Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

As I have mentioned many times in the past, the new role of the pediatrician has given him an increased responsibility in the fields of child development, child psychology, and even, to some degree, in child education.

Recognizing this background, many parents turn first to the pediatrician if their children present any problems in these areas.

And so it is that the pediatrician is often asked for advice when a child is having great difficulty in learning to read. This is as much a diagnostic problem as a fever of unknown origin. Is it due to subnormal mentality or a defect of vision? Is it due to a lack of "reading readiness?" Is it due to a lack of concentration or an increased distractibility? Is it due to emotional difficulty, or is it developmental dyslexia?

I myself had an early introduction into the subject of reading difficulties when I was the pediatrician to a well-known "progressive" school in New York City in the 1930s and 1940s. The principal, a brilliant educator, had an interest in reading problems, and felt very strongly that all normally bright children would eventually learn to read and that most of these difficulties were due to pressuring children to read before they had reached their individual ages of reading readiness. Therefore, no children were taught reading until the age of seven, which she felt was the average age of readiness, and the parents were firmly ordered not to attempt to teach them reading at home before this time.

In spite of this - and they were all bright children - certain of the children did have reading difficulties. As I recall it, the teachers felt these children were not applying themselves, especially when in some cases they were excellent in solving mathematical problems, vocabulary, and art. And so these youngsters were given special tutoring, usually by one of the teachers in the school.

Reading difficulty, as a specific entity, was already well recognized for many years in Europe before the American neurologist Dr. Samuel Orton made his great impact in this country in 1925.

Dr. Malcolm Critchley, in his fascinating and comprehensive book The Dyslexic Child, reviews the whole history of the subject. A few titles and their authors from across the Atlantic, included in Dr. Critchley's volume, give some indication of the long interest in this mysterious condition.

J. Hinshelwood in 1895 wrote Word-blindness and Visual Memory, A. Peters wrote Congenital Word-blindness in 1908, W. J. Rutherford The Etiology of Congenital Word Blindness in 1909, and E. B. McCready, in the same year, published Congenital Word-blindness as a Cause of Backwardness in School Children.

I was an attending at New York Hospital in the mid-3 Os when Dr. Orton was Professor of Neurology at the College of Physicians and Surgeons. From time to time he would visit our department and discuss his interesting theories regarding an anatomic basis for dyslexia. As a result of his findings he was optimistic that a solution to the education of dyslexic children would be found with a specific approach to each individual child affected with the condition. Later, under his guidance, a method of teaching these children to read was devised.

In the course of my practice I observed many children with dyslexia and followed a good deal of the literature on the subject.

In the early 1960s the term "mild brain damage" was given great prominence. An international congress on the subject was held, with a published report in 1962 under the editorship of Dr. Herbert Birch. The condition was presumably due to a temporary lack of oxygen…

As I have mentioned many times in the past, the new role of the pediatrician has given him an increased responsibility in the fields of child development, child psychology, and even, to some degree, in child education.

Recognizing this background, many parents turn first to the pediatrician if their children present any problems in these areas.

And so it is that the pediatrician is often asked for advice when a child is having great difficulty in learning to read. This is as much a diagnostic problem as a fever of unknown origin. Is it due to subnormal mentality or a defect of vision? Is it due to a lack of "reading readiness?" Is it due to a lack of concentration or an increased distractibility? Is it due to emotional difficulty, or is it developmental dyslexia?

I myself had an early introduction into the subject of reading difficulties when I was the pediatrician to a well-known "progressive" school in New York City in the 1930s and 1940s. The principal, a brilliant educator, had an interest in reading problems, and felt very strongly that all normally bright children would eventually learn to read and that most of these difficulties were due to pressuring children to read before they had reached their individual ages of reading readiness. Therefore, no children were taught reading until the age of seven, which she felt was the average age of readiness, and the parents were firmly ordered not to attempt to teach them reading at home before this time.

