Appears to be a concrete thinker because is processing specific part-images. Difficulty grasping oral language, whether stories, conversations, or lectures. Is not interested in listening to stories, cant seem to pay attention. Misses the point of a lecture or conversation. Appears to process irrelevant or incidental parts of what is heard. Often asks and re-asks the same question. May be labeled as a poor listener or inattentive. Weak reading comprehension. Though oral vocabulary and decoding may be sufficient, may only get a few facts from what is read. Has trouble answering higher-order thinking questions, such as the main idea, a conclusion, an inference, and a prediction. Has to read sentences, paragraphs, and chapters more than once. May still not get the big picture or point, and may do poorly on tests that measure more than just facts. Difficulty following directions, oral or written. Gets confused with more than one or two directions. Language appears to go in one ear and out the other. Seems unable to pay attention to language or successfully engage in a social environment. Weakness in expressing language orally. Language expression is a random array of parts, facts, and details. Talks about irrelevant parts or issues. Tells stories out of sequence. Talks very little or talks a lot, but is scattered and disconnected. Difficulty expressing language in writing. Often writes in unrelated parts. Has five essays in one. Does not connect thoughts and make a point, a whole. Does not begin with a topic, support the topic, and summarize the topic. Cannot easily

answer a question due to missing the point of the question. Difficulty understanding humor. Misses the joke. Takes language literally and doesnt see the imagery in humor. May respond to physical humor, such as slipping on a banana, but cant comprehend language-based humor. Laughs at inappropriate times. Difficulty reading social situations. Attends to a part of an expression or situation. Based on a part, makes inappropriate expressions or takes inappropriate actions. Has difficulty understanding cause and effect. Appears to find language and social interaction a confusing mix of disconnected parts. Prefers own company. The world seems to be a puzzling, disconcerting, and meaningless array of parts.

CAUSES AND CONTRIBUTORS TO WEAK CONCEPT IMAGERY Because more research, particularly brain research, is needed, theories about the specific cause of the sensory weakness in creating an imaged gestalt are still speculative, but they are based on substantial experience, clinical insight, and logic. As with other disorders, including dyslexia, heredity appears to be a factor. Children and adults with weak comprehension often have one or both parents exhibiting a similar deficiency. As the issue of imaging and processing a whole is explained, typically one parent acknowledges difficulty comprehending and expressing language. The more severe the concept imagery weakness, the more likely a parent experiences a similar problem or tells of someone else in the family with a similar issue. The familial reference may range from comprehension weakness to autism.


ICDL Clinical Practice Guidelines

Environmental issues appear to contribute to an increased incidence in mild to moderate comprehension problems. For example, in a culture in which television is a primary source of entertainment, the sensory system may not be receiving enough imagery stimulation. This becomes of particular concern when noting the duality of coding for cognition, as in Paivios theory. Paivios dual coding theory (1986) emphasized the critical role of imagery for cognition and stated that cognition is proportional to the extent that mental representations (imagery) and language are integrated. The increased cultural activity of television and video games may have a negative cognitive impact on one-half of the cognitive codeimagery. When someone listens to an old radio shows or story records, sound effects enhance the imagery of language. In contrast, when a person watches television, the mind is provided with images. Watching television may have an atrophying effect on imagery because the images are created for the viewer. Further impacting cognition, the time an individual spends watching television or playing video games may consume the time that individual might otherwise have spent reading, storytelling, or conversing: in other words, time that could have been used for stimulation of concept imagery and language expression. Another concern currently being discussed is the environmental and medical use of chemicals called neurotoxins. For example, childhood vaccines are under investigation as contributors to language processing disorders and learning disabilities, including autism. Whether the cause is a hereditary factor, environmentally induced, or both, the ability to image a gestalt appears to be a function unto itself. Although impaired phonological processing and impaired decoding, weak oral vocabulary, and reduced prior knowledge and

background experiences may contribute to weak concept imagery, these factors do not appear to be causal. As with Marcus, hyperlexics often have good decoding, oral vocabulary, and imagery for isolated words, but they are not able to comprehend concepts and answer higher-order thinking questions. The same applies to individuals considered to have poor reading comprehension but not given the label of hyperlexia. Many individuals with wide experiences and good education are not able to comprehend language effectively and efficiently. In contrast, many poor decoders, including severe dyslexics, are able to comprehend language and create images for concepts. If language is presented orally to these dyslexics, they appear brilliant in their ability to interpret and reason. Their imagery weakness is on the opposite side of the sensory coin and is similar to Hannahs they cant image letters, which are the parts of words. Weak oral vocabulary may interfere with concept imagery and comprehension; however, imagery plays a significant role in the development of appropriate vocabulary. Stimulating imagery for vocabulary aids in the storage and retrieval of meaning for isolated words. Smith, Stahl, and Neil (1987), after a study with 142 university students, stated, The significant difference that occurred between the definition only and the definition and sentence and imagery groups supports Paivios dual coding theory. In accord with Paivios theory the visual image did provide an additional memory trace that improved long term memory for the vocabulary items in the study. This finding mirrors research spanning the years as far back as Kirkpatrick in 1894. Deficits in prior knowledge and background experience may interfere with language comprehension, but instructional techniques designed to access prior knowl-

Chapter 25. Imagery and the Language Processing Spectrum


edge, such as first discussing material, setting the scene, and teaching vocabulary, do not necessarily stimulate independent comprehension. Imagery is assumed. An individual needs to be able to set the scene with language by imaging and interacting with stored images to create and process the new concept. This interaction needs to be quick and easyautomatic. If it is labored and difficult, the whole may be lost and random parts prevail. STIMULATION OF CONCEPT IMAGERY: THE VISUALIZING AND VERBALIZING PROGRAM The firm earth of experience was the basis for the initial hypothesis of two types of imagery: concept imagery and symbol imagery. A clinical environment, laden with individuals of all ages and all types of language processing weakness, led to cognitive theory and the instructional procedures of the Visualizing and Verbalizing for Language Comprehension and Thinking (V/V) program. The first realization in applying theory to procedure was that individuals need to develop the ability to image a whole. The next was that imagery couldnt just be developed by a reminder or simple cue, such as, Visualize what you read. For individuals with a sensory weakness of bringing parts to whole with imagery, specific steps and specific questions needed to be presented. The steps of V/V are sequential and require the teacher or therapist to ask questions directed to the sensory system. Pribram (1971) said, We cannot think about something of which we are not consciously aware, and we cannot be aware of something not perceived sufficiently at the sensory level to come to consciousness. Therefore, teacher language must directly stimulate specific sensory-input.

What did you hear? may not be specific enough to stimulate imagery. Such a question may direct the child to attend primarily to the sensory stimuli of the airplane whirring by or the tapping of the woodpecker on a nearby tree. But the question, What did you picture? directs the childs attention to the specific sensory information of imagery. The next sensory-directed question builds concept imagery by directing the child to continue picturing the same subject while extending it to action. What did you picture the white horse doingrunning or jumping? The language directs the student to compare the input of imagery to the input of languagestimulating the integration of verbal to nonverbal sensory stimuli. The V/V procedure develops concept imagery with the smallest unit of language a wordand extends the imagery to sentences, paragraphs, and pages of content. The specific steps follow. Steps of V/V 1. Picture to Picture The goal is to develop fluent, detailed verbalization from a given picture (prior to requiring detailed verbalization of a generated image in the next step). The individual describes simple, given pictures. Structure wordswhat, size, color, number, shape, where, when, background, movement, mood, perspective, and soundare introduced to provide concrete descriptive elements. The choice and amount of structure words presented depends on the severity of the weakness or age of the individual. The teacher questions with choice and contrast to stimulate verbalization of the picture and directs the student to monitor and compare his verbalization. Not looking at the given picture, but imaging from the students language, the teacher


ICDL Clinical Practice Guidelines

says, What should I picture for the boys pants? Does he have on blue pants or red pants? Are they long pants or short pants? This reference to imagery in the question helps the student think about relevant and detailed verbalizationthe goal of this step and the preparation for the next step. 2. Word Imaging The goal is to develop detailed visualizing and verbalizing (dual coding) for a single word. The individual describes a generated image for a single word, beginning with a personal image and extending it to a high-imagery known noun, such as clown or cowboy. The structure words, introduced earlier, are used to provide detailed, vivid imagery. The teacher uses choice and contrast to ask sensorydriven questions to specifically develop imagery. Are you picturing a white hat or a black hat on the cowboy? Does he have hair or no hair? 3. Phrase and Sentence Imaging The goal is to extend the imagery and language from one word to a phrase and then to a single, simple sentence. As the steps overlap, the individual uses a specifically imaged known noun as the subject of a sentence to be imaged. For example, the clown that was imaged as a single word, with vivid images from the structure words and questioning, is now the imagery to which action, a verb, is attached. Keep the same clown we just visualized, and now picture this, the clown jumped on the red ball. The extent of the imagery stimulation is dictated by the age and severity of the dysfunction (the sentence could have only one subject and one verb to image; that is, the clown

jumped, the clown cried, the clown laughed, the clown snorted). 4. Sentence by Sentence Imaging The goal is to extend the integration of imagery and language to a gestalt sentence by sentence. The procedure begins receptively, from a short, self-contained paragraph, with each sentence read to the individual. As the individual visualizes and verbalizes each sentence, colored squares are placed sequentially in front of him to designate the imaged part (the sentence). Structure words are used to develop detailed imagery for the first sentence (the topic, or gestalt, sentence). At the completion of the paragraph, with approximately four to five colored squares representing the sentences, the individual gives a picture summary. Touching each colored square, he says, Here I saw At the completion of the picture summary, the colored squares are collected and put away. The student then gives a word summary, using his imagery to paraphrase the paragraph. 5. Sentence by Sentence with Higher-Order Thinking Skills (HOTS) The goal is to develop critical thinking from the imaged gestalt developed in the previous step. The same sentence-by-sentence procedure of placing colored squares for the parts, verbalizing with a picture summary to sequentially summarize the imaged parts, and verbalizing with a word summary to paraphrase the whole is used to establish the cognitive base for interpretation. With the imaged whole as the base, the student is asked the main idea, conclusion, and inference questions. What was the main thing you pictured

Chapter 25. Imagery and the Language Processing Spectrum


from that paragraph? Did you picture elephants or fleasand what did you picture about the elephant, how it eats, how it sleeps? From all your images, why do you think the elephant might destroy a forest? What do you picture might happen if? 6. Multiple Sentence, Paragraph, and Whole Page Imaging with HOTS The goal is to increase and extend the language input, either receptive or expressive, to develop the imaged gestalt and apply that cognitive base to critical thinking, problem solving, and interpretation. The succeeding steps increase the language from which the individual visualizes and verbalizes, creating the gestalt. HOTS questions are included for every paragraph, and the material may become longer and denser, depending on the age and level of the student. The stimulation is from oral language as well as from language the student decodes. The steps of V/V develop an individuals ability to bring parts to whole and think with an imaged gestalt. Once the gestalt is able to be imaged, it can be brought to a conscious level for problem solving, paragraph writing, comprehending and studying content, following directions, logical thinking exercises, mathematics, play, and interpreting and responding appropriately to social situations. Dual Coding Theory and Visualizing and Verbalizing The V/V program was developed to meet language processing needs, but its importance and direct relationship to dual coding theory was noted later. Paivio (1979) states, The most general assumption in dual coding theory is that there are two classes of

phenomena handled cognitively by separate subsystems, one specialized for the representation and processing of information concerning nonverbal objects and events, the other specialized for dealing with language. The nonverbal (symbolic) subsystem is referred to as the imagery system because its critical functions include the analysis of scenes and the generation of mental images. The language-specialized system is referred to as the verbal system. The V/V program stimulates and integrates the two systems of language and imagery and heads toward the imaged gestalt for cognition. Paivio also (1986) writes, Human cognition is unique in that it has become specialized for dealing simultaneously with language and with nonverbal objects and events. Moreover, the language system is peculiar in that it deals directly with linguistic input and output (in the form of speech or writing) while at the same time serving a symbolic function with respect to nonverbal objects, events, and behaviors. Any representational theory must accommodate this functional duality. The V/V Program stimulates language and imagery, integrating the two systems in a systematic, sequential formataccommodating the functional duality. The simplicity of dual coding theory the duality of verbal and nonverbal subsystemsis compatible with clinical experience when cognition is observed on the language processing spectrum. From dyslexia on the left to comprehension and expression on the right, the integration of imagery and language is at the core of successful processing. Imagery for partssymbol imageryintegrates imagery and language for processing words. Imagery for wholesconcept imageryintegrates imagery and language for processing concepts, abstractions, and the big picture.


