Pediatric Annals

The Task Ahead

Edwin M Cole, MD

No abstract available for this article.

The situation confronting the dyslexic student in attempting to obtain the education he needs is vastly improved over what it was 30 years ago. The improvement is due largely to our increased understanding of the problem of dyslexia and the development of a continuously expanding group of well-trained personnel to work with the dyslexic student.

Improvement in the methods of treating dyslexic students began in the 1920s as a result of the keen powers of observation and insights of Dr. Samuel T. Orton. He was aided in his work by many colleagues - by his wife, June L. Orton; by medical colleagues, such as Drs. Paul Dozier and Earl Cheshire; by skilled teachers, such as Anna Gillingham, Bessie Stillman, and Ellen Donahue; and by many others.

Many people have helped, through their own experiences and observations, to clarify the picture of the dyslexic student and his needs. However, one question continues to trouble all of us: Why does the promise contained in present-day knowledge, with all its expertise in this field, often fail to be fulfilled? Or, in simpler words, why do so many dyslexic students fail to achieve well, become discouraged, and fall by the wayside in a variety of ways? We can all be gratified by the successes - and there are many successes. But we are all troubled by our failures - failure in the treatment program, failure to achieve results.

I believe that the failures are largely due to ignorance of the special needs of the dyslexic child or inattention to them. These needs are so many and so diverse that their identification and evaluation, as well as the subsequent treatment and education of the child, should be conducted by a team whose members have expertise in many disciplines.

The most important member of the treatment team is the dyslexic child himself. He is the one who has to make progress and profit from the contributions of other team members. Even before his needs are identified, the child starts with feelings of inadequacy and poor self-concept, a history of failure, and many frustrations because of his educational experiences. The negative backlog has to be coped with. Along with the child come his parents, who have also been frustrated and baffled by his failures. Parents live again through their children and hope that their children will find a more successful and achieving life; hence they are apprehensive that their vision of progress and success through education is not being fulfilled.

Most parents take their anxieties first to the teacher or school official, and often they are reassured that most children improve with time. But some are met by criticism. The child does not apply himself. He is bright and could learn if he wanted to, or he is immature and spoiled. Any number of baffling terms are applied to the child. These experiences heighten parental anxiety and frustration.

These parents may find a physician who understands something about educational problems, certainly enough to refer the child and parents to someone with special expertise in this field of learning disorders. The specialist knows that firm information is necessary concerning the child's neurologic intactness and adequacy of his vision and hearing. Additionally, the physician must assess the child's behavior as he understands it through talking with parents, teachers, and the child himself.

At this point, special evaluation techniques are needed, centering around the patient's learning capacities and potential and his actual performance in skill areas. Here we require the help of educational psychologists who are adept at administering tests and measurements and evaluating performance.

With all this information at hand, explanations must be given to the child and his parents. The child must be reassured, and this is not a small part of the treatment program. The parents must be given careful explanations of the causative factors in dyslexia, particularly as these apply to their own child. Explanations should be coupled with recommendations on how to proceed. These involve selecting a school where the educational philosophy, staff, and facilities are available to respond to the child's special needs. Unfortunately, not all areas of the country provide private alternatives, and one may have to modify existing public educational opportunities. The physician may help to bring about such change in public instruction.

Dyslexic students require a well-structured educational setting with a minimum of environmental distraction. Since visual learning is disturbed and auditory mechanisms may also be confusing and unreliable, the environment should be free of extraneous visual and auditory stimuli. The school must also afford opportunities for dyslexic children to have specialized help provided by a teacher trained and experienced in this type of education.

When I went into practice as a young neuropsychiatrist, in 1934, I had just spent several months in Dr. Orton's New York laboratoryclinic. Some evaluations were being made and some children being tutored, but the medical profession was not yet involved to any great extent in specific reading disability, and educators were openly critical and hostile. Although some heads of independent schools were receptive to Dr. Orton's approach, most educators clearly felt that their fortress, the school, was under attack by an alien critic.

Forty-odd years later, the picture has changed considerably. In part this is due to better understanding generally of dyslexia and its remediation. But more important was the general disenchantment on the part of parents and many teachers with the effectiveness of reading instruction. Those were the days of "look-say" or "flash" reading, of de-emphasis on correct spelling and grammar as needed skills. Latin and Greek were dropped from many curricula, so that an intelligent study of word derivations and hence reasons for spellings of words became increasingly difficult. The theory seemed to be that the fewer facts we knew, the better our performance would be. This may be true in some fields, but it is not so when we are attempting to teach a logical system for reading, writing, and spelling. Dyslexic students, with their poor visual memory, need to learn the reasons for things, and there are reasons why words are as they are.

It was probably the common sense of the common man - the category into which most parents fall - that saved many dyslexic students. Parents felt that being unable to read, write, or spell effectively represented an unsatisfactory educational achievement. The fact that many children remain relatively illiterate and national reading scores are steadily falling is unacceptable to growing numbers of parents. So I think that a groundswell of dissatisfaction is aiding the cause of education for dyslexic students.