In spite of this - and they were all bright children - certain of the children did have reading difficulties. As I recall it, the teachers felt these children were not applying themselves, especially when in some cases they were excellent in solving mathematical problems, vocabulary, and art. And so these youngsters were given special tutoring, usually by one of the teachers in the school.

Reading difficulty, as a specific entity, was already well recognized for many years in Europe before the American neurologist Dr. Samuel Orton made his great impact in this country in 1925.

Dr. Malcolm Critchley, in his fascinating and comprehensive book The Dyslexic Child, reviews the whole history of the subject. A few titles and their authors from across the Atlantic, included in Dr. Critchley's volume, give some indication of the long interest in this mysterious condition.

J. Hinshelwood in 1895 wrote Word-blindness and Visual Memory, A. Peters wrote Congenital Word-blindness in 1908, W. J. Rutherford The Etiology of Congenital Word Blindness in 1909, and E. B. McCready, in the same year, published Congenital Word-blindness as a Cause of Backwardness in School Children.

I was an attending at New York Hospital in the mid-3 Os when Dr. Orton was Professor of Neurology at the College of Physicians and Surgeons. From time to time he would visit our department and discuss his interesting theories regarding an anatomic basis for dyslexia. As a result of his findings he was optimistic that a solution to the education of dyslexic children would be found with a specific approach to each individual child affected with the condition. Later, under his guidance, a method of teaching these children to read was devised.

In the course of my practice I observed many children with dyslexia and followed a good deal of the literature on the subject.

In the early 1960s the term "mild brain damage" was given great prominence. An international congress on the subject was held, with a published report in 1962 under the editorship of Dr. Herbert Birch. The condition was presumably due to a temporary lack of oxygen to an infant prenatally, perinatally, or postnatally. Emphasis was placed on the history during these periods - bleeding during pregnancy, prematurity, difficult childbirth, low Apgar scores, high fever in early childhood, or head injury. A child was considered to have the syndrome of "mild brain damage" if he had two or more of the following symptoms: hyperactivity, distractibility, short attention span, perseveration, resistance to discipline, dyslexia, poor control of impulses, and perceptual difficulties. A great deal of attention was paid by pediatricians to this symptom complex. And so, when we had children with dyslexia, hyperactivity, or any of the other features mentioned, we took careful histories of the pregnancy and perinatal and postnatal occurrences and sent the children to psychologists and neurologists, the latter usually reporting "soft signs."

In the course of all this discussion I saw a 10-year-old boy with dyslexia who was one of seven children, five· boys and two girls. On questioning I learned that all five boys had dyslexia. The girls had no difficulty learning to read. Further questioning disclosed that the father also had dyslexia. Presumably other familial cases were found, for the syndrome was changed from "mild brain damage" to "mild brain dysfunction."

I thought familial dyslexia was a new concept, but later I found in Critchley's bibliography a paper written in 1907 by S. Stephenson - "Six Cases of Congenital Word-Blindness Affecting Three Generations of One Family."

However, we pediatricians interested in the subject of dyslexia thought we had some direction from the concept of MBD, especially when the dyslexia was tied in with hyperactivity. The question was how much of dyslexia was related to distractibility, short attention span, and lack of concentration? Dexedrine and Ritalin were found to be effective in controlling the hyperactivity, limiting distractibility, and lengthening the attention span. And so we gave many of our reading-problem children these drugs and found them usually very helpful in making the children more acceptable in school. In certain cases it seemed to help when the child's dyslexia was compounded by hyperactivity and distractibility.

And, as usual, other interested groups claimed to have found the successful treatment of dyslexia. There were the optometrists who prescribed ocular exercises. The few cases I followed were unsuccessful. Then there were those who felt that dyslexia was due to a lack of vitamins and prescribed a regimen of megavitamins. I had the opportunity of following three dyslexic children treated in a special school concentrating on the treatment of dyslexia by megavitamins - a severe ordeal for the children, who were forced to take large numbers of vitamins at school as well as at home at regular intervals. I saw no real improvement after several years.