ICDL Clinical Practice Guidelines

PARTS-WHOLE AND SYMPTOMS OF AUTISM As discussed earlier, the more severe the concept imagery weakness, the more severe the symptoms, which may move onto the autistic spectrum. Although not the only weakness causing the symptoms of autism, it is likely that weak concept imagery is a primary contributing factor. The integration of verbal and nonverbal processing is critical for children on the autistic spectrum. The nonverbal system of imagery provides sensory support for their language processing abilitywith the imaging of concepts foremost. In noting language processing as a parts-whole issue, many of the symptoms on the autistic spectrum can be traced to weakness processing the whole. The following well-accepted symptoms of autism can be separated into parts-whole processing strengths or weaknesses. Ability to process parts contributes to strength in: Rote memory Mechanical tasks Acquisition of simple information Simple procedural tasks Simple associations Word recognition Spelling Rote computational tasks Short-term immediate repetition of oral material Inability to process wholes contributes to weakness in: Complex information processing Concept formation Abstract and critical thinking Interpretive oral language comprehension Interpretive reading comprehension

Complex memory for oral and written material Following complex oral/written directions Problem solving Analysis and synthesis of information Organizational strategies

With the parts-whole issue in mind, the specific type of imagery an autistic child may be able or unable to do needs to be identified. For example, is visual thinking thinking in parts, or is it thinking in wholes? Does visual-spatial thinking mean imagery for parts or imagery for wholes? IMAGERY AND VISUALLY BASED MATERIAL It is often noted that autistic children respond well to visually based material because it makes language and the physical environment concrete for them. Auditory input is supplemented with visual back-up. The following section lists the benefits of using visually based material, such as cue cards, to supplement auditory information (TwachtmanCullen 1998). Note that visual imagery can be substituted in each item, as shown, and that the stimulation of imagery can offer children an internal visual back-up system. Strengths of Visually Based Material Visually based material is stable over time. (Visual imagery is stable over time and internal for children, taken with them wherever they go.) By supplementing the auditory channel with visual back-up, the individual has the benefit of two input channels. (By supplementing the auditory channel with visual imagery, the individual can inte-

Chapter 25. Imagery and the Language Processing Spectrum


grate verbal with nonverbal sensory information, anywhere at anytime.) Visual information is an eye catcher for capturing and maintaining attention. (Visual imagery is the same eye-catcher, only internal, enabling the individual to attend and focus.) Visual supplementation aids processing ability. (Given that visual imagery is the nonverbal code for dual coding, visual imagery aids processing ability and is available to the individual anywhere at anytime.) Visual information helps make concepts more understandable by making them concrete. (Visual imagery makes concepts concrete with sensory information that can be internally manipulated, related, and processed.) Visual information can increase understanding in general. (Visual imagery for the gestalt enables individuals to process concepts, anywhere at anytime.) Visual supports can be used to prompt individuals. (Visual imagery can be used to prompt individuals through conscious questioning of imagery relative to the event or concept, or through the individualsown internal prompt, which allows them to contrast and compare with imagery.) Visual supports can help minimize anxiety. (Visual imagery for concepts helps minimize anxiety by making the world less a jumble of random parts. With the imaged gestalt, meaning can be derived from both oral and written language.) Visual supports can render information more memorable. (As research shows, imagery is related to memory and recall; hence, visual imagery renders information more memorable.)

a conscious level and then supplemented and eventually substituted for visual aids. As the imagery begins to reside within the child, independence is developed for crossover to all environmental situations. Concept Imagery for Floor Time, Play, and Pragmatics With an imaged gestalt developing from V/V stimulation, teachers and therapists can drive the sensory bus by asking specific imagery-related questions or giving specific imagery-related stimulation. The imagery stimulation, either in conjunction with adapted V/V or separate from V/V stimulation, is applicable for floor time (see Greenspan & Wieder, Chapter 12, this volume) and play activities. During floor time and play, imagery can be specifically stimulated with questions that draw attention to mental representations for actions or events. Following the childs lead, imagery can be consciously activated as a connection to the play and the language. Even if imagery cannot be brought to a conscious level for the child, the reference to it causes stimulation in the sensory system and awareness of imagery as a cognitive tool. For example, while following the childs lead in a play activity, ask, Im picturing that the horse is going to fall off the wall. What are you picturing? Lets picture it, then do it. Use choice and contrast by asking, Tell me how you picture him falling, on his head or tail? Now lets do it and check it. Then reverse the stimulation and begin with a play action, followed by talk about the imagery of the action. For example, consciously connect imagery to memory by picturing an action that didnt happen yet. That was fun. Lets see if we can picture it. Im picturing that the horse fell on his tail. Is that what you pictured? Repeat the play action to

Although visual back-up is helpful and effective, visual imagery can be stimulated at


ICDL Clinical Practice Guidelines

compare it to imagery. Hmmm, lets check to see if what we pictured happened. Even if the child cant image easily, and is responding minimally to the language, it is important to connect the concrete activity of play to the concreteness of imagery, helping to move the child into symbolic play based on mental representation ability. The more absurd the play and imagery, the more contrast there is and the more likely the child will engage and begin to make the play-imagery-language connection. As the play interaction progresses, extend the play-imagery-language stimulation to prediction and abstract thinking. Use imagery to make thought concrete. If our big truck (a toy truck) runs into this little fence, what do you picture will happen to the fence? Okay, lets see if what you pictured really happens. Verify imagery with action, then use language to describe both. Language such as, What do you think will happen next? or What do you remember? doesnt direct and specify attention to imagery. However, language such as, What do you picture will happen next? drives the sensory bus and directs the child to attend to the specific and more concrete sensory input of imagery. A young boy, labeled high-functioning autistic, made an illuminating comment, What I like about V/V is that you dont have to think anymore. Regarding pragmatics, the play-imagerylanguage interaction can be used in connection with V/V or separate from formal V/V stimulation. However, using imagery for pragmatics requires that the individual have the ability to image a whole. To meet this prerequisite, as a student is developing gestalt imagery through the steps of V/V, the therapist can overlap concept imagery to have the student vicariously experience social situations, problem solve, and determine appropriate reactions. For example, the therapist can set up an imaged social situa-

tion, visualize the setting and the characters, and then create different actions and reactions. Imagery can be used to interpret the situation, the cause of the event, and the appropriate and/or inappropriate reactions or responses. From the imagery, conclusions, inferences, and predictions can be asked and answered. This imagery practice for social situations allows individuals to use the sensory input of concept imagery to monitor, self-correct, and become independent in a social situation without a parent or therapist present. RESEARCH ON THE V/V PROGRAM The effectiveness of using the V/V program for concept imagery stimulation has been consistently evident for many years in Lindamood-Bell clinical intervention. Significant gains have been noted in following oral directions, reading recall, reading comprehension, and visual-motor skills. The clinical population studied included students on the autistic spectrum, though usually not with what would be described as severe autism or a Type IV classification (Greenspan & Wieder, 2000). What follows is a summary of the research on the V/V Program. Spanning nearly a 10-year period, the data to date note positive effects of V/V on language processing skills. While the data have remained consistent, continued research is needed to further understand and document the role of imagery in language processing skills, specifically for target populations with labels such as hyperlexia and autism. The first reporting of V/V Program success was in 1991, when Bell measured statistically significant gains for 22 males and 23 females, ranging in age from 9 to 57, who had received V/V only stimulation. Although performing poorly in language comprehension, their performance on other

Chapter 25. Imagery and the Language Processing Spectrum


diagnostic tests indicated a normal range for receptive and expressive oral vocabulary, phonemic awareness, word attack, and word recognition. After an average treatment time of 47.26 hours, with a range of 16 to 110 hours, all study participants noted significant improvement in comprehension. For example, pretesting of the group indicated a percentile mean for reading comprehension on the Gray Oral Reading Test, Revised (GORTR), of 43.94 and a post-testing percentile mean of 75.55 (p<.001). A subgroup of 16 of the 45 individuals, who ranged in age from 15 to 57 years old, were given the Descriptive Tests of Language Skills of the College Board, Reading Comprehension subtest. Their percentile mean was 56.06 on the pretesting and 71.29 on the post-testing (p<.001). The Lindamood-Bell clinical gains continue to verify that the V/V program produces statistically significant gains in language processing. With an N of 843, V/V program-only students from 1994 to 1998, including some identified on the autistic spectrum, had an average pretest score in the 15th percentile for reading comprehension on the Gray Oral Reading Test-3, (GORT-3). After an average of 72 hours of instruction, the post-test average was at the 37th percentile (p<.0001). For the same population and time, an N of 302 V/V program-only students achieved similar improvement in following oral directions. For example, the average pretest score in following oral directions was at the 37th percentile. After an average of 82 hours of instruction, the posttest results were at the 63rd percentile (p<.0001). Lindamood-Bell school projects using the V/V program show gains similar to those seen in Lindamood-Bell clinics. For example, for the 1999-2000 school year, 96 students in the Pueblo School District,

Colorado, received V/V program-only instruction for an average of 62 hours. They performed at the 9th percentile in reading comprehension (GORT-3) on the pretest but at the 25th percentile on the post-test (p<.0001). They showed similar statistically significant results in following oral directions (p<.0001). Thirty-two students at the Corwin Middle School in Colorado, many of whom spoke English as a second language, progressed from the 9th to the 25th percentile (p<.0091) in reading comprehension (GORT3) after 41 hours of V/V instruction. The same middle school children demonstrated similar gains in following oral directions, improving from the 16th to the 50th percentile (p<.0001). Additional studies replicate the Lindamood-Bell clinical findings. A 1995 controlled study in the Long Beach, California, public schools involved an entire fourth-grade class for four months. Comparisons between the experimental group and the control group, which received no V/V stimulation, showed that the experimental group made significant improvement in following oral directions and reading comprehension. For example, although both groups were at approximately the 50th percentile in word recognition, both groups were at the low end of the normal range in reading comprehensionthe 27th and 28th percentiles, respectively. Pre- and post-testing on the GORT-3 reading comprehension test showed that the control group improved from the 27th to the 34th percentile, whereas the experimental group, after approximately 40 hours of V/V program instruction, improved from the 28th to the 45th percentile (p< .036). In a federal project study at Window Rock Elementary School on the Navajo Indian Reservation, Kimbrough (1991) studied the effects of the V/V program on language