We were severely handicapped in the past by the scarcity of well-trained teachers and appropriate teaching materials for dyslexic students. Anna Gillingham and Bessie Stillman blazed a new trail; the early teachers have taught others, and now there are numerous centers for teacher training, one of the first being the Language Clinic of the Massachusetts General Hospital. More recently a great deal of useful teaching material has been produced, with the Educators Publishing Service of Cambridge, Massachusetts, a leader in this endeavor.

Some pupils, in those early days, had individual programs created for them in the schools they attended. After the diagnosis had been made, a trained and experienced tutor had to be found; he visited the student's school daily for an individual hour's lesson using the Orton-Gillingham method of instruction. Although many students were rescued educationally in this way, and in many parts of the country it is still the only form of therapy available; it is a poor plan. Outside tutoring is rarely well received by the classroom teacher and seldom integrated into the total school program. Inevitably, if a child fails to read, it is hard for the teacher not to feel responsible, a feeling that is heightened by the outside tutor's success. Teachers are human, and their frustrations may be expressed by antagonism towards the dyslexic child, his tutor, and the total program. Many students cannot take this antagonism and refuse to accept special tutoring, which means that their reading and spelling usually remain rudimentary.

Schools still often find difficulty in adjusting their curricula to the needs of dyslexic students. It has been hard to program oral tests in place of written tests. It has been nearly impossible to convince guidance counselors, principals, and even classroom teachers that a child failing in English, unable to read and write correctly, should not be expected to cope with a foreign language in secondary school.

One of Dr. Orton's original observations was that children with a language disability are often awkward and clumsy. He explained this as evidence of poorly established cerebral dominance. Many schools and clinics are emphasizing the clumsiness and incoordination aspect of language disability and have provided programs to deal with it.

Whether a child has a language handicap or not, if he is awkward, he should certainly receive and benefit from improving motor coordination. Any awkward child whose motor skills are improved can get an emotional boost from success in this area. But many dyslexic children are well coordinated and do not require such help. Also, no amount of improved coordination or improved self-image will teach him to read, write, and spell. Moreover, time taken for extensive exercise may complicate and abbreviate the academic day. The disabled reader cannot afford to have instruction time curtailed, nor does he benefit from distractions from his academic curriculum. Part of the parents' job is to find out how they can help at home - for instance, with regular periods for reading aloud, etc.

Dyslexic children usually suffer from poor selfesteem. Their educational experience has been demoralizing, and often they are made to feel that the fault is entirely theirs. Only a short step lies between this point of view and the attitude "1 am dumb, I can't learn, and there is no use trying." An important part of therapy is to give the dyslexic child a good morale boost. The first step in this is a careful explanation to the child of what dyslexia is, how he came to be dyslexic, and what can be done about it. He should know that many others have suffered from and coped with this condition, including many original thinkers, inventors, and famous men. It is also wise to find some area of performance in which he can succeed, such as sports or art. But no morale boost or improvement in coordination can take the place of careful instruction in alphabetic-phonetic principles. This is the basis on which educational progress must be built with dyslexic children.

It is striking to see the improvement in both morale and performance when the dyslexic child finds himself in a group that understands and shares his problem. When the world around the dyslexic child recognizes and accepts the difficulty, he can begin to accept it himself. Part of this world is the atmosphere of the home, so it is necessary that parents be given a full explanation and have a clear understanding of what is needed. Parents who do not understand dyslexia become pessimistic about the child's education - which, of course, does not help. Similarly, it does not help the child to have unrealistic educational objectives forced upon him. Part of the physician's task is to help the parents become less fixed and more realistic in their views.

The dyslexic child who has experienced baffling failure and received blame from teachers and parents inevitably develops an emotional response and compensatory behavior patterns - often quite unattractive - as the only self-defense he can devise. The remarkable thing is how rapidly behavior improves as the dyslexic child senses that adults believe he can make progress and show him how. He can then begin to have faith in his own powers.

Something must be said about the reckless and frivolous misuse of terms. Mislabeling increases apprehension of both parents and child, and school personnel are apt to dismiss a problem once it has been labeled, no matter how inaccurate the label may be. "Learning disability" is a poor term, because as used it includes many diverse and etiologically unrelated conditions: developmental dyslexia, mental retardation, crippling emotional or psychologic problems, blindness, deafness, seizure disorders, and anything else that interferes with learning. Since the term is imprecise and has damaging connotations, we should not use it. "Brain damage," "minimal brain dysfunction," and "brain injury" are terms currently in vogue. They are frequently used by educators and others who are not equipped to judge their appropriateness. Telling a parent that something is wrong with a child's brain when we do not know this to be the case is worse than inexcusable.

"Specific reading disability," as Orton originally used the term, indicates just that. The brain and mind are normal, but the processing of visual symbols is disturbed by the visual-spatial confusion of the dyslexic child. This is dyslexia.

In conclusion, during the past 40-odd years great strides have been made in creating a better understanding of dyslexia. A well-trained group of teachers is learning the best methods for helping the dyslexic child to learn verbal skills. We need a thoroughly coordinated program that includes the physician, the educational psychologist, and the school administration and teachers to work with the dyslexic child and his parents in order to achieve maximally satisfactory results. Such coordinated efforts, unfortunately, are rarely encountered.


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