I have also observed several children treated by the exclusion of food additives and sugar from their diets and one child treated by the procedure of teaching him to creep, as in infancy. In none of these did I note any improvement.

Of course I realize that my personal experience is very limited on megavitamins and food additives, but in several studies I heard reported to the American Academy of Pediatrics unbiased investigators came to the same conclusion.

There are still many questions to be answered concerning dyslexia. Among these, the pediatricians ask: Is there a rational etiology for the condition? Is there an effective treatment? Does age make any difference on the effectiveness of therapy? Can the usual psychometric tests be given to these children? How important are emotional factors in the etiology of the difficulty? Is an electroencephalogram indicated in making a diagnosis? Can teachers be educated to early recognition of the dyslexic child? What should the teacher's approach be to the child? How can high schools and colleges accommodate the bright child with dyslexia? Where can parents of dyslexic children get advice and assistance in directing the child's future?

It is of special interest to note that an organization to study dyslexia, the Orton Society, was founded years ago and is still active in keeping physicians and educators up to date with worldwide advances in the subject.

This issue of Pediatric Annals is coedited by two people closely connected with the Orton Society. They are Dr. Drake D. Duane, Associate Professor of Neurology at the Mayo Medical School and President of the National Orton Society, and Paula Dozier Rome, founder and codirector of the Remedial Reading Center, Rochester, Minn. She is also the First Vice-President of the National Orton Society. Incidentally, Mrs. Rome is the niece of Dr. Paul Dozier, who pioneered the treatment of children with learning disabilities.

The symposium opens with a paper on the diagnosis of dyslexia by Dr. Duane. First he defines the term dyslexia and then proceeds with the necessary clinical assessment, family history, assessment of reading and writing performance and the indicated psychologic tests. It is to be noted that he does not advise a routine EEG. Dr. Duane emphasizes the great frequency of reading problems, so frequent in fact that they form an important public-health concern.

The second contribution, also by Dr. Duane, deals essentially with the theories as to the cause of dyslexia. Most workers on this problem have long realized that males are much more frequently affected than females. Is this a genetic condition? Does Orton's theory of impaired cerebral dominance as a cause of dyslexia hold up under scientific scrutiny? Are biochemical factors operative? These are among the many etiologic considerations reviewed in this article.

The third section of the symposium deals with many questions relative to dyslexia. These are the questions to which most pediatricians would seek answers. They cover many disciplines and are discussed by a pediatric neurologist, a pediatrician, and another pediatrician dealing with learning disorders of children, an ophthalmologist, a speech pathologist, a psychiatrist, a psychologist, and an educator. This is a most interesting and valuable portion of the symposium. One area covered refers to the bright dyslexic child and what the educational system is doing or not doing to insure his intellectual and productive future and protect him from the emotional trauma that so often accompanies the educational defeats and lack of understanding.

The article that follows, "Procedures for Helping the Dyslexic Child," is by Paula Dozier Rome and Jean Smith Osman, who conduct the Remedial Reading Center in Rochester, Minn.

This is an important article, for it answers the question asked by so many pediatricians and educators - "Now that you've diagnosed a child as dyslexic what are you going to do about it?" The authors review once again the diagnostic features of the condition. Then they advise on the approach to dyslexic children to build up their self-esteem and self-confidence. Finally, they deal with the method of treatment using three pathways to implement learning - visual, auditory, and kinesthetic-tactile. They specify approaches to avoid, such as programs of speed reading, using unsupervised workbooks, using eye-movement exercises, such activities as creeping and crawling, and using machines to any great degree. They suggest, at the onset of treatment, such things as taped reading assignments, oral examinations, and specially designed spelling tests. They state that "to make the diagnosis of dyslexia and not follow through is akin to diagnosing an acute appendicitis and not arranging for surgery."

It is my hope that this wellorganized and clear symposium on dyslexia will be read by all pediatricians and by educators as well.

10.3928/0090-4481-19791101-03

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