ICDL Clinical Practice Guidelines

comprehension on a sample population of fourth- and fifth-graders. The criterion for student selection was a standard score of 3 or below (5 is average) from the Iowa Tests of Basic Skills (ITBS) Reading Comprehension subtest. The measured gains were based on National Curve Equivalent Scores (NCES), and not grade-level equivalent scores. The project students received V/V program instruction in small groups, for approximately 30 minutes a day for 5 weeks, for a total of 12 hours of intervention. The average gain in reading comprehension was 6.6 points on the NCES compared to the national average gain of 3 points. Kimbrough states, In the past, my students have always averaged a gain of 2 to 3 NCES points. After doing V/V for 5 weeks, my students doubled their scores compared to years past. Research from Truch (1996) reports using the V/V program with 66 subjects for 80 hours of instruction. Subjects were of different ages and ability levels. Overall, 60% were in the age group of 6-12, another 25% were between the ages of 13 and 17, and the remaining 15% were adults ages 18 and over. The majority met the traditional criteria for learning disabilities, and some met the criteria for attention deficit disorder. The average age was 21 years. After 80 hours of V/V instruction, the gains in comprehension on the GORT-3 were highly significant, with an average gain of four grade levels in reading comprehension. Word reading was not a factor in the initial weak reading comprehension score, and the influence of vocabulary as a covariant failed to reach statistical significance. The Chance Program at Graceland College in Iowa used the V/V program in the 1988-89 school year study with 16 college students referred for reading comprehension problems and possible dropout potential. Following V/V instruction, their ranking on the Descriptive Tests of Language

Skills of the College Board, Reading Comprehension subtest, improved from a mean percentile of 29.8 to 51.6 (p <.05), placing them well within the normal range of processing. On the Nelson-Denny Reading Comprehension Test, their mean percentile ranking improved from 13.3 to 33.1, again placing the students within the normal range of function, this time showing a significance at p<.001. The number of students at LindamoodBell clinics who are specifically labeled autistic has increased only recently. Prior to the current understanding of autism and a subsequent increase in the number of children diagnosed with this disorder, some of the V/V students were probably severe enough to have had the label of high-functioning autism or Aspergers syndrome applied to their symptoms. Those students are included in the Lindamood-Bell clinical data and were referred to clinically as having a severe V/V profile. The V/V stimulation has been productive for developing language processing in individuals with that severe V/V label. However, while individual gains have been encouraging, modification of the V/V program for younger or more severely impaired autistic students is currently being studied. HANNAH: SYMBOL IMAGERY AND DYSLEXIA Although the focus of this chapter is on the relationship of imagery to the right side of the language processing spectrum, it is also important to understand imagery and the left side. Contrast aids perception. Briefly, symbol imagerythe ability to visualize the identity, number, and order of letters within wordsis a neurological, sensory-cognitive function critical to literacy development. The research documenting difficulty in segmenting phonemes

Chapter 25. Imagery and the Language Processing Spectrum


within spoken syllables has been extensive. This sensory processing problem has been called lack of auditory conceptual function, phonological awareness, and phoneme awareness by various researchers (Calfee, Lindamood, & Lindamood, 1973; Liberman & Shankweiler, 1985; Lundberg, Frost, & Peterson, 1988; Torgesen, Wagner, & Rashotte, 1996; Wagner, Torgesen, & Rashotte, 1994). However, the awareness of the segmental structure of words requires symbol imagery ability in order to process the internal parts. The ability to image letters in words makes phonological processing concrete. The sensory-system function that moves phonological information to a concrete level is the ability to attach meaning to imaged letters so that they form words that also have meanings. When this function is not available rapidly and easily, dyslexia, in mild to severe forms, may occur. Recent research has noted that abnormalities in phonological processing are invariably present in dyslexia; however, deficits in visual processing are also commonly seen (Eden, 1999). The relationship between imagery and reading skills has been considered important by a number of researchers for many years. The difference between good and poor readers on auditory discrimination tasks may arise not only from deficient auditory skills in poor readers, as is commonly thought, but also from the ability, as evidenced in good readers, of imaging written language symbols to improve their ability to discriminate sounds (Ehri, 1980). A measure of phonemic awareness with an instrument as precise as the Lindamood Auditory Conceptualization (LAC) test is a contribution to the field of reading and to an understanding of the role of phonological processing. A new measure of symbol imagery appears to be making a similar

contribution. The Symbol Imagery test (Bell, 1999) documents the correlation between the ability to image letters within words and a students function in phonemic awareness, word attack, word recognition, and spelling. For example, analyzing testings of 330 students on a range of standardized reading and spelling tests demonstrated that symbol imagery ability correlated with phoneme awareness at a .70 level, with word attack at .81, with word recognition at .85, with spelling at .84, and with passage reading at .82. The data further suggested that symbol imagery correlates higher than phoneme awareness to word attack, word recognition, spelling, and paragraph reading. For example, phoneme awareness, as measured on the LAC test, correlated with word attack at .72, with word recognition at .67, with spelling at .59, and with passage reading at .61. Although the information on symbol imagery is an important contribution to understanding the sensory mechanism involved in the acquisition of literacy skills, it is also important to note that not all individuals have this function available to them. For example, Jacob, a 14-year-old dyslexic had undiagnosed difficulties with symbol imagery. Jacob was exceptionally bright, got As on term papers that he dictated orally, had exceptionally high oral language comprehension, and everyone wanted to work with him because he truly contributed to others understanding. A few weeks after he began treatment to develop articulatory feedback to assist him in perceiving sounds within words, he reached a plateau in applying his phonological processing to reading and spelling. His mother a pediatrician, wrote: Jacob was finally moving forward, but something was still missing. After a couple of weeks, Kimberly called me and said she was planning on adding symbol imagery to Jacobs program. I honestly


ICDL Clinical Practice Guidelines

didnt know what that was until Jacob came home and asked, Mom, do you picture letters in your head, because I never have. So, thats why the lists of sight words were a joke throughout school. He was 14 years old and didnt have a single sight word. That was why he had to sound out a word twice if it appeared again in the same sentence. Amidst all the files of information (imagery) crammed into his extensive memory, literature, people, events, geometry, there was not one single letter! Symbol imagery is processing parts and results in the ability to process words rapidly and automatically. To return to Hannah, she was like Jacob in that her weakness in this imaging skill caused a resultant weakness in reading and spelling words. As her symbol imagery was developed and applied to decoding and encoding single through multisyllable words, she began to self-correct rapidly and automatically during the reading and spelling tasks. Her reading fluency developed, as did her orthographic spelling skills. Hannahs improvement is consistent with the clinical work at Lindamood-Bell, which verifies the interrelationship of imagery to print decoding and encoding. The 1997-98 Lindamood-Bell clinical data for children in the 10- to 13-year age range who were trained in only the Seeing Stars Symbol Imagery program (see Lindamood & Lindamood, Chapter 23, this volume) showed significant mean percentile improvement for all standardized tests, with the greatest improvements in word attack, paragraph accuracy, and paragraph reading (combining rate and accuracy). For example, in word attack the students mean percentile improved from 32 to 68 (p<.0001). In paragraph accuracy, their mean percentile improved from 37 to 63 (p<.0001). In

passage reading, their mean percentile improved from 25 to 50 (p<.0001). A 1998-99 controlled study verified that dual coding with symbol imagery and language is applicable for reading and spelling words, as well as processing language concepts. The role of symbol imagery was researched in a Lindamood-Bell controlled study at an elementary school in Idaho, where only the stimulation of symbol imagery was examined. In second- and fifthgrade classrooms (an N of 32 and 26, respectively), the experimental group, receiving an average of 42.5 hours of small-group stimulation in the Seeing Stars Symbol Imagery program, had statistically significant gains in word attack, word recognition, and spelling. For example, in word attack, the secondgrade experimental group had a mean standard score gain of 13.12, compared to the control groups mean standard score gain of 5.94 (p>.01). In word recognition, the experimental group had a standard score gain of 9.62, compared to the control groups mean standard score gain of 2.75 (p<.01). In spelling, the experimental group had a mean standard score gain of 9.56, compared to the control groups mean standard score gain of 3.25 (p< .01). Comparison between the fifth-grade experimental group and control group showed similar gains by the group receiving Seeing Stars Symbol Imagery program instruction. In word attack, the experimental group had a mean standard score gain of 8.85, compared to the control groups mean standard score gain of 1.85 (p<.05). In word recognition, the experimental group had a mean standard score gain of 5.46, compared to the control groups mean standard score gain of .54 (p= .08). In spelling, the fifthgrade experimental group had a mean standard score gain of 4.92, compared to the

Chapter 25. Imagery and the Language Processing Spectrum


control groups mean standard score gain of 3.25 (p = .05). Symbol imagery is a sensory mechanism that places orthography for words in memory as well as enabling phonological processing at an automatic level. When individuals have an extensive sight word base and can quickly self-correct decoding errors, reading fluency is increased (Bell, 1997), and the left side of the language processing spectrum is intact. A BRIEF HISTORICAL PERSPECTIVE OF IMAGERY This chapter focuses on the relationship of imagery to parts-whole thinking and competence in language processing. Within this context, a brief examination of the historical perspective on imagery will be more illuminating. The following historical comments and research with imagery can be viewed from the perspective of parts-whole, symbol, and concept imagery theory. Einstein wasnt alone in his reference to imagery as a primary sensory-cognitive function. References begin as far back as 348 BC, when Aristotle, in his contemplations on the ability to reason, theorized that man cannot think without mental imagery. His summation of memory concludes, Thus, we have explained that memory or remembering is a state induced by mental images related as a likeness to that of which it is an image. Together with the statements from Aristotle and Einstein, there is compelling evidence and historical perspective that imagery is a primary factor in cognition, ranging from reading and spelling words to language comprehension and critical thinking. A few hundred years before Aristotle, Simonides (556-468 BC) taught imagery as a system to improve memory. The great Greek and Roman orators used the system of imagery to enable them to speak for hours

without written notes. This critical role of imagery comprised the classical art of memory for thousands of years, and there was direct stimulation of imagery as a primary sensory function for memory and thinking. Then, modifications of Platos thoughts, neoPlatonic ideas, began to gradually remove imagery from prominence. In the 11th and 12th centuries, memory systems again became useful for purposes of remembering and making memorable the central Christian ideas. Statements such as Thomas Aquinass, Mans mind cannot understand thoughts without images of them were responsible for renewed interest in imagery as a cognitive function. In more modern times, Jean Piaget (1936, cited by Bleasdale, 1983) wrote that knowledge, structures, or schemata are acquired when the infant actively manipulates, touches, and interacts with the environment. As objects are manipulated, sensory-motor schemata are developed and changed to accommodate new information. Over time, schemata become internalized in the form of imaged thought. Perhaps weakness on the right side of the language processing spectrum is caused by an inability to take the last step in Piagets thinking. Perhaps the breakdown is not in the sensory-motor stimulation of manipulating objects, but rather a breakdown at the sensory level of imageryinternalizing the schemata in the form of imaged thought. Perhaps the sensory function of creating images is not developed to a sufficient enough level so as to be able to create imagery from either kinesthetic or language experiences. Seeming to answer the above question, Piaget further stated, It is clear that imaginal representations are not formed with the same facility in each case, and that there is therefore a hierarchy of image levels, which may correspond to stages of development. The


ICDL Clinical Practice Guidelines

evolution of images is a kind of intermediate between that of the perceptions and that of the intelligence. Proceeding chronologically to some of the more interesting research and commentary, Arnheim (1966) wrote, Thinking is concerned with the objects and events of the world we knowwhen the objects are not physically present, they are represented indirectly by what we remember and know about them. In what shape do memory and knowledge deliver the needed facts? In the shape of memory images, we answer most simply. Experiences deposit images. But, for the child or adult for whom imagery is not fast, automatic, vivid, or conceptual, these experiences may not happen easily or automatically. Arnheim quoted the psychologist Edward B. Titchener, My mind, in its ordinary operations, is a fairly complete picture gallery, not of finished paintings, but of impressionist notes. Whenever I read or hear that somebody has done something modestly, or gravely, or proudly or humbly, or courteously, I see a visual hint of the modesty or pride or humility. The visual hint Titchner describes is a higher level of imaging that begins with imaging the concrete and moves to imaging the abstract. Continuing in the 1960s, Paivio (1969) wrote extensively on the role of imagery in cognition. As every psychologist knows, imagery once played a prominent role in the interpretation of associative meaning, mediation, and memory. It was widely regarded as the mental representative of meaningor of concrete meaning at least. William James (1890), for example, suggested that the static meaning of concrete words consists of sensory images awakened. The 1970s brought further illumination from Paivio (1971). He had been attempting to demonstrate the way in which imagery can affect the acquisition, transformation, or

retrieval of different classes of information. His dual coding theory, discussed earlier, defined imagery as one of two types of cognitive code, the other code being a verbal one. Paivio suggested that linguistic competence and performance are based on a substrate of imagery. Imagery includes not only static representations but also dynamic representations of action sequences and relationships between objects and events. Pribram (1971) stated, Recently the importance of the Image concept has started to be recognized: cognitive psychologists analyzing the process of verbal learning have been faced with a variety of Imaging processes which demand neurological underpinnings. Neurological research, as well as insights derived from the information-processing sciences, have helped make understandable the machinery which gives rise to this elusive ghost-making process. He further hypothesized that all thinking has, in addition to sign and symbol manipulation, a holographic component. Also in the 1970s, Kosslyn (1976) conducted a developmental study on the effects and role of imagery in retrieving information from longterm memory. In two blocks of trials, firstgraders, fourth-graders, and adults were asked to determine whether various animals are characterized by various properties, first upon the consultation of a visual image and then without imagery. He reported that imagery provided more opportunity for retrieval. Additional evidence surfaced during the 1980s. For example, Linden and Wittrock (1981) stated, Reading comprehension is the generation of meaning for written language We found that reading comprehension can be facilitated by several different procedures that emphasize attention to the text and to the construction of verbal or imaginal elaborations. In a study comparing fourth-graders with a control group of students given equal time to learn with the same reading teacher, he noted,

Chapter 25. Imagery and the Language Processing Spectrum


the generation of verbal and imaginal relations or associations between the text and experience increased comprehension approximately by fifty percent. Further research by Oliver (1982) was based on three experiments to determine if an instructional set for visual imagery would facilitate reading comprehension in elementary school children. He concluded, These findings indicate that teachers should try to help children develop the metacognitive skill of visual imagery as a strategy for improving comprehension Visualization enhances comprehension. Kosslyn (1983) noted, A number of great thinkers, most notably Albert Einstein, professed to rely heavily on imagery in their work. Consider these words of Einstein: The psychical entities which seem to serve as elements of thoughts are certain signs and more or less clear images which can be voluntarily reproduced this combinatory play seems to be the essential feature in productive thoughtbefore there is any connection with logical construction of words or other kinds of signs which can be communicated to others. Long, Winograd, and Bridge (1989) further summarized, Our results suggest that imagery may be involved in the reading process in a number of ways. First, imagery may increase the capacity of working memory during reading by assimilating details and propositions into chunks, which are carried along during reading. Second, imagery seems to be involved in making comparisons or analogiesthat is, in matching schematic and textual information. Third, imagery seems to function as an organizational tool for coding and storing meaning gained from the reading. As is evident, theories and research on the relationship of imagery to thinking have been held and proven repeatedly throughout history. The 1990s continued to produce supportive

research to uphold the role of imagery in cognition and reading. For example, Bower and Morrow (1990) observed, Readers or listeners construct mental models of the situation a writer or speaker is describing. This is the basis of language comprehension. Another researcher, Sadoski (1992), continues, Imaginative processes, including imagery and emotional responses, are necessary to breathe life into the reading experience. In researching dual coding theory, reading theory, and reading efficiency, Sadoski noted that imagery is directly related to reading comprehension, reading recall, and verbal expression. He validated Paivios dual coding theory in numerous studies involving imagery, comprehensiveness, and recall by carefully proving that the more reading concepts are imaged, the better they are comprehended, the longer they are recalled, and the more interesting they are to the reader. Kosslyn and Koenig (1992) reported that the best clues about what different parts of the brain are doing during reading come from Positron Emission Tomography (PET) studies. These PET studies indicated that even reading single words is a complex activity, which involves several different parts of the brain. In particular, they reported that reading has a visual component and an associate memory component. The visual component clearly appears to involve the preprocessing and pattern activation subsystem, given the locus of the activation, and the associative memory component appears to involve the categorical property look-up subsystem (imagery). SUMMARY It is seemingly simple to think of imagery as a primary sensory system function necessary for efficient language processing skills. However, the premise includes two important considerations: (1) the integration of imagery


ICDL Clinical Practice Guidelines

to language, nonverbal and verbal stimuli, is necessary for cognition, and (2) there are two subtypes of imagerysymbol and concept imageryfor parts-wholes processing. The imagery subtypes move from left to right on the language processing spectrum. Symbol imagery is a primary sensory mechanism for reading and spelling words. Concept imagery is a primary sensory mechanism for language comprehension, expression, and conceptual thinking. Labels such as dyslexia, hyperlexia, and autism reflect weakness on the spectrum. Concept imagery is a primary weakness for hyperlexia; however, more research is needed to know the precise role concept imagery plays in autism. Conceptual thinking is a processing deficit for individuals on the autistic spectrum, hence it is important to look for a primary sensory weakness. While the behavioral complexity involved in conceptual thinking suggests that the mechanism of the process does not involve a single sensory or cognitive process, the inability to create mental representations that rapidly and automatically bring parts to whole is very likely a primary contributing factor in autism. The V/V program was developed on the basis of clinical observation and experience, and without the knowledge of Paivios dual coding theory on the duality of processing verbal and nonverbal stimuli for cognition. However, the V/V program accommodates Paivios theory of duality. Similarly, it stimulates concept imagery. As the program develops an individuals ability to image gestalts, the therapist can apply the imagery to

developing numerous other skills in the individual, such as conceptual thinking, critical thinking, problem solving, oral and written language comprehension and expression, pragmatics, floor time, and play. There are, however, further challenges ahead for program refinement. Although the V/V has produced documented changes in processing ability, the program may need modification to work most effectively with high-functioning autistic individuals as well as with more severely involved autistic children. The research and process of modifying V/V to this level is underway. Important knowledge has been gained about the imagery connection to partswholes processing; however, there are still challenges to be met. For example, tests of imagery need to be further developed to document the relationship of language processing behaviors to imagery. The brain processing ability of children with the label of hyperlexia, Aspergers syndrome, and autism needs to be measured before and after imagery stimulation. If the greatest thinkers of our time attribute their strength in cognitive ability to imagery, it is reasonable to think that weakness in cognitive ability is conversely related to weakness in imagery. Oliver Sacks said that language is the symbolic currency for which we exchange meaning. Understanding the role imagery plays in symbolizing meaning may contribute to our continuing effort to bring children from s darkness into the light.

Chapter 25. Imagery and the Language Processing Spectrum


REFERENCES Aristotle (1972). Aristotle on memory. Providence, RI: Brown University Press. Arnheim, R. (1966). Image and thought. In G. Kepes (Ed.), Sign, image, symbol. New York: George Braziller. Bell, N. (1986). Visualizing and verbalizing for language comprehension and thinking. San Luis Obispo, CA: Gander Educational. Bell, N. (1991). Gestalt imagery: A critical factor in language comprehension. Annals of Dyslexia, 4, 246-260. Bleasdale, F. (1983). Paivios dual coding model of meaning revisited. In J. C. Yuille (Ed.), Imagery, memory and cognition: Essays in honor of Allan Paivio. Hillsdale, NJ: Erlbaum. Bower, G. H., & Morrow, D. G. (1990). Mental models in narrative comprehension. Science: Jan., 44-48. Calfee, R., Lindamood, C., & Lindamood, P. (1973). Acoustic-phonetic skills and readingkindergarten through twelfth grade. Journal of Educational Psychology, 64, 293-298. Eden, G. F. (1999). FMRI studies of remediation in developmental dyslexia. Grant Application for the Department of Health and Human Services. Ehri, L. (1980). The role of orthographic images in learning printed words. In J. F. Kavanaugh and R. L. Venesky (Eds.), Orthography, reading and dyslexia. Baltimore: University Park Press. Greenspan, S. I., & Wieder, S. (2000). Neurodevelopmental disorders of relating and communicating. The Infancy and Early Childhood Training Course, Arlington, VA, April. Kimbrough, J. (in preparation). Project ROLL: Reaching out for lifelong literacy. Kosslyn, S. M. (1976). Using imagery to retrieve semantic information: A developmental study. Child Development, 47, 434-444. Kosslyn, S. M. (1983). Ghosts in the minds machine. New York: W. W. Norton. Kosslyn, S. M., & Koenig, O. (1992). Wet mind, the new cognitive neuroscience. New York: Free Press. Liberman, I., & Shankweiler, D. (1985). Phonology and the problems of learning to read and write. Remedial and Special Education, 6, 8-17. Lindamood, C. H., & Lindamood, P. C. (1979). Lindamood auditory conceptualization test. Austin, TX: PRO-ED Lindamood, P., Bell, N., & Lindamood, P. (1997). Sensory-cognitive factors in the controversy over reading instruction. The Journal of Developmental and Learning Disorders, 1, 143-182. Linden, M. A., & Wittrock, M. C. (1981). The teaching of reading comprehension according to the model of generative learning. Reading Research Quarterly, 17, 44-57. Long, S. A., Winograd, P. N., & Bridge, C. A. (1989). The effects of reader and text characteristics on reports of imagery during and after reading. Reading Research Quarterly, 19(3), 353-372. Lundberg, I., Frost, J., & Peterson, O. (1988). Effects of an extensive program for stimulating phonological awareness in preschool children. Reading Research Quarterly, 23, 263-284. Oliver, M. E. (1982). Improving comprehension with mental imagery. Paper read at the Annual Meeting of the Washington Organization for Reading Development of the International Reading Association, Seattle, WA, March. Piaget, J., & Inhelder, B. (1971). Imagery and the child. New York: Basic Books.


ICDL Clinical Practice Guidelines

Paivio, A. (1969). Mental imagery in associative learning and memory. Psychological Review, 76, 241-263. Paivio, A. (1979). Imagery and verbal processes. New York: Holt, Rinehart, and Winston. (Reprinted 1979, Hillsdale, NJ: Erlbaum.) Paivio, A. (1986). Mental representations: A dual coding approach. New York: Oxford University Press. Pribram, K. (1971). Languages of the brain: Experimental paradoxes and principles in neuropsychology. New York: Brandon House. Sadoski, M. (1983). An exploratory study of the relationship between reported imagery and the comprehension and recall of a story. Reading Research Quarterly, 19(1), 110-123. Smith, B. D., Stahl, N., & Neil, J. (1987). The effect of imagery instruction on vocabulary development. Journal of College Reading and Learning, 20, 131-137.

Torgesen, J., Wagner, B., & C. Rashotte, C. (1996). Approaches to the prevention and remediation of phonologically based reading disabilities. In B. Blachman (Ed.), Cognitive and linguistic foundations of reading acquisition: Implications for intervention research. Hillsdale, NJ: Erlbaum. Truch, S. (In preparation). Stimulating basic recall using the visualizing-verbalizing program. Twachtman-Cullen, D. (1998). Maximizing the effectiveness of socio-communicative interactions in more able verbal children. Paper read at the Child with Special Needs, Autism Preconference, Anaheim, CA, April. Wagner, R. K., Torgesen, J. K., & Rashotte, C. A. (1994). The development of readingrelated phonological processing abilities: New evidence of bi-directional causality from a latent variable longitudinal study. Developmental Psychology, 30, 73-87.

Chapter 26. Adolescents and Adults with Special Needs: The Developmental, Individual Difference, Relationship-Based (DIR) Approach to Intervention



Adolescents and Adults with Special Needs: The Developmental, Individual Differences, Relationship-Based (DIR) Approach to Intervention
Stanley I. Greenspan, M.D., and Henry Mann, M.D. When working therapeutically with developmentally disabled adolescents and adults, there are many challenging issues. The biggest and most significant challenge is to move our thinking beyond the stereotype that children reach a plateau beyond which improvement can only be minimal. In treating severely compromised older children, adolescents, and adults, many therapists give up trying to promote meaningful developmental progress. They teach only superficial skills and routines instead of trying to support and strengthen the patients functional developmental and processing capacities. This limited treatment approach is based on myth and false beliefthere are no data to support the idea that individuals at age 14 or 16 or 25 cannot make significant developmental progress. During this time, the nervous system is still developing. The brain continues to myelinate into the fifth and sixth decades. The frontal cortex areas of the brain that regulate sequencing, as well as parts of the brain that influence abstract thinking and concept building, keep myelinating into what we consider middle to old age. Judgment and wisdom improve during these years. While motor and memory skills degrade with age, our abstract thinking ability, our ability to see the big picture, to reflect, and to have insight improves with age. In addition, there is the factor of exercise of a function. The popular saying, Use it or lose it, describes this process. There has been a popularly held idea that certain math and memory abilities reach their peak in our late 20s and early 30s, but these notions were only based on examining limited or splinter skills and are not representative of later development as a whole. There is another area in which we are being misled into limiting our expectations and our hopes for our patients. As many individuals grow and progress through school, they may have the sort of problems that lead them to be identified as mentally retarded. In part this happens because school systems use standardized testing protocols that may not be appropriate for a particular childs learning profile. Reliance on standardized testing at a point in time (rather then looking at change over time) can lead to an assumption that the child has a permanent and severe mental limitation that is not amenable to change. The label of mental retardation implies a permanent and severe developmental limitation. We believe that the diagnosis of mental retardation should be made only after a child


ICDL Clinical Practice Guidelines

has participated in an optimal program for at least 3 years and has not made intellectual and/or developmental progress. An optimal program for these children would include a strong emphasis on identifying and strengthening the individuals processing profile. Prematurely identifying a child as retarded carries with it a resignation to the status quo rather than fostering an approach that works with a child and family to see if it is possible to improve his processing capacities, including auditory, visual-spacial, motor planning, and affective. It is often assumed that if a child has deficits across the spectrum of cognitive abilities tested this shows that the problems are more likely a part of a global cognitive deficit than specific processing differences. Sometimes however, children may have underlying processing problems, such as deficient motor planning and sequencing, which can affect functioning across the board. Severe motor planning dysfunctions can derail the development of other skills, such as verbal and visualspatial, as well as compromise a childs capacity to participate in a test. In such cases, individuals who have an underlying condition that could improve with proper remediation are misdiagnosed as having an untreatable, chronic developmental limitation. In addition, rather than a global cognitive deficit, many children have multiple processing deficits which can be worked with. If the child has processing problems in two or three pathways, we try to remediate those pathways. If a child has physical problems in different systems of the body, such as concurrent renal, pulmonary, and cardiac problems, we attempt to treat all the problem areas. Similarly, in our patients, the visual-spatial, auditory, and the motor-planning systems often all need to be treated. Each one of these areas may have many components to it, and there may be strengths or weaknesses within

the different components. This approach is more demanding of us as diagnosticians and therapists, but it also allows us to bring hope for developmental progress to a population that has been previously designated as too chronically and permanently developmentally impaired to be helped to a significant degree. We lose sight of the fact that helping an adult go from aimless, nonverbal, self-injurious behavior to having the capacity to purposefully interact with others, take pleasure in relating, engage in problem-solving interactions (e.g., signaling to get food or a game), and even learn some signs or words is a huge gain. Even though the individual still has enormous limitations, the quality, meaning, and competency of his life have grown significantly. Another problem that we have in working with older children, adolescents, and adults is their size. At an unconscious level, older and larger patients often do not generate in us the same sort of nurturing and protective feelings that affect and motivate us when we work with younger children. Our response to an angry and agitated adolescent is generally quite different than our response to a 3-year-old who is clearly anxious in a new situation and is acting in an angry manner. If we have a 3-year-old child who wants to go out into the snow with her shoes off, we attempt to educate and support the child and firmly help her make the correct decision. If we are dealing with a 17-year-old adolescent boy who angrily demands to go out into the snow with his shoes off, we have quite a different response. This sort of unconscious fear inevitably affects the staff of educational institutions, rehabilitation centers, and other institutions. Because of this mindset, the administration and staff may focus on limit setting, containment, and restraints rather than on fully engaging with their clients and bringing them to a higher developmental level.



EVALUATING AND TREATING ADOLESCENTS AND ADULTS WITH DEVELOPMENTAL DISABILITIES In order to work effectively with older children and adults, we need to extend our Developmental, Individual Differences, Relationship-based (DIR) model into the adolescent and adult years and then tease out the principles of intervention that are especially pertinent. If not already familiar with the DIR model, the reader should review Chapters 3, 4, and 12 this volume, as well as Infancy and Early Childhood: The Practice of Clinical Assessment and Intervention with Emotional and Developmental Challenges (Greenspan, 1992), The Child with Special Needs: Intellectual and Emotional Growth (Greenspan & Wieder, 1998), and The Growth of the Mind and the Endangered Origins of Intelligence (Greenspan, 1997). Basic principles of applying the DIR model to adolescents and adults are delineated and described here within the context of a clinical case. Jim: An Adult with Developmental Disabilities A mother recently related to us her concerns about her 30-year-old son, Jim. The questions she asked about her adult son illustrate some of the issues and principles involved in evaluating and treating adolescents and adults with developmental disabilities. The mother was conversant with the functional developmental approach (i.e., the DIR model) She reported that when she began working with Jim about 10 years ago on the process of engagement, she found his abilities in the area of two-way communication to be quite minimal. He was mostly selfabsorbed and had no spoken language. She said that when her son became frustrated or worried he would often scream. Initially, she

had interpreted his screaming as a communication to her that something was wrong and that he needed help from her. Later, she found out that he was having tremendous difficulty with word retrieval and had become overwhelmed with frustration. At a later point in his development, he was able to type the words would not come, and all I could do was scream. Mother noted that she had started working with a typing program as part of increased engagements and gesturing when Jim was 20 years old and had pursued it actively during the following 10 years. Mother reported that she could not get verbal responses. At the same time she was working with Jim on the typing program, she also worked with him on more gesturing and simple imitations of sounds and later words. Eventually, he learned to use some words (e.g., No car or Buy cookie or Go sleep). He had developed this new ability to verbalize very recently. This young mans progression to simple verbal expressions illustrates that appropriate interventions can be initiated at any age and may lead to unexpected progress if they are pursued consistently. In this case, the young man had been actively working with his mother for 10 years, from age 20 to 30, before he began to use spoken words to communicate. Mother described what it was like teaching him first to type and gradually to use some meaningful language. She attended a symposium related to the topic of using typing to teach language and began using it with her son. In order to help her son, who had low muscle tone, she needed to hold his forearm. Jim learned slowly and laboriously, but gradually he could type out one word at a time. She found that sometimes one word would appear within a large group of other letters. This gave her hope, and she continued to pursue her quest. Mother is currently working with facilitating Jims transition to verbal expression by


ICDL Clinical Practice Guidelines

saying to him, Now lets try and say it in words. The typing program may have provided mother with a goal and structure around which engaging and gesturing could occur. Jims mother described how she was dealing with his other developmental challenges. She was trying to help him learn to engage in pretend play, but found this difficult for several reasons. She, herself, was not comfortable with pretend play, but she was concerned that if she did not set the stage for pretend play her son would not initiate it. Her sons low muscle tone also interfered with his development of skills in pretend play. In addition, she reported that her sons ability to engage in pretend play was compromised by his difficulty with twoway communication. However, her son, who was almost completely self-absorbed, is now seeking out other people and says, Come sit with me. When he played with his father recently, he began to engage in spontaneous pretend play on a very limited basis. He had not been able to do this prior to his recent usage of simple words to communicate. Jims mother reported that he loves music and listens to records and tapes. He would look through tapes and select his own music. She believes that he read labels as part of the selection process. Recently he was able to read some simple books to her. She has asked him many times how he learned to read. He says myself. Jims mother has ongoing concerns about how to soothe her son. She had tried using a brushing technique recommended by sensory integration therapists and also found that he responded to the music on some of his favorite videos. Her most frequent problem continues to be dealing with his frustration about not being able to get out the words he is reaching for (at which point he often starts to scream). They are working on soothing and regulating interactions rather than on agitating ones. At this point, it should be clear that this young man struggles with many of the same

issues as does a 3- or 4-year-old child who is just becoming verbal and beginning to piece together several words, is still working on gestural communication, is still working on engagement, and has some splinter skills in the area of reading and word recognition. As he is learning to type and talk however, he is raising the possibility that he may have been perceiving more than he could communicate. This is not an unusual picture. The lesson to be drawn here is that we can use interventions with a 30-year-old man that would be comparable to what we might use with a 3- to 5year-old child. BASIC PRINCIPLES OF INTERVENTION The first principle of intervention is to work with the basic building blocks in the context of the persons interests. Working with Jim would be somewhat different than working with a 3- to 5-year-old child because Jim has some adult interests. He likes different kinds of music; he is a little more set in his ways. He is not going to be as easily drawn in as would a young child. Nonetheless, we still need to work on the same building blocks, but with different, more age-appropriate interests and possibly more understanding and awareness than is obvious. For example, if we were trying to work on pretend play with a teenager or a young adult who was embarrassed by getting down on the floor and pretending because he was aware that this is something that only little kids do, we would be faced with a dilemma. The patient needs the benefits of pretend play but, because of issues of pride and shame, is unwilling to participate. The solution to this dilemma might be to set up an improvisational theater setting, such as a home-based drama program. We might even encourage the teenager to participate in a class of other



teenagers or adults with developmental challenges to do improvisational work. The very act of playing different role parts in acting allows us to learn to improvise and therefore to pretend and imagine. Integrating developmental therapy into an activity that would be considered age-appropriate rather than childish will allow such an individual to obtain the benefits of the treatment without having to feel shame and humiliation. In working with Jim, we would recommend building on his interest in music as a way of beginning and stimulating imaginative play. One of his parents might listen to music with him and then begin to dramatize the music to see what the music brings to mind. Then, perhaps, they could create imagery with the music. If Jim were to select the music, he would select it to fit his mood. Therefore, his choice would be quite revealing. If he selected a vigorous marching piece or a soft and soothing piece, we would have some clue about his feelings at the moment. We might dramatize the music and the story with the use of dolls or cars or pictures. The use of pictures might be particularly helpful here because they allow quick recognition and interaction and also support symbol formation. Because the expressive auditory channel is critically challenging for Jim, we want to give it as much usage as possible even while he is learning to use words. If Jim could sequence pictures that were imaginative, he would also strengthen the same process in his verbal sphere. He should be given the opportunity to select pictures related to his favorite interests by looking through books or magazines in which he already has an interest. Then the pictures could be cut out, and he could use them to tell a story. Another possibility would be to use a digital camera to take pictures of people, pets, and other things that are part of his everyday life. If he combined these pictures

with cutouts from magazines, then he would have a wide range of images from which to draw. Pictures might also be helpful to him if they were kept available for times when he was agitated and upset so that he could point to them quickly to indicate his concerns. The picture system would serve as an intermediary and part of the next step to verbalization. We might anticipate that Jims visual skills are stronger than his oral language skills. The key is to use pictures not just to help him meet basic needs but also as part of a continuous flow of two-way communication in both pretend and reality-based situations. The second principle in working with developmentally challenged individuals is that it is crucial to keep moving sequentially through the functional developmental capacities. Unfortunately, with many older children, adolescents, and young adults, we often stop working with them when they have reached the level of having a partially developed language system. However, much more is needed when the older child or adolescent still is unable to appreciate experiences and to make gradations of thought and feeling. The concrete child might say, I like this, I dont like that, I want this, I dont want that. However, this is insufficient to help a child use language to learn to master complex feeling states and interactions. Children at this level are vulnerable to being impulsive or to having tantrums because they cannot understand relativity (i.e., shades of gray), time concepts, or quantity concepts, such as a little bit of this or a lot of that. These children think concretely and then do not learn to anticipate the future well enough to move into the stage in which they are capable of hypothetical reasoning, a characteristic of adolescence. Techniques for introducing relativistic thinking might include the following. When the individual is feeling angry or upset, we might ask, How upset? A little bit? A lot? A


ICDL Clinical Practice Guidelines

whole lot? And then we might spread our hands to demonstrate the extent of the feeling. If we wanted to present a stronger visual image, we might blow up a balloon and ask him to show whether the feelings state relative to the size of the balloon is small, medium, or large. If we were dealing with a person who was able to operate at a relativistic, gray-area thinking level but not able to anticipate the future very well, we could begin with questions such as, If we do this now, what will this mean for the future? In order to work at this level, we would need to make use of circumstances in the persons life and use a subject that she finds emotionally interesting. For example, if we wanted to discuss an event that is going to occur in the near future, we might ask someone to make choices between goods that they really want, such as, Do you want a chocolate cookie or vanilla ice cream? One we can get in 5 minutes, and the other one we can get tomorrow. An exercise like this one allows us to teach the person to project into the future with two highly cherished emotional items, as well as teaching the person to think in terms of the future. Then we might want to move to hypothetical thinking about possibilities, which is more difficult. An example of the questions might be used here are: Do we take one cookie now or do we gamble and take a chance on maybe getting two ice creams later? We can set up little games of chance around prized things that include the notion of probabilities as well as projections into the future. It must be clear that at this level of interaction we are teaching the person a way of thinking that is crucial to social and emotional self-regulation. At this juncture, we need to ask a general question. Why is it that most adults who remain in special-needs programs rarely function above the 10- to 12-year-old age level in their general functional intellectual

capabilities? We believe that the answer to this question has to do with the limitations of our general educational approach to these individuals. Many of them have the yet undeveloped capacity to progress far beyond the 10- to 12-year-old level of concrete thinking. Yet this capacity is not challenged because of the inadequacies in our understanding and our curriculums. We often end up working on very concrete solutions that reinforce concrete thinking rather than moving forward through the developmental levels in our treatment approach. To review our approach to individuals such as Jim, we would encourage more of the work that his mother initiated in approaching him through the auditory receptive system and through facilitated writing, eventually progressing to the use of oral language. Pictures also should be introduced as part of the intervention. Once an individual is quite verbal or can communicate with written words or other symbols, there should be efforts at gray area thinking and learning to make gradations about feelings. In order to strengthen earlier developmental building blocks of engagement and gestural language, we would recommend looking for opportunities to engage in 20- to 30-minute floor time sessions focused on the individuals interests. For a person like Jim, who is interested in music, we would recommend to his mother that she take him to music stores and help him look at different choices of music and make selections. She should try to get him to negotiate around the selections, meaning that he should have to make choices between one CD and another. There may be times when the individual wants absolutely to be alone, and there will be other times when he will gradually begin to accept his parents offer to listen to music with him. The listening together may start simply with sitting quietly in the room with



him. We would start strengthening basic shared attention and engagement by entering into his rhythm of life. This way, he will learn to share quiet time, relaxed time, and listening time, but through this, he will also begin to learn to interact more and to become more engaged. Concurrently, we would take him out into the community, working with him on making choices, talking about his feelings, and interacting with others. The overall goal is to build gray area thinking as well as an ability to interact with others. Throughout this process, we need to remember that the work we are doing takes time and patience. It took Jims mother approximately 10 years of patient work before Jim was ready to use oral language as well as written language. The third general principle in working with older children and adults is the importance of creating emotionally meaningful learning contexts. For example, consider a typical situation of a child who has learned some speech and is able to answer why questions. The child also has some small ability in math and reading but is not able to master abstract concepts. Therefore, he has a very limited understanding of the world, which then persists into adolescence and adulthood. We now find ourselves dealing with a person who thinks concretely and does not understand issues such as justice, fairness, and unfairness, does not understand what taxes are, and cannot grasp other complex issues. We see this situation in children who come to us with autistic spectrum diagnoses, Aspergers syndrome, cognitive delays, or mental retardation. We see it in some individuals who simply have severe learning disabilities and processing problems. A common underlying factor in all these children is the presence of processing problems. We have found that one way to make progress is to create more emotionally meaningful learning contexts.

Consider the case of a young girl who was unable to understand the meaning of taxation. Her mother was certain that she would never learn to understand the concept. As a way of teaching her about taxation, we involved her in a role-play during which she was required to trade pieces of pizza for things that she needed, such as protection from her aggressive and intrusive brother. She was asked how much would she pay a policeman to protect her from her brother. She decided to pay two pieces of pizza to protect the remaining eight pieces. The two pieces became the taxes she was willing to pay the police, who would then protect her from pizza thieves. This role-play took about 15 minutes. After completing it, she was able to give other examples of the meaning of taxes. She understood that she would need to pay for cleaning the streets and for taking out books from the library, as well as to pay in advance for the services of the fire department. This girl was beginning to understand a difficult abstract concept. She was able to grasp this concept by using it in multiple emotionally significant contexts. How does a child learn about justice? Justice is a vague and abstract notion. We are continually refining our sense of justice through being in situations that are fair and unfair. If we want to give a definition of justice to a child, we could give a dictionary definition, but this approach would not get us very far with most children. But if we create makebelieve situations such as one in which all the familys cookies are going to a brother or sister and not to the individual we are working with, the child will quickly say, Thats unfair. Thats unjust. Through this scenario, the child begins to understand that when he gets to share, that is called justice. This is only one example, but an emotionally meaningful one that helps him grasp an abstract concept. Then the child can refine his understanding of the


ICDL Clinical Practice Guidelines

concept through other experiences. In order for this to happen, however, we need to have emotionally significant experiences that build on the word and concept. Every word and concept begins with its simple definition. More complicated and gradually acquired meanings unfold over time through more and more emotional experiences. For example, concepts such as love or caring acquire more meaning throughout life. As we get older, we change our notion of these concepts. To a young child, love means caring, hugs, and kisses; to an adult, love means devotion, hugs, kisses, warmth, compassion, and empathy. To understand the complex concepts of life, we have to acquire more and more experience with them. The concept of size, which has both physical and mathematical dimensions, expands and becomes more complex as we grow older. When we are very young, there is big, and there is little. As we have experience in play, we note that some things are very big, super big, or super little. The more experience we have, the more the continuum of big vs. little stretches out. We find that the more severe the processing problems, the stronger the emotional meaning of the learning experience has to be to try to break through. Unfortunately, we are geared to certain standard ways of teaching, and frequently we are not working with the individual in this kind of dynamic way. It is essential that we continually remind ourselves that the worse the processing deficits, the more important it is to work in an emotionally meaningful context. The importance of finding an emotionally meaningful context for learning increases when we are attempting to deal with helping individuals establish gray area thinking and then hypothetical probabilistic thinking. The reason for this is that the concrete level of thinking comes much more easily and more

naturally. Simple why questions are relatively easy to answer compared to the challenges faced by an individual entering the gray, or hypothetical, thinking area. Here, without the strong motivation provided by an emotionally meaningful context, progress might be impossible. It is a crucial point in an individuals development to be able to think in these realms. Without this capacity, we cannot understand other peoples motives, and we can only understand a very limited amount of academically important materials. An individual who has only learned memory-based reading and memory-based mathematics will have quite limited academic capacities because the ability to think has not been mastered. In addition, we cannot work effectively with individuals with developmental problemswhether they are 5, 20, or 30 years oldwithout knowing which functional developmental capacities are missing. With each patient, we need a functional developmental road map. For example, if we are working on conceptual thinking, we need to know which concepts present a challenge for the individual, and then we need to develop emotionally meaningful ways to teach these concepts. ADULTS WITH SEVERE DEVELOPMENTAL CHALLENGES So far, we have been discussing some of the issues related to individuals with moderate to severe disabilities. We should consider another group, those individuals who cannot relate at all and whose behavior appears to be aimless, aggressive, and disorganized. These individuals often lack the capacity to put together a sequence of three or four gestures. If we can help such a person move from aimless activity to engagement and then on to some simple purposeful and reciprocal sequencing, we are producing a tremendous change in the quality of life, meaning, and



competency for that individual. Our next step should be to help that same individual reach a level where she can problem solve and participate in five or six interactive sequences so that, for example, she might be able to take us to the refrigerator and show us what she wants. Then we try to move that individual to function at the early symbolic level of development so that she can use a few pictures as words to communicate. With individuals who have profound developmental problems, we may give up because of our own reaction to the persons developmental limitations. In such individuals, there is often no purposeful reciprocity. Because of that, they often display a great deal of aggression toward others and toward themselves, as well as much diffuse and aimless behavior. At this point, the caretakers of such a person have to either resort to physical restraint or the heavy use of medication. Unfortunately, although large doses of tranquilizers may help with behavior management, medication may also reduce an individuals cognitive capacities and his chance of making developmental progress. Henry Manns recent work with the functional developmental approach in an institutional setting with several individuals who have profound developmental delays and range in age from their mid 30s to late 50s shows promise. Two case studies follow that illustrate how this approach is being applied to chronically institutionalized individuals with severe developmental deficits. Peter: A Mentally Retarded Adult Peter is a 34-year-old profoundly retarded man who was institutionalized in the Connecticut division of the mental retardation system when he was 5 years old. Peter was the product of a normal pregnancy and delivery. He was identified as retarded because of his failure to develop language or any non-

verbal communication skills. At the time he entered residential care, he had frequent uncontrollable rages and required full time one-on-one care. As Peter grew, so did his capacity for dangerous and aggressive attacks on other clients and staff. Over the course of many years, he was given large amounts of psychotropic and mood stabilizing medications, including Thorazine, Mellaril, Haldol, Prolixin, Lithium carbonate, and many others. Despite extremely high doses of medication, he did not seem to respond well. He needed a very high level of care until the introduction of Risperdol to his medical treatment. At that point, he was able to handle frustrating situations and changes in schedule without explosive reactions. Peter was never able to function beyond the very earliest developmental stages. He could focus on various objects that might be of interest to him, such as cans of soda, pieces of paper, and pens, which would inevitably end up in his mouth. With the Risperdol, he was better able to regulate his mood to the extent that his decreasing intensity and frequency of rage reactions were indicative of such a change. There was no noticeable engagement with staff or others throughout his time in residential care. He also showed little or no evidence of purposeful, two-way communication. His day-to-day life consisted of being cared for and passively accepting directions. In addition, he also did not seem to understand higher-level problem-solving gestures or words. When the DIR approach was initiated with Peter, he rapidly began to focus his attention on the interviewer. The technique used to engage his attention was simple imitation or mirroring of all his movements and sounds. This technique is one that mothers naturally use to engage their babies attention in the first months of life. It was appropriate for Peter because the first therapeutic task


ICDL Clinical Practice Guidelines

was to engage his attention and then build on this to develop relating and finally some sort of purposeful interaction between him and the therapist. In order to explore what might be helpful for Peter, he was seen for 20- to 30-minute sessions twice monthly. The infrequent sessions were because of the limitation of the therapists schedule: it would have been helpful to see Peter more regularly. The goal was to learn how to engage him and to create opportunities for two-way communication and then to use these insights to work with the staff so that they could work with Peter on a daily basis. During this time, the task was engagement of attention and then creation of conditions that allowed for emotional engagement. Peter responded very quickly during the first floor time session and even reached a point where he leaned toward the therapist and almost touched heads with him. In the second session, he showed what was probably a reaction to the first meeting by coming into the interview room and turning his back to the therapist for nearly 10 minutes. Eventually, the staff persuaded him to come to the other side of the table and to sit next to the therapist. Peter looked away and during that time almost never allowed the therapist to engage his attention. Whenever it was clear to him that the therapist was attending to him, he dropped his gaze or turned his body. The third floor time session showed almost the reverse. Peter came into the meeting making loud guttural sounds. The therapist responded with a similar sound and a friendly tone. For about 10 minutes, they sat next to each other making these sounds. There was no synchronicity on Peters part, meaning that he did not build on the therapists sounds, although his persistence and occasional look of real interest in this activity was a clear indication of fleeting involvement and engagement.

Over a series of sessions, Peter began to increase his repertoire of sounds to include short combinations of consonants and vowels in a somewhat rhythmic pattern, which the therapist imitated. He appeared to be extremely engaged and to be aware that the therapist was picking up on whatever he produced. During some sessions, he was openly interested in the therapist. He showed this by taking the therapists eyeglasses or pens and putting them in his mouth and by moving close to the therapist. During this time, a 2- or 3-minute period of intimacy was usually followed by withdrawal for an equivalent amount of time or longer. A good session, in which there was a great deal of intimacy, was usually followed by a session in which there was some withdrawal and disconnection. However, over time, the periods of intimacy became longer, growing from about 20 seconds to 3 or 4 minutes. In one dramatic recent session, Peter included other staff in the floor time interaction and responded equally well to two staff members during the session. He exchanged looks, had some fleeting smiles, and exchanged objects. During this time, it was noted that Peter was very sensitive to light touch and sound and could use visual-spatial problem solving (find things) much more effectively than verbal strategies (he never followed directions). Currently, Peter has entered a treatment phase in which other staff members have begun daily floor time sessions with him, under supervision by the psychiatrist/therapist. Staff are careful not to intrude on his sensitive tactile or auditory systems and to use lots of gestural animation to appeal to his stronger visual problem-solving skills. They begin with some simple imitation of Peters behavior to get interactions going. The staff has attended an in-service training program; they will make videotapes of their floor time



sessions with Peter to be reviewed by the consulting psychiatrist. The staff now seem to be enthusiastic and fully engaged in learning about floor time whereas initially they were quite skeptical about this new way of communicating with their client. In a recent treatment session with one of the staff, Peter demonstrated his new ability for engagement by maintaining his attention on the staff person for the full length of a 20-minute period. Peter also has increased the complexity of his use of sounds. The typical floor time session with Peter now consists of the purposeful exchange of a wide range of sounds and variations in volume and some motor gestures such as giving or taking objects. The hope is that within several years Peter will extend his use of gestures and sounds to the beginnings of some words or symbolic gestures to communicate with others. Peters mood also has improved during the treatment period. Prior to treatment, Peter would have one to two months of extreme agitation each spring, during which he would become assaultive and aggressive, sleepless, and irritable. Since the beginning of the program and engagement, his seasonal problems appear to have abated. He still demonstrated a considerably increased amount of energy during the spring, but he did not have periods of agitation and depression. His overall mood has been happier, and he has shown more signs of engagement with others. Alice: An Autistic, Mentally Retarded Adult Our next case is Alice, a 59-year-old profoundly retarded woman who was placed in a large residential center when she was a child. Alice is a spastic quadriplegic who also has kyphoscoliosis. She has been withdrawn and avoidant of contact with others and has carried a diagnosis of autism since childhood.

During her time in various residential programs, she has never engaged with others. She has been nonverbal, gaze avoidant, and has shown a complete indifference to her surroundings, to staff, and to other clients. She has had frequent episodes of crying and whining that have appeared unrelated to any external circumstances. Kim, a nurses aide, showed an interest in learning the DIR approach as a way to communicate with autistic clients and asked to work with Alice about 1 year ago. She agreed to come with Alice to the semiweekly psychiatric clinics for training. During a 20-minute period at each clinic, Kim was supervised in how to initiate contact with Alice and how to engage her attention. The initial approach was simply to mirror all of Alices gestures and sounds, which Kim learned fairly quickly. Within several clinics, she was able to very competently engage Alices attention. As Kim worked in Alices residential home, she was able, with her supervisors support, to set aside three 30-minute periods per week for individual floor time with Alice. Alice responded to these meetings by beginning to reach out for Kim and to make eye contact with her. After several months, Alice started to become attached to Kim. She showed signs of pleasure when Kim entered her room. She would reach out for Kims hand and bring it close to her head to rub the side of her face. Alice, who had not been observed to smile or show signs of pleasure for many years, began to smile spontaneously. She reduced the frequency of her episodes of crying and whining. After several more months of regular floor time work, Alice started to reach out for other staff and to show signs of recognition of others. She also made eye contact with other staff. With severely challenged adults, the key is to pay attention to the early functional developmental capacities of attention, en-


ICDL Clinical Practice Guidelines

gagement, and two-way purposeful interaction. Gains in these basic foundations can make an enormous difference to an individuals adaptation, including basic emotional, social, and cognitive capacities (e.g., to be purposeful rather than aimless). Of interest is that initially many of the residential staff that worked with Alice were quite skeptical and unsupportive of this approach. However, within 6 months they became more supportive and began to use some of the floor time techniques to engage Alice themselves. Other staff members have now asked to attend inservice training sessions, and several will be starting to work with other clients within the next few months. The impact on the staff was quite significant. Prior to their experiencing the effect of a functional developmental approach on their retarded or autistic clients, they were unaware of any opportunities to improve their autistic clients quality of life other than trying to make sure that their day-to-day lives were conflict-free and somewhat interesting. There were, however, many hours of aimless activity coupled with attempts at control. Once the staff saw that they could help their clients relate and be purposeful, and as they paid attention to the subtle signs of interaction, they worked more with their clients. Kim has experienced a large change in her self-confidence both in dealing with clients and other staff. One would expect that as further learning and practice of the developmental approach occurs, the staffs overall morale and level of engagement with all their clients may grow. FACILITATING PEER RELATIONSHIPS Another basic principle in working with developmentally challenged adolescents and young adults is that we need to pay very close attention to the quality and extent of their

ability to relate to their peers. Many of us have had the experience of helping children with the diagnosis of Aspergers syndrome who are verbal and academically skillful enough to be in a regular class but cannot interact appropriately with the other children. Therefore, they feel isolated and alienated. As a result, the child often becomes very sad and depressed. The child is aware enough to know that he wants to have friends and be part of a social group, but he is also keenly aware of his deficits and his lack of acceptance by others. Teenagers and adults with these developmental disabilities experience this same phenomenon. Ordinarily, if we were working with a child at a young age, we would start to encourage developing peer relationships as soon as the child had mastered gestural communication. The children who learn complex, preverbal, problem-solving gesturing and who strengthen this through ongoing social interactions become quite socially competent. Even if they have strong deficits in other areas, they have learned to engage other children and can play with them in a manner that is enjoyable both to themselves and to the other children. Children who cannot develop this capacity are viewed by themselves and by others as being different. There is no substitute in this process for lots of practice with peer interaction. A 15-year-old boy, Donald, was seen for therapy because of severe depression and withdrawal following the death of his grandfather. He had previously been seen in therapy by another therapist who had diagnosed him as having Aspergers syndrome and had treated him with a combination of antipsychotic and stimulant medication. The boy had been seen in a supportive therapy, but according to the therapist, was very difficult to engage and generally interacted with the therapist with very little emotion. Donald had adequate use of language and could learn his coursework with the support of special educa-



tion classes and an individual tutor. Although he had auditory and tactile hypersensitivities in addition to low motor tone and problems with fine and gross motor coordination, the family had not been able to obtain adequate occupational and physical therapy services for him. Dr. Mann soon discovered that Donalds greatest concerns were the loss of his grandfather and his lack of peer relationships. Apparently, for several years prior to his grandfathers death, Donald had daily telephone conversations with his grandfather that lasted up to an hour and a half. His grandfather had, in fact, been attempting to fill in for the social contact that was otherwise completely lacking in Donalds life. As part of the treatment plan, Dr. Mann saw Donald weekly or semiweekly for psychotherapy sessions and talked with him on the telephone 7 days a week for 5 to 10 minutes. As part of the regular weekly therapy sessions and the telephone conversations, the therapist offered Donald an opportunity to engage in role-playing. Donald welcomed this chance to do some grown up pretend and to participate in a more dynamic interactive learning experience than he had experienced in prior treatment programs. With Donalds guidance, one element that was especially helpful was when the therapist transformed himself into a personification of a somewhat aggressive, highly verbal, obnoxious, and playful adolescent. The content of the discussions was generally meaningless and irrelevant to the treatment. The substance of the conversations was to engage Donald and to educate him in the nonverbal ways of teenage boys both face-to-face and on the phone. After 4 months of this approach, Donalds initial extraordinarily flat and depressed affect changed. The pace, rhythm, and range of affect in his speech improved and began to approximate that of other adolescents his age. Within the next 5 months, he began, for the

first time in his life, to have some limited friendships, to have a girlfriend, and to start work in a volunteer position at a local hospital. The therapeutic relationship was encouraging these relationships and lots of practice with real peers on a daily basis. In some communities, there are special programs designed to foster and develop social interactions. In Bethesda, Maryland, the Bethesda Academy for the Performing Arts has special groups for children with developmental challenges. In one troop, there are a number of children with Down syndrome and a number with nonspecific developmental delays. Some of them are on the autistic spectrum, and others have Aspergers syndrome. What they have in common is that they are all at least partially verbal. In some of the acting groups, they are integrated with other children who have no developmental challenges, and they work together to do their own productions. They usually write their own scripts and perform plays several times a year. While writing and performing their plays, they create a strong social network that is supportive and positive. The acting is quite good because it is performance- and movement-based, with heavy use of visual imagery. Different people, depending on their ability level, play different roles. Some have very limited parts, and others are leaders; everyone seems to enjoy participating to the degree that they are able. It should be noted that drama is a particularly fruitful activity because it draws upon many functional developmental capacities (engaging, gesturing, pretending) and different kinds and levels of abilities, especially because a play requires that all of the participants, both onstage and off, have a close working relationship with each other. Although some adults require medication, not infrequently medication is used as a substitute for the basic developmental building


ICDL Clinical Practice Guidelines

blocks of engagement: shared attention, reciprocity, and using ideas. Medication can be helpful as an adjunct to developmental work if the patient is overwhelmed by anxiety, depression, or fragmented thinking. It should be noted that medication could be uniquely helpful in assisting the child in beginning to regulate himself so that he can participate in therapy and even get through the day. Unfortunately, as we noted earlier in this chapter, adolescents and young adults who become easily frustrated, aggressive, or in any way threatening to their caretakers usually end up in a medication-based treatment in which the fundamentals of a developmentally based approach are left far behind, along with the individual. THE STAGES OF LATER CHILDHOOD, ADOLESCENCE, AND ADULTHOOD In considering the treatment of adolescents and adults, we need to think about the functional developmental stages that come after the basic first six stages. Many adults will have relative mastery of the early stages and have limitations in the more advanced ones. The first six are shared attention, engagement, simple purposeful movement and gestures, complex problem solving, continuous flow of reciprocal gestural interactions, and using ideas creatively and logically by building bridges between them. At the seventh level, which typically begins between the ages of 4 and 7, the child begins to get very expansive in his thinking and to go from simple logical thinking to triangular logical thinking. An example of triangular logical thinking is when a young boy figures out that if he wants to be friends with Johnny, the way to do that might be to become friends with either Sarah or Billy, who are already friends with Johnny. He decides to take this tack because

Johnny has already rebuffed him several times. In other words, he has learned that not all roads to Rome are linear or direct and that he can go a roundabout way and still get there. At this stage in development, children begin to see three variables in interactions with each other as opposed to just two variables. The child dealing with two variables can answer the why questions, Why do we feel happy or sad with the answers, Because we didnt do this or Because I did not think about that. The three-person system is much more sophisticated and one that is requisite for successful functioning in a family system, social group, or work setting. Without adequate understanding of the threeperson system, the child cannot truly understand higher-level mathematics or life itself. Children who reach this level take a greatly expanded view of life and show an interest in all facets of their world. They become curious about their bodies, sex, anger, death, where their parents came from, and about anything else that even remotely touches their lives. Along with an expanded interest in their world, children at this level also show more fears and anxieties at this stage, coinciding normally with the Oedipal phase of development that is associated both with anxieties and grandiosity. Working with adolescents and adults who begin to engage in triangular thinking for the first time may create some anxiety for therapists because now we are dealing with individuals who are showing an interest in their bodies and in sex and who suddenly become more manipulative. As individuals become more adept at navigating three-person relationships, we should expectand even welcomea certain amount of manipulativeness. Our role as parents or therapists is to support these individuals throughout this period and help them both to learn good judgment and to reduce their anxiety about their newfound assertiveness. We also need to help them keep



their grandiosity and expansive thinking at a realistic and manageable level. We call the eighth developmental level playground politics, or proper, or gray area thinking. At this level, the child goes from simple triangular thinking to being able to see shades of gray. We can ask a child, Gee, whats happening at school? What do you do well? What do other kids do well in? The child will tell us, Well, Im the best at this, Johnny is the best at that, and Sally is the best at that. Im number 4 at this and number 6 at that. The child is developing a relative sense of her place in the social hierarchy. At this time, she can also tell us whether she is a little angry or very angry or super angry or furious or very loving or super loving. She can now see things in shades of gray, which helps her see the world in relativistic terms. Mastering this developmental level is obviously important, not only for the childs social and emotional world but also for her intellectual world. We cannot understand math or physics or interpret stories or understand history without understanding things in their relative contexts. This developmental milestone occurs as the child is also learning to understand the nature of peer relationships better. She is learning to reduce a tendency toward catastrophic thinking and reactions. For example, if she is not chosen to play on a team one day, instead of feeling totally rejected, she can say to herself, Well, they are not nice to me today but maybe they will be a little nicer to me tomorrow, or, I can be friends with Susan and that may change the way Samantha and her group feel about me. Reaching this level of relativistic thinking, which is essential to problem solving, typically occurs between the ages of 7 and 10, but many of the children whom we are concerned with may not arrive at this stage until their mid-teens or even later. The next stage is one that we call the two worlds inside me, during which the child

goes from relativistic thinking to being able to hold onto an internal reality of a self-image with beliefs and values. He can then compare his peer-based relativistic world to those standards he is trying to create. A 7- or 8-year-old defines himself by his relationship with the peer group; that is, I am good or bad by whether I was chosen for this or that game. In the middle latency years, a childs self-definition is very much a social and group-related one. By 10 to 12 years of age, the child begins saying, Im a good person because I was nice to my brother and sister and because I did my homework. And, yeah, Sally was mean to me today at school, but Im still a good person and she was just having a bad day. The 10- to 12-year-old can begin comparing these daily experiences against an internal standard, which the 7- or 8-year-old cannot do. We call that the world inside me, or the ability to create two worlds. Obviously, this ability is crucial for internalizing values, having a conscience, and being able to regulate behavior. During this developmental period, we see what we call the ego ideal, or conscience, becoming consolidated to some degree. Obviously, this is an important emotional, social, and intellectual stage of development because a person cannot really reflect to any significant degree unless he has an internal standard available for comparison. Children then enter into the adolescent years. At this age, we see a flowering of all kinds of abilities and interests. Focus on the larger community and even television characters is increasing, friendship patterns are broadening, and awareness of conflicting values between my generation and others becomes an issue. But the biggest change, by far, is that the body is changing, and children are entering the area of sexuality in a more formal way. There is sexual interest; there is sexual acting out, masturbation, and interest in sexual relationships. Aggression is more


ICDL Clinical Practice Guidelines

dangerous at this time because the body is getting bigger, muscles are developing, and hormones are changing. Particularly in boys, there is much more testosterone, which affects the quality of their aggression. Around this time, identities are forming. Adolescents ask, What am I? Who am I going to be? There is a lot of concern about humiliation around body image issues; the changing body can be very scary and frightening. We cannot describe all the aspects of adolescence, but from this discussion we should understand that adolescence is hard enough for a child who has no processing difficulties and who has mastered all the prior functional capacities. What about a child who is very, very concrete and just has the bare minimum of some verbal concepts, who can answer why questions but can not do gray area and triangular thinking? What about a child who cannot even answer why questions yet, but who can elaborate some simple phrases? What happens when these changes in the body, sexual interests, and level of aggression happen in children whose processing and functional capacities are weaker? If a person does not have strong visual-spatial processing, he or she cannot establish a body image very well. How does the adolescent cope with that? This is where the adults involved begin to have many concerns about the level of the persons propensity toward aggression or sexual acting out. An overriding principle is that the experience of mastery of new stages and new skills is a very important source of self-esteem throughout these different developmental stages. This experience is one of the largest sources of self-esteem available to any of us. We are always trying to master new things. If we stop challenging children and do not provide them opportunities for new mastery, they feel worse about themselves. Children generally do not feel too inadequate if they

are making progress and mastering new things, even if they are far behind other kids. They may not feel wonderful, but they can feel pretty good about the fact that they are making progress. It is very, very important for us to create that experience for our children, ourselves, and for our patients. Consider the previous case of Jim, who has a strong interest in music. By putting together experiences in the area of music that increased Jims knowledge and confidence, we could go a long way toward increasing his sense of self-esteem. Whether it is helping a child to learn to do magic, develop his sense of humor, or develop his artistic abilities, we are helping him develop strong sources of pleasure and identity. The development of sexual interest and acting out is an extremely challenging situation for parents and therapists. A child may have adolescent urges but still function developmentally as a 5-, 6-, 7-, or even a 3-year-old. We need to deal with his sexual urges in the context of his functional developmental capacity. We may tell a simple birds and bees story to one child, whereas we may need to emphasize to another that, while individuals like to touch their bodies in different places, it is a private activity and there is a place and time to do it. We can work with a teenager with a few words to help him understand that we know that he likes doing this but also that this is something that goes on in the bathroom or the bedroom. For the child who is at the 7- or 8-year-old level but is physically a 15-year-old, we could use one of the books that have pictures and explanations about how the body works as a basis for some discussion, as we would ordinarily do with a 9- or 10-year-old. In addition, the notion of how to protect oneself from being exploited sexually or getting diseases is no different than any other discussion about self-protection. It should be addressed to the functional thinking level of the individual.



The key thingand the hardest thing to do during the adolescent yearsis to maintain a nurturing relationship with the adolescent or young adult, because he is larger physically and is moving on with his own different interests. Adolescents and adults are not as cuddly and warm as younger children. So we often find that parents, therapists, and other caregivers hold back nurturing, warmth, and intimacy. When this happens, the adolescent or adult does not have his dependency needs met by his parents and family. He then seeks to have his basic security and dependency needs met in other settings. When this occurs, we are more likely to see the creation of negative identities, such as involvement in substance abuse and other risk-taking activities, because the child is searching out an identity that brings him closeness with someone. With adolescents and adults who are functionally and developmentally compromised, there are ways other than cuddling to meet their dependency needs. These ways may be as simple as the phone calls made to Donald or listening to music with Jim. In other words, spending time with adolescents and adults and focusing with them on their interests will help meet their needs for warmth and intimacy. Obviously, new challenges come up as developmentally compromised individuals move into adulthood. Whether a person lives at home or begins living independently, there is often some relative separation from parents, with other relationships taking over the parental function. Ordinarily, these relationships would be friendships or sexual relationships in which a young person looks to someone else to supply not only a new relationship but also what the parents were providing. However, these transitional relationships can be quite chaotic and often full of conflict because the adolescent is expecting so much from the other person. Unrealistically high

expectations are why late adolescent and early adult relationships are often so difficult. Children with developmental problems who have progressed to the adolescent years in a functional developmental sense will be ready for relationships, but they may not have all the tools they need. They may have processing problems, or they may easily regress into concrete modes of thinking or fragmented thinking. They are going to need more support. They may get more depressed, anxious, and fragmented than children without these problems, but they are clearly struggling with some important issues. We have to be aware of those issues in order to provide more support, either in therapy or through the family to help them have the glue they need to hold together during those times. The issues of adulthoodhaving a family, middle age, the challenge of coming to grips with the past and the future, and the aging processare especially relevant for individuals with milder developmental problems and those who have made good progress. These struggles need to be recognized because these individuals may need support, whether it is from the nuclear family or counseling. The better we are able to help the developmentally compromised child and young adult move into higher functional capacities, the more they will be able to experience new and meaningful challenges. CONCLUSION In this chapter, we have tried to emphasize that working with adolescents and adults involves the same principles as working with younger children. This work, however, involves meeting the adolescent or adult in the context of his unique interests and developmental profile and embarking on a continuing developmental journey. s


ICDL Clinical Practice Guidelines

REFERENCES Greenspan, S. I. (1992). Infancy and early childhood: The practice of clinical assessment and intervention with emotional and developmental challenges. Madison, CT: International Universities Press. Greenspan, S. I. (1997). The growth of the mind and the endangered origins of intelligence. Reading, MA: Addison Wesley Longman. Greenspan, S. I., & Wieder, S. (1998). The child with special needs: Intellectual and emotional growth. Reading, MA: Addison Wesley Longman.